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28)Obstetrics And Gynecology
 

28)Obstetrics And Gynecology

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    28)Obstetrics And Gynecology 28)Obstetrics And Gynecology Presentation Transcript

    • Obstetrics and Gynecology
    • Anatomy and Physiology
      • Fetus
        • Developing unborn baby
      • Uterus
        • Organ in which a fetus matures
        • Responsible for labor and expulsion of infant
      • Birth Canal
        • Vagina and lower part of the uterus
      • Placenta
        • Fetal organ by which nourishment and waste is exchanged from fetus to mother
      • Umbilical Cord
        • Cord that is an extension of the placenta that delivers nourishment to the fetus
      • Amniotic sac
        • Sac that surrounds the fetus inside the uterus
        • “ Bag of Waters”
    •  
    • Anatomy and Physiology
      • Vagina
        • Lower part of the birth canal
      • Perineum
        • Area between vagina and anus
        • Commonly torn during pregnancy
      • Crowning
        • Bulging out of the vagina
        • Opens as the head/presenting part exits the vagina
      • “ Bloody Show”
        • Mucus and blood that may come out of the vagina as labor begins
      • Labor
        • The time and process from the 1 st contraction to delivery
          • Delivery is imminent
          • Crowning
          • Delivery
      • Presenting part
        • Part of the fetus/infant that exits the vagina first
      • Abortion
        • Delivery of products of conception early in pregnancy/ before 20 weeks gestation
        • Miscarriage
    •  
    • Contents of the OB Kit
      • Surgical Scissors
      • Hemostats/Cord Clamps
      • Umbilical tape/Sterilized cord
      • Bulb syringe
      • Towels
      • 2 X 10 Gauze Sponges
      • Sterile Gloves
      • 1 Baby blanket
      • Sanitary Napkins
      • Plastic Bag
    • Predelivery Emergencies Miscarriages
      • Assessment
        • Scene Size Up
        • Initial Assessment
        • Hx and Px Exam
      • Treatment
        • based on S/S
        • Apply external vaginal pads
        • Bring fetal tissue to hospital
        • Support mother
    • Predelivery Emergencies Seizures
      • Assessment
        • Scene Size Up
        • Initial Assessment
        • Baseline vitals
        • Hx and Px Exam
      • Treatment
        • Treatment based on S/S
        • Prevent pt from injury
        • Remove objects in area
        • Transport on left side
    • Hypertensive Disorders “Toxemia of pregnancy “
      • Intro
        • 5% of pregnancies
        • Often in 1 st pregnancies
        • More frequent in pt with HTN/DM
      • Gestational HTN
        • BP usually drops in pregnancy
          • 130/80 may be elevated???
        • BP =/> 140/90 (previously non hypertensive)
      • Preecplamsia
        • Most common complication, 10%
        • 2 nd -3 rd trimester
        • HTN and protein in urine, damaged kidneys/liver
        • HTN, abnormal weight gain, edema, headache, proteinuria, epigastric pain, vision disturbances
    •  
    • Hypertensive Disorders “Toxemia of pregnancy “
      • Eclampsia
        • MOST SERIOUS COMPLICATION
        • Grand mal seizure activity
          • Usually with Hx of Preeclampsia
        • Often preceded by
          • Visual disturbances (flashing spots/lights), RUQ abd pain
        • Appearance differentiates Eclampsia v Epilepsy
          • Marked HTN edematous pt vs
          • Pt with seizure hx, anticonvulsants
        • HIGH fetal/maternal mortality
        • Complications
          • Cerebral hemorrhage, renal failure, pulmonary edema
      • Treatment
        • Magnesium sulfate – Seizures
    • Severe Vaginal Bleeding
      • 1 st Trimester
        • Spontaneous abortion
        • Ectopic pregnancy (1%)
          • Implantation of fertilized ovum in fallopian tubes (98%), ovaries, cervix, abdomen
      • 3 rd Trimester
        • Abruptio placentae (1%)
          • Placental lining detaches from mother
          • 20-40% fetal mortality
        • Placenta previa (0.5%)
          • Placenta attaches close to OR covers the cervix
