OB Emergencies

July 2012 CE Condell Medical Center EMS System Site Code: 107200E -1212 Prepared by: Sharon Hopkins, RN, BSN, EMT-P 1

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.

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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.

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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 4

Female Reproductive System

 Most important organs are internal     Vagina Uterus Fallopian tubes Ovaries 5

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 6

Assessment

  EMS will perform a of the perineum

VISUAL

 Area of tissue of the external genitalia EMS will exam

NEVER

perform a “vaginal”  inspection A “vaginal exam” is the insertion of gloved fingers into the vagina for assessment by palpation 7

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 8

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 9

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 10

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 11

Physiological Changes of Pregnancy

      blood volume     Pink skin; the “glow” of pregnancy O 2 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 12

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 13

Placenta

      Temporary structure An endocrine gland  Secretes hormones during pregnancy Blood-rich Transfers heat Exchanges O 2 , CO 2 , nutrients, waste products Serves as protective barrier against some harmful substances 14

Is She Pregnant?

 Most typical signs or symptoms  Late or missed period  Fatigue/exhaustion       Nausea/vomiting Breast changes Headache Spotting Frequent urination Constipation &/or bloating    body temp Dizziness/ lightheadedness 15

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 16

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 17

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!!!

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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 19

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 20

1

st

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) 21

2

nd

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 22

3

rd

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 23

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?

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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 25

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 26

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 27

OB Kit Contents

Go through your kit – describe how would you use each piece 28

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 29

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 30

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 31

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 3 rd pregnancy Her contractions are 2 minutes apart What are your next actions?

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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 33

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 34

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 35

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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 36

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 37

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 38

Hypertensive Emergencies

  Preeclampsia     Elevated blood pressure Excessive weight gain Extreme swelling face, feet, hands Headache or altered mental status Eclampsia  Seizure activity 39

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 40

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 41

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) 42

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!!!

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Abruptio Placenta

    Placenta prematurely separates from uterine wall  Partial or complete tear Excessive pain Rigid abdominal wall Minimal vaginal blood flow; dark 44

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 45

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 46

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 47

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 48

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 49

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 50

Breech Delivery

     Support infant’s body as soon as the legs deliver Keep infant’s exposed body dry and warm Attempt to loosen cord to create slack After torso and shoulders deliver, gently sweep down arms If face down, gently elevate legs and trunk to facilitate delivery of head 51

Breech cont’d

  Apply firm pressure over fundus to facilitate delivery of head If head not delivered in 30 seconds, reach 2 gloved fingers in to create an airway for infant   Push vaginal wall away from mouth DO NOT place oxygen tubing in the area  Could create an air embolism for the mother 52

Issues of Premature Birth

    Weaker, less developed muscles  Spontaneous breathing more difficult Deficiency in surfactant in lungs  Ventilations more difficult Rapid heat loss  Thin skin, decreased fat Immature tissues  More easily damaged by excessive oxygenation 53

Premature Births

    Watch the airway Protect from heat loss Have available the right equipment  Adult equipment cannot be used to “fit” a newborn Handle the newborn gently 54

Multiple Births

    Often scheduled deliveries in the controlled environment of the hospital Delivered by Caesarian due to odd presentations/positioning of infants Tend to be smaller birth weights If delivered in the field, attend to each baby as if they are one  Clamp and cut each cord as the infant delivers 55

Case Scenario #3

     EMS arrives on the scene of a MVC The driver is 8 ½ months pregnant There is deformity to the front end of the car & the steering wheel with airbag deployment The mother complains of severe upper abdominal pain and pain over her sternum VS: 132/88; P – 96; R – 22; SpO 2 97% 56

Case Scenario #3

  Where in the order of patient transport would this patient be placed if there are multiple patients to transport?

 This patient needs to be transported early; there may be issues with the fetus that are undetected at this point What is your general impression?

 Abruptio placenta is top of the list   Treat for shock Improve blood & oxygen flow to the uterus 57

Case Scenario #3

 Remember:   The mother temporarily has a higher blood volume so can lose more blood volume before signs and symptoms may be detected Normal physiological changes during pregnancy include a slightly lower blood pressure and slightly elevated pulse rate 58

APGAR Score

  What is it?

 An objective method of evaluating the newborn’s condition and overall status and response to resuscitation What is it NOT?

