1. OB Emergencies November 2010 CE Condell EMS System
Objectives by Jeremy Lockwood, FF/PM Mundelein Fire Department
Packet prepared by Sharon Hopkins, RN, BSN, EMT-P

2. Objectives
Upon successful completion of this module, the EMS provider will be able to:
1. Identify appropriate standard precautions in the OB delivery setting.
2. Identify progression of a normal pregnancy.
3. Describe assessment of an obstetrical patient.
4. Identify predelivery complications.
5. Describe indications and signs of imminent delivery.
6. Identify the stages of labor.

3. Objectives cont’d 7. List the contents of the OB kit
8. Describe how to use the contents of the OB kit.
9. Describe the steps in assisting delivery of the newborn.
10. Describe care of the newborn baby.
11. Describe APGAR scoring.
12. Describe when and how to cut the umbilical cord.
13. Describe the delivery of the placenta.
14. Describe post delivery care of the mother.

4. Objectives cont’d 15. Describe abnormal deliveries and procedures.
16. Identify and describe delivery complications.
17. Describe meconium staining and its implication to the newborn.
18. Review documentation components for discussed conditions.
19. Given a manikin, demonstrate use of the OB kit.
20. Demonstrate use of the meconium device.

5. Standard Precautions
Anticipate the exposure to a large amount of blood and body fluids
Full protection is recommended
Don’t assume the absence or presence of disease just by appearances of the patient or situation

6. Standard Precautions Handwashing- still most effective control measure
around

7. Just Protect Yourself!!!
Do what you can

8. Normal Pregnancy Development
Ovulation and what follows
Release of an egg from ovary
Egg travels down fallopian tube toward uterus
Intercourse within hours of ovulation could result in fertilization
Fertilization occurs in the fallopian tube
Fertilized egg will implant in the uterus and pregnancy begins

9. Prenatal Development cont’d
Placental development
Approx 3 weeks after fertilization
Blood rich structure for the fetus
Transfers heat
Exchanges oxygen and carbon dioxide
Delivers nutrients
Carries away waste products
Endocrine gland
Secretes hormones for fetal survival
Secretes hormones to maintain pregnancy

10. Placental Development cont’d
Protective barrier
Connected to the fetus via the umbilical cord
Flexible, rope-like structure
2 feet in length; ¾″ diameter
Contains 2 arteries, 1 vein
2 arteries return relatively deoxygenated blood to the placenta
1 vein transports oxygenated blood to fetus

11. Placental Attachment

12. Amniotic Sac “Bag of waters”
Thin-walled membranous covering holds the amniotic fluid
Surrounds and protects fetus
Allows for fetal movement during development
Volume varies from 500 ml to 1000 ml
500 ml = 1 pint = 2 cups
Premature rupture increases risk of maternal and fetal infection that could be life threatening

13. Physiological Changes of Pregnancy
Due to:
Altered hormone levels
Mechanical effects of enlarging uterus
Increased uterine blood supply
Increasing metabolic demands on the maternal system

14. Physiological Changes to the Systems
Reproductive system
Uterus becomes larger
Contains 16% of the mother’s blood during pregnancy
Respiratory system
Increase in oxygen demands
20% increase in oxygen consumption
40% increase in tidal volume
Slight increase in respiratory rate
Diaphragm pushed upward
Tidal volume is the volume in each breath inhaled or exhaled.

15. Physiological Changes to the Systems
Cardiovascular system
Cardiac output increases
Maternal blood volume increases by 45%
More plasma increase than red blood cells so relative anemia develops
Maternal heart rate increases by beats
B/P decreases slightly 1st & 2nd trimesters
Supine hypotensive syndrome when mother lies supine
Especially by 5 months of pregnancy
CO= HR x stroke volume
Supine hypotensive syndrome more problematic after the 5th month of pregnancy due to the weight of the enlarging uterus.

