OB/GYN Emergencies

Report
OB/GYN Emergencies
Course Objectives
1. Identify the key aspects of evaluating a pregnant
patient to determine if birth is imminent.
2. Identify the purpose and use of tools in an OB kit.
3. Identify the steps for normal delivery of an infant
including how and when to cut an umbilical cord.
4. Identify the steps for post-delivery care of the
newborn and mother including delivery of the
placenta.
5. Identify the critical treatment interventions for
complications of pregnancy including: breech
(buttocks) or two limb presentation, shoulder
dystocia, prolapsed cord, and postpartum bleeding.
6. Identify steps for assessing an infant’s APGAR score.
7. Identify steps for neonatal resuscitation
8. Identify signs/symptoms and proper care for
gynecological emergencies.
Terms

Abruptio placenta — This condition occurs when the placenta
prematurely separates from the uterine wall causing heavy internal
bleeding and pain; it can occur as a result of trauma.

Bloody show — Mucous and blood that comes from the vagina as the
first stage of labor begins. The cervix is sealed by a plug of mucus
during pregnancy to prevent contamination. When the cervix dilates,
the plug is expelled as pink-tinged mucous.

Crowning — The bulging out of the vaginal opening caused by the
baby’s head pressing against it.

Dilation — To get larger or enlarge. The degree of dilation of the cervix is
often a key indicator used by midwives and physicians to determine if
birth is imminent. However, EMTs do not perform this test. The process
occurs over a period of several hours in some women, but can take
much longer.

Eclampsia (toxemia) — A serious condition that can develop in the third
trimester. It is characterized by high blood pressure and excessive
swelling in the extremities and face. Life-threatening seizures
differentiate eclampsia from preeclampsia.
Terms, continued

Ectopic pregnancy — Condition where a fertilized egg implants
outside the uterus, often in the fallopian tubes. Symptoms can
include abdominal pain and vaginal bleeding.

Meconium — A dark-green fecal material found in the intestines of
full-term babies. Ordinarily, the meconium is passed after a baby is
born. In some cases, the meconium is expelled into the amniotic
fluid prior to birth. It gives the fluid a greenish-brown color known as
meconium staining.

Placenta previa — A condition where the placenta sits low in the
uterus blocking the cervix. It can present with painless, bright red
bleeding.

Postpartum — A term used to describe the period shortly after
childbirth.
Terms, continued

Preeclampsia — A condition found 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 — A pregnancy-related condition
where the weight of an unborn fetus and the uterus puts pressure
on the inferior vena cava. The result is inadequate venous blood
return to the heart, reduced cardiac output, and lowered blood
pressure.
Female Anatomy - 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
If 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
Female Anatomy - Reproductive Organs

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
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 to
surround & protect developing
fetus
Fills with amniotic fluid which
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
Umbilical cord is about two
feet long
Fetal Anatomy
Emergency Childbirth
Normal Delivery
Signs of Imminent Delivery



Main task in evaluating
expectant mother is to
determine if delivery is
imminent
Expose abdomen &
genital area, taking care
to be discrete
Visually inspect the
abdominal & vaginal
areas for bleeding or
crowning

Prepare for immediate
delivery if observe any of
the following:
 Crowning
 Contractions less than 2
minutes apart
 Feeling of rectal fullness
 Feeling of imminent delivery
Crowning
 Crowning – appearance of any part of fetus in
mother’s vagina
 Remove enough of mother’s clothing to view
genital region
 Look for bulging at vaginal opening or a
presenting part of infant
Crowning
Contraction Intervals




Occur at regular intervals
ranging from 30 minutes to 2
minutes or less
Labor pain from contractions
lasts from 30 seconds to 1
minute
As birth approaches, interval
between contractions gets
shorter
Contractions that occur
within 2 minutes of each
other, from end of one to
beginning of next, signify
imminent delivery



