Obstetrics and Gynecology

Anatomy and Physiology

• Fetus• Developing unborn baby

• Uterus• Organ in which a fetus matures• Responsible for labor and expulsion of infant

• Birth Canal• Vagina and lower part of the uterus

• Placenta• Fetal organ by which nourishment and waste is exchanged from fetus to

mother• Umbilical Cord

• Cord that is an extension of the placenta that delivers nourishment to the fetus• Amniotic sac

• Sac that surrounds the fetus inside the uterus• “Bag of Waters”

Anatomy and Physiology

• Vagina• Lower part of the birth canal

• Perineum• Area between vagina and anus• Commonly torn during pregnancy

• Crowning• Bulging out of the vagina• Opens as the head/presenting part exits the vagina

• “Bloody Show”• Mucus and blood that may come out of the vagina as labor begins

• Labor• The time and process from the 1st contraction to delivery

• Delivery is imminent• Crowning• Delivery

• Presenting part• Part of the fetus/infant that exits the vagina first

• Abortion• Delivery of products of conception early in pregnancy/ before 20 weeks gestation • Miscarriage

Contents of the OB Kit

• Surgical Scissors• Hemostats/Cord Clamps• Umbilical tape/Sterilized

cord• Bulb syringe• Towels• 2 X 10 Gauze Sponges• Sterile Gloves• 1 Baby blanket• Sanitary Napkins• Plastic Bag

Predelivery Emergencies Miscarriages

• Assessment• Scene Size Up• Initial Assessment• Hx and Px Exam

• Treatment• based on S/S• Apply external vaginal pads• Bring fetal tissue to hospital• Support mother

Predelivery EmergenciesSeizures

• Assessment• Scene Size Up• Initial Assessment• Baseline vitals• Hx and Px Exam

• Treatment• Treatment based on S/S• Prevent pt from injury• Remove objects in area• Transport on left side

Hypertensive Disorders“Toxemia of pregnancy “

Intro– 5% of pregnancies – Often in 1st pregnancies – More frequent in pt with HTN/DM

Gestational HTN– BP usually drops in pregnancy

130/80 may be elevated???– BP =/> 140/90 (previously non hypertensive)

Preecplamsia – Most common complication, 10% – 2nd-3rd trimester– HTN and protein in urine, damaged kidneys/liver– HTN, abnormal weight gain, edema, headache, proteinuria,

epigastric pain, vision disturbances

Hypertensive Disorders“Toxemia of pregnancy “

Eclampsia – MOST SERIOUS COMPLICATION – Grand mal seizure activity

Usually with Hx of Preeclampsia – Often preceded by

Visual disturbances (flashing spots/lights), RUQ abd pain– Appearance differentiates Eclampsia v Epilepsy

Marked HTN edematous pt vs Pt with seizure hx, anticonvulsants

– HIGH fetal/maternal mortality – Complications

Cerebral hemorrhage, renal failure, pulmonary edema Treatment

– Magnesium sulfate – Seizures

Severe Vaginal Bleeding

1st Trimester– Spontaneous abortion– Ectopic pregnancy (1%)

Implantation of fertilized ovum in fallopian tubes (98%), ovaries, cervix, abdomen

3rd Trimester – Abruptio placentae (1%)

Placental lining detaches from mother 20-40% fetal mortality

– Placenta previa (0.5%) Placenta attaches close to OR covers the cervix

Post deliver bleeding– Common, > 500 mL could precipitate shock

Treatment– Airway, O2, IV fluids/volume expanders– IV Pictocin

ECTOPIC PREGNANCY

ABRUPTIO PLACENTA

Obstetrics and GynecologyVaginal Bleeding

• Vaginal bleeding• BSI• Airway• Control bleeding as previously described

• Trauma (external genitalia)• Treat as other bleeding soft tissue injuries• NEVER pack the vagina• Provide O2• On going pt assessment

• Alleged Sexual Assault• BSI• Initial assessment• Non judgmental attitude during SAMPLE Hx and Px exam• Crime scene protection• Exam genitalia ONLY if profuse bleeding is present• Use same sex EMT-B for care when possible• Discourage pt from – voiding – cleaning wounds – bathing• Report requirements

Predelivery EmergenciesTrauma

• Assessment• Scene Size Up• Initial Assessment• Baseline vitals• Hx and Px Exam

• Treatment• Treatment based on S/S• Transport on left side

Normal Delivery

• Hx Questions to consider…:• Are you pregnant?• How long have you been pregnant?• Are there contractions or pain?• Any bleeding or discharge?• Is crowing occurring with contractions?• What is the frequency and duration of contractions?• Does she feel the need to have bowel movement?• Does she feel the need to push?• Rock hard abdomen?

