EMT: Brady Emergency Care 11th Edition - Chapter 24 - Obstetrics and Gynecological Emergencies Flashcards

umbilical cord
Terms Definitions
Define "fetus."
The baby as he develops in the womb
Define "uterus."
The muscular abdominal organ where the fetus develops; the womb
Define "cervix."
The neck of the uterus at the entrance to the birth canal
Define "vagina"
The birth canal
Define "placenta"
The organ of pregnancy where exchange of oxygen, nutrients, and wastes occurs between a mother and fetus
How wide must the cervix dilate in order to allow birth to take place?
About 4" (10 cm)
Does a fetus have its own circulatory system?
Yes -- the fetus has its own blood, heart, and blood vessels. It does NOT share blood directly with the mother.
How large should the umbilical cord be at birth?
About one inch wide and 22 inches long.
Define "umbilical cord"
The fetal structure containing the blood vessels that carry blood to and from the placenta.
Define "amniotic sac"
The "bag of waters" that surrounds the developing fetus.
How much liquid does the amniotic sac hold?
Almost 1 quart.
During what stage of pregnancy does the uterus rapidly increase in size?
After the third month (after the first trimester).
What changes occur in a woman's body as her uterus grows with pregnancy?
Increased blood volume
Increased cardiac output
Increased heart rate
Slowed digestion
Slight dip in BP
Massive increase in vascularity of uterus
Define "crowning."
When the "presenting part" of the baby first bulges from the vaginal opening. Usually, this is the head.
Define "cephalic presentation."
The headfirst presentation that occurs in a normal birth
Define "breech presentation"
When the baby's buttocks or both legs appear first during birth
Define "labor"
The three stages of the delivery of a baby that begin with the contractions of the uterus and end with the expulsion of the placenta.
Define "afterbirth."
The placenta, membranes of the amniotic sac, part of the umbilical cord, and some tissues from the lining of the uterus that are delivered after the birth of the baby.
What makes up the three stages of labor?
1) First stage - regular contractions, thinning and gradual dilation of cervix, ends with fully dilated cervix

2) Second stage - the time from when the baby enters the birth canal until he is born

3) Third stage - the time between birth and afterbirth
What's another name for "first stage" of labor?
Dilation period.
Define "effacement"
The shortening, thinning process of the cervix.
How fast should contractions be at the beginning of labor? And at the end?
30 minutes at the start

3 minutes or less at the end
Define "meconium staining."
Amniotic fluid that is greenish or brownish yellow rather than clear as a result of fetal defecation; an indication of possible maternal or fetal distress during labor
What is the average length of "first stage" or "dilation period" of labor?
16 hours
What is the "bloody show?"
The expulsion of the initial cervical mucus plug. The mucus plug is usually mixed with blood.
Are watery, bloody fluids discharging form the vagina typical during ALL THREE stages of labor?
Yes
How do the labor pains change during the second stage of labor?
1) They become more severe

2) Most women report a painful feeling of needing to move their bowels
How long does the third stage of labor last?
About 10-20 minutes.
How should labor pains change during the third stage of labor?
They may not change at all. In fact, they may be exactly as severe as they were in stage 2.
When contractions last 30 seconds to 1 minute and are 2-3 minutes apart, ____ __ ______.
Delivery is imminent.
Where do labor pains start?
Usually in the lower back, and they move towards the lower abdomen.
What is the primary role of the EMT during a normal out-of-hospital childbirth?
To determine whether the delivery will occur on scene, and to assist the mother if necessary.
What items should be kept in a sterile obstetric kit in the ambulance?
1) Several pairs of gloves

2) Towels or sheets to drape on the mother

3) A dozen gauze pads for wiping and drying the baby

4) A rubber bulb syringe to suction the baby's mouth and nostrils

5) Cord clamps or hemostats to clamp the umbilical cord (plus extra clamps in case of a multiple birth)

6) Umbilical cord tape to tie the cord

7) Surgical scissors to cut the cord

8) A baby blanket

9) Several individually wrapped sanitary napkins to absorb blood and fluids

10) A plastic bag
If you're off duty and need to assist in the delivery of a baby, what supplies should you ask for?
1) Clean sheets and towels

2) Heavy FLAT twine or shoelaces to cut the cord (don't use wire or thread since they may cut the cord)

3) A towel or plastic bag to wrap the placenta

4) Clean, unused rubber gloves and eyewear
What is the best course of action for an EMT to take EVERY TIME, unless childbirth is expected any minute?
Transport the patient!
What questions must be asked in order to assess a mother on the verge of birth?
1) Mother's name

2) Mother's age

3) Mother's expected due date

4) Is this her first pregnancy? (If yes, expect 16-17 hour labor. If she has been pregnant 1-4 times, it will be faster. From 4 up, it could go either way.)

