1

OB Emergencies

July 2012 CECondell Medical Center

EMS SystemSite Code: 107200E -1212

Prepared by: Sharon Hopkins, RN, BSN, EMT-PPrepared by: Sharon Hopkins, RN, BSN, EMT-P

2

Objectives

Upon successful completion of this module, the EMS provider will be able to:

1. Describe normal physiological changes that occur during pregnancy.

2. Describe a normal labor process.3. List indications that birth is imminent.4. List possible complications related to

pregnancy and delivery.

3

Objectives cont’d

5. Discuss EMS actions to take delivery complications related to pregnancy and delivery.

6. Discuss neonatal resuscitation procedures.

7. Given a manikin, demonstrate neonatal CPR technique.

8. Given the equipment in an OB kit, describe how to use it.

9. Successfully complete the post quiz with a score of 80% or better.

4

Obstetrics

Branch of medicine that deals with women throughout their pregnancy

The majority of deliveries are uncomplicated Mother will be doing all the work

Need to be prepared for and expect the unexpected

5

Female Reproductive System

Most important organs are internal Vagina Uterus Fallopian tubes Ovaries

6

Vagina Elastic canal

Referred to as “birth canal” Connects external genitalia to uterus Wall structure allows for stretching

during the birth process

Note: Internal inspection will never be performed by pre-hospital personnel

7

Assessment

EMS will perform a VISUAL inspection of the perineum Area of tissue of the external genitalia

EMS will NEVER perform a “vaginal” exam A “vaginal exam” is the insertion of

gloved fingers into the vagina for assessment by palpation

8

Uterus

Hollow, thick walled, muscular organ Lies in center of pelvis Provides a site for fetal development

Empty measure 3 x 2 inches (7.5 x 5 cm)

At term measures 16 inches (40cm) long Muscle structure allows for

significant stretch and growth

9

Cervix Lower portion of the uterus Canal about 1 inch long (2.5 cm) During labor, thins down and dilates

open to about 4 inches (10 cm) Able to thin out and open due to

elasticity of the muscles Note: Internal inspection will never

be performed by pre-hospital personnel

10

Fallopian Tubes

Thin flexible pair of tubes about 4 inches (10 cm) x <1/2 inch (1 cm)

Conducts eggs from ovary to uterine cavity

Fertilization generally occurs in distal third of fallopian tube Often the site of ectopic pregnancies

11

Ovaries Female sex organs Lie on either side of the uterus in

upper portion of pelvic cavity 2 functions

Secrete hormones Estrogen, progesterone, luteinizing

hormone Present in females and males in

differing levels Develops and secretes eggs for

reproduction

12

Physiological Changes of Pregnancy

blood volume Pink skin; the “glow” of pregnancy

O2 demand with lung capacity Normal to feel short of breath

pulse rate Extra weight carried; ligaments stretched

Sway back posture; more off balance Enlarging fetus; displacement GI tract

Enlarging belly, nausea, heartburn

13

Uterine Blood Flow In non-pregnant state, uterus receives

approximately 2% of the blood flow During pregnancy, the uterus receives

approximately 20% of the blood flow Massive in blood and blood vessels in

uterus and related structures in pregnancy risk to miss blood loss potential prior to

development of signs and symptoms

14

Placenta

Temporary structure An endocrine gland

Secretes hormones during pregnancy Blood-rich Transfers heat Exchanges O2, CO2, nutrients, waste products Serves as protective barrier against some

harmful substances

15

Is She Pregnant?

