OB EMERGENCIES

NOVEMBER 2014 CECONDELL MEDICAL CENTER EMS

SYSTEMIDPH SITE CODE: 107200E-1214

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

Revised 11/19/14 1

OBJECTIVES

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

1. Define obstetrical terms

2. Describe the physiological changes to the patient who is pregnant.

3. Describe potential complications in the antepartum and post

partum periods.

4. Describe EMS interventions for a variety of obstetrical delivery

emergencies following the Region X SOP.

5. Identify imminent delivery. 2

OBJECTIVES CONT’D

6. Describe components of an obstetrical kit and the use of the contents.

7. Discuss post-partum depression.

8. Actively participate in review of selected Region X SOP’s.

9. Actively participate in case scenario discussion.

10. Actively participate in return demonstration of BVM use with a neonate.

11. Actively participate in return demonstration of use of the meconium

aspirator.

12. Actively participate in return demonstration of use of a BVM in a

neonate.

13. Successfully complete the post quiz with a score of 80% or better.3

TERMINOLOGY OF PREGNANCY

Prenatal period – time from conception until delivery of fetus Antepartum – time period prior to delivery Post partum – time interval after delivery Gravidity – number of times pregnant Parity – number of pregnancies to full term Fetus – a developing human in the womb Neonate – the first 30 days of life for the infant Estimated date of confinement (EDC) – estimated birth date

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TERMINOLOGY CONT’D

Placenta – temporary blood-rich structure; lifeline for the fetus Transfers heat Exchanges O2 and carbon dioxide Delivers nutrients Carries away wastes

Bag of waters – amniotic sac; surrounds and protects fetus; volume varies from 500 – 1000ml

Perineum – the skin between the vaginal opening and the anus

Nuchal cord – cord wrapped around the fetal neck

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PHYSIOLOGICAL CHANGES DURING PREGNANCY

Pregnancy is a normal and natural processA woman’s body will undergo many changes in preparation for carrying another life

Complications are uncommon but you must be prepared for them

Pre-existing medical situations could be aggravated during pregnancy and develop into acute problems

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PHYSIOLOGICAL CHANGES OF PREGNANCY

Nausea and vomiting due to hormonal changesDelayed gastric emptying in renal blood flow

Kidneys may not be able to keep up with filtration and reabsorption

Bladder displaced anteriorly and superiorly More likely to be ruptured in trauma

Urinary frequency

Loosened pelvic joints due to hormonal changes7

PHYSIOLOGICAL CHANGES CONT’D

in oxygen demand and consumptionDiaphragm pushed up by enlarging uterus lung capacity in cardiac output to 6-7 L/min by end of 2nd trimester Average in resting non-pregnant female is 4.9L/minute

in maternal blood volume by 45% Can lose 30-35% total blood loss before change in vital signs are evident

venous return to right atrium with gravid uterus compressing

inferior vena cava

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FETAL BLOOD SUPPLY

No direct link between mother’s blood and infantMother’s blood flows to the placentaPlacenta supplies blood to the fetus Placenta acts as a barrier protecting the fetus

Some items cross the placental barrier and can affect the fetusAlcoholSome medications – Valium Versed, oral diabetic meds, narcotics, some antibiotics, steroids

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UMBILICAL CORD

A flexible, rope-like structure approx. 2 feet longContains 2 arteries, 1 veinTransports oxygenated blood to fetusReturns relatively deoxygenated blood to placentaFetus can twist and turn in the uterus and get wrapped up in cord

Fetus can “tie umbilical cord into a knot”

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NORMAL PREGNANCY – 20 WEEKS & TERM

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ANTEPARTUM COMPLICATIONS

Vaginal bleeding Ectopic pregnancyPlacenta previaAbruptioHypertensive disorders Preeclampsia, eclampsia

Supine Hypotensive Syndrome

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VAGINAL BLEEDING

May occur at anytime during the pregnancy If early, patient may not even realize they are pregnant

In the field, exact etiology cannot be determine Keep heightened suspicion that vaginal bleeding may be related to patient being pregnant

This could prove an emotional time for the patient and family

Being supportive is important to these patients13

ECTOPIC PREGNANCY

Fertilized egg has implanted outside the normal uterus

Patient often presents with abdominal pain Starts diffuse and them localizes to lower quadrant on affected side

