EMERGENCY CHILDBIRTH
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INTRODUCTION
Optimal patient care requires that the EMT-I understands the physiology of pregnancy and management of patients experiencing childbirth. The following topics will be discussed during this lesson:
· Female reproductive anatomy and physiology
· Pregnancy; physiologic changes
· Normal delivery process
· Care of the mother and newborn immediately after delivery
· Potential complications during pregnancy and labor
LESSON OBJECTIVES
At the completion of this lesson the participants will be able to:
1. Identify normal anatomy and physiology of the female reproductive system
2. Discuss physiologic changes during pregnancy
3. Define the role of the EMT-I & EMT-P during emergency childbirth
4. State the priorities of care in an uncomplicated field delivery
5. Identify the stages of labor
6. Discuss the postpartum care of the mother and newborn
7. Identify common complications of pregnancy
8. Identify potential complications and treatment during labor
SKILLS
·
Initial assessment, Focused History and Detailed
Physical Examination of the pregnant patient and newborn
· Childbirth
· Abortion: The expulsion of an embryo or fetus from the uterus before the 20th week; can occur spontaneously or through a medicalprocedure
· Abruptio placentae: Sudden separation of the placenta from the wall of the uterus
· Amniotic sac: Fibrous sac that is filled with a clear to straw colored fluid, also called bag of water; protects the fetus
· APGAR: Scoring system used to evaluate the condition of a newborn after one and five minute(s) of life
· Breech birth: A birth in which the presenting part of fetus is either the buttocks, foot, or leg of the fetus
· Cervix: Neck of the uterus which dilates during labor to allow passage of the baby into the vagina (birth canal)
· Crowning: Bulging of the perineum when birth is imminent and the presenting part is visible at the vaginal opening
· Eclampsia: Predelivery increase in blood pressure which ultimately results in seizure activity
· Fallopian tubes: Paired canal approximately four inches long connecting the ovary to the uterus
· Gravida: Total number of pregnancies
· Gynecology: The study of diseases of womens reproductive organs
· Labor: Regular uterine contractions that increase in frequency and intensity that propel the fetus from the uterus
· Meconium: Fetal intestinal contents that stains the amniotic fluid green or black; fetus may expel contents of bowels before birth due to stress; indicates a birth complication
· Menstruation: The periodic sloughing of the uterine lining, which is comprised of blood, issue, and cells
· Mucous plug: An accumulation of mucus that forms and interlocks with the capillaries of the cervix during pregnancy; acts as a protective barrier between the cervix and the vagina for the length of the pregnancy
· Obstetrics: The branch of medicine that deals with the management of women during pregnancy, childbirth and 42 days after the expulsion of all contents of pregnancy
· Ovaries: Paired, almond-shaped organs suspended by ligaments in the left and right lower quadrants of the abdomen that release a mature egg once a month in women and girls from the approximate ages of 9 to 50 years
· Ovulation: The release of a mature egg from an ovary once a month
Total number of viable (20 weeks or greater) births
· Perineum: Space located between the vaginal opening and the anal opening
· Placenta: Highly vascular dishlike structure that links the tissue of the mother with that of the fetus. The placenta exchanges oxygen and carbon dioxide between the fetus and mother, transports nutrients and waste by-products, and serves as a temporary source for hormone production necessary to sustain pregnancy
· Placenta previa: Condition in which the placenta implants itself either on or near the opening of the cervix; severe bleeding in late pregnancy occurs when the cervix begins to dilate in early delivery
· Presenting part: The part of the fetus that protrudes initially during the birthing process
· Prolapsed cord: Premature expulsion of the umbilical cord
· Trimester: A 3-month period; there are three 3-month periods, or three trimesters, during a pregnancy
· Tubal pregnancy: Pregnancy in which the fertilized egg implants in a fallopian tube; also known as an ectopic pregnancy
· Umbilical cord: Fibrous, whitish cord that connects the fetus to the placenta
· Uterine rupture: Rupture of the uterus caused by trauma or previous cesarean scarring
· Uterus: Single, pear-shaped, muscular organ located between the rectum and the bladder that houses the fetus during fetal development
· Vagina: Fibromuscular sheath that lead from the uterus and extends to the vaginal opening
KEY CONCEPTS
The following section provides information and space for taking notes on the key concepts discussed by the instructor.
