CBT 521 EMT 11 OBGYN Emergencies 2010 Seattle

Introduction • Many types of emergencies can occur with female reproductive system • This course will help you refresh your assessment & treatment skills for emergency childbirth & gynecological emergencies © 2011 Seattle / King County EMS

Course Objectives 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Identify anatomic structures of the female reproductive system and their functions. Demonstrate a basic understanding of pregnancy-related physiology by identifying appropriate statements on the menstrual cycle, ovulation, and fetal development. Identify signs/symptoms and proper care for gynecological emergencies. Identify the key aspects of evaluating a pregnant patient to determine if birth is imminent. Identify the purpose and use of tools in an OB kit. Identify the steps for normal delivery of an infant. Identify how and when to cut an umbilical cord. Identify the steps for post-delivery care of the newborn and mother including delivery of the placenta. Identify the critical treatment interventions for complications of pregnancy including: breech (buttocks) or two limb presentation, shoulder dystocia, prolapsed cord, and postpartum bleeding. Identify steps for assessing an infant’s APGAR score. Identify steps for neonatal resuscitation © 2011 Seattle / King County EMS

Terms abruptio placenta — This condition occurs when the placenta prematurely separates from the uterine wall causing heavy internal bleeding and pain; it can occur as a result of trauma. bloody show — Mucous and blood that comes from the vagina as the first stage of labor begins. The cervix is sealed by a plug of mucus during pregnancy to prevent contamination. When the cervix dilates, the plug is expelled as pink-tinged mucous. crowning — The bulging out of the vaginal opening caused by the baby’s head pressing against it. dilation — To get larger or enlarge. The degree of dilation of the cervix is often a key indicator used by midwives and physicians to determine if birth is imminent. However, EMTs do not perform this test. The process occurs over a period of several hours in some women, but can take much longer. eclampsia (toxemia) — A serious condition that can develop in the third trimester. It is characterized by high blood pressure and excessive swelling in the extremities and face. Life-threatening seizures differentiate eclampsia from preeclampsia. © 2011 Seattle / King County EMS

Terms, continued ectopic pregnancy — Condition where a fertilized egg implants outside the uterus, often in the fallopian tubes. Symptoms can include abdominal pain and vaginal bleeding. effacement — A term relating to the thinning of the cervix. meconium — A dark-green fecal material found in the intestines of full-term babies. Ordinarily, the meconium is passed after a baby is born. In some cases, the meconium is expelled into the amniotic fluid prior to birth. It gives the fluid a greenish-brown color known as meconium staining. placenta previa — A condition where the placenta sits low in the uterus blocking the cervix. It can present with painless, bright red bleeding. postpartum — A term used to describe the period shortly after childbirth. © 2011 Seattle / King County EMS

Terms, continued preeclampsia — A condition found in pregnant women characterized by high blood pressure, abnormal weight gain, edema, headache, protein in the urine, and epigastric pain. If untreated, preeclampsia can progress to eclampsia. supine hypotensive syndrome — A pregnancy-related condition where the weight of an unborn fetus and the uterus puts pressure on the inferior vena cava. The result is inadequate venous blood return to the heart, reduced cardiac output, and lowered blood pressure. © 2011 Seattle / King County EMS

New Terms Braxton-Hicks — A Braxton Hicks contraction is defined by Taber's Medical dictionary as an intermittent, painless contraction that may occur every 10 to 20 minutes after the first trimester of pregnancy. These contractions were first described in 1872 by British gynecologist John Braxton Hicks. Sometimes these contractions are also called prelabor contractions or Hicks sign. Not everyone will notice or experience these contractions, and some will have them frequently. Some mothers say that they notice them more in subsequent pregnancies than in their first pregnancy. © 2011 Seattle / King County EMS

Female Anatomy Reproductive Organs • Cervix – opening of the uterus – First stage of birth, cervix opens & thins – Allows fetus to move into vagina – Opening process called dilation • Endometrium – inner lining of uterus – Each month built up in anticipation of implantation of fertilized egg – Fertilization does not occur, lining simply sloughs off • Referred to as menstrual period © 2011 Seattle / King County EMS • Fallopian tubes – long slender passageways connect uterus to ovary – Female egg (ovum) passes through structure on its way to uterus for implantation to uterine wall • ovaries – two almond-sized glands located on each side of uterus behind & below fallopian tubes – Produce estrogen & progesterone in response to follicle stimulation hormone (FSH) & luteinizing hormone (LH) secreted from pituitary gland

