Chapter 33`

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.

when vaginal bleeding occurs before labor you should do what It could possibly mean what

call for ALS backup In early pregnancy, it may be a sign of a spontaneous abortion, or miscarriage. In the later stages of pregnancy, vaginal hemorrhage may indicate a serious condition involving the placenta.

common causes of aburtio placenta

hypertension and trauma

ectopic pregnancy signs

internal bleeding when the fallopian tube ruptures Missed a menstrual cycle and reports sudden, severe, usually unilateral pain in the lower abdomen A history of pelvic inflammatory disease, tubal ligation, or previous ectopic pregnancies

When an egg is released from the ovary

it travels through the fallopian tube to the uterus.

Vagina

outermost cavity of the female reproductive system forms the lower part of the birth canal 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.

The umbilical vein carries

oxygenated blood from the placenta to the heart of the fetus

Breasts

part of the female reproductive system 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.

abruptio placenta and placenta previa if it occurs do what

provide rapid transport life threatning! 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. Also save any tissue that may be passed from the vagina. Do not put anything into the vagina to control bleeding.

Amniotic sac at begining of pregnecy

ruptures and releases fulid which can be a lubercation and flush agent for bacteria

Immediately following ovulation

the endometrium begins to thicken in preparation for the potential implantation of a fertilized egg

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.

Limb presentation

when an infant's limb protrudes from the vagina before the appearance of any other body part

on-time delivery

9 months (40 weeks)

Abuse and pregnant women

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. Pregnant patients who are abused are often afraid to explain how their injuries occurred. 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. 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.

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, guiding 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, allowing 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.

Premature birth

Any newborn who delivers before 8 months (36 weeks of gestation) or weighs less than 5 pounds (2 kg) at birth is considered premature. The vernix caseosa will be absent or minimal. There will also be less body hair. They often require resuscitation, which should be performed unless physically impossible.

How should a patient of third trimester of pregnancy be transported

Any patient in the third trimester of pregnancy should always be positioned on her left side during transport except during delivery.

during secondary assesment of a pregnant patient

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. Check for crowning. Get a complete set of vital signs and pulse oximetry, including pulse; respirations; skin color, temperature, and condition; and blood pressure. Be especially alert for tachycardia and hypotension (which could mean hemorrhage or compression of the vena cava) or hypertension (possibly indicating preeclampsia).

false vs true labor

In false contractions are irregular, stop with walking and felt more in abdomen In true contractions are regular, don't stop with walking and felt in lower back and radiates to front

Cardiovascular system changes because of pregnancy 5 things

Overall blood volume gradually 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. Needs more iron Pregnant women often take prenatal vitamin supplements containing iron to avoid becoming anemic. The speed of clotting increases to protect against excessive bleeding during delivery. By the end of the pregnancy (third trimester), the patient's heart rate increases up to 20% (about 20 more beats per minute) to accommodate the increase in blood volume. Changes in the cardiovascular system and the increased demands of supporting the fetus significantly increase the workload of the heart.

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). During this stage, 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.

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.

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.

abruptio placentae

the placenta separates prematurely from the wall of the uterus.

vertex presentation.

the position of infants are born head first

embryo

the stage from 0 to 10 weeks after fertilization

fetus

the stage from 10 weeks until delivery

limb presentation WTD

transport to hospital 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, administer high-flow oxygen to the woman.

umbilical cord contains

two arteries and one vein

ovaries

two glands, one on each side of the uterus, that are similar in function to the male testes

Hypertensive disorders of pregnancy preeclampsia or pregnancy-induced hypertensione

typically in patients who are pregnant for the first time develop after the 20th week of gestation Signs and symptoms are: Severe hypertension Severe or persistent headache Visual abnormalities such as seeing spots, blurred vision, or sensitivity to light Swelling in the hands and feet (edema) Anxiety

ectopic pregnancy what is it

when an embryo develops outside of the uterus, most often in a fallopian tube. Occurs about once in every 300 pregnancies The leading cause of maternal death in the first trimester is internal hemorrhage into the abdomen following rupture of an ectopic pregnancy.

