OB Delivery Complications

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OB Delivery Complications

• Condell Medical Center
• EMS System
• ECRN Packet
• Module I 2008

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

• Upon successful completion of this module, the
  ECRN 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, a
  breech delivery, meconium staining.
• successfully complete the quiz with a score of
  80 or better.

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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

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Normal Fetal Positioning
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Changes in Pregnancy contd

• 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

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Changes in Pregnancy contd

• 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)

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Changes in Pregnancy contd

• 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

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Changes in Pregnancy contd

• 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

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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 usually longer 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

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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 ruptures in this stage if
  not already ruptured
• Crowning is evident
• Definitive sign of imminent delivery

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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

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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

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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

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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

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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

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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 or scissors
• OB pad
• Plastic bag
• Twist ties
• Infant cap
• 2 wrist ID bands

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OB Kit Contents
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Newborn At Delivery
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Preventing Hypothermia in a Newborn
Dry them Wrap them Cap them
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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
• lt60 start compressions

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APGAR contd

• G grimace (irritability)
• Includes coughing, sneezing, crying
• A activity
• Active motion, flexing of extremities
• R respiratory effort
• Strong cry
• Majority of scores are 710 indicating a healthy
  infant requiring routine care
• Scores 4-6 indicate moderately depressed infant
  requiring oxygen stimulation

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APGAR Score
Criteria 0 1 2
Appearance Blue or pale Blue hands or feet Entirely pink
Pulse Absent lt 100 gt100
Grimace reflex irritability Absent Grimace Cough, sneeze
Activity Limp Some extremity flexion Active motion
Respirations Absent Weak cry, hypoventi-lating Strong cry
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Inverted Pyramid

• Drying, warming, positioning
• Suction, tactile stimulation
• Oxygen
• BVM
• Chest
• Compressions
• Intubation
• Meds

Basic skills
Advanced skills
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OB Complications Supine Hypotensive Syndrome

• Can occur especially after 5 months gestation
• 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 side
• Remember Lay left

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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

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Region X SOP for Seizures from Eclampsia

• Check the blood sugar level on all patients with
  an altered level of consciousness
• For active seizure, administer Valium 5 mg IVP
  slowly over 2 minutes
• May repeat Valium 5 mg slow IVP
• Titrate to control seizure activity
• Maximum total 10 mg
• Valium, if given, has sedating effect on mother
  fetus
• EMS should verbally inform/remind ED and OB staff
  of use of Valium in the field

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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

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Breech Presentation
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Breech Delivery contd

• 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

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Breech contd

• If head not delivered within 30 seconds
• Reach 2 gloved fingers into vagina to locate
  babys mouth
• Push vaginal wall away from babys 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

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OB complications Prolapsed Cord

• Perform a visual exam as soon as possible
  whenever a mother states her bag of waters has
  ruptured
• Elevate the mothers hips or place knee-chest
• Have patient breath through the contractions so
  she doesnt 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

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Prolapsed Cord
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OB Complications Nuchal Cord

• Cord wrapped around infants neck
• Increase mothers O2 to 100 non-rebreather mask
• Slip fingers around cord and lift over infants
  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

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Nuchal Cord (C-section)
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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

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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

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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

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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)

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Meconium Staining

• If infant is not vigorous
• Respiratory rate decreased
• Decreased muscle tone
• Heart rate lt 100
• Use meconium aspirator to clear airway
• This will take coordination and best accomplished
  with 2 persons working as a team

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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

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Meconium Aspirator

• Connect small end of meconium aspirator to
  suction line connecting tube
• Turn suction down to 80 mmHg
• Insert endotracheal tube
• Dont 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 (lt 2 seconds)
• Discard ETT after one use

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Meconium Aspirator
Aspirator can be used a second time on infant
with new ETT each time
Limit suction to lt2 seconds
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Meconium Aspirator ED Location

• CMC
• In peds crash cart
• On Broselow cart
• LFH
• In bins on wire rack shelves

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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 needs to be evaluated during the physical
  assessment

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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?

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Case Study 1

• Physical exam position patient to evaluate
• Crowning
• Evidence of bulging perineum
• Involuntary pushing
• Signs of prolapsed cord
• Evidence of profuse bleeding

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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
• Does EMS stay prepare to deliver or transport?

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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

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What is your role during delivery?
Support the presenting part
Check for nuchal cord Suction mouth Then nose
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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

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Clamping cutting the cord

• After cord is done pulsating, clamp 8? from
  infants navel with 2 clamps placed 2? apart
• Watch for blood leakage from infants cord
• Reinforce with additional clamps as needed

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3rd Stage of Labor Placental stage

• Watch for excessive bleeding (gt500 ml)
• Prepare to perform fundal massage
• Need to feel uterus become firm size of the
  uterus will depend on the size of the fetus

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Fundal Massage
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Newborn dried off, cord clamped cut
Whats his APGAR?
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Case Study 2

• Mother calls EMS because my baby is coming
• Upon EMS arrival, they gained 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
• EMS performed a visual exam

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Case Study 2 This is what you see. Now what do
you do?
If cord is wrapped around the neck, try to loosen
and slip over the head. If too tight, need to
double clamp and cut the cord NOW.
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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
• EMS established rapport and performed a visual
  exam
• EMS determined that delivery is imminent

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Case Study 3 - This is a breech delivery that is
not delivering. How do you handle this?
Head should deliver in 30 seconds. If not,
reach in to create an airway for the
infant. Support body across your forearm.
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Creating an airway for a breech delivery

• Reach 2 fingers into the vagina
• Locate the infants face
• Push the vaginal skin away from the infants
  mouth
• Transport immediately
• Give report to the closest facility
• The crew member CANNOT move their fingers and
  risk losing the airway

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• The golden sounds to a mothers and EMS
  providers ears a newborns cry!!!

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Documentation

• If the patient delivers, EMS and ED need to write
  2 reports one for the mother one for the
  infant
• Both reports can have time of delivery
• On run report, OB delivery is credited to the
  person who delivers (catches)
• Segregate information
• Mothers information on mothers run report
• Infants information on the infants run report

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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

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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

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Wrist Bands

• Apply a wrist band to both the mother and the
  newborn
• Include the same information on both wrist bands
• Mothers name
• Sex of infant
• Time of delivery

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Bibliography

• Bledsoe, B., Porter, R., Cherry, R. Essentials of
  Paramedic Care. 2nd Edition. Brady. 2007.
• Limmer, D., OKeefe, M. Emergency Care 10th
  Edition. Brady. 2005.
• Region X SOPs Effective March 1, 2007