Female Anatomy Reproductive Organs • Perineum – area between vaginal opening & anus – It sometimes is torn during birth which causes bleeding • Uterus – pear-shaped, muscular organ holds fetus during pregnancy – Contracts to push fetus through cervix & into vagina during birth • Vagina – flexible, muscular tube about three inches long – Called birth canal – Fetus moves from uterus through cervix into vagina & then out of mother’s body © 2011 Seattle / King County EMS

Fetal Anatomy • Placenta – develops early in pregnancy & performs important functions – Exchanges respiratory gases – Transports nutrients from mother to fetus – Excretes waste – Transfers heat – Active endocrine gland produces several important hormones – Attached by umbilical cord • Vein - transports oxygenated blood toward fetus • Artery – return deoxygenated blood to placenta • Amniotic sac – develops early in pregnancy – Consists of membranes surround & protect developing fetus – Fills with amniotic fluid cushions fetus & provides stable environment • Umbilical cord – attaches fetus to placenta – Contains one vein & two arteries – Vessels in umbilical cord similar to pulmonary circulation • Arteries carry deoxygenated blood • Veins carry oxygenated blood – Newborn cord is about two feet long © 2011 Seattle / King County EMS

Fetal Anatomy © 2011 Seattle / King County EMS

GYNECOLOGY © 2011 Seattle / King County EMS

Menstrual Cycle • Woman’s monthly hormonal cycle in which uterus prepares to receive egg • Then discharges a bloody fluid • Cycle repeats on average every 28 days, but can vary widely © 2011 Seattle / King County EMS

Menstrual Cycle • Days 1 to 5 – Egg has not been fertilized, hormone levels become lower causing thickened lining of uterus to shed – Results in a woman’s period – First day of menstrual bleeding is Day 1 in menstrual cycle • Days 6 to 14 – Pituitary gland produces hormone stimulates ovaries to develop follicles each containing egg – Only one egg reaches maturity & has potential to become fertilized – Hormone levels increase causing lining of uterus to thicken & prepare to receive mature egg © 2011 Seattle / King County EMS • Days 10 to 18 Hypothalamus & pituitary glands release hormone causes mature follicle to burst & release egg – Ovulation typically occurs midway through menstrual cycle on Day 14 – Egg begins its journey down fallopian tubes to uterus – Time period when a woman is most likely to become pregnant – • Days 16 to 28 – After releasing egg, ruptured follicle takes on a new role & secretes progesterone which continues to thicken lining of uterus in preparation for fertilized egg – If egg is fertilized by sperm, it implants in lining of uterus – If egg not fertilized or does not implant, lining of uterus is shed again at the beginning of the next menstrual cycle

PID • Pelvic inflammatory disease (PID) – infection of female reproductive tract – – – Organs most commonly involved Uterus Fallopian tubes Ovaries Occasionally, peritoneum & intestines © 2011 Seattle / King County EMS

PID Symptoms of PID include: –Lower abdominal pain –Fever –Abnormal vaginal discharge –Painful intercourse –Irregular menstrual bleeding –Pain in right-upper quadrant © 2011 Seattle / King County EMS • Vaginal bleeding & lower abdominal pain can indicate serious gynecological problem • Maintain high index of suspicion when encountered

PID • Causes of PID – Gonorrhea & chlamydia infections • Can progress undetected before PID symptoms appear – Other bacteria, such as staph or strep. • Acute or chronic – Allowed to progress untreated, sepsis can develop • Most common symptom of PID – moderate to severe, lower abdominal pain © 2011 Seattle / King County EMS

Vaginal Bleeding • Vaginal bleeding not result of direct trauma or normal menstrual cycle can indicate a serious problem • Difficult to isolate a specific cause, treat all vaginal bleeding as if there were serious underlying condition • Especially true if bleeding associated with lower abdominal pain © 2011 Seattle / King County EMS

Vaginal Bleeding • Treatment depends on patient’s needs, but may include the following: – – Maintain ABCs Control bleeding, if possible Administer oxygen Place in shock position © 2011 Seattle / King County EMS

