OB Delivery Complications &Use of the Meconium Aspirator

Condell Medical CenterEMS SystemApril 2008Site Code #10-7200E1208

Prepared by: Sharon Hopkins, RN, BSN, EMT-P

Objectives

Upon successful completion of this module, the EMS provider should be able to: list physiological changes in pregnancy. identify the stages of labor. describe the assessment of a patient in

labor. explain the contents of the OB kit. identify obstetrical emergencies. describe how to care for a prolapsed cord

and a breech delivery.

Objectives cont’d

actively participate in discussion of case presentations.

actively participate in hands-on skills of delivery complications.

successfully complete the quiz with a score of 80% or better.

Physiological Changes in Pregnancy

Reproductive system Increase in size of uterus

Increased vulnerability to injury During pregnancy uterus contains

16% of the total blood volume Extremely vascular organ during pregnancy

Uterus and fetus insulted if blood flow diminished

Normal Fetal Positioning

Changes in Pregnancy cont’d

Respiratory system Increase in oxygen demand &

consumption 40% increase in tidal volume

Amount of air in or out in one breath Only slight increase in respiratory rate Diaphragm pushed upward decreasing

lung capacity

Changes in Pregnancy cont’d

Cardiovascular system Cardiac output increases Maternal blood volume increases by 45% Heart rate increases by 10 – 15 beats per

minute B/P decreases slightly in first 2 trimesters B/P normal in 3rd trimester Supine hypotensive syndrome after 5

months if heavy weight of uterus presses on inferior vena cava (when mother lying on her back)

Changes in Pregnancy cont’d

Gastrointestinal system Nausea and vomiting common in 1st

trimester From hormone levels and changed

carbohydrate needs Delayed gastric emptying

Watch for vomiting and airway compromise

Hands-on physical abdominal assessment difficult due to compression and shifting of abdominal organs

Changes in Pregnancy cont’d

Urinary system Increase in renal blood flow Urinary frequency is common

Urinary bladder displaced more forward and higher increasing vulnerability to injury to the urinary bladder

Musculoskeletal system Waddling gait due to loosened pelvic joints Low back pain due to change in center of

gravity

First Stage of Labor Dilatation Stage

Begins with onset of true labor contractions Ends with complete dilatation and thinning of

the cervix Cervix dilates from a closed position to 10

cm (approximately 4 inches) Duration about 8 – 10 hours in 1st pregnancy Early contractions mild, last 15 – 20 seconds

coming every 10 – 20 minutes End of 1st stage contractions last 60 seconds

and are coming every 2 – 3 minutes

Second Stage of Labor

Begins with complete dilatation of cervix

Ends with delivery of fetus Can last 50-60 minutes in 1st deliveries Pain felt in the lower back Mother has the urge to push Bag of waters usually rupture in this

stage Crowning is evident

Definitive sign of imminent delivery

Third Stage of Labor Begins immediately after birth of the

infant Ends with delivery of placenta Placenta generally delivers within 5 – 20

minutes Signs of placental separation

Gush of blood from vagina Change in size, shape, consistency of uterus Umbilical cord length increases Mother has the urge to push

Assessment of the Patient in Labor

Ask expected due date Gravida – number of pregnancies

First time deliveries tend to take longer – 16 – 17 hours

Labor tends to shorten with subsequent pregnancies

Para – number of live births

Is it “gravida and para” or “para and gravida”? Note: “G” comes before “P” in the alphabet; you must

be pregnant before you can deliver

Assessment of the Patient in Labor

Determine how long mother has been in labor

Ask how long previous deliveries took Ask if bag of waters is intact or has

broken Delivery is quicker once bag of waters has

broken Are there any high risk concerns the

mother is aware of

Assessment of the Patient in Labor

Time duration & frequency of contractions Duration is from the beginning of one

contraction to the end of that contraction Frequency is how far apart contractions are

Measured from the beginning of one contraction to the beginning of the next contraction

Contractions lasting 30-60 seconds and coming every 2-3 minutes apart indicate imminent delivery

Signs of Imminent Delivery

Crowning Bulging of the fetal head past the vaginal

opening during contraction Bulging perineum

Presenting part pressing on perineum Urge to push

Note: High index of suspicion in female with abdominal pain and cramping (esp in a pattern) and denies pregnancy

OB Kit Contents

Sterile gloves Drape sheet Gauze sponges Disposable towels 2 alcohol preps 2 OB towelettes Bulb syringe Receiving blanket

2 umbilical clamps 2 nylon tie-offs Scalpel OB pad Plastic bag Twist ties Infant cap 2 wrist ID bands

