OB/GYN Emergencies.

OB/GYN Emergencies

Course Objectives Identify the key aspects of evaluating a pregnant patient to determine if birth is imminent. Identify the purpose and use of tools in an OB kit. Identify the steps for normal delivery of an infant including how and when to cut an umbilical cord. Identify the steps for post-delivery care of the newborn and mother including delivery of the placenta. Identify the critical treatment interventions for complications of pregnancy including: breech (buttocks) or two limb presentation, shoulder dystocia, prolapsed cord, and postpartum bleeding. Identify steps for assessing an infant’s APGAR score. Identify steps for neonatal resuscitation Identify signs/symptoms and proper care for gynecological emergencies.

Terms Abruptio placenta — This condition occurs when the placenta prematurely separates from the uterine wall causing heavy internal bleeding and pain; it can occur as a result of trauma. Bloody show — Mucous and blood that comes from the vagina as the first stage of labor begins. The cervix is sealed by a plug of mucus during pregnancy to prevent contamination. When the cervix dilates, the plug is expelled as pink-tinged mucous. Crowning — The bulging out of the vaginal opening caused by the baby’s head pressing against it. Dilation — To get larger or enlarge. The degree of dilation of the cervix is often a key indicator used by midwives and physicians to determine if birth is imminent. However, EMTs do not perform this test. The process occurs over a period of several hours in some women, but can take much longer. Eclampsia (toxemia) — A serious condition that can develop in the third trimester. It is characterized by high blood pressure and excessive swelling in the extremities and face. Life-threatening seizures differentiate eclampsia from preeclampsia.

Terms, continued Ectopic pregnancy — Condition where a fertilized egg implants outside the uterus, often in the fallopian tubes. Symptoms can include abdominal pain and vaginal bleeding. Meconium — A dark-green fecal material found in the intestines of full-term babies. Ordinarily, the meconium is passed after a baby is born. In some cases, the meconium is expelled into the amniotic fluid prior to birth. It gives the fluid a greenish-brown color known as meconium staining. Placenta previa — A condition where the placenta sits low in the uterus blocking the cervix. It can present with painless, bright red bleeding. Postpartum — A term used to describe the period shortly after childbirth.

Terms, continued Preeclampsia — A condition found in pregnant women characterized by high blood pressure, abnormal weight gain, edema, headache, protein in the urine, and epigastric pain. If untreated, preeclampsia can progress to eclampsia. Supine hypotensive syndrome — A pregnancy-related condition where the weight of an unborn fetus and the uterus puts pressure on the inferior vena cava. The result is inadequate venous blood return to the heart, reduced cardiac output, and lowered blood pressure.

Female Anatomy - Reproductive Organs
Cervix – opening of the uterus First stage of birth, cervix opens & thins Allows fetus to move into vagina Opening process called dilation Endometrium – inner lining of uterus Each month built up in anticipation of implantation of fertilized egg If fertilization does not occur, lining simply sloughs off Referred to as menstrual period Fallopian tubes – long slender passageways connect uterus to ovary Female egg (ovum) passes through structure on its way to uterus for implantation to uterine wall Ovaries – two almond-sized glands located on each side of uterus behind & below fallopian tubes Produce estrogen & progesterone in response to follicle stimulation hormone (FSH) & luteinizing hormone (LH) secreted from pituitary gland

Female Anatomy - Reproductive Organs
Perineum – area between vaginal opening & anus It sometimes is torn during birth which causes bleeding Uterus – pear-shaped, muscular organ holds fetus during pregnancy Contracts to push fetus through cervix & into vagina during birth Vagina – flexible, muscular tube about three inches long Called birth canal Fetus moves from uterus through cervix into vagina & then out of mother’s body

Fetal Anatomy Placenta – develops early in pregnancy & performs important functions Exchanges respiratory gases Transports nutrients from mother to fetus Excretes waste Transfers heat Active endocrine gland produces several important hormones Attached by umbilical cord Vein - transports oxygenated blood toward fetus Artery – return deoxygenated blood to placenta Amniotic sac – develops early in pregnancy Consists of membranes to surround & protect developing fetus Fills with amniotic fluid which cushions fetus & provides stable environment Umbilical cord – attaches fetus to placenta Contains one vein & two arteries Vessels in umbilical cord similar to pulmonary circulation Arteries carry deoxygenated blood Veins carry oxygenated blood Umbilical cord is about two feet long

