As discussed in the The Quick and Dirty Guide to Childbirth I most pregnancies progress normally and will result in a routine delivery. Pre-hospital deliveries seldom present any significant problems for the mother, newborn or the EMS crew but, complications due arise in a small percentage of pre-hospital deliveries. The EMT must be prepared for anything that may arise during a so called, routine delivery.
Trauma during Pregnancy
When a pregnant woman is injured, the fetus is at a high risk of death!
During pregnancy the fetus is well protected within the uterus; as we recall, the fetus is surrounded by the amniotic sac that's sole purpose is "protection". Because of the intact amniotic sac the fetus rarely experiences direct physical trauma except in cases where direct penetrating trauma or severe blunt force trauma are involved. The greatest risk to the fetus is from fetal distress and intrauterine demise caused by the trauma or death of the mother. When dealing with a pregnant trauma patient, the EMT should promptly assess and intervene on behalf of the mother!
Severe abdominal trauma causing fetal death can result in:
- Premature separation of the placenta from the uterine wall
- Premature labor/abortion
- Ruptured uterus
- Fetal death
Pregnant Trauma Assessment/Management
The priorities for treating a pregnant trauma patient are the same as for a non-gravid patient.
The emphasis of treatment for a Pregnant Trauma patient include:
- Airway with spinal precautions
- Assure appropriate ventilatory status (Apply O2 early)
- Check Circulatory status/support adequate circulatory status
- Control any life-threatening hemorrhage
- Assure Proper Spinal Immobilization
For patients beyond the 20th to 24th week of gestation, the patient should be tilted 15° to the left by placing rolled towels beneath the spinal board. This is completed to prevent supine hypotension syndrome, which occurs when the gravid uterus compresses the inferior vena cava. Such compression can decrease cardiac output by up to 28%, which then may cause significant hypotension. Alternatively, one person may be designated to manually displace the uterus to the left. If the patient does not require spinal immobilization, then she can be asked to assume the left lateral decubitus position.
If warranted, fetal heart tones may be auscultated as part of the initial fetal assessment and to reassure the mother. Never delay transport in order to assess the fetal heart tones.
Military anti-shock trousers (MAST) are considered a class III intervention (inappropriate, possibly harmful) for gravid patients.
If they are used, inflate only the leg compartment. (Per Local Protocol)
- Rapid safe transport to the nearest appropriate facility
Resuscitation of the mother is key in the survival of the fetus. Therefore, in the early stages of assessing/treating the patient, the focus should be on stabilizing the mother. Despite the severity of the injury. All pregnant trauma patients should receive high flow O2, full immobilization and rapid safe transport for evaluation of the fetus. The examination should be thorough.
Note: The EMT must detect and mange all injuries that can contribute to hypovolemia or hypoxia.
With an increase in maternal blood while pregnant, the mother can tolerate more of a blood loss without showing the signs and symptoms associated with shock. A 30-35% reduction in blood volume can produce minimal changes in the trauma patients BP, but reduces the fetal blood volume by 20%. Therefore, the pregnant patient is able to maintain a viable BP at the expense of the fetus. The extent of true blood loss is hard to determine so rapid safe transport and requesting ALS for volume replacement is crucial. But, never delay the transport of any critical patient to await ALS units if it is going to prolong the time it would take to reach the receiving facility. Motion is medicine in this case!
Special Considerations for Trauma Patients
Labor is a complication of trauma in a pregnant patient. The EMT should be prepared for the possibility of an emergency childbirth or a spontaneous abortion. Cardiac arrest can occur from a number of causes, but many cardiac causes of death after trauma are due to a decrease in venous return to the right atrium.
Note: The patient can not be resuscitated until the blood flow to the right ventricle of the heart is restored.
If Traumatic arrest occurs CPR should be initiated with the following modifications:
- Relieve the pressure on the aorta and the inferior vena cava by manually repositioning the uterus.
- Perform chest compression's higher on the sternum to adjust for the displaced organs during pregnancy. This will help produce a palpable wave pulse.
