Obstetric and Gynecological Emergencies

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CHAPTER 24
Obstetric and Gynecological Emergencies
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ReproductiveAnatomy
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Anatomy
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Terminology

• Fetus developing unborn baby
• Uterus organ in which a fetus grows,
  responsible for labor and expulsions of infant
  (a.k.a. womb)
• Birth Canal vagina and lower part of the uterus
  (dilates to 10cm/4in)
• Placenta fetal organ through which fetus
  exchanges nourishment and waste products during
  pregnancy attached to the wall of the uterus
  (exchanges everything taken in by the mother
  including alcohol, drugs and nicotine)

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Terminology

• Umbilical Cord cord which is an extension of
  the placenta through which fetus receives
  nourishment while in the uterus (1 wide and 22
  long)
• Amniotic Sac (bag of waters) the sac that
  surrounds the fetus inside the uterus (1 -2
  quarts of fluid allows fetus to float and
  cushions it from minor injury)
• Vagina lower part of the birth canal
• Perineum skin area between vagina and anus,
  commonly torn during delivery (dress with
  sanitary napkin and apply some pressure)

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Terminology

• Crowning the bulging out of the vagina which is
  opening as the fetus head or presenting part
  presses against it (cephalichead
  breechfeet/buttocks)
• Bloody Show mucus and blood that may come out
  of the vagina as labor begins
• Presenting Part the part of ht infant/fetus
  that comes first usually the head
• Abortion miscarriage deliver of products of
  conception early in the pregnancy (can be
  spontaneous or induced)

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Labor/Stages of Delivery

• The time and process (defined in 3 or 4 stages)
  beginning with the first uterine contraction
  until delivery of the placenta
• 1st Stage
• Dilation, Pre-delivery, Delivery is imminent
• 2nd Stage
• Crowning and the process of delivery
• 3rd Stage
• After the baby is born until the completion of
  the delivery of placenta, After-delivery

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Childbirth Delivery Kit
Should contain surgical scissors, hemostats/cord
clamps, umbilical tape/sterilized cord, bulb
syringe, towels, 2x10 gauze sponges, sterile
gloves, baby blanket, sanitary napkins, plastic
bag and gauze pads
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Emergency Childbirth Kit

• Clean sheets or towels (several)
• Heavy flat twine or new shoelaces
• Towel or plastic bag
• Rubber gloves/eyewear

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Pre-deliveryEmergencies
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Miscarriage(Spontaneous Abortion)

• When the fetus and placenta deliver before the
  28th week of pregnancy
• Scene size-up
• Initial assessment
• History and physical exam (be prepared to treat
  for shock)
• Assess baseline vitals.
• contd.

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Miscarriage(Spontaneous Abortion)

• Treat based on signs and symptoms cramping,
  abdominal pain, bleeding ranging from moderate to
  severe, noticeable discharge of fetal tissue
• Apply external pads to vagina do not pack.
• Administer oxygen.
• Bring fetal tissue to hospital.
• Give emotional support.

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Signs and Symptoms of Seizures

• Increase in blood pressure
• Increase weight gain (suddenly)
• Swelling of face, hands, ankles and feet
• Headache

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Treating Seizures During Pregnancy

• Scene size-up
• Initial assessment
• Maintain airway administer oxygen have suction
  available.
• History and physical exam.
• Assess baseline vitals.
• Treatment based on signs and symptoms.
• Transport patient on left side.
• Handle gently at all times could start
  seizures.
• Maintain warmth.
• Prepare for delivery.

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Signs Symptoms of Vaginal Bleeding(Late in
Pregnancy)

• Profuse bleeding from vagina
• May or may not have abdominal pain
• May exhibit signs of shock
• Increase in heart rate

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Vaginal Bleeding Treatment

• Scene size-up
• Initial assessment.
• History and physical exam.
• Assess baseline vitals.
• Treat based on signs and symptoms.
• Apply external vaginal pads do not pack.
• Transport.

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Trauma During Pregnancy

• Greatest danger is from bleeding and shock.
• Blunt trauma to abdomen puts mother fetus at
  high risk.

Continued
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Trauma During Pregnancy

• Scene size-up
• Initial assessment
• History and physical exam (remember the mother
  will have increase blood pressure, pulse and
  blood supply)
• Assess baseline vitals
• Treatment based on signs and symptoms

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Trauma During Pregnancy

• Treat injuries as any trauma patient.
• Transport patient on left side prevents supine
  hypotensive syndrome if you have to backboard,
  prop it up with blankets or pillows.
• Greatest cause of fetal death is
  maternal death!

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Signs Symptoms of Ectopic Pregnancy

• Abdominal pain
• Occasional vaginal bleeding
• Rapid/weak pulse (late sign)
• Hypotension (very late sign)

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Treatment of Ectopic Pregnancy

• Scene size-up
• Initial assessment.
• History and physical exam.
• Baseline vitals.
• Rapid transport.
• Administer oxygen.
• Position for shock.
• Treat for shock.

