During puberty, the maturing female body undergoes multiple physical and hormonal changes, ultimately leading to menarche. The average cycle is 24 days, and the processes that the follicle goes through and the actual release of the egg (ovulation) are stimulated by the release of specific hormones in the female body. Ovulation occurs approximately two weeks prior to menstruation. Immediately following ovulation, the endometrium, or the lining of the inside of the uterus, begins to thicken in preparation for the potential implantation of a fertilized egg. If the egg is not fertilized within 36 to 48 hours after it has been released from the follicle, it will simply die. The fallopian tubes extend out laterally from the uterus, and the egg travels through the fallopian tube. A fertilized egg develops into an embryo 0 to 10 weeks after fertilization and then a fetus from 10 weeks until delivery. The uterus is a muscular organ that encloses and protects the developing fetus. It produces contractions that push the fetus through the birth canal, which is made up of the vagina and the lower third of the uterus called the cervix. During pregnancy, the cervix contains a mucus plug that seals the uterine opening, preventing contamination from the outside. When the cervix begins to dilate, the plug is discharged into the vagina as pink-tinged mucus, sometimes called a bloody show, a small amount of bloody discharge. The area between the vagina and the anus is called the perineum. The placenta is a disk-shaped structure attached to the uterine wall that provides nourishment to the fetus through the umbilical cord. Blood does not normally mix because of the placental barrier. Circulation is separated, but nutrients, oxygen, waste, and carbon dioxide pass through. The umbilical cord connects the woman and the placenta. The amniotic sac contains approximately 500 to 1000 mL of amniotic fluid, which helps insulate and protect the fetus. Term gestation occurs when a pregnancy reaches 39 weeks but has not gone beyond 40 weeks and 6 days.
The reproductive, respiratory, cardiovascular, and musculoskeletal systems undergo major physiologic and anatomic changes during pregnancy. In the reproductive system, there is an increase in hormone levels to support fetal development. There is also the displacement of the uterus out of the pelvic area. By the 20th week, it is above the belly button, which increases the chances of direct fetal injury in trauma. The respiratory system changes are due to the uterus pushing up on the diaphragm, reducing the tidal volume with each breath. Pregnancy also increases the patient’s overall demand for oxygen as the metabolic demands and workload increase to support the fetus. Therefore, there is decreased ability to compensate during times of respiratory distress. Changes in the cardiovascular system lead to blood volume increasing by as much as 50% by the end of pregnancy, which causes an increased need for iron. They may become anemic if there are too few red blood cells. Clotting speed increases to protect against excessive bleeding during delivery. Heart rate by the end of pregnancy is often 20% higher or 20 more beats per minute. Pregnant women are at increased risk for gastroesophageal reflux, nausea, vomiting, and potential aspiration. Weight gain during pregnancy is normal. Certain hormones affect the musculoskeletal system by relaxing ligaments that stabilize bones and joints. There is also a change in the center of gravity, making them prone to slipping and falling.
There are also a number of complications that can develop during pregnancy. One being gestational diabetes, which typically resolves after delivery. Treatment is often the same as treatment for any patient who has diabetes. Hypertension in pregnancy generally manifests as one of the three conditions: gestational hypertension, preeclampsia, or eclampsia. There is typical elevation of blood pressure and the presence of systemic effects, such as protein in the urine, altered mental status, or seizures. Gestational hypertension is the presence of high blood pressure in the absence of other systemic effects. It is severe when blood pressure is over 160 or the diastolic is above 110. Preeclampsia involves new-onset hypertension along with other systemic effects such as protein in the urine. It is characterized by hypertension, severe or persistent headache, visual abnormalities, swelling (edema) in the hands and feet, upper abdominal or epigastric pain, dyspnea, and anxiety. Eclampsia is characterized by the presence of seizures. To treat, have the patient lie on their left side, maintain her airway, and administer supplemental oxygen. This can prevent supine hypotensive syndrome, which is the compression of the inferior vena cava by the pregnant uterus when the patient lies supine, reducing the amount of blood that is returned to the heart.
