Chapter 37: Obstetrics and Care of the Newborn

a full term pregnancy lasts approx:

280 days from the first day of the last normal menstrual cycle each 3 month period of the approx 9 month pregnancy is referred to as a trimester thus months 1 through 3 (weeks 1 to 12) are the first trimester months 4 through 6 (weeks 13 to 27 ) second trimester months 7 through 9 (weeks 28 to 49) are the third trimester most emergencies you will deal with will occur during the first or third trimester however a patient an experience some of these emergencies during the second trimester

at the conclusion of the assessment you should have a numeric value that ranges form 0-10:

7-10 points- the newborn should be active and vigorous, provide routine care 4-6 points- the newborn is moderately depressed, provide stimulation and oxygen 0-3 points- the newborn is severely depressed, you will probably need to provide extensive care including oxygen with bvm ventilation's and CPR

multiple birth:

(twins, triplet, so on) each infant may have its own placenta

prenatal period:

approx 3 weeks after implantation of the fertilized egg on the uterine wall the placenta develops stages of development: pre-embryonic stage: first 14 days after conception embryonic stage is from day 15 to 8 weeks the fetal stage: begins at 8 weeks and ends with delivery of the baby which is termed a neonate pregnancy is also referred to as gestation

antepartum emergencies:

are those that occur in the pregnant patient prior to the onset of labor these complications often involve the potential for severe hemorrhage and fetal death

rupture uterus:

as the uterus enlarges during pregnancy the uterine wall becomes extremely thing especially around the cervix this can lead to spontaneous or traumatic rupture of the uterine wall thereby releasing the fetus into the abdominal cavity mortality to the mother from a ruptured uterus is usually 5 to 20 percent, infant mortality is over 50 percent a ruptured uterus requires immediate surgery

emergency medical care for multiple births:

be prepared to care for more than one infant call for assistance note that about one-third of the deliveries of the second infant will breech so assess carefully and take immediate action if the second infant is not breech handle the delivery as you would for a single infant expect and manage hemorrhage following the second birth if the seond infant has not delivered within 10 minutes if the first transport the mother and the first infant to the hospital for delivery of the second infant multiple birth babies have a tendency to be low birth weight and may require additional resuscitation

pregnancy signs and symptoms:

in general a pregnant patient may be experiencing an antepartum emergency if she presents with one or more of the following: abdominal pain, nausea, vomiting vaginal bleeding, passage of tissue weakness, dizziness altered mental status seizures excessive swelling of the face and/or extremities abdominal trauma shock (hypoperfusion) elevated blood pressure (hypertension) note: pregnancy may mask early signs and symptoms of shock (hypoperfusion) the initial indications may be subtle or absent because the blood volume is increased during pregnancy and even though the mother may be stable the fetus may be in extreme distress any pregnant patient who is currently experiencing or experienced prior to your arrival some type of abnormality (pain, discomfort or bleeding) needs to be seen by a physician

eclampsia:

includes the signs and symptoms of preeclampsia with addition of life threatening seizures or coma

assessment based approach for antepartum (predelivery) emergency:

information provided by the dispatcher may be the first indication that the patient is experiencing a potential obstetric emergency however the stress and anxiety may prevent the patient from relaying information accurately after taking standard precautions and making sure the scene is safe, perform the initial assessment, including the mental status, airway, breathing, and circulation of the patient

for a prolapsed cord follow these guidelines:

instruct the patient not to push to avoid additional compression of the umbilical cord: instruct the patient to pant like a dog to prevent her from contracting her abdominal muscles and pushing position the patient on the stretcher in a "knee chest position" (kneeling and bent forward, face down, head down, chest to knees) with the stretcher in a trendelenburg position if possible insert a sterile gloved hand into the vagina and gently push the presenting parts of the fetus, head or buttocks, up, back or away from the pulsating cord, do not try tor push the cord back into the vagina cover the umbilical cord with a sterile dressing moistened with a sterile saline solution transport the patient rapidly while maintaining pressure on the head or buttocks to keep pressure off the cord, monitor pulsations in the cord

primipara:

is a mother who gave birth for the first time para is not used until after the birth has occurred

postpartum hemorrhage:

is defined as the loss of greater than 500mL of blood following the delivery the most common cause of postpartum hemorrhage is failure of the uterus to regain its muscle tone (uterine atony) postpartum hemorrhage is most common in multigravida patients following multiple births or delivery of a large baby prolonged labor and precipitous delivery can lead to failure of the uterus to tone if uterus fails to return to a normal size hemorrhage can occur up to 2 weeks after the delivery

menstruation:

is marked by the vaginal bleeding of about 60 to 80 mL over 3 to 5 days contained in the blood is tissue and mucus that was built up in the endometrium

precipitous delivery:

is one in which the birth of the fetus occurs after less than 3 hours of labor precipitous loabor is most often seen in patients who have delivered multiple children (multipara) since the delivery occurs so rapidly there is an increased risk of trauma to the fetus, trauma to the mother, and tearing to the umbilical cord the delivery would be conducted in the same manner as any other however it may occur rapidly and without much warning the care for the neonate is same as in a normal delivery

abruptio placentae:

is the abnormal separation the the placenta for the uterine wall prior to birth of the baby it occurs in approx 1 in 120 births small arteries located in the lining between the placenta and the uterus are prone to rupture and bleed , the accumulating blood begins to tear and separate the placenta from the uterine wall as the bleeding continues the placenta continues to tear away from the uterine wall

premature rupture of membranes: (PROM)

is the spontaneous premature rupture of the amniotic sac prior to the onset of true labor and before the end of the 37th week of gestation although this is not an emergency it increases the risk of infection of the uterus and its contents amniotic fluid acts as a lubricant during delivery, thus premature rupture of the amniotic sac prevents adequate lubrication of the vaginal canal at the time of birth which may lead to a more difficult delivery

