EMT Chapter 34: Obstetrics and Neonatal care

Preeclampsia

A condition that occurs in the second half of pregnancy (after 20 weeks' gestation) that presents as new-onset hypertension along with other systemic effects, such as protein in the urine. This condition occurs in approximately 3.4% of pregnancies in the United States. The risk of preeclampsia occurring is 1.5 to 2 times higher in a woman's first pregnancy. If she experiences preeclampsia with her first pregnancy, the risk is increased in subsequent pregnancies. Preeclampsia is characterized by: Hypertension (systolic blood pressure >140 mm Hg, diastolic blood pressure > 90 mm Hg), Severe or persistent headache, Visual abnormalities such as seeing spots, blurred vision, or sensitivity to light, Swelling in the hands and feet (edema), Upper abdominal or epigastric pain, Dyspnea and/or retrosternal chest pain, Anxiety, Altered mental status

vertex presentation

A delivery in which the head of the newborn comes out first.

Fetal alcohol syndrome

A condition caused by the consumption of alcohol by a pregnant woman; characterized by growth and physical problems, mental retardation, and a variety of congenital abnormalities in her child.

placenta previa

A condition in which the placenta develops over and covers the cervix. In placenta previa, the placenta develops over and covers the cervix. When early labor begins and the cervix begins to dilate, the pregnant woman may experience heavy vaginal bleeding, often without significant pain.

umbilical cord around the neck

As soon as the head is delivered, use one finger to feel whether the umbilical cord is wrapped around the neck (called a nuchal cord). A nuchal cord that is wound tightly around the neck could strangle the fetus, so it must be released immediately. Usually, you can slip the cord gently over the delivered head (or over the shoulder, if necessary). If this is not possible, cut the cord by placing two clamps about 2 inches apart on the cord and cutting between the clamps. Once the cord is cut, attempt to speed the delivery by encouraging the woman to push harder and possibly more often because the fetus will have no oxygen supply until it is delivered and breathing spontaneously. In the rare case of the cord being wrapped more than once around the neck, you will need to clamp and cut only once; then you can unwrap the cord from around the neck. Handle the cord very carefully; it is fragile and easily torn.

Respirations

Normally, a newborn's respirations are regular and rapid, with a good strong cry. If the respirations are slow, shallow, or labored, or if the cry is weak, the newborn may have respiratory insufficiency and need assistance with ventilation. Complete absence of respirations or crying is obviously a very serious sign; in addition to assisted ventilation, CPR may be necessary.

Delivering the head

Observe head as it leaves vagina, it may take many contractions Once it's obvious that the head is coming out farther with each contraction, place your sterile gloved hand over the emerging bony parts of the head, avoid the eyes and fontanelles, and, exerting minimal pressure, control the delivery of the head. Continue to support the head as it rotates. Reduce the risk of perineal tearing during labor by applying gentle pressure across the perineum with a sterile gauze pad. Also be prepared for the possibility of the patient having a bowel movement because of the increased pressure on the rectum.

The fallopian tubes

The fallopian tubes extend out laterally from the uterus, with one tube associated with each ovary. When an egg is released from the ovary, it travels through the fallopian tube to the uterus. Fertilization usually takes place when the egg is inside the fallopian tube. The fertilized egg then continues to the uterus where, if implantation occurs, the fertilized egg develops into an embryo (the stage from 0 to 10 weeks after fertilization) and then a fetus (the stage from 10 weeks until delivery) and grows until the time of delivery at approximately 9 months (40 weeks) of gestation.

Anatomy and physiology of the female reproductive system

The female reproductive system includes:The ovariesFallopian tubesUterusCervixVaginaBreasts

Stage 1 of labor: Dialation of the cervix

The first stage begins with the onset of contractions and ends when the cervix is fully dilated. Because the cervix has to be stretched thin by uterine contractions until the opening is large enough for the fetus to pass through into the vagina, the first stage of labor is usually the longest, lasting an average of 16 hours for a first delivery. You will usually have time to transport the woman if she is in the first stage of labor. The onset of labor starts with contractions of the uterus. Other signs of the beginning of labor are the bloody show (blood-streaked mucus) and the rupture of the amniotic sac (water breaking). These occur near the first contraction or early in the first stage Initially, uterine contractions may not occur at regular intervals. Woman may think it is a back ache. In true labor, the frequency and intensity of contractions increase with time. The uterine contractions become more regular and last about 30 to 60 seconds each. Labor is usually longer in a primigravida, a woman who is experiencing her first pregnancy, and shorter in a multigravida, a woman who has experienced previous pregnancies. The table lists characteristics of true labor versus false labor, or Braxton-Hicks contractions. With false labor, provide transport for the patient. With true labor, you may need to prepare for a delivery, depending on the stage of labor, the patient's condition, and transport time. Some women experience a premature rupture of the amniotic sac, before the fetus is ready to be born, and may or may not be go into labor. This can happen months before. Provide supportive care and transport to the hospital. These patients are usually placed on bed rest and followed up closely by an obstetrician. Toward the end of the third trimester of pregnancy, the head of the fetus descends into the woman's pelvis as the fetus positions for delivery. This movement down into the pelvis is called lightening. Some women describe this as a relief because once the fetus has moved from under their rib cage, breathing becomes easier. Lightening may also occur gradually and not be noticed by some patients.

Fetal circulation

The flow of oxygen through the fetal circulation is altered within the womb and changes within minutes after birth. The umbilical vein carries oxygenated blood to the baby and the umbilical arteries carry deoxygenated blood back to the placenta Oxygen and other nutrients cross from the woman's circulation through the placenta and then through the umbilical cord to support the fetus as it grows.

Endometrium

The lining of the inside of the uterus.

spontaneous abortion

The loss of a pregnancy prior to 20 weeks of gestation without any preceding surgical or medical intervention; often called a miscarriage. Asociated with abdominal cramping and vaginal bleeding Although trauma, drugs, underlying shits, and STIs increase risk of miscarridge, direct cause is unknown

Ovaries

The ovaries are two glands, one on each side of the uterus, similar in function to the male testes. Each ovary contains thousands of follicles, and each follicle contains an egg. Females are born with all eggs for their life time. During puberty, the maturing female body undergoes multiple physical and hormonal changes, ultimately leading to menarche. This leads to regular periods, approximately 28 days apart. During each menstrual cycle, only one follicle will be successful at maturing and releasing an egg. The remaining follicles die and are reabsorbed by the body. Ovulation (the process the follicle goes through and the release of the egg) occurs approximately 2 weeks prior to menstruation. Immediately following ovulation, the endometrium begins to thicken in preparation for the potential implantation of a fertilized egg. If the egg is not fertilized within 36 to 48 hours after it has been released from the follicle, it will die, and the thickened endometrium will be shed because it is not needed. This shedding is the menstrual flow that occurs around the 28th day of a woman's cycle.