ANATOMY AND PHYSIOLOGY
Female Reproductive Anatomy
Ovaries
Fallopian Tubes
Uterus
Cervix
Vagina
Perineum
Specialized Structures of Pregnancy
Fetus
Placenta
Umbilical cord
Amniotic sac
Amniotic fluid
Mucus plug
Physiologic Changes During Pregnancy
Cardiovascular
Hypervolemia
Increased perfusion of the uterus
Anemia
Decreased venous return
Amniotic sac
Respiratory
Abdominal
Decreased Response to peritoneal irritation
Bladder elevated out of pelvis
Decreased peristalsis
Musculoskeletal
Softening of most joints
Relaxation of sacroiliac joint
Widening of the symphysis pubis
FOCUSED HISTORY AND DETAILED PHYSICAL EXAMINATION
(after initial assessment completed)
Last menstrual period
Due date
Prenatal care
Prior pregnancy history
Medical problems
Rupture of membranes
Physical Assessment
Vital signs
Mucus plug/bag of waters
Vaginal bleeding/spotting
Abdominal/back pain
Abdomen rigid or hard
Feeling as though bowels need to move
Bulging perineum
Presenting part visible
Contractions
frequency/duration/intensity
Transport vs. Field Delivery Considerations
Number of pregnancies
Signs of imminent delivery
Presence of complications
DELIVERY PROCEDURE
Stages of Labor
First Stage:
From the first contraction, until full dilation of the cervix
Second Stage:
From dilation of the cervix, to the birth of the child
Third Stage:
From the birth of the child, until the delivery of the placenta
Assisting with Normal Delivery Process
Preparation
Universal precautions
Position mother on her back with her knees bent and
spread apart
Elevate the patients buttocks with a towel or
blanket
Create a sterile field around the vaginal opening
if possible
Place a gloved hand on the presenting part and
apply slight pressure to prevent an explosive birth
Delivery of Fetus
Delivery of Fetus
If the amniotic bag has not broken, use a clamp to
puncture a hole in the membrane
Tear the membrane away from the head and mouth of
the infant
Once the head has delivered, feel to ensure that
the umbilical cord is not wrapped around the neck
Aggressively suction the mouth and nose of the
infant
Place both hands on either side of the bays head
and apply gentle downward pressure to deliver the upper shoulder; then
gently apply upward pressure to deliver the lower shoulder
Support the head and shoulders carefully; the baby
will be very slippery
The rest of the baby will deliver quickly, usually
within the next two contractions
Once the baby is delivered, wipe the blood and
mucus from the mouth and nose and suction again
Post-delivery Care of the Mother
500cc blood loss is normal for vaginal delivery
Do not pull on the umbilical cord
Placenta will usually deliver within 20 minutes
Wrap placenta in a towel and place in a plastic
bag; take placenta to hospital
Place a sterile pad over vaginal opening and lay
mothers legs flat
If after delivery of the placenta bleeding is
excessive, massage the fundus or encourage mother to breast-feed the
newborn; this causes the uterus to contract and may slow bleeding
Post-delivery Care of the Newborn
Dry off the baby and wrap in a warm blanket
Keep the baby level with the vagina until the
umbilical cord is cut
Once the cord has stopped pulsating, place one
clamp approximately four inches away from the babys belly
Place the other clamp two inches away from the
first, towards the placenta
Using sterilized scissors, cut between the two
clamps
Perform APGAR at one and five minutes post-delivery
APGAR Scoring System
|
SIGN |
0 |
1 |
2 |
|
Appearance (Skin Color) |
Blue, pale |
Body pink, blue extremities |
Completely pink |
|
Pulse Rate (Heart Rate) |
Absent |
<100/minute |
>100/minute |
|
Grimace (Irritability) |
No response |
Grimace |
Cough, sneeze, cry |
|
Activity (Muscle Tone) |
Limp |
Some flexion |
Active motion |
|
Respiration (Respiratory Effort) |
Absent |
Slow, irregular |
Good, crying |
COMPLICATIONS OF PREGNANCY
First Trimester Complications
Ectopic Pregnancy: Occurs when an ovum implants at a site other than the