Fetal Anatomy

Emergency Childbirth Normal Delivery
Orthostatic hypotension is a sudden fall in blood pressure that occurs when a person moves to an upright position. It is generally related to hypovolemia and caused by blood loss, diuretics, vasodilators or dehydration. To assess for orthostatic hypotension you should perform a postural vital signs check. Consider performing this check in patients who complain of abdominal pain with associated light-headedness or with the possibility of volume depletion including: Suspected GI bleeding or internal hemorrhage Generalized weakness Dizziness, light-headedness or fainting Prolonged vomiting or diarrhea

Signs of Imminent Delivery
Main task in evaluating expectant mother is to determine if delivery is imminent Expose abdomen & genital area, taking care to be discrete Visually inspect the abdominal & vaginal areas for bleeding or crowning Prepare for immediate delivery if observe any of the following: Crowning Contractions less than 2 minutes apart Feeling of rectal fullness Feeling of imminent delivery

Crowning Crowning – appearance of any part of fetus in mother’s vagina
Remove enough of mother’s clothing to view genital region Look for bulging at vaginal opening or a presenting part of infant Crowning

Contraction Intervals
Occur at regular intervals ranging from 30 minutes to 2 minutes or less Labor pain from contractions lasts from 30 seconds to 1 minute As birth approaches, interval between contractions gets shorter Contractions that occur within 2 minutes of each other, from end of one to beginning of next, signify imminent delivery Consider transporting mother if baby does not deliver after 20 minutes of contractions 2 to 3 minutes apart Labor is generally prolonged for mother’s first baby Average is 12 to 17 hours which allows plenty of time for transport

Feeling of Rectal Fullness
Feeling of rectal fullness or sensation of having to move one’s bowels can indicate infant’s head is in vagina & pressing against the rectum Delivery is imminent Do not let the mother sit on the toilet

Feeling of Imminent Delivery
Mothers who have previously given birth often know when ready to deliver Labor tends to be shorter after first child Use your judgment given circumstances Consider transport time

Preparing for Delivery
Request a paramedic unit Don sterile gloves, gown, and eye protection Position mother on her back, legs drawn up Provide supplemental oxygen Prepare OB kit Prepare infant BVM Emergency delivery kit

Preparing for Delivery
Presentations You Can’t Deliver in the Field Single limb Prolapsed cord Presentations You Can Deliver in the Field Head first (normal cephalic) Umbilical cord around the neck (Nuchal Cord) Shoulder dystocia Buttocks first (Frank Breech) Double footling

Assisting With Delivery
Support head with gentle pressure Check if cord is wrapped around baby’s neck— attempt to loosen Apply gentle downward pressure on shoulder & head After anterior shoulder has delivered, apply gentle upward pressure Suction mouth (no more than 1 inch into) & nostrils (no more than ½ inch into each) when head appears Once delivered, stimulate infant if it does not breathe After the umbilical cord stops pulsating put two clamps on cord 6 inches from navel & cut between the clamps Suction mouth & nostrils Delivery anterior shoulder Delivery posterior shoulder

Amniotic Sac During first stage of labor amniotic sac usually breaks, expelling amniotic fluid If sac is still covering infant’s head when head appears, use a finger to rupture sac Note color & character of amniotic fluid Fluid can be clear or straw-colored (which is normal) Tainted & discolored, or thick & “pea soup-like” (which indicates meconium staining)

Detailed Delivery Instructions
Encourage the mother to breath deeply between contractions and push with contractions. As the baby crowns, support with gentle pressure over perineum to avoid an explosive birth. If the amniotic sac is still intact, rupture it with a finger to allow amniotic fluid to leak out. As soon as the baby’s head appears, suction mouth & nostrils with a bulb syringe – squeeze air from syringe before inserting, insert syringe no more than 1 inch into mouth, no more than ½ inch into each nostril. If the umbilical cord is wrapped around the baby’s neck, gently slip it over the head. Do not force it! If the cord is too tight to slip over the head, apply umbilical cord clamps and cut the cord. Clamp and cut the umbilical cord only if he baby’s head has emerged and is in a position that lows you to manage the airway.

