Obstetrics and Genecological Emergencies

Anatomy and Physiology of childbirthPregnancy and delivery• Fetus

developing baby• Uterus

where fetus grows during pregnancy• Cervix

neck of the uterus

• Vagina

birth canal

• Placenta

*attaches to wall of uterus

*an exchange area between mom and fetus of oxygen and nutrients

*expelled at birth

• The fetus has its own circulatory system

blood from the fetus is sent through the umbilical cord to the placenta

• The umbilical cord is 1” wide and 22” long at birth; expelled at birth

• Amniotic sac

encloses the fetus

Nine months of pregnancy are divided into 3 trimesters

• The first pregnancy trimester is the stage of pregnancy from conception to 12 weeks.

• The second pregnancy trimester starts from the 13th week to the 28th week. the baby grows rapidly and shows movements

• The Third Trimester is the last trimester from the 28th week till the birth of the baby.

Changes to a woman’s body

• Increased blood volume

• Increased cardiac output

volume of blood being pumped by the

heart in one minute

• Increased cardiac rate• Blood pressure slightly decreased• Slowed digestionCrowning

presenting part of the baby first bulges from the vaginal opening

• Cephalic presentationhead first

• Breechbuttocks or feet deliver first

Labor

entire process of delivery

Three stages

• First stage

regular contractions and dilation of cervix

stage ends with full dilation

• Second stagewhen the baby enters the birth canal

• Third stageafter baby is born and lasts until

placenta and umbilical cord is delivered• Meconium staining

*fluid that is green or brownish yellow*indicates fetal distress during labor

• Bloody show

*watery, bloody discharge of mucus associated with first stages of labor

*part of discharge is s mucous plug that was in the cervix

Labor pains

• Time or duration

start of one contraction to relaxation of uterus

• Interval or frequency

time of the start of one contraction to the beginning of the next

Normal childbirth

• OB kit

Supplies when OB kit not available

• Clean sheets and towels for draping

• Heavy flat twine or new shoe laces

• Towel or plastic bag to wrap placenta

• Clean, unused rubber gloves and eyewear

Normal delivery

Evaluating the mother

• Name, age, expected due date

• First pregnancy?

• How long and how often contractions

• Water broke?

• Bloody show?

• Time length and frequency of contactions

• Feel the uterus contracting

• VS

if abnormal alert hospital

• Transport decision

• Provide emotional support

Supine hypotension syndrome

• Third trimester

• Weight of the baby, uterus, placenta, and amniotic fluid can compress the inferior vena cava when supine

• Dizziness and drop in blood pressure

blood is shunted

Transport in left lateral recumbent position

Prepare mother for delivery

• Ensure privacy

• BSI

• Place on bed, floor, or on cot

• Elevate buttocks and draw up knees

• Remove any clothing or underclothing that obstructs view of the vaginal opening

• Use sterile sheets or towels to cover• Position someone at the head

provide support, monitor, alert for vomiting• Position OB kit for easy access

Delivering the baby• Have constant view of vaginal opening• Be prepared that there is going to be some

discomfort

• Talk to the mother

• Encourage her to relax between contractions

• Encourage to breathe deeply through the mouth

do not allow to hyperventilate

• Assure that when water breaks that is normal

• Position gloved hand at the vaginal opening upon crowning

• Place one hand below the head as it delivers

spread fingers evenly to avoid soft spot

• Do not pull on the baby

• If amniotic sac has not broken by time baby’s head is delivered, puncture membrane

• Examine for meconium staining

suction

• Once head delivers, check if umbilical cord is wrapped around the neck

*gently loosen cord if necessary and bring over shoulder and head

*if cord can’t be loosened or slipped over shoulder, clamp and cut

• When entire head is delivered check the airway

*wipe mouth and nose with sterile gauze

*suction with bulb syringe

• Help deliver the shoulders

*gently guide the head downwards

*if second shoulder is slow to deliver,

guide head upwards

• Support the head throughout the entire process

• Newborns are slippery*grasp the lower extremities to

assure good hold*never pick up by the feet

• Lay baby on side with head slightly lower than body

• Suction once again• Keep level at level of vagina until umbilical

cord stops pulsating

• Wrap the baby in warm, dry blanket

• Note the exact time of birth

Assessing the newborn

• Apgar score

reassess after 5 minutes

Care

• Place on sterile sheet as close to vagina as possible so infants blood doesn’t transfuse back into the placenta