Consider transporting mother if
baby does not deliver after 20
minutes of contractions 2 to 3
minutes apart
Labor is generally prolonged
for mother’s first baby
Average is 12 to 17 hours
which allows plenty of time for
transport
Feeling of Rectal Fullness
 Feeling of rectal fullness or sensation of
having to move one’s bowels can indicate
infant’s head is in vagina & pressing
against the rectum
 Delivery is imminent
 Do not let the mother sit on the toilet
Feeling of Imminent Delivery
 Mothers who have previously given birth
often know when ready to deliver
 Labor tends to be shorter after first child
 Use your judgment given circumstances
 Consider transport time
Preparing for Delivery






Request a paramedic unit
Don sterile gloves, gown, and eye protection
Position mother on her back, legs drawn up
Provide supplemental oxygen
Prepare OB kit
Prepare infant BVM
Emergency delivery kit
Preparing for Delivery
Presentations You Can’t
Deliver in the Field


Single limb
Prolapsed cord
Presentations You Can
Deliver in the Field





Head first (normal
cephalic)
Umbilical cord around the
neck (Nuchal Cord)
Shoulder dystocia
Buttocks first (Frank
Breech)
Double footling
Assisting With Delivery







Support head with gentle pressure
Check if cord is wrapped around baby’s neck— attempt
to loosen
Apply gentle downward pressure on shoulder & head
After anterior shoulder has delivered, apply gentle
upward pressure
Suction mouth (no more than 1 inch into) & nostrils (no
more than ½ inch into each) when head appears
Once delivered, stimulate infant if it does not breathe
After the umbilical cord stops pulsating put two clamps
on cord 6 inches from navel & cut between the clamps
Suction mouth & nostrils
Delivery anterior shoulder
Delivery posterior shoulder
Amniotic Sac


During first stage of
labor amniotic sac
usually breaks, expelling
amniotic fluid
If sac is still covering
infant’s head when
head appears, use a
finger to rupture sac



Note color & character of
amniotic fluid
Fluid can be clear or
straw-colored (which is
normal)
Tainted & discolored, or
thick & “pea soup-like”
(which indicates
meconium staining)
Detailed Delivery Instructions





Encourage the mother to breath deeply between
contractions and push with contractions.
As the baby crowns, support with gentle pressure over
perineum to avoid an explosive birth.
If the amniotic sac is still intact, rupture it with a finger
to allow amniotic fluid to leak out.
As soon as the baby’s head appears, suction mouth &
nostrils with a bulb syringe – squeeze air from syringe
before inserting, insert syringe no more than 1 inch into
mouth, no more than ½ inch into each nostril.
If the umbilical cord is wrapped around the baby’s neck,
gently slip it over the head. Do not force it! If the cord is
too tight to slip over the head, apply umbilical cord
clamps and cut the cord. Clamp and cut the umbilical
cord only if he baby’s head has emerged and is in a
position that lows you to manage the airway.
Detailed Delivery Instructions






Encourage the mother to push. Support the baby’s head
as it delivers.
To assist in delivery of the anterior shoulder, apply
gentle downward pressure on the shoulder and head.
As soon as the anterior shoulder has delivered, apply
gentle upward pressure to assist in the delivery of the
posterior shoulder.
Once both shoulders have delivered, be ready for the
remainder of the body to deliver quickly. Newborn
babies are slippery so handle carefully.
Stimulate the newborn to breathe by tapping the feet, if
necessary.
Once pulsations have stopped, clamp the cord by
placing a clamp approximately 6 inches from the baby.
Place a second clamp approximately 2 inches from the
first, then cut the cord between the clamps.
Detailed Delivery Instructions




Re-suction the baby’s mouth & nostrils only if baby not
breathing or having respiratory distress
Dry & wrap baby in a warm blanket — cover its head
Place baby on its side to facilitate drainage
Perform an APGAR assessment at 1 minute & 5 minutes
after delivery
Newborn Care
Care of the Infant



If not breathing – stimulate it by rubbing its back or
tapping your fingers on soles of its feet
If newborn does not start breathing effectively within 10
– 15 seconds of stimulation, use infant BVM to deliver
gentle puffs of air — enough to cause the chest to rise
If after 30 seconds of assisted ventilation there is no
response & heart rate is less than 60 beats/min, begin
CPR
Care of the Infant
 Keep newborn warm by drying it & then
wrapping it in warmed blankets
 After cord is clamped & cut, cover head
 Be careful because a wet baby is very
slippery
 Repeat suctioning of nose & mouth, if
needed
 Remember to check APGAR score at 1 & 5
minutes
Meconium Staining
 If signs of meconium are present, do not
stimulate infant before suctioning mouth
& nose
 This avoids aspiration of fecal material
that can cause pneumonia
APGAR




