Obstetrical Emergencies
Silver Cross EMS CME
June 2011 2nd Trimester
Instructor/Author: Lonnie Polhemus RN, NREMT-P
OB/GYN Emergencies
• Many types of emergencies can occur with
female reproductive system
• Gravid and non-gravid
• Following information will help you refresh
assessment & treatment skills for emergency
childbirth & gynecological emergencies
Because we have to have objectives
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Identify anatomic structures and functions of
female reproductive system.
Demonstrate basic understanding of pregnancy
physiology and menstrual cycle, ovulation, and
fetal development.
Identify signs/symptoms and proper care for
gynecological emergencies.
Identify key aspects of evaluating pregnant
patient to determine if birth is imminent.
Identify purpose and use of tools in an OB kit.
More objectives
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Identify steps for normal delivery of infant.
Identify how and when to cut umbilical cord.
Identify steps for post-delivery care of
newborn/mother including placenta delivery.
Identify critical treatment interventions for pregnancy
complications
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breech (buttocks) or limb presentation
shoulder dystocia
prolapsed cord
postpartum bleeding.
Identify steps for assessing infant APGAR score.
Identify steps for neonatal resuscitation
Terms to become familiar with
•abruptio placenta — When placenta prematurely separates
from uterine wall, causing heavy internal bleeding and pain
•Can occur as a result of trauma.
•bloody show — Mucous and blood that comes from vagina
as first stage of labor begins.
•Cervix sealed by a plug of mucus during pregnancy to prevent
contamination.
•When cervix dilates, plug expelled as pink-tinged mucous.
•crowning — Bulging out of the vaginal opening caused by the
baby’s head pressing against it.
And these too
•dilation — To get larger or enlarge.
•Degree of dilation of cervix often key indicator used by midwives
and physicians to determine if birth is imminent.
•EMTs/paramedics do not perform this test.
•Process occurs over a period of several hours in some women, but
can take much longer.
•eclampsia (toxemia) — Serious condition that can develop in
the third trimester.
•Characterized by high blood pressure and excessive swelling in the
extremities and face.
•Life-threatening seizures differentiate eclampsia from
preeclampsia.
A few more terms
•ectopic pregnancy — Condition where fertilized egg implants outside
uterus, often in fallopian tubes.
•Symptoms can include abdominal pain, bleeding (intraperitoneal or
vaginal).
•effacement — Term relating to thinning of cervix.
•meconium — Dark-green fecal material found in intestines of fullterm babies.
•Ordinarily meconium is passed after a baby is born.
•In some cases, meconium expelled into the amniotic fluid prior to birth.
•Gives fluid greenish-brown color known as meconium staining.
Almost done
•placenta previa — A condition where placenta
sits low in uterus, blocking cervix.
•Can present with painless, bright red bleeding.
•postpartum — A term used to describe the
period shortly after childbirth.
Only three more terms
•preeclampsia — Condition in pregnant women
characterized by high blood pressure, abnormal
weight gain, edema, headache, protein in the urine,
and epigastric pain.
•If untreated, preeclampsia can progress to eclampsia.
•supine hypotensive syndrome — Weight of
unborn fetus and uterus puts pressure on inferior
vena cava.
•Result is inadequate venous blood return to the heart,
reduced cardiac output, and lowered blood pressure.
Last one for now
• Braxton-Hicks — Defined by Taber's Medical
dictionary as intermittent, painless contractions that
may occur every 10 to 20 minutes after the first
trimester of pregnancy.
• First described in 1872 by British gynecologist John Braxton
Hicks.
• Sometimes called pre-labor contractions or Hicks sign.
• Not everyone will notice or experience these contractions,
and some will have them frequently.
• Some mothers notice them more in subsequent
pregnancies than in first pregnancy.
