ChapterChapter

Obstetrics andObstetrics and

GynecologyGynecology

TwentyTwenty

ChapterChapter

How to deal with predelivery

emergencies Normal and abnormal deliveries How to treat gynecological

emergencies

TwentyTwenty CORE CONCEPTSCORE CONCEPTS

Anatomy of PregnancyAnatomy of Pregnancy

PPREDELIVERYREDELIVERYEMERGENCIESEMERGENCIES

Complete patient assessment.Complete patient assessment. Base treatment on assessment.Base treatment on assessment. Bring fetal tissue to hospital.Bring fetal tissue to hospital. Give emotional support Give emotional support to mother. to mother.

MiscarriageMiscarriage(Spontaneous Abortion)(Spontaneous Abortion)

Complete patient assessment.Complete patient assessment. Base treatment on assessment.Base treatment on assessment. Administer high-concentrationAdminister high-concentration

oxygen.oxygen. Handle gently at all times.Handle gently at all times.

Seizures during PregnancySeizures during Pregnancy

CCHILDBIRTHHILDBIRTH

Childbirth Delivery KitChildbirth Delivery Kit

Name, age, due dateName, age, due date First delivery?First delivery? Contractions or pain?Contractions or pain? Bleeding or discharge?Bleeding or discharge? Crowning?Crowning?

(Continued)(Continued)

Predelivery EvaluationPredelivery Evaluation

Frequency/duration ofFrequency/duration of contractions? contractions?

Urge to move bowels?Urge to move bowels? Need to push?Need to push? Rock-hard abdomen?Rock-hard abdomen?

Predelivery EvaluationPredelivery Evaluation

Based on evaluationBased on evaluation Number of prior birthsNumber of prior births Distance to hospitalDistance to hospital Complications expectedComplications expected

Transport DecisionTransport Decision

Use body substance isolation.Use body substance isolation. Keep mother out of bathroom.Keep mother out of bathroom. Do not hold mother’s kneesDo not hold mother’s knees together.together.

(Continued)(Continued)

Delivery PrecautionsDelivery Precautions

Do not examine vagina internally.Do not examine vagina internally. Consider limitations of sceneConsider limitations of scene

Contact medical direction perContact medical direction per local protocol.local protocol.

on field delivery.on field delivery.

Delivery PrecautionsDelivery Precautions

Apply gloves, mask, eyeApply gloves, mask, eye protection, gown.protection, gown.

Control the scene to provide:Control the scene to provide:• A safe delivery areaA safe delivery area• Privacy, comfortPrivacy, comfort

(Continued)(Continued)

Delivery ProceduresDelivery Procedures

Have mother lie supine, kneesHave mother lie supine, knees drawn up and spread apart. drawn up and spread apart.

Elevate hips with blanket Elevate hips with blanket and pillow. and pillow.

(Continued)(Continued)

Delivery ProceduresDelivery Procedures

Create sterile field around vaginal opening.Create sterile field around vaginal opening.

Crowning ofCrowning ofInfant’s HeadInfant’s Head

Prevent explosivePrevent explosivedelivery of the head.delivery of the head.

If amniotic sac has not broken,If amniotic sac has not broken, puncture sac and pull it away puncture sac and pull it away from baby’s face. from baby’s face. Determine if umbilical cord is Determine if umbilical cord is around baby’s neck. If so, around baby’s neck. If so, clamp and cut cord. clamp and cut cord.

(Continued)(Continued)

Delivery ProceduresDelivery Procedures

Suction mouth, Suction mouth, then nose.then nose.

Aid in birth of Aid in birth of upper shoulder.upper shoulder.

Support the trunk.Support the trunk.

Support the legs.Support the legs.

Wipe blood, mucus from noseWipe blood, mucus from nose and mouth. and mouth.

Suction again.Suction again. Warmth is critical!Warmth is critical! Wrap baby in warm towel,Wrap baby in warm towel,

head lower than trunk.head lower than trunk.(Continued)(Continued)

Delivery ProceduresDelivery Procedures

Assign partner to initial careAssign partner to initial care and monitoring. and monitoring.

Keep infant level with vagina Keep infant level with vagina until cord is cut. until cord is cut.

Delivery ProceduresDelivery Procedures

(Continued)(Continued)

Clamp or tie cord; then cut.Clamp or tie cord; then cut.

Observe for delivery of Observe for delivery of placenta. placenta.

When placenta delivers, placeWhen placenta delivers, place in plastic bag for transport in plastic bag for transport to hospital. to hospital.