An ectopic pregnancy is one where an embryo develops outside of the uterus, most often in the fallopian tube. Sudden onset of severe abdominal pain and vaginal bleeding in the first trimester of pregnancy should be considered ectopic pregnancy until proven otherwise. In abruptio placentae, the placenta separates prematurely from the wall of the uterus. The most common causes are hypertension and trauma. A patient with abruptio placentae often reports severe pain. In addition, there might also be signs of shock. In placenta previa, the placenta develops over and covers the cervix. The patient may experience heavy vaginal bleeding, often without significant pain. A spontaneous abortion is the loss of a pregnancy prior to 20 weeks without any preceding surgical or medical intervention. This term is often used interchangeably with miscarriage. There is often abdominal cramping and vaginal bleeding. An induced abortion is the elective termination of a pregnancy prior to the time of viability. The most serious complication of abortion is bleeding and infection.
When you are dispatched to a trauma call, you have two patients to consider: the woman and the unborn fetus. Falls can lead to trauma in the fetus. Fetal distress may also be present well before signs of shock are evident. Serious trauma can cause blood supply to the fetus to be reduced. In most cases, the only chance to save the fetus is to adequately resuscitate the woman. If a woman is in the third trimester, manual displacement of the uterus toward the patient’s left side may be necessary to facilitate blood return to the right side of the heart. For a trauma patient, maintain an airway, anticipating vomiting, administer high-flow oxygen by nonrebreather mask, ensure adequate ventilation, assess circulation, and during transport keep the patient on the left side and notify the hospital early.
Cultural sensitivity is important when you are assessing and treating a pregnant patient. Also, once a teenager becomes pregnant, she is considered emancipated. Be aware patients have the right to give or refuse consent.
Patient assessment always begins with a scene size-up and taking standard precautions. For this situation, make sure ALS is on their way. Form a general impression of whether the patient is in active labor and address other possible life threats. Ensure airway and breathing are adequate. External and internal bleeding are potential life threats and should be assessed early. You will need to check mucous membranes inside the lower eyelid or slow capillary refill for signs of shock and treat if there are any. If delivery is imminent, you must prepare to deliver the baby at the scene. The most ideal place to deliver the baby is in the ambulance or the privacy of the woman’s home. Provide rapid transport for pregnant patients who have significant bleeding and pain, are hypertensive, are having a seizure, or have an altered mental status. Obtain a SAMPLE history that includes expected due date and complications she is aware of. Ask whether the woman’s fluid was green due to staining from meconium. The presence of meconium can indicate newborn distress. Perform a complete assessment of the major body systems. Assess the length and frequency of contractions by asking the patient and by placing your hand on the abdomen. Compare what you feel with the patient’s experience during each contraction. If you suspect that delivery is imminent, check for crowning. Secondary assessment should include a complete set of vital signs and pulse oximetry. During reassessment, you can slow vaginal bleeding by stimulating the uterus to contract back toward its prepregnancy size. If a mother is hypoxic, her fetus will be hypoxic. On rare occasions, the delivery of the placenta does not occur within 30 minutes.
There are three stages of labor: dilation of the cervix, delivery of the fetus, and delivery of the placenta. The first stage begins with the onset of contractions and ends when the cervix is fully dilated. The first stage is generally the longest and lasts 12 to 18 hours in a primigravida woman (first birth) compared to 6.5 to 13 hours for a multigravida woman. You typically have time to transport if in the first stage of labor. In true labor, frequency and intensity of contractions increase with time, become more regular, and last about 30 to 60 seconds. False labor, or Braxton-Hicks contractions, are not regular. Pain starts and stays in the lower abdomen as opposed to starting in the lower back and wrapping around to the lower abdomen. Change in position may alleviate the pain, and bloody show is brownish. Fluid leaking also smells of ammonia. The movement down the pelvis is called lightening.
The second stage of labor begins when the fetus enters the birthing canal. Pressure on the rectum may make the woman feel like she needs to have a bowel movement. Never let the woman sit on the toilet. The perineum will begin to bulge significantly. When the top of the fetus’s head begins to appear at the vaginal opening, this is called crowning.
The third stage begins with the birth of the newborn and ends with the delivery of the placenta. The placenta must separate completely from the uterine wall. This may take up to 30 minutes.
If the patient says that she is about to deliver, says she has to move her bowels, or feels the need to push, immediately prepare for a delivery and consider calling for additional resources. Crowning is an indication that the delivery is occurring. Take the following steps to prepare the area where the delivery will occur. Put on a protective face shield and gown. As time allows, place towels or sheets on the floor around the area to help soak up body fluids and to protect the woman and the newborn. Carefully open the OB kit so its contents remain sterile. Put on the sterile gloves. After this, only handle sterile materials. Use the sterile sheets and drapes from the OB kit to make a sterile delivery field. Place one drape under the patient’s buttocks, and unfold it toward her feet. Wrap another behind the patient’s back and drape it over each thigh. Finally, drape a third sheet across her abdomen. Position yourself so that you can see the perineal area at all times. Time the patient’s contractions, starting at the beginning of one and ending with the beginning of the next. Time the duration of each contraction by feeling the patient’s abdomen from the moment the contraction begins to the moment it ends. Remind the patient to take quick, short breaths.
