ATS - obstertrics neonatal

Emergency Medical Technician
19 - Obstetrics & Neonatal
© 2014
• Unexpected
complications during
pregnancy or during
delivery:
– Put both the mother
and the baby at risk
– May require immediate
medical interventions
3

© 2014
• Someday you may have
to help with the delivery
of a baby
• Understanding the
process and knowing
how to assist will better
prepare you
4

© 2014
1. Gynecological Emergencies
2. Stages & Assessment of Labor
3. Childbirth
4. Care for the Mother & Neonate
5. Pregnant Trauma Patients

© 2014
• When treating a female
patient of child-bearing
age:
– Pregnancy should be
considered, especially
if she is complaining
of:
 Unusual bleeding
 Abdominal pain
7

© 2014
Obstetrical Bleeding:
• Causes:
– Miscarriage
– Sexual assault
– Placental abruption
– Placenta Previa
– Uterine rupture
8

© 2014
Obstetrical Bleeding:
• Obstetrical bleeding in
pregnant patients is not
necessarily uncommon
• A discharge or
“spotting” of a small
amount of blood may or
may not be considered
normal
9

© 2014
Known Pregnant :
• With a known pregnant
patient:
– Focus your assessment
on the chief complaint
– Don’t automatically
assume that the
emergency is related to
or caused by the
pregnancy
10

© 2014
Acute Abdominal Pain:
• When treating a female
patient with acute
abdominal pain, ask
questions regarding:
– Menstrual cycle
– Possible pregnancy
– Birth history
11

© 2014
• Acute abdominal pain can
be caused by an ectopic
pregnancy
• Your patient may even be
unaware that she is
pregnant:
– Ruptures may occur 2 to
12 weeks after
fertilization
– Most common within 5
to 9 weeks
– Ectopic pregnancies
are serious
emergencies
 3rd leading cause of
maternal death
12

© 2014
Identifying Pain:
• Perform a physical exam
of the abdomen
• Pay special attention to
all details of pain or
tenderness in the
abdomen
• Look for any bruising or
discoloration
• Ask patient to point to
the area that is most
painful:
− Inspect and palpate each of
the other quadrants first,
before assessing and
palpating the area of pain
13

© 2014
• A dull aching pain that is
poorly localized and
becomes sudden and sharp
on one side in one lower
quadrant
• Shoulder pain, a sign of
referred pain
• Vaginal bleeding, which may
be heavy, light or absent
• Tender, bloated abdomen
• Weakness or dizziness
• Decreased blood pressure
• An increased pulse
• Signs of shock
14

© 2014
• If vaginal bleeding is
present, specifically ask
for how long
• Inquire about pain or
tenderness in the back or
abdomen
• Ask about nausea,
vomiting, cramping or
other discharge
• If the patient is pregnant,
ask about any known risk
factors or complications
with her pregnancy:
– Multiple fetuses
– Gestational diabetes
15

© 2014
• Assess the ABCs
• Obtain baseline vitals.
• Pay close attention to the
blood pressure and heart
rate:
– A decrease in blood
pressure; an increased
heart rate; syncope and
pale, cool, moist skin are
indicators of shock
• Remember:
– The normal heart rate
for a pregnant woman at
rest is about 15 bpm
faster than the average
for an adult at rest, or
about 75-115 bpm
16

© 2014
• Normal blood pressure for a
pregnant woman should be
the same as the average
adult throughout the 1st and
3rd trimesters and will
decrease slightly in her 2nd
trimester
• Ask the patient if she recalls
a recent blood pressure
reading for comparison
• If there is no evidence of
fever, other illness or injury,
a rapid respiratory rate
could indicate shock or the
onset of labor
17

© 2014
• Continue to monitor
vital signs
• Watch for a rising pulse
rate or falling blood
pressure
• Administer oxygen
according to your
protocols
18

© 2014
Allow the patient to
remain in a position of
comfort:
– If in her 3rd trimester,
she may benefit from
positioning on her left
side:
 Helps to shift the
weight of the fetus off
blood vessels, such as
vena cava
19

