Download ob-gyn emergencies - faculty at Chemeketa

OB-GYN EMERGENCIES
Peggy Andrews
EMT-Paramedic
Chemeketa Community College
1
OBJECTIVES






Abuse in pregnancy
Breech presentation
Cystitis
Delivery
Diabetes in
pregnancy
Early antepartum
hemorrhage







Eclampsia
Ectopic pregnancy
Endometritis
Endometriosis
Fertilization
Gestational changes
Late antepartum
hemorrhage
2
Objectives, cont.






Ovulation
PID
PIH
Postpartum
Hemorrhage
Pre-eclampsia
Prolapsed cord






Ruptured ovarian cyst
Sexual Assault
Trauma in pregnancy
Mittelschmertz
Threatened abortion
Vaginal hemorrhage
3
Terminology






Amenorrhea
Antepartum
Birth canal
Bloody show
Cervix
Crowning








EDC
Endometrium
Effacement
Gravida
Menarche
Menstruation
Menopause
Menses
4

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Multigravida
Multipara
Neonate
Ovulation
Parity
Placenta
Polyhydramnios







Postpartum
Prenatal period
Preterm labor
Primipara
Prenatal
Primagravida
Sexual assault
5
Basic Anatomy - External


Protect body openings
Vulva






Perineum
Mons Pubis
Labia
Vestibule
Clitoris
Urethra
6
Gynacoid pelvis
11 cm anteriorposterior
12.75 cm oblique
13.5 cm
transverse
Female pelvis
7
occiputoanterior position
vs
face-to-pubis (sunny-side
up)
8
Basic Anatomy - Internal

Vagina

Elastic, 9-10 cm

Connects external genitalia
to uterus

Vaginal artery
9
Internal anatomy, cont.

Uterus; hollow, muscular organ




Flexed forward between bladder and rectum
~7.5 cm long, 5 cm wide
Provides site for fetal development
At term, measures ~ 40 cm in length
10



Uterine arteries; branches of internal iliac
artery
Enervated by autonomic nervous system
Two major parts
Body (corpus)
 Cervix

11
Internal anatomy, cont.

Fundus


Above point where
fallopian tubes attach
Measurement of
fundal height most
accurate from 22-34
weeks
12

Uterine body
 Endometrium
 Innermost layer
 menses
 Myometrium
 3 distinct layers of smooth
muscle
 Middle layer made up of figure-8
patterns of muscle fibers
 Surround large blood vessels
 Perimetrium
 Serous membrane – layer of
viseral peritoneum
13
Internal anatomy, cont.

Cervix



Connects uterus
with vagina
~ 2.5 cm long
Dilates to 10 cm
diam. during labor
14
Internal Anatomy, cont.

Fallopian tubes; 10 cm
long

Fertilization usually
occurs in distal third
15
Ovaries

connected to uterus by ovarian ligament

produce estrogen & progesterone

Development and release of ovum
16
The menstrual cycle

Menarche


10 – 14 y/o
Menstrual cycle


21 – 32 day cycle
Ovulation –
menstruation
always 14 days
17
The proliferative phase

At birth, ovaries contain ~ 2,000,000 ova


400 eventually released
The first two weeks



Dominated by estrogen
LH (luteinizing Hormone)surge at day 14
Ovulation
18



FSH (Follicle Stimulating Hormone),
estrogen levels increase
Ovum discharges into abdominal cavity
Cilia on fimbriated ends of fallopian tubes
draw egg into tube
19
The secretory phase



Stage of menstrual cycle immediately
surrounding ovulation
If egg not fertilized, estrogen level drops,
progesterone level dominates
Uterine vascularity increases
20
The ischemic phase


Fertilization doesn’t occur; estrogen,
progesterone levels fall
Vascular changes cause endometrium to
become pale, small blood vessels rupture
21
The menstrual phase





Ischemic endometrium is shed
Normal flow lasts 3 – 5 days
Average blood loss 50 cc
PMS
Menopause


45 – 55 y/o
Estrogen levels decrease

Hot flashes, mood swings, night sweats
22
Contraceptives






Rhythm
method
Coitus
interruptus
Diaphragm
Cervical Cap
Condoms
Spermicide
23
Contraceptives







Intrauterine
device
Oral
contraceptives
Norplant
NuvaRing
Tubal ligation
Vasectomy
Abstinence
24





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Ortho Evra
Paragard
Depo-provera
Lunelle
Protectaid sponge
Essure micro-insert
25
26
27
Patient Assessment
Suspect OB emergency in all females!!