Female Anatomy
of the reproductive organs
•Cervix – opening of the uterus
– First stage of birth, cervix opens &
thins
– Allows fetus to move into vagina
– Opening process called dilation
• Endometrium – inner lining of uterus
– Each month built up in anticipation of
implantation of fertilized egg
– Fertilization does not occur, lining
simply sloughs off
• Referred to as menstrual period
•Fallopian tubes – long slender
passageways connect uterus to ovary
– Female egg (ovum) passes through
structure on its way to uterus for
implantation to uterine wall
• Ovaries – two almond-sized glands
located on each side of uterus behind &
below fallopian tubes
– Produce estrogen & progesterone in
response to follicle stimulation hormone
(FSH) & luteinizing hormone (LH)
secreted from pituitary gland
Female Anatomy
•Perineum – area between vaginal
opening & anus
– It sometimes is torn during birth which
causes bleeding
• Uterus – pear-shaped, muscular
organ holds fetus during pregnancy
– Contracts to push fetus through cervix
& into vagina during birth
• Vagina – flexible, muscular tube
about three inches long
– Called birth canal
– Fetus moves from uterus through
cervix into vagina & then out of mother’s
body
Fetal Anatomy
•Placenta – develops early in pregnancy
& performs important functions
– Exchanges respiratory gases
– Transports nutrients from mother to
fetus
– Excretes waste
– Transfers heat
– Active endocrine gland produces
several important hormones
– Attached by umbilical cord
• Vein - transports oxygenated blood
toward fetus
• Artery – return deoxygenated blood to
placenta
•Amniotic sac – develops early in
pregnancy
– Consists of membranes surround &
protect developing fetus
– Fills with amniotic fluid cushions fetus
& provides stable environment
• Umbilical cord – attaches fetus to
placenta
– Contains one vein & two arteries
– Vessels in umbilical cord similar to
pulmonary circulation
• Arteries carry deoxygenated blood
• Veins carry oxygenated blood
– Newborn cord is about two feet long
Fetal Anatomy
Assessment of the OB/GYN
patient
Assessment
• Recognition of pregnancy
– Breast tenderness
– Urinary frequency
– Amenorrhea
– Nausea/Vomiting
Assessment
• Obstetric History
– Gravidity and Parity
• Gravidity = Number of pregnancies
• Parity = Number of live births
Assessment
• Obstetric History
– Last normal menstrual period
– Estimated delivery date (-3/+7)
– Previous Ob-Gyn complications
– Prenatal care (by whom)
– Previous Cesarean sections
Assessment
• Obstetric Physical Exam
– Evaluation of Uterine Size
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12 to 16 weeks: above symphysis pubis
20 weeks: at umbilicus
For each week beyond 20 weeks: 1 cm above umbilicus
At term: near xiphoid process
Assessment
• Obstetric Physical Exam
– Presence of fetal movements
• ~20th week
– Presence of fetal heat tones
• ~20th week
• Normal: 120 to 160/minute
Assessment
• Presence of Pain
– Abdominal pain in last trimester suggests
abruption until proven otherwise
– Appendicitis may present with RUQ pain
Assessment
• Presence of vaginal bleeding
– Always dangerous in first trimester
– Dangerous in late pregnancy if greater than
normal period
Assessment
• General health
– Diabetes may become unstable
• Hypoglycemic episodes in early pregnancy
• Hyperglycemia as pregnancy progresses
– Hypertension complicated by PIH
– Cardiovascular disease may worsen
Assessment
• Warning signs
– Vaginal bleeding
– Swelling of face, hands
– Dimmed, blurred vision
– Abdominal pain
Assessment
• Warning signs
– Persistent vomiting
– Chills, fever
– Dysuria
– Fluid escape from vagina
Gynecology
Menstrual cycle
• Woman’s monthly hormonal cycle in which
uterus prepares to receive egg
• Then discharges a bloody fluid
• Cycle repeats on average every 28 days, but
can vary widely
Menstrual cycle
•Days 1 to 5
– Egg
not fertilized, hormone levels lower,
causes thickened lining of uterus to shed
– Results in a woman’s period
– First day of menstrual bleeding is Day 1 in
menstrual cycle
•
Days 6 to 14
– Pituitary
gland produces hormone, stimulates
ovaries to develop follicles
–Each follicle contains an egg
– Only one egg reaches maturity & has
potential to become fertilized
– Hormone levels increase, lining of uterus
thickens & prepares to receive mature egg
•Days 10 to 18
– Hypothalamus
& pituitary glands release
hormone, mature follicle bursts & releases egg
– Ovulation typically occurs midway through
menstrual cycle on Day 14
– Egg begins its journey down fallopian tubes
to uterus
