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The main ideas from this information are: - The female reproductive system includes the uterus, ovaries, fallopian tubes, cervix, and vagina. - The ovaries produce eggs and release them during ovulation. - Fertilization occurs in the fallopian tubes and can lead to pregnancy. - The menstrual cycle involves the shedding of the uterine lining if fertilization does not occur. - Gynecological emergencies can be caused by infections, trauma, and sexually transmitted diseases. - Pelvic inflammatory disease (PID) is an infection of the reproductive organs and can lead to complications. - Sexually transmitted diseases like chlamydia, gonorrhea, and syphilis can have serious health effects if left untreated. - Abnormal vaginal bleeding can have various causes and should be evaluated by a healthcare professional. during childbirth and there's a reason that there's a way we can do to kind of help stretch that tissue and is the we have the anus right there and then the clitoris is up in this area like I said not a lot of tissue there not a lot of bleeding can be caused externally not a lot of injury but of course a very painful but emotionally painful condition. So the ovaries are the primary internal female reproductive organ lying in each side of the lower abdomen so the ovaries kind of you've got the the uterus which kind of sits here in the woman's pelvis and the fall of the fallopian tubes come out this way and the ovaries kind of sit right about here almost at the iliac spine which is going to remember we talked about PID pelvic dysplasia. That's one of the ways you can tell that is painful ambulation. We'll talk about that. So the ovaries produce an ovum. There's a follicle in the ovary and the follicle contains an egg and there are millions of follicles in the ovary and each follicle releases an egg after it's been stimulated by the follicular stimulating hormone which happens during the second week of the follicular stimulating hormones releases the follicle releases the ovum. The follicle releases the ovum and the egg. The fallopian tube connects the ovaries to the uterus. The uterus is a muscular organ where the fetus grows. The narrowest part is called the cervix. That's like a sphincter like muscle. It closes and protects the pristine environment of the uterus from the normal flora and fauna of the woman's vagina because there's a normal flora and fauna there but you don't want that to get into the uterus. During pregnancy a mucous plug develops there that increases that seal to ensure that the baby doesn't get an infection. The vagina is the outermost cavity of the woman's reproductive system. This forms the lower part of the birth canal. So this is it right here. So we get up here. This is the fundus of the uterus which may end up right up here during the last trimester of pregnancy. The body of the uterus. This is the cervix and this is the vaginal of the vagina or the birth canal. You see the fallopian tube and then the fembrae which are kind of inside that area and it grabs at the ovum and it pulls in. The ovum is 1,000 times larger than the sperm. So the ovum travels down, the sperm come up. Traveling the fallopian tube, 90% of fertilization happens in the fallopian tube. It's important to realize that scar tissue from things like surgeries, traumas, pelvic inflammatory disease can lead to a blockage in the fallopian tube where the egg doesn't travel down. It gets stuck. But the sperm is like on a moped and it goes right around the traffic and it goes right by that scar tissue and can impregnate that cell. And now you've got a growing fetus in that fallopian tube and then it can rupture after about 10 to 12 weeks. That's the next topic. We talked about the four weeks of the menstrual phase or the menstrual cycle. The first phase is called the proliferative phase. That's where a lining, mucosal lining and tissue and blood vessels build up in the inner wall of the uterus. The uterus is preparing for the egg. The second phase, the second week of the phase, is the proliferative, the ovulation phase. That's where follicular stimulating hormone is released. Stimulates the ovum to release the ovary's follicle to release an egg. And it goes corresponding right to left every other month during the four years. If that egg traveling down gets fertilized, it adheres to the uterine wall and begins a pregnancy. If it does not, it's excreted during the menstrual cycle. The third week of the phase is called the ischemic phase. If there is no pregnancy, chemical change has caused the wall of the uterus to contract. It's such that that mucosal lining and those blood vessels begin to start swapping off. And then that leads to the fourth week, which is the menstrual phase. That's where those tissues and some clots and the egg gets released during the period. And then it starts again with the proliferative phase. Ovulation and menstruation begin at puberty. Onset of menstruation is called menarche. It occurs between 11 and 16. My mother got hers at 9. My ex-wife got hers at 17. So, it can run outside the spectrum. The average is 11 to 16. I think both my daughters got right around the 12 year life. They say the older you are to get it, the older you will be when you lose it. When we continue ovulation and menstruating until menopause, which occurs around 50, again anywhere between 45 and 55, somewhere in there. Each