Download EMS Care of OB and GYN Emergencies Richard Vermeer, D.O., FACEP

EMS Care of OB and GYN
Emergencies
Richard Vermeer, D.O., FACEP
January 8, 2016
Topics to be Discussed
 Anatomy and Physiology
 Pre-Delivery Emergencies
 Active Labor and Normal
Delivery
 Active Labor and Abnormal
Delivery
 The Newborn Infant
 Gynecological Emergencies
CH.. Ch.. Changes
The newly pregnant female will undergo
numerous physiological changes.
Understanding some of these major
changes is very important in the proper
management of any obstetric emergency.
The following slides will cover the major
changes.
Vascular Changes
Total blood volume increases 40%
plasma volume increases 45%
• The plasma increase is greater than the
increase of RBC’s*
• This results in lower hematocrit & lower
blood viscosity.
• Cardiac Output increases
Oxygen Capacity
The affinity of maternal hemoglobin for
oxygen decreases, making it easier to offload oxygen as the blood passes through
the placenta.
Cardiovascular
Increased Cardiac Output
–From 4.3 L/min to 6.2 L/min @
32 weeks
–Vasodilation and AV shunting
results in a 30% decrease in
Blood Pressure!
Cardiovascular
Adrenergic compensation occurs in response
to maternal hypoxic insult.
 Trauma
 Sepsis
 Blood loss
Problems arises when the uterine vascular bed
also vaso-constricts, thereby limiting blood
flow to the fetus.
Third-Trimester
Cardiac Output may decrease by as much as
25% with supine positioning because of
compression of IVC.
10% of pregnant women exhibit Supine
hypotensive syndrome.
Place these ladies Left Lateral Recumbent
Risky Business - Early Delivery
Gestation
Survival Rates
Major long-term defects
25 weeks
60% survival
50% long-term
26 weeks
70% survival
40% long-term
27 weeks
80% survival
20% long-term
28 week
90% survival
Results based on hospital with level 3 perinatal center.
RULE # 1
Taking into consideration transport time,
resources, and maternal condition, inutero transport is preferable to
delivery and neo-nate transport!
Gunshot wounds
MVC
Stab wounds
Strangulation
Blunt head trauma
Burns
Falls
Toxic Exposure
Drowning
Other injury
23%
21%
14%
14%
9%
7%
4%
4%
2%
2%
Obstetrical Emergencies
Neurological Changes of
Pregnancy
• Ischemic Stroke may occur in pregnancy
• Hematologic disorders
• Cardiovascular disease
• Thromboembolism
• Bells Palsy – 7x more common in 3rd trimester
• Multiple Sclerosis – Usually unchanged during
pregnancy
• Headache and back ache increased by pregnancy
• Epilepsy – Drugs often Teratogenic
DVT and Thromboembolism
• Deep Venous Thrombosis has increased
incidence in pregnancy.
• Leg swelling and pain
• Venous Doppler is diagnostic
• Pulmonary embolism
• two to five times more common around
delivery time
• persistent risk for six weeks beyond delivery
GI Changes of Pregnancy
• Morning Sickness
• Common during pregnancy, not always in am
• Hyperemesis
• Vomiting with 5% loss of body weight
• Electrolyte abnormalities esp. Potassium
• Loss of Magnesium and Calcium
• Abnormal Liver enzymes on lab testing
• Need IV rehydration sometimes
hospitalization
Miscarriage
• Spontaneous loss of pregnancy before 20
•
•
•
•
weeks gestation
Initial presentation usually cramps and
bleeding
Passage of fetal tissue from vagina
EMS concerns for persistent bleeding –
transport
Patient will need assessment
Miscarriage
Need for medical assessment
• Vaginal bleeding during pregnancy always
•
•
•
•
concern for ectopic pregnancy
Rh typing needed if hasn’t had OB visit
Persistent bleeding may require surgical
care
Transport patient who has called 911.
