Alexander ch43 lecture

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Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 43
Obstetrics and Care of
the Newborn

• Applies a fundamental knowledge of growth,
development, and aging and assessment findings
to provide basic and selected advanced
emergency care and transportation for a patient
with special needs.
Advanced EMT
Education Standard

1. Define key terms introduced in this chapter.
2. Describe the anatomy and physiology of the female
reproductive system.
3. Describe the anatomy and physiology of pregnancy and
delivery of an infant.
4. Elicit a pertinent history from the patient with an obstetric
emergency.
5. Describe the assessment and emergency management
of patients with antepartum emergencies, including
trauma.
Objectives (1 of 3)

6. Describe the assessment and management of a patient
in active labor.
7. Describe the steps of assisting with an out-ofhospital
obstetric delivery.
8. Take steps to manage abnormal out-ofhospital obstetric
deliveries.
9. Take steps to manage postpartum complications,
including postpartum hemorrhage and pulmonary
embolism.
Objectives (2 of 3)

10.Demonstrate the steps of assessing and managing a
neonate, including APGAR scoring, assessing breathing
and circulation, positioning, preventing heat loss, and
suctioning.
11.Recognize signs that indicate the need for neonatal
resuscitation.
12.Apply the concepts of the neonatal resuscitation pyramid
to the care of neonates in need of resuscitative
measures.
13.Communicate effectively to other health care providers a
pertinent patient history, assessment findings, and
interventions for pregnant patients and neonates.
Objectives (3 of 3)

Introduction
• You must be able to recognize indications of
emergencies related to pregnancy and childbirth,
and emergencies in newborns, or neonates.

Think About It
• At 35 weeks’ gestation, what is the risk of distress
if the baby is born now?
• How should Scott and Steve prioritize the order of
the information they need?
• What factors determine how Scott and Steve
should conduct the physical exam?
• What treatment should Scott and Steve anticipate
for the mother and, if a field delivery is performed,
the newborn?

Figure 43-1
(A) (B)
(A) Female external genitalia. (B) Cross-section of female internal and external
reproductive organs.

Anatomy and Physiology Review
(1 of 20)
• Female reproductive system
– Female external genitalia: mons pubis, labia majora,
labia minora, clitoris
– Vagina: hollow tubular passageway that connects
external genitalia with internal genitalia
 In childbirth, the vagina serves as part of birth canal.

Figure 43-2
Frontal view of the uterus, fallopian tubes, and ovaries.

(2 of 20)
• Female reproductive system
– Uterus: small muscular organ
– Lined with endometrial tissue that thickens each month
during reproductive years in preparation for
implantation of fertilized ovum

(3 of 20)
• Female reproductive system (continued)
– Menstrual cycle: ovaries and endometrium undergo
cyclical monthly endocrine changes
– After the uterine lining is shed, hormonal changes
influence it to be rebuilt.
– Ovulation: 14 days after first day of menstrual bleeding,
mature follicle ruptures, discharging ovum into pelvic
cavity near fallopian tube

Figure 43-3
Fertilization, early development of the zygote, and implantation.

(4 of 20)
• Pregnancy
– If sperm is in fallopian tube during ovulation,
fertilization may occur, resulting in pregnancy.
– If pregnancy occurs, fertilized egg travels to uterus,
where it is implanted in thickened endometrium.
– Corpus luteum secretes hormones that support
pregnancy until placenta develops.

(5 of 20)
• Pregnancy (continued)
– Fertilization (conception): union of spermatozoan and
ovum produces zygote
– 30 hours: fertilized ovum divides; 6 days: zygote enters
uterine cavity; cells form blastocyst
– Cells divide and migrate: extraembryonic membranes
form (amniotic sac)
– Villi in endometrium: allows maternal blood to pass and
allows fetal gas exchange.
– Placenta: temporary organ of pregnancy; fetus
attached by umbilical cord

(6 of 20)
– First 60 days: embryo
– From 60 days gestation to birth: fetus
– Normal pregnancy: 37 to 41 weeks; 13-week trimesters
– Full-term infant: weighs 3.0 to 3.5 kg
(6.6 to 7.7 pounds); 50 cm (20 inches) in length

Figure 43-4
A 28-day embryo.
(© Petit Format/Science Source)

Figure 43-5
A fetus near term.

