Obstetric and Gynecology Emergencies docx

1 Obstetric and Gynecology Emergencies Gynecology- The branch of medicine that deals with the female reproductive tract. ANATOMY AND PHYSIOLOGY Reproductive system- Ovaries, Fallopian tubes. Uterus and Vagina Ovaries-walnut shaped, located at the lateral aspect of the fallopian tubes are the female gonads • Provide estrogen and progesterone in response to follicle stimulating hormone (FSH) and luteinizing hormone (LH) secreted from the anterior pituitary gland • They also produce eggs Fallopian tubes (or uterine lubes)- hollow tubes that transport the egg from the ovary to the uterus. They do not connect directly to the ovaries. Fertilization usually occurs in the fallopian tube. Uterus- small pear shaped organ that connects with the vagina. The developing fetus grows in the uterus. Stretches from 5cm in length (usually) to 40 cm in length and is able to hold a 8 lb. fetus. 3" high X 2" wide x 1" thick Layers • Perimetrim- peritoneal covering separates uterus from abdominal cavity • Myometrium- thick muscular well of uterus • Endometrium- inner lining, thickens each month • Fundus- the upper portion of the uterus Cervix- the lower portion of the uterus which extends into the vagina • Visible through the vagina • During labor dilates from closed state to approximately 10 cm allowing passage of the baby Vagina- connection between uterus and outside of body. It is the female sex organ and receives penis during intercourse. Perineum- area surrounding the vagina and anus. Contains anus. vagina, and urethral orifices. Sometimes torn during childbirth. Labia- structures that protect the vagina and utheria 2 • Labia majora- located laterally • Labia minora-located more medial • Both are subject to injury during trauma to the perineal area- such as rape, bicycle accidents etc. Urethra- the urinary bladder drains through the urethra • Located superior and anterior to the vagina • The female urethra is only 2-3 cm long • Because the female urethra is shorter than the males, bacteria travel much easier into the female's bladder, making women more susceptible to bladder infection when they become sexually active. Menstrual Cycles Each month, under the influence of estrogen and progesterone, the endometrium builds up in preparation for the implantation of a fertilized ovum. If fertilization does not occur, the lining simply sloughs off. Menstrual period- sloughing off of the lining of the uterus The female undergoes a monthly hormonal cycle that prepares the uterus to receive a fertilized egg. A girl's menstrual period usually begins when she is between 12 and 14 years old. The beginning of the menses is termed menarche. At first the periods are irregular, later they become more regular and predictable. The menstrual cycle is influenced be estrogen and progesterone , which are produced in the ovaries. A normal cycle depends upon a regular pattern in the individual women; The average women will have a cycle of 28 days. Day 1 of the menstrual cycle is the day on which bleeding begins. The menstrual flow usually lasts from 3 to 5 days, but this varies depending on the females. The first two weeks of the menstrual cycle are dominated by estrogen. Estrogen causes the lining of the uterus to thicken and become engorged with blood vessels. This is the proliferative phase. At approximately day 14 a sudden surge of LH secretion causes the ovary to release an egg, which matured over the two weeks of the menstrual cycle, Release of the egg is ovulation. The egg is grasped by the fine, hair-like structures in the end of the fallopian tube. These structures sweep the egg toward the uterus. If the woman has had sexual intercourse within approximately 24 hours of ovulation, fertilization may take place. If the egg is fertilized, it normally implants in the thickened lining of the uterus, where the fetus subsequently develops. The stage of the menstrual cycle immediately surrounding ovulation is referred to as the secretory phase. If the egg is not fertilized, as normally happens, the women's estrogen level falls. The uterine lining sloughs away, starting a new menstrual cycle. The interval preceding and including the menstrual period is referred to as the menstrual phase. The absence of a menstrual period. especially in women whose periods are usually