Chapter 34: Obstetrics and Neonatal Care

Neonate (0 to 1 mo)

Pulse Rate: 100 to 180 beats/min
Respiratory Rate: 30 to 60 breaths/min
Systolic Blood Pressure: 50 to 70 mm Hg
Body Temperature: 98 to 100 degrees F

Infant (1 mo to 1 yr)

Pulse Rate: 100 to 160 beats/min
Respiratory Rate: 25 to 50 breaths/min
Systolic Blood Pressure: 70 to 95 mm Hg
Body Temperature: 96.8 to 99.6 degrees F

Toddler (1 yr to 3 yrs)

Pulse Rate: 90 to 150 beats/min
Respiratory Rate: 20 to 30 breaths/min
Systolic Blood Pressure: 80 to 100 mm Hg
Body Temperature: 96.8 to 99.6 degrees F

Preschool Age (3 to 6 yrs)

Pulse Rate: 80 to 140 beats/min
Respiratory Rate: 20 to 25 breaths/min
Systolic Blood Pressure: 80 to 100 mm Hg
Body Temperature: 98.6 degrees F

School Age (6 to 12 yrs)

Pulse Rate: 70 to 120 beats/min
Respiratory Rate: 15 to 20 breaths/min
Systolic Blood Pressure: 80 to 110 mm Hg
Body Temperature: 98.6 degrees F

Adolescents (12 to 18 yrs)

Pulse Rate: 60 to 100 beats/min
Respiratory Rate: 12 to 20 breaths/min
Systolic Blood Pressure: 90 to 110 mm Hg
Body Temperature: 98.6 degrees F

Early Adult (19 to 40 yrs)

Pulse Rate: 60 to 100 beats/min
Respiratory Rate: 12 to 20 breaths/min
Systolic Blood Pressure: 90 to 140 mm Hg
Body Temperature: 98.6 degrees F

Middle Adult (41 to 60 yrs)

Pulse Rate: 60 to 100 beats/min
Respiratory Rate: 12 to 20 breaths/min
Systolic Blood Pressure: 90 to 140 mm Hg
Body Temperature: 98.6 degrees F

Late Adult (61 yrs & older)

Pulse Rate: Depends on health
Respiratory Rate: Depends on health
Systolic Blood Pressure: Depends on health
Body Temperature: 98.6 degrees F

The ovaries

are two glands, one on each side of the uterus, that are similar in function to the male testes.

Ovulation occurs

approximately 2 weeks prior to menstruation.

if the egg is fertilized, where does it implant

in the endometrium

if the egg is not fertilized within 26-48 hours what happens?

The lining is shedded as menstrual flow

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 uterus

is a muscular organ that encloses and protects the fetus, produces contractions during labor and helps to push the fetus through the birth canal.

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.

The perineum

is the area between the vagina and the anus.

the breasts

produce milk that is carried through small ducts to the nipple to provide nourishment to the newborn once it is born.

The placenta

is a disk-shaped structure attached to the uterine wall that provides nourishment to the fetus.

Keeps the circulation of the woman and fetus separated but allows substances to pass between them

The umbilical vein

carries oxygenated blood from the placenta to the heart of the fetus.

The umbilical arteries

carry deoxygenated blood from the heart of the fetus to the placenta.

amniotic sac

The fetus develops inside a fluid-filled, baglike membrane, contains about 500 to 1,000 mL of amniotic fluid, which helps insulate and protect the floating fetus

The amniotic fluid is released in a gush when the sac ruptures, usually at the beginning of labor.

Pregnancy is considered full term

when it reaches 39 weeks but has not gone beyond 40 weeks, 6 days.

During pregnancy four body systems undergo major physiologic and anatomic changes.

1. These are the respiratory, cardiovascular, and musculoskeletal systems.

In the reproductive system, hormone levels?

increase to support fetal development and prepare the body for childbirth.

As the uterus grows?

it pushes up on the diaphragm displacing it from its normal position.

With increased respiratory rates and decreased minute volumes.

Respiratory capacity changes

What does the overall blood volume do?

Increases through the pregnancy, may eventually increase as much as 50% by the end of the pregnancy.

