Childbirth (part 1)
Concept 1 • EMS Professionals should be able to use terminology that is specific to Obstetrics and Gynecology. These terms are not part of everyday EMS work and therefore deserve special attention. • EMTs and Paramedics should have general knowledge of anatomy and physiology relevant to OB cases.
Terminology • EDC or EDD or "Due Date“ / LMP • Gravida / Para • Gestational age • Fetal Heart Tones • Meconium staining
Dates • LMP is Last Menstrual Period • Conception is assumed to occur 14 days later � • EDC is the Estimated Date of Confinement � • “Due Date” is the EDC and is also known as “EDD” (Estimated Date of Delivery) � • EDC is calculated by: • Date of start of LMP + 7 days • Count back 3 months • Add 1 year
Gravida-Para • Gravida is number of pregnancies • Para is number of deliveries • Nullipara has yet to birth first child • Primipara has given birth to first child • Multipara has given birth to more than 1 baby (twins etc do not count here) • Grand multipara has given birth 7 or more times (4-7) • “G2P1” indicates 2 pregnancies with one live birth • “G3P1A1” indicates 3 pregnancies, 1 live birth, 1 aborted
Gestation • Fetus develops during gestational period • Normal gestation is 40 weeks (280 days) • Full term is 38-40 weeks • Premature is before the 37th week
Gestational Benchmarks • 8 weeks---fetal stage begins, FHT audible with Doppler • 16 weeks---gender visible • 20 weeks---mother can feel movement • 24 weeks---respiratory motions start • 28 weeks---lungs have surfactant • 37 weeks---no longer premature • 38-40 weeks---full term
Anatomy • Ovaries • Fallopian tube • Uterus • Fundus • Placenta • Cervix---Dilated and effaced
Concept 2 • Determining if the presentation is normal or abnormal is key to effective management of the case. • Prenatal exams and ultrasound studies (sonograms) may provide clues. • Inspection is appropriate. Maintain modesty.
Gather History • Previous pregnancies • Previous live births • Due date (or LMP if uncertain EDD) • Ultrasound results / when was last ultrasound • Amniotic fluid / “membranes” / “water broke”
Assessment • Contractions (strength, regularity, length) • Crowning? • Urge to push / bear down / move bowels?
Concept 3 • Determining whether or not the childbirth is imminent is a key piece of information to make smart tactical decisions.
Imminent Delivery Questions (1 of 2) • How long have you been pregnant? • Have you had prenatal care? • Are you having contractions or pain? • How far apart are the contractions? • Are you aware of any complications with this pregnancy? • How many times previously have you given birth?
Imminent Delivery Questions (2 of 2) • How long does each contraction last? • Have you observed any bleeding or discharge? • Do you think your water broke? • Have you felt a gush of fluid? • Do you feel pressure in the vaginal area or the need to move your bowels? • Do you feel the need to push? • Are you pregnant with twins or triplets (or more)?
Questions to Consider • When to transport? • What transport mode? • What about multiples?
When to transport? • As soon as possible….. • Very difficult to manage birth while moving to the ambulance. • Harder to manage birth in the moving ambulance than at the scene. • Contractions (strength, length, frequency) plus presence of crowning plus mother’s feelings of pressure….add it all up.
Concept 4 • Normal presentations usually result in uncomplicated field childbirths. • There are a few complications that can happen with normal and abnormal presentations.
PPE for Childbirth • Everything you can find !
The "OB Kit" • Contents? • Storage location? • What else do you need? • How many / which supplies do you need extra?
