Chapter 33
OB Kit
3 to 5 on your truck!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! sterile gloves, dont use if you drop it because your nervous, germ free environment, paper, chuck(doggy pee pad), any blankets you want to use.
chest compressions are required use the hand encircling technique for two person resus
3:1, 120 actions per minute (90 compressions and 30 ventilations)
Periods during pregnancy
"bloody shadow" or "bloody show"
fetal demise
, eye protection, gloves, mask, sterile supplies, you may have to deliver without OB kit if you don't have an OB Kit as soon as the placenta is delivered wrap the placenta.
umbilical cord around the neck
as soon as the head is delivered, use one finger to feel whether the umbilical cord is gently over the delivered head, if not you must cut it, speed delivery my encouragement.
rapid uterine growth occurs during the second trimester
as the uterus grows, it pushes up on the diaphragm and displaces it, respiratory capacity changes, with increased respiratory rates and decreased minute volumes. lungs get shallow and breathes are shallow.
pregnant woman
assaults, motor vehicle crashes, shootings, pregnant women have an increased in falling
improper positioning to the seat belt
assess a pregnant woman's abdomen and chest for seatbelt
physical examinations
assess the major body systems as needed. emphases on the chief complaint, assess the fatal movement good sign , if the patient is in labor, focus on contractions and possible delivery(crowning), if you suspect that delivery is imminent, check the crowning.
pregnant woman overall blood volume
increased and a 20% increase in heart rate.
blood volume
increases, allow for adequate perfusion of the uterus, prepare for the blood loss during childbirth, number of red blood cells increases, speed of clotting increases, patients heart rate increases up to 20%
changes in the cardiovascular system
incresed demands of supporting the fetus increase the workload of the heart, not all women are healthy when they begin pregnancy, cardiac compromise is a life threatening possibility
Bleeding
internal bleeding may be a sign of ectopic pregnancy, embryo develops outside the uterus, most often in a fallopian tube. Fertilized egg in the fallopian tube. symptoms, lower abdominal pain and severe, missed menstrual cycle, internal hemorrhaging can happen in trimester.
spontaneous abortion
is a miscarriage
The perineum
is the area of skin between the vagina and the anus
breech delivery
if the buttocks have passed through the vagina, the delivery has begun. provide emergency care preparing for breech delivery position the pregnant woman ob kit place partner allow booty and legs support with hand don't pack the vagina, you'll have to insert fingers. make a V with your gloved fingers and position them in the vagine to keep the walls from compressing the fetus's airway. V shaped fingers to prevent the baby from suffocating on the vaginal wall
use bvm
if the heart rate less than 60 above 6o but not breathing, ventilate and pay attention to pulse
postdelivery care
if the mom is able and willing place the newborn on her abdomen so skin to skin contact can begin immediately, dry off the newborn and wrap him or her in a blanket or towel, wrap the newborn so only the face is exposed.
pregnant woman is involved
in a motor vehicle crash, severe hemorrhage, may occur injuries to the uterus. Abruptio placenta, severe abdominal pain, vaginal bleeding.
head tilt chin lift
itty bitty tip of the nose to the ceiling
more than 100 beats a min,
keep warm and transport
first stage
labor is generally longer in a primigravida (First pregnancy) then in a multigravida. braxton hicks contractions, preterm or false labor.
airway and breathing
life threatening conditions with the woman's airway and breathing are usually not an issue during a birth(jessica has an issue with this one), a motor vehicle crash, assault , or a medical condition may cause a life threat, assess
use appropriate bvm
make sure you use neonatal
breast milk
mama and child bond, first weeks of breast milk (the nipple cracks and bleeds-14 day it goes away) and immunity and free
scene size up
more hands the better, MOI/NOI, do not develop tunnel vision during a call, falls and necessity for spinal immboilization must be considered.
complications of pregnancy
most pregnant women are healthy, some may be ill when they conceive or become ill during pregnancy, use oxygen to treat any heart or lung disease
abortion
passage of the fetus and placenta before 20 weeks
SAMPLE
pertinent history should include questions related specifically to prenatal care, determine the due date, frequency of contraction, a history of previous pregnancies and deliveries, the possibility of multiples, and if she has taken any drugs or medications if her water has broken, ask whether fluid was green (due to meconium). vaginal birth, c section, a possibility of multiples, drugs or medications? Has you water broken? what color is your water(no smell, sweet smell). if it is green (massive problem, meconium).