Dilation and Curettage (D&C) • Dilation – opening of the cervix • Curettage – scraping the walls of uterus • Surgical procedure – usually done on outpatient basis under local anesthesia – Diagnose conditions such as cancer – Remove tissue after miscarriage – Elective abortion © 2011 Seattle / King County EMS • Complications – Heavy bleeding – uncommon • Patients with heavy bleeding – Evaluate for signs of shock – Expedite transport to hospital

Ovarian Cysts • Egg is released from ovary, cyst often left in its place • Cyst – fluid-filled sac that is often enlarged • Can rupture & cause abdominal pain • Occasionally cysts develop independent of ovulation © 2011 Seattle / King County EMS Ovarian Cyst

Sexual Assault • Rape – any genital, oral or anal penetration by a body part or object, through use of force or without victim's consent • It is a crime of violence with serious physical and psychological implications © 2011 Seattle / King County EMS

Sexual Assault • Trauma to woman’s external genitalia can be difficult to treat • Treat open wounds of genitalia with moist, sterile compresses – Need to maintain patient’s • Use direct pressure to modesty control bleeding – Rich network of nerves in • Do not place dressings in external genitalia makes the vagina such injuries painful • Injuries to this area tend to bleed profusely due to rich blood supply © 2011 Seattle / King County EMS

OBSTETRICS © 2011 Seattle / King County EMS

Ovulation • Pregnancy begins with ovulation in female • Fourteen days before beginning of next menstrual period, ovary releases egg into abdominal cavity • Egg enters fallopian tube – transported to uterus –Intercourse 24 -48 hrs before ovulation – Fertilization can occur in fallopian tube © 2011 Seattle / King County EMS Ovulation begins

Ovulation • Once fertilized, egg begins to divide • Fertilized egg continues down fallopian

Fetal Development Some of the significant development changes: Month Development Milestone 1 Development of brain, spinal cord, & heart 2 Feet & hands are distinguishable 5 Fetal heart tones detected by stethoscope 6 Baby capable of surviving on own if born premature 8 Fetus has an excellent chance of survival © 2011 Seattle / King County EMS

Trauma • Direct abdominal trauma can cause: – Premature separation of placenta from uterine wall – Premature labor – Abortion – Uterine rupture – Fetal death © 2011 Seattle / King County EMS • Fetal death can result from: – separation of placenta from uterine wall – maternal shock – uterine rupture – fetal head injury

Gestational Diabetes • Some women develop diabetes during pregnancy • Pregnant diabetics are prescribed insulin if blood sugar cannot be controlled by diet alone • Cannot be managed with oral drugs because they absorbed into placenta & can adversely affect fetus © 2011 Seattle / King County EMS

Ectopic Pregnancy • Implantation of growing fetus in location other than endometrium • Most common site is in one of the fallopian tubes • Surgical emergency because tube can rupture & cause massive bleeding 1 month old embryo 6 week old embryo © 2011 Seattle / King County EMS

Ectopic Pregnancy • Patients with ectopic pregnancy often have one-sided, lower abdominal pain, late or missed menstrual period, & occasionally vaginal bleeding • Life-threatening emergency • Treat for shock & initiate immediate transport © 2011 Seattle / King County EMS

Bleeding • Vaginal bleeding during pregnancy is cause for concern • Bleeding in early pregnancy often associated with spontaneous abortion, ectopic pregnancy, or vaginal trauma © 2011 Seattle / King County EMS • Vaginal bleeding in third trimester is usually caused by: – abruptio placenta – placenta previa – trauma to vagina or cervix • This can be a lifethreatening emergency

Bleeding • Ranges from light spotting to massive hemorrhage • Difficult to determine cause of vaginal bleeding in field • Suspect placenta previa, abruptio placenta, or vaginal trauma when you see vaginal bleeding during third trimester © 2011 Seattle / King County EMS

Abruptio Placenta • Premature separation of placenta from wall of uterus • Separation can either be partial or complete –Complete separation usually results in death of fetus • Several factors may predispose patient to abruptio placenta – – – Preeclampsia Maternal hypertension Multiparity Abdominal trauma Short umbilical cord © 2011 Seattle / King County EMS

Placenta Previa • Attachment of placenta in lower part of uterus covering cervix • Unless sonogram done, placenta previa usually is not detected until third trimester • When fetal pressure on placenta increases or uterine contractions begin, cervix thins out resulting in bleeding from placenta © 2011 Seattle / King County EMS

