MOD F TECH 48 Maternity Flashcards
Obstetric Emergencies
- Birth Imminent (Normal Delivery)
- Maternity Complications
It is essential that control are informed as soon as it is evident that an incident is maternity related and an ambulance crew are dispatched asap
The most important feature of managing an obstetric incident is a rapid and accurate assessment of the mother to ascertain whether there is anything abnormal taking place
Ambulance personnel will follow a maternal assessment process to decide on the dispositon of the mother i.e stay on scene and request a Midwife or transfer to further care immediately
Terminology
- EDD/EDB - estimated date of delivery / birth
- LMP - last menstrual period
- SB – still birth
- Primigravida / primip: 1st pregnancy
- Multigravida / multip: all subs. pregnancies
- G/Gravida: pregnant
- P/Para/parity: number of live births
- Gestation = length of pregnancy in weeks
- 0 – 40 weeks normal
- 37 – 42 term
- 24 – 37 pre-term
- 24 weeks and less – miscarriage
- Fundus: top of uterus
- Meconium – first stool baby passes, thick dark green and sticky
- VBAC – Vaginal birth after caesarean
Gestation
A pregnancy is divided into three ‘trimesters’ each of 13 weeks. It is important to establish the stage in the pregnancy (Measured in weeks of duration of the pregnancy) to inform the crew to determine their course of action. For example, 14/40 on a maternity plan means that the mother is 14 weeks into the 40 week duration of pregnancy
General and Local Organisation of Obstetrics and Gynaecology Services
Stages of Labour
- First stage - the longest part of labour. The cervix is dilating (Opening up) during this stage
- Second stage – starts when the cervix is fully dilated (10cm) and ends with the delivery of the baby
- Third stage – Expulsion (Delivery) of the placenta and membranes
3 stages of Labour
Indicators of the onset of Labour
Imminent Delivery Indicators
•Regular contractions at 1-2minute intervals and an urge to push or bear down
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•Crowning or the top of the babies head/breech presentation visible at the vulva
Indicators of second stage
Management of second stage of labour
- Ask Control to arrange for a midwife or second vehicle/Paramedic to attend if you haven’t yet moved from the home address
- Prepare trolley bed or delivery area with incontinence pads
- Reassure the mother and tell her what you are doing. Remember to include the woman’s partner if present
- Have towels ready, enough to dry the baby and another to wrap the baby
- Support the mother in a semi-recumbent (or other comfortable) position discouraging her to lie flat on her back to avoid supine hypotension
- Encourage her to continue taking entonox to relieve pain and discomfort
- Open and lay out maternity pack
- Cover mother with blanket for warmth and modesty
- Respect ethnicity, religious and personal beliefs in respect of modesty i.e. some women will find it distressing to be attended by males
- As the baby’s head is delivering get the mother to pant rather than push. Instruct the mother to pant or puff allowing the head to advance slowly with the contraction. Consider applying gentle pressure to the top of the baby’s head as it advances through the vagina to prevent very rapid delivery of the head
- Check to see that the umbilical cord is not wrapped around the baby’s head; if it is, you may gently attempt to loop it over the head. If it is too tight leave it where it is; a tight cord should not prevent the baby delivering
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•Quickly dry the baby when it is completely delivered wiping any obvious large collections of mucous from the baby’s mouth and nose
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•Wrap in a dry towel and place the baby on the mothers abdomen
Only cut the cord if the following applies
•Mother or newborn requires resuscitation or medical intervention; examples of risk factors include: pre-term babies or haemorrhage
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•Short umbilical cord where the baby cannot be placed on the mothers abdomen
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(EMAS Clinical Bulletin 05/12/10 issue 15 – supersedes JRCALC guidance)
Third stage of labour
Third stage of labour
Deliver the placenta into a bowl or plastic bag and retain all discharge for inspection by a Doctor or Midwife
Management of the third stage of labour
- Do not pull on the cord during delivery of the placenta as this could rupture the cord making delivery difficult and cause excessive bleeding or inversion of the uterus
- If bleeding continues after delivery of the placenta massage the top or fundus of the uterus (at the level of the umbilicus) with a cupped hand, using a circular motion. This should become firm as gentle massage is applied. Consider the use of entonox to relieve associated pain and discomfort
Newborn assessment
•Place the baby on mother’s abdomen, dry and cover. The mother can assist by holding the baby securely
•
•Assess the newborn based on three factors
–Colour
–Heart Rate
–Respiration
Newborn assessment
Immediate Care
Warmth
Babies are extremely vulnerable to heat loss
Assess APGAR
Primary cause of a floppy baby at birth is hypoxia
Warmth
Babies are extremely vulnerable to heat loss
Assess APGAR
Primary cause of a floppy baby at birth is hypoxia
Pink, Blue, White baby
A healthy baby (Pink) will:
- be born BLUE but will ‘pink up’ rapidly
- have good tone
- cry within a few seconds
- have a good heart rate (120-150) within a few minutes.
