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OB Emergencies. ECRN CE Module IV 2010 Condell EMS System IDPH Site Code #107200E-1210 2 hours CE credit Objectives by Jeremy Lockwood, FF/PM Mundelein Fire Department Packet prepared by Sharon Hopkins, RN, BSN, EMT-P. Objectives.

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Ob emergencies

OB Emergencies

ECRN CE Module IV 2010

Condell EMS System

IDPH Site Code #107200E-1210

2 hours CE credit

Objectives by Jeremy Lockwood, FF/PM Mundelein Fire Department

Packet prepared by Sharon Hopkins, RN, BSN, EMT-P


Objectives
Objectives

Upon successful completion of this module, the ECRN will be able to:

1. Identify appropriate standard precautions taken 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.


Objectives cont d
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.


Objectives cont d1
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.


Standard precautions
Standard Precautions

Anticipate the exposure to a large amount of blood and body fluids

Full protection is recommended

Standard precautions

Don’t assume the absence or presence of disease just by appearances of the patient or situation


Standard precautions1
Standard Precautions

Handwashing-

still most

effective

control

measure

around


Just protect yourself
Just Protect Yourself!!!

  • Do what you can


Normal pregnancy development
Normal Pregnancy Development

  • Ovulation and what follows

    • Release of an egg from ovary

    • Egg travels down fallopian tube toward uterus

    • Intercourse within 24-48 hours of ovulation could result in fertilization

    • Fertilization occurs in the fallopian tube

    • Fertilized egg will implant in the uterus and pregnancy begins


Prenatal development cont d
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


Placental development cont d
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



Amniotic sac
Amniotic Sac

  • “Bag of waters”

    • Thin-walled membranous covering holding 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


Physiological changes of pregnancy
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


Physiological changes to the systems
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


Physiological changes to the systems1
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 10-15 beats

    • B/P decreases slightly 1st & 2nd trimesters

    • Supine hypotensive syndrome when mother lies supine

      • Especially by 5 months of pregnancy


Physiological changes to the systems2
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


Physiological changes to the systems3
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


Physiological changes to the systems4
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


Obstetrical assessment
Obstetrical Assessment

  • Determine if delivery is imminent or if there is time to transport

    • EMS to hospital or ED to OB

  • 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

  • Remain calm (at least on the outside!)


Ob assessment questions
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 16-17 hours

    • Subsequent deliveries tend to shorten from the 1st one


Ob assessment questions1
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 increased 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


Ob visual examination
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


Ob assessment contractions
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 contraction

    • Includes contraction and rest intervals


Ob assessment vital signs
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 10-15 beats over normal

    • Only slight increase in respiratory rate


Supine hypotensive syndrome
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

  • Therefore decreases stroke volume pumping out of the heart

  • Especially after 5 months keep the mother tilted or turned preferably toward the left


Imminent delivery
Imminent Delivery

  • Crowning is present

  • Contractions last 30 – 60 seconds and are 2 - 3 minutes apart

  • Mother has the urge to move her bowels or she says “I HAVE TO PUSH!!!”

  • Bag of waters has ruptured


Stages of labor
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

    • First stage can last approximately 8-10 hours for first labor to about 5-7 hours in multipara


1 st stage of labor cont d
1st Stage of Labor cont’d

  • Contractions

    • Early in this stage are usually mild

      • Duration of 15-20 seconds

      • Frequency every 10-20 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


Timing contractions
Timing Contractions

  • Duration

    • Timed in seconds

    • Timed from the beginning of the contraction to the end the contraction

    • Contractions lasting 60-90 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


2 nd stage of labor expulsion stage
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 60-75-90 seconds

    • Contraction every 2 – 3 minutes


2 nd stage of labor cont d
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


Ob kit
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


Contents of ob kit
Contents of OB Kit

Where are your kits kept in the ED?


Cord clamps
Cord Clamps

  • FYI

    • If not used for a period of time, it has been reported that the OB clamps can become brittle and can break

    • There is no hurry to clamp and cut a cord in the field

    • If EMS transports the mother and baby with the cord intact, so be it

      • The hospital will take care of clamping and cutting the cord


Delivery of the newborn
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 into mouth or 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


Newborn at delivery
Newborn At Delivery

  • They’ll grow into being a Gerber baby!


Care of the newborn cont d
Care of the Newborn cont’d

  • Hold on tight

    • Infant is slippery due to cheesy covering and amniotic fluid

  • Note time of delivery and document

  • Stimulate the infant

    • Suctioning, rubbing the back, flicking at the soles of the feet, drying off


Suctioning the newborn
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


Care of the newborn
Care of the Newborn

  • Suction mouth then nose only as needed

    • Caution – you are removing oxygen with secretions!!!

  • Spontaneous respirations should begin within 15 seconds after stimulation

  • If no respirations, begin BVM support at 40-60 breaths per minute (1 breath every 1-1.5 seconds)

  • If pulse < 60 or between 60-80 and not improving, begin CPR (3:1 ratio)

  • Obtain 1 minute APGAR (ie: record as 9/10)


Apgar score
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 but most visible/obvious



Care of the umbilical cord
Care of the Umbilical Cord

  • Clamp and then cut the cord after pulsations have stopped & cord 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



Fyi what about cord blood
FYI – What About Cord Blood?