elective abortion:

is the termination of the pregnancy upon the request of the mother in a medical setting

shoulder dystocia:

is when the fetal shoulders are larger than the fetal head the head delivers but then it retracts back into the vagina becuase the shoulders are caught between the symphysis pubis and the sacrum the retraction into the vagina is reffered to as a turtle sign it occurs in larger weight babies as seen in diabetic patients and those who are past their due dates if a shoulder dystocia occurs do not pull on the head of the fetus in an attempt to deliver transport immediately have the mother pant to reduce the force of the contractions place the mother on her back with her knees drawn up as close to her chest as possible this is know as the McRobert position this maneuver moves the symphysis pubis anteriorly an superiorly and drops the sacrum creating a larger opening for the delivery of the shoulders

as a general rule:

it is best to transport the mother labor so that the delivery can take place at the hospital however if the delivery is imminent you will need to prepare to assist in the delivery at the scene

appearance:

if the skin of the newbors entire body is blue cyanotic, or pale award 0 points if the newborn has blue hands and feet with pink skin at the core of the body: acrocyanosis award 1 point if the skin of the extremities as well as the trunk is pink award 2 points

a complication of breech delivery is that the body is delivered but the head cannot be delivered:

if this occurs insert your index and middle gloved fingers into the vagina forming a V along the vaginal wall with the babys nose and mouth between the fingers push against the vaginal wall to create space for respiration immediately transport while maintaining this position

there are three cases in which you must assist in the delivery of an infant:

if you have no suitable transportation if the hospital or physician cannot be reached due to bad weather, a natural disaster or some other kind of catastrophe or if delivery is imminent

ectopic pregnancy:

in a normal pregnancy the ovum or egg is implanted in the uterus in an ectopic pregnancy the egg is implanted outside the uterus in one of the following locations: in a Fallopian tube (approx 90 percent, on the abdominal peritoneal covering, on the outside wall of the uterus on an ovary or on the cervix the placenta invades the surrounding tissue and unable to accommodate the growing embryo the tissue ultimately ruptures ectopic pregnancy is the third leading cause of maternal death responsible for 6 percent maternal mortality ectopic pregnancy occurs in 2 percent of all pregnancies and is most common in women 25 to 34 years of age the site of implantation in the Fallopian tube determines the length of time before the patient will experience pain or other associated symptoms and before rupture may occur, rupture may occur from 2 to 12 weeks after fertilization, most commonly rupture will occur in 5 to 9 weeks

emergency care of a spontaneous abortion:

in addition to general emc guidelines provide emotional support to the mother and the members of her family throughout treatment and transport intense grief over the loss of the pregnancy is normal and expected in both parents

seizures during pregnancy can be a life-threatening emergency for the mother and the fetus provide emrgency medical care the same as for any seizure patient:

it is especially important to protect the pregnant patient from injuring herself transport the patient on her left side is she is greater than 20 weeks of gestation since light, noise, and movement can set off seizures in some conditions associated with pregnancy, transport the patient in as calm and quiet manner as possible seizures may be associated with eclampsia

certain physical abnormalities, medical complications or even distressed deliveries can:

lead to a severely depressed newborn in need of immediate and aggressive treatment

eclmapsia is a:

more severe form of preeclampsia and includes coma and seizures

many physiological changes occur in pregnancy:

most are due to alterations in the circulating hormones, expanding of the uterus and increased metabolic demands on the mother

predisposing factors for a placenta previa are:

multiparity (more than two deliveries) rapid succession of pregnancies greater than 35 years of age previous placenta previa history of early vaginal bleeding bleeding immediately after intercourse

respiratory system:

oxygen demands of the mother increases the respiratory tract resistance decreases as a result of hormones causing smooth muscle dilation the tidal volume increases by 40 percent the respiratory system increases only slightly the is an increase in oxygen consumption of approx 20 percent

of those infants who require additional resuscitation most need:

oxygen or bvm ventilation's a minority of newborns are so depressed they will also need chest compression's or resuscitate medications

in the prehospital setting hemorrhage following delivery can be managed with:

oxygen therapy, fundal massage and immediate transport

uterus:

pera shaped organ that contains the developing fetus its special arrangement of smooth muscle and blood vessels allows for great expansion during pregnancy and forcible contractions during labor and delivery the uterus is also capable of rapid contractions after delivery which helps tone up the uterus constricts blood vessels and prevent hemorrhage the top portion of the uterus is referred to as the fundus the middle portion is the body or corpus and the narrow tapered neck is the cervix

assessment for a newborn:

perform a thorough assessment of the infant you can use the Apgar scoring system to get a good overall indication of the babys condition the score should be determined 60 seconds after birth and then repeated in 4 minutes to obtain a 1 minute and 5 minute score following birth a change may indicate improvement, worsening or no change

massage:

place the medial edge of one hand ( fingers extended) horizontally across the abdomen, just above the symphysis pubis cup you other hand around the uterus: use a kneading motion to massage the area allow the infant to suckle on the mothers breast: this will release oxycotin that helps uterus to contract if the bleeding continued to appear to be excessive check your massage technique continue massage and transport immediately

separation of the placenta causes two major problems:

poor gas, nutrient and waste exchange between the fetus and the placenta severe maternal blood loss

a breech delivery is best managed in the hospital you should not attempt to deliver a breech presentation in the field however if the delivery is unavoidable, perform the following emergency care:

position the mother with her buttocks at the edge of a firm surface or bed have her hold her legs in a flexed position as the infant delivers do not pull on the legs but support them allow the entire body to be delivered as you simply support it, continue care for neonate as a normal delivery

postpartum complications:

postpartum complications involve only the mother hemorrhage is the most dangerous of the postpartum conditions

estrogen and progesterone are hormones that:

prepare the uterus for implantation of a fertilized ovum and maintain the uterus during pregnancy

the predisposing factors for an ectopic pregnancy are:

previous ectopic pregnancies pelvic inflammatory disease adhesion's from surgery tubal surgery including elective tubal ligation intrauterine device

care for the newborn:

protecting them against heat loss preserves their energy and avoids the complex problem that hospitals face in trying to rewarm a cold infant immediately dry the infant be sure to dry the head well and cover it then wrap the newborn in a blanket or a plastic bubble-bag swaddle position the newborn on his back with the neck slightly extended in a sniffing position place some padding under the shoulders to maintain the head and neck in a slight sniffing position do not hyper-extend or flex the neck, this may cause airway obstruction suction to clear the airway only if necessary

para:

refers to a woman who has given birth para 1 would indicate a mother who gave birth for the first time once to one or more children para 3 would indicate a mother who has given birth 3 times

gravida:

refers to pregnancies when a roman number is added after gravida it indicates the number of pregnancies for example gravida 1 is being pregnant for the first time also referred to as primigravida

gestational age:

refers to the age of the fetus in weeks from the time of fertilization of the the ovum through delivery

reassessment:

regardless of the estimated blood loss after delivery if the mother appears to be suffering shock treat and transport immediately you can initiate uterine massaging during transport

upon ovulation the ovum is:

released from the ovary and received in the funnel-shaped end of the Fallopian tube fertilization of the ovum with sperm usually occurs in the distal third of the Fallopian tube the ovum whether fertilized or not is transported down the Fallopian tube by peristalsis into the uterus

urinary system:

renal blood flow increases glomerular filtration increases by approximately 50 percent during the second trimester and remains elevated the urinary bladder is displaced superiorly and anteriorly increasing the risk on injury an an increase in urinary frequency is common in the first and third trimester due to compression of the bladder by the uterus

reassessment:

repeat the primary assessment repeat vital signs check any interventions being especially careful about oxygen mask fit and adequate flow of oxygen be attentive for and treat any signs of developing chock if the patient is stable reassess every 15 min if unstable every 5 minutes

the signs of a severely depressed newborn are:

respiratory rate over 60 per minute diminished breath sounds heart rate over 180 per minute or under 100 per minute obvious signs of trauma from the delivery process poor or absent skeletal muscle tone respiratory arrest or severe distress heavy meconium staining of the amniotic fluid and a non-vigorous newborn weak pulses cyanotic body (core and extremities) poor peripheral perfusion lack of poor response to stimulation apgar score under 4

emergency medical care for abruptio placentae:

same as for placenta previa the primary treatment is to administer oxygen regardless of the SpO2 reading and oxygenation status of the pregnant patient via nonrebreather mask at 15 lpm

if you assist the mother in delivery:

stay calm and explain to her that you are trained to help as much as possible ensure the mothers comfort, modesty and peace of mind try to limit distractions and onlookers most importantly recognize your own limitations if you get into a situation you cannot handle call medical direction for help and permission to transport

according to the 2010 AHA guidelines for cardiopulmonary resuscitation and emergency cardiovascular care it is recommended that:

suctioning the nose and mouth in the newborn immediately following birth even with a bulb syringe be perfomed only when secretions are present that obstruct spontaneous breathing or if ppv is necessary

recommended equipment includes:

surgical scissors (for cutting umbilical cord) cord clamps or cord ties umbilical tape or sterilized cord bulb syringe towels, five or more gauze sponges 2 x 10 sterile gloves one infant blanket individually wrapped sanitary napkins, three or more large plastic bag at least one germicidal wipes

during a seizure:

the placenta can seperate from the uterine wall (abruption) causing death of the fetus and severe maternal hemorrhage death of the mother can also result from cerebral hemorrhage, respiratory arrest, kidney failure or circulatory collapse

total placenta previa:

the placenta completely covers the os this blocks the birth canal and can prevent delivery of the baby as the cervix dilates and effaces significant bleeding may occur

complete abruption:

the placenta completely separates from the uterine wall a complete abruptio placentae carries 100 percent fetal mortality rate

partial placenta previa:

the placenta covers the os of the cervix partially but not completely as with the total placenta previa the partial placenta previa may obstruct delivery of the baby

marginal placenta previa:

the placenta is implanted near the neck of the cervix when the cervix effaces and dilates it may cause the placenta to partially tear

partial abruption:

the placenta is partially torn from the uterine wall because it remains partially attached it is associated with a 30 to 60 percent fetal mortality rate

embolism:

the pregnant or postpartum patient is at greater risk for an embolism because of the increased blood volume and coagulation properties of the blood clot formation in the venous system can lead to a pulmonary embolism the patient with a pulmonary embolism may present with: shortness of breath, syncope, tachycardia, sharp chest pain, hypotension, cyanosis, and pale cool clammy skin amniotic fluid embolism: may occur when the amniotic fluid, fetal cells, hair, or other material enter the mothers circulation the condition which is not completely understood may be more associated with an anaphylactic reaction and can lead to cardiopulmonary compromise

reproductive system:

the prepregnant uterus weighs about 2 ounces and holds about 10 mL at the end of the pregnancy the uterus weighs more than 2 pounds and hold 5,000mL the pregnant uterus is extremely vascular and contains about one sixth of the total blood volume of the mother a mucous plug forms in the opening to the cervix to protect the fetus from infection the breasts enlarge and become more nodular in preparation for lactation

emergency medical care of a ruptured uterus:

the primary treatment is to administer oxygen regardless of the SpO2 reading and oxygenation status of the pregnant patient via nonrebreather mask at 15 lpm to maximize oxygenation of the fetus treat for shock and provide immediate transport

