OB/GYN

Rapid Review

• Background
  • Common techniques for incision and drainage of bartholin gland abscesses include marsupialization and fistulization with word catheter
• Indications
  • Symptomatic abscesses that are at least 1 cm in diameter
• Contraindications
  • No absolute contraindications. Relative contraindications include complex abscesses requiring general anesthesia.
• Complications
  • Recurrence (30%), bleeding, infection.

Pearls

• Keep the incision posterior to the labia minora to prevent any noticeable scarring.
• Word catheter’s can be inserted after drainage to reduce the rates of recurrence, though they will need to stay in for at least 2-4 weeks. Keep the initial incision small so that the Word catheter does not fall out. 

Deep Dive

• What’s the Word on Word Catheters? (First 10 EM)

Rapid Review

• Background
  • Uncomplicated, vaginal delivery of full-term (37-42 week) newborn. Represents the majority of births across the world.
• Indications
  • Spontaneous labor mediated by hormone cascade or induction; rupture of amniotic/chorionic membranes.
• Contraindications
  • Prolapsed cord, face/breech presentation, abnormal fetal heart patterns (bradycardia/tachycardia)
• Complications
  • Premature rupture of membranes, failure to progress, postpartum hemorrhage

Pearls

• Once the head presents itself, check immediately for a nuchal cord and reduce as needed. If unable to pull the cord over the infant’s head, clamp/cut the cord once the infant’s face is cleared from the perineum. 
• Newborns can be very slippery post-delivery. Hold them close to your body to avoid dropping them. Do not clamp the umbilical cord until at least 30-60 seconds after delivery.

Deep Dive

• Emergency Delivery (International Emergency Medicine Education Project)

Rapid Review

• Background
  • Speculum examination of the vaginal walls and cervix, as well as a bimanual examination to evaluate the cervical os and evaluate for adnexal masses 
• Indications
  • Vaginal bleeding (if hemodynamically unstable)
  • Acute urinary retention (evaluate for prolapsed organ)
• Contraindications
  • Lack of consent
• Complications:
  • Anxiety, pain

Pearls

• Pelvic exams can be extremely uncomfortable for women, especially if they have any history of sexual assault. Go slow, communicate, and consider pre-treatment with a short-acting benzodiazepine for anxiolysis if needed.
• If you don’t have a bed with foot rests, rotate the speculum handle towards the ceiling instead of the floor.

Deep Dive

• Speculations on the Speculum. Is a Pelvic Exam Ever Needed in the ED? (emDocs)

Rapid Review

• Background
  • Previously known as “perimortem cesarean section”. Involves delivering a fetus from a gravid mother through an abdominal incision during or after maternal cardiopulmonary arrest. Potentially life-saving for both the mother and the fetus.
• Indications
  • Maternal cardiac arrest w/o ROSC within 4 minutes
• Contraindications
  • Gestational age < 24 weeks, ROSC within 4 minutes
• Complications
  • Fetal injury, hemorrhagic shock

Pearls

• Chest compressions should continue during this procedure as long as it can be accomplished safely.
• If the placenta is encountered when entering the uterus, incise through it.

Deep Dive

• Perimortem C-Section (EM Cases)

Rapid Review

• Background
  • Shoulder dystocia occurs when one or both shoulders become impacted against the bones of the maternal pelvis, preventing vaginal delivery. Management techniques include the McRobert’s, Rubin, Jacquemier, and Woods maneuvers.
• Indications
  • Any clinically significant shoulder dystocia
• Contraindications
  • Fundal pressure, strong lateral traction, and head rotation beyond 90 degrees should be avoided.
• Complications
  • Clavicle fracture, brachial plexus injury

Pearls

• For a step-wise approach to shoulder dystocia, you can use the “ALARMER” mnemonic (Ask for help, Legs to chest, Anterior shoulder disimpaction by suprapubic pressure, Release posterior shoulder, Maneuver of wood, Episiotomy, Roll on all fours)
• If conservative measures fail, fracture the baby’s clavicles with direct pressure over the middle of the clavicle to facilitate easier passage.

Deep Dive

• Shoulder Dystocia (Core EM)