1. LESSON 20
PREGNANCY
AND CHILDBIRTH

2. Introduction Childbirth sometimes occurs outside planned setting
Delivery rarely becomes medical emergency
Medical problems or complications can become emergencies

3. Pregnancy and Labor Begins with fertilization of ovum
Growth and development proceed over 40 weeks

4. Stages of Pregnancy Divided into 3 trimesters – 3 months each
Single cell divides into many
First 8 weeks is an embryo; then a fetus
Embryo attached to placenta
Fetus develops inside amniotic sac
All major organ systems developed by week 8

5. Stages of Pregnancy (continued)
Fetus fully formed by week 36
Near end of pregnancy, head of fetus positioned downward in pelvis
Fetus passes through dilated cervix and vagina

6. Stages of Labor and Delivery
“Show” or “bloody show” may occur before labor begins
When mucus plug from cervix released
Can occur up to 10 days before contractions begin
Labor and delivery occurs in 3 stages beginning with contractions

7. Stage 1: Labor to Cervical Dilation
Amniotic sac ruptures before or during first stage
Uterine contractions begin and eventually push infant’s head into cervix
10-15 minutes apart initially
2-3 minutes apart shortly before birth
May last few hours to a day

8. Stage 2: Delivery Typically lasts 1-2 hours Cervix fully dilated
Contractions powerful and painful
Infant’s head presses on floor of pelvis – woman has urge to push down
Vagina stretches open
Head emerges (crowning)
Rest of body pushed out

9. Stage 3: Childbirth to Placenta Delivery
Placenta separates from uterus and delivered –usually within 30 minutes of birth
Uterus contracts and seals off blood vessels

10. Emergency Care During Pregnancy
Women who receive regular care are advised about potential problems to watch for
Although rare, problems may require emergency care

11. Vaginal Bleeding

12. Vaginal Bleeding
Light irregular discharges of a small amount of blood (spotting) may be normal
Vaginal bleeding during pregnancy is abnormal
May be caused by cervical growths or erosion, problem with placenta or miscarriage
In third trimester may be sign of preterm birth
See health care provider immediately

13. Assessing Vaginal Bleeding
Perform standard assessment
Assess for pain and any signs of shock
Take repeated vital signs
The history should include an obstetric history

14. Emergency Care for Vaginal Bleeding
Perform standard patient care
Have female assistant present if possible
Position patient lying on left side
Don’t control bleeding by keeping patient’s legs together
Give patient towel or sanitary napkins

15. Emergency Care for Vaginal Bleeding (continued)
Don’t try to pack vagina
Save expelled material to give to arriving EMS
Follow local protocol re: oxygen administration
Treat for shock
Provide emotional support

16. Miscarriage

17. Miscarriage Loss of embryo or fetus in first 14 weeks
10%  25% of pregnancies end in a miscarriage
May result from:
Genetic disorder
Fetal abnormality
Factor related to woman’s health
No known cause
Most women don’t have problems with later pregnancies

18. Assessing Miscarriage
Perform standard assessment
Take repeated vital signs

19. Signs and Symptoms of Miscarriage
Vaginal bleeding
Abdominal pain or cramping

20. Emergency Care for Miscarriage
Provide same emergency care as vaginal bleeding in pregnancy
Retain expelled materials for EMS personnel
Be calm and reassuring

21. Trauma in Pregnancy

22. Trauma in Pregnancy
Woman’s blood volume increases significantly in pregnancy
Blood loss may not immediately cause signs of shock
Blood flow reduced to fetus
Signs of internal blood loss may not be apparent

23. Emergency Care for Trauma in Pregnancy
Perform standard patient care
Assume there may be internal bleeding
Treat for shock
Follow local protocol for oxygen administration
Don’t let patient late in pregnancy lie flat on her back
Raise right side higher to reduce pressure on vena cava

24. Other Problems

25. Other Problems in Pregnancy
See health care provider if you have:
Abdominal pain
Persistent or severe headache (sign of toxemia)
Sudden leaking of water
Persistent vomiting, chills and fever, convulsions, difficulty breathing
Persistently elevated blood pressure
Signs or symptoms related to diabetes