regular and who is sexually active, should raise the suspicion of pregnancy. Menstrual periods continue to occur until a woman is in her forties or fifties. At this time, they begin to decline in frequency and length, until they stop. This stoppage is referred to as menopause. Surgical menopause is the stopping of a woman's period by surgical removal of ovaries, uterus or both. Monthly cycle: ovulation- one mature ovum a month 14 days after ovulation endometrium is shed (menstrual period) Occurs about every 28 days, lasting 3-7 days Pregnancy Begins with fertilization, outer third of the fallopian tube Fertilized ovum develops into the fetus 3 Placenta- fetal and maternal tissues, two separate blood streams exchange of gases. Umbilical cord- the life line for the fetus, contains two arteries and one vein, spiraled around each other provides nutrients to the fetus and removes waist products. The cord is typically between one and three feet in length. Amniotic sac - "Bag of Water" (BOW)- a sac filled with amniotic fluid that surrounds and protects the fetus. Amniotic fluid- approximately one liter of fluid that surrounds the fetus and provides protection. Produced by the placenta early in the pregnancy that later produced by the baby's kidneys. Can be clear, pink, brown, or green. It has an unusual smell that some people compare to Comet cleanser Meconium- a brown or green substance that may be on the baby. The babies first bowel movement. The lining of the intestines. Can be a sign of fetal distress. Verais caseosum- a slippery white coating that some babies have on their skin at birth. Fertilization is possible about 14 days after the last menstrual period began. 4 week = a lunar month 10 lunar months 3 months = trimester 42 weeks 1 st lunar-Menstruation stops, breast enlarge, sleeps more, urinates more 2 nd lunar-nausea and vomiting 3 rd lunar-uterus felt above the pubic bone 4 th lunar-fetal movement felt by women 5 th lunar-fetal heart sounds heard with stethoscope 6 th lunar- examiner can feel fetal movement 4 1 st Trimester- 0-13 weeks • Vaginal bleeding is quite common • Any bleeding before week 20 is called a threatened miscarriage • Cramping is common • Abdominal pain • Constipation • Headache • Nausea and Vomiting • Dizziness • frequent urination 2 nd Trimester-14-26 weeks • Honeymoon phase-most "morning sickness" symptoms are over and women feel quite well • Vaginal bleeding is not common • Infrequent and irregular cramping is normal • Vaginal pressure is common • Vaginal discharge-normal thin, white and odorless • Vomiting common • Heartburn • Shortness of breath • Lines nigra- a dark line from the belly button to the pubic bone • Breast continue to enlarge • Swelling • Between weeks 15-22 can feel baby begin to move 3 rd Trimester 27-42 weeks • Stress urinary incontinence • Shortness of breath • Belly button may "pop" out • Braxton -Hicks Contractions-early contractions caused by the uterus beginning to contract. 'false labor" Often irregular, not increasing in intensity, usually change when the women changes position • Constipation • Heartburn • Backache • Leg cramps • Insomnia • Swelling • Vaginal pressure • Frequent urination 5 Stages of Labor 1 st stage of Labor- first contraction to cervix completely effaced (1Ocm- Amniotic sac frequently ruptures. 2 nd stage of Labor-Crowning to birth 3 rd stage of Labor- Placenta delivery about 15 minutes after delivery of baby Assessment of the Gynecological patient • Standard initial and focused assessment • Most gynecological patient have abdominal pain / discomfort or vaginal bleeding • If pain is present determine sharp or dull, onset, duration • History, other problems, kidney stones, number or pregnancies, surviving infants, c- sections • Need to document last menstrual period (LMP), was it normal, flow heavy or light (an easy way to determine is to estimate the number of pads used. Types of birth control • GPA ο Gravidity- number or times pregnant ο Paradity- number of births ο Abortions-number of pregnancies aborted either natural or elective Should always assume a late period means the patient is pregnant. Physical examination Physical examination is limited in the field. Complete initial and focused exam. Look for abdominal masses, distention, guarding, or tenderness. Report significant bleeding. Document