BASIC OBSTETRIC EMERGENCIES
Most babies are born in a hospital. However, there will be times when you will be called to the scene of a pregnant woman in labor and you will not have time to get her to the hospital. It will be your responsibility to know how to assist the woman in delivering her baby. Enjoy it! This is probably the rare occasion where everyone is happy on one of your scenes! The following is a review of "birthing babies the basic way" so that you are more comfortable with what you have to do when the time comes. And it will!!!
Anatomy and Physiology
The fetus is the developing, unborn baby. It develops inside of a muscular organ called the uterus which is located between the rectum and the bladder. The fetus receives its nourishment through the placenta via the umbilical cord. Inside the umbilical cord lies three vessels: two arteries that carry deoxygenated blood from the fetus to the placenta and one vein that carries oxygenated blood from the placenta to the fetus. When the fertilized ovum embeds itself in the uterus, the amniotic sac completely surrounds it. This sac acts like a protective covering and contains amniotic fluid. This "bag of waters" acts as a shock absorber and maintains the body temperature of the fetus. The cervix is located at the neck of the uterus. A mucous plug forms here and acts as a protective barrier between the cervix and the vagina. The vagina is known as the birth canal. The area between the vagina and the rectum is the perineum and sometimes is torn during the birth process.
The birth process, or labor, is divided into three phases. The first phase begins with the uterine contractions and ends when the cervix is fully dilated. The cervix dilates to 10 cm in diameter. Sometimes during this phase, the bag of waters ruptures. The second phase begins when the cervix is fully dilated and the baby begins to pass through the birth canal. The contractions are closer together and stronger. Crowning occurs and the baby is born. The third phase begins after the baby is born and ends with the delivery of the placenta.
As with any other emergency you respond to, the very first thing you do is size-up the scene. Make sure it is safe for you to enter before doing so. Consider what body substance isolation equipment you may need and have it ready, if not already on, when you enter the scene. Gloves, gown, and eye protection should be worn due to the possibility of splashing of body fluids. Your initial assessment should give you a general impression of the patient and what is happening. With these types of calls, your patient usually has a patent airway, is breathing and has a pulse. But you should keep them in the back of your mind and assess them if they are not obvious when you arrive at the patient's side. The focused assessment should focus on the obvious - the whole reason you were called. This means you need to begin asking some questions and getting a history of what has happened thus far:
1. Is the patient having contractions?
2. When did the contractions start, what is the duration of each contraction, and how far apart are they?
3. Has the bag of waters broken?
4. Does the patient feel an urge to push or go to the bathroom?
5. When is the patient's due date?
6. Has the patient been under medical care?
7. Is this the first pregnancy? How many times has the patient been pregnant?
8. Were there any complications with the previous pregnancy/birth?
9. How long did the previous labor last?
10. Obtain a SAMPLE
All of these questions will give you pertinent information and should assist you in making a decision about whether to transport the patient now or prepare for a delivery on the scene. You or your partner should time the contractions and gauge how strong they are by palpating the patient's abdomen and watching the patient's reactions to the contractions. You should also visualize the vaginal area for a bulging perineum or crowning during the contractions. These things indicate that the birth is imminent and you should prepare for it quickly.
There are several pre-delivery emergencies you should be aware of.
An abortion is a fetus that is delivered before the 20 th week. If the abortion is spontaneous, it is also called a miscarriage. Watch for hemorrhaging and for any fetal tissue that may be expelled. If any tissue is expelled, take it to the hospital for analysis. Monitor the patient for shock during transport. Provide emotional support.
Pre-eclampsia and Eclampsia
Pre-eclampsia, the first stage of toxemia, is a condition in which the mother-to-be has a history of weight gain, swelling in the extremities, increase in blood pressure, and possibly headaches and visual disturbances. When this condition progresses to the point where the patient experiences a seizure, they are said to be eclamptic. Monitor the airway, give high flow oxygen, use a BVM if necessary to assist respirations, place mom on her left side, monitor vital signs, and transport.
Placenta previa is a condition in which the placenta embeds itself low in the uterus and is close to or over the cervix. When the patient's cervix begins to dilate during labor, the placenta tears and bleeding can be profuse. This is usually painless. Monitor the airway, give high flow oxygen, watch for shock, and transport.
Abruptio placenta occurs when the placenta separates from the uterus. The patient will complain of sudden, severe abdominal pain. The bleeding that occurs with this condition is usually always internal and can be life-threatening. Monitor the airway, give high flow oxygen, watch for shock, and transport.
A ruptured uterus is a rare occurrence. The uterus can tear as a result of trauma or scar tissue. The patient may complain of a tearing sensation in the abdomen or a constant and severe abdominal pain, abdomen will be rigid, and the patient may go into shock. Vaginal bleeding is typically minor, but could be heavy. Monitor the vital signs, give high flow oxygen, treat for shock, and transport quickly.
