Limmer et al., Emergency Care, 11th Edition© 2009 by Pearson Education, Inc., Upper Saddle River, NJ

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PRESENTED BY:-Ms. DEEPTI DAMODARAN

REVIEW OF

Limmer et al., Emergency Care, 11th Edition© 2009 by Pearson Education, Inc., Upper Saddle River, NJ

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ANATOMY OF FEMALE REPRODUCTIVE SYSTEM

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Anatomy

Female reproductive system is divided

into:

External genitalia (vulva)Internal genitalia andAccessory reproductive organs

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PHYSIOLOGY (MENSTRUATION CYCLE)

• Length of menstrual cycle is 28 day• 14th day – Ovulation day

PHASES :- • Menstrual phase :- shedding of endometrium with

discharge through vagina. Release of FSH and low level of LH, ovarian estrogen secretion begins

• Proliferative phase:- endometrium regenrates and thickens in preparation for implantation. Single dominant follicle develops to mature follicle, decrease in FSH level (negative feedback), increase in LH (positive feedback), Ovulation occurs

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• Leutal phase:- begins after ovulation and is a relatively finite time period of about 12 to 14 days under LH secretion , Corpus leuteum is formed from ruptured follicle, release of progestrone and estrogen

Progestrone helps preparation of endometrium

If fertilization does not Corpus leuteum becomes non functional after 10 to 12 days after ovulation and menstruation returns

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EVENTS FOLLOWING FERTILIZATION

Process of fusion of spermatozoon with mature ovum which occurs in Ampulary part of fallopian tube

• MORULA: two cell stage 30 hrs after fertilization

• BLASTOCYST: It possesses an inner cell mass (ICM), or embryoblast, which subsequently forms the embryo, and an outer layer of cells, or trophoblast, surrounding the inner cell mass and a fluid-filled cavity known as the blastocoele 

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• Blastocyst formation begins at day 5 after fertilization 

• IMPLANTATION: occurs in endometrium between 10-11th day.

• TROPHOBLAST: placenta and fetal membrane develop from trophoblast

• DECIDUA: endometrium of the pregnant uterus

• CHORION: outermost layer of the two fetal membrane

• AMNION: inner layer of the fetal membrane

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Limmer et al., Emergency Care, 11th Edition© 2009 by Pearson Education, Inc., Upper Saddle River, NJ

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PLACENTA AND FETAL MEMBRANE

• Placenta is discoid in shape, with two surfaces

Maternal (rough and spongy) Foetal surface (covered by smooth and glistening

amnion with umbilical cord attached) Fetal blood flow through the placenta is 400 ml/mt Fetal membrane has two parts Amnion (inner

smooth layer) and Chorion (outer thick layer)

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UMBILICAL CORD (Funis)

• Wharton’s jelly:- a gelatinous substance within the umbilical cord

• There are 2 umbilical arteries (deoxygenated blood) and one umbilical vein (oxygenated blood)

• Length: 50cm

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PREGNANCY

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Stages of Pregnancy

1st trimester (first 12 weeks)– Fetus is being formed

2nd trimester (13-28 weeks)– Uterus grows rapidly, reaching the

umbilicus

3rd trimester (29-40 weeks)– Uterus now reaches the epigastrium

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LEVEL OF FUNDUS AT DIFFERENT

WEEKS

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EVENTS IN 1ST TRIMESTERSIGNS• Jacquemier’s / Chadwick’s sign:- dusky hue of

vestibule and ant. vaginal wall. (local vascular congestion)

• Vaginal / Osiander’s sign:- increased pulsation felt at laterla fornices (8th week)

• Cervical / Goodle’s sign:- marked softening of the cervix (6th week)

• Piskacek’s sign:- asymmetrical enlargement of uterus in case of lateral implantation

• Hegar’s sign:- upper part of uterus is enlarged with growing ovum and lower part is empty (6-10 weeks)

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EVENTS IN 2ND TRIMESTER

• Quickening :- feeling of fetal movement by mother (18 week, 2wks early in multiparae)

• Chloasma:- pigmentation over forehead and cheek (24th week)

• Linea nigra:- linear pigmented zone from symphysis pubis to ensiform cartilage

• Striae gravidarum:- (pink and white)• Braxton- Hicks contraction:- irregular, infrequent,

spasmodia and painless contraction without effect on dilatation of cervix

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EVENTS IN 3RD TRIMESTER

FUNDAL HEIGHT

Lightening :- at 38th week engagement of presenting part takes place in the pelvis which decreases the fundal height.

