EMT: Chapter 23 - Obstetrics and Neonatal Care

Diabetes and pregnancy

develops during pregnancy in many women who have not had diabetes previously. 2. This condition, called gestational diabetes, resolves in most women after delivery. -------------------------------------------- 3. The treatment is the same as for any other patient with diabetes. a. A pregnant woman may control her blood glucose level with diet and exercise or may take medication. b. In some cases, the woman will have to manage her condition with insulin injections. c. A pregnant woman experiencing hyperglycemia or hypoglycemia should be cared for in the same manner as any patient with diabetes.

fetus

develops inside a fluid-filled, baglike membrane called the amniotic sac. -------------------------------------------- 1. The sac contains about 500 to 1,000 mL of amniotic fluid, which helps insulate and protect the floating fetus. 2. The amniotic fluid is released in a gush when the sac ruptures, usually at the beginning of labor.

Eclampsia (sub section of hypertension)

eclampsia, is characterized by seizures that occur as a result of hypertension. a. To treat a patent having seizures caused by eclampsia: i. Lay the patient on her left side. ii. Maintain her airway. iii. Administer supplemental oxygen if necessary. iv. If vomiting occurs, suction the airway. v. Provide rapid transport. vi. Call for an ALS intercept, if available. -------------------------------------------- Transporting the patient on her left side can also prevent supine hypotensive syndrome. a. This condition is caused by compression of the descending aorta and the inferior vena cava by the pregnant uterus when the patient lies supine. b. Hypotension may result.

fallopian tubes

extend out laterally from the uterus, with one tube associated with each ovary. 1. Fertilization occurs when a sperm meets the egg, usually when the egg is inside the fallopian tube. 2. The fertilized egg then continues to the uterus where, if implantation occurs, it develops into an embryo and then a fetus and grows until the time of delivery.

ectopic pregnancy

implantation of the fertilized egg in any site other than the normal uterine location --> The leading cause of maternal death in the first trimester is internal hemorrhage into the abdomen

Cultural Value Considerations with pregnancy (placenta)

is important when you are assessing and treating a pregnant patient. 1. Women of some cultures may have a value system that will affect: a. The choice of how they care for themselves during pregnancy b. How they have planned the childbirth process 2. Some cultures may not permit a male health care provider, especially in the prehospital setting, to assess or examine a female patient. 3. You should respect these differences and honor requests from the patients. 4. Your responsibility is to the patient and is limited to providing care and transport. 5. A competent, rational adult has the right to refuse all or any part of your assessment or care.

umbilical cord

is the lifeline of the fetus, connecting the woman and fetus through the placenta. a. The umbilical vein carries oxygenated blood from the placenta to the heart of the fetus. b. The umbilical arteries carry deoxygenated blood from the heart of the fetus to the placenta.

What treatment can you always give to a pregnant women?

may safely use oxygen to treat any pregnant patient without harm to the fetus. --> especially for the heart or lung disease in a

Hypertensive disorders and pregnancy

occasionally occurs, typically in patients who are pregnant for the first time, is preeclampsia, or pregnancy-induced hypertension. a. This condition can develop after the 20th week of gestation. -------------------------------------------- b. Characterized by the following signs and symptoms: i. Severe hypertension ii. Severe or persistent headache iii. Visual abnormalities such as seeing spots, blurred vision, or sensitivity to light iv. Swelling in the hands and feet (edema) v. Anxiety

Post-term pregnancy

refers to pregnancies lasting longer than 42 weeks. --> Postterm fetuses can be larger than a typical 40-week fetus, sometimes weighing 10 lb or more. -------------------------------------------- 3. This condition can lead to problems with the woman and fetus. a. A more difficult labor and delivery b. Increased chance of injury to the fetus c. Increased likelihood of cesarean section being required d. Woman is at risk for perineal tears and infection e. Postterm newborns have increased risks of meconium aspiration, infection, and being stillborn. f. Newborns may not have been able to develop normally because of the restricted size of the uterus. 4. You should be prepared to resuscitate the newborn, as respiratory and neurologic functions may have been affected.

vagina

the outermost cavity of the female reproductive system and forms the lower part of the birth canal. 1. It is begins at the cervix and ends as an external opening of the body. 2. The vagina completes the passageway from the uterus to the outside world for the newborn. 3. The perineum is the area between the vagina and the anus.

The Second Birth - After Delivery

the placenta separates from the uterus and is delivered.

Substance Abuse

1. Some pregnant women are addicted to alcohol or other drugs. 2. The effects of the addiction on the fetus include: a. Premature b. Low birth weight c. Severe respiratory distress d. Death 3. Fetal alcohol syndrome describes the condition of infants born to women who have abused alcohol. 4. If you are called to handle a delivery of an addicted woman, --> pay special attention to your own safety. 5. Follow standard precautions. a. Wear eye protection, a face mask, and gloves at all times. 6. Clues that you are dealing with an addicted patient may include: a. The presence of drug paraphernalia b. Empty wine or liquor bottles c. Statements made by family or bystanders or by the patient herself 7. The newborn will probably need immediate resuscitation. a. Assist with the delivery, and be prepared to support the newborn's respirations and administer oxygen during transport.

