OB Delivery Complications
Condell Medical Center
EMS System
ECRN Packet
Module I 2008
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
Objectives

Upon successful completion of this module, the
ECRN should be able to:
 list physiological changes in pregnancy.
 identify the stages of labor.
 describe the assessment of a patient in labor.
 explain the contents of the OB kit.
 identify obstetrical emergencies.
 describe how to care for a prolapsed cord, a
breech delivery, & meconium staining.
 successfully complete the quiz with a score of
80% or better.
Physiological Changes in Pregnancy

Reproductive system
 Increase in size of uterus
 Increased vulnerability to injury
 During pregnancy uterus contains
16% of the total blood volume
 Extremely vascular organ
during pregnancy
 Uterus and fetus insulted if
blood flow diminished
Normal Fetal Positioning
Changes in Pregnancy cont’d

Respiratory system
 Increase in oxygen demand &
consumption
 40% increase in tidal volume

Amount of air in or out in one breath
Only slight increase in respiratory rate
 Diaphragm pushed upward decreasing
lung capacity

Changes in Pregnancy cont’d

Cardiovascular system
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Cardiac output increases
Maternal blood volume increases by 45%
Heart rate increases by 10 – 15 beats per
minute
B/P decreases slightly in first 2 trimesters
B/P normal in 3rd trimester
Supine hypotensive syndrome after 5
months if heavy weight of uterus presses
on inferior vena cava (when mother lying
on her back)
Changes in Pregnancy cont’d

Gastrointestinal system



Nausea and vomiting common in 1st
trimester
 From hormone levels and changed
carbohydrate needs
Delayed gastric emptying
 Watch for vomiting and airway
compromise
Hands-on physical abdominal assessment
difficult due to compression and shifting of
abdominal organs
Changes in Pregnancy cont’d

Urinary system


Increase in renal blood flow
Urinary frequency is common


Urinary bladder displaced more forward and
higher increasing vulnerability to injury to the
urinary bladder
Musculoskeletal system


Waddling gait due to loosened pelvic joints
Low back pain due to change in center of
gravity
First Stage of Labor

Dilatation Stage
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Begins with onset of true labor contractions
Ends with complete dilatation and thinning of
the cervix
 Cervix dilates from a closed position to 10
cm (approximately 4 inches)
Duration usually longer in 1st pregnancy
Early contractions mild, last 15 – 20 seconds
coming every 10 – 20 minutes
End of 1st stage contractions last 60 seconds
and are coming every 2 – 3 minutes
Second Stage of Labor

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Begins with complete dilatation of
cervix
Ends with delivery of fetus
Can last 50-60 minutes in 1st deliveries
Pain felt in the lower back
Mother has the urge to push
Bag of waters usually ruptures in this
stage if not already ruptured
Crowning is evident
 Definitive sign of imminent delivery
Third Stage of Labor


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Begins immediately after birth of the
infant
Ends with delivery of placenta
Placenta generally delivers within 5 –
20 minutes
Signs of placental separation

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Gush of blood from vagina
Change in size, shape, consistency of
uterus
Umbilical cord length increases
Mother has the urge to push
Assessment of the Patient in Labor

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

Ask expected due date
Gravida – number of pregnancies
 First time deliveries tend to take longer –
16 – 17 hours
 Labor tends to shorten with subsequent
pregnancies
Para – number of live births
Is it “gravida and para” or “para and gravida”?
Note: “G” comes before “P” in the alphabet; you
must be pregnant before you can deliver
Assessment of the Patient in Labor


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Determine how long mother has been
in labor
Ask how long previous deliveries took
Ask if bag of waters is intact or has
broken


Delivery is quicker once bag of waters has
broken
Are there any high risk concerns the
mother is aware of
Assessment of the Patient in Labor

Time duration & frequency of
contractions
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Duration is from the beginning of one
contraction to the end of that contraction
Frequency is how far apart contractions are


