OB Emergencies November 2010 CE Condell EMS System Objectives by Jeremy Lockwood, FF/PM Mundelein Fire Department Packet prepared by Sharon Hopkins, RN,

OB Emergencies

November 2010 CE

Condell EMS System

Objectives by Jeremy Lockwood, FF/PM Mundelein Fire Department

Packet prepared by Sharon Hopkins, RN, BSN, EMT-P

ObjectivesUpon successful completion of this module, the EMS

provider will be able to:

1. Identify appropriate standard precautions in the OB delivery setting.

2. Identify progression of a normal pregnancy. 3. Describe assessment of an obstetrical patient. 4. Identify predelivery complications. 5. Describe indications and signs of imminent

delivery. 6. Identify the stages of labor.

Objectives cont’d 7. List the contents of the OB kit 8. Describe how to use the contents of the OB kit. 9. Describe the steps in assisting delivery of the

newborn. 10. Describe care of the newborn baby. 11. Describe APGAR scoring. 12. Describe when and how to cut the umbilical

cord. 13. Describe the delivery of the placenta. 14. Describe post delivery care of the mother.

Objectives cont’d 15. Describe abnormal deliveries and procedures. 16. Identify and describe delivery complications. 17. Describe meconium staining and its implication

to the newborn. 18. Review documentation components for

discussed conditions. 19. Given a manikin, demonstrate use of the OB

kit. 20. Demonstrate use of the meconium device.

Standard Precautions Anticipate the exposure to a large amount of

blood and body fluids Full protection is recommended Don’t assume the absence or presence of

disease just by appearances of the patient or situation

Standard Precautions

Handwashing- still most effectivecontrol measurearound

Just Protect Yourself!!!

Do what you can

Normal Pregnancy Development Ovulation and what follows

Release of an egg from ovary Egg travels down fallopian tube toward uterus Intercourse within 24-48 hours of ovulation could

result in fertilization Fertilization occurs in the fallopian tube Fertilized egg will implant in the uterus and

pregnancy begins

Prenatal Development cont’d Placental development

Approx 3 weeks after fertilization Blood rich structure for the fetus

Transfers heat Exchanges oxygen and carbon dioxide Delivers nutrients Carries away waste products Endocrine gland

Secretes hormones for fetal survival Secretes hormones to maintain pregnancy

Placental Development cont’d Protective barrier Connected to the fetus via the umbilical cord

Flexible, rope-like structure 2 feet in length; ¾″ diameter Contains 2 arteries, 1 vein

2 arteries return relatively deoxygenated blood to the placenta

1 vein transports oxygenated blood to fetus

Placental Attachment

Amniotic Sac “Bag of waters”

Thin-walled membranous covering holds the amniotic fluid Surrounds and protects fetus Allows for fetal movement during

development Volume varies from 500 ml to 1000 ml

500 ml = 1 pint = 2 cups Premature rupture increases risk of maternal

and fetal infection that could be life threatening

Physiological Changes of Pregnancy Due to:

Altered hormone levels Mechanical effects of enlarging uterus Increased uterine blood supply Increasing metabolic demands on the

maternal system

Physiological Changes to the Systems Reproductive system

Uterus becomes larger Contains 16% of the mother’s blood during

pregnancy Respiratory system

Increase in oxygen demands 20% increase in oxygen consumption 40% increase in tidal volume Slight increase in respiratory rate Diaphragm pushed upward

Physiological Changes to the Systems Cardiovascular system

Cardiac output increases Maternal blood volume increases by 45% More plasma increase than red blood cells so

relative anemia develops Maternal heart rate increases by 10-15 beats B/P decreases slightly 1st & 2nd trimesters Supine hypotensive syndrome when mother lies

supine Especially by 5 months of pregnancy

Physiological Changes to the Systems Gastrointestinal system

Nausea & vomiting are common in 1st trimester

Delayed gastric emptying (due to slowed peristalsis)

Bloating and constipation common

Physiological Changes to the Systems Urinary system

Renal blood flow increases More likely to have glucose spilling into

urine Bladder displaced anteriorly & superiorly

increasing likelihood of rupture during trauma

Urinary frequency is common especially 1st trimester

Physiological Changes to the Systems Musculoskeletal system

Pelvic joints loosened causing waddling gait

Center of gravity shifts with enlarging uterus

Postural changes taken to accommodate for increased anterior growth Increased complaints of low back pain

Obstetrical Assessment Need to determine if delivery is imminent or

if there is time to transport Remain calm (at least on the outside!) Ask a few questions

Basically direct or closed ended questions – requiring a simple answer in few words

Perform a visual examination Evaluate vital signs Remain calm (at least on the outside!)

