ob/gyn emergencies

OB/GYN EmergenciesOB/GYN Emergencies

A Paramedic Interaction A Paramedic Interaction PresentationPresentation

Patient ExamPatient Exam

Scene Size-up, Safety, MOI/NOIScene Size-up, Safety, MOI/NOISick/Not SickSick/Not Sick

Initial Assessment (Correct life threats!)Initial Assessment (Correct life threats!)Focused ExamFocused Exam

Patient History & Vital SignsPatient History & Vital SignsDetailed ExamDetailed Exam

Plan Plan = = Best Possible Patient Outcome!Best Possible Patient Outcome!

Roles and ResponsibilitiesRoles and Responsibilities

Be a Patient Advocate!Be a Patient Advocate!

Sick/Not SickSick/Not Sick

Remember the ABCsRemember the ABCs

Define who does what – Define who does what – teamwork?teamwork?

No gang questioning!No gang questioning!

Listen to the patientListen to the patient

Priority is always patient care!Priority is always patient care!

DefinitionsDefinitions

Apgar scoreApgar score Abruptio placentaAbruptio placenta Braxton-Hicks Braxton-Hicks

contractionscontractions EclampsiaEclampsia Ectopic pregnancyEctopic pregnancy Meconium stainingMeconium staining Placenta previaPlacenta previa PIHPIH

PreeclampsiaPreeclampsia Supine Hypotensive Supine Hypotensive

SyndromeSyndrome MittleschermtzMittleschermtz ToxemiaToxemia Nuchal cordNuchal cord Breech presentationBreech presentation Prolapsed cordProlapsed cord Gestational DiabetesGestational Diabetes

Gynecological EmergenciesGynecological Emergencies

Two most common chief complaints:Two most common chief complaints:

Vaginal BleedingVaginal Bleedingandand

Lower Abdominal or Pelvic PainLower Abdominal or Pelvic Pain

GYN Patient HistoryGYN Patient History

Vaginal Bleeding Considerations:Vaginal Bleeding Considerations:Amount?Amount?

When and for how long?When and for how long?

Likelihood of pregnancy?Likelihood of pregnancy?

LMP?LMP?

Associated with pain, other functions? Associated with pain, other functions?

Other medical problems?Other medical problems?

Obstetric history? (Gravida/Para)Obstetric history? (Gravida/Para)

GYN Patient HistoryGYN Patient History

Abdominal/Pelvic Pain Considerations:Abdominal/Pelvic Pain Considerations:Onset? Onset? When did this start?When did this start?

Provocation? Provocation? Anything make it worse or better?Anything make it worse or better?

Quality? Quality? Dull ache or sharp pain?Dull ache or sharp pain?

Radiation? Radiation? Does the pain go anywhere?Does the pain go anywhere?

Severity? Severity? 1-10 Scale (onset & now)1-10 Scale (onset & now)

Time? Time? How long has it been going on?How long has it been going on?

GYN Patient ExamGYN Patient Exam

Respect patient modestyRespect patient modesty

ABCsABCs

Vital signsVital signs

Patient medical historyPatient medical history

Need to palpate the abdomen!Need to palpate the abdomen!

Sexual assault = crime sceneSexual assault = crime scene

Minors and parental rightsMinors and parental rights

Differential DiagnosisDifferential Diagnosis

Pelvic Inflammatory DiseasePelvic Inflammatory DiseaseVaginal BleedingVaginal BleedingSexual AssaultSexual AssaultOvarian CystsOvarian Cysts

CystitisCystitisEndometritisEndometritis

EndometriosisEndometriosisEctopic PregnancyEctopic Pregnancy

Spontaneous abortion/miscarriageSpontaneous abortion/miscarriage

Scenario # 1Scenario # 1

Dispatched to a 23 year old female Dispatched to a 23 year old female complaining of sudden onset of severe complaining of sudden onset of severe

abdominal pain with radiation to the right abdominal pain with radiation to the right shoulder.shoulder.

