CHAPTER Copyright 2004 Prentice Hall Publishing A division of Pearson Inc. Prehospital Emergency...

Copyright 2004 Prentice Hall PublishingA division of Pearson Inc.

Prehospital Emergency Care 7eMistovich/Hafen/Karren

CHAPTERCHAPTER

Chapter 27Chapter 27Obstetric and Gynecological

Emergencies



CHAPTERCHAPTER

• Childbirth and Obstetric Emergencies• Gynecological Emergencies• Enrichment

2727TopicsTopics



CHAPTERCHAPTER

• Anatomy of Pregnancy– Uterus– Cervix– Placenta– Umbilical cord– Amniotic sac– Vagina

2727Childbirth and Obstetrical EmergenciesChildbirth and Obstetrical Emergencies



CHAPTERCHAPTER

• Anatomy of Pregnancy– A full-term pregnancy lasts approximately 280 days

from the first day of the last menstrual cycle.– Each three-month period of the approximately nine-

month pregnancy is referred to as a “trimester.”– Toward the end of the third trimester, the baby

should move into a head down position in preparation for birth.




CHAPTERCHAPTER

• Stages of Labor– Labor describes the process of birth.– Normal labor is divided into three stages:

• Dilation• Expulsion• Placental

– The length of each stage varies from woman to woman and depends on a variety of circumstances.




CHAPTERCHAPTER

• Stages of Labor– First Stage: Dilation

• Begins with first uterine contraction and ends when the cervix is completely dilated.

• “Bloody” show.• Rupture of amniotic sac.• Contractions increase

in frequency and intensity.• May last longer for

woman having first child .




CHAPTERCHAPTER

• Stages of Labor– Second Stage: Expulsion

• Begins with complete cervical dilation and ends with delivery of the baby.

• Contractions are closetogether and last longer.

• Mother has urge to“push.”

• Perineum may tear.• Crowning.




CHAPTERCHAPTER

• Stages of Labor– Third Stage: Placental

• Begins once the baby is delivered and ends when the placenta is expelled.

• Placenta typicallydelivered 5 to 20 minutesafter the baby.

• Gush of blood.• Uterus becomes smaller.• Umbilical cord lengthens.• Maternal urge to push.




CHAPTERCHAPTER

• Assessment and Delivery– Scene Size-Up

• Gather clues prior to physically touching the patient.– Dispatch information.

– High index of suspicion - any female of childbearing age (12 to 50 years) may be experiencing an obstetric emergency.

– Patient appears pregnant on approach.

• Take the appropriate BSI precautions.




CHAPTERCHAPTER

• Assessment and Delivery– Initial Assessment

• Perform the initial assessment on the mother as you would any other patient.

– Mental status– Airway– Breathing– Circulation

• Identify and correct any life threatening conditions within the ABCs.




CHAPTERCHAPTER

• Assessment and Delivery– Focused History and Physical Exam

• Get a SAMPLE history including the OPQRST.– Ask patient if she is pregnant.– Is the patient experiencing any pain or discomfort?– When was the patient’s last menstrual period?– Has there been any unusual vaginal bleeding or discharge?– What is the baby’s due date?

• Some women, especially in early pregnancy, may not know that they are pregnant. Maintain a high index of suspicion




CHAPTERCHAPTER


• Get a SAMPLE history including the OPQRST.– Has the patient ever been pregnant before?– If the patient has been pregnant before, how many

pregnancies?– How many pregnancies resulted in live births?– Where the previous pregnancies vaginal or by caesarian

section?– Any complications with the previous pregnancies?




CHAPTERCHAPTER


• If the patient is experiencing abdominal pain or contractions, perform a focused exam of abdomen and vaginal area.

– Rigidity of abdomen– Bloody show or crowning in vaginal region

• Obtain baseline vital signs.– Pulse and respirations normally increased in pregnancy– Blood pressure normally decreased




CHAPTERCHAPTER

• Assessment and Delivery– Consider a predelivery emergency if the patient is

pregnant and experiencing any of the following:• Abdominal pain• Vaginal bleeding or passage of tissue• Weakness or dizziness• Altered mental status• Seizures• Excessive swelling of the face or extremities• Abdominal trauma• Shock (hypoperfusion)




CHAPTERCHAPTER

• Emergency Medical Care– Provide the same basic medical care that you would to any

other patient with a similar complaint.• Assure a patent airway.• Assure adequate breathing.

