Drill of the Month Developed by Gloria Bizjak

Drill of the Month Developed by Gloria Bizjak
Assessing and Assisting Childbirth Drill of the Month

Assessing and Assisting Childbirth
Student Performance Objective: Given information, resources, and opportunity for discussion and practice, EMTs will be able to: List and define childbirth structures and terms Describe the stages of labor List the steps of evaluation Describe potential complications and emergencies List and demonstrate steps of labor and delivery EMTs will follow acceptable Maryland medical practice and Maryland Medical Protocols for Emergency Medical Providers. Drill of the Month

Overview Anatomical Structures and Terms Stages of Labor Steps of Evaluation Labor and Delivery Complications, Emergencies, and Management Post Natal Care Drill of the Month

Anatomical Structures and Terms
Fetus: The developing baby Uterus (womb): A muscular organ in which the fetus develops Amniotic sac: A membranous “bag of waters” with 1—2 quarts of fluid in which fetus floats Cushions and protects the fetus from injury Maintains a constant fetal body temp Ruptures during labor Drill of the Month

Cervix: Narrow neck of uterus; dilates (widens or effaces) to allow infant’s head to emerge Mucous plug (bloody show): Like nasal mucous Forms at the neck of the cervix Discharges as the cervix dilates and may go unnoticed Usually tinged with blood as cervical vessels rupture Vagina: Birth canal Drill of the Month

Perineum: Area between vagina and anus; may tear during birth Placenta: Exchange organ Carries oxygen, nutrients, other ingestions (meds, drugs, alcohol) to fetal circulation from mother Carries carbon dioxide, wastes from fetal circulation to maternal circulation through cord Afterbirth: Placenta, amniotic sac, tissues Umbilical cord: Connects placenta to fetus; contains two arteries, one vein Drill of the Month

Dilation: Cervical widening measured in centimeters (0—not dilated; 10—fully dilated) Labor: Process of delivery in 3 stages of contractions and dilation, birth, afterbirth Meconium: First feces, greenish-black to light brown, odorless, tarry; normally discharged a day or two after birth Meconium staining: Fetal defecation in utero Drill of the Month

Delivery presentation: Fetal position in birth canal, usually head first Crowning: Infant’s presenting part at vaginal opening—usually the head Cephalic presentation: Normal, head-first presentation Breech presentation: Feet or buttocks; single foot: true emergency Drill of the Month

Shoulder presentation (transverse lie): Shoulder presents first (about 0.3%); true emergency Placenta previa: Placenta attaches low in womb (before infant) May cover cervical opening and ruptures, bleeds painlessly as cervix dilates Placenta abruptio: Premature, sudden (abrupt) separation of placenta from uterus (1%) Serious complication; common cause of late bleeding Drill of the Month

Braxton Hicks contractions: Rhythmic uterine clenching lasting 30—60 seconds Occurs in some about mid—to—end of pregnancy Different from labor contractions Eclampsia: Causes seizures, sometimes coma, usually after 20th week Follows pre-eclampsia of high blood pressure, swelling of hands, feet, and protein in urine Fontanel: Soft (unossified) areas of infant’s skull: anterior, posterior, medial Drill of the Month

Stages of Labor First stage (dilation stage)
Begins: Regular contractions, cervical dilation Contractions about 30 minutes apart; near birth— 3 minutes apart Mucous plug discharges with “bloody show” Amniotic sac breaks; EMTs may have to tear May break hours before (but body continues to produce fluid) or after crowning/head delivery Fluid usually clear; staining indicates fetal defecation Ends: Fully dilated cervix, more frequent contractions, more severe labor pains Pressure on rectum—feel need to move bowels Drill of the Month

Stages of Labor Second stage (Birth stage)
Begins: Infant enters birth canal Decide whether to transport or stay and deliver If birth appears imminent, prepare for delivery Ends: Birth of infant Drill of the Month

Stages of Labor Third stage (Afterbirth stage)
Begins: After infant is born Contractions resume shortly after birth Contractions continue until placenta and other tissue deliver Contractions are usually milder than labor Ends: Delivery of afterbirth: placenta and cord, amniotic sac, uterine lining May take 10—20 minutes Drill of the Month

Steps of Evaluation On arrival: Size up the scene
Approach and perform initial assessment Mental status Airway, breathing, circulation (heart rate, bleeding) Disability Exposure Clinical priority (1, 2, 3, or 4) Disposition (mode, status) Drill of the Month

