Prehospital:

Gynecology
Obstetrics
Childbirth
Care of newborn
November, 2005
Gynecology
Gynecology Review Topics

You should be able to describe...

• Anatomy and physiology of the female genitalia (reproductive

system)

• Assessment of the gynecological patient

• Management some specific gynecological emergencies

Anatomy and
Physiology
Female
External
Genitalia
(1 of 2)
Female External Genitalia (2 of 2)

• Perineum
– Muscular tissue that separates the vagina and the anus.
• Mons Pubis
– Fatty layer of tissue over the pubic symphysis.
• Labia
– Structures that protect the vagina and the urethra.
• Clitoris
– Vascular erectile tissue that lies anterior to the labia minora.
• Urethra
– Drains the urinary bladder.
Female
Internal
Genitalia (1
of 2)
Female Internal Genitalia (2 of 2)

• Vagina
– Female organ of copulation.
– Birth canal.
– Outlet for menstruation.
• Uterus
– Site of fetal development.
• Fallopian Tubes
– Transports the egg from the ovary to the uterus.
– Fertilization usually occurs here.
• Ovaries
– Primary female gonads.
History—Subjective Assessment

• Initial Assessment—SAMPLE.
• Complaints: Does the patient complain of pain? Where?
• Use OPQRST.
– Dysmenorrhea:
Painful menstruation; cramps, sometimes debilitating
– Dyspareunia: Pain during intercourse
• Associated signs or symptoms; pertinent negatives.
• Has she ever been pregnant?
– Gravida / Parity (or Para) / Abortion’; G2P2A1
(pregnancies / live births / abortions and miscarriages)
– Document last menstrual cycle
• Medications—Contraceptives.
Physical Exam—Objective Assessment

• Respect patient’s privacy.

• Be professional.
• Explain procedures.
• Observe patient.
• Check vital signs.
• Assess bleeding or discharge
– Do not perform an internal vaginal exam
• Abdominal examination.
Overview of General Management of
Gynecological Emergencies

• No internal examination

• Do not pack dressings in the vagina

• Supportive care

• Transport
Signs and Symptoms Management

• Pain
– Make the patient comfortable

• Bleeding
– Initiate oxygen
– IV access and ECG monitor based on patient condition
Traumatic Gynecological Emergencies

• Causes of Gynecological Trauma

– Blunt Trauma
– Sexual Assault
– Blunt force to Lower Abdomen
– Foreign Bodies Inserted in Vagina
– Abortion Attempts
Management of
Gynecological Trauma

• Apply direct pressure over laceration

• Apply cold pack to hematoma

• Establish IV and ECG monitor, if warranted.

Sexual Assault

• 1 in 3 women will be raped in their life time

• Only 10 - 30% will report it
Sexual Assault Management
Do

• Protect the scene

• Manage threats to life aggressively
• Be gentle; provide emotional support
• Minimize history taking
• Handle clothing as little as possible
• If removing clothing, bag each item separately
• Place bloody articles in (brown) paper bags (not plastic)
• Carefully document everything
Sexual Assault Management
Do Not

• Do not cut through any tears or holes in clothing.

• Do not ask specific details of a sexual assault.
• Do not examine the external genitalia or perineal area unless there
is a uncontrolled hemorrhage.
• Do not allow patient to change clothes, bathe, or douche.
• Do not allow patient to comb hair, brush teeth, or clean fingernails.
• Do not clean wounds, if possible.
Sexual Assault Documentation

• Write objectively, dispassionately, thoroughly

• State patient remarks accurately
• State your observations of the scene (environment), patient’s
physical condition, torn clothing, interventions and results
• Document all items turned over to hospital staff
• Do NOT include your opinions or conclusions
– Especially whether rape or other crime occurred
• If victim is a minor, remember that you are a mandated reporter of
child abuse
Gynecology Wrap-up

Questions?
Obstetrics
Obstetrics Topics

You should be able to discuss...

