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Obstetrics and Gynecology A lecture about where babies come from Nikhil Natarajan REMT-P Definitions Fetus – developing unborn baby Uterus – organ in which the fetus grows, responsible for labor and expulsion of infant Birth Canal – vagina and lower part of the uterus

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Obstetrics and Gynecology

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Obstetrics and Gynecology

A lecture about where babies come from

Nikhil Natarajan

REMT-P


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Definitions

  • Fetus – developing unborn baby

  • Uterus – organ in which the fetus grows, responsible for labor and expulsion of infant

  • Birth Canal – vagina and lower part of the uterus

  • Placenta – fetal organ through which fetus exchanges nourishment and waste products while in uterus

  • Umbilical Cord – cord which is an extension of the placenta through which the fetus receives nourishment while in the uterus


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  • Amniotic Sac – the sac that surrounds the fetus inside the uterus

  • Vagina – lower part of the birth canal

  • Perineum – skin between the vagina and the anus, commonly torn during delivery

  • Crowning – the bulging-out of the vagina which is opening as the fetus’ head or presenting part presses against it


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  • “Bloody Show” – mucus and blood that may come out of the vagina as labor begins

  • Presenting part – the part of the infant/fetus that comes first (usually the head)

  • Abortion – miscarriage – delivery of products of conception early in pregnancy


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Three Stages of Labor

  • 1st Stage

    • Begins with the first uterine contraction and ends with complete dilation of the cervix

  • 2nd Stage

    • Begins with complete dilation of the cervix and ends with delivery of the infant

  • 3rd Stage

    • Begins with delivery of the infant and ends with delivery of the placenta


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The OB Kit

  • Contents

    • Surgical Scissors

    • Hemostats or cord clamps

    • Umbilical tape or sterilized cord

    • Bulb Syringe

    • Towels

    • 2X10 gauze sponges

    • Sterile gloves

    • Baby blanket

    • Sanitary napkins

    • Plastic bag


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What can possible go wrong?

  • Miscarriage

  • Seizure during pregnancy (Eclampsia)

  • Vaginal Bleeding

  • Trauma

  • Prolapsed Cord

  • Breech Delivery

  • Limb Presentation

  • Meconium Staining

  • Premature Delivery


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Miscarriage

  • Spontaneous abortion

  • Care

    • Size up the scene – is it safe?

    • Initial Assessment

    • History and PE

    • Baseline Vitals

    • Treat the patient based on signs and symptoms

    • Apply external vaginal pads

    • Bring fetal tissue to the hospital

    • Support the mother


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Seizure during pregnancy

  • Eclampsia

  • Care

    • Size up the scene (ALS?)

    • Initial Assessment

    • History and PE

    • Baseline vitals

    • Treatment based on signs and symptoms

    • Transport on left side


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Vaginal Bleeding

  • Late pregnancy vaginal bleeding can present with or without pain!

  • Care

    • Size up the scene – is it safe?

    • Initial Assessment

    • History and PE

    • Baseline Vitals

    • Treat the patient based on signs and symptoms

    • Apply external vaginal pads


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Trauma

  • Care for the pregnant trauma patient is the same as for any other patient, except you have two patients! Which one is more important? The mother or the baby?


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What do I ask?

  • Are you pregnant?

  • How long have you been pregnant?

  • Are there contractions or pain?

  • Any bleeding or discharge?

  • Is crowning occurring with contractions?

  • What is the frequency and duration or contractions?

  • Does she feel as if she is having a bowel movement with increasing pressure in the vaginal area?

  • Does she feel the need to push?

  • Rock hard abdomen?


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What not to do!

  • Never touch the vaginal areas except during delivery and when your partner is present

  • Do not let the mother go to the bathroom

  • Do not hold the mothers legs together

  • Recognize your own limitations and transport even if you must deliver enroute to the hospital

  • Do not flip out!

  • Do not send your partner to boil some water!


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The Delivery!

  • Apply gloves, mask, gown, eye protection for infection control precautions

  • Have the mother lie with knees drawn up and spread apart

  • Elevate buttocks – with blankets or pillows

  • Create a sterile field around the vaginal opening with sterile towels or paper barriers


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  • When the infant’s head appears during crowning, place fingers on the bony part of the skull (NOT the fontanelles or face) and exert gentle pressure to prevent explosive delivery.