– Time period when a woman is most likely to
become pregnant
• Days
16 to 28
– After releasing egg, ruptured follicle secretes
progesterone
–Progesterone continues to thicken lining of
uterus in preparation for fertilized egg
– If egg is fertilized by sperm, it implants in
lining of uterus
– If egg not fertilized or implanted, lining of
uterus shed again at next menstrual cycle
Pelvic Inflammatory Disease
• Pelvic inflammatory disease (PID) – infection
of female reproductive tract
– Organs most commonly involved
– Uterus
– Fallopian tubes
– Ovaries
– Occasionally, peritoneum & intestines
Pelvic Inflammatory Disease
•Symptoms of PID include:
–Lower abdominal pain
–Fever
–Abnormal vaginal discharge
–Painful intercourse
–Irregular menstrual bleeding
–Pain in right-upper quadrant
•Vaginal bleeding & lower
abdominal pain can
indicate serious
gynecological problem
• Maintain high index of
suspicion when
encountered
Pelvic Inflammatory Disease
• Causes of PID
– Gonorrhea & Chlamydia infections
• Can progress undetected before PID symptoms appear
– Other bacteria, such as staph or strep.
• Acute or chronic
– Allowed to progress untreated, sepsis can develop
• Most common symptom of PID – moderate to
severe, lower abdominal pain
Vaginal Bleeding
• Vaginal bleeding not result of direct trauma or
normal menstrual cycle can indicate serious
problem
• Difficult to isolate specific cause, treat all
vaginal bleeding as if there is serious
underlying condition
• Especially true if bleeding associated with
lower abdominal pain
Vaginal Bleeding
• Treatment depends on patient’s needs, but
may include the following:
– Maintain ABCs
– Control bleeding, if possible
– Administer oxygen
– Place in shock position
– Provide fluid replacement
– Large bore IV if needed
Dilation and Curettage (D&C)
•Dilation – opening of the
cervix
• Curettage – scraping the
walls of uterus
• Surgical procedure – usually
done on outpatient basis
under local anesthesia
– Diagnose conditions such as
cancer
– Remove tissue after
miscarriage
– Elective abortion
•Complications
– Heavy bleeding – uncommon
• Patients with heavy bleeding
– Evaluate for signs of shock
– Expedite transport to hospital
Ectopic Pregnancy
•Egg released from ovary,
cyst often left in its place
• Cyst – fluid-filled sac
that is often enlarged
• Can rupture & cause
abdominal pain
• Occasionally cysts
develop independent of
ovulation
Sexual Assault
• Rape – any genital, oral or anal penetration by
a body part or object, through use of force or
without victim's consent
• It is a crime of violence with serious physical
and psychological implications
Sexual Assault
•Trauma to woman’s external
genitalia can be difficult to treat
– Need to maintain patient’s
modesty
– Rich network of nerves in
external genitalia makes such
injuries painful
•Tends to bleed profusely due to
rich blood supply
•Treat open genitalia wounds
with sterile compresses
• Use direct pressure to
control bleeding if severe
• Do not place dressings in
the vagina
Obstetrics
Ovulation
•Pregnancy begins with
ovulation in female
• Fourteen days before
beginning of next menstrual
period, ovary releases egg into
the fallopian tube
• Egg enters fallopian tube for
transportation to uterus
–Intercourse 24-48 hrs before
ovulation
– Fertilization should occur in
fallopian tube
Ovulation
•Once fertilized, egg
begins to divide
• Fertilized egg continues
down fallopian tube to
uterus
• Attaches to
endometrium
Trauma
•Direct abdominal trauma can
cause:
– Premature separation of
placenta from uterine wall
– Premature labor
– Abortion
– Uterine rupture
– Fetal death
•Fetal death can result from:
– separation of placenta from
uterine wall
– maternal shock
– uterine rupture
– fetal head injury
Gestational Diabetes
• Some women develop diabetes during
pregnancy
• Pregnant diabetics prescribed insulin if blood
sugar cannot be controlled by diet alone
• Cannot be managed with oral drugs
• They are absorbed into placenta & can adversely
affect fetus
Ectopic Pregnancy
•Implantation of growing
fetus in location other than
endometrium
• Most common site is in
one of the fallopian tubes
• Surgical emergency
because tube can rupture &
cause massive bleeding
1 month
gestation
6 weeks
gestation
Ectopic Pregnancy
• Patients with ectopic pregnancy often have
one-sided, lower abdominal pain
• Late or missed menstrual period
• Occasionally vaginal bleeding
• Life-threatening emergency
• Treat for shock, initiate immediate transport
Vaginal Bleeding (Gravid)
•Vaginal bleeding during
pregnancy cause for
concern.
