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Obstetric and Gynecologic Emergencies Chapter 20

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Three Stages of Labor First stage Dilation of the cervix Second stage Expulsion of the infant Third stage Delivery of the placenta First stage Dilation of the cervix Second stage Expulsion of the infant Third stage Delivery of the placenta

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Predelivery Emergencies Preeclampsia Headache, vision disturbance, edema, anxiety, high blood pressure Eclampsia Convulsions resulting from hypertension Supine hypotensive syndrome Low blood pressure from lying supine Preeclampsia Headache, vision disturbance, edema, anxiety, high blood pressure Eclampsia Convulsions resulting from hypertension Supine hypotensive syndrome Low blood pressure from lying supine

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Hemorrhage Vaginal bleeding that occurs before labor begins If present in early pregnancy, it may be a spontaneous abortion or ectopic pregnancy. Vaginal bleeding that occurs before labor begins If present in early pregnancy, it may be a spontaneous abortion or ectopic pregnancy.

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Ectopic Pregnancy Pregnancy outside of the uterus Should be considered for any woman of childbearing age with unilateral lower abdominal pain and missed menstrual period History of PID, tubal ligation, or previous ectopic pregnancy Pregnancy outside of the uterus Should be considered for any woman of childbearing age with unilateral lower abdominal pain and missed menstrual period History of PID, tubal ligation, or previous ectopic pregnancy

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Placenta Problems Placenta abruptio Premature separation of the placenta Placenta previa Development of placenta over the cervix Placenta abruptio Premature separation of the placenta Placenta previa Development of placenta over the cervix

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Gestational Diabetes Develops only during pregnancy. Treat as regular patient with diabetes. Develops only during pregnancy. Treat as regular patient with diabetes.

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Scene Size Up: Womans balance is altered. Be aware for falls and the need for spinal stabilization. Use BSI. Usual threats to your safety still exist. Be calm. Protect the mother and the child. Womans balance is altered. Be aware for falls and the need for spinal stabilization. Use BSI. Usual threats to your safety still exist. Be calm. Protect the mother and the child.

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Initial Assessment Is the mother in active labor? Evaluate trauma or medical problems first. Treat ABCs in line with local protocols. Is the mother in active labor? Evaluate trauma or medical problems first. Treat ABCs in line with local protocols.

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Transport Decision If delivery is imminent, prepare for delivery in warm, private location. If delivery is not imminent, transport on left side if in last two trimesters of pregnancy. If the patient was subject to spinal injury, stabilize and prop backboard with towel roll on right side. If delivery is imminent, prepare for delivery in warm, private location. If delivery is not imminent, transport on left side if in last two trimesters of pregnancy. If the patient was subject to spinal injury, stabilize and prop backboard with towel roll on right side.

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Focused History/ Physical Exam Obtain full SAMPLE history, and also: Prenatal history Complications during pregnancy Due date Number of babies (twins) Drugs or alcohol Water broken Green fluid (meconium) Obtain full SAMPLE history, and also: Prenatal history Complications during pregnancy Due date Number of babies (twins) Drugs or alcohol Water broken Green fluid (meconium)

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Focused Physical Exam Mainly abdomen and delivery of fetus Based on her chief complaints and history Pay close attention to tachycardia, hypotension, or hypertension. Mainly abdomen and delivery of fetus Based on her chief complaints and history Pay close attention to tachycardia, hypotension, or hypertension.

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Interventions Childbirth is natural, does not require intervention in most cases. Treating the mother will benefit the baby. Childbirth is natural, does not require intervention in most cases. Treating the mother will benefit the baby.

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Detailed Physical Exam Only if other treatments are not required

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Ongoing Assessment Continue to reassess the patient for changes in vital signs. Watch for hypoperfusion. Notify hospital of your preparations for delivery. Document carefully, especially babys status. Obstetrics is one of the most litigated specialties in medicine. Continue to reassess the patient for changes in vital signs. Watch for hypoperfusion. Notify hospital of your preparations for delivery. Document carefully, especially babys status. Obstetrics is one of the most litigated specialties in medicine.

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When to Consider Field Delivery Delivery can be expected within a few minutes A natural disaster or other catastrophe makes it impossible to reach a hospital No transportation is available Delivery can be expected within a few minutes A natural disaster or other catastrophe makes it impossible to reach a hospital No transportation is available

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Preparing for Delivery Use proper BSI precautions. Be calm and reassuring while protecting the mothers modesty. Contact medical control for a decision to deliver on scene or transport. Prepare OB kit. Use proper BSI precautions. Be calm and reassuring while protecting the mothers modesty. Contact medical control for a decision to deliver on scene or transport. Prepare OB kit.

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Positioning for Delivery

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Delivering the Baby Support the head as it emerges. Once the head emerges, the shoulders will be visible. Support the head and upper body as the shoulders deliver. Handle the infant firmly but gently as the body delivers. Clamp the cord and cut it. Support the head as it emerges. Once the head emerges, the shoulders will be visible. Support the head and upper body as the shoulders deliver. Handle the infant firmly but gently as the body delivers. Clamp the cord and cut it.

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Complications With Normal Vaginal Delivery Unruptured amniotic sac Puncture the sac and push it away from the baby. Umbilical cord around the neck Gently slip the cord over the infants head. It may have to be cut. Unruptured amniotic sac Puncture the sac and push it away from the baby. Umbilical cord around the neck Gently slip the cord over the infants head. It may have to be cut.

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Un-ruptured Amniotic Sac

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Umbilical cord around the neck

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Postdelivery Care Immediately wrap the infant in a towel with the head lower than the body. Suction the mouth and nose again. Clamp and cut the cord. Ensure the infant is pink and breathing well. Immediately wrap the infant in a towel with the head lower than the body. Suction the mouth and nose again. Clamp and cut the cord. Ensure the infant is pink and breathing well.