5) How long has she been having labor pains?

6) How often is she having pains?

7) Has her bag of waters broken? (ask if there has been any bleeding or bloody show)

8) Is she straining, or does she feel she needs to move her bowels? (If yes, the birth is imminent. Don't let her go to the bathroom unless you want a baby in the toilet)

9) Examine for crowning

10) Feel for contractions (Feel abdomen above the navel. Time contractions. The flesh will get more rigid as birth nears)

11) Take vitals. Call medical control if signs are abnormal.
If the mother is having her first delivery, isn't straining, and there is no crowning, then what?
Transport her. You should have plenty of time.
If the mother is on her second delivery and she's straining and crying out, then what?
Time the contractions and contact medical control. You may have to deliver right there.
What do you do if crowning occurs during transport?
Stop the ambulance and deliver the baby.
What is the most important thing you can do for the mother during this process?
Reassure her.
Define "supine hypotensive syndrome"
Dizziness and a drop in blood pressure caused when the mother is in a supine position and the weight of the uterus, infant, placenta, and amniotic sac compress the inferior vena cava, reducing return of blood to the heart and cardiac output.
How much does the baby, placenta, and amniotic fluid weigh during the final trimester?
Roughly 20-24 pounds.
What's another term to describe "supine hypotensive syndrome?"
Vena cava compression syndrome
In what position should expectant mothers be transported, and why?
They should be transported on their left side in order to avoid supine hypotensive syndrome.
When it's determined that birth is imminent and you have to prepare the mother for delivery on scene, what six steps do you take?
1) Control the scene so that the mother will have privacy (her birthing coach may remain)

2) In addition to surgical gloves, don gowns, caps, face masks, and eye protection

3) Place the mother on a bed, floor, or ambulance stretcher, and elevate buttocks with blankets or a pillow. Have the mother lie with knees drawn up and spread apart. ALLOW TWO FEET OF ROOM FOR BABY.

4) Remove clothing that obstructs your view of the vaginal opening. Use clean/sterile sheets to cover mother

5) Position your assistant at the mother's head --- their job is to help the mother turn her head should she vomit, and to emotionally support the mother.

6) Place obstetrics kit within hand's reach.
What should you encourage a mother to do between contractions?
Relax
During delivery, what should you tell a mother?
1) Relax between contractions

2) Don't strain unless you feel you must

3) Remember that the feeling of a pending bowel movement is normal and a side-effect of the baby exerting pressure

4) Encourage her to breathe deeply through the mouth.
What steps do you take in order to assist a mother with a normal delivery?
1) Continue to keep somebody at the mother's head. If you have no help, be alert for vomiting and check vitals between contractions

2) Position gloved hands at the vaginal opening when the baby's head begins to appear. Do not touch the area around the vagina except to assist with the delivery.

3) Place one hand below the baby's head as it delivers -- DO NOT PULL!

4) If amniotic sac hasn't broken by the time the baby's head has delivered, use your finger to puncture the membrane. Pull membranes away from baby's mouth and nose -- fluid should be clear.

5) Once the head delivers, check to see if the umbilical cord is wrapped around the neck. Tell the mother not to push while you check. Loosen cord if necessary. IF YOU CANNOT LOOSEN IT, you MUST clamp the cord and cut it between the two clamps before you proceed.

6) Check the baby's airway, supporting the head with one hand and wiping with the other. Suction the mouth and then the nose.

7) Deliver the shoulders -- the upper shoulder will deliver next, immediately followed by the lower shoulder. Support the baby!

8) Get a good grip on the lower extremities when handling the baby. Once feet are delivered, suction again and lay baby on his side with head slightly lower than body.