Most common complaints; abdominal pain, vaginal
bleeding
OPQRST
LMP


Dysmenorrhea
Associated S/S




Fever, chills
N/V/D or constipation
Urinary frequency, pain, cramping
Dyspareunia
28
Patient assessment, cont.

Vaginal discharge, bleeding?
If bleeding, how does amount compare with
usual period?
 # pads? 30 cc






Syncopal?
Gravida
Para
Ab
Previous ectopic pregnancies, infections,
tubal ligation, D&C’s, trauma
29
Patient Assessment








Be professional
Protect modesty
Maintain privacy
Be considerate
Assess skin and mucous membranes
Vital signs
Auscultate, palpate abdomen
Inspect vaginal area prn
30
Case history

You arrive at the home of a 26 year old
female who c/o acute abdominal pain. She is
pale, diaphoretic, and appears shocky. Her
pulse is 130, BP 90/50, RR 28. She is Para
0, Gravida 0, Ab 0. She says she is sexually
active, and can’t be pregnant, because she is
taking BC Pills. Her LMP was 2 weeks ago.
She smokes 1 – 1 ½ packs of cigarettes/day.
What is her DDX?
31
Case History, cont

DDX




PE
Sepsic/Toxic shock?
?
Tx:

?
32
Management of gynecological
emergencies
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Primarily supportive
Be alert for s/s of shock
Do not pack dressings in vagina
Consider PASG
Auscultate, palpate abdomen
Oxygen prn
IV’s prn
33
PID



Infection; usually involve uterus, fallopian tubes,
ovaries
Sexually active women 15-24
Most common cause;



Gonorrhea
Chlamydia
Predisposing factors


Multiple sexual partners
PMH
34
PID






May result in sepsis,
Sterility
Adhesions
“PID shuffle”
Fever, chills, N/V, discharge, irregular
menses
Tx: antibiotics
35
Case history
36
Case History, cont.

DDX?

Tx:
37
Ruptured Ovarian Cyst




GYN emerg.
Significant internal hemorrhage
A thin walled, fluid-filled sac
Abdominal pain secondary to



Rapid expansion
Torsion
Acute rupture
38
Ruptured Ovarian Cyst



Most common cyst that ruptures – corpus luteum
cyst (space left in ovary after ovulation)
Most ruptures occur ~ 1 week before period
S/s



Localized, unilateral lower abdominal pain
Generalized s/s peritonitis
Onset assoc. minimal abdominal trauma, sexual
intercourse, exercise
39
40
Teratoma Cyst

41
Mature cystic teratoma of the
ovary prior to exision

42

43
Cystitis

Inflammation of inner lining of bladder;


Bacterial infection
S/S
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Urinary urgency
Dysuria
Low-grad fever
Chills
Pain above symphysis pubis
44
Dysmenorrhea – common in
women who have not borne children


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Painful menses
H/A
Faintness
Dizziness
Nausea

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Diarrhea
Backache
Leg pain
Chills
45
Mittelschmerz

Mid-cycle abdominal pain
Possibly secondary to rupture of
graafian follicle, bleeding from ovary

S/S



Unilateral lower quadrant pain, midcycle
Duration about 24-36 hours
46
Endometritis

Inflammation of the uterine lining
 Usually secondary to infection
 Most common after childbirth or
abortion
 May affect fallopian tubes and uterus
47
Endometritis

S/S




Onset 48-72 hours after
procedure/miscarriage
Fever 101 – 104 deg. F
Purulent vaginal discharge
Lower abdominal pain
48
Endometriosis


Abnormal gynecological condition
Females 30 – 40 y/o
 Ectopic growth and functioning of
endometrial tissue
 Fragments regurgitated backward during
menstruation
 Average age of women 37 years
49
Endometriosis

