1. Prepared by: Sharon Hopkins, RN, BSN, EMT-P Revised 11/19/14
OB Emergencies November 2014 CE Condell medical center ems system IDPH Site Code: E-1214
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
Revised 11/19/14

2. Objectives
Upon successful completion of this module, the EMS provider will be able to:
1. Define obstetrical terms
2. Describe the physiological changes to the patient who is pregnant.
3. Describe potential complications in the antepartum and post
partum periods.
4. Describe EMS interventions for a variety of obstetrical delivery
emergencies following the Region X SOP.
5. Identify imminent delivery.

3. Objectives cont’d 7. Discuss post-partum depression.
6. Describe components of an obstetrical kit and the use of the contents.
7. Discuss post-partum depression.
8. Actively participate in review of selected Region X SOP’s.
9. Actively participate in case scenario discussion.
10. Actively participate in return demonstration of BVM use with a neonate.
11. Actively participate in return demonstration of use of the meconium
aspirator.
12. Actively participate in return demonstration of use of a BVM in a
neonate.
13. Successfully complete the post quiz with a score of 80% or better.

4. Terminology of pregnancy
Prenatal period – time from conception until delivery of fetus
Antepartum – time period prior to delivery
Post partum – time interval after delivery
Gravidity – number of times pregnant
Parity – number of pregnancies to full term
Fetus – a developing human in the womb
Neonate – the first 30 days of life for the infant
Estimated date of confinement (EDC) – estimated birth date

5. Terminology cont’d
Placenta – temporary blood-rich structure; lifeline for the fetus
Transfers heat
Exchanges O2 and carbon dioxide
Delivers nutrients
Carries away wastes
Bag of waters – amniotic sac; surrounds and protects fetus; volume varies from 500 – 1000ml
Perineum – the skin between the vaginal opening and the anus
Nuchal cord – cord wrapped around the fetal neck

6. physiological Changes During Pregnancy
Pregnancy is a normal and natural process
A woman’s body will undergo many changes in preparation for carrying another life
Complications are uncommon but you must be prepared for them
Pre-existing medical situations could be aggravated during pregnancy and develop into acute problems

7. physiological changes of pregnancy
Nausea and vomiting due to hormonal changes
Delayed gastric emptying
 in renal blood flow
Kidneys may not be able to keep up with filtration and reabsorption
Bladder displaced anteriorly and superiorly
More likely to be ruptured in trauma
Urinary frequency
Loosened pelvic joints due to hormonal changes

8. Physiological changes cont’d
 in oxygen demand and consumption
Diaphragm pushed up by enlarging uterus  lung capacity
 in cardiac output to 6-7 L/min by end of 2nd trimester
Average in resting non-pregnant female is 4.9L/minute
 in maternal blood volume by 45%
Can lose 30-35% total blood loss before change in vital signs are evident
 venous return to right atrium with gravid uterus compressing
inferior vena cava

9. fetal blood supply No direct link between mother’s blood and infant
Mother’s blood flows to the placenta
Placenta supplies blood to the fetus
Placenta acts as a barrier protecting the fetus
Some items cross the placental barrier and can affect the fetus
Alcohol
Some medications – Valium Versed, oral diabetic meds, narcotics, some antibiotics, steroids

10. Umbilical cord A flexible, rope-like structure approx. 2 feet long
Contains 2 arteries, 1 vein
Transports oxygenated blood to fetus
Returns relatively deoxygenated blood to placenta
Fetus can twist and turn in the uterus and get wrapped up in cord
Fetus can “tie umbilical cord into a knot”

11. Normal pregnancy – 20 weeks & term

12. Antepartum Complications
Vaginal bleeding
Ectopic pregnancy
Placenta previa
Abruptio
Hypertensive disorders
Preeclampsia, eclampsia
Supine Hypotensive Syndrome

13. Vaginal Bleeding May occur at anytime during the pregnancy
If early, patient may not even realize they are pregnant
In the field, exact etiology cannot be determine
Keep heightened suspicion that vaginal bleeding may be related to patient being pregnant
This could prove an emotional time for the patient and family
Being supportive is important to these patients

