Childbirth (part 1) Concept 1 EMS Professionals should be able - - PowerPoint PPT Presentation

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
• f 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
• f 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

• Wrap in blankets
• Cover baby’s head

Custom Medical Stock, Inc

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
• ver 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

• bstructing 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

• r 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

Embolisms

• Amniotic fluid enters maternal circulation

through vascular injury in the uterus.

• Clots in pelvic circulation become mobile.
• Standard pulmonary embolus assessment

and treatment applies.

• Cough, pleuritic chest pain, tachypnea, dyspnea, tachycardia, clear lung sounds

Post-partum Bleeding

• Massage uterine fundus
• May need Pitocin / Oxytocin
• Promotes uterine contraction
• Promotes delivery
• Controls post-partum bleeding
• IV infusion titrated

Oxytocin

• Typical administration could be 10 units added to 500cc NS = 20 milliunits /

ml and infused at 20-40 milliunits / minute until uterine contraction stops the

• bleeding. (60 microdrops = 20 milliunits so drip rates range from 60-120

microdrops per minute)

• Onset is immediate, duration is about 20 minutes after infusion is stopped.
• Some protocols allow Pitocin IM (10 units).
• Caution---verify whether you must wait for the placenta to deliver.
• Caution---be careful in multiples to make sure all babies and their placentas

have delivered.

• Pitocin / management of post-partum bleeding is something that really

deserves medical control consultation.