Obstetrical emergencies i

Barry Kidd 2010 1
CHILDBIRTH AND
OBSTETRICAL
EMERGENCIES

Barry Kidd 2010 2
Emergency Childbirth
Overview
 Childbirth is not an injury or a disease, but
a natural physiologic process
 Remember, you have two patients
 Ideally the patient will make it to the
hospital
 Most patients will require immediate
transport but skills for emergency
childbirth and recognition of complications
are essential

Barry Kidd 2010 3
CHILDBIRTH
Having a baby is one of the most natural
things the female can do
Always remember –
“Mothers deliver babies”
The EMR is just there to assist any
way they can

Barry Kidd 2010 4
CHILDBIRTH
Childbirth Terminology
 Fetus
 Cervix
 Bloody show
 Placenta (afterbirth)
 Umbilical cord
 Amniotic sac (fluid)
 Birth canal

Barry Kidd 2010 5
CHILDBIRTH
Stages of Labour
 During the first stage of labor the cervix
becomes fully dilated. This is described
as contractions.
 Stage one may last longer than 18 hours.
 The women who have had previous
babies may have a very short first stage.
 When contractions are 2 minutes apart,
birth is very near

Barry Kidd 2010 6
CHILDBIRTH
First Stage of
Labour

Barry Kidd 2010 7
CHILDBIRTH
Stages of Labour
 The second stage of labor starts when the
baby moves through the birth canal and
ends when the baby is born.
 During the stage there will most likely be
bloody discharge (bloody show).
 The baby’s head will appear at the
opening of the birth canal (crowning).
 The shoulders and body will follow.

Barry Kidd 2010 8
CHILDBIRTH
Second Stage of
Labour

Barry Kidd 2010 9
CHILDBIRTH
Second Stage of
Labour

Barry Kidd 2010 10
CHILDBIRTH
 As soon as the head is delivered, the
airway must be suctioned.
Suction the mouth first then the nose.
 Although babies are nose breathers, they
will aspirate the fluid in their mouth as they
are stimulated to cry.
 Be sure the baby is supported at all times
during the delivery – They are very
slippery

Barry Kidd 2010 12
CHILDBIRTH
 Once the baby is delivered and the airway
has been cleared (the baby is crying), the
umbilical cord may be cut.
 Apply one cord clamp half way between
the baby and mom and the second one a
couple inches from the first.
 Once the cord stops pulsating, cut it
between the clamps

Barry Kidd 2010 14
CHILDBIRTH
 Dry the baby and wrap it in a warm blanket
as soon as possible.
 The new born looses body heat within
seconds.
 Place the baby at the mother’s breast to
nurse as soon as it is dry and warm.
 Nursing will stimulate the uterus to shrink
and control any bleeding

Barry Kidd 2010 16
CHILDBIRTH
 During the third stage, the placenta
separates from the uterine wall.
 Usually, it is spontaneously expelled from
the uterus
 Make sure you save it in a plastic bag
provided in most OB kits. It will have to be
examined at the health centre

Barry Kidd 2010 17
CHILDBIRTH
Third Stage of
Labour

Barry Kidd 2010 19
OBSTETRICAL EMERGENCIES
Complications of Delivery
 Prolapsed Cord
 Breech Birth
 Umbilical Cord Around the Neck
 Limb Presentation
 Multiple Births
 Premature Births
 Placenta Previa

Barry Kidd 2010 20
Prolapsed Cord
 When the cord is delivered before the
infant, it is in great danger of suffocating
 The cord is compressed against the birth
canal by the baby’s head
 Emergency care is extremely urgent

Barry Kidd 2010 21
Prolapsed Cord

Barry Kidd 2010 22
Emergency Care
 Have the mother lie on her left side with
knees drawn to her chest
 Administer high-flow oxygen
 With a gloved hand, gently push the baby up
the vagina far enough so their head is off the
cord – this is controversial in some areas –
follow local protocol

Barry Kidd 2010 23
Cover the cord with a moist sterile towel
DO NOT PUSH THE CORD BACK IN

Barry Kidd 2010 24
Breech Birth
If baby’s feet or buttocks delivers first then
the mother must be transported to the
health facility as soon as possible.