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NormalDelivery
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Predelivery Evaluation

• It is best to transport an expecting mother,
  unless delivery is expected within a few minutes
  based on assessment of
• What is your name?
• How old are you?
• What is your expected due date?
• How long have you been pregnant?
• What number pregnancy is this?

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Predelivery Evaluation

• When was your last menstrual period?
• Has your water broken?
• Are there contractions or pain? Start timing.
• Is there crowning with contractions?
• Frequency/duration of contractions?
• Any bleeding or discharge?

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Predelivery Evaluation

• Does she feel as if she is having a bowel
  movement with increasing pressure in the vaginal
  area? DO NOT allow her to go to the bathroom!!!
  
• Feel the need to push?
• Rock-hard abdomen?

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Transport Decision

• Based on assessment
• Birth imminent if contractions less than 2
  min apart
• Number of prior births
• Distance to hospital
• Complications expected
• Transport on left side to prevent hypotension

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Delivery Precautions

• Use BSI (i.e. gloves, mask, goggles, caps,
  gowns).
• Do not touch the vaginal areas except during
  delivery an when your partner is present always
  tell her when and what is happening
• Keep the mother out of bathroom.
• Do not hold mothers knees together.

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Delivery Precautions

• Recognize your own limitations and transport even
  if delivery must occur during transport if
  crowning occurs during transport pull over and
  deliver.
• If delivery is eminent with crowning, contact
  medical direction for decision to commit to
  delivery on site. If delivery does not occur
  within 10 minutes, contact medical direction for
  decision to transport.

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Delivery Procedures

• Control the scene to provide
• A safe delivery area
• Privacy, comfort for mother and father
• Apply BSI for infection control precautions.
• Have mother lie supine, knees drawn up and spread
  apart on bed, floor or stretcher.
• Elevate buttocks/hips with blanket and pillow
  you will need about 2 of work space)

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Create sterile field around vaginal opening.
Remove only the clothing that obstructs your view.
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Crowning of Infants Head
When the infants head appears during crowning,
place fingers on bony part of skull (not
fontanelle or face) and exert very gentle
pressure to prevent explosive delivery. Use
caution to avoid fontanelle (spread fingers
evenly).
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Delivery of the HeadPrevent explosivedelivery
Position your gloved hands at the mothers
vaginal opening to guide the baby.
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Delivery Procedures

• If amniotic sac has not broken, puncture sac with
  a clamp or gloved finger and pull away from
  baby's face.
• As the infants head is being born, determine if
  umbilical cord is around babys neck slip over
  the shoulder or clamp, cut, and unwrap cord.
  Tell the mother not to push.

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Delivery of the head
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Suction mouth, then nose.
After the infants head is born, support the
head, suction the mouth two or three times and
then the nostrils. Use caution to avoid the back
of the throat. SUCTION THE MOUTH AND THEN THE
NOSE!!!!
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Aid in birth of upper shoulder.
Guide the baby downwards to aid in the delivery
of the shoulder.
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Support the trunk.
As the torso and full body are born, support the
infant with both hands.
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Support the legs.
As the feet are born, grasp them and lay the baby
on his/her side.
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Delivery Procedures

• Wipe blood and mucus from nose and mouth with
  sterile gauze.
• Suction mouth and nose again allow the babys
  airway to drain.
• Warmth is critical!
• Wrap baby in warm towel, head slightly lower than
  trunk.

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Delivery Procedures

• Have partner provide initial care and monitoring.
• Keep infant level with vagina until cord stops
  pulsating and is cut.

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Clamp or tie cord then cut.
Place a clamp or tie 10 from the baby. Place a
second clamp or tie approximately 4 finger widths
from the proximal end of the 1st clamp in towards
the mother. After pulsations cease, cut between
the clamps or ties.
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Delivering thePlacenta

Observe for delivery of placenta while preparing
the mother and infant for transport. When
placenta delivers, place in plastic bag for
transport to hospital with the mother. The
doctor will examine for completeness.
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After-Delivery Procedures

• Cover vaginal opening with sterile pad.
• Lower mother's knees help her to hold them
  together. Elevate feet, massage uterus, and
  allow mother to nurse if she wishes to.
• Record time of delivery and transport mother,
  infant and placenta to hospital.

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After-Delivery Procedures
Vaginal Bleeding

• A loss of 500 cc is well tolerated. You should
  be prepared for this so as not to cause undue
  psychological stress on either you or the mother
• If blood loss is excessive, massage the uterus.
• Treat for shock.

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Massage uterus to control bleeding.
Hand with fingers fully extended Place on
abdomen above pubis (you should feel a
grapefruit-sized object Massage (knead) over
area Bleeding continues ? check massage
technique and transport immediately with oxygen
applied
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Care of theNewborn
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Care of the Newborn

• Position, dry, wipe, wrap newborn in blanket. Be
  sure to cover the head.
• Repeat suctioning. MOUTH then the NOSE!!!