32 weeks:- level of ensiform cartilage

36-38 weeks:- engagement takes place at fundus comes down to 32 week level at 40 wks

Head floating: 32 wks

Head engaged: 40 weeks

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FETAL SKULL

SUTURES:-

• SAGITTAL – lies between two parietal bones

• CORONAL- run between parietal and frontal bone

• FRONTAL – lies between two frontal bones

• LAMBDOID- separate the occipital bone and two parietal bones

• ENGAGING DIAMETER OF FETUS:- Biparietal or Bitemporal diameter

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FETUS IN UTERO

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Types of Presentation

Cephalic– Normal, head-first birth

Breech-Buttocks or both feet deliver first

Face - mentum or chin presenting first

Brow - frontal bone or brow line

Shoulder – acromian process

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STAGES OF LABOUR

FIRST STAGE: onset of labour pain to full dilatation of cervix (12 hrs primi, 6 hrs multi)

SECOND STAGE: full dilatation of cervix to expulsion of fetus (2 hrs primi, 30 mts multi)

THIRD STAGE: expulsion of fetus to expulsion of placenta and membrane (15 mts)

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MECHANISM OF LABOURDIAMETER OF ENGAGEMENT:

Available transverse diameter

ENGAGEMENT DIAMETER OF HEAD: Suboccipito bregmatic (9.5 cm) / Suboccipito frontal (10 cm)

D Engagement

E

S Internal flexion

C

E Internal rotation of head and simultaneous rotation of shoulder

N

T Crowning

Delivery of head by extension

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D Restitution

E

S External rotation

C

E Delivery of shoulder and trunk by lateral flexion

N

T

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Post Delivery

Same level as mother

Wait for pulsating to stop

Clamp and cut umbilical cord

Note exact time of birth

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Cutting the Umbilical Cord

Infant warm

Sterile clamps or umbilical tape

1st clamp 10 inches

2nd clamp 7 inches

Cut between clamps

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SEPARATION OF PLACENTA

Methods of separation

SCHULTZE :- central separation

MATHEW-DUNCAN :- marginal separation

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Care of the Newly Born

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Care of the Newly Born

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Assessment—Newly Born

Breathing, heart rate, crying, movement, skin color

Pulse greater than 100 bpm

Vigorous crying

Moving extremities

Blue coloration hands and feet ONLY

Reassess after 5 minutes

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Resuscitation—Newly Born

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Respirations

Newborn should begin breathing within 30 secondsProvide only small puffs of air if using mouth to maskRate of 40 to 60 per minute Adequate respirations and a pulse rate greater than 100 per minute– Supplemental oxygen

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Heart Rate

Heart rate less than 100 beats per minute– Ventilate at a rate of 40 to 60 per minute

Heart rate is less than 60 beats per minute – Initiate chest compressions

Rate of 120 compressions per minute3:1 ratio of compressions to respirations90 compressions and 30 ventilations per minute

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NORMAL PUERPERIUM

LOCHIACOLOUR:

Lochia rubra- red ( 1- 4 days)

Lochia serosa- yellowish / pink/pale (5-9 days)

Lochia alba – pale white (10-15 days)

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HEAMORRHAGE IN PREGNANCY

ABORTION:- termination of preg before period of viability (28 wks)

TYPES:-THREATENED: process of abortion has

started but recovery is possibleINEVITABLE:- changes have progressed

to a stage that recovery is impossibleCOMPLETE:- product of conception

expelled en masse

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INCOMPLETE:- entire product of conception not expelled instead a part is left in uterine cavity

