Understanding Obstetrics and Neonatal Care

Hello and welcome to Chapter 35, Obstetrics and Neonatal Care of the Emergency Care and Transportation of the Sick and Injured 12th Edition. If you complete this chapter and the related coursework, you will understand the anatomy and physiology of the female reproductive system as it relates to pregnancy. You will learn the assessment and emergency treatment for childbirth, including stages of labor, normal delivery, complications of pregnancy. and neonatal evaluations and resuscitation. Okay, so let's get started. Most child births in the United States occur in a healthcare setting with trained medical personnel in attendance. Occasionally, the pregnant woman is unable to get to the hospital. You must decide whether to assist the delivery on scene or to transport the patient to the hospital. The ovaries are two glands. one on each side of the uterus, that are similar in function to the male testes. So each ovary contains thousands of follicles, and each follicle contains an egg. Ovulation occurs approximately two weeks prior to menstruation. If fertilized, the egg implants in the endometrium, which is the lining inside of the uterus. If the egg is not fertilized within three weeks, 36 to 48 hours after it is released. It will die and the lining is shed as menstrual flow. And this occurs around the 28th day of the woman's cycle. The fallopian tubes extend out laterally from the uterus with one tube associated with each ovary. Fertilization usually occurs when the egg is inside the fallopian tube. 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. The uterus is a muscular organ that encloses and protects the fetus. The uterus produces contractions during the 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 is called the cervix. The figure on this slide shows the anatomic structures of a pregnant woman. Okay, so the vagina is the outermost cavity of the female reproductive system and forms the lower part of the birth canal. It completes the passageway from the uterus to the outside world for the newborn. The perineum is the area between the vagina and the anus. In a pregnant woman, the breast milk... that is produced is carried through small ducts to the nipple to provide nourishment to the newborn once it is born. The placenta is a disc-shaped structure attached to the uterine wall that provides nourishment to the fetus, keeps the circulation of the woman and fetus separate, but allows substances to pass between them. Anything ingested by the pregnant woman has the potential to affect the fetus. The umbilical cord connects the woman and fetus through the placenta. The umbilical vein carries oxygenated blood from the placenta to the heart of the fetus. And the umbilical artery carries deoxygenated blood from the heart of the fetus to the placenta. The umbilical cord is the lifeline of the fetus. It connects the woman and the fetus through the placenta. And once again, The umbilical vein is oxygenated and the umbilical artery is deoxygenated. The fetus develops inside the fluid-filled bag-like membrane that is called the amniotic sac. The sac contains about 500 to 1,000 milliliters of amniotic fluid, which helps isolate and protects the floating fetus. The amniotic fluid is released in a gush when the sac ruptures, usually at the beginning of labor. So let's talk about some changes during pregnancy. Okay, so there are some normal changes in pregnancy. And during pregnancy, the four body systems undergo major changes, okay? So the four major systems that undergo changes are the respiratory, cardiovascular, and the muscular skeletal systems. In the reproductive system, hormone levels increase to support fetal development and prepare the body for pregnancy. childbirth. This puts pregnant women at an increased risk for complications from trauma, bleeding, and other medical conditions. The uterus is displaced out of its normally well-protected position within the pelvic area, and this increases the chance of direct fetal injury and trauma. Rapid uterine growth occurs during the second trimester of pregnancy. As the uterus grows, it pushes up on the diaphragm, and this displaces it from the normal position. Respiratory capacity changes with increased respiratory rates and decreased minute. volumes and then there's overall blood volume which gradually increases throughout the pregnancy and this allows for adequate perfusion for the uterus it prepares for the blood loss that will occur during childbirth so blood volume may eventually increase as much as 50% by the end of pregnancy the number of red blood cells also increase and the speed of clotting increases to protect against excessive bleeding during pregnancy. By the end of the pregnancy, the pregnant patient's heart rate will increase up to 20% to accommodate for the increased blood volume and cardiac output is significantly increased. The pregnant woman are at an increased risk for gastroesophageal reflex, nausea, vomiting, and potential aspiration because the changes that occur with the GI tract. And then there's weight gain. During pregnancy, this is normal. The increase in the body weight will eventually challenge the heart and impact the muscular skeletal system. Certain hormones affect the muscular skeletal system by making the joints looser or less stable. In the third trimester, the body changes the center of gravity and they're at an increased risk of slips and falls. So let's talk about some complications in pregnancy. Most women, pregnant women, are healthy, but some may be ill when they conceive or become pregnant. So you may safely use oxygen to treat any heart or lung disease in a pregnant patient without harm to the fetus. So diabetes. Diabetes develops during the second half of pregnancy in many women who have not had diabetes previously. This is called gestational diabetes, and it resolves in most women after delivery. The treatment is the same as for any other patient with diabetes. Then there's hypertensive disorders. So gestational hypertension is the presence of high blood pressure. in the absence of systemic effects. Defined as a systolic blood pressure higher than 140 and a diastolic pressure higher than 90. It's considered severe when the systolic pressure is higher than 160 and the diastolic is higher than 110. Preeclampsia or pregnancy-induced hypertension can develop after the 20th week of gestation. It's characterized by the following signs and symptoms. You could have a severe hypertension, severe persistent headache, visual abnormalities such as seeing spots, blurred vision or sensitivity to light, swelling in the hands and feet, upper abdominal or gastric pain, dyspnea or retrosternal chest pain, anxiety or altered mental status. Eclampsia is characterized by seizures that occur as a result of the hypertension. To treat seizures, lay the patient on her side, maintain her airway, administer supplemental oxygen, if vomiting occurs, suction the airway, provide rapid transport, and call for advanced life support early if available. Transporting the patient on their left side can also prevent a thing called supine hypotensive syndrome. And this is caused by compression of the descending aorta and the inferior vena cava by the pregnant uterus when the patient lies supine. Okay, so now let's talk about bleeding. So internal bleeding may be the sign of an atopic pregnancy when an embryo develops outside the uterus, most often in the fallopian tube. Sudden onset of severe abdominal pain and vaginal bleeding in the first trimester of pregnancy should be considered an atopic pregnancy until proven otherwise. Consider the possibility of an atopic pregnancy in a woman who has missed a menstrual cycle and complain of sudden severe, usually unilateral pain in the lower abdomen. Okay, so then a hemorrhage from the vagina that occurs before labor begins may be very serious. In early pregnancy, it may be a sign of a spontaneous abortion or miscarriage. In later stages of pregnancy, it may indicate two separate things. The first is abrupto placenta. Abrupto placenta is when the placenta separates prematurely from the wall of the uterus. And this is most... commonly caused by hypertension or trauma. Okay, and then there's placenta previa, and this is when the placenta develops over or covers the uterus. Any bleeding from the vagina in a pregnant woman is a serious sign and should be treated promptly in a hospital. What you want to do is treat for shock if the signs are present. Place a sterile pad or sanitary pad over the vagina and replace it as necessary. Do not put anything into the vagina to control bleeding. The figure on this slide shows the abrupta placenta and the placenta previa. Next, we're going to talk about abortion. So a spontaneous abortion is the loss of a pregnancy prior to 20 weeks of gestation without any preceding surgical or medical intervention. The term is often used interchangeably with a miscarriage. an induced abortion is the elective termination of the pregnancy prior to the time of viability the most serious complications are bleeding and infection if a woman is in shock treat and transport her promptly to the hospital bring any tissue that passes through the vagina to the hospital and never pull any out of the vagina then there is abuse so pregnant women have an increased chance of being victims of domestic violence and abuse abuse during pregnancy increases the chance of spontaneous abortion premature delivery and low birth weight the woman is at risk for bleeding infection and uterine rupture so pay attention to the environment for any signs of abuse pregnant patients who are abused are often scarred and scared and may not be honest as to how their injuries have occurred. So talk to the patient in a private area away from the potential abuser if possible. And then there's substance abuse. The effects of any addiction on the fetus includes low birth weight, prematurity, severe respiratory distress, or death. And then there's fetal alcohol syndrome. This describes the condition of infants born to women who have abused alcohol. If you are called to handle a delivery of an addicted woman, pay special attention to your own safety. Clues that you're dealing with an addictive patient may include the presence of drug paraphernalia, empty wine or liquor bottles, statements made by the family or bystanders or by the patient themselves. The newborn will probably need immediate... resuscitation. Okay, so