Ch 33 Obstetrics and Neonatal Care (Course 5 OB/Pediatrics)

D. History taking

1. You should obtain a thorough obstetric history, including: a. Her expected due date b. Any complications that she is aware of c. If she has been receiving prenatal care d. A complete medical history

2. To determine if delivery is imminent, ask the patient the following questions: a. How long have you been pregnant? b. When are you due? c. Is this your first pregnancy? d. Are you having contractions? i. How far apart are they? ii. How long do they last? e. Have you had any spotting or bleeding?

f. Has your water broken? g. Do you feel as though you need to have a bowel movement? h. Do you feel the need to push?

2. Follow these guidelines when treating a pregnant trauma patient: a. Maintain an open airway.

i. Be prepared for and anticipate vomiting. ii. Keep your suction unit readily available.

c. Provide rapid transport for pregnant patients who:

i. Have significant bleeding and pain ii. Are hypertensive iii. Are having a seizure iv. Have an altered mental status

b. Administer high-flow oxygen.

i. Keep the oxygen saturation level high. ii. Administer high-flow, 100% oxygen by nonrebreathing mask. c. Ensure adequate ventilation. i. Listen to breath sounds and confirm that bilateral breath sounds are present. ii. If the patient's ventilations are inadequate, provide or assist ventilation with a bag-valve mask and 100% oxygen.

2. A related condition, eclampsia, is characterized by seizures that occur as a result of hypertension. a. To treat a patent having seizures caused by eclampsia:

i. Lay the patient on her left side. ii. Maintain her airway. iii. Administer supplemental oxygen if necessary. iv. If vomiting occurs, suction the airway. v. Provide rapid transport. vi. Call for an ALS intercept, if available.

C. Hypertensive disorders 1. One complication that occasionally occurs, typically in patients who are pregnant for the first time, is preeclampsia, or pregnancy-induced hypertension. a. This condition can develop after the 20th week of gestation. b. Characterized by the following signs and symptoms:

i. Severe hypertension ii. Severe or persistent headache iii. Visual abnormalities such as seeing spots, blurred vision, or sensitivity to light iv. Swelling in the hands and feet (edema) v. Anxiety

IX. Stages of Labor A. The three stages of labor are

(1) dilation of the cervix, (2) delivery of the fetus, and (3) delivery of the placenta.

3. Labor is generally longer in a primigravida

(a woman experiencing her first pregnancy) than in a multigravida (a woman who has experienced previous pregnancies).

V. Special Considerations for Trauma and Pregnancy A. With a trauma call involving a pregnant woman, you have two patients to consider—the woman and the unborn fetus.

1. Trauma to a pregnant woman may have a direct effect on the condition of the fetus. 2. Pregnant women may be victims of many types of trauma, including: a. Assaults b. Motor vehicle crashes c. Shootings

IV. Complications of Pregnancy A. Most pregnant women are healthy, but some may be ill when they conceive or become ill during pregnancy.

1. You may safely use oxygen to treat any heart or lung disease in a pregnant patient without harm to the fetus.

D. In the third trimester, there is an increased risk of vomiting and potential aspiration following trauma because of changes that occur in the gastrointestinal tract.

1. Changes in gastrointestinal motility and the displacement of the stomach upward significantly increase the chance that a pregnant trauma patient will vomit and aspirate if you are unable to clear her airway.

VIII. Patient Assessment A. Childbirth is seldom an unexpected event, but there are occasions when childbirth becomes an emergency.

1. Dispatch protocols usually include the dispatcher asking simple questions to determine whether birth is imminent. 2. Premature contractions may be caused by trauma or medical conditions.

D. The third stage of labor begins with the birth of the newborn and ends with the delivery of the placenta.

1. During this stage, the placenta must completely separate from the uterine wall. 2. This may take up to 30 minutes.

F. In a pregnant woman, the breasts produce milk that is carried through small ducts to the nipple to provide nourishment to the newborn once it is born.

1. Early signs of pregnancy in the breasts include increased size and tenderness.

B. Pregnant women also have an increased risk of falling compared with nonpregnant women.

1. Hormonal changes loosen the joints in the musculoskeletal system. 2. The increased weight of the uterus and displacement of abdominal organs can affect the woman's balance.

