Chapter 15 Childbirth National EMS Education Standard Competencies

Chapter 15 Childbirth

National EMS Education Standard Competencies (1 of 6) Special Patient Populations Recognizes and manages life threats based on simple assessment findings for a patient with special needs while awaiting additional emergency response.

National EMS Education Standard Competencies (2 of 6) Obstetrics Recognition and management of: • Normal delivery • Vaginal bleeding in the pregnant patient Neonatal Care • Newborn care • Neonatal resuscitation

National EMS Education Standard Competencies (3 of 6) Medicine Recognizes and manages life threats based on assessment findings of a patient with a medical emergency while awaiting additional emergency response.

National EMS Education Standard Competencies (4 of 6) Gynecology Recognition and management of shock associated with • Vaginal bleeding

National EMS Education Standard Competencies (5 of 6) Trauma Uses simple knowledge to recognize and manage life threats based on assessment findings of an acutely injured patient while awaiting additional emergency response.

National EMS Education Standard Competencies (6 of 6) Special Considerations in Trauma Recognition and management of trauma in • Pregnant patient • Pediatric patient • Geriatric patient

Introduction • Childbirth is a normal, natural part of life. – Your part of the process involves helping, guiding, and supporting the infant as it is born. – After the birth, you should ensure the infant is breathing adequately and being kept warm. • Two indicators of an impending birth: – Frequency of the contractions – Crowning

Anatomy and Function of the Female Reproductive System (1 of 2) • The ovaries produce eggs. – The egg travels through the fallopian tube to the uterus. • The uterus (womb) holds the fertilized egg as it develops during a pregnancy. – The developing infant (fetus) is encased in an amniotic sac for support and floats in amniotic fluid.

Anatomy and Function of the Female Reproductive System (2 of 2) • The external opening is called the birth canal (vagina).

Stages of Labor (1 of 3) • First stage of labor: the pregnant woman’s body prepares for birth • Characterized by these conditions: – Initial contractions occur. – The bag of waters breaks. – The bloody show occurs. – The infant’s head does not appear during contractions.

Stages of Labor (2 of 3) • Second stage of labor: the birth of the infant – You will see the infant’s head crowning during contractions. – There is no time for transport.

Stages of Labor (3 of 3) • Third stage of labor: delivery of the placenta (afterbirth) – You must assist in stabilizing the condition of the mother and infant and delivering the placenta.

Is There Time to Reach the Hospital? (1 of 3) • Is this the woman’s first pregnancy? – A woman experiencing her first labor will usually have more time to reach the hospital. • Has the woman experienced a bloody show? • Has the bag of waters broken? – The bag of waters usually breaks toward the end of the first stage of labor.

Is There Time to Reach the Hospital? (2 of 3) • How frequent are the contractions? – Contractions less than 2 minutes apart usually indicate that delivery will occur very soon. • Does the woman feel an urge to move her bowels? – When the infant’s head is in the birth canal, it presses against the rectum. – Do not allow her to go to the toilet.

Is There Time to Reach the Hospital? (3 of 3) • Is the infant’s head crowning? • Is transportation available? – Is the ambulance responding? – How far is it to the hospital? – Will bad weather, a natural disaster, or traffic prevent prompt arrival of transportation?

Timing Contraction Cycles • Time the contraction cycles from the beginning of one contraction to the beginning of the next. • If contractions are less than 3 minutes apart, delivery is close.

Detecting Crowning • Observe the vaginal opening during a contraction. • If you see the head crowning during the contraction, prepare for delivery. • Do not risk transporting the woman to the hospital.

Preparing for Delivery (1 of 4) • As you prepare to assist the patient in the delivery, keep two things in mind: – Calm the woman: Delivery is a natural process. – Calm yourself: You are there to help.

Preparing for Delivery (2 of 4) • You will not be able to maintain sterile conditions. – Attempt to be as clean as possible. – Wash your hands thoroughly. – If you do not have a sterile delivery kit, use the gloves from your EMR life support kit. – Have plenty of clean towels ready.