• Bleeding in early
pregnancy often associated
with:
• spontaneous abortion
•ectopic pregnancy
•vaginal trauma
• Vaginal bleeding in third
trimester usually caused by:
– abruptio placenta
– placenta previa
– trauma to vagina or cervix
• Can be a life-threatening
emergency!
Vaginal Bleeding (Gravid)
• Range: light spotting to massive hemorrhage
• Difficult to find cause of in field
• Suspect placenta previa, abruptio placenta, or
vaginal trauma in third trimester bleeding
Abruptio Placenta
•Premature separation of placenta
from wall of uterus
• Separation either partial or
complete
–Complete separation usually
results in death of fetus
•Several factors may predispose
patient to abruptio placenta
– Preeclampsia
– Maternal hypertension
– Multiparity
– Abdominal trauma
– Short umbilical cord
Placenta Previa
•Attachment of placenta in
lower part of uterus
covering cervix
• Unless sonogram done,
placenta previa usually is
not detected until third
trimester
• When fetal pressure on
placenta increases or
uterine contractions begin,
cervix thins out resulting in
bleeding from placenta
Gravid Hypertension
• Preeclampsia – condition characterized by
high blood pressure, abnormal weight gain,
edema, headache, & protein in urine
• Eclampsia – characterized by high blood
pressure & excessive swelling in extremities &
face
• Life-threatening seizures differentiate
eclampsia from preeclampsia
Pre-Eclampsia
• Variety of signs and symptoms including:
– Hypertension
– Abnormal weight gain
– Edema
– Headache
– Protein in the urine
– Epigastric pain
• If untreated, preeclampsia can progress to
eclampsia
Eclampsia
•Eclampsia, also called
toxemia, most serious
manifestation of
hypertensive disorders of
pregnancy
• Characterized by grand
mal seizures
• Often preceded by visual
disturbances such as
flashing lights or spots
before the eyes
•Eclampsia patients often
experience swelling of
hands & feet & markedly
elevated blood pressure
• If eclampsia develops,
death of mother & fetus
frequently results
• Treat by lying mother on
her side, maintaining
airway, & delivering highflow oxygen
Supine Hypertensive Syndrome
• Supine hypotensive syndrome occurs when
increased weight of uterus compresses
inferior vena cava while a patient is supine
• Markedly decreases blood return to heart &
reduces cardiac output
• Some women are predisposed to this
condition because of an overall decrease in
circulating blood volume or anemia
Take 5.
•Take a five minute break.
•Enjoy this movie interlude. Remember the
volume for movies comes from the computer, not
the phone.
•See you in five!
