Obstetrics Emergency Care Module for EMS Providers

1. OB Emergencies July 2012 CE Condell Medical Center EMS System Site Code: 107200E -1212 Prepared 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