Obstetric & Gynecological Emergencies

8/3/2019 Obstetric & Gynecological Emergencies

1/79

1

Obstetric and GynecologicalEmergencies


2/79

2

Anatomy of Pregnancy

Fetus

Uterus

Cervix Bloody show

Placenta

Afterbirth

Umbilical cord

Amniotic sac

Vagina


3/79

3

Fetus The developing baby during pregnancy

Full-term pregnancy last approximately 280 days

or39 to 40 weeks from day of last normalmenstrual cycle

9 calendar months

9

months divided into3

-3

month trimesters EDC (estimated date of confinement)

Approximate date of birth

Based on date of mothers last menstrual period


4/79

4

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


5/79

5

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


6/79

6

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


7/79

7

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


8/79

8

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


9/79

9

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 withdilation of cervix


10/79

10

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


11/79

11

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


12/79

12

Braxton-Hicks Contractions False labor

Caused by changes in uterus as it adjusts in

size and shape

Can happen any time during pregnancy


13/79

13

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 thisstage

1st child, stage can average 18 hours or more


14/79

14

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


15/79

15

Third Stage of Labor Delivery of placenta or afterbirth

Placenta separates from uterine wall and is

expelled


16/79

16

Predelivery Emergencies


17/79

17

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)


18/79

18

Signs and Symptoms/ Treatment Vertigo

Possible syncope

Drop in blood pressure

AssessA,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


19/79

19

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


20/79

20

InducedAbortion

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


21/79

21

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.


22/79

22

Self Induced/Non Medical Abortions

Pain is much greater

Bleeding usually more severe

May be high fever from infection


23/79

23

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


24/79

24

Note: Use the term miscarriage when speaking

with family or where bystanders can hear

you. Most people associate spontaneousabortion with self-induced abortion.


25/79

25

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


26/79

26

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


27/79

27

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


28/79

28

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


29/79

29

Active Labor & Normal Delivery


30/79

30

Assessment

Same as for any predelivery emergency

Transport unless delivery is expected within

a few minutes


31/79

31

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?


32/79

32

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


33/79

33

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


34/79

34

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


35/79

35

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


36/79

36

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'sskull when it crowns

Puncture amniotic sac if not already broken


37/79

37

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

Emergency Care Cont...


38/79

38

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



39/79

39

Place placenta in towel and plastic bag

Place 1 or2 sanitary napkins over vaginal

opening Record time of delivery and transport

500cc normal blood loss

Excessive blood loss appears Provide big Os

Massage uterus



40/79

40

Active Labor with Abnormal

Delivery


41/79

41

A

ssessment Perform all assessments as with any other

delivery emergency


42/79

42

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


43/79

43

General Emergency Care Immediate transport

Big Os

Continuous monitoring of vital signs


44/79


45/79

45

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


46/79

46

Breech Birth Involves buttocks or both feet first

Can involve limb presentations


47/79

47

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


48/79

48

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 or2nd


49/79

49

Meconium Staining

Indication of fetal distress during labor

Passing of bowel movement

Amniotic fluid is a greenish or brownish-yellow incolor

Suction the infants mouth and nose as soon as the

head emerges

Do not stimulate breathing before suctioning


50/79

50

Premature Birth

Infant weighing less than 5pounds 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


51/79

51

Newborn Infant

Assessment


52/79

52

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


53/79

53

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.


54/79

54

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 pink2 points


55/79

55

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


56/79

56

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


57/79

57

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


58/79

58

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 infantsback in a circular motion


59/79

59

Signs & Symptoms Severely Depressed Newborn

Respiratory rate over60 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


60/79

60

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 to80 with no increase, begin CPR

Follow AHA guidelines


61/79

6

1

Dry, Warm, Position, Suction, Tactile Stimuli

Oxygen

Bag-Valve-MaskVentilation

Chest Compressions

Medications

Inverted Pyramid Neonatal Resuscitation


62/79

62

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


63/79

63

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


64/79

64

Emergency Care

Big Os

Control bleeding

Treat for shock

Immediate transport


65/79

65

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


66/79

66

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


67/79

67

Emergency Care

Big Os

Control bleeding (if necessary)

Treat for shock

Immediate transport


68/79

68

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


69/79

69

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


70/79

70

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


71/79

71

Emergency Care

Big Os

Suction (if necessary)

If seizure begins, positive pressure ventilation

Transport in a calm and quiet manner as possible


72/79

72

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 over50%

Requires immediate surgery


73/79

73

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


74/79

74

Emergency Care

Big Os

Control bleeding

Treat for shock

Immediate transport


75/79

75

Ectopic Pregnancy

Implantation of a fertilized egg outside the

uterus

Leading cause of maternal death in the firsttrimester

Any female of childbearing age with acute

abdominal pain is said to have an ectopicpregnancy until proven otherwise


76/79

76

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


77/79

77

Emergency Care

Big Os

Treat for shock

Constantly reassess vital signs

Immediate transport


78/79

78

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


79/79

Emergency Care

Never lie to parents

Allow mother to see baby if she wants to

Baptize the baby if asked

Document time if death

Obstetric & Gynecological Emergencies

Documents

Transcript of Obstetric & Gynecological Emergencies