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 babys 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 NBs APGAR score

Score of 0
Skin color

Score of 1 blue at extremities <100 grimace/feeble cry when stimulated some flexion weak or irregular

Score of 2 no blue cyanosis body and extremities pink >100 sneeze/cough/pulls away when stimulated active movement strong

Component of Acronym Appearance

blue all over

Heart rate Reflex

absent

Pulse Grimace

no response irritability to stimulation Muscle tone none

Activity Respiration

Breathing absent

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 mothers 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 Diastolic BP (proteinuria Headache Visual disturbance Upper abdominal pain Oliguria IUGR Convulsion mild 100 mm Hg trace severe 100 mm Hg 2+ ) + + + + + +

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