Placenta

The tissue attached to the uterine wall that nourishes the fetus through the umbilical cord. Blood does not mix with the fetus because of the placental barrier, which has two layers of cells that keep circulation of woman and fetus blood separate while allowing nutrients, oxygen, waste, and potentially toxins to go across The placenta develops while attached to the inner lining of the wall of the uterus and is connected to the fetus by the umbilical cord. After delivery of the newborn, the placenta separates from the uterus and is delivered.

Uterus

The uterus is a muscular organ that encloses and protects the developing fetus. During labor, it produces contractions and ultimately helps to push the fetus through the birth canal.

Birth canal

The vagina and cervix

Vagina

The vagina is the outermost cavity of the female reproductive system and forms the lower part of the birth canal. It is about 3 to 5 inches (8 to 12 cm) in length, beginning at the cervix and ending as an external opening of the body. The vagina completes the passageway from the uterus to the outside world for the newborn. The area between the vagina and the anus is called the perineum.

menarche

the first menstrual period

supine hypotensive syndrome

Low blood pressure resulting from compression of the inferior vena cava by the weight of the pregnant uterus when the woman is supine.

APGAR Pulse

Measure the pulse by chest auscultation. If a stethoscope is not available, you can measure pulsations with your fingers at the brachial pulse. A newborn with no pulse requires immediate CPR.

Nuchal cord

An umbilical cord that is wrapped around the fetus's neck.

Delivering the Newborn

1. Crowning is the definitive sign that delivery is imminent and transport should be delayed until after the child has been born. 2. Use your hands to support the bony parts of the head as it emerges. The child's body will naturally rotate to the right or left at this point in the delivery. Continue to support the head to allow it to turn in the same direction. 3. As the upper shoulder appears, guide the head down slightly by applying gentle downward traction to deliver the shoulder. 4. Support the head and upper body as the lower shoulder delivers, guide the head up if needed. 5. Handle the newborn firmly but gently, support the head and keep the neck in a neutral position to maintain the airway. Consider placing the newborn on the mother's abdomen with the umbilical cord still intact, allow skin-to-skin contact to warm the newborn. Otherwise, keep the newborn approximately at the level of the vagina until the cord has been cut. 6. After delivery and prior to cutting the cord, if the child is gurgling or shows other signs of respiratory distress, suction the mouth and oropharynx to clear any amniotic fluid and ease the infant's initiation of air exchange. 7. Wait for the umbilical cord to stop pulsing. Place a clamp on the cord. Milk the blood from a small section of the cord on the placental side of the clamp. Place a second clamp 2 to 3 inches away from the first. 8. Cut between the clamps. 9. Allow the placenta to deliver itself. Do not pull on the cord to speed delivery.

Assessing a newborn

1. Quickly calculate the Apgar score to establish a baseline on the newborn's status. 2. If stimulation does not result in an immediate increase in respiration rate, begin ventilations with a bag-mask device. Unlike adults, in whom sudden cardiac arrest may precede respiratory arrest, newborns who are in cardiac arrest usually have had a respiratory arrest first. Therefore, it's essential to keep the newborn ventilating and oxygenating well. 3. If the newborn is breathing well, check the pulse rate by feeling the brachial pulse or auscultating the chest with a stethoscope. The pulse rate should be at least 100 beats/min. If it is not, begin ventilations with a bag-mask device. Begin ventilations without oxygen attached as the 21% oxygen in the atmosphere is often enough, and a change that is too rapid in oxygen levels from the saturation levels before birth may be detrimental. Ventilation alone may increase the newborn's heart rate. Reassess respirations and heart rate at least every 30 seconds to make sure that the pulse rate is increasing and respirations are becoming spontaneous. 4. Assess the newborn's oxygenation via pulse oximetry, which is best taken at the right wrist, and observe for central cyanosis. Remember that the oxygen saturation does not usually reach the 85% to 95% range until about 10 minutes after birth. If central cyanosis is present or the oxygen saturation does not improve but breathing is adequate, administer blow-by oxygen by holding oxygen tubing or an oxygen mask close to the newborn's face. Set the oxygen flow rate at 5 L/min. 5. Remember that you now have two patients. Request a second unit as soon as possible if you determine that the newborn is in any distress and will require resuscitation.

ectopic pregnancy

A pregnancy that develops outside the uterus, typically in a fallopian tube. A patient with an ectopic pregnancy may present with signs of internal bleeding when the fallopian tube ruptures. Ectopic pregnancies account for approximately 1.5% of reported pregnancies in the United States. Consider sudden onset of severe abdominal pain and vaginal bleeding in the first trimester of pregnancy ectopic pregnancy until proven otherwise. Consider the possibility of an ectopic pregnancy in a woman who has missed a menstrual cycle and reports sudden, severe, usually unilateral pain in the lower abdomen. Suspect possible ectopic pregnancy in women with: A history of pelvic inflammatory disease, Tubal ligation, Previous ectopic pregnancies

Term gestation

A pregnancy that has reached full term, between 39 weeks and 40 weeks, 6 days.

Bloody show

A small amount of blood in the vagina that appears at the beginning of labor and may include a plug of pink-tinged mucus that is discharged when the cervix begins to dilate.

vernix caseosa

A white, cheesy substance that covers the body of the fetus.

Normal changes in pregnancy: GI Tract

A woman in the third trimester of pregnancy has an increased risk of GERD, vomiting, naseau and potential aspiration following trauma because of changes in the gastrointestinal tract. The filling and emptying of the stomach into the small intestine is under the control of key hormones and the nervous system. Changes in these systems and the displacement of the stomach upward because of the increased size of the uterus significantly increase the chance that a pregnant trauma patient will vomit and aspirate. Be prepared to quickly manage the patient's airway if needed.

Abuse

Abuse during pregnancy increases the chance of spontaneous abortion, premature delivery, and low birth weight. The woman is at risk of bleeding, infection, and uterine rupture. A calm, professional approach is especially important if you suspect your patient has been abused. Pay attention to the environment for any signs of abuse. If possible, talk to the patient in a private area, away from the potential abuser. Suspect abuse when the story of how an injury happened does not make sense. Attention to detail is important for documentation and in informing the physician and staff who are caring for the patient Those who are abused may be reluctant to disclose it The best way for you to care for the fetus is to treat the pregnant woman. Reassure the patient as you provide treatment. Support the patient's ABCs, control any bleeding, stabilize extremity injuries, treat for shock, and keep her warm

Multiple gestation

According to the CDC, twins occur about once in every 30 births; triplets or higher multiples occur much less frequently. The woman will usually know if she is carrying multiple fetuses. With multiple fetuses, always be prepared for more than one resuscitation, and call for assistance. Twins are usually smaller than single fetuses, and delivery is not typically difficult. Consider the possibility that you are dealing with twins any time the first newborn is small or the woman's abdomen remains fairly large and firm after the birth. You should also ask the patient about the possibility of multiples. If twins are present, the second one is usually born within 45 minutes of the first. About 10 minutes after the first birth, contractions begin again, and the birth process repeats itself. The procedure for delivering twins is the same as that for a single fetus, but you will need some supplies from an additional OB kit. Clamp and cut the cord of the first newborn as soon as it has been delivered and before the second newborn is delivered. The second fetus may deliver before or after the first placenta. There may be only one placenta, or one for each fetus. When the placenta delivers, check whether there is one umbilical cord or two. If you see only one umbilical cord coming out of the first placenta, another placenta is still to be delivered. If both cords are attached to one placenta, the delivery is complete. Record the time of birth of each twin separately. Twins may be so small that they look premature; handle them carefully and keep them warm. Identify the first newborn delivered as "Baby A." With the delivery of two or more newborns, you can indicate the order of delivery by writing on a piece of tape and placing it on the blanket or towel that is wrapped around each newborn.