ovary produces an ovum in alternating months. The process of fertilization begins in the vagina where the sperm is deposited. It passes through the uterus, swims up through the prostatic fluid that allows it to swim up where it needs to go. Embryos travel into the uterus, attach to the uterine wall and continue to grow. If fertilization does not occur after about 14 days, the lining of the uterus begins to separate and menstruation occurs. The ovulation and menstruation is controlled by female hormones. So, causes of gynecological emergencies are varied. They range from sexually transmitted diseases to trauma and things like that. Infection, PID, public inflammatory disease, is the infection of the upper organs of reproduction. The uterus, the fallopian tubes, the ovaries. It occurs almost exclusively in sexually active women because of it. The number one cause of PID is the HPV, human papillomavirus. Ladies, it's our gift to you. It's from men to women. And they actually have a vaccine that both men and women can take. So, boys and girls up to the age of 12 usually they give that. It can result in the risk of ectopic pregnancies by scarring, sterility, ovarian cancer, uterine cancer. Most common sign is general lower, generalized lower abdominal pain. So, the patient is going to develop lower abdominal pain along with possible spotting or, you know, polysomal discharge. But during their, that ovulation phase, what happens is during the ovulation phase, that folliculostimulant hormone causes the ovary to swell and becomes very sensitive because it's ready to release that ovum. So, as the patient walks, because that sits on the iliopress, blood moves when I walk, but my pelvis and all the muscles around it. So, walking actually produces pain. It's called painful ambulation. Pain when ambulating and that's a common sign of PID. STDs can be more serious conditions, can lead to more serious conditions such as PID. Chlamydia is the most common STD caused by bacteria. Easily treated with antibiotics, usually mild to absent symptoms. A lot of times women have it, they don't even know it and they give it to men. Men usually will develop a painful urination, foul smelling discharge, that kind of thing with a fever. Can spread to the rectum, it can progress to PID. Bacterial vaginosis, also called a yeast infection. It is the most common cause of, most common, you know, they call it an STD. It's the most common infection in women. It affects women 15 to 44 and it can be any number of things. It's very common in elderly because they, especially those that wear adult briefs because they don't change, the briefs don't change regularly and that allows the bacteria to migrate up. The normal bacteria in vagina replaced by an overgrowth of other bacteria, if untreated, it can lead to premature birth, low birth weight and PID. This is the reason why they stopped the widespread use of douching. Back when I was a kid, I mean, Nasty Gill advertised that all day, every channel, all the time. You don't feel so fresh, Nasty Gill disposable douche. They don't do that now because what happens when you do that is you wash away the healthy bacteria with the bad bacteria and what you end up with is a breeding ground for more bad bacteria. Gonorrhea grows in rapid, it multiplies in warm, moist areas of the reproductive tract. Cervix, uterus, bloating juices in women. Urethra in men and women. If untreated, it can enter the bloodstream and it can actually be very serious. It can actually lead to sepsis, bacteremia. It actually needs to be treated, especially in a pregnant... One thing I will talk about is you never want to deliver a baby to a woman who has an active STD because it can spread to the baby. Another one we talk about is syphilis. Syphilis is a bacteria found in sheep. We will not discuss how it got from sheep to humans. You can think of that yourself. Syphilis is actually an infection that can actually root its way, a bacterial infection, can root its way into the cerebral tissue, into the nerve cells, into the brain tissue and it can actually cause, let's say, insanity that can cause severe dementia. Alcapone died from it. Beirut died from it. It has an active... It has an incubation, an active and a latent phase. The incubation phase is when it develops. You can get it and not know you have it. Then you have the latent phase. You have the infection, usually colostomy, discharge, painful urination, painful sexual encounter, typhoid fever, aches and that kind of thing, body aches, abdominal pain. Then it goes away. It doesn't really go away. Your body heals that, but then that infection starts migrating up your nerve fibers and it ends up in your brain and you literally go insane. And the problem is it can be treated with antibiotics. As long as it's caught. Get a shot, clears right up. Most of your STDs can be cleared up that way. So vaginal bleeding, possible causes, abnormal menstruation. My daughter, God bless her, she gets, my underdaughter, she gets a menstrual cycle. She bleeds and she literally gets dizzy like she's going to pass out, right? So some people have really heavy bleeds. My wife has another one. She gets really heavy menstrual cycles. So it's important to understand and differentiate between is this a normal menstrual cycle or is this something else? Like it's very difficult sometimes for a woman with a heavy menstrual bleed, if she's bleeding