Red blood cells also do what?

increase

Speed of clotting increases to protect against?

excessive bleeding during delivery.

By the end of pregnancy,

the pregnant patient’s heart rate increases up to 20% to accommodate the increase in blood volume.

Cardiac output is significantly increased by

the end of pregnancy

Pregnant women are at an increased risk for?

gastroesophageal reflux, nausea, vomiting, and potential aspiration because of changes that occur in the gastrointestinal tract.

Certain hormones affect the musculoskeletal system by making the joints

“looser” or less stable.

Diabetes in pregnancy

1. Diabetes develops during the second half of 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.

Gestational hypertension

is the presence of high blood pressure in the absence of other systemic effects.

a. Defined as a systolic blood pressure higher than 140 mm Hg and a diastolic blood pressure higher than 90 mm Hg.

b. Considered severe when the systolic blood pressure is higher than 160 mm Hg and/or the diastolic pressure is higher than 110 mm Hg.

Preeclampsia

or pregnancy-induced hypertension, can develop after the 20th week of gestation.

Preeclampsia signs and symptoms

i. Severe hypertension

ii. Severe or persistent headache

iii. Visual abnormalities such as seeing spots, blurred vision, or sensitivity to light

iv. Swelling in the hands and feet (edema)

v. Upper abdominal or epigastric pain

vi. Dyspnea and/or retrosternal chest pain

vii. Anxiety

viii. Altered mental status

Eclampsia

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

a. To treat seizures:

i. Lay the patient on her left side.

ii. Maintain her airway.

iii. Administer supplemental oxygen if necessary.

iv. If vomiting occurs, suction the airway.

v. Provide rapid transport.

vi. Call for an ALS intercept, if available

Why is transporting on the left side important?

an 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.

Internal bleeding

may be a sign of an ectopic pregnancy, when an embryo develops outside the uterus, most often in a fallopian tube.

a. Sudden onset of severe abdominal pain and vaginal bleeding in the first trimester of pregnancy should be considered ectopic pregnancy until proven otherwise.

b. Consider the possibility of an ectopic pregnancy in a woman who has missed a menstrual cycle and complains of sudden, severe, usually unilateral pain in the lower abdomen.

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.

Abruptio placenta:

the placenta separates prematurely from the wall of the uterus, most commonly caused by hypertension or trauma.

Placenta previa:

the placenta develops over and covers the cervix.

Treating vaginal bleeding

a. Treat for shock if signs are present.

b. Place a sterile pad or sanitary pad over the vagina and replace it as necessary.

c. Do not put anything into the vagina to control bleeding.

Spontaneous abortion

is the loss of a pregnancy prior to 20 weeks of gestation without any preceding surgical or medical intervention.

a. The term is often used interchangeably with miscarriage.

An induced abortion

is the elective termination of a pregnancy prior to the time of viability.

When bringing tissue to the hospital?

Never pull tissue out of the vagina.

Abuse

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.

The effects of the addiction on the fetus include:

a. Prematurity

b. Low birth weight

c. Severe respiratory distress

d. Death

Fetal alcohol syndrome

describes the condition of infants born to women who have abused alcohol.

Hormonal changes

loosen the joints in the musculoskeletal system.

The increased weight of the uterus and displacement of abdominal organs can

affect the woman’s balance.

With a trauma call involving a pregnant woman, you have two patients to consider

the woman and the unborn fetus.

Trauma is one of the leading causes of

abruptio placenta.

common symptoms of trauma is?

vaginal bleeding and severe abdominal pain.

Cultural sensitivity

is important when you are assessing and treating a pregnant patient.

Teenage Pregnancy

may not know they are pregnant or may be in denial about it.

1. As you begin to assess all female teenagers, remember that pregnancy is a possibility.

2. Respect the teenager’s privacy and need for independence.

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

Questions related to prenatal care

i. Identify any complications the patient may have had during the pregnancy or potential complications during delivery.

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.

If her water is broken, ask whether the fluid was green because?

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.

