Obstetrical Patient Assessment

[Music] my name is James McLaughlin I'm a paramedic firefighter for its Black Forest Fire Rescue this is my partner Travis he'll be assisted today by Stephen Buckner paramedic firefighter with tri-lakes Monument Fire Department today we're discussing imminent delivery first thing we need to talk about are the indications of imminent delivery the three things you want to look for that indicate imminent delivery are ruptured membranes and urged to push and crowning so the first thing you want to do is ask the patient ma'am have you had an abnormal discharge from your vaginal area let's say a large rush of water or something of that nature ma'am do you feel like you have an urge to push bare down or have a bowel movement and then the last thing you want to ask the patient is ma'am I need to check to see if the baby is starting to crown can I expose your your lower abdominal area and your peritoneal area and take a look okay when doing this you need to move the patient to a personal and quiet spot and then let the patient know ma'am I'm going to lift up you're down okay and we're going to check the peritoneal area and here you can see presentation our crowning of the baby's head of the infant's head through the peritoneal area and through the vaginal opening okay once you have those indications of imminent delivery you need to make sure that you move the patient into a functional but quiet area that protects the patient's privacy okay once we move the patient into that private area I'm gonna call paramedic Buckner and I'm gonna have him establish an IV for me and place the patient on high-flow oxygen while paramedic Buckner is doing that I'm going to ask the patient a few questions ma'am how many previous pregnancies have you had how many live births have you had have you had good prenatal care are there any expected complications with this pregnancy are you taking any medicines do you have any allergies to medications what kind of medical history do you have do you have diabetes high blood pressure or anything of that nature is there anything else that we should know about this pregnancy next we're gonna go ahead and prepare the mother for delivery and we're gonna have Travis step in and begin to coach the mother and help her understand what's going on and what we need her to do this step is very important if you can keep Mom and control and have her do what you need her to do it will make the delivery safer and more productive so now that we've determined the delivery is imminent we need to get our body substance isolation on okay so I'm going to apply any time you're delivering a child you want to make sure to wear protective eyewear and gloves it's also a good idea to utilize a gown as deliveries can tend to be quite messy the next thing we need to do once we have our body size substance isolation applied is we need to reposition the patient for better position a delivery so my partner Travis is going to step on the other side and we're gonna move mother down so that her buttocks rests on the edge of the gurney this can also be accomplished by putting the mother on the gurney backwards in the back of the ambulance so that she faces so her backside faces the tech seat down just a little bit more there we go then we're gonna hang mom's legs off the side this is a common position and we're gonna make sure that mom's moved into a a quiet and personal private space alright this is the position that's called the c-curve method this is the most commonly used position for delivery in the United States what we're gonna do is mom will go ahead and guide her legs up during contractions okay now we need to get the rest of our stuff in position so we're going to grab a seat and the cart and we're gonna drape sterile dressings over both of moms legs and over her abdominal area and we want to basically maintain an aseptic environment for delivery to reduce the risk of infection for mother and for baby we're gonna put some padding under mothers head and then Travis is going to continue to talk to mother throughout the delivery process now as we head into this phase because we have crowning I want to apply gentle pressure to the baby's head to prevent an explosive delivery when doing so I also want to prevent putting pressure directly over the fontanel area of the baby's head okay so as I'm applying this gentle pressure and and I feel another contraction coming on mom and so Travis is going to instruct mother to take a deep breath in and push for ten seconds and the delivery process will include we want to try and get about three good ten-second pushes in with every contraction with deep breaths in between each push all right ma'am we're gonna need you to take a real deep breath and push when I tell you to take deep breath and push push push push push push push push push okay now I'm gonna slide my hand keep going push alright now I'm gonna slide my hand in up around the neck area and what I'm doing here is I'm checking to see if the cord is wrapped around the neck if the baby's presenting with a brachial presentation and I do not see a cord around the neck now if I did see a cord around the neck what I would need to do is have mother stop pushing and have the coach and this is where a coach comes in handy the coach would instruct mother to take deep breaths and use panting breaths okay men we're gonna need you to take a deep breath and just kind of pant like you're a dog just right and as he does that I'm gonna try and work my fingers in around the cord and gently without using too much pressure because I don't want to tear the cord I want to gently pull the cord from around baby's head at this time if I can't do that or if there's multiple wraps around the neck I may have to take each one off one at a time if I still can't do it then you need to follow your local protocols on the most appropriate way to deal with a cord that is too tight to pull around the head all right now now that the head is completely delivered and the body started to turn I'm going to support the head and neck and this is the perfect time to grab your bulb suction and begin to suction the baby's mouth and nose now we suction the mouth first and you remember that because there's one mouth and two nostrils so we're gonna squeeze the bulb syringe then introduce it into the mouth and then suction on the way out and then squirt the the suck secretions on the ground and then do the same thing in the nose same on the other side and if you're nicer than me you can also do it on the side of the the barrier that