Definitive care for patients with placenta previa, abruptio placenta, or a ruptured uterus is performed in the hospital setting. They will probably need an immediate Cesarean section.
If a patient in her third trimester of pregnancy lies flat on her back, she will most likely develop dizziness, a drop in blood pressure, reduced return of the blood to the heart, and reduced cardiac output. This is a condition known as supine hypotensive syndrome and is caused by the weight of the baby pressing down on the inferior vena cava. All mothers-to-be in their third trimester of pregnancy should be transported on their left side in order to avoid this condition.
When a patient tells you she is having contractions 1-2 minutes apart, she feels the urge to bear down, or you see crowning, then rest assured the birth is imminent and preparations better be underway because that baby is coming whether you are ready or not! You should use body substance isolation precautions now if you haven't already. If at all possible, try to have some privacy for the patient. Place sheets, towels or the sterile sheets from the obstetrics kit over the patient's legs and abdomen and under the buttocks. If crowning is visible, place a gloved hand on the presenting part with a little bit of pressure in order to prevent an explosive delivery. Remember to reassure the mother and help her to breathe if she gets panicky. Panting or breathing deeply may help her during the contractions. If the amniotic sac has not ruptured yet, you need to puncture it. As the baby's head is born, make sure to wipe the amniotic fluids away from the nose and mouth and suction. Make sure that the umbilical cord is not wrapped around the baby's neck. If it is, slip it off. If you cannot slip it off, you will need to clamp it in two places and cut it. The baby's body is usually delivered very quickly after that. Note the time!
Keep the baby's head lower than the body in order to let gravity help keep secretions flowing out. Suction vigorously especially if there was meconium staining in the amniotic fluid. Meconium is the greenish coloring sometimes seen when the baby has its first bowel movement prior to birth. It is a thick, sticky substance that can cause serious lung complications for the baby if inhaled.
Dry the baby and wrap it in a warm, clean blanket. If the umbilical cord has not already been cut, make sure it is no longer pulsating and clamp it approximately 4-5 inches from the baby and a second one 2-3 inches from the first. Cut between the clamps and make sure that there is no leakage of blood on the baby's side. If there is, use a second clamp to prevent further bleeding.
Check the APGAR Score at one and five minutes after birth:
The APGAR scoring system provides a method to document a newborn’s condition at specific intervals after birth. It is also a useful objective indicator to determine effectiveness of resuscitative efforts. The scoring system does not determine the need for resuscitation.
A baby should begin breathing within 30 seconds. If it does not, stimulate it by rubbing its back or flicking the bottom of the soles of the feet. Provide artificial respirations at a rate of 40-60 per minute if it still does not breathe adequately. If the heart rate is less than 100 beats per minute, assist respirations at a rate of 40-60 per minute and reassess. Chest compressions at a rate of 120 per minute should be started if the pulse does not increase or if it is less than 80.
Remember to continue caring for the mother during this time also. The placenta should be delivered within 20-30 minutes after the birth of the baby. Be sure to save it and transport it to the hospital also. Clean mom up, place a sanitary napkin over the vaginal opening. Prepare her for transport to the hospital. As with all patients, an ongoing assessment is necessary. Monitor vital signs, watch for hemorrhaging, and monitor any interventions you may have performed en route. If hemorrhaging is present, massaging the uterus in a circular motion will help the uterus contract and slow down bleeding. If she is able to and there are no complications with the baby, she may choose to nurse her baby.
Complications during Delivery
While most deliveries are normal, the EMT should be aware of those that are not so normal. A prolapsed umbilical cord occurs when the umbilical cord is delivered first. The problem with this situation is that as the baby's head is coming down the birth canal it will compress the umbilical cord. You must place a gloved hand inside the vaginal canal and apply gentle pressure on the head in order to keep it from being born. High flow oxygen should be placed on the mother. She should be told not to bear down and "blow" during contractions. Mother and EMT should be transported in this position to the hospital quickly where a cesarean section will be performed.
If the presenting part is not the head (cephalic delivery), there may be problems with the delivery process. A delivery is said to be a breech delivery if the baby's buttocks or legs are coming first. Support the baby's body as it is born making sure that the umbilical cord is not compressed. The head may or may not deliver immediately. If it does not, slip two fingers inside the birth canal and push the vaginal wall away from the baby's nose and mouth. You will have to transport the mother and baby in this position to the hospital.
If the presenting part is a limb, you will not be able to deliver this baby out in the field. A cesarean section will be necessary. Give the mother high-flow oxygen, instruct her not to bear down and transport quickly to the hospital.
Occasionally you may have a patient who is expecting more than one baby. The delivery process is the same although you will probably need more assistance. Keep in mind that these babies may be smaller and premature. Remember to note the times of ALL the births. Premature babies are more at risk for developing infections and hypothermia. They are typically smaller than a full term baby and sometimes they will not be fully developed and will require respiratory assistance.
The role of the EMT during a birth is mainly supportive in nature. Occasionally there are complications and you must know how to handle them. Good luck and have fun!