CHAPTER 21: OBSTETRICS & NEONATAL CARE

PATIENT ASSESSMENT & CARE II

EMS 246

Dr. HANA OMER

Anatomy and Physiology of the Female Reproductive System (1 of 9)

• Female reproductive system includes:

Ovaries

Fallopian tubes

Uterus

Cervix

Vagina

Breasts

Anatomy and Physiology of the Female Reproductive System (2 of 9)

• The ovaries are two glands, one on each side of the uterus.

Each ovary contains thousands of follicles, and each follicle contains an egg.

Ovulation occurs approximately 2 weeks prior to menstruation.

Anatomy and Physiology of the Female Reproductive System (3 of 9)

• 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 continues to the uterus where it continues to develop into an embryo.

Anatomy and Physiology of the Female Reproductive System (4 of 9)

• The uterus, is a muscular organ where the fetus grows for approximately 9 months (40 weeks).

Responsible for contractions during labor

Helps to push the infant through the birth canal (made up of the vagina and the cervix.)

Anatomy and Physiology of the Female Reproductive System (5 of 9)

Anatomy and Physiology of the Female Reproductive System (6 of 9)

• The vagina is the outermost cavity of the female reproductive system and forms the lower part of the birth canal

The perineum is the area of skin between the vagina and the anus.

Anatomy and Physiology of the Female Reproductive System (7 of 9)

• The placenta attaches to the inner lining of the wall of the uterus and connects to the fetus by the umbilical cord.

Anatomy and Physiology of the Female Reproductive System (8 of 9)

• After delivery, the placenta, or afterbirth, separates from the uterus and delivers.

• The umbilical cord is the lifeline of the fetus.

The umbilical vein carries oxygenated blood from the woman to the fetus.

The umbilical arteries carry deoxygenated blood from the fetus to the woman.

Anatomy and Physiology of the Female Reproductive System (9 of 9)

• The fetus develops inside a fluid-filled, baglike membrane called the amniotic sac, or bag of waters.

Contains about 500 to 1,000 mL of amniotic fluid

Fluid helps insulate and protect the fetus.

Normal Changes in Pregnancy

• Hormone levels increases

• Rapid uterine growth occurs in the second trimester

• Respiratory rates increases and minute volumes decreases.

• Blood volume gradually increases

• Number of red blood cells will increase

• Weight gain is expected ( 12 – 15 ) .

Stages of Labor

• Dilation of the cervix

• Delivery of the infant

• Delivery of the placenta

First Stage (1 of 3)

• The first stage is the longest part of labor and can last up to 20 hours. It begins when your cervix starts to open (dilate) and ends when it is completely open (fully dilated) at 10 centimeters .

• Labor is generally longer in a primigravida than in a multigravida.

A primigravida is a woman experiencing her first pregnancy.

A multigravida is a woman who has experienced previous pregnancies

First Stage (2 of 3)

First Stage (3 of 3)

• Some women experience a premature rupture of the amniotic sac.

The fetus is not ready to be born.

• The head of the fetus descends into the woman’s pelvis as it positions for delivery.

This descent is called lightening.

Second Stage (1 of 2)

• Begins when the fetus begins to encounter the birth canal

Ends when the infant is born (spontaneous birth)

Uterine contractions are usually closer together and last longer.

Never let the mother sit on the toilet.

Second Stage (2 of 2)

• The perineum will bulge and the top of the infant’s head will appear at the vaginal opening.

This is called crowning.

Third Stage

• Begins with the birth of the infant and ends with the delivery of the placenta

Complications of Pregnancy

1.Hypertensive disorder

2.Bleeding

3.Gestational Diabetes

Hypertensive Disorders

• Preeclampsia

Pregnancy-induced hypertension

Can develop after the 30th week of gestation

Signs and symptoms include headache, seeing of spots, swelling in the hands and feet, anxiety, and high blood pressure.

• Eclampsia is characterized by seizures that occur as a result of hypertension.

Bleeding (1 of 4)

• Internal bleeding may be the sign of an ectopic pregnancy.

– A pregnancy that develops outside the uterus, most often in the fallopian tubes

Bleeding (2 of 4)

• The leading cause of maternal death in the first trimester is internal hemorrhage following rupture of an ectopic pregnancy.

• Hemorrhage from the vagina that occurs before labor begins may be very serious.

Bleeding (3 of 4)

• May be a sign of spontaneous abortion, or miscarriage.

In abruptio placenta, the placenta separates prematurely from the wall of the uterus.

In placenta previa, the placenta develops over and covers the cervix.

Bleeding (4 of 4)

Diabetes

• Develops during pregnancy

• Gestational diabetes will clear up after delivery.

• Treatment:

Diet, exercise, or insulin injections

Special Considerations for Trauma and Pregnancy (1 of 2)

• Any trauma to the woman has a direct effect on the fetus.

• Pregnant women also have an increased risk of falls

• When a pregnant woman is involved in a motor vehicle crash, it can cause abruptio placenta( causing vaginal bleeding and severe abdominal pain.)

Special Considerations for Trauma and Pregnancy (2 of 2)

• Follow these guidelines when treating a pregnant trauma patient:

Maintain an open airway.

