20: Obstetric and Gynecologic Emergencies

Cognitive Objectives (1 of 4)

4-9.1 Identify the following structures: uterus, vagina, fetus, placenta, umbilical cord, amniotic sac, perineum.

4-9.2 Identify and explain the use of the contents of an obstetrics kit.

4-9.3 Identify predelivery emergencies.4-9.4 State indications of an imminent delivery. 4-9.5 Differentiate the emergency medical care

provided to a patient with predelivery emergencies from a normal delivery.

Cognitive Objectives (2 of 4)

4-9.6 State the steps in the predelivery preparation of the mother.

4-9.7 Establish the relationship between body substance isolation and childbirth.

4-9.8 State the steps to assist in the delivery.

4-9.9 Describe care of the baby as the head appears.

4-9.10 Describe how and when to cut the umbilical cord.

Cognitive Objectives (3 of 4)

4-9.11 Discuss the steps in the delivery of the placenta.

4-9.12 List the steps in the emergency medical care of the mother postdelivery.

4-9.13 Summarize neonatal resuscitation procedures.

4-9.14 Describe the procedures for the following abnormal deliveries: breech birth, prolapsed cord, limb presentation.

Cognitive Objectives (4 of 4)

4-9.15 Differentiate the special considerations for multiple births.

4-9.16 Describe special considerations of meconium.

4-9.17 Describe special considerations of a premature baby.

4-9.18 Discuss the emergency medical care of a patient with a gynecological emergency.

Affective Objectives

4-9.19 Explain the rationale for understanding the implications of treating two patients (mother and baby).

Psychomotor Objectives (1 of 2)

4-9.20 Demonstrate the steps to assist in the normal cephalic delivery.

4-9.21 Demonstrate necessary care procedures of the fetus as the head appears.

4-9.22 Demonstrate infant neonatal procedures.4-9.23 Demonstrate postdelivery care of infant. 4-9.24 Demonstrate how and when to cut the

umbilical cord. 4-9.25 Attend to the steps in the delivery of the

placenta.

Psychomotor Objectives (2 of 2)

4-9.26 Demonstrate the postdelivery care of the mother.

4-9.27 Demonstrate the procedures for the following abnormal deliveries: vaginal bleeding, breech birth, prolapsed cord, limb presentation.

4-9.28 Demonstrate the steps in the emergency medical care of the mother with excessive bleeding.

4-9.29 Demonstrate completing a prehospital care report for patients with obstetrical/gynecological emergencies.

Female Reproductive System

Three Stages of Labor

• First stage– Dilation of the cervix

• Second stage– Expulsion of the infant

• Third stage– Delivery of the placenta

Predelivery Emergencies

• Preeclampsia

– Headache, vision disturbance, edema, anxiety, high blood pressure

• Eclampsia

– Convulsions resulting from hypertension

• Supine hypotensive syndrome

– Low blood pressure from lying supine

Hemorrhage

• Vaginal bleeding that occurs before labor begins

• If present in early pregnancy, it may be a spontaneous abortion or ectopic pregnancy.

Ectopic Pregnancy

• Pregnancy outside of the uterus

• Should be considered for any woman of childbearing age with unilateral lower abdominal pain and missed menstrual period

• History of PID, tubal ligation, or previous ectopic pregnancy

Placenta Problems

• Placenta abruptio– Premature separation

of the placenta

• Placenta previa– Development of

placenta over the cervix

Gestational Diabetes

• Develops only during pregnancy.• Treat as regular patient with diabetes.

You are the Provider

• You and your partner are dispatched to the A&E Bank for a woman in active labor.

• En route, you discuss previous experiences assisting in a delivery and how you can prepare yourselves.

• What equipment should accompany you and your partner inside the bank?

You are the Provider (continued)

• You find a woman in her mid 30s lying on the couch, holding her abdomen and moaning.

• Between labored breaths she tells you that her name is Jane and that she is a teller.

• She is conscious, alert, and oriented. Breathing in rapid panting breaths. Pulse is strong and bounding. Skin is pale and clammy.

• What questions might you consider asking to assess how far along her labor is?

Scene Size-up

• Woman’s balance is altered. Be aware for falls and the need for spinal stabilization.

• Use BSI.• Usual threats to your safety still exist.• Be calm. Protect the mother and the child.

Initial Assessment

• Is the mother in active labor?• Evaluate trauma or medical problems first.• Treat ABCs in line with local protocols.

Transport Decision

• If delivery is imminent, prepare for delivery in warm, private location.