OB evaluation is prudent to ensure no
emergency
More About Pre-delivery
Emergencies
Placenta Previa
Painless
Vaginal Bleeding in Third
Trimester
 Follow general guidelines for predelivery
emergency
 Administer high-flow oxygen
 Provide immediate transport
0.5% of pregnancies, most present 3036 weeks
Greatest risk group: >40 y/o 2%
Mortality rate 2-3%
Placenta Previa
Placental Abruption
• The signs and symptoms of placental
•
•
•
•
•
abruption include one or more of the
following:
Abdominal pain
Vaginal bleeding (although about 20% of
cases
will have no bleeding)
Uterine tenderness
Rapid contractions
Fetal heart rate abnormalities
Placental Abruption
Ruptured Uterus
• Uterine rupture is a potentially catastrophic
event during childbirth
• A uterine scar from a previous cesarean
section is the most common risk factor
• With a complete rupture the contents of
the uterus may spill into the peritoneal
cavity or the broad ligament.
• A uterine rupture is a life-threatening event
for mother and baby.
Ruptured Uterus
Ruptured Uterus Treatment
• The baby is delivered by emergency C•
•
•
•
section.
May require a hysterectomy if damage is
great.
Uterus may be repaired if less damaged.
Usually requires blood transfusion.
Usually given IV antibiotics to prevent
infection.
Ectopic Pregnancy
Egg is implanted in the fallopian tube,
on the abdominal peritoneal covering,
on the outside wall of the uterus, on an
ovary, on on the cervix
 Follow general guidelines for
pre-delivery emergency
 Administer high-flow oxygen
 Provide immediate transport
More on Ectopic Pregnancy
Leading cause of pregnancyrelated death during first
trimester,
Accounting for 9% of all pregnancy
deaths.
Over 100,000 ectopic pregnancies
occur yearly.
Ectopic Risk Factors
PID ( Chlamydia)
Prior ectopic
pregnancy
Hx of tubal
ligation(35-50%)
Fertility Drugs
IUD use
Increasing Age
(35-44 have 34X more risk)
Smoking
Ruptured
appendix
Ectopic Presentation
 Classic Symptoms:
pain,
amenorrhea
vaginal bleeding.
 Only 40-50% of patients will present
with vaginal bleeding.
 Approximately 20% of ectopic
patients will present hemodynamically
compromised!
Ecto-”pics”
Pre-delivery
Emergency
Pre-delivery Emergencies
Scene Size-Up
Obstetric emergency – emergency
having to do with pregnancy and
childbirth
 First indication usually from
dispatcher, but any woman of childbearing age could potentially be
experiencing an obstetric emergency
Pre-delivery Emergencies
Initial Assessment
 Perform after taking BSI
precautions and assuring the scene
is safe
 Same as for patient who is not
pregnant (mental status, airway,
breathing, circulation)
Pre-delivery Emergencies
Focused History/Physical Exam
 Use SAMPLE questions, including
OPQRST
 If patient is experiencing abdominal
pain, perform focused medical
assessment
 Obtain baseline vital signs
(Continued)
Pre-delivery Emergencies
Focused History/Physical Exam
 Are you experiencing any pain or
discomfort?
 When was you last menstrual period?
 Have you missed a menstrual period?
 Have you had any vaginal
discharge/bleeding?
 When is your due date?
Pre-delivery Emergencies
Signs and Symptoms
 Abdominal pain, nausea, vomiting
 Vaginal bleeding, passing of tissue
 Altered mental status
 Seizures, excessive swelling
 Abdominal trauma
 Shock (hypoperfusion)
If close to full term, take
precautions against supine
hypotensive syndrome by
placing the patient on her
left side
(Continued)
Ensure adequate airway,
breathing, and circulation
Care for bleeding from the
vagina
Treat for shock (hypoperfusion)
(Continued)
Provide emergency medical
care as you would for the
nonpregnant patient based on
signs and symptoms
Transport patient on left side
Ongoing assessment en-route
Miscarriage
Signs and Symptoms
Cramp-like lower abdominal pain
similar to labor
 Moderate-to-severe vaginal bleeding
 Passage of tissue or blood clots
Emergency Care
 Ask when last menstrual period
began
 Provide emotional support
Seizures During Pregnancy
Provide emergency care as for
any seizure patient
Take extra care to protect
patient from injuring herself
Transport patient on left side
Transport in a calm quiet
manner
Pre-Eclampsia
Presents as Hypertension, proteinuria, and nondependent edema.
Usually after 12 weeks, May occur up to 6
weeks post-partum
BP component exists when numbers approach
140 sys and 90 dias. Must be 2 readings 6
hours apart to qualify.