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Suctioning the Newborn
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Normal Assessment Findings Newborn
A Appearance Color No central cyanosis
P Pulse Greater than 100/min
G Grimace Vigorous crying
A Activity Good extremity motion
R Respiratory Effort Normal crying
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Stimulating the Newborn to Breathe
Vigorously rub the infants back
Flick soles of feet
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Resuscitation of the Newborn
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Inverted Pyramid of Neonatal Resuscitation
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Breathing Effort

• If shallow, slow, or absent
• Provide artificial ventilations, 40-60/minute.
• Reassess after 30 seconds.
• If no improvement, continue artificial
  ventilations and reassessments.

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Heart Rate

• If less than 100/minute
• Provide artificial ventilations, 40-60/minute.
• Reassess after 30 seconds.
• If no improvement, continue artificial
  ventilations and reassessments.

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Heart Rate

• If less than 80/minute and not responding to
  ventilation
• Start chest compressions at rate of 120/min.

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Heart Rate
If at any time the heart rate is less than 60,
begin ventilations and compressions immediately
at a rate of 120/minute.
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Color
If central (trunk) cyanosis is present with
spontaneous breathing and an adequate heart rate,
administer free flow oxygen (10 15lpm) using
oxygen tubing held as close as possible to the
newborns face.
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AbnormalDeliveries
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Prolapsed Cord
Condition where the cord presents through the
birth canal before delivery of the head presents
a serious emergency which endangers the life of
the the unborn baby.
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Emergency Care for Prolapsed Cord

• Scene size-up
• Initial assessment
• Administer high-concentration oxygen to mother.
• History and physical exam.
• Assess baseline vital signs.
• Treatment based on signs/symptoms.
• Position mother head down/buttocks up using
  gravity to lessen pressure on the cord

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Emergency Care for Prolapsed Cord

• Wrap exposed cord in moist, sterile towel keep
  cord warm.
• Insert sterile-gloved hand into vagina, pushing
  the fetus away from the pulsating cord. The cord
  must be covered to keep it warm.
• Transport rapidly keeping pressure on presenting
  part, monitoring pulsations in the cord and
  keeping the cord moist and warm.

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Care for Prolapsed Cord
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Breech Presentation

• Babys buttocks or lower extremities are low in
  the uterus and will be the first part of the
  fetus to be delivered.
• Greater risk of delivery trauma, prolapsed cord
  more common meconium staining often occurs
  transport immediately upon recognition

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Emergency Care for Breech Presentation

• Delivery does not occur within 10 minutes.
• Transport immediately upon recognition.
• Place mother on oxygen.
• Place mother in head-down position with hips
  elevated.

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Limb Presentation
Occurs when a limb of the infant protrudes from
the birth canal. Is more commonly a foot when
infant is in breech presentation.
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Emergency Care for Limb Presentation

• Immediate rapid transportation upon recognition.
• Administer oxygen to mother.
• Place mother in head-down position with hips
  elevated. The baby must be kept off of the cord.
• Care is similar to prolapsed cord.

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Multiple Births

• Delivery procedure is the same for each.
  Identify twins/multiples in order of birth.
• Prepare for multiple resuscitations.
• Call for assistance.

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Meconium Staining

• Amniotic fluid that is greenish or
  brownish-yellow rather than clear indicates
  presence of fecal matter.
• Suggests fetal distress during labor.
• Do not stimulate before suctioning oropharynx
• Suction first
• Maintain airway
• Transport ASAP

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Premature Birth

• A fetus that is delivered before the 37th week
• Increased risk of hypothermia
• Usually requires resuscitation
• Should be performed unless physically
  impossible
• Call ahead and inform hospital

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Stillbirth

• When a baby dies in the womb several hours, days
  or even weeks before birth
• Do not stop the mother from seeing her deceased
  baby if she so wishes

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Emergency Care for Stillbirth

• Stillborn babies who have obviously been dead for
  some time (presence of blisters, foul odor, skin
  or tissue deterioration and discoloration, and a
  softened head) before birth are not to receive
  resuscitation
• Any other babies who are born in pulmonary or
  cardiac arrest are to receive basic life support
  measures.
• When the baby is alive but respiratory or cardiac
  appears to be imminent, prepare to provide life
  support
• All resuscitative measures should be continued
  until transfer to the hospital, keep accurate
  records and times

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Gynecological Emergencies
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Vaginal Bleeding

• Body substance isolation
• A-B-Cs
• Treat as soft-tissue injury
• DO NOT pack

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Trauma External Genitalia

• Treat like any other bleeding soft-tissue injury.
• Never pack vagina.
• Administer oxygen.
• Perform ongoing assessment.

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Sexual Assault

• Criminal assault situations require initial and
  on-going assessment/management and psychological
  care
• Body substance isolation
• Airway
• Show nonjudgmental attitude during SAMPLE focused
  assessment.
• Crime scene protection.
• Maintain privacy from bystanders.
• Continued

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Sexual Assault

• Examines genitalia only if profuse bleeding is
  present.
• Use same-sex EMTs for care when possible.
• Discourage patient from bathing, voiding, or
  cleaning wounds.
• Perform local reporting requirements.