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Obstetrical Emergencies

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Obstetrical Emergencies Silver Cross EMS CME June 2011 2nd Trimester Instructor/Author: Lonnie Polhemus RN, NREMT-P Detailed Delivery Instructions Re-suction the baby ... – PowerPoint PPT presentation

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Title: Obstetrical Emergencies


1
Obstetrical Emergencies
  • Silver Cross EMS CME
  • June 2011 2nd Trimester
  • Instructor/Author Lonnie Polhemus RN, NREMT-P

2
OB/GYN Emergencies
  • Many types of emergencies can occur with female
    reproductive system
  • Gravid and non-gravid
  • Following information will help you refresh
    assessment treatment skills for emergency
    childbirth gynecological emergencies

3
Because we have to have objectives
  • Identify anatomic structures and functions of
    female reproductive system.
  • Demonstrate basic understanding of pregnancy
    physiology and menstrual cycle, ovulation, and
    fetal development.
  • Identify signs/symptoms and proper care for
    gynecological emergencies.
  • Identify key aspects of evaluating pregnant
    patient to determine if birth is imminent.
  • Identify purpose and use of tools in an OB kit.

4
More objectives
  • Identify steps for normal delivery of infant.
  • Identify how and when to cut umbilical cord.
  • Identify steps for post-delivery care of
    newborn/mother including placenta delivery.
  • Identify critical treatment interventions for
    pregnancy complications
  • breech (buttocks) or limb presentation
  • shoulder dystocia
  • prolapsed cord
  • postpartum bleeding.
  • Identify steps for assessing infant APGAR score.
  • Identify steps for neonatal resuscitation

5
Terms to become familiar with
  • abruptio placenta When placenta prematurely
    separates from uterine wall, causing heavy
    internal bleeding and pain
  • Can occur as a result of trauma.
  • bloody show Mucous and blood that comes from
    vagina as first stage of labor begins.
  • Cervix sealed by a plug of mucus during pregnancy
    to prevent contamination.
  • When cervix dilates, plug expelled as pink-tinged
    mucous.
  • crowning Bulging out of the vaginal opening
    caused by the babys head pressing against it.

6
And these too
  • dilation To get larger or enlarge.
  • Degree of dilation of cervix often key indicator
    used by midwives and physicians to determine if
    birth is imminent.
  • EMTs/paramedics do not perform this test.
  • Process occurs over a period of several hours in
    some women, but can take much longer.
  • eclampsia (toxemia) Serious condition that can
    develop in the third trimester.
  • Characterized by high blood pressure and
    excessive swelling in the extremities and face.
  • Life-threatening seizures differentiate eclampsia
    from preeclampsia.

7
A few more terms
  • ectopic pregnancy Condition where fertilized
    egg implants outside uterus, often in fallopian
    tubes.
  • Symptoms can include abdominal pain, bleeding
    (intraperitoneal or vaginal).
  • effacement Term relating to thinning of cervix.
  • meconium Dark-green fecal material found in
    intestines of full-term babies.
  • Ordinarily meconium is passed after a baby is
    born.
  • In some cases, meconium expelled into the
    amniotic fluid prior to birth.
  • Gives fluid greenish-brown color known as
    meconium staining.

8
Almost done
  • placenta previa A condition where placenta sits
    low in uterus, blocking cervix.
  • Can present with painless, bright red bleeding.
  • postpartum A term used to describe the period
    shortly after childbirth.

9
Only three more terms
  • preeclampsia Condition in pregnant women
    characterized by high blood pressure, abnormal
    weight gain, edema, headache, protein in the
    urine, and epigastric pain.
  • If untreated, preeclampsia can progress to
    eclampsia.
  • supine hypotensive syndrome Weight of unborn
    fetus and uterus puts pressure on inferior vena
    cava.
  • Result is inadequate venous blood return to the
    heart, reduced cardiac output, and lowered blood
    pressure.

10
Last one for now
  • Braxton-Hicks Defined by Taber's Medical
    dictionary as intermittent, painless contractions
    that may occur every 10 to 20 minutes after the
    first trimester of pregnancy.
  • First described in 1872 by British gynecologist
    John Braxton Hicks.
  • Sometimes called pre-labor contractions or Hicks
    sign.
  • Not everyone will notice or experience these
    contractions, and some will have them frequently.
  • Some mothers notice them more in subsequent
    pregnancies than in first pregnancy.