© 2014
• Save any blood-soaked
dressings or pads the
patient has used for
examination :
– Transport with to
receiving hospital
• Provide reassurance
• Transport or call for ALS
intercept based on
protocols
20

© 2014
• Normally, labor is a long
process that can last
over 16 hours for a
first-time mother
• Subsequent births can
be much quicker
22

© 2014
Stages of Labor:
• First stage of labor:
– Begins with the onset
of contractions
– Continues until the:
 Cervix fully dilates
 Fetus begins to enter
the birth canal
23

© 2014
• Second stage of labor:
– Begins when the fetus
enters the birth canal
– Continues until the
baby is born
• Third stage of labor
involves the delivery of
the placenta
24

© 2014
• Labor contractions:
– Regular and rhythmic
– Intervals that shorten
as the labor progresses
• Braxton Hicks contractions
(false labor):
– Usually occur well
before the delivery due
date
– Do not have the same
rhythmic and regular
intervals of labor
contractions
25

© 2014
• Assess the contractions:
– Regularity
– Interval
– Duration
• The closer together,
more regularly spaced
and longer they are, the
closer to delivery the
mother will be
26

© 2014
• It is NOT normal for a significant
amount of bleeding to occur before
delivery
• This could be a serious problem that
requires immediate emergency
transport

© 2014
• Presence of bloody
show:
– Begins as a blood-
tinged, mucous
discharge
– Becomes a watery,
bloody fluid
– Normal occurrence
– Signals that the cervix
is dilating
28

© 2014
• Rupturing of the amniotic sac is
another indication of labor
• Sack filled with fluid:
– Surrounds the baby in the uterus
– Can break at any stage in the labor
process
– Releases fluid
– Helps lubricate the birth canal for the
birthing process

© 2014
• Regular contractions
that occur at close
intervals
• Contractions may be 30
minutes apart early on
• Contractions become 3
minutes apart or less
before delivery
30

© 2014
• Obtain a:
– SAMPLE history
– Obstetrics history:
 Any known pregnancy
complications
 Other relevant medical
history
• History to relay to
advanced EMTs:
– Seizures
– Diabetes
– Vaginal bleeding
during pregnancy
31

© 2014
• Determine whether:
– Mother has
experienced bloody
show
– Her water has broken
32

© 2014
• Take baseline vital
signs
• Provide oxygen if
permitted by your local
protocols
33

© 2014
• Evaluate the uterine
contractions by
counting the seconds or
minutes between them
34

© 2014
• Assess the contractions:
– Regularity
– Interval
– Duration
• The closer together, more regularly
spaced and longer they are, the closer
to delivery the mother will be

© 2014
• If your patient is in
labor and birth is
imminent:
– Reassure her
– Let her know that you
can help her through
the process
– Providing emotional
support is a critical
part of your care
• Contact Medical
Direction
37

© 2014
• Towels, sheets and
blankets for:
– Draping and placing
under the mother
– Drying and wrapping
the baby
• Sanitary pads or bulky
dressings for bleeding
38

© 2014
• Gauze pads for wiping
the baby’s:
– Mouth
– Nose
• Bulb syringe for
suctioning the baby’s:
– Mouth
– Nose
39

© 2014
• Clamps and ties for use
on the umbilical cord
prior to cutting
• Sterile scissors or a
single-edged razor for
cutting the cord
• Basin and plastic bag
for collecting and
transporting the
placenta
• Biohazard bag for soiled
linens and dressings
40

© 2014
• Help the patient into
position:
– On her back
– Hips elevated
– Knees bent
– Legs apart
• Provide privacy by
draping her knees with
a:
– Blanket
– Towel
41

© 2014
• Make sure you have
taken all standard
precautions, including
donning:
– Gloves
– Gown coverage
– Eye and face protection
42

© 2014
• Discourage any desire
she may express to hold
her knees together
because it can:
– Complicate the birth
– Harm the fetus
43

© 2014
• If the mother expresses
the need for a bowel
movement, let her
know:
– Feeling is normal
– It is caused by
pressure
– She can give in to it
44