let's talk about special considerations for trauma and pregnancy. With a trauma call involving a pregnant woman, you have two patients to consider. You have the woman and the unborn fetus. The pregnant woman also have an increased risk of falling compared to non-pregnant woman. hormonal changes also loosens the joints in the muscular skeletal system and the increased weight of the uterus and displacement of abdominal organs can affect the woman's balance as well pregnant women have an increased amount of overall total blood volume and an approximate 20% increase in their heart rate by the third trimester of pregnant trauma patient may experience a significant amount of blood loss before you detect signs of shock. The fetus also may be in trouble well before signs of shock are present. So be alert to additional concerns and ready to assess and manage unique types of injuries when responding to a pregnant trauma patient. The uterus is usually vulnerable to penetrating trauma and blood injuries. A trauma injury to the pregnant uterus can be life-threatening to a woman and fetus because the uterus has a rich blood supply. In most cases, the only chance to save the fetus is to adequately resuscitate the woman. when a pregnant woman is involved in a motor vehicle crash or a similarly violent mechanism of injury severe hemorrhage may result in injuries to a pregnant uterus trauma is one of the leading causes of abrupt placenta you should suspect abrupt placenta when the mechanism of injury is blunt trauma to the abdomen and the patient's signs and symptoms are suggestive of shock common symptoms include vaginal bleeding and severe abdominal pain. Improper positioning of a seatbelt can result in an injury to a pregnant woman and the fetus if they are involved in a motor vehicle crash. Carefully assess a pregnant woman's abdomen and chest for seatbelt marks, bruising, and obvious trauma. If a pregnant trauma patient goes into cardiac arrest, your focus is the same as with any other patients in cardiac arrest. Perform CPR and provide transport to the hospital according to local protocols. If a woman is in the last month or two of pregnancy, compressions may need to be applied higher on the sternum than usual. Okay, so let's talk about the assessment and management. Your focus is on assessment and management of the woman. suspect shock based on the mechanism of injury and be prepared for vomiting and anticipate the need to manage the airway and protect the patient from aspiring. 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. So maintain an open airway, Be prepared for and anticipate vomiting. Administer high flow oxygen. Ensure adequate ventilation. If the patient's ventilations are inadequate, provide or assist with a bag valve mask device with 100% oxygen. Assess circulation. Control external bleeding. Maintain a high index of suspicion for internal bleeding and shock based on mechanism of injury and transport considers. consideration. So transport the patient on her left side, call for advanced life support early, and transport to a specialty obstetric or trauma center if one is available. Okay, so let's talk about some cultural value considerations. Cultural sensitivity is important when you are assessing and treating a pregnant patient. Women of some cultures may have a value system that will affect the choice of how they care for themselves during pregnancy and also how they planned the child's birth process. Some cultures may not permit a male healthcare provider, especially in the pre-hospital setting, to assess or examine a female patient. So respect these differences and honor the patient's requests. And then there is the teenage pregnancy. So the United States has one of the highest teenage pregnancy rates among developed countries. Pregnant teenagers may not know they are pregnant or may be in denial about it. As you begin to assess all female teenagers, remember that pregnancy is a possibility and respect the teenager's privacy and the need for independence. Okay. So let's start with the patient assessment. Childbirth is seldom an unexpected event, but there are occasions when childbirth becomes an emergency. Let's talk about the scene size up. So of course, you're going to take those standard precautions and then consider calling for additional or specialized resources. Your precautions could be gloves, face protection, and that. eye protection at minimum, and then a gown if time allows. And then of course the mechanism of injury, this is going to be a nature of illness. So you will encounter pregnant patients who are not in labor. So it is important to determine there could be a mechanism of injury. All right, so do not develop tunnel vision during a call. And then there's the primary assessment. So you want to form that general impression. when the patient is in active labor, or whether you have time to assess for immediate or intimate delivery and address other possible life threats. So perform a rapid exam of the patient. And then there's the A and the B. So during an uncomplicated birth, life-threatening conditions involving the woman's airway and breathing are not usually an issue. However, during a motor vehicle crash, an assault, or any number of medical conditions, this may cause a life threat to exist and may result in a complicated delivery. If needed, provide airway management and high flow oxygen. Then there's circulation. So blood loss after delivery is expected. but significant bleeding is not. So quickly assess for any potential life-threatening bleeding and begin treating immediately. If signs and symptoms of shock are present, control the bleeding, give oxygen, and keep the patient warm. And then there's your D and that's that transport decision. So this is completely the exact opposite of a normal load and go situation because if delivery is intimate. you have to prepare to stay there and deliver at scene. So the ideal place to deliver is in the security of your ambulance or the privacy of the woman's home. The area should be warm and private with plenty of room to move around. If delivery is not intimate, prepare the patient for transport and perform the remainder of the assessment and route to the emergency department. Women in the second and third trimesters of pregnancy should be transported laying on their left side when possible. And then we're going to do that rapid transport for pregnant patients who have significant bleeding and pain, are hypertensive, are having a seizure, or are having an altered mental status. And then there's history taking. So obtain a thorough obstetric history, including her expected due date, any complications. If she has been receiving prenatal care or if she expects a complicated delivery, also get the complete medical history of the patient. Obtain a sample history. Also, questions related specifically to the prenatal care are identify any complications the patient may have had during pregnancy or potential complications during. Determine the due date, fetal movement, frequency of contractions, and a history of previous pregnancies and deliveries and their complications. Determine whether there is a possibility of multiple births and whether the woman has taken any drugs or medication. If her water is broken, ask whether the water or the fluid looked greenish. Because green fluid is due to meconium. Meconium is the fecal stool. The presence of meconium can indicate newborn distress, and it is possible for the fetus to aspirate meconium during delivery. And then there's a secondary assessment. Physical examination. So if the patient is in labor, the physical exam should focus on contractions and possible delivery. At any point you suspect that delivery is imminent, you should check for crowning. If you do not suspect it's imminent, and the patient reports other problems related to the delivery, you should not visually inspect the vagina. Then you need to obtain a complete set of vital signs and pulse ox. So be especially alert for tachycardia and hypo or hypertension. Remember, hypertension, even mild, may indicate a more serious problem. And then of course, you're going to do that reassessment. So repeat the primary assessment with a focus on the patient's ABCs and vaginal bleeding, particularly after delivery. Obtain another set of vitals and compare those to the ones obtained earlier, and recheck interventions and treatment to see whether they are effective. Communication and documentation. So, if delivery is intimate, notify the staff at the receiving hospital. You need to provide an update on the status of the woman and the newborn after delivery if it has happened. For pregnant patients with a complaint unrelated to childbirth, be sure to include the pregnancy status of the patient in your radio report. If delivery occurred in the field, you will have two patient care reports to complete. So let's talk about the stages of labor next. And there are three stages of labor. The first is the dilation of the cervix. And then the delivery of the fetus is the second. And then the third stage is delivery of the placenta. The first stage begins when the onset of contractions and ends when the cervix is fully dilated. The first stage is usually the longest. It lasts an average of 16 hours with the first delivery. The onset of labor starts when contractions of the uterus occur. Other signs of the beginning of labor are bloody show and the uterine rupture of the amniotic sac. frequency and intensity of contractions in true labor increase with time. Labor is generally longer in a prima gravita than it is a multigravita. And a woman may experience preterm or false labor when, or it's called Braxton Hicks contractions. And so you The table on this slide shows how to distinguish between true labor or false labor, which is the Braxton-Hicks. 