Preparing for Delivery (3 of 4) • Place the patient on a firm surface that is padded with blankets, folded sheets, or towels. • Elevate the woman’s hips 2" to 4" with pillows and blankets. • Place the woman on her back with knees bent and feet flat on the surface beneath her.

Preparing for Delivery (4 of 4)

Standard Precautions and Childbirth • A woman in childbirth will expel both blood and body fluids. – Use sterile gloves whenever possible. – Follow the steps in Skill Drill 15 -1 to put on sterile gloves. – Wear face and eye protection. – Wearing a surgical gown can help keep fluids off your body.

Equipment (1 of 3) • Your emergency care equipment should include a prepacked obstetric (OB) delivery kit, which includes: – Sterile gloves – Umbilical cord clamp

Equipment (2 of 3) • OB kit contents: (cont’d) – Sterile drapes and towels – Sanitary pads – 4" gauze pads – Towel or blanket for the infant – Bulb syringe

Equipment (3 of 3) • You will also need: – Sheets or towels for the mother – Suction (if available) – Oxygen (if available) – Infant mask • If you do not have a delivery kit, look for appropriate substitute materials.

Assisting With Delivery (1 of 6) • There are two lives to be considered in this situation: the life of the mother and the life of the newborn. – Do not neglect to perform a patient assessment on the woman. – Your primary purpose is to assist in the delivery of the infant. – Be as clean as possible during the entire delivery process.

Assisting With Delivery (2 of 6) • The infant’s head should emerge slowly to prevent undue stress on the infant and tearing of the vaginal tissues. – As the head emerges, support the infant’s head and tell the woman to stop pushing. – Do not attempt to pull the infant during delivery.

Assisting With Delivery (3 of 6) • In a normal birth: – The infant will turn to its side by itself after the head emerges. – The rest of the body will be delivered spontaneously. – The infant will be wet and slippery. • Keep the infant’s head at about the level of the woman’s vagina.

Assisting With Delivery (4 of 6)

Assisting With Delivery (5 of 6) • If the amniotic sac has not broken, tear it with your fingers and push it away from the infant’s head and mouth. • If the umbilical cord is wrapped around the neck, attempt to slip it over the head. – If you cannot disentangle the infant, attempt to reduce the pressure on the cord. – Never pull on the umbilical cord.

Assisting With Delivery (6 of 6)

Caring for the Newborn (1 of 4) • Clear the infant’s mouth and nose. – Use a bulb syringe if one is available. – Suction the mouth first and then the nostrils two to three times until they are clear. – If a bulb syringe is not available, wipe the mouth and nose with a gauze pad. • Place the infant on the mother’s abdomen to keep the infant from losing warmth.

Caring for the Newborn (2 of 4)

Caring for the Newborn (3 of 4) • If the infant is not breathing, suction the mouth and nose again. – Rub the infant’s back or flick the soles of the infant’s feet to stimulate breathing. • Use a towel to dry the infant and then wrap it in a blanket to keep it warm.

Caring for the Newborn (4 of 4) • Place the infant on its side with the head slightly lower than the trunk. • When the umbilical cord stops pulsating, clamp it with umbilical cord clamps or tie it with gauze. • Note the time of the delivery. • If there are multiple births, prepare for the second delivery.

Delivery of the Placenta (1 of 3) • The placenta usually delivers on its own within 30 minutes after delivery. • Never pull on the umbilical cord. • Leave the umbilical cord uncut and attached to the placenta and the infant until the EMS unit arrives.

Delivery of the Placenta (2 of 3) • After the placenta is delivered: – Wrap it in a towel or newspaper with three quarters of the umbilical cord. – Place it in a plastic bag and transport it to the hospital. – Keep it at the same level as the infant.