(7 of 20)
– Most fetuses born before 25 to 27 weeks, birth weight
under 600 g (just over 1 pound), do not survive.
– Those that do survive often have developmental
abnormalities.
– Higher chance of survivability with specialized
advanced medical care: neonatal intensive care unit
(NICU).

Table 43-1
Milestones in Fetal Development
Gestational Age in
Months Approximate Size Development
1 0.25 in.; less than 1 oz Rudimentary formation of vital organ systems. Heartbeat
begins.
2 1.5 in.; less than 1 oz Skin, muscle, and skeletal tissue begin to develop.
3 3 in.; about 1 oz Basic central nervous system structure is complete.
4 5 in.; 5 oz Mother can feel movements. Hair is beginning to develop.
5 10 in.; 1 lb Continued development of systems; nares open.
6 13 in.; 1.5 lb Continued nervous system development; reflexes are
developing, alveoli are forming. Fat deposits are being
stored.
7 16 in.; 3.3 lb Eyelids open and in males, the testes begin to descend.
8 18 in.; 5 lb Alveoli are formed. Fat deposits increase as birth
approaches.
9 20 in.; 7 lb Systems formed and functioning at newborn level.

(8 of 20)
• Pregnancy―maternal changes
– Uterus increases in size; breasts prepare for lactation;
distended uterus and abdomen more prone to trauma.
– Blood volume increases by 45% to 50%; heart rate
increases by 10 to 15 beats per minute.
– Blood pressure may lower during first two trimesters,
returns to normal in the third.
 Hypertensive disorder of pregnancy (preeclampsia)

(9 of 20)
• Pregnancy―maternal changes (continued)
– Pregnancy hormones reduce airway resistance.
– Combined needs of fetus and mother; 20% increase in
oxygen consumption by term
– Tidal volume increases substantially; small increase in
respiratory rate.

(10 of 20)
– Morning sickness: nausea and vomiting of early
pregnancy
– Gastrointestinal system slows during pregnancy.
– Urinary frequency is a common sign of pregnancy.
– Glucose in urine: gestational diabetes
– Protein in urine: preeclampsia
– Sprains and joint injuries occur more readily.

(11 of 20)
– Braxton-Hicks contraction: late in pregnancy; intense,
but painless, tightening of uterus
– Level of oxytocin increases to point where contractions
regular and sustained.

Figure 43-6 (1 of 3)
(A)
(A) The first stage of labor begins with regular uterine contractions and ends with complete
dilation and effacement of the cervix.

(12 of 20)
– Stage one: dilation stage
– Begins with onset of regular contractions; ends when
cervix completely dilated
– Fetus descends further into pelvic area.
– Contractions are 10 or more minutes apart; increase in
frequency and intensity.
– Amniotic sac may rupture.

(B)
(B) The second stage of labor begins with complete cervical dilation and effacement, and
ends with expulsion of the fetus.

(13 of 20)
– Stage two: expulsion stage
– Begins with complete effacement (thinning) and dilation
of cervix; ends when fetus completely emerged from
birth canal
– Parturition: expulsion of fetus through birth canal
– Crowning: fetus’s scalp visible at vaginal opening
 Delivery of the head is usually imminent .
– Fetus's shoulders and body smaller than head

(C)
(C) The third stage of labor begins with expulsion of the fetus and ends with expulsion of
the placenta.

(14 of 20)
– Stage three: placental stage
– Delivery of fetus (neonate or newborn) through delivery
of placenta
– Detachment and expulsion of placenta accompanied
by blood loss
 Up to 500 mL blood loss during delivery is normal.

(15 of 20)
• Neonatal anatomy and physiology
– Fetus does not breathe air into lungs; filled with fluid;
fluid expelled as fetus goes through birth canal.
– Taking air into lungs for first time results in changes in
pulmonary pressure.
– During prenatal life, blood receives oxygen from
mother’s circulation.

