Presentation on theme: "OB Delivery Complications & Use of the Meconium Aspirator"— Presentation transcript:
1OB Delivery Complications & Use of the Meconium Aspirator Condell Medical CenterEMS SystemApril 2008Site Code # E1208Prepared by: Sharon Hopkins, RN, BSN, EMT-P
2ObjectivesUpon successful completion of this module, the EMS provider 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 and a breech delivery.
3Objectives cont’dactively participate in discussion of case presentations.actively participate in hands-on skills of delivery complications.successfully complete the quiz with a score of 80% or better.
4Physiological Changes in Pregnancy Reproductive systemIncrease in size of uterusIncreased vulnerability to injuryDuring pregnancy uterus contains 16% of the total blood volumeExtremely vascular organ during pregnancyUterus and fetus insulted if blood flow diminished
6Changes in Pregnancy cont’d Respiratory systemIncrease in oxygen demand & consumption40% increase in tidal volumeAmount of air in or out in one breathOnly slight increase in respiratory rateDiaphragm pushed upward decreasing lung capacity
7Changes in Pregnancy cont’d Cardiovascular systemCardiac output increasesMaternal blood volume increases by 45%Heart rate increases by 10 – 15 beats per minuteB/P decreases slightly in first 2 trimestersB/P normal in 3rd trimesterSupine hypotensive syndrome after 5 months if heavy weight of uterus presses on inferior vena cava (when mother lying on her back)
8Changes in Pregnancy cont’d Gastrointestinal systemNausea and vomiting common in 1st trimesterFrom hormone levels and changed carbohydrate needsDelayed gastric emptyingWatch for vomiting and airway compromiseHands-on physical abdominal assessment difficult due to compression and shifting of abdominal organs
9Changes in Pregnancy cont’d Urinary systemIncrease in renal blood flowUrinary frequency is commonUrinary bladder displaced more forward and higher increasing vulnerability to injury to the urinary bladderMusculoskeletal systemWaddling gait due to loosened pelvic jointsLow back pain due to change in center of gravity
10First Stage of Labor Dilatation Stage Begins with onset of true labor contractionsEnds with complete dilatation and thinning of the cervixCervix dilates from a closed position to 10 cm (approximately 4 inches)Duration about 8 – 10 hours in 1st pregnancyEarly contractions mild, last 15 – 20 seconds coming every 10 – 20 minutesEnd of 1st stage contractions last 60 seconds and are coming every 2 – 3 minutes
11Second Stage of Labor Begins with complete dilatation of cervix Ends with delivery of fetusCan last minutes in 1st deliveriesPain felt in the lower backMother has the urge to pushBag of waters usually rupture in this stageCrowning is evidentDefinitive sign of imminent delivery
12Third Stage of Labor Begins immediately after birth of the infant Ends with delivery of placentaPlacenta generally delivers within 5 – 20 minutesSigns of placental separationGush of blood from vaginaChange in size, shape, consistency of uterusUmbilical cord length increasesMother has the urge to push
13Assessment of the Patient in Labor Ask expected due dateGravida – number of pregnanciesFirst time deliveries tend to take longer – 16 – 17 hoursLabor tends to shorten with subsequent pregnanciesPara – number of live birthsIs it “gravida and para” or “para and gravida”?Note: “G” comes before “P” in the alphabet; you must be pregnant before you can deliver
14Assessment of the Patient in Labor Determine how long mother has been in laborAsk how long previous deliveries tookAsk if bag of waters is intact or has brokenDelivery is quicker once bag of waters has brokenAre there any high risk concerns the mother is aware of
15Assessment of the Patient in Labor Time duration & frequency of contractionsDuration is from the beginning of one contraction to the end of that contractionFrequency is how far apart contractions areMeasured from the beginning of one contraction to the beginning of the next contractionContractions lasting seconds and coming every 2-3 minutes apart indicate imminent delivery
16Signs of Imminent Delivery CrowningBulging of the fetal head past the vaginal opening during contractionBulging perineumPresenting part pressing on perineumUrge to pushNote: High index of suspicion in female with abdominal pain and cramping (esp in a pattern) and denies pregnancy
21APGAR Assessment – 1 & 5 minutes A – appearanceMost visible, least helpfulTypical for pink trunk and blue distal extremitiesP – pulse100 or above is acceptable– stimulation needed<60 – start compressions
22APGAR cont’d G – grimace (irritability) Includes coughing, sneezing, cryingA – activityActive motion, flexing of extremitiesR – respiratory effortStrong cryMajority of scores are 7–10 indicating a healthy infant requiring routine careScores 4-6 indicate moderately depressed infant requiring oxygen & stimulation