Reassessment

As time allows, repeat the primary assessment with a focus on the patient's ABCs and vaginal bleeding, particularly after delivery. Obtain another set of vital signs and compare the results with those obtained earlier. Recheck interventions and treatments to see whether they were effective. In most cases, childbirth is natural and does not require interventions When childbirth is complicated by trauma or other conditions, any interventions you provide for the patient will benefit the fetus. Administer oxygen if the assessment findings indicate a need, even in the absence of pulse oximetry readings. If your assessment determines that delivery is imminent, notify staff at the receiving hospital. Provide an update on the status of the woman and newborn after delivery. On the rare occasion that the 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. this will help determine if the patient is going the L and D or the ER Thorough documentation is essential, especially in the case of a newborn where delivery occurred in the field. In this situation, you will have two patient care reports to complete. Include pregnancy status (number of weeks, due date and any complications) for trauma or other injuries.

Delivering the body

At this point the body will rotate to allow for easier passage. The head is the largest part of the fetus. Once it is delivered, the body usually delivers easily. Support the head and upper body as the shoulders deliver. Make sure to always support the head with one hand. Lower the head a little to deliver the upper shoulder, and then very gently raise it to deliver the lower shoulder. Do not pull the fetus from the birth canal. Once the shoulders deliver, the abdomen and hips will appear and will slide out easily. The newborn will be extremely slippery, so make sure to support the body with your other hand as it delivers. The newborn may be covered with vernix caseosa. Support and hold the newborn with both of your hands.

Preparing for normal delivery

Can happen when birth is immentnat, or there is something preventing you from getting to the hospital. If this is not the first birth, she may be able to tell you where she is in labor. Ask the following questions: How long have you been pregnant? When are you due? Is this your first pregnancy? Are you having contractions? How far apart are the contractions? How long do the contractions last? Have you had any spotting or bleeding? Has your water broken? Do you feel as though you need to have a bowel movement? Do you feel the need to push? Ask these questions to help determine any potential complications: Were any of your previous deliveries by cesarean section? Have you had any problems in this or any previous pregnancy? Do you use drugs, drink alcohol, or take any medications? Is there a chance you will have multiple deliveries (having more than one baby)? Does your physician expect any other complications? If the patient says that she is about to deliver, she has to move her bowels, or feels the need to push, immediately prepare for a delivery and consider calling for additional resources. The fetus's head is probably pressing on the rectum, and delivery is about to occur. Otherwise, visually inspect the vagina to check for crowning. You should touch the vaginal area only during the delivery. Gently spread the pregnant woman's legs apart, explaining that you are doing so to decide whether the baby should be delivered immediately or whether she should be transported to the hospital for the delivery. Never attempt to hold the patient's legs together. Do not let her go to the bathroom. Reassure her that the sensation of needing to move her bowels is normal and that it means she is about to deliver. If you decide the delivery is imminent, your job is to assist and guide and support the baby Use standard precautions at all times. Administer oxygen to the patient if indicated. Limit distractions. Stay calm and know what you are doing while ensuring the patient's privacy. Recognize when the situation is beyond your level of training. If there is any doubt, contact medical control for further guidance. If you are unsure about what to do, transport the patient even if delivery might occur during transport. Your emer

Eclampsia

Characterized by the presence of seizures To treat a patient having seizures caused by eclampsia: Lay the patient on her left side, Maintain her airway, Administer supplemental oxygen. If vomiting occurs, suction the airway. Provide rapid transport for a pregnant patient having seizures and call for an ALS intercept, if available. Transporting the patient on her left side can also prevent supine hypotensive syndrome. Any patient in the third trimester of pregnancy should always be positioned at least leaning slightly to her left side during transport except during delivery.

Maternal cardiac arrest

Common causes include hemorrhage and sepsis resulting in shock Saving the mother provides the best chance for the fetus Focus resuscitation efforts on aggressively treating with high quality cpr and transport If a woman is in the third trimester, manual displacement of the uterus toward the patient's left side may be necessary to facilitate blood return to the right side of the heart. High-quality, minimally interrupted CPR is essential, as is early use of an AED. Baby has the best chance if the mother is resuscitated Use of mechanical CPR devices has not been tested and is not advised in pregnant women. Notify personnel at the receiving facility as soon as possible. ALS may perform a c section

Critical decision

Delay transport or go to hospital - Factors are trauma, weather, and distance

Complications: diabetes

Diabetes develops during pregnancy (6%, 2nd half of pregnancy) in many women who have not had diabetes previously. This condition, called gestational diabetes, resolves in most women after delivery. Treatment of a pregnant woman with diabetes is the same as treatment for any patient who has diabetes. Pregnant women can control B/G levels with diet, medication, or exercise. Possibly insulin. Care for a pregnant woman experiencing hyperglycemia or hypoglycemia in the same manner as any patient with diabetes. If a pregnant woman has an altered LOC, your assessment should include determining if she has a history of diabetes, and you should check the blood glucose level if local protocols permit. Many women experience nausea before labor and may not have eaten recently. These factors can lead to hypoglycemia and weakness in the woman and fetus. Consult with emdical control if delivery is imminent

Gestational diabetes

Diabetes that develops during pregnancy in women who did not have diabetes before pregnancy.

Patient assessment

Dispatch may ask questions to determine if birht is immenent trauma or medical conditions can cause contractions or the person will be full term

Complications: Hypertensive disorders

Elevated BP - Degree of hypertension, and the presence of systemic affects, such as protein in the urine, altered mental status., or seizures will aid in figuring out whihc condition

Assessment and maangement

Focus should be on the woman. It is difficult to estimate blood loss and the MOI should be the basis for suspicion of shock due to changes form pregnancy Be prepared for vomiting and maintain the airway try to get how far along she is to determine size of fetus and position of uterus. It is next to impossible to determine the status of the fetus so focus on the mother Maintain an open airway. A pregnant patient has an increased risk of vomiting and aspiration. Be prepared for and anticipate vomiting; keep your suction unit readily available. Administer high-flow oxygen. Remember that the patient's body is also supplying oxygen to the fetus. Keep the oxygen saturation level high and administer high-flow, 100% oxygen by nonrebreathing mask. Ensure adequate ventilation. Listen to breath sounds, and confirm that bilateral breath sounds are present.If the patient's ventilations are inadequate, provide or assist ventilation with a bag-mask device and 100% oxygen. Assess circulation. Control any external bleeding with direct pressure. Maintain a high index of suspicion for internal bleeding and shock based on the MOI. Keep the patient warm. Transport considerations: Transport the patient on her left side. If the patient is on a backboard because spinal injury is suspected, tilt the backboard 30 degrees to the left. Call early for ALS assistance or a medical helicopter for significant MOIs or major traumatic injuries. Transport the patient to a trauma center if one is available in your area; give early notification that you have a pregnant trauma patient in transport.