Emergency Childbirth
Usually not a big deal unless
something hits the fan
Signs of Imminent Delivery
•Main task in evaluating
expectant mother is to
determine if delivery is
imminent
• Expose abdomen &
genital area, taking care to
be discrete
• Visually inspect the
abdominal & vaginal areas
for bleeding or crowning
•Prepare for immediate
delivery if observe any of the
following:
– Crowning
– Contractions less than 2
minutes apart
– Rectal fullness
– Feeling of imminent delivery
Crowning
•Crowning – appearance
of any part of fetus in
mother’s vagina
• Remove enough of
mother’s clothing to view
genital region
• Look for bulging at
vaginal opening or a
presenting part of infant
Contractions
•Occur at regular intervals
ranging from 30 minutes to 2
minutes or less
• Labor pain from contractions
lasts from 30 seconds to 1 minute
• As birth approaches, interval
between contractions gets
shorter
• Contractions that occur within 2
minutes of each other, from end
of one to beginning of next,
signify impending delivery
•Consider transporting mother if
baby does not deliver after 20
minutes of contractions 2 to 3
minutes apart
• Labor is generally prolonged for
mother’s first baby
• Average is 12 to 17 hours which
allows plenty of time for
transport
Rectal Fullness
• Rectal fullness or sensation of having to move
one’s bowels can indicate infant’s head is in
vagina & pressing against the rectum
• Delivery is imminent
• Do not let the mother sit on the toilet
Feeling of Imminent Delivery
• Mothers who have previously given birth
often know when ready to deliver
• Labor tends to be shorter after first child
• Use your judgment given circumstances
• When evaluating mother, keep in mind four
signs of imminent delivery
• Consider transport time
Preparing for Delivery
•• Don sterile gloves,
gown, and eye protection
•• Position mother on her
back, legs drawn up
•• Provide supplemental
oxygen
•• Prepare OB kit
•• Prepare infant BVM
•IV is optional at this point
Take a look
• Presentations you can’t
deliver safely
– Single limb
– Prolapsed cord
• Presentations you can
deliver
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Head first
Umbilical cord wrapped
Shoulder dystocia
Breech (Buttocks first)
Double footling
Assisting With Delivery
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Support head with gentle pressure
Check if cord is wrapped around baby’s neck— attempt to loosen
Apply gentle downward pressure on shoulder & head
After anterior shoulder has delivered, apply gentle upward
pressure
• Suction mouth & nostrils when head appears
• Once delivered, stimulate infant if it does not breathe
• Put two clamps on umbilical cord & cut 6 inches from navel
Amniotic sac
•During first stage of labor
amniotic sac usually
breaks, expelling amniotic
fluid
• If sac is still covering
infant’s head when head
appears, use a finger to
pierce sac
•Very tough membrane
•Note color & character of
amniotic fluid
• Fluid can be clear or
straw-colored (which is
normal)
• Tainted, discolored, thick
or “pea soup-like” (which
indicates meconium
staining or a bad intrauterine infection)
Detailed Delivery Instructions
• Encourage the mother to breath deeply
between contractions and push with
contractions.
• As the baby crowns, support with gentle
pressure over perineum to avoid an explosive
birth.
• If the amniotic sac is still intact, rupture it with
a finger to allow amniotic fluid to leak out.
Detailed Delivery Instructions
• If the umbilical cord is wrapped around the
baby’s neck, gently slip it over the head.
• Do not force it.
• If the cord is too tight to slip over the head,
apply umbilical cord clamps and cut the cord.
• Clamp and cut the umbilical cord only if he
baby’s head has emerged and is in a position
that lows you to manage the airway.
Detailed Delivery Instructions
• Re-suction the baby’s mouth & nostrils
• Dry & wrap baby in a warm blanket — cover
its head
• Place baby on its side to facilitate drainage
• Perform an APGAR assessment at 1 minute &
5 minutes after delivery
Infant care
• Baby not breathing – stimulate it
• If newborn does not start breathing effectively
within 10 – 15 seconds of stimulation
• Blow-by oxygen
• If no response
• use infant BVM to deliver gentle puffs of air — enough
to cause the chest to rise
• If after 30 seconds of assisted ventilation there is
no response
• heart rate <60 beats/min
• begin CPR
CPR - Two-Thumb Encircling Hands
Technique
CPR technique for infant with
pulse rate below 60 beats/min
Place infant on a firm, flat surface
Remove clothing from chest
Find compression site which is
just below nipple line on
