Reproductive Emergencies, Pregnancy & Birth

What is Testicular Torsion

Twisting of spermatic cord causing testicular ischemia

- the only male reproductive emergency

Testicular Torsion Demographic

Majority of cases occur in younger patients (<25 years old)

- caused by congenital abnormalities

Testicular Torsion Onset

History of onset may be spontaneous, exertional, or associated with trauma (rare)

Testicular Torsion Signs & Symptoms

- abrupt onset of unilateral scrotal pain

- pain can be intermittent or constant

- scrotal swelling

- testicle may be in abnormal or high position

- can have referred pain into abdomen

- nausea/vomiting

Testicular Torsion Management

- consider patient privacy

- visualize area - typically, no need to palpate area

- place patient on stretcher in position of comfort

- consider symptom relief and pain management: acetaminophen, ibuprofen, ketorolac, ondansetron/Gravol

- if patient is young, consider patching to BHP for orders

What is Pelvic Inflammatory Disease (PID) & What causes it?

Infection of female upper genital tract

Majority of cases are causes by sexually transmitted infections (i.e., gonorrhea, chlamydia), but other causes:

- UTI

- ectopic pregnancy

- sepsis

- endometritis

Pelvic Inflammatory Disease (PID) Signs & Symptoms

- lower abdominal pain

- genital tenderness

- fever

- vaginal discharge

- inability to get comfortable (the PID shuffle)

Pelvic Inflammatory Disease (PID) Management

- supportive care

- transport patient in position of comfort

- pain management

What is Endometriosis?

Inflammation of tissues of the uterus along with endometrial tissue growing outside uterus

- tissue typically ends in ovaries and results in development of cysts

- can also be found in fallopian tubes, GI tract, uterosacral ligaments

Endometriosis Signs & Symptoms

- severe abdominal pain most common during menstrual cycle, usually characterized as chronic, cyclic, and progressive

- vaginal bleeding

- impaired fertility

Endometriosis Management

- supportive care

- place patient into position of comfort

- consider extra padding on stretcher is vaginal bleeding present

- pain management

What is an Ovarion Cyst (& Prevalence)

As a result of ovulation, ovaries can develop fluid-filled sacs known as cysts

- about 20% of women will develop a cyst in their lifetime

- in women of reproductive age, most ovarian cysts are benign and do not require intervention

- at times, sacs can rupture and cause severe bleeding and pain

Risk Factors for Ovarian Cyst

- infertility treatment

- pregnancy

- smoking

- tubal ligation

Ruptured Ovarian Cyst Signs & Symptoms

- sudden, severe lower abdominal pain

- pain can be localized to left or right abdominal quadrant

- can be more painful during menstrual cycle

- nausea/vomiting

Ruptured Ovarian Cyst Management

- keep patient in position of comfort

- consider pain management

- supportive care as required

What is an Ectopic Pregnancy

Implantation of a fertilized egg anywhere except the uterus

- frequently implanted in fallopian tubes

- can also be implanted in ovary, peritoneal cavity, or cervix

- all ectopic pregnancies are considered non-viable

Ectopic Pregnancy Signs & Symptoms

- missed or irregular menstrual cycles

- severe pain in lower abdomen

- vaginal bleeding can be present

- signs of hemorrhagic shocks (hypotension + tachycardia)

Ectopic Pregnancy Management

- primary interventions as required

- treatment of shoch states if present

- consider patching for TXA

- position patient supine on stretcher if patient is hypotensive

- consider pain management: if you believe patient is experiencing an ectopic pregnancy, they are contraindicated for ketorolac and ibuprofen

Considerations for Maternal Medical Cardiac Arrest

- transport after a minimum of one analysis

- pregnancy presumed to be >20 weeks' gestation cannot be TOR-ed under the medical cardiac arrest standard

- manual uterine displacement - push patient's belly to the left side of their body in order to decrease pressure on vena cava

Considerations for Traumatic Maternal Cardiac Arrest

- perform cardiac arrest management per BLS/ALS

- perform manual uterine displacement

- notify receiving hospital ASAP (allows for preparation for emergency C-section on arrival)

- trauma TOR - can be considered, not technically contraindicated

- during patch to BHP, explain patient is pregnant and discuss benefits of transport

Why are pregnant patients more at risk of trauma?