Barry Kidd 2010 25
Breech Birth

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Emergency Care
 Prepare the mother for a normal delivery
 Let the buttocks and trunk deliver on their
own
 Support the infant
 Observe the delivery of the head
 If necessary, form an airway for the baby

Barry Kidd 2010 27
Cord Around the Neck
 Try to slip the cord gently over the baby’s
shoulders or head
 If this cannot be done and the cord is
wrapped too tightly around the neck, place
clamps 3 inches apart and quickly but
carefully, cut between them
 Unwrap the cord and deliver the baby,
supporting the head at all times

Barry Kidd 2010 28
Limb Presentation
 If the baby’s arm or leg delivers first, it means
that the infant has shifted so much in the uterus
that a normal delivery is not possible
 This is a medical emergency – the baby must be
delivered by a physician – delay can be fatal
 The mother must be transported immediately to
the health facility

Barry Kidd 2010 29
Multiple Births

Barry Kidd 2010 30
Multiple Births
 Twins are delivered the same way as
single babies
 Identical twins have 2 umbilical cords
coming out of one placenta
 If the twins are fraternal there will be 2
placentas
 The mother may, or may not be aware
they are carrying twins

Barry Kidd 2010 31
Signs of a Multiple Birth
 The abdomen is still large after one baby
is delivered
 The baby’s size is out of proportion with
the mother’s abdomen
 Strong contractions begin again within 10
minutes of delivering the first baby

Barry Kidd 2010 32

Barry Kidd 2010 33
Premature Birth
 When a baby is delivered before the 36th week
of gestation, or delivery weight is less than 5 ½
pounds, the baby is considered to be premature
 They are much smaller, yet have heads
proportionately larger than full-term babies.
 Special cares is necessary as they are
vulnerable to infection

Barry Kidd 2010 34
Placenta Previa
 This occurs when the placenta is
positioned in the uterus in an abnormally
low position
 When the cervix dilates, the fetus moves
or labor begins, the placenta separates
from the uterus
 This puts both the mother and bay in
danger

Barry Kidd 2010 35
CHILDBIRTH
Lightening
A few weeks before the onset of labor (at
approximately 37 to 38 weeks in the first
pregnancy), the abdomen of the woman
undergoes a change in shape. This is
called lightening. The change is described
as “feeling like the baby has dropped”.
The uterus settles down in the pelvic
cavity.

Barry Kidd 2010 36
CHILDBIRTH
The fetal head descends to or even
through the pelvic opening in preparation
for labor. In subsequent pregnancies,
lightening may not occur until labor begins.

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CHILDBIRTH
False Labor
For a period before true or effective labor
begins, a woman may experience false
labor. Labor is considered false when the
uterine contractions are not associated
with cervical dilation.

Barry Kidd 2010 38
CHILDBIRTH
The contractions are irregular and very
short in duration. The discomfort is
usually confined to the lower abdomen
and groin. In contrast, the uterine
contractions in true labor begin first in the
fundal region, then radiate over the uterus
through the lower back.

Barry Kidd 2010 39
CHILDBIRTH
False labor often stops spontaneously, but
may convert rapidly to true labor.
Therefore, complaints of infrequent and
uncomfortable uterine contractions cannot
be ignored.

Barry Kidd 2010 40
CHILDBIRTH
True Labor
A dependable sign that labor is
approaching is the presence of show or
bloody show, which is a small amount of
blood-tinged mucus. It represents the
expulsion of the mucous plug that fills the
cervical canal during pregnancy. Show is
a late sign. Labor usually begins during
the next few hours or days

Barry Kidd 2010 41
CHILDBIRTH
Normally, only a few drops of blood
escape with the mucous plug. More
substantial bleeding suggests an abnormal
condition

Barry Kidd 2010 42
CHILDBIRTH
Duration of Labor
There are wide variations in the duration of
labor. The duration depends on whether
the woman is pregnant for the first time
(primigravida), whether she already ahs
children (multipara), and the time that has
elapsed since the birth of the last child.

Barry Kidd 2010 43
CHILDBIRTH
The longest part of labor is the first stage.
In the primigravida, the second stage is
seldom less than a half hour. In the
multiparous woman, the second stage
may be fifteen minutes or less. The
duration of the third stage is usually
between five and twenty minutes

Barry Kidd 2010 44
CHILDBIRTH
A considerable number of primigravidas
have labors of under twelve hours. A
number of multiparas have labors of six to
eight hours and, in many cases, less than
six hours. Any labor less than three hours
is referred to as a precipitous delivery.

