Ch. 34 obstetrics and neonatal care

when does ovulation occur

approximately 2 weeks prior to menstruation

female reproductive system

placenta

• disk-shaped

• attached to the uterine wall and provides nourishment to the fetus

• keeps the circulation of the women and fetus separate but allows substances to pass between them

umbilical cord

connects the women and fetus through the placenta

umbilical vein and artery

• umbilical vein: carries oxygenated blood from the placenta to the heart of the fetus

• umbilical artery: carries deoxygenated blood from the heart of the fetus to the placenta

amniotic sac

• fluid-filled, baglike membrane in which the fetus develops

• when the sac ruptures, fluid is released in a gush - usually the beginning of labor

which systems undergo major physiologic and anatomic changes during pregnancy?

• respiratory

• cardiovascular

• musculoskeletal

• reproductive

reproductive system changes

• hormone levels increase

• uterus is displaced

  • increases the chance of direct fetal injury in trauma

rapid uterine growth during 2nd trimester:

• uterus pushes up on the diaphragm displacing it from its normal position

• increased RR, decreased minute volume

• overall blood volume gradually increases

  • number of RBCs increases

• speed of clotting increases

• HR increases

• cardiac output is significantly increased

what are pregnant women at an increased risk for?

• gastroesophageal reflux

• nausea, vomiting

• aspiration

weight gain during pregnancy

• challenges the heart and impacts the musculoskeletal system

• certain hormones make the joints “looser” or less stable

• 3rd trimester → changes in the body’s center of gravity causes an increase risk of falls

diabetes

• develops during the 2nd half of pregnancy in many women who previously did not have it

• gestational diabetes - usually resolves after delivery

• treatment: same as other pts with diabetes

hypertensive disorders

• gestational hypertension

• preeclampsia or pregnancy-induced hypertensin

  • can develop after the 20th week of gestation

• eclampsia

gestational hypertension

• definition: presence of high BP in the absence of other systemic effects

  • SBP higher than 140, DBP higher than 90

  • severe = SBP higher than 160, DBP higher than 110

signs and symptoms of preeclampsia

• severe hypertension

• severe of persistent headache

• visual abnormalities

• edema in the hands and feet

• upper abdominal or epigastric pain

• dyspnea and/or retrosternal chest pain

• anxiety

• altered mental status

eclampsia

• definition: seizures that occur as a result of hypertension

• treatment:

  • lay pt on her left side

  • maintain airway

  • oxygen

  • suction if necessary

  • rapid transport + call for ALS

supine hypotensive syndrome

low BP resulting from compression of the inferior vena cava by the weight of the pregnant uterus when the women is supine

ectopic pregnancy

• definition: an embryo develops outside of the uterus, typically in the fallopian tube

• occurs in the 1st trimester - some pt’s might not know they are pregnant yet

• signs/symptoms: internal bleeding, sudden onset of severe abdominal pain, vaginal bleeding

• it’s important to consider this in pts who have missed their menstrual cycle and are showing signs

spontaneous abortion (miscarriage)

• definition: the loss of pregnancy prior to 20 weeks of gestation without any preceding surgical or medical intervention

• often causes hemorrhage

abruptio placenta

• definition: premature separation of the placenta from the wall of the uterus

• commonly caused by hypertension or trauma

• signs/symptoms: dark vaginal bleeding, severe abdominal/back pain, rigid and tender uterus

placenta previa

• definition: a condition in which the placenta develops over and covers the cervix

• signs/symptoms: bright red, painless vaginal bleeding

treating any bleeding from the vaginal canal in pregnant women

• tret for shock if necessary

• place a sterile pad over the area and replace as needed

• do NOT insert anything to control bleeding

abuse of pregnant women

• increases the chance of spontaneous abortion, premature delivery, and low birth weight

  • high risk of bleeding, infection, and uterine rupture

• talk to the pt in a private area so they feel comfortable

substance abuse

• effects on the fetus - prematurity, low birth weight, severe respiratory distress, death