Pregnant patients are more at risk of trauma due to fainting spells, hyperventilation, hypotension, fatigue, or changes in balance/coordination

Risks following Blunt Trauma for Pregnant Women

- premature labour

- spontaneous abortion

- placental abruption

- ruptured diaphragm

- liver, spleen, or uterine rupture

Physiologic Changes during Pregnancy

Blood volume increased 40-50%

HR increased 10-15%

BP decreased 5-15mmHg

CO increased 20-30%

RR increased 40-50%

Hypovolemia in Pregnancy

Body has mechanisms to protect maternal life, sometimes at risk of fetus

- reduction in uterine blood flow

- fetal HR decreases due to lack of oxygen

Maternal hypovolemic shock has an 80% fetal mortality rate

·Primip vs Multip

Primip - woman during her first delivery

Multip - woman who has previously delivered a baby

Assessing Contractions

Interval - time from beginning of one contraction to beginning of next

Duration - time from beginning to end of one contraction

Regularity - predictable or random

Intensity - strength of contraction and assessment of resting tone

Measuring Fundal Height

Used to calculate age/due date

- nine months plus one week from first day of last menstrual cycle

- at about 20 weeks, fundus sits at umbilicus

- peak fundal height at around 36 weeks (rib cage)

GTPAL

G - gravida (pregnancies to date)

T - term (deliveries at or beyond 38 weeks)

P - premature (deliveries at <37 completed weeks)

A - abortions (spontaneous or therapeutics)

L - living (number of living offspring)

Signs of Imminent Birth

- uncontrolled urge to bear down

- rectal pressure of need for bowel movement

- bulging perineum

- bloody show

- mother saying the baby is coming

- fetal presentation

- contractions: (primip = contractions every 2-3 minutes; multip = contractions every 5 minutes or less)

What is a precipitous birth?

Extremely rapid delivery

- defined as birth of baby less than 3 hours of commencement of regular contractions

Risk associated with precipitous birth

Increase in degree of perineal lacerations and post-partum hemorrhage

Stages of Labour

Stage 1 = dilation

Stage 2 = delivery of newborn

Stage 3 = delivery of placenta

Stages of Delivery

1 = descent

2 = flexion of head

3 = internal rotation of head

4 = extension of head

5 = external rotation of head (restitution)

6 = birth

Observations of Placental Delivery Imminent

- lengthening of cord

- sudden gush/trickle of blood from vagina

- uterine contractions

When to Transport (Not Wait for Delivery)

If delivery has not occurred within 10 minutes of initial assessment, ALS recommends that paramedics consider transport

Other findings to move out:

- lack of progress - birth is no longer imminent/after 10 minutes

- multiple gestation pregnancy - twins or more expected

- neonate presents face up - OP presentation

- preeclampsia - BP >140/90

- presence of vaginal hemorrhage - antepartum o

- preterm labour - labour <37 weeks' gestation

- primip - first birth

Oxytocin: Indications

Post-partum hemorrhage

Oxytocin: Conditions

- SBP <160mmHg

- postpartum delivery and/or placental delivery

Oxytocin: Contraindications

- allergy or sensitivity

- undelivered fetus

- suspected or known pre-eclampsia with current pregnancy

- eclampsia (seizures) with current pregnancy

- >4 hours post-placental delivery

Oxytocin: Dose

Single dose of 10 units delivered IM

Post-Birth Management

- encourage skin-to-skin contact for mother and baby

- monitor vitals for both patients

- assess baby's APGAR score at 1 and 5 minutes post-birth

- ensure baby is kept warm

- ask mother if she would like to breastfeed

- transport to hospital

Special Considerations for Twins

- often associated with smaller birth weights

- 37 weeks is full-term for twin pregnancies, but many are born before

- one twin is breech due to positioning in uterus

- umbilical cord for twin 1 must be clamped immediately after birth

- sometimes twins share same placenta and there can be blood transferred from one twin to the other after delivery if cord is not clamped

Management of Twins

- immediately clamp and cut cord after initial twin delivery

- mean interval between 1st and 2nd twin is 17-21 minutes

- attempt to identify twin A and twin B cords/placentas with each different type of clamp or identify

APGAR: First A

Appearance (Skin Colour)

0 = body and extremities blue, pale

1 = body pink, extremities blue

2 = completely pink

APGAR: P

Pulse

0 = absent

1 = below 100bpm

2 = above 100bpm

APGAR: G

Grimace

0 = no response

1 = grimace

2 = cough, sneeze, cry

APGAR: Second A

Activity (muscle tone)

0 = limp

1 = some flexion of extremities

2 = active motion

APGAR: R

Respiratory Effort

0 = absent

1 = slow and irregular

2 = strong cry

Spontaneous Abortion

Loss of pregnancy less than 20 weeks' gestation

- as many as 26% of all pregnancies end in miscarriage and up to 10% of clinically recognized pregnancies

- risk decreases after 12 weeks' gestation

- miscarriage is loss of pregnancy after 20 weeks

Threatened vs Expected Abortion

Threatened abortion - vaginal bleeding with viable fetus found on ultrasound

Expected abortion - vaginal bleeding with opening of cervix

Placenta Previa

Low-lying placenta that partially or completely covers uterus opening

- major risk factor for postpartum hemorrhage

- can be spontaneously fixed later in pregnancy when uterus physically moves away from cervix and unfolds, pulling placenta away from cervix