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. The patient may or may not go into labor and you will need to provide supportive care and transport to the hospital. Toward the end of the third trimester, a head of the fetus normally descends into the woman's pelvis as the fetus positions for delivery. This movement down into the pelvis is the sensation that may accompany the descent and it's called lightening. The second stage of labor begins when the fetus begins to encounter the birth canal and ends with the delivery of the newborn. You need to make the decision about helping the woman to deliver at the scene or providing transport to the hospital. Uterine contractions are usually closer together and last longer. The perineum will begin to bulge significantly and the top of the fetus's head should begin to appear at the vaginal opening. This is called crowning. The third stage of labor begins with the birth of the newborn and ends with the delivery of the placenta. During this stage, the placenta must completely separate from the uterine wall. This may take up to 30 minutes. Okay, so a normal delivery management. When you prepare for the delivery, consider delivery at the scene when delivery is imminent, and this will occur within a few minutes if it is. A natural disaster, inclement weather, or other environmental factors makes it impossible to reach the hospital. You're going to need to prepare for delivery. How to determine if delivery is imminent? Ask the patient the following questions. So how long have you been pregnant? When are you due? Is this your first pregnancy? Are you having contractions? If so, how far apart are they and how long do they last? Have you had any spotting or bleeding? Has your water broken? Do you feel as though you need to have a bowel movement? And do you feel the need to push? To help determine potential complications, ask these questions. Were any of your previous deliveries by cesarean section? Have you had problems in this or any previous pregnancies? Do you use drugs or alcohol? alcohol or take any medicine? Do you know if there's a chance you will have multiple deliveries and does your physician expect any complications? 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. Visually inspect the vagina to check for crowding and do not touch the vagina. vaginal area until you have determined the delivery is imminent. Once labor has begun, it cannot be slowed or stopped, so never attempt to hold the patient's legs together. Do not let them go to the restroom and instead reassure her that the sensation of needing to move her bowels is normal and that this means she's about to deliver. If your decision is to deliver on the scene, Remember that you are only assisting the woman with the delivery. Your part is just to help, guide, and support the baby as it's born. Your emergency vehicle should always be equipped with a sterile emergency obstetric or OB kit. And that's an example on the slide. All right, so positioning the patient for that delivery. The patient's clothing should be removed or pushed up to her waist in the pants and undergarments should be removed. Pressure or preserve the patient's privacy as much as possible. Place the patient on a firm surface that is padded with blankets, folded sheets, or towels, and elevate the hips about two to four inches with a pillow or blanket. Support the head, neck, and upper back with pillows and blankets, and have her keep her legs and hips flex, with her feet flat on the surface beneath her and her knees spread apart. So when you prepare for delivering the field, 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 protect the woman and the newborn. Open the OB kit carefully so that its contents remain sterile. And use the sterile sheets and drapes from the OB kit. to make a sterile delivery field. The figure on this slide shows how to prepare the delivery field. Okay, and now let's talk about delivery. So your partner should be at the patient's head to comfort, soothe, and reassure her during the delivery. If the patient will allow it, administer oxygen. It is common for patients to begin to become nauseated during delivery. and some will actually vomit. So continually check the patient for crowning. Some patients may experience pre-captious labor and birth. So position yourself so that you can see the perineal area at all times. Time the patient's contractions. Remind the patient to take Quick short breaths during each contraction but not to strain. Between contractions, encourage the patient to rest and breathe deeply through her mouth. You want to follow the steps in skill drill 34-1 to deliver the newborn. Delivering the head. So observe the head as it begins to exit the vagina so that you can provide support as it emerges. Place your sterile gloved hand over the emerging bony parts of the head to control delivery of the head. Continue to support the head as it rotates. Be careful that you do not poke your fingers into the newborn's eyes or into the fontanelles. Okay, so an unruptured amniotic sac. Usually the amniotic sac will rupture at the beginning of labor or during contractions. 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. The sac will suffocate the fetus if 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 head of the fetus's face and only perform this procedure as the head is crowning. Clear the newborn's mouth and nose using a bulb syringe if required by protocols and wipe the mouth and nose with gauze. So, umbilical cord around the neck. As soon as a head is delivered, use one finger to feel whether the umbilical cord is wrapped around the neck. This is called a nuchal cord. Usually you can slip the cord gently over the delivery head. delivered head. If not, you must cut it. And then let's talk about the delivery. So delivering the body, the head is the largest part of the fetus. Once it's born, the body usually delivers very easily. So support the head and the upper body as the shoulders deliver. Do not pull the fetus from the birth canal. Newborn will be slippery and may be covered with a white. cheesy substance and this is called vernix quesosa Post-delivery care. So if the mother is able and willing, hand the newborn to her and place the newborn on her abdomen so skin-to-skin contact can begin immediately. Dry off the newborn and wrap him or her in a warm blanket or towel and ensure the top of the head is covered. And keep the neck of the newborn in a neutral position. Wipe the newborn's mouth with a sterile gauze and pad as needed and clamp and cut the umbilical cord approximately 60 seconds after birth and then you're gonna obtain that first minute Apgar score. So then there's delivery of the placenta. The placenta delivers itself usually within a few minutes after birth, although it may take as long as 30 minutes. After delivery of the placenta and before transport, place a sterile pad or sanitary napkin over the vagina and straighten the woman's legs. You can help to slow bleeding by gently massaging the woman's abdomen with a firm circular motion, a kneading motion, and one hand cupped over the top of the fundus and the other above the pubic bone. To record the time of birth in your patient care report, The following are emergency situations. So if more than 30 minutes has elapsed and the placenta has not delivered, if there is more than 500 milliliters of bleeding before delivery of the placenta, or if there is a significant bleeding after delivery of the placenta, if one or more of these events occur, transport the woman and the newborn to the hospital promptly. So let's talk about neonatal assessment and resuscitation. The first minute after birth is often referred to as the golden minute. During the first minute of life, perform the following initial steps of the newborn care. Position or airway positioning and suctioning if needed. You want to dry, you want to warm and tactilely stimulate the patient. Normally, the newborn will begin breathing within 30 seconds after breath, and the heart rate will be 100 beats per minute or higher. Many newborns require some form of stimulation that will encourage them to breathe and begin circulating blood through their lungs. So, this could include positioning the airway in the normal or sniffing position. If necessary, suction the mouth and then nose. Then vigorously dry the head, body, and back, rub the newborn's back, and gently flick or slap the soles of his or her feet. And then tactile stimulation. So if signs of good tone and adequate ventilation are not present after performing the initial steps for 30 seconds, then positive pressure ventilations with a mask may be necessary. The table on this slide shows how to perform resuscitation for a newborn who is not breathing. So when you talk about additional resuscitation efforts, you want to observe the newborn for spontaneous respiration, skin color, and movement of the extremities. Evaluate the heart rate by palpating the pulse at the base of the umbilical cord. or the brachial artery, or listening to the newborn's chest with a stethoscope. The heart rate is the most important measure in determining the need for further resuscitation. If chest compressions are required, use the hand circling technique for two-person resuscitation. Perform bag valve mass ventilation during a pause after every third compression. using a compression to ventilation ratio of three to one. Hands-only CPR is not as effective as ventilation with CPR. And so the figure on this slide shows how to give chest compressions to a newborn using that hand encircling technique. If you see meconium in the amniotic fluid or meconium staining on the newborn who is not breathing adequacy, consider quickly suctioning the newborn's mouth, then nose after delivery before providing rescue ventilations. Next, we're going to talk about the APGAR score. So the APGAR score is the standard scoring system used to assess the status of a newborn. It's assigned a number and the values are 0, 1, or 2 to five different areas of activity. So the five different areas are appearance, pulse, grimace or irritability, activity or muscle tone, and then finally respirations. The total of the five numbers is the APGAR score. And so you calculate the APGAR score at one minute and five minutes after birth. So one more time, that's one minute and then four minutes later at the fifth minute after birth. The highest possible APGAR score is a 10. The table on this slide shows how to calculate the APGAR score for a newborn. So, steps for assessing a newborn. You want to quickly calculate the APGAR score to establish a baseline of the newborn's status. Stimulation should result in the immediately increase in respiration rate. If not, you must begin bag valve mass ventilations with a BVM. If the newborn is breathing well, you should check the pulse rate by Feeling the brachial pulse or the sensations at the basic of the umbilical cord or auscultating the chest with a stethoscope. The pulse rate should be at least 100 beats per minute. If not, you need to begin ventilations with a BVM and then reassess respirations and