Encourage the mother to push. Support the baby’s head as it delivers. To assist in delivery of the anterior shoulder, apply gentle downward pressure on the shoulder and head. As soon as the anterior shoulder has delivered, apply gentle upward pressure to assist in the delivery of the posterior shoulder. Once both shoulders have delivered, be ready for the remainder of the body to deliver quickly. Newborn babies are slippery so handle carefully. Stimulate the newborn to breathe by tapping the feet, if necessary. Once pulsations have stopped, clamp the cord by placing a clamp approximately 6 inches from the baby. Place a second clamp approximately 2 inches from the first, then cut the cord between the clamps.

Re-suction the baby’s mouth & nostrils only if baby not breathing or having respiratory distress Dry & wrap baby in a warm blanket — cover its head Place baby on its side to facilitate drainage Perform an APGAR assessment at 1 minute & 5 minutes after delivery

Newborn Care Orthostatic hypotension is a sudden fall in blood pressure that occurs when a person moves to an upright position. It is generally related to hypovolemia and caused by blood loss, diuretics, vasodilators or dehydration. To assess for orthostatic hypotension you should perform a postural vital signs check. Consider performing this check in patients who complain of abdominal pain with associated light-headedness or with the possibility of volume depletion including: Suspected GI bleeding or internal hemorrhage Generalized weakness Dizziness, light-headedness or fainting Prolonged vomiting or diarrhea

Care of the Infant If not breathing – stimulate it by rubbing its back or tapping your fingers on soles of its feet If newborn does not start breathing effectively within 10 – 15 seconds of stimulation, use infant BVM to deliver gentle puffs of air — enough to cause the chest to rise If after 30 seconds of assisted ventilation there is no response & heart rate is less than 60 beats/min, begin CPR

Care of the Infant Keep newborn warm by drying it & then wrapping it in warmed blankets After cord is clamped & cut, cover head Be careful because a wet baby is very slippery Repeat suctioning of nose & mouth, if needed Remember to check APGAR score at 1 & 5 minutes

Meconium Staining If signs of meconium are present, do not stimulate infant before suctioning mouth & nose This avoids aspiration of fecal material that can cause pneumonia

APGAR APGAR stands for: Appearance Pulse Grimace Activity Respirations
APGAR scale – numerical measure of baby’s overall condition immediately after birth Perfectly healthy baby will have total score of 10 Many babies score 7 to 8 during first minute By 5 minutes, most babies score 8 to 10 on scale APGAR stands for: Appearance Pulse Grimace Activity Respirations

APGAR Scale Scale Score Sign 1 2 1 min 5 min Appearance Pulse Grimace
1 2 1 min 5 min Appearance (color of skin, nailbeds, or lips) Blue, pale Body pink, extremities blue Completely pink Pulse Absent <100 >100 Grimace (reflex, irritability) No response Grimaces Cries Activity (muscle tone) Limp Some flexion of extermities Active motion Respirations Slow & irregular Strong crying Total

Managing a Poor APGAR Score (PSS)
Three things to remember when managing infant with low APGAR score: position, suction and stimulate (PSS) Position body so head is down & airway is open Suction mucous & fluid from mouth & nostrils Stimulate infant by taping bottoms of feet PSS – memory aid to help recall these steps — position, suction and stimulate

Neonatal Resuscitation

Neonatal Resuscitation
After delivery, if infant not breathing effectively after 10 to 15 seconds of stimulation, begin assisted respirations Use infant BVM with high-flow oxygen at a rate of 40 to 60 breaths/min If pulse rate falls below 60 beats/min, start compressions & ventilations at ratio of 3:1 at 120 events/min (which is 90 compressions & 30 ventilations) Remember, ventilation is the most important action in neonatal resuscitation

CPR - Two-Thumb Encircling Hands Technique (2 Rescuer CPR)
CPR technique for infant with pulse rate below 60 beats/min Place infant on a firm, flat surface Remove clothing from chest Find compression site which is just below nipple line on middle or lower third of sternum Wrap your hands around upper abdomen with your thumbs on compression site Use your thumbs to deliver gentle pressure against sternum, pressing ½ to ¾ inch into chest