• fetal alcohol syndrome - condition of infants born to women who have abused alcohol

• newborn may need immediate resuscitation

trauma to the uterus

• uterus is vulnerable to penetrating and blunt force trauma

  • can be life-threatening due to its rich blood supply

• usually the only chance to save the fetus is to adequately resuscitate the women

CPR on a pregnant pt

may require compressions to be a little higher on the sternum of the pt is far in her pregnancy

delivering on scene

• stay in the house or in the ambulance

• area should be warm and private with lots of space

transporting pts in the 2nd or 3rd trimester

transport them lying on their left side of possible

provide rapid transport for pregnant pts who:

• have significant bleeding and pain

• are hypertensive

• are having a seizure

• have an altered mental status

history taking

• expected due date

• any complications that she is aware of

• if she has been receiving prenatal care

• a complete medical history

• frequency of contractions

• history of previous pregnancies and their complications

• determine if there is a possibility of multiples

• has the mother taken any drugs or medications

• if what broke, ask if it was green (due to meconium)

stages of labor

1.) dilation of the cervix

2.) delivery of the fetus

3.) delivery of the placenta

1st stage of labor

• begins with onset of contractions, ends when the cervix is fully dilated

• usually the longest stage

• rupture of the amniotic sac

• frequency and intensity of contractions increase with time

• lightening occurs

Braxton-Hicks contractions

• sporadic, often painless, or mildly uncomfortable uterine tightenings that act as a “warm-up” exercise for labor

• firm, tightening abdomen - last 30-60 seconds and occur irregularly

lightening

baby descends lower into the pelvis to prepare for birth

2nd stage of labor

• contractions are usually closer together and last longer

• perineum will bulge significantly - crowning will happen

3rd stage of labor

• placenta must completely separate from the uterine wall

  • may take up to 30 min

• begins with the birth of the newborn, ends with the delivery of the placenta

when to consider delivery at the scene

• delivery is imminent

• a natural disaster, inclement weather, or other factors make it impossible to reach the hospital

ask the following questions to determine if the delivery is imminent

• how long have you been pregnant?

• when are you due?

• is this your 1st pregnancy?

• are you having contractions?

  • how far apart?

  • how long do they last?

• have you had any spotting or bleeding?

• has your water broken?

• do you feel as though you need to have a bowel movement?

• do you feel the need to push?

to help determine potential complications, ask the following questions?

• were any of you previous deliveries by c-section?

• have you had problems in this or any previous pregnancies?

• do you use drugs, drink alcohol, or take any meds?

• do you know if there is a chance you will have multiple deliveries?

• does your physician expect any complications?

patient position for delivery

• clothing should be removed/pushed up to waist

• place pt on a firm surface that is padded with blankets, folded sheets, or towels

• elevate the hips about 2-4 inches with a pillow or blankets

• support the head, neck, and upper back with pillows or blankets

• have her keep her legs and hips flexed, with her feet flat on the surface beneath her and knees spread apart

preparing the delivery field

• put on proper BSI

• place towels or sheets on the floor

• open the OB kit

  • use the sterile sheets and drapes from the OB kit

delivery

• someone should be reassuring the pt at the head

• administer oxygen if the pt allows it

• be prepared for the pt to vomit

• continually check for crowning

  • time the contractions

  • during contractions → quick, short breaths

  • between contractions → rest and breathe deeply though mouth

delivering the head

1. observe the head as it begins to exit

2. place your sterile gloved hand over the emerging bony parts of the head to help maintain control

3. continue to support the head as it rotates

4. be careful that you don’t poke the newborn’s eyes or fontanelles

locations of fontanelles

unruptured amniotic sac

• will appear as a fluid-filled sac emerging

• sac will suffocate the fetus if not removed

  • puncture it with a clamp or tear it by twisting it between fingers - make sure the puncture site is away from the fetus’s face

  • clear the newborn’s mouth and nose with a bulb syringe and wipe the mouth and nose

umbilical cord around the neck

1. as soon as the head is delivered, use 1 finger to feel whether the umbilical cord is wrapped around the neck