Delivery ProceduresDelivery Procedures

Delivering the PlacentaDelivering the Placenta

Cover vaginal opening with Cover vaginal opening with sterile pad. sterile pad.

Lower motherLower mother’s knees; help her to s knees; help her to hold them together. hold them together.

Record time of delivery.Record time of delivery.

(Continued)(Continued)

After-Delivery ProceduresAfter-Delivery Procedures

A loss of 500cc is well tolerated.

VaginalVaginal

BleedingBleeding If blood loss is excessive, massage the uterus.

Treat for shock.

After-Delivery ProceduresAfter-Delivery Procedures

Massage uterus to control bleeding.Massage uterus to control bleeding.

CCARE OF THEARE OF THENEWBORNNEWBORN

Position, dry, wipe, wrap.Position, dry, wipe, wrap. Repeat suctioning.Repeat suctioning. Cover the head.Cover the head.

(Continued)(Continued)

Care of the NewbornCare of the Newborn

Suctioning the NewbornSuctioning the Newborn

=====

APGAR

Color: No central cyanosis

Greater than 100/minute

Vigorous and crying

Good extremity motion

Normal, crying

Normal AssessmentNormal AssessmentFindings Findings —— Newborn Newborn

AAppearanceppearancePulsePulseGrimaceGrimaceActivityActivityRespiratory effortRespiratory effort

RRESUSCITATIONESUSCITATIONOF THE NEWBORNOF THE NEWBORN

Inverted Pyramid of Neonatal Inverted Pyramid of Neonatal ResuscitationResuscitation

Resuscitation of the NewbornResuscitation of the Newborn

Drying. Warming. Positioning.Suction. Tactile Stimulation.

Oxygen

Intubation

Medi-cations

Bag-Mask Ventilation

ChestCompressions

Stimulating the Newborn to BreatheStimulating the Newborn to Breathe

If shallow, slow, or absent:If shallow, slow, or absent:• Provide artificial ventilations,Provide artificial ventilations, 40 – 60/minute.40 – 60/minute.• Reassess after 30 seconds.Reassess after 30 seconds.• Continue as necessary.Continue as necessary.

Breathing EffortBreathing Effort

Heart RateHeart Rate If less thanIf less than 100 100/minute:/minute:

• Provide artificial ventilations,Provide artificial ventilations, 40 – 60/minute. 40 – 60/minute.• Reassess after 30 seconds.Reassess after 30 seconds.• If no improvement, continueIf no improvement, continue ventilations. ventilations.

(Continued)(Continued)

Heart RateHeart Rate If less thanIf less than 60–80/ 60–80/minute andminute and not responding to ventilation: not responding to ventilation:

• Start chest compressions at rate of Start chest compressions at rate of 120/min.120/min.

• Deliver compressions to the depth Deliver compressions to the depth of 1/3 to 1/2 the depth of the of 1/3 to 1/2 the depth of the patient’s chest.patient’s chest.

(Continued)(Continued)

Heart RateHeart Rate

If at any time the heart rate is lessIf at any time the heart rate is lessthanthan 60 60, begin ventilations and , begin ventilations and compressions immediately.compressions immediately.

ColorColor

If central (trunk) cyanosis isIf central (trunk) cyanosis ispresent with adequate breathingpresent with adequate breathingand heart rate, administer and heart rate, administer blow-by oxygen. blow-by oxygen.

Tell new EMT-Bs that it is not uncommon to find patients and family members very nervous. This will make the patient exam and decision making very difficult. The patient or her family may want to rush to the hospital, or they may feel that there just isn’t enough time. Encourage new EMT-Bs to carefully and objectively examine the patient and history as the basis for a transport decision. Assure the patient and family that you are equipped to evaluate the situation and handle delivery at home or in the ambulance.

PPRECEPTOR RECEPTOR PPEARLEARL

AABNORMALBNORMALDELIVERIESDELIVERIES

Abnormal Delivery: Prolapsed CordAbnormal Delivery: Prolapsed Cord

Patient Patient CARECARE

Prolapsed CordProlapsed Cord

Emergency Care StepsEmergency Care Steps

Complete patient assessment.Complete patient assessment. Give high-concentration oxygen.Give high-concentration oxygen. Position mother with hips elevatedPosition mother with hips elevated or head down. or head down.