• If delivery is not imminent, transport on left side if in last two trimesters of pregnancy.

• If the patient was subject to spinal injury, stabilize and prop backboard with towel roll on right side.

You are the Provider (continued)

• The woman is one week past her due date. She has been having contractions for the past hour.

• Her water broke just before your arrival. This is her fourth pregnancy, and she has three children.

• She feels like she has to go to the restroom. • Your partner applies high-flow oxygen via a

nonrebreathing mask and begins timing her contractions.

• What does the patient’s request to go to the restroom indicate?

Focused History and Physical Exam

• Obtain full SAMPLE history, and also:– Prenatal history– Complications during pregnancy– Due date– Number of babies (twins)– Drugs or alcohol– Water broken– Green fluid (meconium)

Focused Physical Exam

• Mainly abdomen and delivery of fetus• Based on her chief complaints and history• Pay close attention to tachycardia, hypotension, or

hypertension.

Interventions

• Childbirth is natural, does not require intervention in most cases.

• Treating the mother will benefit the baby.

You are the Provider (continued) (1 of 2)

• You explain that you need to examine the patient before preparing her for transport to the hospital.

• While doing so, she tells you that when she went to the doctor yesterday she was dilated to 3 cm and that she lost her mucous plug about one hour ago.

• Your partner tells you that her contractions are 45 seconds long and are 55 seconds apart.

• Should you check for crowning?

You are the Provider (continued) (2 of 2)

• Upon examination, you find that the baby is crowning. You and your partner prepare for an imminent birth.

• Your partner notifies dispatch and requests ALS backup, and notifies medical control.

• You quickly help move the patient to the floor. Using your OB kit, you prepare a sterile delivery field.

• Your patient tells you that she needs to push. On the next contraction, the baby’s head is delivered, facing downward.

• Why should you feel around the baby’s neck?

Detailed Physical Exam

• Only if other treatments are not required.

Ongoing Assessment

• Continue to reassess the patient for changes in vital signs. Watch for hypoperfusion.

• Notify hospital of your preparations for delivery.• Document carefully, especially baby’s status.• Obstetrics is one of the most litigated specialties in

medicine.

You are the Provider (continued)

• You successfully deliver a beautiful baby girl. • You have suctioned her mouth and nose, dried her

off, and wrapped her in a blanket. • Umbilical cord has been cut and placenta

delivered. ALS personnel arrive.• What care should every infant receive?

When to Consider Field Delivery

• Delivery can be expected within a few minutes

• A natural disaster or other catastrophe makes it impossible to reach a hospital

• No transportation is available

Preparing for Delivery

• Use proper BSI precautions.• Be calm and reassuring while protecting

the mother’s modesty.• Contact medical control for a decision to

deliver on scene or transport.• Prepare OB kit.

Positioning for Delivery

Delivering the Baby

• Support the head as it emerges.

• Once the head emerges, the shoulders will be visible.

• Support the head and upper body as the shoulders deliver.

• Handle the infant firmly but gently as the body delivers.

• Clamp the cord and cut it.

Complications With Normal Vaginal Delivery

• Unruptured amniotic sac

– Puncture the sac and push it away from the baby.

• Umbilical cord around the neck

– Gently slip the cord over the infant’s head.

– It may have to be cut.

Postdelivery Care

• Immediately wrap the infant in a towel with the head lower than the body.

• Suction the mouth and nose again.

• Clamp and cut the cord.

• Ensure the infant is pink and breathing well.

Delivery of Placenta

• Placenta is attached to the end of the umbilical cord.

• It should deliver within 30 minutes.• Once the placenta delivers, wrap it and take to the

hospital so it can be examined.• If the mother continues to bleed, transport promptly

to the hospital.

APGAR Scoring

A Appearance

P Pulse

G Grimace

A Activity

R Respirations

Neonatal Resuscitation

Giving Chest Compressionsto an Infant (1 of 2)

• Find the proper position– Just below the nipple line– Middle third of the sternum

• Wrap your hands around the body, with your thumbs resting at that position.

• Press your thumbs gently against the sternum, compressing 1/2˝ to 3/4˝ deep.

Giving Chest Compressionsto an Infant (2 of 2)

• Ventilate with a BVM device after every third compression.

• 100 compressions to 20 ventilations per minute

• Continue CPR during transport.

Breech Delivery

• Presenting part is the buttocks or legs.

• Breech delivery is usually slow, giving you time to get to the hospital.

• Support the infant as it comes out.

