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Chapter 41 Obstetrics National EMS Education Standard Competencies Special Patient Populations Integrates assessment findings with principles of pathophysiology and knowledge of psychosocial needs to formulate a field impression and implement a comprehensive treatment/disposition plan for patients with special needs. National EMS Education Standard Competencies Obstetrics • Recognition and management of − Normal delivery − Vaginal bleeding in the pregnant patient • Anatomy and physiology of normal pregnancy National EMS Education Standard Competencies Obstetrics • Pathophysiology of complications of pregnancy • Assessment of the pregnant patient National EMS Education Standard Competencies Obstetrics • Psychosocial impact, presentations, prognosis, and management of − Normal delivery − Abnormal delivery • Nuchal cord • Prolapsed cord • Breech delivery National EMS Education Standard Competencies Obstetrics • Psychosocial impact, presentations, prognosis, and management of (cont’d) − Third-trimester bleeding • Placenta previa • Abruptio placenta − Spontaneous abortion/miscarriage National EMS Education Standard Competencies Obstetrics • Psychosocial impact, presentations, prognosis, and management of (cont’d) − − − − Ectopic pregnancy Preeclampsia/eclampsia Antepartum hemorrhage Pregnancy-induced hypertension National EMS Education Standard Competencies Trauma Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient. National EMS Education Standard Competencies Special Considerations in Trauma • Recognition and management of trauma in − Pregnant patient − Pediatric patient − Geriatric patient National EMS Education Standard Competencies Special Considerations in Trauma • Pathophysiology, assessment, and management of trauma in the − − − − Pregnant patient Pediatric patient Geriatric patient Cognitively impaired patient Introduction • Pregnancy is not a disease needing treatment. − Childbirth is usually a happy event. • The number of patients increases from one to a minimum of two. Anatomy and Physiology of the Female Reproductive System • Female reproductive organs include: − Mammary glands − Vagina − Uterus − Ovaries − Fallopian tubes Anatomy and Physiology of the Female Reproductive System • Each ovary contains about 200,000 follicles, with each one containing an oocyte. − Each month, about 20 of the follicles begin the maturation process. − Only a single follicle releases an ovum. Anatomy and Physiology of the Female Reproductive System • The cycle continues with the release of hormones throughout various stages. − The anterior pituitary gland releases: • Follicle-stimulating hormone (FSH) • Luteinizing hormone (LH) − At the end of pregnancy, prostaglandins and oxytocin signal uterine contractions and labor. Anatomy and Physiology of the Female Reproductive System © Nestle/Petit Format/Photo Researchers, Inc. − Secretes progesterone to begin second phase − The egg can then develop into an embryo and then a fetus. © Claude Cortier/Photo Researchers, Inc. • Corpus luteum: what is left of the follicle after the egg is released Anatomy and Physiology of the Female Reproductive System • The ovum travels from the ovaries into the uterus through the fallopian tubes. • Composed of three tissue layers: − Outer layer protects the tubes − Middle layer helps ovum move into uterus − Innermost layer helps move the ovum and provide nutrition Anatomy and Physiology of the Female Reproductive System • Uterus: organ that lies between the urinary bladder and the rectum − The uterus is where: • The fertilized ovum will implant. • The fetus will develop. • Labor takes place. Anatomy and Physiology of the Female Reproductive System • Three layers of tissues in the uterus: − Perimetrium − Myometrium − Endometrium Anatomy and Physiology of the Female Reproductive System • Vagina: highly muscular organ lined with mucous membranes − Functions include: • Receptacle for penis during sexual intercourse • Passage for exit of menstrual flow • Passage for childbirth Anatomy and Physiology of the Female Reproductive System • The vagina is the lower portion of the birth canal. − Stretches to accommodate fetus delivery − If it doesn’t stretch enough: • Tissues in and around perineum can tear. • Significant pain and bleeding may occur. Anatomy and Physiology of the Female Reproductive System • Mammary glands: modified sweat glands − Primary purpose: lactation − Signs that a woman is most likely pregnant: • Breast enlargement • Tenderness • Milk excretion Conception and Fetal Development • Once the egg has been fertilized and implanted, major changes occur. − Cells multiply on outside of the egg surface, forming layers that will generate: • Fetal membrane • Placenta • Embryo Conception and Fetal Development • Blastocyst migrates to the endometrial wall and becomes implanted a week after conception. − Triggers the development of placental tissues − The corpus luteum produces hormones to support pregnancy until placenta develops. Conception and Fetal Development • Two weeks after conception: − The blastocyst evolves into an embryonic disc. − The embryo begins to draw on maternal circulation. • Three weeks after conception: − The blastocyst officially becomes an embryo. − Body systems form. − The heart beats. − Blood cells