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OB Emergencies

OB Emergencies. ECRN CE Module IV 2010 Condell EMS System IDPH Site Code #107200E-1210 2 hours CE credit Objectives by Jeremy Lockwood, FF/PM Mundelein Fire Department Packet prepared by Sharon Hopkins, RN, BSN, EMT-P. Objectives.

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OB Emergencies

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  1. OB Emergencies ECRN CE Module IV 2010 Condell EMS System IDPH Site Code #107200E-1210 2 hours CE credit Objectives by Jeremy Lockwood, FF/PM Mundelein Fire Department Packet prepared by Sharon Hopkins, RN, BSN, EMT-P

  2. Objectives Upon successful completion of this module, the ECRN will be able to: 1. Identify appropriate standard precautions taken 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.

  3. 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.

  4. 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.

  5. Standard Precautions Anticipate the exposure to a large amount of blood and body fluids Full protection is recommended Standard precautions Don’t assume the absence or presence of disease just by appearances of the patient or situation

  6. Standard Precautions Handwashing- still most effective control measure around

  7. Just Protect Yourself!!! • Do what you can

  8. 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

  9. 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

  10. 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

  11. Placental Attachment

  12. Amniotic Sac • “Bag of waters” • Thin-walled membranous covering holding 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. Obstetrical Assessment • Determine if delivery is imminent or if there is time to transport • EMS to hospital or ED to OB • 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!)

  20. 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

  21. 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 increased 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

  22. 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

  23. 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 contraction • Includes contraction and rest intervals

  24. 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

  25. 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 • Therefore decreases stroke volume pumping out of the heart • Especially after 5 months keep the mother tilted or turned preferably toward the left

  26. 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

  27. 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 • First stage can last approximately 8-10 hours for first labor to about 5-7 hours in multipara

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. Contents of OB Kit Where are your kits kept in the ED?

  34. Cord Clamps • FYI • If not used for a period of time, it has been reported that the OB clamps can become brittle and can break • There is no hurry to clamp and cut a cord in the field • If EMS transports the mother and baby with the cord intact, so be it • The hospital will take care of clamping and cutting the cord

  35. 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 into mouth or 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

  36. Newborn At Delivery • They’ll grow into being a Gerber baby!

  37. Care of the Newborn cont’d • Hold on tight • Infant is slippery due to cheesy covering and amniotic fluid • Note time of delivery and document • Stimulate the infant • Suctioning, rubbing the back, flicking at the soles of the feet, drying off

  38. 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

  39. Care of the Newborn • Suction mouth then nose only as needed • Caution – you are removing oxygen with secretions!!! • Spontaneous respirations should begin within 15 seconds after stimulation • If no respirations, begin BVM support at 40-60 breaths per minute (1 breath every 1-1.5 seconds) • If pulse < 60 or between 60-80 and not improving, begin CPR (3:1 ratio) • Obtain 1 minute APGAR (ie: record as 9/10)

  40. 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 but most visible/obvious

  41. APGAR Scoring – 1 & 5 minutes

  42. Care of the Umbilical Cord • Clamp and then cut the cord after pulsations have stopped & cord 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

  43. Cutting the Clamped Cord

  44. FYI – What About Cord Blood? • Obtained in the hospital within 10-15 minutes of delivery (NOT obtained in the field) • 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

  45. 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 but only 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?)

  46. Care of the Newborn • Infant in head down (and side lying) position • Hat placed to minimize heat loss • Cord clamped and cut

  47. 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

  48. 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, collected and transported with the patient • Inspected at the hospital for retained placental parts • For excessive external bleeding, apply dressings externally • For excessive vaginal bleeding, uterine massage AFTER placenta is delivered

  49. Placenta Uterine Wall Side - Rough

  50. Placenta Fetal Side - Smooth

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