20 obstetric and gynecologic emergencies l.
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20: Obstetric and Gynecologic 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

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Presentation Transcript
three stages of labor
Three Stages of Labor
  • First stage
    • Dilation of the cervix
  • Second stage
    • Expulsion of the infant
  • Third stage
    • Delivery of the placenta
predelivery emergencies
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
Hemorrhage
  • Vaginal bleeding that occurs before labor begins
  • If present in early pregnancy, it may be a spontaneous abortion or ectopic pregnancy.
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

Placenta Problems
gestational diabetes
Gestational Diabetes
  • Develops only during pregnancy.
  • Treat as regular patient with diabetes.
you are the provider
You are the Provider
  • 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 continued
You are the Provider (continued)
  • 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?
scene size up
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
Initial Assessment
  • Is the mother in active labor?
  • Evaluate trauma or medical problems first.
  • Treat ABCs in line with local protocols.
transport decision
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.
you are the provider continued14
You are the Provider (continued)
  • 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?
focused history and physical exam
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
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
Interventions
  • Childbirth is natural, does not require intervention in most cases.
  • Treating the mother will benefit the baby.
you are the provider continued 1 of 2
You are the Provider (continued) (1 of 2)
  • 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 2 of 2
You are the Provider (continued) (2 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?
detailed physical exam
Detailed Physical Exam
  • Only if other treatments are not required.
ongoing assessment
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 are the provider continued22
You are the Provider (continued)
  • 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?
when to consider field delivery
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
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.
delivering the baby
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
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
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
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
APGAR Scoring

AAppearance

PPulse

GGrimace

AActivity

RRespirations

giving chest compressions to an infant 1 of 2
Giving Chest Compressionsto 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
Giving Chest Compressionsto 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
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
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
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
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
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
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
  • 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
Delivering an Infantof 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
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
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
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
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.