Welcome to this module in which we will be
discussing obstetrics and gynecology. Upon completion of this module, you should
be able to: Define terms associated with female reproductive anatomy; define terms associated
with the process of labor; discuss cultural values affecting pregnancy; identify special
considerations of adolescent pregnancy; summarize the normal physiology of pregnancy; list and
describe signs and stages of labor; list components of assessment for an obstetrical patient;
identify the contents of an obstetrics kit; state indications of an imminent delivery;
list steps for a normal delivery; discuss initial care of the newborn; summarize neonatal
resuscitation procedures; describe complications of pregnancy, labor, delivery, and postpartum;
discuss gynecological emergencies; and, describe the age-related variations for pediatric and
geriatric assessment and management of the female patient.
You should also be able to appreciate the emotions that a sexual assault victim may
be experiencing. Lastly, as a portion of a subsequent classroom
lab, you should be able to: Demonstrate the steps to assist in the normal delivery of
a baby; demonstrate the steps to assist in complicated deliveries; demonstrate infant
neonatal procedures; demonstrate post-delivery care of an infant; demonstrate the post-delivery
care of the mother; demonstrate the steps in management of the mother with excessive
bleeding; and, demonstrate completing a prehospital care report for patients with obstetrical
or gynecological emergencies. A women�s external genitalia, referred to
as the vulva, consists of four major structures: the labia minora, labia majora, clitoris,
and vaginal vestibule or orifice. The labia minora consists of two thin inner
folds of skin within the vestibule of the vagina.
The labia majora is comprised of the outer folds of skin and adipose tissue surrounding
the vaginal opening; this structure defines the lateral boundaries, if you will, of the
external female genitalia. The clitoris is a small, elongated erectile
organ located anteriorly on the vulva. The vaginal vestibule or orifice is the opening
to the vagina. The opening is protected by the labia minor and majora.
These structures are all contained within an area known as the perineum. The perineum
is a diamond-shaped area corresponding to the outlet of the pelvis. Both men and women
have a perineum. In women, the area encompasses the vulva as well as the anus. It is bounded
by the coccyx posterior, the pubic arch anterior, and the inside of the thighs laterally.
Also located within this are is the urethra, a membranous tube that extends from the urinary
bladder to the exterior of the body for the voiding of urine.
Moving to the internal female reproductive organs, the uterus is a muscular, hollow organ
located along the midline in most women�s lower abdominal quadrants. The organ is designed
for implantation of a fertilized egg where it can develop into a fetus. During the final
stages of pregnancy, the uterus is also responsible for labor and muscular contractions for expulsion
of the baby. Ovaries are small, round organs located on
either side of most women�s lower abdominal quadrants. These organs are responsible for
producing ova (eggs) for conception. The ovaries also produce many of the hormones necessary
for the process of reproduction. The ovaries and uterus are connected via fallopian
tubes. When an egg is released from an ovary, it travels down the fallopian tube into the
uterus. If fertilization of an egg occurs, it commonly does so while in a fallopian tube.
In a normal pregnancy, the fertilized egg will continue its journey down the fallopian
tube into the uterus for implantation and continued development.
Given a pregnancy, the woman is carrying a fetus and other supportive structures. The
fetus is simply the developing baby within the uterus. At eight weeks of development,
the fetal stage officially begins. From that point, until delivery, the developing baby
is referred to as a fetus. The placenta is attached to the wall of the
uterus and exchanges oxygen, nutrients, and wastes between the mother and the fetus through
the umbilical cord. The umbilical cord contains blood vessels
that carry blood containing oxygen and nutrients to the baby, as well as vessels that transport
blood with fetal waste products back to the placenta and the mother.
Some additional terms and definitions as they relate to labor and delivery are as follows:
Labor is the process of having (or delivering) a baby. While various resources define labor
as consisting of either three or four stages, it is commonly held to begin with the first
uterine muscle contraction and it ends once the placenta is expelled from the woman.
Bloody show is mucus and blood that may be expelled from the vagina as labor begins.
Presenting part is the body part of the baby that exits the labor canal first. While this
is commonly the head, given a typical delivery, it can also be an arm, leg, or buttocks.
Crowning is the appearance of the fetal scalp at the vaginal orifice during delivery.
Spontaneous abortion, also known as a miscarriage, is the delivery of the product of conception
early in pregnancy (before the 20th week). While EMS providers must be culturally sensitive
in all patient interactions, calls involving obstetrics and gynecology are even more critical
in this regard. Women in all cultures have a value system that will affect their pregnancy.
This can include how the woman cares for herself during the pregnancy as well as how they have
planned the childbirth process. In some cultures, for instance, it is not permissible for the
woman to have a male healthcare provider assisting in the delivery. These cultural differences
may also involve social, psychological, and emotional factors. In some cultures, being
pregnant is associated with achieving status and recognition within their family unit.
For some women, on the other hand, being pregnant results in a lower self-esteem. As an EMS
provider, respect these differences and honor the patient�s requests, remembering that
any competent adult has the legal right to refuse any part of assessment or care.
Adolescent pregnancy is rampant in the United States with UNICEF reporting in 2001 a birth
rate of 52.1 per 1,000, the highest in the developed world and more than twice the European
average. As of 2011, the CDC has reported a teen birth rate of 31.3. While this rate
has decreased over the course of 10 years, the CDC also recognizes a tremendous disparity
in teen birth rates between racial and ethnic groups with rates anywhere from approximately
10 to 50 per 1,000 based upon the race or ethnicity of the group. In many instances,
socioeconomic factors seem to be involved and one reason why teen pregnancy is deemed
socially undesirable is illustrated by the CDC statistic that one-half of pregnant teenagers
do not finish high school. The trickle-down effect of that is an inability for the mother
to find employment and earn a livable wage without that basic level of education. Regardless
the factors surrounding a teenage pregnancy, the EMS provider assessing a pregnant teenage
female must be professional and non-judgmental at all times. Depending on the age of the
patient, providing care may be complicated by the level of physical and psychological
maturity and development of the patient. Additionally, a pregnant minor is still a minor, meaning
that her parents may still have the legal authority to authorize or decline healthcare
for her. (Remember from the legal module of this course that Wisconsin does not commonly
recognize emancipated minors as other states do.) It can also be common, depending on how
long the patient has been pregnant, for her to not know about the pregnancy, to be in
denial about the pregnancy, or to have not told her parents about the pregnancy. When
assessing female patients, especially those with gastrointestinal or abdominal complaints,
always consider the possibility of the patient being pregnant. Also keep in mind the patient�s
need for independence and privacy. If possible, it may be better for the teenage patient if
any assessment is performed or history is obtained away from her parents.
