OB Emergencies
November 2010 CE
Condell EMS System
Objectives by Jeremy Lockwood, FF/PM Mundelein
Fire Department
Packet prepared by Sharon Hopkins, RN, BSN, EMT-P
Objectives
Upon successful completion of this module, the EMS
provider will be able to:
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1. Identify appropriate standard precautions in the
OB delivery setting.
2. Identify progression of a normal pregnancy.
3. Describe assessment of an obstetrical patient.
4. Identify predelivery complications.
5. Describe indications and signs of imminent
delivery.
6. Identify the stages of labor.
Objectives cont’d
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7. List the contents of the OB kit
8. Describe how to use the contents of the OB kit.
9. Describe the steps in assisting delivery of the
newborn.
10. Describe care of the newborn baby.
11. Describe APGAR scoring.
12. Describe when and how to cut the umbilical
cord.
13. Describe the delivery of the placenta.
14. Describe post delivery care of the mother.
Objectives cont’d
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15. Describe abnormal deliveries and procedures.
16. Identify and describe delivery complications.
17. Describe meconium staining and its implication
to the newborn.
18. Review documentation components for discussed
conditions.
19. Given a manikin, demonstrate use of the OB
kit.
20. Demonstrate use of the meconium device.
Standard Precautions

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Anticipate the exposure to a large amount of
blood and body fluids
Full protection is recommended
Don’t assume the absence or presence of
disease just by appearances of the patient or
situation
Standard Precautions
Handwashingstill most
effective
control
measure
around
Just Protect Yourself!!!

Do
what
you
can
Normal Pregnancy Development

Ovulation and what follows
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Release of an egg from ovary
Egg travels down fallopian tube toward uterus
Intercourse within 24-48 hours of ovulation could
result in fertilization
Fertilization occurs in the fallopian tube
Fertilized egg will implant in the uterus and
pregnancy begins
Prenatal Development cont’d

Placental development
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Approx 3 weeks after fertilization
Blood rich structure for the fetus
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Transfers heat
Exchanges oxygen and carbon dioxide
Delivers nutrients
Carries away waste products
Endocrine gland
 Secretes hormones for fetal survival
 Secretes hormones to maintain pregnancy
Placental Development cont’d
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Protective barrier
Connected to the fetus via the umbilical cord

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Flexible, rope-like structure
2 feet in length; ¾″ diameter
Contains 2 arteries, 1 vein
 2 arteries return relatively deoxygenated blood
to the placenta
 1 vein transports oxygenated blood to fetus
Placental Attachment
Amniotic Sac

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“Bag of waters”
 Thin-walled membranous covering holds the
amniotic fluid
 Surrounds and protects fetus
 Allows for fetal movement during
development
Volume varies from 500 ml to 1000 ml
 500 ml = 1 pint = 2 cups
 Premature rupture increases risk of maternal
and fetal infection that could be life
threatening
Physiological Changes of Pregnancy

Due to:
 Altered hormone levels
 Mechanical effects of enlarging uterus
 Increased uterine blood supply
 Increasing metabolic demands on the
maternal system
Physiological Changes to the Systems

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Reproductive system
 Uterus becomes larger
 Contains 16% of the mother’s blood during
pregnancy
Respiratory system
 Increase in oxygen demands
 20% increase in oxygen consumption
 40% increase in tidal volume
 Slight increase in respiratory rate
 Diaphragm pushed upward
Physiological Changes to the Systems

Cardiovascular system
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Cardiac output increases
Maternal blood volume increases by 45%
More plasma increase than red blood cells so
relative anemia develops
Maternal heart rate increases by 10-15 beats
B/P decreases slightly 1st & 2nd trimesters
Supine hypotensive syndrome when mother lies
supine
 Especially by 5 months of pregnancy
Physiological Changes to the Systems

Gastrointestinal system
 Nausea & vomiting are common in 1st
trimester
 Delayed gastric emptying (due to slowed
peristalsis)
 Bloating and constipation common
Physiological Changes to the Systems

Urinary system
 Renal blood flow increases
 More likely to have glucose spilling into
urine
 Bladder displaced anteriorly & superiorly
increasing likelihood of rupture during
trauma
 Urinary frequency is common especially 1st
trimester
Physiological Changes to the Systems