VII. Teenage Pregnancy A. The United States has one of the highest teenage pregnancy rates among developed countries.

1. It is likely that, during your career, you will respond to a pregnant teenager who may or may not be in labor.

B. Presentation complications

1. On rare occasions, the presenting part of the fetus is neither the head nor the buttocks, but a single arm, leg, or foot. a. This is called a limb presentation.

II. Anatomy and Physiology of the Female Reproductive System A. The female reproductive system includes:

1. Ovaries 2. Fallopian tubes 3. Uterus 4. Cervix 5. Vagina 6. Breasts

E. Changes in the cardiovascular system and the increased demands of supporting the fetus significantly increase the workload of the heart.

1. Remember, not all women are healthy when they begin pregnancy. 2. Cardiac compromise is a life-threatening possibility.

XII. Complicated Delivery Emergencies A. Breech delivery

1. The presentation is the position in which an infant is born or the body part that is delivered first. 2. Most infants are born head first, called a vertex presentation. 3. Occasionally, the buttocks are delivered first, called a breech presentation. a. The fetus is at great risk for trauma from the delivery. b. Prolapsed cords are more common in a breech delivery.

III. Normal Changes in Pregnancy A. During pregnancy, many normal changes occur in the body that are not all directly related to the reproductive system.

1. The primary systems involved with these changes are the respiratory, cardiovascular, and musculoskeletal systems.

H. The fetus develops inside a fluid-filled, baglike membrane called the amniotic sac.

1. The sac contains about 500 to 1,000 mL of amniotic fluid, which helps insulate and protect the floating fetus. 2. The amniotic fluid is released in a gush when the sac ruptures, usually at the beginning of labor.

B. In the reproductive system, hormone levels increase to support fetal development and prepare the body for childbirth. 1. This puts pregnant woman at an increased risk for complications from trauma, bleeding, and some medical conditions.

2. As the fetus develops and grows, the uterus also grows, stretching to accommodate a full-term fetus. 3. As the size of the uterus increases, so does the amount of fluid it contains. a. Uterus is displaced out of its normally well-protected position within the pelvic area. b. This increases the chance of direct fetal injury in trauma.

F. Weight gain during pregnancy is normal. 1. The increase in body weight will eventually challenge the heart and impact the musculoskeletal system.

2. Increased hormones affect the musculoskeletal system by making the joints "looser" or less stable. 3. In the third trimester, changes in the body's center of gravity increase the risk of slips and falls.

C. Rapid uterine growth occurs during the second trimester of pregnancy. 1. As the uterus grows, it pushes up on the diaphragm, displacing it from its normal position.

2. Respiratory capacity changes, with increased respiratory rates and decreased minute volumes.

C. The fallopian tubes extend out laterally from the uterus, with one tube associated with each ovary. 1. Fertilization occurs when a sperm meets the egg, usually when the egg is inside the fallopian tube.

2. The fertilized egg then continues to the uterus where, if implantation occurs, it develops into an embryo and then a fetus and grows until the time of delivery.

C. Pregnant women have an increased amount of overall total blood volume and an approximate 20% increase in their heart rate by the third trimester. 1. A pregnant trauma patient may experience a significant amount of blood loss before you detect signs of shock.

2. The fetus also may be in trouble well before signs of shock are present. 3. The body of a woman who has sustained serious trauma often reduces the blood supply to the fetus.

E. The vagina is the outermost cavity of the female reproductive system and forms the lower part of the birth canal. 1. It is begins at the cervix and ends as an external opening of the body.

2. The vagina completes the passageway from the uterus to the outside world for the newborn. 3. The perineum is the area between the vagina and the anus.

F. If a pregnant trauma patient goes into cardiac arrest, your focus is the same as with other patients in cardiac arrest. 1. Remember that the only chance you have to save the fetus is to do all you can to save the woman. 2. Perform CPR and provide transport to the hospital according to local protocol.

3. If a woman is in the last month or two of pregnancy, compressions may need to be applied a little higher on the sternum than usual. a. If possible, one provider should be assigned to manually displace the uterus toward the patient's left side to facilitate blood return to the right side of the heart. 4. You should notify the receiving facility personnel as soon as possible that you are en route with a pregnant trauma patient in cardiac arrest.