Primary assessment-----

Form a general impression as to whether the patient is in active labor and, if so, whether you have time to assess for imminent delivery and address other possible life threats. Perform a rapid examination to assess for airway, breathing, or circulation problems. Take a moment to determine if the fetus is incoming in a few minutes or whether there is more time to continue assessing. When trauma or medical problems, such as vaginal bleeding or seizures, are the presenting complaint, evaluate these first and then assess the impact of these problems on the fetus. During an uncomplicated brith, life threats involving airway and breathing are not an issue usually, but car crashes or assault or other can cause a life threat and complicate the delivery. In trauma situations, assess the airway and breathing to ensure they are adequate. If needed, provide airway management and administer high-flow oxygen. Assess for any potential life-threatening bleeding and begin treatment immediately. Blood loss during delivery is expected but significant bleeding is not. Assess the skin for color, temperature, and moisture, and check the pulse to determine if it is too fast or too slow. If there are signs of shock, control the bleeding, administer oxygen, and keep the patient warm. If delivery is imminent, prepare to deliver at the scene. The ideal place to deliver is in the security of your ambulance or the privacy of the woman's home. The area should be warm, private, and have room to move around If the delivery is not imminent, prepare the patient for transport and perform the remainder of the assessment en route to the ED. Administer oxygen. Transport women in the second and third trimesters of pregnancy lying on the left side when possible to prevent supine hypotensive syndrome. Provide rapid transport for pregnant patients who: Have significant bleeding and pain, Are hypertensive, Are having a seizure, Have an altered mental status

Premature birth

Full-term gestation is considered to be between 39 weeks and 40 weeks, 6 days, which is approximately 9 calendar months. A normal, full-term, single newborn will weigh approximately 7 pounds at birth. Any newborn who delivers before 8 months, or 36 weeks of gestation, or weighs less than 5 pounds at birth is considered premature. This determination is not always easy to make. Often, the exact gestation time cannot be determined. 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. The vernix caseosa will be absent or minimal on a premature newborn. There will also be less body hair. Premature newborns need special care to survive. They often require resuscitation, which should be performed unless physically impossible. With such care, premature newborns as small as 1 pound have survived.

APGAR grimace or irritability

Grimacing, crying, or withdrawing in response to stimuli is normal and indicates that the newborn is doing well. Test this by snapping a finger against the sole of the newborn's foot.

Delivery of the placenta

Happens after birth, can take 30 minutes, do not delay transport Never pull on the end of the umbilical cord in an attempt to speed delivery of the placenta, as it may tear the cord, the placenta, or both. The normal placenta is round, about 7 inches in diameter, and about 1 inch thick. One surface is smooth and covered with a shiny gray membrane. The other surface is rough, divided into lobes, and is a dark reddish-brown color similar to raw liver. Wrap the entire placenta and cord in a towel, place them into a plastic bag, and take them to the hospital. After delivery of the placenta and before transport, place a sterile pad or sanitary pad over the vagina and straighten the woman's legs. You can help to slow bleeding by massaging the woman's abdomen with a firm, circular, kneading motion. You should be able to feel a firm, grapefruit-sized mass in the lower abdomen; this upper end of the uterus is called the fundus. As you massage the fundus, the uterus will contract and become firmer. it can be uncomfortable, so tell the patient that is how it is sopposed ot be. Emergency situations include: The placenta has not delivered after 30 minutes. More than 500 mL of bleeding occurs before delivery of the placenta. Significant bleeding occurs after delivery of the placenta. If any of these events occur, promptly transport the woman and newborn to the hospital.Never put anything into the vagina. Place a sterile pad or sanitary pad over the woman's vagina, administer oxygen, keep her and the newborn warm by preventing any heat loss, and monitor her vital signs closely.

Normal changes in pregnancy: Reproductive system

Hormone levels increase to support fetal development and prepare the body for childbirth. These increased hormone levels also put the pregnant woman at an increased risk for complications from trauma, bleeding, and some medical conditions. As the fetus grows, so does the uterus As the size of the uterus increases, so does the amount of fluid it contains. These factors eventually result in displacement of the uterus out of its well-protected position within the pelvic area and may expose it to injury. By the 20th week of pregnancy, the top of the uterus is at or above the belly button. This increases the chance of direct fetal injury in trauma.

Postdelivery Care

If the mother is able, give the newborn to the mother for skin to skin contact and cover with a blanket. This can aid perfusiona nd keeps the baby warm. Dry the newborn the wrap it in a towel. Try to warm the towel before. Wrap the newborn so that only the face is exposed, making sure that the top of the head is covered. Keep the neck in a neutral position so the airway remains open. Consider placing the newborn on one side, with the head slightly lower than the rest of the body. If you can not give the bay to the mother, hold it in your arms. Use a sterile gauze pad to wipe the newborn's mouth and nose as needed. If your local protocols specify, keep the newborn at the same level as the woman's vagina until the umbilical cord has been cut. Post delivery care of the umbilical cord is important because infection can be transmitted through it. In a full term newborn who is vigorous and not showing signs of respiratory distress, it is general practice to place it on the mother's chest for 60 seconds before cutting. In any newborn who requries immediate care for respiratory distress, do not delay cutting for care, just care for the thing. Once the umbilical cord has stopped pulsating, using the two clamps in the OB kit, clamp the cord between the woman and the newborn, preferably 6 inches (15 cm) from the newborn's body. Place the clamps about 2 to 4 inches (5 to 10 cm) apart. When they are firmly in place, carefully cut the cord between them with sterile scissors or a scalpel. Once the clamps are in place, there is no need to rush. By now, the newborn should be pink and breathing on his or her own. Evaluate the newborn for term gestation, good muscle tone, and breathing/crying. Obtain the 1-minute Apgar score.