OB Assessment Questions Expected due date

The more premature, the smaller the birth weight and the less mature the lungs

Number of pregnancies The higher the number, the quicker they tend to

deliver Length of labor

1st pregnancies can take up to 16-17 hours Subsequent deliveries tend to shorten from the 1st

one

OB Assessment Questions If bag of waters have ruptured or are intact

Once ruptured, delivery tends to progress faster Once ruptured, must be evaluated due to increase

risk of infection especially if not delivered within 24 hours

Feeling of having to move their bowels This is from pressure of the fetal head moving

through the birth canal

OB Visual Examination Gain rapid rapport with the mother Disrobe the under garments Visually inspect the perineum

Check for crowning or bulging The appearance of the presenting part at the vaginal

opening Prepare for imminent delivery if crowning Best to check during a contraction

Check for blood loss Check for other parts – fingers, toes, cord

OB Assessment - Contractions Place gloved palm on mother’s abdomen Contraction duration

Time from the beginning of one contraction (uterus tightens) to the end (when uterus relaxes)

Contraction interval or frequency Time from the start of one contraction to the

beginning of the next one Includes contraction and rest intervals

OB Assessment – Vital Signs Routine vital signs are taken Remember physiological changes of

pregnancy: Blood pressure, after initial drop, is near normal

in 3rd trimester Heart rate up by 10-15 beats over normal Only slight increase in respiratory rate

Supine Hypotensive Syndrome Caused by the weight of an enlarging uterus

pinching off blood supply in the inferior vena cava

Decreases blood return to the heart Decreases stroke volume pumping out of the

heart Especially after 5 months transport the mother

tilted or turned preferably toward the left

Imminent Delivery Crowning is present Contractions last 30 – 60 seconds and are

2 - 3 minutes apart Mother has the urge to move her bowels or

she says “I HAVE TO PUSH!!!” Bag of waters has ruptured

Stages of Labor 3 stages of labor 1st stage – dilatation stage

Begins with onset of true labor contractions Ends with complete dilatation (10 cm/4″) &

effacement (100%) of the cervix Is manually confirmed in the hospital setting, not field

Stage can last approximately 8-10 hours for first labor to about 5-7 hours in multipara

1st Stage of Labor cont’d Contractions

Early in this stage are usually mild Duration of 15-20 seconds Frequency every 10-20 minutes apart

Increase in intensity as labor progresses Duration of 60 seconds Frequency every 2-3 minutes

Care is supportive at this point in time Allow husband/significant other to time

contractions Keeps them busy, involved, and out of the way

Timing Contractions Duration

Timed in seconds Timed from the beginning of the contraction to the end

the contraction Contractions lasting 60-90 seconds indicate imminent

delivery Frequency

Timed in minutes Timed from the beginning of one contraction to the

beginning of the next contraction Contractions coming every 2-3 minutes indicate imminent

delivery

2nd Stage of Labor – Expulsion Stage Begins with complete dilatation of cervix Ends with delivery of fetus Can last 50 – 60 minutes for the first delivery Can last 30 minutes for future deliveries Contractions strong, uncomfortable

Duration is 60-75-90 seconds Contraction every 2 – 3 minutes

2nd Stage of Labor cont’d Mother has urge to bear down Mother has back pain Crowning is evident on visual inspection Membranes usually rupture now OB kit should be open by now Be ready to support mother in delivery

OB Kit May be supplied in a variety of packaging If extra supplies are needed, where are they

kept? Always anticipate using the OB kit

Better to have it available and not need it / use it than need it and not have it

Kits are usually packaged with disposable products

Practice Standard Precautions Goggles, mask, gloves, gown

Contents of OB Kit

Cord Clamps FYI

If not used for a period of time, it has been reported that the OB clamps become brittle and can break

There is no hurry to clamp and cut a cord If you transport the mother and baby with the

cord intact, so be it The hospital will take care of clamping and

cutting the cord

Delivery of the Newborn

As soon as the head and neck emerges, check for nuchal cord and begin to suction mouth then nose with bulb syringe Depress bulb first before insertion of mouth, then nose

To facilitate delivery of upper shoulder, gently guide head downward

Support and lift head and neck slightly to deliver lower shoulder

Rest of infant delivers passively and very quickly

Newborn At Delivery They’ll

grow into being a Gerber baby!

