OB Emergencies

1
OB Emergencies

• July 2012 CE
• Condell Medical Center
• EMS System
• Site Code 107200E -1212

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

3
Objectives contd

• 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.

4
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

5
Female Reproductive System

• Most important organs are internal
• Vagina
• Uterus
• Fallopian tubes
• Ovaries

6
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

7
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

8
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

9
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

10
Fallopian Tubes

• Thin flexible pair of tubes about 4 inches (10
  cm) x lt1/2 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

11
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

12
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

13
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

14
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

15
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

16
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

17
Case Scenario 1

• EMS is called to the scene for a 16 year-old
  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

18
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 wont always get an honest answer
  (especially if parents are present)
• You should always be prepared for the
  unexpected!!!

19
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

20
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

21
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)

22
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

23
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 infants delivery
• Can last 10-20 minutes
• Do not need to remain on the scene until the
  placenta delivers

24
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?

25
Timing Contractions

• Duration
• From the beginning of the contraction until it
  ends
• Interval/time between
• From the beginning of 1 contraction to the
  beginning of the next
• Contractions coming every 2-3 minutes usually
  indicates imminent birth

26
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, Ive got to push!!!
• No reason not to trust what the mother says

27
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

28
OB Kit Contents

• Go through your kit describe how would you use
  each piece

29
Delivery Process

• Remember Its 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

30
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

31
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

32
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?

33
Case Scenario 2

• Gain quick rapport
• Need to perform a visual exam
• Crowning present?
• Bulging of the perineum present?
• Any blood, cord, fingers, or toes present?
• Position mother for delivery
• Your cot, your ambulance if time
• Open and prepare the OB kit

34
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

35
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

36
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

37
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

38
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

39
Hypertensive Emergencies

• Preeclampsia
• Elevated blood pressure
• Excessive weight gain
• Extreme swelling face, feet, hands
• Headache or altered mental status
• Eclampsia
• Seizure activity

40
Care of the Pregnant Patient with Seizure Activity

• Handle gently
• Minimal CNS stimulation
• Avoid loud noises, flashing lights
• Be prepared to secure the airway
• Have suction available
• Limit suction time to lt10 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 delivered

41
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

42
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)

43
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
  patients hospital of choice
• THIS IS A LIFE THREATENING CONDITION!!!

44
Abruptio Placenta

• Placenta prematurely separates from
  uterine wall
• Partial or complete tear
• Excessive pain
• Rigid abdominal wall
• Minimal vaginal blood flow dark

45
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

46
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

47
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 - Im not in labor
• You need to encourage them to contact their
  doctor ASAP due to risk of infection

48
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

49
Prolapsed Cord

• If cord precedes delivery of
• infant, the fetal blood and
  oxygen flow will be cut off
• Elevate the mothers 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

50
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

51
Breech Delivery

• Support infants body as soon as the legs deliver
• Keep infants 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

52
Breech contd

• 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

53
Issues of Premature Birth

• Weaker, less developed muscles
• Spontaneous breathing more difficult
• Deficiency in surfactant in lungs
• Ventilations more difficult
• Rapid heat loss
• Thin skin, decreased fat
• Immature tissues
• More easily damaged by excessive oxygenation

54
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

55
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

56
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

57
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

58
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

59
APGAR Score

• What is it?
• An objective method of evaluating the newborns
  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

60
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

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APGAR Score
62
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 infants cut end
• Apply another clamp or tie to oozing end if needed

63
Total Blood Volumes Average 75 - 80 ml/kg

• Adult 4 - 5 liters
• Child - 2 liters
• Newborn 335 ml

64
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

65
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

66
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

67
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

68
Inverted Pyramid
69
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 lt100, 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 lt60, start
  compressions 31 ratio

70
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

71
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

72
Fetal Oxygenation

• Fetus oxygenated via O2 diffusing across
  placental membrane from mothers 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

73
Newborn Assessment Do They Require
Resuscitation?

• Is the baby preterm?
• Especially less than 34 weeks increases risk of
  instability
• Is the baby breathing or crying?
• Gasping could indicate severe respiratory
  depression or neurological problems
• Is the muscle tone good?
• Flexed extremities is normal extended and
  flaccid extremities not normal

74
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 gt100

75
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

76
Neonatal Resuscitation

• When do I need to provide resuscitation?
• Heart rate lt100 despite adequate ventilation and
  oxygenation for 30 seconds
• Use the right equipment
  for the right patient

77
Positioning

• Head extension required for adults and children
• Sniffing position best for infants
• Babys nose is as far anterior as possible
• Head extension closes off airway
• Small pad (ie diaper) under shoulder blades
  helps for positioning

78
Sniffing Position
79
Adult/Child/Neonatal BVMs

• 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

80
Revised CPR Guidelines 2012

• C- A- B (not ABC)
• Check responsiveness
• Check for brachial pulses
• Begin compressions
• Open airway
• Provide gentle ventilations

81
Neonatal Resuscitation

• Chest compressions
• 90/minute
• Finger tips on lower half of sternum
• Depress 1 ½ inches or 1/3 the AP diameter
• Compression to ventilation
  ratio 31
• Ventilations are tiny puffs of
  air

82
Neonatal Ventilatory Support

• Pulse present with inadequate breathing
• Deliver 1 breath/second with neonatal BVM until
  heart rate gt100
• If advanced airway in place
• Deliver 1 breath/second with neonatal BVM until
  heart rate gt100

83
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

84
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?

85
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
• Compress to a depth of 1/3 the AP diameter of the
  chest wall

86
Case Scenario 5

• Deliver 2 puffs of air
• Enough to make the chest rise
• Compressions to ventilation ratio 31
• Inadequate breathing with pulse
• Deliver 1 breath per second to achieve heart rate
  gt100
• Ventilations with advanced airway in place
• Deliver 1 breath per second to achieve heart rate
  gt100

87
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

88
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

89
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

90
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

91
Case Scenario 6

• If this is an ectopic, this is a true life
  threatening emergency!
• Patient will go to the OR immediately
• The patients 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

92
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., OKeefe, 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.