1. Obstetrics and Genecological Emergencies

2. Anatomy and Physiology of childbirth
Pregnancy and delivery
Fetus
developing baby
Uterus
where fetus grows during pregnancy
Cervix
neck of the uterus

3. Vagina
birth canal
Placenta
*attaches to wall of uterus
*an exchange area between mom and fetus of oxygen and nutrients
*expelled at birth

4. The fetus has its own circulatory system
blood from the fetus is sent through the umbilical cord to the placenta
The umbilical cord is 1” wide and 22” long at birth; expelled at birth
Amniotic sac
encloses the fetus

5. Nine months of pregnancy are divided into 3 trimesters
The first pregnancy trimester is the stage of pregnancy from conception to 12 weeks.
The second pregnancy trimester starts from the 13th week to the 28th week.
the baby grows rapidly and shows movements

6. The Third Trimester is the last trimester from the 28th week till the birth of the baby.
Changes to a woman’s body
Increased blood volume
Increased cardiac output
volume of blood being pumped by the
heart in one minute

7. Increased cardiac rate
Blood pressure slightly decreased
Slowed digestion
Crowning
presenting part of the baby first bulges from the vaginal opening
Cephalic presentation
head first
Breech
buttocks or feet deliver first

8. Labor
entire process of delivery
Three stages
First stage
regular contractions and dilation of cervix
stage ends with full dilation

9. Second stage
when the baby enters the birth canal
Third stage
after baby is born and lasts until placenta and umbilical cord is delivered
Meconium staining
*fluid that is green or brownish yellow
*indicates fetal distress during labor

10. Bloody show
*watery, bloody discharge of mucus associated with first stages of labor
*part of discharge is s mucous plug that was in the cervix

11. Labor pains
Time or duration
start of one contraction to relaxation of uterus
Interval or frequency
time of the start of one contraction to the beginning of the next

12. Normal childbirth
OB kit
Supplies when OB kit not available
Clean sheets and towels for draping
Heavy flat twine or new shoe laces
Towel or plastic bag to wrap placenta
Clean, unused rubber gloves and eyewear

13. Normal delivery
Evaluating the mother
Name, age, expected due date
First pregnancy?
How long and how often contractions
Water broke?
Bloody show?

14. Time length and frequency of contactions
Feel the uterus contracting VS
if abnormal alert hospital
Transport decision
Provide emotional support

15. Supine hypotension syndrome
Third trimester
Weight of the baby, uterus, placenta, and amniotic fluid can compress the inferior vena cava when supine
Dizziness and drop in blood pressure
blood is shunted
Transport in left lateral recumbent position

16. Prepare mother for delivery
Ensure privacy
BSI
Place on bed, floor, or on cot
Elevate buttocks and draw up knees
Remove any clothing or underclothing that obstructs view of the vaginal opening

17. Use sterile sheets or towels to cover
Position someone at the head
provide support, monitor, alert for vomiting
Position OB kit for easy access
Delivering the baby
Have constant view of vaginal opening
Be prepared that there is going to be some discomfort

18. Talk to the mother
Encourage her to relax between contractions
Encourage to breathe deeply through the mouth
do not allow to hyperventilate
Assure that when water breaks that is normal

19. Position gloved hand at the vaginal opening upon crowning
Place one hand below the head as it delivers
spread fingers evenly to avoid soft spot
Do not pull on the baby

20. If amniotic sac has not broken by time baby’s head is delivered, puncture membrane
Examine for meconium staining
suction

21. Once head delivers, check if umbilical cord is wrapped around the neck
*gently loosen cord if necessary and bring over shoulder and head
*if cord can’t be loosened or slipped over shoulder, clamp and cut
When entire head is delivered check the airway
*wipe mouth and nose with sterile gauze
*suction with bulb syringe

22. Help deliver the shoulders
*gently guide the head downwards
*if second shoulder is slow to deliver,
guide head upwards
Support the head throughout the entire process

23. Newborns are slippery
*grasp the lower extremities to assure good hold
*never pick up by the feet
Lay baby on side with head slightly lower than body
Suction once again
Keep level at level of vagina until umbilical cord stops pulsating