Musculoskeletal system
 Pelvic joints loosened causing waddling
gait
 Center of gravity shifts with enlarging
uterus
 Postural changes taken to accommodate for
increased anterior growth
 Increased complaints of low back pain
Obstetrical Assessment
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Need to determine if delivery is imminent or
if there is time to transport
Remain calm (at least on the outside!)
Ask a few questions
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Basically direct or closed ended questions –
requiring a simple answer in few words
Perform a visual examination
Evaluate vital signs
Remain calm (at least on the outside!)
OB Assessment Questions
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Expected due date
 The more premature, the smaller the birth weight
and the less mature the lungs
Number of pregnancies
 The higher the number, the quicker they tend to
deliver
Length of labor
 1st pregnancies can take up to 16-17 hours
 Subsequent deliveries tend to shorten from the 1st
one
OB Assessment Questions
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If bag of waters have ruptured or are intact
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Once ruptured, delivery tends to progress faster
Once ruptured, must be evaluated due to increase
risk of infection especially if not delivered within
24 hours
Feeling of having to move their bowels

This is from pressure of the fetal head moving
through the birth canal
OB Visual Examination
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Gain rapid rapport with the mother
Disrobe the under garments
Visually inspect the perineum
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Check for crowning or bulging
 The appearance of the presenting part at the vaginal
opening
 Prepare for imminent delivery if crowning
 Best to check during a contraction
Check for blood loss
Check for other parts – fingers, toes, cord
OB Assessment - Contractions
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Place gloved palm on mother’s abdomen
Contraction duration
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Time from the beginning of one contraction
(uterus tightens) to the end (when uterus relaxes)
Contraction interval or frequency
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Time from the start of one contraction to the
beginning of the next one
Includes contraction and rest intervals
OB Assessment – Vital Signs
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Routine vital signs are taken
Remember physiological changes of
pregnancy:
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Blood pressure, after initial drop, is near normal
in 3rd trimester
Heart rate up by 10-15 beats over normal
Only slight increase in respiratory rate
Supine Hypotensive Syndrome
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Caused by the weight of an enlarging uterus
pinching off blood supply in the inferior vena
cava
Decreases blood return to the heart
Decreases stroke volume pumping out of the
heart
Especially after 5 months transport the mother
tilted or turned preferably toward the left
Imminent Delivery
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Crowning is present
Contractions last 30 – 60 seconds and are
2 - 3 minutes apart
Mother has the urge to move her bowels or
she says “I HAVE TO PUSH!!!”
Bag of waters has ruptured
Stages of Labor
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3 stages of labor
1st stage – dilatation stage
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Begins with onset of true labor contractions
Ends with complete dilatation (10 cm/4″) &
effacement (100%) of the cervix
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Is manually confirmed in the hospital setting, not field
Stage can last approximately 8-10 hours for first
labor to about 5-7 hours in multipara
1st Stage of Labor cont’d
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Contractions
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Early in this stage are usually mild
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Increase in intensity as labor progresses
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Duration of 15-20 seconds
Frequency every 10-20 minutes apart
Duration of 60 seconds
Frequency every 2-3 minutes
Care is supportive at this point in time
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Allow husband/significant other to time
contractions
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Keeps them busy, involved, and out of the way
Timing Contractions
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Duration
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Timed in seconds
Timed from the beginning of the contraction to the end
the contraction
Contractions lasting 60-90 seconds indicate imminent
delivery
Frequency
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Timed in minutes
Timed from the beginning of one contraction to the
beginning of the next contraction
Contractions coming every 2-3 minutes indicate imminent
delivery
2nd Stage of Labor – Expulsion Stage
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Begins with complete dilatation of cervix
Ends with delivery of fetus
Can last 50 – 60 minutes for the first delivery
Can last 30 minutes for future deliveries
Contractions strong, uncomfortable
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Duration is 60-75-90 seconds
Contraction every 2 – 3 minutes
2nd Stage of Labor cont’d
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Mother has urge to bear down
Mother has back pain
Crowning is evident on visual inspection
Membranes usually rupture now
OB kit should be open by now
Be ready to support mother in delivery
OB Kit
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May be supplied in a variety of packaging
If extra supplies are needed, where are they
kept?
Always anticipate using the OB kit
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Better to have it available and not need it / use it
than need it and not have it
Kits are usually packaged with disposable
products
Practice Standard Precautions
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Goggles, mask, gloves, gown
Contents of
OB Kit
Cord Clamps
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FYI
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If not used for a period of time, it has been
reported that the OB clamps become brittle and
can break
There is no hurry to clamp and cut a cord
If you transport the mother and baby with the
cord intact, so be it
 The hospital will take care of clamping and
cutting the cord
Delivery of the
Newborn
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As soon as the head and neck
emerges, check for nuchal cord and
begin to suction mouth then nose with bulb syringe
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Depress bulb first before insertion of mouth, then nose
To facilitate delivery of upper shoulder, gently guide
head downward
Support and lift head and neck slightly to deliver
lower shoulder
Rest of infant delivers passively and very quickly
Newborn At Delivery

