Emergency Med - March 5th Lecture - Childbirth, Catheterization Sterilization

EMERGENCY MEDICINE – MARCH 5TH, 2008 EMERGENCY CHILDBIRTH, URINARY CATHETERIZATION, STERILIZATION VS DISINFECTION TECHNIQUES Emergency Childbirth Stages: 1st: longest: begins with water breaking, first contraction. Ends with full dilation of cervix 2nd: birth of infant 3rd: expulsion of placenta Signs/symptoms of imminent delivery: Contractions every 2 minutes Amniotic sac rupture Crowning Feels like she is going to have a bowel movement She says so! Semi-Fowler’s position: for birth outside of hospital. Semi-sitting, put padding under right hip (to prevent obstruction of the inferior vena cava by weight of fetus) BSI = body substance isolation: assume that everything is contagious. Breathing techniques: Deep breathing between contractions (if you can), during contractions, short puffs. Short breaths benefit because you can’t strain while you are breathing like this. Don’t want to bear down during early stage of childbirth. See the crown of the baby’s head in introitus? Put palm over head, just to support it, and control rate at which it is delivered. Too fast? More risk of tearing perineum. Unwrap umbilical cord if around neck. Tying umbilical cord: 1st tie is 15-30cms from infants body, 2nd tie is 7cms further away. Will be cutting between ties. Can use different things to tie off cord (not making knot in cord): string- not so thin that it cuts into cord Position infant with head lower than feet. Stimulate breathing by rubbing back, chest, feet. Placenta: takes 30 minutes after birth to deliver. Expect less than ½ litre of additional bleeding. Never pull on the umbilical cord. Wrap placenta in towel and put in bag for assessment: will make sure that lobe is not still in uterus at hospital. Keep placenta at same level as baby (if cord hasn’t been cut). Don’t want air emboli going from placenta to baby (if placenta is higher) or blood draining out of baby (if baby is higher) Sanitary napkins to absorb blood from delivery. These will be assessed as well. Massage abdomen in circular motions: will help decrease bleeding. Complications: Pre-eclampsia: Causes? Theories include infection, pressure on IVC. Another theory: hypoperfusion of placenta: causes toxins that start the process of pre-eclampsia. But exact cause is unknown. Risk factors: high blood pressure pre-pregnancy, cardio-vascular predisposition. Triad of pre-eclampsia: • Edema (not always), • hypertension (>140/90 or if systolic is 30 over their baseline or if diastolic is 15 mmHg over baseline), • proteinuria Can lead to eclampsia: convulsions, can cause death of fetus and Treat with hypotonic solution: Ringer’s lactate, add magnesium. Anticonvulsive. Antidote for magnesium OD: hypotension… Antidote is calcium. Can stabilize mom with hydration. Will keep mom on bed rest until delivery. After delivery, condition resolves itself. Relatively rare condition: 5% get pre-eclamsia; 1/200 of those develop eclampsia EMERGENCY MEDICINE, MARCH 5TH, 2008 – PAGE 1

Pre-delivery hemorrhage: Be aware of this: could be many different causes. Trendelenberg position: Head down (pelvis is above the head) Attach O2 if it is available. Highest concentration. Use sanitary napkins to absorb blood and save them. Breech presentation: Can be delivered this way, but risks. Trauma to infant. Takes longer to deliver: may get mom to hospital in time. Support buttocks, let them come out. Let feet come out, support. Complication is with arms: usually present one at a time. Have to be wearing sterile gloves: insert 2 fingers into vagina: V shape, and hold vaginal walls away from infants nose and mouth: they may start breathing d/t compression of umbilical cord, more stimulation of chest and back while head is still in vagina. Limb presentation: • Babies presenting this way are normally delivered via C-section. • Call 911 right away • Cover limb with obstetrics tape Umbilical cord prolapse Gets delivered first. Rare, requires rapid transport. High-flow oxygen. With sterile gloves, insert fingers into vagina. Keep umbilical cord off head of infant: don’t want to compress it too much. Put sterile, moist dressing on it. CASE: 28 year old female, 32 weeks pregnant. Headache, blurred vision, edema, dizzy (woke up like this) T: 37.4 LA: 140/92; R leg: 138/90 DDX: Pre-eclampsia: pending… Increased intracranial pressure: pupil reaction is normal Stroke: pending… Toxemia: : ruled out (doesn’t have fever, toxic appearance) Early labour: rule out, doesn’t feel like she is going to have baby Heat emergency (mild): rule out re: temperature Fetal distress: pending… Hypoglycemia: ruled out based on history Constipation: ruled out based on history Diagnosis was a stroke. Woke up with TIA, had a second TIA (they went away), but in waiting room, it didn’t go away. Caught in time, she was fine. May be more prone to strokes during pregnancy. URINARY CATHETERIZATION Bladder is sterile External urethral orifice: unsterile Bladder or pelvic injury? Have to consider if bladder is involved. CHF patients may have catheter Can also be used as direct route to administer medication. Catheter is only the tubing. Syringe filled with sterile water (5-10mL): inject water to keep it in place. Foley catheter has balloon at tip (filled with water), for long-term use. Sterile technique! Wash hands before and after. Use sterile drape around urethra. One swipe (repeat) to clean urethra orifice Length of urethra: 3-5cms for females, 10-15cms for males. Have to lubricate this length of catheter tip. How do you know if you have inserted it far enough? Get urine return. Balloon has to be beyond sphincter. EMERGENCY MEDICINE, MARCH 5TH, 2008 – PAGE 2

May need to remind patients of the process if they are auto-administering catheters. Contraindications (relative): UTI, kidney infection. Urethral obstruction (absolute: if you get resistance, don’t push it in!) Problems, concerns: Always make sure you are cleaning the urethral orifice well. Use sterile procedures at all times. Most common UTI is E. Coli. Don’t need to know exact numbers of sterilizing equipment, but know what takes “more” heat and time. Hot air: not as effective as the autoclave. Boiling: Use for a lot of things, easy to do. Problem: time consuming. Have to boil in 3 cycles. Pressure cookers: low-tech, but have to clean equipment before sterilizing, but can be as effective as autoclaving if done properly. Ethylene oxide: good for things that would be damaged by heat and moisture. CARCINOGENIC! Hazards of gas exploding. Large metal piece of equipment: not a lot of holes for gasses to penetrate, not well-sterilized. Chemical vapours: destroys heat sensitive plastic Alcohol: Can disinfect by soaking in alcohol for minimum of 2 minutes. Eliminates 90% of bacteria. Still has 10% bacteria, spores, moulds, viruses. Can use on skin. Iodine: Gets rid of most things, not spores Sodium hypochlorite (bleach): Doesn’t get rid of slow-growing microbes. Chlorhexidine: cleaning solution for tables, wipes for urine samples. Glutaraldehyde: okay for skin. Have to immerse object in solution for an hour to get it to kill all spores. Quiz: 1. NO 2. YES 3. NO QUIZ IS CUMULATIVE! May include assignment questions too.

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