assessment based approach for an active labor and normal delivery:

the scene size up, primary assessment ad secondary assessment are essentially the same as you would provide in an antepartum (predelivery emergency) you assessment and treatment goals will focus on assisting the mother with delivery and providing initial care to the neonate

nuchal cord:

the umbilical cord is around the infants neck must be managed immediately as it is found use two fingers toe slip the cord over the infants shoulder if you cannot move the cord place two clamps 2 to 3inches apart and cut between the clamps remove the cord from around the neck suction the fluids from the infants airway only id obvious obstruction of breathing exists or if ppv is necessary

the umbilical cord:

the unborn infants lifeline attaching the fetus to the placenta contains one vein and two arteries in a spiral arrangement that is covered in a protective substance called Wharton jelly the structure of the cord and the blood traveling through it keep it from kinking when the infant is born the umbilical cord resembles a sturdy rope about 22 inches long and 1 inch in diameter

the veins in the umbilical cord are unique:

the veins carry oxygenated blood and nutrients to the fetus, and the arteries carry deoxygenated blood and waste products back to the placenta

the signs that the delivery of the placenta is imminent:

there is a sudden increase in bleeding from the vagina the uterus becomes smaller in size the umbilical cord begins to lengthen and the mother has an urge to push NEVER tug or pull on the umbilical cord in an attempt to faciltate the delivery of the placenta

if the head of the fetus is already in the birth canal it will block the bleeding escaping through the vaginal canal:

therefore you may find a patient with a complete abruption who has severe bleeding from separation of the placenta from the uterus but has no vaginal bleeding patient could be in severe hypovolemic shock with no external bleeding thus the amount of vaginal bleeding does not correlate with the amount internal bleeding the mother is experiencing it has been reproted that 2,500 mL of blood can be concealed in the uterus maternal blood loss and resulting hyovolemia and fetal distress and death are the problems associated with abruptio placentae

the hallmark sign of placenta previa is:

third trimester bleeding that is painless the uterus typically remains soft and nontender on palpation

activity:

thus score refers to extremity reflexes/ movement or the degree of flexion of the arms and legs and resistance straightening them the newborns elbow, knees and hips are flexed and you should encounter some degree of resistance when you try and extend them if during your assessment the newborn is limp and displays no extremity movement award 0 points if the newborn only displays some flexion without active movement award 1 point if the newborn is actively moving around award 2 points

emergency medical care for supine hypotensive syndrome:

to avoid supine hypotensive syndrome any patient who is in her 20th week of gestation or later should be placed in a sitting position if appropriate or lying on her side or supine with the right hip elevated, which takes the uterus off the vena cava either side will work and relieve pressure with weight of fetus removed there is an increased venous return to the right atrium which increases preload, stroke volume, cardiac output, systolic blood pressure, and perfusion

three types of placenta previa:

total partial marginal

assessment based approach of an active labor with abnormal delivery:

treat as normal delivery with the primary and secondary assessment signs and symptoms: any fetal presentation other than the normal crowning of the fetus head abnormal color or smell of the amniotic fluid labor before 38 weeks of pregnancy recurrence of contractions after the first infant is born indicating multiple births

emc for ectopic pregnancy:

treat patient for shock (hypoperfusion, administer oxygen as necessary, constantly reassess vital signs and provide immediate transport

supine hypotensive syndrome:

typically a third trimester complication that occurs when the weight of the fetus compresses the inferior vena cava when the patient is in a supine position this reduces blood flow to the right atrium which decreases the preload, reducing stroke volume and cardiac output, the reduction in cardiac output decreases the systolic blood pressure and perfusion patient will typically complain of dizziness or light-headedness when in a supine position in severe cases the patient may experience a decrease in blood pressure, tachycardia, and pale cool clammy skin it is extremely important to assess the patient for blood loss

fetus:

unborn infant

note that there will be vaginal bleed after delivery:

up to 500 mL of blood loss is normal and well tolerated by the mother however if blood loss appears to be excessive provide oxygen to the mother and massage the uterus as follows massage helps to stimulate contractions which decrease the uterine size and help stop bleeding

signs and symptoms of abruptio placentae are :

vaginal bleeding with constant abdominal pain abdominal pain due to muscle spasm of the uterus may be mild, sharp, or acute pain may be found in the lower back uterine contractions are usually present abdomen is tender on palpation bleeding can be dark red or bright red; however the color of the blood does not differentiate the conditions from others vaginal blleding may be severe minimal or absent depending on the location of the head of the fetus signs and symptims of hypovolemic shock are present

peristalsis:

wavelike movement from the muscular contraction

limb presentation:

when one arm or one leg is the first to protrude from the birth canal under no circumstances would you attempt a field delivery of a limb presentation transport immediately, because a cesarean section will be required to deliver the fetus administer oxygen to the mother and place the mother in a knee-chest position with her pelvis elevated never pull on the infant by its arm or leg again never attempt delivery in this situation have the mother pant if she has the urge to push with contractions

toward the end of a full-term pregnancy in the third trimester the fetus moves into a head-down position:

when the head decends through the broad upper inlet of the mothers pelvis the uterus moves downward and forward mothers can feel the difference and say that the infant has "Dropped" this position id the one most common for the infants passage through the cervix to the vagina

placenta previa:

which occurs in about 1 in 250 births is a major cause of third trimester bleeding placent previa is associated with abnormal implantation of the placenta over or near the opening of the cervix the placenta is normally implanted in the fundus (top portion) of the uterus and posteriorly when the fetus changes positions in the uterus the cervix begins to efface (thin) and dilate the placenta is prematurely torn away from the lower portion of the uterine wall this results in bleeding which can be excessive because of the rich blood supply , the blood is not associated with any abnormal uterine contraction or abnormal pain

