WESHARE EMS Instructor

WESHARE EMS Instructor
OB/GYN EMERGENCIES Cheryl Behm, RN CCHS-WR Lakewood Hospital WESHARE EMS Instructor

OBJECTIVES: Describe the organization and function of the specialized structures of pregnancy. Describe the general assessment and management of the pregnant patient. Review the various complications of pregnancy and their management. Describe the stages of labor. Describe the general management of a patient in labor. State the indications of an imminent delivery.

OBJECTIVES (con’t) Describe the necessary preparations for pre-hospital delivery. Review the steps in assisting in the delivery of the baby. Discuss the post-delivery care of the mother and newborn. Summarize neonatal resuscitation procedures.

OBJECTIVES (con’t) Define abnormal delivery situations, delivery complications, and their treatments. Discuss maternal complications of labor and delivery and their treatments.

INTRODUCTION Childbirth can be common in the prehospital setting.
Most often, EMS personnel only assist in this natural process and provide appropriate care for the mother and newborn. Obstetrical emergencies can develop suddenly and become life-threatening. The EMS provider must be prepared to recognize and manage these events and sometimes assist in abnormal deliveries.

ANATOMY REVIEW Fetus Uterus Placenta Umbilical Cord Amniotic Sac
Cervix

SPECIALIZED STRUCTURES OF PREGNANCY
Placenta: Approximately 14 days after ovulation, specialized cells develop and form the placenta. The placenta is a disk like organ composed of interlocking fetal and maternal tissues.

SPECIALIZED STRUCTURES OF PREGNANCY
Placenta: Serves as the organ of exchange between the mother and fetus and is responsible for the following five functions: 1. Transfer of gases 2. Transport of nutrients 3. Excretion of wastes 4. Hormone production 5. Formation of a barrier

FIVE FUNCTIONS OF THE PLACENTA
1. Transfer of gases: The diffusion of O2 and CO2 through the placental membrane is similar to diffusion that occurs through the pulmonary membranes. Dissolved O2 in the maternal blood passes through the placenta into the fetal blood because of the pressure gradient between the blood of the mother and fetus. Conversely, as fetal CO2 accumulates, a low pressure gradient of CO2 develops across the placental membrane, and diffusion of CO2 from the fetal blood to maternal blood occurs.

2. Transport of nutrients Other nutrients needed by the fetus diffuse into fetal blood in the same manner as O2. Example: Glucose levels in the fetus are lower than glucose levels in Mom. - Result: Rapid diffusion of glucose from Mom to the fetus.

3. Excretion of wastes Waste products from the fetal blood diffuse into the maternal blood where they are excreted along with waste products of the mother. The transfer of wastes from the fetus to the Mom occurs the same way as does CO2.

4. Hormone production The placenta becomes a temporary endocrine gland to secrete enough estrogen and progesterone. These hormones are needed to maintain the uterine lining as well as prepare the Mom for delivery.

5. Formation of a barrier Provides a barrier against some harmful substances and chemicals in the Mom’s circulation. Barrier is incomplete, nonselective, and does not provide total protection to the fetus. Drugs that easily cross the placenta – steroids, narcotics, anesthetics, and some antibiotics.

ANATOMY REVIEW (con’t)
Umbilical cord Blood flows from the fetus to the placenta by way of 2 umbilical arteries carrying deoxygenated blood. Oxygenated blood returns to the fetus by an umbilical vein. Closed system independent of and separated from Mom’s circulation.

Maternal Circulation - The ductus venosus is a continuation of the umbilical cord. - Serves as a shunt to allow most blood returning from the placenta to bypass the immature liver of the fetus and empty directly into the inferior vena cava.

Maternal Circulation - The foramen ovale and ductus arteriosum allow blood to bypass the nonfunctional lungs, which remain collapsed until birth. - The foramen ovale shunts blood from the right atrium directly into the left atrium. - The ductus arteriosum connects the aorta and pulmonary artery.

Maternal Circulation

Maternal Circulation - End result: Well oxygenated blood from the placenta enters the left side of the heart rather than the right side and is pumped by the left ventricle into the vessels of the head and limbs.