circulate. Conception and Fetal Development • In the fourth week of pregnancy, the placenta develops. − Serves as an early liver − Produces antibodies − Functions as fetal lungs − Transports nutrients and excretes wastes Conception and Fetal Development • The umbilical cord connects the fetus and placenta. − The umbilical vein carries blood to the fetus. − The umbilical arteries carry blood to the placenta. Conception and Fetal Development • The amniotic sac encloses the fetus in amniotic fluid. • The fourth through eighth week of embryonic development are critical. − Major organs and other body systems are most susceptible to damage as they form. Conception and Fetal Development • Gestational period: time it takes the fetus to develop in utero − Normally 38 weeks − Calculated from the first day of the pregnant woman’s last menstrual period Physiologic Maternal Changes During Pregnancy • Physiologic changes occurring throughout pregnancy can: − Alter normal response to trauma. − Exacerbate or create medical conditions. Physiologic Maternal Changes During Pregnancy • Significant changes occur in the uterus. − Before pregnancy, the uterus: • Weighs about 0.07 oz (2 g) • Has a fluid capacity of about 10 mL − At the end of the pregnancy, the uterus: • Weighs as much as 2.2 lb (1 kg) • Has the capacity to hold about 5,000 mL Physiologic Maternal Changes During Pregnancy • Measurement of the fundus may indicate developmental problems. − If different than expected, it could indicate: • Uterine growth problems or breech position • Possibility of twins Physiologic Maternal Changes During Pregnancy • Pressure occurs on intestine and rectum. • Smooth muscle in the GI tract relaxes. • Kidneys increase in size and volume. • Ureters increase in diameter. • Hormones cause changes to the skin, hair, and eyes. Physiologic Maternal Changes During Pregnancy • Circulatory changes − Blood volume increases up to 50% more to: • Meet fetal metabolic needs. • Adequately perfuse maternal organs. • Help compensate for blood loss in delivery. Physiologic Maternal Changes During Pregnancy • Circulatory changes (cont’d) − Number of red blood cells increases. − Clotting factors increase while fibrinolytic factors are depressed. − Size of heart increases. • Cardiac output increases to about 40% more. Physiologic Maternal Changes During Pregnancy • Heart rate gradually increases by an average of 15 to 20 beats/min by term. − ECG changes may include: • Ectopic beats • Supraventricular tachycardia • Slight left axis deviation • Lead II changes Physiologic Maternal Changes During Pregnancy • Sensitivity to body position increases as gestation increases. − Lying supine can cause compression of the inferior vena cava. − If pressure is not relieved, cardiac output is decreased. Physiologic Maternal Changes During Pregnancy • The birthing position may stress the cardiovascular system. − The lithotomy position is standard in the United States. Physiologic Maternal Changes During Pregnancy • Respiratory changes − The diaphragm is pushed up by the uterus. − Maternal oxygen demand increases. − Progesterone: • Decreases threshold to carbon dioxide • Causes the bronchi to dilate • Regulates mucus production Physiologic Maternal Changes During Pregnancy • Respiratory changes (cont’d) − A decrease in: • Expiratory reserve volume • Functional residual capacity • Residual volume − An increase in: • Tidal volume • Inspiratory reserve volume Physiologic Maternal Changes During Pregnancy • Maternal metabolism − Weight gain averages 27 lb (12.3 kg). • Increased blood volume and intracellular and extracellular fluid • Uterine growth • Placental and fetal growth • Increased breast tissue • Increased proteins and fat deposits Physiologic Maternal Changes During Pregnancy • Maternal metabolism − Relaxin softens collagenous tissues and relaxes the ligamentous system. − Demand for carbohydrates increases. • Several hormones help compensate. Cultural Value Considerations • Some cultures may have a value system that affects their pregnancy. • Some cultures may not permit a male health care provider to examine a pregnant patient. • Different cultures view pregnancy differently. Adolescent Pregnancy • United States has one of the highest teenage pregnancy rates compared with other developed countries. • Pregnancy is a possibility when assessing all female teenagers. Patient Assessment • Special terminology: − Gravidity—number of times pregnant − Parity—delivery of an infant who is alive − Primigravida—woman pregnant for first time − Primipara—woman with only one delivery − Multigravida—two or more pregnancies Patient Assessment • Special terminology (cont’d): − Multipara—two or more deliveries − Grand multipara—more than five deliveries − Nullipara—never delivered Scene Size-Up • Take standard precautions. • Consider calling for specialized resources. • Determine mechanism of injury or nature of illness. Primary Assessment • Form a general impression. − Determine if there is time for further evaluation. − Perform a rapid scan for ABC problems. − Evaluate trauma or other medical problems first. − Use the AVPU scale to determine level of consciousness. Primary Assessment • Airway and breathing − Generally not an issue in uncomplicated birth − If trauma, assess for airway and breathing. • Circulation − Assess early for internal and external bleeding. − Assess for signs of shock and control bleeding. Primary Assessment • Transport decision − If imminent, prepare to deliver at the scene. − If not imminent, transport the woman lying on the left side when possible. Primary Assessment • Transport decision (cont’d) − Provide rapid transport for patients: • With significant bleeding and pain • Who are hypertensive • Who are having a seizure • Who have an altered mental status History Taking • Determine chief complaint using OPQRST. • Obtain the SAMPLE history. • Determine estimated due date. • Determine previous complications or gynecologic problems. History Taking • Was an ultrasound done recently, and what were the findings? • Determine the general impression of the patient’s health. • Determine if there is any vaginal bleeding. History Taking • Determine if the woman’s water has broken. − Does she need to move her bowels or push? • Delivery is imminent. • Inspect the woman for crowning. Secondary Assessment • Base the exam on the chief complaint. − Exam should include fetal heart tones and rate. • Inspect for crowning or vaginal bleeding. • If the water has broken, ask about the color of the fluid. Secondary Assessment • Imminent delivery − Assess the woman’s vital signs. − Estimate the gestational age. − Listen for fetal heart tones. Secondary Assessment • If there is time to reach the hospital: − Place in the lateral recumbent position. − Remove clothing that might obstruct delivery. − Begin transport. • If there is not time: − Try to find a private and clean area. − Keep nervous bystanders busy. − Be calm and professional. Reassessment • Perform ongoing examination, including: − Serial vital signs − Fetal heart rate and heart tones • Time contractions, and perform exam. • Check interventions, and transport. Reassessment • If delivery is imminent: − Notify staff at hospital. − Provide an update on the status after delivery. • If delivery does not occur with 30 minutes or a complication occurs: − Notify staff. − Provide rapid transport. Substance Abuse • Illicit drugs pass through the placenta barrier and enter fetal circulation. • The fetus may have withdrawal signs. • Treatment should concentrate on cardiorespiratory support. Supine Hypotensive Syndrome • Uterus may compress the inferior vena cava. • Can result in significant hypotension and fetal distress Supine Hypotensive Syndrome • Management includes: − Place patient in left lateral recumbent position. − Treat underlying causes. − Monitor blood pressure and other vital signs. − Obtain an ECG. Cardiac Conditions • Determine the nature and treatment of any heart condition. − Cardiac medications? − Diagnosed with dysrhythmias or heart murmurs? − History of rheumatic fever? − Born with congenital heart defect? − Episodes of dizziness, light-headedness? Hypertensive Disorders • Chronic hypertension − Blood pressure equal to or greater than 140/90 mm Hg − Increased risk for stroke or other cardiovascular problems • Pregnancy-induced hypertension − Develops after the 20th week of pregnancy − Resolves spontaneously Hypertensive Disorders • Preeclampsia − Risk factors include: • First pregnancy before age 20 years • Women with advanced maternal age • History of multiple pregnancies • Diabetes Hypertensive Disorders • Preeclampsia (cont’d) − Manifests after 20th week with a triad of symptoms including: • Edema • Gradual onset of hypertension • Protein in the urine Hypertensive Disorders • Preeclampsia (cont’d) − Chronic hypertension can: • Retard growth and development of the fetus. • Impair liver and renal function. • Cause pulmonary edema. • Progress to life-threatening grand mal seizures. Seizures • Treatment is difficult because drugs may cause fetal distress. − Magnesium sulfate is recommended. • Potential complications may include: − Abruptio placenta − Hemorrhage − Disseminated intravascular coagulation Diabetes • Gestational diabetes mellitus (GDM): inability to process carbohydrates during pregnancy • May be asymptomatic or exhibit the same signs as patients with diabetes mellitus • Treatment consists of: − Diet control − Oral hypoglycemic medications Diabetes • Diabetes may be affected by pregnancy. − May manifest as hyperglycemic or hypoglycemic episodes − Insulin-dependent diabetics may need to adjust their dosages during pregnancy. • Patients with a history of diabetes should have a blood glucose level test. Respiratory Disorders • Shortness of breath or general dyspnea is one of the most common complaints. − Often caused by hormone-related changes • Asthma is a common condition that complicates pregnancy. Respiratory Disorders • Maternal asthma complications: • Fetal asthma complications: − Premature labor − Preeclampsia − Premature birth − Low birth rate − Respiratory failure − Vaginal hemorrhage − Growth retardation − Fetal death − Eclampsia Respiratory Disorders • Pneumonia − Especially virulent during pregnancy − Common complications: • Low birth weight • Premature labor • Preterm delivery Hyperemesis Gravidarum • Persistent nausea and vomiting − Leads to dehydration and malnutrition • Exact cause is unknown. • Symptoms include: − Severe and persistent vomiting − Projectile vomiting − Severe nausea Hyperemesis Gravidarum • Prehospital treatment includes: − Administer 