Obstetrics and Gynecology

Slide 1Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Obstetrics and GynecologyObstetrics and GynecologyChapter 24Chapter 24


Case HistoryCase History

A 16-year-old girl reports to the high school nurse’s A 16-year-old girl reports to the high school nurse’s office with severe abdominal pain. The EMTs arrive office with severe abdominal pain. The EMTs arrive just after she gives birth to a premature 4-pound baby just after she gives birth to a premature 4-pound baby boy. The girl is hysterical, the baby is not breathing, boy. The girl is hysterical, the baby is not breathing, and there is a large amount of blood pooling on the and there is a large amount of blood pooling on the sheets.sheets.


Obstetrical EmergenciesObstetrical Emergencies Two patients to care forTwo patients to care for

Emotionally charged situationEmotionally charged situation

Best management for unborn is dynamic management of Best management for unborn is dynamic management of mother.mother. Maintain vital signs and oxygenation.Maintain vital signs and oxygenation.

Be familiar with the steps for dealing with complications.Be familiar with the steps for dealing with complications.


Anatomy and PhysiologyAnatomy and Physiology UterusUterus

Fundus, body, cervixFundus, body, cervix VaginaVagina OvariesOvaries

Endocrine glandsEndocrine glands Egg productionEgg production

Fallopian tubesFallopian tubes Usual site of fertilizationUsual site of fertilization


PregnancyPregnancy

Implantation occurs about 7 days after fertilizationImplantation occurs about 7 days after fertilization Outermost cells become the placenta.Outermost cells become the placenta. Amniotic sac (membranes)Amniotic sac (membranes)

Amniotic fluidAmniotic fluid• Cushions and maintains temperatureCushions and maintains temperature• May become stained with fetal feces (meconium)May become stained with fetal feces (meconium)• 20% of infants with meconium-stained fluid will have some respiratory 20% of infants with meconium-stained fluid will have some respiratory

distress – avoid aspiration.distress – avoid aspiration. Umbilical cordUmbilical cord

Two arteries and one veinTwo arteries and one vein


Physiologic Changes of Physiologic Changes of PregnancyPregnancy

Anatomic changesAnatomic changes

Increased blood supplyIncreased blood supply

Organ crowdingOrgan crowding

Uterus becomes an Uterus becomes an abdominal organ.abdominal organ. More prone to injuryMore prone to injury


Cardiovascular ChangesCardiovascular Changes Heart rate increases 15 - 20 beats per min.Heart rate increases 15 - 20 beats per min.

Blood pressure drops in second trimester.Blood pressure drops in second trimester.

Hypovolemia or hypotension affects fetus first Hypovolemia or hypotension affects fetus first because blood is redirected to major organs.because blood is redirected to major organs.


Supine Hypotensive Supine Hypotensive SyndromeSyndrome

Vena cava is compressed by weight of fetus.Vena cava is compressed by weight of fetus. After 20After 20thth week of pregnancy week of pregnancy Inhibits return of blood to heartInhibits return of blood to heart Blood pressure drops.Blood pressure drops.


Transporting the Pregnant Transporting the Pregnant PatientPatient

Transport on the Transport on the left sideleft side – avoid – avoid supine position.supine position.

If respiratory difficulty, sit patient up.If respiratory difficulty, sit patient up.

For spinal precautions, place wedge For spinal precautions, place wedge (towels or a pillow) under the right side (towels or a pillow) under the right side of the spine board or manually displace of the spine board or manually displace uterus toward the left side.uterus toward the left side.


Pulmonary ChangesPulmonary Changes Respiratory rate remains the same or may increase slightlyRespiratory rate remains the same or may increase slightly

Tidal volume increases 50%.Tidal volume increases 50%.

Fetal demand for oxygen = increased oxygen consumptionFetal demand for oxygen = increased oxygen consumption

Relaxation and upward displacement of the diaphragm may Relaxation and upward displacement of the diaphragm may cause shortness of breath.cause shortness of breath.


Gastrointestinal ChangesGastrointestinal Changes Progesterone slows the GI tract and relaxes Progesterone slows the GI tract and relaxes

the cardiac sphincter (between the stomach the cardiac sphincter (between the stomach and the esophagus)and the esophagus) Stomach remains full longer.Stomach remains full longer. AspirationAspiration IndigestionIndigestion VomitingVomiting ConstipationConstipation


Genitourinary ChangesGenitourinary Changes Urinary bladder becomes abdominal organ.Urinary bladder becomes abdominal organ.