– Provide high flow oxygen if breathing is adequate.– Provide positive pressure ventilation with a bag mask, reservoir, and high

flow oxygen if the breathing is inadequate.– Care for vaginal bleeding.– Treat the patient for shock (hypoperfusion) if present.




CHAPTERCHAPTER

• Emergency Medical Care– If the patient is in cardiac arrest, provide vigorous

resuscitation and rapid transport to the hospital.• Baby may be able to be saved via emergency caesarian

section.




CHAPTERCHAPTER

• Emergency Medical Care– If the patient is in her third trimester, watch for supine

hypotensive syndrome.• Pressure of the enlarged uterus and the weight of the baby

compress the vena cava.• Blood return to the heart is reduced, causing the female to become

relatively hypotensive.• Place the mother in a sitting or the left (or right) lateral recumbent

position if supine hypotensive syndrome is present.• Transport in this position.




CHAPTERCHAPTER

• Emergency Medical Care– Ongoing Assessment

• Perform the ongoing assessment en route to the hospital.• Repeat vital signs.• Continually look for signs of developing shock

(hypoperfusion).




CHAPTERCHAPTER

• Specific Predelivery Emergencies– Spontaneous Abortion

• A spontaneous abortion (miscarriage) is the delivery of the fetus and placenta before the fetus can live on its own (typically after the 20th week).

– Causes include genetic abnormalities, uterine abnormality, infection, drugs, maternal disease(s).




CHAPTERCHAPTER


• The signs and symptoms of a spontaneous abortion include:– Cramping like abdominal pain– Moderate to severe vaginal bleeding which is typically bright or dark

red (Do not mistake a spontaneous abortion for a heavy period.)– Passage of tissue or clots




CHAPTERCHAPTER


• Emergency Medical Care– Assure the ABCs.– Provide high flow oxygen.– Provide supportive care.– Do not pack the vagina to control bleeding.– Transport all clots and tissue with the patient to the hospital.




CHAPTERCHAPTER

• Specific Predelivery Emergencies– Seizures

• Seizures during pregnancy can be a life threatening condition for both the mother and fetus.

– Provide emergency care as you would for any other seizure patient.– Make sure to protect the mother from injuring herself.– Transport patient on her left side if seizure occurs during the third

trimester.– Transport in a calm, quiet manner.




CHAPTERCHAPTER

• Specific Predelivery Emergencies– Vaginal Bleeding

• Vaginal bleeding may occur any time during pregnancy and may represent a life threatening condition for both the mother and fetus.

– Treat the patient as you would any other person suffering from blood loss.

– Look for shock (hypoperfusion).– Place sanitary napkins over the vaginal opening but do not

pack the vaginal canal.– Transport as soon as possible.




CHAPTERCHAPTER

• Specific Predelivery Emergencies– Trauma to a Pregnant Woman

• Moderate to severe blunt force to the abdomen, especially late in pregnancy, can damage or injure the fetus as well as the mother.

– Treat the mother as any other trauma patient.– Assure the ABCs and provide high flow oxygen.– If immobilized, tilt the longboard to the left, especially late in

pregnancy.– Provide rapid transport to the closest appropriate medical facility.




CHAPTERCHAPTER

• Active Labor and Normal Delivery– Perform the scene size-up, initial assessment, and

focused history and physical exam as you would for any other patient.

• Make sure to assess the abdomen and vaginal area if the patient is in active labor.




CHAPTERCHAPTER

• Active Labor and Normal Delivery– Determine whether the patient can be transported or

delivery is imminent and will have to occur on scene:• Crowning has occurred.• Contractions are less than 2 minutes apart and lasting from

60 to 90 seconds.• Mother feels the baby’s head moving down the birth (vaginal)

canal.• Mother has a strong urge to push.• Patient’s abdomen is very hard.




CHAPTERCHAPTER

• Active Labor and Normal Delivery– Preparation for a Field Delivery

• Take appropriate BSI. • Avoid touching the vaginal area prior to actual delivery.• Do not allow the mother to

use the bathroom.• Do not hold the mother’s legs

together to delay delivery.• Obtain the obstetrics kit.• Stay calm and provide

reassurance to the mother.