100% supplemental oxygen. − Start IV line of normal saline. − If protocols allow, administer diphenhydramine. − Check blood glucose levels. − Check orthostatic vital signs; obtain an ECG. − Transport to a hospital. Renal Disorders • During pregnancy, a woman’s kidneys increase in length and ureters get longer. − Changes can lead to urinary stasis and urinary tract infections. • The uterus puts pressure on the bladder, causing increased urinary frequency. Rh Sensitization • If the mother is Rh negative and the father is Rh positive, the fetus may inherit Rh factor. − The fetal blood can enter the woman’s circulation and produce a maternal antibody to the factor. • In subsequent pregnancies the antibodies will attack the fetal RBCs. Infections • Urinary tract infections − If Streptococcus agalactiae is passed to the newborn, it can cause: • Respiratory problems • Pneumonia • Septic shock • Meningitis Infections • Human immunodeficiency virus (HIV) − Pregnant women may infect their fetus: • During pregnancy • During delivery • From breastfeeding Infections • Cholestasis − If the bile cannot flow normally, it builds up in the liver and spills into the bloodstream. − Symptoms include: • Profuse, painful itching • Right upper quadrant pain • Color changes in waste elimination Infections • Cholestasis (cont’d) − High risks include: • Carrying multiple fetuses • A familial history of cholestasis • Previous liver damage Sexually Transmitted Infections • Bacterial vaginosis − Normal vaginal bacteria are replaced by other bacteria. − Can lead to: • Premature birth • Low birth weight • Pelvic inflammatory disease Sexually Transmitted Infections • Candidiasis − Risk factors include: • Poorly controlled diabetes • Taking antibiotics • Wearing tight-fitting clothing • Activities causing irritation Sexually Transmitted Infections • Candidiasis (cont’d) − Treatment includes: • Prescription creams and over-the-counter medications − Fetus may develop thrush in the mouth if infection is active during delivery or if the woman breastfeeds. Sexually Transmitted Infections • Chlamydia − Symptoms are usually mild or absent. − Can spread to the rectum, causing: • Rectal pain • Discharge • Bleeding − Can progress to pelvic inflammatory disease Sexually Transmitted Infections • Gonorrhea − Bacterial infection that multiplies rapidly − Symptoms include: • Dysuria with burning or itching • Yellowish or bloody vaginal discharge • Bleeding with vaginal intercourse Sexually Transmitted Infections • Human papilloma virus (HPV) − May cause warts or be asymptomatic − Warts may affect urination or obstruct birth canal. − The fetus may develop laryngeal papillomatosis. Sexually Transmitted Infections • Syphilis − May remain asymptomatic for years − Primary stage: single sore − Stage two: lesions, skin rash − Late stage: no signs or symptoms, but disease attacks the body Sexually Transmitted Infections • Syphilis (cont’d) − Women with syphilis may have: • Stillborn babies • Babies born blind • Developmentally delayed babies • Babies who die shortly after birth Sexually Transmitted Infections • Trichomoniasis − May be asymptomatic or have signs and symptoms including: • Frothy, yellow-green vaginal discharge • Irritation and itching • Discomfort during intercourse • Dysuria • Lower abdominal pain Sexually Transmitted Infections • Trichomoniasis (cont’d) − If a pregnant woman is not treated, there is an increased chance of: • Low birth weight newborn • Premature birth • Increased susceptibility to HIV infection TORCH Syndrome • TORCH—toxoplasmosis, other agents, rubella, cytomegalovirus, and herpes simplex • Refers to infections that pass through the placenta to the fetus TORCH Syndrome • Toxoplasmosis − Caused from handling or eating contaminated food or from handling cat litter − If early in the pregnancy, there is a decreased chance of passing it on to the fetus. TORCH Syndrome • Rubella − If less than 20 weeks gestation, there is a significant chance of developmental problems with the fetus. − Fetal adverse effects include: • Being born blind or deaf • Significant cardiac and respiratory abnormalities TORCH Syndrome • Cytomegalovirus (CMV) − A member of the herpes virus family − Can remain dormant in the body for years − Pregnant women have an increased risk for active infection and more serious complications. TORCH Syndrome • Cytomegalovirus (CMV) (cont’d) − Newborns with CMV are susceptible to: • Lung problems • Blood problems • Liver problems • Swollen glands • Rash • Poor weight gain TORCH Syndrome • Herpes − Infection of the genitals, buttocks, or anal area, caused by herpes simplex virus type 1 or type 2 − Symptoms may include: • Tingling or sores • Muscle aches and pain • Swollen glands in the groin area Pathophysiology of Bleeding Related to Pregnancy • Abortion − Expulsion of the fetus before the 20th week of gestation − Broadly classified as: • Spontaneous abortion (miscarriage) • Elective (intentional) abortion Pathophysiology of Bleeding Related to Pregnancy • Habitual abortions: three or more consecutive miscarriages − Causes include: • Ovarian issues • Uterine malformations • Cervical conditions Pathophysiology of Bleeding Related to Pregnancy • Threatened abortion: abortion attempting to take place − Characterized by vaginal bleeding in the first half of pregnancy − Can progress or may subside − Prehospital role is transport and support. Pathophysiology of Bleeding Related to Pregnancy • Imminent abortion: spontaneous abortion that cannot be prevented − Signs and symptoms include: • Severe abdominal pain • Vaginal bleeding • Cervical dilation Pathophysiology of Bleeding Related to Pregnancy • Imminent abortion (cont’d) − Treatment includes: • Establishing an IV line of normal saline • Administering 100% supplemental oxygen • Obtaining an ECG • Providing emotional support with rapid transport • Watching for signs of shock Pathophysiology of Bleeding Related to Pregnancy • Incomplete abortion: part of the products of conception remains in the uterus − Vaginal bleeding will be continuous. − Start an IV line of normal saline. − Consult medical control. − Collect all products of conception. Pathophysiology of Bleeding Related to Pregnancy • Missed abortion: fetus dies during the first 20 weeks of gestation but remains in utero − Provide emotional support and transport. − On examination: • Uterus feels like a hard mass. • Fetal heartbeat cannot be heard. Pathophysiology of Bleeding Related to Pregnancy • Septic abortion: uterus becomes infected following abortion − History includes fever and bad-smelling vaginal discharge after abortion. − Physical examination shows fever and abdominal tenderness. Pathophysiology of Bleeding Related to Pregnancy • Septic abortion (cont’d) − Prehospital management includes: • Establishing an IV line of normal saline • Administering 100% supplemental oxygen • ECG monitoring • Rapid transport • Fluid administration Pathophysiology of Bleeding Related to Pregnancy • Third-trimester bleeding − Greatest danger of hemorrhage • Large volume of blood present • Compensatory mechanisms function as a result of pregnancy. Pathophysiology of Bleeding Related to Pregnancy • Ectopic pregnancy − Ovum implants somewhere besides uterus. − Patient usually presents with: • Severe abdominal pain • May be in hypovolemic shock Pathophysiology of Bleeding Related to Pregnancy • Ectopic pregnancy (cont’d) − All female patients of child-bearing age should be considered. − Treat for shock, and provide rapid transport. Pathophysiology of Bleeding Related to Pregnancy • Abruptio placenta − Premature separation of the placenta from the uterine wall Pathophysiology of Bleeding Related to Pregnancy • Abruptio placenta (cont’d) − Patient will report: • Vaginal bleeding with bright red blood • Sudden onset of severe abdominal pain • No longer feeling the fetus moving Pathophysiology of Bleeding Related to Pregnancy • Abruptio placenta (cont’d) − Physical examination will show: • Signs of shock • Tender abdomen and rigid uterus • Fetal heart sounds may be absent. Pathophysiology of Bleeding Related to Pregnancy • Placenta previa − Placenta is implanted low in the uterus and obscures the cervical canal. Pathophysiology of Bleeding Related to Pregnancy • Placenta previa (cont’d) − Chief complaint is usually painless vaginal bleeding with bright red blood. − The uterus is soft and nontender. Assessment of Bleeding Related to Pregnancy • Try to determine the nature of the bleeding. • Use OPQRST to elaborate on the chief complaint of labor pain. • Identify changes in orthostatic vital signs. • Look for positive Grey Turner or Cullen sign. Management of Bleeding Related to Pregnancy • Keep the woman lying on her left side. • Administer 100% supplemental oxygen. • Provide rapid transport. • Start an IV line of normal saline. • Obtain an ECG and baseline vital signs. • Loosely place trauma pads over the vagina. Stages of Labor • First stage − Begins with onset of labor pains − Lasts until cervix is fully dilated − Toward the end of the stage, the amniotic sac often ruptures. Stages of Labor • Second stage − Begins as the head descends to enter birth canal − Fetus will undergo several position changes. • Internal rotation • Extension • Rotation to the side • Movement of the shoulders Stages of Labor • Second stage (cont’d) − Contractions are more intense and frequent. − The cervix becomes fully dilated. − Concluded when the newborn is fully delivered Stages of Labor • Third stage of labor − Placenta is expelled. − Uterine contractions squeeze shut the exposed blood vessels. Maternal and Fetal Response to Labor • Maternal response − Increase in: • Workload of the heart • Blood pressure, pulse, and cardiac output • Breathing rate • WBC production Maternal and Fetal Response to Labor • Fetal response − Decrease in the amount of oxygen and nutrients − Insufficient removal of waste − Decreased fetal heart rate − Fetal acidosis Preparing for Delivery • Birthing positions − Standing birth • Fetal head is moved away from the sacral area. − Semi-Fowler’s position Preparing for Delivery Preparing for Delivery • Birthing positions (cont’d) − Kneeling birth • Fetal head is moved away from the sacrum. − Side-lying position • Fewer perineal tears Preparing for Delivery Preparing for Delivery • Open the OB kit. • Wash hands. • Put on gloves. • Maintain standard precautions. • Drape the woman in sterile towels. Courtesy of AAOS Preparing for Delivery Preparing for Delivery • A safe and controlled delivery takes precedence over the draping. • Have your partner at the woman’s head to help keep her calm and administer oxygen. • Encourage