Hypertension • Preeclampsia – condition characterized by high blood pressure, abnormal weight gain, edema, headache, & protein in urine • Eclampsia – characterized by high blood pressure & excessive swelling in extremities & face • Life-threatening seizures differentiate eclampsia from preeclampsia © 2011 Seattle / King County EMS

Preeclampsia • Variety of signs and symptoms including: – – – Hypertension Abnormal weight gain Edema Headache Protein in the urine Epigastric pain • If untreated, preeclampsia can progress to eclampsia © 2011 Seattle / King County EMS

Eclampsia • Eclampsia, also called toxemia, most serious manifestation of hypertensive disorders of pregnancy • Characterized by grand mal seizures • Often preceded by visual disturbances such as flashing lights or spots before the eyes © 2011 Seattle / King County EMS • Eclampsia patients often experience swelling of hands & feet & markedly elevated blood pressure • If eclampsia develops, death of mother & fetus frequently results • Treat by lying mother on her side, maintaining airway, & delivering highflow oxygen

Supine Hypotensive Syndrome • Supine hypotensive syndrome occurs when increased weight of uterus compresses inferior vena cava while a patient is supine • Markedly decreases blood return to heart & reduces cardiac output • Some women are predisposed to this condition because of an overall decrease in circulating blood volume or anemia © 2011 Seattle / King County EMS

Supine Hypotensive Syndrome • Usually occurs in third trimester of pregnancy • Relieve it by tilting mother to one side Vena cava & aorta compressed by fetus © 2011 Seattle / King County EMS Compression relieved by tilting patient on left side

EMERGENCY CHILDBIRTH © 2011 Seattle / King County EMS

Signs of Imminent Delivery • Main task in evaluating expectant mother is to determine if delivery is imminent • Expose abdomen & genital area, taking care to be discrete • Visually inspect the abdominal & vaginal areas for bleeding or crowning © 2011 Seattle / King County EMS • Prepare for immediate delivery if observe any of the following: – Crowning – Contractions less than 2 minutes apart – Rectal fullness – Feeling of imminent delivery

Crowning • Crowning – appearance of any part of fetus in mother’s vagina • Remove enough of mother’s clothing to view genital region • Look for bulging at vaginal opening or a presenting part of infant © 2011 Seattle / King County EMS Crowning

Contraction Intervals • Occur at regular intervals ranging from 30 minutes to 2 minutes or less • Labor pain from contractions lasts from 30 seconds to 1 minute • As birth approaches, interval between contractions gets shorter • Contractions that occur within 2 minutes of each other, from end of one to beginning of next, signify impending delivery © 2011 Seattle / King County EMS • Consider transporting mother if baby does not deliver after 20 minutes of contractions 2 to 3 minutes apart • Labor is generally prolonged for mother’s first baby • Average is 12 to 17 hours which allows plenty of time for transport

Rectal Fullness • Rectal fullness or sensation of having to move one’s bowels can indicate infant’s head is in vagina & pressing against the rectum • Delivery is imminent • Do not let the mother sit on the toilet © 2011 Seattle / King County EMS

Feeling of Imminent Delivery • Mothers who have previously given birth often know when ready to deliver • Labor tends to be shorter after first child • Use your judgment given circumstances • When evaluating mother, keep in mind four signs of imminent delivery • Consider transport time © 2011 Seattle / King County EMS

Preparing for Delivery • Request a paramedic unit • Don sterile gloves, gown, and eye protection • Position mother on her back, legs drawn up • Provide supplemental oxygen • Prepare OB kit • Prepare infant BVM © 2011 Seattle / King County EMS Emergency delivery kit

Preparing for Delivery Presentations You Can’t Deliver • Single limb • Prolapsed cord © 2011 Seattle / King County EMS Presentations You Can Deliver • Head first (normal cephalic) • Umbilical cord around the neck • Shoulder dystocia • Buttocks first • Double footling

Assisting With Delivery • • Support head with gentle pressure Check if cord is wrapped around baby’s neck— attempt to loosen Apply gentle downward pressure on shoulder & head After anterior shoulder has delivered, apply gentle upward pressure Suction mouth (no more than 1 inch into) & nostrils (no more than ½ inch into each) when head appears Once delivered, stimulate infant if it does not breathe Put two clamps on umbilical cord & cut 6 inches from navel Suction mouth & nostrils © 2011 Seattle / King County EMS Delivery anterior shoulder Delivery posterior shoulder