Occurs in 6-8% of pregnancies.
Accounts for 12-18% of maternal deaths
Pre-Eclampsia
Symptoms
Headache
Focal neurologic symptoms
Visual disturbances
Diffuse edema
Hypertension
Abdominal tenderness
Protein in urine
Shortness of breath
Eclampsia
Defined as seizure activity or coma
unrelated to any other cerebral
conditions in an obstetric patient with
preeclampsia.
Most occur 3rd trimester, or up to 48 hrs
post-delivery.
Eclampsia
1 or more seizures
60-75 sec in duration
May begin in the face
Patient may foam at the mouth
Breathing ceases during seizure activity
Variable post-ictal periods
Vaginal Bleeding, Pre-delivery
Follow general guidelines for
emergency care
Place sanitary napkins over
vaginal opening
Transport as soon as possible
Be alert for signs and
symptoms of shock
Pre-Delivery Considerations
Delivery not imminent –
transport.
Patient in active labor – focus
on assisting the mother with
delivery and providing initial
care to the newborn infant.
Has OB been alerted?
(Continued)
Pre-Delivery Considerations
Is this the patient’s first
delivery?
How long has the patient
been pregnant?
Are there contractions or pain?
Any bleeding or discharge?
BOW intact?
Is crowning occurring
with
(Continued)
contractions?
Pre-Delivery Considerations
What is the frequency and
duration of contractions?
Does patient feel as if she is
having a bowel movement
with increasing pressure in the
vaginal area?
Does patient feel the need to
push?
Rock-hard abdomen?
Pre-Delivery Considerations
Situations in which delivery
must be assisted
 No suitable transportation
 Hospital or physician cannot be
reached due to bad weather/natural
disaster
 Delivery is imminent
(Continued)
What to Do?
Assess probability of imminent
delivery
Follow protocol for assisting
spontaneous delivery
Locate instruments to clamp the cord
and towels to warm infant
Transport the mother if delivery is not
imminent. Have medical control
notify OB.
Pre-Delivery Considerations
Signs and symptoms of
imminent delivery
 Crowning has occurred
 Contractions are less than 2 minutes
apart and last 30-to-90 seconds
 Patient feels as if she is having a
bowel movement
 Patient has strong urge to push
 Patient’s abdomen is rock-hard
Assisting in Delivery
Take all appropriate BSI
precautions, including gloves,
gown, and eye protection
Check for Crowning
Check for abnormal presentation
Cord, Breech, Limb
(Continued)
Assisting in Delivery
Do not allow patient to use the
bathroom
If patient urinates or moves her
bowels, replace linens
Do not hold patient’s legs
together or attempt to delay delivery
Use a sterile obstetrics kit
Access dry towels for the baby
Patient in Active Labor
for Normal Delivery
 Have mother lie
with knees drawn
up and spread
apart.
 Create sterile
field around
vaginal opening
Anatomy and
Physiology
Placenta
Umbilical Cord
Amniotic Sac
Fetus
Uterus
Anatomy
Cervix
Birth Canal
Vagina
Perineum
Reproductive Anatomy
“Bloody Show” – blood-tinged mucus
plug that may be expelled from the
vagina as labor begins
Presenting Part – the part of the
infant/fetus that is first at the vaginal
opening
(Continued)
st
1
Stage
of Labor
Delivery is
imminent
First Contraction to Crowning
2nd Stage
of Labor
Birth of the infant
3rd Stage
of Labor
Delivery of the
Placenta
Don’t pull on the
cord!
Create a sterile field around the
vaginal opening
Monitor the patient for vomiting
Continually assess for crowning
(Continued)
Place your gloved
fingers on the bony
part of the infant’s
skull, and exert
gentle pressure to
prevent explosive
delivery.
Use caution to avoid fontanel
(Continued)
Rupture amniotic sac with your
fingers if it is not already broken.
Push it away from infant’s head
and face as they appear.
Determine position of umbilical
cord.
(Continued)
Check for nuchal cord
If the cord is around neck, use two
fingers to slip it over infant’s shoulder
or the head if it’s loose.
Flex head toward maternal thigh,
deliver baby and perform Somersault
Maneuver to unwrap cord.
If cord cannot be moved, place two
clamps 3” apart and cut between
them.