Pink, Blue, White Baby
A less healthy baby (blue) – primary apnoea
- Born blue
- less tone
- May have a slow heart rate (<100)
- May not establish adequate breathing by 90-120 seconds after birth.
Pink, Blue, White Baby
An Ill baby (white) – terminal apnoea
- Born pale and floppy
- Not breathing
- Slow, very slow or undetectable heart rate (<60)
Airway
Before a baby can breathe effectively the airway must be open.
–Is baby’s head in neutral?
–Do you need a jaw thrust?
–Do you need a second person’s help to maintain neutral?
These manoeuvres will be effective for the majority of babies requiring airway stabilisation at birth.
Suction?
Airway suction immediately following birth should be reserved for babies who have obvious airway obstruction that cannot be rectified by appropriate positioning.
Breathing
The most urgent requirement for an asphyxiated baby at birth is that the lungs be aerated effectively
Breathing
- If baby is not breathing adequately then give 5 inflation breaths with a duration of 2-3seconds.
- With effective aeration the chest should rise and fall.
- If the chest does not rise/fall lungs are not aerated so RECHECK neutral position, jaw thrust, inflation time
- If the heart rate remains slow (<60min) or absent following 5 inflation breaths with good passive chest movement – start chest compressions
Circulation
- Chest compressions should be started only when you are sure that the lungs have aerated successfully
- Most efficient is the encircling hands – thumbs on the sternum, fingers over the spine at the back.
- Compress at a ratio of 3:1 – quickly and firmly to a depth approx. 1 third of the depth of the chest
- Ventilation and chest compressions may fail to resuscitate fewer than 1 in 1000 babies.
Practical Skills Practice
The most urgent requirement for an asphyxiated baby at birth is that the lungs be aerated effectively
Think:
- Airway position
- Aeration – breaths of 2-3secs
- Breathing
- Compressions
Complications of Pregnancy & Labour
Antepartum Haemorrhage
Miscarriage
(up to 24 weeks)
Often cramp like pains and the loss of the baby.
•Threatened miscarriage
–Light bleeding and little or no pain, foetus still alive.
•
•Inevitable miscarriage
–More pain like labour pains, rarely severe bleeding,
–pregnancy unlikely to continue.
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•Incomplete miscarriage
–When whole or part of the placenta is retained,
–bleeding likely to be more severe, this can become septic
Antepartum Haemorrhage
Bleeding from genital tract, gestation of 24 wks+ may indicate
•
•Placenta previa,
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•Placental abruption
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Bleeding may or may not be visible
Pain may or may not be present
Placenta Previa
Placenta Abruption
Placenta Abruption
- Bleeding in late pregnancy – accompanied by severe continuous abdominal pain
- Signs of shock
- Associated with hypertension
- May be some external blood loss, most usually concealed
- Abdomen tender, uterus will feel rigid
Management Placenta Abruption
- Time Critical
- Treat for shock
- Ask “when did you last feel baby move”
- Paramedic interventions – Fluid resuscitation
Ectopic Pregnancy
Ectopic Pregnancy Management
- Time critical
- Be prepared to manage and treat symptoms of shock
- Analgesia - Entonox
- Consider ectopic pregnancy in any woman of child bearing age with abdominal pain. Clinical presentation varies
•
Shoulder Dystocia
Prolapsed Cord
- Acute obstetric emergency
- More common in breech
- Higher risk of occurrence < 34 weeks
- Exposure to air will cause irritation and cooling which in turn produces vasospasm of the cord vessels
- Intermittent compression, compromises the foetal circulation
- Depending on its duration and degree of compression, foetal hypoxia, brain damage and even death can occur
Prolapsed Cord Management
Transport asap
Use two fingers to replace cord gently in the vagina (JRCALC)
Keep cord warm and moist
Use only dry dressing
Minimal handling
Clinical judgement how to move from home to vehicle
Entonox to reduce urge to push
Modified Sims position or prone with knees to chest, buttocks raised
Suggested Positions for Transporting
Postpartum Haemorrhage (PPH)
- Primary occurs at time of delivery
- Definition – 500mls +
- Causes;
–Uterine relaxation (atony)
–Retained placental tissue
–Genital tract trauma during delivery (tears of the perineum, vagina, cervix)
Primary PPH Management
- Oxygen therapy if SpO2 <94%
- Obvious perineal tears – apply direct pressure and pad
- Uterine bleeding = if soft & ‘atonic’ – feel for top of uterus usually around umbilical level massage with cupped hand in circular motion