 NOT used to determine if the newborn needs resuscitation, or what steps are necessary, or when to apply resuscitation 59

APGAR Score

  Obtained at 1 and 5 minutes Evaluate 5 signs      Appearance* (color) Pulse / heart rate* Grimace – reflex irritability Activity – muscle tone Respirations* - crying * Signs also used to determine need for resuscitation 60

APGAR Score

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Umbilical Cord Care

       Low priority to clamp and cut cord Wait at least one minute after delivery Palpate cord to make sure no longer pulsating Clamped & cut AFTER care given to newborn Apply clamps 8 & 10“ from naval Cut in between the clamps Watch for any blood oozing from infant’s cut end  Apply another clamp or tie to oozing end if needed 62

Total Blood Volumes Average 75 - 80 ml/kg

   Adult – 4 - 5 liters Child - 2 liters Newborn – 335 ml 63

Case Scenario #4

   EMS is called to the scene for a patient in active seizure Upon arrival you note the patient to be obviously pregnant in active seizure with tonic/clonic movement What is your immediate action?

  Protect the patient from harm Protect and control the airway  Assist ventilations via BVM – this is a long seizure 64

Case Scenario #4

  What med is used to control the seizure?

    Versed 2 mg IN/IVP/IO Repeat every 2 minutes to desired effect (seizure stops) Maximum total of 10 mg If seizure recurs, contact Medical Control to renew the Versed order What category medication is Versed?

 A benzodiazepine 65

Case Scenario #4

  Would Versed have an effect on the newborn?

 Yes, Versed does cross the placental barrier What would be the effect of the Versed on the infant if delivered soon after Versed is administered to the mother?

 Newborn could have respiratory depression related to the Versed  Verbally remind staff at hospital that the mother received Versed in the field 66

Neonatal Resuscitation

   Neonate is 0 – 28 day old infant Guidelines developed by the American Heart Association (AHA) Remember:      Normal heart rates are faster Normal respiratory rates are faster Relatively larger body surface area Less ability to conserve body heat Most infants respond to warming, drying, & stimulation 67

Inverted Pyramid

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Newborn Resuscitation Algorithm

 Within 1 st  30 seconds of birth Warm the infant, clear airway if necessary, dry, stimulate  Majority of infants respond to this  Assess heart rate   If heart rate <100, gasping, or apneic  Within 60 seconds of birth begin positive pressure ventilation (i.e.: BVM) 40-60/second After 30 seconds if heart rate 60-100 use BVM  After 30 seconds if heart rate <60, start compressions 3:1 ratio 69

Neonatal Statistics

    Approximately 10% of newborns will require some assistance to begin to breath Approximately 1% of newborns will require extensive resuscitation If resuscitation is required, do not delay to obtain the 1 minute APGAR If an infant does not begin to breath immediately after stimulation, begin supportive ventilations via BVM – 40-60/minute  Further attempts at stimulation usually not effective 70

Neonatal Suctioning

  Performed only in the presence of obvious nasal or oral secretions  Can stimulate bradycardia  Can reduce cerebral blood flow when routinely performed Suctioning time must be limited to 3 - 5 seconds  Revised guidelines caution on suctioning – only suction if there is material that must be cleared 71

Fetal Oxygenation

  Fetus oxygenated via O 2 diffusing across placental membrane from mother’s blood to fetal blood  Fetal alveoli filled with fluid Changes shortly after delivery   Fluid in alveoli is absorbed Umbilical arteries and veins close when cord is clamped  Newborn systemic blood pressure increases  Lung tissue blood vessels relax allowing blood flow through the lungs 72

Newborn Assessment – Do They Require Resuscitation?

   Is the baby preterm?

 Especially less than 34 weeks increases risk of instability Is the baby breathing or crying?

 Gasping could indicate severe respiratory depression or neurological problems Is the muscle tone good?

 Flexed extremities is normal; extended and flaccid extremities not normal 73

Distressed Infant

    Gasping is as significant as apnea Bradycardia indicates a significant problem Immediate attention to the airway is important Providing assisted ventilations should result in a rapid increase in heart rate  Goal is to have heart rate >100 74

Obtaining Newborn Heart Rate

   Palpate brachial artery  Inner aspect upper arm Palpate at base of umbilicus Use stethoscope to auscultate the heart for an apical pulse  Note: Normal newborn heart rate can be a range of 100-180  Optimal heart rate is 140-160/minute 75

Neonatal Resuscitation

  When do I need to provide resuscitation?