APGAR scale –
numerical measure of
baby’s overall condition
immediately after birth
Perfectly healthy baby
will have total score of
10
Many babies score 7 to
8 during first minute
By 5 minutes, most
babies score 8 to 10 on
scale
APGAR stands for:
 Appearance
 Pulse
 Grimace
 Activity
 Respirations
APGAR Scale
Scale
Sign
Appearance
Score
0
1
2
Blue, pale
Body pink,
extremities
blue
Completely
pink
Pulse
Absent
<100
>100
Grimace
No response
Grimaces
Cries
Limp
Some flexion
of extermities
Active motion
Absent
Slow &
irregular
Strong crying
(color of skin, nailbeds, or
lips)
(reflex, irritability)
Activity
(muscle tone)
Respirations
Total
1 min 5 min
Managing a Poor APGAR Score (PSS)
 Three things to remember when managing
infant with low APGAR score: position,
suction and stimulate (PSS)
 Position body so head is down & airway is
open
 Suction mucous & fluid from mouth & nostrils
 Stimulate infant by taping bottoms of feet
 PSS – memory aid to help recall these
steps — position, suction and stimulate
Neonatal Resuscitation
Neonatal Resuscitation




After delivery, if infant not breathing effectively after 10
to 15 seconds of stimulation, begin assisted respirations
Use infant BVM with high-flow oxygen at a rate of 40 to
60 breaths/min
If pulse rate falls below 60 beats/min, start
compressions & ventilations at ratio of 3:1 at 120
events/min (which is 90 compressions & 30
ventilations)
Remember, ventilation is the most important action in
neonatal resuscitation
CPR - Two-Thumb Encircling Hands Technique
(2 Rescuer CPR)
CPR technique for infant with pulse rate below 60
beats/min
1. Place infant on a firm, flat surface
2. Remove clothing from chest
3. Find compression site which is just below nipple line on
middle or lower third of sternum
4. Wrap your hands around upper abdomen with your
thumbs on compression site
5. Use your thumbs to deliver
gentle pressure against
sternum, pressing ½ to
¾ inch into chest
Care of the Mother
Care of the Mother

Once baby delivered &
umbilical cord cut &
clamped you should:
 Monitor and control
bleeding from mother
 Begin fundal massage
 Monitor vital signs
 Keep the mother and
baby warm




Transport once infant is
delivered
Do not wait for placenta—
may take up to 30
minutes to deliver
Do not pull on umbilical
cord
If placenta does deliver at
scene, transport with
mother & baby to hospital
Monitor and Control Bleeding
 After placenta delivered, place sanitary
napkin between mother’s legs
 Ask her to hold legs together
 Normal for mother to bleed up to one cup
(about 250 cc) or 5 sanitary napkins of
blood after delivery
 Record number of pads
Postpartum Bleeding
 Important steps in caring for postpartum
bleeding include:




Fundal massage
Treat for shock
Do not force delivery of placenta
Place sanitary napkin at
opening of vagina
Fundal massage
Fundal Massage





Makes uterus contract & diminishes vaginal bleeding
Can feel for fundus of uterus, located in abdomen
between pubic bone & umbilicus
Should feel like a softball
Perform massage like you would a firm muscle massage
Area may be tender & massaging it can cause
discomfort
Video demonstration available at EMS Online:
http://www.emsonline.net/obgyn2011/mother.asp
Abnormal Delivery
Delivery with Complications
(Can be delivered in the field)
Nuchal Cord (Umbilical Cord Around Neck)







