Chapter 20

20: Obstetric and Gynecologic Emergencies

Cognitive Objectives (1 of 4) 4-9.1 Identify the following structures: uterus, vagina, fetus, placenta, umbilical cord, amniotic sac, perineum. 4-9.2 Identify and explain the use of the contents of an obstetrics kit. 4-9.3 Identify predelivery emergencies. 4-9.4 State indications of an imminent delivery. 4-9.5 Differentiate the emergency medical care provided to a patient with predelivery emergencies from a normal delivery.

Cognitive Objectives (2 of 4) 4-9.6

State the steps in the predelivery preparation of the mother. 4-9.7 Establish the relationship between body substance isolation and childbirth. 4-9.8 State the steps to assist in the delivery. 4-9.9 Describe care of the baby as the head appears. 4-9.10 Describe how and when to cut the umbilical cord.

Cognitive Objectives (3 of 4) 4-9.11 Discuss the steps in the delivery of the placenta. 4-9.12 List the steps in the emergency medical care of the mother postdelivery. 4-9.13 Summarize neonatal resuscitation procedures. 4-9.14 Describe the procedures for the following abnormal deliveries: breech birth, prolapsed cord, limb presentation.

Cognitive Objectives (4 of 4) 4-9.15 Differentiate the special considerations for multiple births. 4-9.16 Describe special considerations of meconium. 4-9.17 Describe special considerations of a premature baby. 4-9.18 Discuss the emergency medical care of a patient with a gynecological emergency.

Affective Objectives 4-9.19 Explain the rationale for understanding the implications of treating two patients (mother and baby).

Psychomotor Objectives (1 of 2) 4-9.20 Demonstrate the steps to assist in the normal cephalic delivery. 4-9.21 Demonstrate necessary care procedures of the fetus as the head appears. 4-9.22 Demonstrate infant neonatal procedures. 4-9.23 Demonstrate postdelivery care of infant. 4-9.24 Demonstrate how and when to cut the umbilical cord. 4-9.25 Attend to the steps in the delivery of the placenta.

Psychomotor Objectives (2 of 2) 4-9.26 Demonstrate the postdelivery care of the mother. 4-9.27 Demonstrate the procedures for the following abnormal deliveries: vaginal bleeding, breech birth, prolapsed cord, limb presentation. 4-9.28 Demonstrate the steps in the emergency medical care of the mother with excessive bleeding. 4-9.29 Demonstrate completing a prehospital care report for patients with obstetrical/gynecological emergencies.

Female Reproductive System

Three Stages of Labor • First stage – Dilation of the cervix • Second stage – Expulsion of the infant • Third stage – Delivery of the placenta

Predelivery Emergencies • Preeclampsia – Headache, vision disturbance, edema, anxiety, high blood pressure • Eclampsia – Convulsions resulting from hypertension • Supine hypotensive syndrome – Low blood pressure from lying supine

Hemorrhage • Vaginal bleeding that occurs before labor begins • If present in early pregnancy, it may be a spontaneous abortion or ectopic pregnancy.

Ectopic Pregnancy • Pregnancy outside of the uterus • Should be considered for any woman of childbearing age with unilateral lower abdominal pain and missed menstrual period • History of PID, tubal ligation, or previous ectopic pregnancy

Placenta Problems • Placenta abruptio – Premature separation of the placenta

• Placenta previa – Development of placenta over the cervix

Gestational Diabetes • Develops only during pregnancy. • Treat as regular patient with diabetes.

• You and your partner are dispatched to the A&E Bank for a woman in active labor. • En route, you discuss previous experiences assisting in a delivery and how you can prepare yourselves. • What equipment should accompany you and your partner inside the bank? You are the Provider

• You find a woman in her mid 30s lying on the couch, holding her abdomen and moaning. • Between labored breaths she tells you that her name is Jane and that she is a teller. • She is conscious, alert, and oriented. Breathing in rapid panting breaths. Pulse is strong and bounding. Skin is pale and clammy. • What questions might you consider asking to assess how far along her labor is? You are the Provider (continued)

Scene Size-up

• Woman’s balance is altered. Be aware for falls and the need for spinal stabilization. • Use BSI. • Usual threats to your safety still exist. • Be calm. Protect the mother and the child.

Initial Assessment

• Is the mother in active labor? • Evaluate trauma or medical problems first. • Treat ABCs in line with local protocols.

Transport Decision • If delivery is imminent, prepare for delivery in warm, private location. • If delivery is not imminent, transport on left side if in last two trimesters of pregnancy. • If the patient was subject to spinal injury, stabilize and prop backboard with towel roll on right side.

• The woman is one week past her due date. She has been having contractions for the past hour. • Her water broke just before your arrival. This is her fourth pregnancy, and she has three children. • She feels like she has to go to the restroom. • Your partner applies high-flow oxygen via a nonrebreathing mask and begins timing her contractions. • What does the patient’s request to go to the restroom indicate? You are the Provider (continued)

Focused History and Physical Exam

• Obtain full SAMPLE history, and also: – Prenatal history – Complications during pregnancy – Due date – Number of babies (twins) – Drugs or alcohol – Water broken – Green fluid (meconium)

Focused Physical Exam • Mainly abdomen and delivery of fetus • Based on her chief complaints and history • Pay close attention to tachycardia, hypotension, or hypertension.