Administer high-flow oxygen.

Ensure adequate ventilation.

Assess circulation.

Transport the patient on her left side.

Cultural Value Considerations

• Some cultures may not permit a male health care provider to assess or examine a female patient.

Respect these differences and honor requests from the patient.

Teenage Pregnancy

• Pregnant teenagers may not know they are pregnant or may be in denial.

Respect the patient’s privacy.

Assess history away from her parents.

Patient Assessment

• Patient assessment steps

Scene size-up

Primary assessment

History taking

Secondary assessment

Reassessment

Scene Size-up

• Scene safety

Gloves, eye protection, a mask and gown should be used.

• Mechanism of injury/nature of illness.

Falls and spinal immobilization must be considered.

Primary Assessment (1 of 2)

• Form a general impression.

The general impression should tell you whether the patient is in active labor

Perform a rapid scan.

determine the patient’s level of consciousness.

• Airway and breathing

Assess the airway and breathing

If needed, provide airway management and high-flow oxygen.

Primary Assessment (2 of 2)

• CirculationCheck for any external or internal bleedingAssess the skin for color, temperature, and moisture.Check the pulse.

• Transport decision If delivery is imminent, prepare to deliver at the scene. If delivery is not imminent, prepare the patient for

transport

History Taking

• Investigate the chief complaint. Identify the cause of her complaint

• Obtain a SAMPLE history.

Determine the due date, frequency of contractions, a history of previous pregnancies and deliveries, the possibility of twins, and if she has taken any drugs or medications.

If her water has broken, ask whether the fluid was green.Green fluid is due to meconium (fetal stool). indicate newborn distress

Secondary Assessment

• Physical examination

Assess for fetal movement.

For a pregnant patient in labor, focus on contractions and possible delivery.

• Vital signs

Include pulse; respirations; skin color, temperature, and condition; and BP

Hypertension may indicate more serious problems

Reassessment

• Repeat the primary assessment.

• Obtain another set of vital signs..

• Interventions In most cases, childbirth is a natural process that does not

require your assistance.

• Communication and documentation If delivery is imminent, notify staff at the receiving

hospital. If delivery does not occur within 30 minutes, provide

rapid transport

Preparing for Delivery (1 of 3)

• To determine if delivery is imminent, ask the patient:

How long have you been pregnant?

When are you due?

Is this your first baby?

Are you having contractions?

How far apart?/ How long do they last?

Do you feel as though you will have a bowel movement?

Have you had spotting or bleeding?

Has your water broken?

Were any of your previous children delivered by cesarean section?

Preparing for Delivery (2 of 3)

• To help determine potential complications, ask:

Have you had problems in a previous pregnancy?

Do you use drugs, drink alcohol, or take any medications?

Is there a chance of multiple birth?

Preparing for Delivery (3 of 3)

• Patient position

Place the patient on a firm surface that is padded with blankets, sheets, and towels.

Elevate the hips about 2″ to 4″.

Support the head, neck, and upper back.

• Preparing the delivery field

Put on sterile gloves.

Use the sterile sheets and towels from the OB kit to make a sterile delivery field.

Delivery (1 of 5)

Your partner should be at the patient’s head to comfort, soothe, and reassure.

If she will allow it, apply oxygen.

Continually assess for crowning.

Delivery (2 of 5)

Delivery (3 of 5)

• Delivering the head

If the amniotic sac does not rupture at the beginning of labor, it will appear as a fluid-filled sac emerging from the vagina.

It will suffocate the infant if not removed.

You may puncture the sac with a clamp.

Clear the infant’s mouth and nose immediately.

Delivery (4 of 5)

As soon as the head is delivered, use one finger to feel whether the umbilical cord is wrapped around the neck (nuchal cord).

Usually, you can slip the cord gently over the infant’s head.

If not, you must cut it.

Suction the amniotic fluids from the airway.

Delivery (5 of 5)

• Delivering the body

The head usually rotates to one side or the other.

This rotation helps deliver the body.

The infant will be slippery and covered in vernix caseosa.

Postdelivery Care (1 of 3)

Dry off the infant and wrap in a warm blanket or towel. Place the infant on one side, with the head slightly lower than

the rest of the body. to help prevent aspiration. Wipe the mouth with a sterile gauze pad. Suction the mouth and nose Keep infant at the level of the mother’s vagina until the

umbilical cord is cut Clamp and cut the cord, and tie the end with special

“umbilical tape.”

Postdelivery Care (2 of 3)

Delivery of the placentaThe placenta delivers itself,

usually within a few minutes of the birth.

Never pull on the end of the umbilical cord.

You can help to slow bleeding by gently massaging the mother’s abdomen with a firm, circular, “kneading” motion

Postdelivery Care (3 of 3)

The following are emergency situations:

More than 30 minutes elapse, and the placenta has not delivered

There is more than 500 mL of bleeding before delivery of the placenta.

There is significant bleeding after the delivery of the placenta.

Neonatal Assessment and Resuscitation (1 of 2)

• Follow standard precautions

• Always put on gloves before handling a newborn.Newborn should begin breathing spontaneously within 15

to 30 seconds after birth.Heart rate should be 120 beats/min or higher.