Most typical signs or symptoms Late or missed period Fatigue/exhaustion Nausea/vomiting body temp Breast changes Dizziness/ Headache lightheadedness Spotting Frequent urination Constipation &/or bloating

16

Caring for Female Patients The general rule of thumb:

Any woman of childbearing age with abdominal pain is assumed to be pregnant and experiencing an ectopic pregnancy until proven otherwise

Assume the worst; hope for the best

17

Case Scenario #1

EMS is called to the scene for a 16 year-old female with abdominal pain

Upon arrival the mother states her daughter has had colicky pain for hours

The patient is uncomfortable lying on the couch Awake, alert, pale, moving side to side

18

Case Scenario #1

What is your general impression? Abdominal problem – medical or surgical

problem Issue related to female reproductive

system Patient could be in labor

When asking “is there a chance you might be pregnant”, you won’t always get an honest answer (especially if parents are present)

You should always be prepared for the unexpected!!!

19

Case Scenario #1 EMS activity

Perform your usual assessment/examination Obtain the medical history For any abdominal complaint, you should

visualize the abdominal wall You MUST perform an abdominal palpation

when the complaint is abdominal pain Complete the OPQRST assessment

When trying to hide (or ignore) a pregnancy, you may have an undernourished patient

20

Labor Process

Includes entire process of delivery Begins with contractions Ends with delivery of the placenta

Broken into 3 stages Length of time in the stages differs

mother to mother and can differ based on number of previous pregnancies

21

1st Stage of Labor

Starts with regular contractions and thinning and dilation of cervix Evaluated with internal exam

NEVER performed in the field Ends with full dilation of cervix

Cervix goes from closed to fully dilated or open at 10 cm (5 inches)

22

2nd Stage of Labor

Begins after full dilation of the cervix Ends after delivery of the infant

Mother (and perhaps others) need emotional support, coaching in this stage

Urge to push indicates an imminent delivery

Will need to make a decision to transport or stay and deliver

23

3rd Stage of Labor Placental stage of the delivery Begins after the birth of the infant Ends at delivery of the placenta Contractions resume after the

infant’s delivery Can last 10-20 minutes Do not need to remain on the

scene until the placenta delivers

24

Screening Questions at a Delivery What is your due date? What number pregnancy is this? Have you received prenatal care? What is the timing of your

contractions? Has your bag of waters

ruptured/broken? Do you feel the urge to have a bowel

movement or urge to push?

25

Timing Contractions

Duration From the beginning of the contraction

until it ends Interval/time between

From the beginning of 1 contraction to the beginning of the next

Contractions coming every 2-3 minutes usually indicates imminent birth

26

Imminent Birth

Without a doubt, the birth is very close!!! Crowning Bulging of the perineum Feeling or urge to move her bowels When the mother states, “I’ve got to push!!!”

No reason not to trust what the mother says

27

OB Kit Prepackaged kits; generally

disposable Box Basin Plastic bag

Occasionally need to add-on items Hat for infant ID tags for mother and infant APGAR table for scoring guidance

28

OB Kit Contents

Go through your kit – describe how would you use each piece

29

Delivery Process

Remember: It’s a natural process. You are

just there to help the mother. The mother is doing all the work!

The majority of births are textbook normal Prepare the mother for the delivery Prepare your equipment Notify the receiving hospital

30

Arriving at the Hospital The mother has not delivered yet

and you are pulling into the bays Keep the OB kit with the mother

She may deliver any where, any time You will need some of the equipment

immediately Better to be prepared and not

need the OB kit than to scramble for the equipment and not find it

31

Arriving at the Hospital

If you have delivered in the field, you have 2 patients to care for ALWAYS keep the baby covered and

warm regardless of the time of year or outside temperature

Complete 2 patient care run reports Keep information separated as

appropriately as possible There is some overlap of information but

not everything

32

Case Scenario #2 You are called to the toll way for

an OB delivery Upon arrival the mother is

screaming that she has to push This is her 3rd pregnancy Her contractions are 2 minutes apart

What are your next actions?

33

Case Scenario #2

Gain quick rapport Need to perform a visual exam

Crowning present? Bulging of the perineum present? Any blood, cord, fingers, or toes present?