Compression causes urinary frequency, urgency, and retention.Compression causes urinary frequency, urgency, and retention. Bladder is more prone to injury.Bladder is more prone to injury. Infections are more common.Infections are more common.

• Bladder infections may cause preterm labor.Bladder infections may cause preterm labor.

Uterine blood flow is greatly increased with potential for huge Uterine blood flow is greatly increased with potential for huge blood loss.blood loss.

Blood flow to kidneys is also greatly increased.Blood flow to kidneys is also greatly increased.


Emergency ChildbirthEmergency Childbirth First stage of laborFirst stage of labor

Onset of contractions to fully dilated cervixOnset of contractions to fully dilated cervix• Averages 14 hours for first pregnancyAverages 14 hours for first pregnancy• Time contractions from beginning of one contraction to beginning of Time contractions from beginning of one contraction to beginning of

next.next.• Amniotic sac may rupture at any time, even before the onset of Amniotic sac may rupture at any time, even before the onset of

contractions.contractions.• Toward the end of first stage patient cannot walk or talk during Toward the end of first stage patient cannot walk or talk during

contraction.contraction.

Fear and pain release substances that intensify the uterine Fear and pain release substances that intensify the uterine contractions; calming the patient can slow the process and contractions; calming the patient can slow the process and possibly prevent prehospital delivery.possibly prevent prehospital delivery.


Second Stage of LaborSecond Stage of Labor ““Pushing stage”Pushing stage”

Begins with fully dilated cervix and ends with birth of the babyBegins with fully dilated cervix and ends with birth of the baby

Average time 1 hour with first baby, much faster with second Average time 1 hour with first baby, much faster with second babybaby

Fetal head exerts pressure on the rectum, causing an intense Fetal head exerts pressure on the rectum, causing an intense urge to push.urge to push.


Third Stage of LaborThird Stage of Labor Delivery of the placentaDelivery of the placenta

Uterus decreases in size after the baby is born.Uterus decreases in size after the baby is born. Placenta is squeezed off the wall of the contracting uterus.Placenta is squeezed off the wall of the contracting uterus.

Painless contraction of the uterus into a hard ballPainless contraction of the uterus into a hard ball

Lengthening of the cordLengthening of the cord

Gush of bloodGush of blood


Mechanics of LaborMechanics of Labor


Assessment of the Labor Assessment of the Labor PatientPatient

Obtain SAMPLE history.Obtain SAMPLE history.

Visual examination if any of the following:Visual examination if any of the following: Patient cannot walk or talk during contractions.Patient cannot walk or talk during contractions. Patient is in so much pain she cannot answer your Patient is in so much pain she cannot answer your

questions.questions. Patient appears to be pushing.Patient appears to be pushing. Patient tells you, “The baby is coming!”Patient tells you, “The baby is coming!”


Important QuestionsImportant Questions Is this your first pregnancy?Is this your first pregnancy?

History of rapid labors or cesarean sections?History of rapid labors or cesarean sections?

Onset of labor and how far apart are contractions?Onset of labor and how far apart are contractions?

Have membranes ruptured and what color was the fluid?Have membranes ruptured and what color was the fluid?

Is there vaginal bleeding or “bloody show”?Is there vaginal bleeding or “bloody show”?

When is your due date?When is your due date?

Problems with pregnancy or history of medical or surgical problems? Allergies? Problems with pregnancy or history of medical or surgical problems? Allergies? Diabetes?Diabetes?

Time of last oral intake?Time of last oral intake?


Visual ExaminationVisual Examination Look for bulging of the perineum.Look for bulging of the perineum.

Examine during a contraction.Examine during a contraction. Presenting part may recede between contractions until Presenting part may recede between contractions until

crowning occurs.crowning occurs.


Visual ExaminationVisual Examination


Personal ProtectionPersonal Protection

Abundance of blood and body fluids in childbirth puts Abundance of blood and body fluids in childbirth puts EMT at risk.EMT at risk. HepatitisHepatitis HIVHIV Other pathogens carried by blood and body fluidsOther pathogens carried by blood and body fluids

Personal protective equipmentPersonal protective equipment GogglesGoggles Fluid-resistant gownFluid-resistant gown GlovesGloves MaskMask


Putting on Protective ClothingPutting on Protective Clothing Apply goggles or mask with shield and gown first.Apply goggles or mask with shield and gown first.

