1. OBSTETRICS AND GYNECOLOGY

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

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

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

6. Anatomy Review Fetus Uterus Placenta Umbilical Cord Amniotic Sac
Cervix

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

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

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

10. Other Signs
Bloody show
Rupture of the amniotic sac

11. Predelivery Emergencies
Miscarriage
Seizures
Vaginal Bleeding
Trauma

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

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

14. TX
Apply external vaginal pads
Collect tissues
Transport

15. Seizures
Eclampsia - related to high blood pressure

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

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

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

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

20. Trauma
Severe bleeding
Injury to fetus

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

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

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

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

26. 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?

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

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

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

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

31. 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

32. 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

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

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

35. 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

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

37. 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)

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

39. 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

40. 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

41. 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!

42. Resuscitation of Newborn
Assessing the baby
Respirations
Pulse
Artificial Ventilation
Use BVM
breaths per minute

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

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

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

46. TX
Oxygen
Keep warm
Transport

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

48. 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

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

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

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

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

53. 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

54. 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

55. 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

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

57. Alleged Sexual Assault and Rape
Patient may refuse assistance

58. TX BSI Airway Nonjudgmental attitude during SAMPLE
Crime scene protection

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

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

61. SUMMARY Abnormal Deliveries Multiple Births Premature Infants
Gynecologic Emergencies

62. Questions