CHAPTERCHAPTER

• Active Labor and Normal Delivery– Emergency Medical Care

• Position the mother on her back with head supported and legs flexed.

• Create a sterile environment around the vaginal opening.• Continually assess for crowning.• Gently place your gloved fingers

on the bony part of the infant’s skull when it crowns.

• Tear the amniotic sac if not already ruptured.

• Determine the position of the umbilical cord.




CHAPTERCHAPTER

• Active Labor and Normal Delivery– Emergency Medical Care (continued)

• Remove fluids from the newborn’s airway by suctioning the mouth then nose with a bulb syringe.

• Support the newborn’s body with your hands as he is delivered.

• Grasp the feet as they are born.

• Clean then suction the newborn’s

mouth and nose with a bulb syringe.

• Dry, wrap, warm, and position the

newborn.




CHAPTERCHAPTER


• Assign your partner to monitor and complete the initial care of the newborn.

• Clamp, tie, and cut the umbilical cord.




CHAPTERCHAPTER


• Observe for delivery of the placenta.• Wrap the delivered

placenta.• Place one or two sanitary

napkins over the vaginal opening.

• Record the time of delivery and transport the mother, baby, and placenta to the hospital.




CHAPTERCHAPTER

• Active Labor and Normal Delivery– Emergency

Medical Care • Delivery

summary




CHAPTERCHAPTER

• Active Labor and Abnormal Delivery– If you encounter any one of the following conditions, anticipate

and prepare for an abnormal delivery:• Any fetal presentation other than the normal crowning of the baby’s head• Abnormal color or smell of the amniotic fluid• Labor before the 38th week of pregnancy• Recurrence of contractions after the first baby is born (indicating multiple

births)




CHAPTERCHAPTER

• Active Labor and Abnormal Delivery– Prolapsed Cord

• After rupture of the amniotic sac, the umbilical cord rather than the head is the presenting part.

– The umbilical cord may be compressed between the baby and the wall of the vagina.

– Umbilical cord compression cuts off the supply of oxygen-rich blood to the baby and is a true emergency!




CHAPTERCHAPTER

• Active Labor and Abnormal Delivery– Prolapsed Cord

• Emergency Care:– Position the mother in the “knee-chest” position.– Insert a sterile gloved hand into the vaginal canal and gently

lift the presenting part off of the umbilical cord.– Cover the umbilical cord with a sterile towel moistened with

saline solution.– Transport the mother

rapidly.




CHAPTERCHAPTER

• Active Labor and Abnormal Delivery– Breech Birth

• A breech birth occurs when the fetal buttocks or lower extremities are the presenting parts instead of the head.

– Delivery may be prolonged.

– There is increased risk of delivery related trauma to both mother and baby.




CHAPTERCHAPTER

• Active Labor and Abnormal Delivery– Breech Birth

• Emergency Care:– Position mother in a supine head-down position with her

pelvis elevated.– Transport

immediately.– Birth may still occur.




CHAPTERCHAPTER

• Active Labor and Abnormal Delivery– Limb Presentation

• A limb presentation occurs when one arm or leg is the first to protrude from the birth canal.

– Surgery is frequently required for delivery.

• Provide the following care:– Provide high flow oxygen.– Position the mother in a supine head-down position.– Never pull on the presenting part.– Do not attempt delivery.




CHAPTERCHAPTER

• Active Labor and Abnormal Delivery– Multiple Births (e.g. twins, triplets)

• Suspect multiple births if:– Abdomen still very large following delivery of the first baby.

– Strong uterine contractions continue after the first delivery.

– Uterine contractions start again about 10 minutes after the first delivery.

– The baby’s size is small in relation to the mother’s abdomen.




CHAPTERCHAPTER

• Active Labor and Abnormal Delivery– Multiple Births

• Emergency Medical Care– Provide care as you would for any other delivery.– Be prepared to care for more than one newborn.– Call for assistance early!– Anticipate and prepare for complications since one third of

second deliveries are breech.– Expect and manage significant hemorrhage.– Babies of multiple births tend to be low in birth weight and

may require significant resuscitation.– If second baby has not delivered within 10 minutes of the first,

transport immediately.