color, amount, and presence of clots in any discharge. DO NOT PERFORM AN INTERNAL VAGINAL EXAM IN THE FIELD!!!!!! Two types of gynecological emergencies • Medical • Trauma Medical Gynecological Emergencies Pelvic Inflammatory Disease (PID)- infection of the female reproductive tract. The organs most often involved are the uterus, fallopian tubes, and ovaries. Sometimes intestines and peritoneum can also be involved. Most common cause is gonorrhea and chlamdial infections, which will progress, undetected until a serious case of PID develops. May be acute or chronic. If untreated may cause pelvic organs to stick together causing adhesions (a common cause of chronic pelvic pain). Will increase the risk of ectopic pregnancy. Most common complaint of PID patient is abdominal pain, often located along the lower abdomen. Moderate to severs pain- making hard to distinguish from appendicitis. More pain before or after period also worsens during sexual intercourse. Patients with PID walk in a shuffling gait to help the pain. Severe case may have fever, chills, nausea, and often-yellow vaginal discharge. Bp normal, pulse slightly elevated. Transport in position of comfort. 6 7 Ectopic pregnancy-implantation of growing fetus in a place it does not belong. Most common site is the fallopian tubes. This is a surgical emergency, because rupture will trigger massive hemorrhage, patients with ectopic pregnancy often have one-sided abdominal pain, late or missed menstrual period and sometimes vaginal bleeding. Could have a positive pregnancy test, may also have signs of shock- late sign is periumbilical cyanosis- bluish tint around the navel. Ovarian cysts- cysts are fluid filled pockets. When they develop in the ovary, they can rupture and cause abdominal pain. When the egg is released cysts are often left in its place. If it ruptures it will cause blood to spill into the abdomen, which will irritate the peritoneum causing abdominal pain and rebound tenderness. Appendicitis-Very difficult to tell from PID or even ectopic pregnancy in the field. Usually patient will have abdominal pain around the navel and it will slowly go to the right lower quadrant. Pain may cause anorexia, fever, nausea, and vomiting or even shock. Cystitis-Bladder infection is a common cause of abdominal pain. Bladder lies anterior to the reproductive organs and when inflamed cause pain generally immediately above the symphysis pubis. Mittleschmertz- occasionally a woman will have a day or two of abdominal pain halfway through her menstrual cycle. This pain is related to the release of the egg from the ovary. Pain is self- limited and treatment is symptomatic. Pre-Eclampsia-a seizure disorder of pregnancy caused by hypertension Placenta previa- the placenta implants low in the uterus, covering the cervical opening Placental abruption (abruptio plactentae) - the placenta becomes dislodged from the wall of the uterus, allowing the mother's blood to collect behind it and eventually make it's way to the vagina. Other pelvic infections- women who have had recent gynecological surgery, induced abortions, miscarriages, or delivery of babies can subsequently develop pelvic infections. It is important to determine past problems that may suggest complications from childbirth or surgery. One of these, endometritis is the infection of uterine lining and can be serious if not treated quickly. Treatment • Full assessment • High flow Oxygen • Transport in position of comfort Traumatic Gynecological Emergencies Can be caused by straddle injuries, bike accidents, blows to perineal area, foreign-bodied inserted into vagina, attempts at abortion, sexual assault or lacerations following childbirth. Sexual assault-sexual contact without consent of the person assaulted, one of the most growing crimes in the United States. Can involve adults and children. Rape- the penetration of the vagina or rectum in an unwilling female or male. 8 Most victims of sexual abuse are female, but males and children are also victims. Victims should not be questioned about the incident in the field. It is not important to know if penetration took place. Victim may be withdrawn or hysterical; some will use anger, denial, or fear as defense mechanisms. Approach calmly and professionally, offer a cover if not dressed, respect patient's modesty, explain procedures