Obstetrics/GynecologyEmergency Medical Technician - Basic

Female Reproductive SystemUterusCervixVaginaUrinary BladderRectum

Female Reproductive SystemUterusVaginaFallopian tubeOvaryCervix

OB/Gyn AssessmentHistoryWhen was your last normal menstrual period (LNMP)?Abdominal pain? (location/quality)Vaginal bleeding/discharge?

OB/Gyn AssessmentHistoryIs there a possibility you might be pregnant?Missed period?N/VIncreased urinary frequencyBreast enlargementVaginal discharge

OB/Gyn AssessmentHistoryIf pregnant:Para = # of live birthsGravida = # of pregnancies-3 /+ 7 to estimate due dateSubtract 3 from the month of the LNMPAdd 7 to the date of the LNMPLNMP - 12/9/98Due date - 9/16/99

OB/Gyn Assessment Vital signsHypertensionHypotensionTilt test if blood loss is suspectedFocused examEdema (particularly of face, hands)

Gyn Emergencies

Ectopic PregnancyZygote implants in location other than uterine cavity95% are in Fallopian tube (tubal ectopic)Life threatening!

Ectopic PregnancySigns and SymptomsMissed period, other signs/symptoms of early pregnancyLight vaginal bleed (spotting) 6-8 weeks after LNMPAbdominal pain, may radiate to shoulderPositive tilt testOther signs/symptoms of hypovolemic shock

Ectopic PregnancySigns and SymptomsAbdominal pain may be absentSome patients may NOT miss periodSome patients may have NEGATIVE pregnancy tests

Ectopic PregnancyLower abdominal pain or unexplained hypovolemic shock in a woman of child-bearing ageequalsEctopic Pregnancy Until Proven Otherwise

Ectopic PregnancyManagement100% O2Supportive care for hypovolemic shockTransport immediately

Pelvic Inflammatory DiseaseAcute or chronic infectionInvolves Fallopian tubes, ovaries, uterus, peritoneumMost commonly caused by gonorrheaStaph, strep, coliform bacteria also cause infections

Pelvic Inflammatory DiseaseSigns and SymptomsLower abdominal painGradual onset over 2-3 days, beginning 1-2 weeks after last periodFever, chillsNausea, vomitingYellow-green vaginal dischargeWalks bent forward, holding abdomen

Pelvic Inflammatory DiseaseManagementHigh concentration O2Transport

Spontaneous AbortionMiscarriagePregnancy terminates before 20th weekUsually occurs in first trimester (first three months)

Spontaneous AbortionSigns and SymptomsVaginal bleedingCramping lower abdominal pain or pain in backPassage of fetal tissue

Spontaneous AbortionComplicationsIncomplete abortionHypovolemiaInfection, leading to sepsis

Spontaneous AbortionManagementHigh concentration O2Shock positionTransport any tissue to hospitalProvide emotional support

Pre-eclampsiaAcute hypertension after 24th week of gestation5-7% of pregnanciesMost often in first pregnanciesOther risk factors include young mothers, no prenatal care, multiple gestation, lower socioeconomic status

Pre-eclampsiaTriadHypertensionProteinuriaEdema

Pre-eclampsiaSign and SymptomsHypertensionSystolic > 140 mm HgDiastolic > 90mm HgOr either reading > 30 mmHg above patients normal BPEdema (particularly of hands, face) present early in day

Pre-eclampsiaSigns and SymptomsRapid weight gain>3lbs/wk in 2nd trimester>1lb/wk in 3rd trimesterDecreased urine outputHeadache, blurred visionNausea, vomitingEpigastric painPulmonary edema

Pre-eclampsiaComplicationsEclampsiaPremature separation of placentaCerebral hemorrhageRetinal damagePulmonary edemaLower birth weight infants

Pre-eclampsiaManagement100% O2Left lateral recumbent positionAvoid excessive stimulationReduce light in patient compartmentAvoid use of emergency lights, sirens

EclampsiaGravest form of pregnancy-induced hypertensionOccurs in less than 1% of pregnancies

EclampsiaSigns and SymptomsSigns, symptoms of pre-eclampsia plus: Grand mal seizures Coma

EclampsiaComplicationsSame as pre-eclampsiaMaternal mortality rate: 10%Fetal mortality rate: 25%

EclampsiaManagement100% O2; assist ventilations, as neededLeft lateral recumbent positionReduce lightManage like any major motor seizureEmergency transportConsider ALS intercept for anticonvulsant medication administration

EclampsiaAssess every pregnant patient forIncreased BPEdemaTake all reports of seizures in pregnant females seriously

Abruptio PlacentaePremature separation of placenta from uterusHigh risk groupsOlder pregnant patientsHypertensivesMultigravidas

Abruptio PlacentaeSigns and SymptomsMild to moderate vaginal bleedingContinuous, knife-like abdominal painRigid, tender uterusSigns, symptoms of hypovolemia

Abruptio PlacentaeThird Trimester Abdominal Pain equals Abruptio Placentae until proven otherwise

Abruptio PlacentaeHypovolemic shock out of proportion to visible bleeding equals Abruptio Placentae until proven otherwise

Abruptio PlacentaeManagement100% O2Left lateral recumbent positionSupportive care for hypovolemic shockRapid transport