- Treat for shock
- Transport asap
Secondary PPH
- Occurs > 24 hours post delivery
- Usually retained placental tissue
- Possible uterine infection
- Bleeding usually less severe
- Consider midwife intervention or if severe treat for shock transport to obstetrics unit asap
Breech
Breech
Malpresentation - Other Forms
Breech Management
- Do not attempt to move to hospital once presenting part visible unless one hand or leg is presenting
- Support in squatting or recumbent position
- Moved towards edge of the bed with legs supported in lithotomy position
- Avoid manipulation of the baby’s body – support only – stimulation may cause premature respirations
JRCAL recommend if breech delivery is not in progress or one hand or foot is presenting - transport nearest obstetrics unit ASAP, this is also the recommendation of the midwife (JRCALC overrides IHCD)
Pre-eclampsia
- Cause unknown
- Causes vaso constriction
- Occurs second half of pregnancy onwards
- Predisposing factors – hypertension, age 35+ teenagers plus other factors
- Protein in urine
- BP 140/90 ++
Eclampsia
- Seizures;
- Agitation (severe) - violent twitching
- Unconsciousness
- Photophobia
- Noise sensitivity
Management:
Seizure management
Diazepam – Paramedic only
Obstetrics unit – immediate delivery C-section
Complications of pregnancy
Practical scenarios 1-8
You are called to a Business Park. EOC report a 26yr old female with vaginal bleeding.
On attendance the female is in the office toilets being consoled by a colleague.
Miscarriage
Assess
- C ABCDEF
- Volume of blood loss
- Signs of shock
–Tachcardia >100bpm
–SBP <90mmHg
–Cap Refill > 2secs
Management
•
- Time critical
- Correct C ABC and transport to hospital
- O2 if <94%
- 250ml bolus of fluid early to maintain SBP 90mmHG
- Pain relief
THINK ECTOPIC!
Haemorrhage during pregnancy
Risk factors for miscarriage
- Previous history of miscarriage
- Previously identified miscarriage at scan
- Smoker
Obesity
Risk factors for ectopic pregnancy
- An intra-uterine contraceptive device fitted
- A previous ectopic pregnancy
- Tubal surgery
- Sterilisation or reversal of sterilisation
- Endometriosis
- Pelvic inflammatory disease
You are dispatched to a 38yr old female not feeling well and complaining of severe headache.
On attendance the female begins to fit.
Eclampsia
Assess
•C ABCDEF
•
•Time critical features
–Recurrent convulsions
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•SPO2
Management
- Correct A&B then transfer to Obs unit – Pre-alert
- Obtain IV Access
- Do Not administer fluid
- O2 if <94%
- Diazepam for convulsions > 2-3 mins or continuous
You are dispatched to a 19yr old pregnant female bleeding.
On attendance the female is on the sofa in a confused state, there is obvious blood on the sofa and the partner informs you she’s on the methadone programme.
Placenta Abruption
Assess
- C ABCDEF
- Time critical features
- Signs of Shock
Management
- Correct A&B then transfer to Obs unit – Pre-alert
- O2 if <94%
- IV access large bore cannula
- Fluid therapy if indicated
You are dispatched to a 28yr old woman in a department store, who is pregnant and is leaking lots of fluid.
When you attend the address, EOC inform you that the patient is on the 4th floor of the department store in the lingerie dressing room
Cord Prolapse
Assess
•Whether it is possible to replace the umbilical cord
–Assess the length of the loop of cord
Management
•
- Use two fingers to replace the cord
- Handle as little as possible
- Use dry padding to prevent further prolapse
- Position mother on side with hips raised
- Entonox
- Pre-alert & transfer to Obs unit
You are called to attend a home address where a 38 year old female is complaining of severe headache and photophobia
Mild/Moderate
Pre-eclampsia
Mild/Moderate
Pre-eclampsia
Assess
- C ABCDEF
- Assess for time-critical features
Management – If no time-critical features
- Thorough secondary survey
- Measure BP
- If > 22wks pregnant and BP> 140/90 discuss directly with Midwife or booked obs unit
Severe
Pre-eclampsia
- C ABCDEF
- Assess for time-critical features:
–BP>160/110mmHg
–Proteinuria
–Headaches (severe and frontal)
–Visual disturbances
–Epigastric pain
–R sided upper abdo pain
–Muscle twitching or tremor
–Nausea/ vomiting
–Confusion
–Rapidly progressive oedema
Assess BM
Management
- O2 – aiming for 94% -98%
- IV Access – large bore cannula
- Do not administer Fluids
- Urgent transfer with pre-alert to obs unit (Caution with lights and sirens)
Treat hypoglycaemia
You are called to a 21yr old pregnant female and birth is imminent.
