2-19 OBSTETRICAL EMERGENCIES & CHILDBIRTH

EMR - Emergency Medical Responder

1. Initial Assessment and Care
2. Obtain a history to include
   1. Gravida (number of pregnancies, including this one)
   2. Para (number of previous live births)
   3. Due Date.  A fetus delivered before 20 weeks gestation does not usually survive.
   4. How far apart are the contractions?
   5. Length of previous labors
   6. Has the bag of water ruptured?
   7. Inquire regarding medication, drug or alcohol use
3. Administer oxygen at 4 liter per minute via nasal cannula
4. Position the patient and check to see if crowning is present and if so prepare for delivery.
5. Time the contractions.
6. Perform and record vital signs
   1. If patient has abdominal pain or vaginal bleeding while pregnant monitor closely for hypotension. If >5 months pregnant (20 weeks, uterine fundus above the umbilicus), place on left lateral side, recumbent, for transport.  Otherwise, place in supine position, legs elevated.
   2. If patient is greater than 20 weeks pregnant with BP > 140/90, request ALS intercept and notify of elevated BP.
   3. If patient has elevated BP and seizures, provide quiet and dim environment and notify incoming ambulance immediately of any seizure activity
7. Abnormal presentation
   1. Request ALS Intercept
   2. If umbilical cord or any area other than infant’s head presents first, transport immediately.
   3. Coach mother in shallow respirations and to avoid pushing.
   4. For cord presentation, place gloved hand at vaginal opening to hold vaginal walls away from cord.
8. Delivery
   1. Place patient in a supine position with knees flexed and legs apart.
   2. Open the OB pack, put on sterile gloves and drape the patient’s abdomen and perineum.
   3. If the amniotic membrane is visible and still intact, tear this open to allow the fluid to drain. This will facilitate delivery.
   4. Control delivery of the infants head so it does not emerge too quickly. Use your palm with gentle pressure to support the head as it emerges and protect the perineum.
   5. As the head emerges, check to see if the cord is wrapped around the neck. If so, gently slip over head.
   6. Suction the infant’s mouth with a bulb syringe, then the nose.  Compress the bulb before placing into the mouth or nose.  Note presence of any meconium.  Do not pull on head or neck.
   7. As shoulders emerge, guide the infants head and neck downward to deliver the superior shoulder, and then guide the head gently upward to deliver the inferior shoulder.
   8. The rest of the infant should deliver with passive participation.  Maintain a firm hold on the infant.  It is easiest to grasp ankles with one hand while supporting the body and head with the other until the child is dry and wrapped.
9. Care of the newborn.
   1. Continue to suction the infant’s mouth and nose keeping the baby’s head lower than the rest of the body.
   2. Spontaneous respirations and crying should begin within 15-30 seconds. Tap infant’s feet or buttock to stimulate breaths.  If breathing does not commence within 30 seconds of delivery, ventilate per nose and mouth at rate of 40-60/min.
   3. Pulse should be greater than 100.  If not, ventilate for 30 seconds and reassess.
   4. If pulse less than 60, begin CPR at rate of 120.  See Neonatal Resuscitation.
   5. Keep infant level with vagina until cord is clamped.  Wait for umbilical pulsations to stop (usually one minute), then clamp cord six inches from infants body with two clamps two inches apart.  Cut the cord between clamps.
   6. Dry the infant and keep warm.  Increase heat in patient compartment.
   7. Observe breathing status and color of baby closely while en route to the hospital.
   8. Record APGAR score at 1 and 5 minutes.
   9. Appropriately secure neonate for safe transport.
10. If the perineum is torn and bleeding, apply direct pressure with sanitary pads or gauze.
11. Once baby is born, apply fundal massage through the abdomen.
12. Monitor vital signs closely
13. Document the following:
    1. Time of delivery
    2. Appearance of amniotic fluid (clear, brown or green?)
    3. APGAR score at 1 and 5 minutes
    4. Time of placental delivery

APGAR Score: Record at 1 and 5 minutes, maximum 10 points

Sign	0	1	2
Appearance	blue, pale	extremities blue	pink throughout
Pulse	0	<100/minute	>100/minute
Grimace	none	movement	cry
Activity	limp	some flexion	active flexion
Respirations	0	weak cry	strong cry

EMT - Emergency Medical Technician  Perform/Confirm All Above Interventions

1. ALS intercept for complications such as hypertension, seizures, altered mental status, excessive bleeding, abnormal presentation
2. Notify hospital early so that the OB department will be ready.

AEMT – Advanced Emergency Medicine Tech   Perform/Confirm All Above Interventions

1. Establish IV en route
2. Contact Medical Control for fluid orders.

Intermediate  Perform/Confirm All Above Interventions

Paramedic - Perform/Confirm All Above Interventions

1. If patient is seizing, administer midazolam (Versed) 2 mg IV/IO and contact Medical Control for further benzodiazepine orders.
2. Contact Medical Control for further benzodiazepine order and for consideration of administration of magnesium sulfate 2 gms slow IV/IO over 5 to 20 minutes, monitoring closely for hypotension and respiratory depression.