Obstetrical Emergencies

1. Obstetrical Emergencies Silver Cross EMS CME June 2011 2nd Trimester Instructor/Author: Lonnie Polhemus RN, NREMT-P

2. OB/GYN Emergencies • Many types of emergencies can occur with female reproductive system • Gravid and non-gravid • Following information will help you refresh assessment & treatment skills for emergency childbirth & gynecological emergencies

3. Because we have to have objectives • Identify anatomic structures and functions of female reproductive system. • Demonstrate basic understanding of pregnancy physiology and menstrual cycle, ovulation, and fetal development. • Identify signs/symptoms and proper care for gynecological emergencies. • Identify key aspects of evaluating pregnant patient to determine if birth is imminent. • Identify purpose and use of tools in an OB kit.

4. More objectives • Identify steps for normal delivery of infant. • Identify how and when to cut umbilical cord. • Identify steps for post-delivery care of newborn/mother including placenta delivery. • Identify critical treatment interventions for pregnancy complications • breech (buttocks) or limb presentation • shoulder dystocia • prolapsed cord • postpartum bleeding. • Identify steps for assessing infant APGAR score. • Identify steps for neonatal resuscitation

5. Terms to become familiar with • abruptio placenta — When placenta prematurely separates from uterine wall, causing heavy internal bleeding and pain • Can occur as a result of trauma. • bloody show — Mucous and blood that comes from vagina as first stage of labor begins. • Cervix sealed by a plug of mucus during pregnancy to prevent contamination. • When cervix dilates, plug expelled as pink-tinged mucous. • crowning — Bulging out of the vaginal opening caused by the baby’s head pressing against it.

6. And these too • dilation — To get larger or enlarge. • Degree of dilation of cervix often key indicator used by midwives and physicians to determine if birth is imminent. • EMTs/paramedics do not perform this test. • Process occurs over a period of several hours in some women, but can take much longer. • eclampsia (toxemia) — Serious condition that can develop in the third trimester. • Characterized by high blood pressure and excessive swelling in the extremities and face. • Life-threatening seizures differentiate eclampsia from preeclampsia.

7. A few more terms • ectopic pregnancy — Condition where fertilized egg implants outside uterus, often in fallopian tubes. • Symptoms can include abdominal pain, bleeding (intraperitoneal or vaginal). • effacement — Term relating to thinning of cervix. • meconium — Dark-green fecal material found in intestines of full-term babies. • Ordinarily meconium is passed after a baby is born. • In some cases, meconium expelled into the amniotic fluid prior to birth. • Gives fluid greenish-brown color known as meconium staining.

8. Almost done • placenta previa — A condition where placenta sits low in uterus, blocking cervix. • Can present with painless, bright red bleeding. • postpartum — A term used to describe the period shortly after childbirth.

9. Only three more terms • preeclampsia — Condition 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 — Weight of unborn fetus and uterus puts pressure on inferior vena cava. • Result is inadequate venous blood return to the heart, reduced cardiac output, and lowered blood pressure.

10. Last one for now • Braxton-Hicks — Defined by Taber's Medical dictionary as intermittent, painless contractions that may occur every 10 to 20 minutes after the first trimester of pregnancy. • First described in 1872 by British gynecologist John Braxton Hicks. • Sometimes called pre-labor contractions or Hicks sign. • Not everyone will notice or experience these contractions, and some will have them frequently. • Some mothers notice them more in subsequent pregnancies than in first pregnancy.