Figure 43-8
Fetal circulation bypasses the pulmonary circulation. Gas exchange occurs in the placenta.
Blood is delivered to the placenta by the umbilical arteries and returns to the fetal
circulation through the umbilical vein.

(16 of 20)
• Neonatal anatomy and physiology (continued)
– Umbilical arteries carry deoxygenated blood containing
higher carbon dioxide and waste levels from fetal
circulation, through umbilical cord, allowing gas
exchange.
– Umbilical vein passes through liver, where blood enters
hepatic circulation to deliver nutrients.

(17 of 20)
– To compensate for differences in oxygenation, fetus
has fetal hemoglobin adapted to lower-oxygen
environment.
– When circulation through umbilical cord ceases as cord
clamped, blood bypasses umbilical arteries and
continues through iliac arteries.

(18 of 20)
– At birth, infant is wet and slippery.
– Head elongated; large in proportion to body
– Bones of skull are thin and separated by membranes
(fontanels).
– Acrocyanosis may linger as respiratory and
cardiovascular systems adjust.

(19 of 20)
– Normal heart rate: 100 to 180 beats per minute
– Normal respiratory rate: 30 to 60 breaths per minute
– Normal systolic pressure: 70 to 90 mmHg
– Body temperature: 98°F to 100°F
– Developmental priority is given to organs that must be
most functional at birth.
 Immature systems can result in severe complications.

(20 of 20)
– Neck short; tongue proportionally large; diameter of
airway small and funnel shaped
– Nose is small, flat, soft; neonates are nose breathers.
– Respiratory failure/arrest can ensue quickly from
respiratory distress.

General Assessment and Management
of the Pregnant Patient (1 of 10)
• Scene size-up
– When responding to call for pregnant patient,
remember that domestic violence not uncommon
during pregnancy.
– Look for indications of hazards and violence, potential
for injuries mother may not disclose.
– Do not assume obviously pregnant patient has chief
complaint directly related to pregnancy.

• Primary assessment
– If unresponsive and not breathing normally, check
carotid pulse; begin cardiopulmonary resuscitation
(CPR) if pulse not detected.
– If unresponsive but breathing, ensure open airway,
adequate ventilation and oxygenation, adequate
circulation.

• Primary assessment (continued)
– Cause of hypotension in third trimester is supine
hypotensive syndrome.
– Uterus compresses inferior vena cava, reduces blood
to heart, decreases cardiac output.

Figure 43-9
Supine hypotensive syndrome occurs in the third trimester of pregnancy when the inferior
vena cava is compressed by the gravid uterus, reducing blood return to the heart and
compromising cardiac output.

• Secondary assessment
– Perform rapid medical exam or rapid trauma exam if
patient critical.
– If patient not critical, perform focused exam according
to chief complaint.
– Perform detailed head-to-toe exam for critical trauma
patients or critical medical patients in whom problem
not identified.

• Secondary assessment (continued)
– Internal examination of genitalia not performed in
prehospital setting.
– Reasons for inspecting external genitalia:
 You suspect trauma to external genitalia may be causing
significant hemorrhage that can be controlled by direct
pressure.
 Check for perineal bulging or crowning in active labor with
indications of imminent delivery.

– Obtain complete set of vital signs.
– Obtain medical history and obstetric history.
– If chief complaint indicates labor, additional questions
required.
– Number of pregnancies (G); number times given birth
(P); number of pregnancies that did not result in birth
(Ab)

– Ask whether patient receiving prenatal care.
– Ask about problems with current and past pregnancies.
– Determine date of last menstrual period (LMP).
– Ask about fetal movement.
– SAMPLE history; chief complaint using OPQRST

• Clinical-reasoning process
– Preexisting medical conditions can be aggravated by
pregnancy; new problems can arise during pregnancy.
– Altered mental status, seizures, hypertension,
abdominal or low back pain, vaginal bleeding or
discharge, leaking amniotic fluid can all be indications
of pregnancy-related problems.
– Patients with pregnancy complications and neonates in
need of resuscitation require specialized care.
– Consider transport destination carefully; need for ALS
transport or air medical transport.