Deliver the newborn.
As infant’s head is being born,
support the head, suction mouth
two or three times and then the
nostrils.
(Continued)
Compress syringe before
bringing it to infant’s face.
Insert syringe tip 1-1 1/2” in
to infant’s mouth.
Avoid touching back of the
mouth
(Continued)
Wrap infant in a
warm blanket
and place on its
side, head lower
than trunk.
Receive newborn in
clean or sterile towel.
Grasp feet as they are
born.
Keep infant level with vagina
until the cord is cut.
Partner care for infant
Warm, Dry, Stimulate
Routine initial care of Newborn
(Continued)
1st clamp
3”
2nd clamp
10”
7”
Clamp, tie,
and cut
umbilical
cord.
Wait for pulsations to cease
 1st Clamp approximately 4 finger’s
width from the infant
(Continued)
Observe for
delivery of
placenta.
 Expect delivery within 10 – 20 minutes
 Guide placenta from vagina when it
appears by grasping and rotating –
NEVER PULL
(Continued)
 Do not delay transport
Wrap delivered placenta in a
towel and place in a plastic
bag for transport
Place 1 or 2 sanitary napkins
over vaginal opening
Record time of delivery
Transport mother & infant
Excessive
Post-Delivery
Blood Loss
Vaginal Bleeding
 Place medial edge of one hand
horizontally across abdomen, just
above symphysis pubis
 Cup other hand around uterus
 Massage (knead)
The patient won’t like this
 Allow infant to suckle
Active Labor with
Abnormal Delivery
Signs and Symptoms
 Any fetal presentation other than
normal crowning of the fetal head
 Abnormal color-smell of amniotic
fluid
 Labor before 38 weeks of pregnancy
 Recurrence of contractions after first
infant is born (indicating multiple
births)
In general similar to that of
normal delivery
Exception include an
emphasis on immediate
transport, administration of
high-flow oxygen, and
continued monitoring of
vital signs
Prolapsed Cord
Breech Birth
Limb Presentation
Multiple Births
Meconium
Premature
Prolapsed Cord
Presents a serious emergency
which endangers the life of the
unborn fetus.
Condition where the cord
presents through the birth
canal before delivery of the
head.
(Continued)
Prolapsed Cord
(Continued)
Prolapsed Cord
Emergency Medical Care
Position mother’s head down in
“knee-chest” position, or raise
buttocks with pillows to reduce
pressure of fetal head on cord
 Insert sterile gloved hand into
vagina, pushing presenting part of
fetus away from the pulsating cord
(Continued)
Prolapsed Cord
Emergency Medical Care
 Cover cord with sterile towel
moistened with saline solution
 Transport patient rapidly,
continuing pressure on presenting
part to keep pressure off the cord
 Monitor cord pulsations
Notify Medical Control to alert OB
Treatment is probably C-section
Breech Birth Presentation
The buttocks or lower
extremities are low in the
uterus and will be the first
part of the fetus delivered.
Alert OB of Breech
Presentation
Breech Birth Presentation
Emergency Medical Care
 Immediate rapid transportation
upon recognition.
 Place mother on oxygen.
 Place mother in head down
position with pelvis elevated.
Limb Presentation
Occurs when a limb of the
infant protrudes from the
birth canal.
Is more commonly a foot
when infant is in breech
presentation.
Limb Presentation
Emergency Medical Care
 Transport immediately (surgery is
likely to be required)
 Keep mother in head-down
position with pelvis elevated
 Never attempt delivery in this
situation
 Instruct mother to pant if she has
the urge to push with contractions
Notify Medical Control to alert OB
Multiple Births
Signs and Symptoms
 Abdomen still very large after one
infant is delivered
 Uterine contractions continue to
be strong after delivering first
infant
 Contractions begin again about 10
minutes after one infant is
delivered
Multiple Births
Emergency Medical Care
 Follow general guidelines for
normal delivery
 Call for assistance to provide
second caregiver for the twin
 If second infant is not breech,
handle delivery as you would for a
single infant
 Expect and manage hemorrhage
(Continued)
following second birth
Multiple Births
Emergency Medical Care
 Be prepared for infants to each
have, or to share, placenta
 If second infant has not delivered
within 10 minutes of first,
transport mother and infant to
hospital
Meconium Staining
Fetal bowel movement in
amniotic fluid turning it
greenish or brownish-yellow
rather than clear; an
indication of possible fetal
distress.
