GYNECOLOGY

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Topics
Anatomy and Physiology of the
Female Reproductive Organs
The Menstrual Cycle
Assessment of the Gynecological
Patient
Management of Gynecological
Emergencies
Specific Gynecological Emergencies
Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical
2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy and
Physiology

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy and Physiology of the

Female Reproductive Organs
External Genitalia
Internal Genitalia

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

External Genitalia
Perineum
Muscular tissue that
separates the vagina and
the anus.

Mons Pubis
Fatty layer of tissue over
the pubic symphysis.

Labia
Structures that protect the
vagina and the urethra.

Clitoris
Vascular erectile tissue
that lies anterior to the
labia minora.

Urethra
Drains the urinary bladder.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Internal Genitalia
Vagina
Female organ of
copulation.
Birth canal.
Outlet for menstruation.

Uterus
Site of fetal
development.

Fallopian Tubes
Transports the egg from
the ovary to the uterus.
Fertilization usually
occurs here.

Ovaries
Primary female gonads.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

The Menstrual Cycle

Monthly hormonal cycle, usually 28
days.
Prepares the uterus to receive a
fertilized egg.
The onset of menses, known as
menarche, usually occurs between the
ages of 10 and 14.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Phases of the
Menstrual Cycle
The Proliferative Phase
The Secretory Phase
The Ischemic Phase
The Menstrual Phase

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Proliferative Phase
This is the first two weeks of the menstrual cycle.
Estrogen causes the uterine lining to thicken and
become engorged with blood.
Secretion of LH day 14: ovulation takes place.
If the egg is not fertilized, menstruation takes place.
If the egg is fertilized, the corpus luteum produces
progesterone until the placenta takes over.
Cilia sweep the egg toward the uterus.
A fertilized egg normally implants in the lining of the
uterus.
If the egg is not fertilized, it is expelled from the
uterine cavity.
Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical
2006 by Pearson Education, Inc. Upper Saddle River, NJ

Secretory Phase
The secretory phase is referred to as
ovulation.
Progesterone increases and estrogen
drops if the egg is not fertilized.
The uterus becomes more vascular in
preparation for implantation of a
fertilized egg.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

The Ischemic Phase

Estrogen and progesterone levels fall
without fertilization.
The endometrium breaks down.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

The Menstrual Phase

The Menstrual Cycle
Premenstrual Syndrome
Menopause

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment of the
Gynecological Patient

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

History
Initial AssessmentSAMPLE.
Does the patient complain of pain?
Use OPQRST.
Dysmenorrhea/dyspareunia

Associated signs or symptoms.

Has she ever been pregnant?
Gravida/parity/abortion

Document last menstrual cycle.

MedicationsContraceptives.
Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical
2006 by Pearson Education, Inc. Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Physical Exam
Respect patients privacy.
Be professional.
Explain procedures.
Observe patient.
Check vital signs.
Assess bleeding or discharge: Do not
perform an internal vaginal exam in the field.
Abdominal examination.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Management of Gynecological
Emergencies
General management of gynecological
emergencies is focused on supportive
care.
Do not pack dressings in the vagina.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Specific Gynecological
Emergencies
Medical and Trauma

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Medical Gynecological
Emergencies
Gynecological Abdominal Pain

Pelvic Inflammatory Disease

Ruptured Ovarian Cyst
Cystitis
Mittelschmerz
Endometriosis
Ectopic Pregnancy

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Management of Gynecological
Abdominal Pain
Make the patient comfortable and
transport.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Vaginal Bleeding
Nontraumatic
Menorrhagia
Spontaneous Abortion

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Treatment for Vaginal Bleeding

Do not pack vagina.
Transport.
Initiate oxygen and IV access based
on patient condition.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Traumatic Gynecological
Emergencies
Causes of Gynecological Trauma

Blunt Trauma
Sexual Assault
Blunt force to Lower Abdomen
Foreign Bodies Inserted in Vagina
Abortion Attempts

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Management of
Gynecological Trauma
Apply direct pressure over laceration.
Apply cold pack to hematoma.
Establish IV if patient is severe.
Transport.

