Chapter 34: Obstetrics and Neonatal Care

Anatomy and Physiology of the Female Reproductive System

• The onset of menstruation is menarche

• Ovulation is the release of an ovum into the fallopian tubes

• It occurs approximately 2 weeks before menstruation

• The endometrium begins to thicken in preparation for the egg

• If the egg is not fertilized within 36–48 hours, the lining sheds

• Sperm + egg → embryo (0–10 weeks) → fetus (10 weeks–delivery)

• The uterus contracts during delivery, pushing the fetus into the birth canal

• Bloody show (discharge) signaling labor

• Mammary glands within the breasts produce milk after the baby is born

• The placenta provides nutrients to the fetus via the umbilical cord

  • Oxygenation, nutrition, and waste removal

  • The umbilical vein carries oxygenated blood to the fetus

  • The umbilical arteries carry deoxygenated blood to the placenta

• The amniotic sac contains 500–1000 mL of amniotic fluid to insulate and protect the fetus

• A full-term pregnancy is term gestation

Normal Changes in Pregnancy

The Reproductive System

• Hormone levels increase to support fetal development and prepare for childbirth

• Higher risk for trauma, bleeding, or other conditions

The Respiratory System

• The developing fetus pushes up against the diaphragm → respiratory rate increases

• Demand for O₂ increases to support the fetus

The Cardiovascular System

• Blood volume increases, clotting factor increases, and heart rate increases

The Musculoskeletal System

• Increased chance of vomiting and aspirating

• Ligaments relax

Diabetes | Complications of Pregnancy

• Gestational diabetes usually resolves after delivery

• Should be cared for the same way as patients with diabetes

Hypertension in Pregnancy | Complications of Pregnancy

Gestational hypertension

• High blood pressure in the absence of other systemic effects

• BP higher than 140/90; severe when 160/110

Preeclampsia

• Hypertension in the second half of pregnancy

• Signs and symptoms:

  • Hypertension

  • Severe headache

  • Visual abnormalities

  • Edema

  • Upper abdominal or epigastric pain

  • Dyspnea

  • Anxiety

  • Altered mental status

Eclampsia

• Presence of seizures

• Lay patients on their left side; prevents supine hypotensive syndrome: the compression of the vena cava

Bleeding | Complications of Pregnancy

Ectopic pregnancy

• The embryo develops outside of the uterus

• Severe onset of vaginal bleeding and abdominal pain in the first trimester

• Missed a menstrual cycle and has severe abdominal, unilateral pain in the lower left abdomen

Abruptio placentae

• The placenta separates prematurely from the walls of the uterus

• Caused by hypertension and trauma

• Severe pain and signs of shock

Placenta previa

• The placenta develops and covers the cervix

Treatment

• Place the patient on their left side, administer O₂, and place sterile pads over the vagina

Abortion | Complications of Pregnancy

Spontaneous abortion (miscarriage)

• Loss of pregnancy before 20 weeks of gestation

• Associated with abdominal cramping and vaginal bleeding

Induced abortion

• The elective termination of pregnancy

Bleeding and infection

• Portions of the fetus or placenta remain after abortion or when the walls of the uterus are injured

• Infection from perforation or the use of nonsterile tools

Abuse | Complications of Pregnancy

• Increases the chance of spontaneous abortion, premature delivery, or low birth weight

• Treat the pregnant woman

Substance Abuse | Complications of Pregnancy

• Fetal alcohol syndrome

• Opioid use

Special Considerations for Trauma and Pregnancy

• Changes during pregnancy may mask the signs of shock

• The fetus is vulnerable to penetrating trauma

• Hypoxia

• Severe hemorrhaging from car accidents → abruptio placentae

• The lap belt should be placed underneath the abdomen and above the iliac crests, and the shoulder belt between the breasts

Maternal Cardiac Arrest | Complications of Pregnancy

• Common causes include hemorrhage and septic shock

• Manual placement of the uterus to the left side (third trimester)

Assessment and Management | Complications of Pregnancy

• Be prepared for vomiting and manual positioning of the airway

• Determine gestational age

1. Maintain an open airway. Prepare for vomiting.

2. Administer high-flow O₂. To supply the patient and the fetus.

3. Ensure adequate ventilation.

4. Assess circulation. Use direct pressure and keep the fetus warm

5. Transport considerations. Transport on their left side

Cultural Value Considerations

Respect differences, and your responsibility is caring for the patient.

Teenage Pregnancy

• Respect the teenager’s privacy

• Perform the assessment away from the parents if possible

• Once a teenager is pregnant, they’re considered emancipated

Stages of Labor

(1) Dilation of the cervix

• Onset of contractions

• 12–18 hours for primigravida women

• 6.5–13 hours for multigravida women

• Bloody show or the rupturing of the amniotic sac

• The fetus’s head descends into the pelvis (lightening)

(2) Delivery of the fetus

• The fetus enters the birth canal

• Uterine contractions are close together and last longer

• The fetus’s head appears at the vaginal opening (crowning)

(3) Delivery of the placenta

• Contractions continue and close down blood vessels for the next 30 minutes

Preparing for Delivery | Normal Delivery Management

• Consider delivery if it’s imminent, or an environmental factor makes it impossible to reach the hospital

• Prepare for delivery if the patient needs to push or have a bowel movement

• Administer O₂ if indicated

• The ambulance is equipped with an obstetric (OB) kit

Patient Position | Preparing for Delivery

• Remove clothing or push it up to the patient’s waist

• Have the patient lie on a flat, sturdy floor that is padded

• Support neck, head, and upper back

• Have legs flexed, spread, with feet flat on the ground

Preparing the Delivery Field | Preparing for Delivery

1. Put on a protective face shield and gown. Place padding on the floor.

2. Open the OB kit.

3. Put on sterile gloves.

4. Place a drape underneath the patient’s buttocks. Wrap another behind the patient’s back and drape it over each thigh. Drape a third across her abdomen.

