EMS DISPATCHING IN OB GYN by fla18057

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									EMS DISPATCHING IN OB & GYN



 240308
  WIMOL
 ABNORMAL VAGINAL BLEEDING

*Active vaginal bleeding need immediate
   evaluation and treatment.

   - pregnancy related.
   - non pregnancy causes
ACUTE COMPLICATIONS OF PREGNANCY

• PROBLEMS IN - Early pregnancy
              - Late pregnancy
Complications in Early Pregnancy

   • Abortion
   • Ectopic pregnancy
   • Molar pregnancy
               ABORTION
          BEFORE 20 ( 28 ) WKS
RISKS - Increase maternal and paternal
         age ( 26 % of maternal age > 40 yrs )
      - Increase parity
      - Increase vaginal bleeding
Clinical features

• Amenorrhea
• Increase bleeding per vagina, clots
• Pelvic pain or cramp
            ASSESSMENT

•   Consciousness
•   Vital signs
•   Amount of vaginal bleeding
•   Tissue from vagina with villi / vesicles
Ectopic pregnancy
  ECTOPIC PREGNANCY
• Implantation of fertilized ovum outside
  uterine cavity
• Leading cause of maternal death in first
  trimester
CLINICAL FEATURES

• Abnormal mens ( few → unaware of
  pregnancy)
• Irregular bleeding → no bleeding
• Pain > no pain
• Palor
• Cold sweating
• syncope
RISKS - History of tubal pregnancy
                    tubal infection
                    tubal surgery
      - IUD insertion
• Vaginal bleeding and pain
  is considered to be ectopic
  pregnancy till to be R / O.
    MANAGEMENT
•   Vital signs assessment
•   Oxygenation
•   Adequate fluid infusion
•   NPO till proven of no surgery needed
•   Blood grouping & X-matching for blood
    transfusion
     MOLAR PREGNANCY

•   Incident : 2 – 3 per 1000 live birth
•   Previous molar pregnancy
•   Maternal age > 35 years
•   Race ?
•   Nutrition ?
      MOLAR PREGNANCY
• Abnormal proliferation of chorionic villi
• Absence of fetal tissue = complete
   hydatidiform mole
  Presence of fetal tissue with trophoblastic
   hyperplasia = incomplete hydatidiform
   mole
• 15 % → neoplastic gestational disease
    Clinical features
• Hyperemesis gravidarum
• Intermittent bleeding or bloody
  discharge per vagina
• FHS – negative in GA. 20 – 28wks
• Passage of grapelike hydatid vesicles
• Uterus size > gestation age
Hydatid vesicles
COMPLICATION of MOLAR PREGNANCY

     •   PIH
     •   Eclampsia
     •   Pulmonary embolism
     •   Liver congestion
COMPLICATIONS OF LATE PREGNANCY


       GA > 20 (28) WEEKS
Vg. Bleeding in late pregnancy

  •   4% of pregnancy
  •   Placenta previa
  •   Abruptio placenta
  •   Uterine rupture
  •   Vasa previa
  •   Postpartum haemorrage
  PLACENTA PREVIA

• Painless
     Or very little pain
• Fresh brisk vaginal bleeding

***NO VAGINAL EXAMINATION
  ABRUPTIO PLACENTA

• Uterine tenderness and cramping.
• Back pain
• Dark variable bleeding.
     (20% no bleeding)
• Fetal distress
 ABRUPTIO PLACENTA
RISKS
    - Advanced maternal age
    - Hypertension ( PIH )
    - Smoking
    - Drugs use
    - Abdominal trauma
         UTERINE RUPTURE
•   Uterine tenderness without contraction
•   Brisk blood per vagina
•   Previous uterine surgery
•   Induction of labour
•   Boggy uterine fundus

           *** URGENT
Uterine rupture in recent pregnancy
            (CT SCAN)
          VASA PREVIA

•   Labor pain
•   Abrupt onset
        + rupture of membrane
•   Bright red bleeding > bloody show
•   Decrease fetal movement
POSTPARTUM HEMORRHAGE

•   Within 24 hrs post delivery
•   Mild pain
•   Fresh bleeding and clots
•   Tender abdomen, uterine atony
•   Pale
•   Decrease BP. Increase pulse
POSTPARTUM HEMORRHAGE-2
 • Extended uterus
      ( eg. Multiple pregnancy)
 • Prolong labor
 • Difficult delivery
 • Vaginal laceration


          ***DIC
NON PREGNANCY CAUSES

   •   Trauma
   •   Neoplasm,polyps
   •   malignancy
   •   DUB
  ABNORMAL VAGINAL BLEEDING

HISTORY
 - Child bearing age → possible pregnancy
    - Past history of vaginal bleeding
    - Recent abnormal period
    - Unprotected SI
    - Symptoms of early pregnancy
ABNORMAL VAGINAL BLEEDING