The three stages of labor

(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.

lightening

the head of the fetus normally descends into the woman’s pelvis as the fetus positions for delivery.

a. This movement down into the pelvis and the sensation that may accompany the descent

The second stage of labor

begins when the fetus begins to encounter the birth canal and ends with delivery of the newborn (spontaneous birth)

crowning

The perineum will begin to bulge significantly, and the top of the fetus’s head should begin to appear at the vaginal opening

The third stage of labor begins with

the birth of the newborn and ends with the delivery of the placenta.

1. During this stage, the placenta must completely separate from the uterine wall.

To determine if delivery is imminent, ask the patient the following questions:

a. How long have you been pregnant?

b. When are you due?

c. Is this your first pregnancy?

d. Are you having contractions?

i. How far apart are they?

ii. How long do they last?

e. Have you had any spotting or bleeding?

f. Has your water broken?

g. Do you feel as though you need to have a bowel movement?

h. Do you feel the need to push?

To help determine potential complications, ask these questions:

a. Were any of your previous deliveries by cesarean section?

b. Have you had problems in this or any previous pregnancies?

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

d. Do you know if there is a chance you will have multiple deliveries?

e. Does your physician expect any complications?

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.

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.

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.

Your emergency vehicle should always be equipped with a

sterile emergency obstetric (OB) kit.

Patient position

a. The patient’s clothing should be removed or pushed up to her waist.

b. 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. Elevate the hips about 2 to 4 inches with a pillow or blankets.

e. Support the head, neck, and upper back with pillows and blankets.

f. Have her keep her legs and hips flexed, with her feet flat on the surface beneath her and her knees spread apart.

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.

Your partner should be

at the patient’s head to comfort, soothe, and reassure her during the delivery.

Delivering the head

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.

Unruptured amniotic sac

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 fetus’s face and only perform this procedure as the head is crowning.

f. Clear the newborn’s mouth and nose, using the bulb syringe if required by your protocols and wipe the mouth and nose with gauze.

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.

c. If not, you must cut it.

Delivering the body

a. The head is the largest part of the fetus.

i. Once it is born, the body usually delivers easily.

b. Support the head and upper body as the shoulders deliver.

c. Do not pull the fetus from the birth canal.

d. The newborn will be slippery and may be covered with a white, cheesy substance, called vernix caseosa.

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.

Keep the neck of the newborn in a

neutral position

Clamp and cut the umbilical cord after approximately?

60 seconds

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.

i. You can help to slow bleeding by gently massaging the woman’s abdomen with a firm, circular, kneading motion with one hand cupped over the top of the fundus and the other above the pubic bone.

emergency situations for emergency childbirth

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.

The first minute after birth is often referred to as the

“Golden minute.\”

During the first minute of life, perform the following initial steps of newborn care:

a. Airway positioning and suctioning, if needed

b. Drying

c. Warming

d. Tactile stimulation

Normally the newborn will begin breathing

within 30 seconds after birth, and the heart rate will be 100 beats/min or highe

What are the steps to helping a newborn who requires some form of stimulation to breathe air and start circulation?

a. Position the airway in a neutral or sniffing position.

b. If necessary, then suction the mouth and then the nose

c. Vigorously dry the head, body, and back.

d. Rub the newborn’s back, and gently flick or slap the soles of his or her feet.

e. Tactile stimulation

What if signs of good tone and adequate ventilation are not present after performing the initial steps for 30 seconds?

positive pressure ventilation with a mask may be necessary.

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.

a. The heart rate is the most important measure in determining the need for further resuscitation.

If chest compressions are required

use the hand-encircling technique for two-person resuscitation.

a. Perform bag-mask ventilation during a pause after every third compression, using a compression-to-ventilation ration of 3:1. Hands-only CPR is not as effective as ventilation with CPR.

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

1. The standard scoring system used to assess the status of a newborn.

2. It assigns a number value (0, 1, or 2) to five areas of activity.

a. Appearance

b. Pulse

c. Grimace or irritability

d. Activity or muscle tone

e. Respirations

When do you calculate the APGAR score?

Calculate the Apgar score at 1 minute and 5 minutes after birth.

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.

If the newborn is not breathing well

begin ventilations with a bag-mask device.

Assess the newborn’s oxygenation via

pulse oximetry, which is best taken at the right wrist, 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.

ii. Set oxygen flow rate to 5 L/min.