D. Be alert to additional concerns and ready to assess and manage unique types of injuries when responding to a pregnant trauma patient. 1. The uterus is especially vulnerable to penetrating trauma and blunt injuries. 2. A trauma injury to the pregnant uterus can be life threatening to the woman and fetus because the uterus has a rich blood supply.

3. In most cases, the only chance to save the fetus is to adequately resuscitate the woman.

B. The ovaries are two glands, one on each side of the uterus, that are similar in function to the male testes. 1. Each ovary contains thousands of follicles, and each follicle contains an egg. 2. During each menstrual cycle, there will only be one follicle that is successful at maturing and releasing an egg.

3. Ovulation occurs approximately 2 weeks prior to menstruation. 4. If fertilized, the egg implants in the endometrium, the lining of the inside of the uterus. 5. If the egg is not fertilized within 36 to 48 hours after it has been released, it will die, and the lining is shed as menstrual flow. a. Occurs around the 28th day of a woman's cycle

F. Reassessment 1. Repeat the primary assessment with a focus on the patient's ABCs and vaginal bleeding, particularly after delivery. 2. Obtain another set of vital signs and compare with those obtained earlier.

3. Recheck interventions and treatments to see whether they were effective. a. Is vaginal bleeding slowing with uterine massage? b. In most cases, childbirth is a natural process that does not require your assistance. c. When childbirth is complicated by trauma or other conditions, however, any interventions you provide for the patient will benefit the fetus.

B. Diabetes 1. Diabetes develops during pregnancy in many women who have not had diabetes previously. 2. This condition, called gestational diabetes, resolves in most women after delivery.

3. The treatment is the same as for any other patient with diabetes. a. A pregnant woman may control her blood glucose level with diet and exercise or may take medication. b. In some cases, the woman will have to manage her condition with insulin injections. c. A pregnant woman experiencing hyperglycemia or hypoglycemia should be cared for in the same manner as any patient with diabetes.

F. Abuse 1. Pregnant women have an increased chance of being victims of domestic violence and abuse. 2. Abuse during pregnancy increases the chance of spontaneous abortion, premature delivery, and low birth weight.

3. The woman is at risk from bleeding, infection, and uterine rupture. 4. Use a calm, professional approach. a. Pay attention to the environment for any signs of abuse. b. Your attention to detail will be helpful in your documentation.

C. The second stage of labor begins when the fetus begins to encounter the birth canal and ends with delivery of the newborn (spontaneous birth). 1. During this stage, you will have to make a decision about helping the woman to deliver at the scene or providing transport to the hospital. 2. Uterine contractions are usually closer together and last longer.

3. Under no circumstances should you let the woman sit on the toilet. 4. The perineum will begin to bulge significantly, and the top of the fetus's head should begin to appear at the vaginal opening. a. This is called crowning.

B. Delivery 1. Your partner should be at the patient's head to comfort, soothe, and reassure her during the delivery. 2. If the patient will allow it, administer oxygen. 3. It is common for patients to become nauseated during delivery, and some may vomit. a. If this occurs, have your partner assist her and clear out her airway.

4. Continually check the patient for crowning. a. Some patients may experience precipitous labor and birth. b. Position yourself so that you can see the perineal area at all times.

3. Fetal alcohol syndrome describes the condition of infants born to women who have abused alcohol.

4. If you are called to handle a delivery of an addicted woman, pay special attention to your own safety.

E. Abortion 1. Passage of the fetus and placenta before 20 weeks is called abortion. 2. Abortions may be spontaneous (miscarriage) or induced. 3. Deliberate abortions may be self-induced, or planned and performed in a hospital or clinic.

4. The most serious complications are bleeding and infection. a. Bleeding can result from portions of the fetus or placenta being left in the uterus (incomplete abortion) or from injury to the wall of the uterus. b. Infection can result from such perforation and from the use of nonsterile instruments. 5. If the woman is in shock, treat and transport her promptly to the hospital. a. Never try to pull tissue out of the vagina. b. Place a sterile pad on the vagina.

VI. Cultural Value Considerations A. Cultural sensitivity is important when you are assessing and treating a pregnant patient. 1. Women of some cultures may have a value system that will affect: a. The choice of how they care for themselves during pregnancy b. How they have planned the childbirth process 2. Some cultures may not permit a male health care provider, especially in the prehospital setting, to assess or examine a female patient. 3. You should respect these differences and honor requests from the patients.

