Obstetric and Gynecological Emergencies

Anatomy of Pregnancy
Fetus Uterus Cervix Bloody show Placenta Afterbirth Umbilical cord Amniotic sac Vagina
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Fetus
The developing baby during pregnancy Full-term pregnancy last approximately 280 days or 39 to 40 weeks from day of last normal menstrual cycle 9 calendar months 9 months divided into 3- 3 month trimesters EDC (estimated date of confinement) Approximate date of birth Based on date of mothers last menstrual period
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Uterus
Organ that contains the developing fetus Smooth muscle and blood vessels
Allow for great expansion Forcible contractions during labor & delivery

Rapid contractions after delivery

Constricts blood vessels and prevents hemorrhage
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Cervix
Neck of the uterus Contains mucus plug
Seals uterine opening Prevents contamination

Effacement - thinning of cervix

Mucus plug appears as pink-tinged vaginal discharge or bloody show Signals the first stage of labor
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Placenta
Disk-shaped inner lining Attaches to uterine wall after egg is fertilized Contains blood vessels
Allows for oxygen and nourishment for fetus Eliminates carbon dioxide and waste

Afterbirth
Placenta separates from uterine wall after delivery of infant
Usually weighs about 1 pound, or generally 1 sixth of infants weight

Placenta needs to be saved and examined

Umbilical Cord
Infants lifeline 1 inch wide and 22 inches long Attaches fetus to placenta
1 vein carries oxygenated blood & nutrients to fetus 2 arteries carry deoxygenated blood & waste to placenta

Protected by Whartons jelly

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Amniotic Sac
Bag of waters Insulates and protects the fetus during pregnancy Varies from 500 to 1,000 milliliters Rupturing indicates that labor has started Helps lubricate birth canal & remove bacteria Part of sac serves as resilient wedge to help with dilation of cervix

Vagina
Lower part of birth canal 8 to 12 centimeters in length Undergoes changes during pregnancy to allow for passage of the infant at birth

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Labor Pains
Contraction of uterus Pains generally start in lower back & as labor progresses, pain becomes more noticeable in lower abdomen Intervals last from 30 seconds to 1 minute & occur at 2 to 3 minute intervals

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Braxton-Hicks Contractions
False labor Caused by changes in uterus as it adjusts in size and shape Can happen any time during pregnancy

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First Stage of Labor

Longest stage Beginning of contractions to full dilation Cervix thins (effacement) Contractions (cramp-like pains) Bloody show before or during this stage Amniotic sac may break before or during this stage 1st child, stage can average 18 hours or more
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Second Stage of Labor

Baby enters birth canal and is born Fergusons Reflex
Urge to push as babys body puts pressure on the perineum (area between vagina & rectum)

Crowning - presenting part from vaginal opening

Cephalic presentation - head first Breech birth - buttocks or both feet
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Third Stage of Labor

Delivery of placenta or afterbirth Placenta separates from uterine wall and is expelled

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Predelivery Emergencies

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Supine Hypotensive Syndrome

Near birth, weight of uterus, fetus, placenta, & amniotic fluid can be as much as 20-24 pounds If mother is supine weight can compress inferior vena cava, reducing venous return to the heart, reducing cardiac output. (amount of blood pumped by the heart in 1 minute)
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Signs and Symptoms/ Treatment

Vertigo Possible syncope Drop in blood pressure Assess A,B,Cs All third trimester patients should be transported on their left side Place a pillow or blanket behind their back to ensure proper positioning
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Miscarriage/Spontaneous Abortion
Fetus & placenta delivered before the 28th week of pregnancy When it happens on its own Dont waste time trying to determine if a miscarriage has occurred

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Induced Abortion
Deliberate actions taken to stop pregnancy Therapeutic abortion
Done as a legal medical procedure

Criminal abortion
Illegal attempt to stop abortion
Use drugs, chemicals, poisons, to induce labor Insert objects into the vagina to disrupt pregnancy

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Signs & Symptoms

Cramping abdominal pain Bleeding moderate to severe, bright or dark red Passage of tissue or blood clots NOTE: Ask about starting date of LMP. If more than 24 weeks, prepare OB kit.

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Self Induced/Non Medical Abortions

Pain is much greater Bleeding usually more severe May be high fever from infection

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Emergency Care
Big Os Monitor vitals Sanitary napkin over vagina Treat for shock Immediate transport Replace and save blood soaked pads Save all tissue If poison was ingested contact med-control Provide emotional support
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Note:
Use the term miscarriage when speaking with family or where bystanders can hear you. Most people associate spontaneous abortion with self-induced abortion.