11
Female Anatomy of the reproductive organs
  • Cervix opening of the uterus
  • First stage of birth, cervix opens thins
  • Allows fetus to move into vagina
  • Opening process called dilation
  • Endometrium inner lining of uterus
  • Each month built up in anticipation of
    implantation of fertilized egg
  • Fertilization does not occur, lining simply
    sloughs off
  • Referred to as menstrual period
  • Fallopian tubes long slender passageways
    connect uterus to ovary
  • Female egg (ovum) passes through structure on
    its way to uterus for implantation to uterine
    wall
  • Ovaries two almond-sized glands located on
    each side of uterus behind below fallopian
    tubes
  • Produce estrogen progesterone in response to
    follicle stimulation hormone (FSH) luteinizing
    hormone (LH) secreted from pituitary gland

12
Female Anatomy
  • Perineum area between vaginal opening anus
  • It sometimes is torn during birth which causes
    bleeding
  • Uterus pear-shaped, muscular organ holds fetus
    during pregnancy
  • Contracts to push fetus through cervix into
    vagina during birth
  • Vagina flexible, muscular tube about three
    inches long
  • Called birth canal
  • Fetus moves from uterus through cervix into
    vagina then out of mothers body

13
Fetal Anatomy
  • Placenta develops early in pregnancy performs
    important functions
  • Exchanges respiratory gases
  • Transports nutrients from mother to fetus
  • Excretes waste
  • Transfers heat
  • Active endocrine gland produces several
    important hormones
  • Attached by umbilical cord
  • Vein - transports oxygenated blood toward fetus
  • Artery return deoxygenated blood to placenta
  • Amniotic sac develops early in pregnancy
  • Consists of membranes surround protect
    developing fetus
  • Fills with amniotic fluid cushions fetus
    provides stable environment
  • Umbilical cord attaches fetus to placenta
  • Contains one vein two arteries
  • Vessels in umbilical cord similar to pulmonary
    circulation
  • Arteries carry deoxygenated blood
  • Veins carry oxygenated blood
  • Newborn cord is about two feet long

14
Fetal Anatomy
15
Assessment of the OB/GYN patient
16
Assessment
  • Recognition of pregnancy
  • Breast tenderness
  • Urinary frequency
  • Amenorrhea
  • Nausea/Vomiting

17
Assessment
  • Obstetric History
  • Gravidity and Parity
  • Gravidity Number of pregnancies
  • Parity Number of live births

18
Assessment
  • Obstetric History
  • Last normal menstrual period
  • Estimated delivery date (-3/7)
  • Previous Ob-Gyn complications
  • Prenatal care (by whom)
  • Previous Cesarean sections

19
Assessment
  • Obstetric Physical Exam
  • Evaluation of Uterine Size
  • 12 to 16 weeks above symphysis pubis
  • 20 weeks at umbilicus
  • For each week beyond 20 weeks 1 cm above
    umbilicus
  • At term near xiphoid process

20
Assessment
  • Obstetric Physical Exam
  • Presence of fetal movements
  • 20th week
  • Presence of fetal heat tones
  • 20th week
  • Normal 120 to 160/minute

21
Assessment
  • Presence of Pain
  • Abdominal pain in last trimester suggests
    abruption until proven otherwise
  • Appendicitis may present with RUQ pain

22
Assessment
  • Presence of vaginal bleeding
  • Always dangerous in first trimester
  • Dangerous in late pregnancy if greater than
    normal period

23
Assessment
  • General health
  • Diabetes may become unstable
  • Hypoglycemic episodes in early pregnancy
  • Hyperglycemia as pregnancy progresses
  • Hypertension complicated by PIH
  • Cardiovascular disease may worsen

24
Assessment
  • Warning signs
  • Vaginal bleeding
  • Swelling of face, hands
  • Dimmed, blurred vision
  • Abdominal pain

25
Assessment
  • Warning signs
  • Persistent vomiting
  • Chills, fever
  • Dysuria
  • Fluid escape from vagina

26
Gynecology
27
Menstrual cycle
  • Womans monthly hormonal cycle in which uterus
    prepares to receive egg
  • Then discharges a bloody fluid
  • Cycle repeats on average every 28 days, but can
    vary widely

