28)Obstetrics And Gynecology
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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…
  •