• Make a “V” with your gloved fingers then place them in the vagina to prevent it from compressing infant’s airway.

Rare Presentations (1 of 2)

• Limb presentation– This is a very rare

occurrence.– This is a true emergency

that requires immediate transport.

Rare Presentations (2 of 2)

• Prolapsed cord– Transport immediately.– Place fingers into the

mother’s vagina and push the cord away from the infant’s face.

Excessive Bleeding

• Bleeding always occurs with delivery but should not exceed 500 mL.

• Massage the mother’s uterus to slow bleeding.

• Treat for shock.

• Place pad over vaginal opening.

• Transport to hospital.

Spina Bifida

• Defect in which the portion of the spinal cord or meninges may protrude outside the vertebrae or body.

• Cover area with moist, sterile compresses to prevent infection.

• Maintain body temperature by holding baby against an adult for warmth.

Abortion (Miscarriage)

• Delivery of the fetus or placenta before the 20th week

• Infection and bleeding are the most important complications.

• Treat the mother for shock.• Transport to the hospital.• Bring tissue that has passed through the vagina

to the hospital.

Twins

• Twins are usually smaller than single infants.• Delivery procedures are the same as that for single

infants.• There may be one or two placentas to deliver.

Delivering an Infantof an Addicted Mother

• Ensure proper BSI precautions

• Deliver as normal.

• Watch out for severe respiratory depression and low birth weight.

• Infant may require immediate care.

Premature Infants and Procedures

• Delivery before 8 months or weight less than 5 lb at birth.– Keep the infant warm.– Keep the mouth and

nose clear of mucus.– Give oxygen.– Do not infect the infant.– Notify the hospital.

Fetal Demise

• An infant that has died in the uterus before labor

• This is a very emotional situation for family and providers.

• The infant may be born with skin blisters, skin sloughing, and dark discoloration.

• Do not attempt to resuscitate an obviously dead infant.

Delivery Without Sterile Supplies

• You should always have goggles and sterile gloves with you.

• Use clean sheets and towels.• Do not cut or clamp umbilical cord.• Keep placenta and infant at same level.

Gynecologic Emergencies

• Do not examine genitalia unless there is obvious bleeding.

• Leave any foreign bodies in place, after packing with bandages

• Treat as any other patient with blood loss.

Review

1. The first stage of labor ends when:

A. the presenting part of the baby is visible.

B. contractions are less than 10 minutes apart.

C. the mother experiences her first contraction.

D. the amniotic sac ruptures and labor pains begin.

Review

Answer: A

Rationale: The first stage of labor begins with the onset of contractions and ends when the cervix is fully dilated. However, since cervical dilation cannot be assessed in the field, the first stage of labor is considered over when the presenting part of the baby is visible at the vaginal opening (crowning).

Review

1. The first stage of labor ends when:

A. the presenting part of the baby is visible.

Rationale: Correct answer

B. contractions are less than 10 minutes apart.

Rationale: True labor is when the frequency and intensity of contractions increase and is part of the first stage of labor.

C. the mother experiences her first contraction.

Rationale: This is the beginning of the first stage of labor.

D. the amniotic sac ruptures and labor pains begin.

Rationale: This is considered to be a part of the first stage of labor.

Review

2. A newborn is considered to be “term” if it is born after ____ weeks and before ____ weeks.

A. 34, 37

B. 37, 42

C. 38, 44

D. 39, 43

Review

Answer: B

Rationale: A term gestation ranges between 37 and 42 weeks. An infant who is born before 37 weeks gestation (or weighs less than 5.5 lb, regardless of gestational age) is considered premature. An infant born after 42 weeks is considered past due.

Review2. A newborn is considered to be “term” if it is born after ____ weeks

and before ____ weeks.

A. 34, 37 Rationale: A newborn is considered premature if he/she is born

before 37 weeks.B. 37, 42 Rationale: Correct answerC. 38, 44 Rationale: A newborn is considered past due if he/she is born after

42 weeks.D. 39, 43Rationale: A newborn is considered past due if he/she is born after

42 weeks.

Review

3. Upon delivery of the baby's head, you note that the umbilical cord is wrapped around its neck. You should:

A. immediately clamp and cut the cord.

B. make one attempt to slide the cord over the head.

C. keep the cord moist and transport as soon as possible.

D. give the mother high-flow oxygen and transport rapidly.

Review

Answer: B

Rationale: If the umbilical cord is wrapped around the baby's neck (nuchal cord), you should make one attempt to gently remove the cord from around the baby's neck. If this is not possible, the cord should be clamped and cut. Keep the cord moist, administer high-flow oxygen to the mother, and transport at once.