Amniotic Sac • During first stage of labor amniotic sac usually breaks, expelling amniotic fluid • If sac is still covering infant’s head when head appears, use a finger to pierce sac • Find it very tough © 2011 Seattle / King County EMS • Note color & character of amniotic fluid • Fluid can be clear or straw-colored (which is normal) • Tainted & discolored, or thick & “pea soup-like” (which indicates meconium staining)

Detailed Delivery Instructions 1. Encourage the mother to breath deeply between contractions and push with contractions. 2. As the baby crowns, support with gentle pressure over perineum to avoid an explosive birth. 3. If the amniotic sac is still intact, rupture it with a finger to allow amniotic fluid to leak out. 4. As soon as the baby’s head appears, suction mouth & nostrils with a bulb syringe – squeeze air from syringe before inserting, insert syringe no more than 1 inch into mouth, no more than ½ inch into each nostril. 5. If the umbilical cord is wrapped around the baby’s neck, gently slip it over the head. Do not force it! If the cord is too tight to slip over the head, apply umbilical cord clamps and cut the cord. Clamp and cut the umbilical cord only if he baby’s head has emerged and is in a position that lows you to manage the airway. © 2011 Seattle / King County EMS

Detailed Delivery Instructions 6. Encourage the mother to push. Support the baby’s head as it delivers. Caution, babies are slippery! 7. To assist in delivery of the anterior shoulder, apply gentle downward pressure on the shoulder and head. 8. As soon as the anterior shoulder has delivered, apply gentle upward pressure to assist in the delivery of the posterior shoulder. 9. Once both shoulders have delivered, be ready for the remainder of the body to deliver quickly. Newborn babies are slippery so handle carefully. 10. Stimulate the newborn to breathe by tapping the feet, if necessary. 11. Once pulsations have stopped, clamp the cord by placing a clamp approximately 6 inches from the baby. Place a second clamp approximately 2 inches from the first, then cut the cord between the clamps. © 2011 Seattle / King County EMS

Detailed Delivery Instructions 12. Re-suction the baby’s mouth & nostrils only if baby not breathing or having respiratory distress 13. Dry & wrap baby in a warm blanket — cover its head 14. Place baby on its side to facilitate drainage 15. Perform an APGAR assessment at 1 minute & 5 minutes after delivery © 2011 Seattle / King County EMS

Care of the Infant • Baby not breathing – stimulate it by rubbing its back or tapping your fingers on soles of its feet • If newborn does not start breathing effectively within 10 – 15 seconds of stimulation, use infant BVM to deliver gentle puffs of air — enough to cause the chest to rise • If after 30 seconds of assisted ventilation there is no response & heart rate is less than 60 beats/min, begin CPR © 2011 Seattle / King County EMS

Care of the Infant • Keep newborn warm by drying it & then wrapping it in warmed blankets • After cord is clamped & cut, cover head • Be careful because a wet baby is very slippery • Repeat suctioning of nose & mouth, if needed • Remember to check APGAR score at 1 & 5 minutes © 2011 Seattle / King County EMS

Meconium Staining • If see signs of meconium staining, do not stimulate infant before suctioning mouth & nose • This avoids aspiration of fecal material that can cause pneumonia © 2011 Seattle / King County EMS

APGAR • APGAR scale – numerical measure of baby’s overall condition immediately after birth • Perfectly healthy baby will have total score of 10 • Many babies score 7 to 8 during first minute • By 5 minutes, most babies score 8 to 10 on scale © 2011 Seattle / King County EMS APGAR stands for: • Appearance • Pulse • Grimace • Activity • Respirations

APGAR Scale Sign Score 1 2 Blue, pale Body pink, extremities blue Completely pink Pulse Absent <100 >100 Grimace No response Grimaces Cries Limp Some flexion of extermities Active motion Absent Slow & irregular Strong crying Appearance 0 (color of skin, nailbeds, or lips) (reflex, irritability) Activity (muscle tone) Respirations Total © 2011 Seattle / King County EMS 1 min 5 min