emergency care for embolism of AFE:

will focus on ensuring adequate ventilation and maximizing oxygenation provide oxygen via nonrebreather mask at 15 lpm if inadequately breathing provide ppv with supplemental oxygen connected to the ventilation device

be sure to stimulate the newborn if he is still not breathing adequately:

you can stimulate respiration's by gently flicking the soles of the feet or by rubbing the back in a circular motion with three fingers en route to the hospital provide continual assessment of the newborn pay particular attention to body temperature, airway breathing oxygenation status, heart rate, color, and activity level contact medical direction to update them on the mothers and the newborns condition

emergency medical care for placenta previa:

your major concern is blood loss for the mother and hypoxia and distress for the fetus this is a situation where regardless of the SpO2 reading and oxygenation status of the pregnant patient oxygen is administered vis nonrebreather mask at 15lpm to maximize oxygenation of the fetus treat for shock transport immediately

NOTE: if the pregnant patient dies as a result of an accident:

CPR started immediately or within the first few minutes may save the life of the infant by continuing the oxygenation and circulation of the mothers blood if you do begin CPR it must be continued throughout transport until you reach the medical facility where the infant may be delivered surgically the key to saving the infant is to prevent the mothers condition from deteriorating in the field that is protect the airway, support breathing, oxygenation and blood pressure, transport rapidly and notify the receiving facility as soon as possible vigorous resuscitation of a mother to save a fetus is acceptable even if you believe the mother will not successfully be resuscitated

post maturity syndrome:

a deterioration of conditions necessary to support the well-being of the fetus

preeclampsia is characterized by :

a high blood pressure and swelling in the extremities history and assessment findings also include the following: history of hypertension, diabetes, kidney disease, liver dieases or heart disease no previous pregnancies history of poor nutrition sudden weight gain (2 pounds a week or more) altered mental status abdominal pain blurred vision or spots before the eyes excessive swelling of the face, fingers, legs or feet decreased urine output severe persistent headache persistent vomiting elevated blood pressure usually greater than 140/90 mmHg or systolic increase over 30 mmHg and or a diastolic increase of over 15 mmHg of prepregnancy pressure

prolapsed cord:

after the amniotic sac ruptures, the umbilical cord rather than the head may be the first part presenting at the vaginal opening in this situation the umbilical cord may get compressed against the walls of the vagina and the bony pelvis by the pressure of the infants head or buttocks as a result the infants blood supply of oxygenated blood can be cut off this is a true emergency predisposing factors include prematurity, multiple births and premature rupture of the amniotic sac

afterbirth:

after the infant is born the placenta separates from the uterine wall and is delivered as the afterbirth it usually weighs about a pound or one-sixth of the infants weight

preterm labor:

also known as premature labor occurs after the 20th but prior to the 27th week of gestation, this is a different condition from preterm birth preterm labor refers specifically to the onset of labor it does not always lead to the birth of the baby if the labor can be stopped a mother with a history of preterm labor is usually placed on bed rest during the pregnancy carries a higher incidence of abnormal presentations of the fetus during delivery cocaine and other drugs are known to induce labor if you suspect preterm labor keep the mother calm and do not allow her to push place the patient on oxygen consider calling an advanced life support unit

the placenta:

also known as the organ of pregnancy is a disk shaped inner lining of the uterus that begins to develop after the ovum is fertilized and attaches itself to the uterine wall rich is blood vessels the placenta is the sole organ through which the fetus recives oxygen and nourishment from the mother and discharges carbon dioxide and waste products the exchange is made between the mothers and infants bloodstreams within the placenta the blood of the fetus and the blood of the mother do not mix except during birth or miscarriage

Fallopian tubes:

also known as uterine tubes are thin flexible structures that extend from the uterus to the ovaries the end near the ovary is funnel shaped with finger-like projections, this end is not directly connected to the ovary and is open to the abdominal cavity the opposite end is connected to the uterus

the amniotic sac:

also referred to as the bag of waters is filled with fluid in which the infant floats, insulating and protecting it throughout the pregnancy the amount of amniotic fluid varies from 500 to 1000 millimeters at the onset of labor the bag usually tears rupturing the bag of waters is one of the first indicators to the pregnant mother that her labor has started the amniotic fluid helps to lubricate the birth canal and remove any bacteria during labor part of the amniotic sac is forced ahead of the infants head serving as a resilient wedge to help dilate the cervix

premature birth:

an infant that weighs less than 5 pounds or born before the 38th week of development is defined as a premature infant and requires special care because of their underdevelopment premature babies are more susceptible to hypothermia and respiratory distress a premature infant is thinner and smaller and its skin has reddened and wrinkled appearence there will be a singlw crease across the sole of the foot, there will be fuzzy scalp hair that is very fine and the external ear cartilage will not be fully developed may require more vigorous resuscitation than a full-term infant

respiration:

another important assessment sign is the newborns breathing effort the newborn should have regular respiration's and a vigorous cry distress is indicated by irregular shallow, gasping or absent respirations if the newborn displays no respiratory effort award 0 points if the newborn displays only a slow or irregular breathing effort with a weak cry award 1 point if the newborn displays good respiration's and a strong cry award 2 points

as a general rule:

any women of childbearing age (about 12 to 50 years old) could potentially be experiencing a obstetric emergency use a high index of suspicion when assessing such a patient

provide this additional care for a premature infant:

be sure to dry the infant thoroughly and avoid heat loss, keep the infant warm by using warmed blankets or a plastic bubble-bag swaddle, making sure that the head is covered but the face is unobstructed use gentle suction if it necessary to clear the airway prevent bleeding from the umbilical cord, a premature infant cannot tolerate losing even the smallest amount of blood administer supplemental oxygen if necessary by blowing oxygen across the infants face with the end of the oxygen tube approx 1 inch above the infants mouth and nose, never blow oxygen directly into the face, support ventilation if breathing is inadequate premature babies are highly susceptible to infection , prevent contamination dont let anyone breathe into the infants face wrap the infant securely to keep it warm, and heat the vehicle during transport