MISSED:- when fetus is dead and retained inside uterus for a viable period

SEPTIC :- associated with clinical evidence of infection of the uterus

CIRCLAGE OPERATION:- Shirodkar and McDonald surgery

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CHILDBIRTH COMPLICATIONS

Breech presentation

Prolapsed cord

Limb presentation

Multiple births

Premature birth

Meconium

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Most common abnormal delivery

Buttocks first or both legs first

Increased risk of prolapsed cord

Possible meconium staining

Breech Presentation

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BREECH PRESENTATION

• Frank breech (buttocks alone)

• Complete breech (buttocks ans feet)

• Footling breech (both feet)

• COMPLICATION:- cord prolapse

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Patient Care—Breech Presentation

Provide high-concentration oxygen.

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Prolapsed Cord

Position mother head down and buttocks raised.

Provide high-concentration oxygen.

Check for pulses and wrap cord.

Insert several fingers into vagina to push up on baby’s head.

Transport.

(cont.)

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Prolapsed Cord

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Limb Presentation

Limb protrudes from vagina

Commonly a foot or arm

Cannot be delivered in prehospital

Rapid transport

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Assessment—Limb Presentation

Look for crowning

Arm or leg

Arm and leg together

Shoulder and arm

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Patient Care—Limb Presentation

High-concentration oxygen

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Multiple Births

More than one baby born during single delivery

Twins not considered complication

Call for assistance.

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Patient Care—Multiple Births

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Premature Birth

Infant weighs < 5-1/2 lbs (2.5 kgs)

Born before 37th week

Assessment– Full term vs. premature– Head is larger

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Patient Care—Premature Birth

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Meconium

Results from fetus defecating

Sign of fetal or maternal distress

Assessment– Amniotic fluid greenish or brownish-

yellow– Risk for respiratory problems

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Patient Care—Meconium

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EMERGENCIES IN PREGNANCY

Ante partum hemorrhage

Rupture uterus

Ectopic Pregnancy

Seizures

Miscarriage and Abortion

Stillbirths

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Placenta Previa

Placenta is situated in the lower uterine segment

Painless bright red vaginal bleeding

TYPES:• Lateral • Marginal • Complete • Incomplete

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Abruptio Placentae

Premature separation of the placenta

Severe abdominal pain

Dark red bleeding

TYPES:-• Revealed• Concealed • Mixed

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Ruptured Uterus

As the uterus enlarges throughout pregnancy,

the uterine wall becomes extremely thin and is prone to spontaneous or traumatic rupture

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Signs and Symptoms

Main sign—profuse bleeding

Associated abdominal pain

Shock

Rapid heartbeat

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Patient Care—Excessive Bleeding

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Ectopic PregnancyNormal pregnancy—egg divides in the oviduct (fallopian tube)Ectopic pregnancy—egg implanted anywhere outside the uterine cavity Acute abdominal painVaginal bleedingRapid and weak pulse (later sign)Low blood pressure (a very late sign)Features of shock CULLEN’S SIGN : dark bluish discolouration around umbilicus (intraperitoneal bleeding)

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Ectopic Pregnancy

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Patient Care: Ectopic Pregnancy

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Seizures in Pregnancy

Pre eclampsia – Hypertension + proteinuria + oedema

after 20th week

Eclampsia– Preeclampsia superimposed by

convulsions or fits

Assessment– Elevated BP (above 140/90 mm of Hg)– Excessive weight gain (>1lb a week/ 0.45

kg)– Swelling of face and extremities– Headache

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Patient Care—Seizures

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Miscarriage and AbortionTermination of pregnancy before 28th week

Induced abortion- legal and illegal

TYPES: THREATENED (preg can be continued) INEVITABLE (impossible to continue preg) COMPLETE (product of conception expelled en

masse) INCOMPLETE ( product of conception expelled

in parts) MISSED (dead fetus retained In uterus for long

time) SEPTIC (evidence of infection of uterus)

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Signs and Symptoms

Cramping abdominal pains– Associated with 1st stage of labor

Bleeding– Moderate– Severe

Discharge – Tissue– Blood

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Patient Care—Miscarriage

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Stillbirths

Baby dies in the womb

Continue resuscitation

Records

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Patient Assessment—Stillbirth

Obvious blisters

Foul odor

Skin or tissue deterioration and discoloration

Softened head

Cardiac or pulmonary arrest

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Patient Care—Stillbirth

Obviously dead– No resuscitation

Pulmonary or cardiac arrest– Basic life support

Imminent death– Prepare to provide life support.