• General Assessment of the Obstetric Patient

• General Management of the Obstetric Patient
• Complications of Pregnancy
• Abnormal Delivery Situations
• Other Delivery Complications
• Maternal Complications of Labor and Delivery
General Assessment of
the Obstetric Patient (1 of 3)

• Initial Assessment • Obstetrical history

• History—SAMPLE – LMP or EDC (Expected
– Pre-existing Medical Date of Confinement—Due
Conditions Date)
• Diabetes, heart disease, – Gravida and para
hypertension, seizure – Previous cesarean or
• Chief Complaint abdominal surgery
– Pain? – Maternal life style
– Vaginal Bleeding? – Recent infections
– Labor? – Course of this pregnancy:
any complications
General Assessment of
the Obstetric Patient (2 of 3)
• Determine if delivery is
imminent:
– Hard labor
– Urge to push
– Crowning
• Determine fetal risk
– < 39 – 40 weeks
– Multiple birth
– Drug use last 4 hours
– Water broke showing
meconium staining
• Physical Exam: ABC, VSx2
• Determine possibility of “true
emergency”:
– Ectopic pregnancy
– Preeclampsia/Eclampsia
– Placenta previa
– Abrutio placentae
Note: If immanent delivery and
any serious maternal or fetal
risks, get a second or third
ambulance with ALS for all.
General Assessment of
the Obstetric Patient (3 of 3)

• Assess fundal height to

determine gestation.
General Management of
the Obstetric Patient

• Do not perform an internal vaginal examination in the field.

• Always remember that you are caring for two patients, the mother
and the fetus.
• If history suggests immanent delivery, check for crowning.
• ABC and VS
• Monitor mother for shock and fetus for distress.
• Transport or deliver ⇦ It’s not safe to do both!
• Consider oxygen
• ALS options: IV access, glucose stick.
Complications of Pregnancy
Trauma Management
• Transport all trauma patients at 20 weeks or more gestation
• Anticipate the development of shock
• Apply c-collar for cervical stabilization and immobilize on a long
backboard
– Place patient tilted to the left to minimize supine hypotension
• Administer high-flow, high-concentration oxygen
• Reassess patient
• Monitor the fetus
ALS
• Initiate one or two large-bore IVs per protocol
• Monitor ECG
Medical Conditions

• Any pregnant patient with abdominal pain should be evaluated by a

physician.
Causes of Bleeding
During Pregnancy

• Abortion

• Ectopic Pregnancy

• Placenta Previa

• Abruptio Placentae
Abortion

• Termination of pregnancy before the 20th week of gestation.

• Different classifications.
• Signs and symptoms include cramping, abdominal pain, backache,
and vaginal bleeding.
• Treat for shock (BLS and ALS).
• Provide emotional support.

Note: < 20 weeks expect ER; > 20 weeks expect L&D

Ectopic Pregnancy (1 of 2)
Ectopic Pregnancy (2 of 2)

• Assume that any female of childbearing age with lower abdominal

pain is experiencing an ectopic pregnancy.
• Ectopic pregnancy is life-threatening. Surgery required.
Transport the patient immediately.
• Anticipate shock
– Oxygen
ALS
• IV access
• Monitor ECG
Placenta Previa (1 of 2)
Placenta Previa (2 of 2)

• Usually presents with painless bleeding.

• Never attempt vaginal exam.
• Treat for shock (BLS and ALS).
• Transport immediately
– Life threat to baby; ultimately life threat to mother
– Treatment is delivery by c-section.
Abruptio Placentae (1 of 2)
Abruptio Placentae (2 of 2)

• Signs and symptoms vary.

• Classified as partial, severe, or complete.
• Immediate life-threat to mother and baby.
• Treat for shock
– Oxygen
– IV x2
– Monitor ECG
– Fluid resuscitation PRN.
• Transport in left lateral recumbent position.
Other Complications
of Pregnancy

• Supine hypotensive syndrome

• Hypertensive disorders
– Preeclampsia and eclampsia
– Chronic hypertension
– Chronic hypertension Superimposed with Preeclampsia
– Transient hypertension
• Gestational diabetes
• Braxton-Hicks contractions
• Preterm labor
Supine Hypotensive Syndrome (1 of 2)
Supine Hypotensive Syndrome (2 of 2)

• Also known as vena caval syndrome.