  • If amniotic sac does not break, or has not broken, use a clamp to puncture the sac and push it away from the infant’s head and mouth as they appear


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  • As the infant’s head is being born, determine if the umbilical cord is around the infants neck; slip over the shoulder or clamp, cut, and unwrap

  • After the infant’s head is born, support the head, suction the mouth two or three times and the nostrils. Use caution to avoid contact with the back of the mouth


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  • As the torso and full body are born, support the infant with both hands

    BABIE’S ARE SLIPPERY!!


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  • As the feet are born, grasp the feet

  • Wipe blood and mucus from the mouth and nose with a sterile gauze, suction mouth and nose again

  • Wrap the infant in a warm blanket and place on its side, head slightly lower than the trunk


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  • Keep the infant level with the vagina until the cord is cut

  • Assign partner to monitor infant and complete initial care of the newborn

  • Place a clamp or tie on the umbilical cord 8 to 10 inches from the baby

  • Place a second clamp or tie approximately 4 fingers from the baby

  • After pulsations cease, cut between the clamps or ties


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  • Observe for delivery of the placenta while preparing mother and infant for transport

  • When the placenta is delivered, wrap the placenta in towel and put in a plastic bag and transport it with the mother to the hospital

  • Place sterile pads over the opening of the vagina, lower the mother’s legs, and help her hold them together


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As usual, paperwork

  • Record the time of delivery and what county you are in. Both must be documented on the PCR.


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Vaginal Bleeding

  • A 500cc blood loss after the delivery is well tolerated by the mother and is to be expected. Don’t flip out!

  • If there is excessive bleeding, massage the uterus

    • Hand with fingers fully extended

    • Place on lower abdomen above pubis

    • Massage over the area

    • If it continues, check technique, provide oxygen and rapid transport


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Care of the Newborn

  • Initial care of the newborn consists of

    • Dry

    • Warm

    • Position

    • Suction

    • Stimulate


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APGAR

  • Appearance

  • Pulse

  • Grimace

  • Activity

  • Respiratory

  • Done at 1 minute after delivery and 5 minutes after delivery


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APGAR


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Newborn Resuscitation

  • Breathing effort

    • If it is shallow, slow, or absent, provide artificial ventilations

  • Heart Rate

    • If less than 100 beats provide artificial ventilations

    • If less than 80 beats and not responding to ventilations begin chest compressions

    • If less than 60, begin chest compressions


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  • Color

    • If central cyanosis is present with spontaneous breathing and an adequate heart rate administer free flow oxygen (10-15 LPM) using oxygen tubing held as close to the newborn’s face as possible


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Prolapsed Cord

  • Condition where the cord presents through the birth canal before delivery of the head; presents a serious medical emergency which endangers the life of the unborn fetus

  • Care

    • Standard Initial assessment, VS, and PE

    • Position the mother with head down or buttocks raised using gravity to lessen pressure on the birth canal


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  • Insert sterile gloved hand into vagina pushing the presenting part of the fetus away from the pulsating cord

  • Rapidly transport, keeping pressure on the presenting part, monitoring pulsations in the cord and keep the cord moist and warm


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Breech Birth Presentation

  • Breech presentation occurs when the buttocks or lower extremity are low in the uterus and will be the first part of the fetus delivered

  • The newborn is at great risk for delivery trauma and prolapsed cord

  • Place mother in head down position with pelvis elevated and transport rapidly


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Limb Presentation

  • Occurs when a limb of the infant protrudes from the birth canal (usually a foot)

  • Transport rapidly with mother in head down/pelvis elevated position


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Multiple Births

  • Call for additional resources

  • Be prepared for more than one resuscitation


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Meconium Staining

  • Amniotic fluid that is greenish or brownish-yellow rather than clear. It is a sign of possible fetal distress during labor

  • DO NOT STIMULATE the infant prior to SUCTIONING the oropharynx


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Premature Delivery

  • Always at risk for hypothermia

  • Usually requires resuscitation; should be done unless physically impossible


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Gynecological Emergencies

  • Vaginal Bleeding

    • BSI, airway, normal BLS

  • Trauma

    • Treat any trauma to the external genitalia as any other soft-tissue injury. Never pack the vagina!


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Sexual Assault

  • Criminal assault situations require initial and on-going assessment/management and psychological care

  • Remember:

    • BSI

    • Airway

    • Non-judgmental attitude during SAMPLE focused assessment

    • Crime Scene Protection

    • Examine external genitalia only if profuse bleeding is present

    • Discourage the patient to bathe, void, or clean wounds

    • Document very thoroughly!!


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The End

Any questions???


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