Patient CarePatient Care

Patient position of comfort.Patient position of comfort. Reassure and provide emotional support.Reassure and provide emotional support. Monitor vital signs.Monitor vital signs. Control bleeding.Control bleeding. Oxygen therapy.Oxygen therapy. Nothing by mouth.Nothing by mouth. Police notification for sexual assault.Police notification for sexual assault. Remember when to invite the Medics!Remember when to invite the Medics!

ALS IndicatorsALS Indicatorsfor the GYN patientfor the GYN patient

Altered level of consciousnessAltered level of consciousness

BP < 90 systolicBP < 90 systolic

Sustained tachycardia > 100 -120Sustained tachycardia > 100 -120

Pelvis pain with high likelihood of Pelvis pain with high likelihood of unstable condition during transportunstable condition during transport

Excessive vaginal bleedingExcessive vaginal bleeding

SeizuresSeizures

Obstetrical EmergenciesObstetrical Emergencies

These could be the best calls These could be the best calls that you will ever go on or that you will ever go on or

the absolute worst the absolute worst nightmares you could ever nightmares you could ever

imagine!imagine!

OB Emergency ConsiderationsOB Emergency Considerations

Remember that you have Remember that you have TWOTWO patients patientsHistory is important, don’t forget to askHistory is important, don’t forget to ask

about prenatal careabout prenatal careThird trimester bleeding is not normalThird trimester bleeding is not normal

Prepare for the unexpectedPrepare for the unexpectedUse Dad as the coach (if you can)Use Dad as the coach (if you can)

Fetal heart tones?Fetal heart tones?Ask about last time baby movement feltAsk about last time baby movement felt

ALS Indicators ALS Indicators for the Obstetrical Patientfor the Obstetrical Patient

Imminent or recent birthImminent or recent birthDecreased LOC of mother/newbornDecreased LOC of mother/newborn

BP<90 systolic or >140 systolicBP<90 systolic or >140 systolicThird trimester vaginal bleed/pelvic painThird trimester vaginal bleed/pelvic pain

History of complications at birthHistory of complications at birthMultiple birthsMultiple births

Breech presentationsBreech presentationsProlapsed or nuchal cordProlapsed or nuchal cord

Shoulder dystociaShoulder dystociaPostpartum hemmorhagePostpartum hemmorhage

Abruptio PlacentaeAbruptio Placentae

The partial or complete detachment of a normally The partial or complete detachment of a normally implanted placenta at more than 20 weeks.implanted placenta at more than 20 weeks.

Occurs in 0.5-2.0% of all pregnancies and will Occurs in 0.5-2.0% of all pregnancies and will result in fetal death in 1 out of 400 cases of result in fetal death in 1 out of 400 cases of

abruption.abruption.

Predisposing conditions include maternal Predisposing conditions include maternal hypertension, preeclampsia, multiple births, hypertension, preeclampsia, multiple births,

trauma, and previous abruptiontrauma, and previous abruption

Abrutio PlacentaeAbrutio Placentae

Placenta PreviaPlacenta Previa

Placental implantation in the lower uterine Placental implantation in the lower uterine segment encroaching on or covering the cervix.segment encroaching on or covering the cervix.

Occurs in approximately 1 in 200 to 1 in 400 Occurs in approximately 1 in 200 to 1 in 400 deliveries with the highest incidence in preterm deliveries with the highest incidence in preterm

births.births.

Associated with increased maternal age, multiple Associated with increased maternal age, multiple births, previous cesarean and placenta previa.births, previous cesarean and placenta previa.

Placenta PreviaPlacenta Previa

Uterine RuptureUterine Rupture

Spontaneous or traumatic rupture of the uterine Spontaneous or traumatic rupture of the uterine wall.wall.

Occurs in approximately 1 in 1400 deliveries with a Occurs in approximately 1 in 1400 deliveries with a 5 – 15% maternal mortality rate and a 50% fetal 5 – 15% maternal mortality rate and a 50% fetal

death rate.death rate.

Abdomen is usually rigid with diffuse pain, fetal Abdomen is usually rigid with diffuse pain, fetal parts easily palpated through the abdominal parts easily palpated through the abdominal

wall. wall.


Dispatched to a 32 year old female, 26 Dispatched to a 32 year old female, 26 weeks pregnant, has skipped her last 3 weeks pregnant, has skipped her last 3 MD visits because of lack of insurance. MD visits because of lack of insurance.