middle or lower third of
sternum
Wrap your hands around upper
abdomen with your thumbs
on compression site
Use your thumbs to deliver gentle
pressure against sternum,
pressing ½ to ¾ inch into chest
Infant Care
• If signs of meconium are present, do not
stimulate infant
• suction mouth & nose
• This avoids aspiration of fecal material that
can cause pneumonia
• Good antibiotics to treat bacteria but we would
rather not need to
APGAR
•APGAR scale – numerical
measure of baby’s overall
condition immediately
after birth
• Healthy baby will have
total score of 10
• Many babies score 7 to 8
during first minute
• By 5 minutes, most
babies score 8 to 10
APGAR stands for:
• Appearance
• Pulse
• Grimace
• Activity
• Respirations
Scale
Sign
0
Score
1
2
Appearance
(skin, nailbeds or
lips)
Blue, pale
Body pink,
extremities
blue
All pink
Pulse
Absent
<100
>100
Grimace
(reflex or
irritability)
No response
Grimaces
Cries
Some flexion
of extremities
Purposeful
movement
Activity
(muscle tone)
Respirations
Limp
No response Slow or
irregular
Strong or
crying
Total
1 minute
5 minute
Managing a Poor APGAR Score
• Three things to remember when managing
infant with low APGAR score: position, suction
and stimulate (PSS)
– Position body so head is down & airway is open
– Suction mucous & fluid from mouth & nostrils
– Stimulate infant by taping bottoms of feet
• PSS – memory aid to help recall these steps —
position, suction and stimulate
Care for mom after birth
•Once baby delivered &
umbilical cord cut &
clamped you should:
– Monitor and control
bleeding from mother
– Begin fundal
massage
– Monitor vital signs
– Keep the mother and
baby warm
•Transport once infant is
delivered
• Do not wait for placenta—
may take up to 30 minutes
to deliver
• Do not pull on umbilical
cord
• If placenta does deliver at
scene, transport with
mother & baby to hospital
Care for mom after birth
• After placenta delivered, place sanitary napkin
between mother’s legs
• Ask her to hold legs together
• Normal for mother to bleed up to one cup
(about 250 cc) or 5 sanitary napkins of blood
after delivery
• Record number of pads
• Now it is time for an IV for fluid replacement
Fundal Massage
•Makes uterus contract & diminishes vaginal
bleeding
• Can feel for fundus of uterus
• located in abdomen between pubic bone & umbilicus
• Should feel like a softball
• Perform massage like you would a muscle
massage
• Area may be tender & massaging it can cause
discomfort
•Be gentle but use some muscle
Complications
Field care
Nuccal Cord
• Once head delivered ask mother to stop
pushing so you can check if cord is wrapped
around infant’s neck
• If cord looks like it is wrapped tightly, so as to
constrict airway, need to loosen it
• Gently slip cord over baby’s head by placing
two fingers under cord at back of neck
Nuccal Cord
• Bring cord over shoulders & head
• Cord durable, it can tear if handled roughly so
don’t use excessive force
• Too tight to loosen, clamp cord in two places
two inches apart
• Cut cord between clamps
• Unwrap cord from around neck & take care
not to injure baby
Shoulder Dystocia
• Labor progresses normally & head delivered routinely
• However, immediately after head delivers, shoulders become
trapped between symphysis pubis & sacrum, preventing
further delivery
• First step in treating shoulder dystocia is recognizing when it
occurs
• Two main signs of shoulder dystocia are:
– Baby’s body does not emerge with standard moderate traction &
maternal pushing after delivery of baby’s head
– “Turtle Sign” –head suddenly retracts back against mother’s perineum
after it emerges from vagina
Buttocks & Double Footling
Presentation
•If buttocks or two feet
present first, you can
attempt delivery in field
• These are generally slow
deliveries & you likely
have time to transport
•Position mother with
buttocks at edge of bed
•Hold mother’s legs in
flexed position
• Support infant’s legs —
do not pull
• As head passes pubis,
apply gentle upward
traction until mouth
appears
• If head is stuck, create
airway by pushing away
vaginal wall — transport
immediately
When the head does not deliver
• Create airway for infant
• First, place gloved hand into vagina with your
palm towards infant’s face
• Form a “V” with index & middle finger on
either side of infant’s nose
• Push vaginal wall away from infant’s face to
allow unrestricted breathing
• Maintain airway & transport immediately
Single limb presentation
• Support baby with your hands
• Provide airway for baby using your fingers if
possible
• Transport immediately — do not attempt
delivery in field
• Supportive care for mother
Cord Presentation