third stage: placental

begins following the delivery of the baby and ends with the expulsion of the placenta the placenta separates from the uterine wall and is expelled from the uterus the placenta is usually delivered 5 to 20 minutes following the birth of the baby the mother will continue to have contractions even though not as severe until the placenta is expelled

second stage: expulsion

begins with complete cervical dilation and ends with delivery of the baby during this stage the infant moves through the vagina and is born contractions are closer together 2 to 3 minutes apart and last longer 60 to 90 seconds each as the infant moves downward the mother experiences pressure in her rectum much like the feeling of a bowel movement when the mother has this sensation it is usually an indication that the delivery is imminent the mother often complains that she needs to defecate the tightening and bearing down sensations will become stronger and more frequent the mother will have an uncontrollable urge to push down which she may do the mother may experience low back pain there probably will be more bloody discharge from the vagina at this point the perineum the area of the skin between the vagina and anus bulges significantly a sign of impending birth infants head will crown the mother should be coached to push down the shoulders and body should follow the head this stage lasts 50 to 60 for first time delivery or only 20 to 30 minutes for a patient who has had more than two children

cardiovascular system:

cardiac output increases maternal blood volume increases by 45 percent there is also an increase in red blood cell content causing a relative anemia, the pregnant patient is given iron supplements to increase oxygen binding on the RBC this blood volume increase delays the signs and symptoms of shock

if suction is applied make sure you:

compress the bulb syringe before you bring it to the infants face insert the tip of the compressed bulb 1 to 1.5 inches into the infants mouth slowly releasing the bulb to allow mucus and fluids to be drawn into the syringe avoid touching the back of the infants mouth remove the syringe then discharge the contents onto a towel and repeat same with nose note any greenish substance (meconium in the amniotic fluid or on the baby or in the airway

cervix:

connects with the vagina contains a plug of mucus that seals the uterine opening during pregnancy preventing contamination from entering the uterus the plug is discharged when the cervix starts to dilate or open and appears as a pink tinged mucus in the vaginal discharge

the signs and symptoms of a possible spontaneous abortion include:

cramp-like lower abdominal pain similar to labor moderate to severe vaginal bleeding which may be bright or dark red passage of tissue or blood clots

delivery can probably be expected within a few minutes if the following signs and symptoms are present:

crowning has occurred contractions are 2 minutes apart or closer and they are intense an last from 60 to 90 seconds the patient feels the infants head moving down the birth canal (sensation of the urge to defecate) the patient has a strong urge to push the patients abdomen is very hard if the birth is imminent with crowning, contact medical direction for a decision to commit to delivery on site if the delivery does not occur within 10 minutes contact medical direction for permission to transport

pregnancy induced hyper tension:

defined as a blood pressure in a pregnant woman that is greater than 140/90 mmHg on two or more occasions at 6 hours apart if the patient has a low blood pressure prior to the pregnancy an increase in the systolic blood pressure of greater than 30 mmHg and a diastolic blood pressure greater than 15 mmHg above the baseline blood pressure is used to define the condition

normal labor can be divided into three stages:

dilation, expulsion, and placental the length of each stage varies in different women and under different circumstances

the following history and assessment finding should alert you to an ectopic pregnancy:

dull aching-type pain that is poorly localized and becomes sudden, sharp or knife-like abdominal pain, localized on one side of the lower quadrants shoulder pain from blood in the abdominal cavity that irritates the diaphragm vaginal bleeding that may be haevy, light or absent lower abdominal pain, possibly radiating to one or both shoulders tender bloated abdomen a palpable mass in the abdomen (either the embryo or a blood clot) -very rare weakness or dizziness when sitting or standing decreased blood pressure increased pulse rate signs of shock (hypoperfusion) discoloration around the navel, if rupture occurred hours earlier urge to deficate

meconium:

during a difficult labor the fetus may undergo significant distress one result of this distress is the passing of a bowel movement in the amniotic fluid causing the normally clear fluid to turn greenish or brownish yellow this coloring is called meconium staining it is an indication that the fetus has experienced a hypoxic event if the infant aspirates, infection and pneumonia can result most often seen in breech births if meconium is present but the newborn has a good cry or vigorous activity do not suction if the baby is depressed or non-vigorous, do not dry or stimulate until you have aggressively suctioned the airway until clear to avoid aspiration of the meconium

when edema and protein in the urine are found with:

elevated blood pressure it is defined as preeclampsia

emergency care and reassessment of abnormal delivery:

emergency medical care of the mother and newborn is similar to that of a normal delivery exceptions are outlined as follow and include an emphasis on immediate transport, administration of high concentration oxygen, and continuous monitoring of vital signs during reassessment

the uterine wall is made up of three layers:

endometrium: inner most lining each month estrogne and progestrone build up the lining for implantation of a fertilized ovum if the ovum is not fertilized or does not implant the lining is shred during menstrual period myometrium: thick middle layer of smooth muscle the smooth muscle contracts from the fundus downward during labor to expel the fetus perimetrium: is a serous membrane that partially covers the corpus of the uterus

in general provide the pregnant patient with the same emergency medical care you would provide to any patient with the same signs and symptoms:

ensure adequate airway, breathing, oxygenation and circulation: administer oxygen via nonrebreather mask at 15lpm regardless of SpO2 because the patient may be compensating for shock but the fetus might be hypoxic care for bleeding from the vagina: place a sanitary pad, never pack the vagina insert fingers or touch vaginal area, save and transport with the patient any passed tissue or any evidence of blood loss (such as bloody sheets, towels, sanitary pads or underwear) treat for shock if indicated provide emergency medical care as you would for the nonpregnant patient based on any other signs and symptoms transport the patient on her side: if the pregnant patient is in her twetieth week transport her on her side or with her right hip elevated if she is placed in a lying position, if she is on a backboard tilt the board to the left

ovaries:

female gonads or sex glands located in upper portion of pelvic cavity responsible for secreting the hormones estrogen and progesterone and for development and release of the mature egg necessary for reproduction the mature egg is called an ovum

first stage: dilation

from the beginning or true contractions to complete cervical dilation the cervix becomes fully dilated at 10 cm which allows the infants head to progress from the body of the uterus to the birth canal through the uterine contractions the cervix gradually dilates and effaces until the opening is large enough to allow the infant to pass through contractions usually begin as an aching sensation in the small of the back, within a short time the contractions become cramplike pains in the lower abdomen these recur at regular intervals each one lasting about 30 to 60 seconds at first the contractions occur about 10 to 20 minutes apart and are not very severe they may even stop completely for a while and then start again appearance of the pug of mucus may occur before or during this stage of labor, also the amniotic sac may rupture before or during this stage this stage is usually 8-10 hours women who have had children before may only be 5-7 hours the dilation stage ends when contractions are at a regular 3 to 4 minute intervals that last at least 60 seconds each and feel very intense

secondary assessment of a antepartum emergency:

gather a history some patients may not realize they are pregnant and experiencing an obstetric emergency ask following questions: have you ever been pregnant before? are you experiencing any pain or discomfort? when was your last normal menstrual period? have you missed a menstrual period? have you had an unusual period? have you had any unusual vaginal discharge? when (if the patient knows she is pregnant) is yout due date? examine the abdominal region, look for any abnormalities distention or signs of injury palpation can help to determine the location of the pain as well as identify if there is any abnormal guarding, tenderness or abnormal masses if there is abdominal pain, consider conditions related to an acute abdomen

grimace (reflex irritability):

gently flick the soles of the newborns feet or observe the facial expressions during suctioning if performed if the newborn displays no reflexive activity to your stimulation award 0 points if the newborn displays only some facial grimace award 1 point if the stimulation causes the newborn too grimace and cough, sneeze or cry award 2 points

if the first time mother delivers twins she would be:

gravida 1, para 1 because para refers to the number of delivery events and not the number of children

pulse:

heart rate is one of the most improtant signs of whether oxygen is reaching the newborns tissues following birth count the heart for at least 30 seconds preferably with a stethescope if you do not have a stethoscope feel the pulse of the umbilical cord where it joins the abdomen or at the brachial artery if no pulse is present award 0 points if the heart rate is under 100 award 1 point if the heart rate is over 100 award 2 points

antepartum conditions causing hemorrhage:

hemorrhage is one of the leading causes of death in the pregnant patient the uterus is very vascular thus it is very prone to severe bleeding if injured uterine bleeding may or may not be associated with vaginal bleeding depending on the site of bleeding and position of the fetus if the bleeding occurs behind the placenta where the margins of the placenta are intact there will be no vaginal bleeding even thought the patient may lose a significant amount of blood and present in hypovolemic shock if the margin of placenta is torn away from the uterine wall the patient will likely present with vaginal bleeding if the uterine bleeding occurs late in the pregnancy the fetus may be engaged low in the pelvis and vaginal canal which would block external blood flow vaginal bleeding may sometimes occur later in the pregnancy with or without pain if the bleeding is excessive it can be life-threatening emergency for the mother and the fetus the bleeding may be due to spontaneous abortion, placenta previa, abruptio placentae, ruptured uterus, or an ectopic pregnancy be ESPECIALLY alert to the signs and symptoms of shock (hypoperfusion)

preeclampsia is characterized by:

high blood pressure swelling headaches and visual disturbances

the following history and assessment findings should alert you to a ruptured uterus:

history of previous uterine rupture history or findings of abdominal trauma history of a large fetus having borne more than two children history of a prolonged and difficult labor (which may force a large infant out through the uterine wall history of prior cesarean section or uterine surgery a tearing or shearing sensation in the abdomen constant and severe abdominal pain nausea signs and symptoms of hypoperfusion vaginal bleeding (typically minor bleeding, but could be heavy) cessation of noticeable uterine contractions ability to palpate the infant in the abdominal cavity

it was once though that the bleeding with placenta previa was characteristically bright red:

however it is now understood that the color of the blood does not differentiate between placenta previa and other conditions the bleeding may be bright, dark, or an intermediate color in addition to vaginal bleeding also look for signs of hypovolemic shock

the predisposing factors for an abruptio placentae are:

hypertension use of cocaine or other vasoactive drugs preeclmapsia multiparity (several births) previous abruption smoking short umbilical cord premature rupture of the amniotic sac diabetes mellitus

gastrointestinal system:

nausea and vomiting commonly occur during the first trimester as a result of hormone changes and the change in the need for carbohydrates bloating and constipation may occur from a decrease in peristalsis in the gastrointestinal tract

most newborns require:

no resuscitation beyond temperature maintenance, mild stimulation and suctioning

braxton-hicks contractions:

often referred to as false labor are painless, short duration, irregular contractions that occur as early as the 13th week of gestation these are thought to be the conditioning process for the uterus in preparation for actual labor also thought to improve placental blood flow no cervical dilation or effacement with the contractions contractions may become more frequent and intense however typically remain irregular there is no way to differentiate braxton hicks from true labor in the prehospital setting, thus any patient with contractions should be transported

preeclampsia/eclampsia:

once known as toxemia during pregnancy is a common condition affecting 1 in 20 pregnant women occurs most frequently in the last trimester and is most likely to affect women in their 20s who are pregnant for the first time women with a history of diabetes, heart disease, kidney problems or a high blood pressure are at the greatest risk as those whose mothers or sisters have had preeclampsia the exact cause of preeclamosia and eclampsia is not clearly understood, one theory is that a disorder of the placenta causes the vessels throughout the body to spasm leading to a reduction in blood flow to organs

breech birth:

one in which the fetal buttocks or lower extremities are low in the uterus and are the first to be delivered delivery may be prolonged for these new borns who are at great risk for delivery trauma the mother is also at risk for delivery trauma there is an increased risk of prolapsed cord, compression of the cord or an anoxic insult during delivery where oxygenation is cut off to the fetus transport immediately upon recognition of a breech presentation administer oxygen to the mother and keep the mother in a supine head-down position where her pelvis is elevated so gravity will discourage the movement of the fetus into the birth canal

intrapartum emergencies:

one that occurs during the period of onset of labor to the actual delivery of the neonate delivery is not possible a continued attempt at delivery puts the pregnant patient and fetus at great risk for injury or even death this immediate transport is key in the emergency care of abnormal delivery emergencies

spontaneous abortion:

or miscarriage may occur for a number of reasons and is defined as delivery of the fetus and placenta before the fetus is viable viability is usually considered to begin after the twentieth week of pregnancy approx 80 percent of spontaneous abortions occur prior to the 12th week of gestation which is during the first trimester of pregnancy spontaneous abortions occurs in 15 to 20 percent of all recognizable pregnancies the cause is usually genetic (50 percent of cases) or it may be caused by a uterine abnormality, infection, drugs, or maternal disease cramping and vaginal bleeding are usually present at 8 to 12 weeks of gestation the patient history is extremely important ask the patient about the pregnancy history also important to ask about a confirmed pregnancy ask the patient about uterine cramping and vaginal bleeding do NOT mistake a spontaneous abortion for a heavy period

if you determine that you must assist in the delivery of the infant remember:

take all appropriate standard precautions, including gloves, gown and eye protection do not touch the patients vaginal area except during delivery and in the presence of your partner do not allow the patient to use the bathroom, if the patient does move her bowels or urinate replace the soiled linens with clean ones do not hold the mothers legs together, do not do anything to attempt to delay or restrain the delivery use a sterile obstetrics (OB) kit

emergency medical care for delivery:

take all standard precautions handle blood and fluid soaked dressing pads and linens carefully and bag them in moisture proof bags to prevent leakage: seal and label the bags position the patient if there are no signs of hypoxia or if the SpO2 reading is 94% or greater, still apply a nasal cannila to the pregnant patient at 2 to 4 lpm to provide additional oxygenation of the fetus during the labor ad delivery process create a sterile field around the vaginal opening if time permits monitor the patient for vomiting continually assess for crowning place your gloved fingers on the bony part of the infants skull when it crowns tear the amniotic sac if it is not already ruptured determine the position of the umbilical cord suction fluids from the infants airway only if obvious obstruction to breathing exists or if ppv is necessary as the torso and full body are expelled support the newborn with both hands grasp the feet as they are born dry, wrap, warm and position the infant and suction if necessary assign your partner to monito and complete intial care of the newborn clamp, tie and cut the umbilical cord as pulsations cease observe the delivery of the placenta transport the delivered placenta place one or two sanitary napkins over the vaginal opening record the time of the delivery and transport the mother, infant and placenta to the hospital

labor:

term used to describe the process of birth it consists of the contraction of the uterine wall, which expel the fetus and the placenta out of the uterus and vagina

even if the mother is unaware that she is carrying more than one infant you should be prepared for a multiple birth if one or more of the following is observed:

the abdomen is still very large after one infant is delivered uterine contractions continue to be extremely strong after delivering the first infant uterine contractions beginning again after 10 min after one infant has been delivered the infants size is small in proportion the mothers abdomen

blood show:

the expulsion of the plug signals the fist stage of labor

menstrual cycle:

the female goes through a monthly menstrual cycle that is controlled by estrogen and progesterone the cycle last from 24 to 35 days with an average of 28 days the first day begins with menstruation: the sloughing of of the endometrial tissue that was preparing for implantation of the fertilized ovum once menstruation is over estrogen levels increase and again begin to prepare the endometrium for implantation of a fertilized ovum on the 14th day of the cycle ovulation occurs and the mature ovum is released from the ovary the ovum descends through the Fallopian tube within the next 5 to 7 days if it is fertilized it implants itself in the prepared endometrial lining of the uterus if it is not fertilized it is discharged with the outer layer of endometrial tissue during menstruation which occurs 14 days after ovulation

post-term pregnancy:

the gestation of the fetus extends beyond 42 weeks post-term pregnancy causes postmaturity syndrome at 42 weeks the placenta begins to decline leading to a decrease in oxygenation and nutrient delivery to the fetus from decreased placental blood flow the postmature baby is more prone to insufficient oxygen and nutrient delivery, hypoxia, a hardened skull that causes a more difficult delivery and the presence of meconium from increased bowel maturity the postmature fetus is at greater risk from intrapartum hypoxia because of the inability of the placenta to meet the demands of the fetus during labor

the vagina:

the lower part of the birth canal about 8 to 12 centimeters in length the vagina originates at the cervix of the uterus and extends through the external opening of the body during pregnancy the vagina undergoes a change that prepares it for passage of the infant the smooth muscle layer of the vagina allows it to stretch gently to accommodate the infant during delivery

musculoskeletal system:

the pelvic joints loosed as a result of hormone changes there is a change in the center of gravity for the mother caused by a heavy uterus the patient compensates and therefore often experiences lower back pain