Pull gloves on over the cuffs of the gown so fluids do Pull gloves on over the cuffs of the gown so fluids do not seep in.not seep in.


Removing Protective Removing Protective EquipmentEquipment

Gown and gloves should be Gown and gloves should be removed inside out as if they were removed inside out as if they were one article.one article.

Dispose of soiled articles as medical Dispose of soiled articles as medical waste.waste.

Frequent handwashing is best Frequent handwashing is best defense against the spread of defense against the spread of disease.disease.


Preparing for DeliveryPreparing for Delivery

Position mother on stretcher in semi-sitting position with Position mother on stretcher in semi-sitting position with knees bent and legs spread apart.knees bent and legs spread apart. Allows you to transport if you encounter complications mid-Allows you to transport if you encounter complications mid-

deliverydelivery

If possible, have patient deliver inside ambulance for the If possible, have patient deliver inside ambulance for the same reason.same reason. Also provides privacyAlso provides privacy


Unwrap the OB KitUnwrap the OB Kit Place two towels on mothers Place two towels on mothers

abdomen and one under her abdomen and one under her buttocks.buttocks. Baby will be placed on Baby will be placed on

towels on her abdomen.towels on her abdomen. Towel under her hips will Towel under her hips will

absorb fluids.absorb fluids.

The blue towel can be used The blue towel can be used to support the perineum.to support the perineum.


Using the OB KitUsing the OB Kit Use the 4 Use the 4 4s to clean blood and mucus from the 4s to clean blood and mucus from the

infant’s face before suctioning with the bulb syringe.infant’s face before suctioning with the bulb syringe.

Reserve the cord clamps and bulbs for delivery.Reserve the cord clamps and bulbs for delivery.

The clean waterproof pad is placed under the mother The clean waterproof pad is placed under the mother with the sanitary pads after delivery.with the sanitary pads after delivery.


DeliveryDelivery Control delivery of the Control delivery of the

head with one hand on head with one hand on the back of baby’s head the back of baby’s head and one supporting the and one supporting the perineum with a towel.perineum with a towel.


After the Head Is BornAfter the Head Is Born

Support head with one hand while clearing mucus and blood Support head with one hand while clearing mucus and blood from infant’s face with 4 from infant’s face with 4 4s. 4s.

Suction the infant’s mouth first with a bulb syringe.Suction the infant’s mouth first with a bulb syringe. Take care to squeeze bulb before inserting it or you will blow material Take care to squeeze bulb before inserting it or you will blow material

farther into the baby’s air passagesfarther into the baby’s air passages

Baby may take a huge breath after first suction . This is why you must clear Baby may take a huge breath after first suction . This is why you must clear mouth first; suctioning nose first might cause aspiration of the huge clog of mouth first; suctioning nose first might cause aspiration of the huge clog of blood, meconium, or mucus that might be in the mouth.blood, meconium, or mucus that might be in the mouth.

Next, suction the nostrils.Next, suction the nostrils.


Checking for a CordChecking for a Cord After the mouth and nose are suctioned, check for a After the mouth and nose are suctioned, check for a

cord around the neck.cord around the neck.

If the cord is loose, you may be able to pull it over the If the cord is loose, you may be able to pull it over the baby’s head.baby’s head. Never stretch or pull hard on the cord; it may break and Never stretch or pull hard on the cord; it may break and

cause the infant to hemorrhage.cause the infant to hemorrhage.


Tight CordTight Cord If cord is tight around If cord is tight around

neck, clamp in two neck, clamp in two places and cut between places and cut between clamps.clamps.


Delivery of the ShouldersDelivery of the Shoulders Most out-of-hospital deliveries Most out-of-hospital deliveries

will occur without “extra help.”will occur without “extra help.”

If the shoulders do not deliver If the shoulders do not deliver right after the head, tell the right after the head, tell the mother to push while you mother to push while you support the head with both support the head with both hands and give gentle hands and give gentle downward traction to guide the downward traction to guide the anterior shoulder under the anterior shoulder under the pubic bone.pubic bone.


Delivering the Posterior ShoulderDelivering the Posterior Shoulder

When the anterior shoulder When the anterior shoulder is visible, guide the head is visible, guide the head upward to deliver the upward to deliver the posterior shoulder.posterior shoulder.