uterus, most often in a fallopian tube
Signs and Symptoms
History of missed or scanty menstrual period
Possible vaginal bleeding
Unilateral abdominal pain
Possible positive orthostatic vital signs
Possible syncope
Miscarriage/Abortion: Any embryo or fetus that is expelled from the
uterus before the 20th week; whether by nature or choice
Signs and Symptoms
Vaginal bleeding; may be mild or profuse
Cramp-like pain or pain in the back
Possible history of passing tissue
Fever (due to sepsis)
Field Treatment for First Trimester Complications
BLS
Supplemental oxygen
Place sterile pad or sanitary napkin over vagina
Count saturated pads; bring tissue or clots, that
may have been passed, to the hospital
Shock position as needed ALS
IV access
Fluid resuscitation as needed
Second Trimester Complications
Pregnancy Induced Hypertension-Preeclampsia
Signs and Symptoms
Occurs during the 2nd or 3rd
trimester
More common in primigravidas
May be mild or severe
Headache/visual disturbances/seeing spots
Weight increase/facial and dependent edema
Hypertension
Anxiety
Eclampsia: Sequela of Preeclampsia with seizure activity
Signs and Symptoms
Seizure with a history of Preeclampsia
Seizure activity is the only differentiating factor
between preeclampsia and eclampsia
Field Treatment for Pregnancy Induced Hypertension
BLS
Monitor airway, breathing, and circulation
Provide patient safety
Administer supplemental oxygen ALS
Advanced airway as needed
Cardiac monitor PRN
Establish venous access
Administer medications as ordered by base
Third Trimester Complications
Placenta Previa: Painless vaginal bleeding; occurs when the placenta is
attached too low in the uterus
Signs and Symptoms
Sudden onset of bleeding
Occurs as the cervix dilates during labor
Blood is bright red in color
Abdomen soft on palpation
Placenta Abrupto: Sudden separation of placenta from uterine wall;
may occur spontaneously, or may be caused by trauma
Sign and Symptoms
Vaginal bleeding may or may not be present
Blood will be dark red
Abdominal pain
Abdomen will be hard and rigid on palpation
Hypotension
Tachycardia
Uterine Rupture: Rupture of uterus caused by trauma or previous cesarean scarring
Signs and Symptoms
Tearing-like abdominal pain
May occur during labor or due to trauma
vaginal bleeding may or may not be present
Firm, rigid abdomen; occasionally, fetus can be
palpated
Hypotension
Tachycardia
BLS
Monitor airway, breathing, and circulation
Supplemental oxygen
treat for shock
Apply sanitary napkin for vaginal bleeding
Position patine in shock position on left-lateral
side if indicated ALS
Establish venous access
Rapid transport
Field Management for Third Trimester Complications
COMPLICATIONS OF DELIVERY
Abnormal Presentations
Breech
The buttocks will be the presenting part
Deliveries are usually slow
If buttocks and legs are delivered, use your
fingers to keep the wall of the vagina away from the babys mouth and nose
during transport or until the head is delivered
Limb
Foot, arm, or leg are the presenting part
Transport immediately
Usually requires surgical intervention
Place a sterile towel over the presenting part
Umbilical Cord
Do not attempt to push the cord back into the
vagina
Transport immediately
Keep the babys head from compressing the cord
Transport the mother on a backboard with her hips
elevated or kneeling, leaning
forward, and face down
Wrap a sterile towel around the exposed cord
Multiple Births
Twins occur in one out of every 80 births
The infants are usually smaller than single birth
babies
May require resuscitation
Meconium
Occurs when the fetus is under stress
The fetus has a bowel movement in the amniotic sac
Requires aggressive suctioning upon delivery
Newborn Distress
Multiple births
Drug addicted mother
Delivery prior to the seventh month
Prolonged labor
Abnormal presentation
Presence of meconium
Compromised respiratory status
Decreased heart rate
Cyanotic chest and abdomen