If you have not covered it yet, one of the modules within this course will discuss the
legal obligation of an EMT to report to law enforcement any suspected child abuse or neglect.
This becomes pertinent when discussing adolescent pregnancies because it is considered sexual
abuse of a child in Wisconsin for a person to have sex with a minor under the age of
16 (meaning 15 years of age or younger). If the minor is either 16 or 17 years of age,
the crime is a misdemeanor that is not considered sexual abuse of a child and is not subject
to the mandatory reporting requirements of state statute 48 (sections 48.02 and 48.981).
If the sex was nonconsensual, it is considered sexual abuse of a child, regardless of the
victim�s age. Remember as well that it takes time for a pregnancy to show. Just because
a pregnant female is 16, 17, or 18 years of age at the time of an EMS contact does not
mean she was that age at conception. The law also does not consider the age of the individual
who had sex with the pregnant female, so just because the father is also a minor does not
necessarily mean a crime did not occur. If providing care to a pregnant, minor female,
it is recommended that the EMT contact law enforcement to report the incident and law
enforcement can then make a determination as to whether or not the statutory requirements
for sexual assault of a minor were met. For the woman who becomes pregnant, she is
about to experience numerous, significant changes to her body.
Her reproductive system begins producing increased hormones to support fetal development. These
hormones will commonly impact the woman�s emotional status.
The respiratory system must begin handling greater oxygen demand while pressure on the
diaphragm from the developing fetus results in a decreased minute volume. As a result,
the mother�s respiratory rate is commonly faster than it would be if she were not pregnant.
The cardiovascular system must meet the demand for oxygen and other nutrients for the fetus,
which results in an increase in both blood volume as well as the heart rate. The fetus
commonly places pressure on the mother�s vena cava, which can impact the effectiveness
of circulation to her lower extremities and clotting factor changes occur to accommodate
the fetus. The musculoskeletal system must adapt to changes
in the woman�s center of gravity given the addition of a developing fetus, which can
result in back pain, leg pain, and fatigue, especially in the later stages of fetal development.
The body also must prepare for the process of delivery and the joints loosen, especially
in the hips, which can cause instability for the mother.
The gastrointestinal system is also impacted by the pregnancy. Digestion slows, which can
lead to nausea and vomiting. The fetus also places pressure on the bladder and intestines,
which results in increased need to urinate and possible incontinence.
For the purposes of providing emergency medicine, it is important to understand the timeline
associated with conception and fetal development as medical emergencies associated with pregnancy
can vary in terms of type and severity over the duration of a pregnancy.
The process begins with ovulation in which the ovaries discharge an egg. Fertilization
occurs if a male sperm is introduced to the female egg. Once the egg is fertilized, it
must then implant itself into the lining of the uterus. (If this implantation takes place
someplace else, an ectopic pregnancy will result. This type of medical emergency will
be discussed a little later in this module.) The next stage is called the embryonic stage,
which is the period of time from fertilization to about eight weeks afterward. The last stage
is the fetal stage, which begins approximately eight weeks after fertilization (after the
embryonic stage) until delivery, approximately 40 weeks after fertilization.
Before discussing the delivery of a baby, the EMT must be able to recognize the signs
of labor. Lightening, also referred to as the baby dropping,
is a sensation of pressure caused by the descent of the uterus into the pelvic cavity. This
occurs as the fetus changes position within the uterus to prepare for delivery. In first-time
mothers, this is commonly noticeable a few weeks prior to delivery. For women who have
delivered before, this sensation may not be noticeable until just prior to delivery.
Braxton Hicks contractions are sporadic uterine contractions that occur during pregnancy.
These can start as early as six weeks into the pregnancy for some women. Typically, most
women will not notice them, even if they are occurring, until sometime in the mid- to late-second
trimester. As the delivery date nears, Braxton Hicks contractions may increase in frequency,
becoming rhythmic and relatively close together. They may also produce pain, which can lead
some women to believe they are entering labor. The difference between Braxton Hicks contractions
and true labor contractions is that these false labor contractions do not grow consistently
longer, stronger, and closer together. If the woman has not reached her 37th week yet
and the contractions are becoming more frequent, rhythmic, or painful, that may be a sign of
preterm labor. If the woman is past 36 weeks, contractions that last longer than a minute
and occur within five minutes of each other for at least an hour may be indicative of
the start of labor. Cervical dilation begins to occur as the woman
nears labor. Because the cervix cannot be visualized by the EMT, knowledge of dilation
is commonly not an assessment finding unless the pregnant female recently had a physician�s
examination and was told at that time that her cervix is dilating. (Dilation of zero
to three centimeters is considered to be latent. Active labor usually begins at four centimeters.)
What may be noticeable as a result of cervical dilation, however, is the appearance of a
mucous discharge from the vagina. During pregnancy, the opening of the cervix is blocked by a
thick mucus plug to prevent bacteria from entering the uterus. As the cervix dilates,
this plug will loosen and may be passed as one piece or as a mucus discharge from the
vagina. Not all women will notice this discharge, however.
Bloody show can commonly accompany the passing of the mucus plug. This is a light bleeding
from the vagina that will make the mucus discharge appear tinged pink, red, or brown.
Rupture of membranes occurs when the amniotic sac ruptures. Given the subsequent release
of amniotic fluid, this rupture is commonly known as �breaking the water.�
Wisconsin Administrative Rule TRANS 309 governs ambulance requirements within the state and
one such requirement pertinent to the subject of childbirth and delivery (at least at the
time of creation for this presentation) is that the ambulance carry a obstetrical kit
containing sterile gloves, scissors or disposable scalpels, two umbilical cord clamps, sterile
dressings, towels, plastic bags, blanket or other heat-reflective material large enough
to cover a newborn, and a bulb syringe. We will soon be discussing labor and delivery
in the field by an EMT. It is important to ensure access to this essential equipment
as a part of that process. For the purposes of this course, we will discuss
labor in three different stages. The first stage is somewhat preparatory, of sorts. Regular
contractions occur, along with a thinning and gradual dilation of the cervix. Once the
cervix is fully dilated and the baby enters the birth canal, the second stage of delivery
begins. This stage is the actual delivery stage where the baby moves through the birth
canal. Once the baby is delivered, the third stage of delivery begins. Within this final
stage of delivery, all remaining tissues related to the development of the baby are expelled
from the mother. These materials include the placenta, umbilical cord, and the amniotic
sac. When responding for a woman in labor, it may
be necessary to decide whether to deliver in the field or transport to the hospital.
