1. Copyright 2008 Seattle/King County EMS CBT/OTEP 521 OB/GYN Emergencies

2. Copyright 2008 Seattle/King County EMS Introduction This course will help refresh your assessment and treatment skills for emergency childbirth and gynecological emergencies.

3. Copyright 2008 Seattle/King County EMS New Terms compartment syndrome – Elevation of pressure within the fibrous tissue that surrounds and supports muscles and neurovascular structures, characterized by extreme pain, pain on movement, pulselessness, and pallor. effacement – A term relating to the thinning of the cervix.

4. Copyright 2008 Seattle/King County EMS New Terms, continued meconium – A dark-green fecal material found in the intestines of full-term babies. postpartum – A term used to describe the period shortly after childbirth.

5. Copyright 2008 Seattle/King County EMS Female Reproductive Organs Image credit: Copyright 2007 Seattle/King County EMS

6. Copyright 2008 Seattle/King County EMS Fetal Anatomy Image credit: Copyright 2007 Seattle/King County EMS

7. Copyright 2008 Seattle/King County EMS Menstrual Cycle Monthly hormonal cycle in which uterus prepares to receive an egg Cycle repeats average every 28 days

8. Copyright 2008 Seattle/King County EMS Pelvic Inflammatory Disease (PID) Infection Uterus, fallopian tubes, and ovaries Lower abdominal pain Fever Abnormal vaginal discharge Painful intercourse Irregular menstrual bleeding Pain in right-upper quadrant

9. Copyright 2008 Seattle/King County EMS Vaginal Bleeding Treat all vaginal bleeding as a serious condition Maintain ABCs Control bleeding, if possible Administer oxygen Place in shock position

10. Copyright 2008 Seattle/King County EMS Ovarian Cysts When egg is released from ovary, a cyst is often left in its place Can rupture and cause abdominal pain Image credit: Copyright 2007 Seattle/King County EMS

11. Copyright 2008 Seattle/King County EMS Sexual Assault Rich network of nerves in external genitalia makes injuries painful Tend to bleed profusely Treat open wounds with moist, sterile compresses Use direct pressure to control bleeding Do not place dressings in vagina

12. Copyright 2008 Seattle/King County EMS Ovulation On day 14 ovary releases egg Egg enters fallopian tube If woman has intercourse 24 to 48 hours before ovulation, fertilization can occur Once fertilized, egg continues to uterus where it attaches to endometrium

13. Copyright 2008 Seattle/King County EMS Fetal Development Month 1Development of brain, spinal cord, and heart Month 2Feet and hands are distinguishable Month 5Fetal heart tones can be detected by stethoscope Month 6Baby is capable of surviving on its own Month 8Fetus has an excellent chance of survival

14. Copyright 2008 Seattle/King County EMS Trauma Separation of placenta from uterine wall Premature labor Abortion Uterine rupture Fetal death

15. Copyright 2008 Seattle/King County EMS Gestational Diabetes Develop diabetes during pregnancy Cannot be managed with oral drugs

16. Copyright 2008 Seattle/King County EMS Ectopic Pregnancy Implantation of fetus in a location other than endometrium Most common site is in a fallopian tube Surgical emergency Photo Credit: Ed Uthman, MD

17. Copyright 2008 Seattle/King County EMS Vaginal Bleeding In third trimester usually caused by abruptio placenta, placenta previa, or trauma to vagina Abruptio placenta Placenta previa

18. Copyright 2008 Seattle/King County EMS Pelvis Result of MVA/pedestrian, falls Vessels, nerves, organs in pelvic area Indirect force transferred through femur

19. Copyright 2008 Seattle/King County EMS Hypertension Mother’s blood pressure generally is lower during pregnancy Preeclampsia Eclampsia

20. Copyright 2008 Seattle/King County EMS Supine Hypotensive Syndrome Usually occurs in the third trimester of pregnancy Relieve it by tilting the mother to one side

21. Copyright 2008 Seattle/King County EMS Signs of Imminent Delivery Crowning Contractions less than 2 min apart Rectal fullness Feeling of imminent delivery

22. Copyright 2008 Seattle/King County EMS Preparing for Delivery Request paramedic unit Don sterile gloves, gown, and eye protection Position mother on back, legs drawn up Provide supplemental oxygen Prepare OB kit Prepare infant BVM

23. Copyright 2008 Seattle/King County EMS Presentations You Can Deliver Head first Umbilical cord around neck Shoulder dystocia Buttocks first Double-footling

24. Copyright 2008 Seattle/King County EMS Presentations You Can’t Deliver Single limb Prolapsed cord Image credit: Copyright 2007 Seattle/King County EMS