- Address the need for left lateral tilt of the torso to prevent compression of the vena cava. This can be accomplished with wedge shaped pillows that support the tilted torso during chest compression's.
An aggressive resuscitation effort is justified in patients that are near full term!
Medical & Disease processes of OB
Pregnancy can mask or worsen certain medical conditions and disease including:
A woman’s blood pressure generally is lower during pregnancy. However, women who have borderline hypertension before becoming pregnant, may become dangerously hypertensive as the pregnancy progresses. Persistent hypertension can adversely affect the placenta, thus compromising the fetus, as well as placing the mother at increased risk for stroke or renal failure. Two hypertensive emergencies specific to pregnancy are Pre-eclampsia and Eclampsia (toxemia).
Pre-eclampsia is a disease of unknown origin and usually afflicts normotensive young females during there first pregnancy after the twenty fourth week gestation. The pathophysiology of pre-eclampsia, which does not reverse until after delivery, is characterized by vasospasm, increased capillary permeability, and activation of the clotting cascade.
Pre-eclampsia is characterized by:
- High blood pressure
- Abnormal weight gain
- Epigastric pain
Also called toxemia, eclampsia is the most serious manifestation of hypertensive disorders of pregnancy. It is characterized by grand mal seizures. Eclampsia is often preceded by visual disturbances such as flashing lights or spots before the eyes. Eclampsia patients often experience swelling of the hands and feet and a markedly elevated blood pressure. If eclampsia develops, death of the mother and the fetus frequently results.
Note: Not all hypertensive pregnant patients have pre-eclampsia; Not all pre-eclampsia patients have hypertension.
The illness has many serious complications and the EMT should suspect pre-eclampsia or eclampsia when hypertension is present in late pregnancy. If suspected, pre-hospital treatment is directed at controlling seizures and treating hypertension therefore, if the EMT finds a pregnant patient to be hypertensive with S & S of Pre-Eclampsia/Eclampsia they should immediately request ACLS assistance.
1. Place the patient in the left lateral recumbent position. This will help to maintain uteroplacenatal blood flow, lessening the chance of insult to the unborn fetus.
2. Handle patient gently by minimizing sensory stimulation (i.e., darken the unit to help educe the possibility of seizures).
3. Administer high flow O2 via NRB @ 15 LPM; Assist ventilation as needed via BVM, 100% O2.
4. Treat for shock; be prepared for seizure activity. Be prepared to provide ABC support until ACLS interventions are initiated.
5. Initiate IV therapy, per local protocol.
6. Be prepared to administer the following medications, per local protocol and MCP:
- Magnesium Sulfate 10%. The antidote (calcium gluconate) should be close at hand to treat possible respiratory distress.
- Diazepam or lorazepam - May precipitate a drop in BP and can jeopardize fetal circulation. Monitor vitals closely
7. Safe, rapid transport to an appropriate facility.
Some women may develop diabetes during pregnancy called gestational diabetes. Pregnant diabetics are prescribed insulin if their blood sugar cannot be controlled by diet alone. Gestational diabetes cannot be managed with oral drugs because they are absorbed into the placenta and can adversely affect the fetus. Most women with GDM are aware of their condition and have had good prenatal care. Without treatment however, the diabetic patient will deliver a very large baby, making delivery more difficult with increased risk of fetal demise.
Management for GDM
Pre-hospital care for patients with GDM includes:
1. Airway control
Assure appropriate ventilatory status (Apply O2 early)
Check Circulatory status/support adequate circulatory status
2. Check patients blood sugar:
Paramedics can manage hypoglycemia with Dextrose and IV fluids
Patients with hyperglycemia may receive insulin in some ares (Per local protocol/MCP)
3. Initiate IV therapy with volume expanding fluids
4. Closely monitor the patients vitals during transport
Abruptio placenta is the premature separation of the placenta from the wall of the uterus. Separation can either be partial or complete. Complete separation usually results in death of the fetus. Several factors may predispose a patient to abruptio placentae. These include pre-eclampsia, maternal hypertension, multi parity, abdominal trauma or a short umbilical cord. When abruptio placenta occurs, blood collects behind the separated placenta. As a result, vaginal bleeding is minimal. If the placenta is not completely separated from the uterine wall, it can impede bleeding. If the placenta separates completely, the pressure is lost and severe hemorrhaging can occur suddenly.