Position mother for delivery Your cot, your ambulance if time

Open and prepare the OB kit

34

Case Scenario #2

Steps during delivery As the head emerges, check for nuchal

cord Clear airway with bulb syringe as needed

Suction mouth then nose Gently guide head downward to deliver

top shoulder Support & lift head & neck slightly to

deliver bottom shoulder Rest of newborn should easily slip out

35

Case Scenario #2

How would you stimulate the infant immediately after the delivery if needed Drying them off with a towel is stimulation Gently rubbing their back Flicking at the soles of their feet Suctioning with the bulb syringe (only if

secretions are present) will be stimulation Keep the infant in a head down position

to facilitate drainage

36

Potential Complications Supine Hypotensive Syndrome Hypertensive Emergencies Ectopic pregnancy Abruptio placenta Placenta previa Premature rupture of membranes Nuchal Cord Prolapsed cord Breech birth Premature birth Multiple births

37

Supine Hypotensive Syndrome

Heavy weighted mass of uterus will compress inferior vena cava return of blood to the heart cardiac output

Dizziness Drop in blood pressure in uterine blood flow

Body compensates by diverting blood flow from uterus to other parts of the body Fetus would be severely deprived of blood flow

38

Treating Supine Hypotensive Syndrome Any patient over 5 months pregnant

should be transported tilted or lying preferably left Think lay left Maintains blood flow through the

inferior vena cava returning blood to the heart

If secured to a backboard, can just slightly tilt the back board toward the side, preferably left

39

Hypertensive Emergencies

Preeclampsia Elevated blood pressure Excessive weight gain Extreme swelling face, feet, hands Headache or altered mental status

Eclampsia Seizure activity

40

Care of the Pregnant Patient with Seizure Activity

Handle gently Minimal CNS stimulation

Avoid loud noises, flashing lights Be prepared to secure the airway Have suction available

Limit suction time to <10 seconds at a time To treat active seizures

Versed 2 mg IN/IVP/IO every 2 minutes to max total 10 mg

Can cause resp depression of newborn if delivered

41

Ectopic Pregnancy

Implantation of the egg outside the normal uterus Most common site is

fallopian tube Fetal growth will stretch the tube until it

ruptures Critical internal bleeding can occur with rupture

Early complication Patient may not even know or suspect that they

are pregnant

42

Ectopic Pregnancy

Be watchful for these signs & symptoms Acute abdominal pain

Often on one side; can be referred to the shoulder

Missed/late period Vaginal bleeding Rapid & weak pulse (late sign) Hypotension (a VERY late sign)

43

Care For Ectopic Pregnancy In unstable patients, provide rapid

transport Closely monitor vital signs

Note: Hypotension is a LATE sign Provide care for shock May need to go to the closest

hospital versus patient’s hospital of choice

THIS IS A LIFE THREATENING CONDITION!!!

44

Abruptio Placenta

Placenta prematurely separates from uterine wall Partial or complete tear

Excessive pain Rigid abdominal wall Minimal vaginal blood flow; dark

45

Placenta Previa

Placenta attached in an abnormally low position in uterus Covers cervical opening so infant cannot

deliver first If known, mother scheduled for cesarean

section Bright red, painless vaginal bleeding

46

Care For Preterm Bleeding Alert the receiving hospital as soon as

possible Gain IV access

Based on assessment, consider fluid replacement in 200 ml increments

Evaluate need for supplemental oxygen

Transport mother tilted (left if possible) Monitor for possible delivery

47

Premature Rupture of Membranes

Often, once the bag of waters ruptures the labor progresses faster

Occasionally, the bag of waters prematurely ruptures and mother is not in labor

Once ruptured, the fetus is at higher risk for infection if not delivered within 24 hours