24. Wrap the baby in warm, dry blanket
Note the exact time of birth
Assessing the newborn
Apgar score
reassess after 5 minutes

25. Care
Place on sterile sheet as close to vagina as possible so infants blood doesn’t transfuse back into the placenta
Do not place on mother’s ABD until cord has been clamped

26. Resuscitation of the newborn
Provide warmth and clear airway
suction
Keep the baby on it’s side
Establish
breathing
heart rate
color

27. If heart rate is < 100
artificial ventilations at 40 to 60
If heart rate is < 60
CPR {3:1} 120 compressions/minute
If cyanotic with adequate respirations and pulse rate, give oxygen

28. Cutting the umbilical cord
Keep warm
cover the head; keep ambulance warm
Use sterile clamps or umbilical tape
Apply 10” from baby; 7” (4 finger) from distal clamp
Cut the cord between clamp
Place placenta end of cord on the drape over the mother’s legs

29. When moving the baby take care to not cause trauma to the cord
Caring for the mother
Delivering the placenta
Third stage of labor
Usually expels within a few minutes
but can take 30 minutes or longer
Save and transport
Label with name of mother and time expelled

30. Transport if the placenta doesn’t deliver within 20 minutes after delivery
Hemorrhage
500cc of blood loss is normal
Hemorrhage control
Place sanitary napkin or vagina, never pack
Lower legs and keep together

31. Elevate feet
Massage uterus to help it contract
Mother can nurse
If perineum is torn, treat as a wound
Comforting mom
Communicate
Frequent VS
Keep mother and baby warm

32. CHILDBIRTH COMPLICATIONS
Breech presentation
buttocks or both legs first
Complications rate high
Immediate transport
Never attempt to deliver by pulling on the legs O2

33. Place mother in head down position with pelvis elevated
If the body delivers support it and prevent and explosive delivery of the head
Insert gloved index and middle finger inside vagina and forma V around the nose

34. After delivery care is the same as for a cephalic delivery
Prolapsed cord
Umbilical cord presents first
Position mother with head down and buttocks raised with a blanket or pillow, using gravity to lessen the pressure on birth canal

35. O2
Check cord for pulses
Wrap with towel; must be kept warm
Insert several fingers of a gloved hand inside the vagina and push up on the baby’s head or buttocks to keep pressure off cord- - - continue until releived by a physician

36. Keeping mother, child and EMT as a unit, rapid transportVS
Limb presentation
Arm, single leg or arm and leg present
Often a prolapsed cord as well
Rapid transport
head-down, pelvis elevated

37. Do not attempt to pull on the limb or place into vagina
Do not insert hand/fingers into the vagina other than to manage a prolapsed cord
Multiple birth
Deliver in same manner of single birth
requires 2x the supplies and help

38. When delivered identify the infants in order of birth
If it is unknown there are multiple babies
Large before delivery
Remains large after the first delivers
Contractions continue after delivery of first
Second baby may be breech within minutes of the first

39. Placenta delivered normally
Care
Clamp or tie cord after birth of first and before birth of second
Second baby may be born before or after delivery of the placenta
Babies, umbilical cords, placenta, mother are all cared for as with a single birth

40. Babies will probably be smaller than with a single birth
important to keep warm
Premature birth
< 5.5#
Born before 37th week of pregnancy
Keep warm
Place cap on head
Airway management; suction with bulb syringe

41. If heart rate is < 100
artificial ventilations at 40 to 60
If heart rate is < 60
CPR {3:1} 120 compressions/minute
If cyanotic with adequate respirations and pulse rate, give oxygen

42. Watch the umbilical cord for bleeding
Avoid contamination
Transport in warm ambulance
Call ahead

43. Meconium staining
*fluid that is green or brownish yellow
*indicates fetal distress during labor
Reduce risk of apiration
do not stmulate until suctioned
Airway management

44. If heart rate is < 100
artificial ventilations at 40 to 60
If heart rate is < 60
CPR {3:1} 120 compressions/minute
If cyanotic with adequate respirations and pulse rate, give oxygen