the woman to rest between contractions and to resist bearing down. Assisting Delivery • Control delivery. • Support the head as it emerges. • Check for nuchal cord. • Clear the airway by suctioning with a bulb syringe. Courtesy of AAOS Assisting Delivery Courtesy of AAOS • Gently guide the head downward so the upper shoulder can deliver. • Gently guide the head upward to allow delivery of the lower shoulder. Courtesy of AAOS Assisting Delivery • Once delivered, maintain at the same level as the vagina. • Wipe blood or mucus from the newborn’s nose and mouth with sterile gauze. Courtesy of AAOS Assisting Delivery • Dry the newborn with sterile towels, and wrap in a dry blanket. • Record the time of birth for the PCR. Assisting Delivery • Apgar scoring − Evaluates newborn’s vital functions • Heart rate • Respiratory effort • Muscle tone • Reflex irritability • Color Assisting Delivery • Cutting the umbilical cord − Handle the cord with care. − Tie or clamp the cord with clamps 2 inches apart, then cut the cord between them. − Examine the ends to ensure there is no bleeding. − Once cut, wrap the newborn in a dry blanket. Assisting Delivery • Delivery of the placenta − Usually within 20 minutes after delivery − Do not pull on the umbilical cord to speed up placental delivery. − Instruct the patient to bear down. Assisting Delivery • Delivery of the placenta (cont’d) − Fetal side should be gray, shiny, and smooth. − Maternal side should be dark maroon with a rough texture. © Hattie Young/Photo Researchers, Inc. Assisting Delivery • Delivery of the placenta (cont’d) − Place in a plastic bag, and transport. − Examine the perineum for lacerations. − Prepare for transport. • If the placenta has not delivered after 15 minutes, begin transport. Postpartum Care • Obtain the mother’s vital signs. • Place a sanitary napkin in front of the vagina. • Monitor the mother’s condition closely. Postpartum Care • Assess the fundus. • Note the lochia. • Cover the mother with blankets. Emergency Pharmacology in Pregnancy • Maternal physiology changes may have an impact on pharmacologic therapies. − IV medications may pass quickly through the maternal system. − Higher doses may be needed. − Oral drugs may take longer to work. Magnesium Sulfate • In pregnancy, used to manage eclampsia • Can cause: − Respiratory depression − Hypotension − Circulatory collapse • Must be administered slowly Calcium Chloride • Mainly used to manage hypocalcemia • Side effects include: − Nausea and vomiting − Syncope − Bradycardia − Dysrhythmias Terbutaline • Administered to suppress preterm labor • Used to treat pregnancy-induced asthma • Side effects include: − Hypertension − Chest pain − Cardiac dysrhythmias Valium • Indicated in eclampsia when seizures do not respond to magnesium sulfate • Principle side effects: − Nausea and vomiting − Respiratory depression − Hypotension Diphenhydramine • Used to treat hyperemesis gravidarum. • Side effects include: − Drowsiness − Headache − Tachycardia − Hypotension Oxytocin • A naturally occurring hormone that causes uterine contractions and can be used to: − Induce labor. − Control postpartum hemorrhage. Oxytocin • Side effect include: − Nausea and vomiting − Tachycardia − Seizures − Cardiac dysrhythmias Premature Rupture of Membranes • The amniotic sac ruptures, or opens, more than an hour before labor. − The sac may self-seal and heal itself. − Often, labor will begin within 48 hours. • If not near term, a risk of infection exists. Preterm Labor • Labor that begins after the 20th week but before the 37th week • Patient may be admitted to the hospital for medication, bed rest, and monitoring. Fetal Distress • Caused by many conditions • Difficult to assess in the field − Most women will know if fetal movement has slowed or stopped. • Provide support and rapid transport. Uterine Rupture • Occurs during labor • Signs and symptoms include: − Weakness, dizziness, and thirst − Initial strong contractions that have lessened − Signs of shock • Treat for shock, and provide rapid transport. Precipitous Labor and Birth • Entire labor time and birth usually occurs in less than 3 hours. • Contractions are usually more intense. • Assess the woman postdelivery for tears and bleeding. Postterm Pregnancy • The fetus has not been born after 42 weeks. • Cause is unknown. • High-risk because: − Fetus may become malnourished. − Increased chance of meconium aspiration Meconium Staining • Meconium: first stool the fetus passes • May be voided into the amniotic fluid and cause chemical pneumonia in the newborn. • Assess for need of suctioning if staining is present. Fetal Macrosomia • Weighs more than 4,500 grams (almost 9 lb) • Treatment should focus on: − Support and rapid transport − If field delivery: • Encourage breastfeeding. • Check newborn’s blood glucose level. Multiple Gestation • Prepare for more than one resuscitation. • Consider the possibility of multiples if: − First newborn is small − Abdomen is still fairly large after the birth. • The second newborn is usually born within 45 minutes. Multiple Gestation • The procedure is the same as a single birth. − Check if there are one or two cords coming out of the placenta when it delivers. • Record the time of birth for each newborn. Intrauterine Fetal Death • Fetus died in the uterus before labor. • Care