Patient c/o sudden onset of left-sided, very Patient c/o sudden onset of left-sided, very sharp abdominal pain now with bright red sharp abdominal pain now with bright red

vaginal bleeding. vaginal bleeding.


ABCsABCs Oxygen therapyOxygen therapy Place patient in left lateral recumbent Place patient in left lateral recumbent

position.position. Control bleeding.Control bleeding. Monitor vital signs.Monitor vital signs. Invite the Medics?Invite the Medics?

Supine Hypotensive SyndromeSupine Hypotensive Syndrome

Usually occurs in the third trimester of Usually occurs in the third trimester of pregnancy, occurs when the gravid uterus pregnancy, occurs when the gravid uterus compresses the inferior vena cava when compresses the inferior vena cava when

the mother lies in a supine position.the mother lies in a supine position.

Hypotension and dizziness are the main Hypotension and dizziness are the main characteristicscharacteristics

INFERIOR VENA CAVAINFERIOR VENA CAVA

AORTA

Preeclampsia (Toxemia)Preeclampsia (Toxemia)

Hypertensive disorder of unknown origin that Hypertensive disorder of unknown origin that usually occurs in 5 – 8% of all pregnancies.usually occurs in 5 – 8% of all pregnancies.

Responsible for approximately 25% of all maternal Responsible for approximately 25% of all maternal and preterm fetal deaths.and preterm fetal deaths.

Associated with maternal age, chronic HTN, renal Associated with maternal age, chronic HTN, renal disease, diabetes, systemic lupus, and multiple disease, diabetes, systemic lupus, and multiple

births.births.

EclampsiaEclampsia(aka Preeclampsia that is really bad)(aka Preeclampsia that is really bad)

Characterized by the same signs and Characterized by the same signs and symptoms as preeclampsia plus seizures symptoms as preeclampsia plus seizures

or coma.or coma.


Dispatched to a dental office for a 33 year-Dispatched to a dental office for a 33 year-old pregnant female, in active seizures.old pregnant female, in active seizures.

You enter the office and find the patient You enter the office and find the patient unconscious/unresponsive in tonic/clonic unconscious/unresponsive in tonic/clonic

seizures. The dental staff informs you that seizures. The dental staff informs you that the patient is 34 weeks pregnant and her the patient is 34 weeks pregnant and her

blood pressure prior to the dental blood pressure prior to the dental procedure was 142/90.procedure was 142/90.


ABCsABCs Oxygen therapyOxygen therapy Place patient in left lateral recumbent Place patient in left lateral recumbent

position.position. Handle he patient gently and minimize Handle he patient gently and minimize

sensory stimulation to avoid precipitating sensory stimulation to avoid precipitating seizures.seizures.

Blood glucose check?Blood glucose check? Invite the Medics?Invite the Medics?

Imminent DeliveryImminent Delivery

Crowning or bulging of fetal Crowning or bulging of fetal head at vaginal opening.head at vaginal opening.

Contractions less than 2 Contractions less than 2 minutes apart.minutes apart.

Feeling of rectal fullness.Feeling of rectal fullness. Feeling of imminent delivery Feeling of imminent delivery

or need to push (especially or need to push (especially in a women who has had a in a women who has had a child before).child before).

Water breaking?Water breaking?

Now what?Now what?

Other Complications to ConsiderOther Complications to Consider

Premature delivery (under 37 weeks)Premature delivery (under 37 weeks)Multiple birthsMultiple births

Precipitous delivery (spontaneous delivery Precipitous delivery (spontaneous delivery less than 3 hours from labor to birth)less than 3 hours from labor to birth)

Pulmonary Embolism Pulmonary Embolism (most common cause of maternal death)(most common cause of maternal death)

Excessive postpartum hemorrhageExcessive postpartum hemorrhagePerineal lacerationsPerineal lacerations

Perineal LacerationsPerineal Lacerations

Nuchal CordNuchal CordPotentially Lethal!Potentially Lethal!