non-menstrually, you may not know it because she has a heavy menstrual bleed anyway, the bleeding could be massified. So we have to ask questions. Do you have a normal menstrual cycle? Are you in your menstrual cycle right now? Because if you're not and you're bleeding, that's something different. Vaginal trauma, ectopic pregnancy, spontaneous abortions, we're going to talk about those, cervical polyps and cancer. So getting an accurate and detailed assessment is critical. You'll be able to gain only primary impression of the problem in the field. In other words, we don't have scarabs, speculums, we don't go inside and do internal exams. That's not what we do. As a matter of fact, most of the time, I don't even want to look. I'm going to ask you, do you have any bleeding or injury I need to see? And if you say no, good enough for me, right? Because that's not our job. Our job is to treat and transport. Thorough patient assessment will determine how sick the patient is and whether the life-saving measures are needed. And most of the time, like I said, most times the life-threatening issues are bleeding related. Call ALS. We can give a patient TXA, trans-apnectic acid. That was actually designed, it's originally, medication was designed years ago to treat postpartum bleeding, bleeding after birth. So it's a great for pelvic bleeding. It's a great for reproductive bleeding. It's a great for internal bleeding, but it's specifically designed for that. So see, besides that, make sure the scene is safe. Gynecological emergencies could have a large amount of blood and bodily fluids. They could be potentially infectious, so make sure you're wearing gloves, goggles, masks. Involve police if sexual assault is suspected. If so, try to have a female or try to have an EMT of the same gender if you can. It doesn't always get to work. We don't get to pick the victim. Sometimes I've gone to calls, sexual assault, where there were no females available. That's it. I'm the man. Sometimes the mechanism of injury may be easily understood from dispatch information, such as sexual assault. Sometimes it's not, and sometimes patients don't want to tell you, and so they'll give you some vague explanation, which doesn't make any sense. So you want to form your general patient impression. Is the patient stable or unstable? As a general rule, most of the time, they're going to be stable. These patients are probably going to be walking out to the ambulance. They'll probably meet you outside, or they'll be sitting down in their living room with a backpack. Use the afterscale. Make sure the patient is bleeding. Check the skin. We want to identify and estimate the amount of blood flow. How much blood does a maxi pad hold? About 50 cc. How much does a heavy flow tampon hold? About 30. So if a woman tells you, how many pads do you normally go through, ma'am? I usually have a couple of heavy pads, and then a few light pads. How many have you gone through this time? Oh, I soaked through 10 pads. That's 500 milliliters of blood. That's a half a liter. That's huge. Or if she's gone through 20 tampons, that's 600 milliliters. That's a lot. So ask, is this normal for you? And if it's not, how much more than what you normally get is. Most grad class emergencies are not life-threatening. And again, those that are, will probably have time to shop and transport. Uncontrolled bleeding will be warranted. If a patient has bleeding through their underwear, have the patient take a face cloth or abdominal dressing, a big dressing or towel, put it between her legs. In the underwear or between her legs, close her legs around it, and then raise her buttocks by putting pillows and blankets underneath her buttocks. Raise it up so you can get that kind of raising up, that less blood flow that will travel to that area. Investigate a chief complaint. Some questions are extremely personal, so just ensure the patient's privacy and dignity. Do it in the back of the ambulance, or if you're in a room, get everybody out of the room so that there's minimum number of people in there. And if it's a child, like a female, I always like to have the parents there before I start asking questions, because then the parents won't come up to me afterwards and say, well, what did she say? Well, you were there, so you know. If the patient says to me, I don't want my parents here, well, then I have to honor the child's wishes when it comes to gynecological emergencies. For abdominal pain, ask about the onset, duration, quality, and radiation. What makes it better, what makes it worse? Provocation, palliation. Associated symptoms, things like syncope, lightheadedness, nausea, vomiting, and fever. Nausea, vomiting, and fever are particularly important because what does that signify? Nausea, vomiting, and fever. Infection. Infection, right? For vaginal pain, ask about onset, duration, quantity, and associated symptoms, such as syncope and lightheadedness. If I have a patient with significant blood loss, you know, significant number of ads or tampons used, and they're dizzy, or they had a fickle episode like my daughter does, that's high blood. Ask about birth control or devices, and ask about medical conditions and the last menstrual cycle. We also might ask the gravida parastatus. Gravida, think about gravity, right, or gravity weighing on a belly. Gravida is the number of pregnancies. Para, think of parent, para is the number of live