Chapter 33 Obstetrics and Neonatal Care

Chapt 33 Obstetrics and Neonatal Care Anatomy and Physiology of the Female Reproductive System -The ovaries 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. 2. Ovulation occurs approximately 2 weeks prior to menstruation. 3. If fertilized, the egg implants in the endometrium, the lining of the inside of the uterus. 4. 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. -The fallopian tubes extend out laterally from the uterus, with one tube associated with each ovary. 1. Fertilization, when a sperm meets the egg, usually occurs when the egg is inside the fallopian tube. 2. The fertilized egg then continues to the uterus where it develops into an embryo. -The uterus is a muscular organ that encloses and protects the fetus. 1. Uterus produces contractions during labor and helps to push the fetus through the birth canal 2. The birth canal is made up of the vagina and the lower third of the uterus, called the cervix. -The vagina is the outermost cavity of the female reproductive system and forms the lower part of the birth canal. 1. Completes the passageway from the uterus to the outside world for the newborn -In a pregnant woman, the breasts produce milk that is carried through small ducts to the nipple to provide nourishment to the infant newborn once it is born. -The placenta is a disk-shaped structure attached to the uterine wall that provides nourishment to the fetus. 1. Keeps the circulation of the woman and fetus separated but allows substances to pass between them 2. Anything ingested by a pregnant woman has the potential to affect the fetus. 3. The umbilical cord connects 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. -The fetus develops inside a fluid-filled, baglike membrane called the amniotic sac 1. Contains about 500 to 1,000 mL of amniotic fluid, which helps insulate and protect the floating fetus Normal Changes in Pregnancy -During pregnancy other body systems undergo changes. 1. The primary systems involved with these changes are the respiratory, cardiovascular, and musculoskeletal systems. -In the reproductive system, hormone levels increase to support fetal development and prepare the body for childbirth. 1. This puts pregnant women at an increased risk for complications from trauma, bleeding, and some medical conditions. 2. Uterus is displaced out of its normally well-protected position within the pelvic area. a. This increases the chance of direct fetal injury in trauma. -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. a. Speed of clotting increases to protect against excessive bleeding during delivery. 4. Cardiac output is significantly increased. -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. -Changes in the cardiovascular system and the increased demands of supporting the fetus significantly increase the workload of the heart. -Weight gain during pregnancy is normal. 1. 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. Complications of Pregnancy -Diabetes 1. Diabetes develops during pregnancy in many women who have not had diabetes previously. 2. Gestational diabetes resolves in most women after delivery. 3. The treatment is the same as for any other patient with diabetes. Hypertensive disorders 1. Preeclampsia, or pregnancy-induced hypertension, can develop after the 20th week of gestation. a. Signs/symptoms: Severe hypertension, Severe headache, Swelling in hands and feet (edema) 2. Eclampsia is characterized by seizures that occur as a result of hypertension. a. To treat seizures: i. Lay the patient on her left side, Maintain her airway, Administer O2, if necessary. iv. If vomiting occurs, suction the airway, Provide rapid transport, Call for an ALS 3. Transporting the patient on her left side can also prevent supine hypotensive syndrome. a. Caused by compression of the descending aorta and the inferior vena cava by the pregnant uterus when the patient lies supine. Bleeding 1. Internal bleeding may be a sign of an ectopic pregnancy, when an embryo develops outside the uterus, most often in a fallopian tube. a. The leading cause of maternal death in the first trimester is internal hemorrhage into the abdomen following rupture of an ectopic pregnancy. b. Consider the possibility of an ectopic pregnancy in a woman who has missed a menstrual cycle and complain of sudden, severe, usually unilateral pain in the lower abdomen. 2. Hemorrhage from the vagina that occurs before labor begins may be very serious. 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 **State test*** i. Abruptio placenta: the placenta separates prematurely from the wall of the uterus, most commonly from caused by hypertension or trauma ii. Placenta previa: the placenta develops over and covers the cervix Abortion 1. Passage of the fetus and placenta before 20 weeks is called abortion. 2. Abortions may be spontaneous (miscarriage) or induced. 3. The most serious complications are bleeding and infection. 4. If the woman is in shock, treat and transport her promptly to the hospital. Abuse 1. Pregnant women have 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. 3. The woman is at risk from bleeding, infection, and uterine rupture. 4. Pay attention to the environment for any signs of abuse. 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. Substance abuse 1. The effects of the addiction on the fetus include: a. Prematurity, Low birth weight, Severe respiratory distress, Death 2. Fetal alcohol syndrome describes the condition of infants born to women who have abused alcohol. 5. The newborn may need immediate resuscitation. Special Considerations for Trauma and Pregnancy -With a trauma call involving a pregnant woman, you have two patients to consider—the woman and the unborn fetus. -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. -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. Pregnant trauma pt. 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. 