Obstetric and Gynecologic Emergencies

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Obstetric and Gynecologic Emergencies
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Objectives 1 of 5

• Identify structures of the females reproductive
  system.
• Identify and explain the use of an obstetrics
  (OB) kit.
• Identify predelivery emergencies.
• State indicators of imminent birth.

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Objectives 2 of 5

• Differentiate care provided to a patient with
  predelivery emergencies from a normal delivery.
• State the steps in preparation of the mother.
• Establish the relationship between BSI and
  childbirth.
• State the steps to assist in the delivery.

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Objectives 3 of 5

• Describe care of the baby as the head appears.
• Describe how and when to cut the cord.
• Discuss the steps in the delivery of the
  placenta.
• List the steps in the postdelivery care of the
  mother.

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Objectives 4 of 5

• Summarize neonatal resuscitation procedures.
• Describe procedures for abnormal deliveries.
• Differentiate the special considerations for
  multiple births.

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Objectives 5 of 5

• Describe special considerations of meconium.
• Describe special considerations of a premature
  baby.
• Discuss care of a patient with a gynecologic
  emergency.

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Female Reproductive Organs
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Female Reproductive System
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Stages of Pregnancy
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Increased Blood Volume
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Increased Cardiac Output
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Decreased Stroke Volume
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Predelivery Emergencies 1 of 2

• Pre-eclampsia
• Pregnancy induced hypertension
• Visual disturbances, elevated blood pressure,
  headache, extremity swelling
• Eclampsia
• Convulsions resulting from hypertension
• Supine hypotensive syndrome
• Low blood pressure from lying supine. Fetus
  compresses the inferior vena cava decreasing
  preload.

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Supine Hypotensive Syndrome
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Predelivery Emergencies 2 of 2

• Ectopic pregnancy
• Pregnancy outside of the uterus, life-threatening
  if ruptures
• Placenta abruptio
• Premature separation of the placenta, bleeding
  may or may not be present, painful for mother
• Placenta previa
• Development of placenta over the cervix, bleeding
  may or may not be present, no pain

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Abruptio Placenta
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Abruptio Placenta
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Placenta Previa
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Placenta Previa
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Miscarriage

• Abortion (miscarriage)
• Delivery before the 20th week
• Infection and bleeding are the most important
  considerations.
• Treat the mother for shock, monitor amount of
  bleeding.
• Transport to the hospital.
• Bring tissue that has passed through the vagina
  to the hospital.

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Trauma and Pregnancy

• Do not mistake normal vital signs in pregnant
  patients as signs of shock.
• Abdominal injury may be difficult to assess.
• The leading cause of fetal demise due to trauma
  is death to the mother.
• If mother dies, continue CPR and notify hospital
  immediately.
• Cardiac arrest in the pregnant patient is treated
  the same as for other victims.

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Labor and Delivery

• Three stages of labor
• First stage
• Begins with contractions
• 8-10 hours for 1st time moms, 5-7 for 2nd time
  moms
• Second stage
• Begins when the cervix is fully dilated and ends
  when infant is born
• 50-60 minutes for 1st time moms, 20-30 for 2nd
  time moms
• Third stage
• Begins with birth of the infant and ends with the
  delivery of the placenta
• 5-30 minutes

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Beginning Labor
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Engagement
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When to Consider Field Delivery

• When delivery can be expected within a few
  minutes
• Look for crowning
• Does mother have the urge to move her bowels?
• Contractions less than 2 minutes apart or greater
  than 60-90 seconds in duration.
• When a natural disaster or other catastrophe
  makes it impossible to reach hospital
• When no transportation is available

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OB Kit (review location and contents)

• Contents
• Surgical scissors
• Umbilical cord clamps
• Umbilical tape
• Small rubber bulb syringe
• Towels
• 4x4 s
• Sterile gloves
• Infant blanket (including cover for head)
• Sanitary napkins
• Goggles
• Plastic bag

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Preparing for Delivery

• Use proper BSI.
• Act calm and reassuring.
• Prepare OB kit.
• Push away or remove mothers clothing while
  preserving modesty.
• Place the mother in a semi-Fowlers position.
• Pad under and around the mothers hips (raise
  hips approximately 4 with padding)

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Positioning for Delivery
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Delivering the Baby

• Support the head as it emerges, using caution not
  to push on soft area of scalp.
• Once the head emerges, check to make sure the
  cord is not around the infants neck. If it is ,
  slide it over the babys head. If unable to
  slide over the babys head, clamp and cut cord
  now.
• Suction airway with bulb suction, always suction
  mouth first then nose.
• The shoulder will be visible.
• Support the head and upper body as the shoulders
  deliver.
• Handle the infant firmly but gently as the body
  is delivered.
• Suction airway again.
• Dry and wrap baby.
• Clamp the cord and cut it.
• Place clamps 2-3 inches apart, first one 4-6
  inches from baby.
• Wait until pulsation stops, then cut with sterile
  scissors.
• Monitor end for bleeding, if bleeding occurs
  place another clamp proximal to the initial clamp.

