OB Delivery Complications & Use of the Meconium Aspirator

1. OB Delivery Complications &Use of the Meconium Aspirator Condell Medical Center EMS System April 2008 Site Code #10-7200E1208 Prepared by: Sharon Hopkins, RN, BSN, EMT-P

2. Objectives • Upon successful completion of this module, the EMS provider should be able to: • list physiological changes in pregnancy. • identify the stages of labor. • describe the assessment of a patient in labor. • explain the contents of the OB kit. • identify obstetrical emergencies. • describe how to care for a prolapsed cord and a breech delivery.

3. Objectives cont’d • actively participate in discussion of case presentations. • actively participate in hands-on skills of delivery complications. • successfully complete the quiz with a score of 80% or better.

4. Physiological Changes in Pregnancy • Reproductive system • Increase in size of uterus • Increased vulnerability to injury • During pregnancy uterus contains 16% of the total blood volume • Extremely vascular organ during pregnancy • Uterus and fetus insulted if blood flow diminished

5. Normal Fetal Positioning

6. Changes in Pregnancy cont’d • Respiratory system • Increase in oxygen demand & consumption • 40% increase in tidal volume • Amount of air in or out in one breath • Only slight increase in respiratory rate • Diaphragm pushed upward decreasing lung capacity

7. Changes in Pregnancy cont’d • Cardiovascular system • Cardiac output increases • Maternal blood volume increases by 45% • Heart rate increases by 10 – 15 beats per minute • B/P decreases slightly in first 2 trimesters • B/P normal in 3rd trimester • Supine hypotensive syndrome after 5 months if heavy weight of uterus presses on inferior vena cava (when mother lying on her back)

8. Changes in Pregnancy cont’d • Gastrointestinal system • Nausea and vomiting common in 1st trimester • From hormone levels and changed carbohydrate needs • Delayed gastric emptying • Watch for vomiting and airway compromise • Hands-on physical abdominal assessment difficult due to compression and shifting of abdominal organs

9. Changes in Pregnancy cont’d • Urinary system • Increase in renal blood flow • Urinary frequency is common • Urinary bladder displaced more forward and higher increasing vulnerability to injury to the urinary bladder • Musculoskeletal system • Waddling gait due to loosened pelvic joints • Low back pain due to change in center of gravity

10. First Stage of Labor • Dilatation Stage • Begins with onset of true labor contractions • Ends with complete dilatation and thinning of the cervix • Cervix dilates from a closed position to 10 cm (approximately 4 inches) • Duration about 8 – 10 hours in 1st pregnancy • Early contractions mild, last 15 – 20 seconds coming every 10 – 20 minutes • End of 1st stage contractions last 60 seconds and are coming every 2 – 3 minutes

11. Second Stage of Labor • Begins with complete dilatation of cervix • Ends with delivery of fetus • Can last 50-60 minutes in 1st deliveries • Pain felt in the lower back • Mother has the urge to push • Bag of waters usually rupture in this stage • Crowning is evident • Definitive sign of imminent delivery

12. Third Stage of Labor • Begins immediately after birth of the infant • Ends with delivery of placenta • Placenta generally delivers within 5 – 20 minutes • Signs of placental separation • Gush of blood from vagina • Change in size, shape, consistency of uterus • Umbilical cord length increases • Mother has the urge to push

13. Assessment of the Patient in Labor • Ask expected due date • Gravida – number of pregnancies • First time deliveries tend to take longer – 16 – 17 hours • Labor tends to shorten with subsequent pregnancies • Para – number of live births • Is it “gravida and para” or “para and gravida”? • Note: “G” comes before “P” in the alphabet; you must be pregnant beforeyou can deliver

14. Assessment of the Patient in Labor • Determine how long mother has been in labor • Ask how long previous deliveries took • Ask if bag of waters is intact or has broken • Delivery is quicker once bag of waters has broken • Are there any high risk concerns the mother is aware of

15. Assessment of the Patient in Labor • Time duration & frequency of contractions • Duration is from the beginning of one contraction to the end of that contraction • Frequency is how far apart contractions are • Measured from the beginning of one contraction to the beginning of the next contraction • Contractions lasting 30-60 seconds and coming every 2-3 minutes apart indicate imminent delivery

16. Signs of Imminent Delivery • Crowning • Bulging of the fetal head past the vaginal opening during contraction • Bulging perineum • Presenting part pressing on perineum • Urge to push • Note: High index of suspicion in female with abdominal pain and cramping (esp in a pattern) and denies pregnancy

17. Sterile gloves Drape sheet Gauze sponges Disposable towels 2 alcohol preps 2 OB towelettes Bulb syringe Receiving blanket 2 umbilical clamps 2 nylon tie-offs Scalpel OB pad Plastic bag Twist ties Infant cap 2 wrist ID bands OB Kit Contents

18. OB Kit Contents

19. Newborn At Delivery

20. Preventing Hypothermia in a Newborn

21. APGAR Assessment – 1 & 5 minutes • A – appearance • Most visible, least helpful • Typical for pink trunk and blue distal extremities • P – pulse • 100 or above is acceptable • 80-100 – stimulation needed • <60 – start compressions

22. APGAR cont’d • G – grimace (irritability) • Includes coughing, sneezing, crying • A – activity • Active motion, flexing of extremities • R – respiratory effort • Strong cry • Majority of scores are 7–10 indicating a healthy infant requiring routine care • Scores 4-6 indicate moderately depressed infant requiring oxygen & stimulation

23. APGAR Score

24. Inverted Pyramid Drying, warming, positioning Suction, tactile stimulation Oxygen BVM Chest Compressions Intubation Meds Basic skills Advanced skills