The three stages of labor are:

Dilation of the cervix Delivery of the fetus Delivery of the placenta

newborn's usually neeed

Positioning of the airway Drying Warming Suctioning Tactile stimulation

breech presentation.

buttocks are delivered first

perineum

The area between the vagina and the anus

Musculoskeletal system changes in pregnancy 3 things

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 making the joints "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.

The fetus develops inside

a fluid-filled, bag-like membrane called the amniotic sac, or bag of waters.

presentation

The position in which an infant is born or the body part that is delivered first

term gestation

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

Prolapse of the umbilical cord

A situation in which the umbilical cord comes out of the vagina before the fetus.

Placenta

A structure that allows an embryo to be nourished with the mother's blood supply

Gastrointestinal tract changes because of pregnancy 2 things plus a hint about patient care

A woman in the third trimester of pregnancy has an increased risk of vomiting and potential aspiration following trauma because of changes in the gastrointestinal tract. 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. You should be prepared to quickly manage the patient's airway if needed.

Breech deliveries

Breech deliveries are usually longer than a normal delivery, so there is time to get the pregnant woman to the hospital.' If the buttocks have already passed through the vagina, delivery has begun. Provide emergency care and call for ALS backup if available. If the woman does not deliver within 10 minutes of the buttocks presentation, provide prompt transport. Consult medical control to guide you. 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. 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 lifesaving procedure to manage the newborn's airway. Make a "V" with your gloved fingers and position them in the vagina to keep the walls of the vagina 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.

Multiple gestation

Call for backup 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. If twins are present, the second one will usually be born within 45 minutes of the first. About 10 minutes after the first birth, contractions will begin again, and the birth process will repeat itself. The procedure for delivering twins is the same as that for a single fetus; however, 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.

Special Considerations for Trauma and Pregnancy

Contributing factors for falls in pregnant women include: Hormonal changes that loosen the joints, Increased weight of the uterus, Displacement of abdominal organs, which can affect the woman's balance Pregnant women have an increased overall total blood volume and an approximate 20% increase in their heart rate by the third trimester of pregnancy. A pregnant trauma patient may experience a significant amount of blood loss before you detect signs of shock. The body of a woman who has sustained serious trauma often reduces the blood supply to the fetus so that the woman receives an adequate amount of blood. 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. 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. 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.

diabetes complication pregnancy

Diabetes develops during pregnancy in many women who have not had diabetes previously, which is called gestational diabetes. (it usually resolves after labor). Treatment of a pregnant woman with diabetes is the same as treatment for any patient who has diabetes. She may control her blood glucose level with diet and exercise or may take medication. May use insulin injections. TREAT THEM THE SAME AS ANY OTHER DIABETIC PATIENT! Just know it is a more of a possibility due to pregnancy - maintain a history, if she is altered LOC; if protocols allow, get blood glucose levels 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 medical control if delivery is imminent.

Prolapse of the umbilical cord WTD

Do not attempt to push the cord back into the vagina. 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 cot raised 6 to 12 inches (15 to 30 cm) higher than the head, with her hips elevated on a pillow or folded sheet. Alternatively, the woman may be placed in the knee-chest position: kneeling and bent forward, facedown. Carefully insert your sterile gloved hand into the vagina, and gently push the fetus's head away from the umbilical cord. 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.

Bleeding complications in pregnant women

Ectopic pregnancy Vaginal hemorrhage

Delivery without sterile supplies

Even if you do not have an OB kit, you should always have eye protection, gloves, and a protective mask with you. Carry out the delivery as if sterile supplies were available. If possible, use freshly laundered sheets and towels. As soon as the newborn is delivered, wipe the inside of the mouth with your finger to clear away blood and mucus. Without the OB kit, you should not cut or clamp the umbilical cord. As soon as the placenta delivers, wrap it in a clean towel or put it in a plastic bag and transport it with the newborn and mother to the hospital. Always keep the placenta and the newborn at the same level. Be sure to keep the newborn warm.

Reproductive changes during pregnacy And how said factor relates to trauma complications (not necessarily one) 2 different factors

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 size of the uterus increases, so does the amount of fluid it contains. By the 20th week of pregnancy, the top of the uterus is at or above the belly button. - 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. - This increases the chance of direct fetal injury in trauma.