The Delivery | Normal Delivery Management

• Have your partner at the head of the patient for comfort and suctioning if required

• Continually check for crowning

• Time the patient’s contractions

Delivering the Head | The Delivery

• Place hands on the bony parts of the fetus and support the head as it rotates

• Apply gentle pressure with a sterile gauze pad on the perineum to prevent tearing

Unruptured Amniotic Sac | Delivering the Head

• It may suffocate the fetus

• Puncture it with clamps or twist with your fingers when the head is crowning

• Wipe the nose and mouth

• If the amniotic fluid is greenish (meconium), it means the fetus is in respiratory distress or there is an airway obstruction

Umbilical Cord Around the Neck | Normal Delivery Management

• Called nuchal cord

• The umbilical cord may wrap around the fetus’s neck and strangle them

• The cord may need to be cut between 2 clamps, 2 inches apart

  • The patient may need to make faster contractions because the fetus no longer has O₂

Delivering the Body | The Delivery

• The fetus rotates

• Lower the head to deliver the upper shoulder, and raise the head to deliver the lower shoulder

• The newborn may be covered with a white substance called vernix caseosa

Postdelivery Care

• Place the newborn on the mother

• Wrap the newborn in a blanket so that only the face is exposed

• For a newborn not in respiratory distress, delay cord clamping for 60 seconds

• From the OB kit, place a clamp 6 inches from the newborn, and place another clamp 2–4 inches apart

Delivery of the Placenta | Neonatal Assessment and Resuscitation

• A gush of bloody fluid comes out before the placenta

• Wrap the entire placenta and cord in a towel and place them in a plastic bag

• Place a sterile pad over the vagina and straighten the patient’s legs

• Massage the patient’s fundus on the abdomen to contract the uterus

• Breastfeeding produces oxytocin, which helps contract the uterus

• Emergency situations:

  • The placenta hasn’t arrived after 30 minutes

  • More than 500 mL of fluids have escaped

  • Bleeding occurs after delivery of the placenta

Neonatal Assessment and Resuscitation

• During the golden minute:

  • Airway positioning and suctioning, if needed

  • Drying

  • Warming

  • Tactile stimulation

• Newborns will begin breathing spontaneously 30 seconds after birth, and the heart rate will be 100 beats/min

• Position the newborn on their back

• Suction if necessary

• Rub the newborn’s back and flick their feet

• No breathing after 30 seconds, begin positive-pressure ventilation

Additional Resuscitation Efforts | Neonatal Assessment and Resuscitation

• Hand-encircling technique for two-rescuer CPR

• 3:1 ratio of 120 compressions and 30 ventilations

The Apgar Score | Neonatal Assessment and Resuscitation

• Appearance.

• Pulse.

• Grimace or irritability.

• Activity or muscle tone.

• Respirations.

• 7–10 is considered reassuring

• O₂ saturation of a newborn does not reach 85–95% until 10 minutes after birth

  • Give O₂ L/min

Breech Delivery | Complicated Delivery Emergencies

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

• Head first is called the vertex presentation

• Buttocks first is called the breech presentation

• Provide emergency care and call for ALS backup

• Make a “V” and place it on the vagina to prevent collapse and protect the fetus’s airway

Presentation Complications | Complicated Delivery Emergencies

• Limb presentation

  • Prompt transport

  • Cover the limb with a sterile towel

  • Place the patient on her back, head down, and pelvis elevated

  • Administer high-flow O₂

• Prolapse of the umbilical cord

  • Occurs when the umbilical cord comes out of the vagina before the fetus

  • Place the pregnant woman supine with the foot end of the stretcher elevated 6–12 inches

  • Knee-chest position

  • Place your sterile hand into the vagina and push the fetus’s head away

  • Wrap a sterile towel, moistened with saline, around the exposed cord

  • Administer O₂ and prompt transport

Spina Bifida | Complicated Delivery Emergencies

• A portion of the spinal cord or meninges is exposed

• Cover the spinal area with a moist, sterile dressing and then an occlusive dressing to seal the area to prevent infection

Multiple Gestation | Complicated Delivery Emergencies

• If twins are present, the second one will be born 45 minutes after the first

• The second fetus may be born before or after the first placenta

• Identical twins are always the same sex, and paternal twins may be the same or different sex

• Indicate the newborn as “Baby A” and record the times between

Premature birth | Complicated Delivery Emergencies

• A normal full-term baby will weigh 7 pounds at birth

• Any newborn who weighs less than 5 pounds or is born before 8 months is premature

• Smaller and thinner

• The vernix caseosa is absent or minimal

• Often require resuscitations

Postterm Pregnancy | Complicated Delivery Emergencies

• The gestation period is longer than 41 weeks

• Increased risk of a cesarean section

• Compresses vessels due to size

Fetal Death | Complicated Delivery Emergencies

• Intrauterine infection

• Skin blisters, skin sloughing, and a dark discoloration

• The head is soft and grossly deformed

Postpartum complications

• Bleeding that exceeds 1000 mL is dangerous

• If bleeding continues, massage the uterus en route to the hospital

• Bleeding from the uterus is not fully contracted

• Cover the vagina with a sterile pad

• Pulmonary embolism