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.
2
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.
3
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 VISUAL inspection
of the perineum


Area of tissue of the external genitalia
EMS will NEVER perform a “vaginal”
exam

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
 O2 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 O2, CO2, 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
  body temp
Breast changes
 Dizziness/
Headache
lightheadedness
Spotting
Frequent urination
Constipation &/or bloating
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 yearold 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!!!
18
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
1st 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
2nd 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
3rd 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?
24
Timing Contractions

Duration


Interval/time between


From the beginning of the contraction until
it ends
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 3rd pregnancy
Her contractions are 2 minutes apart
What are your next actions?
32
Case Scenario #2

Gain quick rapport

Need to perform a visual exam




Position mother for delivery


Crowning present?
Bulging of the perineum present?
Any blood, cord, fingers, or toes present?
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
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



Be prepared to secure the airway
Have suction available


Avoid loud noises, flashing lights
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 delivered40
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!!!
43
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


Deficiency in surfactant in lungs


Ventilations more difficult
Rapid heat loss


Spontaneous breathing more difficult
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; SpO2 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
61
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
68
Newborn Resuscitation
Algorithm

Within 1st 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 O2 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?


Is the baby breathing or crying?


Especially less than 34 weeks increases risk
of instability
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
78
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
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Neonatal Resuscitation

Chest compressions



90/minute
Finger tips on lower half of sternum
1
 Depress 1 ½ inches or /3 the AP
diameter
Compression to ventilation
ratio: 3:1
 Ventilations are tiny puffs
of air
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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
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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
1
 Compress to a depth of /3 the AP diameter
of the chest wall
85
Case Scenario #5

Deliver 2 puffs of air



Inadequate breathing with pulse


Enough to make the chest rise
Compressions to ventilation ratio: 3:1
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;
SpO2 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 SpO2 drops or patient has
respiratory complaint
 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 6th 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 12th 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. 3rd edition. Lippincott. 2013.
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