Over the next five weeks, we will be discussing many aspects of Obstetrics / Gynecology from an EMS perspective. There were 821 OB calls for departments under the UH Medical Command in 2020. As you know, most of those runs do not end with the field birth of a child, and there are very few that qualify as true OB emergencies. Because we have a relatively low run volume of OB / GYN calls, we must stay on top of current standards and protocol treatment options for these patients.

This week let’s take a look at the uncomplicated delivery. You are on the scene, delivery is imminent, and you decide you will need to stay on the scene and deliver the child. First and foremost, check a pulse, not the patient's, yours. Babies have been delivered since the beginning of time. Most deliveries are uncomplicated. The bottom line is to relax and look confident and competent. It will help the patient to feel more at ease and have greater trust in you. 

Try to obtain a detailed history that includes:

1. How many weeks pregnant the patient is and the expected due date.

2. How many pregnancies (Gravida) and how many live births (Parity or Para) the patient has had.

3. Has the patient had pre-natal care?

4. Are there any expected complications with this pregnancy or birth?

5. Obtain all other SAMPLE/OPQRST questions/answers.

Next, you need to decide if this birth is imminent meaning an on-scene delivery. Some signs that delivery is imminent are:

1. Has there been any bloody show or expulsion of the mucus plug?

2. Has the amniotic sac (water) broken, is there crowning, or is there an urge to push?

3. How far apart are the contractions, and what is the duration of each one? (To time contractions start at the beginning of one contraction and end at the beginning of the next contraction. This tells you how far apart the contractions are; note the duration of each contraction.) 

If you decide that a field delivery is necessary, you will need to open and set up your OB kit, position the patient for delivery, and establish an IV if there is time. It is also helpful if you have someone to document times and assist with equipment. Call for backup units as soon as possible if additional staff will be needed.

Per the UH Pre-Hospital care protocol and treatment guidelines:

• Delivery of the head – Firm, gentile pressure with a flat hand to slow expulsion. Allow the head to rotate normally, check for the cord around the neck and free up if necessary, wipe the face of debris, and suction the mouth and nose with a bulb syringe.

• Delivery of the body – Place one palm over each ear and with the next contraction gently move the baby downward to free the upper shoulder then gently ease out the lower shoulder. The child should easily come out at this point. Remember, babies are slippery.

• Newborn and cord – Keep the newborn at the level of the vaginal opening. Keep the baby warm and dry. After 10 seconds, clamp the cord placing 2 clamps at least 6” to 8” from the newborn 1 – 2 inches apart, and cut the cord between the clamps.

• Allow the placenta to deliver itself but do not delay transport while waiting. Take the placenta with the patient to the hospital.

• Remember to perform an Apgar score 1 minute and 5 minutes post-delivery.

The UH EMS protocol also calls for the administration of Oxytocin (Pitocin) 10 units IM by a Paramedic, if available, for all deliveries regardless of bleeding. This is to be administered only after delivery of the fetus. Do not administer if there are multiple fetuses until all babies have been delivered.

In the coming weeks, we will discuss neonatal care, abnormal birth emergencies, pre-and post-partum emergencies, and other OB / GYN issues.

Respectfully yours,

Dominic Silvestro EMT-P, EMS-I

University Hospitals EMS Training and Disaster Preparedness Institute 

APGAR - August 9, 2021

Last week we discussed the uncomplicated delivery. We reviewed proper history taking, the timing of contractions, signs of imminent delivery, and the protocol for a newborn delivery without complications. This week we will review what to do with the neonate after successful delivery.

Following the birth of the neonate patient, there are several procedures we need to follow to ensure that the patient is not in any distress and to recognize when the neonate patient is in distress and in need of resuscitative efforts.

Once the child is delivered and the cord has been cut, every effort should be made to dry the infant and keep them warm. During the drying process, you are stimulating the infant. This stimulation should result in the infant crying, breathing well, and actively moving. If not, try rubbing the infant’s back or flicking their feet. If the infants breathing and activity are still not adequate, you will want to begin BVM ventilations on room air at 40 – 60 breaths per minute to see if the infant begins to adequately breathe on their own. Remember that the neonate is used to very low oxygen saturations before birth. Typically 58% +/- 10% in the womb. It is not uncommon for oxygen saturations between 60 – 65% 1 minute after birth and even 85 – 95% 10 minutes after birth. Initial BVM on room air for the first minute is preferred over BVM with supplemental oxygen. Suction should only be used if the airway appears obstructed.

