VAO MATERNITY MODULE · VAO MATERNITY MODULE AMBULANCE TASMANIA 6 Education and Professional...

VAO MATERNITY MODULE

AMBULANCE TASMANIA Education and Professional Development Unit V2.8 January 2015

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Clinical Field Protocols

To complete this module, you will need to become familiar with the following clinical protocols: • Clinical Approach to a Patient • VAO CFP07 Obstetrics • VAO CFP02 Assessment and Management of Newborn

Baby • VAO CFP09 Foreign Body Choking

…. and the following reference material: • VAO RM01 – Perfusion Status Assessment • VAO RM01 – Respiratory Status Assessment • VAO RM01 – APGAR Scoring System



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Obstetric Patients Aim For AT Volunteers to demonstrate the knowledge required to manage a variety of obstetric conditions including the pregnant trauma patient to a level as laid down by Ambulance Tasmania.

Objectives At the completion of this session the Volunteer will be able to: • Recognise the progression of child birth (stay and deliver or go) • Identify the three stages of childbirth. • Demonstrate an awareness of the common risks involved in

childbirth and manage them within AT guidelines • Determine and record the relative vital signs of mother and baby • Complete a patient report form and APGAR sheet to AT standards. • Identify the risks to mother and baby and manage appropriately the

traumatised pregnant patient.

REFERENCE ♦ Volunteer Ambulance Officer Clinical Field Protocols (CFP07

Obstetrics)



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INTRODUCTION Thankfully the progression of most pregnancies is normal, but on occasions there can be troublesome problems for the baby and or mother. We need to understand what is considered to be normal and how to assist in the delivery. There is potential for serious complications, during pregnancy, childbirth and post delivery, some of which require skills beyond the scope of the ambulance volunteer, and therefore require Paramedic / Medical backup. Presentation

Refer to Clinical Field Protocols The stages of labour are: Stage 1: The onset of labour to full dilation of the cervix Stage 2: From full dilation of the cervix to delivery of the infant/s Stage 3: Expulsion of the placenta, cord and membranes



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Refer to Clinical Field Protocols for : Management of the three stages of an uncomplicated birth In stage 1: History - Movement of patient – Posture – Oxygen – Cleanliness – Vital signs – Transport In stage 2: Modesty / privacy – Prepare equipment – Universal precautions – Instructions to mother on “pushing” – Faecal cleanliness – Support head – Break membranes PRN – Head delivery – Clean face - ? Aspirate* – Check cord is not around neck – Baby turns as shoulders pass through canal – Head slightly downwards at first then up as both of shoulders delivered – Check airway – Wrap baby – Note time, colour, response, cry – Dry baby and keep warm – write down APGAR score – Clamp cord x 3 – Cut cord – Gauze over wounds – Wrap baby suitably – Second APGAR score – Hand baby to mother – Maybe to breast – Pad mother’s perineum – Clean sheet under mother.

* Do not aspirate unless obvious signs such as blood or meconium



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FUNDUS

In stage 3 : It is not necessary to wait for the placenta to be expelled before transport. If the placenta has not delivered within 15 minutes then there is a strong possibility that it will not deliver without medical assistance. Check for signs of separation – Ensure uterus is firmly contracted – mother to push placenta out naturally – Placenta into plastic bag – Note delivery time of placenta – constantly check FUNDUS at umbilical level for firmness (cricket ball size) – Check vital signs of baby and mother – Check for haemorrhage



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Some of the complications of childbirth are :

Gestational diabetes:

Type 1 Shows signs of diabetes only during the pregnancy Type 2 The diagnosed diabetic pregnant patient likely to have diabetic complications during the pregnancy. The concerns are: With mother - Ketoacidosis – Pre-eclampsia – Amniotic fluid increases. With baby - Greater risk of congenital abnormality – Ketoacidosis from mother can be fatal – problems post delivery such as diabetes – respiratory distress – infection may result.