CHAPTERCHAPTER

• Active Labor and Abnormal Delivery– Meconium

• The passing of fetal bowel contents (meconium) may occur during birth and indicate a difficult labor for the baby.

– The normally clear clear amniotic fluid appears cloudy to greenish to yellow.

– Aspiration of the meconium into the baby’s lungs can result in aspiration pneumonia.




CHAPTERCHAPTER

• Active Labor and Abnormal Delivery– Meconium

• Emergency care:– Do not stimulate the baby before suctioning the mouth and

nose!– Attempt to clear the baby’s mouth and nose before taking his

or her first breath.– Transport as soon as possible while assuring a patent airway

and adequate ventilation.




CHAPTERCHAPTER

• Active Labor and Abnormal Delivery– Premature Birth

• An infant is considered premature if he or she is born before the 38th week of pregnancy or is less than 5 pounds.

• Due to decreased development, premature babies are susceptible to a host of problems including hypothermia and respiratory distress.




CHAPTERCHAPTER

• Active Labor and Abnormal Delivery– Premature Birth

• Emergency Medical Care:– Dry the baby thoroughly to avoid heat loss.– Gently suction the mouth and nose to keep the airway clear of fluid.– Administer blow-by oxygen.– Support ventilation as needed.– Prevent contamination since the premature baby is very susceptible to infection.– Wrap the baby securely to keep it warm.




CHAPTERCHAPTER

• Assessment and Care of the Healthy Newborn– Protecting the newborn against heat loss is critical!

• Heat loss can deplete the newborn of vital energy needed for survival

• Assure that the newborn is completely dried and covered

– Also assure that the airway is clear of all secretion or birth fluids. Perform additional suctioning as needed.




CHAPTERCHAPTER

• Assessment and Care of the Healthy Newborn– Perform the APGAR score 1 and 5 minutes after

birth:• A - Appearance• P - Pulse• G - Grimace• A - Activity• R - Respirations




CHAPTERCHAPTER

• Assessment and Care of the Healthy Newborn– APGAR Score: Appearance

• The skin of a newborn should be pink. Assess the newborn’s skin color and score as follows:

– Entire body blue or pale - 0 points

– Blue hands and feet - 1 point

– Entire body pink - 2 points




CHAPTERCHAPTER

• Assessment and Care of the Healthy Newborn– APGAR Score: Pulse

• The pulse of a newborn should be greater than 100 beats per minute. Assess the newborn’s brachial pulse or use a stethoscope and score as follows:

– Pulse absent - 0 points– Pulse less than 100 - 1 point– Pulse greater than 100 - 2 points




CHAPTERCHAPTER

• Assessment and Care of the Healthy Newborn– APGAR Score: Activity

• A newborn should exhibit active flexion and extension of the extremities. Assess the newborn’s activity and score as follows:

– No extremity movement - 0 points– Minimal activity - 1 point– Strong activity - 2 points




CHAPTERCHAPTER

• Assessment and Care of the Healthy Newborn– APGAR Score: Respirations

• A newborn should breathe between 30 and 60 times a minute or exhibit a strong cry. Assess the newborn’s breathing and score as follows:

– No respiratory effort - 0 points– Slow (<30/minute), irregular, or weak cry - 1 point– Normal respirations or strong cry - 2 points




CHAPTERCHAPTER

• Assessment and Care of the Healthy Newborn– APGAR Score

• At the conclusion of the APGAR score, add the numbers together and consider the following:

– 7-10 points - The newborn should be active and vigorous. Provide routine care.

– 4-6 points - The newborn is moderately depressed. Provide stimulation and oxygen.

– 0-3 points - The newborn is severely depressed and requires extensive resuscitation.




CHAPTERCHAPTER

• Emergency Care of the Depressed Newborn– A minority of newborns will require some form of

resuscitation aside from drying, warming, positioning, and suctioning. Additional resuscitation measures include:

• Oxygen administration• Ventilation with the bag mask• CPR




CHAPTERCHAPTER




CHAPTERCHAPTER

• Emergency Care of the Depressed Newborn– Oxygen administration

• Administer blow-by oxygen if the newborn displays:

– Cyanosis of the skin– Spontaneous and

adequate breathing– Heart rate above 100

beats per minute




CHAPTERCHAPTER

• Emergency Care of the Depressed Newborn– Ventilation with the Bag Mask

• Provide ventilations with the bag mask at a rate of 30 to 60 breaths per minute if:

– The newborn’s breathing is slow or otherwise inadequate.