14. Ectopic Pregnancy
Fertilized egg has implanted outside the normal uterus
Patient often presents with abdominal pain
Starts diffuse and them localizes to lower quadrant on affected side
Patient may not even be aware that they are pregnant
If in fallopian tube and tube ruptures, maternal death due to internal hemorrhage is a real possibility
Abdomen becomes rigid with  pain
Often referred shoulder pain on affected side

15. Placenta previa
Abnormal implantation of placenta on lower half of uterine wall
Cervical opening partially or completely covered
Placenta can start pulling away from attachment starting at 7th month
Painless bright red vaginal bleeding
Uterus usually soft
Potential for profuse hemorrhage
Definitive treatment is cesarean section delivery

16. Abruptio placenta
Premature separation of normally implanted placenta from uterine wall
Life threat for mother and fetus
20-30% mortality for fetus
Signs & symptoms depend on extent of abruption
Can have sudden sharp, tearing pain and stiff, board like abdomen
Vaginal bleeding could range from none to some
Blood could be trapped between placenta and uterine wall
Maintain maternal oxygenation and perfusion

17. Pre-hospital Care of antepartum bleeding
Maintain high index of suspicion
Treat for blood loss
Positioning – lay or tilt left
Monitor for adequate oxygenation
Providing supplemental oxygen is also for benefit of the fetus
Maintain adequate perfusion
Consider fluid challenge as needed
200 ml increments with ongoing assessment/ evaluation
Expedited transport; transport as soon as possible
Early report to receiving facility

18. Hypertensive disorder of pregnancy
Major cause of maternal, fetal and neonatal morbidity and mortality
Morbidity – presence of a disease state
Mortality – relating to death
A common medical problem in pregnancy
Includes gestational hypertension (hypertension that develops during pregnancy usually after the 20th week) and pre-existing hypertension (typically defined as a blood pressure > 140/90)

19. Preeclampsia Most common hypertensive disorder of pregnancy
Increased risk in diabetic, those with history of preeclampsia, and those carrying more than one fetus
Progressive disorder; most commonly seen last 10 weeks of gestation, during labor, or first 480 postpartum
Have a 30 mmHg increase in systolic B/P and 15 mmHg increase in diastolic B/P over baseline

20. Signs and symptoms pre-eclampsia
Elevated blood pressure
Headache
Visual disturbances – blurred vision, flashing before the eyes
Severe epigastric pain
Vomiting
Shortness of breath
Tissue edema related to third spacing with fluid shift into tissues
Swelling of face, hands, and feet

21. eclampsia Most serious side of hypertensive disorders of pregnancy
Generalized tonic-clonic seizure activity
Often preceded by flashing lights or spots before their eyes
Epigastric pain or pain RUQ often precedes seizure
Note grossly edematous patient with markedly elevated B/P
High mortality rates for mother and fetus
Definitive treatment is delivery
EMS needs to provide support until delivery at closest appropriate facility

22. Managing Seizures during pregnancy
Positioning of patient
To protect from harm, protect airway
Maintain patent airway
Potential need for intermittent suction
Support ventilations
Patient’s respirations altered during active seizure activity
Will need supportive ventilations especially in presence of long lasting seizure activity
Manage seizure with Versed 2 mg IN/IVP/IO every 2 minutes up to 10 mg (does cross the placental barrier; could depress fetus)

23. Supine hypotensive syndrome
Usually occurs in 3rd trimester
Gravid uterus compresses inferior vena cava when mother lies supine
Mother may experience dizziness
Evaluate for volume depletion versus positioning problem
Place mother in left lateral recumbent position (“lay left”) for assessment, treatment, and transportation to prevent this problem

24. Identifying Imminent delivery
Mother entering the 2nd stage of labor
Measured from complete dilation of cervix (10cm) to delivery of fetus
Could last minutes for first pregnancy
Contractions strong lasting seconds and 2 -3 minutes apart
Membranes may rupture
Has urge to push
Perineum bulging
Crowning evident when head or other presenting part is evident at vaginal opening during a contraction