OB Kit
place towels or sheets on the floor around the delivery area, open the OB kit carefully, put on sterile gloves, use the sterile sheets and draps from the OB kit to make a sterile delivery field
after delivery
placenta separates from the uterus and delivers, umbilical cord is the lifeline of the fetus, umbilical veins carries oxygenated blood from the placenta to the fetus, the umbilical arteries carry deoxygenated blood from the fetus to the placenta.
no pulse or heart rate is less than 60
position the newborn on his or her back with the head down and the neck slightly extended, if necessary suction the mouth and then the nose, flick or slap the soles of the feet.
cover the vagina with a sterile pad, let mom put the pad on, ask mom first, do not discard any blood soaked pads
postpartum patients are at an increased risk of an embolism, lodged in the pulmonary circulation. Shortness of breath, following delivery,
Preeclampsia
pregnancy induced hypertension, can develop after the 20th week of gestation, severe hypertension, severe, or persistent headache, visual abnormalities, swelling in the hands and feet, and anxiety. Is deadly. and the only thing is to deliver the baby. water weight causes the swelling (1-2 pounds a week)
premature birth
premature newborns require special care to survive 1 pound, 16oz have survived. no deficits. Premie girls usually survive most than premie boys. pregnancies lasting longer than 42 weeks, fetus's 10lb or more problems increased change of injury to the fetus, and perineal tears and infections,
vital signs
pulse: respirations; skin color, temperature, and
60 breaths/min
reassess the newborn every 90 seconds gets als
60-100
reassess the newborn every 90 seconds, begin around ventilations with a BVM and 100% oxygen,
Obstetrics
recognition and management of -normal delivery - abnormal delivery
post delivery
report the time of birth in your patient care report more than 30 mins elapse and the placenta has not delivered there is more than 500 mL of bleeding before delivery of the placenta record the time of birth in your patient care
first trimester
risky trimester, embryo can miscarry, mom can be sick, the sicker you are the healthier you are. The baby is sucking all the nutrients from mamas body.
heart rate and skin color
skin color can change very quickly, they can become cyanosis or central or lower extremities
cultural value considerations
some cultures may not permit a male heatlh care provider to assess or examine a female patient, respect these differences and honor requests from the patient, a competent, rational adult has the right to refuse all or any part of your assessment care.
Hypertensiive disorders
spine hypotensive syndrome, compression of the descending aorta and the inferior vena cava, pregnant uterus. Or have them sit up.
abuse
spontaneous abortion, premature delivery, low birth weight. Financial reasons, problem with control or an affair. risk from bleeding, infection, and uterine rupture. use a calm and professional approach. talk to the patient in a private area. Uncleanliness, demeanor, bruises, suspiticious of houses that are really clean, holes in the wall, broken furniture. EMT partner would stall and ask partner questions. While ask mom questions.
apgar score
standard scoring system, assign a number value into five areas 1. appearance 2. pulse 3. grimace or irritability 4. activity or muscle tone 5. respiration the total of the five numbers is the apgar score, a perfect score is 10, calculate apgar score at 1 mins and 5 mins after birth assessing a newborn. calculate the apgar score. stimulation should result in an immediate increase in respiratoins if the newborn is breathing well, assess the pulse, assess oxygenations. request a second unit and require resuscitation assisted ventilation is required use a newborn bvm no adequate heart rate, continue CPR and rapid transport
Communication and documentation
status of newborn and mom about pregnancy, within 30 mins from crowning. the number of weeks of gestation, her due date, any known complications of the pregnancy, two patient care reports,
abruptio placentae
the placenta separates prematurely from the wall of the uterus, in placenta previa the placenta develops over and covers the cervix
teenage pregnancy
the united states has one of the highest teenage pregnancy rates respect the teenager's privacy, assess and obtain her history away from her parents. Know teenage pregnancies usually are in denial.
rapid uterine growth second trimester
the uterus grows, pushes up on the diaphragm and displaces it,
multiple gestation
there may be one placenta, or there may be two. record the time of birth of each twin separately twins may be so small that they look premature handle carefully and keep them warm
delivery
time the patients contractions, encourage the patient to take quick, short breaths, during each contraction but not to shock, encourage to rest, delivering the head observe the head as it exits the vagina, support the head with your gloved hand as it rotates,
hormone levels increase
to support fetal development and prepare the body for childbirth, fetus develops and grows, the uterus grows, as the size of the uterus increases so does the amount of fluid it contains, uterus and organs are shifted from their normal position.
multiple gestations
twins occur once in every 30 births, more than one resuscitation, and call for assistance. 3 or 4 or 5 babies, twins are small than single fetus's. 10 mins after first birth, the contractions will begin again. usually second one is born 45 mins after the first. get the times of the births
prolapse
umbilical cord must be treated in the hospital umbilical cord comes out of the vagina do not push cord back into the vagina place the woman supine hips elevated letting gravity work with us she can grab knees a pull in insert a gloved hand into the vagina and push the fetus's hand into the umbilical cord
a fetus with a limb presentation cannot be delivered in the field
usually surgery is needed transport immediately if a limb is protruding cover it with a sterile towel never try to push it in or pull on it place the patient on her back, with her head down and pelvis elevated.