23APGAR Score Criteria 1 2 Appearance Blue or pale Blue hands or feet 12AppearanceBlue or paleBlue hands or feetEntirely pinkPulseAbsent< 100>100Grimace – reflex irritabilityGrimaceCough, sneezeActivityLimpSome extremity flexionActive motionRespirationsWeak cry, hypoventi-latingStrong cry
25OB Complications – Supine Hypotensive Syndrome Occurs in the 3rd trimesterHeavy weight of uterus compresses inferior vena cava when mother in the supine positionInterferes with blood flow returning back to the heartInterventionTransport women over 5 months pregnant lying or tilted towards their left sideRemember: Lay left
26OB Complications – Seizures Consider causesHypoglycemia – check glucose levels on all patients with altered level of consciousnessEpilepsy – check for ID; protect airwayEclampsia – protect airwayInterventionFor any prolonged seizure activity, need to consider using BVM to support ventilations and provide oxygenationTransport lying/tilted left if over 5 months gestationValium, if given, has effect on mother & fetus5 mg IVP over 2 min; titrate; max total 10mg
27OB Complications – Breech Delivery Buttocks or feet present firstApproximately 4% of all birthsIncreased riskMaternal traumaProlapse of cordCord compressionAnoxia to the infantInterventionAdvanced medical intervention at the hospitalRapid transport important
29Breech Delivery cont’d InterventionAs legs deliver, support legs across forearmIf cord is accessible, palpate oftenIf able, loosen cord to create slackAfter torso and shoulders deliver, gently sweep down armsIf face down, gently elevate legs & trunk to facilitate delivery of headNEVER PULL INFANT BY LEGS OR TRUNK
30Breech cont’d If head not delivered within 30 seconds Reach 2 gloved fingers into vagina to locate baby’s mouthPush vaginal wall away from baby’s mouth to form an airwayKeep your fingers in place and transport immediatelyKeep delivered part of baby warmCover with a blanketIf head delivers, anticipate neonatal distress
31OB complications – Prolapsed Cord Perform a visual exam as soon as possible whenever a mother states her bag of waters has rupturedElevate the mother’s hips or place knee-chestHave patient breath through the contractions so she doesn’t pushPlaced gloved hand into vagina and raise presenting part to get pressure off cordKeep cord between fingers to monitor for pulsationsCover cord with moist dressing, keep warm
33OB Complications – Nuchal Cord Cord wrapped around infant’s neckIncrease mother’s O2 to 100% non-rebreather maskSlip fingers around cord and lift over infant’s headProceed with deliveryIf unable to reposition cord, place 2 OB clamps, cut cord between clamp, release cord from around neck
35MeconiumDark 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
36Meconium Staining Fetus has passed feces into amniotic fluid Occurs between 10-30% all deliveriesNot unusual to observe in breech deliveryIn normal head-down delivery indicates fetal hypoxiaHypoxia increases fetal peristalsis and relaxation of anal sphincterThe darker the color/staining, higher the risk of fetal morbidity
37Meconium Stained BabyAirway needs to be cleared to avoid aspiration of meconiumSuction and clear airway before infant needs to take that first breath
38Meconium StainingIf meconium is thin and light in color and the infant is vigorousMost meconium can be cleared away with bulb syringeALWAYS suction mouth then nose, in that orderSuctioning the nose stimulates breathing in the newbornWant to clear the mouth 1st so first breath is as clean as possibleLimit suction (2 seconds per Region X SOP)
39Meconium Staining If infant is not vigorous Respiratory rate decreasedDecreased muscle toneHeart rate < 100Use meconium aspirator to clear airwayThis will take coordination and best accomplished with 2 persons working as a team
40Meconium Suctioning Steps include intubation Most efficient when performed as a 2 person teamTime is essentialMay need to perform 2 intubation insertionsUse each ETT once
41Meconium AspiratorConnect small end of meconium aspirator to suction line connecting tubeTurn suction down to 80 mmHgInsert endotracheal tubeDon’t anticipate visualizing landmarks – they may be obscured by meconiumConnect larger end of aspirator to ETTPlace thumb over suction control port and slowly withdraw ETT (< 2 seconds)Discard ETT after one use
42Meconium Aspirator Aspirator can be used a second time on infant with new ETT each timeLimit suction to<2 seconds
43Case Study #1 EMS arrives on the scene for OB call Patient is 24 y/o and states she is in laborWhat assessment questions specific to an imminent delivery need to be asked?What type of EMS physical assessment needs to be performed?