25. Ob kit contents and add-ons
Cap
ID bands

26. Steps to take during delivery
Try for a private area if out in public
Place patient on her back with room to flex knees and hips
Prepare equipment – OB kit
Coach mother to breath between contractions and to push with contractions once crowning is evident
Support head as it emerges
Check for nuchal cord
Clear the airway with a bulb syringe if secretions present

27. Delivering the baby

28. Delivery cont’d Gently guide baby’s head downward
Facilitates delivery of upper shoulder
Then gently guide baby’s body upward
Facilitates delivery of lower shoulder
Rest of baby quickly delivers
Be prepared!
Infant will be slippery!
Note time of delivery – when baby totally out
Keep baby in head down position

29. Delivering the baby

30. Use of bulb syringe Routine suctioning is no longer recommended
Suctioning has been associated with bradycardia and other problems
Suctioning is limited to necessity
If performed, suction MOUTH, then nose
Suctioning the nose is the stimulus to breath
Want the airway clear prior to stimulation to take a breath
Infant will not start to breath until their chest clears the birth canal and can then expand

31. Delivering the baby

32. Normal Appearance of Newly born
Infants will be wet and slippery
Covered with a cheesy like substance that wears off shortly after delivery
Hands and feet may be cyanotic longer that other parts of the body
Extremities should be actively moving

33. Newly born appearance
Risk for blood and body fluid contamination during all deliveries
Have high regard for use of appropriate PPE’s!
Drying off preserves heat and acts as a stimulus by the rubbing activity

34. Initial assessment of newborn
Begin steps of inverted pyramid as you are assessing newborn
Begin to dry infant; change to dry towel as needed
Cold infants can deteriorate quickly
Infants have difficult time generating & maintaining body heat; they cannot shiver to generate heat
Suction with bulb syringe only when secretions are present
Suctioning when not necessary associated with bradycardia and other problems
Assess newborn as soon as possible after birth
Normal respiratory rate averages breaths per minute
Normal heart rate ranges from 100 – 180 beats per minute

35. Inverted pyramid
(Always needed)
(Infrequently
needed)

36. Apgar score
Developed in 1953 by Dr. Apgar, a surgeon turned anesthesiologist
An assessment is taken at 1 and 5 minutes after birth
The 1 minute score reflects how well the infant tolerated the birthing process and indicates need for early intervention
The 5 minute score reflects how well the infant is tolerating being outside the womb as well as response to interventions provided
The higher the score (closer to 10), the better the infant’s transition
Early duskiness of distal extremities is common often leading to a minute score of 9
The score does NOT predict the future health of the child

37. APGAR cont’d Any score less than 7 merits an intervention
Supplemental airway
Clearing the airway
Physical stimulation
Rubbing the back
Flicking the bottom of the foot
Most low initial scores at 1 minute improve with the usual interventions listed at the top of the pyramid and by the 5 minute assessment, are usually at higher, acceptable scores
Providing assessment/reassessment will be key

39. Care of the cord Do not pull on the cord
Avoid cutting the cord prematurely
Want the last kick of blood available to be delivered to the infant
Once the cord has stopped pulsating and gone limp, can prepare to clamp and tie it
Place one clamp 8 inches from newborn’s navel
Place 2nd clamp about 2 inches further away
Cut exposed cord between the clamps – it’s tougher than anticipated
Continue to assess the newborn’s end of exposed cord for any bleeding

40. Care of the cord There is no rush to clamp and cut the cord
You want to give enough time for all blood possible to infuse from mother to the placenta to the infant
Infant's have a very limited blood volume to begin with (80 ml/kg)

41. Preventing heat loss Heat loss can be life threatening for the newborn
Most heat loss is via evaporation while wet with amniotic fluid
Can lose heat via convection depending on temperature of room and movement of air around newborn
Can lose heat via conduction if in contact with cooler objects
Can radiate heat to colder nearby objects

42. Preserving the newborn’s body temperature
Dry the newborn immediately after birth
Maintain a warm ambient temperature
Close all windows and doors
Replace wet towels with dry
Keep infant wrapped and head covered to prevent heat loss
Mother holding the newborn transfers her body heat