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Gynecological Emergencies

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MEDICAL PROBLEMS ASSOCIATED WITH

PREGNANCY

Anaemia

Diabetes

Hypertension

Heart disease

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ANAEMIA

• Hb level is 11gm/100ml or less (acc to WHO)

CLASSIFICATION• Mild (b/w 8 to 10 gm%)• Moderate (6.5 to less than 8 gm%)• Severe (< 6.5 gm%)

TREATMENT• Daily administration of oral iron ferrous sulphate

200 mg (containing 60 mg of element iron)• Along with 1mg Folic acid • Dietary supplementation

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Intravenous and Intramuscular iron therapy

• Iron dextran (imferon) which contains 50mg elemental iron in one millimeter

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DIABETES IN PREGNANCY

• Glucose travels across the placental membrane via facilitated diffusion

• Glucagon is present in the fetal circulation at 8 weeks of gestation

• FIRST TRIMESTER : Maternal fasting blood glucose level decreases slightly to approximately 75mg/ 100ml of blood because of the increased glucose supplied to the fetus

• SECOND TRIMESTER : Placental hormones (human placental lactogen,progesterone, estrogen) have a diabetogenic effect (producing diabetic-like state). HPL breaks down adipose tissue and release glycerol and fatty acid for the use of primary maternal fuel

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• Third trimester: Delivery of placenta brings about an abrupt drop in the levels of circulating placental hormones, insulinase, & cortisol

CRITERIA FOR DIAGNOSIS OF GESTATIONAL DIABETES MELLITUS

Criteria for diagnosis of GDM with 100gm of oral glucose

GTT: Venous plasma (mg/dl) TIME mg/dl Fasting 1 hour 2 hours 3 hours

95 mg/dl 180 mg/dl 155 mg/dl 140 mg/dl

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EFFECT OF DIABETES

MOTHER

• Abortion

• Preterm labour

• Pre-eclampsia

• Polyhydramnios

• Maternal distress

• Diabetic retinopathy

• KETOACIDOSIS

FETUS

• Fetal macrosomia

• Congenital malformation

• Birth trauma and perineal asphyxia

• Hyperbilirubinemia

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HYPERTENSION

Pre-eclampsia

• A pregnancy-induced hypertension

• ≥ 20 weeks gestation

• Previously normotensive

• ≥140/90 mmHg on at least two occasions

• + proteinuria ≥ 0.3g in 24h

• ± oedema

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Complications (fetal)

• IUGR

• Oligohydramnios

• Placental infarcts

• Placental abruption

• Uteroplacental insufficiency

• Prematurity

• PPH

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ECLAMPSIA

• Pre eclampsia superimposed by convulsions is called eclampsia

• Magnesium sulphate given IV by infusion pump to prevent or limit seizure

• Antihypertensive: methyldopa, hydralazine

• Monitor FHR

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HEART DISEASE IN PREGNANCY

• 50% have origin from rheumatic fever, congenital and mitral valve disorder

• Oxygen consumption increased 10% to 20%related to growing fetus

• Plasma level and blood volume increase

MANAGEMENT:- Give semi fowlers position Assisted birth / Cesarean delivery Monitor heart rate Monitor fetus for IUGR, preterm birth and hypoxia

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POST PARTUM HAEMORRHAGE

• Bleeding in excess of 500 ml following delivery is called PPH

TYPES:-

• Primary PPH - occurs in the third stage of labour. It is defined as a loss of blood from the genital tract within the first 24 hours after birth.  

• Secondary PPH - occurs 24h-12 weeks after birth (end of puerperium).