HISTORY-2
 - Trauma
 - Sexually or body assault
 - Past history of vaginal bleeding
    medical disorder
AVERAGE MENSTRUAL CYCLE

   • Interval 21 – 30 days
   • Duration of 5 – 7 days
   • Amout 35 mls
ABNORMAL VAGINAL BLEEDING
          DUB
• Irregular menstral cycle
      - <25 interval >30 days
      - Metrorrhagia 21 days
      - Menorrhagia
            - Heavy bleeding
            - Duration >7 days
            - > 80 mls per cycle
                  soak pads,clots
 DUB

• 90% related to anovulatory cycle
• Medical complication,
   bleeding disorder
UTERINE DISORDERS
 •   Uterine myoma
 •   Uterine polyps
 •   Carcinoma
 •   Foreign body
 •   IUDs
 •   Infections
   EMERGENCY DELIVERY
ASSESSEMENT
   - Gravidity,parity,abortion
   - LMP, EDC
   - Vaginal discharge: watery or blood
        amount, duration
   - Any illness
   - Consciousness
   - appearance
 CHARACTERISTICS OF LABOR
• TRUE LABOR
    - Regular interval pain
    - Gradually shorten interval
    - Gradually increased pain intensity
    - Vaginal discharge : watery / blood
• FALSE LABOR
    - Irregular interval / intensity
 TO DELIVER OR NOT TO DELIVER

ANY SYMPTOM
    - The uncontrollable urge to push
    - A desire to open her bowel
    - Evidence of “ CROWNING”
         (presenting part on view)

IF YES : Assist with home childbirth
   NO : Transport to LR
NO GO!
       DURING TRANSIT
• Reassure the mother to be
• Position in lateral posture
• Equipments preparation
• Observe - uterine contraction
           - perineum
• Notify to the nearest or ANC hospital
  YES

 HOME
DELIVERY
         HOME DELIVERY
• Position the mother to be supine with Flexed
  knee
• Clean perineum with soap and clean water
• Put sterile/clean towel under her buttocks
• Instruct the mother to breath and push
     until the baby delivered
• Clean the baby‟s face
• Aspirate mouth and nose
      UMBILICAL CORD
• DO NOT PULL THE CORD
• Apply one cord clamp 20 cms. away
  from the NB
• A second clamp 5 cms apart
• Apply antiseptic solution
      HOME DELIVERY - 2
• Record time of delivery
• Check the abdomen of the mother
     To R/O multiple pregnancy
• Check bleeding
• Clean and keep mother and child warm
  and dry
• Assessement of vital signs of mother
     and NB‟s APGAR score
              Score of 0         Score of 1             Score of 2      Component
                                                                        of Acronym
Skin color   blue all over   blue at             no blue cyanosis       Appearance
                             extremities         body and extremities
                                                 pink
 Heart       absent          <100                >100                   Pulse
 rate
Reflex       no response     grimace/feeble      sneeze/cough/pulls     Grimace
irritability to              cry when            away when
             stimulation     stimulated          stimulated
Muscle       none            some flexion        active movement        Activity
 tone
Breathing absent             weak or irregular   strong                 Respiration
          NUCHAL CORD
• Slip the cord over the head of the baby
• Apply two cord clamps and cut
  between
• Instruct the mother to push
• Check Apgar score
• Resuscitate in case of low Apgar score
  and transport
  BREECH PRESENTATION

• DO NOT PULL
• Transport to hospital immediately with
  the mother‟s buttocks and thighs
  elevated
• Delivered by supporting the baby „s
  body slowly pushed down by the
  mother
       PROLASED CORD
• PROM
• Place the mother in prone knee- chest
  position
• Push the presenting part upward
     by inserting fingers in the vagina
• Transport to hospital immediately
PREGNANCY INDUCED HYPERTENSION

Abnormality                mild       severe
Diastolic BP           ≤ 100 mm Hg   ≥100 mm Hg
(proteinuria             trace         ≥2+ )
Headache                   -             +
Visual disturbance         -             +
Upper abdominal pain       -             +
Oliguria                   -             +
IUGR                       -             +
Convulsion                 -             +
RISK FACTORS OF HT DISEASE IN PREGNANCY

  •   Nulliparity
  •   Advanced age
  •   Race, low socioeconomic group
  •   Previous HT (25%)
  •   DM.,obesity,renal disease
  •   Family Hx.
  •   Hydatidiform mole
  •   Multiple pregnancy
COMPLICATION OF HT IN PREGNANCY

• Abruptio placenta
• Preterm, IUGR
• Maternal or fetal death
• Neurological damage from convulsion
     - Cerebral hemorrhage
• DIC
            MANAGEMENT

•   Oxygenation
•   Anticonvulsants, MgSO4
•   Left lateral position
•   Antihypertensive :hydrazine 5 -10 mg IV.
THANK YOU

								
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