28
Menstrual cycle
  • Days 1 to 5
  • Egg not fertilized, hormone levels lower, causes
    thickened lining of uterus to shed
  • Results in a womans period
  • First day of menstrual bleeding is Day 1 in
    menstrual cycle
  • Days 6 to 14
  • Pituitary gland produces hormone, stimulates
    ovaries to develop follicles
  • Each follicle contains an egg
  • Only one egg reaches maturity has potential to
    become fertilized
  • Hormone levels increase, lining of uterus
    thickens prepares to receive mature egg
  • Days 10 to 18
  • Hypothalamus pituitary glands release hormone,
    mature follicle bursts releases egg
  • Ovulation typically occurs midway through
    menstrual cycle on Day 14
  • Egg begins its journey down fallopian tubes to
    uterus
  • Time period when a woman is most likely to
    become pregnant
  • Days 16 to 28
  • After releasing egg, ruptured follicle secretes
    progesterone
  • Progesterone continues to thicken lining of
    uterus in preparation for fertilized egg
  • If egg is fertilized by sperm, it implants in
    lining of uterus
  • If egg not fertilized or implanted, lining of
    uterus shed again at next menstrual cycle

29
Pelvic Inflammatory Disease
  • Pelvic inflammatory disease (PID) infection of
    female reproductive tract
  • Organs most commonly involved
  • Uterus
  • Fallopian tubes
  • Ovaries
  • Occasionally, peritoneum intestines

30
Pelvic Inflammatory Disease
  • Symptoms of PID include
  • Lower abdominal pain
  • Fever
  • Abnormal vaginal discharge
  • Painful intercourse
  • Irregular menstrual bleeding
  • Pain in right-upper quadrant
  • Vaginal bleeding lower abdominal pain can
    indicate serious gynecological problem
  • Maintain high index of suspicion when
    encountered

31
Pelvic Inflammatory Disease
  • Causes of PID
  • Gonorrhea Chlamydia infections
  • Can progress undetected before PID symptoms
    appear
  • Other bacteria, such as staph or strep.
  • Acute or chronic
  • Allowed to progress untreated, sepsis can develop
  • Most common symptom of PID moderate to severe,
    lower abdominal pain

32
Vaginal Bleeding
  • Vaginal bleeding not result of direct trauma or
    normal menstrual cycle can indicate serious
    problem
  • Difficult to isolate specific cause, treat all
    vaginal bleeding as if there is serious
    underlying condition
  • Especially true if bleeding associated with lower
    abdominal pain

33
Vaginal Bleeding
  • Treatment depends on patients needs, but may
    include the following
  • Maintain ABCs
  • Control bleeding, if possible
  • Administer oxygen
  • Place in shock position
  • Provide fluid replacement
  • Large bore IV if needed

34
Dilation and Curettage (DC)
  • Dilation opening of the cervix
  • Curettage scraping the walls of uterus
  • Surgical procedure usually done on outpatient
    basis under local anesthesia
  • Diagnose conditions such as cancer
  • Remove tissue after miscarriage
  • Elective abortion
  • Complications
  • Heavy bleeding uncommon
  • Patients with heavy bleeding
  • Evaluate for signs of shock
  • Expedite transport to hospital

35
Ectopic Pregnancy
  • Egg released from ovary, cyst often left in its
    place
  • Cyst fluid-filled sac that is often enlarged
  • Can rupture cause abdominal pain
  • Occasionally cysts develop independent of
    ovulation

36
Sexual Assault
  • Rape any genital, oral or anal penetration by a
    body part or object, through use of force or
    without victim's consent
  • It is a crime of violence with serious physical
    and psychological implications

37
Sexual Assault
  • Trauma to womans external genitalia can be
    difficult to treat
  • Need to maintain patients modesty
  • Rich network of nerves in external genitalia
    makes such injuries painful
  • Tends to bleed profusely due to rich blood supply
  • Treat open genitalia wounds with sterile
    compresses
  • Use direct pressure to control bleeding if
    severe
  • Do not place dressings in the vagina

38
Obstetrics
39
Ovulation
  • Pregnancy begins with ovulation in female
  • Fourteen days before beginning of next menstrual
    period, ovary releases egg into the fallopian
    tube
  • Egg enters fallopian tube for transportation to
    uterus
  • Intercourse 24-48 hrs before ovulation
  • Fertilization should occur in fallopian tube

40
Ovulation
  • Once fertilized, egg begins to divide
  • Fertilized egg continues down fallopian tube to
    uterus
  • Attaches to endometrium