heart rate at least every 30 seconds. Assess the newborn's oxygen via pulse ox, which is best taken at the right wrist and observe for central cyanosis. If present, administer blow-by by holding oxygen tubing at high flow close to the newborn's face. Set oxygen flow rate at 5 liters per minute. You want to request a second unit as soon as possible. If you determine that a newborn is in any distress and will require resuscitation. In situations where assisted ventilation is required, you should use a newborn bag valve mask. Make sure you have a good mask to face seal. Using gentle pressure, make the chest rise with each ventilation. If the newborn does not begin breathing on his or her own or does not have an adequate heart rate, continue CPR and rapidly transport. Once CPR has been started, do not stop until the newborn responds or is pronounced dead by a physician. So let's talk about some complications. The first complication of delivery we're going to talk about is breach delivery. The presentation is the position in which the infant is born or the body part that is delivered first. Most infants are born head first. This is called the vortex presentation. Occasionally, the buttocks are delivered, and this is called a breach presentation. The fetus is at great risk for trauma from the delivery. And then prolapse cords are more common with a breach delivery. Breach deliveries usually take longer. so you will often have time to transport the pregnant woman to the hospital however if the buttocks has already passed through the vagina the delivery has begun preparing for a breech delivery is the same as for normal childbirth allow the buttocks and legs to deliver spontaneously supporting them with your hand to prevent a rapid expulsion let the legs dangle on either side of your arm while you support the trunk and chest as they are delivered. The head is almost always face down and should be allowed to deliver spontaneously. Make a V with your glove finger and position them in the vagina to keep the walls of the vagina from compressing the fetus's airway. Okay, so the next one we're going to talk about is on rare occasions, the present time. The presenting part of the fetus is either, neither the head nor the buttocks, but an arm, okay? Leg or foot, and this is called a limb presentation. An infant with a limb presentation cannot be successfully delivered in the field. You need to transport the patient to the hospital immediately. If a limb is protruding, cover it with a sterile towel. Never try and push it back in and never pull on it. Place the patient on her back with her head down and her pelvis elevated. And then there's the prolapsed. cord, so a prolapse of the umbilical cord, where the umbilical cord comes out of the vagina before the fetus must be treated in the hospital. Do not attempt to push the cord back in. Your job is to try to keep the fetus's head from compressing the cord. So you need to carefully insert your gloved hand into the vagina and gently push the fetus's head away from the umbilical cord. Place the woman supine with the feet, foot of the stretcher raised about 6 to 12 inches higher than her head with her hips elevated on a pillow or folded sheet. Alternatively, the woman may be placed in the kneel to chest position. You can wrap a sterile towel, moistened saline around the exposed cord and give the patient high flow oxygen and transport rapidly. And then there's spina bifida. So spina bifida is a developmental defect in which a portion of the spinal cord or meninges may protrude outside of the vertebrae and possibly outside of the body. Cover the area of the spinal cord with a sterile moist dressing immediately after birth to prevent potential fatal infections. Maintain the newborn's body temperature. And it's important when applying moist dressings because the moisture can lower the newborn's body temperature. And then you could have multiple gestations. So twins occur once every 30 births. Twins are usually smaller than single fetuses. And a delivery is typically not difficult. About 10 minutes after the first birth, contractions will begin. again and the birth process will repeat itself. The procedure for delivering twins is the same as that for a single fetus. However, you will need some supplies from additional OB kits. Clamp and cut the cord of the first newborn as soon as it is born and before the second delivery has happened. Record the time of the birth of each twin separately. Twins may also be so small that they look premature. And then the next thing we're going to talk about is premature births. Okay, so any newborn that delivers before eight months, and that's 36 weeks, or weighs less than five pounds at birth is considered premature. A premature newborn is smaller and thinner than a full-term newborn, and the head is a proportionate. proportionately larger in comparison to the rest of the body. Okay, so the vernix casuosa will be absent or minimal on a premature newborn, and there will also be less body hair. Premature newborns require special care to survive. They often require resuscitation efforts, which should be performed unless it is physically impossible. With such care, premature newborns as small as one pound have survived and developed normally. And then there's post-term pregnancy. And so post-term pregnancy refers to pregnancies lasting longer than 41 weeks. Post-term fetuses can be larger than a typical 40-week fetus and sometimes weighing 10 pounds or more. The larger size can lead to problems with the woman and the fetus, and it could be a more difficult labor and delivery. It could have an increased chance of injury to the fetus, increased likelihood of a c-section being required. The woman is at an increased risk for perineal tears and infection. Post-term newborns have increased risk of meconium aspiration infections and being stillborn. Newborns may not have been able to develop normally because of the restricted size of the feet of the uterus and be prepared to resuscitate the newborn. as respiratory and neurologic functions may have been affected. And next we're going to talk about fetal demise. So the onset of labor may be premature, but labor will otherwise progress normally in most cases. If an inner uterine infection has caused the demise, you may note an extremely foul odor. The delivered fetus may have skin blisters, slothing, and a dark, discoloration. The head will be soft and perhaps grossly formed. Do not attempt to resuscitate an obviously dead neonate. Then there's postpartum complications. So if bleeding exceeds approximately 100 milliliters, consider this excessive. If bleeding continues after delivery of the placenta, you should continue to massage the uterus. Treat signs and symptoms of shock. An excessive bleeding after birth is usually caused by muscles of the uterus not fully contracting and is potentially life-threatening. So cover the vagina with a sterile pad, changing the pad as often as possible. Consider oxygen if necessary, monitor the vital signs frequently, and transport the patient immediately to the hospital. Never hold the woman's legs together or pack anything into the vagina. and in an attempt to control the bleeding. Postpartum patients are also at an increased risk of a venous emboli, most commonly a pulmonary embolus. The pulmonary embolism results from a clot that travels through the bloodstream and becomes lodged in the pulmonary circulation, blocking blood flow to the lungs. It is potentially life-threatening. This obstruction will block the flow to the lungs if you deliver a newborn in the field and the woman begins to report a sudden difficulty breathing or shortness of breath consider a pulmonary embolism as a possibility also suspect a pulmonary embolism in patients of childbearing age with respiratory complaints who have recently delivered especially with a sudden onset of difficulty breathing, or altered mental status. Okay, so that ends the lecture part of chapter 34, obstetrics and neonatal care. Now we're just going to go through the review questions to see what we've learned. All right, so the first stage of labor ends when? And when do we know that the first stage, it ends when? The presenting part of the baby is visible. All right. So a 23-year-old woman who is 24 weeks pregnant with her first baby complains of edema in her hands, a headache, and visual disturbances. Oh, and look at her blood pressure. What do we think that she's having? And I'm going to say preeclampsia. Yep. Because eclampsia is when they are having the actual seizure from the high blood pressure. You're transporting a woman who's eight months pregnant to prevent supine hypotensive syndrome. How should we do it? And we're supposed to do it always on the left side. Immediately after delivery, if of the new infant's head, you should. And what should we do? We're going to check the position of that umbilical cord. cord. So the very first thing we want to do is see if there's a nuchal cord around the neck. Upon delivery of the head, you should note the umbilical cord is wrapped around the neck. What should you do? What should we do? I think we're going to make one attempt to gently kind of get it off, right? Slide it back over. The need for an extent of newborn resuscitation is based on what? And we know that it's going to be based on the respiratory effort, heart rate, and color. The one-minute APGAR score of a newborn reveals that the baby has a heart rate of 90. Oh, that's below 100, so that's a 1. The body is the pink body, but blue hands, and that's a 1. But has rapid respirations. Okay, so that is a 2. And then flicked. and resists attempts to straighten legs, two and two. All right, so I think that's an eight. Yep, an eight. We're just subtracting one for the heart rate and one for the body. All right, the most effective way to prevent cardiopulmonary arrest in a newborn is to, what do we think? Ensure adequate oxygenation and ventilation. When assessing a woman in labor, you realize her vaginal area and you see an arm protruding. She tells you she feels the urge to push. What should we do? All right, so this is a limb presentation, and we're going to cover that limb and transport immediately. All right, the newborn is considered to be term if it's born after how many weeks? We know. that if it's born in the ranges of 37 weeks and before 42 weeks, it's considered term. Okay, so thank you for joining us for the Chapter 34 lecture. We hope you've enjoyed.