4. Your responsibility is to the patient and is limited to providing care and transport. 5. A competent, rational adult has the right to refuse all or any part of your assessment or care.

4. Blood volume may eventually increase as much as 50% by the end of the pregnancy. 5. The number of red blood cells also increases. 6. The speed of clotting increases to protect against excessive bleeding during delivery.

7. By the end of pregnancy, the pregnant patient's heart rate increases up to 20% to accommodate the increase in blood volume. 8. Cardiac output is significantly increased.

2. Mechanism of injury/nature of illness a. You will encounter pregnant patients who are not in labor, so it is important to determine the MOI or NOI.

b. Do not develop tunnel vision during a call. c. Falls and the necessity for spinal immobilization must be considered.

3. Overall blood volume gradually increases throughout the pregnancy to:

a. Allow for adequate perfusion of the uterus b. Prepare for the blood loss that will occur during childbirth

4. Improper positioning of the seat belt can result in injury to a pregnant woman and the fetus if they are involved in a motor vehicle crash.

a. Carefully assess a pregnant woman's abdomen and chest for seatbelt marks, bruising, and obvious trauma.

X. Normal Delivery Management A. Preparing for delivery 1. Consider delivery at the scene when:

a. Delivery is imminent (will occur within a few minutes) b. A natural disaster, inclement weather, or other environmental factor makes it impossible to reach the hospital

D. The uterus is a muscular organ that encloses and protects the developing fetus for approximately 9 months (40 weeks). 1. The uterus produces contractions during labor and ultimately helps to push the fetus through the birth canal. 2. The birth canal is made up of the vagina and the lower third of the uterus, called the cervix.

a. During pregnancy, the cervix contains a mucous plug that seals the uterine opening, preventing contamination. b. When the cervix begins to dilate, this plug is discharged into the vagina as pink-tinged mucus, or bloody show. c. This small amount of bloody discharge often signals the beginning of labor.

B. Pregnant teenagers may not know they are pregnant or may be in denial about it. 1. As you begin to assess all female teenagers, remember that pregnancy is a possibility. 2. Respect the teenager's privacy and need for independence.

a. If possible, perform your assessment and obtain the history away from the teenager's parents. b. Become familiar with the laws in your state so that you will know when pregnant teenagers can give or refuse consent for themselves.

5. Once labor has begun, it cannot be slowed or stopped.

a. Never attempt to hold the patient's legs together. b. Do not let her go to the bathroom. c. Instead, reassure her that the sensation of needing to move her bowels is normal and that it means she is about to deliver.

3. Anything ingested by a pregnant woman has the potential to affect the fetus, including:

a. Nutrients b. Oxygen c. Waste d. Carbon dioxide e. Many toxins f. Most medications

B. The first stage begins with the onset of contractions and ends when the cervix is fully dilated. 1. The first stage is usually the longest, lasting an average of 16 hours for a first delivery. 2. The onset of labor starts with contractions of the uterus.

a. Other signs of the beginning of labor are the bloody show and the rupture of the amniotic sac. b. The frequency and intensity of contractions in true labor increase with time. c. The uterine contractions become more regular and last about 30 to 60 seconds each.

4. If the patient says that she is about to deliver, says she has to move her bowels, or feels the need to push, you should immediately prepare for delivery.

a. Otherwise, does she have an extremely firm abdomen? b. Visually inspect the vagina to check for crowning. c. Do not touch the vaginal area until you have determined that delivery is imminent.

G. Substance abuse 1. Some pregnant women are addicted to alcohol or other drugs. 2. The effects of the addiction on the fetus include:

a. Prematurity b. Low birth weight c. Severe respiratory distress d. Death

E. When a pregnant woman is involved in a motor vehicle crash or a similarly violent mechanism of injury (MOI), severe hemorrhage may result from injuries to the pregnant uterus. 1. Trauma is one of the leading causes of abruptio placenta. 2. You should suspect abruptio placenta when the MOI is blunt trauma to the abdomen and the patient's signs and symptoms are suggestive of shock. 3. Common symptoms include vaginal bleeding and severe abdominal pain.

a. Quickly assess and transport the patient. b. Support the airway. c. Administer high-flow oxygen. d. Place sanitary pads on the vagina. e. Position the patient on her left side. f. Call for ALS backup.