It is important that you also obtain an initial APGAR Score at 1 and 5 minutes after delivery. At 1 minute post-delivery, the APGAR score determines how well the neonate tolerated the birthing process. The 5-minute score tells you how well the baby is doing with the outside environment.

While obtaining the APGAR score, assess the neonate’s heart rate.

If the heart rate is greater than 100 BPM, monitor that reassesses. If necessary, provide blow-by oxygen, keep the baby warm, and transport to an appropriate facility.

If the neonate’s heart rate is between 60 – 100 BPM, continue with effective ventilation, initiate an IV/IO, and transport.

If however, the neonate has a heart rate less than 60 BPM, you must begin CPR at a ratio of 3:1. initiate an IV/IO, and follow the appropriate dysrhythmia or cardiac arrest protocol. Also, consider a saline bolus of normal saline 10ml/kg. If glucose reading is less than 45, administer Dextrose 10% at 2 ml/kg IV/IO.

As we have learned from the Inverted Pyramid of Neonatal Resuscitation, most neonates will only require Drying, Warming, Positioning, Suction, and Tactile Stimulation to begin to thrive in their new outside world. Fewer neonates will need additional oxygen, BVM ventilation, or chest compressions. Even less require advanced airway and medications. 

However, it is critical that every provider be prepared for any complication that may develop in the care of the neonate patient regardless of their level of certification. Remember that newborn arrest is typically not cardiac arrest. It is usually a respiratory arrest. Effective ventilation is the key to successful resuscitation. The use of a length-based tape system is critical to successful resuscitative efforts. There are too many variables in equipment and drug doses to remember when a small life is on the line. When in doubt, call medical command for guidance in these stressful situations.

Next week we will look at some abnormal birth emergencies you may encounter in the field. We will discuss the presentation and the field management of a cord around the baby’s neck, prolapsed cord, breech birth, and shoulder dystocia.

Dominic Silvestro EMT-P, EMS-I

University Hospitals EMS Training and Disaster Preparedness Institute  

Delivery - August 16, 2021

On the first two Mondays of this month, I discussed the uncomplicated delivery of a baby and neonate resuscitation. This week we will cover some abnormal birth emergencies that the EMS provider can encounter in the field. These emergencies do not require any paramedic or advanced EMT skills. However, they may require quick transport to an appropriate medical facility where more advanced care or emergency caesarian deliveries need to be performed. The abnormal birth deliveries we will discuss in this article will be umbilical cord prolapse, cord around the baby’s neck, shoulder dystocia, breech birth, and limb presentation.

Umbilical Cord Prolapse

The umbilical cord, as you know, contains two arteries and one vein and is the conduit between the fetus and the placenta. It is responsible for delivering oxygen and nutrient-rich blood to the fetus and removing oxygen and nutrient-depleted blood from the fetus. Umbilical cord prolapse occurs when the cord presents from the vaginal opening before the fetus and is exposed. While uncommon, this can be fatal to the fetus and requires immediate action. First, check the exposed cord for a pulse. Field care also includes placing the mother in hips elevated and knees to chest position for transport. If the cord is seen outside of or felt in the vagina, insert two fingers to keep the presenting part of the fetus away from the cord. Cover the exposed cord with a sterile saline dressing and transport it to the most appropriate facility. 

Cord around the Baby’s Neck

As the baby’s head passes out of the vaginal opening during delivery, you should feel for, and see, if the cord is wrapped around the baby’s neck. If this occurs, every effort should be made to loosen the cord and slip it over the baby’s head. If the cord is caught or too tight to slip over the baby’s head, clamp the cord in two places and cut between the clamps. Allow the normal process of delivery to continue, follow all appropriate delivery and neonate care protocols, and transport to the most appropriate facility. 

Shoulder Dystocia

Most common in mothers who are diabetic or obese, shoulder dystocia occurs when the infant’s shoulders are bigger than the head. In shoulder dystocia, the head is delivered routinely. However, after the head is delivered, the shoulders become trapped between the sacrum and the symphysis pubis preventing the infant from further delivery. The infant will either be stuck, and delivery will stop, or you may see “Turtle Sign” where the infant’s head suddenly retracts back inside the vaginal opening. Field treatment is the same as it is with a prolapsed cord. Transport the mother with the hips elevated and knees to chest, insert two fingers to relieve any pressure on the cord, and rapidly transport to the most appropriate facility.

