Childbirth Happens!

Your Job Falls Somewhere Between the Catcher Johnny Bench and the Psychologist Dr. Joyce Brothers

OB - GYN OVERVIEW

• Identify a Patient About to Give Birth
• Delivery Care of the Mother
• Before, During & After
• Care of the Baby During & After Delivery
• Including Potential Complications
• Procedures for Neonatal Resuscitation

OB - GYN ANATOMY

OB - GYN DEFINITIONS

• Perineum - Skin Between Vagina & Anus
• Commonly Tears During Childbirth
• Bloody Show - Mucus & Blood From Vagina as Labor Begins
• Spontaneous Abortion - Miscarriage - Early Delivery of Products of Conception
• Never use the term "Spontaneous Abortion" near the Patient or Family

OB - GYN DEFINITIONS

• Meconium Staining - Baby Poop in the Uterus
• Crowning - Bulging of Vagina Due to the Presenting Part
• Cephalic Presentation - Normal Head First
• Breech Presentation - Part That Presents First, Other Than the Head

PREGNANCY

• Nine Months
• 38 to 42 Weeks
• Trimester
• Three 3-month Sections
• First Trimester
• Fetus Forms, Small
• Second Trimester
• Growing Quickly

PREGNANCY

• Third Trimester
• Mom is Also Changing
• Increase
• Blood Volume, Cardiac Output, Heart Rate
• Decrease
• BP Slightly
• Digestion
• Big Increase of Vascularity
• Uterus
• Breasts
• Other

LABOR

• Labor - Entire Process of Delivery
• 3 Stages
• First Stage
• Regular Contractions
• Thinning & Dilation of the Uterus
• Ends When Cervix is Fully Dilated
• 10 Centimeters / 4 Inches

LABOR

• Second Stage
• Baby Enters Birth Canal
• Ends When Born
• Third Stage
• Birth of Baby
• Ends When Afterbirth is Delivered
• Placenta, Umbilical Cord, Uterine Lining, Amniotic Tissue

LABOR PAIN

• Contraction Time / Duration
• Time From Start to End of Contraction
• Start to End of 1
• Contraction Interval / Frequency
• Time From Start of 1 Contraction to the Start of the Next Contraction
• Start to Start

LABOR PAIN

• Onset May Occur in Lower Back
• Pain in Lower Abdomen
• Contractions / Pain Comes & Goes
• Birth May Be Imminent
• Contraction Lasts 30 Seconds to 1 Minute
• Interval 2 to 3 Minutes Apart

OB KIT

• Surgical Scissors
• Cord Clamps/Hemostats
• Bulb Syringe
• Towels / Sheets
• 2 x 10 Gauze Sponges
• Sterile Gloves
• Baby Blanket
• Sanitary Napkins
• Plastic Bag
• Umbilical Tape / Cord

EMERGENCY CARE of
PREDELIVERY EMERGENCIES

• Scene Safe, BSI
• Initial Assessment - ABC’s
• History & Exam
• Vital Signs
• Treatment Based On Signs & Symptoms

EMERGENCY CARE of
PREDELIVERY EMERGENCIES

• Miscarriage - Spontaneous Abortion
• Initial Assessment & O2
• External Vaginal Pads
• Tx Fetal Tissue / Products of Conception
• Support Mother Emotionally
• Never use the term "Spontaneous Abortion" near the Patient or Family

EMERGENCY CARE of
PREDELIVERY EMERGENCIES

• Vaginal Bleeding (Late in Pregnancy)
• May Be Profuse
• May Have Abdominal Pain
• May Have Signs of Shock
• Treatment
• External Vaginal Pads
• O2, Treat for Shock

EMERGENCY CARE of
PREDELIVERY EMERGENCIES

• Seizure During Pregnancy
• Maintain Airway, O2
• Transport On Left Side
• Handle Gently
• Maintain Warmth
• Prepare for Delivery

EMERGENCIES IN PREGNANCY

• Placenta Previa
• Forms in Abnormal Location in Uterus
• Cervix Dilates, Placenta Tears
• Life Threatening