Crowning • Observe vaginal area • Do not do any physical exam of external or internal genitalia • Look for crowning • Place hand on infants head to prevent explosive birth • Avoid anterior fontanels and face
Amniotic Sac • If amniotic sac has not broken, rupture sac and remove from infant’s face
Nuchal Cord---Cord Around the Neck • Observe to ensure cord is not wrapped around infant’s neck • If cord is around neck • Gently slip cord over infant’s head, or • If unable to, clamp and cut cord
Clear Airway • Once head is delivered, clear airway • Suction mouth, then nose • Expel air from suction bulb before placing in infant’s mouth • Do not touch the back of the mouth with the syringe
Meconium • Definition • Complication • Emergency medical care
Meconium • Fecal matter excreted by the baby while still in the uterus appears as dark green or yellow-brown substance in amniotic fluid. • Suction before baby begins to breathe • Do not let baby aspirate meconium • Monitor airway throughout transport
Deliver Body • Hold baby carefully— body will be slippery! • Torso and remainder of body will deliver more quickly than head • Again suction mouth, then nose • Use gauze to clear fluids from around mouth • Note and document time of birth
Maintain Warmth • Keep infant warm • Dry to prevent heat loss Custom Medical Stock, Inc • Wrap in blankets • Cover baby’s head
Cord cutting • When? • Where? • Why? • How? • Who?
Cut Cord • Keep baby at level of vagina until cord is cut • Clamp in two places • First clamp 4 inches from baby • Second clamp 3–4 inches further away • Cut between clamps using sterile scissors from OB kit
Post-delivery Care • Place baby in mother’s arms or on abdomen • Infant may begin nursing • Assess and monitor both patients • Transport as soon as practical
Placenta Care • Placenta often delivers within 30 min • Watch for delivery during transport • Wrap in towel and place in plastic bag • Place sterile pad over mother’s vagina, lower her legs • Instruct mother to keep legs together
Concept 5 • There are a few situations involving complications where childbirth is an acute emergency. First Responders, EMTs and Paramedics should be prepared for these uncommon cases.
Complications With Any Presentation • Nuchal cord • Meconium • Shoulder dystocia • Post-partum hemorrhage or embolism
Complications • Nuchal cord---usually slips over head, may have to clamp and cut • Meconium---suction, suction, suction • Shoulder dystocia---position (assist in maintaining), guide shoulders
Shoulder Dystocia • Definition • “Turtle sign” • Emergency medical care
Complicated Presentation • Prolapsed cord • Breech presentation • Limb presentation
Prolapsed Cord • Position • Knee-Chest position if stationary • If transporting, position supine with head down and hips up (use gravity to help keep baby off the cord). • May need to gently push baby off cord • Not a field delivery
Breech Presentation • Position same as for prolapsed cord • Not a field delivery • May need to use fingers in a "V" to keep vaginal wall from obstructing infant's airway • Don't be caught off guard in multiple births.
Limb Presentation • Position same as for prolapsed cord or breech • Not a field delivery • Don't be surprised at abnormal position with second twin.
Cephalopelvic Disproportion • Not a field birth. • Large baby or small pelvis or combination of those two factors. • Excessive pushing can cause uterine rupture.
Concept 6 • EMS providers must be ready to handle complications of childbirth. • Pulmonary emboli and post-partum bleeding are two of these complications.
Uterine Rupture • 1 in 1400 deliveries • Uterine scar, prolonged / obstructed labor, direct trauma • Assessed as rigid abdomen, shock, “tearing” pain, possibly palpable fetal parts through abdominal wall. • Rapid transport---surgical emergency
Uterine Rupture • As the uterus enlarges throughout pregnancy, the uterine wall becomes extremely thin and is prone to spontaneous or traumatic rupture. • The fetus can be released into the abdominal cavity. • Blood loss can be severe: Maternal mortality is between 5 and 20%. Fetal mortality is 50% • Uterine rupture requires emergency surgery.
Uterine Inversion • 1 in 2100 deliveries • Possibly from placenta attached to the fundus • Uterus protruding through cervix / vagina • Medical control may direct replacement
Post-partum Dyspnea - Chest Pain • Treat for pulmonary embolus if needed---O2 and rapid transport. • Embolus may be amniotic fluid or a blood clot
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