During delivery, use your hands to support the bony parts of the head as it emerges. The child’s body will naturally rotate to the right or left. Continue to support the head to allow it to turn in the same direction. As the upper shoulder appears, guide the head down slightly to deliver the shoulder. Feel the neck and make sure the umbilical cord is not wrapped around the neck. Do not poke fingers into the newborn’s eyes or fontanelles. Handle the newborn firmly but gently, support the head, and keep the neck in a neutral position to maintain the airway. Consider placing the newborn on the mother’s abdomen with the umbilical cord still intact, allowing skin-to-skin contact to warm the newborn. Otherwise, keep the newborn approximately at the level of the vagina until the cord has been cut. After delivery and prior to cutting the cord, if the child is gurgling or shows other signs of respiratory distress, suction the mouth and oropharynx gently with a bulb syringe to clear any amniotic fluid and ease the infant’s initiation of exchange. Wait 30 to 60 seconds for the umbilical cord to stop pulsing. Place a clamp on the cord. Place a second clamp 2 to 3 inches away from the first. Cut between the clamps. Allow the placenta to deliver itself. Do not pull on the cord to speed the delivery.
When delivering, if there is an unruptured amniotic sac, you may puncture it with a clamp or tear it by twisting between your fingers. Make sure the puncture site is away from the fetus’s face and perform this procedure only as the head is crowning. Do not puncture the sac if the fetus’s head is not crowning. Make sure to note if the fluid is greenish (indicating meconium staining) instead of clear or has a foul odor. When there is an umbilical cord around the neck, it is called a nuchal cord. It is present in 15 to 34% of term births. Usually, you can slip the cord gently over the delivered head. If that is not possible, you must cut the cord by placing two clamps 2 inches apart on the cord and cutting between the clamps. Once the cord is cut, you must attempt to speed the delivery by encouraging the woman to push harder because the fetus will have no oxygen supply until it is delivered and breathing spontaneously. Handle the cord very carefully because it is fragile and easily torn.
When delivering the body, the head typically rotates to the left or right, and the head is the largest part, so once it is delivered, the rest is typically easier. Support the head and upper body as the shoulders deliver. Make sure to always support the head with one hand. Lower the head a little to deliver the upper shoulder, and then very gently raise it to deliver the lower shoulder. Once the shoulders deliver, the abdomen and hips will appear and will slide out easily. The newborn will be extremely slippery, so make sure to support the body with your other hand as it delivers. Newborns may be covered with a white, cheese-like substance called vernix caseosa. Make sure not to pull the fetus from the birth canal.
As soon as the newborn is delivered, if the mother is able and willing, hand the newborn to the mother or place the newborn on her chest or abdomen with skin-to-skin contact and cover with a blanket. Wrap the newborn so that only the face is exposed, making sure the top of the head is covered. It has become generally accepted practice to place the newborn on the mother’s chest and delay cord clamping for approximately 40 seconds. If respiratory distress or another complication is present, prompt care takes priority over delayed cord clamping. Cut the cord preferably 6 inches from the newborn’s body. Place the clamps about 2 to 4 inches (5 to 10 cm) apart. The cord is fragile; if handled too roughly, it could be torn from the newborn’s abdomen, resulting in a fatal hemorrhage. Obtain the 1-minute Apgar score.
The placenta is usually delivered within a few minutes of the birth, although it can take as long as 30 minutes, so do not delay transport waiting for the placenta to deliver. Wrap the entire placenta in a towel and place it into a plastic bag and take it to the hospital. You can help to slow bleeding by placing a sterile pad or sanitary pad over the vagina and straightening the woman’s legs. You can help to slow bleeding by massaging the woman’s abdomen using a firm, circular, kneading motion with one cupped over the top of the fundus and the other above the pubic bone. The fundus is the upper end of the uterus. Emergency situations occur when the placenta has not delivered after 30 minutes, more than 500 mL of bleeding occurs before delivery of the placenta, and significant bleeding occurs after delivery of the placenta.