Care of the Mother Orthostatic hypotension is a sudden fall in blood pressure that occurs when a person moves to an upright position. It is generally related to hypovolemia and caused by blood loss, diuretics, vasodilators or dehydration. To assess for orthostatic hypotension you should perform a postural vital signs check. Consider performing this check in patients who complain of abdominal pain with associated light-headedness or with the possibility of volume depletion including: Suspected GI bleeding or internal hemorrhage Generalized weakness Dizziness, light-headedness or fainting Prolonged vomiting or diarrhea

Care of the Mother Once baby delivered & umbilical cord cut & clamped you should: Monitor and control bleeding from mother Begin fundal massage Monitor vital signs Keep the mother and baby warm Transport once infant is delivered Do not wait for placenta—may take up to 30 minutes to deliver Do not pull on umbilical cord If placenta does deliver at scene, transport with mother & baby to hospital

Monitor and Control Bleeding
After placenta delivered, place sanitary napkin between mother’s legs Ask her to hold legs together Normal for mother to bleed up to one cup (about 250 cc) or 5 sanitary napkins of blood after delivery Record number of pads

Postpartum Bleeding Important steps in caring for postpartum bleeding include: Fundal massage Treat for shock Do not force delivery of placenta Place sanitary napkin at opening of vagina Fundal massage

Fundal Massage Makes uterus contract & diminishes vaginal bleeding
Can feel for fundus of uterus, located in abdomen between pubic bone & umbilicus Should feel like a softball Perform massage like you would a firm muscle massage Area may be tender & massaging it can cause discomfort Video demonstration available at EMS Online:

Abnormal Delivery Delivery with Complications
(Can be delivered in the field) Orthostatic hypotension is a sudden fall in blood pressure that occurs when a person moves to an upright position. It is generally related to hypovolemia and caused by blood loss, diuretics, vasodilators or dehydration. To assess for orthostatic hypotension you should perform a postural vital signs check. Consider performing this check in patients who complain of abdominal pain with associated light-headedness or with the possibility of volume depletion including: Suspected GI bleeding or internal hemorrhage Generalized weakness Dizziness, light-headedness or fainting Prolonged vomiting or diarrhea

Nuchal Cord (Umbilical Cord Around Neck)
Once head delivered ask mother to stop pushing so you can check if cord is wrapped around infant’s neck If cord looks like it is wrapped tightly, so as to constrict airway, need to loosen it Gently slip cord over baby’s head by placing two fingers under cord at back of neck Bring cord over shoulders & head Cord is durable but it can tear if handled roughly so don’t use excessive force If too tight to loosen, clamp cord in two places two inches apart and cut cord between clamps Unwrap cord from around neck & take care not to injure baby Video demonstration available at EMS Online:

Shoulder Dystocia Labor progresses normally & head delivered routinely however, immediately after head delivers, shoulders become trapped between symphysis pubis & sacrum, preventing further delivery First step in treating shoulder dystocia is recognizing when it occurs Two main signs of shoulder dystocia are: Baby’s body does not emerge with standard moderate traction & maternal pushing after delivery of baby’s head “Turtle Sign” –head suddenly retracts back against mother’s perineum after it emerges from vagina

Shoulder Dystocia Do’s & Don’ts of McRoberts Maneuver Do Do Not
Pull knees backwards (towards patient’s ears) & out to side to rotate & open the pelvis Use suprapubic pressure to release the shoulder from behind pelvis Do Not Do not pull forcefully on baby’s head Absolutely, no fundal pressure Video demonstration available at EMS Online:

Buttocks & Double Footling Presentation
If buttocks or two feet present first, you can attempt delivery in field These are generally slow deliveries & you likely have time to transport Key points are: Request paramedic unit Position mother with buttocks at edge of bed Hold mother’s legs in flexed position Support infant’s legs — do not pull As head passes pubis, apply gentle upward traction until mouth appears If head is stuck, create airway by pushing away vaginal wall — transport immediately

If Head Does Not Deliver
Create airway for infant First, place gloved hand into vagina with your palm towards infant’s face Form a “V” with index & middle finger on either side of infant’s nose Push vaginal wall away from infant’s face to allow unrestricted breathing Maintain airway & transport immediately

