Obstetric and Gynecologic Emergencies

Physiologic changes in pregnancy

Pregnancy changes the mother's body in ways that matter to the EMT. As the uterus grows it becomes thinner-walled and less protected, and so more vulnerable to injury. The cardiovascular system adapts as well: blood volume, cardiac output and heart rate all increase, but the red blood cell (RBC) count rises less than the plasma volume does, so the added volume dilutes the cells that are present and produces a dilutional anemia.

The respiratory system is affected too. The mother's demand for oxygen (O2) rises, and in late pregnancy the fetus presses upward on the diaphragm and reduces lung volume. A pregnant patient therefore has less reserve at the very time she needs more oxygen.

Supine hypotensive syndrome

In the third trimester, the weight of the uterus and fetus can compress the inferior vena cava when the mother lies on her back. Compression of the vena cava reduces venous return to the heart, which in turn reduces cardiac output, and the mother becomes dizzy and her blood pressure (BP) drops. This is supine hypotensive syndrome.

Standard treatment for shock does not work here, because the problem is the position of the patient rather than a loss of volume. The fix is positional: transport all third-trimester patients on their left side, which takes the weight of the uterus off the vena cava.

Labor & delivery — 3 stages

Labor is divided into three stages, and the table below sets out where each begins and ends.

Table 36.1Labor & delivery — 3 stages

Contractions progress from roughly 30 minutes apart to 3 minutes apart or less as delivery nears. Bloody show, the watery, blood-tinged mucus that passes from the vagina, is a normal sign that labor has begun.

Assessing the woman in labor — transport decision

When you are called to a woman in labor, the first question is whether there is time to transport. Begin with the history: ask for her due date, whether this is her first pregnancy, and whether she has had prenatal care. Then look for crowning, a visual check for a bulging or presenting part at the vaginal opening, which is best seen during a contraction. A cephalic presentation, head first, is normal. A breech presentation means the buttocks or feet present first.

The general rule is to transport unless delivery is expected within a few minutes. If crowning or other signs of imminent delivery are present, consult medical direction, and if delivery has not occurred within 10 minutes, contact medical direction again to request transport. If crowning occurs during transport, stop the ambulance and prepare for delivery.

Assisting the delivery

If the baby is coming on scene, your job is to assist a process that will happen on its own. The steps are as follows:

1. Keep a constant view of the vaginal opening and be ready at any moment.
2. Place one hand with slight pressure on the baby's head as it emerges. Never squeeze the head, and never pull on the baby.
3. If the amniotic sac has not broken, puncture it with your finger and clear the membrane from the baby's mouth and nose. Check the fluid for meconium staining.
4. Check for a nuchal cord, a cord wrapped around the baby's neck. Gently loosen it; if it cannot be loosened, clamp the cord in two places and cut between the clamps.
5. Deliver the shoulders. Guide the head downward to deliver the upper shoulder, then upward to deliver the lower shoulder.
6. Support the baby, who will be very slippery. Dry the baby, wrap it in a warm blanket, and suction only if needed, the mouth first and then the nose.
7. Note the exact time of birth.

The neonate & the APGAR score

A normal newborn has a pulse above 100 beats per minute, breathes easily, cries vigorously, and shows blue coloration, if any, only at the hands and feet. The APGAR score records the newborn's condition in five categories, each scored from 0 to 2, and the table below gives the criteria for each score.

Table 36.2The neonate & the APGAR score

APGAR does not guide resuscitation and must never delay it. It is a documentation and scoring tool, not a decision-making tool in the moment. Warmth is the number one priority for the newborn.

Neonatal resuscitation — the inverted pyramid

Most neonates need only simple maneuvers, and the sequence of care is drawn as an inverted pyramid: the simple steps at the wide top are needed by almost every baby, and each step below is needed by fewer. Each step is performed for 30 seconds, and the baby is then reassessed before you move to the next. The steps are:

1. Dry, warm and stimulate the baby.
2. If the baby is apneic or gasping, or the heart rate (HR) is below 100, begin positive pressure ventilation at 40 to 60 breaths per minute.
3. If the HR is below 60, begin chest compressions using the two-thumbs-encircling technique, at a compression-to-ventilation ratio of 3:1.

Childbirth complications

Three abnormal presentations can be recognized at the scene, and in each the most important decision is what not to do. The table below sets out the findings and the critical actions for each.

Table 36.3Childbirth complications

In breech and limb presentations the harm comes from pulling; in a prolapsed cord it comes from compression of the cord. Never pull on a presenting limb or on the legs of a breech, and never push a presenting limb back in.

Excessive prebirth bleeding & ectopic pregnancy

Heavy bleeding before birth usually comes from one of two problems with the placenta, and the table below contrasts them.

Table 36.4Excessive prebirth bleeding & ectopic pregnancy

In placenta previa, the bleeding comes in the third trimester and is heavy, and it often occurs without abdominal pain. In abruptio placentae, the third-trimester bleeding is accompanied by abdominal or back pain, and the condition is often related to trauma.

Ectopic pregnancy is the other bleeding emergency you must keep in mind. Assume that any woman of childbearing age with abdominal pain, and especially abdominal pain with vaginal bleeding, has an ectopic pregnancy until proven otherwise. The signs are one-sided acute abdominal pain, a rapid and weak pulse, which is a later sign, and a low BP, which is a very late sign.

Seizures in pregnancy & trauma

Preeclampsia presents with altered mental status (AMS), swelling and hypertension. When it progresses to seizures, the condition is eclampsia. Care for the seizing pregnant patient is to open the airway, give O2, transport her on the left side, keep her warm, and call for ALS.

Trauma in pregnancy raises particular concerns. The uterus acts as a natural shock absorber for minor abdominal trauma, but major forces can cause uterine rupture, abruptio placentae or organ injury. The pregnant patient's baseline pulse is 10 to 15 beats per minute faster than a nonpregnant woman's, and she can lose 30 to 35 percent of her blood volume before obvious signs of shock appear. Shock is therefore genuinely harder to detect in pregnancy, and it remains the most likely cause of prehospital fetal death.

Cardiac arrest in the pregnant patient

When a pregnant patient goes into cardiac arrest, resuscitation stays focused on the mother, because a resuscitated mother is the best hope for the baby as well. If the patient is more than 20 weeks pregnant, manually displace the uterus to the left during CPR, or tilt her 27 to 30 degrees to the left lateral position on a backboard, to take the uterus off the vena cava. Place your hands in the usual position on the lower half of the sternum; current AHA guidance does not recommend moving them higher. An AED and defibrillation are appropriate in pregnancy and should be used as needed.

Gynecologic emergencies (non-pregnancy)

Vaginal bleeding in a woman who is not known to be pregnant still calls for the same thinking as before: consider pregnancy-related causes, especially ectopic pregnancy, first in any woman of childbearing age.

A call for sexual assault demands care for both the patient and the evidence. Ensure scene safety first. Be nonjudgmental, and treat life threats before anything else. Avoid disturbing evidence unless doing so is necessary for care, and examine the genitals only if severe bleeding is present. Discourage the patient from bathing or voiding, because both destroy evidence.