S/S




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Pain
Painful defecation
Suprapubic soreness
Premenstrual vaginal staining
infertility
50
Ectopic
Pregnancy





Common
occurrence
Develops outside of
uterus
Dx first 2 months
@ 1/200
Most symptomatic
and/or detected 2-12
weeks gestation
51
Ectopic
Pregnancy



Leading cause of
pregnancy related
death in first trimester.
Black teens and other
minority races
mortality 5x higher
than white teens.
Most occur in females
25-34 y/o.
52
H&P

History:
 Amenorrhea

Physical:
 Severe abd. Pain
 Shock S/S
 Vaginal bleed
 absent or
minimal
53
Causes:



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

PID
tubal ligation
abdominal or pelvic surgery
previous elective abortions
history of infertility
prior ectopic
current IUD use
54
Prehospital Care


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
Tx:
oxygen
position of comfort
keep warm
IV’s
Prognosis:
 good with early diagnosis
55
Case History
56
Case history, cont.
57
Causes of Gynecological Trauma

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Straddle injury
Direct blows
Seat-belt injuries
Foreign bodies inserted into vagina
Attempted self-abortion
Lacerations after child-birth
58
Management of trauma



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
Direct pressure over laceration
Cold packs
IV’s prn
Never pack vagina regardless of bleeding
Transport rapidly
59
Sexual assault






700,000 women annually (est. 60% never
reported)
Males represent 5%
Sexual abuse in children 50,000 –
350,000/yr
Most victims know their assailant (80 %)
Definition of sexual assault varies stateto-state
Sexual contact without consent
60
Assessment



Limited history – privacy
 Provide safe environment
 Specific questions - NOT about incident
 Paramedic of same sex, if possible
 Expect various reactions from patient
Don’t allow pt. To drink, brush teeth, shower,
urinate or defecate
Handle clothing as little as possible; – PAPER
bags
61
Save Evidence




Don’t cut through cuts or tears
Don’t examine perineal area
Don’t clean wounds
If patient is covered with sheet, submit as
evidence
62
Documentation



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

State patient remarks accurately.
Use quotation marks
Objectively state your observations
Document any evidence turned over to
hospital staff; include name of staff
Do NOT include personal opinion
CHART CAREFULLY – YOU’RE
PROBABLY GOING TO COURT!
63
Case history
64
65
66
Pregnancy

Fertilization
 One egg
 Avg >200 million sperm
 Sex chromosome from sperm that
determines gender
67
Placenta development


Starts forming at day 10, complete at 12
weeks
Active endocrine gland
68
Pregnancy

Implantation
 Blastocyst
 Trophoblast; days 5-10
 Heart beat at 3 ½ weeks
 Brain waves at 8 weeks
69
Fetal Development

Attached by umbilical cord
2
arteries – deoxygenated blood
1
vein – oxygenated blood

Exchange of gases, nutrients

Excretion of waste

Heat transfer
70
Fetal Development

Ductus venosus


Foramen ovale


Continuation of umbilical cord – a shunt to
bypass liver
Shunts blood from RA to LA
Ductus arteriosus

Connects aorta and pulmonary artery
71

Amniotic sac forms days 10-12
 500 – 1000 ml of fluid at birth
Fetal urine
 Secretions from respiratory tract, skin and
amniotic membranes


Functions; protect fetus, permit
movement, regulate temperature
72
Fetal Development

Heart chambers & valves develop at 4-7
weeks


Fetal circulation does not rely on lungs for
oxygenation
At birth, pressure changes cause ductus
arteriosus & ductus venosus to close.
Foramen ovale closes also.
73
Lung Development
74
75
When is she due?