Care of the Newborn cont’d Hold on tight

Infant is slippery due to cheesy covering and amniotic fluid

Note time of delivery and record on the infant’s run report

Stimulate the infant Suctioning, rubbing the

back, flicking at the soles of the feet, drying off

Suctioning the Newborn Suction mouth then nose always in that

sequence Infant’s are obligate nasal breathers Want to clear the airway before stimulating

them to take a breath Always depress bulb

syringe and THEN place into infant’s mouth, then nose

Care of the Newborn Continue to suction mouth then nose Spontaneous respirations should begin within

15 seconds after stimulation If no respirations, begin BVM support at 30-

40 breaths per minute If pulse < 60 or between 60-80 and not

improving, begin CPR Obtain 1 minute APGAR (ie: record as 9/10)

APGAR Score Assesses newborn adjustment to extrauterine life 1 minute score indicates need for resuscitation 5 minute score predicts mortality and neurological

deficits Order of importance

Heart rate Respiratory rate Muscle tone Reflex irritability Finally color – least helpful; most visible/obvious

APGAR Scoring – 1 & 5 minutes

Care of the Umbilical Cord Clamp and then cut the cord after pulsations

have stopped & cored is limp Clamps placed 8″ from infant’s navel 2″ apart Watch the end of the cord

for leakage of blood If leaking, add additional

clamps moving toward the infant’s navel

Cutting the Clamped Cord

FYI – What About Cord Blood? Obtained in the hospital within 10-15 minutes of

delivery Collected from umbilical cord after delivery and

after care of newborn provided Consists of stem cells that can transform into variety

of healthy tissue Useful to treat leukemia, lymphomas and other

diseases Fee charged for private donations and storage NOT the same as embryonic stem cells

Care of The Newborn cont’d Continue to dry and wrap infant to preserve

body temperature Obtain 5 minute APGAR (ie: record as 10/10) Continue to suction mouth then nose as

needed Keep infant in head downward position

Facilitates drainage from the airway Assess vital signs of infant (is it time to retake

mom’s?)

Care of the Newborn Infant in head

down (and side lying) position

Hat placed to minimize heat loss

Cord clamped and cut

3rd Stage of Labor – Placental Stage Begins immediately after delivery of infant Ends with delivery of placenta Do not need to delay transport waiting for

placenta to deliver Signs of separation

Gush of blood from vagina Change in size, consistency, shape of uterus Lengthening of cord protruding from vagina

Delivery of the Placenta Allow to deliver spontaneously May take up to 20 minutes after infant delivered to

deliver the placenta If delivered at the scene, collect and transport with

the patient Inspected for retained placental parts

For excessive external bleeding, apply dressings externally

For excessive vaginal bleeding, uterine massage AFTER placenta is delivered

Placenta Uterine Wall Side

Placenta Fetal Side

Post Partum Care of the Mother What is post partum hemorrhage?

Loss of more than 500 ml of blood (1 pint; 2 cups) To control, massage uterus AFTER delivery of

placenta Will feel uncomfortable to the mother Massage until the uterus feels firm Recheck every 5 minutes Check your rate of IV fluids Are you administering oxygen?

Fundal Massage Performed AFTER delivery of placenta Uterus should be firm Place one hand immediately above symphysis

pubis Place one hand on uterine

fundus (top) Massage with 2 hands

Post Partum Care Congratulate the new parents! Inform them if it is a boy or girl If possible, offer the mother a towel to wipe

her face and hands By holding the wrapped infant, the mother’s

body heat will help maintain the body heat of the infant

Abnormal Delivery Presentations If you are prepared for the worst and get the

best, hidden bonus!!!