Barry Kidd 2010 45
CHILDBIRTH
A woman who has had a precipitous
delivery in the past will probably deliver
precipitously in the subsequent
pregnancies.
Any woman will have a shorter labor and
delivery with subsequent pregnancies.

Barry Kidd 2010 46
CHILDBIRTH
Assessment and Management
Use the primary and secondary surveys of
your patient assessment model for the
obstetrical patient. But there are
differences which you must remember.
Keep in mind that the pregnant woman is
neither ill or traumatized. She is
experiencing a normal biological
phenomenon.

Barry Kidd 2010 47
CHILDBIRTH
Primary Survey:
Airway
Few obstetrical problems affect the
woman’s airway, with exception of an
eclamptic patient who has a seizure.

Barry Kidd 2010 48
CHILDBIRTH
Breathing
Assess her respirations. Except mild
shortness of breath. Remember that the
pregnant patient will have mild SOB if the
uterus crowds her diaphragm. This is
especially true in late pregnancies and
with twins

Barry Kidd 2010 49
CHILDBIRTH
The semi fowler position allows maximum
lung expansion. Rapid breathing may be
due to hemorrhage or anxiety. Determine
which condition is causing the shortness of
breath. If the patient is anxious and
hyperventilating, she may complain of light
headedness and tingling in her
extremities.
Her anxiety may also stress the fetus.

Barry Kidd 2010 50
CHILDBIRTH
Calm her by slowly and gently directing
her attention to her breathing. Help her to
slow down. Provide emotional support
and explain each step as you go.

Barry Kidd 2010 51
CHILDBIRTH
Circulation
Any compromise to the woman’s
circulation affects the circulation of blood
and oxygen to the fetus.
The most common cause of hypotension
in the pregnant patient is lying supine.
When lying supine, her uterus compresses
her vena cava against her vertebral
column

Barry Kidd 2010 52
CHILDBIRTH
Blood return to the heart decreases,
resulting in hypotension and reduced
blood flow to the fetus. Place the patient
on her left side in order to displace the
uterus away from the vena cava.
If the patient’s chief complaint is bleeding,
she must be assessed for signs of shock.

Barry Kidd 2010 53
CHILDBIRTH
The pregnant woman is normally
hypervolemic (has a large amount of fluid
in her circulatory system, which also must
be taken into consideration when
assessing the pulse. The pulse may be up
to fifteen beats faster per minute by full
term. She may not show signs of
hypovolemic shock until blood loss is
much greater than a non-pregnant patient

Barry Kidd 2010 54
CHILDBIRTH
The fetus is compromised as the woman’s
compensatory mechanisms redirect blood
flow to her vital organs, reducing blood
flow to the fetus.

Barry Kidd 2010 55
CHILDBIRTH
Secondary Survey
Vital signs:
Temperature: Are there signs of shock,
skin cool, clammy? Are there signs of
infection, elevated temperature?
Pulse: Expect the pulse rate to be greater
tan normal because of the increased blood
volume.

Barry Kidd 2010 56
CHILDBIRTH
Respirations: The patient may be short of
breath because of the diaphragm is being
crowded by the uterus.
Blood Pressure: Refer to circulation in
the primary survey. Hypotension is often
the result of a supine position. Blood loss
will be apparent before the B/P shows
hypovolemic changes.

Barry Kidd 2010 57
CHILDBIRTH
Therefore be aware that there has been
significant blood loss if the patient is
hypotensive and bleeding.
If the B/P is low and bleeding is not
apparent, check the pulse. Hypertension
is a complication of pregnancy referred to
has Pregnancy Induced Hypertension.

Barry Kidd 2010 58
CHILDBIRTH
Level of Consciousness
A decreased level of consciousness is very
rare in the pregnant patient. It may occur
when advanced hypovolemic shock or
pregnancy induced hypertension is
present. Remember that a patient who is
in extreme pain or preparing to deliver
may be unable to concentrate or interact.

Barry Kidd 2010 59
CHILDBIRTH
Patient History
Ask the following questions to obtain a
history of the pregnancy:
 Have you been seeing a doctor during
your pregnancy?
 Try to determine if the woman has
received prenatal care.
 Has there been anything unusual about
this pregnancy?