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Meconium

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Delivery of Placenta Placenta is attached to the end of the umbilical cord. It should deliver within 30 minutes. Once the placenta delivers, wrap it and take to the hospital so it can be examined. If the mother continues to bleed, transport promptly to the hospital. Placenta is attached to the end of the umbilical cord. It should deliver within 30 minutes. Once the placenta delivers, wrap it and take to the hospital so it can be examined. If the mother continues to bleed, transport promptly to the hospital.

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APGAR Scoring AActivity P Pulse G Grimace A Appearance R Respirations AActivity P Pulse G Grimace A Appearance R Respirations

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Neonatal Resuscitation

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Giving Chest Compressions to an Infant Find the proper position Just below the nipple line Middle third of the sternum Wrap your hands around the body, with your thumbs resting at that position. Press your thumbs gently against the sternum, compressing 1/3 the depth of the chest Ventilate with a BVM device after every third compression. 90 compressions to 30 ventilations per minute Continue CPR during transport Find the proper position Just below the nipple line Middle third of the sternum Wrap your hands around the body, with your thumbs resting at that position. Press your thumbs gently against the sternum, compressing 1/3 the depth of the chest Ventilate with a BVM device after every third compression. 90 compressions to 30 ventilations per minute Continue CPR during transport

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Breech Delivery Presenting part is the buttocks or legs. Breech delivery is usually slow, giving you time to get to the hospital. Support the infant as it comes out. Make a V with your gloved fingers then place them in the vagina to prevent it from compressing infants airway. Presenting part is the buttocks or legs. Breech delivery is usually slow, giving you time to get to the hospital. Support the infant as it comes out. Make a V with your gloved fingers then place them in the vagina to prevent it from compressing infants airway.

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Breech Presentation

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Rare Presentations Limb presentation This is a very rare occurrence. This is a true emergency that requires immediate transport. Prolapsed cord Transport immediately. Place fingers into the mothers vagina and push the cord away from the infants face. Limb presentation This is a very rare occurrence. This is a true emergency that requires immediate transport. Prolapsed cord Transport immediately. Place fingers into the mothers vagina and push the cord away from the infants face.

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Limb Presentation

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Prolapsed umbilical cord

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Excessive Bleeding Bleeding always occurs with delivery but should not exceed 500 mL. Massage the mothers uterus to slow bleeding. Treat for shock. Place pad over vaginal opening. Transport to hospital. Bleeding always occurs with delivery but should not exceed 500 mL. Massage the mothers uterus to slow bleeding. Treat for shock. Place pad over vaginal opening. Transport to hospital.

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Spina Bifida Defect in which the portion of the spinal cord or meninges may protrude outside the vertebrae or body. Cover area with moist, sterile compresses to prevent infection. Maintain body temperature by holding baby against an adult for warmth. Defect in which the portion of the spinal cord or meninges may protrude outside the vertebrae or body. Cover area with moist, sterile compresses to prevent infection. Maintain body temperature by holding baby against an adult for warmth.

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Spina bifida

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Abortion (Miscarriage) Delivery of the fetus or placenta before the 20th week Infection and bleeding are the most important complications. Treat the mother for shock. Transport to the hospital. Bring tissue that has passed through the vagina to the hospital. Delivery of the fetus or placenta before the 20th week Infection and bleeding are the most important complications. Treat the mother for shock. Transport to the hospital. Bring tissue that has passed through the vagina to the hospital.

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Abortion or miscarriage

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Twins Twins are usually smaller than single infants. Delivery procedures are the same as that for single infants. There may be one or two placentas to deliver. Twins are usually smaller than single infants. Delivery procedures are the same as that for single infants. There may be one or two placentas to deliver.

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Twins

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Delivering an Infant of an Addicted Mother Ensure proper BSI precautions Deliver as normal. Watch out for severe respiratory depression and low birth weight. Infant may require immediate care. Ensure proper BSI precautions Deliver as normal. Watch out for severe respiratory depression and low birth weight. Infant may require immediate care.

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Premature Infants and Procedures Delivery before 8 months or weight less than 5 lb at birth. Keep the infant warm. Keep the mouth and nose clear of mucus. Give oxygen. Do not infect the infant. Notify the hospital. Delivery before 8 months or weight less than 5 lb at birth. Keep the infant warm. Keep the mouth and nose clear of mucus. Give oxygen. Do not infect the infant. Notify the hospital.

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Fetal Demise An infant that has died in the uterus before labor This is a very emotional situation for family and providers. The infant may be born with skin blisters, skin sloughing, and dark discoloration. Do not attempt to resuscitate an obviously dead infant. An infant that has died in the uterus before labor This is a very emotional situation for family and providers. The infant may be born with skin blisters, skin sloughing, and dark discoloration. Do not attempt to resuscitate an obviously dead infant.

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Fetal Demise

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Delivery Without Sterile Supplies You should always have goggles and sterile gloves with you. Use clean sheets and towels. Do not cut or clamp umbilical cord. Keep placenta and infant at same level You should always have goggles and sterile gloves with you. Use clean sheets and towels. Do not cut or clamp umbilical cord. Keep placenta and infant at same level

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Premature infant

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Gynecologic Emergencies Do not examine genitalia unless there is obvious bleeding. Leave any foreign bodies in place, after packing with bandages Treat as any other patient with blood loss. Do not examine genitalia unless there is obvious bleeding. Leave any foreign bodies in place, after packing with bandages Treat as any other patient with blood loss.