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•
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•
•
If you see umbilical cord
presenting before the
baby, initiate the
following steps:
Place mother in kneechest position
Check umbilical cord for
pulsations
No pulsations - press
presenting part of fetus
away from umbilical
cord, towards mother’s
head
Re-check cord for
pulsations
•
•
•
•
•
Administer high flow
oxygen to mother
Transport immediately –
fetus will die without
rapid intervention
Continue holding
presenting part of baby
away from umbilical cord
Apply moistened
dressing on exposed
umbilical cord
Do not push umbilical
cord back into vagina
Summary
•Key structures of female
reproductive system include:
– Cervix
– Endometrium
– Fallopian tubes
– Ovaries
– Perineum
– Uterus
– Vagina
•The key structures of fetal
anatomy include:
– Placenta
– Amniotic sac
– Umbilical cord
Summary
• Fetus has excellent chance of survival after the
seventh month of pregnancy
• Pregnant women more susceptible to traumatic
injury because of the increased vascularity of
uterus
• Patients with ectopic pregnancy often have onesided abdominal pain, late or missed period, &
occasionally vaginal bleeding
• Vaginal bleeding in third trimester usually caused
by abruptio placenta, placenta previa, or trauma
• To relieve supine hypotensive syndrome tilt the
pregnant patient to one side
Summary
Key points for assisting with normal delivery:
• Support head with gentle pressure
• Check if cord wrapped around baby’s neck—if so,
attempt to loosen
• Apply gentle downward pressure on anterior
shoulder and head
• After anterior shoulder has delivered, apply
gentle upward pressure on posterior shoulder &
head
• Suction mouth and nostrils when head appears
• Once delivered, stimulate newborn if it does not
breathe
• Put two clamps on umbilical cord & cut 6 inches
from navel
Summary
Care for newborn infant includes:
• Stimulate infant if not breathing sufficiently
• Start CPR if no response after 30 seconds
• Keep infant warm
• Repeat suctioning of mouth & nose
• Check APGAR score at 1 & 5 minutes
Summary
• APGAR stands for appearance, pulse, grimace, activity, &
respirations
• Care of mother includes:
–
–
–
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Monitor & control bleeding from mother
Begin fundal massage
Monitor vital signs
Keep mother & baby warm
• If head remains stuck during buttocks or double footling
presentation, create airway by pushing away vaginal wall then
transport immediately
• Important steps in caring for postpartum bleeding include
fundal massage and treatment of shock
Silver Cross EMS skill o’ the month!
Dexi!
No, not Dixie…
Dexi – as in blood sugar
• Should be checked on every ALS patient.
– After all, we are starting IV’s anyway, so we have
plenty of blood.
• Should also be checked on every altered mental
status, dizziness, weakness and fall.
– Falling is a symptom, not a complaint.
• Also, any patient who is a diabetic should have a
sugar tested.
• Low blood sugar is scary to have and easy to fix,
that’s why we should always check for it.
Testing Tips
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•
Of course you should always be wearing gloves.
Choose a finger.
– Diabetic patients will often tell you which finger they prefer.
– Wipe finger with alcohol wipe, let dry completely.
•
Insert a test strip into your meter.
– Some models like you to put the blood on the strip before testing. Know your model.
•
Use lancing device on SIDE of fingertip to get drop of blood.
– Closer to the nail the better… people need the pads of their fingers to do stuff!
– Or use whatever method you prefer to get the blood from an IV catheter.
•
You may have to squeeze or massage the finger to get enough blood out.
– But too much squeezing/massaging can change the character of the blood.
– Hold hand downward to allow gravity to help.
Dexi tips continued
• Touch and hold the edge of the test strip to the drop of blood, and wait
for the result.
• Blood glucose level will appear on the meter's display.
– Many models read “hi” or “low” when sugar is below 20 or above 600. Know
your meter.
• Some newer meters out there let you use forearm, thigh or fleshy part
of hand.
• It’s OK to use the patient’s meter in a pinch, or let him/her do it, but
always check with yours as well.
– Patient’s glucometer may not have been calibrated lately.
– Plus a lot of patients are not too good at finger hygiene… eww!
References:
King County EMS
American Heart Association
Taber’s Medical Dictionary
American Diabetes Association
Ask Dr Dave:
Send extra questions to AFinkel@Silvercross.org