Breech 4% of term deliveries Head is not the presenting

part!!! Transport immediately to

closest ED with OB capacity

Higher risk to infant and mother

Potential need for C-section

To Facilitate Delivery of Breech As soon as legs deliver, support infant’s body If accessible, palpate cord for pulsations Attempt to loosen cord to create slack After torso & shoulders deliver, gently sweep

arms down If face down, gently elevate legs & trunk to

facilitate delivery of head DO NOT HYEREXTEND HEAD DO NOT PULL ON INFANT

If Head Does Not Deliver in 30 Seconds

Reach 2 gloved fingers into vagina to locate newborn’s mouth

Push vaginal wall away from newborn’s mouth Keep fingers in place and transport immediately Call report ASAP Keep delivered portion of infant warm & dry If infant delivers, anticipate distressed newborn

Anticipate maternal hemorrhage

Footling Breech – Not a Field Delivery If one foot is visible, wonder “where is the rest of

the baby?” Encourage mother to breath through a contraction

so she does not add to the pushing

Keep infant’s extremity warm Rapid transport Early report

Prolapsed Cord Cord is delivering before

the infant Infant’s oxygen and blood

supply will be compromised

Need to take pressure off the cord Don’t want mother pushing with contractions

Have mother breath through the contractions

Prolapsed Cord True emergency High fetal death rate Must immediately

recognize the emergency Rapid transport Place gloved fingers into vagina between

pubic bone and presenting part Cover exposed cord with moist saline

dressing

Placenta Previa Abnormal implantation

of placenta on lower half of uterine wall

Partial or complete blockage of cervical opening

Hallmark: Painless, bright red vaginal bleeding

Uterus usually soft

Abruptio Placenta Premature separation of normally

implanted placenta from the uterine wall

20-30% fetal mortality rate Bleeding concealed Sudden, sharp, tearing pain and stiff, boardlike

abdomen Life threatening OB emergency Support mother’s oxygenation Transport tilted or lying left

Meconium Staining Meconium is fetal stool Release by the fetus may

indicate intrauterine stress, like hypoxia

If observed, prepare for a distressed baby who may need ventilatory support

Fortunately, most meconium can be dealt with by using a bulb syringe

Meconium Aspiration Equipment Intubation equipment

Blade, handle 2 ET tubes

Meconium aspirator Suction

Suction turned down to 80mmHg

Meconium aspirator connected to suction tubing Intubate in usual manner May not visualize landmarks due to meconium Quickly connect aspirator to ET tube Withdraw in twisting fashion while

suctioning Minimize suction time to 2 seconds

or less If time, repeat at least once more

Meconium Aspiration Procedure

Meconium Aspirator Time available to intervene is minimal Must be prepared and move fast

While runningslide show,left click anywhere onscreen at rightto play video

Multiple Births

Prepare for more than one delivery

Where is your extra equipment? Expect smaller birth weight infants

Poorer ability to conserve body heat Immature respiratory system Need for the smallest equipment you carry

Stressed Newborn Infant flaccid, no muscle tone Heart rate < 100

If < 60 begin chest compressions Apneia or respiratory distress

Newborn respiratory rate 40-60 per minute Support ventilations via BVM

One breath every 3 seconds Just enough volume to make chest rise and fall

Documentation After delivery you have 2 patients Complete run report for both the mother and the

newborn Include time of delivery Note the one person who actually “caught” the infant

at time of delivery Keep mother’s information on the mother’s report;

infant’s on the infant’s Apply wristbands to both mother and newborn

Case Scenario #1 You have arrived on the scene. 27 year-old woman says she is in labor What are the indications for imminent labor?

Urge to move bowels Urge to push Crowning Ruptured bag of waters Contractions every 2-3 minutes lasting 60-90

seconds

Case Scenario #1 What questions do you need to ask specific to

mother being in labor? What number pregnancy is this? What is her due date? What are her contractions like? Does she have the urge to push? Is her bag of waters intact or broken? Is she aware of any complications?