45. Rapid transport
Emergencies in pregnancy
Excessive prebirth hemorrhage
Miscarriage
Placenta previa

46. Placenta Previa
*placenta is formed low in uterus and close to or over the cervical opening
*will not allow for a normal delivery
Abruptio Placentae
*placenta separates from the uterine wall
Either of above may occur in 3rd trimester
Both are life threatening

47. Assessment
Usually profuse bleeding from the vagina
May or may not complain of ABD pain
Initial assessment; look for signs of shock
Baseline VS
Care
Shock; O2
Rapid Transport

48. Place sanitary napkin over vaginal opening and note the time; never pack
Save all soaked material as well as any tissue that is passed

49. Ectopic pregnancy
An ectopic pregnancy is a complication of pregnancy in which the fertilized ovum is developed in any tissue other than the uterine wall. Most ectopic pregnancies occur in the Fallopian tube (so-called tubal pregnancies), but implantation can also occur in the cervix, ovaries, and abdomen. The fetus produces enzymes that allow it to implant in varied types of tissues, and thus an embryo implanted elsewhere than the uterus can cause great tissue damage in its efforts to reach a sufficient supply of blood. An ectopic pregnancy is a medical emergency, and, if not treated properly, can lead to the death of the woman.

50. Assessment
Any woman of childbearing age with abdominal pain has an ectopic pregnancy until proven otherwise
May have s/s of shock due to internal bleeding
Acute abdominal pain
Often with vaginal bleeding

51. Care
Rapid transport
Position for shock 02
NPO

52. Seizures in pregnancy
Sometimes called eclampsia
Preeclampsia; swelling of the extremities
Assessment
Elevated blood pressure
Excessive weight gain
Gross swelling of face, hands, ankles, feet
headache

53. Care
Ensure and maintain airway O2
Transport on left side
Handle gently
Keep warm but don’t overheat
Have suction ready
Have OB kit ready

54. Miscarriage and abortion
Spontaneous abortion
Miscarriage
Induced abortion

55. Assessment
Cramping abdominal pains
Bleeding {moderate to severe}
Dicharge of tissue and blood from vagina
Care
Baseline VS
Treat for s/s of shock O2

56. Place sanitary napkins over vaginal opening
Rapid transport
Replace and save all soaked pads
Save all expelled tissue
Provide emotional support

57. Trauma in pregnancy
Most common is MVA
Uterus is frequently injured
Sudden blunt trauma in later months may cause uterine rupture or premature separation; massive bleeding and shock
Treat as for any other trauma pt.

58. Assessment
Pulse 10 to 15 bpm faster than non-pregnant female
Increased blood volume
Ascertain if there were any blows to ABD, pelvis, or back
Ascertain if water has broke

59. Care
Examine unconscious for ABD injuries
consider MOI
Cardiac arrest management
Airway management O2
Suction
Rapid transport
left lateral recumbent VS
Provide emotional support

60. Stillbirths
Baby who dies in the womb
Do not lie to mother
Allow her to see the baby if she wishes
Obvious death
blisters
foul odor
skin or tissue deterioration and discoloration
softened head

61. Obviously dead sometime before birth
no resuscitation
Born in pulmonary or cardiac arrest
resuscitative measures
Baby is alive but pulmonary or cardiac arrest seems imminent

62. Accidental death of a pregnant woman
Aggressive resuscitation efforts should be taken
Reposition hands 1 to 2” higher
Efforts will be ceased in the E.R.

63. Gynecological Emergencies
Vaginal bleeding
Potentially life threatening especially if accompanied with ABD pain
Hypovelemic shock
Care
Standard precautions
Airway
Treat for shock
transort

64. Trauma to external genitalia
MOI
Assess for severe blood loss and shock and treat accordingly
Care
Control bleeding O2
Maintain a professional attitude
Respect patient’s privacy

65. Sexual Assault
Scene safety
may need to stage
Treat both medically and psychologically
Airway
Take care not to disturb any potential evidence
Examine genitalia only if there is sign of trauma
Do not allow to bathe, void or clean wounds
Reporting requirements