Mothers can sign a release - “sorry I called you - false alarm - I’m not in labor” You need to encourage them to contact their

doctor ASAP due to risk of infection

48

Nuchal Cord

Be prepared Check for cord around the neck as

soon as the head and neck deliver If loose, slip cord over the head Have mother continue to breath

through the contractions and not push

If too tight, place 2 cord clamps and carefully cut cord

Loosen cord from around neck

49

Prolapsed Cord

If cord precedes delivery of infant, the fetal blood and

oxygen flow will be cut off Elevate the mother’s hips Have mother breathe through a

contraction; she cannot push! Place gloved fingers into vagina Apply counter pressure to presenting

part Cover exposed cord with moist saline

dressings

50

Breech Birth

Most common abnormal delivery

Risk of birth trauma is high Increased risk of prolapsed cord Meconium staining often a normal

event in a breech – prepare to use a bulb syringe

If the presentation is not the buttocks or 2 feet, then transport immediately

51

Breech Delivery Support infant’s body as soon as the

legs deliver Keep infant’s exposed body dry and

warm Attempt to loosen cord to create slack After torso and shoulders deliver,

gently sweep down arms If face down, gently elevate legs and

trunk to facilitate delivery of head

52

Breech cont’d

Apply firm pressure over fundus to facilitate delivery of head

If head not delivered in 30 seconds, reach 2 gloved fingers in to create an airway for infant Push vaginal wall away from mouth DO NOT place oxygen tubing in the area

Could create an air embolism for the mother

53

Issues of Premature Birth Weaker, less developed muscles

Spontaneous breathing more difficult Deficiency in surfactant in lungs

Ventilations more difficult Rapid heat loss

Thin skin, decreased fat Immature tissues

More easily damaged by excessive oxygenation

54

Premature Births

Watch the airway Protect from heat loss Have available the right equipment

Adult equipment cannot be used to “fit” a newborn

Handle the newborn gently

55

Multiple Births

Often scheduled deliveries in the controlled environment of the hospital

Delivered by Caesarian due to odd presentations/positioning of infants

Tend to be smaller birth weights If delivered in the field, attend to

each baby as if they are one Clamp and cut each cord as the infant

delivers

56

Case Scenario #3 EMS arrives on the scene of a MVC The driver is 8 ½ months pregnant There is deformity to the front end of

the car & the steering wheel with airbag deployment

The mother complains of severe upper abdominal pain and pain over her sternum

VS: 132/88; P – 96; R – 22; SpO2 97%

57

Case Scenario #3 Where in the order of patient transport

would this patient be placed if there are multiple patients to transport? This patient needs to be transported

early; there may be issues with the fetus that are undetected at this point

What is your general impression? Abruptio placenta is top of the list

Treat for shock Improve blood & oxygen flow to the

uterus

58

Case Scenario #3

Remember: The mother temporarily has a higher

blood volume so can lose more blood volume before signs and symptoms may be detected

Normal physiological changes during pregnancy include a slightly lower blood pressure and slightly elevated pulse rate

59

APGAR Score

What is it? An objective method of evaluating the

newborn’s condition and overall status and response to resuscitation

What is it NOT? NOT used to determine if the newborn

needs resuscitation, or what steps are necessary, or when to apply resuscitation

60

APGAR Score Obtained at 1 and 5 minutes Evaluate 5 signs

Appearance* (color) Pulse / heart rate* Grimace – reflex irritability Activity – muscle tone Respirations* - crying

* Signs also used to determine need for resuscitation

61

APGAR Score

62

Umbilical Cord Care

Low priority to clamp and cut cord Wait at least one minute after delivery Palpate cord to make sure no longer pulsating Clamped & cut AFTER care given to newborn Apply clamps 8 & 10“ from naval Cut in between the clamps Watch for any blood oozing from infant’s cut

end Apply another clamp or tie to oozing end if needed

63

Total Blood Volumes Average 75 - 80 ml/kg Adult – 4 - 5 liters Child - 2 liters Newborn – 335 ml

64

Case Scenario #4 EMS is called to the scene for a

patient in active seizure Upon arrival you note the patient to

be obviously pregnant in active seizure with tonic/clonic movement

What is your immediate action? Protect the patient from harm Protect and control the airway

Assist ventilations via BVM – this is a long seizure

65

Case Scenario #4

What med is used to control the seizure? Versed 2 mg IN/IVP/IO Repeat every 2 minutes to desired effect

(seizure stops) Maximum total of 10 mg If seizure recurs, contact Medical Control

to renew the Versed order What category medication is Versed?

