Obstetrics and Gynecology
Emergencies
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Copyright © Texas Education Agency,
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2014. All rights reserved.
Female Reproductive Anatomy and
Physiology
• A woman’s external genitalia consist of three
major structures: the labia, the perineum, and
the mons pubis.
• The vagina is the birth canal made up of smooth
muscle. It connects the uterus to the outside
world.
• Ovaries are small round organs located on either
side of most women’s lower abdominal
quadrants. Fallopian tubes are also called
oviducts. They connect to the uterus.
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2014. All rights reserved.
Female Reproductive Anatomy and
Physiology
• The monthly reproductive cycle produces
predictable changes to the reproductive organs in
anticipation of fetal implantation and
development. If fertilization does not occur, the
reproductive cycle ends with menses.
• The embryonic stage occurs roughly from the
point of fertilization through the first 8 weeks of
pregnancy. From this point until delivery, the
developing baby is referred to as the fetus, which
will develop over the next 32 weeks (a typical
pregnancy lasts about 40 weeks).
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2014. All rights reserved.
Physiologic Changes during Pregnancy
• A growing fetus creates massive changes to the
reproductive system. Most important, the uterus gets
larger. Pregnancy increases oxygen demand, increases
maternal blood volume, puts pressure on the GI system,
and causes ligaments to stretch.
• Supine hypotensive syndrome causes late-term pregnant
females’ blood pressure to drop when they lie flat. EMTs
can prevent this by positioning them in a lateral recumbent
position.
• The development of the fetus has immediate physical
effects on neighboring body systems as well as making
other systems in the body work harder to sustain the
growing fetus.
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2014. All rights reserved.
Labor and Delivery
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First stage of labor starts with regular contractions and thinning and gradual
dilation of the cervix. It ends with the cervix fully dilated. This occurs over several
days or weeks and leads to Braxton-Hicks contractions, which are usually irregular
and not sustained. In actual labor, the uterus will contract regularly and the cervix
will dilate. As this happens the fetus’s head moves downward. Contractions are
timed from the start of one contraction to the beginning of the next.
The second stage is when the EMT must make the decision to stay on scene or to
transport. It begins with full dilation of the cervix. During this time contraction
becomes more frequent and labor pains more severe. As the baby’s head moves
down, the mother will feel the urge to push and move her bowels. This stage ends
when the baby is born.
Third stage begins after the baby is born. The placenta detaches itself from the
wall of the uterus and is expelled. The third stage usually lasts 10–20 minutes and
ends as the placenta is delivered.
Far from involving just the reproductive system, childbirth involves the woman’s
whole body. Not only is all her strength called for, but her body undergoes massive
change in a very short time.
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2014. All rights reserved.
Labor and Delivery
• The questions used in this assessment are additions to the
traditional patient assessment. Remind students not to forget the
primary and secondary assessments. There are no absolutes with
birth. Remind students that findings only generally predict
outcomes. EMTs always should be prepared for surprises. Practice
makes perfect.
• Assessment of the woman in labor is designed to predict imminent
delivery and to recognize likely resuscitation of the neonate.
• Assessment can also help indicate the level of resources necessary
to deliver the baby.
• Assessing a woman in labor includes all of the elements of
traditional patient assessment including ABC’s as well as vital signs
and SAMPLE history. There are also a few elements specific to
pregnancy. The average time of labor for a woman having her first
baby is normally 16–17 hours.
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2014. All rights reserved.
Labor and Delivery
• Prenatal care is important in regard to being aware of medical
complications and multiple births.
• The urge to push and crowning indicate imminent delivery.
Transport typically should be deferred to ready for a delivery on
scene.
• You should also ask the patient if she feels the need to move her
bowels.
• Do not allow the mother to go to the bathroom even if she says she
has to. It is best to transport an expecting mother unless you expect
imminent delivery based on your evaluation.
• The presenting part is defined as the part of the infant that is first
to appear at the vaginal opening during labor. Usually, the
presenting part of the baby is the head.
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2014. All rights reserved.
Labor and Delivery
• The normal head-first birth is called a cephalic
presentation. If the buttocks or both feet of the baby
deliver first, the birth is called a breech presentation or
breech birth. If part of the baby’s head or presenting part is
visible with each contraction, then birth is imminent.
• A lack of prenatal care, premature labor, multiple gestation,
and underlying conditions indicate a likelihood of neonatal
resuscitation.
• The most important outcome of anticipating neonatal
resuscitation is getting help.
• Meconium staining is a sign of fetal distress.
• Childbirth requires a high level of personal protective
equipment.
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2014. All rights reserved.
Labor and Delivery
• Emotional support for the mother is important during
childbirth.
• Control the scene so the mother has privacy. (Her birthing
coach may remain.)
• Proper PPE for you and your partner: surgical gloves,
gowns, face mask, and eye protection.