2. Obtain a SAMPLE history

a. Some pregnant women have a history of medical problems for which they take prescription medications. b. Some women with no history of medical problems require medications during pregnancy.

7. Your emergency vehicle should always be equipped with a sterile emergency obstetric (OB) kit, including:

a. Surgical scissors or scalpel b. Umbilical cord clamps c. Umbilical tape d. A small rubber bulb syringe e. Towels, drapes, or sheets f. 4˝ × 4˝ and/or 2˝ × 10˝ gauze sponges g. Sterile gloves h. Infant blanket i. Sanitary pads j. An infant-sized BVM k. Goggles l. A plastic bag

5. Pregnant patients who are abused are often scared and may not be honest as to how their injuries may have occurred.

a. Talk to the patient in a private area, away from the potential abuser if possible. b. The best way for you to care for the fetus is to treat the pregnant woman.

5. Some women experience a premature rupture of the membranes, in which the amniotic sac ruptures too early and the fetus is not developed or ready to be born.

a. The patient may or may not go into labor. b. You will need to provide supportive care and transport to the hospital.

5. Follow standard precautions. a. Wear eye protection, a face mask, and gloves at all times. 6. Clues that you are dealing with an addicted patient may include:

a. The presence of drug paraphernalia b. Empty wine or liquor bottles c. Statements made by family or bystanders or by the patient herself 7. The newborn will probably need immediate resuscitation. a. Assist with the delivery, and be prepared to support the newborn's respirations and administer oxygen during transport.

4. After delivery, the placenta separates from the uterus and is delivered. 5. The umbilical cord is the lifeline of the fetus, connecting the woman and fetus through the placenta.

a. The umbilical vein carries oxygenated blood from the placenta to the heart of the fetus. b. The umbilical arteries carry deoxygenated blood from the heart of the fetus to the placenta.

3. A premature newborn is smaller and thinner than a full-term newborn, and the head is proportionately larger in comparison with the rest of the body.

a. The vernix caseosa will be absent or minimal on the premature newborn. b. There will also be less body hair.

6. Toward the end of the third trimester, the head of the fetus normally descends into the woman's pelvis as the fetus positions for delivery.

a. This movement down into the pelvis and the sensation that may accompany the descent is called lightening.

4. A woman may experience preterm or false labor, or Braxton-Hicks contractions.

a. You should provide transport for the patient. b. If true labor is occurring, you may need to prepare for a delivery.

6. If your decision is to deliver at the scene, remember that you are only assisting the woman with the delivery.

a. Your part is to help, guide, and support the baby as it is born. b. You want to appear calm and reassuring while protecting the woman's modesty. c. Recognize when the situation is beyond your level of training. d. If there is any doubt, contact medical control for a decision to deliver on the scene or to transport.

2. Airway and breathing a. During an uncomplicated birth, life-threatening conditions involving the woman's airway and breathing are not usually an issue.

b. However, a motor vehicle crash, an assault, or any number of medical conditions may cause a life threat to exist, and may result in a complicated delivery. i. Assess the airway and breathing to ensure they are adequate. ii. If needed, provide airway management and high-flow oxygen.

3. Transporting the patient on her left side can also prevent supine hypotensive syndrome. a. This condition is caused by compression of the descending aorta and the inferior vena cava by the pregnant uterus when the patient lies supine.

b. Hypotension may result.

4. Transport decision a. If delivery is imminent, you must prepare to deliver at the scene. i. The ideal place to deliver is in the security of your ambulance or the privacy of the woman's home. ii. The area should be warm and private with plenty of room to move around.

b. If delivery is not imminent, prepare the patient for transport and perform the remainder of the assessment en route to the emergency department. i. Administer oxygen. ii. Women in the second and third trimesters of pregnancy should be transported lying on the left side when possible. iii. If spinal immobilization is indicated, secure the woman to the backboard and elevate the right side of the board with rolled towels or blankets.

B. Scene size-up 1. Take standard precautions. a. Gloves and eye and face protection are a minimum if delivery has already begun or is complete.

b. If the call is going to result in a field delivery and time allows, a gown should also be used. c. Do not be lax in your safety observations and precautions. d. Remain calm and professional. e. Consider calling for additional or specialized resources.