births. And so the gravida parastatus is important for patients with gynecological emergencies, especially OB. We're going to talk about that in the next chapter as well. You could be, you could be premagravida, which is your first pregnancy. You could be nullgravida, never been pregnant, or you could be multigravida, which means you've had multiple pregnancies. You could be nullpara, which means no children, or you could have, you could be multipara, multiple children. So, with that said, is it possible to be gravida 1, is it possible to be nullpara gravida 4? What would that mean? Say it again? No, no, no. No children, but four pregnancies. Nullpara, gravida 4. So, gravida means, you know, no pregnancy, so that's four pregnancies, but no births. Could I be para 4, gravida 1? No. Why not? Because I had pregnancy. Alright. So, just remember the gravida parastatus, because if you're dealing with an OB patient especially, doctors are going to not know the gravida parastatus. You're going to want to know because a prima gravida patient is going to take a lot longer in labor than a multigravida. You could write it that way, but you should write gravida para because you're a medical professional. And you may need, you may, and you will probably see that on the exam. You'll probably have to know the gravida parastatus. Wait, wait, wait. Secondary assessment findings should include vital signs, abdomen, is it distended, is it rigid, tender, any visible bleeding, and your neurological status. And again, I'm not going to do an internal exam. I'm going to ask the patient about their status. Your physical examination should be limited and professional. Only examine the genitalia if necessary to treat the patient. I'm going to ask the patient. Now, if the patient is unresponsive or in active labor, I've got to look. It is what it is. Patients aged 65 may have concerns related to hormonal replacement therapy, cancers, pelvic floor collapse, or urinary incontinence. Do you know what they mean by pelvic floor collapse? A prolapsed uterus. Do you know what that is? The uterus falls out of the vaginal opening. That's when you have like too many babies, right? Well, yeah, a number of different reasons, but that's one of them. Large babies. Can they remove it? No, they can remove it. They usually will excise and then insert it back in. They'll fix it. The pelvic floor, you know, remodeled. But you can also have a rectum. You can have a prolapsed rectum, too. The rectum can come out as well. It's not common, but it's seen more in the elderly. Vaginal bleeding. Visualize the bleeding and ask about the quantity and quality of the bleeding. Use external pads to control bleeding. Observe for vaginal discharge. Syncope, fever, nausea, and vomiting are significant in gynecological emergency. Use it as a sign of infection. Assess all your vital signs. You're going to do your orthostatic vitals. Lie down. Take your blood pressure pulse. Sit up. Wait three to five minutes. Take blood pressure pulse again. If the pulse goes up by more than ten points and the blood pressure drops by more than ten points, the patient is positive for orthostatic vitals. In other words, orthostatic hypertension. They, the body cannot adjust because of the low volume. They're hypovolemic. So they have orthostatic hypertension. You're going to repeat your primary assessment. There are very few interventions. We've got to call it an emergency. Stop the bleeding. Oxygen and transport. It's really all we do. Communicate all relevant information to the hospital. Include the power of gravity status, the possibility of being pregnant. Carefully document everything. If it's a sexual assault patient or the potential for one. You might not know it is one until after. Document your shit out of it. Like diarrhea of the keyboard, diarrhea of the pen. The more documentation you put down, the less likely you are to end up in court. Maintain the patient's privacy as much as possible. Get them out of a public area. Put them in the ambulance. If you're in a room, put a blanket on them. Cover them up. Have a female EMT participate in the patient's care as possible. Use sanitary pads on the external genitalia to absorb blood and document the amount. Never throw anything away. Like if you have bleeding, we usually don't. Like when you go to surgery, if you have surgery, they count the number of gauze, the number of cotton swabs and things like that. They count all that. At the end of the surgery, they'll go and count everything to make sure they didn't leave anything in. You're going to save it and count it because it's going to give you an idea of the amount of bleeding. You clean up after the ambulance, after the call, so that you can give a good idea as to the amount of bleeding that was involved. External genitals have a rich nerve supply. It makes injuries very painful, both physically and emotionally painful. Treat external lacerations with moist sterile dressings. Again, any mucosal tissue that's injured, moist sterile dressings. Never pack or place anything inside the vagina. PID, a patient with PID will complain of abdominal pain. Usually starts during or after menstruation. Made worse by walking that painful ambulation, especially during that ovulation phase. Pre-hospital treatment is limited. There's not much we can do. We can make you feel comfortable, transport you to the hospital, maybe give you some oxygen. But