26. Childbirth

27. Childbirth Remember it is a natural process
Woman may be fearful or distressed
Remain calm

28. Supportive Care During Labor
Ensure plan for transport
Help woman rest
Provide comfort measures
Do not let woman have bath
Write down contraction intervals and length
Remind woman to control breathing
Continue to provide reassurance

29. Assessing Whether Delivery Is Imminent
Labor usually lasts for several hours
In rare occasions, labor progresses quickly
May begin weeks before due date
Prepare to assist in childbirth if delivery may be imminent
Braxton Hicks contractions do not signal beginning of labor, but do not assume woman is not in labor when she feels contractions

30. Gather Information from the Woman
Name, age and due date
Physician’s name and telephone number
Ask if she:
Has given birth before
Knows whether she may be having twins
Has broken her water and to describe it
Has experienced any bleeding
Has any past or present medical problems
Give this information to arriving EMS personnel

31. Assessing Childbirth Imminence
Has the “bloody show” occurred?
When did contractions begin?
How close together are they?
How long does each last?
When contractions are about 2 minutes apart, delivery will likely occur very soon
Feels strong urge to push?
Check whether infant’s head is crowning

32. Preparing for Delivery
Someone must stay with woman
Gather the items needed or helpful for delivery
Many EMRs carry obstetrics kit

33. Items Needed for Delivery
Clean blanket or coverlet
Several pillows
Plastic sheet or stack of newspapers (to cover bed surface)
Clean towels and washcloths
Sanitary napkins or pads of clean cloth
Medical examination gloves
Basin and plastic bags (for afterbirth)
Medical hazard bag or designated plastic bag (for clean-up)

34. Items Needed for Delivery (continued)
Bowl of hot water (for washing  but not the infant)
Empty bowl (in case of vomiting)
Clean handkerchief (to wear as facemask)
Clean, soft towel, sheet or blanket (to wrap newborn)
Eye and face protection for yourself, if available
Oxygen if available
Bulb syringe (to suction infant’s mouth)

35. Items Needed for Delivery (continued)
If help may be delayed:
Clean strong string, shoelaces or cloth strips (to tie cord)
Sharp scissors, knife or razor (to cut cord)
Sterilize first in boiling water for 5 minutes
Or sterilize by holding over flame for 30 seconds

36. Preparation for Childbirth
Provide privacy for the mother
Prepare birthing bed
Roll up sleeves, wash hands thoroughly for 5 minutes, put on medical examination gloves
Protect your eyes, mouth and nose from blood and other fluids

37. Preparation for Childbirth (continued)
Do not let woman use bathroom
Do not touch vaginal areas except during delivery
Call dispatch or health care provider for additional instructions
Do not make an internal vaginal examination
When crowning occurs, move woman into birthing position
Assist with delivery

38. Skill: Assisting with Delivery

39. Help woman lie on back with knees bent and apart and feet flat

40. As infant’s head appears, have gloved hands ready to receive and support the head

41. As the head emerges (usually face down), support the head
After the head is out, have the woman stop pushing and breathe in a panting manner

42. Hold infant with head lower than feet
Suction nose and mouth with bulb syringe

43. Gently dry and wrap the infant in a towel or blanket to prevent heat loss, keeping the cord loose
Follow your local protocol to clamp or tie the umbilical cord or leave it intact for arriving EMS personnel

44. Wait for delivery of afterbirth, placenta and umbilical cord – do not pull on umbilical cord in an attempt to pull out placenta
Continue to monitor both mother and newborn

45. Care of the Mother After Delivery
Support and comfort mother
Monitor pulse and breathing
Replace any blood-soaked sheets or blankets, dispose of used supplies
Mother may drink water now

46. Bleeding After Delivery
Some bleeding normally occurs with childbirth and delivery of placenta
Usually stops after placenta is delivered
Use sanitary pads or clean folded cloths to absorb blood

47. Care for Bleeding After Delivery
To help stop bleeding, massage abdomen below navel with a continuous circular motion
Be sure you are kneading with your palms
Keep mother still and try to calm her
Treat for shock
Follow local protocol for oxygen administration
Encourage breastfeeding