43. Newborn resuscitation
Additional efforts required when the respiratory rate is decreased, heart rate <100, or there is decreased muscle tone
Attempt positive pressure ventilations via BVM
Rate of breaths per minute
Watch that the volume is enough to make the chest rise and fall
Reassess after 30 seconds
IF heart rate is beats per minute
Continue positive pressure ventilation
IF heart rate is less than 60
Begin chest compressions at a ratio of 3:1; reevaluate every 30 seconds

44. 3rd stage of labor – placental stage
Uterus continues to contract
Cord appears to lengthen
May have increase in bloody discharge
If delivered, transport with mother to the hospital

45. Complications – prolapsed cord
Umbilical cord visible prior to delivery
Cord will be compressed if fetus passes through birth canal
Goal
Prevent mother from delivering vaginally

46. Prolapsed cord
This is one of the complications you want to visually check for as quickly as possible once on the scene of an imminent delivery
If the cord is visible protruding from the vagina
Elevate the mother’s hips
Instruct patient to pant during contractions or just keep her breathing during a contraction
Place gloved hand into vagina between pubic bone and presenting part
Monitor cord between fingers for pulsations
Keep exposed cord moist with dressings and keep warm
Transport with hand in place – DO NOT REMOVE YOUR FINGERS

47. Meconium Staining Occurs in approximately 10-15% of deliveries
Meconium is dark green and can be of thin or thick consistency
Fetal distress and hypoxia cause meconium to pass from the fetal GI tract into the amniotic fluid
If infant is breech, meconium staining is anticipated and expected as the abdomen is compressed in the birth canal
Meconium aspiration increases neonatal mortality rate
If aspirated can obstruct small airways & cause aspiration pneumonia and lead to respiratory distress

48. Normal meconium stool Usually passed within 480 of birth
Typically transitions to normal stool beginning by day 4
Meconium is thick, dark almost black stool normally found in the infant’s intestines
Becomes a problem when aspirated or otherwise blocks the infant’s small airways

49. Meconium – thin or thick?
If thin, may not require any intervention if infant is vigorous
No problems with respiratory rate
Normal muscle tone
Heart rate over 100 beats per minute
Bulb syringe easily takes care of most cases of meconium
Infant is not vigorous – will need interventions
Decreased respirations
Decreased muscle tone
Heart rate < 100 beats per minute

50. If intervention required for Meconium
If interventions required, must move quickly
You have limited time to intervene
You must be proactive and anticipate use of equipment
Suctioning with meconium aspirator needs to be performed prior to the infant’s need to take their first breath
If you are organized and efficient, you MAY get the opportunity to suction twice
You probably won’t get the opportunity for more than two attempts

51. Equipment for meconium aspiration
Suction tool
Suction force turned down to 80 mmHg
Meconium aspirator
Intubation blade and handle
2 ETT of anticipated size
Additional ETT sized below and above anticipated size to use
Stylet
Neonatal BVM

52. Presence of Meconium
Suctioning must occur prior to infant being stimulated
It is more efficient if performed as a team effort in the non-vigorous infant
Provide blow-by oxygen during procedure to keep environment oxygen enriched
Blade can be left in position as first ETT is removed
Assistant should be ready to attach meconium aspirator to proximal end of ETT as soon as stylet is removed
New, clean ETT with stylet needs to be prepared & ready to be used as soon as 1st ETT is removed

53. Meconium aspirator
Connect small end of meconium aspirator to suction connecting tube
Set suction down to 80 mmHg
Endotracheal tube inserted using blade and handle
Meconium may obscure your view
Wider end of aspirator connected to proximal end of ETT
Thumb placed over suction port while withdrawing ET tube within 2 seconds
Discard ETT after 1 sweep and use new ETT if 2nd attempt made

54. Supportive ventilation
Proper positioning is a small towel under the torso
Volume is enough to make the chest rise gently
Rate is breaths per minute
Do not flow oxygen into the infant’s eyes or put pressure over the eyes
Newborns are sensitive to vagal stimulation and will respond with bradycardia