A benzodiazepine

66

Case Scenario #4 Would Versed have an effect on the

newborn? Yes, Versed does cross the placental barrier

What would be the effect of the Versed on the infant if delivered soon after Versed is administered to the mother? Newborn could have respiratory depression

related to the Versed Verbally remind staff at hospital that the

mother received Versed in the field

67

Neonatal Resuscitation Neonate is 0 – 28 day old infant Guidelines developed by the

American Heart Association (AHA) Remember:

Normal heart rates are faster Normal respiratory rates are faster Relatively larger body surface area Less ability to conserve body heat Most infants respond to warming,

drying, & stimulation

68

Inverted Pyramid

69

Newborn Resuscitation Algorithm

Within 1st 30 seconds of birth Warm the infant, clear airway if

necessary, dry, stimulate Majority of infants respond to this

Assess heart rate If heart rate <100, gasping, or apneic

Within 60 seconds of birth begin positive pressure ventilation (i.e.: BVM) 40-60/second

After 30 seconds if heart rate 60-100 use BVM After 30 seconds if heart rate <60, start

compressions 3:1 ratio

70

Neonatal Statistics Approximately 10% of newborns will require

some assistance to begin to breath Approximately 1% of newborns will require

extensive resuscitation If resuscitation is required, do not delay to

obtain the 1 minute APGAR If an infant does not begin to breath

immediately after stimulation, begin supportive ventilations via BVM – 40-60/minute Further attempts at stimulation usually not

effective

71

Neonatal Suctioning Performed only in the presence of

obvious nasal or oral secretions Can stimulate bradycardia Can reduce cerebral blood flow when

routinely performed Suctioning time must be limited to

3 - 5 seconds Revised guidelines caution on

suctioning – only suction if there is material that must be cleared

72

Fetal Oxygenation Fetus oxygenated via O2 diffusing

across placental membrane from mother’s blood to fetal blood Fetal alveoli filled with fluid

Changes shortly after delivery Fluid in alveoli is absorbed Umbilical arteries and veins close

when cord is clamped Newborn systemic blood pressure

increases Lung tissue blood vessels relax

allowing blood flow through the lungs

73

Newborn Assessment – Do They Require Resuscitation?

Is the baby preterm? Especially less than 34 weeks increases

risk of instability Is the baby breathing or crying?

Gasping could indicate severe respiratory depression or neurological problems

Is the muscle tone good? Flexed extremities is normal; extended

and flaccid extremities not normal

74

Distressed Infant Gasping is as significant as apnea Bradycardia indicates a significant

problem Immediate attention to the airway

is important Providing assisted ventilations

should result in a rapid increase in heart rate Goal is to have heart rate >100

75

Obtaining Newborn Heart Rate Palpate brachial artery

Inner aspect upper arm Palpate at base of umbilicus Use stethoscope to auscultate the