Measured from the beginning of one
contraction to the beginning of the next
contraction
Contractions lasting 30-60 seconds and
coming every 2-3 minutes apart
indicate imminent delivery
Signs of Imminent Delivery

Crowning


Bulging perineum
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

Bulging of the fetal head past the vaginal
opening during contraction
Presenting part pressing on perineum
Urge to push
Note: High index of suspicion in female
with abdominal pain and cramping (esp
in a pattern) and denies pregnancy
OB Kit Contents
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Sterile gloves
Drape sheet
Gauze sponges
Disposable towels
2 alcohol preps
2 OB towelettes
Bulb syringe
Receiving blanket
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2 umbilical clamps
2 nylon tie-offs
Scalpel or scissors
OB pad
Plastic bag
Twist ties
Infant cap
2 wrist ID bands
OB Kit Contents
Newborn At Delivery
Preventing Hypothermia in a Newborn
Dry
them;
Wrap
them;
Cap
them
APGAR Assessment – 1 & 5 minutes


A – appearance
 Most visible, least helpful
 Typical for pink trunk and blue distal
extremities
P – pulse
 100 or above is acceptable
 80-100 – stimulation needed
 <60 – start compressions
APGAR cont’d
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G – grimace (irritability)
 Includes coughing, sneezing, crying
A – activity
 Active motion, flexing of extremities
R – respiratory effort
 Strong cry
Majority of scores are 7–10 indicating a
healthy infant requiring routine care
Scores 4-6 indicate moderately depressed
infant requiring oxygen & stimulation
APGAR Score
Criteria
1
2
Appearance Blue or
pale
Pulse
Absent
Blue hands
or feet
< 100
Entirely
pink
>100
Grimace –
Absent
Grimace
Cough,
sneeze
Activity
Limp
Active
motion
Respirations
Absent
Some
extremity
flexion
Weak cry,
hypoventilating
reflex
irritability
0
Strong cry
Inverted Pyramid
Drying, warming, positioning
Suction, tactile stimulation
Oxygen
Basic
BVM
skills
Chest
Compressions
Intubation
Advanced
Meds
skills
OB Complications – Supine
Hypotensive Syndrome

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Can occur especially after 5 months
gestation
Heavy weight of uterus compresses
inferior vena cava when mother in the
supine position
Interferes with blood flow returning
back to the heart
Intervention

Transport women over 5 months pregnant
lying or tilted towards their left side
Remember: Lay left
OB Complications – Seizures


Consider causes
 Hypoglycemia – check glucose levels on all
patients with altered level of consciousness
 Epilepsy – check for ID; protect airway
 Eclampsia – protect airway
Intervention
 For any prolonged seizure activity, need to
consider using BVM to support ventilations
and provide oxygenation
 Transport lying/tilted left if over 5 months
gestation
Region X SOP for Seizures from
Eclampsia
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Check the blood sugar level on all patients
with an altered level of consciousness
For active seizure, administer Valium 5 mg
IVP slowly over 2 minutes
May repeat Valium 5 mg slow IVP
Titrate to control seizure activity
Maximum total 10 mg
Valium, if given, has sedating effect on
mother & fetus
 EMS should verbally inform/remind ED and
OB staff of use of Valium in the field
OB Complications – Breech Delivery
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Buttocks or feet present first
Approximately 4% of all births
Increased risk
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Maternal trauma
Prolapse of cord
Cord compression
Anoxia to the infant
Intervention
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Advanced medical intervention at the hospital
Rapid transport important
Breech Presentation
Breech Delivery cont’d

Intervention
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As legs deliver, support legs across forearm
If cord is accessible, palpate often
If able, loosen cord to create slack
After torso and shoulders deliver, gently
sweep down arms
If face down, gently elevate legs & trunk to
facilitate delivery of head
NEVER PULL INFANT BY LEGS OR TRUNK
Breech cont’d
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If head not delivered within 30 seconds
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Reach 2 gloved fingers into vagina to locate
baby’s mouth
Push vaginal wall away from baby’s mouth
to form an airway
Keep your fingers in place and transport
immediately
Keep delivered part of baby warm