Steps of Evaluation Perform history and physical assessment
General questions Name, age, due date First pregnancy? Labor for first pregnancy: 16—20 hours Labor for subsequent pregnancies progresses more quickly Drill of the Month

Questions about labor (help determine transport or stay and deliver) How long having labor pains? Several hours (possibly prepare to deliver) Couple of hours (possibly transport) How often are pains? (Most mothers time them) Far apart (transport) Frequently (prepare to delivery) Drill of the Month

Questions about labor Has water broken? If so, how long ago? Response may not affect delivery or transport decision Bleeding or bloody show? Straining or feeling urge to move bowels? If so, infant’s head is in birth canal (prepare to deliver) If no, transport Drill of the Month

Questions about labor Examine mother for bleeding Some bleeding is normal with dilation If excessive Apply sanitary pads Treat for shock Consider ALS Rapid transport Notify receiving facility Drill of the Month

Questions about labor Examine mother for crowning Explain what you will do before visually inspecting Prepare for delivery If presenting part is visible, mother is crying out, straining, and wanting to move bowels For first delivery with no straining or crowning, transport Transport rapidly if there is a single limb presentation Drill of the Month

Questions about labor Feel abdomen for uterine contractions Explain what you will do Place gloved hand over naval Time duration of contraction Time frequency Take vital signs Drill of the Month

Labor and Delivery Labor (first stage) Normal labor pains
Begin with ache in lower back Become stronger in lower abdomen Come at regular intervals lasting 30 seconds to a minute Drill of the Month

Labor and Delivery Labor (first stage) Contractions
Uterus contracts causing pain; relaxes relieving pain May start and last for a while, stop and start again Characteristics Contraction time: beginning of uterine contraction until relaxation Contraction interval (frequency): start of one contraction to start of next Contractions times of 30 seconds to 1 minute, intervals of 2—3 minutes: delivery is imminent Drill of the Month

Labor and Delivery Delivery (second stage) Preparation: Assemble items
Personal protective equipment Towels and sheets Gauze pads Bulb syringe Clamps/hemostats/cord tape Scissors Baby blanket/towels Sanitary pads Plastic bag or container Drill of the Month

Labor and Delivery Delivery (second stage)
Preparation: Evaluate and prepare mother History: name, age, due date, first pregnancy, attended by physician? Current condition: when labor pains started, how often, bleeding/bloody show, straining Evaluate: examine for crowning, feel abdomen and time contraction frequency, duration, take vital signs Drill of the Month

Labor and Delivery Delivery (second stage)
Decision to transport or stay and deliver Transport: first delivery, no straining, no crowning Stay and deliver: not a first delivery and/or is straining, needing to move bowels, contractions 2 minutes apart Drill of the Month

Labor and Delivery Delivery (second stage): Stay and deliver
Ensure privacy; remove clothing (waist down) position and drape mother Position on left side with signs of supine hypotension syndrome Elevate buttocks with bedding or towels Knees bent, legs apart Drill of the Month

Have someone at mothers head Partner: monitor vital signs, vomiting Family for comfort, emotional support Position self To view vaginal area To assist birth with supplies close by Drill of the Month

Deliver infant Hands at vaginal opening when head appears Spread fingers, avoid pressure on fontanels Support emerging head Apply slight pressure to prevent explosive birth Keep clear of anal area, discharges Place pressure on perineum to prevent tearing Drill of the Month

Unbroken amniotic sac: tear and peel from face Amniotic fluid should be clear Staining indicates fetal feces—suction immediately, repeatedly: mouth then nose Provide ventilations/compressions as needed Rapid transport Drill of the Month

After head delivers, ensure that umbilical cord is not around infant’s neck Cord around neck: tell mother to pant, not push Loosen cord with fingers Slip it from around neck Can’t remove cord: Clamp in two places, cut, remove from neck Drill of the Month

Infant usually presents face down, rotates to side Support head with one hand and wipe nose, mouth with gauze pads Use bulb syringe to suction mouth first, then nose Suction the mouth 2-3 times, inserting the syringe 1 ½ inches Suction the nose 2-3 times, inserting the syringe ½ inch Drill of the Month