• Place the mother on bed, floor, or ambulance stretcher and
elevate her buttocks with blanket or pillow.
• You will need about 2 feet of workspace below the patient’s
buttocks to initially care for the newborn.
• Remove any restrictive clothing.
• Drape the patient with sterile sheets or sterile towels.
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2014. All rights reserved.
Labor and Delivery
• Keep someone at the mother’s head to provide
support, monitor vital signs, and be alert for vomiting.
• Position your gloved hand over the mother’s vaginal
opening when the baby’s head starts to appear.
• Place one hand below the baby’s head as it delivers,
remembering the baby’s head has soft spots.
• A slight, well-distributed pressure may help prevent an
explosive delivery.
• Do not pull on the baby!
• If the amniotic sac has not ruptured by the time the
baby’s head has delivered, use your finger to puncture
the membrane.
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2014. All rights reserved.
Labor and Delivery
• Examine the fluid for meconium staining, which will be a
green-black or mustard yellow color.
• Once the head delivers, check if the umbilical cord is
around the neck. While doing this, ask the mother to pant.
• If you are unable to slip the cord over the baby’s head, you
will have to cut it. Clamp the cord and be extremely careful
as you cut between the clamps.
• As soon as the baby’s head is visible, support the head with
one hand. Wipe the mouth and nose with a gauze pad.
Then suction the mouth and nose with a bulb syringe.
(Follow your local protocol.) Compress the syringe prior to
inserting it into the baby’s mouth and insert 1–1½ inches.
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2014. All rights reserved.
Labor and Delivery
• The upper shoulder usually delivers with some
delay, followed quickly by the lower shoulder.
Support the baby throughout this process. Gently
guide the baby’s head downward as the upper
shoulder delivers, then gently upward as the
lower shoulder delivers.
• As the lower extremities are delivered, grasp
them to have a good hold on the baby.
• Once delivered, lay the baby on his side with
head slightly lower than the body to facilitate
drainage of fluids from the mouth and nose.
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2014. All rights reserved.
Labor and Delivery
• Keep the baby at the same level as the
mother’s vagina until the umbilical cord stops
pulsating.
• Dry the infant and wrap in a warm, dry
blanket. Note the exact time of birth.
• Write the mother’s last name and the time of
birth on a piece of tape, and attach tape to
baby’s wrist. (Fold tape so adhesive does not
touch baby’s skin.)
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2014. All rights reserved.
Neonate
• Neonatal resuscitation is an infrequently used skill that
requires immediate action. Emphasize the need to
learn and memorize the basic, immediate steps.
Practice!
• Neonate is the term used for a baby from birth to one
month old. The term infant is used for a baby in its first
year of life.
• A neonate should be assessed as soon as it’s born.
• Pulse should be greater than 100/min. An Apgar score
(appearance, pulse, grimace, activity, respiratory effort)
is done one minute after birth and then again 5
minutes after birth.
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2014. All rights reserved.
Neonate
• The total Apgar score is done on a scale of 0–10.
• The most important aspect of caring for a neonate is
keeping the baby warm.
• Heat loss not only drops the neonate’s body
temperature, but also drops glucose levels.
• Do not tie, clamp, or cut an umbilical cord on a baby
who is not breathing unless the cord is around the
baby’s neck. Do not cut or clamp a cord that is still
pulsating. Apply one clamp or tie about 10 inches from
the baby. This leaves enough cord for paramedics and
hospital staff to start IV lines.
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2014. All rights reserved.
Neonate
• Babies are passive throughout birth, but should quickly
become active (i.e., breathe), usually on their own.
Stimulating babies ensures that they will start breathing on
their own.
• Neonatal resuscitation begins with stimulating the baby. If
no breathing occurs, begin positive pressure ventilations.
• Few neonates require CPR or ALS interventions.
• The first steps in resuscitation are drying, warming,
positioning to keep the airway clear, suctioning, and tactile
stimulation. Central cyanosis is blue coloration of the torso.
If the heart rate is below 100 beats per minute, ventilations
are provided at 40–60 per minute.
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2014. All rights reserved.
Care After Delivery
• Emphasize that the mother may be the more serious
patient. Post-partum hemorrhage can kill. Use previous
discussions about shock to describe the treatment of a
hemorrhaging mother. Advise students that uterine
massage can be quite painful to the mother. Nonetheless, it
is necessary in the event of excessive hemorrhage.
• After delivery, there are two patients to care for: the infant
and the mother. Although it is easy to make the baby the
primary focus, there are many risks of childbirth for the
mother.
• Typically it is not necessary to delay transport as the
placenta is delivered. EMTs should retain the delivered
placenta for examination at the hospital.
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2014. All rights reserved.