Do not use excessive force Do not use excessive force or twist the neck.or twist the neck.


Catching the BabyCatching the Baby Slide your hand along Slide your hand along

the emerging body and the emerging body and prepare to catch the prepare to catch the feet.feet. Be prepared. The baby is Be prepared. The baby is

slippery and may shoot slippery and may shoot out suddenly!out suddenly!


Immediate Care of the InfantImmediate Care of the Infant Hold the infant at the level of Hold the infant at the level of

the vagina.the vagina.

Wipe mucus from the infant’s Wipe mucus from the infant’s face with gauze.face with gauze.

Suction the mouth, then the Suction the mouth, then the nostrils.nostrils. Compress bulb before Compress bulb before

placing it in the mouth or placing it in the mouth or nose.nose.


Clamp and Cut the CordClamp and Cut the Cord Place the first clamp 1 inch from Place the first clamp 1 inch from

the baby’s abdomen.the baby’s abdomen.

Place a second clamp 2 inches Place a second clamp 2 inches away from the first clamp.away from the first clamp.

Make sure the clamps are Make sure the clamps are locked securely before you cut locked securely before you cut the cord.the cord.

Be careful not to cut the baby.Be careful not to cut the baby.


Third Stage Care –Third Stage Care – Delivery of the Placenta Delivery of the Placenta

Signs the placenta will soon deliverSigns the placenta will soon deliver Lengthening of the cordLengthening of the cord Gush of bloodGush of blood Contraction of the uterus into a raised globular shape (painless)Contraction of the uterus into a raised globular shape (painless)

Have a basin or plastic bag ready for the placenta.Have a basin or plastic bag ready for the placenta.

If the placenta has not delivered by the time baby is resuscitated If the placenta has not delivered by the time baby is resuscitated and wrapped and the mother cleaned, proceed to the hospital.and wrapped and the mother cleaned, proceed to the hospital.


Never Pull on the Placenta or Never Pull on the Placenta or Cord!Cord!

There may be an abnormal placenta, such as this one with an There may be an abnormal placenta, such as this one with an extra lobe.extra lobe.

The cord may break off inside, causing the mother to The cord may break off inside, causing the mother to hemorrhage through the open vessels.hemorrhage through the open vessels.


Fourth-Stage CareFourth-Stage Care After the placenta has delivered, After the placenta has delivered,

control the bleeding.control the bleeding.

If the uterus does not contract and If the uterus does not contract and the mother starts to hemorrhage, the mother starts to hemorrhage, support the lower part of the uterus support the lower part of the uterus with one hand just above the pubic with one hand just above the pubic bone (to prevent uterine prolapse) bone (to prevent uterine prolapse) and massage the top of the uterus and massage the top of the uterus with the other hand.with the other hand.


Make Mom ComfortableMake Mom Comfortable Remove wet towels from Mom’s abdomen and under her buttocks.Remove wet towels from Mom’s abdomen and under her buttocks.

Place a clean towel under her and a sanitary pad between her legs.Place a clean towel under her and a sanitary pad between her legs.

Cover her with a warm blanket.Cover her with a warm blanket.

Allow her to nurse after you have examined infant (only if the baby did Allow her to nurse after you have examined infant (only if the baby did not require resuscitation).not require resuscitation). Suckling helps contract the uterus.Suckling helps contract the uterus. Can also restore the infant’s glucose supply.Can also restore the infant’s glucose supply.


Before the Mother NursesBefore the Mother Nurses Examine for a cleft Examine for a cleft

palate.palate. May require more suctionMay require more suction Do not allow nursing.Do not allow nursing.

Check for spinal cord Check for spinal cord defects.defects.


Spinal Cord DefectsSpinal Cord Defects Place infant in prone Place infant in prone

position.position.

Cover defect with moistened Cover defect with moistened sterile gauze.sterile gauze.

Wrap loosely or hold in place Wrap loosely or hold in place with blanket.with blanket.

CPR takes precedence.CPR takes precedence.


Four Objectives of Newborn Four Objectives of Newborn CareCare

Provide warmth.Provide warmth.

Continuously evaluate respirations, heart rate, and color.Continuously evaluate respirations, heart rate, and color.

Provide airway and adequate ventilation through positioning, Provide airway and adequate ventilation through positioning, suction and, if needed, oxygen and PPV.suction and, if needed, oxygen and PPV.

