Obstetrical Emergencies

Paramedic Rounds Presentation2009

11

Learning Objectives

Use terminology relating to pregnancyDiscuss fetal developmentRelate complications of pregnancy and childbirth to patient presentationsApply the appropriate techniques for delivery

22

TerminologyAnte partum - before deliveryPostpartum - after deliveryPrenatal - occurring before the birthGravida - number of pregnanciesPara - number of pregnancies carried to full termAbortion - pregnancy that ends before full termGestation - period of time for intrauterine fetal developmentPremature Infants - < 35 weeks (BLS) gestation, OR < 5 pounds birth weight

33

Determining Stage of Pregnancy

History

• When was your last normal menstrual period (LNMP)?

• Abdominal pain? (location/quality)• Vaginal bleeding/discharge?

44

Determining Stage of Pregnancy

HistoryIs there a possibility you might be pregnant?• Missed period• Increased urinary frequency• Breast enlargement • Vaginal discharge• Weight gain

55

Determining Stage of Pregnancy

HistoryIf pregnant

•Subtract 3 from the month of the LNMP•Add 7 to the day of the LNMP

LNMP 2006/08/29Due date 2007/05/05

66

Changes During Pregnancy

77

Fetal Growth Process

First Trimester (months 1-3)• Critical Development stage for fetus• Heart is beating• Every structure found at birth is present

Second Trimester (months 4-6)• Fetal heart tones can be detected• Fetal movement may be felt by mother• Fetal growth phase

88

Fetal Growth Process

Third Trimester (months 7-8)• May be capable to survive if born prematurely (fetus > 23 weeks)

• Rapid growth phase for fetus

40 weeks• Considered to have reached full term• Expected date of confinement (EDC)

Note: “youngest” to survive is 21 weeks 5 days

99

Anatomy/PhysiologyUmbilical Cord

• Connects placenta to fetus

• Two arteries• One vein

Amniotic Sac• Membrane surrounding fetus

• 500 - 1000 cc (after 20 weeks)

PlacentaTransfer of gasesTransport of nutrients Excretion of wastesHormone productionProtection

1010

TRAUMA

During Pregnancy

1111

Morbidity & Mortality Rates

Accidental Injury complicates 6-7% of all pregnancies.

Most common cause of death of fetus is the death of the mother

Fetal Death with maternal survival occurs with placental separation or ruptured uterus

1212

Trauma in Pregnancy

Unique challenge for the provider

Two Patients each with unique needs

Mom will save herself at the expense of the fetus

1313

Mechanism of Injury

•Motor Vehicle Collisions•Penetrating Injuries•Falls•Burns•Blunt Trauma

1414

Assessment

Mother• Initial• Rapid Trauma Assessment/ Focused Assessment

Fetus• Abdominal tenderness, guarding, rigidity, rebound tenderness

• Uterus• Fetal body movements?• Contractions

1515

ShockBody protects the mother•uterine vasoconstriction (20-30%)•decreased blood flow to fetus

Loss of 30 - 35% blood volume before developing hypotensionSlower onset of sign/symptoms

The infant will already have been stressed by the time the mom show signs/symptoms

1616

ManagementC-Spine (if immobilized, tilt board)AirwayAssist ventilations if requiredHigh flow O2

(Oxygen requirements 10 - 20 % greater)Control external bleedingTransport on left side (tilt 15 to 30 degrees should be enough)Establish IV access if trained and required

Note: No servicing pregnant trauma (MVC) patients is a good way to get famous.

1717

EmergenciesDuring Pregnancy

1818

Pre-eclampsia

• Acute hypertension after 24th week of gestation• 5-7% of pregnancies• Most often in first pregnancies• Other risk factors include young mothers, no

prenatal care, multiple gestation, lower socioeconomic status

1919

Pre-eclampsiaSign and Symptoms

Hypertension•Systolic > 140 mm Hg•Diastolic > 90mm Hg / 115 Severe Pre-EOr either reading > 30 mmHg above patient’s normal BP•Edema (particularly of hands, face) present early in day