EMERGENCIES IN PREGNANCY

• Abruptio Placentae
• Separates From Uterine Wall
• Life Threatening

EMERGENCIES IN PREGNANCY

• Ectopic Pregnancy
• Egg Develops in Fallopian Tube
• Acute Abdominal Pain
• Vaginal Bleeding
• Pump & Pressure

• Late Sign

EMERGENCIES IN PREGNANCY

EMERGENCIES IN PREGNANCY

• Preeclampsia
• Swelling of the Extremities
• Eclampsia
• Preeclampsia
• High Blood Pressure
• Seizures
• Brought on by Eclampsia
• Life Threatening to Mom & Baby

NORMAL DELIVERY

NORMAL DELIVERY

• Transport, Unless Delivery is Imminent
• Are U Pregnant?
• Is This Your First Child? How Many?
• Contractions? Labor Pain?
• Any Bleeding or Discharge?
• Is There Crowning? -LOOK-

NORMAL DELIVERY

• Frequency / Duration of Contractions?
• Does Mom Have the Urge to Move Bowels?
• As Opposed to the EMT - We Know That Answer!
• Does She Need to Push?
• Is the Abdomen Rock Hard?

NORMAL DELIVERY

• BSI - More Than Just Gloves - Eyes, Gown
• Don’t Touch Genitals - Unless
• During Delivery
• And Make Sure Your Partner Is Present
• Don’t Let Mom Go to Bathroom
• Holding Knees Together Won’t Help

NORMAL DELIVERY

• Know Your Limitations
• You May Have to Deliver During Transport
• Contact Command
• MD Can Help
• If Crowning
• Stay & Deliver or Transport
• If Crowning More Than 10 Minutes
• Stay & Deliver or S & G

NORMAL DELIVERY

• BSI BSI BSI - Its Gonna B Messy
• Mom - Lie w/ Legs Drawn Up & Spread
• Elevate Butt - Pillow / Blankets
• Create Sterile Field Around Vagina
• Be Prepared For Other Bodily Things to Come Out of Other Body Orifices
• No One Told U About That - Did They?

NORMAL DELIVERY

• Prevent Explosive Delivery
• AVOID FONTANEL
• Fingers Gentle Pressure On Bony Skull
• Avoid Face & Fontanel
• Start During Crowning

NORMAL DELIVERY

• Wrap Baby In Blanket - Conserve Heat
• Aluminum Foil Will Aid in Heat Reflection
• On Side, Head Lower Than Torso
• Level w/ Vagina Until Cord is Cut
• Be Sure Baby is Breathing On Own
• Check Umbilical Cord - Pulsing Stops

NORMAL DELIVERY

• Clamp 10" From Baby
• 2nd Clamp 7" From Baby
• Width of 4 Fingers
• Cut - Watch for Squirt of Blood
• Check Cord End for Bleeding
• If Bleeding - Apply Another Clamp
• NEVER LOOSEN CLAMP
• Babies Die From Small Blood Loss

UMBILICAL CORD

• Anatomy

NORMAL DELIVERY

• If You Are Not In Transit Yet - Get Going
• Record Time of Birth
• Prepare for Delivery of Placenta
• Save and Transport Placenta
• It Must Be Examined at the Hospital
• Mom Will Likely Lose 500ml of Blood

Vaginal Bleeding After Delivery

• 500ml Blood Loss is Normal
• Tolerated Well
• Don’t Get Yourself or Mom in a Tizzy
• If Shocky - Treat for Shock
• Massage Uterus
• No Dummy…On the Outside!!!

CARE of the NEWBORN

• Position & Keep Warm
• Blanket, Aluminum Foil Over Blanket, Heater
• Repeat Suctioning
• Stimulate
• Flick Feet, Rub Back
• Be Prepared for Neonatal Resuscitation
• APGAR Score?