55. Nuchal cord Cord is wrapped around the infant’s neck
Problem exists if the cord is too tight and prevents infant from delivering
Remember: fetus is receiving their oxygen and blood supply via the cord
If cord clamped and cut prematurely, infant needs to be delivered without delay to begin to ventilate on own
Goal:
If cord too tight for infant to deliver, then unwrap or clamp & cut
Prevent mother from pushing until cord is unwrapped or cut

56. Postpartum hemorrhage
Loss of more than 500 ml of blood immediately following delivery
500 ml = 2 cups = 16 oz = 1 pint = 1 pound by weight of soaked pad
Most common cause is uterine atony – lack of uterine tone; failure of uterus to contract after delivery
Occurs more frequently in multigravida and more common following multiple births or births of large infants
Rely on clinical appearance of mother and vital signs
Uterus often feels boggy on palpation
Need to perform fundal massage

57. Fundal massage – 2 handed technique
Must NOT be performed until after delivery of the placenta
Is a 2 handed technique
Performed to get uterus to contract to minimize blood loss
Need the uterus to firm up
Should feel like a grapefruit or fist

58. Fetal alcohol syndrome (fas)
Life long effects started from the womb
When the mother drinks, alcohol crosses the placenta and passes to the fetus
Alcohol affects neurons and the central nervous system (CNS) of the fetus
Damages physical structures and growth
Defects more pronounced as the child grows

59. Crisis at birth If FAS is suspected: Anticipate a small weight newborn
Anticipate a newborn who may need some resuscitative efforts
Assisted ventilations
Extra attention to be kept warm due to typically a smaller birth weight

60. Fetal alcohol syndrome (FAS)
Signs and symptoms noted at birth related to effects of hypoglycemia and dehydration
Newborn has a “hangover” following binge drinking of the mother
Typical appearance
Underweight; “skinny”
Irritable
Poor reserves
Changes in facial features

61. Fetal alcohol syndrome

62. Fetal alcohol syndrome (FAS)
All defects last a lifetime
Neurological defects include
Motor skills; poor pace of walking
Memory impairment; learning disabilities
Poor social skills
Potential for heart murmur, joint defects, hearing problems, renal problems

63. sids
Sudden infant death syndrome describes the unexplained sudden death of an infant
Major cause of death in infant’s first month of life
Most victims appear healthy prior to death
There is still no cause of SIDS but theories do exist
Stress in infant possibly from infection or other factors
A birth defect
Failure to develop
A critical period of rapid growth

64. sids SIDS cannot be prevented or predicted
Death seems to occur during sleep
There are no warning signs or symptoms
Parents will need emotional support
Parents will often blame themselves
“I should have…”
“I should not have…”
Each case is handled individually in regards to EMS response

65. Post partum depression
Many symptoms may be experienced by the new mother
EMS responding to “an accident” may be caring for a mother experiencing postpartum depression
Our biggest fear is that the patient may be experiencing issues that may take over and lead them to do harmful things to themselves and/or the children
Just be alert to potential situations that may be more than they appear to be
Like the MVC that may be a suicide attempt

66. Post partum depression symptoms
Being overwhelmed, irritated, angry, no patience
Feel this is more than just “hard”; feels like she can’t handle being a mother
Sadness to the depth of their soul
Inability to stop crying
Can’t concentrate; feel disconnected
Having thought of running away, or of hurting self or the baby
Confused and scared

67. Case scenario discussion
Review the following cases and determine what your general impression is
Discuss what your intervention needs to be
Refer to the Region X SOP’s as necessary

68. Case scenario #1
EMS is called to the scene of a mother who is in labor
What questions are important to ask early?
Number of pregnancies
Due date
Known complications
Previous labor history if any
If bag of waters are intact or broken
The duration and frequency of contractions
In report, provide weeks of gestation and not the months
Provides more precise picture of age of infant (i.e.: premature or not)

69. Case scenario #1 What indicates that delivery is imminent? Crowning
Bulging of the perineum
Contractions that are lasting seconds and coming every minutes
Urge to push
Feeling that she wants to have a bowel movement

