1. Obstetrical and Gynecological Emergencies

2. General Strategy
Primary Survey / Resuscitation
Secondary Survey

3. Psychological, Social, Environmental Factors
Age: consider in ages 12 years to 55 years
Nationality / ethnicity
Occupation
Economic capabilities and resources
Social support system
Reproductive history
Nutritional
Genetic

4. Focused Survey Subjective Data History of present illness LNMP
EDC or + pregnancy test
Bleeding, discharge, pain, N&V, fever / chills
Visual disturbances
Fetal movement
ROM ?
Contractions
Urinary symptoms
Trauma

5. Focused Survey Subjective Data Medical History Reproductive
Prenatal care
Recent delivery ??
Abd / pelvic surgery
Sexual activity
Contraceptive use
STD’s
Substance abuse
Meds, Allergies etc.

6. Focused Survey Objective Data Physical Exam Diagnostic Procedures
Radiology
Other
12 lead ECG
pH for amniotic fluid

7. Assessment Assumptions
Any pregnant patient should be assessed for…
EDC / LNMP
Reproductive history including complications with current and previous pregnancies
Uterine size, tone, presence of contractions
Vaginal discharge or bleeding, fluid leaking?
FHT’s

8. Planning and Interventions
ABC’s first
IV’s and O2 as indicated
Monitor and treat…
Hemodynamic status
Vaginal bleeding, passage of clots, products of conception
Pain
Anticipate educational and emotional needs fo patient and family.
Anticipate equipment needs

9. Age Related Considerations
Pediatrics
Sexual abuse
STD’s / PID
Teen preganancy
Geriatrics

10. Specific Obstetrical Emergencies
Vaginal Bleeding in Early Pregnancy / Abortion Vaginal Bleeding in Late Pregnancy Ectopic Pregnancy PIH: preeclampsia / eclampsia Hyperemesis gravidarum Postpartum hemorrhage Emergency Delivery Neonatal Resuscitation Trauma in Pregnancy

11. Abortion Termination of pregnancy before viability (20-24 weeks).
10% to 15% of all recognized pregnancies
Etiology
Endocrine dysfunction
Chromosomal abnormalities
Maldevelopment
Trauma

12. Abortion Additional factors Maternal infections Malnutrition
Substance abuse
Immunological incompatibility
Surgery
Structural abnormalities of the uterus

13. Abortion: Classification
Threatened
Incomplete
Complete
Missed
Septic

14. Abortion: Assessment
Subjective and Objective information same for any pregnant patient
Diagnostic procedures
Pregnancy test - ? Quantitative
CBC
Blood type and Rh
STD
Pelvic US

15. Abortion: Interventions
IV access
Assist with US, exam
Prep for surgery as appropriate
Drug Therapy
Rh immune globulin to all Rh negative mothers
Oxytocin
Methergine
Analgesics
Antibiotics
Conscious sedation
Supportive / Psychosocial care

16. Abortion : Teaching Bedrest x 24-48 hours or until bleeding stops
Pelvic rest until bleeding / cramping cease
Pads only
Temp. four times a day, return for > 100.6
Save clots / tissue
Follow up care with OB

17. Bleeding in Late Pregnancy
Placenta Previa
Abnormally implanted placenta partially or completely obstructs cervical os
45% in second trimester
1% at term
Painless bright red bleeding occurs as cervix effaces / dilates
Multiparity, multigestation, advanced maternal age, uterine surgery, smoking.

18. Bleeding in Late Pregnancy
Abruptio placenta
3% of all pregnancies, 15% of all perinatal deaths
Partial or complete separation of a normally implanted placenta
Significant blood loss
Risk for DIC
Etiology: HTN, trauma, substance abuse, PROM, …

19. Ectopic Pregnancy
Implantation of fertilized ovum outside of the normal uterine cavity
95% in the fallopian tube, frequently right
Rupture leads to severe pain, intraperitoneal hemorrhage and shock

20. Ectopic – Assessment
Pain: diffuse, unilateral or bilateral, tube rupture is sharp, sudden, severe
Referred shoulder pain
Vaginal bleeding irregular / mild
Fatigue, dizziness, syncope
History: LNMP, reproductive hx, PID / STD’s, IUD use, tubal surgery, infertility, meds, allergies

21. Ectopic Assessment Physical Exam:
orthostatic VS
abdominal exam
pelvic
Quantitative BHcG, CBC, T&C, PT/PTT, electrolytes, U/S

22. Ectopic – Interventions
ABC’s
2 large bore IV’s
Reassess hemodynamic status / pain
Prepare for OR
Methotrexate
Supportive care / pregnancy loss

23. PIH: Preeclampsia / Eclampsia
PIH: hypertension
unique to pregnancy
Preeclampsia: HTN, proteinuria and non-dependent edema after 20 weeks
Eclampsia: includes convulsions, coma or both
HELLP: hemolysis, elevated liver enzymes, low platelets. The most severe form of preeclampsia.