Placenta previa is the attachment of the placenta in the lower part of the uterus covering the cervix. Unless a sonogram is done, placenta previa usually is not detected until the third trimester. When fetal pressure on the placenta increases or uterine contractions begin, the cervix thins out resulting in bleeding from the placenta.
1. Provide adequate airway, ventilatory, and circulatory support
2. Place the patient in the left lateral recumbent position
3. Begin transport ASAP, consider the need for ACLS intervention/intercept
4. Initiate IV therapy with volume expanding fluids
5. Apply a fresh perineal pad in case of hemorrhage
6. Check fundal height, document for a baseline measurement for the receiving facility
7. Closely monitor the patients vitals during transport
Abnormal Presentation of Labor/Delivery
Remember, during normal childbirth the head will present first but, with a breech presentation the fetus has turned within the womb, therefore the presenting part may be the buttocks. There are 3 distinct types of breech presentations:
- Frank Breech:
In a frank breech, the fetal hips are flexed and the legs extend in front of the fetus. The buttocks are the presenting part; this is the most common type breech.
- Complete Breech:
The fetus has both the knees and hips flexed. The buttocks present first; this type of breech delivery is rare.
- Incomplete Breech:
The fetus has one or both hips incompletely flexed resulting in presentation of one or both lower extremities (usually a foot).
Breech Presentation Management
It doesn't take all of our intelligence to know that a breech presentation just like any complications of childbirth is best managed in the hospital but, that isn't always possible. So,
we have to be completely prepared to manage the situation; adapt and overcome! If delivery is imminent, the EMS crew should:
1. Prepare the mother and your unit as if it were a normal delivery.
2. If ACLS personnel are not on board request them ASAP
3. Provide supplemental O2 prn
4. Establish IV access; Nacl.09
5. Continually monitor fetal heart rate
6. Allow the fetus to deliver spontaneously up to the level of the umbilicus.
If the fetus is in front presentation, gently extract the legs downward after the buttocks is delivered.
7. After the fetuses legs are clear, support their body with the palm of your hand and forearm.
8. When the umbilicus becomes visible, gently extract a 4-6 inch loop of umbilical cord to allow delivery without excessive pressure being placed on the cord.
Gently rotate the fetus to align the shoulders in an anterior-posterior position. Continue with gentle traction until the axilla is visible.
9. Gently guide the infant upward to deliver the posterior shoulder.
10. Gently guide the infant downward to deliver the anterior shoulder.
11. Ensure that the fetuses face or abdomen is turned away from the mother's symphysis.
12. Be alert; the newborns head is often delivered easily after the shoulders are cleared. Be careful to avoid excessive head and spinal manipulation, if the head does not deliver immediately, the medic must action to prevent infant suffocation. The paramedic must place a gloved hand in the vagina to prevent the newborn from suffocating. This is the only time you should place a gloved hand into the vagina.
13. The medic's palm should be toward the newborns face, while forming a "V" with the gloved hand; allowing air to enter the birth canal and reach the newborn's mouth and nose.
14. If the head doesn't deliver after 3 minutes, transport should be expedited while maintaining the newborns airway with the gloved hand "V" formation.
Shoulder dystocia occurs when an infant’s shoulders are larger than its head, happening most commonly with diabetic and obese mothers.
In shoulder dystocia, labor progresses normally and the head is delivered routinely. But, immediately after the head is delivered, the shoulders become trapped between
the symphysis pubis and the sacrum, preventing further delivery.
The first step in treating shoulder dystocia is recognizing when it occurs.