Breech Birth      

Defined in the Oxford Dictionary as a birth in which the baby’s bottom or feet come out of the mother first, breech births provide unique challenges to the EMS provider in the field. Franks Breech occurs when the buttock presents first in the vaginal opening, and Footling Breech occurs when one or both feet deliver first. If the upper thighs or the buttocks have come out, then delivery is imminent. Once the child’s body is delivered, the EMT must support the child’s body and insert two fingers with the palm toward the newborn’s face, form a "V" with the gloved hand, and allow air to enter the birth canal, then reach the newborn's mouth and nose. If unable to deliver the baby, transport the mother with hips elevated and knees to chest to the most appropriate facility. 

Limb Presentation

Limb presentation occurs when the presenting body part that emerges first from the vaginal opening is a single-arm or leg. Field delivery is virtually impossible in this situation and usually requires an emergency C-Section. Do not encourage the mother to push, support, but do not pull on the presenting part and transport the mother with hips elevated and knees to chest to the most appropriate facility. 

Next week our fourth Monday message will cover Pre and Post-Partum Obstetrics Emergencies, and we will round out the month with a week five message on trauma in pregnancy.

Respectfully Yours,

Dominic Silvestro EMT-P, EMS-I

University Hospitals EMS Training and Disaster Preparedness Institute  

Bleeding - August 23, 2021

Over the past few Mondays, we have looked at the uncomplicated and complicated deliveries as well as neonatal resuscitation. This week I would like to look at some pre and postpartum emergencies that you may run into in the field. Treatment protocols may vary. However, the treatment options listed in this article are widely accepted for pre-hospitals care.

Bleeding During Pregnancy

There are many causes of bleeding during pregnancy. While some small spot bleeding may not be a sign of anything to worry about, any bleeding during pregnancy should be evaluated by a physician no matter how small.

Post – Partum Hemorrhage

While some bleeding immediately after childbirth is normal, excessive bleeding, greater than 300 – 500 ml, is an emergency and needs rapid treatment to prevent hypotension and shock. The University Hospitals Prehospital Care Protocol and Treatment Guidelines call for establishing an IV with fluid bolus to maintain a MAP of 65 or a systolic blood pressure of 90. A fundal massage should be given. If on the scene, the paramedic should administer 10 units of Oxytocin, and if the hemorrhage is uncontrolled with an HR > 120 and or SBP < 90, consider Tranexamic Acid (TXA) 1 gram in 100ml D5W over 10 mins.

Ectopic Pregnancy

Ectopic Pregnancy is defined as a pregnancy in which the fertilized egg implants outside the uterus. It typically occurs in the fallopian tubes but can also occur anywhere outside the uterus. If the egg begins to grow, it may burst the fallopian tube or other structures causing pain and /or life-threatening bleeding. This is a first-trimester emergency. The patient may present with severe pain on one side of the lower abdomen, sharp waves of pain in the abdomen, pelvis, shoulder, or neck. Vaginal bleeding can be severe. Weakness or dizziness may also be present. Treatment in the field is primarily supportive. If possible, establish an IV and transport to an appropriate facility. Any female patient of childbearing age that presents with abdominal pain should be considered to have an Ectopic Pregnancy until proven otherwise.

2nd and 3rd Trimester Bleeding

Placenta Previa

Placenta Previa usually occurs in the second half of pregnancy and presents itself as painless bright red vaginal bleeding. It occurs when the placenta attaches low in the uterus and fully, or partially, covers the mother’s cervix. Mothers with prenatal care usually know they have this condition and are being monitored carefully by their doctor.

Abruptio Placenta

 Any pregnant patient in the second half of the pregnancy with painful or tearing abdominal pain and/or bleeding must be suspected to have abruption placenta. This is a serious condition in which the placenta has detached from the uterus.

In both Placenta Previa and Abruptio Placenta, the field treatments are the same. Establish an IV and monitor for shock. IV Bolus may be given to maintain a MAP of 65 or systolic blood pressure of 90.

Next let’s look at two other Obstetrical Emergencies, which can be very dangerous to the mother and fetus:

Pre-Eclampsia and Eclampsia 

Pre-Eclampsia presents during the last half of a pregnancy or as late as six weeks post-partum. The main symptom is hypertension (SBP >140 and/or DBP >90), peddle edema, headache, possible vision problems, and epigastric discomfort. The mother may have also been diagnosed with the presence of protein in her urine. Any pre-eclampsia patients with the above-mentioned signs and symptoms should be treated with Magnesium Sulfate 4 – 6 grams IV/IO, given slowly, over 20 – 60 minutes until the patient has a loss of reflexes when you tap on the knees. If the patient’s SBP is >160 and /or DBP >110, some protocols call for Labetalol 20mg slow IV/IO with a repeat dose of 40mg IV/IO can be considered with Medical Control approval.