you have set up then you're gonna set that off to the side and as another contraction comes you're going to deliver that anterior shorter that answer your shoulder first by supporting the neck you're going to put slight downward pressure on baby so that that anterior shoulder delivers there we go so we're gonna deliver that anterior shoulder and then after we deliver that anterior shoulder we're gonna bring slight upward pressure and deliver that posterior shoulder now once both shoulders are delivered the next part comes pretty quickly so be careful and hold onto baby well and then immediately upon delivery the best thing you can do his place baby right onto mother's belly making sure not to pull pressure on that umbilical cord okay once baby's there resting on mom's abdomen you can then take your clamps and the first clamp is going to be placed about ten centimeters from baby okay and then close it and then you're gonna place the second one about five centimeters away from the first now we're not going to close these because this is a scenario situation but in real life we would close these clamps completely then we're gonna take our scalpel and we're gonna remove our safety shield from our scalpel and then in between the two clamps we're gonna cut away from us and away from mom severing the the umbilical cord completely this will then immediately go into a sharps container so now that baby is delivered and the court has been separated we mean to warm dry and stimulate baby we start by taking a towel and removing baby from Mom's abdominal area supporting the head and we vigorously warm and dry baby by by using good friction we're stimulating baby and we're warming and drying baby at the same time okay this is a great opportunity to suction baby's mouth out again so again we start with the mouth and we suction on the way out and again and we suction on the way out and then with the nose and the other nostril okay and when we're done with that if we have a cap that should be in our OB kit we can place the cap on baby's head and we can swaddle baby if baby's still not responding well another we can do is place baby on mom's abdominal abdominal area and we can actually tap the foot and stimulate baby that way once we get good response from baby we can get our 1 minute and 5 minute Apgar scores then we can swaddle baby up support baby's head and then give baby to mother and allow mother to put baby to breast then we can refocus our attention on mother okay at this point we also want to record delivery time and as we focus on mother we want to look to see where the placenta is as far as are we ready to deliver the placenta we also want to check for signs of peritoneal tearing peritoneal tearing is a very common complication with childbirth and you often see tearing to the lower part of the perineum the upper part of the perineum and to either side so if we see tearing and we see outside bleeding associated with it we can take a feminine pad and apply that to the area and provide gentle pressure to that area and control that bleeding in that manner okay as contractions return and mother prepares for the delivery of the placenta we can grab a biohazard bag and assist now what we don't want to do is we don't want to pull on the umbilical cord pulling on the umbilical cord can cause the placenta to disintegrate and actually cause significant bleeding inside the uterine wall so whenever we just we want to make sure that we avoid that okay and we just want to assist with the delivery of the placenta and and the delivery of the placenta pretty much happens on its own the the uterus is very effective at delivering the placenta so as a placenta is delivered we're gonna look at it and we're gonna check for signs of disintegration of the placenta we want to make sure that the placentas whole and intact this is especially important with prolonged deliveries or with patients that are overturned so then we're gonna set that off to the side and we're gonna focus our attention back on mom it's very common to see a little bit of postpartum bleeding and I'll and some vaginal bloody discharge associated with the delivery of the placenta after the delivery of the placenta if we continue to see excessive bleeding we may want to make sure that baby's on breasts because that will stimulate the nipples and increase production of oxytocin causing the uterus to contract and decreasing bleeding another thing that we can do to help control bleeding after the delivery the placenta is we can do some fundal massage okay and fundal massage is accomplished by taking both of your fingers on your dominant hand and placing them on either side of the bottom part of the uterus that will be just above the super pubic bone so you place your fingers on either side of the bottom portion of the uterus holding the uterus up in place this is important because when we start putting downward pressure we could cause a uterus to exit through the vaginal wall and we ed through the vaginal opening and we don't want to do that so we'll hold pressure on either side of the uterine wall on the bottom half we'll make a fist with our other hand and we'll bring our fist down into the abdominal area until we meet resistance and we're gonna feel a hard formation at the bottom portion of the abdominal cavity and as we come down into that that's the top of our uterus and we're gonna use gentle rocking massaging motions and it's going to be a little uncomfortable for Mom and just explain to mom what you're doing ma'am you have a little bit of bleeding and we're going to control that uterine bleed by massaging the fundus or the top part of your uterine wall it's a little uncomfortable so take slow deep breaths and have their coach work with them to continue breathing and so you're gonna do that fundal massage and you're gonna do that for about thirty to sixty seconds at a time and then reassess look for the amount of bleeding that you have coming out of the vaginal opening and that uterus should start to contract and become much smaller okay if that does not control the bleeding consider more aggressive methods consider having mother utilize nipple stimulation have mom grab her nipples and manipulate her nipples to increase the release of oxytocin if none of those methods work consider utilization of pitocin to control the bleeding this concludes the scenario for a non complicated delivery [Music] you

Channel: emsce1

Views: 69,001

Keywords: Patient, Assess, Obstetrical, desktop

Id: __KT82dTGE0

Length: 16min 39sec (999 seconds)

Published: Thu Apr 14 2011