OB/GYN Emergencies

1. OB/GYN Emergencies

2. Course Objectives • Identify the key aspects of evaluating a pregnant patient to determine if birth is imminent. • Identify the purpose and use of tools in an OB kit. • Identify the steps for normal delivery of an infant including how and when to cut an umbilical cord. • Identify the steps for post-delivery care of the newborn and mother including delivery of the placenta. • Identify the critical treatment interventions for complications of pregnancy including: breech (buttocks) or two limb presentation, shoulder dystocia, prolapsed cord, and postpartum bleeding. • Identify steps for assessing an infant’s APGAR score. • Identify steps for neonatal resuscitation • Identify signs/symptoms and proper care for gynecological emergencies.

3. Terms • Abruptio placenta — This condition occurs when the placenta prematurely separates from the uterine wall causing heavy internal bleeding and pain; it can occur as a result of trauma. • Bloody show — Mucous and blood that comes from the vagina as the first stage of labor begins. The cervix is sealed by a plug of mucus during pregnancy to prevent contamination. When the cervix dilates, the plug is expelled as pink-tinged mucous. • Crowning — The bulging out of the vaginal opening caused by the baby’s head pressing against it. • Dilation — To get larger or enlarge. The degree of dilation of the cervix is often a key indicator used by midwives and physicians to determine if birth is imminent. However, EMTs do not perform this test. The process occurs over a period of several hours in some women, but can take much longer. • Eclampsia (toxemia) — A serious condition that can develop in the third trimester. It is characterized by high blood pressure and excessive swelling in the extremities and face. Life-threatening seizures differentiate eclampsia from preeclampsia.

4. Terms, continued • Ectopic pregnancy — Condition where a fertilized egg implants outside the uterus, often in the fallopian tubes. Symptoms can include abdominal pain and vaginal bleeding. • Meconium — A dark-green fecal material found in the intestines of full-term babies. Ordinarily, the meconium is passed after a baby is born. In some cases, the meconium is expelled into the amniotic fluid prior to birth. It gives the fluid a greenish-brown color known as meconium staining. • Placenta previa — A condition where the placenta sits low in the uterus blocking the cervix. It can present with painless, bright red bleeding. • Postpartum — A term used to describe the period shortly after childbirth.

5. Terms, continued • Preeclampsia — A condition found in pregnant women characterized by high blood pressure, abnormal weight gain, edema, headache, protein in the urine, and epigastric pain. If untreated, preeclampsia can progress to eclampsia. • Supine hypotensive syndrome — A pregnancy-related condition where the weight of an unborn fetus and the uterus puts pressure on the inferior vena cava. The result is inadequate venous blood return to the heart, reduced cardiac output, and lowered blood pressure.

6. Female Anatomy - Reproductive Organs • Cervix – opening of the uterus • First stage of birth, cervix opens & thins • Allows fetus to move into vagina • Opening process called dilation • Endometrium – inner lining of uterus • Each month built up in anticipation of implantation of fertilized egg • If fertilization does not occur, lining simply sloughs off • Referred to as menstrual period • Fallopian tubes – long slender passageways connect uterus to ovary • Female egg (ovum) passes through structure on its way to uterus for implantation to uterine wall • Ovaries – two almond-sized glands located on each side of uterus behind & below fallopian tubes • Produce estrogen & progesterone in response to follicle stimulation hormone (FSH) & luteinizing hormone (LH) secreted from pituitary gland

7. Female Anatomy - Reproductive Organs • Perineum – area between vaginal opening & anus • It sometimes is torn during birth which causes bleeding • Uterus – pear-shaped, muscular organ holds fetus during pregnancy • Contracts to push fetus through cervix & into vagina during birth • Vagina – flexible, muscular tube about three inches long • Called birth canal • Fetus moves from uterus throughcervix into vagina & then out of mother’s body