9. Preparing the delivery field a. Put on a protective face shield and gown. As time allows, place towels or sheets on the floor around the delivery area to help soak up body fluids and to protect the woman and the newborn.

b. Open the OB kit carefully so that its contents remain sterile. c. Put on the sterile gloves. After this, handle only sterile materials. d. Use the sterile sheets and drapes from the OB kit to make a sterile delivery field. i. Place one drape under the patient's buttocks, and unfold it toward her feet. ii. Wrap another drape behind the patient's back and drape over each thigh. Drape another sheet across her abdomen.

C. Primary assessment 1. Form a general impression. a. Whether the patient is in active labor or whether you have time to assess for imminent delivery and address other possible life threats

b. Perform a rapid examination of the patient. c. Take a moment to confirm whether the fetus will be delivered in the next few minutes or whether you have time to continue to evaluate the situation. d. When trauma or other medical problems are the presenting complaint, evaluate these first and then assess the impact of these problems on the fetus.

8. Umbilical cord around the neck a. As soon as the head is delivered, use one finger to feel whether the umbilical cord is wrapped around the neck.

b. This commonly is called a nuchal cord. c. A nuchal cord that is wound tightly around the neck could strangle the fetus. d. Usually, you can slip the cord gently over the delivered head. e. If not, you must cut it. f. Once the cord is cut, you must attempt to speed the delivery by encouraging the woman to push harder and possibly more often because the fetus will now have no oxygen supply until it is delivered and breathing spontaneously.

E. Secondary assessment 1. Physical examinations a. Perform complete assessment of the major body systems as needed, with emphasis on the patient's chief complaint. b. Assess for fetal movement by asking the patient whether she can feel the baby moving.

c. If the patient is in labor, the physical examination should be focused on contractions and possible delivery. d. If at any point you suspect that delivery is imminent, you should check for crowning. e. If you do not suspect an imminent delivery and the patient reports other problems unrelated to delivery, you should not visually inspect the vaginal area.

G. Assessment and management 1. Your focus is on the assessment and the management of the woman. a. You should suspect shock based on the MOI. b. Be prepared for vomiting, and anticipate the need to manage the airway to protect the patient from aspirating.

c. Attempt to determine the gestational age to assist you with determining the size of the fetus and the position of the uterus.

Bleeding b. The leading cause of maternal death in the first trimester is internal hemorrhage into the abdomen following rupture of an ectopic pregnancy.

c. Consider the possibility of an ectopic pregnancy in a woman who has missed a menstrual cycle and complains of sudden, severe, usually unilateral pain in the lower abdomen.

6. Delivering the head a. Observe the head as it begins to exit the vagina so you can provide support as it emerges. b. Place your sterile gloved hand over the emerging bony parts of the head to control the delivery of the head.

c. Continue to support the head as it rotates. d. Apply gentle pressure across the perineum with a sterile gauze pad to reduce the risk of perineal tearing. e. Be prepared for the possibility of the patient having a bowel movement because of the increased pressure on the rectum. f. Be careful that you do not poke your fingers into the newborn's eyes or into the fontanelles.

3. To help determine potential complications, ask these questions: a. Were any of your previous deliveries by cesarean section? b. Have you had problems in this or any previous pregnancies?

c. Do you use drugs, drink alcohol, or take any medications? d. Do you know if there is a chance you will have multiple deliveries? e. Does your physician expect any complications?

4. Communication and documentation a. If your assessment determines that delivery is imminent, notify staff at the receiving hospital. i. Provide an update on the status of the woman and the newborn after delivery. b. On the rare occasions that delivery of the placenta does not occur within 30 minutes or you determine that a complication is occurring that cannot be treated in the field, notify the hospital and provide rapid transport.

c. For a pregnant patient with a complaint unrelated to childbirth, be sure to include the pregnancy status of the patient in your radio report. d. The hospital staff will want to know: i. The number of weeks of gestation ii. Her due date iii. Any known complications of the pregnancy e. If delivery occurred in the field, you will have two patient care reports to complete.