Upper shoulder delivers first: guide infant’s head downward Lower shoulder delivers; guide infant’s head upward Deliver torso and legs: Infant is slippery Position on side, head slightly lower than body, same level as mother until cord stops pulsing Suction mouth and nose again Record time of birth Drill of the Month

Complications, Emergencies, Management
Positional complications: Supine Hypotensive Syndrome Occurs in the third trimester Weight of uterus, infant, placenta, amniotic fluid compress inferior vena cava Pressure on inferior vena cave reduces blood flow return to heart and cardiac output Body compensates: contracts uterine arteries Dangerous to fetus; restricts blood to mother’s organs Drill of the Month

Positional complications: Supine Hypotensive Syndrome Signs and symptoms Dizziness and a drop in blood pressure when the mother is in a supine position Other shock signs and symptoms but are also related to labor Drill of the Month

Positional complications: Supine Hypotensive Syndrome Management Check vital signs and continue to monitor Position mother on left side to relieve weight on vena cava Treat for shock: elevating legs will not relieve low blood pressure or reduce constriction of vena cava Drill of the Month

Birth complications: Breech presentation Most common abnormal presentation: buttocks, both legs Can deliver spontaneously Risk of birth trauma is high Meconium staining is frequent Risk of prolapsed cord is increased Drill of the Month

Birth complications: Breech presentation Management Check for crowning; do not pull on legs Provide oxygen Consider ALS; rapid transport Notify receiving facility Assist delivery if necessary Deliver and support torso Insert gloved fingers in V to form airway for infant Prevent explosive delivery of head Provide post-natal care Drill of the Month

Birth complications: Prolapsed cord Common in breech births; cord is pressed between vaginal wall and infant’s head, cutting off oxygen to infant Management Position mother: head down, buttocks raised Provide oxygen Care for cord: wrap and keep moist, insert gloved hand to lift infant from vaginal tissue—provides airway, keeps head off cord, maintains pulsations Consider ALS; rapid transport; notify receiving facility Drill of the Month

Birth complications: Single limb Arm, more commonly—one leg usually with prolapsed cord; cannot be delivered in field Management Care for cord: wrap, keep moist, ensure pulsation by keeping infant’s head off cord Position mother: head down, buttocks raised Provide oxygen Consider ALS, rapid transport, notify receiving facility Drill of the Month

Other possible birth events: Multiple Considerations Usually twins, uncomplicated Second infant may deliver in breech position Rapid transport if complications develop Determine multiple birth Mother informs you Unusually large abdomen, which remains large after first birth Strong labor pains, contractions resume after first birth Drill of the Month

Other possible birth events: Multiple Management (Call for additional personnel) Assist with delivery of first infant Clamp/tie cord before birth of second infant Assist with delivery of second infant (may deliver before or after placenta) Provide post-natal care Assist with delivery of placenta(s) Transport and ensure infants’ warmth Drill of the Month

Other possible birth events: Premature Infant weights < 5 ½ lbs at birth Head is large proportionate to body Mother provides due date information Infant delivers prior to 28th week Drill of the Month

Other possible birth events: Premature Management: Follow Universal Algorithm for Newly Born, Inverted Pyramid of Neonatal Resuscitation Suction mouth and nose; provide blow-by oxygen Keep warm and dry Monitor airway, continue suctioning as needed Protect from exposure: birth discharges, other individuals Notify receiving facility Drill of the Month

Pre-birth bleeding emergencies: Vaginal bleeding Considerations: Serious gynecological emergency if not trauma or menstrual related Potentially life-threatening with abdominal pain Hypovolemic shock a serious complication Management BSI Ensure Airway, assess/treat for shock, oxygen Rapid transport Drill of the Month

Pre-birth bleeding emergencies: Placenta previa (potentially life threatening) Placenta forms or attaches low in uterus, close to or over cervix previous to fetus It lies between infant and cervical opening preventing delivery Cervix dilates, tears placenta, which bleeds profusely Infant’s head presses on placenta, causing further bleeding to torn placenta Drill of the Month

Pre-birth bleeding emergencies: Placenta abruptio (potentially life threatening) Placenta partially or completely separates from uterine wall Signs and symptoms Possible obvious profuse bleeding with complete abruption Possible little or no obvious bleeding with partial abruption: blood is trapped between placenta and uterine wall Signs of shock Abdominal pain may or may not be present Drill of the Month