OB Kit Contents

Newborn At Delivery

Preventing Hypothermia in a Newborn

APGAR Assessment – 1 & 5 minutes

A – appearance Most visible, least helpful Typical for pink trunk and blue distal

extremities P – pulse

100 or above is acceptable 80-100 – stimulation needed <60 – start compressions

APGAR cont’d G – grimace (irritability)

Includes coughing, sneezing, crying A – activity

Active motion, flexing of extremities R – respiratory effort

Strong cry

Majority of scores are 7–10 indicating a healthy infant requiring routine care

Scores 4-6 indicate moderately depressed infant requiring oxygen & stimulation

APGAR ScoreCriteria 0 1 2

Appearance

Blue or pale

Blue hands or feet

Entirely pink

Pulse Absent < 100 >100

Grimace – reflex irritability

Absent Grimace Cough, sneeze

Activity Limp Some extremity flexion

Active motion

Respirations Absent Weak cry, hypoventi-lating

Strong cry

Inverted Pyramid

Drying, warming, positioningSuction, tactile stimulation

OxygenBVMChest

CompressionsIntubation

MedsAdvanced skills

Basicskills

OB Complications – Supine Hypotensive Syndrome

Occurs in the 3rd trimester Heavy weight of uterus compresses

inferior vena cava when mother in the supine position

Interferes with blood flow returning back to the heart

Intervention Transport women over 5 months pregnant

lying or tilted towards their left sideRemember: Lay left

OB Complications – Seizures Consider causes

Hypoglycemia – check glucose levels on all patients with altered level of consciousness

Epilepsy – check for ID; protect airway Eclampsia – protect airway

Intervention For any prolonged seizure activity, need to

consider using BVM to support ventilations and provide oxygenation

Transport lying/tilted left if over 5 months gestation

Valium, if given, has effect on mother & fetus 5 mg IVP over 2 min; titrate; max total 10mg

OB Complications – Breech Delivery Buttocks or feet present first Approximately 4% of all births Increased risk

Maternal trauma Prolapse of cord Cord compression Anoxia to the infant

Intervention Advanced medical intervention at the hospital Rapid transport important

Breech Presentation

Breech Delivery cont’d

Intervention As legs deliver, support legs across forearm If cord is accessible, palpate often If able, loosen cord to create slack After torso and shoulders deliver, gently

sweep down arms If face down, gently elevate legs & trunk to

facilitate delivery of head NEVER PULL INFANT BY LEGS OR TRUNK

Breech cont’d If head not delivered within 30 seconds

Reach 2 gloved fingers into vagina to locate baby’s mouth

Push vaginal wall away from baby’s mouth to form an airway

Keep your fingers in place and transport immediately

Keep delivered part of baby warm Cover with a blanket

If head delivers, anticipate neonatal distress

OB complications – Prolapsed Cord

Perform a visual exam as soon as possible whenever a mother states her bag of waters has ruptured

Elevate the mother’s hips or place knee-chest Have patient breath through the contractions

so she doesn’t push Placed gloved hand into vagina and raise

presenting part to get pressure off cord Keep cord between fingers to monitor for

pulsations Cover cord with moist dressing, keep warm

Prolapsed Cord

OB Complications – Nuchal Cord

Cord wrapped around infant’s neck Increase mother’s O2 to 100% non-

rebreather mask Slip fingers around cord and lift over

infant’s head Proceed with delivery If unable to reposition cord, place 2 OB

clamps, cut cord between clamp, release cord from around neck

Proceed with delivery

Nuchal Cord (C-section)

Meconium Dark green material found in the

intestine of the full-term newborn. It can be expelled during

periods of fetal distress (ie: hypoxia)

If found in the infant airway, could compromise ventilations

Meconium Staining Fetus has passed feces into amniotic

fluid Occurs between 10-30% all deliveries Not unusual to observe in breech

delivery In normal head-down delivery indicates

fetal hypoxia Hypoxia increases fetal peristalsis and

relaxation of anal sphincter The darker the color/staining, higher

the risk of fetal morbidity

Meconium Stained Baby

Airway needs to be cleared to avoid aspiration of meconium

Suction and clear airway before infant needs to take that first breath

Meconium Staining

If meconium is thin and light in color and the infant is vigorous Most meconium can be cleared away with

bulb syringe ALWAYS suction mouth then nose, in that

order Suctioning the nose stimulates breathing in the

newborn Want to clear the mouth 1st so first breath is as

clean as possible Limit suction (2 seconds per Region X SOP)

Meconium Staining

If infant is not vigorous Respiratory rate decreased Decreased muscle tone Heart rate < 100

Use meconium aspirator to clear airway This will take coordination and best

accomplished with 2 persons working as a team

Meconium Suctioning

Steps include intubation

Most efficient when performed as a 2 person team

Time is essential May need to perform

2 intubation insertions

Use each ETT once

Meconium Aspirator Connect small end of meconium aspirator

to suction line connecting tube Turn suction down to 80 mmHg Insert endotracheal tube

Don’t anticipate visualizing landmarks – they may be obscured by meconium

Connect larger end of aspirator to ETT Place thumb over suction control port

and slowly withdraw ETT (< 2 seconds) Discard ETT after one use

Meconium Aspirator

Limit suction to <2 seconds

Aspirator can be used a second time on infant with new ETT each time

Case Study #1

EMS arrives on the scene for OB call Patient is 24 y/o and states she is in

labor What assessment questions specific to

an imminent delivery need to be asked? What type of EMS physical assessment

needs to be performed?

