and Obstetrics Gynecological Emergencies Reproductive Anatomy and Physiology Fetus-developing unborn baby Uterus-organ in which a fetus grows, responsible for labor and expulsion of infant. The cervix is the neck of the uterus. Birth canal-vagina and lower part of the uterus Placenta-fetal organ through which fetus exchanges nourishment and waste products during pregnancy Umbilical cord-cord that is an extension of the placenta through which fetus receives nourishment while in the uterus Amniotic sac (bag of waters)-the sac that surrounds the fetus inside the uterus Vagina-lower part of the birth canal Perineum-skin area between vagina and anus, commonly torn during Delivery "Bloody show"-mucus and blood that may come out of the vagina as labor begins Crowning-the bulging-out of the vagina, which is opening as the fetus's head or presenting part presses against it
Labor-the time and process beginning with the first uterine muscle contraction until delivery of the placenta. Labor can be defined as having three stages. Stage 1 Stage 2 Stage 3
Contents of a Childbirth Delivery Kit
Surgical scissors Hemostats or cord clamps Umbilical tape or sterilized cord Bulb syringe Towels Gauze sponges Sterile gloves One baby blanket Sanitary napkins Plastic bag Delivery is imminent. Normal Delivery Predelivery considerations Is this your first child? How long have you been pregnant? Are there contractions or pain? What is the frequency and duration of contractions? Any bleeding or discharge? Is crowning occurring with contractions? Do you feel as if you are having a bowel movement with increasing pressure in the vaginal area?
Do you feel the need to push? Rock hard abdomen?
Average first child labor 16 hours. If delivery is eminent with crowning prepare for emergency child birth Assist in delivery of baby Contact medical direction if problem or question. If delivery does not occur within 10 min. Contact medical control for guidance regarding transportation Delivery Precautions Use body substance isolation. Do not let the mother go to bathroom Control Scene Delivery procedures Apply gloves, masks, gown, and eye protection for infection control precautions. Have mother lie with knees drawn up and spread apart. Elevate buttocks using blankets or pillow. Create a sterile field around vaginal opening with sterile towels or paper barriers.
If the amniotic sac does not break, or has not broken, use a clamp to puncture the sac and push it away from the infant's head and mouth as they appear. As the infant's head appears, determine if the umbilical cord is around the infant's neck; if it is, slip the cord over the shoulder or clamp cut, and unwrap. As the head & shoulders appear guide in a downward motion to assist in delivery.
After the infant's head appears, support the head, suction the mouth two or three times and the nostrils. Use caution to avoid contact with the back of the mouth. As the torso and full body appear, support the infant with both hands.As the feet appear, grasp the feet. Wipe blood and mucus from mouth and nose with sterile gauze, suction mouth and nose again. Wrap infant in a warm blanket before clamping the umbilical cord.
Keep infant level with vagina until the cord is cut. Assign partner to monitor infant and complete initial care of the newborn. Clamp, tie, and cut umbilical cord (between the clamps) approximately ten inches width from infant as pulsations cease. Observe for delivery of placenta while preparing mother and infant for transport. When delivered, put placenta plastic bag; transport placenta to hospital with mother. Place sterile pad over vaginal opening, lower mother's legs, help her hold them together. Record time of delivery and transport mother, infant, and placenta to hospital. Vaginal bleeding following delivery
A 500 cc blood loss is well tolerated by the mother following delivery. The CFR must be aware of this loss so as not to cause undue psychological stress to himself or the new mother. With excessive blood loss, manage the uterus. The CFR should use a hand with fingers fully extended. Place the hand on lower abdomen over pubis. Massage (knead) over area.