25. OB Complications – Supine Hypotensive Syndrome • Occurs in the 3rd trimester • Heavy weight of uterus compresses inferior vena cava when mother in the supine position • Interferes with blood flow returning back to the heart • Intervention • Transport women over 5 months pregnant lying or tilted towards their left side Remember: Lay left

26. OB Complications – Seizures • Consider causes • Hypoglycemia – check glucose levels on all patients with altered level of consciousness • Epilepsy – check for ID; protect airway • Eclampsia – protect airway • Intervention • For any prolonged seizure activity, need to consider using BVM to support ventilations and provide oxygenation • Transport lying/tilted left if over 5 months gestation • Valium, if given, has effect on mother & fetus • 5 mg IVP over 2 min; titrate; max total 10mg

27. OB Complications – Breech Delivery • Buttocks or feet present first • Approximately 4% of all births • Increased risk • Maternal trauma • Prolapse of cord • Cord compression • Anoxia to the infant • Intervention • Advanced medical intervention at the hospital • Rapid transport important

28. Breech Presentation

29. Breech Delivery cont’d • Intervention • As legs deliver, support legs across forearm • If cord is accessible, palpate often • If able, loosen cord to create slack • After torso and shoulders deliver, gently sweep down arms • If face down, gently elevate legs & trunk to facilitate delivery of head • NEVER PULL INFANT BY LEGS OR TRUNK

30. Breech cont’d • If head not delivered within 30 seconds • Reach 2 gloved fingers into vagina to locate baby’s mouth • Push vaginal wall away from baby’s mouth to form an airway • Keep your fingers in place and transport immediately • Keep delivered part of baby warm • Cover with a blanket • If head delivers, anticipate neonatal distress

31. OB complications – Prolapsed Cord • Perform a visual exam as soon as possible whenever a mother states her bag of waters has ruptured • Elevate the mother’s hips or place knee-chest • Have patient breath through the contractions so she doesn’t push • Placed gloved hand into vagina and raise presenting part to get pressure off cord • Keep cord between fingers to monitor for pulsations • Cover cord with moist dressing, keep warm

32. Prolapsed Cord

33. OB Complications – Nuchal Cord • Cord wrapped around infant’s neck • Increase mother’s O2 to 100% non-rebreather mask • Slip fingers around cord and lift over infant’s head • Proceed with delivery • If unable to reposition cord, place 2 OB clamps, cut cord between clamp, release cord from around neck • Proceed with delivery

34. Nuchal Cord (C-section)

35. Meconium • Dark green material found in the intestine of the full-term newborn. • It can be expelled during periods of fetal distress (ie: hypoxia) • If found in the infant airway, could compromise ventilations

36. Meconium Staining • Fetus has passed feces into amniotic fluid • Occurs between 10-30% all deliveries • Not unusual to observe in breech delivery • In normal head-down delivery indicates fetal hypoxia • Hypoxia increases fetal peristalsis and relaxation of anal sphincter • The darker the color/staining, higher the risk of fetal morbidity

37. Meconium Stained Baby • Airway needs to be cleared to avoid aspiration of meconium • Suction and clear airway before infant needs to take that first breath

38. Meconium Staining • If meconium is thin and light in color and the infant is vigorous • Most meconium can be cleared away with bulb syringe • ALWAYS suction mouth then nose, in that order • Suctioning the nose stimulates breathing in the newborn • Want to clear the mouth 1st so first breath is as clean as possible • Limit suction (2 seconds per Region X SOP)

39. Meconium Staining • If infant is not vigorous • Respiratory rate decreased • Decreased muscle tone • Heart rate < 100 • Use meconium aspirator to clear airway • This will take coordination and best accomplished with 2 persons working as a team

40. Meconium Suctioning • Steps include intubation • Most efficient when performed as a 2 person team • Time is essential • May need to perform 2 intubation insertions • Use each ETT once

41. Meconium Aspirator • Connect small end of meconium aspirator to suction line connecting tube • Turn suction down to 80 mmHg • Insert endotracheal tube • Don’t anticipate visualizing landmarks – they may be obscured by meconium • Connect larger end of aspirator to ETT • Place thumb over suction control port and slowly withdraw ETT (< 2 seconds) • Discard ETT after one use

42. Meconium Aspirator Aspirator can be used a second time on infant with new ETT each time Limit suction to <2 seconds

43. Case Study #1 • EMS arrives on the scene for OB call • Patient is 24 y/o and states she is in labor • What assessment questions specific to an imminent delivery need to be asked? • What type of EMS physical assessment needs to be performed?

44. Case Study #1 • Assessment questions • Gravida? • Para? • Due date? • High risk concerns? • Length of previous labors? • Bag of waters intact? Ruptured? • Duration and frequency of contractions?

45. Case Study #1 • Physical exam – position patient to evaluate • Crowning • Evidence of bulging perineum • Involuntary pushing • Signs of prolapsed cord • Evidence of profuse bleeding

46. Case Study #1 History • G2P1 • EDC in 1 week • No complications anticipated • Previous labor 12 hours • Bag of waters has ruptured • Contractions are 5-6 minutes apart and lasting 20-30 seconds • There is no bulging or crowning Do you stay & prepare to deliver or transport?

47. Case Study #1 • You could most likely begin transport with OB kit reached out in case labor progresses • What stage of labor is the patient in? • First stage • If the patient delivers, how many run reports need to be written? • Two – one for the mother, one for the infant

48. What is your role during delivery? Support the presenting part Check for nuchal cord Suction mouth Then nose

49. Head and shoulders delivered • Have a firm grip on infant • Cheesy covering and moisture make them slippery • After shoulders, rest of the body will slip out fast

50. Clamping & cutting the cord • After cord is done pulsating, clamp 8″ from infant’s navel with 2 clamps placed 2″ apart • Watch for blood leakage from infant’s cord • Reinforce with additional clamps as needed