heart for an apical pulse Note: Normal newborn heart rate

can be a range of 100-180 Optimal heart rate is

140-160/minute

76

Neonatal Resuscitation

When do I need to provide resuscitation? Heart rate <100 despite adequate

ventilation and oxygenation for 30 seconds

Use the right equipment for the right patient

77

Positioning

Head extension required for adults and children

Sniffing position best for infants Baby’s nose is as far anterior as

possible Head extension closes off airway

Small pad (ie: diaper) under shoulder blades helps for positioning

78

Sniffing Position

79

Adult/Child/Neonatal BVM’s

Size does matter for BVM Little puffs of air

Enough to make the chest rise and fall

If too much volume or too aggressive could cause pneumothorax

80

Revised CPR Guidelines 2012

C- A- B (not ABC) Check responsiveness Check for brachial

pulses Begin compressions Open airway Provide gentle

ventilations

81

Neonatal Resuscitation

Chest compressions 90/minute Finger tips on lower half of sternum

Depress 1 ½ inches or 1/3 the AP diameter

Compression to ventilation ratio: 3:1

Ventilations are tiny puffs of air

82

Neonatal Ventilatory Support

Pulse present with inadequate breathing Deliver 1 breath/second with neonatal

BVM until heart rate >100 If advanced airway in place

Deliver 1 breath/second with neonatal BVM until heart rate >100

83

Maternal Resuscitation

Modifications may need to occur due to the enlarged uterus During CPR 1 person performs left

uterine displacement while patient is supine

Manually pull/push uterus toward the left

Chest compressions should be performed slightly higher on the sternum

No modifications for defibrillation Performed following usual technique

84

Case Scenario #5

EMS is called to the scene for a newborn choking

Upon arrival, EMS notes a 10 day old infant lying limp; cyanotic; no signs of respiratory effort

What is your response/action?

85

Case Scenario #5 Immediately begin assessment

Is the baby responsive? No Look for signs of life – there are none Deliver 90 compressions /minute

2 finger tips (or thumbs if wrapping the chest wall with your hands in 2 person CPR) 1 finger width below the nipple line

Compress to a depth of 1/3 the AP diameter of the chest wall

86

Case Scenario #5

Deliver 2 puffs of air Enough to make the chest rise Compressions to ventilation ratio: 3:1

Inadequate breathing with pulse Deliver 1 breath per second to achieve

heart rate >100 Ventilations with advanced airway in

place Deliver 1 breath per second to achieve

heart rate >100

87

Case Scenario #5 If rhythm is VF or pulseless VT, a

manual defibrillator is preferred Can dial down defibrillator to 2

joules /kg followed by 4 j/kg for subsequent events

In absence of manual defibrillator, AED may be used preferably with pediatric attenuator

Immediately after defibrillation attempts, resume compressions

Note: Most infants have a respiratory arrest, not cardiac

88

Case Scenario #6

EMS is called to the scene for a 34 year-old female with abdominal pain who feels like they are going to pass out

Patient is pale, diaphoretic VS: B/P 92/60; P – 104; R – 22 shallow;

SpO2 97% Pain is on the right side of the abdomen Patient cannot find a comfortable

position

89

Case Scenario #6 What is your impression?

Ectopic pregnancy Appendicitis Colon spasm

What action do you take? Perform assessment for abdominal pain

Include questioning for possible pregnancy Keep possibility of ectopic high on list

even if patient denies pregnancy

90

Case Scenario #6 What interventions are performed?

IV Be prepared for fluid resuscitation in

200 ml increments Hold oxygen

Unless SpO2 drops or patient has respiratory complaint

Monitor No indication for cardiac assessment

but not faulted if monitor applied No indication for 12 lead EKG though

91

Case Scenario #6

If this is an ectopic, this is a true life threatening emergency!

Patient will go to the OR immediately The patient’s life is threatened There is no salvage for the fetus in this

case Often, the patient is unaware that

they are even pregnant at this point in time

92

Bibliography American Academy of Pediatrics. Neonatal

Resuscitation 6th Edition. 2011. American Heart Association. 2010 Guidelines for

CPR and ECC Bledsoe, B., Porter, R., Cherry, R. Paramedic Care

Principles & Practices Third Edition. Brady. 2009. Limmer, D., O’Keefe, M. Emergency Care 12th

Edition. Brady. 2012. Region X Advanced Life Support Standard

Operating Procedures February 1, 2012 Troiano, N., Harvey, C., Chez, B. High-Risk &

Critical Care Obstetrics. 3rd edition. Lippincott. 2013.