9) Note the exact time of birth.
Besides vitals, etc., what must be assessed as soon as the child is born?
Vigor. Note breathing, heart rate, crying, movement, and skin color. It's normal to see blue in the extremities, but it should not spread.
What is the Apgar score?
It's a formal assessment of a newly born's vigor.
What is the maximum apgar score?
10
Define the following:

1) Fetus
2) Newly born
3) Newborn or neonate
4) Infant
1)Fetus: A baby as it develops in the womb

2) Newly born: The baby at the time of birth

3) Newborn or Neonate: The baby during its initial hospitalization

4) Infant: A baby in the first year of life
What do you do if the baby doesn't begin to breathe on his own after suctioning, drying, and warming for 30 seconds?
Begin resuscitative measures
When is it appropriate to begin resuscitative measures on a newly-born?
If the child doesn't begin to breathe on it's own after 30 seconds of drying, suctioning, and warming.
What steps do you follow to resuscitate a newly born?
1) Provide warmth

2) Clear the airway

3) Keep baby on his side and suction mouth then nose again

4) Evaluate respirations, heart rate, and color

5) If no breathing, vigorously rub baby's back to try to start breathing

6) If still no breathing, snap a finger against the baby's foot

7) If breathing is inadequate or absent, provide artificial ventilations at 40-60 breaths per minute, make them VERY SHALLOW!

8) Assess heart rate. If less than 100 BPM, begin artificial ventilations. If less than 60 BPM, initiate chest compressions

9) If respiration and pulse are OK but cyanosis persists in face or torso, provide oxygen by placing oxygen tubing near (but not directly on) the infant's face, at 15 lpm
When can you clamp and cut the umbilical cord?
Once it's done pulsating.
What is the general procedure for umbilical cord care?
1) Keep infant warm and wrapped in blankets

2) Use sterile clamps or umbilical tape to tie/clamp once about 10 inches from the baby, and once about 7 inches from the baby (about 4 finger-lengths)

3) Cut the cord using sterile scissors
What should you do with the vernix (protective coating on a baby) after birth outside the hospital?
Keep it on the baby until arrival at the hospital. Don't remove it. Don't wash the baby.
What do you do in the case of a knot tied to secure the umbilical cord coming loose?
Do not adjust it -- tie another knot as close as possible to the original.
What do you do if you assist a birth off-duty and the baby is still attached to the placenta when it is delivered?
Keep the two attached. Wrap the placenta, and keep the baby and the placenta at the same level. Transport to the hospital.
What should you do with the placenta after birth?
Wrap it and save it. The attending physician will want to examine it.
If you assist an out-of-hospital delivery and the placenta doesn't deliver within 20 minutes of the infant's birth, what must you do?
Transport immediately! Stop the ambulance if the placenta crowns.
What steps do you take in order to control vaginal bleeding?
1) Place sanitary napkin over vagina

2) Have mother lower legs and keep them together, and elevate her feet

3) Palpate the abdomen until you feel the uterus and massage it lightly with a circular motion so it contracts and becomes firm

4) Follow local protocol
Define "perineum"
The surface area between the vagina and the anus. Tearing here is common during childbirth, treat it like any other wound.
How do you care for a patient with a breech presentation?
1) Initiate rapid transport

2) Never attempt to deliver baby by pulling on legs

3) Provide high-concentration oxygen

4) Place the mother in a head-down position with pelvis elevated

5) If body delivers, support it and prevent an explosive delivery of the head. Insert gloved index and middle fingers into vagina to form a "v" on either side of the baby's nose to lift it away from the vaginal wall in case the baby begins to breathe spontaneously