Pre-birth bleeding emergencies: Ectopic pregnancy (potentially life threatening) Problems occur early in pregnancy Egg implants outside uterus usually in a fallopian tube, grows, ruptures tube, causes internal bleeding, pain Signs and symptoms Shock: low blood pressure, rapid weak pulse—late signs Abdominal pain Drill of the Month

Pre-birth bleeding emergencies: Placenta previa, abriptio; ectopic pregnancy Management Obtain baseline vital signs and monitor Treat for shock: position, oxygen Manage bleeding Replace and save soaked pads, expelled tissues Consider ALS, rapid transport Notify receiving facility Drill of the Month

Pre-birth bleeding emergencies: Miscarriage—spontaneous abortion Fetus miscarries/aborts before 28th week Signs and symptoms Moderate to severe bleeding Abdominal pain, cramping Tissue discharge Signs and symptoms of shock Drill of the Month

Pre-birth bleeding emergencies: Miscarriage—spontaneous abortion Management Obtain baseline vitals and monitor Provide care for shock Manage bleeding Replace, save soaked pads, expelled tissues Provide emotional support Prepare for delivery if necessary Notify receiving facility, rapid transport, call ALS for neonatal intensive care of premie Drill of the Month

Pre-birth bleeding emergencies: Miscarriage—spontaneous abortion Management Obtain baseline vitals and monitor Provide care for shock, manage bleeding Replace, save soaked pads, expelled tissues Provide emotional support Prepare for delivery if necessary Notify receiving facility, rapid transport, call ALS for neonatal intensive care of premie Drill of the Month

Seizures: Caused by eclampsia Occurs late in pregnancy or after delivery May result in coma Precursor is pre-eclampsia Begins mid-way through pregnancy Swollen hands and feet Increasing hypertension Headaches Drill of the Month

Seizures: Caused by eclampsia Signs and symptoms High blood pressure, rapid pulse High temperature Headache, dizziness, seeing spots Epigastric pain, nausea Puffy face, swollen hands, ankles, feet Excessive weight gain Seizures beginning with twitching of face, arms, hands Coma Drill of the Month

Seizures: Caused by eclampsia Management Check for and maintain patent airway Administer oxygen Suction as needed Position and transport on left side Maintain body warmth Handle patient gently Rapid transport Drill of the Month

Trauma: Types Falls (soft tissue injuries, fractures) Violence, e.g., beatings (soft tissue injuries) External force blunt trauma, e.g. vehicle collisions (fractures, ruptured organs, soft tissue injuries) Penetrating injuries (soft tissue injuries) Sexual assault (soft tissue injuries) Drill of the Month

Trauma: Physiology Fetus is relatively protected in first two trimesters: amniotic fluid, muscular uterus Minor trauma poses no harm Vehicle collisions: grater magnitude of force Fetus: more likely injured in last trimester Mother: injury w/shock, bleeding affects fetus Drill of the Month

Trauma: Physiology Blunt trauma injuries in last trimester Uterus: rupture, placenta abruptio Rupture other organs: internal bleeding, difficulty breathing Spleen, liver, diaphragm Soft tissue injuries, fractures Massive bleeding, shock Affects mother and fetus Drill of the Month

Trauma: Management Size-up scene for safety (collisions, violence) Check ABC’s, treat for shock Patient history, specifically blunt force trauma Blows to abdomen, pelvis, back Has water broken, vaginal/genitalia bleeding? Assess based on mechanism of injury Not significant: focused history, physical exam Significant: rapid trauma assessment Check for bruised abdomen, vaginal bleeding Drill of the Month

Trauma: Management Take baseline vitals, monitor (Vital signs may not indicate shock in a pregnant woman) Heart rate: 10—15 beats faster Blood volume: 48% higher; loses 35% blood volume before showing signs of shock Treat for shock and watch for vomiting Have suction ready Provide emotional support Drill of the Month

Post Natal Care Care of infant: Initial impression at birth
Breathing easily Heart beating Crying vigorously Moving extremities Hands and feet only are cyanotic Drill of the Month

Post Natal Care Care of infant: APGAR check at 1 and 5 minutes after birth: 0—1—2 scale Activity—muscle tone/movement Pulse Grimace—reflex irritability/reaction to suction, flicking feet Appearance—color (hands/feet are cyanotic for a few minutes shortly after birth) Respirations Drill of the Month