EDC - Gestation
 40 weeks (10 lunar months)
 From first day of last period; count
back 3 months, forward 10 days
 Why is this date so important?
76
Fetal Viability
(N Engl J Med 1993)
Weeks Gestation 6-Month
Survival %
22 *
14.8
Survival w/o
severe abnorm %
0*
23
25
2
24
42
21
25 *
57
69 *
77
78
Case Review
79
Maternal Physiology Changes
During Pregnancy
The First Trimester

Morning sickness



Any time; usually
by 6th week
Better by 14th week
Nutritional
requirements

appetite increases
80
During the second trimester

GI motility decreases
= constipation

Gastric acid increases
= heartburn
Gallbladder function
slows = gallstones


Diaphragm up 4 cm
81
The third trimester
Metabolism changes - wt.
Gain 12 kg
 Kidneys increase in length
 Ureters lengthen,
change shape = UTI

82
The third trimester
Bladder moves up,
flattens; incr. Capacity to
1500 ml

Blood volume
increases up to 45-50%
at term

83
The third trimester, cont.




RBC’s increase
33%
WBC count
increases
Clotting factors
change
Tidal volume incr.
Up to 50%
84
More changes…
Heart displaced to left
 Flat or negative T-waves
in lead III
 Cardiac capacity
increases by 30%; size
incr. 12%
 Cardiac output incr.40%
by 20 weeks

85
And still more changes…



Pulse rate
increases
Murmurs
common;
lowered blood
viscosity
Systolic BP
decreases
11
86
Still more…



Diastolic
pressure
decreases
then increases
by 12-26 weeks
Stroke Volume
declines
87




Uterine size
increases from 70
g to 1000 g
Uterus triples in
size and weight by
2nd month
Palpable
suprapubically by
3rd month
At level of
umbilicus by 20th
week
And more….
11
88
And more…




Cervix
 Blood and lymph flow increases; softened
and bluish discoloration of cervix;
Chadwick’s sign
Vagina
 Characteristic violet color; increased
vascularity
 Vaginal secretions increase
 pH decreases to ~ 3.5
Hemorrhoids
Pedal edema
89
History







Length of gestation
Parity
Gravidity
TAb or Ab
Maternal lifestyle
Infectious disease status
Hx of previous OB-GYN
problems
90
History




Pain
Vaginal bleeding
Presence of show
Current general health and
prenatal care
91
Exam





Anticipate variations in
vital signs
Assess and monitor vitals
frequently
Examine abdomen
Gentle palpation
Evaluation of uterine size
92
Case history
93
Case history, cont.
94
Fetal monitoring

Auscultate heart
sounds after 16 weeks
gestation


Move stethoscope in
circular pattern about
6-8” around umbilicus
Normal fetal heart rate
is 120-160/min.
95
Early Antepartum
Hemorrhage



The spontaneous or artificial loss of
early pregnancy (< 20 weeks
gestation).
5-15%
25% have some degree of vaginal
bleeding during first 2 trimesters. @
50% result in abortion.
96
Threatened Abortion



early symptoms of pregnancy.
Mild cramps with bleeding.
Inevitable Abortion


persistent cramps and moderate bleeding.
Cervical os is open.
97
Incomplete Abortion


some retained products of conception.
Ongoing cramping and excessive bleeding
98
Complete Abortion

entire conceptus expelled with decreasing
or ceasing of cramps and bleeding
99


Missed abortion
 products of conception retained 3 or more
weeks after fetal death. S/s of pregnancy
abate.
 Brownish vagina discharge.
Septic abortion
 any of above scenarios with temp > 38
degrees C. Associated with IUD.
100
Causes Of Abortions


Embryonic abnormalities = 80-90% first
trimester abortions.
Maternal factors = majority of second
trimester abortions.
 Chronic maternal health factors;
 30% pregnancies in women with
IDDM = Spont. Ab.; severe
hypertension; renal disease
101
Causes of Abortions

Acute maternal health factors



infections, etc.
Diseases, abnormalities of reproductive
system
Exogenous factors
102
History

History:
 suggestive of
pregnancy
 vaginal bleeding
and/or abdominal
pain.
 Quantify
bleeding - > 1
pad per hour;
103
History



abdominal pain usually in one or both lower
quadrants
Suprapubic pain
Pain may radiate to lower back, buttocks,
genitalia, perineum.
104
Always Remember!
Any woman of childbearing age
with vaginal bleeding should be
considered to be pregnant.
105
106
Prehospital Care:

Assess
 bleeding - # pads per hour?
 Vitals


Oxygen
Position of comfort
107



Trendelenburg position if
shock sx.
Monitor
 check for fetal heart
tones with Doppler if 1012 weeks (if available).
IV (bilateral IV’s if shock
sx.)
108
Diabetes in Pregnancy



May become unstable during pregnancy
Higher incidence of coma
Infants
 5 x normal risk of RDS (Respiratory
Distress Syndrome)
 Increased incidence of hypoglycemia,
hypocalcemia & jaundice
 congenital anomalies increased with firsttrimester hyperglycemia
109
Pregnancy-Induced
Hypertension (PIH)






Diastolic BP > 90 mmHg
Systolic BP > 140 mmHg
Systolic BP rises at least 20 mmHg over
base value
Diastolic BP rises at least 10 mmHg over
base value
Proteinuria
Weight Gain with edema
110
Risk Factors for PIH





First pregnancy
multiple gestation
Polyhydramnios
malnutrition
family history
111
H&P


Document risk factors
Look for evidence of edema
 hands
 face
 BP changes
112
Prehospital treatment

Without s/s preeclampsia
 bed rest
 home BP monitoring
 Antihypertensive therapy
 only if BP persistently > 160/110
 Diuretics never indicated.
113
Preeclampsia/
Eclampsia


Defined as the presence of PIH with
proteinuria, edema or both.
Mild:
 HTN
 Mild edema (wt gain > 2 lb/week or
>6 lb/month)
 Urine output >500 ml/24 hours
114
Severe PIH:




BP 160/110 on 2 occasions at least 6 hours
apart with patient on bed rest
Systolic BP >60 mmHg over baseline
Diastolic BP > 30 mmHg over baseline
Any systemic symptoms listed below
regardless of BP
115
Severe PIH

Any systemic symptoms listed below regardless
of BP







Proteinuria
Massive edema
Oliguria < 400 ml/24 hours
Pulmonary edema
Headaches
Visual changes
RUQ pain
116
H&P


Document risk
factors and any
symptoms
Look for evidence
of edema, BP
changes,
hyperreflexia, RUQ
tenderness.
117
Case history
118
Case history, cont.
119
Prehospital Care




Oxygen
position left lateral
recumbent
IV BSS
monitor
120
Seizure Management 


Valium or Versed per orders
Loading Dose: Magnesium Sulfate 4-6 g IV
over 20 minutes and continued at 2 g/hr.
Treatment of seizures: Magnesium Sulfate 1
g/min IV until seizure controlled up to 4-6 g
maximum. (2-5 gm Mag Sulf. Diluted in 50
cc D5W)
121
Placenta Previa




Implantation of
placenta over or near
internal os of cervix.
Occurs in 1/200
deliveries.
Very common in 2nd
trimester, but more
than 95% of these do
not have placenta
previa at delivery.
May be marginal,
partial or total.
122
Maternal Risk Factors







Increasing age
Multiparity
prior uterine scar
PG after C section
Associated with breech and transverse
positions.
Prior abortion
Possibly increased risk for Asians and African
Americans.
123
H&P


Painless Vaginal bright red bleeding.
Blood loss not massive, but tends to recur
and become heavier as pregnancy
progresses.
124
Case history
125
Case history, cont.
126
Prehospital care





Oxygen
Left lateral recumbent
Bilateral IV’s w/ BSS
ECG monitor
Transport immediately for
cesarean section.
127
Abruptio Placentae



Separation of the normally located
placenta prior to birth of the fetus, after
20 weeks gestation - typically 3rd
trimester
Occurs in about 2% of all pregnancies
Occasionally, a small separation occurs
without further problem.
128
H&P






Vaginal bleeding - 80%
Abdominal or back pain and uterine
tenderness - 70%
Fetal distress - 60%
Abnormal uterine contractions - 35%
Idiopathic premature labor - 25%
Fetal death - 15%
129
130
Abruptio Placentae

Class 0



asymptomatic
diagnosis is made retrospectively
Class 1





mild and represents @ 48% of all cases.
None to mild vaginal bleeding
uterus slightly tender
maternal BP and HR normal
no fetal distress
131
Abruptio Placentae