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CHILDBIRTH
 Has the doctor told you anything about
this pregnancy?
 Try to determine whether the pregnancy
has progressed normally or whether there
is any risk.

Barry Kidd 2010 61
CHILDBIRTH
Past Obstetrical History
Ask the following questions to obtain the
woman’s past obstetrical history.
 What was the outcome of your previous
pregnancies?
 How many pregnancies, including
spontaneous or therapeutic abortions?
 How long was the gestation?

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CHILDBIRTH
 Was the baby preterm or posterm?
 Did the birth weight correspond to the
gestation period?
 Was the infant’s intrauterine growth
retarded or were the dates incorrect?
 Was the birth weight excessive (this may
indicate latent gestational diabetes)

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CHILDBIRTH
 Was the baby born alive?
 Was the baby normally developed?
 Was labor spontaneous or induced?
 Was labor unusually short or long? Was
delivery accomplished spontaneously, with
forceps or by Cesarean section?
 Why was an operative procedure
necessary?

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CHILDBIRTH
 Was presentation abnormal, breech etc?
 Were there any complications during
pregnancy, labor or in post partum?

Barry Kidd 2010 65
CHILDBIRTH
Past Medical History
Obtain the woman’s past medical history.
Ask about pertinent illnesses, such as
diabetes mellitus, TB, rheumatic heart
disease any renal, collagen, metabolic, or
hematologic disorders. These could
influence intrauterine development

Barry Kidd 2010 66
CHILDBIRTH
You must judge how much history you
should take prior to transport and what
history you should take on route to the
hospital.
As a rule of thumb, take the history you
need to assess the chief complaint and the
possibility of imminent delivery prior to
transport.

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CHILDBIRTH
Chief Complaint
If the chief complaint is labor, ask the
following questions.
 When is the baby due?
 Are you having contractions?
 When did they begin?
 How long do they last?
 How far apart are they?

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CHILDBIRTH
 How many in ten minutes?
 Describe the intensity of the contractions:
mild, moderate, hard.
 Do you feel that you need to move your
bowels?
 Has your water broken?

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CHILDBIRTH
 If the chief complaint is bleeding, ask the
following questions.
 How much blood has been lost?
 When did the bleeding begin?
 Is there pain with the bleeding?

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CHILDBIRTH
Decision to Transport
A critical decision in imminent childbirth is
whether to transport the mother to the
hospital before or after birth. Once you
have completed your assessment, you
must make that decision based on your
findings.

Barry Kidd 2010 71
CHILDBIRTH
As a general rule, if the mother’s labor
pains are longer than 5 minutes apart, she
is not straining, and does not feel the urge
to move her bowels, you should:
ﾔ Instruct the mother to take deep breaths
by mouth during contractions and not bear
down at this time, obtain vital signs.

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CHILDBIRTH
헐Transport the patient to the hospital/HC.
Take into account the time to the hospital
and other environmental factors or factors
that might delay you.
헐Ask your partner to notify the
physician/hospital/HC via dispatch.
헐Transport the mother on her left side.

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Imminent Birth
If the mother’s contractions are less than 5
minutes apart or if she is straining and
feels she has to move her bowels, you
should:
Not transport the patient to the hospital at
this time

Barry Kidd 2010 74
阐Do not allow the mother to sit on the toilet.
Explain to her that the sensation to move
her bowels is natural and is caused by the
baby’s head pressing against the rectum.
阐Examine the mother for crowning. If
crowning prepare for delivery.

Barry Kidd 2010 75
Placenta Previa

Barry Kidd 2010 76
Signs & Symptoms
Severe, usually painless bleeding from
the vagina and shock

Barry Kidd 2010 77
Miscarriage
A miscarriage is defined as a termination
of pregnancy from any cause before the
first twenty weeks of gestation.
This is the most common cause of vaginal
bleeding in the first trimester of pregnancy.
This occurs in about 1 in ten pregnancies

Barry Kidd 2010 78
EMRs need to get a detailed history
including:
 time of onset of pain and bleeding
 amount of blood loss
 whether the patient has passed any tissue
during bleeding, any of which needs to be
collected for analysis

Barry Kidd 2010 79
Management of all first trimester
emergencies include:
 Closely monitoring the patient’s vital signs
observing for shock
 positioning the patient in a comfortable
position.
 administering high concentration oxygen
 Transport to advanced care facility