will focus on the woman. • Actual cause is usually difficult to determine. Intrauterine Fetal Death • Labor can occur up to 2 weeks or more after the fetal death. − Labor usually progresses normally. − Do not attempt resuscitation of an obviously dead fetus. Amniotic Fluid Embolism • Amniotic fluid enters the woman’s pulmonary and circulatory system through the placenta. • Results in an allergic reaction response • Signs and symptoms include: − Respiratory distress and hypotension − Cyanosis − Possible seizures Amniotic Fluid Embolism • If the patient survives the initial reaction, they will likely develop coagulopathies. • Treatment includes: − Supporting respiratory and circulatory systems − Providing rapid transport Hydramnios • Too much amniotic fluid • Patients are at risk for: − Prolapsed cord and abruptio placenta − Postpartum hemorrhage Cephalopelvic Disproportion • Head of the fetus is larger than the pelvis. • A cesarean section is usually required. Cephalic Presentation • Newborn’s head is overly extended, creating a face presentation at birth. − Brow presentation − Occiput-posterior presentation − Military presentation Cephalic Presentation • If the newborn’s head cannot be externally rotated or the delivery cannot be completed: − Support the woman and fetus. − Provide rapid delivery. Breech Presentations • A different part of the body besides the head leads the way through the birth canal. • Types: − Frank − Incomplete − Complete Breech Presentations • Position the woman with buttocks at edge of bed or stretcher, legs flexed. • Allow newborn’s buttocks and trunk to deliver spontaneously. • Once the legs are clear, support the body. • Lower the newborn slightly. Breech Presentations • Once the hairline is spotted, grasp the newborn’s ankles and lift upward. • If the head does not deliver within 3 minutes, the newborn may suffocate. • Do not try to forcibly pull the newborn out. Breech Presentations • Other presentations are rare. − Footling breech − Transverse presentation • In abnormal presentations, do not attempt delivery in the field. Shoulder Dystocia • Difficulty in delivering the shoulders • If the shoulders cannot clear the birth canal, the fetus cannot breathe. • A major concern once born is brachial nerve plexus damage. Shoulder Dystocia • McRoberts maneuver − Hyperflex the woman’s legs tightly to the abdomen. − May need to apply pressure to the lower abdomen and gently pull on the fetus’s head. Nuchal Cord • The umbilical cord becomes wrapped around the newborn’s neck during delivery. − May cause fetal heart rate to slow • Slip a finder under the cord and gently attempt to slip it over the shoulder and head. − If unsuccessful, cut the cord. Prolapsed Umbilical Cord • The cord emerges before the fetus. − Shuts off the oxygenated blood supply from the placenta. − Leads to fetal asphyxia Prolapsed Umbilical Cord • Keep the woman supine with hips elevated. • Administer 100% supplemental oxygen. • Have the woman pant with each contraction. • Gently push the presenting part back up the vagina until it no longer presses on the cord. Prolapsed Umbilical Cord • Maintain pressure while another paramedic covers the exposed cord with dressings. • Maintain position throughout urgent transport. Uterine Inversion • Placenta fails to detach properly from the uterine wall when it is expelled. − Uterus turns inside out as a result. • Severity graded by how much the uterus has reversed itself. • Very painful and may rapidly cause shock. Uterine Inversion • Keep the patient recumbent. • Administer 100% supplemental oxygen. • Start two IV lines with normal saline. • Do not attempt to remove placenta if still attached to the uterus. Uterine Inversion • Carefully monitor vital signs. • Consider oxytocin to control hemorrhage. • Make one attempt to replace the uterus. Postpartum Hemorrhage • Can be either early or late hemorrhage − Early—bleeding within 24 hours of delivery − Late—bleeding occurring from 24 hours to 6 weeks after delivery • Blood loss exceeds 500 mL during first 24 hours after birth. Postpartum Hemorrhage • Causes of postpartum hemorrhage include: − Prolonged labor or multiple baby deliver − Retained products of conception − Placenta previa − Full bladder Postpartum Hemorrhage • Continue uterine massage. • Encourage the woman to breastfeed. • Notify the receiving facility of status. • Transport immediately. • Add a large-bore IV line en route. Pulmonary Embolism • Frequently caused by a clot arising in pelvic circulation from: − Amniotic embolism − Pregnancy-related venous thromboembolism − Water embolism Pulmonary Embolism • Suspect if a woman in the postpartum state experiences: − Sudden dyspnea − Tachycardia − − − − Atrial fibrillation Hypotension Sharp, sudden chest or abdominal pain Syncope Postpartum Depression • May appear up to 1 year after birth • Signs and symptoms include: − Signs similar to others with depression − Anger directed toward the infant − Little or no interest in the infant − Thoughts of harming themselves or their infant Trauma and Pregnancy • Trauma is a complicating factor in pregnancy. • Leading cause of maternal death in United States Pathophysiology and Assessment Considerations • Anatomic changes are important in trauma. − Abdominal contents compress into upper abdomen. − Diaphragm elevates