Patient may not even be aware that they are pregnant If in fallopian tube and tube ruptures, maternal death due to internal hemorrhage is a real possibility Abdomen becomes rigid with pain

Often referred shoulder pain on affected side14

PLACENTA PREVIA

Abnormal implantation of placenta on lower half of uterine wall

Cervical opening partially or completely covered Placenta can start pulling away from attachment starting at 7th month

Painless bright red vaginal bleeding Uterus usually soft Potential for profuse hemorrhage Definitive treatment is cesarean section delivery

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ABRUPTIO PLACENTA

Premature separation of normally implanted placenta from uterine wall

Life threat for mother and fetus 20-30% mortality for fetus

Signs & symptoms depend on extent of abruption Can have sudden sharp, tearing pain and stiff, board like abdomen

Vaginal bleeding could range from none to some Blood could be trapped between placenta and uterine wall

Maintain maternal oxygenation and perfusion16

PRE-HOSPITAL CARE OF ANTEPARTUM BLEEDING

Maintain high index of suspicionTreat for blood loss Positioning – lay or tilt left Monitor for adequate oxygenation

Providing supplemental oxygen is also for benefit of the fetus Maintain adequate perfusion Consider fluid challenge as needed

200 ml increments with ongoing assessment/ evaluation Expedited transport; transport as soon as possible Early report to receiving facility

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HYPERTENSIVE DISORDER OF PREGNANCY

Major cause of maternal, fetal and neonatal morbidity and mortality Morbidity – presence of a disease state Mortality – relating to death

A common medical problem in pregnancy Includes gestational hypertension (hypertension that develops during pregnancy usually after the 20th week) and pre-existing hypertension (typically defined as a blood pressure > 140/90)

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PREECLAMPSIA

Most common hypertensive disorder of pregnancy Increased risk in diabetic, those with history of preeclampsia, and those carrying more than one fetus

Progressive disorder; most commonly seen last 10 weeks of gestation, during labor, or first 480 postpartum

Have a 30 mmHg increase in systolic B/P and 15 mmHg increase in diastolic B/P over baseline

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SIGNS AND SYMPTOMS PRE-ECLAMPSIA

Elevated blood pressure Headache Visual disturbances – blurred vision, flashing before the eyes Severe epigastric pain Vomiting Shortness of breath Tissue edema related to third spacing with fluid shift into tissues Swelling of face, hands, and feet

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ECLAMPSIA

Most serious side of hypertensive disorders of pregnancy Generalized tonic-clonic seizure activity Often preceded by flashing lights or spots before their eyes Epigastric pain or pain RUQ often precedes seizure

Note grossly edematous patient with markedly elevated B/P High mortality rates for mother and fetus Definitive treatment is delivery EMS needs to provide support until delivery at closest appropriate facility

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MANAGING SEIZURES DURING PREGNANCY

Positioning of patient To protect from harm, protect airway

Maintain patent airway Potential need for intermittent suction

Support ventilations Patient’s respirations altered during active seizure activity Will need supportive ventilations especially in presence of long lasting seizure activity

Manage seizure with Versed 2 mg IN/IVP/IO every 2 minutes up to 10 mg (does cross the placental barrier; could depress fetus)

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SUPINE HYPOTENSIVE SYNDROME

Usually occurs in 3rd trimesterGravid uterus compresses inferior vena cava when mother lies supine

Mother may experience dizzinessEvaluate for volume depletion versus positioning problem

Place mother in left lateral recumbent position (“lay left”) for assessment, treatment, and transportation to prevent this problem

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IDENTIFYING IMMINENT DELIVERY

Mother entering the 2nd stage of labor Measured from complete dilation of cervix (10cm) to delivery of fetus Could last 50-60 minutes for first pregnancy

Contractions strong lasting 60-75 seconds and 2 -3 minutes apart Membranes may rupture

Has urge to push Perineum bulging Crowning evident when head or other presenting part is evident at vaginal opening during a contraction

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OB KIT CONTENTS AND ADD-ONS

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Cap

ID bands

STEPS TO TAKE DURING DELIVERY

Try for a private area if out in public Place patient on her back with room to flex knees and hips

Prepare equipment – OB kit Coach mother to breath between contractions and to push with contractions once crowning is evident

Support head as it emerges Check for nuchal cord Clear the airway with a bulb syringe if secretions present

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DELIVERING THE BABY

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DELIVERY CONT’D

Gently guide baby’s head downward Facilitates delivery of upper shoulder

Then gently guide baby’s body upward Facilitates delivery of lower shoulder

Rest of baby quickly delivers Be prepared! Infant will be slippery!