Provide cardiac compressions if heart rate <60 bpm.Provide cardiac compressions if heart rate <60 bpm.


Neonatal Resuscitation – Neonatal Resuscitation – Initial StepsInitial Steps

5% - 10% of infants will require resuscitation.5% - 10% of infants will require resuscitation.

If meconium-stained fluid, suction mouth and nose before proceeding.If meconium-stained fluid, suction mouth and nose before proceeding.

Place on towels and dry infant, then remove wet linen.Place on towels and dry infant, then remove wet linen.

Place infant in neutral position and stimulate to cry by rubbing the back Place infant in neutral position and stimulate to cry by rubbing the back twice or flicking soles of feet.twice or flicking soles of feet.

As infant cries, more mucus may be brought up; turn head to side and As infant cries, more mucus may be brought up; turn head to side and suction inside cheek as needed.suction inside cheek as needed.


Three Criteria of Neonatal Three Criteria of Neonatal ResuscitationResuscitation

RespirationsRespirations

Heart rateHeart rate

ColorColor


RespirationsRespirations The most important aspect of neonatal resuscitation The most important aspect of neonatal resuscitation

Must be sufficient to fully expand lungs and remove Must be sufficient to fully expand lungs and remove fluid from alveolifluid from alveoli

Time is critical – delay will cause blood vessels in the Time is critical – delay will cause blood vessels in the lungs to remain constricted, preventing oxygen from lungs to remain constricted, preventing oxygen from reaching the baby, even with PPVreaching the baby, even with PPV


Absent or Inadequate Absent or Inadequate RespirationsRespirations

Begin PPV (bag <750 mL; Begin PPV (bag <750 mL; newborn lungs hold only 20-newborn lungs hold only 20-30 mL of air)30 mL of air)

Oxygen reservoir for 90%-Oxygen reservoir for 90%-100% oxygen100% oxygen

40-60 breaths/minute for 15-40-60 breaths/minute for 15-30 seconds30 seconds


After 30 Seconds of PPVAfter 30 Seconds of PPV

Check the heart rate for 6 seconds.Check the heart rate for 6 seconds.

If <100, or infant still not breathing, continue PPV.If <100, or infant still not breathing, continue PPV.

If <60, begin chest compressions.If <60, begin chest compressions.

Always continue PPV with chest compressions.Always continue PPV with chest compressions.


Newborn Chest CompressionsNewborn Chest Compressions

Compress to a depth of 1/3 of Compress to a depth of 1/3 of the anterior-posterior diameter the anterior-posterior diameter of the chest.of the chest.

Interpose 1 breath after 3 Interpose 1 breath after 3 compressions.compressions.

Rate is 120 events (30 Rate is 120 events (30 respirations and 90 respirations and 90 compressions) per minute.compressions) per minute.


After 30 Seconds of PPV and After 30 Seconds of PPV and Chest CompressionsChest Compressions

Recheck the heart rateRecheck the heart rate If <60, continue both PPV and chest compressions and If <60, continue both PPV and chest compressions and

proceed to hospital.proceed to hospital. If >60, stop compressions.If >60, stop compressions. If <100 or infant still not breathing adequately, continue PPV.If <100 or infant still not breathing adequately, continue PPV. If >100 and infant breathing adequately after resuscitation, If >100 and infant breathing adequately after resuscitation,

administer free-flow oxygen (5-7 L/min).administer free-flow oxygen (5-7 L/min).


Check ColorCheck Color If adequate respirations and heart rate <100, check color.If adequate respirations and heart rate <100, check color.

Observe mucous membranes .Observe mucous membranes . Acrocyanosis is normal.Acrocyanosis is normal.

If pale, mottled, or cyanotic, give 100% free-flow oxygen.If pale, mottled, or cyanotic, give 100% free-flow oxygen.

If cyanosis persists despite oxygen, give a 30-second trial of If cyanosis persists despite oxygen, give a 30-second trial of PPV.PPV.


Signs of Respiratory Distress in Signs of Respiratory Distress in the Newbornthe Newborn

Nasal flaringNasal flaring

Sternal retractionsSternal retractions

GruntingGrunting


Apgar ScoreApgar Score


Give 1- and 5-minute Apgar Give 1- and 5-minute Apgar ScoresScores

Most healthy newborns have an Apgar score of 9.Most healthy newborns have an Apgar score of 9. 1 point deducted for cyanosis in extremities only1 point deducted for cyanosis in extremities only

After 5 minutes, score should be 10 (pink).After 5 minutes, score should be 10 (pink).