Obviously, the hospital setting is arguably better given the availability of both equipment
and personnel resources. With that being said, however, there are instances where delivery
is imminent and there is no time to transport the mother. To assist in making that determination,
the EMT should ask the mother some of the following questions: Is she experiencing contractions
or pain? If she is having contractions, what is their frequency and duration. As contractions
increase in duration, strength, and frequency, delivery is rapidly approaching. Is there
any bleeding or discharge from the vagina? Does the mother feel the need to push? Does
she feel as though she is having a bowel movement with increasing pressure in the vaginal area?
Is the baby crowning? If so, delivery is imminent. Also ask if this is the woman�s first delivery.
Subsequent deliveries are known to occur faster than the first time a woman delivers a baby,
which may impact your decision to either transport or deliver in the field.
Regardless of the transport decision, do not let the mother go to the bathroom. The pressure
she feels is probably not the need for a bowel movement, but the movement of the baby through
the birth canal (and the pressure placed on other body structures as the baby makes that
journey). Also do not hold the mother�s legs together. If the baby is coming out,
he or she is coming out. Trying to keep the baby within the uterus or birth canal by having
a mother close her legs is an exercise in futility that may actually create unnecessary
complications. Lastly, if delivery in the field is unavoidable,
remember that childbirth is a natural process. Women have been delivering babies on their
own for millennia without intervention or help from EMS providers. While there are benefits
to having medical care available during the birthing process, in many instances, there
is no pressing biological or other need for medical intervention. The mother and baby
will essentially take care of things on their own; the EMT is there to simply assist or
intervene if a problem does arise. In the upcoming discussion of delivery procedures,
it is recognized that an online presentation of this nature is less than adequate to prepare
someone, such as an EMT, to assist with delivery of a baby. If watching this presentation as
part of a formal EMT offering, please be aware that the EMS training center should also incorporate
the use of videos and simulated lab experiences to prepare EMT students for assisting delivery.
While not always possible, participating in a clinical rotation at a birthing facility
can also be a valuable experience. In terms of delivery procedures, first be
certain to utilize body substance isolation precautions. There will be bodily fluids involved
in childbirth, which may include splashing, so be certain to wear gloves and eye protection;
a gown and facemask are highly recommended. Also have the ambulance�s delivery kit available
as many of the supplies will be required. Administer oxygen to the mother and position
her so that she is supine with her knees drawn up and spread apart. If available, use pillows,
blankets, or something else to support the mother�s shoulders and head. It is not a
bad idea to also elevate the mother�s buttocks, again using pillows or blankets. Once positioned,
create a sterile field around the vagina with sterile towels, blankets, dressings, or other
supplies available within the OB kit. Until the baby�s head crowns, there is not
a great deal for the EMT to do but coach the mother to push as she feels contractions.
Once the baby�s head does appear in the vaginal opening, the EMT should place his
or her finger�s against the bony part of the baby�s skull, exerting gentle pressure
to ensure the delivery does not occur explosively. Once the baby�s head is out of the vaginal
opening, support it and ensure the amniotic sac has indeed ruptured. If the sac is still
intact, puncture it with fingers, an umbilical clamp, or some other dull implement and ensure
it is away from the baby�s head, nose, and mouth. Also look to ensure the umbilical cord
is not wrapped around the baby�s neck. If it is, remove it by sliding it over the baby�s
shoulder. If the cord is tight and is difficult to move, it may be necessary to clamp and
cut the cord immediately, even before the remainder of the baby has yet to be delivered
(such a need is rare). As soon as the baby�s mouth and nose are available, the EMT should
use a bulb syringe to suction the airway in that order, mouth first, followed by the nose.
(Be careful to not insert the syringe too far in the baby�s mouth; avoid contact with
the back of the baby�s oral cavity.) Once the baby has a clear airway, guide the
head downward to facilitate delivery of the upper shoulder, then elevate the head to facilitate
delivery of the lower shoulder. Be aware that the baby is commonly covered in something
known as vernix caseosa, which, in addition to the fluids involved in the process of delivery,
will make the baby very slippery. Once the shoulders are free of the vaginal opening,
the remainder of the baby will commonly deliver very quickly. Again, the baby will be very
slippery; be prepared to cradle the baby during this process and anticipate the baby moving
quickly once the shoulders are free of the vaginal opening.
Once delivered, wipe blood and mucus from the baby�s mouth and nose and assess the
status of the baby (we will be discussing the newborn assessment process shortly). Wipe
the baby down with a towel, wrap the baby in a warm blanket, and give the newborn to
the mother. At this point, while the mother and baby are
becoming reacquainted with each other, the EMT needs to watch the umbilical cord. Once
pulsation ceases, the cord should be clamped in two places (the first clamp should be closer
to the baby and the second clamp should be closer to the mother) and cut between the
two clamps. The placenta should deliver on its own relatively soon after the baby delivers.
It is possible to provide a uterine massage to assist in the delivery of the placenta
by firmly massaging the mother�s lower abdomen until the placenta delivers. Beyond that,
however, no further intervention is necessary for the placenta to deliver; do not pull on
the umbilical cord to hasten the process, the placenta will deliver on its own.
After the placenta is delivered, wrap it in a towel, place it in a plastic bag, and transport
along with the mother and baby. Lastly, place a sterile pad over the vaginal
opening and prepare both mother and baby for transport.