weight gain during pregnancy is normal
weight gain will challenge the heart and impact the musculoskeletal system, changes in the body's center of gravity increase the risk of slips and falls
second stage
when fetus begins to encounter the birth canal, ends when the newborn is born, uterine contractions are usually closer together and last longer, the perineum will bulge significantly
Eclampsia
when moms start seizing, treatment: lie the patient on her left side, maintain her airway, administer 02 administer supplemental oxygen, vomitting occurs, suction the airway, provide rapid transport and call for ALS. Left side because its compressing the vena cava, and cutting off the circulation to the baby. and displaces weight.
special considerations for trauma and pregnancy
with a trauma call involving pregnant woman, you have two patients the woman, the unborn fetus. trauma to a pregnant woman may have a direct effect on the fetus. Make sure to put it on the PCR if the woman is abusing substances and putting the baby in harm.
postdelivery care
you can pick up and cradle the newborn
assessment and management
your focus is on the woman, suspect shock based on the MOI, attempt to determine the gestational age to assist you with determining the size of the fetus and the position of the uterus.
spina bifida
A developmental defect in which a portion of the spinal cord or meninges may protrude outside of the vertebrae and possibly even outside of the body, usually at the lower third of the spine in the lumbar area
supine hypotensive syndrome
Dizziness and a drop in blood pressure caused when the mother is in a supine position and the weight of the uterus, infant, placenta, and amniotic fluid compress the inferior vena cava, reducing return of blood to the heart and cardiac output.
Pregnancies varies,
With multiples it varies. There can be multiple placentas, or the placenta can be shared.
premature birth
a normal, full term single newborn will weigh about 7lb at birth any newborn who delivers before 8 months (36) weeks or under 5lbs is premie baby
premature birth
a premature newborn is smaller and thinner, and the head is proportionately larger. the vernix caeosa will be absent or minimal, there will be less body hair pluck birds
Level III 3 neonatal ICU
about 12% to 16% of deliveries are complicated by the presence of meconium, consider quickly suctioning the newborns mouth, then nose the delivery before providing rescue ventilations. The bulb is for meconium babies.
the fetus develops insides a fluid filled baglike membrane called
amniotic sac, contains about 500 to 1,000 mL of amniotic fluid, helps insulate and protect the fetus, fluid is released in a gush when the sac ruptures, USUALLY at the beginning of labor. patients are not textbook.
delivering the head
apply gentle pressure across the perineum with a sterile gauze pad to reduce the risk of perineal tearing, be prepared for the possibility of the patient having a bowel movement, do not poke your fingers on the fontanelles
third stage
begins with the birth of the newborn and ends with delivery of the placenta, the placenta must completely separate from the uterine wall, may take up to 30 mins. delivery of the placenta, doctor has to check it's all in tact, and that nothing is left behind causing infection
preparing for delivery
blankets, sheets on the ground. elevate the hips 2-4 inches, support the head, neck, and upper back, have her legs and hips flexed with her feet flat and her knees spread apart. sometimes on all fours, what helps to open the pelvis.
postpartum complications
bleedings; uterus has stopped contracting enough to clamp down on blood vessels. F massage, kneading motion into the abdomen. or start nursing the baby/ get the baby on the boob. start contractions. on the UTERUS
in the third trimester
blood pressure decreases, increased risk of vomiting and potential aspiration, due to changes in gastrointestinal motility and the displacement of the stomach upward
presenting part of the fetus is a single arm, leg, or foot
called a limb presentation
Perineal tears
can happen multiple times, control the bleeding, get a history beforehand. have you had any complications with deliveries,
Unruptured amniotic sac
if the amniotic sac does not rupture by the time the head is crowing, it will appear as a fluid filled sac emerging from the vagina, it will suffocate the fetus if not removed, scratch with finger nail, clear the newborns mouth and nose immediately,
reassessment
check our interventions, get vitals, primary assessment.
delivery
crowning, comfort soothe and reassure, if the patient will allow it apply oxygen, continually check for crowning, some patients experience preciptious labor and birth, position yourself so that you can see the parineal area at all times
Gestational diabetes
diabetes during pregnancy, resolves after pregnancy, diet, exercise, or insulin injections. Usually before she gets diabetes or when she gets diabetes she goes to the hospital
stages of labor
dilation of the cervix, delivery of the fetus, delivery of the placenta.
bulb syringe
don't use a regular suction machine on a newborn use a bulb syringe. they want the baby to breathe spontaneously. get sterile gauze and wipe the babies nose and mouth.