before touching patient, Keep physical contact to a minimal except vitals and to examine for physical injuries. Do not examine genitalia unless life-threatening hemorrhage, Psychological and emotional support is the most important care you can give. maintain nonjudgmental attitude and assure the patient confidentially. Try to allow a female provider to care for patient if available. Remember this is a crime, try to maintain physical evidence as possible by: • Handle clothing a little as possible • Do not examine the perineal area • Do not use plastic bags for blood stained articles • Bag each item separately, if they must be bagged • Do not allow patient to comb hair or clean fingernails • Do not allow patient to change cloths or shower or douche • Do not allow patient to use restroom if possible • Do not clean wounds, if possible In Virginia penis must have contact with vagina for rape to occur, anything else is an assault. Types of Rape 1. Blitz-out of the blue 2. Acquaintance-some type of relationship, date rape 3. Anger- getting revenge at woman or women in life by attacking other women 4. Power-socially, sexually inadequate-this makes someone else less powerful then them 5. Sadism-held longer, torture, abuse, murder, most likely to kill victim 6. Authority-professional who crosses overt he line-doctor, dentist, police officer. EMT etc. Abortion-loss of pregnancy before the 20 th week of gestation, "miscarriage", can be spontaneous or induced Spontaneous abortion-occurred naturally Criminal abortion- illegal attempt, unsterile conditions that produce a hazard to the mother. Therapeutic abortion-justifiable medical reasons Stages of Abortion Threatened abortion- bleeding, pain resembles menstrual cramps Inevitable abortion- bleeding, could be massive, uterine contraction cervical dilation 9 Incomplete abortion-uterus not entirely rid on contents Missed abortion- fetus dies before the 20 th week, but remains in the uterus Complication of delivery Internal bleeding-retained placental tissue or clotting disorder External bleeding- perineal tears Uterine inversion- (turning inside out)- Pulmonary Embolism—sudden dyspnea, tachycardia, hypotension Abnormal Deliveries Breech Presentation-buttocks present first • If head is not delivered within 3 minutes, provide airway • Gloved hand in vagina, form a "V" with fingers • Elevate mother buttocks, or place in knee to chest position Prolapsed Umbilical cord-cord delivers before baby • Gloved hand inserted into vagina to keep pressure off cord • Cover cord with moist dressings • Place mother with buttocks elevated, or knee to chest position Limb Presentation- arm or leg presenting • Immediate transport Multiple Births-tie cord between deliveries Premature Births- any birth before 7 months or less than 5.5 Ibs. • Head is larger in proportion to the body • Reduce loss of heat • Lungs may not be fully developed • Other organs may not be fall developed Nuchal Cord-umbilical cord wrapped around baby's neck • Carefully slip cord from around neck • If necessary clamp and cut cord n two places Meconium Stained Babies-brown or green substance signs of baby's first bowel movement • Quickly and thoroughly suction the baby's airway • Oropharynx first • Nasopharynx second 10 Normal deliveries • Apply gentle pressure to top of infants head to prevent an explosive delivers • Support infant as it is delivered • Suction Oropharynx • Suction nasopharynx • Clamp and tie cord • Stimulate and warm baby • Warm and dry • Provide supplemental oxygen if needed • CPR if needed Goals of Neonatal care 1. Clear airway 2. Keep baby warm 3. Prevent bleeding from umbilical cord 4. Give Oxygen carefully 5. Prevent contamination APGAR Scoring- means of determine the status of the newborn. Should be done one minute after birth and five minutes after birth Appearance Color All Pink 2 Some Pink 1 No Pink 0 Pulse Above 100 2 Under 100 1 Absent 0 Grimace Reflex Strong 2 Weak 1 None 0 Activity Muscle Tone Good 2 Fair 1 Absent 0 Respirations Rapid 2 Weak 1 Absent 0 . 1 Obstetric and Gynecology Emergencies Gynecology- The branch of medicine that deals with the female reproductive tract. ANATOMY AND PHYSIOLOGY . between uterus and outside of body. It is the female sex organ and receives penis during intercourse. Perineum- area surrounding the vagina and anus. Contains