Important question to ask those in labor (outside of standard ones)

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, and it is possible for the fetus to aspirate meconium during delivery. Assess for fetal movement by asking the patient whether she can feel the fetus moving.

Follow these guidelines when treating a pregnant trauma patient:

Maintain an open airway. Administer high-flow oxygen - 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-valve mask (BVM) and 100% oxygen. Assess circulation. DNF to keep the patient warm. Transport considerations - left side or tilt the backboard 30 degrees to the left, Call early for ALS/med helicopters,

abortion

Passage of the fetus and placenta before 20 weeks miscarriage may be induced, may not be induced 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.

Post-term pregnancy

Post-term fetuses can be larger than a typical 40-week fetus, sometimes weighing more than 10 pounds (5 kg), 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. 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, as 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.

Respiratory system changes due to pregnancy 3 different factors (maybe 2 depending on how you ration it)

Rapid uterine growth occurs during the second trimester of pregnancy. As the uterus grows, it pushes up on the diaphragm, displacing it from its normal position. - As the pregnancy continues, respiratory capacity changes, with increased respiratory rates and decreased minute volumes. You may observe that a pregnant patient has an increased breathing rate and a decreased ability to breathe deeply. These changes result in a less-than-normal respiratory reserve. The pregnancy also increases the patient's overall demand for oxygen as her metabolic demands and workload increase to support the developing fetus.

Substance abuse and pregnant women

The effects of the addiction on the fetus can include prematurity, low birth weight, and severe respiratory depression. Fetal alcohol syndrome is a condition seen in infants born to women who have abused alcohol. 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.

Fetal demise

The onset of labor may be premature, but labor will otherwise progress normally in most cases. If an intrauterine infection has caused the demise, 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. You must attempt to resuscitate normal-appearing newborns.

Signs of abruptio placenta

The patient 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.

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?

spina bifida

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. 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.

Apgar score

appearance should be pink pulse should be present grimance/cry should happen when flick foot infant should resist straitening leg cry/resperations should happen

Dilation of the cervix

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. Other signs of the beginning of labor are the bloody show (blood-streaked mucus) and the rupture of the amniotic sac (water breaking). 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. Some women experience a premature rupture of the amniotic sac, before the fetus is ready to be born. 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.

Cervix

birth canal that's made up of the vagina and the lower third, or neck, of the uterus. 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.

eclampsia another hypertensive disorder

characterized by seizures that occur as a result of hypertension To treat a patient having seizures caused by eclampsia, lay the patient on her left side, maintain her airway, and administer supplemental oxygen, if necessary. If vomiting occurs, suction the airway. Provide rapid transport and call for an ALS intercept, if available. Transporting the patient on her left side can also prevent supine hypotensive syndrome. This condition is caused by compression of the inferior vena cava by the pregnant uterus when the patient lies supine, reducing the amount of blood that is returned to the heart. Hypotension may result from this compression. Any patient in the third trimester of pregnancy should always be positioned on her left side during transport except during delivery.

follicles

clusters of cells surrounding a single egg

Pregnant CPR

compressions may need to be applied a little higher on the sternum than usual. 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. Notify receiving facility personnel as soon as possible that you are en route with a pregnant trauma patient in cardiac arrest so they will have time to prepare.

umbilical cord

connects the woman and fetus through the placenta.

the amniotic sac contains

contains about 500 to 1,000 mL of amniotic fluid, which helps insulate and protect the fetus

The umbilical arteries carry ________.

deoxygenated blood from the heart of the fetus to the placenta.

Pregnancy complications

diabetes hypertensive disorders

The fertilized egg then continues to the uterus where, if implantation occurs, the fertilized egg develops into an what?

embryo

fallopian tubes

extend out laterally from the uterus, with one tube associated with each ovary.

Fertilization usually takes place when the egg is inside the

fallopian tube.

immediately prepare for a delivery and consider calling for additional resources IF

the patient says that she is about to deliver, she has to move her bowels, or feels the need to push,