Here, the baby is crowning. You don’t have to touch the mom at all; you can just watch
for the head. Except if she’s pushing really fast and hard, you may want to put your hand
on the baby’s head lightly as so she doesn’t injure her perineum or tear excessively and
— cause you like the most controlled delivery as possible. Usually, the babies that come
fast are the ones that are not the first time mom. Usually those moms have to push a few
minutes, a half-hour, an hour; but the second, third, fourth babies� Those are the babies
that come really fast and sometimes just kind of explode out. You can see this baby is coming,
and have the mom, like, take some deep breaths in between the contractions; she doesn’t have
to push the baby out completely. Just let her go at her own pace and how she feels the
pressure. This baby’s coming right now, and the first thing that’s going to come out is
the baby’s face, hopefully, and you’re going to have your bulb syringe ready and you’re
going to depress the bulb syringe and suction the baby’s mouth out first. See the baby is
exposed here� there is a cord here; wait until the baby is completely out. See if you
can separate that cord around the baby’s head nicely like this. Okay, now you can tell the
mom, “Stop pushing,” and you can suction the baby’s mouth out — pull it out (squish it
out there) cause this is what the first gulp of air they take in they can aspirate into
the lungs, and that’s why that’s important. It’s not so important to do the nose, but
you can gently just go to the nose and squish some of that out. So, as you deliver the anterior
shoulder, which means the top shoulder first, and you bring that out and then the rest of
the baby will come out. Again you’re going to suction the baby’s mouth out. Tell the
mom, “You did a great job. Do some deep breathing.” You don’t have to clamp the cord right away.
In fact, if you leave it pumping for about two or three minutes, that gives the baby
a little extra blood, which may be beneficial to the baby. And, when you use your clamp,
just clamp it in two different spots and then cut in between. Leave enough of umbilical
cord in case the doctors do have to insert umbilical vein/artery catheter in case the
baby needed some IV fluids or whatever, so don’t cut it too short. In a few minutes,
the placenta may deliver; it may not. I would not tug on it; don’t pull on the cord. Again,
get her to the hospital and staff there can deal with that. It’s not necessary to get
that delivered. Give yourself a pat on the back and put the baby on the mom’s tummy.
Dry the baby off; that’s the most important thing. Hopefully, the baby’s crying. If not,
that would be the next important thing to do is stimulate the baby by drying the baby
and, once the baby’s turning pink and moving, again give the baby to the mom and have her
do skin-to-skin. If she wants to try breast feeding, she can; otherwise, just put a nice
warm blanket around both mom and baby, but make sure she’s skin-to-skin with the baby.
Given a normal delivery, there are still some things to keep in mind. First, be sure to
document the time of the delivery. Also recognize that there are now two patients that require
attention, the mother and her newborn baby. When transporting, do not forget to take the
placenta along with the mother and baby. Also, keep in mind the safe transport of both the
mother and the newborn. For the newborn, this means using an approved child safety seat.
(While the mother will probably want to cradle or hold the baby herself during transport,
this could be a fatal decision for the baby if the ambulance would be involved in a collision
during transport.) If a child safety seat is not available, follow local protocols for
transporting newborns along with the mother. Vaginal bleeding is normal after a delivery.
With that being said, there are holistic ways to assist the mother�s body in recuperating
from the childbirth process. After delivery, the woman�s uterus will continue contracting,
which will begin to stop the bleeding associated with the delivery. Elevating the mother�s
pelvis can help control the bleeding. Allowing the baby to breast feed from the mother will
also help the process. An external uterine massage (as discussed previously) can also
assist the uterus in its contraction. The EMS crew must be vigilant when assessing and
reassessing the mother, especially if the vaginal bleeding does not stop or seems excessive.
If the mother begins displaying the signs and symptoms of shock, she should be treated
appropriately and, depending on her presentation, transport to the hospital may need to be on
an exigent basis. As discussed previously, a routine examination
and assessment of the newborn is required after birth. Dry, wipe, and wrap the newborn.
Be certain to cover his or her head as well. Remember that the baby was used to a warm,
protected environment and is now being exposed to ambient air temperature. Use blankets to
keep the baby warm. If necessary, repeat suctioning so that the baby has a clear airway. Approximately
one minute after birth, the baby should be assessed using what is known as an APGAR assessment.
In this assessment, the EMT evaluates the baby�s appearance (skin coloration), pulse
rate, grimace (responsiveness), activity (muscle tone), and respiratory effort. A score of
zero to two is awarded in each category with zero being a bad score. When the scores from
the categories are added, a final score of eight or higher is considered normal. Less
than eight may be cause for concern and that concern grows as the number approaches zero.
For trending purposes, an APGAR score should be determined approximately five minutes after
birth as well. This table includes the categories and scoring
associated with a newborn APGAR assessment. Again, a rating of zero is bad and a rating
of two is ideal. The first category, appearance, assesses the
baby�s color. If the baby is bluish-grey or pale all over, the score in this category
is zero. If the baby is a normal color, except for the hands and feet, which are bluish in
color, a one is awarded. If the baby is a normal color, meaning that the hands and feet
are pink, the baby�s appearance score is two. When assessing the baby, do not be fooled
by any vernix caseosa covering his or her body. Vernix caseosa is the white, waxy or
cheese-like coating on a newborn baby�s skin. Be sure to evaluate the baby�s skin
itself. If the baby has not been wiped down already, do so with a towel to remove at least
some of the vernix to adequately assess the baby�s color.
The P in APGAR is for pulse. Assess the baby�s pulse, commonly at the brachial artery (at
the crease of the elbow) and obtain a rate. No pulse is a zero, a pulse above 100 is two,
and anything in between is a one. Grimace is the next APGAR category, and it
refers to how the baby reacts to stimulation, such as rubbing the back, �flicking� the
feet, or gently poking the torso. If the baby does not respond, a zero is associated with
this category. Facial response without any extremity movement is scored as a one. If
the baby pulls away, sneezes, coughs, cries, or otherwise responds normally to stimulation,
this category is scored as a two. Activity refers to the baby�s natural positioning
and movement. If the baby is not moving at all and seems �floppy,� zero is the score
for this category. If the arms and legs are flexed, but are not moving much, if at all,
a one is scored. If the baby has active, spontaneous movement, this category is scored as a two.
Lastly, the baby�s respiratory system is assessed. A zero is scored if the baby is
not breathing. If the baby is breathing normally, meaning with a normal rate and effort, or
the baby is having a good cry, this category is scored as a two. Something in between those
two, such as slow or irregular breathing, or a weak cry, is scored as a one.
Again, once a score is determined for each category, they are added and an eight or more
is considered to be normal. Anything less may spell trouble, depending on the circumstances.
