Outdoor emergency care

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OUTDOOR EMERGENCY CARE, 5th Edition Instructor’s Manual

Chapter 34 Obstetric and Gynecologic Emergencies
OEC Instructor Resources: Student text, Instructor’s Manual, PowerPoints, Test Bank, IRCD, myNSPkit (online resource), sample OB kit, gloves

OEC Student Resources: Student text, Student CD, myNSPkit (online resource)
Chapter Objectives

Upon completion of this chapter, the OEC Technician will be able to:

34-1. Identify the major anatomical structures within the pelvic cavity.

34-2. List the functions of the female genitourinary and reproductive system.

34-3. List the functions of the major gynecologic structures.

34-4. List three causes of abdominal pain of gynecologic or obstetrical origin.

34-5. List four possible causes of vaginal bleeding.

34-6. List the three stages of a normal pregnancy.

34-7. List three possible consequences of abdominal trauma in a pregnant patient.

34-8. Describe four possible complications of pregnancy.

34-9. Demonstrate how to examine a female patient with abdominal or pelvic pain.

34-10. Describe how to assess the abdomen of a pregnant patient.

34-11. Describe the process of assisting an emergency delivery.

34-12. Describe the management of a pregnant patient with abdominal trauma.

Essential Content

I. Chapter overview

A. Definition of obstetrical emergencies

B. Goal for managing gynecologic and obstetrical emergencies

II. Anatomy and physiology

A. Pelvic cavity

B. Ovaries are one of two solid reproductive organs located in the lower right and left quadrants

C. Fallopian tubes are hollow structures and extend downward into the pelvic cavity

D. Uterus is hollow muscular organ where the fertilized ovum develops

E. Vagina is hollow muscular tube extending from uterus to exterior opening; part of the birth canal

F. Perineum is the outer soft tissue that extends from the vaginal opening to the anus

III. Reproductive system

A. Cycle begins with ovulation, about once every 28 days

B. Fetus is the embryo from the 9th week of pregnancy until delivery

C. Gestation is the time between conception and delivery of a child (approximately 266 days)

D. Premature delivery is a delivery before the 37th week

E. Fetus develops in the amniotic sac, which is filled with clear amniotic fluid

F. Nourishment is provided by the placenta, which adheres to the uterine wall and is connected to the baby by the umbilical cord

G. At 20 weeks, the uterus rises to the level of the umbilicus

H. Increased blood volume at 28 weeks of gestation

I. Increased heart rate and oxygen needs, blood pressure decreases

J. 30–35 percent of blood volume loss before signs of shock

IV. Common obstetrical and gynecological emergencies

A. Causes of abdominal pain

  1. Dysmenorrhea—cramps, painful menstruation, other symptoms including NVD; relief with OTC medications

  2. Cystitis—inflammation of bladder caused by bacterial infection, symptoms include painful urination

  3. Ovarian cysts can be chronic and multiple; severe pain; relief in some cases with OTC medications, others will need to see a doctor

  4. Pelvic inflammatory disease is an inflammatory condition usually caused by sexually transmitted microorganisms; symptoms begin after the menstrual period

  5. Ectopic pregnancy is serious life-threatening condition; fertilized egg implants outside of the uterus; must seek medical attention

B. Vaginal bleeding

C. Normal versus abnormal

  1. Abnormal bleeding, including increase in flow, needs to seek medical attention

V. Gynecological trauma

A. Blunt force injuries

  1. Straddle injuries, vulvar hematomas, perineal lacerations, vaginal bleeding, or pelvic fractures

  2. Urethra or bladder tears, hematuria, inability to urinate, urinary retention

  3. Vascular—external profuse bleeding, direct pressure; requires immediate treatment by a physician

B. Sexual assault

  1. Defined as any physical contact of a sexual nature without voluntary consent

  2. Resulting psychological trauma is often more severe than the physical trauma

VI. Pregnancy: Normal physiologic changes

A. First trimester—early symptoms include swelling of breasts, fatigue, nausea, and frequent urination

B. Second trimester—mother will feel baby’s movement

C. Third trimester—mother will have weight gain, will feel off balance, swelling of hands and feet, indigestion, fatigue, and difficulty breathing

VII. Complications of pregnancy

A. Hemorrhage

  1. First trimester

  2. Second trimester and third trimester, placenta previa and abruptio placentae

B. Pregnancy-induced hypertension (PIH), toxemia, preeclampsia

  1. After 20 weeks, first-time pregnancy, twins, preexisting diabetes

  2. Blood pressure greater than 140/90

  3. Edema of hands and/or face

  4. Complicated by seizures—eclampsia (severe form), late in pregnancy close to time of delivery

  5. Supplemental oxygen, position patient on left side, emergent delivery of infant

C. Miscarriage

  1. Defined as spontaneous abortion, loss of pregnancy prior to 20 weeks of gestation

  2. Symptoms include spotting or bleeding accompanied by lower abdominal cramping

D. Supine hypotension syndrome

  1. Defined as compression to the vena cava resulting in hypotension

  2. Prevention: elevate right hip 1 to 2 inches; spine board tipped up so patient is slightly tilted onto her left side; abdomen and uterus can be manually pushed and displaced to the left off the vena cava