Post-term pregnancy

In 2018, approximately 6.2 percent of pregnancies were post-term. Post-term means the gestation period is longer than 41 completed weeks of gestation. The rate of post-term pregnancies has been steadily declining for the past decade. A true post-term pregnancy can lead to complications in both the woman and fetus. Post-term fetuses can be larger than a typical 40-week fetus, sometimes weighing more than 10 pounds, which can lead to a more difficult labor and delivery and an increased chance of injury to the fetus as it travels through the birth canal. The likelihood of the need for a cesarean section increases. The woman is also at increased risk for perineal tears and infection. Post-term newborns have an increased risk of meconium aspiration, infection, and being stillborn and may not have developed normally because of the restricted size of the uterus. Be prepared to resuscitate the newborn, because respiratory and neurologic functions may have been affected. The larger size of the fetus causes it to take up more space inside the uterus, resulting in compression of the structures, including the blood vessels of the placenta and the umbilical cord.

Breasts

In a pregnant woman, after the baby is born, the breasts produce milk that is carried through small ducts to the nipples to provide nourishment for the newborn. Early signs of pregnancy include increased size and tenderness in the breasts.

Assessing a newborn after steps

In situations where assisted ventilation is required, use a newborn bag-mask device. Cover the newborn's mouth and nose with the mask and begin ventilation with high-flow oxygen at a rate of 40 to 60 breaths per minute. Make sure you have a good mask-to-face seal. Use gentle pressure to make the chest rise with each ventilation. You may need to bypass the pop-off valve to accomplish this, especially during the first few breaths. If the newborn does not begin breathing on his or her own or does not have an adequate heart rate, continue CPR and rapidly transport. Once CPR has been started, do not stop until the newborn responds with adequate respirations and heart rate or is pronounced dead by a physician. Do not give up! If the newborn presents in distress, do not take time to assess the Apgar score—begin resuscitation immediately.

Additional Resuscitation efforts

Observe the newborn for spontaneous respirations, skin color, and movement of the extremities. If the respiratory effort appears appropriate, evaluate the heart rate by palpating the pulse at the brachial artery or listening to the newborn's chest with a stethoscope. The heart rate is the most important measure in determining the need for further resuscitation. If chest compressions are required, use the hand-encircling technique for two-person resuscitation. Perform bag-mask ventilation during a pause after every third compression. Avoid giving a compression and a ventilation simultaneously, because one will decrease the effectiveness of the other. Cardiac arrest in neonates is nearly always the result of ventilation compromise. Use a compression-to-ventilation ratio of 3 to 1, which will yield a total of 120 "actions" per minute (90 compressions and 30 ventilations). Remember that adequate ventilation is absolutely critical to the successful resuscitation of the neonate. Transport any newborn who requires more than routine resuscitation to a hospital with a level three neonatal intensive care unit, if available in your area. This type of unit is designed for newborns who require specialized care. If a level three neonatal intensive care unit is not available in your area, provide rapid transport to the closest appropriate facility. Meconium-stained amniotic fluid is seen in approximately 17 percent of term births. The risk of meconium-stained amniotic fluid generally increases with gestational age, and post-term newborns, those 42 weeks' gestation and beyond, are at highest risk. Meconium can be thick or thin. If the newborn aspirates thick meconium, significant lung disease and even death can occur. If you see meconium in the amniotic fluid or meconium staining and the newborn is not breathing adequately, consider quickly suctioning the newborn's mouth and then nose after delivery before providing rescue ventilations.

History taking

Obtain a thorough history that includes the patient's expected due date, any complications, if she has been receiving prenatal care, and a complete medical history. Obtain a SAMPLE history. Some may have medical problems that they take prescriptions for or they may have new medications to help with the pregnancy (iron supplements). Pertinent history should include questions related specifically to prenatal care. Identify any complications the patient may have had during the pregnancy or potential complications during delivery that her physician has identified. can include size and psition of the fetus or position and health of the placenta Determine: Due date, Fetal movement, Frequency of contractions, History of previous pregnancies and deliveries and their complications, if any, and Whether there is a possibility of multiples Ask whether the woman has taken any drugs or medications during the pregnancy. If her water has broken, ask whether the fluid was green. Green fluid is due to meconium (fetal stool). The presence of meconium can indicate newborn distress.

Limb presentations

On rare occasions, the presenting part of the fetus is neither the head nor the buttocks but a single arm or leg. This is called a limb presentation. You cannot successfully deliver a fetus with a limb presentation in the field. They usually need to be delivered surgically. If you are faced with a limb presentation, you must transport the patient to the hospital immediately. If a limb is protruding, cover it with a sterile towel. Never try to push it back in, and never pull on it. Place the patient on her back, with her head down and pelvis elevated. Because the woman and fetus are likely to be physically stressed, remember to administer high-flow oxygen to the woman.

Normal changes in pregnancy: Cardiovascular system

Overall blood volume increases throughout the pregnancy to allow for adequate perfusion of the uterus as the fetus grows and to prepare for the blood loss that will occur during childbirth. Blood volume may increase by as much as 50% by the end of the pregnancy. The number of red blood cells also increases, which increases the woman's need for iron. Pregnant women often take prenatal vitamin supplements containing iron to avoid becoming anemic. Blood clotting factors change as woman prepares for childbirth. The speed of clotting increases to protect against excessive bleeding during delivery. By the end of the pregnancy, the patient's heart rate increases up to 20% (about 20 more beats per minute) to accommodate the increase in blood volume. Cardiac output is significantly increased by the end of the pregnancy. Changes in the cardiovascular system and the increased demands of supporting the fetus significantly increase the workload of the heart. Women with underlying medical conditions may be more susceptible to cardiac compromise.

Abortion

Passage of the fetus and placenta before 20 weeks Abortions may be spontaneous abortions (commonly called miscarriage), often without any obvious known cause, or induced. Induced abortions may be self-induced, by the pregnant woman herself or by someone else, or planned and performed in a hospital or clinic. The most serious complications are bleeding and infection. Bleeding can result when: Portions of the fetus or placenta are left in the uterus (incomplete abortion). The wall of the uterus is injured (perforation of the uterus and possibly the adjacent bowel or bladder) Infection can result from perforation and from the use of nonsterile instruments. If the patient is in shock, treat and transport her promptly to the hospital. Collect and bring any tissue that passes through the vagina. Never try to pull tissue out of the vagina. Place a sterile pad or sanitary pad on the vagina. In rare cases, massive bleeding may occur and cause severe hypovolemic or hemorrhagic shock.In these cases, treat for shock and provide immediate transport.

Secondary assessment

Perform an assessment of the body systems with emphasis on the chief complaint. Assess for fetal movement by asking the patient whether she can feel the fetus moving. If the patient is in labor, focus the physical examination on contractions and possible delivery. Assess the length and frequency of contractions by asking the patient and by placing your hand on the abdomen. Compare what you feel with the patient's experience during each contraction. If you suspect delivery is immenent, Check for crowning. This assessment should be performed only when appropriate and according to local protocol. If you do not suspect delivery, do not inspect the vagina. Get a complete set of vital signs and pulse oximetry, including pulse; respirations; skin color, temperature, and condition; and blood pressure. Be alert for tachycardia and hypotension (which could mean hemorrhage or compression of the vena cava) or hypertension (possibly indicating preeclampsia). A woman's blood pressure typically drops slightly during the first two trimesters of pregnancy but returns to normal during the third trimester. Compare your findings with previous blood pressure readings the patient may know of from prenatal visits. Hypertension, even when mild, may indicate more serious problems.

abruptio placentae

Premature separation of the placenta from the wall of the uterus. In abruptio placentae, the placenta separates prematurely from the wall of the uterus. The most common causes are hypertension and trauma. A patient with abruptio placentae often reports severe pain; however, vaginal bleeding may not be heavy. She may also present with signs of shock such as weak, rapid pulse and pale, cool, diaphoretic skin.