Class 2





moderate; represents @ 27% of all cases.
None to moderate vaginal bleeding
Moderate to severely tender uterus
Maternal tachycardia with orthostatic changes
Fetal distress
132
Abruptio Placentae

Class 3






Severe; represents @ 24% of all cases.
None to heavy vaginal bleeding.
Very painful
Tetanic uterus
Maternal shock
Fetal death
133
Causes:







Maternal hypertension (44% of all cases)
Maternal trauma (9% of all cases)
Cigarette smoking
Alcohol consumption
Cocaine use
Short umbilical cord
Sudden decompression of uterus



premature rupture of membranes, delivery of first twin
Advanced maternal age
Idiopathic
134
Case history
135
136
Prehospital management





high flow oxygen
Bilateral IV’s w/ BSS
position left lateral recumbent
Monitor vaginal bleed and fetal heart
transport immediately
137
Rh factor




Measured in + or –
+ = Anti-Rh antibodies present
-- Ok.
- = No Anti-Rh antibodies pres.



-- Ok
+ = Sensitization
++ = Severe reaction / death
138
First Trimester of Pregnancy
First 3 months of
pregnancy (13 weeks)
 Mother
 Amenorrhea
 Urinary frequency
 Breasts tender

139
First Trimester of Pregnancy



N/V
Uterus enlarges
Fetus

Most organs develop
140
Second Trimester





Middle 3 months (13
weeks)
Fetal movement
increased energy
Uterus enlarges
After 20 weeks,
uterine size related
to gestational age
141
Third Trimester



Last 3 months (13 weeks)
Supine-hypotensive syndrome
 occurs near term
 reduces pre-load, cardiac
output
Braxton-Hicks contractions
 simulates labor
 usually painless, may be
helped by walking
142
143
Characteristics of Labor




Discomfort in the back and/or abdomen
Contractions occur at regular intervals
 increasing frequency & intensity
 Time from beginning of one
contraction to beginning of next AND
from beginning to end of contraction
Term Labor
 After 38 weeks gestation
Preterm labor
 Before 38 weeks gestation
144
First Stage of Labor
Bloody show
rupture of
membranes
 Cervical dilation
@ 1 cm/hr for
primigravidae
 Cervix dilates
to 10 cm


145
First Stage of Labor



Contractions begin short and gently
Occur at 10-15 min. intervals
Effacement

Thinning and shortening of cervix
146
Second Stage of Labor
Full dilation to
delivery of
newborn
Avg time:
45 min. in
primapara
15 min. in
multigravida

147



Contractions stronger, longer; last 50-70
seconds at 2 - 3 minute intervals
Amniotic sac typically ruptures
Urge to push
148


Crowning
Decision to transport
 multiparity
 contractions two min.
apart
 urge to push
149
Imminent Delivery







Prepare
Protect modesty
Oxygen for mother
IV, tko
Position of comfort
Coach
BSI
150
Perineal support
to prevent
contamination,
tearing
151
Episiotomy - cutting
of
the pudenda or
genitals
- small surgical
incision
into perineum
Mediaolateral
Episiotomy; replaces
a ragged tear with
clean
incision
152
Support infants head with gentle backwards pressure
to prevent forceful delivery
153
154
155
156
157
Head begins to
rotate usually to
left
158
Immediately suction mouth
and then nose
Note vernix on face
159
With next
contraction,
gentle caudal
traction
is applied
downward to
deliver shoulder
160
Immediately
gently apply
upward
traction to
deliver other
shoulder.
161
162
163
Clean clamps
Clean Scissors
Clamp 7” & 10”
Watch for blood
Splatter
Clamp again prn
164
165
•After resuctioning,
stimulate with
vigorous
rubbing on
back and/
or by flicking
bottom
of foot.
•Don’t dangle
by ankles
or spank.
166
167
IN THE FIRST MINUTE




Support
Dry
Warm
Position
168


Neonate should take
first breath w/in
seconds. Unrelated
to cutting of cord.
Stimulating factors:
 mild acidosis,
initiation of
stretch reflexes,
hypoxia,
hypothermia
169
Apgar Score
One and Five minute intervals