Amniotic sac and fluid - The amniotic sac is a fluid-filled cavity that surrounds and protects the fetus. - Amniotic fluid originates from several fetal sources, including fetal urine and secretions from the respiratory tract, skin, and amniotic membranes. - The fluid accumulates rapidly and amounts to about 175 to 225 ml by the fifteenth week of pregnancy and about 1 L at birth. - The rupture of the amniotic membranes produces a watery discharge at the time of delivery.

FETAL GROWTH AND DEVELOPMENT

GENERAL ASSESSMENT OF THE OB PATIENT
Initial assessment SAMPLE History including: - Estimated date of confinement (due date) - Pre-existing medical conditions - Pain - Vaginal bleeding - Labor Physical Examination

DO NOT perform an internal vaginal exam in the field! Always remember that you are caring for TWO patients – Mom and fetus. Meticulous attention to the ABCs is of utmost importance to both patients. Monitor for shock.

History - First gather information on the chief complaint – may not be related to the pregnancy. - R/O life-threatening illness/injury. - Interview the patient to obtain relevant information such as: Length of gestation (how pregnant is she).

History (con’t) Number of all the woman’s current and past pregnancies, as well as how many pregnancies have remained viable to delivery. History of any previous C-sections.

History (con’t) - Maternal lifestyle (alcohol/drug use/smoking history) - Infectious disease status - History of previous OB/GYN complications (eclampsia, premature labor, ectopic pregnancy)

History (con’t) - Presence of pain: Onset (gradual or sudden) Character Duration and evolution over time Location and radiation - Presence, quantity, and character of vaginal bleeding - Presence of abnormal vaginal discharge

History (con’t) - Presence of "show" (expulsion of the mucous plug in early labor) or rupture of membranes. - Current general health and prenatal care (none, physician, nurse midwife). - Allergies - Meds taken (especially narcotics in the last 4 hours). - Urge to bear down or the sensation of an imminent bowel movement suggesting imminent delivery.

GENERAL MANAGEMENT OF THE OB PATIENT
If birth is not imminent, prehospital care for the healthy patient will often be limited to basic treatment modalities (airway, ventilatory, and circulatory support) and transport for physician evaluation. In the absence of distress or injury, the patient should be transported in a position of comfort (usually left lateral recumbent).

GENERAL MANAGEMENT OF THE OB PATIENT
ECG monitoring and high-concentration oxygen administration may be indicated for some patients, based on patient assessment and vital sign determinations. Medical direction may recommend that IV access be established. Medication administration is usually inappropriate because they may mask symptoms of a deteriorating condition.

COMPLICATIONS OF PREGNANCY
Trauma: - Transport all trauma patients at 20 weeks or more gestation. - Anticipate the development of shock!

Trauma Management: - Apply c-collar for cervical stabilization and immobilize on a long backboard. - Place patient tilted to the left to minimize supine hypotension. - Administer high-flow oxygen concentration. - Initiate two large-bore IVs per protocol. - Reassess patient. - Monitor the fetus.

Medical: - Any pregnant patient with abdominal pain should be evaluated by a physician!

Medical: - Preeclampsia and eclampsia are two hypertensive disorders specific to pregnancy. - Hypertensive disorders occur in about 5% of all pregnancies in the United States and increases the risk to both the mother and fetus.

Preeclampsia: - Preeclampsia is a disease of unknown origin that primarily affects previously healthy, normotensive women having their 1st baby. - Occurs after the twentieth week of gestation, often near term.

Preeclampsia: - Signs and symptoms of preeclampsia result from poor perfusion to the tissue or organs involved. - Brain: Headache Dizziness Confusion

Preeclampsia: - Eyes: Blurred vision - GI system: Nausea/vomiting Right upper quadrant or epigastric pain and tenderness

Preeclampsia: - Vasculature: High BP Peripheral edema

Preeclampsia: - Placenta: Abruptio placenta Fetal distress

Preeclampsia: - The criteria for diagnosis are based on the presence of the “classic triad”: 1.) Hypertension: BP>140/90, and acute rise of 20 mm Hg SBP, or a rise of 10 mm Hg DBP over pre-pregnancy BP. 2.) Protein in the urine 3.) Excessive weight gain with edema

Eclampsia: - Eclampsia is characterized by the same signs and symptoms plus seizures or coma.