Prolapsed CordProlapsed Cord

Occurs when the umbilical cord slips down into the Occurs when the umbilical cord slips down into the vagina or presents externally which can cause vagina or presents externally which can cause

fetal asphyxiation.fetal asphyxiation.

Occurs in approximately 1 in every 200 Occurs in approximately 1 in every 200 pregnancies and should be suspected when pregnancies and should be suspected when

fetal distress is presentfetal distress is present

Most common with breech presentations, Most common with breech presentations, premature membrane ruptures, large fetus, long premature membrane ruptures, large fetus, long

cord, multiple gestation, preterm laborcord, multiple gestation, preterm labor


Dispatched to a 28 year old female home Dispatched to a 28 year old female home alone, first pregnancy, no previous alone, first pregnancy, no previous

pregnancies, with good prenatal care. pregnancies, with good prenatal care. Due date > two weeks, mother in good Due date > two weeks, mother in good medical health. Was on the toilet when medical health. Was on the toilet when

she felt the urge to bear down, water she felt the urge to bear down, water broke, and discovered the following:broke, and discovered the following:


Place two fingers in vagina to relieve pressure Place two fingers in vagina to relieve pressure off cord, raising fetus off cord.off cord, raising fetus off cord.

Check cord for pulsationsCheck cord for pulsations Mother in knee-chest or hips elevated position.Mother in knee-chest or hips elevated position. Oxygen therapyOxygen therapy Transport while keeping pressure off cord.Transport while keeping pressure off cord. Moist dressing to exposed cord, do not push Moist dressing to exposed cord, do not push

back into vagina.back into vagina. Medics! Medics!

Breech PresentationsBreech Presentations

3% of all presentations will be breech: either 3% of all presentations will be breech: either limb or buttocks, more common in limb or buttocks, more common in premature infants and with uterine premature infants and with uterine

abnormalities.abnormalities.

Increased risk for fetal trauma, anoxia, and Increased risk for fetal trauma, anoxia, and prolapsed cordprolapsed cord


Dispatched to 37 year female (non-English speaking), Dispatched to 37 year female (non-English speaking), unable to ascertain any medical history due to language unable to ascertain any medical history due to language

barrier.barrier.

One of the many “midwives” in attendance states that One of the many “midwives” in attendance states that mother has been in labor for a “very long time”. mother has been in labor for a “very long time”.

You walk into the house and find the mother (in complete You walk into the house and find the mother (in complete state of exhaustion) leaning over the couch:state of exhaustion) leaning over the couch:

Patient CarePatient Care Place patient in knee-chest position or with buttocks on Place patient in knee-chest position or with buttocks on

edge of bed, legs flexed as much as possible.edge of bed, legs flexed as much as possible. Instruct mother to pant with each contraction to prevent Instruct mother to pant with each contraction to prevent

bearing down.bearing down. Allow infant to be delivered with contractions, apply Allow infant to be delivered with contractions, apply

pressure at pubis as head passes, support baby.pressure at pubis as head passes, support baby. Moist dressing to cord to prevent umbilical artery spasmMoist dressing to cord to prevent umbilical artery spasm Gloved hand to prevent delivery if unable to deliver in Gloved hand to prevent delivery if unable to deliver in

field, relieve pressure from cord!field, relieve pressure from cord! Oxygen therapy.Oxygen therapy. Rapid transport.Rapid transport. Would you like to invite the Medics?Would you like to invite the Medics?

Shoulder DystociaShoulder Dystocia

Occurs when the infant’s shoulders are Occurs when the infant’s shoulders are larger than it’s head, most common with larger than it’s head, most common with

diabetic and obese mothers.diabetic and obese mothers.

Labor progresses normally with routine head Labor progresses normally with routine head delivery which will retract back into the delivery which will retract back into the

perineum because shoulders are trapped perineum because shoulders are trapped between the pubis and the sacrum.between the pubis and the sacrum.

Shoulder DystociaShoulder Dystocia


Dispatched to a 29 year old, obese female, Dispatched to a 29 year old, obese female, full term pregnancy delivering at home. full term pregnancy delivering at home. Patient without consistent prenatal care Patient without consistent prenatal care

and three previous births.and three previous births.