the breasts produce milk that is carried through small ducts to the nipple to provide nourishment to the newborn once it is born
each signs of pregnancy in the breasts include increased size and tenderness
substance abuse
effects of addiction on the fetus; prematurity, low birth weight, severe respiratory distress, death. Fetal alcohol syndrome, women who have abused alcohol. Can't get any medication when the baby is addicted, it takes a lot of months. stroking their head, and holding them helps them with the withdrawal process.
circulation
external and internal bleeding are potential life threats and should be assessed early, blood loss after delivery is expected
Anatomy and Physiology of the female reproductive system
fallopian tubes extend our laterally from the uterus, with one tube associated with each ovary. The uterus is a muscular organ that encloses and protects the developing fetus as it grows for approx 9 months. Produces contractions during labor, helps to push the fetus through the birth canal, the birth canal is made up of the vagina and the lower third of the uterus, called the cervix (40 weeks complete process)
first stage
false labor: stop and stay in the lower abdomen, physical activity: may intensify the contractions blood show: the bloody show is pink or red generally accompanied by mucous, happens a few day before, typically if leakage fluid occurs; the amniotic sac may have before the contractions started, a moderate amount of fluid firs stage: some women experience a premature rupture of the amniotic sac ; patient may or may not go into labor provide supportive care and transport the head of the fetus descends into the woman's pelvis as it positions for delivery, this descent is called lightening
cardiac arrest
focus is the same with other patients, perform CPR and provide transport, notify the receiving facility personnel that you are en route with a pregnant trauma patient in cardiac arrest
Neonatal assessment and resuscitation
follow standard precautions always put on gloves before handling a newborn, newborn will usually begin breathing spontaneously within 15 to 30 seconds after birth heart rate will be 130 beats/min or higher
the vagina is the outermost cavity of the female reproductive system
forms the lower part of the birth canal
pregnant woman
has the potential to affect the fetus nutrients, oxygen, waste, carbon dioxide, many toxins, most medications. Prenatal vitamins.
Cultural Sensitivity
how they care for themselves during pregnancy, how they have planned the childbirth process.
transport decision
if delievery is imminent, prepare to deliver at the scene, ideal place to deliver is NOT in the ambulance, cannot deliver baby in a MOVING ambulance. Provide rapid transport for pregnant patients Have significant bleeding and pain are hypersensitive any altered status
preparing for delivery
natural disaster, inclement weather, how long have you been pregnant? first bby? contractions, how far apart? do they last ? has your water broken? feel the need to push? do you have lower back pain? woman will feel the woman needs a bowel movement, never have a baby in a toilet. don't let her go to the bathroom. to determine potential complications : C section before, will have it again. open abdomen, going all the way through the uterus, when they sow it up the integrity is compromised. uteran tear, abdominal tear, call medical director. to determine potential complications any problems or pregnancy , drugs drink alcohol, medication, if the patient says that she is about to deliver, prepare for delivery. does she have an extremely firm abdomen, rock hard abdomen, visually inspect the vagina for crowning. the placenta should not come first. once labor has begun it cannot be slowed or stopped. never attempt the patient's legs together, only assisting.
additional resuscitation efforts
observe the newborn for spontaneous respirations, skin color, and movement of the extremities. Evaluate the heart rate at the base of umbilical cord or brachial artery or by listening to the newborns chest
history taking
obtain a thorough obstetric history, her expected due date, any complications, prenatal care(vitamins), a complete medical history.
Postdelivery Care
once the cord has stopped pulsing, clamp and cut the cord obtain the 1 mins apgar score and 5 mins delivery of the placenta , your job is only to assist the placenta delivers itself, usually within a few minutes of the birth never pull at the end of the umbilical cord
delivering the body, the body delivers easily
once the head is born, the body usually delivers easily, support the head and upper body as the shoulders deliver, do not pull the fetus from the birth canal, the newborn will be slippery and covered in vernix caseosa.
First stage
onset of contractions and ends when the cervix is fully dilated. lasting an average of 16 hours, uterine contractions become more regular and last about 30 to 60 seconds each. frequency and internally increase.
female reproductive system
ovaries, fallopian tubes, uterus, cervic, vagina, breasts Ovaries are two glands, one on each side of the uterus. Each ovary contains thousands of follicles, and each follicle contains an egg. ovulation occurs approx 2 weeks prior to menustration.
primary assessment
the general impression should tell you whether you have time to assess and address other possible life threats, perform a rapid examination, other medical problems, present, evaluate these first.
meconium
the greenish material that collects in the intestine of a fetus and forms the first stools of a newborn, why was the baby in distress? the baby has breathed in waste.
anatomy and physiology of the female reproductive system part 2
the placenta attaches to the uterine wall and connects to the fetus by the umbilical cord; the placental barrier consists of two layers of cells.