41
Trauma
  • Direct abdominal trauma can cause
  • Premature separation of placenta from uterine
    wall
  • Premature labor
  • Abortion
  • Uterine rupture
  • Fetal death
  • Fetal death can result from
  • separation of placenta from uterine wall
  • maternal shock
  • uterine rupture
  • fetal head injury

42
Gestational Diabetes
  • Some women develop diabetes during pregnancy
  • Pregnant diabetics prescribed insulin if blood
    sugar cannot be controlled by diet alone
  • Cannot be managed with oral drugs
  • They are absorbed into placenta can adversely
    affect fetus

43
Ectopic Pregnancy
  • Implantation of growing fetus in location other
    than endometrium
  • Most common site is in one of the fallopian
    tubes
  • Surgical emergency because tube can rupture
    cause massive bleeding

1 month gestation
6 weeks gestation
44
Ectopic Pregnancy
  • Patients with ectopic pregnancy often have
    one-sided, lower abdominal pain
  • Late or missed menstrual period
  • Occasionally vaginal bleeding
  • Life-threatening emergency
  • Treat for shock, initiate immediate transport

45
Vaginal Bleeding (Gravid)
  • Vaginal bleeding during pregnancy cause for
    concern.
  • Bleeding in early pregnancy often associated
    with
  • spontaneous abortion
  • ectopic pregnancy
  • vaginal trauma
  • Vaginal bleeding in third trimester usually
    caused by
  • abruptio placenta
  • placenta previa
  • trauma to vagina or cervix
  • Can be a life-threatening emergency!

46
Vaginal Bleeding (Gravid)
  • Range light spotting to massive hemorrhage
  • Difficult to find cause of in field
  • Suspect placenta previa, abruptio placenta, or
    vaginal trauma in third trimester bleeding

47
Abruptio Placenta
  • Premature separation of placenta from wall of
    uterus
  • Separation either partial or complete
  • Complete separation usually results in death of
    fetus
  • Several factors may predispose patient to
    abruptio placenta
  • Preeclampsia
  • Maternal hypertension
  • Multiparity
  • Abdominal trauma
  • Short umbilical cord

48
Placenta Previa
  • Attachment of placenta in lower part of uterus
    covering cervix
  • Unless sonogram done, placenta previa usually is
    not detected until third trimester
  • When fetal pressure on placenta increases or
    uterine contractions begin, cervix thins out
    resulting in bleeding from placenta

49
Gravid Hypertension
  • Preeclampsia condition characterized by high
    blood pressure, abnormal weight gain, edema,
    headache, protein in urine
  • Eclampsia characterized by high blood pressure
    excessive swelling in extremities face
  • Life-threatening seizures differentiate eclampsia
    from preeclampsia

50
Pre-Eclampsia
  • Variety of signs and symptoms including
  • Hypertension
  • Abnormal weight gain
  • Edema
  • Headache
  • Protein in the urine
  • Epigastric pain
  • If untreated, preeclampsia can progress to
    eclampsia

51
Eclampsia
  • Eclampsia, also called toxemia, most serious
    manifestation of hypertensive disorders of
    pregnancy
  • Characterized by grand mal seizures
  • Often preceded by visual disturbances such as
    flashing lights or spots before the eyes
  • Eclampsia patients often experience swelling of
    hands feet markedly elevated blood pressure
  • If eclampsia develops, death of mother fetus
    frequently results
  • Treat by lying mother on her side, maintaining
    airway, delivering high-flow oxygen

52
Supine Hypertensive Syndrome
  • Supine hypotensive syndrome occurs when increased
    weight of uterus compresses inferior vena cava
    while a patient is supine
  • Markedly decreases blood return to heart
    reduces cardiac output
  • Some women are predisposed to this condition
    because of an overall decrease in circulating
    blood volume or anemia

53
Take 5.
  • Take a five minute break.
  • Enjoy this movie interlude. Remember the volume
    for movies comes from the computer, not the
    phone.
  • See you in five!