The lower the score, the worse off the newborn is doing. Be certain to trend this score as
well by performing an APGAR assessment one minute after birth and five minutes after
birth. The score should stay the same or increase in that time. If the score diminishes, that
may also be cause for concern. Unfortunately, there are instances in which
a delivery does not go as planned or there is a problem of some sort and the baby does
not appear to be breathing. Immediately after birth, that can be normal. After all, prior
to that moment, the baby was in a fluid-filled sac and never had to worry about adequate
oxygen as everything he or she needed was provided by the mother via the umbilical cord.
Given a lack of spontaneous breathing on the part of the newborn, stimulate him or her
by flicking the soles of the feet or by rubbing the infant�s back. Those activities are
usually enough to kick start the newborn�s respiratory system, if you will.
If those efforts do not spur spontaneous breathing, however, it may be necessary to begin resuscitation
efforts of the newborn. If that is the case, the EMT should follow what is known as the
inverted pyramid of neonatal resuscitation. The reason the pyramid is inverted, so to
speak, is because adult resuscitation focuses predominantly on the heart and the circulatory
system. In newborn resuscitation, however, the focus is on the respiratory system. Begin
by vigorously drying, warming, positioning, suctioning, and stimulating the newborn. Administer
oxygen and prepare to ventilate the newborn. Following those activities, it may be necessary
to begin chest compressions if spontaneous breathing does not occur.
If the newborn�s breathing is shallow, slow, absent, or otherwise inadequate, the EMT should
ventilate the baby at the rate of 40 to 60 breaths per minute. Reassess after 30 seconds
and see if the newborn�s respiratory effort has improved. If not, continue ventilations,
assess for a pulse, and continue resuscitation efforts.
Assessing the newborn�s heart rate is also important. If the heart rate is less than
100 beats per minute, the baby�s respiratory effort should be checked and, more than likely,
assisted following the guidelines just discussed. If the heart rate is less than 60 beats per
minute, the EMT needs to perform compressions at the rate of 120 per minute. Continue to
provide ventilations as well at a ratio of three compressions to every one ventilation.
If the baby has spontaneous breathing and an adequate heart rate, yet appears cyanotic,
10 to 15 liters per minute of oxygen should be administered with tubing held as close
to the newborn�s face as possible. Complications during pregnancy may arise from
any number of causes. Some of these complications may impact the delivery process and subsequent
care of the mother and baby after delivery. Other complications may occur well before
delivery. Regardless of the complication and when it occurs during the pregnancy, the EMT
must be prepared to assess and manage the mother and, possibly, the baby.
According to a 1998 study cited by the Pan American Health Organization, pregnant women
are 60.6% more likely to be physically abused than non-pregnant women. Violence is actually
cited as a pregnancy complication more often than diabetes, hypertension, or any other
serious complication. Violence during pregnancy may result in insufficient weight gain; vaginal,
cervical, or kidney infections; vaginal bleeding; abdominal trauma; hemorrhage; exacerbation
of chronic illnesses; complications during labor; delayed prenatal care; miscarriage;
low birth weight; ruptured membranes; abruptio placenta; uterine infection; fetal bruising,
fractures, or hematomas; or, even death of the fetus.
Being addicted to drugs or alcohol while pregnant can create some serious life-long complications
for the baby. According to the National Organization on Fetal Alcohol Syndrome, one in 100 babies
are born with fetal alcohol spectrum disorders (FASD) from mothers who consume alcohol during
pregnancy. There is no safe amount or type of alcohol to consume during pregnancy because
the fetus cannot process alcohol� Whatever alcohol concentration is in the mother�s
bloodstream will be passed directly onto the fetus. As a matter of fact, the Institute
of Medicine has stated that alcohol produces more serious neurobehavioral effects in the
fetus than even cocaine, heroin, or marijuana (not that these substances are any better
to take while pregnant, mind you). FASD is more prevalent than Down Syndrome, Cerebral
Palsy, SIDS, Cystic Fibrosis, and Spina Bifida combined. The effects of FASD can include
abnormal facial features, small head size, shorter-than-average height, low body weight,
poor coordination, hyperactive behavior, attention deficit, poor memory, learning disabilities,
speech and language delays, intellectual disability, poor reasoning and judgment skills, sleep
and sucking problems, vision or hearing problems, or problems with the heart, kidneys, or bones.
Along those lines, prenatal cocaine exposure or the use of other drugs, even some prescription
medications, can be damaging to the fetus at different levels. The immediate impact
of substance abuse during delivery is respiratory depression or cardiac issues that must be
managed by the EMT. Diabetes is another complication that can
occur during pregnancy in women who previously were not diabetics. Known as gestational diabetes,
this complication impacts approximately 18% of pregnancies according to the American Diabetes
Association. It is believed that hormones from the placenta block the action of the
mother�s insulin in her body, resulting in an elevated blood sugar. This impacts the
baby by increasing birth weight and may increase the risk for obesity and diabetes later in
life. During delivery, the baby�s size may cause complications that include the inability
for the baby to pass through the birth canal, resulting in the need for a C-section delivery.
With adequate prenatal care, however, gestational diabetes can typically be controlled.
While some vaginal bleeding in the form of �spotting� can be normal during pregnancy,
significant bleeding (hemorrhaging) during pregnancy is commonly indicative of significant
underlying problems. One reason for hemorrhage is an abortion of the fetus and placenta before
20 weeks of development. Elective abortions are commonly performed by physicians in a
controlled environment, but it is not unheard of for a woman to attempt an abortion on her
own or with assistance, typically with the application of blunt force trauma to the abdomen
or via an implement inserted up into the vagina. Bleeding associated with such a traumatic
event can be life threatening and should be handled accordingly by the EMS crew. There
is also something known as a spontaneous abortion, or a miscarriage. This is when the fetus and
placenta are expelled by the woman�s body without any intent or attempt to abort by
the mother. Such events, whether planned or not, can be extremely turbulent for the woman
and others involved. Sensitivity and discretion are a must for an EMS crew treating a woman
with complications from an abortion, whether planned or not.
Bleeding can also result from an ectopic pregnancy, where a fertilized egg implants itself somewhere
other than within the uterus, such as a fallopian tube. As other abdominal organs are not designed
to stretch and grow to accommodate the developing fetus, bleeding related to an ectopic pregnancy
is commonly indicative of some type of internal structure rupture as the fetus grew larger
than could be accommodated by the structure. Supine hypotensive syndrome occurs when supine
positioning results in the fetus resting on the mother�s inferior vena cava. This reduces
the amount of blood returning to the heart from the lower extremities, which reduces
cardiac output and drops the mother�s blood pressure, resulting in syncopal episodes.