 Heart rate <100 despite adequate ventilation and oxygenation for 30 seconds Use the right equipment for the right patient 76

Positioning

   Head extension required for adults and children Sniffing position best for infants   Baby’s nose is as far anterior as possible Head extension closes off airway Small pad (ie: diaper) under shoulder blades helps for positioning 77

Sniffing Position

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Adult/Child/Neonatal BVM’s

  Size does matter for BVM Little puffs of air   Enough to make the chest rise and fall If too much volume or too aggressive could cause pneumothorax 79

Revised CPR Guidelines 2012

 C- A- B (not ABC)      Check responsiveness Check for brachial pulses Begin compressions Open airway Provide gentle ventilations 80

Neonatal Resuscitation

 Chest compressions    90/minute Finger tips on lower half of sternum  Depress 1 ½ inches or diameter 1 / 3 the AP Compression to ventilation ratio: 3:1  Ventilations are tiny puffs of air 81

Neonatal Ventilatory Support

  Pulse present with inadequate breathing  Deliver 1 breath/second with neonatal BVM until heart rate >100 If advanced airway in place  Deliver 1 breath/second with neonatal BVM until heart rate >100 82

Maternal Resuscitation

  Modifications may need to occur due to the enlarged uterus   During CPR 1 person performs left uterine displacement while patient is supine  Manually pull/push uterus toward the left Chest compressions should be performed slightly higher on the sternum No modifications for defibrillation  Performed following usual technique 83

Case Scenario #5

   EMS is called to the scene for a newborn choking Upon arrival, EMS notes a 10 day old infant lying limp; cyanotic; no signs of respiratory effort What is your response/action?

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Case Scenario #5

 Immediately begin assessment    Is the baby responsive? No Look for signs of life – there are none Deliver 90 compressions /minute  2 finger tips (or thumbs if wrapping the chest wall with your hands in 2 person CPR) 1 finger width below the nipple line  Compress to a depth of 1 / 3 of the chest wall the AP diameter 85

Case Scenario #5

   Deliver 2 puffs of air   Enough to make the chest rise Compressions to ventilation ratio: 3:1 Inadequate breathing with pulse  Deliver 1 breath per second to achieve heart rate >100 Ventilations with advanced airway in place  Deliver 1 breath per second to achieve heart rate >100 86

Case Scenario #5

   If rhythm is VF or pulseless VT, a manual defibrillator is preferred  Can dial down defibrillator to 2 joules /kg followed by 4 j/kg for subsequent events  In absence of manual defibrillator, AED may be used preferably with pediatric attenuator Immediately after defibrillation attempts, resume compressions Note: Most infants have a respiratory arrest, not cardiac 87

Case Scenario #6

     EMS is called to the scene for a 34 year-old female with abdominal pain who feels like they are going to pass out Patient is pale, diaphoretic VS: B/P 92/60; P – 104; R – 22 shallow; SpO 2 97% Pain is on the right side of the abdomen Patient cannot find a comfortable position 88

Case Scenario #6

  What is your impression?

   Ectopic pregnancy Appendicitis Colon spasm What action do you take?

 Perform assessment for abdominal pain  Include questioning for possible pregnancy  Keep possibility of ectopic high on list even if patient denies pregnancy 89

Case Scenario #6

 What interventions are performed?

 IV   Be prepared for fluid resuscitation in 200 ml increments Hold oxygen  Unless SpO 2 drops or patient has  Monitor  No indication for cardiac assessment but not faulted if monitor applied  No indication for 12 lead EKG though 90

Case Scenario #6

   If this is an ectopic, this is a true life threatening emergency!

Patient will go to the OR immediately   The patient’s life is threatened There is no salvage for the fetus in this case Often, the patient is unaware that they are even pregnant at this point in time 91

Bibliography

      American Academy of Pediatrics. Neonatal Resuscitation 6 th Edition. 2011.

American Heart Association. 2010 Guidelines for CPR and ECC Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices Third Edition. Brady. 2009.

Limmer, D., O’Keefe, M. Emergency Care 12 th Edition. Brady. 2012.

Region X Advanced Life Support Standard Operating Procedures February 1, 2012 Troiano, N., Harvey, C., Chez, B. High-Risk & Critical Care Obstetrics. 3 rd edition. Lippincott. 2013.

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