Eclampsia Management: - Because of the potentially devastating course of the illness, the disease should always be considered when hypertension is present in late pregnancy.

Eclampsia Management: - If preeclampsia or eclampsia is suspected, EMS care is directed at preventing or controlling seizures and treating hypertension. - Seizure activity in eclampsia is similar to generalized grand mal seizures of other etiologies and is characterized by tonic-clonic activity. - The seizure often begins around the mouth as facial twitching.

Eclampsia Management: - Place patient in the left lateral recumbent position to help maintain/improve blood flow to the uterus and placenta. - Handle the patient gently and minimize sensory stimulation (darken the ambulance) to avoid precipitating seizures. - Administer high-concentration oxygen and assist respirations as needed. - Initiate IV therapy per protocol.

Eclampsia Management: - Anticipate seizures at any moment and be prepared to provide airway, ventilatory, and circulatory support. - Be prepared to administer the following medications per medical direction and per protocol: Valium: May cause a fall in BP. May cause problems with the fetal circulation. Monitor VS closely!

Vaginal Bleeding: - May result during pregnancy from abortion (miscarriage), ectopic pregnancy, abruptio placenta , placenta previa, uterine rupture, or postpartum hemorrhage. - Patients who have vaginal bleeding develop varying degrees of blood loss. - Some require aggressive resuscitation.

Vaginal bleeding: Abortion - The termination of pregnancy from any cause before the twentieth week of gestation (after which it is known as a preterm birth). - The most frequent cause of vaginal bleeding in pregnant women and occurs in about 1 in 10 pregnancies.

Vaginal bleeding: Classification of Abortion - Complete abortion: an abortion in which the patient has passed all of the products of conception. - Criminal abortion: an intentional ending of any pregnancy under any condition not allowed by law. - Incomplete abortion: an abortion in which the patient has passed some but not all of the products of conception.

Vaginal bleeding: Classification of Abortion (con’t) - Induced abortion: an abortion in which the pregnancy is intentionally terminated. - Missed abortion: the retention of the fetus in utero for 4 or more weeks after fetal death.

Vaginal bleeding: Classification of Abortion (con’t) - Spontaneous abortion: Lay term is miscarriage. An abortion that usually occurs before the twelfth week of gestation. - Therapeutic abortion: a pregnancy legally terminated for reasons of maternal well-being.

Vaginal bleeding: Classification of Abortion (con’t) - Most abortions occur in the first trimester, usually before the tenth week. - The patient is often anxious and apprehensive and complains of vaginal bleeding, which may be slight or profuse. - The patient may have suprapubic pain referred to the lower back and described as "cramp-like" and similar to the pain of labor or menstruation.

Vaginal Bleeding: History from patient - The time of onset of pain and bleeding. - Amount of blood loss. - A soaked sanitary pad suggests 20 to 30 ml of blood loss. - If the patient passed any tissue with the blood. - Tissue should be collected and transported with patient for ID.

Vaginal bleeding: Abortion-Management - Assessment of all first-trimester emergencies should include close observation for signs of significant blood loss and hypovolemia. - Measure and frequently monitor vital signs during transport. - Depending on the patient's hemodynamic status, IV fluid therapy may be indicated. - Provide oxygen, emotional support, and transport for physician evaluation.

Ectopic Pregnancy: - Occurs when a fertilized egg implants anywhere other than the endometrium of the uterine cavity. - Ectopic pregnancy occurs in 1 of every 200 pregnancies. - It is the leading cause of first-trimester death and accounts for more than 11% of all maternal deaths in the United States. - Death from ectopic pregnancy is usually the result of hemorrhage. - Although ectopic pregnancy has many causes, most involve factors that delay or prevent passage of the fertilized egg to its normal site of implantation.