16. Physiological Changes to the Systems
Gastrointestinal system
Nausea & vomiting are common in 1st trimester
Delayed gastric emptying (due to slowed peristalsis)
Bloating and constipation common

17. Physiological Changes to the Systems
Urinary system
Renal blood flow increases
More likely to have glucose spilling into urine
Bladder displaced anteriorly & superiorly increasing likelihood of rupture during trauma
Urinary frequency is common especially 1st trimester

18. Physiological Changes to the Systems
Musculoskeletal system
Pelvic joints loosened causing waddling gait
Center of gravity shifts with enlarging uterus
Postural changes taken to accommodate for increased anterior growth
Increased complaints of low back pain

19. Obstetrical Assessment
Need to determine if delivery is imminent or if there is time to transport
Remain calm (at least on the outside!)
Ask a few questions
Basically direct or closed ended questions – requiring a simple answer in few words
Perform a visual examination
Evaluate vital signs

20. OB Assessment Questions
Expected due date
The more premature, the smaller the birth weight and the less mature the lungs
Number of pregnancies
The higher the number, the quicker they tend to deliver
Length of labor
1st pregnancies can take up to hours
Subsequent deliveries tend to shorten from the 1st one

21. OB Assessment Questions
If bag of waters have ruptured or are intact
Once ruptured, delivery tends to progress faster
Once ruptured, must be evaluated due to increase risk of infection especially if not delivered within 24 hours
Feeling of having to move their bowels
This is from pressure of the fetal head moving through the birth canal

22. OB Visual Examination Gain rapid rapport with the mother
Disrobe the under garments
Visually inspect the perineum
Check for crowning or bulging
The appearance of the presenting part at the vaginal opening
Prepare for imminent delivery if crowning
Best to check during a contraction
Check for blood loss
Check for other parts – fingers, toes, cord

23. OB Assessment - Contractions
Place gloved palm on mother’s abdomen
Contraction duration
Time from the beginning of one contraction (uterus tightens) to the end (when uterus relaxes)
Contraction interval or frequency
Time from the start of one contraction to the beginning of the next one
Includes contraction and rest intervals

24. OB Assessment – Vital Signs
Routine vital signs are taken
Remember physiological changes of pregnancy:
Blood pressure, after initial drop, is near normal in 3rd trimester
Heart rate up by beats over normal
Only slight increase in respiratory rate

25. Supine Hypotensive Syndrome
Caused by the weight of an enlarging uterus pinching off blood supply in the inferior vena cava
Decreases blood return to the heart
Decreases stroke volume pumping out of the heart
Especially after 5 months transport the mother tilted or turned preferably toward the left

26. Imminent Delivery Crowning is present
Contractions last 30 – 60 seconds and are minutes apart
Mother has the urge to move her bowels or she says “I HAVE TO PUSH!!!”
Bag of waters has ruptured

27. Stages of Labor 3 stages of labor 1st stage – dilatation stage
Begins with onset of true labor contractions
Ends with complete dilatation (10 cm/4″) & effacement (100%) of the cervix
Is manually confirmed in the hospital setting, not field
Stage can last approximately 8-10 hours for first labor to about 5-7 hours in multipara
10 cm dilatation of the cervix is approximately 4 inches.
Cervix starts in the closed position and must thin out and become paper thin which is considered to be 100% effaced.

28. 1st Stage of Labor cont’d
Contractions
Early in this stage are usually mild
Duration of seconds
Frequency every minutes apart
Increase in intensity as labor progresses
Duration of 60 seconds
Frequency every 2-3 minutes
Care is supportive at this point in time
Allow husband/significant other to time contractions
Keeps them busy, involved, and out of the way

29. Timing Contractions Duration Frequency Timed in seconds
Timed from the beginning of the contraction to the end the contraction
Contractions lasting seconds indicate imminent delivery
Frequency
Timed in minutes
Timed from the beginning of one contraction to the beginning of the next contraction
Contractions coming every 2-3 minutes indicate imminent delivery
Contractions can be felt by placing the palm over the top of the uterus and when the uterus becomes hard, the contraction is beginning. As the uterus softens, the contraction has ended.

30. 2nd Stage of Labor – Expulsion Stage
Begins with complete dilatation of cervix
Ends with delivery of fetus
Can last 50 – 60 minutes for the first delivery
Can last 30 minutes for future deliveries
Contractions strong, uncomfortable
Duration is seconds
Contraction every 2 – 3 minutes

31. 2nd Stage of Labor cont’d
Mother has urge to bear down
Mother has back pain
Crowning is evident on visual inspection
Membranes usually rupture now
OB kit should be open by now
Be ready to support mother in delivery

32. OB Kit May be supplied in a variety of packaging
If extra supplies are needed, where are they kept?
Always anticipate using the OB kit
Better to have it available and not need it / use it than need it and not have it
Kits are usually packaged with disposable products
Practice Standard Precautions
Goggles, mask, gloves, gown

33. Contents of OB Kit

34. Cord Clamps
FYI
If not used for a period of time, it has been reported that the OB clamps become brittle and can break
There is no hurry to clamp and cut a cord
If you transport the mother and baby with the cord intact, so be it
The hospital will take care of clamping and cutting the cord

35. Delivery of the Newborn
As soon as the head and neck emerges, check for nuchal cord and begin to suction mouth then nose with bulb syringe
Depress bulb first before insertion of mouth, then nose
To facilitate delivery of upper shoulder, gently guide head downward
Support and lift head and neck slightly to deliver lower shoulder
Rest of infant delivers passively and very quickly
Nuchal cord is the cord wrapped around the neck. If delivery progresses, the infant will be strangled.