and neonatal evaluations and resuscitation. Okay, so let's get started. Most child births in the United States occur in a healthcare setting with trained medical personnel in attendance. Occasionally, the pregnant woman is unable to get to the hospital.

You must decide whether to assist the delivery on scene or to transport the patient to the hospital. The ovaries are two glands. one on each side of the uterus, that are similar in function to the male testes. So each ovary contains thousands of follicles, and each follicle contains an egg.

Ovulation occurs approximately two weeks prior to menstruation. If fertilized, the egg implants in the endometrium, which is the lining inside of the uterus. If the egg is not fertilized within three weeks, 36 to 48 hours after it is released. It will die and the lining is shed as menstrual flow.

And this occurs around the 28th day of the woman's cycle. The fallopian tubes extend out laterally from the uterus with one tube associated with each ovary. Fertilization usually occurs when the egg is inside the fallopian tube.

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. The uterus is a muscular organ that encloses and protects the fetus. The uterus produces contractions during the 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 is called the cervix. The figure on this slide shows the anatomic structures of a pregnant woman. Okay, so the vagina is the outermost cavity of the female reproductive system and forms the lower part of the birth canal.

It completes the passageway from the uterus to the outside world for the newborn. The perineum is the area between the vagina and the anus. In a pregnant woman, the breast milk... that is produced is carried through small ducts to the nipple to provide nourishment to the newborn once it is born. The placenta is a disc-shaped structure attached to the uterine wall that provides nourishment to the fetus, keeps the circulation of the woman and fetus separate, but allows substances to pass between them.

Anything ingested by the pregnant woman has the potential to affect the fetus. The umbilical cord connects the woman and fetus through the placenta. The umbilical vein carries oxygenated blood from the placenta to the heart of the fetus.

And the umbilical artery carries deoxygenated blood from the heart of the fetus to the placenta. The umbilical cord is the lifeline of the fetus. It connects the woman and the fetus through the placenta. And once again, The umbilical vein is oxygenated and the umbilical artery is deoxygenated.

The fetus develops inside the fluid-filled bag-like membrane that is called the amniotic sac. The sac contains about 500 to 1,000 milliliters of amniotic fluid, which helps isolate and protects the floating fetus. The amniotic fluid is released in a gush when the sac ruptures, usually at the beginning of labor.

So let's talk about some changes during pregnancy. Okay, so there are some normal changes in pregnancy. And during pregnancy, the four body systems undergo major changes, okay?

So the four major systems that undergo changes are the respiratory, cardiovascular, and the muscular skeletal systems. In the reproductive system, hormone levels increase to support fetal development and prepare the body for pregnancy. childbirth.

This puts pregnant women at an increased risk for complications from trauma, bleeding, and other medical conditions. The uterus is displaced out of its normally well-protected position within the pelvic area, and this increases the chance of direct fetal injury and trauma. Rapid uterine growth occurs during the second trimester of pregnancy. As the uterus grows, it pushes up on the diaphragm, and this displaces it from the normal position.

Respiratory capacity changes with increased respiratory rates and decreased minute. volumes and then there's overall blood volume which gradually increases throughout the pregnancy and this allows for adequate perfusion for the uterus it prepares for the blood loss that will occur during childbirth so blood volume may eventually increase as much as 50% by the end of pregnancy the number of red blood cells also increase and the speed of clotting increases to protect against excessive bleeding during pregnancy. By the end of the pregnancy, the pregnant patient's heart rate will increase up to 20% to accommodate for the increased blood volume and cardiac output is significantly increased. The pregnant woman are at an increased risk for gastroesophageal reflex, nausea, vomiting, and potential aspiration because the changes that occur with the GI tract. And then there's weight gain.

During pregnancy, this is normal. The increase in the body weight will eventually challenge the heart and impact the muscular skeletal system. Certain hormones affect the muscular skeletal system by making the joints looser or less stable.

In the third trimester, the body changes the center of gravity and they're at an increased risk of slips and falls. So let's talk about some complications in pregnancy. Most women, pregnant women, are healthy, but some may be ill when they conceive or become pregnant.

So you may safely use oxygen to treat any heart or lung disease in a pregnant patient without harm to the fetus. So diabetes. Diabetes develops during the second half of pregnancy in many women who have not had diabetes previously. This is called gestational diabetes, and it resolves in most women after delivery.

The treatment is the same as for any other patient with diabetes. Then there's hypertensive disorders. So gestational hypertension is the presence of high blood pressure. in the absence of systemic effects. Defined as a systolic blood pressure higher than 140 and a diastolic pressure higher than 90. It's considered severe when the systolic pressure is higher than 160 and the diastolic is higher than 110. Preeclampsia or pregnancy-induced hypertension can develop after the 20th week of gestation.

It's characterized by the following signs and symptoms. You could have a severe hypertension, severe persistent headache, visual abnormalities such as seeing spots, blurred vision or sensitivity to light, swelling in the hands and feet, upper abdominal or gastric pain, dyspnea or retrosternal chest pain, anxiety or altered mental status. Eclampsia is characterized by seizures that occur as a result of the hypertension. To treat seizures, lay the patient on her side, maintain her airway, administer supplemental oxygen, if vomiting occurs, suction the airway, provide rapid transport, and call for advanced life support early if available.

Transporting the patient on their left side can also prevent a thing called supine hypotensive syndrome. And this is caused by compression of the descending aorta and the inferior vena cava by the pregnant uterus when the patient lies supine. Okay, so now let's talk about bleeding. So internal bleeding may be the sign of an atopic pregnancy when an embryo develops outside the uterus, most often in the fallopian tube. Sudden onset of severe abdominal pain and vaginal bleeding in the first trimester of pregnancy should be considered an atopic pregnancy until proven otherwise.

Consider the possibility of an atopic pregnancy in a woman who has missed a menstrual cycle and complain of sudden severe, usually unilateral pain in the lower abdomen. Okay, so then a hemorrhage from the vagina that occurs before labor begins may be very serious. In early pregnancy, it may be a sign of a spontaneous abortion or miscarriage.

In later stages of pregnancy, it may indicate two separate things. The first is abrupto placenta. Abrupto placenta is when the placenta separates prematurely from the wall of the uterus. And this is most... commonly caused by hypertension or trauma.

Okay, and then there's placenta previa, and this is when the placenta develops over or covers the uterus. Any bleeding from the vagina in a pregnant woman is a serious sign and should be treated promptly in a hospital. What you want to do is treat for shock if the signs are present. Place a sterile pad or sanitary pad over the vagina and replace it as necessary. Do not put anything into the vagina to control bleeding.

The figure on this slide shows the abrupta placenta and the placenta previa. Next, we're going to talk about abortion. So a spontaneous abortion is the loss of a pregnancy prior to 20 weeks of gestation without any preceding surgical or medical intervention. The term is often used interchangeably with a miscarriage.

an induced abortion is the elective termination of the pregnancy prior to the time of viability the most serious complications are bleeding and infection if a woman is in shock treat and transport her promptly to the hospital bring any tissue that passes through the vagina to the hospital and never pull any out of the vagina then there is abuse so pregnant women have an increased chance of being victims of domestic violence and abuse abuse during pregnancy increases the chance of spontaneous abortion premature delivery and low birth weight the woman is at risk for bleeding infection and uterine rupture so pay attention to the environment for any signs of abuse pregnant patients who are abused are often scarred and scared and may not be honest as to how their injuries have occurred. So talk to the patient in a private area away from the potential abuser if possible. And then there's substance abuse. The effects of any addiction on the fetus includes low birth weight, prematurity, severe respiratory distress, or death. And then there's fetal alcohol syndrome.

This describes the condition of infants born to women who have abused alcohol. If you are called to handle a delivery of an addicted woman, pay special attention to your own safety. Clues that you're dealing with an addictive patient may include the presence of drug paraphernalia, empty wine or liquor bottles, statements made by the family or bystanders or by the patient themselves. The newborn will probably need immediate...

resuscitation. Okay, so let's talk about special considerations for trauma and pregnancy. With a trauma call involving a pregnant woman, you have two patients to consider. You have the woman and the unborn fetus.