6) Care for baby, cord, mother, and placenta as in after cephalic delivery
Define "prolapsed umbilical cord."
When the umbilical cord presents first and is squeezed between the vaginal wall and the baby's head.
Define "abruptio placentae."
Premature placental separation
Full dilation of the cervix occurs in the ___ stage of labor.
First
What do you do if the baby's head delivers and you see the umbilical cord wrapped around his neck?
Insert two fingers under the cord and gently remove it from the baby's neck. If that fails, clamp it off and cut it.
What is a very late and very severe sign of an ectopic pregnancy?
Low blood pressure
About how much blood can a woman who is eight months pregnant lose before she would exhibit signs of shock?
30%-35%, due to the vastly increased blood volume present in a pregnant woman
True or false: If the umbilical cord is protruding from the vaginal opening (prolapsed), the patient should be transported on her side with her knees together.
False
True or false: EMTs should never try to determine the specific cause of a patient's vaginal bleeding.
True
True or false: Drugs, nicotine, and alcohol can pass from the mother's bloodstream to the fetus.
True
True or false: A pregnant patient who requires spinal immobilization should be secured to a long spine board that is tilted to the left during transport.
True
True or false: Meconium staining is an indicator of gestational diabetes.
False
Define "prolapsed umbilical cord"
When the umbilical cord presents first and is squeezed between the vaginal wall and the baby's head
What steps do you take in order to treat for a prolapsed umbilical cord?
1) Position mother with her head down and buttocks raised with a blanket or pillow, using gravity to lessen pressure on the birth canal.

2) Provide the mother with high-concentration oxygen by way of a nonrebreather mask to increase the concentration carried over to the infant.

3) Check the cord for pulses and cover the exposed cord using a sterile towel. Keep the cord warm.

4) Insert several fingers of your gloved hand into the mother's vagina so that you can gently push up on the baby's head or buttocks to keep pressure off of the cord You will be pushing up through the cervix. This may be the only change that the baby has for survival, so continue to push up on the baby until a physician relieves you.

5) Keeping mother, child, and EMT as a unit, transport immediately

6) All patients with prolapsed cords require rapid transport. Have your partner obtain vitals while en route to the hospital if possible
Define "limb presentation."
When an infant's limb protrudes from the vagina before the appearance of any other body part.
Define "multiple birth."
When more than one baby is born during a single delivery.
If one or more limbs present, there is also often a ____ _____ ____.
Prolapsed umbilical cord
What four steps do you take to care for a limb presentation?
1) If there is a prolapsed cord, follow the same procedures as you would for delivery involving a prolapsed cord. You MUST keep pressing up until you are relieved by a physician.

2) Transport the mother immediately

3) Place the mother in a head-down position with the pelvis elevated

4) Administer high-concentration oxygen with a nonrebreather mask
What four steps do you take to assist in the delivery of twins?
1) Clamp or tie the cord of the first baby before the second is born

2) The second baby may be born either before or after the placenta is delivered, assist mother with delivery of second baby.

3) Provide care for the babies as you would in a single-baby delivery

4) Take special care to warm the babies during transport since they will be abnormally small
Define "premature infant."
Any newborn weighing less than 5.5 lbs or born before the 37th week of pregnancy.
What eight steps do you take to care for a premature infant?
1) Keep the baby warm above all, using multiple layers and a stockinet cap if possible

2) Keep the airway clear

3) Provide resuscitation if necessary and possible

4) Watch umbilical cord for bleeding -- if there is even slight bleeding after cutting the cord, clamp once more closer to the baby

5) Provide oxygen flow past the baby's face

6) Avoid contamination

7) Transport in a warm ambulance --- preferred temperature is 90-100 degrees

8) Call ahead to the emergency dept.
What five care steps do you take in the case of meconium staining?
1) Do not stimulate infant before suctioning the oropharynx (to avoid aspiration)

2) Suction the mouth and then the nose

3) Maintain an open airway

4) Provide artificial ventilations/chest compression if necessary

5) Transport immediately
Define "placenta previa."
A condition in which the placenta is formed in an abnormal location (low in the uterus and close to or over the cervical opening) that will not allow for a normal delivery of the fetus; a cause of excessive prebirth bleeding
Define "abruptio placentae"
A condition in which the placenta separates from the uterine wall -- a cause of prebirth bleeding
Define "oviduct"
The fallopian tube; a tube that carries eggs from an ovary to the uterus
Define "ectopic pregnancy"
When implantation of the fertilized egg is not in the body of the uterus, occurring instead in the oviduct, cervix, or abdominopelvic cavity.
What are some signs and symptoms of excessive prebirth bleeding?
1) Main sign is usually profuse bleeding from vagina

2) Mother may or may not experience abdominal pain

3) Signs of shock

4) Rapid, thready heartbeat
What three steps do you take to care for generalized excessive prebirth bleeding?
1) Treat with high-concentration oxygen and transport immediately

2) Place sanitary napkin over the vagina, and replace napkins as they become soaked.