36. Newborn At Delivery
They’ll grow into being a Gerber baby!

37. Care of the Newborn cont’d
Hold on tight
Infant is slippery due to cheesy covering and amniotic fluid
Note time of delivery and record on the infant’s run report
Stimulate the infant
Suctioning, rubbing the back, flicking at the soles of the feet, drying off

38. Suctioning the Newborn
Suction mouth then nose always in that sequence
Infant’s are obligate nasal breathers
Want to clear the airway before stimulating them to take a breath
Always depress bulb syringe and THEN place into infant’s mouth, then nose

39. Care of the Newborn Continue to suction mouth then nose
Spontaneous respirations should begin within 15 seconds after stimulation
If no respirations, begin BVM support at breaths per minute
If pulse < 60 or between and not improving, begin CPR
Obtain 1 minute APGAR (ie: record as 9/10)

40. APGAR Score Assesses newborn adjustment to extrauterine life
1 minute score indicates need for resuscitation
5 minute score predicts mortality and neurological deficits
Order of importance
Heart rate
Respiratory rate
Muscle tone
Reflex irritability
Finally color – least helpful; most visible/obvious

41. APGAR Scoring – 1 & 5 minutes

42. Care of the Umbilical Cord
Clamp and then cut the cord after pulsations have stopped & cored is limp
Clamps placed 8″ from infant’s navel 2″ apart
Watch the end of the cord for leakage of blood
If leaking, add additional clamps moving toward the infant’s navel

43. Cutting the Clamped Cord

44. FYI – What About Cord Blood?
Obtained in the hospital within minutes of delivery
Collected from umbilical cord after delivery and after care of newborn provided
Consists of stem cells that can transform into variety of healthy tissue
Useful to treat leukemia, lymphomas and other diseases
Fee charged for private donations and storage
NOT the same as embryonic stem cells
Embryonic stem cells derived from embryos taken from an egg fertilized in vitro in the lab; not fertilized in a woman’s body.

45. Care of The Newborn cont’d
Continue to dry and wrap infant to preserve body temperature
Obtain 5 minute APGAR (ie: record as 10/10)
Continue to suction mouth then nose as needed
Keep infant in head downward position
Facilitates drainage from the airway
Assess vital signs of infant (is it time to retake mom’s?)

46. Care of the Newborn Infant in head down (and side lying) position
Hat placed to minimize heat loss
Cord clamped and cut

47. 3rd Stage of Labor – Placental Stage
Begins immediately after delivery of infant
Ends with delivery of placenta
Do not need to delay transport waiting for placenta to deliver
Signs of separation
Gush of blood from vagina
Change in size, consistency, shape of uterus
Lengthening of cord protruding from vagina

48. Delivery of the Placenta
Allow to deliver spontaneously
May take up to 20 minutes after infant delivered to deliver the placenta
If delivered at the scene, collect and transport with the patient
Inspected for retained placental parts
For excessive external bleeding, apply dressings externally
For excessive vaginal bleeding, uterine massage AFTER placenta is delivered

49. Placenta Uterine Wall Side

50. Placenta Fetal Side

51. Post Partum Care of the Mother
What is post partum hemorrhage?
Loss of more than 500 ml of blood (1 pint; 2 cups)
To control, massage uterus AFTER delivery of placenta
Will feel uncomfortable to the mother
Massage until the uterus feels firm
Recheck every 5 minutes
Check your rate of IV fluids
Are you administering oxygen?

52. Fundal Massage Performed AFTER delivery of placenta
Uterus should be firm
Place one hand immediately above symphysis pubis
Place one hand on uterine fundus (top)
Massage with 2 hands

53. Post Partum Care Congratulate the new parents!
Inform them if it is a boy or girl
If possible, offer the mother a towel to wipe her face and hands
By holding the wrapped infant, the mother’s body heat will help maintain the body heat of the infant

54. Abnormal Delivery Presentations
If you are prepared for the worst and get the best, hidden bonus!!!
Blow by oxygen.

55. Breech 4% of term deliveries Head is not the presenting part!!!
Transport immediately to closest ED with OB capacity
Higher risk to infant and mother
Potential need for C-section
It is not uncommon to observe meconium in a breech delivery. Be diligent in taking care of the meconium that may be in the airway.