The Apgar score

1. The Apgar score is the standard scoring system used to assess the status of a newborn. 2. It assigns a number value (0, 1, or 2) to five areas of activity. a. Appearance i. The skin of a light-skinned newborn and the mucous membranes of a dark-skinned newborn should turn pink. ii. Blue skin all over or blue mucous membranes signal a central cyanosis. b. Pulse i. If a stethoscope is unavailable, you can measure pulsations with your fingers in the umbilical cord or at the brachial pulse. ii. A newborn with no pulse requires immediate CPR. c. Grimace or irritability i. Grimacing, crying, or withdrawing in response to stimuli is normal in a newborn and indicates that the newborn is doing well. ii. The way to test this is to snap a finger against the sole of the newborn's foot. d. Activity or muscle tone i. The degree of muscle tone indicates the oxygenation of the tissues. The total of the five numbers is the Apgar score. a. A perfect score is 10. b. Calculate the Apgar score at 1 minute and 5 minutes after birth.

Pulmonary Embolism in PostPartum Patients

A pulmonary embolism results from a clot that travels through the bloodstream and becomes lodged in the pulmonary circulation, blocking blood flow to the lungs, and is potentially life threatening. 3. If you deliver a newborn in the field and the woman begins to report sudden difficulty breathing or shortness of breath, consider pulmonary embolism as a possibility. 4. Also suspect a pulmonary embolism in patients of childbearing age with respiratory complaints who have recently delivered, especially with the sudden onset of difficulty breathing or altered mental status. a. Provide supportive care of the ABCs with high-flow oxygen and rapid transport to the hospital.

Postpartum Complications

A. Bleeding that exceeds approximately 500 mL is considered excessive. 1. If bleeding continues after delivery of the placenta, you should continue to massage the uterus. 2. Check your technique and hand placement if bleeding continues. 3. Treat the woman if she appears to be in shock. 4. Excessive bleeding after birth is usually caused by the muscles of the uterus not fully contracting due to: a. Delivery of more than one infant b. A long labor process that causes the uterus to be too "tired" to contract c. Parts of the placenta still being inside the uterus 5. Cover the vagina with a sterile pad, changing the pad as often as possible. a. Do not discard any blood-soaked pads. b. Hospital personnel will use them to estimate the amount of blood loss. c. Save any tissues that may have passed from the vagina. 6. Administer oxygen if necessary, monitor vital signs frequently, and transport the patient immediately to the hospital. a. Never hold the woman's legs together or pack the vagina with gauze pads in an attempt to control bleeding.

Patient assessment for Pregnant Patient

A. Childbirth is seldom an unexpected event, but there are occasions when childbirth becomes an emergency. 1. Dispatch protocols usually include the dispatcher asking simple questions to determine whether birth is imminent. 2. Premature contractions may be caused by trauma or medical conditions. B. Scene size-up 1. Take standard precautions. a. Gloves and eye and face protection are a minimum if delivery has already begun or is complete. b. If the call is going to result in a field delivery and time allows, a gown should also be used. c. Do not be lax in your safety observations and precautions. d. Remain calm and professional. e. Consider calling for additional or specialized resources. --- 2. Mechanism of injury/nature of illness a. You will encounter pregnant patients who are not in labor, so it is important to determine the MOI or NOI. b. Do not develop tunnel vision during a call. c. Falls and the necessity for spinal immobilization must be considered. C. Primary assessment 1. Form a general impression. a. Whether the patient is in active labor or whether you have time to assess for imminent delivery and address other possible life threats b. Perform a rapid examination of the patient. c. Take a moment to confirm whether the fetus will be delivered in the next few minutes or whether you have time to continue to evaluate the situation. d. When trauma or other medical problems are the presenting complaint, evaluate these first and then assess the impact of these problems on the fetus. Airway and breathing a. During an uncomplicated birth, life-threatening conditions involving the woman's airway and breathing are not usually an issue. b. However, a motor vehicle crash, an assault, or any number of medical conditions may cause a life threat to exist, and may result in a complicated delivery. i. Assess the airway and breathing to ensure they are adequate. ii. If needed, provide airway management and high-flow oxygen. --- Circulation a. External and internal bleeding are potential life threats to the patient and should be assessed early. b. Blood loss after delivery is expected, but significant bleeding is not. c. Quickly assess for any potential life-threatening bleeding, and begin treatment immediately. d. Assess the skin for color, temperature, and moisture. e. Check the pulse to determine if it is too fast or too slow. f. If there are signs of shock, control the bleeding, give oxygen, and keep the patient warm. Transport decision a. If delivery is imminent, you must prepare to deliver at the scene. i. The ideal place to deliver is in the security of your ambulance or the privacy of the woman's home. ii. The area should be warm and private with plenty of room to move around. b. If delivery is not imminent, prepare the patient for transport and perform the remainder of the assessment en route to the emergency department. i. Administer oxygen. ii. Women in the second and third trimesters of pregnancy should be transported lying on the left side when possible. iii. If spinal immobilization is indicated, secure the woman to the backboard and elevate the right side of the board with rolled towels or blankets. --- Provide rapid transport for pregnant patients who: i. Have significant bleeding and pain ii. Are hypertensive iii. Are having a seizure iv. Have an altered mental status --- D. History taking 1. You should obtain a thorough obstetric history, including: a. Her expected due date b. Any complications that she is aware of c. If she has been receiving prenatal care d. A complete medical history Obtain a SAMPLE history. a. Some pregnant women have a history of medical problems for which they take prescription medications. b. Some women with no history of medical problems require medications during pregnancy. c. Pertinent history should include questions related specifically to prenatal care. i. Identify any complications the patient may have had during the pregnancy or potential complications during delivery. ii. Determine the due date, fetal movements, frequency of contractions, and a history of previous pregnancies and deliveries and their complications. iii. Determine whether there is a possibility of multiples and whether the woman has taken any drugs or medications. d. If her water is broken, ask whether the fluid was green. i. Green fluid is due to meconium (fetal stool). ii. The presence of meconium can indicate newborn distress, and it is possible for the fetus to aspirate meconium during delivery. E. Secondary assessment 1. Physical examinations a. Perform a complete assessment of the major body systems as needed, with emphasis on the patient's chief complaint. b. Assess for fetal movement by asking the patient whether she can feel the baby moving. c. If the patient is in labor, the physical examination should be focused on contractions and possible delivery. d. If at any point you suspect that delivery is imminent, you should check for crowning. e. If you do not suspect an imminent delivery and the patient reports other problems unrelated to delivery, you should not visually inspect the vaginal area. --- Vital signs should include pulse; respirations; skin color, temperature, and condition; and blood pressure. a. Be especially alert for tachycardia and hypo- or hypertension. b. It is typical for a woman's blood pressure to drop slightly during the first two trimesters of pregnancy but return to normal during the third trimester. c. Hypertension, even mild, may indicate more serious problems. F. Reassessment 1. Repeat the primary assessment with a focus on the patient's ABCs and vaginal bleeding, particularly after delivery. 2. Obtain another set of vital signs and compare with those obtained earlier. 3. Recheck interventions and treatments to see whether they were effective. a. Is vaginal bleeding slowing with uterine massage? b. In most cases, childbirth is a natural process that does not require your assistance. c. When childbirth is complicated by trauma or other conditions, however, any interventions you provide for the patient will benefit the fetus. Communication and documentation a. If your assessment determines that delivery is imminent, notify staff at the receiving hospital. i. Provide an update on the status of the woman and the newborn after delivery. b. On the rare occasions that delivery of the placenta does not occur within 30 minutes or you determine that a complication is occurring that cannot be treated in the field, notify the hospital and provide rapid transport. c. For a pregnant patient with a complaint unrelated to childbirth, be sure to include the pregnancy status of the patient in your radio report. d. The hospital staff will want to know: i. The number of weeks of gestation ii. Her due date iii. Any known complications of the pregnancy e. If delivery occurred in the field, you will have two patient care reports to complete.