Cover with a blanket
If head delivers, anticipate neonatal
distress
OB complications – Prolapsed Cord
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Perform a visual exam as soon as possible
whenever a mother states her bag of waters
has ruptured
Elevate the mother’s hips or place knee-chest
Have patient breath through the contractions
so she doesn’t push
Placed gloved hand into vagina and raise
presenting part to get pressure off cord
Keep cord between fingers to monitor for
pulsations
Cover cord with moist dressing, keep warm
Prolapsed Cord
OB Complications – Nuchal Cord
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Cord wrapped around infant’s neck
Increase mother’s O2 to 100% nonrebreather mask
Slip fingers around cord and lift over
infant’s head
Proceed with delivery
If unable to reposition cord, place 2 OB
clamps, cut cord between clamp,
release cord from around neck
Proceed with delivery
Nuchal Cord (C-section)
Meconium



Dark green material found in the
intestine of the full-term newborn.
It can be expelled
during periods of
fetal distress
(ie: hypoxia)
If found in the infant
airway, could
compromise
ventilations
Meconium Staining
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Fetus has passed feces into amniotic
fluid
Occurs between 10-30% all deliveries
Not unusual to observe in breech
delivery
In normal head-down delivery indicates
fetal hypoxia


Hypoxia increases fetal peristalsis and
relaxation of anal sphincter
The darker the color/staining, higher
the risk of fetal morbidity
Meconium Stained Baby


Airway needs to
be cleared to
avoid aspiration
of meconium
Suction and
clear airway
before infant
needs to take
that first breath
Meconium Staining

If meconium is thin and light in color
and the infant is vigorous


Most meconium can be cleared away with
bulb syringe
ALWAYS suction mouth then nose, in that
order



Suctioning the nose stimulates breathing in the
newborn
Want to clear the mouth 1st so first breath is
as clean as possible
Limit suction (2 seconds per Region X SOP)
Meconium Staining
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If infant is not vigorous
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Respiratory rate decreased
Decreased muscle tone
Heart rate < 100
Use meconium aspirator to clear airway
This will take coordination and best
accomplished with 2 persons working
as a team
Meconium Suctioning
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Steps include
intubation
Most efficient when
performed as a 2
person team
Time is essential
May need to
perform 2
intubation
insertions
Use each ETT once
Meconium Aspirator
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Connect small end of meconium aspirator
to suction line connecting tube
Turn suction down to 80 mmHg
Insert endotracheal tube
 Don’t anticipate visualizing landmarks
– they may be obscured by meconium
Connect larger end of aspirator to ETT
Place thumb over suction control port
and slowly withdraw ETT (< 2 seconds)
Discard ETT after one use
Meconium Aspirator
Aspirator can be used a
second time on infant
with new ETT each time
Limit suction to
<2 seconds
Meconium Aspirator ED Location
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CMC
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In peds crash cart
On Broselow cart
LFH

In bins on wire rack shelves
Case Study #1
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EMS arrives on the scene for OB call
Patient is 24 y/o and states she is in
labor
What assessment questions specific to
an imminent delivery need to be asked?
What needs to be evaluated during the
physical assessment
Case Study #1

Assessment questions
 Gravida?
 Para?
 Due date?
 High risk concerns?
 Length of previous labors?
 Bag of waters intact? Ruptured?
 Duration and frequency of
contractions?
Case Study #1

Physical exam – position patient to
evaluate
 Crowning
 Evidence of bulging perineum
 Involuntary pushing
 Signs of prolapsed cord
 Evidence of profuse bleeding
Case Study #1 History
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G2P1
EDC in 1 week
No complications anticipated
Previous labor 12 hours
Bag of waters has ruptured
Contractions are 5-6 minutes apart and
lasting 20-30 seconds
There is no bulging or crowning
Does EMS stay & prepare to deliver
or transport?
Case Study #1

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You could most likely begin transport
with OB kit reached out in case labor
progresses
What stage of labor is the patient in?