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Dispatch Information
Its 0345 hrs, and you and your partner
are dispatched to a college dormitory for
a reported intoxicated person.
Upon arrival, you note that there are
three first responders from the university
volunteer ambulance squad, two
members of campus security, and two
police officers in the room.
2007 by Pearson Education, Inc.
Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Dispatch Information

Photo 1.5-1

2007 by Pearson Education, Inc.

Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Initial Assessment
You are presented
with a 19 y/o
female, conscious
and alert, though
lethargic.

2007 by Pearson Education, Inc.

Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Initial Assessment
You note that she is crying and overhear
her angrily tell the male EMT who is
interviewing her, I dont know who he
was, and I would not have had sex with
him if I knew what I was doing!

2007 by Pearson Education, Inc.

Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Discussion
What are your concerns at this point?
What would you do to change the
dynamics of this situation?
Why is it important to change the
atmosphere that exists?

2007 by Pearson Education, Inc.

Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment
Being female, you tell
your partner, Ill
handle this one.
As you introduce
yourself to the patient,
your partner quietly
suggests that
everyone except one
member each from
security, police, and
EMS exit the room to
give the patient some
privacy.
2007 by Pearson Education, Inc.
Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment
The patient is conscious, alert, and oriented
and tells you that

She went to a party around 4 p.m.

She met a guy who gave her two beers.
She felt way too drunk after the two beers.
She and the male returned to her room about
5:30 p.m.
She woke up, unclothed, about 3 a.m., unable to
remember anything, but she can tell that I had
sex.
She dressed herself in clean clothes.
2007 by Pearson Education, Inc.
Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment
The patient denies any
pain, difficulty
breathing, dizziness, or
nausea but states that
she feels groggy.
When asked if she was
physically injured, she
replies No, and
states, I even looked
down there, and Im not
bruised or bleeding.

2007 by Pearson Education, Inc.

Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment
Vital signs
HR = 82
regular
RR = 12
regular
BP = 116/78
SpO2 = 97%
on room air

2007 by Pearson Education, Inc.

Pearson Prentice Hall, Upper Saddle River, NJ

Photo 1.5-5

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Discussion
With the information provided, is a
detailed physical exam necessary?
Why or why not?
If an exam is necessary, how thorough
should it be?

2007 by Pearson Education, Inc.

Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Assessment
Based on your initial assessment findings,
the patients history of the event, and your
gut impression, you decide that foregoing
a detailed ongoing assessment would be
appropriate.

2007 by Pearson Education, Inc.

Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Treatment
After confirming with
the police officer that it
is okay to transport at
this time, you ask the
patient if she would like
transport to the ED for
evaluation, which she
accepts.
The patient asks if she
can shower and brush
her teeth before
leaving.
2007 by Pearson Education, Inc.
Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Discussion
What concerns must be addressed with
regard to the preservation of evidence?
As you prepare for transport, what are
some ways that you can help preserve
patient privacy, modesty, and dignity?

2007 by Pearson Education, Inc.

Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Treatment
You persuade the patient not to shower or
brush her teeth.
She points out to the police officer the
clothes she wore earlier that night.
When asked if she would like to walk out or
use the stretcher, the patient chooses to
walk.
You ask a female EMT from the volunteer
squad to assist you with the patient.
2007 by Pearson Education, Inc.
Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Treatment
You offer a blanket to the patient, which
she accepts.

Photo 1.5-7

2007 by Pearson Education, Inc.

Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Treatment
You ask security to secure a maintenance
elevator and a side door to avoid taking
the patient out through the dormitory
lobby.
During transport, the patient states that
she feels more awake, and less groggy.

2007 by Pearson Education, Inc.

Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Ongoing Assessment
Vital signs
HR = 80
regular
RR = 12
regular
BP = 122/76
SpO2 = 98%
on room air

2007 by Pearson Education, Inc.