(Continued)(Continued)

Patient Patient CARECARE

Prolapsed CordProlapsed Cord

Emergency Care StepsEmergency Care Steps

Insert sterile-gloved hand into Insert sterile-gloved hand into vagina,vagina, pushing the fetus away from the pushing the fetus away from the pulsating cord. pulsating cord. Transport rapidly.Transport rapidly.

Care for Prolapsed CordCare for Prolapsed Cord

AABNORMALBNORMALDELIVERY: BREECH DELIVERY: BREECH

PRESENTATIONPRESENTATION

Patient Patient ASSESSMENTASSESSMENT

Breech PresentationBreech Presentation

Signs and SymptomsSigns and Symptoms

Baby’s buttocks or lower extremitiesBaby’s buttocks or lower extremities presenting presenting Greater risk with prolapsed cordGreater risk with prolapsed cord

Patient Patient CARECARE

Breech PresentationBreech Presentation

Emergency Care StepsEmergency Care Steps

Place mother on oxygen.Place mother on oxygen. Transport immediately.Transport immediately. Place mother in head-down positionPlace mother in head-down position with hips elevated. with hips elevated.

Abnormal Delivery:Abnormal Delivery:Limb PresentationLimb Presentation

Patient Patient ASSESSMENTASSESSMENT

Limb PresentationLimb Presentation

Signs and SymptomsSigns and Symptoms

Baby’s limb protrudes fromBaby’s limb protrudes from birth canal. birth canal.

Patient Patient CARECARE

Limb PresentationLimb Presentation

Emergency Care StepsEmergency Care Steps

Transport immediately on recognition.Transport immediately on recognition. Place mother in head-down positionPlace mother in head-down position with hips elevated. with hips elevated. Place mother on oxygen.Place mother on oxygen.

Patient Patient ASSESSMENTASSESSMENT

MeconiumMeconium

Signs and SymptomsSigns and Symptoms

Green or brown amniotic fluidGreen or brown amniotic fluidindicates presence of fecal matter.indicates presence of fecal matter.

Suggests fetal distress during labor. Suggests fetal distress during labor.

Patient Patient CARECARE

MeconiumMeconium

Emergency Care StepsEmergency Care Steps

Do not stimulate before suctioning.Do not stimulate before suctioning. Suction.Suction. Maintain airway.Maintain airway. Ventilate if necessary.Ventilate if necessary. Transport as soon as possible.Transport as soon as possible.

CCOMPLICATIONSOMPLICATIONSOF CHILDBIRTHOF CHILDBIRTH

Complications ofComplications ofChildbirthChildbirth

MeconiumMeconium Multiple BirthsMultiple Births Premature BirthsPremature Births

Delivery procedure is theDelivery procedure is the same for each. same for each. Prepare for multiple Prepare for multiple resuscitations. resuscitations.

Call for assistance.Call for assistance.

Multiple BirthsMultiple Births

Always at risk of hypothermia.Always at risk of hypothermia.

Usually requires resuscitation.Usually requires resuscitation.• Should be performed unlessShould be performed unless physically impossible. physically impossible.

Premature BirthsPremature Births

GGYNECOLOGICALYNECOLOGICALEMERGENCIESEMERGENCIES

Complete patient assessment.Complete patient assessment. Base treatment on assessment.Base treatment on assessment. Apply external vaginal pads.Apply external vaginal pads. Transport.Transport.

Vaginal BleedingVaginal Bleeding(Late in Pregnancy)(Late in Pregnancy)

Treat like any soft-tissue injury.Treat like any soft-tissue injury. Never pack vagina.Never pack vagina. Administer oxygen.Administer oxygen. Perform ongoing assessment.Perform ongoing assessment.

Trauma–External GenitaliaTrauma–External Genitalia

Complete patient assessmentComplete patient assessment and care. and care. Maintain nonjudgmentalMaintain nonjudgmental attitude. attitude. Psychological care is required.Psychological care is required.

(Continued)(Continued)

Sexual AssaultSexual Assault

Preserve potential evidence.Preserve potential evidence. Discourage patient fromDiscourage patient from bathing, voiding. bathing, voiding. Fulfill reporting Fulfill reporting requirements. requirements.

Sexual AssaultSexual Assault

1. Describe how to deal with predelivery 1. Describe how to deal with predelivery emergencies. emergencies.

2. List three abnormal deliveries and how 2. List three abnormal deliveries and how they are handled in the field. they are handled in the field.

3. How should sexual assault be managed 3. How should sexual assault be managed in the field? in the field?

RREVIEW QUESTIONSEVIEW QUESTIONS