Once head delivered ask mother to stop pushing so you
can check if cord is wrapped around infant’s neck
If cord looks like it is wrapped tightly, so as to constrict
airway, need to loosen it
Gently slip cord over baby’s head by placing two fingers
under cord at back of neck
Bring cord over shoulders & head
Cord is durable but it can tear if handled roughly so
don’t use excessive force
If too tight to loosen, clamp cord in two places two
inches apart and cut cord between clamps
Unwrap cord from around neck & take care not to injure
baby
Video demonstration available at EMS Online:
http://www.emsonline.net/obgyn2011/neck.asp
Shoulder Dystocia
 Labor progresses normally & head delivered
routinely however, immediately after head
delivers, shoulders become trapped between
symphysis pubis & sacrum, preventing further
delivery
 First step in treating shoulder dystocia is
recognizing when it occurs

Two main signs of shoulder dystocia are:
 Baby’s body does not emerge with standard moderate
traction & maternal pushing after delivery of baby’s head
 “Turtle Sign” –head suddenly retracts back against mother’s
perineum after it emerges from vagina
Shoulder Dystocia
Do’s & Don’ts of McRoberts Maneuver
Do


Pull knees backwards (towards patient’s ears) & out
to side to rotate & open the pelvis
Use suprapubic pressure to release the shoulder
from behind pelvis
Do Not


Do not pull forcefully on baby’s head
Absolutely, no fundal pressure
Video demonstration available at EMS Online:
http://www.emsonline.net/obgyn2011/dystocia.asp
Buttocks & Double Footling Presentation
 If buttocks or two
 Key points are:
 Request paramedic unit
feet present first,
 Position mother with
you can attempt
buttocks at edge of bed
delivery in field
 Hold mother’s legs in flexed
position
 These are generally
 Support infant’s legs — do
slow deliveries & you
not pull
likely have time to
 As head passes pubis,
transport
apply gentle upward
traction until mouth
appears
 If head is stuck, create
airway by pushing away
vaginal wall — transport
immediately
If Head Does Not Deliver
 Create airway for infant
 First, place gloved hand into vagina with
your palm towards infant’s face
 Form a “V” with index & middle finger on
either side of infant’s nose
 Push vaginal wall away from infant’s face
to allow unrestricted breathing
 Maintain airway & transport immediately
Abnormal Delivery
Delivery with Complications
(Cannot be delivered in the field)
Single Limb Presentation
 Key points of assisting with single limb
presentation include:
 Support baby with your hands
 Provide airway for baby using your fingers
 Transport immediately — do not attempt
delivery in field
Prolapsed Cord
If you see umbilical cord in vagina, presenting before the baby, initiate the following
steps:
1. Request a paramedic unit
2. Place mother in knee-chest position
3. Check umbilical cord for pulsations
4. No pulsations - press presenting part of fetus away from umbilical cord, towards
mother’s head
5. Re-check cord for pulsations
6. Administer high flow oxygen to mother
7. Transport immediately – fetus will die quickly without rapid intervention
8. Continue holding presenting part of baby away from umbilical cord
9. Apply moistened dressing on exposed umbilical cord
10. Do not push umbilical cord back into vagina
Prolapsed cord
Knee-chest position
Case Study
 Video Case Study
http://www.emsonline.net/obgyn2011/case1.asp
Obstetric
Emergencies/Complications
Complications in the First
Trimester – Ectopic Pregnancy
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
6 week old embryo
1 month old embryo
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 (ALS)
Complications in the 2nd and 3rd
Trimester
Gestational Diabetes
 Some women develop diabetes during
pregnancy
 Pregnant diabetics are prescribed insulin
if blood sugar cannot be controlled by diet
alone
 Cannot be managed with oral drugs
because they are absorbed into placenta
& can adversely affect fetus
Abruptio Placenta



Premature separation of placenta from wall of uterus
Causes heavy bleeding and pain
Separation can either be 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
Supine Hypotensive Syndrome
 Supine hypotensive syndrome occurs
when increased weight of uterus
compresses inferior vena cava while a
patient is supine
 Markedly decreases blood return to heart
& reduces cardiac output
 Some women are predisposed to this
condition because of an overall decrease
in circulating blood volume or anemia
Supine Hypotensive Syndrome
 Usually occurs in third trimester of
pregnancy
 Relieve it by tilting mother to one side
Vena cava & aorta
compressed by fetus
Compression relieved by
tilting patient on left side
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