If bleeding continues, check massage technique and transport immediately, providing oxygen and ongoing assessment. Regardless of estimated blood loss, if mother appears in shock (hypoperfusion), treat as such and transport prior to uterine massage. Massage en route. Initial care of the newborn Position, dry, wipe, and wrap newborn in blanket and cover the head. Repeat suctioning. Assessment of infant-normal findings Appearance-color: no central (trunk) cyanosis Pulse-greater than 100/min Grimace-vigorous and crying Activity-good motion in extremities Breathing effort-normal, crying
Stimulate newborn if not breathing. Flick soles of the infant's feet. Rub infant's back. Resuscitation of the newborn follows the inverted pyramid. After assessment, if signs and symptoms require either cardiac or pulmonary resuscitation, do the following when appropriate: Breathing effort-if shallow, slow, or absent, provide artificial ventilations 60/min Reassess after 30 seconds. If no improvement, continue artificial ventilations and reassessments. Heart rate
If less than 100 beats per minute, provide artificial ventilations 60/min Reassess after 30 seconds. If no improvement, continue artificial ventilations and reassessments. If HR is ever less than 60 beats per minute start chest compressions and ventilations.
Color-if central cyanosis is present with spontaneous breathing and an adequate heart rate, administer free-flow oxygen at 10-15L per minute using oxygen tubing held as close as possible to the newborn's face. Abnormal Deliveries Prolapsed cord. This is a condition where the cord presents through the birth canal before delivery of the head; it presents a serious emergency that endangers the life of the unborn fetus.
Perform scene size-up. Perform initial assessment. Mother should have high-flow oxygen. Obtain history and perform physical exam. Assess baseline vitals. Base treatment on signs and symptoms. Position mother with head down or buttocks raised using gravity to lessen pressure in birth canal. Insert sterile gloved hand into vagina pushing the presenting part of the fetus away from the pulsating cord. Rapidly transport, keeping pressure on presenting part and monitoring pulsations in the cord.
Breech birth presentation. This condition occurs when the buttocks
or lower extremities are low in the uterus and will be the first part of the fetus delivered.
Newborn at great risk for delivery trauma and a prolapsed cord is more common; transport immediately upon recognition of breech presentation. Delivery does not occur within 10 minutes. Emergency medical care Provide immediate rapid transportation upon recognition. Place mother on oxygen. Place mother in head-down position with pelvis elevated. Delivery does not occur within 3 min. Form a V over the baby's nose inside the area & push the uterine wall away to form an airway for the infant vaginal
Limb presentation. This condition occurs when a limb of the infant protrudes from the birth canal. The presenting limb is more commonly a foot when infant is in breech presentation.
Provide immediate rapid transportation upon recognition. Place mother on oxygen. Place mother in head-down position with pelvis elevated. Multiple births Be prepared for more than one resuscitation. Call for assistance.
Premature birth : Less than 5.5 lbs or prior to 37 weeks gestation
Premature infants are always at risk for hypothermia. These infants usually require resuscitation; it should be provided unless physically impossible.
Meconium-amniotic fluid that is greenish or brownish-yellow rather than clear. Its presence is an indication of possible fetal distress during labor. Do not stimulate the infant before suctioning oropharynx. Suction. Maintain airway. Transport as soon as possible. Miscarriage Perform patient assessment Bring any tissue to the hospital Provide emotional support
Seizure during pregnancy: Eclampsia Perform Patient assessment. Base treatment based on signs and symptoms.
Vaginal bleeding-late pregnancy vaginal bleeding, with or without pain Perform patient assessment. Base treatment on signs and symptoms. Apply external vaginal pads. Transport.
. Trauma-same as other trauma patients Perform Patient assessment. Base treatment on signs and symptoms. Trauma-external genitalia. Treat as other bleeding in soft tissue injuries; never pack vagina, provide oxygen and ongoing patient assessment. Sexual assault. Maintain a nonjudgmental attitude. Attempt as far as possible to protect evidence at the crime scene. Examine genitalia only if profuse bleeding is present. Use same-sex EMT-Bs for care when possible. Discourage the patient from bathing, or voiding, cleaning wounds. Follow reporting requirements. Infants and Children
Developmental concerns Newborns and infants--birth to 1 year of age Children: 1-puberty Anatomical and physiological concerns Airway Small airways throughout the respiratory system are easily blocked by secretions and airway swelling. Tongue is large relative to small mandible Infants are NOSE Breathers Suctioning the nasopharynx improves breathing
Caution: If child exhibits signs & symptoms of upper respiratory infection or seal bark cough do not put anything in child's mouth
Positioning the airway is different in infants and children-do not hyperextend the neck. Children can compensate well for short periods of time. They compensate by increasing breathing rate and increased effort of breathing.Compensation is followed rapidly by decompensation due to rapid respiratory muscle fatigue and general fatigue of the infant. Airway Airway opening Position to open airway is different--head-tilt, chin-lift, but do not hyperextend.