VIII. Childbirth

A. Three stages of labor

  1. First stage—contractions to complete dilation of cervix

  2. Second stage—delivery of fetus

  3. Third stage—delivery of placenta

B. Signs of imminent delivery

  1. Bloody show

  2. Rupture of amniotic sac

  3. Urge to push or defecate; do not allow the mother to go to bathroom

C. Crowning—bulging; check for umbilical cord visible

D. Evacuate patient to location accessible to EMS if:

  1. Access point can be reached in 20 minutes

  2. Umbilical cord or a part other than the baby’s head is visible in the vaginal opening

  3. Mother indicates breech presentation or need for c-section

  4. Baby’s head is not visible on inspection of the perineum during a contraction

E. Delivery not imminent, place patient on left side in lateral recumbent position, give oxygen, transport to hospital

F. Baby is crowning

  1. Use disposable sterile OB delivery kit

  2. If kit not available, improvise by obtaining clean towels and sheets, blanket for baby, 4x4 gauze sponges, scissors or straight-edged razor, soft rubber bulb syringe, white cloth tape, two clean shoelaces (sterilize all if time)

  3. Standard Precautions throughout, place all supplies soiled with body fluids in biohazard bag and dispose of properly

  4. Assist mother, remove clothing from waist down, place her on a firm padded surface, elevate pelvis 2–4 inches

  5. Place clean sterile sheet under mother’s buttocks, creating delivery field

  6. Time contractions

  7. Crowning—allow mother to push, apply gentle pressure to head, suction baby’s mouth, then nostrils (note if fluid in mouth does not appear clear, sign of meconium)

  8. Feel for umbilical cord around neck, remove, and recheck

  9. If unable to lift cord over baby’s head, immediately place two clamps or umbilical ties around the cord about 2 inches apart and cut cord between the clamps

  10. See upper shoulder, gently guide head down slightly to help deliver the shoulders

  11. Support head

  12. Never pull the baby

  13. Once delivered, football hold, suction mouth and nose again, maintain airway

  14. Record time and location

  15. If EMS delayed more than 20 minutes, cut umbilical cord (placement of clamps/ties, where to cut)

  16. Delivery of placenta, spontaneous; never pull on umbilical cord, save placenta, place in plastic bag and send with patient

G. Postdelivery care of mother

  1. Sanitary napkin over the vagina

  2. Massage lower abdomen, contracts uterus and slows vaginal bleeding

  3. Allow newborn to nurse

H. Evacuate mother and baby immediately to medical facility or ALS

  1. Provide supplemental oxygen, Trendelenburg position, monitor vital signs

  2. Do not place anything inside the vagina

IX. Basic care of newborns

A. Vigorously dry off baby; wrap in blanket, towel, or space blanket; cover entire baby except face

B. Assess APGAR score at 1 minute, 5 minutes, and 10 minutes

C. If infant needs resuscitation, do not delay, begin immediately

D. If 5-minute APGAR less than 7, continue to score every 5 minutes for 20 minutes

E. Usually infant vigorously cries within 15–20 seconds, if not use your fingers to flick soles of feet or rub infant’s back

F. If infant does not begin to breathe after 10–15 seconds, begin resuscitation

G. If breathing appears adequate, check pulse (brachial or umbilical cord)

H. If pulse less than 100 beats/minute begin positive pressure ventilations with supplemental oxygen, using infant bag-valve mask at 40–60 breaths/minute, just enough to observe chest rise

I. Reassess pulse after 30 seconds

J. Skin color, cyanosis of face and trunk, blow-by oxygen

K. If cyanosis persists after 30 seconds of blow-by oxygen, provide assisted ventilations

L. If pulse less than 60 or between 60 and 100 beats/min and not rising despite adequate ventilation with supplementary oxygen for 30 seconds, require chest compression

M. Chest compression technique and rate should be performed according to current standards for health professionals as published by approved NSP CPR providers

X. Trauma with pregnancy

A. Most forms of exercise are safe during pregnancy

B. Some positions and movements may be uncomfortable, tiring, or harmful for pregnant women

C. No standard timelines for permissibility of competition during pregnancy

D. Two main risks

  1. Falling

  2. Collisions

E. Indirect blow can be as dangerous as a direct blow

1. Potentially harmful to fetus or mother’s enlarging uterus

F. Three dangerous consequences of fall or collision

  1. Ruptured uterus

  2. Abruptio placentae

  3. Premature labor or rupture of membranes

G. Uterine penetration by a foreign body is possible but rare

H. Abruptio placentae is most common cause of fetal death; result of shearing force when the body stops moving before the internal organs do

  1. Signs and symptoms include vaginal bleeding, abdominal pain, constant uterine contractions, expanding uterine height

I. Uterine rupture is less common

  1. Signs and symptoms include sharp pain following direct trauma to the abdomen

  2. Death is a common outcome of uterine rupture for fetus and can be for the mother as well unless she is able to receive emergent medical care