56. To Facilitate Delivery of Breech
As soon as legs deliver, support infant’s body
If accessible, palpate cord for pulsations
Attempt to loosen cord to create slack
After torso & shoulders deliver, gently sweep arms down
If face down, gently elevate legs & trunk to facilitate delivery of head
DO NOT HYEREXTEND HEAD
DO NOT PULL ON INFANT

57. If Head Does Not Deliver in 30 Seconds
Reach 2 gloved fingers into vagina to locate newborn’s mouth
Push vaginal wall away from newborn’s mouth
Keep fingers in place and transport immediately
Call report ASAP
Keep delivered portion of infant warm & dry
If infant delivers, anticipate distressed newborn
Anticipate maternal hemorrhage

58. Footling Breech – Not a Field Delivery
If one foot is visible, wonder “where is the rest of the baby?”
Encourage mother to breath through a contraction so she does not add to the pushing
Keep infant’s extremity warm
Rapid transport
Early report

59. Prolapsed Cord Cord is delivering before the infant
Infant’s oxygen and blood supply will be compromised
Need to take pressure off the cord
Don’t want mother pushing with contractions
Have mother breath through the contractions

60. Prolapsed Cord True emergency High fetal death rate
Must immediately recognize the emergency
Rapid transport
Place gloved fingers into vagina between pubic bone and presenting part
Cover exposed cord with moist saline dressing

61. Placenta Previa
Abnormal implantation of placenta on lower half of uterine wall
Partial or complete blockage of cervical opening
Hallmark: Painless, bright red vaginal bleeding
Uterus usually soft

62. Abruptio Placenta
Premature separation of normally implanted placenta from the uterine wall
20-30% fetal mortality rate
Bleeding concealed
Sudden, sharp, tearing pain and stiff, boardlike abdomen
Life threatening OB emergency
Support mother’s oxygenation
Transport tilted or lying left

63. Meconium Staining Meconium is fetal stool
Release by the fetus may indicate intrauterine stress, like hypoxia
If observed, prepare for a distressed baby who may need ventilatory support
Fortunately, most meconium can be dealt with by using a bulb syringe

64. Meconium Aspiration Equipment
Intubation equipment
Blade, handle
2 ET tubes
Meconium aspirator
Suction
Suction turned down to 80mmHg

65. Meconium Aspiration Procedure
Meconium aspirator connected to suction tubing
Intubate in usual manner
May not visualize landmarks due to meconium
Quickly connect aspirator to ET tube
Withdraw in twisting fashion while suctioning
Minimize suction time to 2 seconds or less
If time, repeat at least once more

66. Meconium Aspirator Time available to intervene is minimal
Must be prepared and move fast
While running
slide show,
left click
anywhere on
screen at right
to play video

67. Multiple Births Prepare for more than one delivery
Where is your extra equipment?
Expect smaller birth weight infants
Poorer ability to conserve body heat
Immature respiratory system
Need for the smallest equipment you carry

68. Stressed Newborn Infant flaccid, no muscle tone Heart rate < 100
If < 60 begin chest compressions
Apneia or respiratory distress
Newborn respiratory rate per minute
Support ventilations via BVM
One breath every 3 seconds
Just enough volume to make chest rise and fall

69. Documentation After delivery you have 2 patients
Complete run report for both the mother and the newborn
Include time of delivery
Note the one person who actually “caught” the infant at time of delivery
Keep mother’s information on the mother’s report; infant’s on the infant’s
Apply wristbands to both mother and newborn

70. Case Scenario #1 You have arrived on the scene.
27 year-old woman says she is in labor
What are the indications for imminent labor?
Urge to move bowels
Urge to push
Crowning
Ruptured bag of waters
Contractions every 2-3 minutes lasting seconds

71. Case Scenario #1
What questions do you need to ask specific to mother being in labor?
What number pregnancy is this?
What is her due date?
What are her contractions like?
Does she have the urge to push?
Is her bag of waters intact or broken?
Is she aware of any complications?