Score <7 is poorScore <7 is poor Requires some type of resuscitation effortRequires some type of resuscitation effort

Score 8-10 is goodScore 8-10 is good


Premature InfantPremature Infant Birth before 37 weeks gestation or <5½ pounds is Birth before 37 weeks gestation or <5½ pounds is

considered premature.considered premature.

Insufficient pulmonary surfactant leads to respiratory Insufficient pulmonary surfactant leads to respiratory distress – alveoli collapsedistress – alveoli collapse

Undeveloped temperature-regulating systemUndeveloped temperature-regulating system Turn up ambulance heater to provide warmth.Turn up ambulance heater to provide warmth. Skin-to-skin contact with mother.Skin-to-skin contact with mother.


Shoulder DystociaShoulder Dystocia Head is delivered but shoulders remain wedged Head is delivered but shoulders remain wedged

under pubic bone.under pubic bone.

Attempt McRoberts’ maneuver.Attempt McRoberts’ maneuver. Supine positionSupine position Legs spread widely and flexed sharply back against Legs spread widely and flexed sharply back against

abdomenabdomen

If this fails, apply suprapubic pressure while mother If this fails, apply suprapubic pressure while mother pushes.pushes.


Abnormal PresentationAbnormal Presentation

Presentation: The lowermost part of the fetus to enter Presentation: The lowermost part of the fetus to enter the birth canalthe birth canal Normal = back of headNormal = back of head AbnormalAbnormal

• Frank breech (buttocks) Frank breech (buttocks) The only abnormal presentation that may deliver out-of-hospitalThe only abnormal presentation that may deliver out-of-hospital

Limb presentation (foot or arm)Limb presentation (foot or arm)• May protrude from vagina with only a partial dilatation of the May protrude from vagina with only a partial dilatation of the

cervix and does not signal imminent deliverycervix and does not signal imminent delivery ChinChin BrowBrow


Frank BreechFrank Breech Do not attempt delivery Do not attempt delivery

unless the entire buttocks is unless the entire buttocks is visible and about to emerge.visible and about to emerge.

Transport all other patients Transport all other patients on their left side with hips on their left side with hips elevated; administer 100% elevated; administer 100% oxygen.oxygen.


Complications of Complications of Breech PresentationBreech Presentation

Head entrapmentHead entrapment More common in premature infantsMore common in premature infants

Thick meconium, meconium aspirationThick meconium, meconium aspiration Prolapsed cordProlapsed cord Abruption of placentaAbruption of placenta Fractured clavicleFractured clavicle Nerve damage/paralysis of one or both armsNerve damage/paralysis of one or both arms Head or neck injury, fractured skull, intracranial hemorrhageHead or neck injury, fractured skull, intracranial hemorrhage


Assisting a Breech DeliveryAssisting a Breech Delivery Hands off until infant Hands off until infant

has been born to the has been born to the level of scapula (or level of scapula (or nipple line)nipple line)


Breech: Delivery of the ShouldersBreech: Delivery of the Shoulders

Upward traction was used to Upward traction was used to deliver the posterior shoulder deliver the posterior shoulder of this breech. Now use of this breech. Now use downward traction to assist downward traction to assist delivery of the anterior delivery of the anterior shoulder.shoulder.


Breech: Delivery of the HeadBreech: Delivery of the Head Head must be flexed (chin Head must be flexed (chin

on chest).on chest).

Suprapubic pressure may Suprapubic pressure may help.help.

If head does not deliver, If head does not deliver, continue to provide an continue to provide an airway, elevate mother’s airway, elevate mother’s hips, give oxygen, and hips, give oxygen, and transport.transport.


Prolapsed CordProlapsed Cord

Cord slips down past Cord slips down past presenting part and presenting part and becomes compressed, becomes compressed, cutting off oxygen to the cutting off oxygen to the fetusfetus


Prolapsed CordProlapsed Cord Elevate mother’s hips or Elevate mother’s hips or

place in knee-chest position.place in knee-chest position.

Elevate the presenting part – Elevate the presenting part – not the cord.not the cord.

Rapid transport with oxygen.Rapid transport with oxygen.


Multiple BirthsMultiple Births Call for assistance: Anticipate need for extra Call for assistance: Anticipate need for extra

equipment and personnel.equipment and personnel.

