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Gynecologic Emergencies - Coggle Diagram
Gynecologic Emergencies
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Vaginal Bleeding
Possible causes include:
- Abnormal menstruation
- Vaginal trauma
- Ectopic pregnancy
- Spontaneous abortion
- Cervical polyps
- Cancer
Patient Assessment
Scene Size-Up
- Scene Safety
- Gynecologic emergencies can involve large amounts of blood
- Involve police if assault is suspected
- The MOI may be easily understood from the dispatch information, such as sexual assault
Primary Assessment
- Form a general impression
- always evaluate airway and breathing
- Pulse, skin color, temperature, and moisture can to help identify blood loss
- Most gynecologic emergencies are not life threatening
History Taking
Investigate Chief Complaint
- Some questions are extremely personal
- Ensure the patient's privacy and dignity are protected
For abdominal pain, ask about:
- Onset, duration, quality, and radiation
- Provoking or relieving factors
- Associated symptoms
For vaginal bleeding, ask about:
- Onset
- Duration
- Quantity (number of sanitary pads soaked)
- Associated symptoms such as syncope and light-headedness
SAMPLE History
- Ask about birth control pills or devices
- Ask about last menstrual period and STDs
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Normal Changes in Pregnancy:
- Hormone levels increase
-To support fetal development and prepare the body for childbirth
-Pregnant women are at an increased risk for complications from trauma, bleeding, and some medical conditions.
-Uterus is shifted from its normal position
- Rapid uterine growth occurs during the second trimester
-As the uterus grows, it pushes up on the diaphragm and displaces it
-Respiratory capacity changes, with increased respiratory rates and decreased minute volumes.
-Blood volume and speed of clotting increase
-Cardiac output is increased
- In the third trimester, there is an increased risk of vomiting and potential aspiration following trauma.
- Changes in the cardiovascular system and the increased demands of supporting the fetus increase the workload of the heart.
- Weight gain during pregnancy is normal
-Challenges the heart and impacts the musculoskeletal system
-The joints become "looser" or less stable
-Changes in the body's center of gravity increase the risk of slips and falls.
Complications of Pregnancy:
- Most pregnant women are healthy
- Some may be ill when they conceive or become ill during pregnancy
-Oxygen poses no harm to the fetus
Diabetes:
- Develops during pregnancy in many women who have not had it previously
- Gestational diabetes usually resolves after delivery
- Treatment is the same as for any other patient with diabetes.
Hypertensive Disorders:
- Preeclampsia is a common complication
-Pregnancy-induced hypertension
-Can develop after the 20th week of gestation
-Signs and symptoms include severe hypertension, severe or persistent headache, visual abnormalities, swelling in the hands and feet and anxiety.
- Eclampsia is characterized by seizures that occur as a result of hypertension
-To treat seizures:
Lie the patient on her left side
Maintain a patent airway
Administer supplemental oxygen if necessary
If vomiting occurs, suction the airway
Provide rapid transport and call for ALS
- Transporting the patient on her left side can also prevent supine hypotensive syndrome
-Caused by compression of the descending aorta and the inferior vena cava by the pregnant uterus when the patient lies supine.
Bleeding:
- Ectopic pregnancy
-An embryo develops outside the uterus, most often in a fallopian tubes.
- The leading cause of maternal death in the first trimester is internal hemorrhage following rupture of an ectopic pregnancy.
- Consider the possibility in a woman who has missed a menstrual cycle and complains of sudden, severe pain in the abdomen.
Abortion:
- Passage of the fetus and placenta before 20 weeks
- May be spontaneous or induced
- Most serious complications are bleeding and infection
- Treat for shock and transport promptly
Substance Abuse:
- Effects of addiction on the fetus include:
. Prematurity
. Low birth weight
. Severe respiratory distress
. Death
- Fetal alcohol syndrome describes the condition of infants born to women who have abused alcohol.
- Pay special attention to your safety
- Look for clues that you are dealing with an addicted patient.
- The newborn will probably need immediate resuscitation
Special Considerations for Trauma and Pregnancy:
- With a trauma call involving a pregnant woman, you have 2 patients:
. The woman
. The unborn fetus
- Pregnant women also have an increased risk of falling
- Pregnant women have an increased amount of overall total blood volume and a 20% increase in heart rate
. May experience a significant amount of blood loss before you will see signs of shock
. Uterus is vulnerable to penetrating trauma and blunt injuries
- In a motor vehicle crash, severe hemorrhage may occur from injuries to the pregnant uterus.
. Trauma is one of the leading causes of abruption placenta.
. Common symptoms include vaginal bleeding and severe abdominal pain
- Improper positioning of the seat belt can result in injury to a pregnant woman and the fetus.
- Cardiac arrest
. Focus is the same as with other patients
. Perform CPR and provide transport
. Compressions may need to be applied higher on the sternum.
Cultural Value Considerations:
- Cultural sensitivity is important
- Women of some cultures may have a value system that will affect:
. The choice of how they care for themselves
. How they have planned for childbirth
- Some cultures may not permit a male health care provider to assess or examine a female patient
. Respect these differences and honor requests from the patient.
Teenage Pregnancy:
- The United States has one of the highest teenage pregnancy rates.
- Pregnant teenagers may not know they are pregnant or may be in denial.
- Respect the teenager's privacy.
Scene Size-up:
- Scene safety
. Take standard precautions.
. Gloves and eye and face protection are a minimum if delivery is already begun or is complete.
. If time allows, a gown should also be used.