CARE of the NEWBORN

• APGAR Score

NEONATAL RESUSCITATION INVERTED TRIANGLE

• Drying, Warming, Positioning, Suction, Tactile Stimulation
• Oxygen
• Bag-Mask Ventilation
• Chest Compressions
• Intubation
• Medications

NEONATAL RESUSCITATION

• Breathing - Slow, Shallow or Absent
• Ventilate - 60 / Minute
• 1 Puff per Second
• Reassess After 30 Seconds
• Continue if Not Improved

NEONATAL RESUSCITATION

• Heart Rate
• If < 100 - Ventilate
• Same Ventilation Rules
• If < 80 - And Not Responding to Vent.
• Start Chest Compressions
• If < 60 - CPR
• Chest Compressions & Ventilate

NEONATAL RESUSCITATION

• Skin Color
• If Central Cyanosis
• With Spontaneous Breathing
• And Adequate Heart Rate
• Administer O2
• 10 - 15 L / Min
• Use O2 Tubing
• Hold Close to Face

ABNORMAL DELIVERIES

• Cord Presents Before the Baby
• Endangers Baby’s Life - Serious Emergency
• All BLS Assessment & Treatment
• Mom’s Head Down & Bum Up
• "Doggie Style"
• Moist Sterile Dressing On Cord

ABNORMAL DELIVERIES – PROLAPSED UMBILICAL CORD

• Sterile Gloved Hand Into Vagina
• Push Presenting Part Away From Cord
• Monitor Cord for Pulsation
• Get Moving

ABNORMAL DELIVERIES – BREECH DELIVERY

• Baby’s Butt or Lower Extremity Presents First
• Baby at Risk for Delivery Trauma
• Prolapsed Cord Common
• Transport Immediately
• O2
• Mom’s Head Down & Bum Up ("doggie style")

ABNORMAL DELIVERIES

• Get Help - Call for Assist
• Be Prepared for More Than 1 Resuscitation

ABNORMAL DELIVERIES

• Hypothermia Risk
• Must Conserve and Add Heat
• Crank the Ambulance Heater for All Births
• Resuscitation Usually Required

ABNORMAL DELIVERIES

• Baby’s First Bowel Movements
• Extremely Dangerous if it Occurs in the Uterus
• Suggests Fetal Distress During Birth
• Tarry, Black, Brown, Green, Yellow
• DO NOT STIMULATE UNTIL SUCTIONED
• SUCTION SUCTION SUCTION
• Mouth Before Nose
• Maintain Airway

STILLBORN

• Very Obvious Death While in the Uterus
• Blisters, Foul Odor, Deterioration of Tissue, Discoloration, Softened Head
• If Obvious Death
• Don’t Try to Resuscitate
• Very Tragic for Parents & Family
• Your Actions Can Be Comforting
• If Mom Wants to See - Make Baby Presentable
• Baptize??? - "I Bless You in the Name of the Father, Son and Holy Spirit."
• If Not Obvious Death - Start CPR

ACCIDENTAL DEATH of PREGNANT WOMAN

• Start Life Saving Actions Immediately
• Even if Mother Dies, Baby May Survive
• Chest Compressions
• Slightly Superior Than Normal
• Organs Have Been Moved, Including Heart
• Get to the Hospital for Emergency C-Section

GYNECOLOGY EMERGENCY

• Trauma - External Genitalia
• Treat as Soft Tissue Injury
• Never Pack Vagina
• Administer O2
• Ongoing Assessment

GYNECOLOGY EMERGENCY

• Vaginal Bleeding
• BSI, Airway, Sanitary Pad
• How Many Pads Has She Used?

GYNECOLOGY EMERGENCY – SEXUAL ASSAULT

• Criminal Situation
• BLS Care
• Be Non-Judgmental
• Protect Crime Scene
• Preserve Evidence

GYNECOLOGY EMERGENCY – SEXUAL ASSAULT

• Same Sex EMT When Possible
• Examine Only if Profuse Bleeding
• Discourage Washing or Voiding
• Preserve Evidence
• Document - Prepare for the Court Room