Note time of delivery – when baby totally outKeep baby in head down position

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DELIVERING THE BABY

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USE OF BULB SYRINGE

Routine suctioning is no longer recommendedSuctioning has been associated with bradycardia and other problems

Suctioning is limited to necessity If performed, suction MOUTH, then nose Suctioning the nose is the stimulus to breath Want the airway clear prior to stimulation to take a breath

Infant will not start to breath until their chest clears the birth canal and can then expand

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DELIVERING THE BABY

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NORMAL APPEARANCE OF NEWLY BORN

Infants will be wet and slippery

Covered with a cheesy like substance that wears off shortly after delivery

Hands and feet may be cyanotic longer that other parts of the body

Extremities should be actively moving

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NEWLY BORN APPEARANCE

Risk for blood and body fluid contamination during all deliveries

Have high regard for use of appropriate PPE’s!

Drying off preserves heat and acts as a stimulus by the rubbing activity

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INITIAL ASSESSMENT OF NEWBORN

Begin steps of inverted pyramid as you are assessing newborn Begin to dry infant; change to dry towel as needed

Cold infants can deteriorate quickly Infants have difficult time generating & maintaining body heat; they cannot shiver to generate heat

Suction with bulb syringe only when secretions are present Suctioning when not necessary associated with bradycardia and other problems

Assess newborn as soon as possible after birth Normal respiratory rate averages 30-60 breaths per minute Normal heart rate ranges from 100 – 180 beats per minute

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INVERTED PYRAMID

(Always needed)

(Infrequently needed)

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APGAR SCORE

Developed in 1953 by Dr. Apgar, a surgeon turned anesthesiologist An assessment is taken at 1 and 5 minutes after birth The 1 minute score reflects how well the infant tolerated the birthing process and indicates need for early intervention

The 5 minute score reflects how well the infant is tolerating being outside the womb as well as response to interventions provided

The higher the score (closer to 10), the better the infant’s transition Early duskiness of distal extremities is common often leading to a 1 minute score of 9

The score does NOT predict the future health of the child

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APGAR CONT’D

Any score less than 7 merits an interventionSupplemental airwayClearing the airwayPhysical stimulationRubbing the backFlicking the bottom of the foot

Most low initial scores at 1 minute improve with the usual interventions listed at the top of the pyramid and by the 5 minute assessment, are usually at higher, acceptable scoresProviding assessment/reassessment will be key

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CARE OF THE CORD

Do not pull on the cord Avoid cutting the cord prematurely Want the last kick of blood available to be delivered to the infant

Once the cord has stopped pulsating and gone limp, can prepare to clamp and tie it Place one clamp 8 inches from newborn’s navel Place 2nd clamp about 2 inches further away Cut exposed cord between the clamps – it’s tougher than anticipated

Continue to assess the newborn’s end of exposed cord for any bleeding

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CARE OF THE CORD

There is no rush to clamp and cut the cordYou want to give enough time for all blood possible to infuse from mother to the placenta to the infant Infant's have a very limited blood volume to begin with (80 ml/kg)

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PREVENTING HEAT LOSS

Heat loss can be life threatening for the newbornMost heat loss is via evaporation while wet with amniotic fluid

Can lose heat via convection depending on temperature of room and movement of air around newborn

Can lose heat via conduction if in contact with cooler objects

Can radiate heat to colder nearby objects

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PRESERVING THE NEWBORN’S BODY TEMPERATURE

Dry the newborn immediately after birthMaintain a warm ambient temperatureClose all windows and doorsReplace wet towels with dryKeep infant wrapped and head covered to prevent heat loss

Mother holding the newborn transfers her body heat

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NEWBORN RESUSCITATION

Additional efforts required when the respiratory rate is decreased, heart rate <100, or there is decreased muscle tone

Attempt positive pressure ventilations via BVM Rate of 40- 60 breaths per minute Watch that the volume is enough to make the chest rise and fall Reassess after 30 seconds