• Do not place on mother’s ABD until cord has been clamped

Resuscitation of the newborn• Provide warmth and clear airway

suction• Keep the baby on it’s sideEstablish

breathingheart ratecolor

• If heart rate is < 100

artificial ventilations at 40 to 60

• If heart rate is < 60

CPR {3:1} 120 compressions/minute

• If cyanotic with adequate respirations and pulse rate, give oxygen

Cutting the umbilical cord• Keep warm

cover the head; keep ambulance warm• Use sterile clamps or umbilical tape• Apply 10” from baby; 7” (4 finger) from distal

clamp• Cut the cord between clamp• Place placenta end of cord on the drape over the

mother’s legs

• When moving the baby take care to not cause trauma to the cord

Caring for the motherDelivering the placenta• Third stage of labor• Usually expels within a few minutes

but can take 30 minutes or longer• Save and transport• Label with name of mother and time expelled

• Transport if the placenta doesn’t deliver within 20 minutes after delivery

Hemorrhage

500cc of blood loss is normal

Hemorrhage control

• Place sanitary napkin or vagina, never pack

• Lower legs and keep together

• Elevate feet• Massage uterus to help it contract• Mother can nurse• If perineum is torn, treat as a woundComforting mom• Communicate• Frequent VS• Keep mother and baby warm

CHILDBIRTH COMPLICATIONSBreech presentation

buttocks or both legs first• Complications rate high• Immediate transport• Never attempt to deliver by pulling on the

legs• O2

• Place mother in head down position with pelvis elevated

• If the body delivers support it and prevent and explosive delivery of the head

• Insert gloved index and middle finger inside vagina and forma V around the nose

• After delivery care is the same as for a cephalic delivery

Prolapsed cord

• Umbilical cord presents first

• Position mother with head down and buttocks raised with a blanket or pillow, using gravity to lessen the pressure on birth canal

• O2

• Check cord for pulses

• Wrap with towel; must be kept warm

• Insert several fingers of a gloved hand inside the vagina and push up on the baby’s head or buttocks to keep pressure off cord- - - continue until releived by a physician

• Keeping mother, child and EMT as a unit, rapid transport

• VSLimb presentation• Arm, single leg or arm and leg present• Often a prolapsed cord as well• Rapid transport

head-down, pelvis elevated

• Do not attempt to pull on the limb or place into vagina

• Do not insert hand/fingers into the vagina other than to manage a prolapsed cord

Multiple birth

• Deliver in same manner of single birth

requires 2x the supplies and help

• When delivered identify the infants in order of birth

If it is unknown there are multiple babies

• Large before delivery

• Remains large after the first delivers

• Contractions continue after delivery of first

Second baby may be breech within minutes of the first

• Placenta delivered normally

Care

• Clamp or tie cord after birth of first and before birth of second

• Second baby may be born before or after delivery of the placenta

• Babies, umbilical cords, placenta, mother are all cared for as with a single birth

• Babies will probably be smaller than with a single birth

important to keep warmPremature birth• < 5.5#• Born before 37th week of pregnancy• Keep warm• Place cap on head• Airway management; suction with bulb syringe

• If heart rate is < 100

artificial ventilations at 40 to 60

• If heart rate is < 60

CPR {3:1} 120 compressions/minute

• If cyanotic with adequate respirations and pulse rate, give oxygen

• Watch the umbilical cord for bleeding

• O2

• Avoid contamination

• Transport in warm ambulance

• Call ahead

• Meconium staining

*fluid that is green or brownish yellow

*indicates fetal distress during labor

• Reduce risk of apiration

do not stmulate until suctioned

Airway management

• If heart rate is < 100

artificial ventilations at 40 to 60

• If heart rate is < 60

CPR {3:1} 120 compressions/minute

• If cyanotic with adequate respirations and pulse rate, give oxygen

• Rapid transport

Emergencies in pregnancy

Excessive prebirth hemorrhage

• Miscarriage

• Placenta previa

• Placenta Previa

*placenta is formed low in uterus and close to or over the cervical opening

*will not allow for a normal delivery• Abruptio Placentae

*placenta separates from the uterine wall

Either of above may occur in 3rd trimester

Both are life threatening

Assessment• Usually profuse bleeding from the vagina• May or may not complain of ABD pain• Initial assessment; look for signs of shock• Baseline VSCare• Shock; O2• Rapid Transport