Neonatal Assessment and Resuscitation

A. Follow standard precautions, and always put on gloves before handling a newborn. 1. A newborn will usually begin breathing spontaneously within 15 to 30 seconds after birth, and the heart rate will be 120 beats/min or higher. ^^^^^^^^^^^ 2. If you do not observe these responses: a. Gently tap or flick the soles of the feet or rub the back. 3. Many newborns require some form of stimulation that will encourage them to breathe air and begin circulating blood through the lungs, including: a. Positioning of the airway b. Drying c. Warming d. Suctioning e. Tactile stimulation

What should the EMT remember about what pregnant women ingest?

Anything ingested by a pregnant woman has the potential to affect the fetus, including: a. Nutrients b. Oxygen c. Waste d. Carbon dioxide e. Many toxins f. Most medications

Umbilical cord around the neck

As soon as the head is delivered, use one finger to feel whether the umbilical cord is wrapped around the neck. --> This commonly is called a nuchal cord. --> A nuchal cord that is wound tightly around the neck could strangle the fetus. Once the cord is cut, you must attempt to speed the delivery by encouraging the woman to push harder and possibly more often because the fetus will now have no oxygen supply until it is delivered and breathing spontaneously.

(OB) kit, includes...

(OB) kit, including: a. Surgical scissors or scalpel b. Umbilical cord clamps c. Umbilical tape d. A small rubber bulb syringe e. Towels, drapes, or sheets f. 4˝ × 4˝ and/or 2˝ × 10˝ gauze sponges g. Sterile gloves h. Infant blanket i. Sanitary pads j. An infant-sized BVM k. Goggles l. A plastic bag

Cardiac Arrest in Pregnant Women

If a pregnant trauma patient goes into cardiac arrest, your focus is the same as with other patients in cardiac arrest. 1. Remember that the only chance you have to save the fetus is to do all you can to save the woman. 2. Perform CPR and provide transport to the hospital according to local protocol. 3. If a woman is in the last month or two of pregnancy, compressions may need to be applied a little higher on the sternum than usual. a. 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. 4. You should notify the receiving facility personnel as soon as possible that you are en route with a pregnant trauma patient in cardiac arrest.

ovaries / egg

are two glands, one on each side of the uterus, that are similar in function to the male testes. 1. Each ovary contains thousands of follicles, and each follicle contains an egg. -------------------------------------------- - During each menstrual cycle, there will only be one follicle that is successful at maturing and releasing an egg. - Ovulation occurs approximately 2 weeks prior to menstruation. 4. If fertilized, the egg implants in the endometrium, the lining of the inside of the uterus. 5. If the egg is not fertilized within 36 to 48 hours after it has been released, it will die, and the lining is shed as menstrual flow. a. Occurs around the 28th day of a woman's cycle

Breasts during pregnancy

breasts produce milk that is carried through small ducts to the nipple to provide nourishment to the newborn once it is born. 1. Early signs of pregnancy in the breasts include increased size and tenderness.

Premature birth

1. A normal, full term, single newborn will weigh approximately 7 lb at birth. 2. Any newborn who delivers before 8 months (36 weeks) or weighs less than 5 lb at birth is considered premature. -------------------------------------------- ---> A premature newborn is smaller and thinner than a full-term newborn, and the head is proportionately larger in comparison with the rest of the body. a. The vernix caseosa will be absent or minimal on the premature newborn. b. There will also be less body hair. ------------------------------------------ require special care to survive. a. They often require resuscitation efforts, which should be performed unless it is physically impossible. b. With such care, premature newborns as small as 1 lb have survived and developed normally.