Post Natal Care Care of infant: Universal Algorithm for the Newly Born for BLS/Inverted Pyramid of Neonatal Resuscitation Dry, warm, position, stimulate, suction mouth/nose (multiple times w/meconium) Position infant on side, suction Ensure breathing after suctioning w/i 30 seconds No breathing: rub back; still no breathing: snap finger against foot Drill of the Month

Post Natal Care Care of infant: Universal Algorithm for the Newly Born for BLS/Inverted Pyramid of Neonatal Resuscitation If cyanotic: Provide oxygen Apnea/gasping, heart rate ,100 Ventilate with neonatal BVM at 40—60/min or small puffs via mouth-to-mask Drill of the Month

Post Natal Care Care of infant: Universal Algorithm for the Newly Born for BLS/Inverted Pyramid of Neonatal Resuscitation Heart rate <60 after 30 seconds of BVM Provide chest compressions: 120/min at 3:1 ratio If no change, continue ventilations, reassessment Heart rate > 100 but infant shows cyanosis in face/torso, provide blow=by oxygen, 10—15 lpm Drill of the Month

Post Natal Care Care of infant: Cut the cord Before cutting
Ensure infant is warm and dry Ensure cord has stopped pulsating Clamp/tie 10” and 7” from infant Cut between two clamps/ties Do not unclamp/untie; add a second clamp/tie if bleeding continues Protect placental end from exposure to contaminants Drill of the Month

Post Natal Care Care of infant: Keep infant warm
Warmed towel and blanket or warmed bubble wrap and blanket Place wrapped infant on mother’s abdomen Transport in warmed ambulance Drill of the Month

Post Natal Care Delivery of afterbirth (third stage of labor)
Include placenta, attached umbilical cord, amniotic sac, uterine lining Delivery: brief, milder labor pains resume Usually w/i 20 min of delivery; longer—transport May take 30 min to deliver Save all tissues in container or towel, wrap in plastic, label Transport decision Mother, infant stable: stay and deliver Mother, infant unstable: rapid transport Drill of the Month

Post Natal Care Control bleeding
Sanitary pads over vaginal opening; nothing in vagina Mother holds pads in place with legs Elevate legs Massage abdomen from pubis to umbilicus Helps contract uterus, control bleeding Allow mother to nurse Drill of the Month

Post Natal Care Care of mother Take vital signs and monitor
Make comfortable Wipe face Cover and keep her and infant warm Remove blood-soaked towels, drapes Replace blood-soaked pads Transport Drill of the Month

Student Performance Objective: Given information, resources, and opportunity for discussion and practice, EMTs will be able to: List and define childbirth structures and terms Describe the stages of labor List the steps of evaluation Describe potential complications and emergencies List and demonstrate steps of labor and delivery EMTs will follow acceptable Maryland medical practice and Maryland Medical Protocols for Emergency Medical Providers. Drill of the Month

Review: Anatomical Structures and Terms List and describe the structures of pregnancy Name and define the terms of pregnancy Stages of Labor List and describe the beginning and endings of the three stages of labor Steps of Evaluation Describes the steps to take on arrival at the scene Describe the steps to take to evaluate the mother Drill of the Month

Review: Labor and Delivery Describe labor and EMT actions during labor List preparation steps for delivery Explain decision to transport or stay and deliver Describe delivery process and EMT actions during delivery Drill of the Month

Review: Complications, Emergencies, and Management Describe Supine Hypotensive Syndrome, list signs and symptoms and EMS care Describe birth complications and management Breech presentation Prolapsed cord Limb presentation Describe other birth incidents and management Multiple birth Premature birth Drill of the Month

Review: Complications, Emergencies, Management List pre-birth bleeding emergencies and management Vaginal bleeding Placenta previo and abruption Ectopic pregnancy Miscarriage (spontaneous abortion) Describe eclampsia, signs and symptoms, management of seizures List types of trauma, physiological effects on mother and fetus, and management Drill of the Month

Review: Post Natal Care Describe care of the newly born Initial impressions APGAR scoring Universal Algorithm How to cut the cord Delivery of afterbirth List afterbirth tissues Describe delivery process and EMT actions Describe care of mother Drill of the Month

Drill of the Month Developed by Gloria Bizjak

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Drill of the Month Developed by Gloria Bizjak

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