They’ll
grow into
being a
Gerber
baby!
Care of the Newborn cont’d
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Hold on tight
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Infant is slippery due to cheesy covering and
amniotic fluid
Note time of delivery and record on the
infant’s run report
Stimulate the infant

Suctioning, rubbing the
back, flicking at the soles
of the feet, drying off
Suctioning the Newborn
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Suction mouth then nose always in that
sequence
Infant’s are obligate nasal breathers
Want to clear the airway before stimulating
them to take a breath
Always depress bulb
syringe and THEN place
into infant’s mouth, then
nose
Care of the Newborn
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Continue to suction mouth then nose
Spontaneous respirations should begin within
15 seconds after stimulation
If no respirations, begin BVM support at 3040 breaths per minute
If pulse < 60 or between 60-80 and not
improving, begin CPR
Obtain 1 minute APGAR (ie: record as 9/10)
APGAR Score
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Assesses newborn adjustment to extrauterine life
1 minute score indicates need for resuscitation
5 minute score predicts mortality and neurological
deficits
Order of importance
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Heart rate
Respiratory rate
Muscle tone
Reflex irritability
Finally color – least helpful; most visible/obvious
APGAR Scoring – 1 & 5 minutes
Care of the Umbilical Cord
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Clamp and then cut the cord after pulsations
have stopped & cored is limp
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Clamps placed 8″ from infant’s navel 2″ apart
Watch the end of the cord
for leakage of blood
If leaking, add additional
clamps moving toward
the infant’s navel
Cutting the Clamped Cord
FYI – What About Cord Blood?
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Obtained in the hospital within 10-15 minutes of
delivery
Collected from umbilical cord after delivery and
after care of newborn provided
Consists of stem cells that can transform into variety
of healthy tissue
Useful to treat leukemia, lymphomas and other
diseases
Fee charged for private donations and storage
NOT the same as embryonic stem cells
Care of The Newborn cont’d
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Continue to dry and wrap infant to preserve
body temperature
Obtain 5 minute APGAR (ie: record as 10/10)
Continue to suction mouth then nose as
needed
Keep infant in head downward position
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Facilitates drainage from the airway
Assess vital signs of infant (is it time to retake
mom’s?)
Care of the Newborn
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Infant in head
down (and side
lying) position
Hat placed to
minimize heat
loss
Cord clamped
and cut
3rd Stage of Labor – Placental Stage
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Begins immediately after delivery of infant
Ends with delivery of placenta
Do not need to delay transport waiting for
placenta to deliver
Signs of separation
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Gush of blood from vagina
Change in size, consistency, shape of uterus
Lengthening of cord protruding from vagina
Delivery of the Placenta
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Allow to deliver spontaneously
May take up to 20 minutes after infant delivered to
deliver the placenta
If delivered at the scene, collect and transport with
the patient
 Inspected for retained placental parts
For excessive external bleeding, apply dressings
externally
For excessive vaginal bleeding, uterine massage
AFTER placenta is delivered
Placenta Uterine Wall Side
Placenta Fetal Side
Post Partum Care of the Mother
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What is post partum hemorrhage?
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Loss of more than 500 ml of blood (1 pint; 2 cups)
To control, massage uterus AFTER delivery of
placenta
 Will feel uncomfortable to the mother
 Massage until the uterus feels firm
 Recheck every 5 minutes
 Check your rate of IV fluids
 Are you administering oxygen?
Fundal Massage
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Performed AFTER delivery of placenta
Uterus should be firm
Place one hand immediately above symphysis
pubis
Place one hand on uterine
fundus (top)
Massage with 2 hands
Post Partum Care
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Congratulate the new parents!
Inform them if it is a boy or girl
If possible, offer the mother a towel to wipe
her face and hands
By holding the wrapped infant, the mother’s
body heat will help maintain the body heat of
the infant
Abnormal Delivery Presentations
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If you are prepared for the worst and get the
best, hidden bonus!!!
Breech
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4% of term deliveries
Head is not the presenting
part!!!
Transport immediately to
closest ED with OB
capacity
Higher risk to infant and
mother
Potential need for C-section
To Facilitate Delivery of Breech
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As soon as legs deliver, support infant’s body
If accessible, palpate cord for pulsations
Attempt to loosen cord to create slack
After torso & shoulders deliver, gently sweep
arms down
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If face down, gently elevate legs & trunk to
facilitate delivery of head
DO NOT HYEREXTEND HEAD
DO NOT PULL ON INFANT
If Head Does Not Deliver in 30 Seconds
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Reach 2 gloved fingers into vagina to locate
newborn’s mouth
Push vaginal wall away from newborn’s mouth
Keep fingers in place and transport immediately
Call report ASAP
Keep delivered portion of infant warm & dry
If infant delivers, anticipate distressed newborn