other than that, you need antibiotics. That's what you need. Maybe some IV fluids. Usually we transport without lights and sirens. You can go with traffic. Sexual assault and rape are common. We've covered these already. One in five women have reported being raped. One in three sexually molested. EMTs treating sexual assault victims face many complex issues. You may be the first. I have been the first person on scene to rape sexual assault. So your interaction with that patient, the way you treat that patient, your empathy, your caring, your understanding, your being a patient advocate will go a long way to get that, to begin the healing process. And you give that patient the confidence and the courage to continue with the rape kit collection and the evidence collection and the questioning and the treatment at the hospital. It's a very personal, very emotional thing. And this patient is going to need that confidence and they're going to need that courage. Your treatment of them will go a long way in giving them that. You may be the first person. Again, like I said, professionalism, tact, kindness, and simplicity are paramount. Be aware of drugs that are used to facilitate. Like I told you, I've gone to the patients who all, you know, ETOH. We arrive on scene, I don't smell any alcohol, and the patient's confused and they're like, I just woke up on this bed, these aren't my pants, or my bra's on backwards, or something like that. All right, this is no more an ETOH deal. What's going on here? If possible, give the patient an option of being treated by a female EMT if you can. Don't offer it if you can't. Don't say, do you want a female EMT? Let me call. Call first. Don't offer it if you can't. Provide medical treatment to the patient. Offer psychological care. Preserve evidence. Do the best you can to preserve evidence. Wrap the patient up in a sheet, just as they are. Don't let them change, take a shower, brush their teeth, defecate, urinate, whatever. Wrap them up just as they are in the sheet. That sheet, when you open it up, clean, got nothing on it. So the only thing that'll be in the patient and the perpetrator. Get a good history and produce a patient care report. Make it well-documented. Remember, your job, you're not an investigatory body. You're not investigating the what, the when, the where, the how. That's not what you want. Your job is to focus on patient care. Now, if the patient should give you evidence, if they start talking to you about things, who did it, why it happened, whatever, you are responsible to tell that to law enforcement. Even if the patient says to you, don't tell anybody, but I want to tell you, but I want to tell you. Okay, but I want to tell somebody anyway. Principle treatments for sexual assault. I'm not going to read through this because I've already mentioned these a dozen times, but 44-1, I want you to be good and kind of familiarize, reorientate yourself to the things that I've said. If someone were to say, don't tell anybody, but I want to tell you, you'd have to tell them No. You can lie through your teeth. In law enforcement, it is okay to lie in law enforcement. Police officers lie all the time. And that's okay, you can do that. Because my ultimate goal is to get you to the hospital and get you the treatment you need. What is the narrowest portion of the uterus? Feet. Feet, certainly. What is the outermost cavity of the woman's reproductive system? Feet. Feet. Feet in the vagina. The flower. If fertilization has not occurred within blank days following ovulation, the lining of the uterus begins to separate and menstruation occurs. Feet. Feet. Feet. Two sevens. Feet. Feet. Fourteen. The onset of menstruation is called? Menarche. Menarche. Menarche. I guess I'd say menarche. I don't know. Nobody ever told me I had a menarche, but I'd say menarche. Sounds frank. Which of the following can cause vaginal bleeding? All of the above. So let's read them. True. All of the above. Ectopic pregnancy, spontaneous abortions, and trauma. What is the most common presenting sign of PIE? Lower abdominal cavity. When obtaining a sample history, which of the following pieces of information is important to obtain? Last pit and last menstrual. Well, yeah, all of the above. All of the above. But let's read them. Do you use birth control devices or birth control pills? The date of your last menstrual cycle, period, possibility of pregnancy, among other questions. What is the ENT's first priority when dealing with a patient experiencing excessive vaginal movement? Pain. Treat for shock and transport. Absolutely. Most important thing to do. Which of the following drugs is commonly used to facilitate sexual assault? Pain. Ropinol. Ropinol. It's called Rupes. But you also, Versed is used too. Versed? Versed. How do people get a hold of that? Versed? People get a hold of it. Because that's a sedative, right? It's a sedative. It's a hypnotic anesiatic. So it sedates you and gives you anesia. What is Rupes called? Ropinol? Ropinol. You should discourage a rape or sexual assault victim from doing which of the following? All of these. Urinating, cleaning themselves, changing their clothes, brushing their teeth, all of that stuff. Any questions on any of that? Can you just tell me that prolapse thing again? Prolapse rectum? No, no, before that. Prolapse uterus? Yeah. That's what they call pelvic floor collapse. Thank you. Pelvic floor collapse.