• Treatment
– If medications required, benefits of treating mother
must outweigh risks of medication.
– Rich vascular supply means many complications of
pregnancy and childbirth accompanied by hemorrhage
and may result in hypovolemic shock.
– Hemorrhage with obstetrical emergencies cannot be
accessed and controlled by direct pressure.
– Anticipate shock; be prepared to treat it.

• Treatment and reassessment
– Manage airway, ventilation, oxygenation.
– Avoid supine hypotensive syndrome by positioning
patient tilted slightly onto left side.
– Establish intravenous access; keep patient warm.
– Patient’s condition may change quickly; maintain
ongoing assessment.

Table 43-2
Differential Diagnoses to Consider with Obstetric
Emergencies
 Spontaneous abortion
 Complications of abortion
 Dysmenorrhea
 Pregnancy
 Pregnancy complications
 Ectopic pregnancy
 Appendicitis
 Cholecystitis
 Trauma
 Dysfunctional uterine bleeding
 Urinary tract infection
 Pelvic inflammatory disease
 Endometriosis
 Ovarian cyst
 Ovarian torsion

Obstetrical Complications and
Emergencies (1 of 16)
• Ectopic pregnancy
– Fertilized ovum is implanted and begins to develop
somewhere other than in endometrium within uterine
cavity, most often in fallopian tube.
– Risk factors: scarring of fallopian tubes from prior
pelvic inflammatory disease (PID), endometriosis,
some forms of contraception

• Ectopic pregnancy (continued)
– Unless condition ia recognized and managed
surgically, fallopian tube ruptures with hemorrhage; can
be fatal.
– Chief complaints: lower abdominal pain and syncope
– Patients in hemorrhagic shock from ruptured ectopic
pregnancy may not exhibit tachycardia.

• Abortion
– Termination of pregnancy from any cause prior to 20th
week.
– Spontaneous abortion (miscarriage)
– Stillbirth: pregnancy terminates spontaneously after 20
weeks without survival of fetus

• Abortion (continued)
– Lower abdominal cramping, vaginal bleeding
 Hemorrhage can be severe enough to result in hypovolemia.
– Threatened abortion: cramping and bleeding occur in
early pregnancy; pregnancy maintained
– Induced abortion: therapeutic abortion when medically
necessary

• Abortion (continued)
– Complications: immediate or delayed hemorrhage and
infection (endometritis)
– Assess for hypovolemic shock.
– Ensure airway, ventilation, oxygenation.
– Administer IV fluids according to your protocol.
– Provide emotional support.

• Gestational diabetes
– Patients without history of diabetes may develop
gestational diabetes during pregnancy; increases risk
of complications to mother and fetus.
– Higher risk: over age 35, obese, family history of
diabetes, history of stillbirth
– Altered mental status; check blood glucose
– Hyperglycemia: untreated diabetes, nausea, vomiting,
abdominal pain, thirst, increased urination
– Hypoglycemia: seizure

• Gestational diabetes (continued)
– Manage airway, breathing, circulation.
– Start IV of normal saline; give fluids for hyperglycemia.
– Administer oral glucose to conscious patient.
– IV 50% dextrose, patient with decreased LOR

• Hypertensive emergencies
– Preeclampsia: progressive disorder that can progress
to eclampsia.
– Increase 30 mmHg in systolic blood pressure or
increase in diastolic blood pressure 15 mmHg
sustained across two readings at least 6 hours apart.
– Suspect preeclampsia when the blood pressure is
140/90 mmHg or greater without a baseline from early
in the pregnancy.

• Hypertensive emergencies (continued)
– Maternal vasospasm: raises blood pressure, decreases
placental circulation
– Protein in mother’s urine: preeclampsia/edema
– Signs/symptoms of preeclampsia progression:
headache, visual disturbances, and decreased urine
output

– Suspect preeclampsia with: edema, sudden weight
gain, visual disturbances, pain in epigastric area or
right upper quadrant of abdomen, headache, seizures.
– Onset of seizures or coma marks transition from
preeclampsia to eclampsia; high maternal and fetal
mortality.