Delivery of the Placenta (3 of 3) • The mother’s bleeding usually stops after the placenta is delivered. • If it does not, massage the uterus. – Place one hand just above the mother’s pubic bone. – Use your other hand to press down into the abdomen and, using a circular motion, massage the uterus until it becomes firm. – This should take 3 to 5 minutes.

Aftercare of the Mother and Newborn (1 of 2) • Continue to observe the mother and infant and keep both warm. • About every 3 to 5 minutes, check the uterus for firmness. • Recheck the vagina for any excessive bleeding. – In a normal delivery, the mother will lose 300 to 500 m. L (1 to 2 cups) of blood.

Aftercare of the Mother and Newborn (2 of 2) • Continue to massage the uterus if it is not firm or if bleeding continues. • Clean the mother with clean, moist towels or cloths. • Give her small amounts of water to drink if she is thirsty.

Resuscitating the Newborn • If the infant does not breathe on its own within the first minute after birth, proceed with the steps listed in Skill Drill 15 -2.

Complications of Pregnancy and Childbirth (1 of 14) • Ectopic pregnancy and shock in pregnant women – An ectopic pregnancy occurs when a fertilized egg becomes implanted in the fallopian tube rather than in the uterus. – As the embryo starts to grow, it expands and causes the fallopian tube to rupture.

Complications of Pregnancy and Childbirth (2 of 14) • Ectopic pregnancy and shock in pregnant women (cont’d) – This rupture causes acute abdominal pain, internal bleeding, and shock. – Treat the patient for shock. – Arrange for prompt transport.

Complications of Pregnancy and Childbirth (3 of 14) • Miscarriage and vaginal bleeding – A miscarriage (spontaneous abortion) is the delivery of an incomplete or underdeveloped fetus. – If a miscarriage occurs: • Save the fetus and all the tissues that pass from the vagina. • Control the woman’s bleeding and treat for shock. • Arrange for prompt transport.

Complications of Pregnancy and Childbirth (4 of 14) • Miscarriage and vaginal bleeding (cont’d) – Vaginal bleeding is often the first sign of a miscarriage. – When a woman experiences vaginal bleeding: • Perform a patient assessment. • Obtain a good medical history. • Obtain a set of vital signs. • Arrange for prompt transport. • Provide psychological support if she miscarried.

Complications of Pregnancy and Childbirth (5 of 14) • Premature birth – Any newborn weighing less than 5 pounds or delivered before 36 weeks is premature. – Premature infants are smaller, thinner, and usually redder than full-term newborns. – Keep premature infants warm because they lose heat rapidly. – Arrange for prompt transport.

Complications of Pregnancy and Childbirth (6 of 14) • Unbroken bag of waters – Carefully break the bag and push it away from the nose and mouth so the newborn can breathe. – Be careful not to injure the newborn in the process. – Suction the newborn’s mouth and then the nose to help it to breathe.

Complications of Pregnancy and Childbirth (7 of 14) • Prolapse of the umbilical cord – The cord may be compressed between the infant and the woman’s pelvis during contractions. – Place the pregnant patient in a position that raises her hips. – Keep the cord covered and moist, and do not try to push it back into the vagina.

Complications of Pregnancy and Childbirth (8 of 14) • Prolapse of the umbilical cord (cont’d) – Administer oxygen if it is available. – Arrange for prompt transport. – Some EMS systems recommend placing the woman in a kneeling position to take the pressure off the cord.

Complications of Pregnancy and Childbirth (9 of 14) • Breech birth – The infant’s buttocks come down the birth canal first, rather than the head. – Arrange for prompt transport. – Support the infant’s buttocks and legs as they are delivered. – The head usually follows on its own.

Complications of Pregnancy and Childbirth (10 of 14) • Breech birth (cont’d) – If the head does not deliver within 3 minutes: • Arrange for prompt transport. • Insert a gloved hand into the vagina and use your fingers to keep the infant’s airway open. – In very rare cases, the arm or the leg is the first part of the infant to appear in the birth canal. • Limb presentation cannot be handled in the field.