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. -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. 2. 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. 4. 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. -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. Assessment and management 1. Your focus is on the assessment and the management of the woman. 2. Follow these guidelines when treating a pregnant trauma patient: a. Maintain an open airway. b. Administer high-flow oxygen. c. Ensure adequate ventilation. i. 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. e. Transport considerations i. Transport the patient on her left side. Cultural Value Considerations -Cultural sensitivity 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. Patient Assessment -Childbirth is seldom an unexpected event, but are occasions when childbirth becomes an emergency -Scene size-up 1. Take standard precautions. Gloves, eye, face protection are minimum if delivery has begun/is complete -Primary assessment 1. Form a general impression (in active labor or whether you have time to assess for imminent delivery) b. Perform a rapid scan examination of the patient. 2. 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, sometimes, result in a complicated delivery. 3. Circulation a. Blood loss after delivery is expected, but significant bleeding is not. b. Quickly assess for any potential life-threatening bleeding, and begin treatment immediately. -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 2. Obtain a SAMPLE history. a. Questions related to prenatal care ii. Determine the due date, fetal movements, frequency of contractions, 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. b. 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. -Secondary assessment 1. Physical examinations a. Perform complete assessment of the major body systems as needed , with emphasis on the patient’s chief complaint. b. If the patient is in labor, the physical examination should be focused on contractions and possible delivery. d. 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. 2. Vital signs should include pulse; respirations; skin color, temperature, and condition; and blood pressure. -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. In most cases, childbirth is a natural process that does not require your assistance. b. When childbirth is complicated by trauma or other conditions, however, any interventions you provide for the patient will benefit the fetus. Stages of Labor -The three stages of labor are (1) dilation of the cervix, (2) delivery of the fetus, and (3) delivery of the placenta. -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. 3. Labor is generally longer in a primigravida than in a multigravida. 4. A woman may experience preterm or false labor, or Braxton-Hicks contractions **Pg 1194 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. -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. 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. The perineum will begin to bulge significantly, and the top of the fetus’s head should begin to appear at the vaginal opening (crowning). -Third stage of labor begins with the birth of 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. Normal Delivery Management -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? When are you due? Is this first pregnancy? Are you having contractions? 4. Prepare for delivery if the patient says she has to move her bowels or feels the need to push. a. Visually inspect the vagina to check for crowning. b. 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. 7. Your emergency vehicle should always be equipped with a sterile emergency obstetric (OB) kit. 8. Patient position a. The patient’s clothing should be removed or pushed up to her waist. 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. Support the head, neck, and upper back with pillows and blankets. 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. Use the sterile sheets and drapes from the OB kit to make a sterile delivery field. Delivery 1. Your partner should be at the patient’s head to comfort, soothe, and reassure her during the delivery. 2. It is common for patients to become nauseated during delivery, and some may vomit. 3. 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. 4. Follow the steps in Skill Drill 33-1 to deliver the newborn. 5. 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. Be careful that you do not poke your fingers into the newborn’s eyes or into the fontanelles. 6. 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 infant’s the fetus’s face and only perform this procedure as the head is crowning. f. Clear the infant’s newborn’s mouth and nose, using the bulb syringe if required by your protocols and wipe the mouth and nose with gauze. 7. 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 (nuchal cord). b. Usually, you can slip the cord gently over the delivered head. **MUST cut if not 8. Delivering the body a. The head is the largest part of the fetus. b. Support the head and upper body as the shoulders deliver. c. Do not pull the fetus from the birth canal. d. Newborn will be slippery and covered with a white, cheesy substance, called vernix caseosa Post-delivery 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 warm blanket or towel. 3. Place the newborn on one side, with the head slightly lower than the rest of the body. 4. Once the umbilical cord has stopped pulsing, clamp and cut the cord. 5. Obtain the 1-minute Apgar score. 6. Delivery of the placenta a. The placenta delivers itself, usually within a few minutes of the birth, although it may take as long as 30 minutes. b. After delivery of the placenta and before transport, place a sterile pad or sanitary napkin over the vagina and straighten the woman’s legs. c. Record the time of birth in your patient care report d. 