The pregnant woman also have an increased risk of falling compared to non-pregnant woman. hormonal changes also loosens the joints in the muscular skeletal system and the increased weight of the uterus and displacement of abdominal organs can affect the woman's balance as well pregnant women have an increased amount of overall total blood volume and an approximate 20% increase in their heart rate by the third trimester of pregnant trauma patient may experience a significant amount of blood loss before you detect signs of shock. The fetus also may be in trouble well before signs of shock are present.

So be alert to additional concerns and ready to assess and manage unique types of injuries when responding to a pregnant trauma patient. The uterus is usually vulnerable to penetrating trauma and blood injuries. A trauma injury to the pregnant uterus can be life-threatening to a woman and fetus because the uterus has a rich blood supply.

In most cases, the only chance to save the fetus is to adequately resuscitate the woman. when a pregnant woman is involved in a motor vehicle crash or a similarly violent mechanism of injury severe hemorrhage may result in injuries to a pregnant uterus trauma is one of the leading causes of abrupt placenta you should suspect abrupt placenta when the mechanism of injury is blunt trauma to the abdomen and the patient's signs and symptoms are suggestive of shock common symptoms include vaginal bleeding and severe abdominal pain. Improper positioning of a seatbelt can result in an injury to a pregnant woman and the fetus if they are involved in a motor vehicle crash. Carefully assess a pregnant woman's abdomen and chest for seatbelt marks, bruising, and obvious trauma.

If a pregnant trauma patient goes into cardiac arrest, your focus is the same as with any other patients in cardiac arrest. Perform CPR and provide transport to the hospital according to local protocols. If a woman is in the last month or two of pregnancy, compressions may need to be applied higher on the sternum than usual. Okay, so let's talk about the assessment and management.

Your focus is on assessment and management of the woman. suspect shock based on the mechanism of injury and be prepared for vomiting and anticipate the need to manage the airway and protect the patient from aspiring. 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.

So maintain an open airway, Be prepared for and anticipate vomiting. Administer high flow oxygen. Ensure adequate ventilation. If the patient's ventilations are inadequate, provide or assist with a bag valve mask device with 100% oxygen.

Assess circulation. Control external bleeding. Maintain a high index of suspicion for internal bleeding and shock based on mechanism of injury and transport considers.

consideration. So transport the patient on her left side, call for advanced life support early, and transport to a specialty obstetric or trauma center if one is available. Okay, so let's talk about some cultural value considerations.

Cultural sensitivity is important when you are assessing and treating a pregnant patient. Women of some cultures may have a value system that will affect the choice of how they care for themselves during pregnancy and also how they planned the child's birth process. Some cultures may not permit a male healthcare provider, especially in the pre-hospital setting, to assess or examine a female patient.

So respect these differences and honor the patient's requests. And then there is the teenage pregnancy. So the United States has one of the highest teenage pregnancy rates among developed countries.

Pregnant teenagers may not know they are pregnant or may be in denial about it. As you begin to assess all female teenagers, remember that pregnancy is a possibility and respect the teenager's privacy and the need for independence. Okay.

So let's start with the patient assessment. Childbirth is seldom an unexpected event, but there are occasions when childbirth becomes an emergency. Let's talk about the scene size up. So of course, you're going to take those standard precautions and then consider calling for additional or specialized resources. Your precautions could be gloves, face protection, and that.

eye protection at minimum, and then a gown if time allows. And then of course the mechanism of injury, this is going to be a nature of illness. So you will encounter pregnant patients who are not in labor. So it is important to determine there could be a mechanism of injury.

All right, so do not develop tunnel vision during a call. And then there's the primary assessment. So you want to form that general impression.

when the patient is in active labor, or whether you have time to assess for immediate or intimate delivery and address other possible life threats. So perform a rapid exam of the patient. And then there's the A and the B. So during an uncomplicated birth, life-threatening conditions involving the woman's airway and breathing are not usually an issue.

However, during a motor vehicle crash, an assault, or any number of medical conditions, this may cause a life threat to exist and may result in a complicated delivery. If needed, provide airway management and high flow oxygen. Then there's circulation. So blood loss after delivery is expected.

but significant bleeding is not. So quickly assess for any potential life-threatening bleeding and begin treating immediately. If signs and symptoms of shock are present, control the bleeding, give oxygen, and keep the patient warm. And then there's your D and that's that transport decision.

So this is completely the exact opposite of a normal load and go situation because if delivery is intimate. you have to prepare to stay there and deliver at scene. So the ideal place to deliver is in the security of your ambulance or the privacy of the woman's home.

The area should be warm and private with plenty of room to move around. If delivery is not intimate, prepare the patient for transport and perform the remainder of the assessment and route to the emergency department. Women in the second and third trimesters of pregnancy should be transported laying on their left side when possible.

And then we're going to do that rapid transport for pregnant patients who have significant bleeding and pain, are hypertensive, are having a seizure, or are having an altered mental status. And then there's history taking. So obtain a thorough obstetric history, including her expected due date, any complications. If she has been receiving prenatal care or if she expects a complicated delivery, also get the complete medical history of the patient.

Obtain a sample history. Also, questions related specifically to the prenatal care are identify any complications the patient may have had during pregnancy or potential complications during. Determine the due date, fetal movement, frequency of contractions, and a history of previous pregnancies and deliveries and their complications. Determine whether there is a possibility of multiple births and whether the woman has taken any drugs or medication.

If her water is broken, ask whether the water or the fluid looked greenish. Because green fluid is due to meconium. Meconium is the fecal stool.

The presence of meconium can indicate newborn distress, and it is possible for the fetus to aspirate meconium during delivery. And then there's a secondary assessment. Physical examination. So if the patient is in labor, the physical exam should focus on contractions and possible delivery.

At any point you suspect that delivery is imminent, you should check for crowning. If you do not suspect it's imminent, and the patient reports other problems related to the delivery, you should not visually inspect the vagina. Then you need to obtain a complete set of vital signs and pulse ox.

So be especially alert for tachycardia and hypo or hypertension. Remember, hypertension, even mild, may indicate a more serious problem. And then of course, you're going to do that reassessment. So repeat the primary assessment with a focus on the patient's ABCs and vaginal bleeding, particularly after delivery.

Obtain another set of vitals and compare those to the ones obtained earlier, and recheck interventions and treatment to see whether they are effective. Communication and documentation. So, if delivery is intimate, notify the staff at the receiving hospital.

You need to provide an update on the status of the woman and the newborn after delivery if it has happened. For pregnant patients with a complaint unrelated to childbirth, be sure to include the pregnancy status of the patient in your radio report. If delivery occurred in the field, you will have two patient care reports to complete. So let's talk about the stages of labor next. And there are three stages of labor.

The first is the dilation of the cervix. And then the delivery of the fetus is the second. And then the third stage is delivery of the placenta. The first stage begins when the onset of contractions and ends when the cervix is fully dilated.

The first stage is usually the longest. It lasts an average of 16 hours with the first delivery. The onset of labor starts when contractions of the uterus occur. Other signs of the beginning of labor are bloody show and the uterine rupture of the amniotic sac.

frequency and intensity of contractions in true labor increase with time. Labor is generally longer in a prima gravita than it is a multigravita. And a woman may experience preterm or false labor when, or it's called Braxton Hicks contractions.

And so you The table on this slide shows how to distinguish between true labor or false labor, which is the Braxton-Hicks. 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. The patient may or may not go into labor and you will need to provide supportive care and transport to the hospital.

Toward the end of the third trimester, a head of the fetus normally descends into the woman's pelvis as the fetus positions for delivery. This movement down into the pelvis is the sensation that may accompany the descent and it's called lightening. The second stage of labor begins when the fetus begins to encounter the birth canal and ends with the delivery of the newborn. You need to make the decision about helping the woman to deliver at the scene or providing transport to the hospital. Uterine contractions are usually closer together and last longer.

The perineum will begin to bulge significantly and the top of the fetus's head should begin to appear at the vaginal opening. This is called crowning. The third stage of labor begins with the birth of the newborn and ends with the delivery of the placenta. During this stage, the placenta must completely separate from the uterine wall. This may take up to 30 minutes.

