28)Obstetrics And Gynecology

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28)Obstetrics And Gynecology

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

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