2. Vital signs should include pulse; respirations; skin color, temperature, and condition; and blood pressure. a. Be especially alert for tachycardia and hypo- or hypertension. b. It is typical for a woman's blood pressure to drop slightly during the first two trimesters of pregnancy but return to normal during the third trimester.

c. Hypertension, even mild, may indicate more serious problems.

3. Circulation a. External and internal bleeding are potential life threats to the patient and should be assessed early. b. Blood loss after delivery is expected, but significant bleeding is not.

c. Quickly assess for any potential life-threatening bleeding, and begin treatment immediately. d. Assess the skin for color, temperature, and moisture. e. Check the pulse to determine if it is too fast or too slow. f. If there are signs of shock, control the bleeding, give oxygen, and keep the patient warm.

8. Patient position a. The patient's clothing should be removed or pushed up to her waist, and pants and undergarments should be removed. b. Remember to preserve the patient's privacy as much as possible. c. Place the patient on a firm surface that is padded with blankets, folded sheets, or towels.

d. Elevate the hips about 2" to 4" with a pillow or blankets. e. Support the head, neck, and upper back with pillows and blankets. f. Have her keep her legs and hips flexed, with her feet flat on the surface beneath her and her knees spread apart. g. Communicate with your crew and plan who will be responsible for caring for the mother and newborn after delivery. h. If the emergency delivery is occurring at home, you should move the patient to a sturdy, flat surface or the floor if she will allow it. i. Track the progression of the delivery closely at all times.

9. Delivering the body a. Once the head has been delivered, it usually rotates to one side or the other. b. This rotation places the body in a better position for delivery. c. The head is the largest part of the fetus. i. Once it is born, the body usually delivers easily.

d. Support the head and upper body as the shoulders deliver. e. Do not pull the fetus from the birth canal. f. The newborn will be slippery and covered with a white, cheesy substance, called vernix caseosa.

7. Unruptured amniotic sac a. Usually, the amniotic sac will rupture at the beginning of labor or during contractions. b. If it has not ruptured by the time the fetal head is crowning, it will appear as a fluid-filled sac emerging from the vagina. c. The sac will suffocate the fetus if it is not removed.

d. You may puncture the sac with a clamp or tear it by twisting it between your fingers. e. Make sure that the puncture site is away from the fetus's face and only perform this procedure as the head is crowning. f. Clear the newborn's mouth and nose, using the bulb syringe if required by your protocols, and wipe the mouth and nose with gauze. g. If the amniotic fluid is greenish, notify the receiving hospital.

c. Time the patient's contractions. d. Remind the patient to take quick, short breaths during each contraction but not to strain.

e. Between contractions, encourage the patient to rest and breathe deeply through her mouth. 5. Follow the steps in Skill Drill 33-1 to deliver the newborn.

d. Assess circulation. i. Control external bleeding. ii. Maintain a high index of suspicion for internal bleeding and shock based on the MOI. iii. Keep the patient warm.

e. Transport considerations i. Transport the patient on her left side. ii. If spinal injury is suspected, tilt the backboard 30° to the left. iii. Transport the patient to a trauma center if one is available in your area.

2. Hemorrhage from the vagina that occurs before labor begins may be very serious; call for ALS backup. a. In early pregnancy, it may be a sign of a spontaneous abortion, or miscarriage. b. In the later stages of pregnancy, vaginal hemorrhage may indicate a serious condition involving the placenta. i. In abruptio placenta, the placenta separates prematurely from the wall of the uterus, most commonly caused by hypertension or trauma. (a) Patient often reports severe pain but vaginal bleeding may not be heavy

ii. In placenta previa, the placenta develops over and covers the cervix. (a) Patient may experience heavy vaginal bleeding without significant pain 3. Decreasing the patient's anxiety during these situations can impact how she and the fetus may respond during the emergency.

c. Pertinent history should include questions related specifically to prenatal care. i. Identify any complications the patient may have had during the pregnancy or potential complications during delivery. ii. Determine the due date, fetal movements, frequency of contractions, and a history of previous pregnancies and deliveries and their complications.

iii. Determine whether there is a possibility of multiples and whether the woman has taken any drugs or medications. d. If her water is broken, ask whether the fluid was green. i. Green fluid is due to meconium (fetal stool). ii. The presence of meconium can indicate newborn distress, and it is possible for the fetus to aspirate meconium during delivery