– The newborn’s heart rate is less than 100 beats per minute.

– The newborn’s trunk remains cyanotic despite the administration of blow-by oxygen.

• Reassess the infant’s color, respiratory effort, and heart rate after 30 seconds of ventilation.




CHAPTERCHAPTER

• Emergency Care of the Depressed Newborn– Cardiopulmonary Resuscitation

• Provide CPR if:– The newborn’s heart rate is less than 60 beats per minute.

• Reassess the infant’s

color, respiratory effort,

and heart rate after 30

seconds of CPR and

treat according to

findings.




CHAPTERCHAPTER

• General Information– Gynecological emergencies are those that apply to the

female reproductive system and typically present with:• Abdominal pain• Vaginal bleeding• Fever and chills (infection)• Sexual assault or rape

2727Gynecological EmergenciesGynecological Emergencies



CHAPTERCHAPTER

• Assessment– Assess the patient as you would any other person with

similar complaints.– Consider the following guidelines:

• Maintain a high regard for privacy and question the female in a discreet manner.

• If performing a rapid trauma assessment, cover the patient to protect her privacy.

• Never examine the genitalia of a sexual assault or rape victim unless there is profuse or life threatening hemorrhage.

• Preserve all evidence associated with a sexual assault or rape. Handle the patient’s clothing as little as possible.

• Follow local protocols for crime scene protection.




CHAPTERCHAPTER

• Treatment– Treat the patient as you would any other person with

similar complaints.• Ensure an adequate airway, breathing, and circulation. • Look for and treat shock (hypoperfusion) if present.• Place a sanitary napkin over the vaginal opening if

hemorrhage is present. Never pack the vagina to control bleeding.

• Provide additional care based on the patient’s complaint(s) or assessment findings.

• Transport.




CHAPTERCHAPTER

• Placenta Previa– Placenta previa occurs when the placenta is

abnormally implanted at the bottom of the uterus over the cervix.

• When the fetus changes position or the cervix dilates in preparation for birth, the placenta tears resulting in painless vaginal bleeding.

– Placenta previa is a major cause of third trimester bleeding (1 in 250 pregnancies) .

2727EnrichmentEnrichment



CHAPTERCHAPTER

• Placenta Previa– The hallmark sign of placenta previa is painless

vaginal bleeding during the third trimester.




CHAPTERCHAPTER

• Placenta Previa– Predisposing factors for placenta previa include:

• Greater than 2 deliveries• Rapid succession of pregnancies• Greater than 35 years of age• Previous placenta previa• History of early vaginal bleeding during pregnancy• Bleeding after intercourse during third trimester




CHAPTERCHAPTER

• Placenta Previa– Emergency Care

• Assess and care for the female as you would any other predelivery patient.

• Actively examine for shock (hypoperfusion).• Placenta previa can cause harm to both the mother and

baby and requires hospital evaluation.




CHAPTERCHAPTER

• Abruptio Placenta– Abruptio placenta is the abnormal separation of the

placenta from the uterine wall prior to birth and jeopardizes both mother and baby by:

• Providing inadequate gas

exchange (oxygen, carbon

dioxide, and waste removal)

between mother and fetus• Severe maternal blood loss

resulting in hypovolemic shock




CHAPTERCHAPTER

• Abruptio Placenta– Signs and symptoms of abruptio placenta include:

• Vaginal bleeding associated with pain• Abdominal pain due to muscle spasm of the uterus• Pain to the mid to lower back• Presence of uterine contractions (usually)• Tender abdomen on palpation• Vaginal bleeding (varies)

– The amount of active bleeding does not necessarily correlate to the actual blood loss due to blood trapping.




CHAPTERCHAPTER

• Abruptio Placenta– Predisposing factors for abruptio placenta include:

• Hypertension• Use of cocaine or other vasoconstrictive drugs• Preeclampsia• Several births• Previous abruption• Smoking• Short umbilical cord• Premature rupture of the amniotic sac• Diabetes mellitus




CHAPTERCHAPTER

• Abruptio placenta– Emergency Care


• Actively examine for shock (hypoperfusion).• Provide oxygen and rapid transport.