by about 1.5 inches. − Peritoneum maximally stretches. Pathophysiology and Assessment Considerations • Pregnant patients will have different signs or responses to trauma. − May be more difficult to interpret tachycardia − Signs of hypovolemia may be hidden. − Higher chance of bleeding to death in case of pelvic fractures − Respiratory rate less than 20 breaths/min is not adequate. Considerations for the Fetus and Trauma • Fetal injury can occur from: − Rapid deceleration − Impaired fetal circulation • If a pregnant woman has massive bleeding, maternal circulation will reroute blood from the fetus. Considerations for the Fetus and Trauma • Fetal heart rate is the best indication of fetal status after trauma. − Normal fetal heart rate is between 120 and 160 beats/min. − Rate slower than 120 beats/min means fetal distress and a dire emergency. Management of the Pregnant Trauma Patient • Can only treat the woman directly − Determine gestational age of fetus if possible. • Transport a pregnant woman on left side if no spinal injury is suspected. Management of the Pregnant Trauma Patient • Ensure adequate airway. • Administer oxygen. • Assist ventilations when needed and provide a higher-than-usual minute volume. • Control external bleeding and splint fractures. Management of the Pregnant Trauma Patient • Start one or two IV lines of normal saline. • Inform the receiving facility of the patient’s status and estimated time of arrival. • Transport the patient in the lateral recumbent position. Postpartum Complications • Maternal cardiac arrest − Provide CPR and ALS like any other trauma patient. − CPR and ventilator support may keep the fetus viable, even if the mother is already dead. Summary • Ovaries are the beginning of reproduction. During the menstrual cycle, one follicle releases an ovum which, if fertilized, develops into an embryo, then a fetus. • The fallopian tubes transport the ovum from the ovary to the uterus. Once fertilized, it implants in the endometrium. • The fetus is enclosed in the amniotic sac. Summary • The gestational period normally lasts 38 weeks. • In the first trimester, the placenta, umbilical cord, specialized body systems, and limbs form. In the second trimester, the fetus gains weight and body systems become more specialized. In the third trimester, the fetus adds weight. Summary • Pregnancy is considered at term by week 37 of gestation. • Physiologic changes during pregnancy can alter a woman’s response to trauma and create or exacerbate medical conditions. • In an obstetric emergency, find out the length of gestation, estimated due date, complications with this or other pregnancies, and if there is any vaginal bleeding. Summary • Potential complications related to pregnancy include abuse of the pregnant woman, substance abuse by the pregnant women, and disorders that can develop during or be exacerbated by pregnancy. • Preeclampsia manifests after the 20th week, with symptoms of edema, hypertension, protein in the urine, severe headache, nausea and vomiting, agitation, rapid weight gain, and visual disturbances. Summary • Abortion, or fetal expulsion from any cause before the 20th week of gestation, can cause bleeding during pregnancy. • An incomplete abortion occurs when only some of the fetal material are expelled. • Causes of bleeding during pregnancy include ectopic pregnancy, abruptio placenta, or placenta previa. Summary • Vaginal bleeding may cause shock. • Labor may begins with a bloody show. • First stage of labor begins with contraction onset. • The second stage begins with the fetus’s head enters the birth canal. • The third stage occurs when the placenta is expelled. Summary • When assessing, determine if there is time to get to the hospital. • If delivery is imminent, prepare a private, clean area. • Never pull on the umbilical cord to deliver the placenta. • Pharmacology may include magnesium sulfate, calcium chloride, terbutaline, diphenhydramine, and oxytocin. Summary • High-risk pregnancy complications include precipitous labor and birth, postterm pregnancy, meconium staining, fetal macrosomia, multiple gestation, intrauterine fetal death, amniotic fluid embolism, hydramnios, and cephalopelvic disproportion. Summary • Meconium may be a yellow or greenish black tint in the amniotic fluid. If the newborn is depressed and meconium staining is present, suction the infant. • Labor complications include premature rupture of membranes, preterm labor, uterine rupture, and fetal distress. • Delivery complications include cephalic presentation, breech presentation, shoulder dystocia, nuchal cord, and prolapsed cord. Summary • Postpartum complications include uterine inversion, postpartum hemorrhage, pulmonary embolism, and postpartum depression. • Suspect pulmonary embolism if the pregnant patient experiences sudden dyspnea, tachycardia, atrial fibrillation or hypotension. Summary • Treat trauma in a pregnant woman the same as in a nonpregnant women, except transport a pregnant patient on her left side unless a spinal injury is suspected. Credits • Chapter opener: © Jones & Bartlett Learning. Courtesy of MIEMSS. • Backgrounds: Red—© Margo Harrison/ ShutterStock, Inc.; Green—Courtesy of Rhonda Beck; Lime—© Photodisc; Purple—Courtesy of Rhonda Beck. • Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.