Postdelivery care

1. If the mother is able and willing, hand the newborn to her or place the newborn on her abdomen so skin-to-skin contact can begin immediately. 2. Dry off the newborn and wrap him or her in a blanket or towel. 3. Wrap the newborn so that only the face is exposed, making sure that the top of the head is covered. 4. Place the newborn on one side, with the head slightly lower than the rest of the body. 5. You can pick up and cradle the newborn. a. If local protocols specify, keep the newborn at the level of the woman's vagina until the umbilical cord is cut. b. Always keep the head slightly downward to help prevent aspiration. 6. Wipe the newborn's mouth with a sterile gauze pad as needed. 7. Postdelivery care of the umbilical cord is important because infection is easily transmitted through the cord to the newborn. a. Once the cord has stopped pulsing, clamp and cut the cord. 8. Evaluate the newborn for term gestation, good muscle tone, and breathing/crying, and obtain the 1-minute Apgar score. 9. Give the wrapped newborn to your partner to complete the initial care. a. You can give the newborn to the mother if she is alert and in stable condition. 10. Delivery of the placenta a. The placenta is attached to the end of the umbilical cord that is coming out of the woman's vagina. b. Again, your job is only to assist. c. The placenta delivers itself, usually within a few minutes of the birth, although it may take as long as 30 minutes. i. Do not delay transport waiting for the placenta to deliver. d. Never pull on the end of the umbilical cord. e. Some bleeding, usually less than 500 mL, occurs before the placenta delivers and is normal and expected. f. Wrap the entire placenta and cord in a towel, place them in a plastic bag, and take them to the hospital. g. After delivery of the placenta and before transport, place a sterile pad or sanitary napkin over the vagina and straighten the woman's legs. i. You can help to slow the bleeding by gently massaging the woman's abdomen with a firm, circular, "kneading" motion. ii. You should be able to feel a firm, grapefruit-sized mass in the lower abdomen, called the fundus. Record the time of birth in your patient care report. i. The following are emergency situations: i. More than 30 minutes elapse and the placenta has not delivered. ii. There is more than 500 mL of bleeding before delivery of the placenta. iii. There is significant bleeding after the delivery of the placenta. j. If one or more of these events occur, transport the woman and the newborn to the hospital promptly.

Delivery without sterile supplies

1. On rare occasions, you may have to deliver a newborn without a sterile OB kit. 2. Even without the OB kit, you should always have eye protection, gloves, and a protective mask with you. 3. Carry out the delivery as if sterile supplies were available. a. If possible, use freshly laundered sheets and towels. b. As soon as the newborn is delivered, wipe the inside of the mouth with your finger to clear away blood and mucus. c. You should not cut or clamp the umbilical cord. d. Instead, as soon as the placenta delivers, wrap it in a clean towel or put it in a plastic bag and transport it to the hospital. e. Always keep the placenta and the newborn at the same level, or elevate the placenta slightly if possible. f. Keep the newborn warm.

Breech Delivery

1. The presentation is the position in which an infant is born or the body part that is delivered first. 2. Most infants are born head first, called a vertex presentation. 3. Occasionally, the buttocks are delivered first, called a breech presentation. a. The fetus is at great risk for trauma from the delivery. b. Prolapsed cords are more common in a breech delivery. 4. Breech deliveries usually take longer, so you will often have time to transport the pregnant woman to the hospital. a. However, if the buttocks have already passed through the vagina, the delivery has begun. b. Provide emergency care and call for ALS backup. c. If the woman does not deliver within 10 minutes of the buttocks presentation, provide prompt transport. d. Consult medical control to guide you. 5. Preparing for a breech delivery is the same as for a normal childbirth. a. Position the pregnant woman. b. Prepare the OB kit. c. Place yourself and your partner as you would for a normal delivery. d. Allow the buttocks and legs to deliver spontaneously, supporting them with your hand to prevent rapid expulsion. e. Let the legs dangle on either side of your arm while you support the trunk and chest as they are delivered. f. The head is almost always facedown and should be allowed to deliver spontaneously. g. 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.

Multiple Gestation ( Twins, Triplets, Quad...)

1. Twins occur about once in every 30 births. a. Usually, multiple fetuses are diagnosed early in pregnancy with modern ultrasound techniques. b. With multiple fetuses, always be prepared for more than one resuscitation, and call for assistance. 2. Twins are usually smaller than single fetuses, and delivery is typically not difficult. a. Consider the possibility of twins any time the first newborn is small or the woman's abdomen remains fairly large and firm after birth. b. If twins are present, the second one will usually be born within 45 minutes of the first. c. About 10 minutes after the first birth, contractions will begin again, and the birth process will repeat itself. 3. 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. a. Clamp and cut the cord of the first newborn as soon as it has been born and before the second newborn is delivered. b. There may only be one placenta, or there may be two. 4. Record the time of birth of each twin separately. 5. Twins may be so small that they look premature. a. Handle them carefully and keep them warm.

Fetal demise

1. You may find yourself delivering a fetus who died in the woman's uterus before labor. 2. The onset of labor may be premature, but labor will otherwise progress normally in most cases. 3. If an intrauterine infection has caused the demise, you may note an extremely foul odor. a. The delivered fetus may have skin blisters, skin sloughing, and a dark discoloration. b. The head will be soft and perhaps grossly deformed. 4. Do not attempt to resuscitate an obviously dead neonate.