• Treat by placing patient in the left lateral recumbent position, or
elevate right hip.
• Monitor fetal heart tones and maternal vital signs.
• If volume is depleted, treat for shock:
– Oxygen
– IV with NS bolus
– Monitor ECG
Preeclampsia Characteristics
• A sharp rise in blood pressure during the third trimester of
pregnancy
– Systolic blood pressure elevated 30 mmHg above normal
– diastolic 15 mmHg above normal
• Headache, dizziness, blurred vision, spots before the eyes
• Epigastric pain, nausea, vomiting
• May be accompanied by edema (swelling), and kidney problems, as
evidenced by protein in the urine.
• Occurs in about 5 percent of all pregnancies and more frequently
in first pregnancies
• Can be a sign of serious problems (toxemia of pregnancy)
• May progress to eclampsia
• Support, monitor, transport (ALS if available)
Management of Preeclampsia

• Left lateral position

• Minimize noise and light

• Oxygen

• Gently transport

• Anticipate seizures

• Be prepared for labor and birth

Eclampsia Characteristics

• A life-threatening situation for both mother and

baby
• Preceded by preeclampsia
• Mother develops seizures (convulsions) and
perhaps coma
• ALS
– Valium 5 mg IV
– Request Med Control order
Magnesium Sulfate 4 to 6 grams IV (fast drip)
Gestational Diabetes

• Consider hypoglycemia when encountering a pregnant patient with

altered mental status
• Signs include diaphoresis and tachycardia
BLS
• Treat for shock
• Give oral glucose, if not contraindicated
ALS
• If blood glucose is below 60 mg/dl; start IV-NS, and give 25 grams
of D50
• If blood glucose is above 200 mg/dl, start IV-NS, contact med
control and request NS 1–2 liters IV fast drip
Braxton-Hicks Contractions

• False labor

• Increases in intensity and frequency but does not cause cervical

changes
Preterm Labor

• Maternal Factors
– Cardiovascular disease, renal disease, diabetes, uterine and
cervical abnormalities, maternal infection, trauma, contributory
factors
• Placental Factors
– Placenta previa
– Abruptio placentae
• Fetal Factors
– Multiple gestation
– Excessive amniotic fluid
– Fetal infection
Obstetrics Wrap-up

Questions?
Childbirth

Delivery for the mother

Birth for the baby
Childbirth Topics

You should be able to discuss...

• The stages of normal labor and delivery

• Management of labor
• Management of delivery
• Management of newborn and post partum mother
• Recognition and management of certain complications
Labor and
Delivery

• Stage One
(Dilation)
• Stage Two
(Expulsion)
• Stage Three
(Placental
Stage)
• Stage Four
(The next
hour)

Puerperium: The time period surrounding birth

Management of
a Patient in Labor

• Transport the patient in labor unless delivery is imminent

• Maternal urge to push and the presence of crowning indicate

imminent delivery

• Delivery at the scene or in the ambulance will be necessary.

Management of Field Delivery
• Set up delivery area
• Give oxygen to mother and
start IV-NS TKO
• Position mother semi-reclined
or supine
• Drape mother with toweling
from OB kit.
• Monitor fetal heart rate.
• As head crowns, apply gentle
pressure.
Mother nature knows her business; hands off – mostly!
• At extension, suction the
mouth first and then the nose.
• Check for nuchal cord
• Note the time
• Clamp and cut the cord.
• Dry the infant and keep it
warm.
• Deliver the placenta and save
for transport with the mother.
Fetal Engagement and Descent
Internal Rotation
Extension Beginning
Head Emerging
Crowning
Extension Complete
External Rotation
(Restitution)
External Rotation (Shoulder Rotation)
Expulsion
Abnormal Delivery Situations
Breech Presentation (1 of 2)
Breech Presentation (2 of 2)

• The buttocks or both feet present first

• If the infant starts to breathe with its face pressed against the
vaginal wall, form a “V” and push the vaginal wall away from
infant’s face. Continue during transport.
Prolapsed Cord (1 of 2)
Prolapsed Cord (2 of 2)

• The umbilical cord precedes the fetal presenting part

• Elevate the hips, administer oxygen, and keep warm

• If the umbilical cord is seen in the vagina, insert two gloved fingers
to raise the fetus off the cord. Do not push cord back

• Wrap cord in sterile moist towel

• Transport immediately; do not attempt delivery

Limb Presentation

• With limb presentation, place the mother in knee–chest position,

administer oxygen, and transport immediately.