54
Emergency Childbirth
  • Usually not a big deal unless something hits the
    fan

55
Signs of Imminent Delivery
  • Main task in evaluating expectant mother is to
    determine if delivery is imminent
  • Expose abdomen genital area, taking care to be
    discrete
  • Visually inspect the abdominal vaginal areas
    for bleeding or crowning
  • Prepare for immediate delivery if observe any of
    the following
  • Crowning
  • Contractions less than 2 minutes apart
  • Rectal fullness
  • Feeling of imminent delivery

56
Crowning
  • Crowning appearance of any part of fetus in
    mothers vagina
  • Remove enough of mothers clothing to view
    genital region
  • Look for bulging at vaginal opening or a
    presenting part of infant

57
Contractions
  • Occur at regular intervals ranging from 30
    minutes to 2 minutes or less
  • Labor pain from contractions lasts from 30
    seconds to 1 minute
  • As birth approaches, interval between
    contractions gets shorter
  • Contractions that occur within 2 minutes of each
    other, from end of one to beginning of next,
    signify impending delivery
  • Consider transporting mother if baby does not
    deliver after 20 minutes of contractions 2 to 3
    minutes apart
  • Labor is generally prolonged for mothers first
    baby
  • Average is 12 to 17 hours which allows plenty of
    time for transport

58
Rectal Fullness
  • Rectal fullness or sensation of having to move
    ones bowels can indicate infants head is in
    vagina pressing against the rectum
  • Delivery is imminent
  • Do not let the mother sit on the toilet

59
Feeling of Imminent Delivery
  • Mothers who have previously given birth often
    know when ready to deliver
  • Labor tends to be shorter after first child
  • Use your judgment given circumstances
  • When evaluating mother, keep in mind four signs
    of imminent delivery
  • Consider transport time

60
Preparing for Delivery
  • Don sterile gloves, gown, and eye protection
  • Position mother on her back, legs drawn up
  • Provide supplemental oxygen
  • Prepare OB kit
  • Prepare infant BVM
  • IV is optional at this point

61
Take a look
  • Presentations you cant deliver safely
  • Single limb
  • Prolapsed cord
  • Presentations you can deliver
  • Head first
  • Umbilical cord wrapped
  • Shoulder dystocia
  • Breech (Buttocks first)
  • Double footling

62
Assisting With Delivery
  • Support head with gentle pressure
  • Check if cord is wrapped around babys neck
    attempt to loosen
  • Apply gentle downward pressure on shoulder head
  • After anterior shoulder has delivered, apply
    gentle upward pressure
  • Suction mouth nostrils when head appears
  • Once delivered, stimulate infant if it does not
    breathe
  • Put two clamps on umbilical cord cut 6 inches
    from navel

63
Amniotic sac
  • During first stage of labor amniotic sac usually
    breaks, expelling amniotic fluid
  • If sac is still covering infants head when head
    appears, use a finger to pierce sac
  • Very tough membrane
  • Note color character of amniotic fluid
  • Fluid can be clear or straw-colored (which is
    normal)
  • Tainted, discolored, thick or pea soup-like
    (which indicates meconium staining or a bad
    intra-uterine infection)

64
Detailed Delivery Instructions
  • Encourage the mother to breath deeply between
    contractions and push with contractions.
  • As the baby crowns, support with gentle pressure
    over perineum to avoid an explosive birth.
  • If the amniotic sac is still intact, rupture it
    with a finger to allow amniotic fluid to leak
    out.

65
Detailed Delivery Instructions
  • If the umbilical cord is wrapped around the
    babys neck, gently slip it over the head.
  • Do not force it.
  • If the cord is too tight to slip over the head,
    apply umbilical cord clamps and cut the cord.
  • Clamp and cut the umbilical cord only if he
    babys head has emerged and is in a position that
    lows you to manage the airway.

66
Detailed Delivery Instructions
  • Re-suction the babys mouth nostrils
  • Dry wrap baby in a warm blanket cover its
    head
  • Place baby on its side to facilitate drainage
  • Perform an APGAR assessment at 1 minute 5
    minutes after delivery

67
Infant care
  • Baby not breathing stimulate it
  • If newborn does not start breathing effectively
    within 10 15 seconds of stimulation
  • Blow-by oxygen
  • If no response
  • use infant BVM to deliver gentle puffs of air
    enough to cause the chest to rise
  • If after 30 seconds of assisted ventilation there
    is no response
  • heart rate lt60 beats/min
  • begin CPR

68
CPR - Two-Thumb Encircling Hands Technique
  • CPR technique for infant with pulse rate below 60
    beats/min
  • Place infant on a firm, flat surface
  • Remove clothing from chest
  • Find compression site which is just below nipple
    line on middle or lower third of sternum
  • Wrap your hands around upper abdomen with your
    thumbs on compression site
  • Use your thumbs to deliver gentle pressure
    against sternum, pressing ½ to ¾ inch into chest