Eclampsia is a severe complication of pre-eclampsia where the patient begins to have seizure activity. This is a true emergency that can be fatal to the mother and fetus. The field treatment of eclampsia is geared at stopping the seizure activity. Give Magnesium Sulfate 4 – 6 grams IV/IO, fast over 2 – 4 minutes or until the seizures stop. If the Magnesium Sulfate fails to stop the seizures, treat the patient with a benzodiazepine-like Versed, Ativan, or Valium per protocol. If the patient’s SBP is >160 and /or DBP >110, some protocols call for Labetalol 20mg slow IV/IO with a repeat dose of 40mg IV/IO can be considered with medical control approval.

Next week in our final message on OB / GYN prehospital care, we will discuss trauma in pregnancy.

Respectfully Yours,

Dominic Silvestro EMT-P, EMS-I

University Hospitals EMS Training and Disaster Preparedness Institute     

Maternal Trauma - August 30, 2021

You are dispatched to a motor vehicle accident. Dispatch advises you that they have received multiple 911 calls stating that this is a head-on collision and that one of the vehicles was traveling at a very high rate of speed when it crossed the center line and hit the other vehicle. On arrival, you approach one of the vehicles. It has heavy front-end damage, and airbags have been deployed. There is a young female slumped over the steering wheel. As you approach, she sits back and mumbles to you, “I am 37 weeks pregnant”. All proper immobilization procedures are followed, and the patient is moved to the ambulance. The patient is conscious but confused with adequate ABCs, multiple facial lacerations, an obvious left leg deformity, and as your partner cuts the patient’s clothes off, you notice that her 37-week pregnant abdomen is depressed approximately 4-5 inches on the right side of the navel. What are your treatment priorities? How and where should you transport? What concerns do you have for this patient and her unborn baby?

According to a publication updated in May 2021 by Krywko DM, Toy FK, Mahan ME, et al.: Trauma in pregnancy has dramatically increased in the past 25 years and is now the number one cause of non-obstetrical maternal death in the United States. Trauma occurs in 8% of all pregnancies, and with major trauma, there is a 40 to 50% risk of fetal death. They further go on to say that motor vehicle accidents account for 50% of all traumatic injuries during pregnancy and 82% of trauma-related fetal death. Domestic violence also increases during pregnancy occurring in 4 to 8% of pregnancies and is associated with a 5% risk of fetal death.

After maternal trauma, placental abruption is the most common cause of fetal death. There is also a risk of spontaneous abortion, uterine rupture, rupture of the membranes, premature labor, and direct fetal trauma from blunt or penetrating mechanisms just to name a few. Unfortunately, while we can treat the mother, there is no specific field treatment when it comes to the fetus. 

Runs involving trauma in pregnancy can be emotionally charged events. Try not to get tunnel vision. Yes, you have an unborn fetus and an injured mother. Remember that the fetus is unlikely to survive if the mother dies. Treatment should be geared towards managing the mother as you would any other trauma patient by supporting and correcting issues with the patient’s ABCs, Manage and control any major hemorrhage, managing any other life= threatening injuries, and conducting a detailed exam while transporting the patient to a trauma center, preferably one that can also handle OB Emergencies when possible.

During treatment and transport, remember to be on the lookout for early signs of shock. The pregnant patient can compensate well and may not show classic signs of shock until they have had significant blood loss. The pregnant patient’s body does not consider the uterus to be a “vital organ”. The body will naturally start to shunt blood away from the uterus to compensate for blood loss further placing the fetus at risk. Watch for respiratory failure, and do not be fooled by normal SpO2 readings. The use of supplemental oxygen is a good idea for the pregnant trauma patient. Reassess the patient frequently remembering to transport with their right side slightly elevated to relieve pressure from the fetus on the inferior vena cava.

It is also important to remember that as the fetus grows the uterine wall and amniotic fluid provides less protection. Ground-level falls, mild impact to the abdomen, another small child jumping up and hitting the abdomen, and many more minor incidents can lead to possible fetal injury or loss. Even if the patient appears and states that she is fine, every effort should be made to convince her that it is in her best interest, as well as her unborn child, to allow you to transport her to an appropriate hospital to be evaluated. In these cases, it is always better to error on the side of caution.  

Respectfully Yours,

Dominic Silvestro EMT-P, EMS-I

University Hospitals EMS Training and Disaster Preparedness Institute