During the first minute of life, perform the following four initial steps of newborn care. The first is airway positioning and suctioning if needed, then drying, followed by warming, and then tactile stimulation. If signs of good tone and adequate ventilation are not present after performing initial steps for approximately 30 seconds, then provide positive-pressure ventilation with a bag mask. If the newborn has good color, a strong cry, and spontaneous respirations in the first minute of life, then note the Apgar score and place the baby onto the mother’s chest. Heart rate will be 100 beats or higher. If there is apnea, gasping, or HR below 100/min, provide PPV and an SpO2 monitor. If there is labored breathing or persistent cyanosis, position and clear the airway, monitor SpO2, and provide supplementary O2 as needed. If heart rate is below 60/min, begin chest compressions in coordination with PPV and 100% O2. If chest compressions are required, perform bag-mask ventilation during a pause after every third compression. Provide 90 compressions and 30 ventilations. If you see meconium present, quickly suction the newborn’s mouth and nose before delivering rescue ventilations.
Apgar score should be calculated 1 minute after birth and 5 minutes after birth. A score of 7 or higher is generally considered reassuring. The Apgar score has five areas it looks at and judges between a 2 and 0: appearance, pulse, grimace or irritability, activity or muscle tone, and respiration. For appearance, the baby gets a perfect score of 2 if they are entirely pink, but if the body is pink and the hands and feet remain blue, that is a score of 1, and they receive 0 if they are blue or pale. For pulse, if it is above 100 bpm, it is a 2, and if it is lower than 100, it is a 1. An absent pulse results in a 0. For grimace or irritability, the baby receives a 2 if the newborn cries and tries to move the foot away from a finger snapped against the foot. It is a 1 if they only weakly cry and a 0 if there is no reaction. Activity or muscle tone is judged by the newborn’s ability to resist attempts to straighten the hips and knees; doing that results in a 2. However, if the newborn makes weak attempts to resist straightening, then it is a 1, with a 0 occurring when the baby is limp with no muscle tone. Finally, the Apgar score checks respiration, with a 2 going to rapid respirations and a 1 going to slow respirations, but absent respirations are scored at a 0.
There are a few complications with delivery of a baby. The first being a breech delivery, where the position in which the infant is born, or presentation, is not vertex presentation but the buttocks are delivered first. They take longer, so there may be time to transport to the hospital. Call ALS backup. If they do not deliver within 10 minutes of the buttocks presentation, provide prompt transport and consult medical control. The head is almost always face down, so you will need to perform a life-saving procedure to manage the newborn’s airway. Make a “V” with your gloved fingers and position them in the vagina to keep the walls of the vagina from compressing the fetus’s airway. This situation and a prolapsed cord are the only two circumstances in which you should insert your fingers into the vagina.
With limb presentation, you cannot successfully deliver in the field and it must be delivered surgically. You must transport the patient to the hospital immediately. Cover the limb with a sterile towel. Remember to administer high-flow oxygen to the woman. The prolapse of the umbilical cord is another situation where the umbilical cord comes out of the vagina before the fetus and must be treated in the hospital. This situation is dangerous because the head will compress the cord and cut off circulation during birth. The EMS job is to keep the fetus’s head from compressing the cord. Place the woman supine with the foot end of the stretcher raised 6 to 12 inches higher than the head, with her hips elevated on a pillow or folded sheet. Alternatively, the woman may be placed in a knee-chest position, kneeling and bent forward facedown. Carefully insert a sterile gloved hand into the vagina, and gently push the fetus’s head away from the umbilical cord. Wrap a sterile towel moistened with saline around the exposed cord. Administer high-flow oxygen and transport rapidly.
Spina bifida is a developmental defect where a portion of the spinal cord or meninges may protrude outside of the vertebrae and possibly outside the body. It is important to cover the open area of the spinal cord with a moist sterile dressing and then an occlusive dressing to seal the area immediately after birth to help prevent a potential fatal infection.
With multiple gestation, there are sometimes two placentas, and the order in which they are delivered is random, meaning you could deliver the first placenta or the second baby first. A premature newborn is any baby less than 5 pounds or 8 months, or before term, and they often require resuscitation. Post-term pregnancy is also complicated and is any period longer than 41 completed weeks of gestation. Fetal death is the worst possible outcome. Be concerned about excessive bleeding and pulmonary embolisms. You should suspect a pulmonary embolism in patients of childbearing age who have recently delivered, especially with the sudden onset of difficulty breathing or altered mental status.
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