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Seizure
Can be life-threatening emergency Provide care based on signs & symptoms Protect patient from hurting themselves Transport on left side Minimize lights and sirens Provide support
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Vaginal Bleeding
Can often occur late in pregnancy With or without pain Excessive bleeding can be life-threatening Assure ABCs Big Os Apply sanitary napkin and transport Treat for hypoperfusion
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Trauma
Treat as you would any other trauma patient Pay close attention to abdominal pain, cramping Asses for vaginal bleeding or loss of amniotic fluid Do not touch the vagina Tilt spine board so patient is left lateral
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General Care Predelivery Emergencies

Airway Big Os Ensure adequate circulation Treat for shock Control bleeding Never place anything into vagina Provide same care as for any other patient Transport left lateral recumbent
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Active Labor & Normal Delivery

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Assessment
Same as for any predelivery emergency Transport unless delivery is expected within a few minutes

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On Scene Delivery vs..Transport

Patients first delivery? How long has patient been pregnant? Any bleeding or discharge? Any contractions or pain present? What is the frequency and duration of contractions? Is the patient crowning? Feel the urge to push? Is uterus hard upon palpation?
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3 Cases When Delivery Must be Assisted No suitable transportation Hospital or physician cant be reached due to bad weather Natural disaster, or if delivery is imminent

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Signs & Symptoms of Probable Delivery Crowning has occurred Contractions closer than 2 minutes apart, intense, last 30 to 90 seconds Patient has the urge to push Patients abdomen is hard If birth does not occur within 10 minutes, contact medical control for permission to transport
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Delivery
BSI precautions Do not touch vaginal area except to deliver & in the presence of your partner Dont allow the patient to use the bathroom Do not hold the mothers legs together Use sterile OB kit

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Things to Remember
Stay calm Explain that you are trained to help Ensure mothers comfort, modesty, & peace of mind Be able to recognize your limitations

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Emergency Care
Position patient Create sterile field around vaginal opening Monitor patient for vomiting Continually assess for crowning Place glove fingers on bony part of infant's skull when it crowns Puncture amniotic sac if not already broken
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Emergency Care Cont...

Determine position of umbilical cord Suction infants airway As torso is born support with 2 hands Grasp feet as they are born Clean and suction mouth and nose Dry, wrap, and position infant
On back, level with vagina until cord is cut
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Emergency Care Cont...

Assign care of infant to partner and you continue care of mother Clamp, tie ,& cut cord as pulsation ceases
1st clamp 6 to 7 inches from infant 2nd clamp 3 inches from first

Deliver placenta
Usually delivers within 10 to 20 minutes Do not delay transport for delivery of placenta
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Emergency Care Cont...

Place placenta in towel and plastic bag Place 1 or 2 sanitary napkins over vaginal opening Record time of delivery and transport 500cc normal blood loss Excessive blood loss appears
Provide big Os Massage uterus
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Active Labor with Abnormal Delivery

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Assessment
Perform all assessments as with any other delivery emergency

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Signs and Symptoms

Fetal presentation other than head Abnormal color or smell of amniotic fluid Labor before 38th week of pregnancy Recurrence of contractions after first infant is born

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General Emergency Care

Immediate transport Big Os Continuous monitoring of vital signs

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Specific Abnormal Deliveries

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Prolapsed Cord
Umbilical cord presents first Cord is pinched off between the head and vaginal wall Transport mother in knee chest position or elevate hips Wrap cord in moist sterile towel soaked with saline, then a warm dry towel to prevent heat loss Insert sterile fingers into vagina to gently lift head or buttocks to decrease pressure on cord Transport in this position and check for pulsation in the cord
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Breech Birth
Involves buttocks or both feet first Can involve limb presentations

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Emergency Care
Transport immediately Big Os Position mother in Trendelenberg with pelvis elevated If prolonged delivery of head, form a V with 2 fingers and place in vaginal opening to maintain airway for infant
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Multiple Births
Most mothers know if they are expecting twins If abdomen appears to be unusually large after 1st delivery, there may be another baby. Usually will deliver within minutes after the 1st Second baby may be breech Can share placentas or have their own Use same delivery method Be sure to identify which baby was 1st or 2nd
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Meconium Staining
Indication of fetal distress during labor Passing of bowel movement Amniotic fluid is a greenish or brownish-yellow in color Suction the infants mouth and nose as soon as the head emerges Do not stimulate breathing before suctioning

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Premature Birth
Infant weighing less than 5 pounds or born before the 38th week Dry infant and maintain warmth Use gentle suction Prevent bleeding from umbilical cord Administer Oxygen by blow by method Oxygen tubing inch above infants face or tent

Prevent contamination Keep infant warm and heat vehicle

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Newborn Infant
Assessment

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APGAR
Appearance Pulse Grimace Activity Respiration Gives a good indication of the infants condition Should be performed 1 minute after birth and 4 minutes later
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APGAR Scale
Ranges from 0 to 10 points 7-10 points -newborn should be active, routine care 4-6 points - newborn is moderately depressed. Provide stimulation & oxygen 0-3 points - severely depressed. Provide extensive care with BVM & CPR.
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Appearance
Skin or entire body blue or pale 0 points Blue hands & feet with pink skin at the core 1 point (acrocyanosis) Extremities and trunk pink 2 points

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Pulse
Count heart rate for at least 30 seconds apical pulse No pulse - 0 points Pulse rate under 100 - 1 point Pulse rate over 100 award 2 points