IF heart rate is 60 -100 beats per minute Continue positive pressure ventilation

IF heart rate is less than 60 Begin chest compressions at a ratio of 3:1; reevaluate every 30 seconds

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3RD STAGE OF LABOR – PLACENTAL STAGE

Uterus continues to contractCord appears to lengthenMay have increase in bloody discharge

If delivered, transport with mother to the hospital

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COMPLICATIONS – PROLAPSED CORD

Umbilical cord visible prior to delivery Cord will be compressed if fetus passes through birth canal

Goal Prevent mother from delivering vaginally

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PROLAPSED CORD

This is one of the complications you want to visually check for as quickly as possible once on the scene of an imminent delivery

If the cord is visible protruding from the vagina Elevate the mother’s hips Instruct patient to pant during contractions or just keep her breathing during a contraction

Place gloved hand into vagina between pubic bone and presenting part Monitor cord between fingers for pulsations

Keep exposed cord moist with dressings and keep warm Transport with hand in place – DO NOT REMOVE YOUR FINGERS

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MECONIUM STAINING

Occurs in approximately 10-15% of deliveriesMeconium is dark green and can be of thin or thick consistency

Fetal distress and hypoxia cause meconium to pass from the fetal GI tract into the amniotic fluid

If infant is breech, meconium staining is anticipated and expected as the abdomen is compressed in the birth canal

Meconium aspiration increases neonatal mortality rate If aspirated can obstruct small airways & cause aspiration pneumonia and lead to respiratory distress

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NORMAL MECONIUM STOOL

Usually passed within 480 of birthTypically transitions to normal stool beginning by day 4

Meconium is thick, dark almost black stool normally found in the infant’s intestines

Becomes a problem when aspirated or otherwise blocks the infant’s small airways

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MECONIUM – THIN OR THICK?

If thin, may not require any intervention if infant is vigorous No problems with respiratory rate Normal muscle tone Heart rate over 100 beats per minute Bulb syringe easily takes care of most cases of meconium

Infant is not vigorous – will need interventions Decreased respirations Decreased muscle tone Heart rate < 100 beats per minute

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IF INTERVENTION REQUIRED FOR MECONIUM

If interventions required, must move quickly You have limited time to intervene You must be proactive and anticipate use of equipment Suctioning with meconium aspirator needs to be performed prior to the infant’s need to take their first breath

If you are organized and efficient, you MAY get the opportunity to suction twice You probably won’t get the opportunity for more than two attempts

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EQUIPMENT FOR MECONIUM ASPIRATION Suction tool Suction force turned down to 80 mmHg

Meconium aspirator Intubation blade and handle 2 ETT of anticipated size Additional ETT sized below and above anticipated size to use

Stylet Neonatal BVM

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PRESENCE OF MECONIUM

Suctioning must occur prior to infant being stimulated It is more efficient if performed as a team effort in the non-vigorous infant

Provide blow-by oxygen during procedure to keep environment oxygen enriched

Blade can be left in position as first ETT is removed Assistant should be ready to attach meconium aspirator to proximal end of ETT as soon as stylet is removed

New, clean ETT with stylet needs to be prepared & ready to be used as soon as 1st ETT is removed

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MECONIUM ASPIRATOR

Connect small end of meconium aspirator to suction connecting tube

Set suction down to 80 mmHg Endotracheal tube inserted using blade and handle Meconium may obscure your view

Wider end of aspirator connected to proximal end of ETT Thumb placed over suction port while withdrawing ET tube within 2 seconds

Discard ETT after 1 sweep and use new ETT if 2nd attempt made

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SUPPORTIVE VENTILATION

Proper positioning is a small towel under the torsoVolume is enough to make the chest rise gentlyRate is 40-60 breaths per minuteDo not flow oxygen into the infant’s eyes or put pressure over the eyes Newborns are sensitive to vagal stimulation and will respond with bradycardia

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NUCHAL CORD

Cord is wrapped around the infant’s neckProblem exists if the cord is too tight and prevents infant from delivering Remember: fetus is receiving their oxygen and blood supply via the cord

If cord clamped and cut prematurely, infant needs to be delivered without delay to begin to ventilate on own