      • Post deliver bleeding
        • Common, > 500 mL could precipitate shock
      • Treatment
        • Airway, O2, IV fluids/volume expanders
        • IV Pictocin
    • ECTOPIC PREGNANCY ABRUPTIO PLACENTA
    • Obstetrics and Gynecology Vaginal Bleeding
      • Vaginal bleeding
        • BSI
        • Airway
        • Control bleeding as previously described
      • Trauma (external genitalia)
        • Treat as other bleeding soft tissue injuries
        • NEVER pack the vagina
        • Provide O2
        • On going pt assessment
      • Alleged Sexual Assault
        • BSI
        • Initial assessment
        • Non judgmental attitude during SAMPLE Hx and Px exam
        • Crime scene protection
        • Exam genitalia ONLY if profuse bleeding is present
        • Use same sex EMT-B for care when possible
        • Discourage pt from – voiding – cleaning wounds – bathing
        • Report requirements
    • Predelivery Emergencies Trauma
      • Assessment
        • Scene Size Up
        • Initial Assessment
        • Baseline vitals
        • Hx and Px Exam
      • Treatment
        • Treatment based on S/S
        • Transport on left side
    • Normal Delivery
      • Hx Questions to consider…:
        • Are you pregnant?
        • How long have you been pregnant?
        • Are there contractions or pain?
        • Any bleeding or discharge?
        • Is crowing occurring with contractions?
        • What is the frequency and duration of contractions?
        • Does she feel the need to have bowel movement?
        • Does she feel the need to push?
        • Rock hard abdomen?
      • Precautions
        • Use BSI
        • DO NOT touch vaginal area except during delivery and when your partner is present
        • DO NOT let the mother go the restroom
        • DO NOT hold mothers legs together
        • Recognize your own limitations and transport even if delivery occurs in transport
        • IF delivery is imminent:
          • Contact med control for permission to deliver on scene
          • If no delivery within 10 minutes contact med control for permission to transport
    • The Full Body Condom
    • Delivery Procedures
      • Apply full body condom
      • Have mother lie with knees drawn up and spread apart
      • Elevate buttocks (Pillows/blankets)
      • Create sterile field around vaginal area
        • Sterile towels or paper barriers
      • When infants head appears
        • Place fingers on bony part of skull
        • Exert gentle pressure to prevent explosive delivery
        • Use caution to avoid fontanelle
      • If the amniotic sac does not break/has not broken
        • Use a clamp to break the sac
        • Push away from infants head and mouth as it appears
      • As the infants head is exposed determine if the cord is wrapped around the neck
        • Slip over the shoulder or clamp
        • Cut and unwrap
      • After the head is born
        • Support the head
        • Suction the mouth 2-3 times and then the nostrils
        • DO NOT contact the back of the infants mouth
      • As the torso and full body are born support the infant with both hands
    • Delivery Procedures cont’d
      • As the feet are born, grasp them
      • Wipe mucus and blood from mouth and nose
      • Suction mouth and nose again
      • Wrap infant in blanket and place on its side
        • Head slightly lower than trunk
      • Keep infant level with vagina until cord is cut
      • Assign partner to initially assess and care for newborn
      • Clamp, tie and cut the cord (b/t clamps) when pulsation stops
        • 1 st clamp= 7” from infant
        • 2 nd clamp = 3” from 1 st clamp
      • Observe for delivery of placenta while preparing to transport
      • When placenta delivers:
        • Wrap in towel
        • Place in plastic bag
        • Transport with mother
      • Place sterile bad over vaginal opening
      • Lower mothers legs and help hold them together
      • Record time of delivery and transport
    •  
    •  
    • Vaginal Bleeding Following Delivery
      • Expected Blood Loss
        • 500 cc (1/2 liter)
        • Well tolerated by mother