• Precautions• Use BSI• DO NOT touch vaginal area except during delivery and when your partner is present• DO NOT let the mother go the restroom• DO NOT hold mothers legs together• Recognize your own limitations and transport even if delivery occurs in transport• IF delivery is imminent:

• Contact med control for permission to deliver on scene• If no delivery within 10 minutes contact med control for permission to transport

The Full Body Condom

Delivery Procedures

• Apply full body condom• Have mother lie with knees drawn up and spread apart• Elevate buttocks (Pillows/blankets)• Create sterile field around vaginal area

• Sterile towels or paper barriers• When infants head appears

• Place fingers on bony part of skull• Exert gentle pressure to prevent explosive delivery• Use caution to avoid fontanelle

• If the amniotic sac does not break/has not broken• Use a clamp to break the sac• Push away from infants head and mouth as it appears

• As the infants head is exposed determine if the cord is wrapped around the neck• Slip over the shoulder or clamp• Cut and unwrap

• After the head is born• Support the head • Suction the mouth 2-3 times and then the nostrils• DO NOT contact the back of the infants mouth

• As the torso and full body are born support the infant with both hands

Delivery Procedures cont’d

• As the feet are born, grasp them• Wipe mucus and blood from mouth and nose• Suction mouth and nose again• Wrap infant in blanket and place on its side

• Head slightly lower than trunk• Keep infant level with vagina until cord is cut• Assign partner to initially assess and care for newborn• Clamp, tie and cut the cord (b/t clamps) when pulsation stops

• 1st clamp= 7” from infant• 2nd clamp = 3” from 1st clamp

• Observe for delivery of placenta while preparing to transport• When placenta delivers:

• Wrap in towel• Place in plastic bag • Transport with mother

• Place sterile bad over vaginal opening• Lower mothers legs and help hold them together• Record time of delivery and transport

Vaginal Bleeding Following Delivery

• Expected Blood Loss• 500 cc (1/2 liter)• Well tolerated by mother

• With excessive blood loss• Massage the uterus

• Hands with fingers fully extended

• Place on lower abd above pubis

• Massage/knead over the area• If continued bleeding

• Reassess massage technique• Transport immediately

• Regardless of estimated blood loss if pt has S/S shock

• Treat as such• Transport • Perform uterine massage en

route

Initial Care of the Newborn

• -Position – Dry – Wipe – Wrap in blanket –Cover the head• Repeat suctioning• Assessment of infant (APGAR)

• Appearance = No central(trunk) cyanosis• Pulse = Greater than 100 bpm• Grimace = Vigorous and crying• Activity = Good motion in extremities• Breathing effort = Normal, crying

• Stimulate the newborn if not breathing• Flick soles of feet• Rub infants back

Resuscitation of the Newborn

• Breathing Effort• If –Shallow –Slow – Absent

• Provide positive pressure ventilation• 60 bpm for 30 seconds• Reassess and if no improvement continue

• Heart Rate• If less than 100 beats per minute

• Provide positive pressure ventilation• 60 bpm for 30 seconds

• If less than 80 beats per minute and no response to BVM• Start chest compressions

• If less than 60 beats per minute• Start compressions and artificial ventilations

• Color• If central cyanosis is present with spontaneous breathing and adequate heart rate

• Administer “blow by” O2 at 10-15 Lpm • Hold O2 tubing as close to pt face as possible

Abnormal Deliveries Proplapsed Cord

• Prolapsed Cord• Cord presents through the birth canal before delivery of the head• SERIOUS emergency endangering life of fetus

• Emergency Care• Scene size up• Initial Assessment• High flow O2• Hx and Px exam• Assess baseline vitals• Treatment based on S/S• Position mother

• Head down and buttock raised• Uses gravity to reduce pressure on the cord• McRobert’s position

• Insert sterile gloved hand into vagina• Push presenting part of fetus away from the pulsating cord

• Transport IMMEDIATELY• Keep pressure against presenting part• Reassess for pulsation of cord

Abnormal DeliveriesBreech Birth

• Breech birth• Fetal buttock or lower extremities

are low in the birth canal• Buttock or legs are presenting

part• Considerations

• Newborn is at GREAT risk for trauma

• Transport IMMEDATELY on recognition of breech presentation

• Emergency Care• IMMEDATE RAPID

TRANSPORT• O2• Place pt in McRobert’s position

Abnormal DeliveriesLimb Presentation

• Limb presentation• A limb of the infant protrudes

from the birth canal• Usually a foot in breech

position

• Emergency Care• IMMEDIATE RAPID

TRANSPORT• O2• Place pt in McRobert’s

position

Abnormal DeliveriesMultiple Births, Meconium, Premature

• Multiple Births• Be prepared for more than one

resuscitation• Call for assistance

• Meconium• Amniotic fluid that is greenish or

brownish yellow• Indicates fetal distress

• Do not stimulate before suctioning oropharynx

• Suction• Maintain airway• Transport as soon as possible

• Premature• Before 36 weeks• ALWAYS at risk for hypothermia• Usually requires resuscitation• Should be done unless physically

impossible

Pseudo Realistic Observations on OB

• Don’t drop the baby…• The umbilical cord is not a handle…• If the baby is quiet be VERY afraid…• Blue is very very bad. Pinks is very very

good.• Air goes in and out, blood goes ‘round and

‘round. ANY variation on this is usually a bad thing…