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First stage
If the patient delivers, how many run
reports need to be written?

Two – one for the mother, one for the infant
What is your role during delivery?
Support the presenting part
Check for
nuchal cord
Suction mouth
Then nose
Head and shoulders delivered
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Have a firm grip
on infant
Cheesy covering
and moisture
make them
slippery
After shoulders,
rest of the body
will slip out fast
Clamping & cutting the cord
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After cord is done
pulsating, clamp 8″
from infant’s navel
with 2 clamps
placed 2″ apart
Watch for blood
leakage from
infant’s cord
Reinforce with
additional clamps
as needed
3rd Stage of Labor – Placental stage
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Watch for
excessive bleeding
(>500 ml)
Prepare to perform
fundal massage
Need to feel uterus
become firm – size
of the uterus will
depend on the size
of the fetus
Fundal Massage
Newborn dried off, cord clamped & cut
What’s his APGAR?
Case Study #2
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Mother calls EMS because “my baby is
coming”
Upon EMS arrival, they gained quick
rapport
Contractions are coming every 2-3
minutes and are 60-90 seconds long
The mother states she wants to push
and feels her baby is coming right now
EMS performed a visual exam
Case Study #2 This is what you see.
Now what do you do?
If cord is
wrapped
around the neck,
try to loosen and
slip over the
head.
If too tight, need
to double clamp
and cut the cord
NOW.
Case Study #3
Mother calls EMS and states she is
in labor
 Mother is G3P2 due tomorrow
 No known complications
 She has been in labor for 4 hours
 Contractions are 3 minutes apart
 EMS established rapport and
performed a visual exam
 EMS determined that delivery is
imminent

Case Study #3 - This is a breech
delivery that is not delivering. How do
you handle this?
Head should
deliver in
30 seconds.
If not, reach
in to create
an airway for
the infant.
Support body
across your
forearm.
Creating an airway for a breech
delivery

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Reach 2 fingers into the vagina
Locate the infant’s face
Push the vaginal skin away from the
infant’s mouth
Transport immediately
Give report to the closest facility
The crew member CANNOT move their
fingers and risk losing the airway

The golden sounds to a mother’s and
EMS provider’s ears – a newborn’s
cry!!!
Documentation
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If the patient delivers, EMS and ED
need to write 2 reports – one for the
mother & one for the infant
Both reports can have time of delivery
On run report, OB delivery is credited
to the person who delivers (“catches”)
Segregate information
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Mother’s information on mother’s run report
Infant’s information on the infant’s run
report
Documentation - Mother
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Due date (ie: EDC June 15th)
Gravida/para (ie: G3P2)
Presence of high risk concerns
Bag of waters – Ruptured? Intact
Status of contractions
Signs of imminent delivery
 Crowning
 Bulging
 Urge to push
Time of delivery (when last of baby delivers) & sex
Complications during/after delivery (ie: bleeding)
If placenta delivered or not
Documentation - Infant
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Time of delivery
Appearance of amniotic fluid (ie: clear,
meconium staining)
APGAR 1 and 5 minutes (ie: APGAR 9/9)
Completion of assessment per physical
condition boxes on run report
Vital signs – B/P not necessary
That cord was clamped and cut
Time placenta delivered
Special interventions required after delivery
Wrist Bands
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Apply a wrist band to both the mother
and the newborn
Include the same information on both
wrist bands
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Mother’s name
Sex of infant
Time of delivery
Bibliography
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Bledsoe, B., Porter, R., Cherry, R.
Essentials of Paramedic Care. 2nd
Edition. Brady. 2007.
Limmer, D., O’Keefe, M. Emergency
Care 10th Edition. Brady. 2005.
Region X SOP’s Effective March 1, 2007