2. usually, you can slip the cord gently over the delivered head

3. if not, it must be cut

delivering the body

1. support the head and upper body as the shoulders deliver

2. do not put the fetus from the birth canal

3. the newborn may be slippery and covered in vernix caseosa

postdelivery care

1. place the newborn on the mother’s abdomen is she is able and willing so skin-to-skin contact can begin

2. dry off the newborn and wrap him/her in a warm blanket or towel - ensure the top of the head is also covered

3. keep the newborn’s neck in a neutral position

4. wipe secretions

5. clamp and cut the umbilical cord after approximately 60 seconds

6. obtain the 1-minute Apgar score

7. after delivery of the placenta, place a sanitary pad

8. record time of birth

emergency situations after delivery

• more than 30 min 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

what is the golden minute?

the 1st minute after birth

the following should be done during the newborn’s 1st minute of life

• airway positioning and suctioning, if needed

• drying

• warming

• tactile stimulation

stimulation that can be done to encourage the newborn to breathe

• position the airway in a neutral or sniffing position

• if necessary, then suction the mouth and nose

• vigorously dry the head, body, and back

• rub the newborn’s back, and gently flick or slap the soles of his or her feet

• tactile stimulation

• if signs of adequate ventilation are not present after 30 sec, then positive pressure ventilations may be necessary

additional resuscitation efforts

1. observe the newborn for spontaneous respirations, skin color, and movement of the extremities

2. evaluate the HR - should be 100 or higher

3. listen to heart/lung sounds

4. use hand-encircling technique for compressions - 3:1 ratio

5. if you see meconium staining consider quickly suctioning the newborn’s mouth and nose after delivery

The Apgar score

• calculate at 1 min and 5 min after birth

• highest score = 10

assessing newborn’s pulse ox

• best taken at the right wrist

• observe for central cyanosis

  • administer blow-by oxygen if cyanosis is present

  • set flow rate to 5 L/min

breech delivery

• definition: buttocks or feet are delivered 1st

• usually take longer

• during delivery

  • support the chest and trunk

  • make sure the airway is not compressed

limb presentation

• cannot be delivered in the field so you must transport immediately

• cover the protruding limb with a sterile towel

• place the pt on her back, with her dead down and pelvis elevated

prolapse of the umbilical cord

• keep the cord from compressing the fetus’s head

  • push the head away from the cord

• place the women supine with the foot of the stretcher raised 6-12 inches higher than her head, with hips elevated on a pillow or folded sheet

  • or knee-chest position

• wrap a sterile moist towel with saline around the exposed core

• give the pt high-flow oxygen and transport

spina bifida

• definition: developmental defect in which a portion of the spinal cord or meninges may protrude outside of the vertebrae and possibly outside of the body

• treatment: cover the open area of the spinal cord with a sterile, moist dressing and then an occlusive dressing immediately after birth

  • maintenance of the newborn’s body temp is important when applying the moist dressings

multiple gestation

• twins occur about 1/30 births

• 10 minutes after the 1st birth, the process will begin again

• clamp and cut the cord of the 1st newborn as soon as it has been born and before the 2nd newborn is delivered

• record the time of birth of each twin separately

premature birth

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

• head is proportionately larger than the rest of the body

• vernix caseosa will be absent or minimal and there will be less body hair

postterm pregnancy

• definition: pregnancies lasting longer than 41 weeks of completed gestation

• fetuses can be larger than a typical 40-week fetus, sometimes weighing 10 lb or more

• more difficult labor

  • increased chance of c-section

• the women is at risk for tears and infection

• postterm newborns have increased risks of meconium aspiration, infection, and being stillborn

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 deceased neonate

postpartum pts are at an increased risk of a _____ ______

venous embolism

postpartum pts and pulmonary embolisms

• after delivery in the field, if the woman begins to report sudden difficulty breathing or shortness of breath, consider PE

• suspect PE in pts of childbearing age with respiratory complaints who have recently delivered, especially with the sudden onset of difficulty breathing or altered mental status