In labor for over three hours with father In labor for over three hours with father assisting delivery. 911 was called when assisting delivery. 911 was called when

father realized baby was “stuck”.father realized baby was “stuck”.

Anterior shoulder

Posterior shoulder


Do not pull on baby’s head!Do not pull on baby’s head! Oxygen therapy.Oxygen therapy. Have mother flex thighs to assist in Have mother flex thighs to assist in

delivery.delivery. Apply firm pressure with your open hand Apply firm pressure with your open hand

above symphysis pubis.above symphysis pubis. Oxygen and transport.Oxygen and transport. Are you thinking about inviting the Are you thinking about inviting the

Medics?Medics?

Shoulder PresentationShoulder Presentation

Fetal shoulder lies over the pelvic inletFetal shoulder lies over the pelvic inletSpontaneous delivery is not possible, Spontaneous delivery is not possible, delivery of fetus through cesarean only.delivery of fetus through cesarean only.

Position of comfort for mother.Position of comfort for mother. Oxygen therapy.Oxygen therapy. Rapid transport.Rapid transport. Please, invite the Medics! Please, invite the Medics!

Postpartum HemorrhagePostpartum Hemorrhage


Begin fundal massage/nursing of infant.Begin fundal massage/nursing of infant. Position of comfort for mother.Position of comfort for mother. Oxygen therapy.Oxygen therapy. Do not force delivery of placenta.Do not force delivery of placenta. Do not pack vagina with dressings.Do not pack vagina with dressings. Maintain patient warmth.Maintain patient warmth. Transport.Transport. Why not invite the Medics!Why not invite the Medics!

Uterine InversionUterine Inversion

A rare event in which the uterus turns inside A rare event in which the uterus turns inside out after birth. Note hypovolemic shock out after birth. Note hypovolemic shock

may develop quickly.may develop quickly.

Do not attempt to manually replace the Do not attempt to manually replace the uterus. uterus.

ABCs, position of comfort, oxygen therapyABCs, position of comfort, oxygen therapy TransportTransport Are you thinking about the Medics?Are you thinking about the Medics?

Fetal Membrane DisordersFetal Membrane Disorders

Premature rupture of membranesPremature rupture of membranes

Amniotic fluid embolismAmniotic fluid embolism

Meconium stainingMeconium staining

Neonatal Resuscitation BasicsNeonatal Resuscitation Basics

Open the airway, position, suctionOpen the airway, position, suction

Prevent heat lossPrevent heat loss

Provide tactile stimulationProvide tactile stimulation

Evaluate the infant with the Apgar scoreEvaluate the infant with the Apgar score

The majority of newborns will respond very The majority of newborns will respond very well to these simple procedureswell to these simple procedures

And, as always, invite the Medics!And, as always, invite the Medics!

Neonatal ResuscitationNeonatal Resuscitation

APGAR ScoringAPGAR Scoring

AppearanceAppearance

Grimace and ActivityGrimace and Activity


Dispatched to a 40 year old mother Dispatched to a 40 year old mother imminent childbirth. Patient is full term imminent childbirth. Patient is full term

with three previous “very quick” deliveries.with three previous “very quick” deliveries.

Enroute dispatch informs you that baby is Enroute dispatch informs you that baby is crowning, you walk in and find mother has crowning, you walk in and find mother has

delivered the baby.delivered the baby.

< 80 80 To 100 beats/min > 100


Prevent heat loss, keep baby warm.Prevent heat loss, keep baby warm. Open the airway, side or back position, Open the airway, side or back position,

suction airway with bulb syringe.suction airway with bulb syringe. Provide tactile stimulation.Provide tactile stimulation. Evaluate and re-evaluate the infant’s Evaluate and re-evaluate the infant’s

respirations, heart rate, and color.respirations, heart rate, and color. If necessary, provide O2 via BVMIf necessary, provide O2 via BVM Don’t hesitate to call on your friend in Don’t hesitate to call on your friend in

emergency care…the Medics! emergency care…the Medics!

Questions?Questions?

Thanks!Thanks!

ob/gyn emergencies

Documents

patient advocate

pelvis pain

sharp pain

best possible patient

control bleeding

scale onset nowtime

obstetric history

best calls