Obstetric and Gynecologic Emergencies

1. Obstetric and Gynecologic Emergencies Chapter 20

2. Three Stages of Labor • First stage • Dilation of the cervix • Second stage • Expulsion of the infant • Third stage • Delivery of the placenta

3. Predelivery Emergencies • Preeclampsia • Headache, vision disturbance, edema, anxiety, high blood pressure • Eclampsia • Convulsions resulting from hypertension • Supine hypotensive syndrome • Low blood pressure from lying supine

4. Hemorrhage • Vaginal bleeding that occurs before labor begins • If present in early pregnancy, it may be a spontaneous abortion or ectopic pregnancy.

5. Ectopic Pregnancy • Pregnancy outside of the uterus • Should be considered for any woman of childbearing age with unilateral lower abdominal pain and missed menstrual period • History of PID, tubal ligation, or previous ectopic pregnancy

6. Placenta Problems • Placenta abruptio • Premature separation of the placenta • Placenta previa • Development of placenta over the cervix

7. Gestational Diabetes • Develops only during pregnancy. • Treat as regular patient with diabetes.

8. Scene Size Up: • Woman’s balance is altered. Be aware for falls and the need for spinal stabilization. • Use BSI. • Usual threats to your safety still exist. • Be calm. Protect the mother and the child.

9. Initial Assessment • Is the mother in active labor? • Evaluate trauma or medical problems first. • Treat ABCs in line with local protocols.

10. Transport Decision • If delivery is imminent, prepare for delivery in warm, private location. • If delivery is not imminent, transport on left side if in last two trimesters of pregnancy. • If the patient was subject to spinal injury, stabilize and prop backboard with towel roll on right side.

11. Focused History/ Physical Exam • Obtain full SAMPLE history, and also: • Prenatal history • Complications during pregnancy • Due date • Number of babies (twins) • Drugs or alcohol • Water broken • Green fluid (meconium)

12. Focused Physical Exam • Mainly abdomen and delivery of fetus • Based on her chief complaints and history • Pay close attention to tachycardia, hypotension, or hypertension.

13. Interventions • Childbirth is natural, does not require intervention in most cases. • Treating the mother will benefit the baby.

14. Detailed Physical Exam • Only if other treatments are not required

15. Ongoing Assessment • Continue to reassess the patient for changes in vital signs. Watch for hypoperfusion. • Notify hospital of your preparations for delivery. • Document carefully, especially baby’s status. • Obstetrics is one of the most litigated specialties in medicine.

16. When to Consider Field Delivery • Delivery can be expected within a few minutes • A natural disaster or other catastrophe makes it impossible to reach a hospital • No transportation is available

17. Preparing for Delivery • Use proper BSI precautions. • Be calm and reassuring while protecting the mother’s modesty. • Contact medical control for a decision to deliver on scene or transport. • Prepare OB kit.

18. Positioning for Delivery

19. Delivering the Baby • Support the head as it emerges. • Once the head emerges, the shoulders will be visible. • Support the head and upper body as the shoulders deliver. • Handle the infant firmly but gently as the body delivers. • Clamp the cord and cut it.

20. Complications With Normal Vaginal Delivery • Unruptured amniotic sac • Puncture the sac and push it away from the baby. • Umbilical cord around the neck • Gently slip the cord over the infant’s head. • It may have to be cut.

21. Un-ruptured Amniotic Sac

22. Umbilical cord around the neck

23. Postdelivery Care • Immediately wrap the infant in a towel with the head lower than the body. • Suction the mouth and nose again. • Clamp and cut the cord. • Ensure the infant is pink and breathing well.

24. Meconium

25. Delivery of Placenta • Placenta is attached to the end of the umbilical cord. • It should deliver within 30 minutes. • Once the placenta delivers, wrap it and take to the hospital so it can be examined. • If the mother continues to bleed, transport promptly to the hospital.

26. APGAR Scoring AActivity PPulse GGrimace A Appearance RRespirations

27. Neonatal Resuscitation • Neonatal Resuscitation

28. Giving Chest Compressions to an Infant • Find the proper position • Just below the nipple line • Middle third of the sternum • Wrap your hands around the body, with your thumbs resting at that position. • Press your thumbs gently against the sternum, compressing 1/3 the depth of the chest • Ventilate with a BVM device after every third compression. • 90 compressions to 30 ventilations per minute • Continue CPR during transport

29. Breech Delivery • Presenting part is the buttocks or legs. • Breech delivery is usually slow, giving you time to get to the hospital. • Support the infant as it comes out. • Make a “V” with your gloved fingers then place them in the vagina to prevent it from compressing infant’s airway.

30. Breech Presentation

31. Rare Presentations • Limb presentation • This is a very rare occurrence. • This is a true emergency that requires immediate transport. • Prolapsed cord • Transport immediately. • Place fingers into the mother’s vagina and push the cord away from the infant’s face.

32. Limb Presentation

33. Prolapsed umbilical cord

34. Excessive Bleeding • Bleeding always occurs with delivery but should not exceed 500 mL. • Massage the mother’s uterus to slow bleeding. • Treat for shock. • Place pad over vaginal opening. • Transport to hospital.

35. Spina Bifida • Defect in which the portion of the spinal cord or meninges may protrude outside the vertebrae or body. • Cover area with moist, sterile compresses to prevent infection. • Maintain body temperature by holding baby against an adult for warmth.

36. Spina bifida

37. Abortion (Miscarriage) • Delivery of the fetus or placenta before the 20th week • Infection and bleeding are the most important complications. • Treat the mother for shock. • Transport to the hospital. • Bring tissue that has passed through the vagina to the hospital.

38. Abortion or miscarriage

39. Twins • Twins are usually smaller than single infants. • Delivery procedures are the same as that for single infants. • There may be one or two placentas to deliver.

40. Twins

41. Delivering an Infant of an Addicted Mother • Ensure proper BSI precautions • Deliver as normal. • Watch out for severe respiratory depression and low birth weight. • Infant may require immediate care.

42. Premature Infants and Procedures • Delivery before 8 months or weight less than 5 lb at birth. • Keep the infant warm. • Keep the mouth and nose clear of mucus. • Give oxygen. • Do not infect the infant. • Notify the hospital.

43. Fetal Demise • An infant that has died in the uterus before labor • This is a very emotional situation for family and providers. • The infant may be born with skin blisters, skin sloughing, and dark discoloration. • Do not attempt to resuscitate an obviously dead infant.

44. Fetal Demise

45. Delivery Without Sterile Supplies • You should always have goggles and sterile gloves with you. • Use clean sheets and towels. • Do not cut or clamp umbilical cord. • Keep placenta and infant at same level

46. Premature infant

47. Gynecologic Emergencies • Do not examine genitalia unless there is obvious bleeding. • Leave any foreign bodies in place, after packing with bandages • Treat as any other patient with blood loss.