72. Case Scenario #1 Describe the exam you need to perform
Visual inspection of perineum
Looking for crowning
Looking for abnormal presentation – fingers or toes, anything not expected
Looking for a prolapsed cord
Checking for blood loss
Evaluate contraction duration and frequency

73. Case Scenario #2
You have responded to the scene of a year-old mother in labor
Upon visual inspection, you note flecks of meconium in the leaking amniotic fluid
What does this indicate?
Anticipate a distressed infant
The infant will need gentle, aggressive airway care with the bulb syringe and possibly the meconium aspirator

74. Case Scenario #2 What equipment is necessary? Bulb syringe
Intubation equipment
Blade
Handle
ETT – 2 available (if the first one is clogged with meconium)
Stylet
Suction tubing
Meconium aspirator

75. Case Scenario #2
What adjustment needs to be made with the suction when using the meconium aspirator?
Suction needs to be turned down to 80 mmHg
Suction generally set at 300 mmHg for the adult population
Limit suctioning to less than 2 seconds

76. Case Scenario #3 You are on the scene for a 17 year-old in labor
Upon visual inspection, you note a prolapsed cord
What interventions do you take?
Immediately place gloved fingers into the vagina to take pressure off the cord
Place the mother in the knee-chest position
Provide rapid transport with early report
End of this case discussion; move to next case

77. End of case discussion; move to next case
Case Scenario #4
You are on the scene of a 2 car collision
One of the patients is 16 years-old and is 6 months pregnant
What would be the recommended position if transported?
Lying or tilted left to keep pressure off vena cava
Can this patient sign a release if she wants to?
She is emancipated and can sign a release
If she remains the parent after delivery, she remains emancipated
End of case discussion; move to next case

78. Case Scenario #5 - Documentation
What’s right? What’s wrong/missing?
MVC –this is what’s provided:
Deformity to steering wheel; windshield starred
Extrication took 15 minutes
Patient complained of back pain; able to move upper extremities
Swelling noted to left upper quadrant

79. Case Scenario #5 What’s right regarding documentation?
Description of damage to car
Need and length of time for extrication
Patient complaints listed
Visual inspection result to abdomen

80. Case Scenario #5 What’s wrong/missing?
Is there any other information from the accident available or not?
Speed; what was hit or what hit car
Location of occupant in car
More descriptive of head to toe assessment
Distal CMS with back pain
Movement of lower extremities
Palpation results of abdomen

81. Case Scenario #5 What does SMV’s stand for?
Sensation, movement, vascular
What does CMS stand for?
Circulation, motor, sensation
How do you test for them (yes, they are the same)?
Feel for pulses
Ask the patient to move a distal digit
Ask the patient if they can feel a touch that they are not staring at

82. Case Scenario #6 - Documentation
What’s right? What’s wrong/missing?
78 year-old with chest pain – this is what’s provided
Onset at 0800 while watching TV
Not relieved with rest or 2 Nitroglycerin tablets
8/10 pain scale
EKG sinus rhythm
12 lead done
IV, O2, Aspirin and nitroglycerin given

83. Case Scenario #6 What’s right regarding documentation?
Onset – what patient was doing
Palliation/provocation
Severity
Time of onset
Care provided
Rhythm strip results
12 lead obtained
Interventions appropriate

84. Case Scenario #6 What’s wrong/missing? OPQRST not complete
Missing quality of chest pain in patient’s own words
Missing if the pain radiates or not
Was any ST elevation observed on 12 lead?
Was 12 lead faxed to Medical Control?
O – onset – what was the patient doing at the time of onset
P – what provokes the situation? What makes it better (palliation)?
Q – what is the quality in the patient’s own words?
R – radiation to where?
S – severity on scale
T – time of onset

85. Case Scenario #7 EKG Interpretation
Any ST elevation?

86. Case Scenario #7 – Acute MI ST Elevation I, aVL, V2, V3, V4, V5, V6

87. Case Scenario #8 – EKG Interpretation
Any ST elevation?

88. Case Scenario #8 – Acute MI ST Elevation II, III, aVF
Hold nitroglycerin until consult with Medical Control (hypotension a possibility with inferior wall MI)

89. Hands-on Practice Practice with contents of OB kit
Practice positioning newborn in head down position
Practice using the bulb syringe to clear first the mouth then the nose
Paramedics to use the meconium aspirator
Practice in pairs to become most efficient with time

90. Bibliography
American Academy of Pediatrics. Pediatric Education for Prehospital Professionals 2nd Edition
American Academy of Pediatrics. Neonatal Resuscitation
Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles and Practices. Prentice Hall
Limmer, D., O’Keefe, M. Emergency Care 10th Edition. Brady
Region X SOP, March 2007; amended January 1, 2008.