If this occurs, the woman is encouraged to lie on her left side, instead of her back,
to relieve the pressure on the inferior vena cava.
Given the slowing of her digestive system and sometimes frequent bouts of nausea and
vomiting (called hyperemesis or morning sickness), it is possible for the mother to dehydrate.
Drinking fluids is important, but may not be wholly effective if the vomiting continues.
The placenta itself may create some complications depending its formation or integrity. Abruptio
placenta occurs when the placenta separates from the uterine wall prior to the delivery
of the baby. This is a significant emergency requiring rapid transport to a hospital. Placenta
previa is when the placenta forms abnormally low in the uterus, either fully or partially
covering the cervix. Delivery for a woman with placenta previa must be managed at a
hospital or other definitive care facility. It is not entirely uncommon for some women
to experience hypertensive disorders during pregnancy. Gestational hypertension is the
existence of a blood pressure higher than 140/90 without the presence of protein in
the urine. If not monitored or treated adequately, the woman may develop preeclampsia where the
high blood pressure continues but is now accompanied with excess protein in the urine. Eclampsia
occurs when the mother begins experiencing tonic-clonic seizures as a result of her hypertension
and proteinuria. When preparing for an eminent delivery, there
are some factors related to the pregnancy which may be indicative of potential complications.
If the mother is in labor prior to 36 or 37 weeks of gestation (resources vary slightly
in defining this threshold), any resulting birth is considered to be preterm. The problem
is not for the mother so much as it is for the delivered baby who has organs that are
not developed enough to allow for normal postnatal survival. While medical science continues
to evolve, allowing for neonatal care and viability at even younger ages, so to speak,
such care cannot be provided by an EMT as these premature babies require special equipment
and other interventions. Rapid transport is imperative.
On the other end of the spectrum are deliveries past 42 weeks of pregnancy (remember, normal
pregnancy lasts approximately 40 weeks). These post-term pregnancies can create complications
for both the fetus and the mother. The fetus can outgrow the ability of the placenta to
provide adequate nutrition and oxygen. As the fetus continues to grow in utero, the
fetus may grow too large to pass through the mother�s birth canal, which can create complications
for both the baby and the mother during delivery (potentially prompting an emergency C-section).
If the baby is delivered with amniotic fluid that appears stained with an olive green,
brown, or yellow tint, the baby likely had a bowel movement within the uterus and amniotic
sac prior to delivery. The product of such a bowel movement is called meconium. Meconium
is the byproduct of the materials ingested during fetal development and it is considered
a sign of fetal distress at some point either before or during the delivery process. Meconium
aspiration on the part of the baby can lead to infection, pneumonia, and other problems.
Definitive medical care is required for these infants. If meconium is present upon delivery,
suction the newborn first before stimulating him or her. Be certain to maintain an adequate
airway, transport rapidly, and consider an ALS intercept if the newborn exhibits signs
of respiratory distress or other related issues. If the mother is pregnant with more than one
fetus (what is known as a multiple gestation), the resulting delivery is commonly considered
to be high-risk. If all goes well, this kind of delivery can readily be handled by a single
EMS crew. If one or more of the babies is in distress upon delivery, however, providing
adequate care to one while still having to deliver the other sibling or siblings as well
as care for the mother will be too much of a strain for the crew and additional personnel
resources will be necessary. If there are issues, the EMS crew must also be prepared
for more than one resuscitation. If one baby is in distress upon delivery, it is very possible
that the other may be as well. If there are issues with a multiple gestation delivery,
utilization of ALS resources, if available, is recommended. Keep in mind as well that,
depending on the level of neonatal care received by the mother, she may or may not know that
she is carrying twins, triplets, or more. There are also some unfortunate instances
in which the fetus is delivered in a nonviable state. Referred to as intrauterine fetal death,
still born, or fetal demise, this occurs when the fetus dies within the uterus before labor.
In some rare instances, the mother may already be aware of this and it was considered �safer�
for her to finish the term and deliver naturally. In most instances involving a stillborn birth,
however, the parents may have not had any warning or the mother was fearful that there
was a problem because something just did not feel right in the time leading up to the delivery,
yet the death of the fetus was not able to be diagnosed prior to delivery. These deliveries,
while rare, will test any EMS provider on his or her abilities to not only control personal
emotions, but to also maintain control of the scene and provide for the emotional and
other needs of the mother and family. Professionalism, compassion, and empathy are just some of the
EMT�s behaviors that will be tested under such circumstances.
Even if a delivery is not anticipated to be high-risk, complications can still occur.
One such complication is the premature rupture of membranes (the amniotic sac). If the mother
is at term, this premature rupture (which occurs prior to labor) will commonly result
in the mother entering labor. If labor does not begin relatively soon after this event,
labor will commonly be induced by a physician. Preterm premature rupture of membranes is
a more serious complication in which this rupture of membranes occurs prior to the 37th
week of gestation, which carries its own set of risks for the fetus and mother, resulting
in premature deliveries in many instances. Premature deliveries or labor can occur as
well without the premature rupture of membranes. The further away the mother is from being
at full term (40 weeks), the greater the risk to the viability of the fetus. In instances
involving premature rupture of membranes or preterm labor, there is not much the EMS provider
can do but rapidly transport the mother to a definitive care facility. The EMT cannot
stop labor if it occurs prematurely, nor is there anything the EMT can do to repair a
ruptured amniotic sac. If delivery occurs, the EMS providers must be prepared to assist
the delivery and perform resuscitation or other life-saving interventions for the baby
once delivered. Beyond complications associated with labor,
the delivery itself may also encounter complications. One such complication is a breech birth presentation
where the baby�s buttocks is delivered first, with the head still in the birth canal. Limb
presentations are also possible, which may include either one or both of the arms or
the legs. There are rare instances in which the umbilical cord may present first. Providers
must also be wary of a nuchal cord where the umbilical cord is wrapped around the baby�s
neck. Multiple births can also complicate the process of assisting a delivery.