• Do not attempt delivery.

Other Abnormal Presentations

• Whenever an abnormal presentation or position of the fetus makes

normal delivery impossible, reassure the mother

• Administer oxygen

• Transport immediately

• Do not attempt field delivery in these circumstances

Other Delivery Complications
Multiple Births

• Follow normal guidelines, but have additional personnel and

equipment

• In twin births, labor starts earlier and babies are smaller

• Prevent hypothermia.
Cephalopelvic Disproportion

• Infant’s head is too big to pass through pelvis easily

• Causes include oversized fetus, hydrocephalus, conjoined twins, or
fetal tumors
• If not recognized, can cause uterine rupture
• Usually requires cesarean section
• Give oxygen to mother and start IV
• Rapid transport
Precipitous Delivery

• Occurs in less than 3 hours of labor

• Usually in patients in grand multipara, fetal trauma, tearing of cord,

or maternal lacerations

• Be ready for rapid delivery, and attempt to control the head

• Keep the baby warm

Shoulder Dystocia

• Infant’s shoulders are larger than its head

• Turtle sign (recoil of head on perineum)

• Do not pull on the infant’s head

• If baby does not deliver, transport the patient immediately

Meconium Staining

• Fetus passes feces into the amniotic fluid

• Occurs in approximately 10–15% of deliveries

• An infant born in the presence of thin meconium may not require

treatment, but those born through thick meconium should be
intubated immediately

• Management reviewed (below) in care of newborn

Maternal Complications
of Labor and Delivery
Postpartum Hemorrhage

• Defined as a loss of more than 500 cc of blood following delivery

• Treat for shock as necessary
– Oxygen
– Warmth
• For very low BP consider MAST
• Establish two large-bore IVs of normal saline
• Paramedic
– Pitocin (oxytocin), 10 IU in 1000 mL NS, IV drip
– Titrate to effect
Uterine Rupture

• Tearing, or rupture, of the uterus.

• Patient complains of severe abdominal pain and will often be in
shock. Abdomen is often tender and rigid.
• Fetal heart tones are absent.
• Treat for shock.
• Give high-flow, high-concentration oxygen and start two large-
bore IVs of normal saline.
• Transport patient rapidly.
Uterine Inversion

• Uterus turns inside out after delivery and extends through the
cervix.
• Blood loss ranges from 800 to 1,800 cc.
• Begin fluid resuscitation.
• Make one attempt to replace the uterus. If this fails, cover the
uterus with towels moistened with saline and transport
immediately.
Pulmonary Embolism

• Presents with sudden severe dyspnea and sharp chest pain

• Administer high-flow, high-concentration oxygen and support

ventilations as needed

• Establish an IV of normal saline

• Transport immediately, monitoring the heart, vital signs, and

oxygen saturation
Childbirth Wrap-up

Questions?
Newborn Care
Neonatal Care and Resuscitation

You should be able to discuss...

• The routine care of a newborn

• APGAR scoring

• Newborn resuscitation triangle (BLS and ALS)

• Some special situations

Definitions

• Newborn
– A baby in the first few hours of its life
– Also known as newly born infant

• Neonate
– An infant from the time of birth to one month of age

• Infant
– A person from birth to one year of age
Full Term Newborn
Epidemiology of Problem Newborns

• Approximately 6% of field deliveries require life support

• The incidence of complications increases as the birth weight

decreases

• Approximately 80% of newborns weighing 1500 grams

(3 pounds, 5 ounces) at birth require resuscitation
Risk Factors
Newborn’s Care

• When handling a newborn, support the head and torso, using both
hands.
• Maintain warmth!
• Clear infant’s airway by suctioning mouth first and then nose
– During delivery
– Later
• Suction...Dry, Warm, Position, Suction, Stimulate...Suction
• Assess the neonate using Apgar score at 1 and 5 minutes (low
priority)
APGAR Scoring

Characteristic Score 0 Score 1 Score 2

Appearance Body and Body pink, Completely pink
(skin color) extremities blue extremities blue
Pulse Rate Absent Below 100/min 100/min or above

Grimace Unresponsive Grimace Active crying

(irritability)
Activity Limp Some flexion of Active movement
(muscle tone) extremities
Reparatory Effort Absent RR below 30/min; Strong cry or RR
weak, irregular above 30/min
Physiology of First Breath

• Fluid in the fetal lungs is forced out of the lungs during delivery by
compression of the chest and by entry of air into the lungs.