  • Obtained in the hospital within 10-15 minutes of delivery (NOT obtained in the field)

  • 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


Care of the newborn cont d1
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 but only 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?)


Care of the newborn1
Care of the Newborn

  • Infant in head down (and side lying) position

  • Hat placed to minimize heat loss

  • Cord clamped and cut


3 rd stage of labor placental stage
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


Delivery of the placenta
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, collected and transported with the patient

    • Inspected at the hospital for retained placental parts

  • For excessive external bleeding, apply dressings externally

  • For excessive vaginal bleeding, uterine massage AFTER placenta is delivered




Post partum care of the mother
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, uterus massaged 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?


Fundal massage
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


Post partum care
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


Abnormal delivery presentations
Abnormal Delivery Presentations

  • If you are prepared for the worst and get the best, hidden bonus!!!


Breech
Breech

  • 4% of term deliveries

  • Head is not the presenting part!!!

  • Mother transported immediately to closest ED with OB capacity

  • Higher risk to infant and mother

  • Potential need for C-section


To facilitate delivery of breech
To Facilitate Delivery of Breech

  • As soon as legs delivered, infant’s body supported

  • If accessible, cord palpated checking for pulsations

  • Attempt made to loosen cord to create slack

  • After torso & shoulders deliver, arms gently swept down

    • If face down, legs & trunk gently elevated to facilitate delivery of head

    • DO NOT HYEREXTEND HEAD

    • DO NOT PULL ON INFANT


If head does not deliver in 30 seconds
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

  • EMS to call report ASAP

  • Keep delivered portion of infant warm & dry

  • If infant delivers, anticipate distressed newborn

    • Anticipate maternal hemorrhage


Footling breech not a field delivery
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 EMS report to hospital


Prolapsed cord
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


Prolapsed cord1
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

  • Elevate mother’s hips


Ems arrival to ed with predelivery emergency
EMS Arrival To ED With Predelivery Emergency

  • Head not delivered in breech or prolapsed cord

    • EMS to have fingers in the mother’s vagina

      • For stuck breech, pushing skin away from infant’s mouth to allow ventilations

      • For prolapsed cord, to keep pressure of infant head off cord to maintain blood flow to infant

    • Keep EMS in position with their fingers

    • Assist with rapid transport to OB

      • OB needs to be prepared with an earlier phone call


Placenta previa
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


Abruptio placenta
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


Meconium staining
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

    • Rarely use a meconium aspirator to clear airway


Meconium aspiration equipment
Meconium Aspiration Equipment

  • Intubation equipment

    • Blade, handle

    • 2 ET tubes

  • Meconium aspirator

  • Suction

    • Suction MUST BE turned down to 80mmHg


Meconium aspiration procedure
Meconium Aspiration Procedure

  • Meconium aspirator connected to suction tubing

  • Infant intubated in usual manner

  • Landmarks may not be visualized due to meconium

  • Quickly connect aspirator to ET tube

  • Withdraw ETT in twisting fashion while suction applied

    • Minimize suction time to 2 seconds or less

  • If time, repeat at least one more intubation and 2 second suctioning


Meconium aspirator
Meconium Aspirator

  • Time available to intervene is minimal

  • Must be prepared and move fast

While running

slide show,

left click

anywhere on

screen at left

to play video


Multiple births
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


Stressed newborn
Stressed Newborn

  • Infant flaccid, no muscle tone

  • Heart rate < 100

    • If < 60 begin chest compressions

  • Apneia or respiratory distress

    • Newborn respiratory rate 40-60 per minute

    • Support ventilations via BVM

      • One breath every 1-1.5 seconds

      • Just enough volume to make chest rise and fall


Documentation
Documentation

  • After delivery you have 2 patients

  • EMS to 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


Case scenario 1
Case Scenario #1

  • EMS has arrived on the scene (or mother presents to ED)

  • 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 60-90 seconds


Case scenario 11
Case Scenario #1

  • What questions need to be asked 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?


Case scenario 12
Case Scenario #1

  • Describe the exam that needs to be performed

    • 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

    • Evaluation of contraction duration and frequency


Case scenario 2
Case Scenario #2

  • EMS has responded to the scene of a 34 year-old mother in labor (or presents to ED)

  • 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


Case scenario 21
Case Scenario #2

  • What equipment is necessary?

    • Bulb syringe

    • Intubation equipment if meconium aspirator needed

      • Blade

      • Handle

      • ETT – 2 available (if the first one is clogged with meconium)

      • Stylet

      • Suction tubing

      • Meconium aspirator – where is this equipment for ED?


Case scenario 22
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


Case scenario 3
Case Scenario #3

  • A 17 year-old presents in active 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 or otherwise to elevate hips

    • Rapid transport with early report to OB


Case scenario 4
Case Scenario #4

  • EMS is 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


Bibliography
Bibliography

  • American Academy of Pediatrics. Pediatric Education for Prehospital Professionals 2nd Edition. 2006.

  • American Academy of Pediatrics. Neonatal Resuscitation. 2000.

  • Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles and Practices. Prentice Hall. 2009.

  • Limmer, D., O’Keefe, M. Emergency Care 10th Edition. Brady. 2005.

  • Region X SOP, March 2007; amended January 1, 2008.


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