44Case 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?
45Case Study #1 Physical exam – position patient to evaluate Crowning Evidence of bulging perineumInvoluntary pushingSigns of prolapsed cordEvidence of profuse bleeding
46Do you stay & prepare to deliver or transport? Case Study #1 HistoryG2P1EDC in 1 weekNo complications anticipatedPrevious labor 12 hoursBag of waters has rupturedContractions are 5-6 minutes apart and lasting secondsThere is no bulging or crowningDo you stay & prepare to deliver or transport?
47Case Study #1You could most likely begin transport with OB kit reached out in case labor progressesWhat stage of labor is the patient in?First stageIf the patient delivers, how many run reports need to be written?Two – one for the mother, one for the infant
48What is your role during delivery? Support the presenting partCheck fornuchal cordSuction mouthThen nose
49Head and shoulders delivered Have a firm grip on infantCheesy covering and moisture make them slipperyAfter shoulders, rest of the body will slip out fast
50Clamping & cutting the cord After cord is done pulsating, clamp 8″ from infant’s navel with 2 clamps placed 2″ apartWatch for blood leakage from infant’s cordReinforce with additional clamps as needed
513rd Stage of Labor – Placental stage Watch for excessive bleeding (>500 ml)Prepare to perform fundal massageNeed to feel uterus become firm – size of the uterus will depend on the size of the fetus
53Newborn dried off, cord clamped & cut What’s his APGAR?
54Case Study #2 Mother calls EMS because “my baby is coming” Upon EMS arrival, you gain quick rapportContractions are coming every 2-3 minutes and are seconds longThe mother states she wants to push and feels her baby is coming right nowYou perform a visual exam
55Case Study #2 This is what you see. Now what do you do? If cord is wrappedaround the neck,try to loosen andslip over the head.If too tight, need to double clamp and cut the cord NOW.
56Case Study #3 Mother calls EMS and states she is in labor Mother is G3P2 due tomorrowNo known complicationsShe has been in labor for 4 hoursContractions are 3 minutes apartYou establish rapport and perform a visual examAnd you determine that delivery is imminent
57Case Study #3 - This is a breech delivery that is not delivering Case Study #3 - This is a breech delivery that is not delivering. What do you do?Head shoulddeliver in30 seconds.If not, reachin to createan airway forthe infant.Support bodyacross yourforearm.
58Creating an airway for a breech delivery Reach 2 fingers into the vaginaLocate the infant’s facePush the vaginal skin away from the infant’s mouthTransport immediatelyGive report to the closest facilityThe crew member CANNOT move their fingers and risk losing the airway
59The golden sounds to a mother’s and EMS provider’s ears – a newborn’s cry!!!
60DocumentationOnce your patient delivers, EMS is to write 2 reports – mother & infantBoth reports can have time of deliveryOn run report, OB delivery is credited to the person who delivers (“catches”)Segregate informationMother’s information on mother’s run reportInfant’s information on the infant’s run report
61Documentation - Mother Due date (ie: EDC June 15th)Gravida/para (ie: G3P2)Presence of high risk concernsBag of waters – Ruptured? IntactStatus of contractionsSigns of imminent deliveryCrowningBulgingUrge to pushTime of delivery (when last of baby delivers) & sexComplications during/after delivery (ie: bleeding)If placenta delivered or not
62Documentation - Infant Time of deliveryAppearance 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 reportVital signs – B/P not necessaryThat cord was clamped and cutTime placenta deliveredSpecial interventions required after delivery
63Wrist Bands Apply a wrist band to both the mother and the newborn Include the same information on both wrist bandsMother’s nameSex of infantTime of delivery
64BibliographyBledsoe, B., Porter, R., Cherry, R. Essentials of Paramedic Care. 2nd Edition. BradyLimmer, D., O’Keefe, M. Emergency Care 10th Edition. BradyRegion X SOP’s Effective March 1, 2007