0-2 values for five
elements





Appearance
Pulse
Grimace
Activity
Respiration
170
171
Neonatal Resuscitation





Begin when stimulation fails
Positive pressure ventilation
 BVM & oxygen
 40-60/min.
HR
Chest compressions if HR less than 80
Fluid, medication access
172

Neonate


Less than one
month old (41
days)
Post-delivery,
two patients to
manage.
173
Anatomic & physiologic changes
at birth

Respiratory system





non-functional in the uterus
Must now initiate and maintain respirations
in utero, amniotic fluid fills lungs, capillaries
and arterioles of the lung are closed.
Most blood pumped by the heart bypasses the
resp. system through the ductus arteriosus.
1/3 fetal lung fluid is removed during vag.
Delivery.
174


With first few breaths, lungs rapidly fill with
air, , displacing remaining fluid. Pulmonary
arterioles and capillaries open, = decreased
pulmonary vascular resistance.
Resistance to blood flow in lungs is less than
resistance of ductus arteriosus. Blood flow
diverted from ductus arteriosus to lungs. D.
arteriosus eventually closes.
175


After delivery,
maintain neonate
at same level as
vagina with head
@ 15 deg. Below
its torso. Use
DeLee suction
prn.
If neonate does
not cry
immediately,
stimulate by
rubbing its back.
176

Prevent heat loss in neonate

One of the most important risks. Occurs through
evaporation, convection, conduction, or
radiation.
177



Immediately after birth, core temp can drop 1
degree or more
Dry immediately
Ambient temp should be 74-76 deg.
Swaddle
neonate in
warm, dry
blanket.
178
The Apgar Score






Assess at 1 and 5 minutes.
Appearance
Pulse
Grimace
Activity
Respiratory effort



Apgars of 7 - 10 desirable.
Apgars of 4 – 6 = moderately depressed
infant and requires intervention.
Apgars < 4 requires resuscitation
179
The premature infant




Weighs less than 2500 gm (5.5 lbs)
Born before 38 weeks gestation.
At risk for hypothermia, hypoglycemia,
volume depletion, respiratory problems,
cardiovascular problems.
Keep airway clear. Administer
supplemental oxygen, and ventilate prn.
180
The distressed neonate

Meconium aspiration





presence of meconium at birth indicates
possibility of fetal respiratory distress.
Aspiration can causes severe pneumonia.
Suction under direct visualization.
Resuscitation involves ventilation and
oxygenation.
Suctioning, drying, and stimulating infant
is critical
181




Fetal heart rate is the single most important
indicator of neonatal distress.
CO is directly related to HR
Bradycardia results in decreased CO,
ultimately poor perfusion.
A HR of < 60/min. requires CPR.
182
Neonatal resuscitation
Drying, warming, positioning, suction, tactile
stimulation
Oxygen
BVM
Chest compressions
Intubation
Medications
183

Step 1: Drying, Warming, Positioning, Suction,
and Tactile Stimulation.




Immediately after delivery, dry neonate. Place in a
warm, dry blanket. Make sure environment is warm
and free of drafts.
Place infant on its back with head slightly below
body and neck slightly extended. Place small blanket
under shoulders.
Suction neonate again, using a bulb syringe or DeLee
suction trap. (Deep suction can cause a vagal
response). Suction no longer than 10 seconds.
Stimulate by rubbing back, flicking soles of feet.
184

Now assess patient.

RR - rate and depth. BVM prn.

Heart rate - listen to apex of heart with
stethoscope, check pulse at umbilical cord, or
brachial or femoral pulse. If HR < 100, begin
BVM immediately.

Color- If central cyanosis is present, ventilate.

APGAR
185

Step 2 - Supplemental oxygen



Step 3 -Ventilation


blow-by oxygen - warmed if possible.
NEVER DEPRIVE NEONATE OF OXYGEN.
Positive pressure if HR < 100/min., Apneic, or
central cyanosis after administ. Of supplemental
oxygen.
Step 4 - Chest compressions 1/2-1” at 120/min.