11. Female Anatomy of the 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 • 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

12. Female Anatomy • 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 through cervix into vagina & then out of mother’s body

13. 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 surround & protect developing fetus • Fills with amniotic fluid 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 • Newborn cord is about two feet long

14. Fetal Anatomy

15. Assessment of the OB/GYN patient

16. Assessment • Recognition of pregnancy • Breast tenderness • Urinary frequency • Amenorrhea • Nausea/Vomiting

17. Assessment • Obstetric History • Gravidity and Parity • Gravidity = Number of pregnancies • Parity = Number of live births

18. Assessment • Obstetric History • Last normal menstrual period • Estimated delivery date (-3/+7) • Previous Ob-Gyn complications • Prenatal care (by whom) • Previous Cesarean sections

19. Assessment • Obstetric Physical Exam • Evaluation of Uterine Size • 12 to 16 weeks: above symphysis pubis • 20 weeks: at umbilicus • For each week beyond 20 weeks: 1 cm above umbilicus • At term: near xiphoid process

20. Assessment • Obstetric Physical Exam • Presence of fetal movements • ~20th week • Presence of fetal heat tones • ~20th week • Normal: 120 to 160/minute

21. Assessment • Presence of Pain • Abdominal pain in last trimester suggests abruption until proven otherwise • Appendicitis may present with RUQ pain

22. Assessment • Presence of vaginal bleeding • Always dangerous in first trimester • Dangerous in late pregnancy if greater than normal period

23. Assessment • General health • Diabetes may become unstable • Hypoglycemic episodes in early pregnancy • Hyperglycemia as pregnancy progresses • Hypertension complicated by PIH • Cardiovascular disease may worsen

24. Assessment • Warning signs • Vaginal bleeding • Swelling of face, hands • Dimmed, blurred vision • Abdominal pain

25. Assessment • Warning signs • Persistent vomiting • Chills, fever • Dysuria • Fluid escape from vagina

26. Gynecology

27. Menstrual cycle • Woman’s monthly hormonal cycle in which uterus prepares to receive egg • Then discharges a bloody fluid • Cycle repeats on average every 28 days, but can vary widely

28. Menstrual cycle • Days 1 to 5 • Egg not fertilized, hormone levels lower, causes thickened lining of uterus to shed • Results in a woman’s period • First day of menstrual bleeding is Day 1 in menstrual cycle • Days 6 to 14 • Pituitary gland produces hormone, stimulates ovaries to develop follicles • Each follicle contains an egg • Only one egg reaches maturity & has potential to become fertilized • Hormone levels increase, lining of uterus thickens & prepares to receive mature egg • Days 10 to 18 • Hypothalamus & pituitary glands release hormone, mature follicle bursts & releases egg • Ovulation typically occurs midway through menstrual cycle on Day 14 • Egg begins its journey down fallopian tubes to uterus • Time period when a woman is most likely to become pregnant • Days 16 to 28 • After releasing egg, ruptured follicle secretes progesterone • Progesterone continues to thicken lining of uterus in preparation for fertilized egg • If egg is fertilized by sperm, it implants in lining of uterus • If egg not fertilized or implanted, lining of uterus shed again at next menstrual cycle

29. Pelvic Inflammatory Disease • Pelvic inflammatory disease (PID) – infection of female reproductive tract • Organs most commonly involved • Uterus • Fallopian tubes • Ovaries • Occasionally, peritoneum & intestines

30. Pelvic Inflammatory Disease • Symptoms of PID include: • Lower abdominal pain • Fever • Abnormal vaginal discharge • Painful intercourse • Irregular menstrual bleeding • Pain in right-upper quadrant • Vaginal bleeding & lower abdominal pain can indicate serious gynecological problem • Maintain high index of suspicion when encountered

31. Pelvic Inflammatory Disease • Causes of PID • Gonorrhea & Chlamydia infections • Can progress undetected before PID symptoms appear • Other bacteria, such as staph or strep. • Acute or chronic • Allowed to progress untreated, sepsis can develop • Most common symptom of PID – moderate to severe, lower abdominal pain

32. Vaginal Bleeding • Vaginal bleeding not result of direct trauma or normal menstrual cycle can indicate serious problem • Difficult to isolate specific cause, treat all vaginal bleeding as if there is serious underlying condition • Especially true if bleeding associated with lower abdominal pain

33. Vaginal Bleeding • Treatment depends on patient’s needs, but may include the following: • Maintain ABCs • Control bleeding, if possible • Administer oxygen • Place in shock position • Provide fluid replacement • Large bore IV if needed