• Place sanitary napkin over vaginal opening and note the time; never pack

• Save all soaked material as well as any tissue that is passed

Ectopic pregnancyAn ectopic pregnancy is a complication of pregnancy in

which the fertilized ovum is developed in any tissue other than the uterine wall. Most ectopic pregnancies occur in the Fallopian tube (so-called tubal pregnancies), but implantation can also occur in the cervix, ovaries, and abdomen. The fetus produces enzymes that allow it to implant in varied types of tissues, and thus an embryo implanted elsewhere than the uterus can cause great tissue damage in its efforts to reach a sufficient supply of blood. An ectopic pregnancy is a medical emergency, and, if not treated properly, can lead to the death of the woman.

Assessment

Any woman of childbearing age with abdominal pain has an ectopic pregnancy until proven otherwise

• May have s/s of shock due to internal bleeding

• Acute abdominal pain

• Often with vaginal bleeding

Care

• Rapid transport

• Position for shock

• 02

• NPO

Seizures in pregnancy• Sometimes called eclampsia• Preeclampsia; swelling of the extremitiesAssessment• Elevated blood pressure• Excessive weight gain• Gross swelling of face, hands, ankles, feet• headache

Care• Ensure and maintain airway• O2• Transport on left side• Handle gently• Keep warm but don’t overheat• Have suction ready• Have OB kit ready

Miscarriage and abortion

Abortion

• Spontaneous abortion

• Miscarriage

• Induced abortion

Assessment• Cramping abdominal pains• Bleeding {moderate to severe}• Dicharge of tissue and blood from vaginaCare• Baseline VS• Treat for s/s of shock• O2

• Place sanitary napkins over vaginal opening

• Rapid transport

• Replace and save all soaked pads

• Save all expelled tissue

• Provide emotional support

Trauma in pregnancy

• Most common is MVA

• Uterus is frequently injured

• Sudden blunt trauma in later months may cause uterine rupture or premature separation; massive bleeding and shock

• Treat as for any other trauma pt.

Assessment

• Pulse 10 to 15 bpm faster than non-pregnant female

• Increased blood volume

• Ascertain if there were any blows to ABD, pelvis, or back

• Ascertain if water has broke

Care• Examine unconscious for ABD injuries

consider MOI• Cardiac arrest management• Airway management• O2• Suction• Rapid transport

left lateral recumbent • VS• Provide emotional support

StillbirthsBaby who dies in the womb• Do not lie to mother• Allow her to see the baby if she wishes• Obvious death

blistersfoul odorskin or tissue deterioration and

discolorationsoftened head

• Obviously dead sometime before birth

no resuscitation

• Born in pulmonary or cardiac arrest

resuscitative measures

• Baby is alive but pulmonary or cardiac arrest seems imminent

resuscitative measures

Accidental death of a pregnant woman

• Aggressive resuscitation efforts should be taken

• Reposition hands 1 to 2” higher

• Efforts will be ceased in the E.R.

Gynecological EmergenciesVaginal bleeding• Potentially life threatening especially if

accompanied with ABD pain• Hypovelemic shockCare• Standard precautions• Airway• Treat for shock• transort

Trauma to external genitalia• MOI• Assess for severe blood loss and shock and

treat accordinglyCare• Control bleeding• O2• Maintain a professional attitude• Respect patient’s privacy

Sexual Assault• Scene safety

may need to stage• Treat both medically and psychologically• Airway• Take care not to disturb any potential evidence• Examine genitalia only if there is sign of trauma• Do not allow to bathe, void or clean wounds• Reporting requirements