OB/GYN Emergencies for the EMT and Paramedic Presented for the East Cleveland Fire Department 23 SEP 04

The Prenatal Period Fetal development begins immediately after implantation The date of the expected delivery in known as the “estimated date of confinement” or EDC Sex determined…end of 3 months Fetal Heart Tones by 5 months can be detected with your stethoscope

Terminology Gravidity- the number of times a woman has been pregnant (also: primi-,multi-, and nulli-) Parity- the number of times a woman has deliver a viable fetus (also: primi-, multi-, and nulli-) EX: A pt who has been pregnant 5 times and has 3 children has a P and G of ?? ANSWER: P=5 G=3

Complications of Delivery Cephalopelvic Disproportion Abnormal Presentations Prolapsed Cord Shoulder Dystocia Postpartum Hemorrage Uterine Rupture Uterine Inversion

Cephalopelvic Disproportion Babies head is larger than the vaginal opening Occurs in 1 of ~500 Usually delivery will require a cesarean section Causes fetal distress IV, O2 Monitor

Abnormal Presentation Approx. 3% of births Positioning the mother Support versus pulling Spontaneous breathing Which way is the baby facing? Breech presentations Baby should be facing posterior and then rotate. But if baby if facing anterior or forward already, passage through the vagina will be delayed or impossible

Prolapsed Cord Compression cuts fetal circulation If seen in vagina, insert fingers to check for pulsation and remove pressure off cord Position, O2, IV, continue insertion, and moisten exposed cord

Shoulder Dystocia When shoulders are larger than its head Head delivers normal, but… Rest of body cannot deliver Have mother modify position Apply pressure, NOT TRACTION Occurs with diabetic and/or obese mothers and in postmature pregnancies Position to place mother: Buttocks off of bed. Thighs elevated and pressure above symphsis pubis Tends to cause nerve damage, Erb’s Paulsey? Much litigation concerning delivety techniques…lawyers!

Postpartum Hemorrage Defined as loss of 500mL over 24hr period Occurs in 5% of deliveries Placenta previa, abruptio placenae, and clotting disorders O2, IV, and fundal massage

Uterine Rupture Actual tearing of uterus Occurs mostly during labor or at onset ALSO OCCURS DURING TRAUMA Scar tissue in uterus from previous cesarians can causethis emergency Mgmnt: IV, O2, monitor fetal heart tones and treat for shock!

Pulmonary Embolism Usually occurs after pregnancy from blood clot or venous thromboembolism. Most common cause of maternal death! Occurs more frequently in cesarean than vaginal delivery S/S: very sudden SOB, sharp C/P, may show tachycardia, and hypotension Outcome is poor: support as necessary with IV, O2 and monitor frequently for changes Be aware of this in the field with new mothers after discharge

APGAR APGAR is an acronym for newborn assessment Appearance– Color Pulse– The heart rate of the newborn Grimace– also known as irritability Activity– How active is the neonate Respirations– Breathing rate (this one is important)

Appearance Score of zero is central cyanosis Score of one is pink body but blue extremities Score of two is pink all over.

Pulse Score of zero= no pulse Score of one= pulse rate < 100 Score of two= pulse rate > 100

Grimace Big purple guy who likes milk shakes Hang’n with Ronald McDonald Can I get a Big Mac?

Grimace (For real) Score of zero= No Response Score of one= mild irritability Score of two= vigorous irritability and crying

Activity Score of zero= limp Score of one= some flexion with agitation Score of two= active with good motion in extremities

Respirations Score of Zero= absent resps Score of One= slow and irregular or ineffective Score of Two= crying, rhythmic and effective

When DO you do it!!??!! APGAR is obtained after the first minute and after five minutes. It is taken at this time because of two reasons: 1) to document “trend” 2) because someone smarter than us said so

Inverted Pyramid This is a diagram for the priorities of resuscitation, stemming from the most frequently used care to the less often used interventions.

So When do I Transport? Transport priorities depend largely upon your findings from these assessment tools. It is situational dependant. Lower APGAR scores indicate the need for higher transport priority. Remember the golden rule: Air goes in and out, blood goes ‘round and ‘round, and blue is called “not too good”. Anything different is a bad thing!

This concludes the presentation Are there any questions, concerns, gripes, or complaints?