3) Save napkins to evaluate blood loss
What are some signs of an ectopic pregnancy?
1) Acute abdominal pain, often occurring first on one side.

2) Vaginal bleeding

3) Rapid and weak pulse (a later sign)

4) Low blood pressure (a very late sign)

WATCH FOR SIGNS OF SHOCK
What three steps do you take to care for an ectopic pregnancy?
1) Begin transport

2) Treat for shock

3) Don't give patient anything orally
Define "eclampsia."
A severe complication of pregnancy that produces seizures and coma
Define "preeclampsia."
A complication of pregnancy where the woman retains large amounts of fluid and has hypertension. She may also experience seizures and/or coma during birth.
What three steps do you take to care for generalized excessive prebirth bleeding?
1) Treat with high-concentration oxygen and transport immediately

2) Place sanitary napkin over the vagina, and replace napkins as they become soaked.

3) Save napkins to evaluate blood loss
What are some signs of an ectopic pregnancy?
1) Acute abdominal pain, often occurring first on one side.

2) Vaginal bleeding

3) Rapid and weak pulse (a later sign)

4) Low blood pressure (a very late sign)

WATCH FOR SIGNS OF SHOCK
What three steps do you take to care for an ectopic pregnancy?
1) Begin transport

2) Treat for shock

3) Don't give patient anything orally
Define "eclampsia."
A severe complication of pregnancy that produces seizures and coma
Define "preeclampsia."
A complication of pregnancy where the woman retains large amounts of fluid and has hypertension. She may also experience seizures and/or coma during birth.
What factors may be signs of an imminent seizure during pregnancy?
1) Elevated blood pressure, which increases the risk of abruptio placentae

2) Excessive weight gain

3) Extreme swelling of hands, ankles, and feet

4) Headache
What seven steps do you take to care for a pregnant patient with seizures?
1) Maintain open airway

2) Administer oxygen by nonrebreather

3) Transport patient on her left side

4) Handle her gently

5) Keep her warm

6) Have suction ready

7) Have a delivery kit ready
What's another word for "spontaneous abortion?"
Miscarriage
What symptoms may indicate a spontaneous abortion/miscarriage?
1) cramping abdominal pains not unlike those associated with labor

2) Moderate to severe bleeding

3) A noticeable discharge of tissue and blood from the vagina
An EMT should be prepared to attempt delivery on ANY baby if they have been in gestation for at least ___ weeks
24 weeks
What are the seven steps in caring for miscarriage or abortion?
1) Obtain baseline vitals

2) Treat with oxygen

3) Help absorb vaginal bleeding using sanitary napkins

4) Transport ASAP

5) Replace and save all blood-soaked pads

6) Save all tissues that are expelled

7) Provide emotional support to the mother
What are the most common problems with blunt injuries to the pregnant abdomen?
Massive bleeding and shock
What factors must you remember in order to properly assess a pregnant patient who has undergone trauma?
1) Pulse will be 10-15 BPM faster than a nonpregnant female

2) Blood volume in pregnant females is up to 48% higher than in nonpregnant females, so more blood loss may occur

3) Shock is the most common cause of prehospital death due to injury of the uterus. Treat for shock!

4) Ask patient if she has had bleeding or rupture of the bag of waters, examining vaginal area if necessary
Define "stillborn"
Born dead
What are some signs that a baby died some time before birth?
1) Blisters

2) Foul odor

3) Skin or tissue deterioration and discoloration

4) Softened head
If a pregnant woman dies, how can you save the baby?
Provide CPR until an emergency C-section can be performed.
When providing chest compressions to a pregnant female, what must you remember?
Position hands 1-2 inches higher since the heart has shifted to accommodate the large fetus.
All women with vaginal bleeding must be treated as if there is a ___-____ ______.
Life-threatening condition
What four things must be remembered during treatment of trauma to the external genitalia?
1) Let patient hold the sanitary pad used to apply pressure to the wound.

2) Don't remove undergarments unless necessary

3) Maintain a professional attitude

4) Respect the patient's privacy
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