OB Emergencies November 2014 CE Condell medical center ems system IDPH Site Code: 107200E-1214

1. OB EmergenciesNovember 2014 CECondell medical center ems systemIDPH Site Code: 107200E-1214 Prepared by: Sharon Hopkins, RN, BSN, EMT-P Revised 11/19/14

2. 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.

3. 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.

4. 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

5. 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

6. physiological Changes During Pregnancy • Pregnancy is a normal and natural process • A 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

7. physiological changes of pregnancy • Nausea and vomiting due to hormonal changes • Delayed 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 changes

8. Physiological changes cont’d •  in oxygen demand and consumption • Diaphragm 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

9. fetal blood supply • No direct link between mother’s blood and infant • Mother’s blood flows to the placenta • Placenta supplies blood to the fetus • Placenta acts as a barrier protecting the fetus • Some items cross the placental barrier and can affect the fetus • Alcohol • Some medications – Valium Versed, oral diabetic meds, narcotics, some antibiotics, steroids

10. Umbilical cord • A flexible, rope-like structure approx. 2 feet long • Contains 2 arteries, 1 vein • Transports oxygenated blood to fetus • Returns relatively deoxygenated blood to placenta • Fetus can twist and turn in the uterus and get wrapped up in cord • Fetus can “tie umbilical cord into a knot”

11. Normal pregnancy – 20 weeks & term

12. Antepartum Complications • Vaginal bleeding • Ectopic pregnancy • Placenta previa • Abruptio • Hypertensive disorders • Preeclampsia, eclampsia • Supine Hypotensive Syndrome

13. 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 patients

14. 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 side

15. 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

16. 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 perfusion

17. Pre-hospital Care of antepartum bleeding • Maintain high index of suspicion • Treat 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

18. 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)

19. 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

20. 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

21. 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

22. 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)

23. Supine hypotensive syndrome • Usually occurs in 3rd trimester • Gravid uterus compresses inferior vena cava when mother lies supine • Mother may experience dizziness • Evaluate for volume depletion versus positioning problem • Place mother in left lateral recumbent position (“lay left”) for assessment, treatment, and transportation to prevent this problem

24. 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

25. Ob kit contents and add-ons Cap ID bands

26. 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

27. Delivering the baby

28. 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 out • Keep baby in head down position

29. Delivering the baby

30. Use of bulb syringe • Routine suctioning is no longer recommended • Suctioning 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

31. Delivering the baby

32. 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

33. 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

34. 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

35. Inverted pyramid (Always needed) (Infrequently needed)

36. 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

37. APGAR cont’d • Any score less than 7 merits an intervention • Supplemental airway • Clearing the airway • Physical stimulation • Rubbing the back • Flicking 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 scores • Providing assessment/reassessment will be key

39. 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

40. Care of the cord • There is no rush to clamp and cut the cord • You 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)

41. Preventing heat loss • Heat loss can be life threatening for the newborn • Most 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

42. Preserving the newborn’s body temperature • Dry the newborn immediately after birth • Maintain a warm ambient temperature • Close all windows and doors • Replace wet towels with dry • Keep infant wrapped and head covered to prevent heat loss • Mother holding the newborn transfers her body heat

43. 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

44. 3rd stage of labor – placental stage • Uterus continues to contract • Cord appears to lengthen • May have increase in bloody discharge • If delivered, transport with mother to the hospital

45. 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

46. 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

47. Meconium Staining • Occurs in approximately 10-15% of deliveries • Meconium 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

48. Normal meconium stool • Usually passed within 480 of birth • Typically 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

49. 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

50. 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