CHAPTERCHAPTER

• Preeclampsia and Eclampsia– Preeclampsia is a condition characterized by high

blood pressure, swelling in the extremities, headaches, and visual disturbances

– Eclampsia involves more severe cases of eclampsia with the addition of seizure activity

• Seizure can cause premature labor or abruptio placenta and prove life threatening to the fetus




CHAPTERCHAPTER

• Preeclampsia and Eclampsia– Signs and symptoms of preeclampsia and eclampsia

include:• Altered mental status• Hypertension• Abdominal pain• Blurred vision or other visual disturbances• Swelling of the extremities and/or face• Decreased urine output• Persistent vomiting• Seizures (specific to eclampsia)




CHAPTERCHAPTER

• Preeclampsia and Eclampsia– Predisposing factors for preeclampsia and eclampsia

include:• History of hypertension, diabetes, kidney disease, liver

disease, or heart disease• No previous pregnancies• History of poor nutrition




CHAPTERCHAPTER

• Preeclampsia and Eclampsia– Emergency Care


• Treat the seizing female like any other seizure patient.• Provide oxygen and quiet transport if a life threatening

condition like seizure activity is not present.




CHAPTERCHAPTER

• Ruptured Uterus– As the uterus enlarges throughout pregnancy, the

uterine wall becomes extremely thin and is prone to spontaneous or traumatic rupture.

• The fetus can be released into the abdominal cavity.

• Blood loss can be severe:– Maternal mortality is between

5 and 20%– Fetal mortality is 50%

• Uterine rupture requires emergency surgery.




CHAPTERCHAPTER

• Ruptured Uterus– Signs and symptoms of ruptured uterus include:

• Tearing or shearing sensation in the abdomen• Constant and severe abdominal pain• Nausea and vomiting• Shock (hypoperfusion)• Vaginal bleeding ranging from minor to severe• Cessation of noticeable contractions• Ability to palpate fetus in the abdominal cavity




CHAPTERCHAPTER

• Ruptured Uterus– Predisposing factors for ruptured uterus include:

• History of previous uterine rupture

• Abdominal trauma

• Large fetus

• History of birthing more than two children

• Prolonged and difficult labor

• Previous caesarean section or abdominal surgery




CHAPTERCHAPTER

• Ruptured Uterus– Emergency Care


• Treat shock (hypoperfusion) if present.• Provide oxygen and rapid transport.




CHAPTERCHAPTER

• Ectopic Pregnancy– An ectopic pregnancy occurs when the fertilized egg

implants in an area other than the uterus.• Fallopian tube (90%)• Abdominal cavity (6%)• Outside wall of the uterus• Ovary

– The growing embryo and placenta will eventually rupture the tissue causing life threatening hemorrhage.




CHAPTERCHAPTER

• Ectopic Pregnancy– Rupture typically occurs during the first semester

between 2 and 12 weeks.– Ectopic pregnancy occurs in 1 in 200 pregnancies.– Rupture ectopic pregnancy is the leading cause of

maternal death during pregnancy.




CHAPTERCHAPTER

• Ectopic Pregnancy– Signs and symptoms of an ectopic pregnancy

include:• Sudden, sharp abdominal pain to one side of the abdomen• Vaginal bleeding (varies in intensity)• Lower abdominal pain• Tender, bloated abdomen• Palpable mass in the abdomen• Weakness or dizziness when standing or sitting• Decreased BP and increased pulse rate• Signs of shock (hypoperfusion)• Urge to defecate




CHAPTERCHAPTER

• Ectopic Pregnancy– Predisposing factors for an ectopic pregnancy include:

• Previous ectopic pregnancy

• Pelvic inflammatory disease

• Adhesions from surgery

• Tubal ligation




CHAPTERCHAPTER

• Ectopic Pregnancy– Emergency Care


• Treat shock (hypoperfusion)if present.• Provide oxygen and rapid transport.


CHAPTER Copyright 2004 Prentice Hall Publishing A division of Pearson Inc. Prehospital Emergency...

Documents

Transcript of CHAPTER Copyright 2004 Prentice Hall Publishing A division of Pearson Inc. Prehospital Emergency...