Abnormal Delivery Delivery with Complications
(Cannot be delivered in the field) Orthostatic hypotension is a sudden fall in blood pressure that occurs when a person moves to an upright position. It is generally related to hypovolemia and caused by blood loss, diuretics, vasodilators or dehydration. To assess for orthostatic hypotension you should perform a postural vital signs check. Consider performing this check in patients who complain of abdominal pain with associated light-headedness or with the possibility of volume depletion including: Suspected GI bleeding or internal hemorrhage Generalized weakness Dizziness, light-headedness or fainting Prolonged vomiting or diarrhea

Single Limb Presentation
Key points of assisting with single limb presentation include: Support baby with your hands Provide airway for baby using your fingers Transport immediately — do not attempt delivery in field

Prolapsed Cord If you see umbilical cord in vagina, presenting before the baby, initiate the following steps: 1. Request a paramedic unit 2. Place mother in knee-chest position 3. Check umbilical cord for pulsations 4. No pulsations - press presenting part of fetus away from umbilical cord, towards mother’s head 5. Re-check cord for pulsations 6. Administer high flow oxygen to mother 7. Transport immediately – fetus will die quickly without rapid intervention 8. Continue holding presenting part of baby away from umbilical cord 9. Apply moistened dressing on exposed umbilical cord 10. Do not push umbilical cord back into vagina Prolapsed cord Knee-chest position

Case Study Video Case Study

Obstetric Emergencies/Complications

Complications in the First Trimester – Ectopic Pregnancy

Ectopic Pregnancy Implantation of growing fetus in location other than endometrium Most common site is in one of the fallopian tubes Surgical emergency because tube can rupture & cause massive bleeding 6 week old embryo 1 month old embryo

Ectopic Pregnancy Patients with ectopic pregnancy often have one-sided, lower abdominal pain, late or missed menstrual period, & occasionally vaginal bleeding Life-threatening emergency Treat for shock & initiate immediate transport (ALS)

Complications in the 2nd and 3rd Trimester

Gestational Diabetes Some women develop diabetes during pregnancy
Pregnant diabetics are prescribed insulin if blood sugar cannot be controlled by diet alone Cannot be managed with oral drugs because they are absorbed into placenta & can adversely affect fetus

Abruptio Placenta Premature separation of placenta from wall of uterus
Causes heavy bleeding and pain Separation can either be partial or complete Complete separation usually results in death of fetus Several factors may predispose patient to abruptio placenta Preeclampsia Maternal hypertension Multiparity Abdominal trauma Short umbilical cord

Supine Hypotensive Syndrome
Supine hypotensive syndrome occurs when increased weight of uterus compresses inferior vena cava while a patient is supine Markedly decreases blood return to heart & reduces cardiac output Some women are predisposed to this condition because of an overall decrease in circulating blood volume or anemia

Supine Hypotensive Syndrome
Usually occurs in third trimester of pregnancy Relieve it by tilting mother to one side Vena cava & aorta compressed by fetus Compression relieved by tilting patient on left side

Placenta Previa Attachment of placenta in lower part of uterus covering cervix Unless sonogram done, placenta previa usually is not detected until third trimester When fetal pressure on placenta increases or uterine contractions begin, cervix thins out resulting in bleeding from placenta Bleeding is bright red and is usually painless

Hypertension Preeclampsia – condition characterized by high blood pressure, abnormal weight gain, edema, headache, & protein in urine Eclampsia – characterized by high blood pressure, excessive swelling in extremities/ face and seizures Life-threatening seizures differentiate eclampsia from preeclampsia

Preeclampsia Variety of signs and symptoms including:
Hypertension Abnormal weight gain Edema Headache Protein in the urine Epigastric pain If untreated, preeclampsia can progress to eclampsia

Eclampsia Eclampsia, also called toxemia, most serious manifestation of hypertensive disorders of pregnancy Characterized by grand mal seizures Often preceded by visual disturbances such as flashing lights or spots before the eyes Eclampsia patients often experience swelling of hands & feet & markedly elevated blood pressure If eclampsia develops, death of mother & fetus frequently results Treat by lying mother on her side, maintaining airway, & delivering high-flow oxygen

Trauma Direct abdominal trauma can cause: Fetal death can result from:
Premature separation of placenta from uterine wall Premature labor Abortion Uterine rupture Fetal death Fetal death can result from: Separation of placenta from uterine wall Maternal shock Uterine rupture Fetal head injury