Interventions • Childbirth is natural, does not require intervention in most cases. • Treating the mother will benefit the baby.

• You explain that you need to examine the patient before preparing her for transport to the hospital. • While doing so, she tells you that when she went to the doctor yesterday she was dilated to 3 cm and that she lost her mucous plug about one hour ago. • Your partner tells you that her contractions are 45 seconds long and are 55 seconds apart. • Should you check for crowning? You are the Provider (continued) (1 of 2)

• Upon examination, you find that the baby is crowning. You and your partner prepare for an imminent birth. • Your partner notifies dispatch and requests ALS backup, and notifies medical control. • You quickly help move the patient to the floor. Using your OB kit, you prepare a sterile delivery field. • Your patient tells you that she needs to push. On the next contraction, the baby’s head is delivered, facing downward. • Why should you feel around the baby’s neck? You are the Provider (continued) (2 of 2)

Detailed Physical Exam

• Only if other treatments are not required.

Ongoing Assessment

• Continue to reassess the patient for changes in vital signs. Watch for hypoperfusion. • Notify hospital of your preparations for delivery. • Document carefully, especially baby’s status. • Obstetrics is one of the most litigated specialties in medicine.

• You successfully deliver a beautiful baby girl. • You have suctioned her mouth and nose, dried her off, and wrapped her in a blanket. • Umbilical cord has been cut and placenta delivered. ALS personnel arrive. • What care should every infant receive? You are the Provider (continued)

When to Consider Field Delivery • Delivery can be expected within a few minutes • A natural disaster or other catastrophe makes it impossible to reach a hospital • No transportation is available

Preparing for Delivery • Use proper BSI precautions. • Be calm and reassuring while protecting the mother’s modesty. • Contact medical control for a decision to deliver on scene or transport. • Prepare OB kit.

Positioning for Delivery

Delivering the Baby • Support the head as it emerges. • Once the head emerges, the shoulders will be visible. • Support the head and upper body as the shoulders deliver. • Handle the infant firmly but gently as the body delivers. • Clamp the cord and cut it.

Complications With Normal Vaginal 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 infant’s head. – It may have to be cut.

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. • Ensure the infant is pink and breathing well.

Delivery of Placenta • Placenta is attached to the end of the umbilical cord. • It should deliver within 30 minutes. • Once the placenta delivers, wrap it and take to the hospital so it can be examined. • If the mother continues to bleed, transport promptly to the hospital.

APGAR Scoring A

Appearance

P

Pulse

G

Grimace

A

Activity

R

Respirations

Neonatal Resuscitation

Giving Chest Compressions to an Infant (1 of 2) • Find the proper position – Just below the nipple line – Middle third of the sternum • Wrap your hands around the body, with your thumbs resting at that position. • Press your thumbs gently against the sternum, compressing 1/2˝ to 3/4˝ deep.

Giving Chest Compressions to an Infant (2 of 2) • Ventilate with a BVM device after every third compression. • 100 compressions to 20 ventilations per minute • Continue CPR during transport.

Breech Delivery • Presenting part is the buttocks or legs. • Breech delivery is usually slow, giving you time to get to the hospital. • Support the infant as it comes out. • Make a “V” with your gloved fingers then place them in the vagina to prevent it from compressing infant’s airway.

Rare Presentations (1 of 2) • Limb presentation – This is a very rare occurrence. – This is a true emergency that requires immediate transport.

Rare Presentations (2 of 2) • Prolapsed cord – Transport immediately. – Place fingers into the mother’s vagina and push the cord away from the infant’s face.

Excessive Bleeding • Bleeding always occurs with delivery but should not exceed 500 mL. • Massage the mother’s uterus to slow bleeding. • Treat for shock. • Place pad over vaginal opening. • Transport to hospital.

Spina Bifida • Defect in which the portion of the spinal cord or meninges may protrude outside the vertebrae or body. • Cover area with moist, sterile compresses to prevent infection. • Maintain body temperature by holding baby against an adult for warmth.

Abortion (Miscarriage) • Delivery of the fetus or placenta before the 20th week • Infection and bleeding are the most important complications. • Treat the mother for shock. • Transport to the hospital. • Bring tissue that has passed through the vagina to the hospital.

Twins • Twins are usually smaller than single infants. • Delivery procedures are the same as that for single infants. • There may be one or two placentas to deliver.

Delivering an Infant of an Addicted Mother • Ensure proper BSI precautions • Deliver as normal. • Watch out for severe respiratory depression and low birth weight. • Infant may require immediate care.

Premature Infants and Procedures • Delivery before 8 months or weight less than 5 lb at birth. – Keep the infant warm. – Keep the mouth and nose clear of mucus. – Give oxygen. – Do not infect the infant. – Notify the hospital.

Fetal Demise • An infant that has died in the uterus before labor • This is a 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.

Delivery Without Sterile Supplies • You should always have goggles and sterile gloves with you. • Use clean sheets and towels. • Do not cut or clamp umbilical cord. • Keep placenta and infant at same level.

Gynecologic Emergencies • Do not examine genitalia unless there is obvious bleeding. • Leave any foreign bodies in place, after packing with bandages • Treat as any other patient with blood loss.