Ectopic Pregnancy: - Signs and symptoms are often difficult to distinguish from those of a ruptured ovarian cyst, PID, appendicitis, or abortion (thus the name the great imitator). - The classic triad of symptoms includes: 1.) Abdominal pain 2.) Vaginal bleeding – may be absent or spotty. 3.) Amenorrhea

Ectopic Pregnancy - Management: - A true emergency that requires initial resuscitation measures and rapid transport for surgical intervention. - Manage the patient like any other with hemorrhagic shock: airway, ventilatory, and circulatory support and aggressive IV fluid resuscitation.

Third-trimester bleeding occurs in 3% of all pregnancies and is never normal. The majority of bleeding episodes are a result of abruptio placenta, placenta previa, or uterine rupture.

Abruptio Placenta: - A partial or complete detachment of a normally implanted placenta at more than 20 weeks’ gestation. - Occurs in up to 2% of all pregnancies and is severe enough to result in fetal death in 1 of 400 cases of abruption.

Abruptio Placenta: - The common presentation of abruptio placenta is sudden, third-trimester vaginal bleeding and pain. - Vaginal bleeding may be minimal and often is out of proportion to the degree of shock, since much of the hemorrhage may be concealed.

Abruptio Placenta: - The more extensive the abruption, the greater the uterine irritability, resulting in a tender abdomen and rigid uterus. - Contractions may be present. - In its severe form, fetal heart sounds are absent because fetal death is likely.

Placenta Previa: - Placenta is implanted in the lower uterine segment encroaching on or covering the cervix. - Characterized by painless, bright red bleeding without uterine contraction.

Placenta Previa: - Bleeding may occur in repetitive episodes and be slight to moderate, becoming more profuse if active labor ensues. - Fetal heart rate is often diminished because of placental insufficiency and hypoxia.

Uterine Rupture: - A spontaneous or traumatic rupture of the uterine wall. - May result from - Reopening of a previous uterine scar (e.g., a previous cesarean section). - Prolonged or obstructed labor. - Direct trauma.

Uterine Rupture: - Characterized by: - Sudden abdominal pain described as steady and "tearing“. - Active labor. - Early signs of shock (complaints of weakness, dizziness, anxiety). - Vaginal bleeding, which may not be visible. - On examination, the abdomen is usually rigid with diffuse pain.

Management of 3rd Trimester Bleeding: - Prehospital management of a patient with third-trimester bleeding is aimed at preventing shock. - No attempt should be made to examine the patient vaginally. - Doing so may increase hemorrhage and precipitate labor.

Emergency care measures for management of 3rd trimester bleeding should include the following: - Provide adequate airway, ventilation, and circulatory support as needed (with spinal precautions if indicated). - Place patient in left lateral recumbent position. - Begin transport immediately.

Emergency Care Con’t): - Initiate IV therapy with NS. - Apply a fresh perineal pad and note the time of application to assess bleeding during transport. - Closely monitor the patient's vital signs en route to the hospital.

LABOR AND DELIVERY Near the end of pregnancy the uterus becomes progressively more irritable and exhibits occasional contractions, which become stronger and more frequent. During and because of these contractions, the cervix begins to dilate. As uterine contractions increase, complete cervical dilation occurs to about 10 cm. The amniotic sac ruptures, and the fetus, and shortly after that the placenta, is expelled from the uterus through the vaginal canal.

STAGES OF LABOR Labor follows several distinct stages.
The length of these stages varies, depending on whether the mother is a first time Mom or has had many children. The stages of labor should be used only as a guideline in estimating labor progression in the average pregnancy.

STAGES OF LABOR Stage I (Dilation Stage):
- The onset of regular contractions to complete cervical dilation. - Average time: hours for a first time Mom. - 7 hours for most others.

STAGES OF LABOR Stage II (Expulsion Stage):
- The full dilation of cervix to delivery of the newborn. - Average time: - 80 minutes for a first time Mom. - 30 minutes for most others.

STAGES OF LABOR Stage III (Placental Stage):
- Immediately follows delivery of the baby until expulsion of the placenta. - Average time: - 5 to 20 minutes.