Care After Delivery
• Avoid putting pressure on the abdomen over the uterus to hasten
delivery. If mother and baby are doing well, and there are no
respiratory problems or significant uncontrolled bleeding,
transportation to the hospital can be delayed up to 20 minutes
while awaiting delivery of the placenta.
• The attending physician will want to examine the placenta and
other tissues for completeness, since any afterbirth tissues
remaining in the uterus pose a serious threat of infection and
prolonged bleeding. Try to catch the afterbirth in a container. Label
this material “placenta” and include the name of the mother and
the time the tissues were expelled.
• Excessive post-partum bleeding can lead to shock. Assess and treat
accordingly.
• Controlling vaginal bleeding for the mother is a priority.
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2014. All rights reserved.
Care After Delivery
• If the placenta hasn’t delivered in 20 minutes, transport
mother and neonate. Blood loss is not usually more than
500 cc, but it may be profuse. Have mother lower her legs
after placing a sanitary napkin over the vagina. Have her
squeeze legs together. Elevate her feet. Massaging the
fundus of the uterus (felt as a grapefruit-sized object) will
be painful to the mother, but it controls bleeding. Nursing
the baby also helps control bleeding.
• Talking to the mother and paying attention to her new baby
are part of total patient care. A good rule to follow is to
treat the patient as you would wish a member of your
family to be treated.
• Dispose of all items that have been in contact with blood or
body fluids in a biohazard container.
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2014. All rights reserved.
Childbirth Complications
• Emphasize that the steps necessary to treat a prolapsed cord or a
difficult breech delivery need to be undertaken immediately.
• Relate this to your previous discussions about neonatal CPR. How
many ventilations of a newborn are lost with just a minute’s delay?
Consider inviting a midwife, OB physician, or OB nurse to discuss
treating complications of delivery.
• Breech presentations occur when the head is not the first
presenting part of the baby during birth. Breech presentations can
spontaneously deliver successfully, but the complication rate is
high.
• Initiate rapid transport. Never attempt to deliver by pulling on legs.
Provide high-concentration oxygen. Place mother in head-down
position with pelvis elevated. Insert gloved hand and form V on
either side of the baby’s nose to lift away from the vaginal wall.
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2014. All rights reserved.
Childbirth Complications
• When presented with a limb presentation Place mother in head-down
position and give high-concentration oxygen by non-rebreather mask.
Initiate rapid transport.
• With a prolapsed cord the oxygen supply to the baby may be totally
interrupted due to the cord being pinched. Elevate the mother’s hips and
give her high-concentration oxygen. Keep the cord warm by wrapping it in
a moist, sterile towel, and check for pulsation. Do not attempt to push the
cord back inside. Insert gloved fingers into the mother’s vagina to keep
pressure off the cord by pushing up on the baby’s head and buttocks.
Transport to hospital, continuing pressure on the baby’s head.
• By definition, a premature infant is one who weighs less than 51/2 pounds
at birth, or one who is born before the 37th week of pregnancy.
• Placenta previa and abruptio placentae are common causes of excessive
pre-birth bleeding.
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2014. All rights reserved.
Childbirth Complications
• Placenta previa is a condition in which the placenta is
formed in an abnormal location and does not allow for
normal delivery. As the cervix dilates, the placenta
tears. The similar abruptio placentae is a condition in
which the placenta separates from the uterine wall.
This can be partial or complete.
• Low blood pressure is a late sign of ectopic pregnancy.
• Keep accurate records of the time of stillbirth and care
rendered for fetal death certificate. Resuscitative
efforts should be withheld from stillborn babies who
have been obviously dead for some time.
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2014. All rights reserved.
Gynecological Emergencies
• Vaginal bleeding is another form of internal bleeding and can have
the same level of risk. Sexual assault is a difficult situation for EMTs.
Recruit expert help for your presentation.
• Many domestic violence/sexual assault advocacy groups have
professional educators who are willing to lend a hand. Invite a law
enforcement officer or sexual assault nurse to class to discuss
evidence collection and crime scene preservation.
• Vaginal bleeding that is not a result of direct trauma or a woman’s
normal menstrual cycle may indicate a serious gynecological
emergency.
• Asking the patient how many pads she has used to block bleeding
may be helpful in assessing blood loss.
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2014. All rights reserved.
Gynecological Emergencies
• Consider assault a likely cause of any trauma
to external genitalia.
• Caring for these injuries may be difficult due
to patient modesty.
• Describe the treatment steps for external
genitalia trauma.
• Care of the sexual assault patient must include
medical, legal, and psychological
considerations.
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2014. All rights reserved.
Gynecological Emergencies
• When treating sexual assault patients, EMTs
should be professional, nonjudgmental, and
conscious of personal space.
• EMTs should explain examinations and
treatments beforehand and should be
sensitive to fears and embarrassment.
• It may be necessary for you to stage your unit
near the scene until it is rendered safe by
police.
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2014. All rights reserved.