Anticipate maternal hemorrhage
Footling Breech – Not a Field Delivery
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If one foot is visible, wonder “where is the
rest of the baby?”
Encourage mother to breath through a
contraction so she does not
add to the pushing
Keep infant’s extremity
warm
Rapid transport
Early report
Prolapsed Cord
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Cord is delivering before
the infant
Infant’s oxygen and blood
supply will be
compromised
Need to take pressure off the cord
Don’t want mother pushing with contractions

Have mother breath through the contractions
Prolapsed Cord
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True emergency
High fetal death rate
Must immediately
recognize the emergency
Rapid transport
Place gloved fingers into vagina between
pubic bone and presenting part
Cover exposed cord with moist saline
dressing
Placenta Previa
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Abnormal implantation
of placenta on lower half
of uterine wall
Partial or complete blockage
of cervical opening
Hallmark: Painless, bright red vaginal
bleeding
Uterus usually soft
Abruptio Placenta
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Premature separation of normally
implanted placenta from the
uterine wall
20-30% fetal mortality rate
Bleeding concealed
Sudden, sharp, tearing pain and stiff, boardlike
abdomen
Life threatening OB emergency
Support mother’s oxygenation
Transport tilted or lying left
Meconium Staining
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Meconium is fetal stool
Release by the fetus may
indicate intrauterine stress,
like hypoxia
If observed, prepare for a
distressed baby who may need ventilatory
support
Fortunately, most meconium can be dealt with
by using a bulb syringe
Meconium Aspiration Equipment

Intubation equipment

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Blade, handle
2 ET tubes
Meconium aspirator
Suction

Suction turned down
to 80mmHg
Meconium Aspiration Procedure
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Meconium aspirator connected to suction tubing
Intubate in usual manner
May not visualize landmarks due to meconium
Quickly connect aspirator to ET tube
Withdraw in twisting fashion while
suctioning
 Minimize suction time to 2 seconds
or less
If time, repeat at least once more
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Meconium Aspirator
Time available to intervene is minimal
Must be prepared and move fast
While running
slide show,
left click
anywhere on
screen at right
to play video
Multiple Births
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Prepare for more than one
delivery
Where is your extra equipment?
Expect smaller birth weight infants

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Poorer ability to conserve body heat
Immature respiratory system
Need for the smallest equipment you carry
Stressed Newborn
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Infant flaccid, no muscle tone
Heart rate < 100

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If < 60 begin chest compressions
Apneia or respiratory distress
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Newborn respiratory rate 40-60 per minute
Support ventilations via BVM
 One breath every 3 seconds
 Just enough volume to make chest rise and fall
Documentation
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After delivery you have 2 patients
Complete run report for both the mother and the
newborn
Include time of delivery
Note the one person who actually “caught” the infant
at time of delivery
Keep mother’s information on the mother’s report;
infant’s on the infant’s
Apply wristbands to both mother and newborn
Case Scenario #1
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You have arrived on the scene.
27 year-old woman says she is in labor
What are the indications for imminent labor?
 Urge to move bowels
 Urge to push
 Crowning
 Ruptured bag of waters
 Contractions every 2-3 minutes lasting 60-90
seconds
Case Scenario #1

What questions do you need to ask specific to
mother being in labor?
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What number pregnancy is this?
What is her due date?
What are her contractions like?
Does she have the urge to push?
Is her bag of waters intact or broken?
Is she aware of any complications?
Case Scenario #1

Describe the exam you need to perform

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Visual inspection of perineum
 Looking for crowning
 Looking for abnormal presentation – fingers
or toes, anything not expected
 Looking for a prolapsed cord
 Checking for blood loss
Evaluate contraction duration and frequency
Case Scenario #2
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
You have responded to the scene of a
34 year-old mother in labor
Upon visual inspection, you note flecks of
meconium in the leaking amniotic fluid

What does this indicate?
 Anticipate a distressed infant
 The infant will need gentle, aggressive airway
care with the bulb syringe and possibly the
meconium aspirator
Case Scenario #2

What equipment is necessary?