© 2014
• Be prepared for the
mother to experience
pain
• Let her know that
Nausea and vomiting
are also common
• Check for any crowning,
or showing of the baby,
which is usually the
head
• Do not perform any
internal vaginal
examination
45

© 2014
• Continue to provide the
mother with emotional
support:
– Birthing can be a
frightening process
– Your reassurance will
help reduce her stress
46

© 2014
• Clues that indicate birth
is imminent include the:
– Crowning of the baby’s
head
– Mother’s urge to:
 Bear down
 Move her bowels
• You should immediately
prepare for delivery
47

© 2014
• If you have just arrived on scene:
– Thoroughly wash your hands
– Take standard precautions
• Provide reassurance throughout the
birthing process
• Explain what is happening and what
you are doing
48

© 2014
• If available, position
someone by the
mother’s side to:
– Provide emotional
support and
encouragement
– Help turn her head if
she vomits
• Once the baby’s head
emerges, the rest of the
body typically follows in
a fast and natural way
49

© 2014
• Support the baby’s head
as it emerges by placing
one hand below the
head with your fingers
spread evenly around it
• Avoid pressing the soft
areas at the top, back
and sides
• Do not pull
50

© 2014
• Apply a slight counter
pressure on the head
to:
– Control the speed of
delivery
– Help to prevent
significant tearing of
the mother’s perineal
tissue
• Use your other hand to
help cradle the baby’s
head as it emerges
51

© 2014
• If the umbilical cord is
around the baby’s neck:
– Advise the mother not
to push
– Gently slip the cord
over the baby’s head
– If the cord is too tight:
 Push it down over the
baby’s body as the
baby emerges
52

© 2014
• Most babies are
facedown as they
emerge
• The head will rotate to
the left or right as the
shoulders emerge
• Continue to support the
head through this
process
• Guide the head gently
downward to help the
delivery of the shoulder
53

© 2014
• Once one shoulder is
out, the rest of the body
will easily emerge
• Newborns are slippery
• Grip the baby firmly
• Have a towel ready
54

© 2014
• After the delivery of the
feet:
– Position the baby on
his or her side
– Head slightly lower
than the body
– Fluids can drain from
the mouth and nose
55

© 2014
• Clear the baby’s airway:
– Clear secretions from
the mouth and nose
wiping by gently with
gauze pads
• Suction only if needed
56

© 2014
• Suctioning Guidelines:
– Compress the bulb first
– Then insert the tip
about 1 to 1½ inches
(3–4 cm) into the
baby’s mouth
– Gently release the bulb
to draw fluids from the
mouth into the bulb
– Discharge them onto a
cloth or gauze
• Repeat suctioning 2 or 3
times for the mouth, as
needed
57

© 2014
• Guidelines:
– Suction each nostril:
 Compress the bulb first
 Then place it ½ inch
(1 cm) into the nostril
 Release the bulb to
draw fluid from the
nose
58

© 2014
• If the baby is not
breathing:
– Provide stimulation by
rubbing his or her back
vigorously but gently
• If rubbing the baby’s
back is not successful:
– Gently flick one of your
fingers against the
soles of the feet
59

© 2014
• If spontaneous
breathing does not
occur with drying,
warmth and stimulation
begin positive pressure
respirations
• Follow your protocols
for neonatal
resuscitation
• Crying is a good sign,
indicating a clear
airway
60

© 2014
• Keep the baby at the level of the vagina
until the cord stops pulsating
• Clamp the cord about 10” (25 cm) from
the baby’s belly
• Place another clamp about 7“ (18 cm)
from the baby’s belly
61

© 2014
• Cut the cord between
the clamps, but do so
only if:
– Your jurisdiction
permits it
– Sterile equipment is
available
62

© 2014
• The afterbirth, or
placenta, will be
delivered by itself,
usually 5–15 minutes
after the birth
• It should never be
removed by pulling on
the umbilical cord
63

© 2014
• The entire placenta
should be:
– Put in a plastic bag
– Transported with the
mother to the hospital
for inspection later
64

© 2014
• Continue to provide the
mother with emotional
support:
– Birthing can be a
frightening process
– Your reassurance will
help reduce her stress
66