If heart rate is < 60/min.
If heart rate is 60-80 but does not increase with 30
seconds of positive pressure vent. And supplemental
oxygen.
186

Neonatal transport



Maintain body temp.
Control oxygen admin.
Maintain vent. Support
187
Third Stage of Labor
Usually occurs 5-20
minutes
after delivery
Don’t delay transport
Place placenta in
plastic
bag
188
189
190
191
192
193
Additional Care for the Mother




Excessive bleeding (more than 500cc)
 Fundal massage
Observe and monitor vitals
Encourage the mother to breastfeed the
neonate
Keep warm
194
Postpartum Hemorrhage


Any bleeding that results in s/s of
hemodynamic instability (more than 500
cc of blood)
1-10% pregnancies will be complicated
by PPH
195
H&P



Family history of coagulation disorder or
bleeding
Hypertensive meds
Other Causes:
 uterine atony
 lacerations of cervix or vagina
 retained placenta
196




Trauma
Uterine inversion (may be assoc. with
blood loss of 2 liters)
Uterine rupture
Risk Factors include:
 prolonged 3rd stage of labor
 pre-eclampsia
 multiple gestation
 Asian or Hispanic ethnicity
 Multiparous/Multiple gestations
 Polyhydramnios
197
Prehospital care








Assist with delivery; be vigilant for
potential complications
Oxygen
IV’s w/ BSS
Assess both patients & prioritize care
divide responsibilities
Gentle massage of the fundus
Consider Oxytocin if available
Rapid transport
198

Prognosis:
 depends on cause of PPH, duration
and amount of blood loss, co-morbid
conditions, and effectiveness of
treatment.
199
Abnormal Presentations

Sunny side up

Face presentation
200
Breech presentation
Frank breech – fetal
hips flexed, knees
extended.

Complete
breech – hips
and knees flexed

•If buttocks are
delivered, stay on
scene no more
than 10 min.
201
Breech Presentations



premature infants
Don’t pull on legs
Apply gentle upward
traction until mouth
appears
•
As head is delivering,
keep airway open
•
if no delivery w/in 3
min., emerg. transport
202
Rare presentations



Single or double
footling breech
Can’t deliver in the
field
Transport immed.
203
Prolapsed cord
Prolapsed cord;
Do not attempt
To replace cord;
Keep infant’s head from
Compressing the cord
Place pt. In Trendelenberg
Or knees-chest position
204
Prolapsed Cord






Umbilical cord may be first
presenting part
Position patient
DON’T let patient walk
Insert sterile, gloved hand
into vagina and push back
presenting part of fetus.
Do not push cord back
A true emergency –
Transport rapidly
205
206
Trauma in Pregnancy



Frequency greatest in third trimester
 6-7% of all pregnant women
Tachycardia/hypotension may be
significant
Most common cause of fetal death is
maternal shock - 80% fetal mortality
rate.
207




Maternal death 2ndary to head
trauma most common.
67%MVA’s
 falls
 physical abuse
Placental abruption occurs in up to
50% of patients with major trauma
Penetrating wounds injure the fetus
in up to 70% of cases.
208
History, Exam



Mechanism
 Direct abdominal trauma
 Weaponry
 Seatbelt use
LMP
EDC
209



Abdomen

Inspect

Palpate

Fetal movement, heart tones
Uterine contractions
Vaginal bleeding, membranes ruptured
210
Prehospital care

Supplemental oxygen

Avoid supine
hypotension
syndrome


Tilt LBB 15 deg.
Bilateral IV’s
211
Abuse of pregnant women
Homicide is now the leading cause
of death in pregnant women!

Estimated at 21 - 25%



Of these, 40% of the time, the abuse began
during the pregnancy
If abused, 18% will suffer miscarriage or
other internal injuries
Abdominal trauma can lead to
 fetal loss
 early labor and delivery of low-weight
or preterm infant
 fetal fractures
 uterine rupture
 chronic illness; hypertension, asthma,
etc.
212
Summary




Remember you’re treating
two patients.
You can care for the fetus if
you care for the mother.
Maintain a high index of
suspicion for complications
Always provide oxygen!
213
Do you know the difference
between living and being alive?
Thanks for
your attention
214