• If you do not observe these responses:Gently tap or flick the soles of the feet or rub the back.Begin resuscitation efforts.

Neonatal Assessment and Resuscitation (2 of 2)

Additional Resuscitation Efforts

• If chest compressions are required, give them at a rate of 120 beats/min.

The Apgar Score (1 of 2)

• Standard scoring system used to assess the status of a newborn.Includes:

Appearance

Pulse

Grimace or irritability

Activity or muscle tone

Respirations

• The total of the five numbers is the Apgar score.

A perfect score is 10. Calculate at 1 min and 5 min after birth.

The Apgar Score (2 of 2)

Breech Delivery

• The presentation is the position in which an infant is born

– Most infants are born headfirst.

• Breech deliveries usually take longer

• Preparing for a breech delivery is the same as for a normal childbirth.

Presentation Complications (1 of 2)• On rare occasions, the

presenting part of the infant is a single arm, leg, or foot.This is called a limb

presentation.

• An infant with a limb presentation cannot be delivered in the field.Usually surgery is needed

Presentation Complications (2 of 2)

The umbilical cord comes out of the vagina before the infant. This is called “Prolapse of the umbilical cord”.

Place the pregnant woman on a backboard in Trendelenburg’s or knee-chest position.

Insert your gloved hand into the vagina, and push the infant’s head away from the umbilical cord.

Spina Bifida

• Developmental defect in which a portion of the spinal cord or meninges may protrude outside of the vertebrae

Easily seen on the newborn’s back

Abortion

• Passage of the fetus and placenta before 20 weeks

• May be spontaneous or intentional

• Most serious complications are bleeding and infection

Multiple Gestation

• Twins are smaller than single infants, and delivery is typically not difficult.

After 10 minutes after the first birth, contractions will begin again, and the birth process will repeat itself.

There may only be one placenta, or there may be two.

Abuse

Abuse increases the chance of:

Miscarriage

Premature delivery

Low birth weight

The woman is at risk from bleeding, infection, and uterine rupture

Substance Abuse

• Effects of addiction on the fetus include:

Prematurity

Low birth weight

Severe respiratory distress

Death

• Fetal alcohol syndrome describes the condition of infants born to mothers who have abused alcohol.

Premature Infant

• Any infant who delivers before 8 months (36 weeks) or weighs less than 5 lb at birth is considered premature.

• A premature infant is smaller, thinner, and the head is proportionately larger.

The vernix will be missing or minimal.

There will be less body hair.

Postterm Pregnancy

• Pregnancies lasting longer than 42 weeks

• Infants can be larger, sometimes weighing 10 lb or more.

• Problems: Increased chance of injury to the fetus Increased chance of cesarean sectionWoman is at risk for perineal tears and infection. Infants have increased risks of meconium aspirations,

infection, and being stillborn.

Fetal Demise

• You may deliver an infant who died in the mother’s uterus before labor.

labor will progress normally in most cases.

Do not attempt to resuscitate an obviously dead infant.

Delivery Without Sterile Supplies

• You should always have eye protection, gloves, and a mask with you.

Use clean sheets and towels.

Wipe the inside of the infant’s mouth with your finger.

Do not cut or tie the umbilical cord.

As soon as the placenta delivers, wrap it in a clean towel and transport.

Keep the placenta and the infant at the same level, and keep the infant warm.

Postpartum Complications

• Bleeding that exceeds 500 mL is considered excessive.

usually caused by the uterine muscles not fully contracting.

• Increased risk of an pulmonary embolism.

Results from a clot that travels through the bloodstream and becomes lodged in the pulmonary circulation.

potentially life threatening.

SUMMARY

• Inside the uterus, the developing fetus floats in the amniotic sac. The umbilical cord connects the mother and fetus through the placenta. Eventually, contractions of the uterus will propel the neonate through the birth canal.

• As a result of enlargement of the uterus, a pregnant patient’s respiratory capacity changes with increased respiratory rates and decreasing minute volumes.

• The first stage of labor, dilation, begins with the onset of contractions and ends when the cervix is fully dilated.

• The second stage of labor, expulsion of the fetus, begins when the cervix is fully dilated and ends when the infant is born.

SUMMARY

• The third stage of labor, delivery of the placenta, begins with the birth of the infant and ends with the delivery of the placenta.

• Once labor has begun, it cannot be slowed or stopped; however, there is usually time to transport the patient to the hospital during the first stage of labor.

• During the second stage of labor, you must decide whether to deliver the infant at the scene or transport the patient.

• During the third stage of labor, once the infant has been born, you will probably not transport the patient until the placenta has been delivered.

SUMMARY

• Complications of pregnancy include hypertensive disorders, bleeding, and diabetes.

• Abnormal or complicated deliveries include breech deliveries, limb presentations, and prolapse of the umbilical cord. Quickly transport the patient with a limb presentation or prolapsed umbilical cord to the hospital.

UNIT ASSESSMENT

Which stage of labor is usually the longest?

What signs and symptoms characterize preeclampsia?

What is an ectopic pregnancy?