The two main signs of shoulder dystocia are:
1. The baby’s body does not emerge with standard moderate traction and maternal pushing after delivery of the baby’s head
2. “Turtle Sign” – the head suddenly retracts back against the mother’s perineum after it emerges from the vagina.
Typically, babies born with shoulder dystocia, do not suffer long-term complications. If complications do occur, they are usually because the baby has become stuck too long in the birth canal. There are a variety of reasons why a baby's shoulders may become lodged during delivery. The most common reasons include:
- Delivering very large babies with unusually high birth weights
- Often caused by diabetes or mothers who are very overweight
- Mother's pelvic opening being too small to allow the baby's shoulders to fit
A shoulder dystocia delivery calls for dislodging one shoulder and then rotating the shoulder girdle at an angle in to the wider part of the pelvic opening. Because the shoulder is pressing against the pelvis, there is a possibility of cord compression. Therefore, it is important to deliver the anterior shoulder immediately after the head. This should be accomplished before suctioning the newborn's nose and mouth. There are several methods the paramedic can employ to deliver an infant with shoulder dystocia. Use the method that is taught and approved in your area, below are standard methods taught in many areas of the country.
Two maneuvers may assist in releasing an infant presenting with shoulder dystocia:
- The McRobert's maneuver is accomplished by having the mother flex her legs into a knee-chest position. This maneuver allows the pubic symphysis to slide over the infant’s anterior shoulder and also flattens the maternal sacrum, allowing the posterior shoulder to slide past as well. The McRoberts maneuver is successful about 40% of the time.
If the McRoberts maneuver is unsuccessful:
- Suprapubic pressure may dislodge the impacted shoulder. The goal is to displace the infant posteriorly, allowing the anterior shoulder to slip under the pubic symphysis. As the name implies, suprapubic pressure is applied just above the pubic symphysis, and the goal is to push directly on the infant, still within the uterus. It is important to not apply pressure to the uterine fundus, as it will not aid in delivery, will increase intrauterine pressure and can result in uterine rupture.
Great lecture on shoulder dystocia by a paramedic/midwife!
A shoulder presentation (transverse presentation results when the long axis of the fetus lies perpendicular to that of the mother. The position usually results in the fetal shoulders lying over the pelvic opening. The fetal hand/arm is usually the presenting part.
Normal delivery of a shoulder presentation is not impossible
The EMS crew should provide supportive measures and rapid transport to an appropriate facility for a cesarean section.
1. Provide O2 via NC at 6 lpm; monitor SpO2
2. If ALS is available; establish IV of nacl 0.9 kvo for receiving facility
3. Treat for shock
4. Prepare for the possibility of a delivery (Place the mother in a head-down position with the pelvis elevated)
A cord presentation occurs when the umbilical cord slips down into or out of the vagina after the amniotic sac has ruptured. The umbilical cord is compressed against the presenting part of the fetus; diminishing the oxygen that reaches the fetus through the cord. The medic should suspect a prolapsed cord when fetal distress of unknown origin is detected. Predisposing factors include:
- Breech Presentation
- Premature membrane rupture
- Large Fetus
- Multiple Gestation's
- Pre-term Labor
Fetal asphyxia can ensue rapidly if the circulation through the cord is not re-established and maintained throughout delivery, very quickly. If the Medic can see or feel the umbilical cord in the vagina, take the following actions, quickly:
1. Position mothers hips elevated as much as possible. The Trendelenburg or knee-high positions may relieve the pressure on the cord.
2. Administer O2 via NC @ 6 LPM, monitor SpO2.
3. Instruct the mother to pant through the contractions and resist the urge to push.
4.If assistance is available, apply moist sterile dressings to the exposed cord.. This will minimize temperature change that can cause arterial spasms in the umbilical artery.
5. With a gloved hand, gently push the fetus back in the vagina. Elevate the presenting part to relieve pressure on the cord, it may retract spontaneously. Do Not reposition cord.
6. Maintain this hand position during rapid, safe transport to the nearest appropriate facility. The definitive treatment is a c-section.