Case Study #1

Assessment questions Gravida? Para? Due date? High risk concerns? Length of previous labors? Bag of waters intact? Ruptured? Duration and frequency of

contractions?

Case Study #1

Physical exam – position patient to evaluateCrowningEvidence of bulging perineum Involuntary pushingSigns of prolapsed cordEvidence of profuse bleeding

Case Study #1 History G2P1 EDC in 1 week No complications anticipated Previous labor 12 hours Bag of waters has ruptured Contractions are 5-6 minutes apart and lasting

20-30 seconds There is no bulging or crowning

Do you stay & prepare to deliver or transport?

Case Study #1

You could most likely begin transport with OB kit reached out in case labor progresses

What stage of labor is the patient in? First stage

If the patient delivers, how many run reports need to be written? Two – one for the mother, one for the infant

What is your role during delivery?

Support the presenting part

Check for nuchal cord

Suction mouthThen nose

Head and shoulders delivered

Have a firm grip on infant

Cheesy covering and moisture make them slippery

After shoulders, rest of the body will slip out fast

Clamping & cutting the cord

After cord is done pulsating, clamp 8″ from infant’s navel with 2 clamps placed 2″ apart

Watch for blood leakage from infant’s cord

Reinforce with additional clamps as needed

3rd Stage of Labor – Placental stage

Watch for excessive bleeding (>500 ml)

Prepare to perform fundal massage

Need to feel uterus become firm – size of the uterus will depend on the size of the fetus

Fundal Massage

Newborn dried off, cord clamped & cut

What’s his APGAR?

Case Study #2

Mother calls EMS because “my baby is coming”

Upon EMS arrival, you gain quick rapport

Contractions are coming every 2-3 minutes and are 60-90 seconds long

The mother states she wants to push and feels her baby is coming right now

You perform a visual exam

Case Study #2 This is what you see. Now what do you do?

If cord is wrappedaround the neck,try to loosen andslip over the head.

If too tight, need to double clamp and cut the cord NOW.

Case Study #3

Mother calls EMS and states she is in labor

Mother is G3P2 due tomorrow No known complications She has been in labor for 4 hours Contractions are 3 minutes apart You establish rapport and perform a

visual exam And you determine that delivery is

imminent

Case Study #3 - This is a breech delivery that is not delivering. What do you do?

Head shoulddeliver in30 seconds.

If not, reachin to createan airway for the infant.

Support bodyacross yourforearm.

Creating an airway for a breech delivery

Reach 2 fingers into the vagina Locate the infant’s face Push the vaginal skin away from the

infant’s mouth Transport immediately Give report to the closest facility The crew member CANNOT move their

fingers and risk losing the airway

The golden sounds to a mother’s and EMS provider’s ears – a newborn’s cry!!!

Documentation Once your patient delivers, EMS is to

write 2 reports – mother & infant Both reports can have time of delivery On run report, OB delivery is credited to

the person who delivers (“catches”) Segregate information

Mother’s information on mother’s run report Infant’s information on the infant’s run

report

Documentation - Mother

Due date (ie: EDC June 15th) Gravida/para (ie: G3P2) Presence of high risk concerns Bag of waters – Ruptured? Intact Status of contractions Signs of imminent delivery

Crowning Bulging Urge to push

Time of delivery (when last of baby delivers) & sex Complications during/after delivery (ie: bleeding) If placenta delivered or not

Documentation - Infant Time of delivery Appearance of amniotic fluid (ie: clear,

meconium staining) APGAR 1 and 5 minutes (ie: APGAR 9/9) Completion of assessment per physical

condition boxes on run report Vital signs – B/P not necessary That cord was clamped and cut Time placenta delivered Special interventions required after delivery

Wrist Bands

Apply a wrist band to both the mother and the newborn

Include the same information on both wrist bands Mother’s name Sex of infant Time of delivery

Bibliography

Bledsoe, B., Porter, R., Cherry, R. Essentials of Paramedic Care. 2nd Edition. Brady. 2007.

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

Region X SOP’s Effective March 1, 2007