If the baby�s buttocks presents first, this is known as a breech birth and, if possible,
it is imperative to transport as rapidly as possible to the hospital. Try to position
the mother with her head down and buttocks raised to reduce pressure on the birth canal.
Coach the mother to not push with contractions. If the delivery continues, support the baby�s
body and, once the torso and shoulders are clear, attempt to insert wide-spread fingers
into the birth canal over the baby�s face to provide a pathway for air to reach the
baby�s mouth. Also use this technique to exert pressure on the baby to keep the head
off the umbilical cord during this stage of delivery. Lastly, attempt to prevent an explosive
delivery of the head by continuing to support the baby�s body while also providing a makeshift
air passage with the other hand. Handling a limb presentation will vary depending
on whether the baby presents with an arm or a leg. If an arm presents first, it should
still be possible to deliver the baby as previously described (although there can be some concern
of trauma to the baby�s shoulder joint). If a leg presents first, however, this is
a breech delivery with a leg presentation, which makes the breech delivery even more
complicated. In either instance, do not pull on a presenting limb in an attempt to assist
the delivery. As with a breech delivery, try to coach the mother to not push with contractions,
position the mother head down and buttocks up, and transport as quickly and safely possible
to the hospital. If the delivery progresses, however, follow the steps provided for delivery
as necessary for either a head-first or breech delivery.
If the umbilical cord presents in the vaginal opening before delivery of the head, the concern
is that a subsequent delivery of the baby will exert pressure on the cord, thus disrupting
the flow of blood and oxygen from the mother to the baby during that timeframe. Such an
occurrence can have catastrophic results for the baby. If a prolapsed umbilical cord is
noted, do not attempt to push it back into the vagina. As with a breech birth, position
the mother with her head down and buttocks elevated and transport as rapidly as possible.
If the delivery cannot be stopped, try to insert several fingers into the vagina underneath
the cord and exert upward pressure on the baby�s head or buttocks (if a breech birth)
to relieve pressure on the umbilical cord. A nuchal cord occurs when the umbilical cord
is wrapped around the baby�s neck. If not resolved quickly, the cord can strangulate
the baby during delivery, preventing blood and oxygen from reaching his or her brain.
If it is noted during delivery that the umbilical cord is wrapped around the baby�s neck,
attempt to loosen the cord from around the neck, preferably by moving the cord down over
the baby�s shoulders. Be cautious when moving the cord as the EMT does not want to tear
the cord. If the cord is tight and it is not possible to remove it from around the neck,
the EMT must rapidly clamp and cut the cord before the baby is fully delivered. If the
cord is cut in such fashion, it is important to coach the mother to push hard and frequently
because the baby no longer has an oxygen supply from the mother; the baby must breathe on
his or her own, which can be difficult while the chest, lungs, and diaphragm are all being
squeezed within the birth canal. Delivery must occur rapidly after a nuchal cord is
cut. Multiple births can also be challenging to
manage, especially if there are any of the aforementioned complications present with
the delivery of any of the newborns. Remember that multiple births encompasses not only
twins, but triplets or possibly more babies. If the ambulance only has a single OB kit
available, it would be prudent to call for an additional ambulance (or ambulances, if
necessary) to have ample OB kits accessible for each delivery (as each baby will require
two cord clamps at the very least). As babies are delivered, clamp and cut the cord of the
delivered baby prior to delivering the next baby. It is also possible that subsequent
babies are delivered before the placenta of the preceding baby.
If, at some point during the delivery process, the mother complaints of severe, shearing,
sudden pain during contractions, the EMT must be concerned with the possibility of a uterine
rupture. If there is a palpable hard mass in the uterus beside the fetus or the mother
begins exhibiting signs of shock, this concern is well warranted and the need to transport
rapidly is even more urgent. Once delivery is completed, whether there
were complications or not, the EMS crew must now care for multiple patients. While it is
easy to focus on the newborn baby (or babies), do not forget about the health and well-being
of the mother as well. Labor is called �labor� for a reason. The mother will probably be
tired, if not exhausted, and may be dehydrated as well. Of particular concern as well is
the potential for internal hemorrhage. The process of childbirth is traumatic for the
mother�s body, particularly the uterus. For weeks after delivery, it is normal for
the woman to experience bleeding, mucus, and other tissue discharge from the vagina. This
normal bleeding and discharge is commonly described to being similar to menstruation,
but significantly heavier. For various reasons, however, there are instances in which the
bleeding is profuse or excessive, which is not normal. Early postpartum hemorrhage occurs
within 24 hours of delivery and late postpartum hemorrhage is that which occurs more than
24 hours after delivery (although not typically after six weeks have elapsed). If the EMS
crew assists with delivery, be mindful of profuse or excessive bleeding following the
delivery. Monitor the mother for signs of shock and treat as appropriate. If called
for a woman with severe vaginal bleeding or discharge, be certain to find out if she delivered
a baby recently (within the past six weeks). If so, she may be experiencing postpartum
hemorrhage. Again, assess for signs of shock and treat as necessary.
After delivery, women are also at increased risk for a pulmonary embolism given hypercoagulability
following labor and delivery. If called to respond for a woman with a rapid onset of
difficulty breathing, and she recently delivered a child, a pulmonary embolism may be the culprit.
While not commonly a concern for EMS providers, some women have emotional disturbances after
delivery as the hormone levels within the body experience a rapid change. These disturbances
can be mild mood swings to something as drastic and serious as suicidal ideation. As with
any patient, a thorough assessment is an absolute necessity to assist in the development of
a field impression and treatment plan. Given a psychiatric issue, whether related to postpartum
complications or not, always remember to evaluate the safety of the scene for the EMS crew and
do not hesitate to utilize law enforcement for assistance if necessary.
Beyond obstetrics (pregnancy, labor, and delivery), women may experience other gynecological emergencies,
such as a sexually transmitted disease or pelvic inflammatory disease.
According to the CDC, there are 20 million new sexually transmitted infections within
the United States every year. Some of these diseases strike both men and women alike,
such as chlamydia, gonorrhea, hepatitis, herpes, syphilis, genital warts, HIV/AIDS, and others.