8. Fetal Anatomy • Placenta – develops early in pregnancy & performs important functions • Exchanges respiratory gases • Transports nutrients from mother to fetus • Excretes waste • Transfers heat • Active endocrine gland produces several important hormones • Attached by umbilical cord • Vein - transports oxygenated blood toward fetus • Artery – return deoxygenated blood to placenta • Amniotic sac – develops early in pregnancy • Consists of membranes to surround & protect developing fetus • Fills with amniotic fluid which cushions fetus & provides stable environment • Umbilical cord – attaches fetus to placenta • Contains one vein & two arteries • Vessels in umbilical cord similar to pulmonary circulation • Arteries carry deoxygenated blood • Veins carry oxygenated blood • Umbilical cord is about two feet long

9. Fetal Anatomy

10. Emergency ChildbirthNormal Delivery

11. Signs of Imminent Delivery • Main task in evaluating expectant mother is to determine if delivery is imminent • Expose abdomen & genital area, taking care to be discrete • Visually inspect the abdominal & vaginal areas for bleeding or crowning • Prepare for immediate delivery if observe any of the following: • Crowning • Contractions less than 2 minutes apart • Feeling of rectal fullness • Feeling of imminent delivery

12. Crowning • Crowning – appearance of any part of fetus in mother’s vagina • Remove enough of mother’s clothing to view genital region • Look for bulging at vaginal opening or a presenting part of infant Crowning

13. Contraction Intervals • Occur at regular intervals ranging from 30 minutes to 2 minutes or less • Labor pain from contractions lasts from 30 seconds to 1 minute • As birth approaches, interval between contractions gets shorter • Contractions that occur within 2 minutes of each other, from end of one to beginning of next, signify imminent delivery • Consider transporting mother if baby does not deliver after 20 minutes of contractions 2 to 3 minutes apart • Labor is generally prolonged for mother’s first baby • Average is 12 to 17 hours which allows plenty of time for transport

14. Feeling of Rectal Fullness • Feeling of rectal fullness or sensation of having to move one’s bowels can indicate infant’s head is in vagina & pressing against the rectum • Delivery is imminent • Do not let the mother sit on the toilet

15. Mothers who have previously given birth often know when ready to deliver Labor tends to be shorter after first child Use your judgment given circumstances Consider transport time Feeling of Imminent Delivery

16. Preparing for Delivery • Request a paramedic unit • Don sterile gloves, gown, and eye protection • Position mother on her back, legs drawn up • Provide supplemental oxygen • Prepare OB kit • Prepare infant BVM Emergency delivery kit

17. Preparing for Delivery Presentations You Can’t Deliver in the Field • Single limb • Prolapsed cord Presentations You CanDeliver in the Field • Head first (normal cephalic) • Umbilical cord around the neck (Nuchal Cord) • Shoulder dystocia • Buttocks first (Frank Breech) • Double footling

18. Assisting With Delivery • Support head with gentle pressure • Check if cord is wrapped around baby’s neck— attempt to loosen • Apply gentle downward pressure on shoulder & head • After anterior shoulder has delivered, apply gentle upward pressure • Suction mouth (no more than 1 inch into) & nostrils (no more than ½ inch into each) when head appears • Once delivered, stimulate infant if it does not breathe • After the umbilical cord stops pulsating put two clamps on cord 6 inches from navel & cut between the clamps Suction mouth & nostrils Delivery posterior shoulder Delivery anterior shoulder

19. Amniotic Sac • During first stage of labor amniotic sac usually breaks, expelling amniotic fluid • If sac is still covering infant’s head when head appears, use a finger to rupture sac • Note color & character of amniotic fluid • Fluid can be clear or straw-colored (which is normal) • Tainted & discolored, or thick & “pea soup-like” (which indicates meconium staining)

20. Detailed Delivery Instructions • Encourage the mother to breath deeply between contractions and push with contractions. • As the baby crowns, support with gentle pressure over perineum to avoid an explosive birth. • If the amniotic sac is still intact, rupture it with a finger to allow amniotic fluid to leak out. • As soon as the baby’s head appears, suction mouth & nostrils with a bulb syringe – squeeze air from syringe before inserting, insert syringe no more than 1 inch into mouth, no more than ½ inch into each nostril. • If the umbilical cord is wrapped around the baby’s neck, gently slip it over the head. Do not force it! If the cord is too tight to slip over the head, apply umbilical cord clamps and cut the cord. Clamp and cut the umbilical cord only if he baby’s head has emerged and is in a position that lows you to manage the airway.