• First breath stimulated by

– Mild acidosis
– Initiation of stretch reflexes in the lungs
– Hypoxia
– Hypothermia
Newborn Assessment

• Assess the newborn immediately after birth

• Ideally, one EMT attends the mother while the other attends the
newborn
• Remember—newborns are slippery and require both hands
• Normal heart rate 150–180 at birth
– Slowing to 130–140 thereafter
– A pulse less than 100 indicates distress
• Normal respiratory rate 40–60 per minute
• Evaluate skin color as well
• Determine the APGAR score at 1 and 5 minutes
Newborn Care / Treatment
Establishing an Airway

• Airway management is one of the most critical steps in caring for

the newborn.

• Suction the baby’s mouth first, then the nose, to avoid risk of
aspiration.

• Position newborn flat. While umbilical cord is attached, at level of

mother’s uterus (between her legs)

• Consider a towel or bath blanket under torso to assure a neutral

alignment of neck and airway
Positioning the newborn
to open the airway
Meconium in Airway

• Fetus passes feces into the amniotic fluid.

• Occurs in approximately 10–15% of deliveries.
• An infant born in the presence of thin meconium may not require
treatment, but those born through thick meconium should be
intubated immediately.
• If meconium is thin with no particulates, treat as normal
• If meconium is thick, suction thoroughly
– ALS: Suction hypopharynx and trachea using an endotracheal
tube and meconium aspirator
– No more than 3 passes, or less if all meconium has been
cleared from the airway
– Leave clean tube in trachea
Heat loss can be life threatening

• Most heat loss results from evaporation.

• Core temperature can quickly drop 1° Celsius from its original

temp.
Dry the infant to prevent
loss of evaporative heat.
Heat loss prevention measures…

• Dry the newborn immediately

• Maintain room temperature at 74–76 degrees

• Close all windows and doors

• Swaddle the infant in a warm, dry receiving blanket or other

suitable material

• In colder areas, use water bottles or rubber gloves filled with warm
water.
Position

• Immediately post delivery place the newborn horizontal (head is

neither up nor down) between mother’s legs

• After initial interventions and cord is cut keep newborn horizontal

(even on mother’s abdomen or chest)

• Consider padding under torso to maintain airway

Stimulate

• Stimulate, as required: flick feet, rub back, move arms

• DO NOT spank or vigorously rub a newborn baby!
Cutting the
Umbilical Cord

• AFTER you have stabilized the patient’s airway and minimized

heat loss, clamp and cut the umbilical cord

• Do not “milk” or strip the cord

• Apply the clamps normally within 30–45 seconds after birth

– If baby is in distress or has airway issues, consider delaying
cutting of cord until situation is resolved or cord is pulseless

If cord has pulse, newborn is being oxygenated!

Clamping and cutting the cord

5 cm ≃ 2 inches
Healthy newborns should be allowed to begin the bonding
process with the mother as soon as possible.
Placenta Delivery—Stage 3

• After delivery consider massage of fundus

– Minimize bleeding
– Encourage delivery of placenta
– Caution: The massage is painful
• Encourage mother to suckle newborn
(even if she does not plan to nurse)
– Minimize bleeding
– Encourage delivery of placenta
– Keeps newborn warm
– Bonding
• Placenta should deliver within 20 minutes
• Preserve it in red-bag for examination
Placenta Delivery
The next hour—Stage 4

• Uterus retracts
• Hormones shift
• Mother-Child bonding
• Watch for postpartum hemorrhage
– More than 500 cc blood loss after the birth
– Can occur anytime in the first few hours after birth, but can be
delayed up to a week
– Occurs in 5% of births
– Usually the result of a uterus that won’t contract effectively or
retained placental fragments or membranes
• If mother was preeclamptic, she is still at risk
• Newborn’s problems may surface
Resuscitation of the
Distressed Newborn
The Distressed Newborn

• The distressed newborn can either be full term or premature.

