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OB Emergencies

OB Emergencies. November 2010 CE Condell EMS System Objectives by Jeremy Lockwood, FF/PM Mundelein Fire Department Packet prepared by Sharon Hopkins, RN, BSN, EMT-P. Objectives. Upon successful completion of this module, the EMS provider will be able to:

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OB Emergencies

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  1. OB Emergencies November 2010 CE Condell EMS System 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 EMS provider will be able to: • 1. Identify appropriate standard precautions 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. • 18. Review documentation components for discussed conditions. • 19. Given a manikin, demonstrate use of the OB kit. • 20. Demonstrate use of the meconium device.

  5. Standard Precautions • Anticipate the exposure to a large amount of blood and body fluids • Full protection is recommended • 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 holds 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 • Need to determine if delivery is imminent or if there is time to transport • 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 increase 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 one • 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 • Decreases stroke volume pumping out of the heart • Especially after 5 months transport 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 • 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

  34. Cord Clamps • FYI • If not used for a period of time, it has been reported that the OB clamps become brittle and can break • There is no hurry to clamp and cut a cord • If you transport 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 of mouth, then 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 record on the infant’s run report • 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 • Continue to suction mouth then nose • Spontaneous respirations should begin within 15 seconds after stimulation • If no respirations, begin BVM support at 30-40 breaths per minute • If pulse < 60 or between 60-80 and not improving, begin CPR • 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; 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 & cored 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 • 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 • 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, collect and transport with the patient • Inspected 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

  50. Placenta Fetal Side

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