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Grimace
Gently flick the soles of the infants feet & observe facial expressions No reflex activity to stimulation - 0 points Some facial grimace - 1 point Grimace, cough, sneeze, or cry - 2 points

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Activity
Flexion of arms and legs Resistance when you try to extend them Limp , displays no extremity movement - 0 points Some flexion without active movement - 1 point Actively moving - 2 points
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Respiration
No respiratory effort - 0 points Slow irregular breathing effort, weak cry - 1 point Strong cry and good respirations - 2 points Be sure to stimulate breathing by flicking the soles of the feet or rubbing the infants back in a circular motion
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Signs & Symptoms Severely Depressed Newborn

Respiratory rate over 60 per minute Diminished breath sounds Heart rate over 180 or under 100 per min. Obvious signs of trauma from delivery Poor or absent skeletal muscle tone Respiratory arrest, or severe distress Meconium staining Weak pulses Cyanotic body Poor peripheral perfususion Lack of or poor response to stimulation Apgar score under 4
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Emergency Care
Airway & warmth are most crucial for newborn BVM 40 to 60 per min. if Breathing is shallow,gasping, slow, or absent Heart rate less than 100 Core remains cyanotic even with blow by O2

Heart rate drops below 60 or between 60 to 80 with no increase, begin CPR Follow AHA guidelines
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Inverted Pyramid Neonatal Resuscitation

Dry, Warm, Position, Suction, Tactile Stimuli Oxygen Bag-Valve-MaskVentilation Chest Compressions Medications

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Placenta Previa
Placenta is low and may cover the uterine outlet Can tear or separate from uterus
Results in painless hemorrhaging
Placenta has no nerve endings

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Assessment History
Having born more than 2 children Early vaginal bleeding or spotting Previous cesarean section Recent sexual intercourse Bright red vaginal bleeding during third trimester Soft uterus without tenderness upon palpation Present fetal heart tones & movement

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Emergency Care
Big Os Control bleeding Treat for shock Immediate transport

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Abruptio Placenta
Normal placenta tears away from the uterine wall during the last trimester Little or no external vaginal bleeding Severe abdominal pain Patient may feel a tearing sensation Uterine sensory fibers detect placenta separation
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Assessment History
History of hypertension Born more than 2 children Previous abruption or placenta previa Recent strenuous exercise Abdominal trauma Sharp severe abdominal pain Possible dark red vaginal bleeding Blood loss out of proportion for degree of shock Possible uterine contractions Tender, rigid, firm abdomen Absent fetal heart tones
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Emergency Care
Big Os Control bleeding (if necessary) Treat for shock Immediate transport

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Toxemia/Preeclampsia
Poisoning of the blood during pregnancy Most frequent in last trimester Women in 20s first time pregnancy At risk mothers:
Diabetes Heart disease Renal problems Hypertension
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Signs & Symptoms/Preeclampsia

Hypertension Edema Excessive weight gain Extreme swelling of face, hands, and feet Severe cases Headache Sensitivity to light Visual difficulties Pain in upper abdomen Apprehension and shakiness
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Eclampsia
Second stage of toxemia Difference between preeclampsia and eclampsia is the onset of seizures or coma. During seizure placenta can separate from uterine wall Death can also result from Cerebral hemorrhage Respiratory arrest Renal failure Circulatory collapse
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Emergency Care
Big Os Suction (if necessary) If seizure begins, positive pressure ventilation Transport in a calm and quiet manner as possible

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Ruptured Uterus
Uterine wall thins too much around cervix as fetus grows Uterine wall ruptures Fetus released into abdominal cavity Mortality to mother usually 5 to 20% Infant mortality over 50% Requires immediate surgery
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Assessment Findings
Previous uterine rupture Abdominal trauma Large fetus Born more than 2 children Prolonged or difficult labor Tearing or shearing sensation in abdomen Constant severe abdominal pain Nausea Signs of shock Vaginal bleeding (minor, or heavy) Cessation of noticeable uterine contractions Palpation of infant in abdominal cavity
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Emergency Care
Big Os Control bleeding Treat for shock Immediate transport

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Ectopic Pregnancy
Implantation of a fertilized egg outside the uterus Leading cause of maternal death in the first trimester Any female of childbearing age with acute abdominal pain is said to have an ectopic pregnancy until proven otherwise
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Assessment History
Previous ectopic pregnancies History of PID Missed menstrual cycles Sudden, sharp, or knife-like abdominal pain localized on one side Vaginal spotting Pain radiating to one or both shoulders Tender, bloated abdomen Palpable mass in abdomen Weakness or dizziness when sitting or standing Decreased BP. (late sign) Increased heart rate Shock Bluish discoloration around naval (late sign) Urge to defecate
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Emergency Care
Big Os Treat for shock Constantly reassess vital signs Immediate transport

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Stillborn Infants
Baby dies sometime before birth Death is obvious
Blisters Foul odor Skin or tissue deterioration Discoloration Softened head

If baby is born in respiratory or cardiac arrest begin resuscitative measures

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Emergency Care
Never lie to parents Allow mother to see baby if she wants to Baptize the baby if asked Document time if death

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