Managing a Poor APGAR Score (PSS) • Three things to remember when managing infant with low APGAR score: position, suction and stimulate (PSS) – Position body so head is down & airway is open – Suction mucous & fluid from mouth & nostrils – Stimulate infant by taping bottoms of feet • PSS – memory aid to help recall these steps — position, suction and stimulate © 2011 Seattle / King County EMS

Care of the Mother • Once baby delivered & umbilical cord cut & clamped you should: – Monitor and control bleeding from mother – Begin fundal massage – Monitor vital signs – Keep the mother and baby warm © 2011 Seattle / King County EMS • Transport once infant is delivered • Do not wait for placenta —may take up to 30 minutes to deliver • Do not pull on umbilical cord • If placenta does deliver at scene, transport with mother & baby to hospital

Monitor and Control Bleeding • After placenta delivered, place sanitary napkin between mother’s legs • Ask her to hold legs together • Normal for mother to bleed up to one cup (about 250 cc) or 5 sanitary napkins of blood after delivery • Record number of pads © 2011 Seattle / King County EMS

Fundal Massage • Makes uterus contract & diminishes vaginal bleeding • Can feel for fundus of uterus, located in abdomen between pubic bone & umbilicus Video demonstration available at EMS • Should feel like a softball Online: • Perform massage like you http: //www. emsonline. net/obgyn 2011/ mother. asp would a firm muscle massage • Area may be tender & massaging it can cause discomfort © 2011 Seattle / King County EMS

COMPLICATIONS FIELD CARE © 2011 Seattle / King County EMS

Umbilical Cord Around Neck • Once head delivered ask mother to stop pushing so you can check if cord is wrapped around infant’s neck • If cord looks like it is wrapped tightly, so as to constrict airway, need to loosen it • Gently slip cord over baby’s head by placing two fingers under cord at back of neck • Bring cord over shoulders & head • Cord durable, it can tear if handled roughly so don’t use excessive force • Too tight to loosen, clamp cord in two places two inches apart • Cut cord between clamps • Unwrap cord from around neck & take care not to injure baby Video demonstration available at EMS Online: http: //www. emsonline. net/obgyn 2011/neck. asp © 2011 Seattle / King County EMS

Shoulder Dystocia • Labor progresses normally & head delivered routinely • However, immediately after head deliveres, shoulders become trapped between symphysis pubis & sacrum, preventing further delivery • First step in treating shoulder dystocia is recognizing when it occurs • Two main signs of shoulder dystocia are: – Baby’s body does not emerge with standard moderate traction & maternal pushing after delivery of baby’s head – “Turtle Sign” –head suddenly retracts back against mother’s perineum after it emerges from vagina © 2011 Seattle / King County EMS

Shoulder Dystocia Do’s & Don’ts of Mc. Roberts Maneuver Do • Pull knees backwards (towards patient’s ears) & out to side to rotate & open the Video demonstration available at EMS pelvis Online: • Use suprapubic pressure to http: //www. emsonline. net/obgyn 2011/ dystocia. asp untrap the shoulder from behind pelvis Do Not • Do not pull forcefully on baby’s head • Absolutely, no fundal pressure © 2011 Seattle / King County EMS

Buttocks & Double Footling Presentation • If buttocks or two feet present first, you can attempt delivery in field • These are generally slow deliveries & you likely have time to transport © 2011 Seattle / King County EMS Key points are: • Request paramedic unit • Position mother with buttocks at edge of bed • Hold mother’s legs in flexed position • Support infant’s legs — do not pull • As head passes pubis, apply gentle upward traction until mouth appears • If head is stuck, create airway by pushing away vaginal wall — transport immediately

If Head Does Not Deliver • Create airway for infant • First, place gloved hand into vagina with your palm towards infant’s face • Form a “V” with index & middle finger on either side of infant’s nose • Push vaginal wall away from infant’s face to allow unrestricted breathing • Maintain airway & transport immediately © 2011 Seattle / King County EMS

Postpartum Bleeding • Important steps in caring for postpartum bleeding include: – Fundal massage – Treat for shock – Do not force delivery of placenta – Place sanitary napkin at opening of vagina Fundal massage © 2011 Seattle / King County EMS