Hypertension in pregnancy : (see management in C/P Manual)

There are three indicators of pre-eclampsia (which may lead to eclampsia an extremely serious manifestation of convulsions in the pregnant woman)

I. B/P greater than 140/90 or increase of 30/15 on previous B/P II. Oedema of hands, face, trunk & lower limbs III. Proteinuria (undetermined in the field) Warning signs are: visual disturbances – headaches – vomiting – liver dysfunction – epigastric pain Management of the hypertensive pregnant patient – No bright lights, no rough transport, if fitting treat as per seizure patient – urgent backup required – Paramedic / Medical Officer



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Ectopic Pregnancy :

A PREGNANCY WHICH HAS DEVELOPED OUTSIDE THE UTERUS (usually within a fallopian tube)

Presenting Signs & symptoms:

I. Amenorrhoea (at least one missed period) II. Severe low abdominal pain (over fallopian tube) III. Shoulder tip pain (blood aggravation of diaphragm) IV. Abnormal vaginal bleeding V. Abdominal tenderness / distension VI. Signs of shock = low B/P - rapid weak pulse – pale clammy

skin

Follow Clinical Field Protocols – treat for shock – Paramedic backup

Threatened Preterm Delivery:

Defined as less than 37 weeks following last menstruation. The likely problems following delivery are: Respiratory distress (major concern) – Hypothermia (manage) Predisposition to infection ,feeding problems and jaundice

Haemorrhage:

Antetpartum haemorrhage that occurs before the 20th week of gestation The commonest cause of vaginal bleeding at this time is due to threatened miscarriage and blood loss is usually slight. The problems begin when this progresses into miscarriage when the bleeding increases The expulsion of the products of conception during this time is termed miscarriage or spontaneous abortion, spontaneous abortion (30% of pregnancies) is a natural process occurring in the first trimester of pregnancy.

Postpartum haemorrhage that occurs during or following delivery Blood loss greater than 600 mls (usually within first hour) often happens as a result of inadequate uterine tone (contraction of uterus stops bleeding normally) may be as a result of retained products of conception or partial separation of the placenta. Excessive bleeding may follow and place mother at serious risk (shock) Treatment as per Clinical Practice manual and Patient Care Guidelines for Haemorrhage and Shock. Paramedic backup essential



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THE PREGNANT TRAUMA PATIENT

It is obvious that the pregnant woman (two or more patients) are more difficult to diagnose following trauma. In late pregnancy the enlarged abdomen can lead to severe complications in trauma. Blunt trauma being very common and often leading to fetal injury. Likely signs and symptoms are: Upper quadrant pain – Referred pain to shoulder – Haemorrhage – S & S of shock – Pelvic fracture commonly occurs with major body trauma and can lead to serious blood loss – shock Uterine rupture sudden extreme impacts from falls or other accidents can lead to rupture of the uterus with devastating effects on the baby. Pain around the supra-pubic area diaphragm - S.O.Breath – vaginal bleeding Abruptio placenta trauma may cause the placenta to be torn away from the uterine wall leading to severe bleeding and loss of fetal circulation – the second most common cause of fetal death (most common is following the death of the mother) Watch for: Vaginal bleeding – Signs of shock – Severe abdominal pain – Rigid abdomen

“Points to ponder” • What can I do to check the unborn traumatised baby ? • During the primary survey what treatment should given which will

assist the unborn baby ? “Points to ponder” • Pregnant patients should be transported in left lateral position or

with a pillow placed under the right hip to elevate that side of the abdomen.

• What is the rationale for this ? • What should we take particular care to check ? (i.e. which relevant

V/S ?)



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APGAR SCORE (BABY’S FIRST SCORE SHEET) NAME – DATE - TIME OF SCORE SCORE 0 1 2 COLOUR BLUE –

PALE PINK BLUE EXTREM-ITIES

PINK

RESPS ABSENT SLOW IRREG-ULAR

GOOD CRYING

HEART RATE

ABSENT BELOW 100

ABOVE 100

MUSCLE TONE

FLACID SOFT FLECTION EXTEM-ITIES

ACTIVE MOTION

REFLEX NO GRIMACE

COUGH VIGOR-OUS CRY

COMPLETE AT 1 MINUTE AFTER BIRTH AND AGAIN 5 MINUTES LATER

VAO MATERNITY MODULE · VAO MATERNITY MODULE AMBULANCE TASMANIA 6 Education and Professional...

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