21. Encourage the mother to push. Support the baby’s head as it delivers. To assist in delivery of the anterior shoulder, apply gentle downward pressure on the shoulder and head. As soon as the anterior shoulder has delivered, apply gentle upward pressure to assist in the delivery of the posterior shoulder. Once both shoulders have delivered, be ready for the remainder of the body to deliver quickly. Newborn babies are slippery so handle carefully. Stimulate the newborn to breathe by tapping the feet, if necessary. Once pulsations have stopped, clamp the cord by placing a clamp approximately 6 inches from the baby. Place a second clamp approximately 2 inches from the first, then cut the cord between the clamps. Detailed Delivery Instructions

22. Re-suction the baby’s mouth & nostrils only if baby not breathing or having respiratory distress Dry & wrap baby in a warm blanket — cover its head Place baby on its side to facilitate drainage Perform an APGAR assessment at 1 minute & 5 minutes after delivery Detailed Delivery Instructions

23. Newborn Care

24. Care of the Infant • If not breathing – stimulate it by rubbing its back or tapping your fingers on soles of its feet • If newborn does not start breathing effectively within 10 – 15 seconds of stimulation, use infant BVM to deliver gentle puffs of air — enough to cause the chest to rise • If after 30 seconds of assisted ventilation there is no response & heart rate is less than 60 beats/min, begin CPR

25. Care of the Infant • Keep newborn warm by drying it & then wrapping it in warmed blankets • After cord is clamped & cut, cover head • Be careful because a wet baby is very slippery • Repeat suctioning of nose & mouth, if needed • Remember to check APGAR score at 1 & 5 minutes

26. Meconium Staining • If signs of meconium are present, do not stimulate infant before suctioning mouth & nose • This avoids aspiration of fecal material that can cause pneumonia

27. APGAR • APGAR scale – numerical measure of baby’s overall condition immediately after birth • Perfectly healthy baby will have total score of 10 • Many babies score 7 to 8 during first minute • By 5 minutes, most babies score 8 to 10 on scale APGAR stands for: • Appearance • Pulse • Grimace • Activity • Respirations

28. APGAR Scale

29. Managing a Poor APGAR Score (PSS) • Three things to remember when managing infant with low APGAR score: position, suction and stimulate (PSS) • Position body so head is down & airway is open • Suction mucous & fluid from mouth & nostrils • Stimulate infant by taping bottoms of feet • PSS – memory aid to help recall these steps — position, suction and stimulate

30. Neonatal Resuscitation

31. Neonatal Resuscitation • After delivery, if infant not breathing effectively after 10 to 15 seconds of stimulation, begin assisted respirations • Use infant BVM with high-flow oxygen at a rate of 40 to 60 breaths/min • If pulse rate falls below 60 beats/min, start compressions & ventilations at ratio of 3:1 at 120 events/min (which is 90 compressions & 30 ventilations) • Remember, ventilation is the most important action in neonatal resuscitation

32. CPR - Two-Thumb Encircling Hands Technique(2 Rescuer CPR) CPR technique for infant with pulse rate below 60 beats/min • Place infant on a firm, flat surface • Remove clothing from chest • Find compression site which is just below nipple line on middle or lower third of sternum • Wrap your hands around upper abdomen with your thumbs on compression site • Use your thumbs to deliver gentle pressure against sternum, pressing ½ to ¾ inch into chest

33. Care of the Mother

34. Care of the Mother • Once baby delivered & umbilical cord cut & clamped you should: • Monitor and control bleeding from mother • Begin fundal massage • Monitor vital signs • Keep the mother and baby warm • Transport once infant is delivered • Do not wait for placenta—may take up to 30 minutes to deliver • Do not pull on umbilical cord • If placenta does deliver at scene, transport with mother & baby to hospital

35. Monitor and Control Bleeding • After placenta delivered, place sanitary napkin between mother’s legs • Ask her to hold legs together • Normal for mother to bleed up to one cup (about 250 cc) or 5 sanitary napkins of blood after delivery • Record number of pads