How to manage Trauma in a Pregnant Patient

1. Your focus is on the assessment and the management of the woman. a. You should suspect shock based on the MOI. b. Be prepared for vomiting, and anticipate the need to manage the airway to protect the patient from aspirating. c. Attempt to determine the gestational age to assist you with determining the size of the fetus and the position of the uterus. --------------------------------------------------------------------------------------------------------------------------- Follow these guidelines when treating a pregnant trauma patient: a. Maintain an open airway. i. Be prepared for and anticipate vomiting. ii. Keep your suction unit readily available. b. Administer high-flow oxygen. i. Keep the oxygen saturation level high. ii. Administer high-flow, 100% oxygen by nonrebreathing mask. c. Ensure adequate ventilation. i. Listen to breath sounds and confirm that bilateral breath sounds are present. ii. If the patient's ventilations are inadequate, provide or assist ventilation with a bag-valve mask and 100% oxygen. d. Assess circulation. i. Control external bleeding. ii. Maintain a high index of suspicion for internal bleeding and shock based on the MOI. iii. Keep the patient warm. e. Transport considerations i. Transport the patient on her left side. ii. If spinal injury is suspected, tilt the backboard 30° to the left. iii. Transport the patient to a trauma center if one is available in your area.

Delivery

1. Your partner should be at the patient's head to comfort, soothe, and reassure her during the delivery. 2. If the patient will allow it, administer oxygen. 3. It is common for patients to become nauseated during delivery, and some may vomit. a. If this occurs, have your partner assist her and clear out her airway. 4. Continually check the patient for crowning. a. Some patients may experience precipitous labor and birth. b. Position yourself so that you can see the perineal area at all times. c. Time the patient's contractions. d. Remind the patient to take quick, short breaths during each contraction but not to strain. e. Between contractions, encourage the patient to rest and breathe deeply through her mouth. 5. Follow the steps in Skill Drill 33-1 to deliver the newborn. 6. Delivering the head a. Observe the head as it begins to exit the vagina so you can provide support as it emerges. b. Place your sterile gloved hand over the emerging bony parts of the head to control the delivery of the head. c. Continue to support the head as it rotates. d. Apply gentle pressure across the perineum with a sterile gauze pad to reduce the risk of perineal tearing. e. Be prepared for the possibility of the patient having a bowel movement because of the increased pressure on the rectum. f. Be careful that you do not poke your fingers into the newborn's eyes or into the fontanelles. 7. Unruptured amniotic sac a. Usually, the amniotic sac will rupture at the beginning of labor or during contractions. b. If it has not ruptured by the time the fetal head is crowning, it will appear as a fluid-filled sac emerging from the vagina. c. The sac will suffocate the fetus if it is not removed. d. You may puncture the sac with a clamp or tear it by twisting it between your fingers. e. Make sure that the puncture site is away from the fetus's face and only perform this procedure as the head is crowning. f. Clear the newborn's mouth and nose, using the bulb syringe if required by your protocols, and wipe the mouth and nose with gauze. g. If the amniotic fluid is greenish, notify the receiving hospital. 8. Umbilical cord around the neck a. As soon as the head is delivered, use one finger to feel whether the umbilical cord is wrapped around the neck. b. This commonly is called a nuchal cord. c. A nuchal cord that is wound tightly around the neck could strangle the fetus. d. Usually, you can slip the cord gently over the delivered head. e. If not, you must cut it. f. Once the cord is cut, you must attempt to speed the delivery by encouraging the woman to push harder and possibly more often because the fetus will now have no oxygen supply until it is delivered and breathing spontaneously. 9. Delivering the body a. Once the head has been delivered, it usually rotates to one side or the other. b. This rotation places the body in a better position for delivery. c. The head is the largest part of the fetus. i. Once it is born, the body usually delivers easily. d. Support the head and upper body as the shoulders deliver. e. Do not pull the fetus from the birth canal. f. The newborn will be slippery and covered with a white, cheesy substance, called vernix caseosa.

Assessment measures / resuscitation efforts

A. Position the newborn on his or her back with the head down and the neck slightly extended. i. Place a towel or blanket under the shoulders to help maintain the position. B. If necessary, suction the mouth and then the nose using a bulb syringe or suction device with an 8- or 10-French catheter. i. Suction both sides of the back of the mouth, but avoid deep suctioning of the mouth and throat. ii. Aim blow-by oxygen at the newborn's mouth and nose during resuscitation. C. In addition to drying the newborn's head, back, and body vigorously with dry towels, you may rub the newborn's back and flick or slap the soles of his or her feet. --> Additional resuscitation efforts 1. Observe the newborn for spontaneous respirations, skin color, and movement of the extremities. 2. Evaluate the heart rate by palpating the pulse at the base of the umbilical cord or at the brachial artery or listening to the newborn's chest with a stethoscope. a. The heart rate is the most important measure in determining the need for further resuscitation. 3. If chest compressions are required, use the hand-encircling technique for two-person resuscitation. a. Perform BVM ventilation during a pause after every third compression, using a compression-to-ventilation ration of 3:1. b. This will yield a total of 120 "actions" per minute (90 compressions and 30 ventilations). 4. Any newborn who requires more than routine resuscitation requires transport to a hospital with a Level III neonatal intensive care unit. 5. About 12% to 16% of deliveries are complicated by the presence of meconium. a. If you see meconium in the amniotic fluid or meconium staining and the newborn is not breathing adequately, consider quickly suctioning the newborn's mouth then nose after delivery before providing rescue ventilations.