34. Dilation and Curettage (D&C) • Dilation – opening of the cervix • Curettage – scraping the walls of uterus • Surgical procedure – usually done on outpatient basis under local anesthesia • Diagnose conditions such as cancer • Remove tissue after miscarriage • Elective abortion • Complications • Heavy bleeding – uncommon • Patients with heavy bleeding • Evaluate for signs of shock • Expedite transport to hospital

35. Ectopic Pregnancy • Egg released from ovary, cyst often left in its place • Cyst – fluid-filled sac that is often enlarged • Can rupture & cause abdominal pain • Occasionally cysts develop independent of ovulation

36. Sexual Assault • Rape – any genital, oral or anal penetration by a body part or object, through use of force or without victim's consent • It is a crime of violence with serious physical and psychological implications

37. Sexual Assault • Trauma to woman’s external genitalia can be difficult to treat • Need to maintain patient’s modesty • Rich network of nerves in external genitalia makes such injuries painful • Tends to bleed profusely due to rich blood supply • Treat open genitalia wounds with sterile compresses • Use direct pressure to control bleeding if severe • Do not place dressings in the vagina

38. Obstetrics

39. Ovulation • Pregnancy begins with ovulation in female • Fourteen days before beginning of next menstrual period, ovary releases egg into the fallopian tube • Egg enters fallopian tube for transportation to uterus • Intercourse 24-48 hrs before ovulation • Fertilization should occur in fallopian tube

40. Ovulation • Once fertilized, egg begins to divide • Fertilized egg continues down fallopian tube to uterus • Attaches to endometrium

41. Trauma • Direct abdominal trauma can cause: • Premature separation of placenta from uterine wall • Premature labor • Abortion • Uterine rupture • Fetal death • Fetal death can result from: • separation of placenta from uterine wall • maternal shock • uterine rupture • fetal head injury

42. Gestational Diabetes • Some women develop diabetes during pregnancy • Pregnant diabetics prescribed insulin if blood sugar cannot be controlled by diet alone • Cannot be managed with oral drugs • They are absorbed into placenta & can adversely affect fetus

43. 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 1 month gestation 6 weeks gestation

44. Ectopic Pregnancy • Patients with ectopic pregnancy often have one-sided, lower abdominal pain • Late or missed menstrual period • Occasionally vaginal bleeding • Life-threatening emergency • Treat for shock, initiate immediate transport

45. Vaginal Bleeding (Gravid) • Vaginal bleeding during pregnancy cause for concern. • Bleeding in early pregnancy often associated with: • spontaneous abortion • ectopic pregnancy • vaginal trauma • Vaginal bleeding in third trimester usually caused by: • abruptio placenta • placenta previa • trauma to vagina or cervix • Can be a life-threatening emergency!

46. Vaginal Bleeding (Gravid) • Range: light spotting to massive hemorrhage • Difficult to find cause of in field • Suspect placenta previa, abruptio placenta, or vaginal trauma in third trimester bleeding

47. Abruptio Placenta • Premature separation of placenta from wall of uterus • Separation either partial or complete • Complete separation usually results in death of fetus • Several factors may predispose patient to abruptio placenta • Preeclampsia • Maternal hypertension • Multiparity • Abdominal trauma • Short umbilical cord

48. Placenta Previa • Attachment of placenta in lower part of uterus covering cervix • Unless sonogram done, placenta previa usually is not detected until third trimester • When fetal pressure on placenta increases or uterine contractions begin, cervix thins out resulting in bleeding from placenta

49. Gravid Hypertension • Preeclampsia – condition characterized by high blood pressure, abnormal weight gain, edema, headache, & protein in urine • Eclampsia – characterized by high blood pressure & excessive swelling in extremities & face • Life-threatening seizures differentiate eclampsia from preeclampsia

50. Pre-Eclampsia • Variety of signs and symptoms including: • Hypertension • Abnormal weight gain • Edema • Headache • Protein in the urine • Epigastric pain • If untreated, preeclampsia can progress to eclampsia