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. e. If one or more of these events occur, transport the woman and the newborn to the hospital promptly. Neonatal Assessment and Resuscitation 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. **If pulse less than 60 beats, do CPR 2. If you do not observe these responses 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. a. Positioning of the airway, Drying, Warming, Suctioning 4. Position the newborn on his or her back with the head down and the neck slightly extended. a. Place a towel or blanket under the shoulders to help maintain the position. 5. Suction the mouth & then nose using a bulb syringe or suction device with an 8 or 10 French catheter 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. 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 compressionto-ventilation ratio of 3:1. 4. 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. The Apgar score **LOOK IN BOOK 3. The total of the five numbers is the Apgar score. a. Calculate the Apgar score at 1 minute and 5 minutes after birth. 4. Steps for assessing the 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 respirations. 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’s face. Set oxygen flow rate to 5 L/min. Complicated Delivery Emergencies - 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. 5. Preparing for a breech delivery is the same as for a normal childbirth. a. Allow the buttocks and legs to deliver spontaneously, supporting them with your hand to prevent rapid expulsion. b. Let the legs dangle on either side of your arm while you support the trunk and chest as they are delivered. c. The head is almost always face down and should be allowed to deliver spontaneously. d. 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. Presentation complications 1. On rare occasions, the presenting part of the fetus is neither the head nor the buttocks, but a single arm, leg, or foot. a. This is called a limb presentation. b. An infant with a limb presentation cannot be successfully delivered in the field. c. You must transport the patient to the hospital immediately. d. If a limb is protruding, cover it with a sterile towel. e. Never try to push it back in, and never pull on it. 2. Prolapse of the umbilical cord, where the umbilical cord comes out of the vagina before the fetus, must be treated in the hospital. a. Do not attempt to push the cord back into the vagina. b. Your job is to try to keep the fetus’s head from compressing the cord. c. Carefully insert your sterile gloved hand into the vagina, and gently push the fetus’s head away from the umbilical cord. d. Wrap a sterile towel, moistened with saline, around the exposed cord. e. Give the patient high-flow oxygen and transport rapidly. Spina bifida 1. This 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. a. Cover the open area of the spinal cord with a sterile, moist dressing immediately after birth to help prevent a potentially fatal infection. b. Maintenance of the newborn’s body temperature is important when applying moist dressings because the moisture can lower the newborn’s body temperature. Multiple gestation 1. Twins occur about once in every 30 births. 2. Twins are usually smaller than single fetuses, and delivery is typically not difficult. a. 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. 4. Record the time of birth of each twin separately. 5. Twins may be so small that they look premature. Premature birth 1. Any newborn who delivers before 8 months (36 weeks) or weighs less than 5 lb at birth is considered premature. 2. 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. 3. Premature newborns require special care to survive. Postterm pregnancy 1. Postterm pregnancy refers to pregnancies lasting longer than 42 weeks. 2. Postterm fetuses can be larger than a typical 40-week fetus, sometimes weighing 10 lb or more. 3. The larger size can lead to problems with the woman and fetus. a. A more difficult labor and delivery, Increased chance of injury to the fetus c. Increased chance of cesarean section (c-section), Woman is at risk for perineal tears/ infection. e. Postterm newborns have increased risks of aspiration, infection, and being stillborn. 4. Be prepared to resuscitate the newborn, as respiratory and neurologic functions may have been affected. Fetal demise 1. The onset of labor may be premature, but labor will otherwise progress normally in most cases. 2. If an intrauterine infection has caused the demise, you may note an extremely foul odor. 3. Do not attempt to resuscitate an obviously dead neonate. Delivery without sterile supplies 1. Even without OB kit, you should always have eye protection, gloves, and a protective mask with you. 2. Deliver the fetus 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. Do not cut or clamp the umbilical cord. d. 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 placenta and newborn at same level, or elevate the placenta slightly if possible. f. Keep the newborn warm. Postpartum Complications -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 and check your technique and hand position. 2. Treat signs and symptoms of shock. 3. Excessive bleeding after birth is usually caused by the muscles of the uterus not fully contracting. 4. Cover the vagina with a sterile pad, changing the pad as often as possible. 5. Administer O2 if necessary, monitor vital signs frequently, transport patient immediately to hospital. a. Never hold the woman’s legs together in an effort to stop bleeding. b. Never pack the vagina with gauze pads in an attempt to control bleeding. -Postpartum patients are also at an increased risk of an embolism, most commonly a pulmonary embolism 1. A pulmonary embolism results from a clot that travels through the bloodstream and becomes lodged in the pulmonary circulation. 2. This obstruction will block 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. Suspect a pulmonary embolism in patients of childbearing age w/ respiratory complaints who have recently delivered, especially with sudden onset of difficulty breathing or altered mental status