• Aspiration of meconium can cause significant problems and should
be prevented.
• The most common problems experienced by newborns during the
first minutes of life involve the airway.
• Of the vital signs, heart rate is the most important indicator of
neonatal distress.
– A heart rate <60 should be treated with chest compressions.

Likelihood of success in treating at-risk newborns

increases with training, ongoing practice, and proper
stocking of equipment on board your rig.
Inverted Pyramid
for Resuscitation

All newborns

Cyanosis HR < 120

RR < 30
HR < 100
Cyanosis

HR < 60*
(continue
until > 80)

* or 60 < HR < 80, and does not

increase with 30 seconds of BVM
Oxygen Blow-by

• If central cyanosis is present, administer supplemental oxygen.

• If possible, oxygen should be warmed and humidified.

• Never deprive a newborn of oxygen in the prehospital setting for

fear of toxicity.
Estimating oxygen concentration
Ventilation

• If apnea, begin positive-pressure ventilation with oxygen

• Begin positive-pressure ventilation with oxygen if any of the

following is present after 30 seconds of blow-by oxygen:
– Heart rate less than 100 beats per minute
– RR < 30
– Persistent central cyanosis
Ventilate with 100% oxygen for 15–30 seconds.
Evaluate heart rate.
Initiate chest compressions if HR is less than 60 or
is between 60 and 80 and is NOT increasing.
Chest Compressions

• Initiate chest compressions if either of the following conditions

exists:
– The heart rate is less than 60 beats per minute.
– The heart rate is between 60 and 80, but does not increase
with 30 seconds of positive-pressure ventilation and
oxygenation

• Continue compression until HR > 80

CPR Finger
Positions
for Infant
Sizes
Medications and Fluids

• Most cardiopulmonary arrests in newborns result from hypoxia, so

initial therapy consists of oxygen and ventilation.

• When oxygen and ventilation fail, fluids and medications should be

administered.

• Vascular access can be managed by using the umbilical vein.

The umbilical cord stump—Your IV access site
Newborn Resuscitation
Most Likely Prehospital Fluids and Meds
• Oxygen up to 100%
• Norma Saline (NS) 10 mL/Kg (warmed if possible)
• Dextrose 1g/Kg; use Dextrose 10% (D10) [To make: from NS 50
mL bag withdraw and discard 10 mL; add 10 mL D50]
• Naloxone (Narcan) 0.1 mg/Kg IV, IM, SC
(caution if mother addicted or bradycardia)
• Epinephrine 0.01 mg/Kg; use 1:10,000 IV bolus
– If endotracheal, 0.03 mg/KG of 1:10,000
– 0.1 to 1.0 mcg/Kg/min IV drip
• Atropine 0.02 mg/Kg; min dose 0.1 mg; max dose 0.04 mg/Kg
• Sodium Bicarbonate 2 mEq/Kg; use 4.2% [To make: draw desired
dose of 8.4% into large syringe; add same volume NS]
Other Newborn Resuscitation Meds

• Valium (diazepam) 0.1 to 0.3 mg/Kg (slow bolus)

• Amiodarone 5 mg/Kg
• Lidocaine 1 mg/Kg
• Dopamine 5 to 20 mcg/Kg/min
• Magnesium Sulfate 25 to 50 mg/Kg
Newborn Care Wrap-up

Questions?
CME Quiz (OB/GYN/Birth)
1. The “birth canal” is also know
as the:
a) Mons pubis
b) Vagina
c) Fallopian tube
d) Perineum
2. A patient who may have an
ectopic pregnancy is:
a) 8 y/o, prepubescent
b) 26 y/o, trans-sexual
c) 32 y/o, G2P2
d) 74 y/o post menopausal
(1 of 2)
3. Immanent birth is character-
ized by crowning and:
a) an “urge to push”
b) air hunger
c) fetal movement
d) “water breaking”
4. In a high percentage of births
there:
a) are multiple cords
b) are triplets
c) is a nuchal cord
d) is a limb presentation
CME Quiz (OB/GYN/Birth) (2 of 2)

