ob emergencies november 2010 ce condell ems system objectives by jeremy lockwood, ff/pm mundelein...
TRANSCRIPT
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
ObjectivesUpon 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.
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’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.
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
Standard Precautions
Handwashing- still most effectivecontrol measurearound
Just Protect Yourself!!!
Do what you can
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 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 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
Placental Attachment
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
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 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 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 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 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 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 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 Remain calm (at least on the outside!)
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 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
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 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
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 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
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 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
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 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
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
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 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
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
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
Newborn At Delivery They’ll
grow into being a Gerber baby!
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
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 Continue to suction mouth then nose Spontaneous respirations should begin within
15 seconds after stimulation If no respirations, begin BVM support at 30-
40 breaths per minute If pulse < 60 or between 60-80 and not
improving, begin CPR Obtain 1 minute APGAR (ie: record as 9/10)
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
APGAR Scoring – 1 & 5 minutes
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
Cutting the Clamped Cord
FYI – What About Cord Blood? Obtained in the hospital within 10-15 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
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?)
Care of the Newborn Infant in head
down (and side lying) position
Hat placed to minimize heat loss
Cord clamped and cut
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 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
Placenta Uterine Wall Side
Placenta Fetal Side
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?
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 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 If you are prepared for the worst and get the
best, hidden bonus!!!
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
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
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
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
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 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
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 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 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
Meconium Aspiration Equipment Intubation equipment
Blade, handle 2 ET tubes
Meconium aspirator Suction
Suction turned down to 80mmHg
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
Meconium Aspiration Procedure
Meconium Aspirator Time available to intervene is minimal Must be prepared and move fast
While runningslide show,left click anywhere onscreen at rightto play video
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 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 3 seconds Just enough volume to make chest rise and fall
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
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 60-90
seconds
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?
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
Case Scenario #2 You have responded to the scene of a
34 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
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
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 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
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
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
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
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
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
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
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
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?
Case Scenario #7 EKG Interpretation
Any ST elevation?
Case Scenario #7 – Acute MIST Elevation I, aVL, V2, V3, V4, V5, V6
Case Scenario #8 – EKG Interpretation Any ST elevation?
Case Scenario #8 – Acute MI ST Elevation II, III, aVF
Hold nitroglycerin until consult with Medical Control (hypotension a possibility with inferior wall MI)
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
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.