LABOR AND DELIVERY About 2 to 3 weeks before the onset of active labor, while the cervix undergoes the process of softening, effacement (thinning), and dilation, the uterus begins to become a contractile organ. Contractions, which before 30 weeks gestation were uncoordinated and of low intensity (Braxton-Hicks contractions), begin to steadily increase in intensity and duration.

LABOR AND DELIVERY

MANAGEMENT OF A PATIENT IN LABOR
Transport the patient in labor unless delivery is imminent. Maternal urge to push or the presence of crowning indicates imminent delivery. Delivery at the scene or in the ambulance will be necessary.

PREPARING FOR DELIVERY
Assessing the need for emergency delivery: - First decision: Do you have time to transport?

Decision based on three factors: 1.) Is the delivery expected within few minutes? Are you pregnant? How long have you been pregnant?

Is this your first baby? Are you having contractions or pain? How many minutes apart are your contractions? Are you bleeding?

Have you had any kind of discharge? Did your water break? Do you feel like you need to push? Move your bowels? Is crowning occurring?

Assessing the need for emergency delivery: 2.) Hospital cannot be reached due to a natural disaster, weather, or traffic conditions. 3.) No transportation is available.

EQUIPMENT Get out the OB kit which should contain something like:
- Surgical scissors-1 pair - Hemostats or cord clamps-3 - Umbilical tape/sterile cord - Small rubber bulb syringe - Towels

EQUIPMENT OB kit (con’t): - Gauze sponges - Rubber gloves
- Baby blanket-1 - Sanitary napkins - Plastic bag

DELIVERING THE BABY Set up the delivery area.
Position and support Mom: - Flat, sturdy surface. - Lie with knees drawn up and spread apart. - Elevate butt with blankets. Give O2 to the mother and start an IV of NS TKO (if needed).

POSITION AND SUPPORT Create sterile field: Partner at head:
One towel under buttocks One between her legs One across her abdomen Partner at head: Reassure/comfort Assess/Assist airway

DELIVERING THE HEAD Place flat hand on bony part of skull.
As the head crowns, apply gentle, steady pressure to prevent an explosive delivery. If amniotic sac does not break, or has not broken: Use clamp to puncture. Push away from nose and mouth.

DELIVERING THE HEAD Umbilical cord around neck? Slip over shoulder.
Suction the mouth and then the nose.

DELIVERING THE BODY Support head and body. Grasp feet.
Support with both hands: Baby will be slippery! Do not squeeze neck or chest.

POST DELIVERY CARE Initial care of baby Set baby down:
- Same level or lower than birth canal. - On side with head slightly lower than body. - Continue to suction mouth and nose.

INITIAL CARE OF THE BABY
Dry the infant and wrap in warm (if available) blanket. Leave only face exposed. If not breathing, perform CPR

CUTTING THE UMBILICAL CORD
Clamp the cord 4-6 inches away from the infant in 2 places. Four fingers width from the baby Place clamps two to six inches apart Cut between clamps with sterile scissors. Tie off the end of the cord coming from the infant: Place loop of umbilical tape 1” nearer to the infant than the clamp. Tighten the tape slowly, then tie it firmly with a square knot, leaving the clamp in place.

NEONATAL CARE Support the infant’s head and torso, using both hands.
Maintain warmth! Clear infant’s airway by suctioning mouth and nose. Assess the neonate using Apgar score.

APGAR SCORE Measured at 1 and 5 minutes. Healthy baby will score 10.
Five areas are evaluated.

APGAR Appearance - pink shortly after birth
Pulse- greater than 100/min Grimace - crying, or withdrawing in response to stimuli Activity - resistance or muscle tone when attempts are made to straighten legs Respirations - regular and rapid

RESUSCITATION OF THE NEWBORN
Assessing the newborn: Respirations: If the RR<30/min, and stimulation doesn’t increase RR to normal, assist respirations with BVM and high-flow O2.

RESUSCITATION OF THE NEWBORN
Pulse: If the HR<60 or between bpm and not rising in response to ventilations, start chest compressions. - Both thumbs on middle third of the sternum or one thumb over the other. Transport to a facility with NICU.