Bleeding is bright red and
is usually painless
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 and seizures
 Life-threatening seizures differentiate
eclampsia from preeclampsia
Preeclampsia
 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
Eclampsia



Eclampsia, also called
toxemia, most serious
manifestation of
hypertensive disorders
of pregnancy
Characterized by grand
mal seizures
Often preceded by
visual disturbances
such as flashing lights
or spots before the eyes



Eclampsia patients often
experience swelling of
hands & feet & markedly
elevated blood pressure
If eclampsia develops,
death of mother & fetus
frequently results
Treat by lying mother on
her side, maintaining
airway, & delivering highflow oxygen
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
Bleeding
 Vaginal bleeding
during pregnancy is
cause for concern
 Bleeding in early
pregnancy often
associated with
spontaneous
abortion, ectopic
pregnancy, or
vaginal trauma
 Vaginal bleeding in
third trimester is
usually caused by:
 abruptio placenta
 placenta previa
 trauma to vagina or
cervix
 This can be a lifethreatening
emergency
Bleeding
 Ranges from light spotting to massive
hemorrhage
 Difficult to determine cause of vaginal
bleeding in field
 Suspect placenta previa, abruptio
placenta, or vaginal trauma when you see
vaginal bleeding during third trimester
Gynecological Emergencies
Vaginal Bleeding
 Vaginal bleeding that is not a result of
direct trauma or normal menstrual cycle
can indicate a serious problem
 Difficult to isolate a specific cause, treat
all vaginal bleeding as if there were
serious underlying condition
 Especially true if bleeding associated with
lower abdominal pain
PID
 Pelvic inflammatory disease (PID) –
infection of female reproductive tract





Organs most commonly involved
Uterus
Fallopian tubes
Ovaries
Occasionally, peritoneum & intestines
PID
 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
PID
 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
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
Ovarian Cysts

Egg is 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
Ovarian Cyst
Dilation and Curettage (D&C)
 Dilation – opening of  Complications
the cervix
 Heavy bleeding is
uncommon but
 Curettage – scraping
important to recognize
the walls of uterus
 Surgical procedure –  Patients with heavy
bleeding
usually done on
 Evaluate for signs of
outpatient basis
shock
under local
 Expedite transport to
anesthesia
hospital
 Diagnose conditions
such as cancer
 Remove tissue after
miscarriage
 Elective abortion
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
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

Injuries to this area tend
to bleed profusely due
to rich blood supply

Treat open wounds of
genitalia with moist,
sterile compresses
Use direct pressure to
control bleeding
Do not place dressings in
the vagina
Summary
 Signs of imminent delivery include:




Crowning
Contractions less than 2 minutes apart
Feeling of rectal fullness
Feeling of imminent delivery
Summary
 Care for vaginal bleeding includes:




Maintain ABCs
Control bleeding, if possible
Administer oxygen
Place in shock position
Summary
Key points for assisting with normal delivery:







Support head with gentle pressure
Check if cord wrapped around baby’s neck—if so, attempt to loosen
Apply gentle downward pressure on anterior shoulder and head
After anterior shoulder has delivered, apply gentle upward pressure
on posterior shoulder & head
Suction mouth and nostrils when head appears
Once delivered, stimulate newborn if it does not breathe
Put two clamps on umbilical cord & cut 6 inches from navel
Care for newborn infant includes:





Stimulate infant if not breathing sufficiently
Start CPR if no response after 30 seconds
Keep infant warm
Repeat suctioning of mouth & nose
Check APGAR score at 1 & 5 minutes
Summary


APGAR stands for appearance, pulse, grimace, activity,
& respirations
Care of mother includes:






Monitor & control bleeding from mother
Begin fundal massage
Monitor vital signs
Keep mother & baby warm
If head remains stuck during buttocks or double footling
presentation, create airway by pushing away vaginal wall
then transport immediately
Important steps in caring for postpartum bleeding
include fundal massage and treatment of shock
Questions
EMS Online
Guidelines and Standing Orders
http://www.emsonline.net/downloads.asp
Email support: [email protected]
Dr. Mickey Eisenberg
Medical Director
Ask the Doc: http://www.emsonline.net/doc.asp

similar documents