. Consider calling for additional resources.
Patient Assessment:
- Childbirth is seldom an unexpected event, but there are occasions when it becomes an emergency.
Primary Assessment:
- Circulation
. Blood loss after delivery is expected, but significant bleeding is not.
. Assess for and treat life-threatening bleeding.
- Transport decision
. If delivery is imminent, prepare to deliver at the scene.
. If delivery is not imminent, prepare the patient for transport
History Taking:
- Obtain a thorough obstetric history
. Her expected due date
. Any complications that she is aware of
. If she has been receiving prenatal care
. A complete medical history
- Obtain a SAMPLE history.
. Determine the due date, frequency of contractions, a history of previous pregnancies and deliveries, the possibility of multiples, and if she has taken any drugs or medications.
. If her water has broken, ask whether the fluid was green (due to meconium).
Reassessment:
- Communication and documentation
. Provide an update on the status of the status of the woman and the newborn after delivery.
. For a pregnant patient with a complaint unrelated to childbirth, be sure to include the pregnancy status in your radio report.
. If delivery occurs in the field, you will have two patient care reports to complete.
Neonatal Assessment and Resuscitation:
- Follow standard precautions
- Always put on gloves before handling a newbornl
. Newborn will usually begin breathing spontaneously within 15 to 30 seconds after birth.
. Heart rate will be 120 beats/min or higher
Assess and support:
Temperature (warm and dry)
Airway (position and suction)
Breathing (stimulate to cry)
Circulation (heart rate and skin color)Basic life support interventions:
Dry and warm the newborn
Clear the airway with 3 bulb syringe if needed
Stimulate the newborn if he or she is unresponsive
Use a BVM to ventilate the newborn if needed. This is seldom required
Perform chest compressions if there is no pulse or if the heart rate is <60 after 30 seconds of ventilation and heart rate is not increasing
- Position the newborn on his or her back with the head down and the neck slightly extended.
- If necessary, suction the mouth and then the nose
Additional Resuscitation Efforts:
If the Heart Rate is:
- More than 100 beats/min -
. Keep the newborn warm. Transport the newborn. Assess the newborn continuously
- 60 to 100 Beats/min:
. Begin assisted ventilation with a BVM and room air
. Reassess the newborn after 90 seconds and if the heart rate and respirations are not normal, begin to ventilate with 100% oxygen. Continue to reassess the newborn. Call for ALS backup if available. Keep the newborn warm.
- Fewer than 60 beats/min:
. Begin assisted ventilation with a BVM and 100% oxygen.
. Reassess the newborn every 90 seconds until heart rate and respirations are normal.
. Begin chest compressions. Call for ALS backup if available.
. If the heart rate does not increase, medication and ALS will be needed.
The Apgar Score:
- Standard scoring system used to assess the status of a newborn
- Assigns a number value to five areas:
. Appearance
. Pulse
. Grimace or irritability
. Activity or muscle tone
. Respirations
- The total of the five numbers is the Apgar score.
. Calculate the Apgar score at 1 minute and 5 minutes after birth
Breech Delivery:
- Breech deliveries usually take longer, so you will often have time to transport the pregnant woman to the hospital.
. If the buttocks have passed through the vagina, the delivery has begun.
- Preparing for a breech deldelivery is the same as for a normal childbirth.
. Allow the buttocks and legs to deliver spontaneously, supporting them with your hand
. The head is almost always facedown and should be allowed to deliver spontaneously.
. Make a "V" with your gloved fingers and position them in the vagina to keep the walls from compressing the fetus's airway
Fetal Demise:
- Onset of labor may be premature, but labor will progress normally in most cases.
- If an intrauterine infection caused the demise, you may not a foul odor.
- Do not attempt to resuscitate an obviously dead neonate
Presentation Complications:
- On rare occasions, the presenting part of the fetus is a single arm, leg, or foot.
. Called a limb presentation.
- An fetus with a limb presentation cannot be delivered in the field.
. Transport immediately
. if a limb is protruding, cover it with a sterile towel.
. Never try to push it in or pull on it.
- Do not push the cord back into the vagina.
. Keep the fetus's head from compressing the cord.
. Insert your gloved hand into the vagina and push the fetus's head away from the umbilical cord
. Transport rapidly
Premature Birth:
- Any newborn who delivers before 8 months (36 weeks) or weighs less than 5 lb at birth is considered premature.
- A premature newborn is smaller and thinner, and the head is proportionately larger
Postpartum Complications:
- If bleeding continues after delivery of the placenta:
. Continue to massage the uterus
. Check your technique and hand placement if bleeding continues
. Cover the vagina with a sterile pad
Administer oxygen, monitor vital signs, and transport the patient immediately
Multiple Gestation:
- Twins occur once in every 30 births
- Twins are smaller than single fetuses, and delivery is typically not difficult
. After 10 minutes after the first birth, contractions will begin again, and the birth process will repeat itself.
- The procedure is the same as that for a single fetus.
- Record the time of birth of each twin separately.
- Twins may be so small that they look premature.
Postterm Pregnancy:
- Pregnancies lasting longer than 42 weeks
- Fetuses can be larger, sometimes weighing 10 lb or more.
- Can lead to problems with the woman and fetus:
. A more difficult labor and delivery
- Problems
. Increased chance of injury to the fetus
. Increased likelihood of cesarean section
. Woman is at risk for perineal tears and infection
. Postterm newborns have increased risk of meconium aspirations, infection, and being stillborn.