CH41 Obstetrics - Normal Childbirth

Preparing for Delivery: 1 - Position the Pregnant woman

1. Position the pregnant woman If taking place in the patient's home, the woman is usually lying supine in her bed or other flat surface. - Easier for the paramedic but harder for the woman because she has to push against gravity. - Some women may prefer sitting at edge of a chair or to squat for delivery. Alternative "pushing" positions are becoming more popular.

Preparing for Delivery: 2 - Birthing positions

2. Birthing positions Standing birth - Allows the woman total freedom to move up to the point of delivery - Allows the woman to take advantage of gravity - The fetal head is moved away from the sacral area when the woman arches her back Semi-Fowler's position - Woman's torso is propped up to a high Fowler's or Fowler's position. - Helps some women with pushing because they can lie back to rest between contractions Kneeling birth - The woman kneels with her buttocks in the air and resting on her elbows. - Has some of the same advantages as squatting: (a) Allows her to arch her back to assist delivery (b) Allows the fetal head to move away from the sacrum - Some use this method in a water birth. Side-lying position - A left-Sims position, with the upper torso supported with pillows - Ensures the uterus and fetus are moved away from the inferior aorta - Some report significantly fewer perineal tears with this method.

Assisting Delivery: Apgar Scoring

Apgar scoring Evaluates the newborn's vital functions immediately after birth Five parameters are given a score from 0 to 2 at 60 seconds and again at 5 minutes after birth: - Heart rate - Respiratory effort - Muscle tone - Reflex irritability - Color Most newborns have a total score of 7 to 10. A score of 4 to 6 will need resuscitation.

Assisting delivery: Cutting the umbilical cord

Cutting the umbilical cord Once the newborn is delivered and breathing well, the umbilical cord can be cut, following these steps: Handle the cord with care because it tears easily. Tie or clamp the cord about 8 inches from the navel with clamps 2 inches apart, then cut the cord between them. Examine the two ends to ensure there is no bleeding. - If there is bleeding on the end attached to the newborn, tie or clamp the cord proximal to the previous clamp. - Do not remove the first clamp. - Once the cord is cut, wrap the newborn in a dry blanket. - If the mother is stable, give her the baby.

Assisting Delivery: Delivery of the placenta

Delivery of the placenta Usually delivers within 20 minutes after the newborn is delivered. - Reassure the mother while waiting for the placenta to separate spontaneously. - Do not pull on the umbilical cord to speed up placental delivery. The patient usually reports that her contractions are beginning again. - The uterus rises in the abdomen and feels hard when palpated. - The end of the cord protruding from the vagina lengthens and blood usually gushes from the vagina. - Instruct the patient to bear down, expelling the placenta. The fetal side of the placenta should be gray, shiny, and smooth. The maternal side should be dark maroon with a rough texture. Place the placenta in a plastic bag from the OB kit, and transport it with the patient. Examine the perineum for lacerations, applying pressure on any bleeding areas. Clean the patient, and place a sanitary pad over the vaginal opening. Prepare for transport. - If the placenta has not delivered after 15 minutes, begin transport. Some women request to keep the placenta. - If possible, respect such requests.

Maternal and Fetal response to Labor: Mother Responses

During labor, the woman experiences: Increased workload of the heart Increased blood pressure, pulse, and cardiac output Increased breathing rate to accommodate the increased oxygen demand - Also occurs due to pain from labor and perineal stretching Increased WBC production in response to stress and exertion of labor Preservation of fluids and electrolytes by the renal system Protein breakdown and increased temperature from physical exertion Blood flow diverted from the gastrointestinal system, resulting in: - Delayed stomach emptying - Loose bowel movements - Nausea, vomiting, and diarrhea

Stages of Labor: First Stage of Labor

First stage of labor: Begins with onset of labor pains Early contractions come at 5- and 15-minute intervals. Latent phase—cervix begins to dilate and efface. - The lower segment of the uterus is pulled upward over the presenting part, resulting in effacement (thinning and shortening) of the cervix. - Cervix stretches until wide enough to accommodate the fetus passing through. First stage of labor lasts until cervix is fully dilated. - Averages about 12 hours in a nullipara birth - Up to 8 hours in a multipara - Toward the end of the stage, the amniotic sac often ruptures. (Gush of fluid pours out of the vagina.)