Okay, so a normal delivery management. When you prepare for the delivery, consider delivery at the scene when delivery is imminent, and this will occur within a few minutes if it is. A natural disaster, inclement weather, or other environmental factors makes it impossible to reach the hospital.

You're going to need to prepare for delivery. How to determine if delivery is imminent? Ask the patient the following questions. So how long have you been pregnant? When are you due?

Is this your first pregnancy? Are you having contractions? If so, how far apart are they and how long do they last?

Have you had any spotting or bleeding? Has your water broken? Do you feel as though you need to have a bowel movement? And do you feel the need to push? To help determine potential complications, ask these questions.

Were any of your previous deliveries by cesarean section? Have you had problems in this or any previous pregnancies? Do you use drugs or alcohol?

alcohol or take any medicine? Do you know if there's a chance you will have multiple deliveries and does your physician expect any complications? 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.

Visually inspect the vagina to check for crowding and do not touch the vagina. vaginal area until you have determined the delivery is imminent. Once labor has begun, it cannot be slowed or stopped, so never attempt to hold the patient's legs together.

Do not let them go to the restroom and instead reassure her that the sensation of needing to move her bowels is normal and that this means she's about to deliver. If your decision is to deliver on the scene, Remember that you are only assisting the woman with the delivery. Your part is just to help, guide, and support the baby as it's born.

Your emergency vehicle should always be equipped with a sterile emergency obstetric or OB kit. And that's an example on the slide. All right, so positioning the patient for that delivery. The patient's clothing should be removed or pushed up to her waist in the pants and undergarments should be removed. Pressure or preserve the patient's privacy as much as possible.

Place the patient on a firm surface that is padded with blankets, folded sheets, or towels, and elevate the hips about two to four inches with a pillow or blanket. Support the head, neck, and upper back with pillows and blankets, and have her keep her legs and hips flex, with her feet flat on the surface beneath her and her knees spread apart. So when you prepare for delivering the field, 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 protect the woman and the newborn. Open the OB kit carefully so that its contents remain sterile. And use the sterile sheets and drapes from the OB kit. to make a sterile delivery field.

The figure on this slide shows how to prepare the delivery field. Okay, and now let's talk about delivery. So your partner should be at the patient's head to comfort, soothe, and reassure her during the delivery. If the patient will allow it, administer oxygen. It is common for patients to begin to become nauseated during delivery.

and some will actually vomit. So continually check the patient for crowning. Some patients may experience pre-captious labor and birth.

So position yourself so that you can see the perineal area at all times. Time the patient's contractions. Remind the patient to take Quick short breaths during each contraction but not to strain. Between contractions, encourage the patient to rest and breathe deeply through her mouth.

You want to follow the steps in skill drill 34-1 to deliver the newborn. Delivering the head. So observe the head as it begins to exit the vagina so that you can provide support as it emerges.

Place your sterile gloved hand over the emerging bony parts of the head to control delivery of the head. Continue to support the head as it rotates. Be careful that you do not poke your fingers into the newborn's eyes or into the fontanelles.

Okay, so an unruptured amniotic sac. Usually the amniotic sac will rupture at the beginning of labor or during contractions. 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.

The sac will suffocate the fetus if 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 head of the fetus's face and only perform this procedure as the head is crowning.

Clear the newborn's mouth and nose using a bulb syringe if required by protocols and wipe the mouth and nose with gauze. So, umbilical cord around the neck. As soon as a head is delivered, use one finger to feel whether the umbilical cord is wrapped around the neck.

This is called a nuchal cord. Usually you can slip the cord gently over the delivery head. delivered head.

If not, you must cut it. And then let's talk about the delivery. So delivering the body, the head is the largest part of the fetus. Once it's born, the body usually delivers very easily. So support the head and the upper body as the shoulders deliver.

Do not pull the fetus from the birth canal. Newborn will be slippery and may be covered with a white. cheesy substance and this is called vernix quesosa Post-delivery care.

So if the mother is able and willing, hand the newborn to her and place the newborn on her abdomen so skin-to-skin contact can begin immediately. Dry off the newborn and wrap him or her in a warm blanket or towel and ensure the top of the head is covered. And keep the neck of the newborn in a neutral position.

Wipe the newborn's mouth with a sterile gauze and pad as needed and clamp and cut the umbilical cord approximately 60 seconds after birth and then you're gonna obtain that first minute Apgar score. So then there's delivery of the placenta. The placenta delivers itself usually within a few minutes after birth, although it may take as long as 30 minutes. After delivery of the placenta and before transport, place a sterile pad or sanitary napkin over the vagina and straighten the woman's legs. You can help to slow bleeding by gently massaging the woman's abdomen with a firm circular motion, a kneading motion, and one hand cupped over the top of the fundus and the other above the pubic bone.

To record the time of birth in your patient care report, The following are emergency situations. So if more than 30 minutes has elapsed and the placenta has not delivered, if there is more than 500 milliliters of bleeding before delivery of the placenta, or if there is a significant bleeding after delivery of the placenta, if one or more of these events occur, transport the woman and the newborn to the hospital promptly. So let's talk about neonatal assessment and resuscitation. The first minute after birth is often referred to as the golden minute. During the first minute of life, perform the following initial steps of the newborn care.

Position or airway positioning and suctioning if needed. You want to dry, you want to warm and tactilely stimulate the patient. Normally, the newborn will begin breathing within 30 seconds after breath, and the heart rate will be 100 beats per minute or higher.

Many newborns require some form of stimulation that will encourage them to breathe and begin circulating blood through their lungs. So, this could include positioning the airway in the normal or sniffing position. If necessary, suction the mouth and then nose. Then vigorously dry the head, body, and back, rub the newborn's back, and gently flick or slap the soles of his or her feet.

And then tactile stimulation. So if signs of good tone and adequate ventilation are not present after performing the initial steps for 30 seconds, then positive pressure ventilations with a mask may be necessary. The table on this slide shows how to perform resuscitation for a newborn who is not breathing. So when you talk about additional resuscitation efforts, you want to observe the newborn for spontaneous respiration, skin color, and movement of the extremities. Evaluate the heart rate by palpating the pulse at the base of the umbilical cord.

or the brachial artery, or listening to the newborn's chest with a stethoscope. The heart rate is the most important measure in determining the need for further resuscitation. If chest compressions are required, use the hand circling technique for two-person resuscitation.

Perform bag valve mass ventilation during a pause after every third compression. using a compression to ventilation ratio of three to one. Hands-only CPR is not as effective as ventilation with CPR.

And so the figure on this slide shows how to give chest compressions to a newborn using that hand encircling technique. If you see meconium in the amniotic fluid or meconium staining on the newborn who is not breathing adequacy, consider quickly suctioning the newborn's mouth, then nose after delivery before providing rescue ventilations. Next, we're going to talk about the APGAR score. So the APGAR score is the standard scoring system used to assess the status of a newborn. It's assigned a number and the values are 0, 1, or 2 to five different areas of activity.

So the five different areas are appearance, pulse, grimace or irritability, activity or muscle tone, and then finally respirations. The total of the five numbers is the APGAR score. And so you calculate the APGAR score at one minute and five minutes after birth.

So one more time, that's one minute and then four minutes later at the fifth minute after birth. The highest possible APGAR score is a 10. The table on this slide shows how to calculate the APGAR score for a newborn. So, steps for assessing a newborn.

You want to quickly calculate the APGAR score to establish a baseline of the newborn's status. Stimulation should result in the immediately increase in respiration rate. If not, you must begin bag valve mass ventilations with a BVM. If the newborn is breathing well, you should check the pulse rate by Feeling the brachial pulse or the sensations at the basic of the umbilical cord or auscultating the chest with a stethoscope.

The pulse rate should be at least 100 beats per minute. If not, you need to begin ventilations with a BVM and then reassess respirations and heart rate at least every 30 seconds. Assess the newborn's oxygen via pulse ox, which is best taken at the right wrist and observe for central cyanosis. If present, administer blow-by by holding oxygen tubing at high flow close to the newborn's face.

Set oxygen flow rate at 5 liters per minute. You want to request a second unit as soon as possible. If you determine that a newborn is in any distress and will require resuscitation.