Placenta Previa Implantation of placenta over cervical opening

Placenta PreviaSigns and SymptomsPainless, bright-red vaginal bleedingSoft, non-tender uterusSigns and symptoms of hypovolemia

Placenta PreviaManagement100% O2Left lateral recumbent positionSupportive care for hypovolemic shockNever perform a vaginal exam on a pt in the 3rd trimester with vaginal bleeding

Placenta PreviaA vaginal exam should NEVER be performed on a patient in the 3rd trimester with vaginal bleeding

Uterine RuptureCausesBlunt trauma to pregnant uterusProlonged labor against an obstructionLabor against weakened uterine wallOld Cesarian section scarGrand multiparous patients

Uterine RuptureSigns and SymptomsTearing abdominal painSevere hypovolemic shockFirm, rigid abdomenPossible palpation of fetal parts through abdominal wallVaginal bleeding may or may not be present

Uterine RuptureManagement100% O2Anticipate shockALS/helicopter intercept

Emergency Childbirth

Developing FetusPlacentaAmniotic Sac Bag of watersUmbilical cordFetus

Labor1st stage: Onset of contractions to dilation of cervix2nd stage: Complete dilation of cervix to delivery of baby3rd stage: Delivery of baby to delivery of placenta

Signs of Imminent DeliveryCrowningRupture of Amniotic SacNeed to bear downSensation of needing to move bowelsContractions1 to 2 minutes apartRegularLasting 45 to 60 seconds

DeliveryPlace gloved hand on presenting part to prevent explosive deliveryOn delivery of head, suction mouth then nose

DeliveryGently guide babys head down to deliver upper shoulder Gently guide babys head up to deliver lower shoulderGently assist with delivery of rest of baby; Do NOT pullNote time of delivery of baby

DeliveryControl slippery baby during deliverySupport head, shoulders, feetKeep head lower then feet to facilitate drainage of secretions from mouthDry baby Keep baby warm

DeliveryClamp, cut cordFirst clamp about 4 from babySecond clamp 2 further away from firstCut between clampsUse umbilical tape to control any bleeding from cord

DeliveryFlick babys feet, rub back to stimulateDo NOT shake infantDo NOT slap buttocksBlow by O2 if:Heart rate < 100Persistent central cyanosis presentResuscitate if necessary

DeliveryDeliver PlacentaPlace placenta in plastic bag and deliver to hospital to be examined for completenessIf placenta does not deliver within 10 minutes, transport

APGAR ScoreDeveloped by Virginia ApgarQuick evaluation of infants pulmonary, cardiovascular, neurological functionUseful in identifying infants needing resuscitation

APGAR ScoreDetermine at 1 and 5 minutes postpartum!

Maternal Care: PostpartumBleedingPlace sterile pad over vaginal openingIf bleeding is excessive:Rapidly transport to hospitalUterine massageEncourage breastfeeding

Maternal Care: PostpartumShockIf mother shows signs, symptoms of shock:High concentration O2Rapid transportALS intercept

Complicated Deliveries

Breech Presentation

Breech PresentationManagementHigh concentration O2Rapid transportPrepare for neonatal resuscitationAssist delivery

Breech PresentationManagementIf head does not deliver within 3 minutes of body:Insert gloved hand into vagina forming V around babys nose, mouth Push vaginal wall away from babys face to create airway

Limb Presentation

Limb PresentationManagementHigh concentration O2Rapid transport

Prolapsed CordUmbilical cord enters vagina before infants headPressure of head on cord occludes blood flow, O2 delivery to fetus

Prolapsed CordManagementHigh concentration O2Knee-chest position or exaggerated shock positionPlace gloved hand in vaginaApply gentle pressure inward to presenting part; relieve pressure on cord

Umbilical Cord around NeckManagementUpon delivery of head look for cord is looped around neckGENTLY slip cord over head if possibleIf cord cannot be slipped over head:Clamp in two placesCut between clamps with surgical scissors

Amniotic Sac IntactManagementUse clamp to tear sac, release fluidMove sac away from babys nose, mouth

MeconiumFirst stool of newbornMeconium-stained amniotic fluidBaby has had bowel movement in uteroGreenish, black (pea soup) colorIndicative of distress

MeconiumMeconium can:Occlude airwayCause pneumonitis

MeconiumManagement Avoid early stimulation of baby to prevent aspirationAggressively suction airway until all meconium is removed

Multiple Births

Multiple BirthsConsider as possibility if: Mothers abdomen appears abnormally large prior to deliveryMothers abdomen remains large after delivery of first babyContractions continue after delivery of first baby

Multiple BirthsDeliveryClamp cord of first baby before delivery of secondUsually second baby will deliver shortly after firstCare for babies, mother, and placenta(s) as you would in a single birth

Multiple BirthsMultiple babies are usually smallIt is important to keep them warm!

Premature InfantsDefinition< 28 weeks gestation, or< 5.5 pounds birth weight

Premature InfantsManagementKeep baby warmKeep airway clearAssist ventilations if necessaryResuscitate if necessaryWatch umbilical cord for bleedingBlow by O2Avoid contaminationConsider ALS intercept

Temple College EMS Professions