J. Premature rupture of membranes and possible early labor

  1. Signs and symptoms include leakage of clear or blood-tinged fluid from the vagina

XI. Assessment

A. ABCDs and vital signs


  1. When was last period

  2. When is next period expected

  3. If late for an expected menstrual period, inquire about possible pregnancy

  4. Has patient had a recent pregnancy test

C. If vaginal bleeding:

  1. How many pads or tampons has the patient used in the past 24 hours

  2. Has the patient passed any clots

  3. Has the patient noted any dizziness upon standing

  4. Has the patient received any trauma to the genital area

D. If abdominal pain:

  1. Has the patient experienced this type of pain before (with menstruation or between menses)

  2. Has the patient had any recent vaginal bleeding or spotting

  3. Does the patient have any abnormal vaginal discharge, burning during urination, fever, or back pain

E. If known pregnancy:

  1. When is the expected due date

  2. Has the patient had any prenatal care

  3. Has the patient been pregnant before (if yes, did the patient deliver the baby and were there problems with the delivery)

  4. Does the patient have any prenatal or preexisting medical conditions such as gestational diabetes, high blood pressure, or twins

  5. Has the water broken

  6. Has the patient had any vaginal bleeding since the injury

  7. Has the patient felt the baby move since the injury

F. Exam

  1. Protect privacy

  2. Observe abdomen, noting any distension or discoloration

  3. Have patient use one finger to point to where the pain is most intense

  4. Palpate four quadrants of abdomen and suprapubic region, note if there is tenderness or guarding

  5. No need to examine genital region unless there is history of trauma, ongoing hemorrhage, or impending delivery

  6. Known pregnancy—note if uterus feels tight, as with a contraction or if there is tenderness

  7. If uterus is easily palpable, note if there is fetal movement

XII. Management

A. Most require further medical evaluation by a physician

B. OEC goal is to help patient into comfortable position; in the second or third trimester on patient’s left side

C. Heavy vaginal bleeding, severe abdominal pain, signs or symptoms of shock

  1. High-flow oxygen, rapid transport, monitor vital signs

  2. Position patient on her left side

  3. Anticipate nausea and vomiting

D. Pregnant trauma patient

  1. Standard Precautions, ABCDs, rapid survey, early critical interventions include high-flow oxygen

  2. Spine board needed, tip to patient’s left side

  3. Transport rapidly, EMS

Case Presentation

You are called to the ski school instruction area, where a 26-year-old woman who is observing her toddler in a class has slipped and fallen on hard packed snow. The woman is 34 weeks pregnant and is complaining of severe abdominal pain. Upon your arrival, the woman is lying supine on the snow with both knees flexed. She is awake and oriented, and very worried that her unborn child may have been injured. A ski school instructor witnessed the incident and reports that she fell onto her left side, striking her abdomen. The woman describes her abdominal pain as “sharp” and “all over,” and unlike the labor contractions she had during her first delivery. She does not feel any leakage of fluid and denies feeling lightheaded. She reports that her second pregnancy has been uncomplicated to date, and that a recent ultrasound showed a single male fetus. She denies any injury other than that to her abdomen. As you assess the patient, you notice that her radial pulse is quite weak and seems faster than normal.

What should you do?
Case Update

Recognizing that this woman, who is 34 weeks pregnant, has sustained blunt abdominal trauma, you assess her for additional trauma, including any obvious bleeding, tenderness in the neck, spine, or abdomen, and neurological deficits. You note that the patient’s abdomen is diffusely tender. The uterus rises to about 5 finger widths above the umbilicus and is very firm to the touch. You get assistance in positioning the patient onto her left side and obtain her vital signs. Her blood pressure is 90/60, her pulse is 110, and her respirations are 20 and shallow.

What are the potential consequences of blunt abdominal trauma during pregnancy?

What should you do next?
Case Disposition

After placing your patient on her left side, her pulse rate remains at 110 but is much stronger, and a repeat blood pressure reading is now 105/70. She continues to complain of severe abdominal pain, and reassessment shows her uterus to be continuously firm. You place the patient on high-flow oxygen by nonrebreather mask while arranging emergency transportation to the hospital.

You transport the patient, lying on her left side, by toboggan to the patrol facility, where an ALS ambulance crew is awaiting her arrival. Two days later, the patient’s husband stops by the patrol room to thank you and the other patrollers. He reports that his wife was diagnosed at the hospital with abruptio placentae. She underwent an emergency caesarian section to deliver a 3-pound baby boy who is on a ventilator in the neonatal intensive care unit but is doing well. He tearfully notes that without your prompt care and rapid evacuation, he could have lost not just his wife, but his newborn son as well!

Discussion Points

Have you ever witnessed a live birth? What was it like?

Does your area have an OB kit? Where is it kept? What is included in the kit?

Has there ever been a live birth at your area?

What are some of the accidents that could occur at your area that could result in gynecological trauma?

Are OEC Technicians mandated by law to report suspected sexual assault to law enforcement?

Does your area have a protocol for reporting assaults?

©2012 National Ski Patrol

Outdoor Emergency Care, 5th Ed.

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