69
Infant Care
  • If signs of meconium are present, do not
    stimulate infant
  • suction mouth nose
  • This avoids aspiration of fecal material that can
    cause pneumonia
  • Good antibiotics to treat bacteria but we would
    rather not need to

70
APGAR
  • APGAR scale numerical measure of babys overall
    condition immediately after birth
  • Healthy baby will have total score of 10
  • Many babies score 7 to 8 during first minute
  • By 5 minutes, most babies score 8 to 10
  • APGAR stands for
  • Appearance
  • Pulse
  • Grimace
  • Activity
  • Respirations

71

72
Managing a Poor APGAR Score
  • Three things to remember when managing infant
    with low APGAR score position, suction and
    stimulate (PSS)
  • Position body so head is down airway is open
  • Suction mucous fluid from mouth nostrils
  • Stimulate infant by taping bottoms of feet
  • PSS memory aid to help recall these steps
    position, suction and stimulate

73
Care for mom after birth
  • Once baby delivered umbilical cord cut
    clamped you should
  • Monitor and control bleeding from mother
  • Begin fundal massage
  • Monitor vital signs
  • Keep the mother and baby warm
  • Transport once infant is delivered
  • Do not wait for placentamay take up to 30
    minutes to deliver
  • Do not pull on umbilical cord
  • If placenta does deliver at scene, transport
    with mother baby to hospital

74
Care for mom after birth
  • After placenta delivered, place sanitary napkin
    between mothers legs
  • Ask her to hold legs together
  • Normal for mother to bleed up to one cup (about
    250 cc) or 5 sanitary napkins of blood after
    delivery
  • Record number of pads
  • Now it is time for an IV for fluid replacement

75
Fundal Massage
  • Makes uterus contract diminishes vaginal
    bleeding
  • Can feel for fundus of uterus
  • located in abdomen between pubic bone
    umbilicus
  • Should feel like a softball
  • Perform massage like you would a muscle massage
  • Area may be tender massaging it can cause
    discomfort
  • Be gentle but use some muscle

76
Complications
  • Field care

77
Nuccal Cord
  • Once head delivered ask mother to stop pushing so
    you can check if cord is wrapped around infants
    neck
  • If cord looks like it is wrapped tightly, so as
    to constrict airway, need to loosen it
  • Gently slip cord over babys head by placing two
    fingers under cord at back of neck

78
Nuccal Cord
  • Bring cord over shoulders head
  • Cord durable, it can tear if handled roughly so
    dont use excessive force
  • Too tight to loosen, clamp cord in two places two
    inches apart
  • Cut cord between clamps
  • Unwrap cord from around neck take care not to
    injure baby

79
Shoulder Dystocia
  • Labor progresses normally head delivered
    routinely
  • However, immediately after head delivers,
    shoulders become trapped between symphysis pubis
    sacrum, preventing further delivery
  • First step in treating shoulder dystocia is
    recognizing when it occurs
  • Two main signs of shoulder dystocia are
  • Babys body does not emerge with standard
    moderate traction maternal pushing after
    delivery of babys head
  • Turtle Sign head suddenly retracts back
    against mothers perineum after it emerges from
    vagina

80
Buttocks Double Footling Presentation
  • If buttocks or two feet present first, you can
    attempt delivery in field
  • These are generally slow deliveries you likely
    have time to transport
  • Position mother with buttocks at edge of bed
  • Hold mothers legs in flexed position
  • Support infants legs do not pull
  • As head passes pubis, apply gentle upward
    traction until mouth appears
  • If head is stuck, create airway by pushing away
    vaginal wall transport immediately

81
When the head does not deliver
  • Create airway for infant
  • First, place gloved hand into vagina with your
    palm towards infants face
  • Form a V with index middle finger on either
    side of infants nose
  • Push vaginal wall away from infants face to
    allow unrestricted breathing
  • Maintain airway transport immediately

82
Single limb presentation
  • Support baby with your hands
  • Provide airway for baby using your fingers if
    possible
  • Transport immediately do not attempt delivery
    in field
  • Supportive care for mother