Review3. Upon delivery of the baby's head, you note that the umbilical cord is

wrapped around its neck. You should:

A. immediately clamp and cut the cord.Rationale: Do this only after an attempt is made to slide the cord over

the infant’s head.B. make one attempt to slide the cord over the head. Rationale: Correct answerC. keep the cord moist and transport as soon as possible. Rationale: This is the treatment for deliveries where the cord presents

and not the infant’s head.D. give the mother high-flow oxygen and transport rapidly. Rationale: Do this only after an attempt to slide the cord over the

infant’s head.

Review

4. Immediately after delivery of the infant’s head, you should:

A. suction the baby's mouth and then nose.

B. suction the baby's nose and then mouth.

C. assess its breathing effort and skin color.

D. check the position of the umbilical cord.

Review

Answer: D

Rationale: Immediately following delivery of the infant’s head, you should check the position of the umbilical cord to make sure it is not wrapped around the baby's neck (nuchal cord). If a nuchal cord is not present, suction the infant’s mouth and nose.

Review4. Immediately after delivery of the infant’s head, you should:

A. suction the baby's mouth and then nose.Rationale: After EMS has confirmed that the cord is not around the

infant’s head, suctioning of the mouth and then the nose should be performed.

B. suction the baby's nose and then mouth.Rationale: After EMS has confirmed that the cord is not around the

infant’s head, suctioning of the mouth and then the nose should be performed.

C. assess its breathing effort and skin color. Rationale: This cannot be performed until the entire infant has been

delivered completely.D. check the position of the umbilical cord. Rationale: Correct answer

Review

5. The MOST effective way to prevent cardiopulmonary arrest in a newborn is to:

A. rapidly increase its body temperature.

B. allow it to remain slightly hypothermic.

C. ensure adequate oxygenation and ventilation.

D. start CPR if the heart rate is less than 100 beats/min.

Review

Answer: C

Rationale: Cardiopulmonary arrest in infants and children (including newborns) is most often the result of respiratory arrest. Therefore, ensuring adequate oxygenation and ventilation at all times is critical. It is also important to maintain the infant’s body temperature and to prevent hypothermia.

Review

5. The MOST effective way to prevent cardiopulmonary arrest in a newborn is to:

A. rapidly increase its body temperature.

Rationale: It is important to maintain the infant’s body temperature and prevent hypothermia.

B. allow it to remain slightly hypothermic.

Rationale: Hypothermia and shivering will deplete the infant’s glucose and cause hypoglycemia.

C. ensure adequate oxygenation and ventilation.

Rationale: Correct answer

D. start CPR if the heart rate is less than 100 beats/min.

Rationale: Start CPR when the heart rate is less than 60 beats/min and not increasing with adequate ventilations.

Review

6. A 23-year-old woman, who is 24 weeks pregnant with her first baby, complains of edema to her hands, a headache, and visual disturbances. When you assess her vital signs, you note that her blood pressure is 160/94 mm Hg. She is MOST likely experiencing:

A. eclampsia. B. preeclampsia. C. a hypertensive crisis. D. chronic water retention.

Review

Answer: B

Rationale: Preeclampsia—also called pregnancy-induced hypertension—usually develops after the 20th week of gestation and most commonly affects primagravida (first pregnancy) patients. It is characterized by a headache, visual disturbances, edema of the hands and feet, anxiety, and high blood pressure. Preeclampsia can lead to eclampsia, a life-threatening condition that is characterized by seizures.

Review6. A 23-year-old woman, who is 24 weeks pregnant with her first baby,

complains of edema to her hands, a headache, and visual disturbances. When you assess her vital signs, you note that her blood pressure is 160/94 mm Hg. She is MOST likely experiencing:

A. eclampsia. Rationale: Eclampsia is a seizure that results from severe

hypertension.B. preeclampsia. Rationale: Correct answerC. a hypertensive crisis. Rationale: This is a severe, sudden increase in blood pressure,

typically greater than 110 diastolic, that can lead to a stroke.D. chronic water retention. Rationale: This is a fluid imbalance usually caused by too much sodium

in the body.

Review

7. The 1-minute APGAR score of a newborn reveals that the baby has a heart rate of 90 beats/min, a pink body but blue hands and feet, and rapid respirations. The baby cries when the soles of its feet are flicked and resists attempts to straighten its legs. You should assign an APGAR score of:

A. 4B. 6C. 8D. 9

Review

Answer: C

Rationale: The APGAR score, which is obtained at 1 and 5 minutes after birth, assigns a numeric value (0, 1, or 2) to the following five areas: Appearance, Pulse, Grimace, Activity, Respirations. Most newborns have a 1-minute APGAR of 7 or 8, with the 5-minute score usually being 8-10.