24. PIH: Preeclampsia / Eclampsia

25. PIH: Preeclampsia / Eclampsia -
Exact cause unknown
Underlying pathology is vasospasm
Complicates 5-8% of preganancies
Leading obstetric cause of maternal death

26. Pre-eclampsia / Eclampsia
Risk factors:
extremes of maternal age,chronic hypertension
hx of eclampsia
mother or sister with hx
multiple gestation
diabetes, SLE, vascular disease
molar pregnancy
More common in primigravida

27. Preeclampsia / Eclampsia: Assessment
Headache, weight gain, epigastric or RUQ tenderness, generalized edema, visual disturbances, anxiety
BP > 140/90 or 30 mmHg systolic or 15 mmHg diastolic over baseline. 2 BP readings 6 hours apart with Mom on L. side.

28. Preeclampsia / Eclampsia: Diagnostics
Urinalysis: proteinuria greater than 1+
CBC
Electrolytes, creatinine, liver enzymes
PT / PTT

29. Preeclampsia / Eclampsia: Interventions
ABC’s
Supplemental O2
Foley - monitor hourly UO
Magnesium sulfate for seizure prophylaxis
Seizure precautions
Benzodiazepines for seizures
Antihypertensive therapy
Reassess ABC’s, FHT’s, signs of Mg++toxicity (Ca gluconate is antidote)

30. Hyperemesis Gravidarum
Severe vomiting occurring before 20th week.
Lasts 4-8 weeks
Significant weight loss, dehydration, malnutrition
Metabolic acidosis, ketonuria, hypokalemic alkalosis, oliguria, hemoconcentration, constipation
Complications: G.I. Bleeding, Mallory – Weiss tears, and Boerhaave’s esophogeal disruption

31. Hyperemesis: Management
ABC’s
IV access, 1-2 liters NS rapidly
Antiemetics as ordered
Gradual oral rehydration as tolerated

32. Postpartum Hemorrhage
Blood loss exceeding 500 ml
Early – within 24 hours of delivery
Uterine atony
Retained placental fragments
Lower genital tract lacerations
Uterine inversion or rupture
Maternal coagulopathy
Late - usually 6-10 days
Retained products of conception
Infection
Episiotomy breakdown
Coital trauma

33. Postpartum Hemorrhage: Risk Factors
Overdistention of uterus
High parity
Prolonged difficult labor, especially after oxytocin induction
History of PPH
Preeclampsia
Placenta previa
Precipitous labor

34. Postpartum Hemorrhage: Management
Assessment to include: orthostatic VS, Uterine size / tone, amount / color of bleeding
Diagnostics: CBC, T&C, Coagulation profile, fibrinogen, fibrin split products, US
2 large bore IV’s – fluids / blood as appropriate
Firm bimanual massage of uterus
Oxytocin, Methergine as ordered
Prepare for surgery

35. Emergency Delivery Rapid obstetric assessment / history FHT’s
Contractions: frequency, intensity, duration
Rupture of membranes: time, color, odor
Bloody show?
Rectal pressure or passage of feces
FHT’s
Pelvic Exam for effacement, dilation, station

36. Emergency Delivery Position side lying or fowlers
Encourage mother to “pant” to prevent uncontrolled delivery
Allow head to emerge slowly
Once head delivered, assess for nuchal cord
Loose – slip over head
Tight – clamp in 2 places and cut between clamps
Wipe infants face, suction mouth then nose.
Support head, deliver anterior then posterior shoulder.
Body will follow rapidly….slippery, don’t drop 

37. Emergency Delivery continued
Hold infant head down at level of perineum, suction mouth then nose again
Clamp cord 4-5 cm from infants abdomen when cord stops pulsating. Cut between clamps
Dry wrap, warm, stimulate infant
Apgar at birth and 5 minutes
Do not massage uterus until placenta is delivered

38. Neonatal Resuscitation

39. Trauma in Pregnancy
Trauma is primary cause of mortality in pregnancy causing up to 22% of maternal deaths
Maternal death is leading cause of fetal death
Management priorities for pregnant trauma patient are identical to those for any trauma patient.

40. Review of A&P Changes in Pregnancy
ABDOMINAL
CARDIOVASCULAR
PULMONARY

41. Specific Gynecological Emergencies
Vaginal bleeding / Dysfunctional uterine bleeding Pelvic pain Vaginal discharge Sexually Transmitted diseases Pelvic Inflammatory Disease Sexual Assault

42. Vaginal Bleeding / Dysfunctional Uterine Bleeding
Vaginal bleeding: uterine fibroids, menstrual cycle irregularities, trauma, infection, malignancy or coagulopathy
DUB: hormonal imbalance
Assessment: include sexual and contraceptive history, quantity, duration, quality of bleeding
Diagnostics: BHCG, CBC, coags, T&S, UA, STD screening, Thyroid, liver function, FSH, LH as appropriate.

43. Pelvic Pain
Variety of causes…assess pain carefully (PQRST).

44. Vaginal Discharge Variety of causes. Bacterial 40-50%
Candida albicans 20-25%
Trichomonas 15-20%
Non-infectious processes
Retained FB
Chemicals
Hormonal changes
Alteration in vaginal flora due to pregnancy, antibiotics, diabetes, HIV infection, poor hygiene
See table 13-5

45. Sexually Transmitted Disease
Vaginitis, cervicitis, PID, urethritis, epididymitis, pharyngitis, proctitis, skin and mucous membrane lesions, AIDS
See table 13-6

46. Sexual Assault
One RN will triage, assess, provide care, perform the sexual assault kit, provide referrals as needed, and discharge this patient. There is to be no more than one RN giving care