Preparing for the delivery

A. Preparing for delivery -------------------------------------------- 1. Consider delivery at the scene when: a. Delivery is imminent (will occur within a few minutes) b. A natural disaster, inclement weather, or other environmental factor makes it impossible to reach the hospital --- 2. To determine if delivery is imminent, ask the patient the following questions: a. How long have you been pregnant? b. When are you due? c. Is this your first pregnancy? d. Are you having contractions? i. How far apart are they? ii. How long do they last? e. Have you had any spotting or bleeding? f. Has your water broken? g. Do you feel as though you need to have a bowel movement? h. Do you feel the need to push? --- 3. To help determine potential complications, ask these questions: a. Were any of your previous deliveries by cesarean section? b. Have you had problems in this or any previous pregnancies? c. Do you use drugs, drink alcohol, or take any medications? d. Do you know if there is a chance you will have multiple deliveries? e. Does your physician expect any complications? --- 4. If the patient says that she is about to deliver, says she has to move her bowels, or feels the need to push, you should immediately prepare for delivery. a. Otherwise, does she have an extremely firm abdomen? b. Visually inspect the vagina to check for crowning. c. Do not touch the vaginal area until you have determined that delivery is imminent. --- 5. Once labor has begun, it cannot be slowed or stopped. a. Never attempt to hold the patient's legs together. b. Do not let her go to the bathroom. c. Instead, reassure her that the sensation of needing to move her bowels is normal and that it means she is about to deliver. --- 6. If your decision is to deliver at the scene, remember that you are only assisting the woman with the delivery. a. Your part is to help, guide, and support the baby as it is born. b. You want to appear calm and reassuring while protecting the woman's modesty. c. Recognize when the situation is beyond your level of training. d. If there is any doubt, contact medical control for a decision to deliver on the scene or to transport. --- 8. Patient position a. The patient's clothing should be removed or pushed up to her waist, and pants and undergarments should be removed. b. Remember to preserve the patient's privacy as much as possible. c. Place the patient on a firm surface that is padded with blankets, folded sheets, or towels. d. Elevate the hips about 2" to 4" with a pillow or blankets. e. Support the head, neck, and upper back with pillows and blankets. f. Have her keep her legs and hips flexed, with her feet flat on the surface beneath her and her knees spread apart. g. Communicate with your crew and plan who will be responsible for caring for the mother and newborn after delivery. h. If the emergency delivery is occurring at home, you should move the patient to a sturdy, flat surface or the floor if she will allow it. i. Track the progression of the delivery closely at all times. --- 9. Preparing the delivery field a. Put on a protective face shield and gown. As time allows, place towels or sheets on the floor around the delivery area to help soak up body fluids and to protect the woman and the newborn. b. Open the OB kit carefully so that its contents remain sterile. c. Put on the sterile gloves. After this, handle only sterile materials. d. Use the sterile sheets and drapes from the OB kit to make a sterile delivery field. i. Place one drape under the patient's buttocks, and unfold it toward her feet. ii. Wrap another drape behind the patient's back and drape over each thigh. Drape another sheet across her abdomen.

Teen Pregnancy

A. The United States has one of the highest teenage pregnancy rates among developed countries. 1. It is likely that, during your career, you will respond to a pregnant teenager who may or may not be in labor. B. Pregnant teenagers may not know they are pregnant or may be in denial about it. 1. As you begin to assess all female teenagers, remember that pregnancy is a possibility. 2. Respect the teenager's privacy and need for independence. a. If possible, perform your assessment and obtain the history away from the teenager's parents. b. Become familiar with the laws in your state so that you will know when pregnant teenagers can give or refuse consent for themselves.

Special Considerations for Trauma and Pregnancy

A. With a trauma call involving a pregnant woman, you have two patients to consider—the woman and the unborn fetus. 1. Trauma to a pregnant woman may have a direct effect on the condition of the fetus. 2. Pregnant women may be victims of many types of trauma, including: a. Assaults b. Motor vehicle crashes c. Shootings B. Pregnant women also have an increased risk of falling compared with nonpregnant women. 1. Hormonal changes loosen the joints in the musculoskeletal system. 2. The increased weight of the uterus and displacement of abdominal organs can affect the woman's balance. C. Pregnant women have an increased amount of overall total blood volume and an approximate 20% increase in their heart rate by the third trimester. 1. A pregnant trauma patient may experience a significant amount of blood loss before you detect signs of shock. 2. The fetus also may be in trouble well before signs of shock are present. 3. The body of a woman who has sustained serious trauma often reduces the blood supply to the fetus. D. Be alert to additional concerns and ready to assess and manage unique types of injuries when responding to a pregnant trauma patient. 1. The uterus is especially vulnerable to penetrating trauma and blunt injuries. 2. A trauma injury to the pregnant uterus can be life threatening to the woman and fetus because the uterus has a rich blood supply. 3. In most cases, the only chance to save the fetus is to adequately resuscitate the woman.

Normal Changes in Pregnancy

During pregnancy, many normal changes occur in the body that are not all directly related to the reproductive system. -------------------------------------------- The primary systems involved with these changes are the respiratory, cardiovascular, and musculoskeletal systems. -------------------------------------------- hormone levels increase to support fetal development and prepare the body for childbirth. 1. This puts pregnant woman at an increased risk for complications from trauma, bleeding, and some medical conditions. 2. As the fetus develops and grows, the uterus also grows, stretching to accommodate a full-term fetus. 3. As the size of the uterus increases, so does the amount of fluid it contains. a. Uterus is displaced out of its normally well-protected position within the pelvic area. b. This increases the chance of direct fetal injury in trauma. C. Rapid uterine growth occurs during the second trimester of pregnancy. 1. As the uterus grows, it pushes up on the diaphragm, displacing it from its normal position. 2. Respiratory capacity changes, with increased respiratory rates and decreased minute volumes. -------------------------------------------- C. Rapid uterine growth occurs during the second trimester of pregnancy. 1. As the uterus grows, it pushes up on the diaphragm, displacing it from its normal position. 2. Respiratory capacity changes, with increased respiratory rates and decreased minute volumes. -------------------------------------------- 3. Overall blood volume gradually increases throughout the pregnancy to: a. Allow for adequate perfusion of the uterus b. Prepare for the blood loss that will occur during childbirth 4. Blood volume may eventually increase as much as 50% by the end of the pregnancy. 5. The number of red blood cells also increases. 6. The speed of clotting increases to protect against excessive bleeding during delivery. 7. By the end of pregnancy, the pregnant patient's heart rate increases up to 20% to accommodate the increase in blood volume. 8. Cardiac output is significantly increased. -------------------------------------------- F. Weight gain during pregnancy is normal. 1. The increase in body weight will eventually challenge the heart and impact the musculoskeletal system. 2. Increased hormones affect the musculoskeletal system by making the joints "looser" or less stable. 3. In the third trimester, changes in the body's center of gravity increase the risk of slips and falls.