36. Postpartum Bleeding • Important steps in caring for postpartum bleeding include: • Fundal massage • Treat for shock • Do not force delivery of placenta • Place sanitary napkin at opening of vagina Fundal massage

37. Fundal Massage • Makes uterus contract & diminishes vaginal bleeding • Can feel for fundus of uterus, located in abdomen between pubic bone & umbilicus • Should feel like a softball • Perform massage like you would a firm muscle massage • Area may be tender & massaging it can cause discomfort Video demonstration available at EMS Online: http://www.emsonline.net/obgyn2011/mother.asp

38. Abnormal DeliveryDelivery with Complications (Can be delivered in the field)

39. Nuchal Cord (Umbilical Cord Around Neck) • Once head delivered ask mother to stop pushing so you can check if cord is wrapped around infant’s neck • If cord looks like it is wrapped tightly, so as to constrict airway, need to loosen it • Gently slip cord over baby’s head by placing two fingers under cord at back of neck • Bring cord over shoulders & head • Cord is durable but it can tear if handled roughly so don’t use excessive force • If too tight to loosen, clamp cord in two places two inches apart and cut cord between clamps • Unwrap cord from around neck & take care not to injure baby Video demonstration available at EMS Online: http://www.emsonline.net/obgyn2011/neck.asp

40. Shoulder Dystocia • Labor progresses normally & head delivered routinely however, immediately after head delivers, shoulders become trapped between symphysis pubis & sacrum, preventing further delivery • First step in treating shoulder dystocia is recognizing when it occurs • Two main signs of shoulder dystocia are: • Baby’s body does not emerge with standard moderate traction & maternal pushing after delivery of baby’s head • “Turtle Sign” –head suddenly retracts back against mother’s perineum after it emerges from vagina

41. Shoulder Dystocia Do’s & Don’ts of McRoberts Maneuver Do • Pull knees backwards (towards patient’s ears) & out to side to rotate & open the pelvis • Use suprapubic pressure to release the shoulder from behind pelvis Do Not • Do not pull forcefully on baby’s head • Absolutely, no fundal pressure Video demonstration available at EMS Online: http://www.emsonline.net/obgyn2011/dystocia.asp

42. Buttocks & Double Footling Presentation • If buttocks or two feet present first, you can attempt delivery in field • These are generally slow deliveries & you likely have time to transport • Key points are: • Request paramedic unit • Position mother with buttocks at edge of bed • Hold mother’s legs in flexed position • Support infant’s legs — do not pull • As head passes pubis, apply gentle upward traction until mouth appears • If head is stuck, create airway by pushing away vaginal wall — transport immediately

43. If Head Does Not Deliver • Create airway for infant • First, place gloved hand into vagina with your palm towards infant’s face • Form a “V” with index & middle finger on either side of infant’s nose • Push vaginal wall away from infant’s face to allow unrestricted breathing • Maintain airway & transport immediately

44. Abnormal DeliveryDelivery with Complications (Cannot be delivered in the field)

45. Single Limb Presentation • Key points of assisting with single limb presentation include: • Support baby with your hands • Provide airway for baby using your fingers • Transport immediately — do not attempt delivery in field

46. Prolapsed Cord If you see umbilical cord in vagina, presenting before the baby, initiate the following steps: 1. Request a paramedic unit 2. Place mother in knee-chest position 3. Check umbilical cord for pulsations 4. No pulsations - press presenting part of fetus away from umbilical cord, towards mother’s head 5. Re-check cord for pulsations 6. Administer high flow oxygen to mother 7. Transport immediately – fetus will die quickly without rapid intervention 8. Continue holding presenting part of baby away from umbilical cord 9. Apply moistened dressing on exposed umbilical cord 10. Do not push umbilical cord back into vagina Prolapsed cord Knee-chest position

47. Case Study • Video Case Study http://www.emsonline.net/obgyn2011/case1.asp

48. Obstetric Emergencies/Complications

49. Complications in the First Trimester – Ectopic Pregnancy

50. Ectopic Pregnancy • Implantation of growing fetus in location other than endometrium • Most common site is in one of the fallopian tubes • Surgical emergency because tube can rupture & cause massive bleeding 6 week old embryo 1 month old embryo