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Clamp and Cut the Cord
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Suction the Airway
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Shoulder Delivery
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Shoulder Delivery
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Complications with Head 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 infants head.
• It may have to be cut.

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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.
• If unable to clamp and cut the cord, keep the
  placenta at the same height or slightly higher
  than the baby
• Ensure the infant is pink and breathing well.

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Meconium Aspiration

• First bowel movement occurs in the uterus
• Signs include green-tinged amniotic fluid
• Risk of aspiration of fecal material leading to
  pneumonia
• Must aggressively suction airway if meconium is
  present.

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Neonatal Evaluation and Resuscitation

• APGAR Scoring, done at 1 minute and 5 minutes.
• A Appearance
• P Pulse
• G Grimace
• A Activity
• R Respirations

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Apgar Score
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Neonatal Resuscitation
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Delivery of Placenta

• Placenta is attached to the end of the umbilical
  cord.
• It should deliver within 30 minutes.
• Never pull on the umbilical cord.
• Once it delivers, wrap the placenta and take to
  the hospital so it can be examined.
• If the mother continues to bleed, transport
  promptly to the hospital, and massage the uterus
  to stimulate contractions.

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Delivery of Placenta
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Placenta
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Abnormal or Complicated Delivery Emergencies 1 of
7

• Breech delivery
• Presenting part is the buttocks or legs
• Delivery is the same as normal birth.
• Support the infant as it comes out.
• You may have to insert fingers into the mothers
  vagina and push vaginal wall away from the
  infants face as the head is being delivered.

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Breech Presentation
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Abnormal or Complicated Delivery Emergencies 2 of
7

• Limb presentation
• Uncommon occurrences
• This is a true emergency. Transport the patient
  to the hospital immediately.
• Prolapsed cord
• Transport immediately.
• Cover cord with moist sterile dressing.
• Place fingers into the mothers vagina and push
  the cord away from the infants face.

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Limb Presentation
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Prolapsed Cord
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Abnormal or Complicated Delivery Emergencies 3
of 7

• Twins
• Twins are usually smaller.
• If the mothers abdomen remains large after the
  first delivery, suspect twins.
• Delivery procedures are the same.
• There may be one or two placentas to deliver.

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Abnormal or Complicated Delivery Emergencies 4 of
7

• Premature infants
• Keep the infant warm.
• Keep the mouth and nose clear of mucus.
• Carefully observe.
• Give oxygen by blow-by.
• Do not infect the infant. (healthcare workers
  should wear a mask)
• Notify the hospital.

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Normal vs. Pre-term
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Abnormal or Complicated Delivery Emergencies 5 of
7

• Delivering an infant of an addicted mother
• Assure proper BSI.
• Deliver as normal.
• Watch out for severe respiratory depression and
  low birth weight.

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Abnormal or Complicated Delivery Emergencies 6 of
7

• Fetal demise
• 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.

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Abnormal or Complicated Delivery Emergencies 7 of
7

• Excessive bleeding
• Massage the mothers uterus to slow down
  bleeding.
• Place pad over vaginal opening.
• Transport to hospital.
• Treat for shock.

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Other Complications

• Ruptured Uterus- needs surgery
• Uterine inversion- hospital to fix
• Pulmonary embolism- blood clot in the lung
• Shoulder dystocia- shoulders too wide for delivery

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• Please review the following questions and send
  answers to Shelley.Peelman_at_provena.org

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• 1. Name two predelivery emergencies and describe
  them.
• 2. List the three stages of labor and what marks
  the beginning and end of each.

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• 3. When do you consider a field delivery?
• 4. Where does your department keep the OB Kit?
  Name 5 items in the kit.

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• 5. While delivering a baby, how is the airway
  suctioned?
• 6. List the steps involved in cutting the
  umbilical cord.
• 7. Identify the steps to take if the umbilical
  cord is around the infants neck.

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• 8. List the five categories assessed in an APGAR
  score. When is the score obtained?
• 9. Review the neonatal resuscitation triangle.
• 10. Name three potential complications with
  delivery, and how to handle those situations.