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  • 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 asbreaking 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 babiesThose 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 herethere 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, �flickingthe 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 seemsfloppy,� 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 alcoholWhatever

  • 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

  • spottingcan 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 consideredsaferfor 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 calledlabor

  • 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 thechain of evidencemust 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.

Welcome to this module in which we will be discussing obstetrics and gynecology.

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