83
Cord Presentation
  • If you see umbilical cord presenting before the
    baby, initiate the following steps
  • Place mother in knee-chest position
  • Check umbilical cord for pulsations
  • No pulsations - press presenting part of fetus
    away from umbilical cord, towards mothers head
  • Re-check cord for pulsations
  • Administer high flow oxygen to mother
  • Transport immediately fetus will die without
    rapid intervention
  • Continue holding presenting part of baby away
    from umbilical cord
  • Apply moistened dressing on exposed umbilical
    cord
  • Do not push umbilical cord back into vagina

84
Summary
  • Key structures of female reproductive system
    include
  • Cervix
  • Endometrium
  • Fallopian tubes
  • Ovaries
  • Perineum
  • Uterus
  • Vagina
  • The key structures of fetal anatomy include
  • Placenta
  • Amniotic sac
  • Umbilical cord

85
Summary
  • Fetus has excellent chance of survival after the
    seventh month of pregnancy
  • Pregnant women more susceptible to traumatic
    injury because of the increased vascularity of
    uterus
  • Patients with ectopic pregnancy often have
    one-sided abdominal pain, late or missed period,
    occasionally vaginal bleeding
  • Vaginal bleeding in third trimester usually
    caused by abruptio placenta, placenta previa, or
    trauma
  • To relieve supine hypotensive syndrome tilt the
    pregnant patient to one side

86
Summary
  • Key points for assisting with normal delivery
  • Support head with gentle pressure
  • Check if cord wrapped around babys neckif so,
    attempt to loosen
  • Apply gentle downward pressure on anterior
    shoulder and head
  • After anterior shoulder has delivered, apply
    gentle upward pressure on posterior shoulder
    head
  • Suction mouth and nostrils when head appears
  • Once delivered, stimulate newborn if it does not
    breathe
  • Put two clamps on umbilical cord cut 6 inches
    from navel

87
Summary
  • Care for newborn infant includes
  • Stimulate infant if not breathing sufficiently
  • Start CPR if no response after 30 seconds
  • Keep infant warm
  • Repeat suctioning of mouth nose
  • Check APGAR score at 1 5 minutes

88
Summary
  • APGAR stands for appearance, pulse, grimace,
    activity, respirations
  • Care of mother includes
  • Monitor control bleeding from mother
  • Begin fundal massage
  • Monitor vital signs
  • Keep mother baby warm
  • If head remains stuck during buttocks or double
    footling presentation, create airway by pushing
    away vaginal wall then transport immediately
  • Important steps in caring for postpartum bleeding
    include fundal massage and treatment of shock

89
Silver Cross EMS skill o the month!
  • Dexi!

90
No, not Dixie
91
Dexi as in blood sugar
  • Should be checked on every ALS patient.
  • After all, we are starting IVs anyway, so we
    have plenty of blood.
  • Should also be checked on every altered mental
    status, dizziness, weakness and fall.
  • Falling is a symptom, not a complaint.
  • Also, any patient who is a diabetic should have a
    sugar tested.
  • Low blood sugar is scary to have and easy to fix,
    thats why we should always check for it.

92
Testing Tips
  • Of course you should always be wearing gloves.
  • Choose a finger.
  • Diabetic patients will often tell you which
    finger they prefer.
  • Wipe finger with alcohol wipe, let dry
    completely.
  • Insert a test strip into your meter.
  • Some models like you to put the blood on the
    strip before testing. Know your model.
  • Use lancing device on SIDE of fingertip to get
    drop of blood.
  • Closer to the nail the better people need the
    pads of their fingers to do stuff!
  • Or use whatever method you prefer to get the
    blood from an IV catheter.
  • You may have to squeeze or massage the finger to
    get enough blood out.
  • But too much squeezing/massaging can change the
    character of the blood.
  • Hold hand downward to allow gravity to help.

93
Dexi tips continued
  • Touch and hold the edge of the test strip to the
    drop of blood, and wait for the result.
  • Blood glucose level will appear on the meter's
    display.
  • Many models read hi or low when sugar is
    below 20 or above 600. Know your meter.
  • Some newer meters out there let you use forearm,
    thigh or fleshy part of hand.
  • Its OK to use the patients meter in a pinch, or
    let him/her do it, but always check with yours as
    well.
  • Patients glucometer may not have been calibrated
    lately.
  • Plus a lot of patients are not too good at finger
    hygiene eww!

94
References King County EMS American Heart
Association Tabers Medical Dictionary American
Diabetes Association
  • Ask Dr Dave
  • Send extra questions to AFinkel_at_Silvercross.org
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