© 2014
• Assess the ABCs
• Keep the baby warm:
– Immediately cover him
or her with a warm
blanket
– Cover the head with a
hat or blanket
– Gently rub the blanket
to dry the baby
– Replace it with another
dry one
68

© 2014
• Respirations should be
approximately 30–50
breaths per minute
• If the airway is clear and
breathing is normal:
– Place the baby on the
mother’s abdomen
• Continue to periodically
check that the baby’s
nose is clear:
– Babies breathe through
the nose
– Any blockage can be
problematic
69

© 2014
• Assess the baby’s pulse:
– Rate should be
approximately 120–160
beats per minute
• Note whether the skin
color is:
– Pale
– Bluish
• Listen for whether the
cry is strong or weak
• Observe whether the
baby moves or lies still
70

© 2014
• Advise the mother to
lower her legs and keep
them together
• Monitor and reassess
her vital signs
periodically
• Expect there to be some
bleeding:
– Normal
– Can be managed by
placing a sanitary pad
over the vaginal
opening
72

© 2014
• Once the placenta has been delivered:
– Palpate the mother’s abdomen
– Feel for the uterus, which will feel like
a grapefruit-sized object
– Continuously and lightly massage the
uterus in a circular motion:
 Explain that even though massaging is
painful, it will help:
o Uterus contract
o Control bleeding
73

© 2014
• Suggest that the mother
try to nurse the baby if
she is able
• Nursing helps to:
– Contract the uterus
– Control bleeding
74

© 2014
• Treat pregnant trauma
patients and their
injuries as you would
any other patient
• However, there are
some physiological
effects of pregnancy
and special
considerations you
should keep in mind
77

© 2014
• In a trauma incident:
– Presence of a larger blood volume will
enable the mother’s body to
compensate for blood loss
– She may not show early signs of shock
– A pregnant patient can suffer the loss
of almost 40% of her blood volume
before signs of shock appear
• When shock occurs:
– Mother’s body directs blood away from
the uterus

© 2014
• Bleeding could be
internal and not obvious
• Always suspect that
internal bleeding is
present in any pregnant
trauma patient, even if:
– Her vital signs are
normal
– There is no apparent
injury
79

© 2014
• The uterus and amniotic
fluid are designed to
protect the fetus:
– However, severe
trauma late in the
pregnancy can have
serious consequences
• Expect that the fetus
may have sustained
injury, even if you
confirm that there has
been no injury to the
mother
80

© 2014
• When you size up the
scene:
– Look at the mechanism
of injury
– Consider what kind of
injuries might likely
have resulted
81

© 2014
• Penetrating injuries:
– Gunshot
– Stab wound
– Punctures from vehicle
collision debris
• Blunt force injuries:
– Falls
– Vehicle incidents
– Abuse
– Assaults
82

© 2014
• Regardless of the type
of injuries involved, the
greatest dangers to
both the mother and the
fetus are:
– Bleeding
– Shock
83

© 2014
• If she is in or near the
3rd trimester with NO
suspected spinal injury:
– Place patient on her
left side
• Control any external
bleeding
85

© 2014
• If she is in shock and
you can determine that
the pregnancy is early
or midway through:
– Place her in the supine
position
• Cover her with a
blanket to maintain
warmth
86

© 2014
• Monitor her to prevent
overheating
• Focusing your care on
the mother will provide
indirect care for the
fetus as well
• The fetus is vulnerable
to a reduction in oxygen
and can become
severely hypoxic before
the mother shows any
signs of it
87

© 2014
– Then tilt the board to
the left during
transport
 This positioning helps
relieve pressure and
weight on abdominal
organs and vena cava
90

© 2014
• Gynecological Emergencies
• Stages & Assessment of Labor
• Childbirth
• Care for the Mother & Neonate
• Pregnant Trauma Patients

© 2014
• When a pregnant patient has an
emergency medical need or has
sustained trauma, the risk is to
more than her alone
• Whether she is experiencing a
health or safety complication or is
preparing to deliver her baby, she
will need your immediate help

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