5. During L&D, the placenta is 7. The “key” vital sign of a

delivered during: newborn is
a) Stage 1 a) Respiration rate
b) Stage 2 b) Pulse rate
c) Stage 3 c) Skin color
d) Stage 4 d) Pupil reflex
6. The EMT’s first priority for a 8. The lowest to highest APGAR
newborn is: scores are:
a) Cutting the cord a) 0 to 10
b) Airway management b) 0 to 15
c) Stimulation c) 1 to 5
d) Bonding d) 5 to 10
Supplemental / Back-up Information
Ovulation to Implantation
Anatomy and Physiology of the Obstetric
Patient
• Placenta—organ of pregnancy

• Afterbirth—placenta and membranes that are expelled from uterus

after the birth of a child

• Umbilical cord—structure that connects fetus and placenta

• Amniotic sac—membranes that surround and protect the

developing fetus

• Amniotic fluid—clear watery fluid that surrounds and protects the

developing fetus
Organs of Pregnancy
Physiologic Changes
of Pregnancy (1 of 2)
• Reproductive System
– Uterus increases in size.
– Vascular system.
– Formation of mucous plug in cervix.
– Estrogen causes vaginal mucosa to thicken.
– Breast enlargement.
• Respiratory System
– Progesterone causes a decrease in airway resistance.
– Increase in oxygen consumption.
– Increase in tidal volume.
– Slight increase in respiratory rate.
Physiologic Changes
of Pregnancy (2 of 2)
• Cardiovascular System
– Cardiac output increases.
– Blood volume increases.
– Supine hypotension.
• Gastrointestinal System
– Hormone levels.
– Peristalsis is slowed.
• Urinary System
– Urinary frequency is common.
• Musculoskeletal System
– Loosened pelvic joints.
Fetal Developmental Milestones
Fetal Circulation
Fetal Blood Supply
Fertilization
Second Trimester
Third Trimester
General Assessment of
the Obstetric Patient (2 of 3)
• Physical Examination
– Asses fundal height to determine gestation.
Hemodynamic changes
in the newborn at birth
Endotracheal Intubation and Tracheal
Suctioning in the Newborn
Intubating the infant
Endotracheal Intubation

• Endotracheal intubation of a newborn should be carried out in the

following situations:
– The BVM does not work.
– Tracheal suctioning is required.
– Prolonged ventilation will be required.
– A diaphragmatic hernia is suspected.
Tracheal Tubes
Specific Neonatal Situations
Maternal Narcotic Use

• May complicate delivery.

• Shown to produce low birth weight infants.
• Such infants may demonstrate withdrawal symptoms, such as
tremors, startles, decreased alertness, and respiratory distress.
• Naloxone is the drug of choice for respiratory depression
secondary to maternal narcotic use
– Do not administer Narcan to newborn if mother is addicted to
opiates. (It is likely to precipitate “withdrawal”, including
seizures.)
– Dose 0.1 mg/Kg
Apnea Causes

• Usually due to hypoxia or hypothermia

• Other causes include:
– Narcotics or CNS depressants
– Weakness of respiratory muscles
– Septicemia
– Metabolic disorders
– CNS disorders
Diaphragmatic Hernia

• Most common posterolaterally.

• A rare condition (1 in every 2200 births).

• Survival rate is 50%.

• Do not use BVM; if necessary, provide positive-pressure

ventilation via ET tube.
Head and thorax elevated
Management of
Congenital Heart Defects

• Acyanotic defects
– Oxygenate
– Provide judicious fluid administration
– Consult medical direction early and as needed

• Cyanotic defects
– Oxygenate to a target pulse oximeter reading
– Provide judicious fluid administration
– Consult medical direction early and as needed
 Bradycardia

• Most commonly caused by hypoxia.

• Resist the temptation to treat bradycardia in a newborn with

pharmacological measures alone.
Premature Infants

…are at a greater risk of respiratory depression, head injury, changes

in blood pressure, intraventricular hemorrhage, and fluctuations in
fluid osmolarity.
Other Problems

• Seizures
– May indicate serious illness
• Fever
– Uncommon and may also indicate serious underlying illness
• Hypothermia
– May indicate sepsis
• Vomiting/diarrhea
– May cause dehydration and electrolyte imbalance
Hypoglycemia

• Check blood glucose levels (BGL) on all sick infants.

– Normal BGL could be as low as 40.