Complications of Pregnancy and Childbirth (11 of 14) • Stillborn delivery – Sometimes an infant dies in the uterus before labor. – The fetus will generally have an unpleasant odor and will not exhibit any signs of life. – Carefully wrap the stillborn infant in a blanket. – Turn your attention to the mother and provide physical care and psychological support.

Complications of Pregnancy and Childbirth (12 of 14) • Multiple births – Another set of labor contractions will begin shortly after the delivery of the first infant. – Get ready to repeat the procedure you completed for delivering the first infant. • Excessive bleeding after delivery – Approximately 1 to 2 cups of blood is lost during normal childbirth.

Complications of Pregnancy and Childbirth (13 of 14) • Excessive bleeding after delivery (cont’d) – If the mother is bleeding severely: • Place one or more clean sanitary pads at the opening of the vagina. • Elevate her legs and hips. • Treat her for shock. • Arrange for rapid transport.

Complications of Pregnancy and Childbirth (14 of 14) • Excessive bleeding after delivery (cont’d) – Encourage the newborn to nurse at the mother’s breast. – Massage the uterus with your hand. – If the area between the mother’s vagina and anus is torn and bleeding, treat it as you would an open wound.

Automobile Collisions and Pregnant Women (1 of 3) • The woman should be examined by a physician. – The forces involved in even a minor crash may be great enough to injure the woman or the unborn child. • Promptly assess the patient and arrange transport to the hospital.

Automobile Collisions and Pregnant Women (2 of 3) • If the woman exhibits signs or symptoms of shock: – Monitor the airway, breathing, and circulation. – Arrange for administration of high-flow oxygen. – Have the woman lie on her left side rather than on her back.

Automobile Collisions and Pregnant Women (3 of 3) • In rare cases, a crash can be severe enough to kill the pregnant woman but not the fetus. – Provide CPR to the woman while transporting her to the closest medical facility.

Summary (1 of 4) • The key indicators in estimating how soon a delivery will occur are crowning and the time between contractions. • Stage one of labor is characterized by the following conditions: initial contractions occur; the bag of waters breaks; the bloody show occurs; but the infant’s head does not appear.

Summary (2 of 4) • Stage two of labor involves the actual birth. You will see the infant’s head crowning during contractions, at which time you must prepare to assist the woman with delivery. • Stage three of labor involves delivery of the placenta. You must assist in stabilizing the condition of the mother and newborn and delivering the placenta.

Summary (3 of 4) • Exercise standard precautions when assisting with a delivery. • After the delivery, you have two patients to care for—the mother and the infant. • If the infant does not breathe on its own within the first minute after birth, proceed with the steps to resuscitate.

Summary (4 of 4) • Although most pregnancies and births are uneventful, you should be aware of possible complications, including ectopic pregnancies and shock, vaginal bleeding and miscarriage, premature births, an unbroken bag of waters, a prolapsed umbilical cord, breech birth, a stillborn delivery, multiple births, and excessive bleeding after delivery.

Review 1. For the EMR, assisting with delivery involves: A. determining exactly when the woman will deliver. B. transporting the pregnant woman only. C. supporting the infant’s head as it emerges and telling the woman to stop pushing. D. pulling on the infant to expedite the birth.

Review Answer: C. supporting the infant’s head as it emerges and telling the woman to stop pushing.

Review 2. As soon as a baby is born, it is important to: A. cool the baby to stimulate breathing. B. ensure that the baby is dried and warmed. C. keep the newborn’s head higher than its body. D. immediately cut the umbilical cord.

Review Answer: B. ensure that the baby is dried and warmed.

Review 3. Complications of pregnancy include all of the following EXCEPT: A. premature birth. B. prolapsed cord. C. breech birth. D. multiple births.

Review Answer: D. multiple births.