Barry Kidd 2010 80
Ectopic Pregnancy
Ectopic pregnancy occurs when a fertilized
ovum implants anywhere other than the
uterus.
It occurs in about 1 in every 200
pregnancies
It is the leading cause first trimester death
of the mother that usually results from
hemorrhage

Barry Kidd 2010 81
There are numerous causes of ectopic
pregnancy; however, most involve factors
that delay or prevent passage of the
fertilized ovum to the uterus.
The predisposing factors include: previous
surgery, previous ectopic pregnancy, tubes
blocked as a sterilization method

Barry Kidd 2010 82
The EMR should obtain a detailed history
from the patient
Most ruptures occur by 2 to 12 weeks of
gestation. A ruptured ectopic pregnancy is
a true medical emergency.
Management includes: monitoring vitals,
supplemental high concentration oxygen,
rapid transport to advanced facility

Barry Kidd 2010 83
Third Trimester Bleeding
Third trimester bleeding occurs in a very
small percentage of pregnancies and is
never normal
Third trimester bleeding is usually as a
result of: abruptio placenta, placenta
previa and uterine rupture

Barry Kidd 2010 84
Uterine rupture is a spontaneous or traumatic
rupture of the uterus wall. The condition may
result of a previous scar from a Cesarean birth,
prolonged or obstructed labor, or direct trauma
Management includes: treating for shock,
monitoring vitals, placing the patient in a left
lateral recumbent position, supplemental high
concentration oxygen and rapid transport to a
advanced care facility

Barry Kidd 2010 85
Postpartum Complications
Postpartum bleeding refers to bleeding after the
birth of the new born.
It is characterized by more than 500 ml of blood
loss.
It frequently occurs within the first few hours
after delivery but can be delayed for up to 24
hours

Barry Kidd 2010 86
Causes of postpartum bleeding include the
following: uterine muscles are not contracting
fully after birth, pieces of the placenta or
membranes remain in the uterus, vaginal or
cervical tears were caused during the delivery
Management includes: Managing any external
bleeding, positioning the patient in antishock
position, monitor vitals, supplemental high
concentration oxygen, transport to advanced
care facility

Barry Kidd 2010 87
Eclampsia and Preeclamsia
Also referred to as toxemia, preeclampsia is a
condition that pregnant women can get. It is
marked by high blood pressure accompanied
with a high level of protein in the urine. Women
with preeclampsia will often also have swelling
of the feet, legs and hands.

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Preeclampsia, when present, usually
appears during the second half of
pregnancy, generally in the latter part of
the second or in the third trimesters,
although it can occur earlier.

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Eclampsia is the final and most severe
phase of preeclampsia and occurs when
preeclampsia is left untreated. In addition
to the previously mentioned symptoms,
women with eclampsia often have
seizures. Eclampsia can cause coma and
even death of the mother and baby and
can occur before, during or after childbirth.

Barry Kidd 2010 90
What Causes Preeclampsia and
Eclampsia?
The exact causes of preeclampsia and
eclampsia are not known, although some
researchers suspect poor nutrition, high
body fat or insufficient blood flow to the
uterus as possible causes.

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Who Is at Risk for Preeclampsia?
Preeclampsia is most often seen in first-
time pregnancies and in pregnant teens
and women over 40. Other risk factors
include:
A history of chronic high blood
pressure prior to pregnancy.
Previous history of preeclampsia

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A history of preeclampsia in mother or
sisters.
Obesity prior to pregnancy.
Carrying more than one baby.
History of Diabetes, kidney disease, lupus
or rheumatoid arthritis

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Signs and Symptoms
In addition to swelling, protein in the urine,
and high blood pressure, symptoms of
preeclampsia can include:
Rapid weight gain caused by a significant
increase in bodily fluid, abdominal pain
and severe headaches

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Also includes change in reflexes, reduced
output of urine or no urine, blood in the
urine, dizziness and excessive vomiting
and nausea

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CHILDBIRTH
95Trauma in Pregnancy -

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CHILDBIRTH
96Trauma in Pregnancy -

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Summary
 Remember child birth is a
natural, normal,
physiologic human event
 Most deliveries are
routine
 Be prepared for
complications

Obstetrical emergencies i

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