Bulb syringe
Intubation equipment




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
Blade
Handle
ETT – 2 available (if the first one is clogged with
meconium)
Stylet
Suction tubing
Meconium aspirator
Case Scenario #2

What adjustment needs to be made with the
suction when using the meconium aspirator?


Suction needs to be turned down to 80 mmHg
 Suction generally set at 300 mmHg for the
adult population
Limit suctioning to less than 2 seconds
Case Scenario #3
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You are on the scene for a 17 year-old in labor
Upon visual inspection, you note a prolapsed cord
What interventions do you take?
 Immediately place gloved fingers into the vagina
to take pressure off the cord
 Place the mother in the knee-chest position
 Provide rapid transport with early report
End of this case discussion; move to next case
Case Scenario #4



You are on the scene of a 2 car collision
One of the patients is 16 years-old and is 6 months
pregnant
What would be the recommended position if
transported?


Lying or tilted left to keep pressure off vena cava
Can this patient sign a release if she wants to?


She is emancipated and can sign a release
If she remains the parent after delivery, she remains
emancipated

End of case discussion; move to next case
Case Scenario #5 - Documentation


What’s right? What’s wrong/missing?
MVC –this is what’s provided:




Deformity to steering wheel; windshield starred
Extrication took 15 minutes
Patient complained of back pain; able to move
upper extremities
Swelling noted to left upper quadrant
Case Scenario #5

What’s right regarding documentation?




Description of damage to car
Need and length of time for extrication
Patient complaints listed
Visual inspection result to abdomen
Case Scenario #5

What’s wrong/missing?


Is there any other information from the accident
available or not?
 Speed; what was hit or what hit car
 Location of occupant in car
More descriptive of head to toe assessment
 Distal CMS with back pain
 Movement of lower extremities
 Palpation results of abdomen
Case Scenario #5



What does SMV’s stand for?
 Sensation, movement, vascular
What does CMS stand for?
 Circulation, motor, sensation
How do you test for them (yes, they are the same)?
 Feel for pulses
 Ask the patient to move a distal digit
 Ask the patient if they can feel a touch that they
are not staring at
Case Scenario #6 - Documentation


What’s right? What’s wrong/missing?
78 year-old with chest pain – this is what’s provided
 Onset at 0800 while watching TV
 Not relieved with rest or 2 Nitroglycerin tablets
 8/10 pain scale
 EKG sinus rhythm
 12 lead done
 IV, O2, Aspirin and nitroglycerin given
Case Scenario #6

What’s right regarding documentation?


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
Onset – what patient was doing
Palliation/provocation
Severity
Time of onset
Care provided
Rhythm strip results
12 lead obtained
Interventions appropriate
Case Scenario #6

What’s wrong/missing?



OPQRST not complete
 Missing quality of chest pain in patient’s own
words
 Missing if the pain radiates or not
Was any ST elevation observed on 12 lead?
Was 12 lead faxed to Medical Control?
Case Scenario #7 EKG Interpretation

Any ST elevation?
Case Scenario #7 – Acute MI
ST Elevation I, aVL, V2, V3, V4, V5, V6
Case Scenario #8 – EKG Interpretation

Any ST elevation?
Case Scenario #8 – Acute MI
ST Elevation II, III, aVF

Hold nitroglycerin until consult with Medical Control
(hypotension a possibility with inferior wall MI)
Hands-on Practice




Practice with contents of OB kit
Practice positioning newborn in head down
position
Practice using the bulb syringe to clear first
the mouth then the nose
Paramedics to use the meconium aspirator

Practice in pairs to become most efficient with
time
Bibliography





American Academy of Pediatrics. Pediatric
Education for Prehospital Professionals 2nd Edition.
2006.
American Academy of Pediatrics. Neonatal
Resuscitation. 2000.
Bledsoe, B., Porter, R., Cherry, R. Paramedic Care
Principles and Practices. Prentice Hall. 2009.
Limmer, D., O’Keefe, M. Emergency Care 10th
Edition. Brady. 2005.
Region X SOP, March 2007; amended January 1,
2008.