Placenta Previa S/S

- bright red vaginal bleeding that is painless

- can be light, moderate, or profuse bleeding

- can cause bleeding during labour

- recent sexual intercourse can trigger bleeding

Placenta Previa: Risk Factors

- advanced maternal age (35+)

- multiparity

- history of c-section or placenta previa

- smoking or cocaine use

- assisted reproductive technology

Placenta Abruption

Separation of a normally implanted placenta >20 weeks' gestation

- bleeding from spiral arteries rupturing, then can push placenta off enough so blood exits through vagina

Placenta Abruption: Signs & Symptoms

- painful cramping or abdominal pain with vaginal bleeding

- dark red blood

Placenta Abruption: Risk Factors

- maternal HTN

- pre-eclampsia

- multip

- patient has sustained recent traumatic injuries

- previous history

Gestational Diabetes

Diabetes that develops during pregnancy

- often affects those who are pre-diabetic before pregnancy

- litmus test for mother developing Type 2 Diabetes

Gestational Diabetes Risks to Baby

1) Patient's fetus is usually large

- increases chance of shoulder dystocia occurring

- concern is baby gets too much glucose

2) When fetus is born, it is typically hypoglycemic

Pre-Eclampsia

Disease of unknown origin that usually occurs after 20 weeks' gestation

- signs and symptoms do not start to resolve until after delivery

Pre-Eclampsia: Signs & Symptoms

- HTN (>140/90)

- generalized edema (face, arms, legs)

- headache

- visual disturbances (due to pressure on optic nerve)

- nausea

- fatigue

- rapid weight gain (from swelling)

- abdominal pain

Eclampsia Signs & Symptoms

- all of pre-eclampsia

- seizures (typically status or frequently occurring)

- coma

- stroke symptoms

Transverse Lie Fetal Presentation

Position of the fetus in uterus along long axis

- baby cannot deliver this way

- discourage patient from pushing

- cover limb with dry sheet to maintain warmth

Cord Prolapse

Cord presents first into vaginal canal

- patient may state they feel something falling out of them

Cord Prolapse is more common in...

- breech birth

- twins

- placenta previa - base of cord is lower than normal due to lower sitting placenta

Cord Prolapse Risk Factors

- high or ill-fitting head or other presenting part (if membranes rupture when presenting part is high, the cord may slip in front of the presenting part)

- malpresentation

- LBW or preterm labour

- polyhydramnios

- multiple pregnancy

Cord Prolapse Management

- manual elevation of presenting fetal part off the cord is lifesaving to maintain oxygen flow through the cord to fetus

- move patient into a knees to chest position, or exaggerated Sims position

- calm, concise discussion with mother regarding risks to baby and herself, and need to perform next task

- in order to apply sufficient force, may need to place your hand into vagina

Cord Prolapse Management: Strong vs Weak Cord Pulse

Strong - direct patient to replace cord into vagina

- if patient refuses, position them into exaggerated sims

- minimize handling of cord and keep patient warm

Weak - cradle cord in gloved hand and replace cord into vagina

- may need to use hand to lift fetal body part compressing cord to restore a strong pulse

Types of Positions of Baby

Cephalic - normal position, head down facing towards the back

Occiput position - head down, but facing forward (longer and more painful labour)

Breech - baby is head up and both legs out

Transverse - baby is horizontal in uterus

When to Assess Perineum

- mother states she feels something between her legs

- ruptured membranes

- near term and decreased LOC

- heavy vaginal bleeding

- urge to push, bear down, or have a bowel movement

- saying 'the baby is coming'

Shoulder Dystocia

Uncommon occurrence where the anterior shoulder gets stuck on the pubic symphysis

Shoulder Dystocia: Signs & Symptoms

- head seems to be progressing very slowly with chin getting stuck

- once the head is born, it retracts against perineum (Turtle sign)

- labour does not seem to be progressing despite strong contractions

Shoulder Dystocia: Risk Factors

- increased birth weight

- pregestational or gestational diabetes

- prior history of shoulder dystocia

- maternal obesity

Shoulder Dystocia: Associated Complications

Fetus - clavicular or humoral fractures, brachial plexus injuries, hypoxia and asphyxia, death

Mom - postpartum hemorrhage, severe tissue lacerations

Shoulder Dystocia: Identification

- fetal head emerges, then chin has difficulty sliding over perineum

- turtling - repeated withdrawal of head after emerging from vagina

- restitution rarely takes place spontaneously

- cyanosis of fetal head

- should be considered when patient's expulsive effort and typical maneuvers used by paramedic fail to deliver shoulders