Case Scenario #1 Describe the exam you need to perform

Visual inspection of perineum Looking for crowning Looking for abnormal presentation – fingers

or toes, anything not expected Looking for a prolapsed cord Checking for blood loss

Evaluate contraction duration and frequency

Case Scenario #2 You have responded to the scene of a

34 year-old mother in labor Upon visual inspection, you note flecks of

meconium in the leaking amniotic fluid What does this indicate?

Anticipate a distressed infant The infant will need gentle, aggressive airway

care with the bulb syringe and possibly the meconium aspirator

Case Scenario #2 What equipment is necessary?

Bulb syringe Intubation equipment

Blade Handle ETT – 2 available (if the first one is clogged with

meconium) Stylet Suction tubing

Meconium aspirator

Case Scenario #2 What adjustment needs to be made with the

suction when using the meconium aspirator? Suction needs to be turned down to 80 mmHg

Suction generally set at 300 mmHg for the adult population

Limit suctioning to less than 2 seconds

Case Scenario #3 You are on the scene for a 17 year-old in labor Upon visual inspection, you note a prolapsed cord What interventions do you take?

Immediately place gloved fingers into the vagina to take pressure off the cord

Place the mother in the knee-chest position Provide rapid transport with early report

End of this case discussion; move to next case

Case Scenario #4 You are on the scene of a 2 car collision One of the patients is 16 years-old and is 6 months

pregnant What would be the recommended position if

transported? Lying or tilted left to keep pressure off vena cava

Can this patient sign a release if she wants to? She is emancipated and can sign a release If she remains the parent after delivery, she remains

emancipated End of case discussion; move to next case

Case Scenario #5 - Documentation What’s right? What’s wrong/missing? MVC –this is what’s provided:

Deformity to steering wheel; windshield starred Extrication took 15 minutes Patient complained of back pain; able to move

upper extremities Swelling noted to left upper quadrant

Case Scenario #5 What’s right regarding documentation?

Description of damage to car Need and length of time for extrication Patient complaints listed Visual inspection result to abdomen

Case Scenario #5 What’s wrong/missing?

Is there any other information from the accident available or not? Speed; what was hit or what hit car Location of occupant in car

More descriptive of head to toe assessment Distal CMS with back pain Movement of lower extremities Palpation results of abdomen

Case Scenario #5 What does SMV’s stand for?

Sensation, movement, vascular What does CMS stand for?

Circulation, motor, sensation How do you test for them (yes, they are the same)?

Feel for pulses Ask the patient to move a distal digit Ask the patient if they can feel a touch that they

are not staring at

Case Scenario #6 - Documentation What’s right? What’s wrong/missing? 78 year-old with chest pain – this is what’s provided

Onset at 0800 while watching TV Not relieved with rest or 2 Nitroglycerin tablets 8/10 pain scale EKG sinus rhythm 12 lead done IV, O2, Aspirin and nitroglycerin given

Case Scenario #6 What’s right regarding documentation?

Onset – what patient was doing Palliation/provocation Severity Time of onset Care provided Rhythm strip results 12 lead obtained Interventions appropriate

Case Scenario #6 What’s wrong/missing?

OPQRST not complete Missing quality of chest pain in patient’s own

words Missing if the pain radiates or not

Was any ST elevation observed on 12 lead? Was 12 lead faxed to Medical Control?

Case Scenario #7 EKG Interpretation

Any ST elevation?

Case Scenario #7 – Acute MIST Elevation I, aVL, V2, V3, V4, V5, V6

Case Scenario #8 – EKG Interpretation Any ST elevation?

Case Scenario #8 – Acute MI ST Elevation II, III, aVF

Hold nitroglycerin until consult with Medical Control (hypotension a possibility with inferior wall MI)

Hands-on Practice Practice with contents of OB kit Practice positioning newborn in head down

position Practice using the bulb syringe to clear first

the mouth then the nose Paramedics to use the meconium aspirator

Practice in pairs to become most efficient with time

Bibliography American Academy of Pediatrics. Pediatric

Education for Prehospital Professionals 2nd Edition. 2006.

American Academy of Pediatrics. Neonatal Resuscitation. 2000.

Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles and Practices. Prentice Hall. 2009.

Limmer, D., O’Keefe, M. Emergency Care 10th Edition. Brady. 2005.

Region X SOP, March 2007; amended January 1, 2008.