70. Case scenario #1 What is assessed with the APGAR score?
A – appearance or coloring
Fingers and toes often bluish for a few minutes
P – pulse
Best to have a pulse over 100 beats per minute
G – grimace or reflexes
Grimacing, coughing, sneezing are good to see
A – activity or muscle tone
Want to see flexed extremities
R – respiratory effort
Want to hear a strong cry

71. Case scenario #1
What are the interventions listed at the top of the inverted pyramid that each newborn typically receives?
Drying – to prevent heat loss by evaporation
Warming the infant to stop the heat loss
Stimulation by touching and rubbing the infant
Flicking the bottom of the feet or rubbing the back if more tactile stimulation is required
Keeping the newborn in a head down position to facilitate drainage from the lungs

72. Case scenario #2
You have arrived on the scene and determined that you will need to deliver a newborn
During assessment and in preparation of the event, you notice dark, thick greenish-black flecks of material in the leaking bag of waters
What does this indicate?
Evidence of meconium staining
What does this mean?
If not a breech delivery, the fetus may be in distress and require extra resuscitative efforts

73. Case scenario #2 What equipment do you need to prepare? Neonatal BVM
Meconium aspirator
Several endotracheal tubes
Several stylets
Blade and handle
Oxygen source
Suction device – turned down to 80 mmHg

74. Case scenario #2
What assessment of the newborn would indicate a need to use a meconium aspirator?
If the infant is not vigorous
The respiratory rate is decreased
There is decreased muscle tone – newborn is limp
Heart rate is below 100 beats per minute
Remember: a bulb syringe works just fine for most situations involving the presence of meconium at birth
Depress the bulb prior to inserting into the mouth and nose

75. Case scenario #3
You are on the scene and have just assisted the mother in delivering her 3rd child
The infant is not as responsive to drying and stimulation as you feel they should be and extremities are dusky
You want to provide blow-by oxygen
How would you deliver blow-by oxygen?
Hold a source of oxygen next to the infant's nose and mouth and let the oxygen source “blow-by”

76. Case scenario #3 The infant is not responding to the blow-by efforts
The respiratory rate is low and the heart rate is less than 100
What is your next intervention?
Begin positive pressure ventilations at breaths per minute
Ventilate with small puffs of air
Reevaluate every 30 seconds

77. Case Scenario #3
What would you do if the pulse remained between 60 and 100?
Continue positive pressure ventilations
Reassess every 30 seconds
What would you do if the pulse dropped below 60 in the newborn?
Begin chest compressions
3 compressions to 1 ventilation
Depress the sternum 1/3 the AP diameter of the chest on lower half of sternum

78. Case Scenario #4 You are on the scene for a patient who fell
Upon your arrival you note an unresponsive adult on the floor who is obviously pregnant
Your patient is in a tonic-clonic seizure
What is your general impression?
First thought is eclampsia
Need to consider an epileptic seizure
Need to be thinking possible hypoglycemia
Need to determine presence of head injury

79. Case Scenario #4
What are your actions during this on-going seizure activity?
Protect the patient from harm
Maintain a patent airway
Suction available
Turn patient on left side
Also avoids supine hypotensive syndrome
Consider supporting ventilations via BVM
1 breath every 5-6 seconds (10-12 breathe per minute)
Obtain any medical history available

80. Case Scenario #4
What medication is used in the presence of seizure activity in the patient who is pregnant?
Versed 2mg IN/IVP/IO
May repeat every 2 minutes titrated to desired effect
Maximum dose of 10 mg
If seizure activity continues or reoccurs, contact Medical Control for additional orders of Versed up to an additional mg

81. Case scenario #4
What would be important to relay in your face to face hand-off report with this case once at the hospital?
Fact that Versed was administered
Versed crosses the placental barrier
If administered close to the time of delivery, may witness side effects in the newborn related to the Versed
Respiratory depression
Hypotension
Would be important for OB to try to differentiate if signs or symptoms are due to the condition of the newborn or related to interventions performed

82. Bibliography
Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4th edition. Brady
Mistovich, J., Karren, K. Prehospital Emergency Care 9th Edition. Brady
Region X SOP’s; IDPH Approved January 6, 2012.
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