2020

Pre-eclampsiaSigns and Symptoms•Rapid weight gain

>3lbs/wk in 2nd trimester>1lb/wk in 3rd trimester

•Decreased urine output•Headache, blurred vision•Nausea, vomiting•Epigastric pain•Pulmonary edema

2121

Pre-eclampsiaComplications

• Eclampsia• Premature separation of placenta• Cerebral hemorrhage• Retinal damage• Pulmonary edema• Pulmonary embolus• Lower birth weight infants, chronic fetal hypoxia

2222

Pre-eclampsia

Management100% O2Left lateral recumbent positionAvoid excessive stimulationReduce light in patient compartmentEstablish IV access if trained

2323

EclampsiaGravest form of pregnancy-induced hypertension Occurs in less than 1% of pregnancies

Signs and SymptomsSigns, symptoms of pre-eclampsia plus: Tonic/Clonic seizures Coma

2424

Eclampsia

Complications• Same as pre-eclampsia• Maternal mortality rate: 10%• Fetal mortality rate: 25%

Management• 100% O2; assist ventilations, as needed• Left lateral recumbent position• Reduce light• Manage like any major motor seizure• Emergency transport• Establish IV access if trained

2525

Ectopic PregnancyPathophysiology

Outside uterine cavity95% Fallopian tubes1 in every 200 pregnanciesMost are symptomaticPredisposing factors•Tubal infections•Previous tubal surgery•IUD use•Previous ectopic pregnancy

2626

Ectopic PregnancySigns and Symptoms

Missed menses or a decreased menstrual flow that is brownish in color

Vaginal bleed (spotting)Localized sharp pain to the affected side Abdominal pain, may radiate to shoulder from the affected sideRigid abdomen

2727

Ectopic PregnancyLower abdominal pain or unexplained hypovolemic

shock in a woman of child-bearing age equals Ectopic Pregnancy until proven otherwise

Management100% O2Supportive care for hypovolemic shockEstablish IV access if trainedTransport immediately

2828

Spontaneous AbortionAlso referred to as a “Miscarriage”Pregnancy terminates before 20th weekUsually occurs in first trimester

Signs and SymptomsVaginal bleedingCramping lower abdominal pain or pain in backPassage of fetal tissue

2929

Spontaneous AbortionComplications

Incomplete abortionHypovolemiaInfection, leading to sepsis

ManagementHigh concentration O2Shock positionEstablish IV access if trained and requiredTransport tissue to hospitalProvide emotional support

3030

Placenta PreviaImplantation of placenta over cervical opening

Signs and Symptoms•Painless, bright-red vaginal bleeding•Soft, non-tender uterus•Signs and symptoms of hypovolemia

3131

Placenta Previa

Management

100% O2Left lateral recumbent positionSupportive care for hypovolemic shockEstablish IV access if trained and required

3232

Abruptio Placentae

Premature separation of placenta from uterusHigh risk groups:•Older pregnant patients•Hypertensives•Multigravidas

3333

Abruptio PlacentaeSigns and Symptoms

Mild to moderate vaginal bleedingContinuous, knife-like abdominal painRigid, tender uterusSigns, symptoms of hypovolemia

Third Trimester Abdominal Pain equals Abruptio Placentae until proven otherwise

Hypovolemic shock out of proportion to visible bleeding equals Abruptio Placentae until proven otherwise

3434

Abruptio PlacentaeManagement

100% O2Left lateral recumbent positionSupportive care for hypovolemic shockEstablish IV access if trainedRapid transport

Note: Painless vaginal bleeding is usually placenta previa and painful vaginal bleeding is usually abruption

3535

Uterine RuptureCauses

• Blunt trauma to pregnant uterus• Prolonged labor against an obstruction• Labor against weakened uterine wall•Old Cesarian section scar•Grand multiparous patients

Signs and Symptoms• “Tearing” abdominal pain• Severe hypovolemic shock• Firm, rigid abdomen• Possible palpation of fetal parts through abdominal wall• Vaginal bleeding may or may not be present

3636

Uterine Rupture

Management

100% O2Anticipate shockEstablish IV access if trainedRequires immediate C-Section at Hospital

3737

Emergency Childbirth

3838

ChildbirthComplications that can occur:

Breech/limb presentationMultiple BirthsUmbilical cord problemsDisproportion (Head to body size)Excessive bleedingAmniotic fluid embolism (most common cause Maternal death)Neonate requiring resuscitationPre-term labor

3939

Labor

1St stageOnset of contractions to dilation of cervix

2nd stageComplete dilation of cervix to delivery of baby

3rd StageDelivery of baby to delivery of placenta

4040

Signs of Imminent Delivery

CrowningRupture of Amniotic Sac, showNeed to bear downSensation of needing to move bowelsContractions•2 minutes (primips) to 5 minutes (multips) apart•Regular•Lasting 60-90 seconds

4141

DeliveryDeliver the babies head (normal delivery)Gently guide baby’s head down to deliver upper

shoulder Gently guide baby’s head up to deliver lower

shoulderGently assist with delivery of rest of babyDo NOT pull

Note time of delivery of baby

4242

DeliveryControl slippery baby during delivery•Support head, shoulders, feet•Keep head lower then feet to facilitate drainage of secretions from mouth

Provide warmth, keep the baby warmPosition, wipe mouth and nose unless suction is

indicatedKeep infant at mothers levelDry baby, stimulate, provide 02Assess infant, manage as required

4343

APGAR Score

• Developed by Virginia Apgar• Quick evaluation of infant’s pulmonary,

cardiovascular, neurological function• Useful in identifying infant’s needing

resuscitation

4444

4545

Maternal Care: Postpartum

Bleeding• Place sterile pad over vaginal opening• If bleeding is excessive:

• Rapidly transport to hospital• Uterine massage• Encourage breastfeeding

4646

Complicated Deliveries

4747

Breech Presentation

Management (Feet presentation)•High concentration O2•Rapid transport if birth not imminent•Prepare for neonatal resuscitation•Establish IV access if trained•Assist delivery•Frank (butt), Load and GO

4848

Limb Presentation

Management

•DO NOT attempt delivery•Position on Left side with knees / hips flexed•Administer Oxygen•Establish IV access if trained•Discourage pushing (have patient “pant & blow)•Prepare for deliver / resuscitation

4949

Prolapsed CordUmbilical cord enters vagina before infant’s headPressure of head on cord occludes blood flow, O2 delivery to fetus

Management•With a gloved hand palpate the cord for a pulse (If pulse is weak or absent – relieve cord compression by inserting two gloved fingers into the vagina and gently move the part away from the cord)•Administer oxygen•Cover the cord with gauze moistened with saline•IV access if trained•Transport patient in prone (knees to chest) position

5050

Amniotic Sac Intact

ManagementUse clamp to tear sac, release fluidMove sac away from baby’s nose, mouthPrepare to suction at the perineum and post delivery

5151

Multiple BirthsConsider as possibility if: •Mother’s abdomen appears abnormally large prior to delivery•Mother’s abdomen remains large after delivery of first baby•Contractions continue after delivery of first baby

5252

Multiple BirthsDelivery of Multips:

• Clamp cord of first baby before delivery of second

• Usually second baby will deliver shortly after first

• Care for babies, mother, and placenta(s) as you would in a single birth

Multiple babies are usually smallIt is important to keep them warm!

5353

Review (of objectives)

Self evaluation – After attending this …..Can you effectively communicate usingterminology related to pregnancy?Can you discuss maternal changes and fetal

development that occur during pregnancy?Can you relate the complications of pregnancyand childbirth covered to patient presentations?

5454

References

Bledsoe, Porter, Cherry and Clayden.(2000).Essentials of Paramedic CareCanada: Pearson Education Canada

Emergency Health Services Branch. Ontario Ministry of Health and Long Term Care.(2007). Basic Life Support Patient Care Standards, version 2.0 . Toronto, CA.

Hill,C.C, & Pickinpaugh, J. (2008). Trauma and Surgical Emergencies in the Obstetric patient. Surg Clin North Am, 88(2):421-40,viii.

Kornelsen, J.A. & Grzybowski, S.W. (2008). Obstetric Services in small rural communities: What are the risks to care providers? Rural Remote Health. 8(2):943

5555

QUESTIONS?