Do not wait more than 10 minutes for second twin, Do not wait more than 10 minutes for second twin, even if first baby was born rapidly.even if first baby was born rapidly. Higher risk for abruptionHigher risk for abruption May be abnormal presentationMay be abnormal presentation


Early Postpartum HemorrhageEarly Postpartum Hemorrhage Blood loss > than 500 mL within 24 hoursBlood loss > than 500 mL within 24 hours

Uterine atonyUterine atony

Retained placental tissueRetained placental tissue

Uterine ruptureUterine rupture

Coagulation defectsCoagulation defects

Uterine prolapseUterine prolapse

Uterine inversionUterine inversion


Uterine AtonyUterine Atony Most common cause is Most common cause is

retention of placental tissue.retention of placental tissue.

Massage uterus to maintain Massage uterus to maintain contraction.contraction.

Always support lower part of Always support lower part of uterus to prevent prolapse.uterus to prevent prolapse.


Uterine InversionUterine Inversion Massive blood lossMassive blood loss

Replace inside-out uterus with gloved fist and apply counter Replace inside-out uterus with gloved fist and apply counter pressure with other hand over abdomen.pressure with other hand over abdomen. Should control bleedingShould control bleeding

Elevate hips.Elevate hips.

Rapid transportRapid transport


Late Postpartum HemorrhageLate Postpartum Hemorrhage Usually occurs 6-10 days after deliveryUsually occurs 6-10 days after delivery

Most common cause is retained placenta.Most common cause is retained placenta.

Other causesOther causes InfectionInfection Sexual traumaSexual trauma Rupture of episiotomy woundRupture of episiotomy wound

Treat for shockTreat for shock


Predelivery EmergenciesPredelivery Emergencies Vaginal bleedingVaginal bleeding

Threatened abortion (miscarriage) <20 weeks’ gestationThreatened abortion (miscarriage) <20 weeks’ gestation Stillbirth (fetus dies >20 weeks’ gestation)Stillbirth (fetus dies >20 weeks’ gestation) Ruptured uterusRuptured uterus

ManagementManagement Elevate hips; position on left side if >20 weeks.Elevate hips; position on left side if >20 weeks. Treat for shock Treat for shock Transport without delayTransport without delay Resuscitate fetus unless macerated or confirmed <23 weeks’ Resuscitate fetus unless macerated or confirmed <23 weeks’

gestationgestation Provide emotional supportProvide emotional support


Seizures in the Pregnant Seizures in the Pregnant PatientPatient

Preeclampsia/eclampsiaPreeclampsia/eclampsia Avoid sirens, lights, loud Avoid sirens, lights, loud

noise.noise. Danger of aspiration is high.Danger of aspiration is high. Provide oxygen.Provide oxygen. Transport on left side.Transport on left side.


Trauma in PregnancyTrauma in Pregnancy Encourage use of lap and shoulder restraint or pregnancy Encourage use of lap and shoulder restraint or pregnancy

restraint for pregnant women.restraint for pregnant women.

Abruption or ruptured uterus is possible.Abruption or ruptured uterus is possible.

Observe spinal precautions with wedge under right side of spine Observe spinal precautions with wedge under right side of spine board to tilt patient toward left side.board to tilt patient toward left side.

Control ABCs.Control ABCs.


Gynecologic EmergenciesGynecologic Emergencies Vaginal bleedingVaginal bleeding

Ruptured ectopic pregnancy (usually tubal)Ruptured ectopic pregnancy (usually tubal)• 4-6 weeks into pregnancy4-6 weeks into pregnancy

Ruptured ovarian cystRuptured ovarian cyst Complaint of shoulder pain frequentComplaint of shoulder pain frequent

• Caused by pressure from retroperitoneal bleedingCaused by pressure from retroperitoneal bleeding• Bleeding may not be visible.Bleeding may not be visible.

Potentially life-threatening loss of bloodPotentially life-threatening loss of blood Rapid transport/treatment for shockRapid transport/treatment for shock


Rape and Perineal InjuriesRape and Perineal Injuries Attempt to preserve evidence.Attempt to preserve evidence.

Receiving facility may have rape victim team.Receiving facility may have rape victim team.

Perineal and straddle injuriesPerineal and straddle injuries LacerationsLacerations HematomasHematomas Treat bleeding with direct pressure and ice pack.Treat bleeding with direct pressure and ice pack.

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