OB Delivery Complications - PowerPoint PPT Presentation

1 / 65
About This Presentation
Title:

OB Delivery Complications

Description:

If face down, gently elevate legs & trunk to facilitate delivery of head ... The mother states she wants to push and feels her baby is coming right now ... – PowerPoint PPT presentation

Number of Views:137
Avg rating:3.0/5.0
Slides: 66
Provided by: sha226
Category:

less

Transcript and Presenter's Notes

Title: OB Delivery Complications


1
OB Delivery Complications
  • Condell Medical Center
  • EMS System
  • ECRN Packet
  • Module I 2008

Prepared by Sharon Hopkins, RN, BSN, EMT-P
2
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.

3
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

4
Normal Fetal Positioning
5
Changes in Pregnancy contd
  • 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

6
Changes in Pregnancy contd
  • Cardiovascular system
  • 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)

7
Changes in Pregnancy contd
  • 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

8
Changes in Pregnancy contd
  • 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

9
First Stage of Labor
  • Dilatation Stage
  • 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

10
Second Stage of Labor
  • 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

11
Third Stage of Labor
  • Begins immediately after birth of the infant
  • Ends with delivery of placenta
  • Placenta generally delivers within 5 20 minutes
  • Signs of placental separation
  • Gush of blood from vagina
  • Change in size, shape, consistency of uterus
  • Umbilical cord length increases
  • Mother has the urge to push

12
Assessment of the Patient in Labor
  • 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

13
Assessment of the Patient in Labor
  • 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

14
Assessment of the Patient in Labor
  • Time duration frequency of contractions
  • 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

15
Signs of Imminent Delivery
  • Crowning
  • Bulging of the fetal head past the vaginal
    opening during contraction
  • Bulging perineum
  • 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

16
OB Kit Contents
  • Sterile gloves
  • Drape sheet
  • Gauze sponges
  • Disposable towels
  • 2 alcohol preps
  • 2 OB towelettes
  • Bulb syringe
  • Receiving blanket
  • 2 umbilical clamps
  • 2 nylon tie-offs
  • Scalpel or scissors
  • OB pad
  • Plastic bag
  • Twist ties
  • Infant cap
  • 2 wrist ID bands

17
OB Kit Contents
18
Newborn At Delivery
19
Preventing Hypothermia in a Newborn
Dry them Wrap them Cap them
20
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
  • lt60 start compressions

21
APGAR contd
  • G grimace (irritability)
  • Includes coughing, sneezing, crying
  • A activity
  • Active motion, flexing of extremities
  • R respiratory effort
  • Strong cry
  • Majority of scores are 710 indicating a healthy
    infant requiring routine care
  • Scores 4-6 indicate moderately depressed infant
    requiring oxygen stimulation

22
APGAR Score
23
Inverted Pyramid
  • Drying, warming, positioning
  • Suction, tactile stimulation
  • Oxygen
  • BVM
  • Chest
  • Compressions
  • Intubation
  • Meds

Basic skills
Advanced skills
24
OB Complications Supine Hypotensive Syndrome
  • 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

25
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

26
Region X SOP for Seizures from Eclampsia
  • 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

27
OB Complications Breech Delivery
  • Buttocks or feet present first
  • Approximately 4 of all births
  • Increased risk
  • Maternal trauma
  • Prolapse of cord
  • Cord compression
  • Anoxia to the infant
  • Intervention
  • Advanced medical intervention at the hospital
  • Rapid transport important

28
Breech Presentation
29
Breech Delivery contd
  • Intervention
  • 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

30
Breech contd
  • If head not delivered within 30 seconds
  • Reach 2 gloved fingers into vagina to locate
    babys mouth
  • Push vaginal wall away from babys 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

31
OB complications Prolapsed Cord
  • Perform a visual exam as soon as possible
    whenever a mother states her bag of waters has
    ruptured
  • Elevate the mothers hips or place knee-chest
  • Have patient breath through the contractions so
    she doesnt 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

32
Prolapsed Cord
33
OB Complications Nuchal Cord
  • Cord wrapped around infants neck
  • Increase mothers O2 to 100 non-rebreather mask
  • Slip fingers around cord and lift over infants
    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

34
Nuchal Cord (C-section)
35
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

36
Meconium Staining
  • 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

37
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

38
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)

39
Meconium Staining
  • If infant is not vigorous
  • Respiratory rate decreased
  • Decreased muscle tone
  • Heart rate lt 100
  • Use meconium aspirator to clear airway
  • This will take coordination and best accomplished
    with 2 persons working as a team

40
Meconium Suctioning
  • 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

41
Meconium Aspirator
  • Connect small end of meconium aspirator to
    suction line connecting tube
  • Turn suction down to 80 mmHg
  • Insert endotracheal tube
  • Dont 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 (lt 2 seconds)
  • Discard ETT after one use

42
Meconium Aspirator
Aspirator can be used a second time on infant
with new ETT each time
Limit suction to lt2 seconds
43
Meconium Aspirator ED Location
  • CMC
  • In peds crash cart
  • On Broselow cart
  • LFH
  • In bins on wire rack shelves

44
Case Study 1
  • 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

45
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?

46
Case Study 1
  • Physical exam position patient to evaluate
  • Crowning
  • Evidence of bulging perineum
  • Involuntary pushing
  • Signs of prolapsed cord
  • Evidence of profuse bleeding

47
Case Study 1 History
  • 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?

48
Case Study 1
  • You could most likely begin transport with OB kit
    reached out in case labor progresses
  • What stage of labor is the patient in?
  • First stage
  • If the patient delivers, how many run reports
    need to be written?
  • Two one for the mother, one for the infant

49
What is your role during delivery?
Support the presenting part
Check for nuchal cord Suction mouth Then nose
50
Head and shoulders delivered
  • Have a firm grip on infant
  • Cheesy covering and
    moisture make them slippery
  • After shoulders, rest of the body will slip out
    fast

51
Clamping cutting the cord
  • After cord is done pulsating, clamp 8? from
    infants navel with 2 clamps placed 2? apart
  • Watch for blood leakage from infants cord
  • Reinforce with additional clamps as needed

52
3rd Stage of Labor Placental stage
  • Watch for excessive bleeding (gt500 ml)
  • Prepare to perform fundal massage
  • Need to feel uterus become firm size of the
    uterus will depend on the size of the fetus

53
Fundal Massage
54
Newborn dried off, cord clamped cut
Whats his APGAR?
55
Case Study 2
  • 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

56
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.
57
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

58
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.
59
Creating an airway for a breech delivery
  • Reach 2 fingers into the vagina
  • Locate the infants face
  • Push the vaginal skin away from the infants
    mouth
  • Transport immediately
  • Give report to the closest facility
  • The crew member CANNOT move their fingers and
    risk losing the airway

60
  • The golden sounds to a mothers and EMS
    providers ears a newborns cry!!!

61
Documentation
  • 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
  • Mothers information on mothers run report
  • Infants information on the infants run report

62
Documentation - Mother
  • 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

63
Documentation - Infant
  • 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

64
Wrist Bands
  • Apply a wrist band to both the mother and the
    newborn
  • Include the same information on both wrist bands
  • Mothers name
  • Sex of infant
  • Time of delivery

65
Bibliography
  • Bledsoe, B., Porter, R., Cherry, R. Essentials of
    Paramedic Care. 2nd Edition. Brady. 2007.
  • Limmer, D., OKeefe, M. Emergency Care 10th
    Edition. Brady. 2005.
  • Region X SOPs Effective March 1, 2007
Write a Comment
User Comments (0)
About PowerShow.com