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 • Placenta previa
– Premature separation – Development of
of the placenta placenta over the
cervix
 Gestational Diabetes
• Develops only during pregnancy.
• Treat as regular patient with diabetes.
• 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
• 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? You are the Provider
(continued)
 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.
• 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.
You are the Provider

• What does the patient’s request to go to the(continued)

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 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) (1 of 2)
• Upon examination, you find that the baby is
crowning. You and your partner prepare for an
imminent birth. You are the Provider
(continued) (2 of 2)

• 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 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. You are the Provider (continued)

• 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 Compressions
to 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 Compressions
to 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 Infant
of 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.