Goal: If cord too tight for infant to deliver, then unwrap or clamp & cut

Prevent mother from pushing until cord is unwrapped or cut55

POSTPARTUM HEMORRHAGE

Loss of more than 500 ml of blood immediately following delivery 500 ml = 2 cups = 16 oz = 1 pint = 1 pound by weight of soaked pad

Most common cause is uterine atony – lack of uterine tone; failure of uterus to contract after delivery

Occurs more frequently in multigravida and more common following multiple births or births of large infants

Rely on clinical appearance of mother and vital signsUterus often feels boggy on palpationNeed to perform fundal massage

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FUNDAL MASSAGE – 2 HANDED TECHNIQUE

Must NOT be performed until after delivery of the placenta

Is a 2 handed techniquePerformed to get uterus to contract to minimize blood loss

Need the uterus to firm up Should feel like a grapefruit or fist

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FETAL ALCOHOL SYNDROME (FAS)

Life long effects started from the wombWhen the mother drinks, alcohol crosses the placenta and passes to the fetus

Alcohol affects neurons and the central nervous system (CNS) of the fetus

Damages physical structures and growthDefects more pronounced as the child grows

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CRISIS AT BIRTH

If FAS is suspected:Anticipate a small weight newbornAnticipate a newborn who may need some resuscitative effortsAssisted ventilationsExtra attention to be kept warm due to typically a smaller birth weight

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FETAL ALCOHOL SYNDROME (FAS)

Signs and symptoms noted at birth related to effects of hypoglycemia and dehydration

Newborn has a “hangover” following binge drinking of the mother

Typical appearance Underweight; “skinny” Irritable Poor reserves Changes in facial features

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FETAL ALCOHOL SYNDROME

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FETAL ALCOHOL SYNDROME (FAS)

All defects last a lifetimeNeurological defects include Motor skills; poor pace of walking Memory impairment; learning disabilities Poor social skills Potential for heart murmur, joint defects, hearing problems, renal problems

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SIDS

Sudden infant death syndrome describes the unexplained sudden death of an infant

Major cause of death in infant’s first month of lifeMost victims appear healthy prior to deathThere is still no cause of SIDS but theories do exist Stress in infant possibly from infection or other factors A birth defect Failure to develop A critical period of rapid growth

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SIDS

SIDS cannot be prevented or predictedDeath seems to occur during sleepThere are no warning signs or symptomsParents will need emotional support Parents will often blame themselves

“I should have…” “I should not have…”

Each case is handled individually in regards to EMS response

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POST PARTUM DEPRESSION

Many symptoms may be experienced by the new mother

EMS responding to “an accident” may be caring for a mother experiencing postpartum depression

Our biggest fear is that the patient may be experiencing issues that may take over and lead them to do harmful things to themselves and/or the children

Just be alert to potential situations that may be more than they appear to be Like the MVC that may be a suicide attempt

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POST PARTUM DEPRESSION SYMPTOMS

Being overwhelmed, irritated, angry, no patienceFeel this is more than just “hard”; feels like she can’t handle being a mother

Sadness to the depth of their soul Inability to stop cryingCan’t concentrate; feel disconnectedHaving thought of running away, or of hurting self or the baby

Confused and scared66

CASE SCENARIO DISCUSSION

Review the following cases and determine what your general impression is

Discuss what your intervention needs to beRefer to the Region X SOP’s as necessary

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CASE SCENARIO #1

EMS is called to the scene of a mother who is in laborWhat questions are important to ask early? Number of pregnancies Due date Known complications Previous labor history if any If bag of waters are intact or broken The duration and frequency of contractions

In report, provide weeks of gestation and not the months Provides more precise picture of age of infant (i.e.: premature or not) 68

CASE SCENARIO #1

What indicates that delivery is imminent?