The issue for women in particular, however, is that many of these diseases, such as chlamydia
and gonorrhea, can result in infertility if left untreated. A pregnant woman with a sexually
transmitted disease can infect her baby before, during, or after the baby�s birth. She is
also at increased risk for premature labor or rupture of membranes. Some sexually transmitted
diseases are indeed treatable, while others cannot be cured (only the symptoms can be
treated). Women can also suffer from related diseases unique to their gender, such as pelvic
inflammatory disease where bacteria infect the uterus, fallopian tubes, and other reproductive
organs. The CDC reports that 10 to 15 percent of women with pelvic inflammatory disease
will become infertile. A female patient suffering from the effects
of a sexually transmitted disease will commonly complain of abdominal or vaginal pain. There
may also be vaginal bleeding or discharge, along with a fever, nausea, and/or vomiting.
Some sexually transmitted diseases target specific organs or body systems. A person
with untreated syphilis, for instance, will suffer damage to the brain, nerves, eyes,
heart, blood vessels, liver, bones, and joints. Hepatitis, by comparison, impacts the liver
specifically. Depending on how far the disease has progressed, the patient may present with
signs and symptoms related to the dysfunction of impacted organs and body systems.
From an emergency medicine standpoint, there is not much an EMT can do for a patient with
a sexually transmitted disease complaint. Be certain to protect the patient�s privacy
and modesty. Employ appropriate communication techniques to assess the patient and avoid
being judgmental or critical of the patient. Provide supportive care as appropriate and
transport the patient in a position of comfort. While sexual assault can occur to anyone,
statistics show that women are more often victims than men. According to the National
Sexual Violence Resource Center, an estimated 92,700 men are forcibly raped each year in
the United States, as opposed to approximately 683,000 women. These numbers are just for
the crime of rape, which is a single type of sexual assault. The statistics are even
more staggering for sexual assault as a broader category with one in four girls being sexually
assaulted by the age of 18 (by comparison, one in six boys are sexually assaulted by
the time they reach 18 years of age). With these statistics in mind, it is highly
probable that an EMT will be called to provide care to a female victim of sexual assault
on more than one occasion throughout his or her career. As with all patient contacts,
be certain to utilize standard precautions and BSI. It is also important to be non-judgmental
of the patient. Regardless of the individual�s demeanor, dress, or other circumstances, sexual
assault is a crime and the patient is a victim who deserves the best care possible (just
like any other patient). Reassure the patient and let her know she is safe. In many instances,
the perpetrator of the sexual assault was male and the female patient may associate
any man she encounters with the violation she just suffered. When possible, try to have
a female EMT conduct the assessment and care of the female sexual assault patient. Examine
the genitalia only if there is profuse bleeding or significant injury requiring intervention.
Be certain to manage all other injuries as appropriate and, if available in your area,
transport to a facility with personnel trained to examine victims of sexual assault.
Sexual assault is a crime of varying degrees, which will require law enforcement involvement.
Law enforcement should be contacted when a sexual assault has occurred. In the case of
a minor or geriatric patient, reporting is mandated by law. For other age groups, the
victim should be encouraged to speak with law enforcement about the assault. Given the
likelihood of criminal charges and potential prosecution given a sexual assault, preservation
of the crime scene and evidence is very important. Minimize contamination of the scene. Do not
move items or disturb the scene any more than necessary to treat and transport the patient.
One way to accomplish this is to minimize the number of rescue personnel entering the
scene. Any evidence collected must be documented and the �chain of evidence� must be maintained.
(Utilize law enforcement to assist with the collection and preservation of evidence.)
It is also important to preserve destructible evidence until it can be collected. This usually
means telling the victim to not bathe, shower, have a bowel movement, urinate, drink fluids,
brush teeth, or clean wounds until evidence can be collected off her body by someone trained
in retrieving, documenting, and maintaining such evidence (which is why the EMT should
transport to a facility with expertise and resources to perform such evidence collection
activities). If the patient insists on changing clothes, have her stand on a clean or sterile
sheet to undress, and then collect the sheet and the clothing in a paper bag for transport
along with the patient. Part of protecting the patient is to help law enforcement in
apprehending the suspect so that he (or she) can be prosecuted as appropriate to prevent
others (or the same person) from falling victim to the perpetrator at a later date.
When discussing age-related variations as they impact obstetrics and gynecology, pediatric
females commonly do not experience significant gynecological issues unless victims of a sexual
assault. At some point, the pediatric female will experience menarche (her first menstrual
cycle). This is commonly considered the central event of female puberty and signals the possibility
of fertility. From that point forward, abdominal complaint assessment must include considerations
for possible obstetric emergencies or problems. Older females will experience menopause at
some point, typically during the late 40s to early 50s. While menopause typically indicates
the woman is transitioning or has transitioned into a non-reproductive (non-fertile) state
given cessation of the functioning of the ovaries, it is still possible (albeit rare)
for a post-menopausal woman to become pregnant. When assessing older females with abdominal
complaints, it is important to ask about the woman�s last menstrual cycle, whether or
not she has been through menopause, and whether or not she has had any gynecological or obstetrical
surgeries, such as a hysterectomy, C-section, or birth control intervention (including endometrial
ablation and tying of the fallopian tubes). These can all be important factors in developing
a differential diagnosis and treatment plan for the geriatric woman with abdominal-related
complaints. Given your completion of this module, you
should now be able to: Define terms associated with female reproductive anatomy; define terms
associated with the process of labor; discuss cultural values affecting pregnancy; identify
special considerations of adolescent pregnancy; summarize the normal physiology of pregnancy;
list and describe signs and stages of labor; list components of assessment for an obstetrical
patient; identify the contents of an obstetrics kit; state indications of an imminent delivery;
list steps for a normal delivery; discuss initial care of the newborn; summarize neonatal
resuscitation procedures; describe complications of pregnancy, labor, delivery and postpartum;
discuss gynecological emergencies; describe the age-related variations for pediatric and
geriatric assessment and management of the female patient; and, appreciate the emotions
a sexual assault victim is feeling. Once completed with your classroom lab, if
you have not already participated in it, this information should assist you in: Demonstrating
the steps to assist in the normal delivery of a baby; demonstrating the steps to assist
in complicated deliveries; demonstrating infant neonatal procedures; demonstrating post-delivery
care of an infant; demonstrating the post-delivery care of the mother; demonstrating the steps
in management of the mother with excessive bleeding; and, demonstrating the completion
of a prehospital care report for patients with obstetrical or gynecological emergencies.
This presentation was created by Waukesha County Technical College with grant funding
from the Wisconsin Technical College System.