When you attend her birthing partner informs you that “she wants a homebirth and will not go into hospital”
Breech
Breech
Assess
•Whether delivery is in progress or not.
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•Transfer to nearest Obs unit
–If delivery is not in progress
–If one foot or hand is presenting
Management
(if delivery is in progress)
•No handling of baby or cord Until body is free of canal & nape of neck is visible
–Only exception is to turn baby if the back is facing the mother’s anus
Note – cord prolapse is more common in breech births
Breech management
•Position mother
–Similar to McRoberts on edge of bed with legs supported
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•Buttocks and body deliver
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•With the next contraction the shoulder blades should appear
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•Allow the baby to hang by their own weight to encourage descent and flexion of the head
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•Support the baby during the birth of the head
You are dispatched to a 25yr old pregnant woman and birth is imminent.
When you attend, her partner informs you that he can see the head.
Shoulder Dystocia
Shoulder Dystocia
•Midwives and Obstetricians use HELPERR techniques.
–
–Help
–Evaluate for Episiotomy
–Leg, McRoberts
–Suprapubic constant/intermittent pressure
–Enter, rotational manoeuvres
–Remove posterior arm
–Roll onto all 4’s
Nb. Attending crew are advised to use the actions highlighted in red.
•Head delivered
–2 contractions
•McRoberts position
–2 attempts
•Suprapubic pressure
–2 attempts
•Intermittent pressure
–2 attempts
•All-fours position
2 attempts
Time critical
O2 and Pre-alert
McRoberts Manoeuvre &
Suprapubic Pressure
McRoberts Maneuver
http://www.youtube.com/watch?v=iIj8we3z5hc&sns=em
You are dispatched to a 17yr old pregnant female, birth imminent.
When you attend the boyfriend is just placing the newborn into a towel.
PPH
Assess
•Primary PPH
–Blood loss> 500ml within 24hrs of delivery
•
•Massive PPH
–50% of blood volume within 3hrs of delivery
Management
- Fluid replacement
- Direct pressure to tear with gauze or mat. pad
- Placenta delivered:
–Massage fundus
–Entonox
•Placenta not delivered:
Do not massage fundus
Transfer mother and baby to Obs unit with pre-alert
Sepsis S&S
- Pyrexia > 38oC
- Sustained tachycardia > 100 bpm
- Breathlessness (RR > 20; a serious symptom)
- Abdominal or chest pain
- Diarrhoea and/or vomiting
- Reduced or absent fetal movements, or absent fetal heart
- Spontaneous rupture of membranes or significant vaginal discharge
- Uterine or renal angle pain and tenderness
- The woman is generally unwell or seems unduly anxious, distressed or panicky.
Management of Sepsis
- 250ml bolus of crystalloid (Max 2000ml) (Paramedic)
- 02 @ 15ltrs/min via Non-rebreathing mask
- Rapid transfer to Emergency Department
- Pre-alert
Prevalence
- Breech: 3-4% (term)
- Shoulder Dystocia: 0.5 – 1.5%
- Cord Prolapse: 0.1- 0.6%
- PPH: 5%
- Eclampsia: 1% women with pre-eclampsia develop eclampsia (pre-eclampsia 2-8%)
Pre-Term Babies & Incubators
- Pre-term = >24 <38 Weeks
- Physical Characteristics
ØSkull Bones – soft & wide spaced or overlapping
ØLength – Under 44cm (17 inches)
ØWeight 2.5kg or less
ØSkin – Dull, wrinkly and covered with Lanugo, in very young it may be shiny, thin with prominent veins
ØGeneral - infant will be feeble, drowsy and unable to suck well
Health
•Respiratory Centre – not fully developed nor respiratory muscles
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•Thermo Regulation – not fully developed also no fat layer and minimal heat production.
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•Feeding – poor sucking and swallowing reflex leads to increases risk of aspiration and broncho-pneumonia.
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•Infection – Pre-term babies are at a greatley increased risk of infection predominantly Respiratory and Gastro-intestinal.
Incubators
Functions:-
- Control Temperature
- Supply Oxygen
- Maintain Humidity at 60% to 65%
- Reduce risk of infection
- Reduce unnecessary handling
- Provide ventilation