Steps for assessing a newborn with the Apgar Score

Follow these steps in assessing a newborn: a. Quickly calculate the Apgar score to establish a baseline of the newborn's status. b. Stimulation should result in an immediate increase in respiration rate. i. If not, you must begin ventilations with a BVM. c. If the newborn is breathing well, you should next check the pulse rate by feeling the brachial pulse or the pulsations at the base of the umbilical cord or auscultating the chest with a stethoscope. i. The pulse rate should be at least 100 beats/min. ii. If it is not, begin ventilations with a BVM. iii. Reassess respirations and heart rate at least every 30 seconds. d. Assess the newborn's oxygenation via pulse oximetry and observe for central cyanosis. i. If present, administer blow-by oxygen by holding oxygen tubing at high-flow close to the newborn newborn's face. ii. Set oxygen flow rate to 5 L/min. e. You should request a second unit as soon as possible if you determine that the newborn is in any distress and will require resuscitation. 5. In situations where assisted ventilation is required, you should use a newborn BVM. a. Make sure you have a good mask-to-face seal. b. Using gentle pressure, make the chest rise with each ventilation. 6. If the newborn does not begin breathing on his or her own or does not have an adequate heart rate, continue CPR and rapidly transport. a. Once CPR has been started, do not stop until the newborn responds or is pronounced dead by a physician.

Bleeding in pregnancy

Internal bleeding may be a sign of an ectopic pregnancy, when an embryo develops outside the uterus, most often in a fallopian tube. -------------------------------------------- a. 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. c. Consider the possibility of an ectopic pregnancy in a woman who has missed a menstrual cycle and complains of sudden, severe, usually unilateral pain in the lower abdomen. -------------------------------------------- 2. Hemorrhage from the vagina that occurs before labor begins may be very serious; call for ALS backup. a. In early pregnancy, it may be a sign of a spontaneous abortion, or miscarriage. b. In the later stages of pregnancy, vaginal hemorrhage may indicate a serious condition involving the placenta. i. In abruptio placenta, the placenta separates prematurely from the wall of the uterus, most commonly caused by hypertension or trauma. (a) Patient often reports severe pain but vaginal bleeding may not be heavy ii. In placenta previa, the placenta develops over and covers the cervix. (a) Patient may experience heavy vaginal bleeding without significant pain 3. Decreasing the patient's anxiety during these situations can impact how she and the fetus may respond during the emergency.

Baby Delivery

Most deliveries occur in a hospital, with doctors and nurses in attendance. ----------------------------------- ---> Occasionally, the birth process moves faster than the pregnant woman expects or she is unable to get to a hospital. C. You must then decide whether to: 1. Assist the delivery on scene. 2. Transport the patient to the hospital

limb presentation.

On rare occasions, the presenting part of the fetus is neither the head nor the buttocks, but a single arm, leg, or foot. ================================= 2. An infant with a limb presentation cannot be successfully delivered in the field. a. Usually surgery is needed. b. You must transport the patient to the hospital immediately. c. If a limb is protruding, cover it with a sterile towel. d. Never try to push it back in, and never pull on it. e. Place the patient on her back, with her head down and pelvis elevated. f. Remember to give the woman high-flow oxygen.

Abortion- Medical

Passage of the fetus and placenta before 20 weeks is called abortion. --> Abortions may be spontaneous (miscarriage) or induced. --> Deliberate abortions may be self-induced, or planned and performed in a hospital or clinic. -------------------------------------------- 4. The most serious complications are bleeding and infection. a. Bleeding can result from portions of the fetus or placenta being left in the uterus (incomplete abortion) or from injury to the wall of the uterus. b. Infection can result from such perforation and from the use of non sterile instruments. 5. If the woman is in shock, treat and transport her promptly to the hospital. a. Never try to pull tissue out of the vagina. b. Place a sterile pad on the vagina.

Abuse / DV

Pregnant women have an increased chance of being victims of domestic violence and abuse. 2. Abuse during pregnancy increases the chance of spontaneous abortion, premature delivery, and low birth weight. -------------------------------------------- 1. Pregnant women have an increased chance of being victims of domestic violence and abuse. 2. Abuse during pregnancy increases the chance of spontaneous abortion, premature delivery, and low birth weight. ------------------------------------------- The woman is at risk from bleeding, infection, and uterine rupture. 4. Use a calm, professional approach. a. Pay attention to the environment for any signs of abuse. b. Your attention to detail will be helpful in your documentation. 5. Pregnant patients who are abused are often scared and may not be honest as to how their injuries may have occurred. a. Talk to the patient in a private area, away from the potential abuser if possible. b. The best way for you to care for the fetus is to treat the pregnant woman.