DELIVERY OF THE PLACENTA
Normal Delivery: Within 20 minutes of baby’s birth. Usually less than 250 ml blood loss. Record delivery time of placenta. Place placenta in a plastic bag and transport with the Mom and baby to the hospital.

DELIVERY OF THE PLACENTA
Provide prompt transport: If not delivered within 30 minutes. 250ml of bleeding occurs before delivery of placenta. Significant bleeding occurs after delivery of placenta. Do not pull cord!

ABNORMAL DELIVERY SITUATIONS

BREECH PRESENTATION: - The buttocks or both feet present first. - If the infant starts to breath with its face pressed against the vaginal wall, form a “V” and push the vaginal wall away from infant’s face. - Continue during transport.

Prolapsed Cord: - The umbilical cord precedes the fetal presenting part. - Elevate the hips, administer oxygen, and keep the Mom warm. - If the umbilical cord is seen in the vagina, insert two gloved fingers to raise the fetus off the cord. - Do not push cord back. - Wrap cord in sterile moist towel. - Transport immediately. - Do not attempt delivery.

LIMB PRESENTATION: With limb presentation, place the mother in knee–chest position, administer oxygen, and transport immediately. Do not attempt delivery!

OTHER ABNORMAL PRESENTATIONS
Whenever an abnormal presentation or position of the fetus makes normal delivery impossible, reassure the mother. Administer oxygen. Transport immediately. Do not attempt field delivery in these circumstances.

OTHER DELIVERY COMPLICATIONS
Multiple births: - Follow normal guidelines, but have additional personnel and equipment. - In twin births, labor starts earlier and babies are smaller. - Prevent hypothermia.

Cephalopelvic Disproportion: - Infant’s head is too big to pass through pelvis easily. - Causes include oversized fetus, hydrocephalus, conjoined twins, or fetal tumors. - If not recognized, can cause uterine rupture. - Usually requires cesarean section. - Give oxygen to mother and start IV. - Rapid transport!

Precipitous Delivery: - Occurs in less than 3 hours of labor. - Usually occurs with Moms who have had many children, fetal trauma, tearing of cord, or maternal lacerations. - Be ready for rapid delivery, and attempt to control the head. - Keep the baby warm.

Shoulder Dystocia: - Infant’s shoulders are larger than its head. - Turtle sign. - Do not pull on the infant’s head. - If baby does not deliver, transport the patient immediately.

Meconium Staining: - Fetus passes feces into the amniotic fluid. - If meconium is thick, suction the hypopharynx and trachea using an endotracheal tube until all meconium has been cleared from the airway.

MATERNAL COMPLICATIONS OF LABOR AND DELIVERY

MATERNAL COMPLICATIONS
Postpartum Hemorrhage: - Defined as a loss of more than 500 cc of blood following delivery. - Establish two large-bore IVs of normal saline. - Treat for shock as necessary.

Uterine Rupture: - Tearing, or rupture, of the uterus. - Patient complains of severe abdominal pain and will often be in shock Abdomen is often tender and rigid. - Fetal heart tones are absent. - Treat for shock. - Give high-flow oxygen and start two large-bore IVs of normal saline. - Transport patient rapidly.

Uterine Inversion: - Uterus turns inside out after delivery and extends through the cervix. - Blood loss ranges from 800 to 1,800 cc. - Begin fluid resuscitation. - Cover the uterus with towels moistened with saline and transport immediately.

Pulmonary Embolism: - Presents with sudden severe dyspnea and sharp chest pain. - Administer high-flow oxygen and support ventilations as needed. - Establish an IV of normal saline. - Transport immediately, monitoring the heart, vital signs, and oxygen saturation.

SUMMARY Anatomy review General assessment
Complications of pregnancy and management Stages of labor Management of patient in labor Preparing for delivery Assisting in delivery

SUMMARY Post delivery care Resuscitation of the newborn
Abnormal deliveries Delivery complications Maternal complications of labor and delivery

QUESTIONS ????????????

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