Suctioning Sizing Depth Technique Bulb Syringe Airway obstructions Clearing conscious complete obstructions Infants to 1 year old Back blows/chest thrusts Visual foreign body removal Children 1 year old - puberty Abdominal thrusts Visual foreign body removal
Airway adjuncts Oral airways Adjunct, not for initial artificial ventilation Patient should not have a gag reflex. Sizing Techniques of insertion--Use tongue depressor. Insert oropharyngeal airway directly in without rotation. Oxygen Therapy Oxygen delivery Nonrebreathers Blow-by techniques Hold tubing two inches from face. Insert tubing into a paper cup. Artificial ventilations Mask sizing/bag sizing Trauma considerations Mask seal Two hand One hand Use of bag-valve mask Use E - C Clamp BVM Grip Use squeeze, release, relax cadence. Ventilate so that the chest rises.
Ventilate child/infant 20 times a minute. Use reservoir to provide 100% oxygen. Pediatric Assessment Triangle Appearance Mental Status Muscle Tone Body Position Breathing Chest and Abdomen Movement Effort Circulation Color Cap Refill
General Impression (From the Doorway) Interaction with parents Normal behavior for age? Playing or moving? Attentive? Eye contact? Recognize & respond Assessment Mental Status Breathing Color Quality of cry or speech Emotional state Response to your presence Tone & body position
From the Door Mechanism of injury Surroundings Healthy or sick appearance Chest expansion & symmetry Effort of breathing Nasal flaring Retractions
Assess Respirations Crowing or noisy respirations Stridor Grunting Respiratory rate (noise is not good!) Assess perfusion. Skin color Capillary Refill Approach to Evaluation When you reach child, continue breathing assessment by using stethoscope: Breath sounds Present or absent? Stridor? Wheezing? Detailed Physical Exam Generally, evaluate toe to head last. Alter order of steps to fit situation. Avoid making child more anxious. Respect child modesty Partial Airway Obstruction Good Air Exchange Signs and Symptoms
Stridor, crowing or noisy respiration Seal bark cough Retractions on inspiration Pink nail beds and skin Alert
Respiratory Distress Signs And Symptoms Rate > 60 Cyanosis Decreased muscle tone Severe use of accessory muscles Poor peripheral perfusion Altered mental status Retractions Grunting Respiratory arrest or failure Increased effort at sternal notch Breathing rate less than 10 per minute Limp muscle tone AMS/Unconsciousness/Head Bobbing Slow, absent heart rate Poor Perfusion Absent or shallow chest wall motion Severe grunting or use of accessory muscles Emergency medical care
Provide oxygen to all children with respiratory emergencies. Provide oxygen and assist ventilations for severe respiratory distress. Ventilate if Distress is Severe Altered mental status Presence of cyanosis with oxygen Poor muscle tone Respiratory failure Respiratory arrest Altered Mental Status/ Seizures Fever Head trauma Infection Poisoning Hypoglycemia Trauma Hypoxia Idiopathic (Unknown Cause) Emergency medical care Assure airway position and patency. Position patient on left side if there is no possibility of cervical spine trauma. Have suction ready. Provide oxygen Ventilate if patient is in respiratory arrest or severe respiratory distress.