Prolapse umbilical cord

Prolapse of the umbilical cord, a situation in which the umbilical cord comes out of the vagina before the fetus, is another rare presentation that must be treated in the hospital. This situation is dangerous because the fetus's head will compress the cord during birth and cut off circulation, depriving the fetus of oxygenated blood. Do not attempt to push the cord back into the vagina. Prolapse of the umbilical cord usually occurs early in labor when the amniotic sac ruptures. There is usually time to get the patient to the hospital. Your job is to try to keep the fetus's head from compressing the cord. Place the pregnant woman supine with the foot end of the stretcher raised 6 to 12 inches higher than the head, with her hips elevated on a pillow or folded sheet. Alternatively, place her in the knee-chest position: kneeling and bent forward, facedown. Either of these positions will help keep the weight of the fetus off the prolapsed cord. Carefully insert your sterile gloved hand into the vagina, and gently push the fetus's head away from the umbilical cord. Note that this is one of only two situations, the other being a breech presentation, in which you should place a hand or finger into the vagina. Maintain this position and continue to keep the pressure off of the cord continuously throughout the transport to the hospital and possibly until the patient is in the operating room. Wrap a sterile towel, moistened with saline, around the exposed cord. Administer high-flow oxygen, and transport rapidly.

Normal changes in pregnancy: Respiratory system

Rapid uterine growth occurs during the SECOND TRIMESTER of pregnancy. The increased size of the uterus directly affects the respiratory system. As the uterus grows, it pushes up on the diaphragm, displacing it from its normal position and reducing tidal volume. As the pregnancy continues, respiratory capacity changes, with increased respiratory rates and decreased minute volumes. The pregnancy also increases the patient's overall demand for oxygen as her metabolic demands and workload increase to support the developing fetus. These changes lead to an overall reduction in respiratory reserve and decreased ability to compensate during times of respiratory distress

Patient posistion

Remove the patient's clothing and undergarments or push them up to her waist. Preserve the patient's privacy as much as you can. If the emergency delivery is occurring at home, move the patient to a sturdy, flat surface or the floor if she'll allow it. it is easier on a flat surface than a bed. Put a pillow or blankets beneath her hips to elevate them about 2 to 4 inches. Sometimes it is more comforatble to only elevate one hip. Allow the patient to get comfortable. Support the patient's head, neck, and upper back with pillows and blankets. Have her keep her legs and hips flexed, with her feet flat on the surface beneath her and her knees spread apart. Track the progression of the delivery closely at all times. Avoid an explosive delivery

APGAR Appearance

Shortly after birth, the skin of a light-skinned newborn and the mucous membranes of a dark-skinned newborn should turn pink. Newborns often have cyanosis of the extremities for a few minutes after birth, but hands and feet should "pink up" quickly. Blue skin all over or blue mucous membranes signal a central cyanosis.

Postpartum complications

Some bleeding always occurs with delivery, but bleeding that exceeds approximately 1,000 milliliters is considered high risk for maternal mortality and morbidity. If bleeding continues after delivery of the placenta, continue to massage the uterus, but check your technique and hand placement. If the woman appears to be in shock, treat her accordingly and transport, massaging the uterus en route. Excessive bleeding after birth is usually caused by the muscles of the uterus not fully contracting. This can be from delivering more than one infant, a long labor process so the uterus is too "tired" to contract, or parts of the placenta still being inside the uterus. This condition is potentially life threatening for the woman. Cover the vagina with a sterile pad, changing the pad as often as necessary. Do not discard any blood-soaked pads; hospital personnel will use them to estimate the amount of blood loss. Also save any tissue that may have passed from the vagina. Administer oxygen if necessary, monitor vital signs frequently, and transport the patient immediately to the hospital. Never hold the woman's legs together or pack the vagina with gauze pads in an attempt to control bleeding. Postpartum patients are also at an increased risk of a venous embolism. One reason is the increased clotting ability that is a normal change of pregnancy. Also, a pregnant woman who has been on bed rest for any length of time is more prone to clots. The most common embolism seen in postpartum women is a pulmonary embolism, which is a clot that travels through the bloodstream and becomes lodged in the pulmonary circulation. This obstruction will block blood flow to the lungs and is potentially life threatening. If you deliver a newborn in the field and the woman begins to report sudden difficulty breathing or shortness of breath, consider the possibility that she has a pulmonary embolism. You should also suspect a pulmonary embolism in patients of childbearing age with respiratory complaints who have recently delivered, especially with the sudden onset of difficulty breathing or altered mental status. Women have died of a postpartum pulmonary embolism from days to several weeks or months after childbirth. Provide supportive care of

Cultural value considerations and teenage pregnancy

Some cultures have values that affect the care of themselves and how they plan the childbirth Some cultures may not permit a male health care provider, especially in the prehospital setting, to assess or examine a female patient. Some may see pregnancy as a means of achieving status and recognition within the family unit, whereas others may experience a drop in self-esteem. Respect these differences and honor requests from the patients. Your responsibility is to the patient and is limited to providing care and transport. Keep in mind that a competent, rational adult has the right to refuse all or any part of your assessment or care. When treating a pregnant teenager: Respect the patient's privacy and need for independence. If possible, perform your assessment and obtain the history away from the teenager's parents. Consider the possibility that the pregnancy resulted from rape or incest. They amy not know, or be in denial, of the pregnancy and refuse prenatal care.

Spina bifida

Spina bifida is a developmental defect in which a portion of the spinal cord or meninges may protrude outside of the vertebrae and possibly outside of the body. When it protrudes outside the body, the protrusion is seen on the newborn's back, usually in the lumbar area. It is important to cover the open area of the spinal cord with a moist, sterile dressing and then an occlusive dressing to seal the area immediately after birth to help prevent a potentially fatal infection. Maintenance of the newborn's body temperature is important, so if you must use moist dressings, which can lower the body temperature, have someone hold the newborn against his or her body.

Scene size up

Take standard precautions—gloves and eye and face protection are a minimum if delivery has already begun or is complete. If the call is going to result in a field delivery and if time allows, use a gown. Do not be relaxed in safety precaution because delivery is in progress. Rushing can endanger everyone. Remain calm and professional. Consider calling for additional or specialized resources. Determine the MOI or nature of illness in a pregnant patient. Do not develop tunnel vision and assume the call is for the pregnancy alone. Not every call will be for labor Because a pregnant woman's balance may be altered, consider trauma from falls and the necessity of spinal immobilization.

