OBSTETRICS AND GYNECOLOGY

Lesson Objective: Indicate procedures for emergency (pre -hospital) childbirth.

OVERVIEW Anatomy Review Beginning of Labor Predelivery Emergencies Preparing for Delivery Delivering the Baby

OVERVIEW cont. Postdelivery Care Resuscitation of the Newborn Abnormal Deliveries & Complications Gynecologic Emergencies

Anatomy Review Fetus Uterus Placenta Umbilical Cord Amniotic Sac Cervix

The Beginning of Labor First Stage - begins with 1st contraction and ends when the cervix is fully dilated.

The Beginning of Labor Second Stage - time cervix is fully dilated, until baby is born

The Beginning of Labor Third Stage - birth of baby, until after delivery of placenta

Other Signs Bloody show Rupture of the amniotic sac

Predelivery Emergencies Miscarriage Seizures Vaginal Bleeding Trauma

Miscarriage Delivery of fetus & placenta before 20 weeks Danger - bleeding & infection

TX Initial assessment History & physical exam Ask if she is pregnant Ask date of last cycle

TX Apply external vaginal pads Collect tissues Transport

Seizures Eclampsia - related to high blood pressure

TX Initial assessment HX & vitals Transport on left side Monitor airway & give O2 Transport

Vaginal Bleeding Early pregnancy Later stages of pregnancy Placenta abruptio - placenta separates prematurely Placenta previa - placenta develops over & covers the mouth of the uterus

TX BSI Initial assessment History and physical exam Ask patient if she has any pain.

TX Transport on left side Sterile pad or sanitary napkin Save any tissue Transport

Trauma Severe bleeding Injury to fetus

TX Initial assessment O2 Place on left side Control external bleeding Transport

Preparing for Delivery Assessing the need for emergency delivery First decision - whether or not you have time to transport?

Decision based on three factors: Is the delivery expected within few minutes? Are you pregnant? How long have you been pregnant?

Is this your first baby? Are you having contractions or pain? How many minutes apart are your contractions? Are you bleeding?

Have you had any kind of discharge? Did your water break? Do you feel like you need to push? Move your bowels? Is crowning occurring?

Assessing the need for emergency delivery Hospital cannot be reached due to a natural disaster, weather, or traffic conditions No transportation is available

Equipment Surgical scissors-1 pair Hemostats or cord clamps-3 Umbilical tape/sterile cord Small rubber bulb syringe Towels-5

Equipment 1 dozen 2” x 10” gauze sponges Rubber gloves Baby blanket-1 Sanitary napkins Plastic bag

Delivering The Baby Position and support Flat, sturdy surface Lie with knees drawn up and spread apart Elevate buttocks with blankets

Position and support Create sterile field One towel under buttocks One between her legs One across her abdomen Partner at head Reassure/comfort Assist airway

Delivering the Head Place fingers on bony part of skull If amniotic sac does not break, or has not broken: Use clamp to puncture Push away from nose and mouth

Delivering the Head Umbilical cord around neck? Slip over shoulder Clamp and cut it

Delivering the Body Support head and body Grasp feet Support with both hands Baby will be slippery Do not squeeze neck or chest

Post Delivery Care Initial care of baby Set baby down Same level or lower than birth canal On side with head slightly lower than body Continue to aspirate

Initial care of the baby Wrap in blanket Warm prior if possible Leave only face expose If not breathing, perform CPR

Cutting the Umbilical cord Clamp with two clamps Four fingers width from the baby Place clamps two to six inches apart Cut between clamps Tie cord off 1” closer to navel from clamp Umbilical tape (square knot)

Apgar score 1 and 5 minutes Healthy baby will score 10 Five areas

APGAR Appearance - pink shortly after birth Pulse- greater than 100/min Grimace - crying, or withdrawing in response to stimuli Activity - resistance or muscle tone when attempts are made to straighten legs Respirations - regular and rapid

Delivery of Placenta Normal Delivery Within a few minutes of baby’s birth Usually less than 250 ml blood loss Record delivery time Take to hospital

Delivery of Placenta Provide prompt transport If not delivered within 30 minutes 250ml of bleeding occurs before delivery of placenta Significant bleeding occurs after delivery of placenta Do not pull cord!

Resuscitation of Newborn Assessing the baby Respirations Pulse Artificial Ventilation Use BVM 40- 60 breaths per minute

Resuscitation of Newborn Chest compressions Heart rate is < 60 bpm, or between 60- 80 bpm and not rising Both thumbs on middle third of the sternum or one thumb over the other

Prolapsed umbilical cord Abnormal Deliveries Prolapsed umbilical cord Cord comes out before baby Do not replace! Danger: Decreased O2 to the baby

TX Place mother with legs and buttocks elevated Exert gentle counter pressure with gloved hand Wrap moistened sterile towel around cord

TX Oxygen Keep warm Transport

Breech Delivery Presenting part - buttocks or feet Treatment Position and drape mother Allow buttocks and feet to deliver Support legs and trunk

TX Head usually delivers on its own If not within 3 minutes of buttocks and trunk, do not pull! Cup hand over baby’s face/mouth (MOA) and transport Head delivers- procedures the same

Limb Presentation Presenting part single arm, leg, or foot Cannot successfully deliver in the field

TX Give mother O2 Place mother on back, head lower than pelvis Cover with sterile towel Transport

Multiple Births 1st baby is small Abdomen still large Contractions about 10 minutes after first baby

TX Cut cord on first baby Follow normal delivery procedures May be considered premature

Premature Infants Premature - born before 8th month or weighing less than 5 1/2 lbs. Judge weight Thinner, smaller, redder than full term Head larger

5 important steps in management Keep warm 90-95 degrees F Place in special carrier Keep mouth, nose, and throat clear Make sure cord not bleeding Apply additional clamps or ties Slightest bleeding serious

5 important steps in management Increase O2 in enviroment Make tent over head Aim O2 at top of tent Do not administer directly Avoid infection Use sterile equipment Avoid unnecessary handling

Gynecologic Emergencies Trauma to external genetalia Treat as other bleeding and soft tissue injuries O2 Never pack vagina Transport

Alleged Sexual Assault and Rape Patient may refuse assistance

TX BSI Airway Nonjudgmental attitude during SAMPLE Crime scene protection

TX Examine genitalia only if profuse bleeding Use same sex EMT-B’s if possible Discourage bathing, voiding, or cleaning wounds

SUMMARY Anatomy Review Beginning of Labor Predelivery Emergencies Preparing for Delivery Post Delivery Care Resuscitation of the Newborn

SUMMARY Abnormal Deliveries Multiple Births Premature Infants Gynecologic Emergencies

Questions