Pearson Prentice Hall, Upper Saddle River, NJ

Photo 1.5-8

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

ED Treatment and Beyond

Patient is placed in a private, quiet, welllit room.
Female nurse and rape counselor greet
the patient in the room.
A more detailed event history and
physical exam are performed.
A rape kit is utilized to collect
specimens.

2007 by Pearson Education, Inc.

Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Sexual Assault

Review Material

2007 by Pearson Education, Inc.

Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Epidemiology
Sexual assault accounts for about 1% of all
violent crime reported in the U.S.
Most assaults reported are female rapes.
> 300,000 female rapes reported a year
> 90,000 male rapes reported a year
About 65% of rapes go unreported.
General body trauma is reported in 45%67%
of sexual-assault victims seeking medical care.

2007 by Pearson Education, Inc.

Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology
Definitions of rape and sexual assault may vary
by state.
A common element among variations is sexual
contact without consent.
Sexual assault
Unwanted oral, genital, rectal, or manual
sexual contact
Rape
Penetration of the genitalia or rectum without
consent of victim
2007 by Pearson Education, Inc.
Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology
It is generally accepted that the causes of
sexual assaults are the result of
inappropriate violent impulse, not
sexuality.
Rape is often motivated by the need for
power and control or by anger.

2007 by Pearson Education, Inc.

Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology
Bodily injury to the victim is common.
45%67% of victims seek medical
care.
Incidences of genital injury from 9%
45%
Lack of injury does not imply consent.

2007 by Pearson Education, Inc.

Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology
Drugs are commonly used to facilitate
sexual assault.
Alcohol
Rohypnol
GHB
Ketamine
MDMA

2007 by Pearson Education, Inc.

Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Clinical Assessment
Ideally, caregiver of same sex should
perform examination.
Your objectivity is important.
Attitude of prehospital care providers
may affect long-term psychological
impact.
Clinical exam should be performed
tactfully and compassionately in a private
environment.
Respect patients modesty.
2007 by Pearson Education, Inc.
Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Clinical Assessment
Physical exam
General rule is to be as minimally
invasive as possible.
Physical exam is based on patient
complaint, presentation.
Avoid unnecessary exposure of patient.
Genital exam is unnecessary unless
patient complaint or exam findings
indicate necessity.
2007 by Pearson Education, Inc.
Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Clinical Assessment
As a rule, victims should not be
questioned in the field about the specifics
of the assault.
Specific questions determined by patient
complaints and presentation
Should be done in a private environment

When situation demands potentially

troubling questions, a tactful, caring,
professional method is obligatory.
2007 by Pearson Education, Inc.
Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Clinical Assessment
Past medical history, present medications,
and allergies
Attempt to ascertain, tactfully, if a datefacilitated drug or alcohol was involved.
Interactions with patient medications
CNS depression
Can be determined with physical exam,
questioning
2007 by Pearson Education, Inc.
Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Treatment
Patient has physical as well as psychological
needs.
Care best provided by member of same sex
as victim
Treatment for specific injuries same as in
nonsexual assault situation
Provide a safe environment for the patient.
Preservation of physical evidence a concern

2007 by Pearson Education, Inc.

Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Treatment: Hospital
Hospital staff will secure more detailed account of
assault and medical history.
Detailed physical exam including
Inspection of genitalia, rectum, oral cavity
Use of Woods lamp, toluidine blue, colposcope
Anoscopy, sigmoidoscopy, speculum
examination
Evidentiary examination
Use of rape kit
2007 by Pearson Education, Inc.
Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Treatment: Hospital
Pregnancy test to identify preexisting
pregnancy
Pregnancy prophylaxis
Sexually transmitted disease prophylaxis
HIV testing
Counseling

2007 by Pearson Education, Inc.

Pearson Prentice Hall, Upper Saddle River, NJ

Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Summary
Anatomy and Physiology of the
Female Reproductive Organs
The Menstrual Cycle
Assessment of the Gynecological
Patient
Management of Gynecological
Emergencies
Specific Gynecological Emergencies
Bledsoe et al., Paramedic Care Principles & Practice Volume 3: Medical
2006 by Pearson Education, Inc. Upper Saddle River, NJ