Transport. Ask the following questions:
Has the child had prior seizure(s)? If yes, is this the child's normal seizure pattern? Has the child taken his anti-seizure medication? Has the child had a fever? Poisoning Contact medical direction. Administer 02 or ventilate as PRN. Rule out trauma. Establish airway. Administer oxygen; Transport & monitor patient.
Shock (Hypoperfusion) Common causes Diarrhea, Vomiting and dehydration Trauma & Blood loss Infection Abdominal injuries Uncommon Allergic reactions Poisoning Cardiac Signs and symptoms Rapid respiratory rate Pale, cool, clammy skin Weak or absent peripheral pulses
Delayed capillary refill Decreased urine output-measured by asking parents about diaper wetting and looking at diaper Mental status changes Absence of tears, even when crying Emergency medical care Assure airway Oxygen Be prepared to artificially ventilate. S/S Hypoperfusion & H/R<60 Do Chest Compressions Manage bleeding if present. Elevate legs. Keep warm. Transport. Note need for rapid transport. Sudden Infant Death Syndrome (SIDS) Sudden death of infant in first year of life. Causes are many and not clearly understood. Baby most commonly discovered in the early morning. Emergency Care Try to resuscitate & transport. Avoid comments of blame parents. Expect parents to feel guilt. Provide emotional support for family
Trauma
Injuries are the number one cause of death in infants and children. Blunt injury is most common. Motor vehicle crashes Unrestrained passengers have head and neck injuries. Restrained passengers have abdominal and lower spine injuries. Struck while riding bicycle--head injury, spinal injury, abdominal injury Pedestrian struck by vehicle--abdominal injury with internal bleeding; possible painful, swollen, deformed thigh; head injury Falls from height, Diving into shallow water--head and neck injuries Burns Sports injuries--head and neck Child abuse Head The single most important maneuver is to assure an open airway by means of the jaw-thrust maneuver. Children are likely to sustain head injury along with internal injuries. Can cause: Respiratory Arrest Nausea Vomiting Chest Children have very soft pliable ribs. There may be significant injuries without external signs.
Down's syndrome children even with low impact trauma can have a high likelihood of C-Spine injury. This is because of congenital defects affecting C1-C2.
Abdomen More common site of injury in children than adults Often a source of hidden injury Always consider abdominal injury in the multiple-trauma patient who is deteriorating without external signs Air in stomach can distend abdomen, interfere with artificial ventilation efforts. Extremities--Extremity injuries are managed in the same manner as with adults. Emergency medical care Assure airway position and patency. Use modified jaw thrust. Suction as necessary with large-bore suction catheter. Provide oxygen. Assist ventilations for severe respiratory distress and ventilate with a bag-valve mask for respiratory arrest. Provide spinal immobilization. Transport immediately. Child Abuse and Neglect Abuse--Improper or excessive action so as to injure or cause harm. Neglect--Giving insufficient attention or respect to someone who has a claim to that attention. CFR must be aware of condition to be able to recognize the problem. Physical abuse and neglect are the two forms of child abuse that theEMT-B is likely to suspect.
Signs and symptoms of abuse Multiple bruises Various stages of healing Injury inconsistent with mechanism described Repeated calls to the same address Fresh burns, old burns, slap marks, welts, bite marks, and so on Parents seem inappropriately unconcerned, have trouble controlling anger, seem depressed, or have a history of substance abuse. Conflicting stories Fear on the part of the child to discuss how the injury occurred Missing Hair Head Injury (Shaken Baby Syndrome) Lacerations in unusual places Refusal to remove outer garments Fear of going home Signs and symptoms of neglect Lack of adult supervision Malnourished-appearing child Unsafe living environment Poor Hygiene Untreated chronic illness (e.g., asthmatic with no meds) Constant Hunger Handling Abuse and Neglect The primary objective of an CFR in cases of abuse/neglect is patient care.
The second most important objective is to get the patient to a safe environment Head injuries most lethal (shaken baby syndrome) Do not accuse anyone in the field. Document objective information. (what you SEE & HEAR, not what you THINK)