Delivery

Take the following steps to prepare the area where the delivery will occur: 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. Carefully open the OB kit so its contents remain sterile. Put on the sterile gloves. After this, handle only sterile materials. Use the sterile sheets and drapes from the OB kit to make a sterile delivery field. Place one drape under the patient's buttocks, and unfold it toward her feet. Wrap another behind the patient's back and drape it over each thigh. Finally, drape a third sheet across her abdomen. Your partner should be at the patient's head to comfort, soothe, and reassure her. She may scream, cry, say nothing, and ask for a hand to hold. She may be nauseas and may vomit. If vomiting occurs, have your partner assist her and ensure that her airway remains clear. Continually check for crowning. For not a first birth (precipitous), and that can increase the risk for perineal tears because the tissue does not have time to stretch. Position yourself so that you can see the perineal area at all times. Time the patient's contractions, starting at the beginning of one and ending with the beginning of the next. Time the duration of each contraction by feeling the patient's abdomen from the moment the contraction begins to the moment it ends. Remind the patient to take short rapid breaths during contractions. Encourage the patient to rest and breathe deeply through her mouth between contractions.

Neonatal Assessment and Resuscitation

The American Heart Association and American Academy of Pediatrics have published guidelines on the routine care and resuscitation of newborns. The first minute after birth is often referred to as the "golden minute," and during this time all newborns should be assessed to determine the need for resuscitation. Follow standard precautions, and always wear gloves when handling a newborn. During the first minute of life, perform the following four initial steps of newborn care: Airway positioning and suctioning, if needed, drying, warming, and tactile stimulation. These initial steps should be carried out in all newborns. If signs of good tone and adequate ventilation are not present after performing the initial steps for approximately 30 seconds, positive pressure ventilation with a bag-mask device may be necessary. If the newborn is vigorous with good tone and has adequate respirations in the first minute of life, note the Apgar score and place the baby onto the mother's chest for skin-to-skin bonding and routine care. The normal respiratory and cardiovascular physiologic responses expected are that the newborn will begin breathing spontaneously within 30 seconds after birth, and the heart rate will be 100 beats per minute or higher. Many newborns require some form of stimulation that will encourage them to breathe air and begin circulating blood through the lungs. Additional details regarding the initial steps of newborn care are listed here.: - Positioning the newborn on his or her back with a towel or blanket under the shoulders so that the head is down and the neck is slightly extended. - Suctioning the mouth and nose using a bulb syringe or suction device with an 8- or 10-French catheter. - Suctioning both sides of the back of the mouth, where secretions tend to collect, but avoiding deep suctioning of the mouth and throat. - Aiming blow-by oxygen at the newborn's mouth and nose during resuscitation. - Rubbing the newborn's back and gently flicking the soles of his or her feet. If the newborn does not breathe after 30 seconds of stimulation, then begin positive pressure ventilation with an appropriately sized bag-mask device. You should be properly equipped for resuscitation measures in case the newborn is

The Apgar score

The Apgar score is the standard scoring system used to assess the status of a newborn. This system assigns a numeric value of 0, 1, or 2 to five areas of activity of the newborn. The total of the five numbers is the Apgar score. The highest possible score is 10. The Apgar score should be calculated at 1 minute and again at 5 minutes after birth. Calculation of the Apgar score should not delay resuscitation efforts and is generally deferred when resuscitation is required. A score of 7 or higher is generally considered reassuring. The table shows the Apgar scoring system. The figure shows a photo of a newborn with an Apgar score of less than 9.

Crowning

The appearance of the fetus's head at the vaginal opening during labor.

perineum

The area of the skin between the vagina and the anus.

Cervix

The birth canal is made up of the vagina and the lower third, or neck, of the uterus, called the cervix. During pregnancy, the cervix contains a mucous plug that seals the uterine opening, preventing contamination from the outside. When the cervix begins to dilate, this plug is discharged into the vagina as pink-tinged mucus, sometimes called bloody show. This small amount of bloody discharge often signals the beginning of labor.

APGAR Activity or muscle tone

The degree of muscle tone indicates the oxygenation of the tissues. Normally, the hips and knees are flexed at birth, and, to some degree, the newborn will resist attempts to straighten them. A newborn should not be floppy or limp.

Fetus

The developing, unborn infant inside the uterus, from 10 weeks after fertilization until birth.

Embryo

The early stage of development after the fertilization of the egg (first 10 weeks).

Induced abortion

The elective termination of a pregnancy prior to the time of viability. Performed by a licensed health care provider using medicine or surgery Can also be illegally by untrained person or oneself

Breech delivery

The position in which an infant is born or the body part that is delivered first is called the presentation. Most infants are born headfirst, in what is called a vertex presentation. Occasionally, the buttocks are delivered first. This is called a breech presentation. With a breech presentation, the fetus is at significant risk for trauma from the delivery. In addition, a prolapsed cord is more common. Breech deliveries are usually longer than a normal delivery, so there may be time to get the pregnant woman to the hospital. If the buttocks have already passed through the vagina, however, the delivery has begun. Provide emergency care and call for ALS backup. In general, if the woman does not deliver within 10 minutes of the buttocks presentation, provide prompt transport. Consult medical control to guide you in this difficult situation. Preparing for a breech delivery is the same as for a normal childbirth. Position the pregnant woman, prepare the OB kit, and place yourself and your partner as you would for a normal delivery. Allow the buttocks and legs to deliver spontaneously, supporting them with your hand to prevent rapid expulsion. The buttocks will usually come out easily. Let the legs dangle on either side of your arm while you support the trunk and chest as they are delivered. The head is almost always facedown and should be allowed to deliver spontaneously.As the head is delivering, you will need to perform a potentially life-saving procedure to manage the newborn's airway. Make a "V" with your gloved fingers and position them in the vagina to keep the walls from compressing the fetus's airway. This situation and a prolapsed cord are the only two circumstances in which you should insert your fingers into the vagina.

Gestational hypertension

The presence of high blood pressure in the absence of other systemic effects High blood pressure is defined as systolic blood pressure higher than 140 mm Hg and diastolic blood pressure higher than 90 mm Hg. The condition is considered severe when the systolic blood pressure is higher than 160 mm Hg and/or the diastolic blood pressure is higher than 110 mm Hg.

Unruptured amniotic sac

The sac may tear during labor or during contractions If the amniotic sac has not ruptured by the time the fetal head is crowning, it will appear as a fluid-filled sac (like a water balloon) emerging from the vagina. The sac will suffocate the fetus if it is not removed. If the sac has not ruptured spontaneously, puncture it with a clamp or tear it by twisting it between your fingers. Make sure that the puncture site is away from the fetus's face, and perform this procedure only as the head is crowning. As the sac is punctured, amniotic fluid will gush out. Push the ruptured sac away from the fetus's face as the head is delivered. Clear the newborn's mouth and nose, using the bulb syringe if required by your protocols, and wipe the mouth and nose with gauze. If the amniotic fluid is greenish (indicating meconium staining) instead of clear or has a foul odor, notify the receiving hospital. Meconium in the amniotic fluid may result in respiratory distress or an airway obstruction in the newborn.