Assisting Delivery: Control the Delivery

Follow these steps to assist with delivery: Control the delivery. - When crown begins, place gentle pressure on the head to prevent it from delivering too quickly and tearing the vagina. Support the newborn's head as it emerges from the vagina and begins to turn. - Do not attempt to pull the newborn out. - If membranes cover the head, tear the amniotic sac with fingers or forceps so the newborn can breathe. Slip a middle finger alongside the head to check for nuchal cord. - Cord compression can occur, causing a slowed fetal heart rate and fetal distress. - Try to slip the cord gently over the newborn's shoulder and head. - If the cord is wrapped tightly around the neck, place umbilical clamps 2 inches apart and cut between the clamps. With the head supported, clear the airway by suctioning with a bulb syringe. Gently guide the head downward so the upper shoulder can deliver. Gently guide the head upward to allow delivery of the lower shoulder. The trunk and legs will follow rapidly. - Grasp and support the newborn as it emerges. - Remember: Newborns are wet and slippery. Once delivered, maintain the newborn at the same level as the vagina to prevent blood drainage. - Wipe blood or mucus from the newborn's nose and mouth with sterile gauze. - Suction the mouth and nostrils with the bulb syringe. - Squeeze the bulb before inserting the tip, then place the tip in the mouth or nostril and release slowly. - Withdraw the bulb, expel the contents in a waste container, and repeat as needed. Dry the newborn with sterile towels, and wrap in a dry blanket. Record the time of birth for the PCR.

Stages of Labor:

Labor: Mechanism by which the products of conception are expelled from the uterus The length of time for each stage depends on whether the woman is going through her first pregnancy or if she has delivered before. First signs of labor (which often go unnoticed): - Relief of pressure in the upper abdomen (lightening) - Increase of pressure in the pelvis - Bloody show (a plug of mucus sometimes mixed with blood) discharged from the vagina 1 - First Stage of Labor - BEGINS with ONSET of Labor pains. 2 - Second Stage of Labor - Begins as the head of the fetus descends and flexes to enter the birth canal 3 - The placenta separates from the uterine wall and is expelled.

Postpartum Care

Postpartum care 1. After delivery, obtain the mother's vital signs. 2. Place a sanitary napkin in front of the vagina. 3. Monitor the mother's condition closely for: Hemorrhage and shock Seizure activity Respiratory difficult 4. Assess the fundus—it should be firm on palpation. Massage the fundus to control excessive postpartum hemorrhage (more than 500 mL). 5. Note the lochia—vaginal discharge of blood and mucus following delivery. Usually red the first few days, decreasing in amount and changing to a brownish color for several weeks after delivery. 6. Cover the mother with blankets.

Stages of Labor: Second stage of labor

Second stage of labor Begins as the head of the fetus descends and flexes to enter the birth canal Fetus will undergo several changes in position to pass through the birth canal. - Second position: Internal rotation (head rotates with the face toward the woman's rectum) - Third position: Extension (fetus tilted so the crown of the head is seen at the vaginal opening) - The head rotates to the side to align it with the shoulders. - The final rotation is movement of the shoulders that expulse the fetus from the vagina. Contractions are more intense and frequent—2 to 3 minutes apart. The cervix becomes fully dilated and effaced. When the presenting part of the fetus crowns, delivery is imminent. The second stage of labor is concluded when the newborn is fully delivered. - Takes 1 to 2 hours in a nullipara - Takes about 30 minutes in a multipara

Preparing for Delivery: 4 - OB kit and preparation

The OB kit and preparation Use the following steps in preparing for delivery: - Open the sterile OB kit—maintain sterility by touching only the outside. - Wash hands thoroughly with a providone-iodine or chlorhexidine scrub solution if available. - Put on sterile gloves. - Maintain standard precautions. Use sterile gown, surgical mask, and eye protection. - Drape the woman in sterile towels from the OB kit. Place the first towel beneath her buttocks. Lay a second sterile towel flat between the woman's legs just below the vaginal opening. Drape a sterile towel on her abdomen and on each thigh. A safe and controlled delivery takes precedence over the draping if there is no time. Attend to the emotional needs of the patient and bystanders. Have your partner at the woman's head to help keep her calm and administer oxygen if needed. - The partner should have an emesis basin and portable suction available. - If time, establish an IV line and apply the ECG monitor. - Consider IV fluid boluses if the woman is hypotensive. Encourage the woman to rest between contractions and to resist bearing down until you can assist with delivery.

Maternal and Fetal response to Labor: Fetal Responses

The fetal responses to labor result from powerful uterine contractions on the fetal body. A decrease in the amount of oxygen and nutrients to the fetus Insufficient removal of waste from the fetus A decreased fetal heart rate Fetal acidosis—acid-base response from hypoxia and a buildup of lactic acid caused by: - Nuchal cord - Multiple births - Abnormal fetal position - Respiratory conditions - Shoulder dystocia - Other childbirth complications

Stages of Labor: Third Stage of Labor

Third stage of labor The placenta separates from the uterine wall and is expelled. Uterine contractions squeeze shut the exposed blood vessels from where the placenta separated from the uterine wall.