Neonatal Resuscitation • After delivery, if infant not breathing effectively after 10 to 15 seconds of stimulation, begin assisted respirations • Use infant BVM with high-flow oxygen at a rate of 40 to 60 breaths/min • If pulse rate falls below 60 beats/min, start compressions & ventilations at ratio of 3: 1 at 120 events/min (which is 90 compressions & 30 ventilations) • Remember, ventilation is the most important action in neonatal resuscitation © 2011 Seattle / King County EMS

CPR - Two-Thumb Encircling Hands Technique CPR technique for infant with pulse rate below 60 beats/min 1. Place infant on a firm, flat surface 2. Remove clothing from chest 3. Find compression site which is just below nipple line on middle or lower third of sternum 4. Wrap your hands around upper abdomen with your thumbs on compression site 5. Use your thumbs to deliver gentle pressure against sternum, pressing ½ to ¾ inch into chest © 2011 Seattle / King County EMS

MUST TRANSPORT © 2011 Seattle / King County EMS

Single Limb Presentation Key points of assisting with single limb presentation include: • Support baby with your hands • Provide airway for baby using your fingers • Transport immediately — do not attempt delivery in field © 2011 Seattle / King County EMS

Prolapsed Cord If you see umbilical cord in vagina, presenting before the baby, initiate the following steps: 1. Request a paramedic unit 2. Place mother in knee-chest position 3. Check umbilical cord for pulsations 4. No pulsations - press presenting part of fetus away from umbilical cord, towards mother’s head 5. Re-check cord for pulsations Prolapsed cord © 2011 Seattle / King County EMS 6. Administer high flow oxygen to mother 7. Transport immediately – fetus will die quickly without rapid intervention 8. Continue holding presenting part of baby away from umbilical cord 9. Apply moistened dressing on exposed umbilical cord 10. Do not push umbilical cord back into vagina Knee-chest position

Case Study Video Case Study http: //www. emsonline. net/obgyn 2011/case 1. asp © 2011

Summary Key structures of female reproductive system include: – – – – Cervix Endometrium Fallopian tubes Ovaries Perineum Uterus Vagina © 2011 Seattle / King County EMS The key structures of fetal anatomy include: – Placenta – Amniotic sac – Umbilical cord

Summary Care for vaginal bleeding includes: – Maintain ABCs – Control bleeding, if possible – Administer oxygen – Place in shock position © 2011 Seattle / King County EMS Signs of imminent delivery include: – Crowning – Contractions less than 2 minutes apart – Rectal fullness – Feeling of imminent delivery

Summary • Fetus has excellent chance of survival after the seventh month of pregnancy • Pregnant women more susceptible to traumatic injury because of th increased vascularity of uterus • Patients with ectopic pregnancy often have one-sided abdominal pain, late or missed period, & occasionally vaginal bleeding • Vaginal bleeding in third trimester usually caused by abruptio placenta, placenta previa, or trauma • To relieve supine hypotensive syndrome tilt the pregnant patient to one side © 2011 Seattle / King County EMS

Summary Key points for assisting with normal delivery: • Support head with gentle pressure • Check if cord wrapped around baby’s neck—if so, attempt to loosen • Apply gentle downward pressure on anterior shoulder and head • After anterior shoulder has delivered, apply gentle upward pressure on posterior shoulder & head • Suction mouth and nostrils when head appears • Once delivered, stimulate newborn if it does not breathe • Put two clamps on umbilical cord & cut 6 inches from navel Care for newborn infant includes: • Stimulate infant if not breathing sufficiently • Start CPR if no response after 30 seconds • Keep infant warm • Repeat suctioning of mouth & nose • Check APGAR score at 1 & 5 minutes © 2011 Seattle / King County EMS

Summary • APGAR stands for appearance, pulse, grimace, activity, & respirations • Care of mother includes: – – Monitor & control bleeding from mother Begin fundal massage Monitor vital signs Keep mother & baby warm • If head remains stuck during buttocks or double footling presentation, create airway by pushing away vaginal wall then transport immediately • Important steps in caring for postpartum bleeding include fundal massage and treatment of shock © 2011 Seattle / King County EMS

Questions EMS Online Guidelines and Standing Orders http: //www. emsonline. net/downloads. asp Susan Kolwitz Program Manager Email support: help@emsonline. net Dr. Mickey Eisenberg Medical Director Ask the Doc: http: //www. emsonline. net/doc. asp © 2011 Seattle / King County EMS