Review7. The 1-minute APGAR score of a newborn reveals that the

baby has a heart rate of 90 beats/min, a pink body but blue hands and feet, and rapid respirations. The baby cries when the soles of its feet are flicked and resists attempts to straighten its legs. You should assign an APGAR score of:

A. 4Rationale: A normal APGAR score is 7-8. A 4 would mean that

the infant is truly in a depressed condition.B. 6Rationale: A normal 1-minute APGAR score is 7-8.C. 8Rationale: Correct answerD. 9Rationale: This is a typical score that EMS would get at the

5-minute APGAR.

Review

8. While assisting a woman in labor, you visualize her vaginal area and see an arm protruding from her vagina. She tells you that she feels the urge to push. You should:

A. cover the arm with a sterile towel and transport immediately.

B. encourage her to keep pushing as you prepare for rapid transport.

C. insert your gloved fingers into the vagina and try to turn the baby.

D. instruct the mother to keep pushing and give her high-flow oxygen.

Review

Answer: A

Rationale: Limb presentations do not deliver in the field—period! If the mother feels the urge to push, instruct her to stop; she should pant instead. Cover the protruding limb with a sterile towel, administer high-flow oxygen to the mother, and transport immediately. Delivery must take place in the hospital.

Review8. While assisting a woman in labor, you visualize her vaginal area and

see an arm protruding from her vagina. She tells you that she feels the urge to push. You should:

A. cover the arm with a sterile towel and transport immediately. Rationale: Correct answerB. encourage her to keep pushing as you prepare for rapid transport. Rationale: EMS cannot successfully deliver such a presentation in the

field.C. insert your gloved fingers into the vagina and try to turn the baby.Rationale: You should only do this to create an airway for the infant in a

breech presentation.D. instruct the mother to keep pushing and give her high-flow oxygen. Rationale: EMS cannot successfully deliver such a presentation in the

field.

Review

9. The need for and extent of newborn resuscitation is based on:

A. the 1-minute APGAR score.

B. the gestational age of the newborn.

C. the newborn’s response to oxygen.

D. respiratory effort, heart rate, and color.

Review

Answer: D

Rationale: The need for and extent of newborn resuscitation is based on respiratory effort, heart rate, and skin color. The APGAR score is not used to determine if resuscitation is needed; the first score is not assigned until the newborn is 1 minute of age. Resuscitation, if needed, should commence immediately.

Review

9. The need for and extent of newborn resuscitation is based on:

A. the 1-minute APGAR score.

Rationale: APGAR is not used to determine if resuscitation is needed.

B. the gestational age of the newborn.

Rationale: A premature gestational age may indicate a greater risk for the infant, but does not indicate if resuscitation is required.

C. the newborn’s response to oxygen.

Rationale: Oxygen response is evaluated by respiratory rate, heart rate, and color.

D. respiratory effort, heart rate, and color.

Rationale: Correct answer

Review

10. A 30-year-old woman is 28 weeks pregnant. She had a spontaneous abortion with her first child and gave birth to three healthy children. Her obstetric history should be documented as:

A. Gravida 5; para, 4.

B. Gravida, 5; para, 3.

C. Gravida, 1, para, 4.

D. Gravida, 4; para, 1.

Review

Answer: B

Rationale: Gravida refers to the number of times a woman has been pregnant, and para refers to the number of living babies she’s delivered. She is currently pregnant, had one spontaneous abortion in the past, and has three living children; therefore, she has been pregnant five times (gravida, 5). However, since one of her pregnancies spontaneously aborted, and she has not delivered her current baby, she has only given birth to three living babies (para, 3). If her current pregnancy yields a living baby, she will become gravida, 5; para, 4.

Review

10. A 30-year-old woman is 28 weeks pregnant. She had a spontaneous abortion with her first child and gave birth to three healthy children. Her obstetric history should be documented as:

A. Gravida 5; para, 4.

Rationale: This means 5 pregnancies and 4 births.

B. Gravida, 5; para, 3.

Rationale: Correct answer

C. Gravida, 1, para, 4.

Rationale: This means 1 pregnancy and 4 births.

D. Gravida, 4; para, 1.

Rationale: This means 4 pregnancies and 1 birth.