Delivery of the fetus

The second stage of labor begins when the fetus enters the birth canal, and it ends with delivery of the newborn (spontaneous birth). You will have to make a decision about whether to help the woman deliver at the scene or provide transport to the hospital. Because the fetus goes through positional changes as it moves through the birth canal, uterine contractions are usually closer together and last longer. Pressure on the rectum may make the woman feel as if she needs to have a bowel movement. Under no circumstances should you let the woman sit on the toilet. She may also have the uncontrollable urge to push down. The perineum will begin to bulge significantly. When the top of the fetus's head begins to appear at the vaginal opening, this is called crowning.

umbilical cord

The structure that connects the pregnant woman to the fetus via the placenta; contains two arteries and one vein. Oxygenation, nutrition, and waste removal all rely on keeping this intact The umbilical cord connects the woman and fetus through the placenta.It contains two arteries and one vein. The umbilical vein carries oxygenated blood from the placenta to the heart of the fetus, and the umbilical arteries carry deoxygenated blood from the heart of the fetus to the placenta. Oxygen and other nutrients cross from the woman's circulation through the placenta and then The flow of oxygen through the fetal circulation is altered within the womb and changes within minutes after birth.

Delivery of the placenta

The third stage of labor begins with the birth of the newborn and ends with the delivery of the placenta. During this stage, the placenta must separate completely from the uterine wall. Contractions continue, assisting the separation process and clamping down and closing the blood vessels that connected the placenta to the uterine lining. This may take up to 30 minutes.

breech presentation

birth position in which the buttocks emerge first

Substance abuse

These women typically have has little to no prenatal care. The effects of the addiction on the fetus can include prematurity, low birth weight, and severe respiratory depression. some will die Fetal alcohol syndrome is a condition seen in infants born to women who have abused alcohol. Consider opioid addiction. Some women will be using an opioid antagonist to treat the disorder and prevent ongoing use. Report this history. Clues for addiction are in the surroundings, may include bottles of liquor or pills, or statements by bystanders or the woman. If you are called to handle a delivery of an addicted woman, pay special attention to your own safety. Follow standard precautions. Wear eye protection, a face mask, and gloves at all times. The newborn of an addicted woman will probably need immediate resuscitation. Assist with the delivery, and be prepared to support the newborn's respirations and administer oxygen during transport. Do not judge or lecture the patient. Your job is to help with the delivery, provide treatment to the mother and the newborn, and transport both to the hospital.

Bleeding complications

Timing of the bleeding and the location of the presence of pain can help identify

Fetal Demise

Unfortunately, you may find yourself delivering a fetus that died in the woman's uterus before labor began. This situation will test your medical, emotional, and social abilities. Grieving parents will be emotionally distraught and may be hostile, requiring all of your professionalism and support skills. The onset of labor may be premature, but labor will otherwise progress normally in most cases. If an intrauterine infection has caused the death of the fetus, you may note an extremely foul odor. Depending on the stage of decomposition, the delivered fetus may have skin blisters, skin sloughing, and a dark discoloration. The head will be soft and perhaps grossly deformed. Do not attempt to resuscitate an obviously dead neonate. However, do not confuse this situation with that in which a newborn is in cardiopulmonary arrest as a complication of the birthing process. Always attempt to resuscitate newborns if there is any question about viability.

vaginal hemorrhage

Vaginal bleeding in early pregnancy may also be a sign of a spontaneous abortion. Both abruptio placentae and placenta previa are life-threatening conditions and require immediate rapid transport. Any bleeding from the vagina in a pregnant woman is a serious sign and should be treated promptly in the hospital. - If the patient shows signs of shock, position her on her left side and administer high-flow oxygen per local protocols. - Place a sterile pad or sanitary pad over the vagina and replace it as often as necessary. - Save the pads so that hospital personnel can estimate how much blood loss the patient experienced. - Save any tissue that may be passed from the vagina. - Don't put anything into the vagina to control bleeding.

Normal changes in pregnancy: Musculoskeletal system

Weight gain during pregnancy is normal; however, the increase in body weight eventually challenges the heart and impacts the musculoskeletal system. Increased hormones affect the musculoskeletal system by relaxing ligaments that stabilize the joints, so the joints become "looser," or less stable. Women in the third trimester of pregnancy also experience a change in the body's center of gravity, making them prone to slipping and falling.

Special considerations for trauma and pregnancy

When you pull up you have 2 patients, the baby and the woman. Injuries to the woman can have a direct affect on the fetus. The leading causes of trauma in pregnant women are: 1. Intimate partner violence 2. Motor vehicle accidents 3. Falls Contributing factors for falls in pregnant women include: Hormonal changes that loosen the joints, Increased weight of the uterus, and Displacement of abdominal organs, which can affect the woman's balance by changing the center of gravity Increased heart rate and blood volume can mask shock symptoms. Fetal distress will be present before signs of shock will be evident. Serious trauma will reduce blood supply to the fetus as a physiological response, so the woman receives enough blood. Uterus enlarges during pregnancy and makes it more vulnerable to penetrating trauma, and if hit, can be devastating since it is rich with blood. A pregnant trauma patient may experience a significant amount of blood loss before you detect signs of shock. If the woman is hypoxic, in shock, or has hypovolemia, the fetus will be in distress. In most cases, the only chance to save the fetus is to adequately resuscitate the woman. Suspect abruptio placenta when the MOI is blunt trauma to the abdomen and the patient's signs and symptoms suggest shock. Common symptoms include vaginal bleeding and severe abdominal pain. Quickly assess and transport the patient, support the airway, administer high-flow oxygen, place sanitary pads on the vagina, position the patient on her left side, and call for ALS backup. 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. The lap belt should be placed under the abdomen and over the pelvic bones (iliac crests), and the shoulder belt should be positioned between the breasts. Carefully assess a pregnant woman's abdomen and chest for seat belt marks, bruising, and obvious trauma. Maintain a high index of suspicion for internal abdominal bleeding in the woman and possible direct injury to the fetus, regardless of seat belt placement.

Complications

Ypou can sefely administer Oxygen to help with a heart or lung disease without harming the baby

Amniotic sac

a thin, fluid-filled membrane that surrounds and protects the developing embryo The fetus develops inside the amniotic sac. This sac contains about 500 to 1,000 mL of amniotic fluid, which helps insulate and protect the fetus. When the sac ruptures, usually at the beginning of labor, the amniotic fluid is released in a gush. Water break. This fluid helps to lubricate the birth canal and remove any bacteria. A pregnancy that has reached full term is referred to as term gestation.