48. Care for the Newborn

49. Assess the Newborn
Note skin color, movement and whether crying is strong or weak
Normal respiratory rate is more than 40 breaths/minute
The normal pulse is more than 100 beats/minute
Note any changes over time
Provide this information EMS personnel

50. Care of the Newborn (continued)
Dry newborn
Ensure infant stays wrapped, including the head, to stay warm
Support newborn’s head if it must be moved for any reason
Continue to check breathing and airway

51. APGAR Score for Newborn Assessment
Newborn quickly assessed and given a score of 0-2 in each area:
A – Appearance
P – Pulse
G – Grimace (flick soles, observe face)
A – Activity
R – Respiratory Effort
Scoring:
7–10 Provide routine care
4–6 Provide oxygen and stimulation
0–3 Provide oxygen and CPR

52. Premature Infants Premature infant at greater risk for complications
It is crucial to keep a small newborn warm
Resuscitation is more likely to be needed

53. Non-Breathing Newborn
If newborn is not crying, gently flick bottom of feet or gently rub its back
If it is still not crying, check for breathing

54. Non-Breathing Newborn (continued)
If infant is not breathing:
Provide 2 gentle ventilations mouth-to-mask or with BVM
Assess breathing and pulse
If breathing is absent, slow or very shallow:
Provide ventilations at rate of breaths/minute
Follow local protocol for oxygen administration

55. Non-Breathing Newborn (continued)
If infant is not breathing
If pulse is beats/minute, continue ventilations
If pulse is <60 beats/minute, start chest compressions at rate of 120/minute
Use thumb-encircling method with second responder
Ratio of 3 compressions to 1 breath

56. Non-Breathing Newborn (continued)
Reassess breathing and pulse after 30 seconds
If pulse is >100 and respiration has improved, gradually discontinue ventilations

57. Childbirth Problems Most deliveries occur without problems
Common problems involve presentation of infant or maternal bleeding

58. Meconium Staining
Infant may defecate before or during childbirth, staining amniotic fluid brown or green with meconium
Newborn may inhale fluid with first breath, causing lung infection
If mother describes amniotic fluid as having color or if you observe this, tell arriving EMS personnel

59. Breech Birth Buttocks or feet appear in birth canal
Umbilical cord is squeezed and blood flow is compromised
If infant’s head becomes lodged in birth canal and it tries to breathe, it may suffocate

60. Breech Birth (continued)
Tell woman not to push, and calm and reassure her
Support body as it emerges, do not try to pull head out
If head does not emerge soon, create breathing space for infant
Check infant immediately and give CPR if needed

61. Limb Presentation Rarely, arm or leg may emerge first
Emergency requiring immediate medical assistance
Tell the woman not to push, calm and reassure her
Update responding EMTs

62. Limb Presentation (continued)
Put woman in knee-chest position
Do not try to pull infant out or push arm or leg back in

63. Prolapsed Cord
Segment of cord protrudes through birth canal before childbirth
Cord will be compressed as infant moves through canal, cutting off blood flow

64. Emergency Care for Prolapsed Cord
Follow local protocol to position woman either in the knee-chest position or lying on the left side
Place dressings soaked in sterile or clean water on cord
Follow local protocol for oxygen administration
Don’t push cord back inside mother
If medical personnel have not arrived when infant presents or begins to emerge, follow local protocol

65. Emergency Care for Prolapsed Cord (continued)
Carefully insert sterile gloved hand into birth canal and gently push presenting part away from cord while allowing birth to continue
If not possible, open a breathing space with your fingers as for breech presentation
Check infant immediately and be prepared to give CPR

66. Cord Around Neck Umbilical cord may be around neck when infant emerges
Slip it over head or shoulder
If it is too tight and you cannot release infant’s head, it is a life-threatening emergency
Tie off cord in 2 places and cut cord between the 2, then unwrap it

67. Care for Premature Infant
Keep premature newborn warm
Provide ventilations or CPR if needed
Follow local protocol for blow-by oxygen

68. Stillborn Infant
Rarely, infant is born dead or dies shortly after birth
Use all resuscitation measures available
Provide comfort for mother