© 2011 National Safety Council 20-1

PREGNANCYAND CHILDBIRTH

LESSON 20

© 2011 National Safety Council 20-2

Introduction

• Childbirth sometimes occurs outside planned setting

• Delivery rarely becomes medical emergency

• Medical problems or complications can become emergencies

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Pregnancy and Labor

• Begins with fertilization of ovum

• Growth and development proceed over 40 weeks

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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

© 2011 National Safety Council 20-5

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

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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

© 2011 National Safety Council 20-7

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

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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

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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

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Emergency Care During Pregnancy

• Women who receive regular care are advised about potential problems to watch for

• Although rare, problems may require emergency care

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Vaginal Bleeding

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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

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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

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Emergency Care forVaginal 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

© 2011 National Safety Council 20-15

Emergency Care forVaginal 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

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Miscarriage

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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

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Assessing Miscarriage

• Perform standard assessment

• Take repeated vital signs

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Signs and Symptoms of Miscarriage

• Vaginal bleeding

• Abdominal pain or cramping

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Emergency Care for Miscarriage

• Provide same emergency care as vaginal bleeding in pregnancy

• Retain expelled materials for EMS personnel

• Be calm and reassuring

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Trauma in Pregnancy

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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

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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

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Other Problems

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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

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Childbirth

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Childbirth

• Remember it is a natural process

• Woman may be fearful or distressed

• Remain calm

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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

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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

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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

© 2011 National Safety Council 20-31

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

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Preparing for Delivery

• Someone must stay with woman

• Gather the items needed or helpful for delivery

• Many EMRs carry obstetrics kit

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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)

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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)

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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

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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

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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

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Skill: Assisting with Delivery

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

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

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3. As the head emerges (usually face down), support the head

4. After the head is out, have the woman stop pushing and breathe in a panting manner

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5. Hold infant with head lower than feet

6. Suction nose and mouth with bulb syringe

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7. Gently dry and wrap the infant in a towel or blanket to prevent heat loss, keeping the cord loose

8. Follow your local protocol to clamp or tie the umbilical cord or leave it intact for arriving EMS personnel

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9. Wait for delivery of afterbirth, placenta and umbilical cord – do not pull on umbilical cord in an attempt to pull out placenta

10.Continue to monitor both mother and newborn

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Care of the Mother After Delivery

1. Support and comfort mother

2. Monitor pulse and breathing

3. Replace any blood-soaked sheets or blankets, dispose of used supplies

4. Mother may drink water now

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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

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Care for BleedingAfter 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

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Care for the Newborn

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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

© 2011 National Safety Council 20-50

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

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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

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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

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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

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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 40-60 breaths/minute

- Follow local protocol for oxygen administration

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Non-Breathing Newborn (continued)

• If infant is not breathing

- If pulse is 60-100 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

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• Reassess breathing and pulse after 30 seconds

• If pulse is >100 and respiration has improved, gradually discontinue ventilations

Non-Breathing Newborn (continued)

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Childbirth Problems

• Most deliveries occur without problems

• Common problems involve presentation of infant or maternal bleeding

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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

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Breech Birth

• Buttocks or feet appear inbirth canal

• Umbilical cord is squeezedand blood flow is compromised

• If infant’s head becomes lodged in birth canal and it tries to breathe, it may suffocate

© 2011 National Safety Council 20-60

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

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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

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Limb Presentation (continued)

• Put woman in knee-chest position

• Do not try to pull infant out or push arm or leg back in

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Prolapsed Cord

• Segment of cord protrudes through birth canal before childbirth

• Cord will be compressed as infant moves through canal, cutting off blood flow

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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

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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

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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

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Care for Premature Infant

• Keep premature newborn warm

• Provide ventilations or CPR if needed

• Follow local protocol for blow-by oxygen

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Stillborn Infant

• Rarely, infant is born dead or dies shortly after birth

• Use all resuscitation measures available

• Provide comfort for mother