      • With excessive blood loss
        • Massage the uterus
          • Hands with fingers fully extended
          • Place on lower abd above pubis
          • Massage/knead over the area
        • If continued bleeding
          • Reassess massage technique
          • Transport immediately
      • Regardless of estimated blood loss if pt has S/S shock
        • Treat as such
        • Transport
        • Perform uterine massage en route
    • Initial Care of the Newborn
      • -Position – Dry – Wipe – Wrap in blanket –Cover the head
      • Repeat suctioning
      • Assessment of infant (APGAR)
        • Appearance = No central(trunk) cyanosis
        • Pulse = Greater than 100 bpm
        • Grimace = Vigorous and crying
        • Activity = Good motion in extremities
        • Breathing effort = Normal, crying
      • Stimulate the newborn if not breathing
        • Flick soles of feet
        • Rub infants back
    •  
    • Resuscitation of the Newborn
      • Breathing Effort
        • If –Shallow –Slow – Absent
          • Provide positive pressure ventilation
          • 60 bpm for 30 seconds
          • Reassess and if no improvement continue
      • Heart Rate
        • If less than 100 beats per minute
          • Provide positive pressure ventilation
          • 60 bpm for 30 seconds
        • If less than 80 beats per minute and no response to BVM
          • Start chest compressions
        • If less than 60 beats per minute
          • Start compressions and artificial ventilations
      • Color
        • If central cyanosis is present with spontaneous breathing and adequate heart rate
          • Administer “blow by” O2 at 10-15 Lpm
          • Hold O2 tubing as close to pt face as possible
    • Abnormal Deliveries Proplapsed Cord
      • Prolapsed Cord
        • Cord presents through the birth canal before delivery of the head
        • SERIOUS emergency endangering life of fetus
      • Emergency Care
        • Scene size up
        • Initial Assessment
        • High flow O2
        • Hx and Px exam
        • Assess baseline vitals
        • Treatment based on S/S
        • Position mother
          • Head down and buttock raised
          • Uses gravity to reduce pressure on the cord
          • McRobert’s position
        • Insert sterile gloved hand into vagina
          • Push presenting part of fetus away from the pulsating cord
        • Transport IMMEDIATELY
        • Keep pressure against presenting part
        • Reassess for pulsation of cord
    •  
    • Abnormal Deliveries Breech Birth
      • Breech birth
        • Fetal buttock or lower extremities are low in the birth canal
        • Buttock or legs are presenting part
      • Considerations
        • Newborn is at GREAT risk for trauma
        • Transport IMMEDATELY on recognition of breech presentation
      • Emergency Care
        • IMMEDATE RAPID TRANSPORT
        • O2
        • Place pt in McRobert’s position
    • Abnormal Deliveries Limb Presentation
      • Limb presentation
        • A limb of the infant protrudes from the birth canal
        • Usually a foot in breech position
      • Emergency Care
        • IMMEDIATE RAPID TRANSPORT
        • O2
        • Place pt in McRobert’s position
    • Abnormal Deliveries Multiple Births, Meconium, Premature
      • Multiple Births
        • Be prepared for more than one resuscitation
        • Call for assistance
      • Meconium
        • Amniotic fluid that is greenish or brownish yellow
        • Indicates fetal distress
          • Do not stimulate before suctioning oropharynx
          • Suction
          • Maintain airway
          • Transport as soon as possible
      • Premature
        • Before 36 weeks
        • ALWAYS at risk for hypothermia
        • Usually requires resuscitation
        • Should be done unless physically impossible
    • Pseudo Realistic Observations on OB
      • Don’t drop the baby…
      • The umbilical cord is not a handle…
      • If the baby is quiet be VERY afraid…
      • Blue is very very bad. Pinks is very very good.
      • Air goes in and out, blood goes ‘round and ‘round. ANY variation on this is usually a bad thing…
    •