First Stage of Pregnancy - (1) dilation of the cervix

The first stage begins with the onset of contractions and ends when the cervix is fully dilated. -------------------------------------------- 1. The first stage is usually the longest, lasting an average of 16 hours for a first delivery. 2. The onset of labor starts with contractions of the uterus. a. Other signs of the beginning of labor are the bloody show and the rupture of the amniotic sac. b. The frequency and intensity of contractions in true labor increase with time. c. The uterine contractions become more regular and last about 30 to 60 seconds each. 3. Labor is generally longer in a primigravida (a woman experiencing her first pregnancy) than in a multigravida (a woman who has experienced previous pregnancies). 4. A woman may experience preterm or false labor, or Braxton-Hicks contractions. a. You should provide transport for the patient. b. If true labor is occurring, you may need to prepare for a delivery. 5. Some women experience a premature rupture of the membranes, in which the amniotic sac ruptures too early and the fetus is not developed or ready to be born. a. The patient may or may not go into labor. b. You will need to provide supportive care and transport to the hospital. 6. Toward the end of the third trimester, the head of the fetus normally descends into the woman's pelvis as the fetus positions for delivery. a. This movement down into the pelvis and the sensation that may accompany the descent is called lightening.

UN-Ruptured Amniotic Sac

The sac will suffocate the fetus if it is not removed. --> You may puncture the sac with a clamp or tear it by twisting it between your fingers. --> Make sure that the puncture site is away from the fetus's face and only perform this procedure as the head is crowning.

Second Stage of Pregnancy - (2) delivery of the fetus

The second stage of labor begins when the fetus begins to encounter the birth canal and ends with delivery of the newborn (spontaneous birth). 1. During this stage, you will have to make a decision about helping the woman to deliver at the scene or providing transport to the hospital. 2. Uterine contractions are usually closer together and last longer. 3. Under no circumstances should you let the woman sit on the toilet. 4. The perineum will begin to bulge significantly, and the top of the fetus's head should begin to appear at the vaginal opening. a. This is called crowning.

Third stage of pregnancy - (3) delivery of the placenta.

The third stage of labor begins with the birth of the newborn and ends with the delivery of the placenta. 1. During this stage, the placenta must completely separate from the uterine wall. 2. This may take up to 30 minutes.

Stages of Labor

The three stages of labor are... (1) dilation of the cervix (2) delivery of the fetus (3) delivery of the placenta.

MVA and Pregnancy

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. 1. Trauma is one of the leading causes of abruptio placenta. --> You should suspect abruptio placenta when the MOI is blunt trauma to the abdomen and the patient's signs and symptoms are suggestive of shock. 3. Common symptoms include vaginal bleeding and severe abdominal pain. a. Quickly assess and transport the patient. b. Support the airway. c. Administer high-flow oxygen. d. Place sanitary pads on the vagina. e. Position the patient on her left side. f. 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. a. Carefully assess a pregnant woman's abdomen and chest for seatbelt marks, bruising, and obvious trauma.

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. a. When it protrudes outside the body, it is seen on a newborn's back and usually occurs in the lower third of the back in the lumbar area. b. Cover the open area of the spinal cord with a sterile, moist dressing immediately after birth to help prevent a potentially fatal infection. c. Maintenance of the newborn's body temperature is important when applying moist dressings because the moisture can lower the newborn's body temperature. i. Have someone hold the newborn against his or her body.

The Placenta

a disk-shaped structure attached to the uterine wall that provides nourishment to the fetus. 1. It is connected to the fetus by the umbilical cord. 2. The placental barrier consists of two layers of cells, keeping the circulation of the woman and fetus separated but allowing substances to pass between them

uterus

a muscular organ that encloses and protects the developing fetus for approximately 9 months (40 weeks). 1. The uterus produces contractions during labor and ultimately helps to push the fetus through the birth canal. ----------------------------------- The birth canal is made up of the vagina and the lower third of the uterus, called the cervix. --> a. During pregnancy, the cervix contains a mucous plug that seals the uterine opening, preventing contamination. --> b. When the cervix begins to dilate, this plug is discharged into the vagina as pink-tinged mucus or bloody show. --> c. This small amount of bloody discharge often signals the beginning of labor.

In the third trimester,

there is an increased risk of vomiting and potential aspiration following trauma because of changes that occur in the gastrointestinal tract. -------------------------------------------- 1. Changes in gastrointestinal motility and the displacement of the stomach upward significantly increase the chance that a pregnant trauma patient will vomit and aspirate if you are unable to clear her airway. -------------------------------------------- E. Changes in the cardiovascular system and the increased demands of supporting the fetus significantly increase the workload of the heart. 1. Remember, not all women are healthy when they begin pregnancy. 2. Cardiac compromise is a life-threatening possibility. -------------------------------------------- Weight gain during pregnancy is normal. ---> In the third trimester, changes in the body's center of gravity increase the risk of slips and falls.

Prolapse of the umbilical cord

where the umbilical cord comes out of the vagina before the fetus, must be treated in the hospital. ================================= The fetus's head will compress the cord during birth and cut off circulation to the fetus, depriving it of oxygenated blood. b. Do not attempt to push the cord back into the vagina. c. There is usually time to get the patient to the hospital. d. Your job is to try to keep the fetus's head from compressing the cord. e. Place the pregnant woman supine with the foot of the cot raised 6 to 12 inches higher than the head, with her hips elevated on a pillow or folded sheet. i. Alternatively, the woman may be placed in the knee-chest position; kneeling and bent forward, facedown. ii. Either of these positions will help keep the weight of the fetus off the prolapsed cord. f. Carefully insert your sterile gloved hand into the vagina, and gently push the fetus's head away from the umbilical cord. g. Wrap a sterile towel, moistened with saline, around the exposed cord. h. Give the patient high-flow oxygen and transport rapidly.