Meconium Staining
Emergency Medical Care
 DO NOT stimulate before
suctioning – goal is to clear
mouth and nose before infant
takes first breath
 Transport as soon as possible –
maintain airway and supporting
ventilations as necessary
Premature Birth
Infant weighing less than
5 ½ pounds or one born
before 38 weeks of
development.
(Continued)
Premature Birth
At risk for hypothermia and
respiratory distress
May require more vigorous
resuscitation than full-term
infant
Initial Care of
The Newborn
Normal Findings
Appearance
Pulse
No central
cyanosis
Greater than 100
Grimace
Vigorous & Crying
Activity
Motion in all
Extremities
Normal, crying
Respiration
Stimulate
Newborn if
Not Breathing
Infant Needing Aggressive Care
Signs and Symptoms
 Respiratory Rate over 60/min
 Diminished breath sounds
 Heart rate + 180 or below 100/min
 Obvious signs of delivery trauma
 Poor or absent skeletal muscle tone
 Respiratory arrest or severe distress
Infant Needing Aggressive Care
Signs and Symptoms
 Heavy meconium staining of
amniotic fluid
 Weak pulses
 Cyanotic body (core & extremities)
 Poor peripheral perfusion
 Lack of, or poor, response to
stimulation
Drying, warming, positioning,
suction, tactile stimulation
BVM
Intubation
Resuscitation of
Newborn follows
Inverted Pyramid
Meds
BASIC
Oxygen
Majority of newborn infants
respond to routine care;
only a few require
aggressive resuscitation
(Continued)
Provide free-flow oxygen with
tube ½” from from nose and
mouth if:
 Bluish discoloration of skin
 Spontaneous breathing
 Adequate heart rate
(Continued)
Provide ventilations by BVM at
40-60/min and reassess after 30
seconds if:
 Breathing is shallow, slow,
gasping or absent
 Heart rate is less than 100/min
 Trunk remains cyanotic despite
blow-by oxygen
Continue ventilations and begin
chest compressions at 120/min
if:
 Heart rate drops to less than
60/min
 Heart rate is between 60-80/min
and is not rapidly increasing
Gynecological
Emergencies
Gynecological Emergencies
Scene Size-Up
 Note any mechanism of injury that
may have caused abdominal or
pelvic trauma
 If a crime scene, do not approach
patient until police assure that
scene is safe
Gynecological Emergencies
Initial Assessment
 Have female EMT conduct
assessment on sexual assault
victim whenever possible.
 After taking all BSI precautions,
perform initial assessment
Gynecological Emergencies
Focused History/Physical Exam
 Get SAMPLE history using
OPQRST and remaining
nonjudgmental
 If sexual assault, make treatment of
injuries priority
 Question discreetly about potential
injuries
 Protect patient’s privacy
Gynecological Emergencies
Focused History/Physical Exam
 Do not examine the genitalia of a
sexual assault victim unless profuse
or life-threatening bleeding
 Obtain baseline vital signs
 Help preserve evidence in cases of
sexual assault
Do not have patient shower or toilet
Gynecological Emergencies
Signs and Symptoms
 Abdominal pain
 Vaginal bleeding
 Soft tissue injuries
 Shock (hypo-perfusion) if blood loss
is great
Gynecological Emergencies
Emergency Medical Care
 Ensure adequate airway, breathing,
and circulation
 Care for vaginal bleeding
 Provide emergency medical care as
for any patient, based on any other
signs and symptoms
 Transport and ongoing assessment
en route
Summary
 Physiology changes during pregnancy
Bleeding during pregnancy may be a
symptom of serious underlying problem
Miscarriage
Placenta Previa
Placental Abruption
Possible Rh auto-immunization in patient who
is Rh negative
Summary
 Other serious conditions attendant to
the pregnant state
Pre-eclampsia
Eclampsia
Ectopic pregnancy
Complications of Vaginal delivery
Prolapse of the cord
nuchal cord
Breech presentation
Limb presentation
Summary
 Field management of precipitous
delivery
Management of the newborn
GYN Emergency care and transport
Questions?