Shoulder Dystocia: Management

ALARM

- only have 8 minutes once identified before transport

- one partner goes for 4 minutes (2 minutes of McRoberts, 2 of Gaskins), then other partner goes for 4 minutes (2 minutes of McRoberts, 2 of Gaskins)

Shoulder Dystocia: Steps of Alarm

A - Ask for help (need two people)

L - lift legs (McRoberts Maneuver)

- opens up pelvic girdle to make more space

- assist patient to lay flat on firm surface or edge of bed

- hyperflex patient's thighs into squatting position

- best done by 2 people

A - adduct baby's shoulder (Suprapubic pressure)

- take heel of hand, put above symphysis pubis, and use body weight to compress shoulder, push it down and slide out

R - roll over (Gaskins Maneuver)

- assist quick position change

- guide patient onto hands and knees

- shoulder may dislodge with this change in position

- paramedic will apply upward lateral flexion of the head to facilitate delivery of body

M - manual delivery of posterior arm

- if hand is visible, follow humerus and sweep arm across fetal chest and out to deliver

Breech Birth

Occurs when breech of the fetus (buttocks) enters pelvis instead of the head, and is the first part of the fetus to emerge at birth

- only two foot or bum first are able to be delivered in pre-hospital environment

Breech Birth: Observations

- fresh dark meconium visible at perineum

- butt/foot/legs may be visible with contraction

Breech Birth: Risk Factors

- polyhydramnios

- oligohydramnios

- previous breech

- uterine anomalies

- prematurity

- multiple pregnancies

- low-lying placenta/placenta previa

- congenital anomalies

Breech Birth: Management

- position patient in birthing position close to an edge

- let gravity do works and use hands off approach

- once fetus is delivered to umbilicus, you want to start a timer for 3 minutes

- once hairline is visible, get ready to catch the fetus

- if labour does not progress after 3 minutes of delivering the umbilicus, attempt MSV maneuver to finish delivery

Breech Birth: Delivery

- do not pull or intervene if there is progress

- allow baby to deliver/descend with gravity

- gently sweep arms or legs as needed

- once umbilicus is delivered, allow rest of the body to deliver with gravity, until hairline is delivered

Breech Birth: Mauriceau Smellie-Veit Maneuver

- lie baby along your forearm with palm supporting chest

- place 2 fingers against malar (cheek) bones exerting pressure to increase flexion

- place other hand over baby's back with two fingers hooked over the shoulders and middle finger pushing up on the occiput to aid in flexion

Nuchal Cord

Occurs when umbilical cord becomes wrapped around fetal neck 360 degrees

- cccurs in about 10-29% of fetuses

- incidence increases with advancing gestational age

Nuchal Cord: S/S

Infants with a tight nuchal cord may develop S/S due to impedance of blood flow caused by compression of the cord:

- hypovolemia

- hypotension

- decreased perfusion

- mild respiratory distress

Nuchal Cord: Management

- during delivery, attempt to slip cord over the head from around the neck once enough of the head is delivered or down over shoulders

- if the cord is tight and cannot be slipped over the head, the cord should be clamped and cut at this time

- once cord is clamped and cut, finish delivery of the fetus

- may have to use somersault technique

Nuchal Cord: Complications for Baby

- umbilical cord knots

- developmental delays

- decreased amounts of amniotic fluid

- decreased fetal movement

- longer gestation periods

- intrauterine growth restriction (IUGR) - baby's growth is restricted in utero, so it may be underdeveloped for gestational age

- anemia

- low levels of circulating blood (hypovolemia)

- high levels of blood acid (metabolic acidosis)

- stillbirth

Risks Associated with Preterm Labour

- anatomically and physiologically immature

- heat loss

- tissues can be more easily damaged due to O2

- weak muscles = issues with breathing

- immature lungs - deficient in surfactant

- fragile capillaries prone to rupture

- small blood volume

- weak immune system

Priorities with Preterm Labour

1) Prevent hypothermia

- skin to skin with parent

- warm blanket

- hat

- increase temperature in space

2) Manage airway

- appropriate mask and BVM

- SpO2 may be low, but rise

Plastic Bags for Premature Babies

- premature infants have even harder time maintaining heat

- studies show plastic bag can help maintain body temperatures for 1-2 hours following delivery

- food grade plastic bag up to patient's neck

- easily potable during transportation

- explain to parents what is happening and why

Stillbirth or Miscarriage

- delivery of fetus less than 20 weeks is considered not viable

- if not certain of gestational age, assess to see if they have fully formed mouth and nose

- if eyes are still fused, baby is generally not viable

- no NRP will be performed

- can be very emotional for parents