Bleeding Vaginal bleeding during pregnancy is cause for concern
Bleeding in early pregnancy often associated with spontaneous abortion, ectopic pregnancy, or vaginal trauma Vaginal bleeding in third trimester is usually caused by: abruptio placenta placenta previa trauma to vagina or cervix This can be a life-threatening emergency

Bleeding Ranges from light spotting to massive hemorrhage
Difficult to determine cause of vaginal bleeding in field Suspect placenta previa, abruptio placenta, or vaginal trauma when you see vaginal bleeding during third trimester

Gynecological Emergencies

Vaginal Bleeding Vaginal bleeding that is not a result of direct trauma or normal menstrual cycle can indicate a serious problem Difficult to isolate a specific cause, treat all vaginal bleeding as if there were serious underlying condition Especially true if bleeding associated with lower abdominal pain

PID Pelvic inflammatory disease (PID) – infection of female reproductive tract Organs most commonly involved Uterus Fallopian tubes Ovaries Occasionally, peritoneum & intestines

PID Symptoms of PID include:
Lower abdominal pain Fever Abnormal vaginal discharge Painful intercourse Irregular menstrual bleeding Pain in right-upper quadrant Vaginal bleeding & lower abdominal pain can indicate serious gynecological problem Maintain high index of suspicion when encountered

PID Causes of PID Acute or chronic
Gonorrhea & chlamydia infections Can progress undetected before PID symptoms appear Other bacteria, such as staph or strep. Acute or chronic Allowed to progress untreated, sepsis can develop Most common symptom of PID – moderate to severe, lower abdominal pain

Vaginal Bleeding Treatment depends on patient’s needs, but may include the following: Maintain ABCs Control bleeding, if possible Administer oxygen Place in shock position

Ovarian Cysts Egg is released from ovary, cyst often left in its place
Cyst – fluid-filled sac that is often enlarged Can rupture & cause abdominal pain Occasionally cysts develop independent of ovulation Ovarian Cyst

Dilation and Curettage (D&C)
Dilation – opening of the cervix Curettage – scraping the walls of uterus Surgical procedure – usually done on outpatient basis under local anesthesia Diagnose conditions such as cancer Remove tissue after miscarriage Elective abortion Complications Heavy bleeding is uncommon but important to recognize Patients with heavy bleeding Evaluate for signs of shock Expedite transport to hospital

Sexual Assault Rape – any genital, oral or anal penetration by a body part or object, through use of force or without victim's consent It is a crime of violence with serious physical and psychological implications

Sexual Assault Trauma to woman’s external genitalia can be difficult to treat Need to maintain patient’s modesty Rich network of nerves in external genitalia makes such injuries painful Injuries to this area tend to bleed profusely due to rich blood supply Treat open wounds of genitalia with moist, sterile compresses Use direct pressure to control bleeding Do not place dressings in the vagina

Summary Signs of imminent delivery include: Crowning
Contractions less than 2 minutes apart Feeling of rectal fullness Feeling of imminent delivery

Summary Care for vaginal bleeding includes: Maintain ABCs
Control bleeding, if possible Administer oxygen Place in shock position

Summary Key points for assisting with normal delivery:
Support head with gentle pressure Check if cord wrapped around baby’s neck—if so, attempt to loosen Apply gentle downward pressure on anterior shoulder and head After anterior shoulder has delivered, apply gentle upward pressure on posterior shoulder & head Suction mouth and nostrils when head appears Once delivered, stimulate newborn if it does not breathe Put two clamps on umbilical cord & cut 6 inches from navel Care for newborn infant includes: Stimulate infant if not breathing sufficiently Start CPR if no response after 30 seconds Keep infant warm Repeat suctioning of mouth & nose Check APGAR score at 1 & 5 minutes

Summary APGAR stands for appearance, pulse, grimace, activity, & respirations Care of mother includes: Monitor & control bleeding from mother Begin fundal massage Monitor vital signs Keep mother & baby warm If head remains stuck during buttocks or double footling presentation, create airway by pushing away vaginal wall then transport immediately Important steps in caring for postpartum bleeding include fundal massage and treatment of shock

Questions EMS Online Guidelines and Standing Orders
support: Dr. Mickey Eisenberg Medical Director Ask the Doc:

OB/GYN Emergencies.

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