In situations where assisted ventilation is required, you should use a newborn bag valve mask. Make sure you have a good mask to face seal. Using gentle pressure, make the chest rise with each ventilation. If the newborn does not begin breathing on his or her own or does not have an adequate heart rate, continue CPR and rapidly transport. Once CPR has been started, do not stop until the newborn responds or is pronounced dead by a physician.

So let's talk about some complications. The first complication of delivery we're going to talk about is breach delivery. The presentation is the position in which the infant is born or the body part that is delivered first.

Most infants are born head first. This is called the vortex presentation. Occasionally, the buttocks are delivered, and this is called a breach presentation. The fetus is at great risk for trauma from the delivery. And then prolapse cords are more common with a breach delivery.

Breach deliveries usually take longer. so you will often have time to transport the pregnant woman to the hospital however if the buttocks has already passed through the vagina the delivery has begun preparing for a breech delivery is the same as for normal childbirth allow the buttocks and legs to deliver spontaneously supporting them with your hand to prevent a rapid expulsion let the legs dangle on either side of your arm while you support the trunk and chest as they are delivered. The head is almost always face down and should be allowed to deliver spontaneously.

Make a V with your glove finger and position them in the vagina to keep the walls of the vagina from compressing the fetus's airway. Okay, so the next one we're going to talk about is on rare occasions, the present time. The presenting part of the fetus is either, neither the head nor the buttocks, but an arm, okay?

Leg or foot, and this is called a limb presentation. An infant with a limb presentation cannot be successfully delivered in the field. You need to transport the patient to the hospital immediately. If a limb is protruding, cover it with a sterile towel.

Never try and push it back in and never pull on it. Place the patient on her back with her head down and her pelvis elevated. And then there's the prolapsed. cord, so a prolapse of the umbilical cord, where the umbilical cord comes out of the vagina before the fetus must be treated in the hospital.

Do not attempt to push the cord back in. Your job is to try to keep the fetus's head from compressing the cord. So you need to carefully insert your gloved hand into the vagina and gently push the fetus's head away from the umbilical cord. Place the woman supine with the feet, foot of the stretcher raised about 6 to 12 inches higher than her head with her hips elevated on a pillow or folded sheet. Alternatively, the woman may be placed in the kneel to chest position.

You can wrap a sterile towel, moistened saline around the exposed cord and give the patient high flow oxygen and transport rapidly. And then there's spina bifida. So spina bifida is a developmental defect in which a portion of the spinal cord or meninges may protrude outside of the vertebrae and possibly outside of the body. Cover the area of the spinal cord with a sterile moist dressing immediately after birth to prevent potential fatal infections. Maintain the newborn's body temperature.

And it's important when applying moist dressings because the moisture can lower the newborn's body temperature. And then you could have multiple gestations. So twins occur once every 30 births. Twins are usually smaller than single fetuses.

And a delivery is typically not difficult. About 10 minutes after the first birth, contractions will begin. again and the birth process will repeat itself. The procedure for delivering twins is the same as that for a single fetus. However, you will need some supplies from additional OB kits.

Clamp and cut the cord of the first newborn as soon as it is born and before the second delivery has happened. Record the time of the birth of each twin separately. Twins may also be so small that they look premature.

And then the next thing we're going to talk about is premature births. Okay, so any newborn that delivers before eight months, and that's 36 weeks, or weighs less than five pounds at birth is considered premature. A premature newborn is smaller and thinner than a full-term newborn, and the head is a proportionate. proportionately larger in comparison to the rest of the body. Okay, so the vernix casuosa will be absent or minimal on a premature newborn, and there will also be less body hair.

Premature newborns require special care to survive. They often require resuscitation efforts, which should be performed unless it is physically impossible. With such care, premature newborns as small as one pound have survived and developed normally. And then there's post-term pregnancy.

And so post-term pregnancy refers to pregnancies lasting longer than 41 weeks. Post-term fetuses can be larger than a typical 40-week fetus and sometimes weighing 10 pounds or more. The larger size can lead to problems with the woman and the fetus, and it could be a more difficult labor and delivery. It could have an increased chance of injury to the fetus, increased likelihood of a c-section being required.

The woman is at an increased risk for perineal tears and infection. Post-term newborns have increased risk of meconium aspiration infections and being stillborn. Newborns may not have been able to develop normally because of the restricted size of the feet of the uterus and be prepared to resuscitate the newborn. as respiratory and neurologic functions may have been affected. And next we're going to talk about fetal demise.

So the onset of labor may be premature, but labor will otherwise progress normally in most cases. If an inner uterine infection has caused the demise, you may note an extremely foul odor. The delivered fetus may have skin blisters, slothing, and a dark, discoloration.

The head will be soft and perhaps grossly formed. Do not attempt to resuscitate an obviously dead neonate. Then there's postpartum complications. So if bleeding exceeds approximately 100 milliliters, consider this excessive. If bleeding continues after delivery of the placenta, you should continue to massage the uterus.

Treat signs and symptoms of shock. An excessive bleeding after birth is usually caused by muscles of the uterus not fully contracting and is potentially life-threatening. So cover the vagina with a sterile pad, changing the pad as often as possible. Consider oxygen if necessary, monitor the vital signs frequently, and transport the patient immediately to the hospital. Never hold the woman's legs together or pack anything into the vagina.

and in an attempt to control the bleeding. Postpartum patients are also at an increased risk of a venous emboli, most commonly a pulmonary embolus. The pulmonary embolism results from a clot that travels through the bloodstream and becomes lodged in the pulmonary circulation, blocking blood flow to the lungs. It is potentially life-threatening. This obstruction will block the flow to the lungs if you deliver a newborn in the field and the woman begins to report a sudden difficulty breathing or shortness of breath consider a pulmonary embolism as a possibility also suspect a pulmonary embolism in patients of childbearing age with respiratory complaints who have recently delivered especially with a sudden onset of difficulty breathing, or altered mental status.

Okay, so that ends the lecture part of chapter 34, obstetrics and neonatal care. Now we're just going to go through the review questions to see what we've learned. All right, so the first stage of labor ends when?

And when do we know that the first stage, it ends when? The presenting part of the baby is visible. All right.

So a 23-year-old woman who is 24 weeks pregnant with her first baby complains of edema in her hands, a headache, and visual disturbances. Oh, and look at her blood pressure. What do we think that she's having?

And I'm going to say preeclampsia. Yep. Because eclampsia is when they are having the actual seizure from the high blood pressure.

You're transporting a woman who's eight months pregnant to prevent supine hypotensive syndrome. How should we do it? And we're supposed to do it always on the left side. Immediately after delivery, if of the new infant's head, you should. And what should we do?

We're going to check the position of that umbilical cord. cord. So the very first thing we want to do is see if there's a nuchal cord around the neck.

Upon delivery of the head, you should note the umbilical cord is wrapped around the neck. What should you do? What should we do?

I think we're going to make one attempt to gently kind of get it off, right? Slide it back over. The need for an extent of newborn resuscitation is based on what?

And we know that it's going to be based on the respiratory effort, heart rate, and color. The one-minute APGAR score of a newborn reveals that the baby has a heart rate of 90. Oh, that's below 100, so that's a 1. The body is the pink body, but blue hands, and that's a 1. But has rapid respirations. Okay, so that is a 2. And then flicked. and resists attempts to straighten legs, two and two. All right, so I think that's an eight.

Yep, an eight. We're just subtracting one for the heart rate and one for the body. All right, the most effective way to prevent cardiopulmonary arrest in a newborn is to, what do we think?

Ensure adequate oxygenation and ventilation. When assessing a woman in labor, you realize her vaginal area and you see an arm protruding. She tells you she feels the urge to push. What should we do? All right, so this is a limb presentation, and we're going to cover that limb and transport immediately.

All right, the newborn is considered to be term if it's born after how many weeks? We know. that if it's born in the ranges of 37 weeks and before 42 weeks, it's considered term.

Okay, so thank you for joining us for the Chapter 34 lecture. We hope you've enjoyed.

Transcript for:Understanding Obstetrics and Neonatal Care

Transcript for:
Understanding Obstetrics and Neonatal Care