25. Copyright 2008 Seattle/King County EMS Assisting With Delivery Support head with gentle pressure If cord wrapped around neck, attempt to loosen Gentle downward pressure on shoulder/head After anterior shoulder is delivered, apply gentle upward pressure Suction mouth and nostrils when head appears Once out, stimulate infant if not breathing Put two clamps on umbilical cord 6 in. away from navel and 2-3 in. apart - cut between clamps

26. Copyright 2008 Seattle/King County EMS Care of the Infant Stimulate to breathe, if not doing so (PSS) If not breathing, use infant BVM to deliver gentle puffs of air — enough to cause chest to rise If after 30 secs no response, begin CPR Keep warm by drying and wrapping in warmed blankets Repeat suctioning of the nose and mouth, if needed Check the APGAR score at 1 and 5 min

27. Copyright 2008 Seattle/King County EMS APGAR

28. Copyright 2008 Seattle/King County EMS Care of the Mother Monitor and control bleeding Begin fundal massage Monitor vital signs Keep mother and baby warm Do not wait for placenta

29. Copyright 2008 Seattle/King County EMS Umbilical Cord Around Neck Try to loosen cord gently and slip it over head If it is too tight, clamp in two places and cut between clamps

30. Copyright 2008 Seattle/King County EMS Shoulder Dystocia Flex legs and push toward her head Apply firm pressure with an open hand above symphysis pubis Do not pull on baby’s head Image credit: Copyright 2007 Seattle/King County EMS

31. Copyright 2008 Seattle/King County EMS Buttocks and Double Footling Position with buttocks at edge of bed Hold mother’s legs in a 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

32. Copyright 2008 Seattle/King County EMS Postpartum Bleeding Fundal massage Treat for shock Do not force delivery of placenta Place sanitary napkin at opening of vagina

33. Copyright 2008 Seattle/King County EMS Neonatal Resuscitation If not breathing effectively after 10 - 15 seconds of stimulation, begin assisted respirations Infant BVM with high-flow oxygen at 40 to 60/min If pulse rate falls below 60, start 3:1 CPR at 120 events/min Must deliver effective ventilations (chest rise)

34. Copyright 2008 Seattle/King County EMS Single Limb Presentation Support baby with your hands Provide airway for baby using your fingers Transport immediately — do not attempt delivery in the field

35. Copyright 2008 Seattle/King County EMS Prolapsed Cord Cord falls into birth canal and is compressed Must keep head out of birth canal and off the cord Place mother in knee-chest position Administer high flow oxygen to mother If no pulsations in cord, press presenting part of fetus away from umbilical cord

36. Copyright 2008 Seattle/King County EMS Summary Key structures of female reproductive system: Cervix Endometrium Fallopian tubes Ovaries Perineum Uterus Vagina

37. Copyright 2008 Seattle/King County EMS Summary, continued Key structures of fetal anatomy: Placenta Amniotic sac Umbilical cord

38. Copyright 2008 Seattle/King County EMS Summary, continued Care for vaginal bleeding: Maintain ABCs Control bleeding, if possible Administer oxygen Place in shock position

39. Copyright 2008 Seattle/King County EMS Summary, continued Fetus has excellent chance of survival after 7 months Pregnant women are more susceptible to traumatic injury because of increased vascularity of uterus Ectopic pregnancy often presents with one- sided abdominal pain, late or missed period, and occasionally, vaginal bleeding

40. Copyright 2008 Seattle/King County EMS Summary, continued Vaginal bleeding in third trimester is usually caused by abruptio placenta, placenta previa, or trauma To relieve supine hypotensive syndrome tilt mother to one side

41. Copyright 2008 Seattle/King County EMS Summary, continued Signs of imminent delivery: Crowning Contractions less than 2 minutes apart Rectal fullness Feeling of imminent delivery

42. Copyright 2008 Seattle/King County EMS Summary, continued Key points for normal delivery: Support head If cord is wrapped around neck, loosen Gentle downward pressure on shoulder/head After anterior shoulder has delivered, apply gentle upward pressure Suction mouth and nostrils Stimulate if not breathing (PSS) Put two clamps on umbilical cord 6 in. away from navel and 2-3 in. apart - cut between clamps

43. Copyright 2008 Seattle/King County EMS Summary, continued Care for newborn infant: Stimulate infant if not breathing sufficiently Start CPR if no response after 30 seconds Keep infant warm Repeat suctioning of mouth and nose Check APGAR at 1 and 5 minutes

44. Copyright 2008 Seattle/King County EMS Summary, continued If head is stuck during buttocks or double- footling presentation, create airway by pushing away vaginal wall Postpartum bleeding treatment: fundal massage and treat for shock

45. Copyright 2008 Seattle/King County EMS Summary, continued Care of mother: Monitor and control bleeding from mother Begin fundal massage Monitor vital signs Keep the mother and baby warm