Obstetrics and Gynecology

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Obstetrics and Gynecology

• A lecture about where babies come from
• Nikhil Natarajan
• REMT-P

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Definitions

• Fetus developing unborn baby
• Uterus organ in which the fetus grows,
  responsible for labor and expulsion of infant
• Birth Canal vagina and lower part of the uterus
• Placenta fetal organ through which fetus
  exchanges nourishment and waste products while in
  uterus
• Umbilical Cord cord which is an extension of
  the placenta through which the fetus receives
  nourishment while in the uterus

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• Amniotic Sac the sac that surrounds the fetus
  inside the uterus
• Vagina lower part of the birth canal
• Perineum skin between the vagina and the anus,
  commonly torn during delivery
• Crowning the bulging-out of the vagina which is
  opening as the fetus head or presenting part
  presses against it

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• Bloody Show mucus and blood that may come out
  of the vagina as labor begins
• Presenting part the part of the infant/fetus
  that comes first (usually the head)
• Abortion miscarriage delivery of products of
  conception early in pregnancy

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Three Stages of Labor

• 1st Stage
• Begins with the first uterine contraction and
  ends with complete dilation of the cervix
• 2nd Stage
• Begins with complete dilation of the cervix and
  ends with delivery of the infant
• 3rd Stage
• Begins with delivery of the infant and ends with
  delivery of the placenta

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The OB Kit

• Contents
• Surgical Scissors
• Hemostats or cord clamps
• Umbilical tape or sterilized cord
• Bulb Syringe
• Towels
• 2X10 gauze sponges
• Sterile gloves
• Baby blanket
• Sanitary napkins
• Plastic bag

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What can possible go wrong?

• Miscarriage
• Seizure during pregnancy (Eclampsia)
• Vaginal Bleeding
• Trauma
• Prolapsed Cord
• Breech Delivery
• Limb Presentation
• Meconium Staining
• Premature Delivery

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Miscarriage

• Spontaneous abortion
• Care
• Size up the scene is it safe?
• Initial Assessment
• History and PE
• Baseline Vitals
• Treat the patient based on signs and symptoms
• Apply external vaginal pads
• Bring fetal tissue to the hospital
• Support the mother

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Seizure during pregnancy

• Eclampsia
• Care
• Size up the scene (ALS?)
• Initial Assessment
• History and PE
• Baseline vitals
• Treatment based on signs and symptoms
• Transport on left side

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Vaginal Bleeding

• Late pregnancy vaginal bleeding can present with
  or without pain!
• Care
• Size up the scene is it safe?
• Initial Assessment
• History and PE
• Baseline Vitals
• Treat the patient based on signs and symptoms
• Apply external vaginal pads

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Trauma

• Care for the pregnant trauma patient is the same
  as for any other patient, except you have two
  patients! Which one is more important? The mother
  or the baby?

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What do I ask?

• Are you pregnant?
• How long have you been pregnant?
• Are there contractions or pain?
• Any bleeding or discharge?
• Is crowning occurring with contractions?
• What is the frequency and duration or
  contractions?
• Does she feel as if she is having a bowel
  movement with increasing pressure in the vaginal
  area?
• Does she feel the need to push?
• Rock hard abdomen?

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What not to do!

• Never touch the vaginal areas except during
  delivery and when your partner is present
• Do not let the mother go to the bathroom
• Do not hold the mothers legs together
• Recognize your own limitations and transport even
  if you must deliver enroute to the hospital
• Do not flip out!
• Do not send your partner to boil some water!

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The Delivery!

• Apply gloves, mask, gown, eye protection for
  infection control precautions
• Have the mother lie with knees drawn up and
  spread apart
• Elevate buttocks with blankets or pillows
• Create a sterile field around the vaginal opening
  with sterile towels or paper barriers

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• When the infants head appears during crowning,
  place fingers on the bony part of the skull (NOT
  the fontanelles or face) and exert gentle
  pressure to prevent explosive delivery.
• If amniotic sac does not break, or has not
  broken, use a clamp to puncture the sac and push
  it away from the infants head and mouth as they
  appear

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• As the infants head is being born, determine if
  the umbilical cord is around the infants neck
  slip over the shoulder or clamp, cut, and unwrap
• After the infants head is born, support the
  head, suction the mouth two or three times and
  the nostrils. Use caution to avoid contact with
  the back of the mouth

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• As the torso and full body are born, support the
  infant with both hands
• BABIES ARE SLIPPERY!!