CrowningBulging of the perineumContractions that are lasting 60-75 seconds and coming every 2-3 minutes

Urge to pushFeeling that she wants to have a bowel movement

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CASE SCENARIO #1

What is assessed with the APGAR score? A – appearance or coloring

Fingers and toes often bluish for a few minutes P – pulse

Best to have a pulse over 100 beats per minute G – grimace or reflexes

Grimacing, coughing, sneezing are good to see A – activity or muscle tone

Want to see flexed extremities R – respiratory effort

Want to hear a strong cry

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CASE SCENARIO #1

What are the interventions listed at the top of the inverted pyramid that each newborn typically receives? Drying – to prevent heat loss by evaporation Warming the infant to stop the heat loss Stimulation by touching and rubbing the infant Flicking the bottom of the feet or rubbing the back if more tactile stimulation is required

Keeping the newborn in a head down position to facilitate drainage from the lungs

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CASE SCENARIO #2

You have arrived on the scene and determined that you will need to deliver a newborn

During assessment and in preparation of the event, you notice dark, thick greenish-black flecks of material in the leaking bag of waters

What does this indicate? Evidence of meconium staining

What does this mean? If not a breech delivery, the fetus may be in distress and require extra resuscitative efforts

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CASE SCENARIO #2

What equipment do you need to prepare? Neonatal BVM Meconium aspirator Several endotracheal tubes Several stylets Blade and handle Oxygen source Suction device – turned down to 80 mmHg

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CASE SCENARIO #2

What assessment of the newborn would indicate a need to use a meconium aspirator? If the infant is not vigorous The respiratory rate is decreased There is decreased muscle tone – newborn is limp Heart rate is below 100 beats per minute

Remember: a bulb syringe works just fine for most situations involving the presence of meconium at birthDepress the bulb prior to inserting into the mouth and nose

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CASE SCENARIO #3

You are on the scene and have just assisted the mother in delivering her 3rd child

The infant is not as responsive to drying and stimulation as you feel they should be and extremities are dusky

You want to provide blow-by oxygenHow would you deliver blow-by oxygen? Hold a source of oxygen next to the infant's nose and mouth and let the oxygen source “blow-by”

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CASE SCENARIO #3

The infant is not responding to the blow-by effortsThe respiratory rate is low and the heart rate is less than 100

What is your next intervention? Begin positive pressure ventilations at 40-60 breaths per minute Ventilate with small puffs of air Reevaluate every 30 seconds

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CASE SCENARIO #3

What would you do if the pulse remained between 60 and 100? Continue positive pressure ventilations Reassess every 30 seconds

What would you do if the pulse dropped below 60 in the newborn? Begin chest compressions

3 compressions to 1 ventilation Depress the sternum 1/3 the AP diameter of the chest on lower half of sternum

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CASE SCENARIO #4

You are on the scene for a patient who fellUpon your arrival you note an unresponsive adult on the floor who is obviously pregnant

Your patient is in a tonic-clonic seizureWhat is your general impression? First thought is eclampsia Need to consider an epileptic seizure Need to be thinking possible hypoglycemia Need to determine presence of head injury

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CASE SCENARIO #4

What are your actions during this on-going seizure activity? Protect the patient from harm Maintain a patent airway

Suction available Turn patient on left side

Also avoids supine hypotensive syndrome Consider supporting ventilations via BVM

1 breath every 5-6 seconds (10-12 breathe per minute) Obtain any medical history available

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CASE SCENARIO #4

What medication is used in the presence of seizure activity in the patient who is pregnant?Versed 2mg IN/IVP/IOMay repeat every 2 minutes titrated to desired effect

Maximum dose of 10 mg If seizure activity continues or reoccurs, contact Medical Control for additional orders of Versed up to an additional 10 mg

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CASE SCENARIO #4

What would be important to relay in your face to face hand-off report with this case once at the hospital?

Fact that Versed was administered Versed crosses the placental barrier If administered close to the time of delivery, may witness side

effects in the newborn related to the VersedRespiratory depressionHypotension

Would be important for OB to try to differentiate if signs or symptoms are due to the condition of the newborn or related to interventions performed

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BIBLIOGRAPHY

Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4th edition. Brady. 2013.

Mistovich, J., Karren, K. Prehospital Emergency Care 9th Edition. Brady. 2010.

Region X SOP’s; IDPH Approved January 6, 2012.

http://www.primehealthchannel.com/fetal-alcohol-syndrome-pictures-symptoms-statistics-and-treatment.html

http://www.emedicinehealth.com/postpartum_depression/article_em.htm

http://www.nlm.nih.gov/medlineplus/ency/article/003402.htm

http://www.pphprevention.org/pph.php

http://calsprogram.org/manual/volume1/Section4_Path/05-PATH4NeonatalEmergencies13.html

http://www.cdc.gov/vhf/ebola/hcp/procedures-for-ppe.html82