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• As the feet are born, grasp the feet
• Wipe blood and mucus from the mouth and nose with
  a sterile gauze, suction mouth and nose again
• Wrap the infant in a warm blanket and place on
  its side, head slightly lower than the trunk

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• Keep the infant level with the vagina until the
  cord is cut
• Assign partner to monitor infant and complete
  initial care of the newborn
• Place a clamp or tie on the umbilical cord 8 to
  10 inches from the baby
• Place a second clamp or tie approximately 4
  fingers from the baby
• After pulsations cease, cut between the clamps or
  ties

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• Observe for delivery of the placenta while
  preparing mother and infant for transport
• When the placenta is delivered, wrap the placenta
  in towel and put in a plastic bag and transport
  it with the mother to the hospital
• Place sterile pads over the opening of the
  vagina, lower the mothers legs, and help her
  hold them together

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As usual, paperwork

• Record the time of delivery and what county you
  are in. Both must be documented on the PCR.

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Vaginal Bleeding

• A 500cc blood loss after the delivery is well
  tolerated by the mother and is to be expected.
  Dont flip out!
• If there is excessive bleeding, massage the
  uterus
• Hand with fingers fully extended
• Place on lower abdomen above pubis
• Massage over the area
• If it continues, check technique, provide oxygen
  and rapid transport

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Care of the Newborn

• Initial care of the newborn consists of
• Dry
• Warm
• Position
• Suction
• Stimulate

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APGAR

• Appearance
• Pulse
• Grimace
• Activity
• Respiratory
• Done at 1 minute after delivery and 5 minutes
  after delivery

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APGAR
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Newborn Resuscitation

• Breathing effort
• If it is shallow, slow, or absent, provide
  artificial ventilations
• Heart Rate
• If less than 100 beats provide artificial
  ventilations
• If less than 80 beats and not responding to
  ventilations begin chest compressions
• If less than 60, begin chest compressions

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• Color
• If central cyanosis is present with spontaneous
  breathing and an adequate heart rate administer
  free flow oxygen (10-15 LPM) using oxygen tubing
  held as close to the newborns face as possible

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Prolapsed Cord

• Condition where the cord presents through the
  birth canal before delivery of the head presents
  a serious medical emergency which endangers the
  life of the unborn fetus
• Care
• Standard Initial assessment, VS, and PE
• Position the mother with head down or buttocks
  raised using gravity to lessen pressure on the
  birth canal

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• Insert sterile gloved hand into vagina pushing
  the presenting part of the fetus away from the
  pulsating cord
• Rapidly transport, keeping pressure on the
  presenting part, monitoring pulsations in the
  cord and keep the cord moist and warm

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Breech Birth Presentation

• Breech presentation occurs when the buttocks or
  lower extremity are low in the uterus and will be
  the first part of the fetus delivered
• The newborn is at great risk for delivery trauma
  and prolapsed cord
• Place mother in head down position with pelvis
  elevated and transport rapidly

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Limb Presentation

• Occurs when a limb of the infant protrudes from
  the birth canal (usually a foot)
• Transport rapidly with mother in head down/pelvis
  elevated position

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Multiple Births

• Call for additional resources
• Be prepared for more than one resuscitation

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Meconium Staining

• Amniotic fluid that is greenish or
  brownish-yellow rather than clear. It is a sign
  of possible fetal distress during labor
• DO NOT STIMULATE the infant prior to SUCTIONING
  the oropharynx

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Premature Delivery

• Always at risk for hypothermia
• Usually requires resuscitation should be done
  unless physically impossible

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Gynecological Emergencies

• Vaginal Bleeding
• BSI, airway, normal BLS
• Trauma
• Treat any trauma to the external genitalia as any
  other soft-tissue injury. Never pack the vagina!

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Sexual Assault

• Criminal assault situations require initial and
  on-going assessment/management and psychological
  care
• Remember
• BSI
• Airway
• Non-judgmental attitude during SAMPLE focused
  assessment
• Crime Scene Protection
• Examine external genitalia only if profuse
  bleeding is present
• Discourage the patient to bathe, void, or clean
  wounds
• Document very thoroughly!!

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The End

• Any questions???