– Chronic hypertension: blood pressure elevated before
pregnancy or early in pregnancy, or persists after
pregnancy
– Transient hypertension: in labor or immediately after
delivery, resolves within 10 days

– Manage airway and breathing; supplemental oxygen;
mother in left lateral recumbent position; obtain IV
access; monitor blood pressure.
– Keep patient calm; reduce sensory stimulation.
– ALS ground transport or air medical transport
– Specialized facility with advanced obstetrical
capabilities and neonatal intensive care

Figure 43-10
(A) (B)
Placenta previa. (A) Total placenta previa. (B) Partial placenta previa.

• Placenta previa
– Implantation of placenta proximity of/directly over
cervix; partial or complete; bleeding during cervical
dilation/labor; interferes with delivery
– When detected, cesarean section scheduled; neonate
cannot be delivered in field.
– Bright red vaginal bleeding, usually painless
– Left lateral recumbent position; provide oxygen,
establish IV access, transport without delay

Figure 43-11
(A) (B) (C)
Abruptio placentae. (A) Partial abruption with concealed hemorrhage. (B) Partial abruption
with hemorrhage. (C) Complete abruption with concealed hemorrhage.

• Placental abruption
– Placenta prematurely detaches (partially or completely)
from uterine wall, compromising fetal perfusion
– Condition is life threatening for both mother and fetus.
– Fetal mortality: 20% with lesser degrees of placental
separation; 100% with complete separation
– Increased maternal age, multiparity, hypertension,
trauma, and cocaine use all increase risk.

• Placental abruption (continued)
– Marginal separation: vaginal bleeding, often no pain
– Central separation: bleeding trapped by attachment of
placenta at edges; sudden sharp, tearing pain with
abdominal rigidity
– Complete separation: massive vaginal bleeding and
hypotension
– Left lateral recumbent position; oxygen, IV access,
treat for hypovolemic shock, transport

• Trauma in pregnancy
– Motor vehicle collisions, falls, domestic violence
– Position and increased vascularity of uterus
(particularly beyond 20 weeks gestation) increases risk
of serious maternal injury and hemorrhage.
– Fetus jeopardized: maternal hemorrhage; placental
abruption; premature labor; uterine rupture
– Anticipate shock based on MOI; never transport
patient in third trimester in supine position.

Normal Labor and Delivery (1 of 9)
• Signs and symptoms of labor
– Braxton-Hicks contractions
– Increasing levels of pregnancy hormones and vaginal
secretions
– Loss of mucus plug; labor 24 to 48 hours
– Bloody show: discharge of blood-tinged mucus
– Lightening: fetus drops lower in pelvic cavity.

• Signs and symptoms of labor (continued)
– Contractions of active labor: regular, increase in
intensity
– If the water breaks, determine if clear or yellowish or
greenish in color, indicating presence of meconium.
– Meconium: contents of fetal bowel; if aspirated into
neonate’s airway, can cause respiratory distress

• Deciding to transport or prepare for delivery
– Assess whether delivery is imminent.
 Indications mother is in second stage of labor
 Mother feels urge to bear down or push.
 Perineal bulging or crowning
 If decision to deliver at scene, request additional personnel.

• Deciding to transport or prepare for delivery
(continued)
– If decision to transport mother, continue to monitor for
indications of imminent delivery.
– If you must deliver in back of ambulance, stop
ambulance in safe place.
– Keep doors closed, compartment warm.
– If delivery complicated, begin transport.

• Preparing for delivery
– If crowning, be prepared to gently place gloved hand
over head to prevent explosive delivery.
– Uncontrolled expulsion can increase severity of trauma
to mother’s perineum and of fetal injury.
– Use correct positioning to help the fetus to clear the
pubic bone.
– Preferably supine, with someone to help her elevate
her head and shoulders to push
– Mother’s hips and knees flexed
– Place drape or towel beneath patient’s buttocks

• Preparing for delivery (continued)
– Have equipment you need: prepackaged obstetrical
(OB) kit.
– If time permits, start IV at a keep-open rate; administer
oxygen to mother.

• Assisting with the delivery
– As head emerges, gently place gloved hand over it to
prevent explosive delivery.
– When head is fully delivered, tell mother to stop
pushing.
– Check to see if umbilical cord is wrapped around the
infant's neck. If possible try and slip it over the infant’s
head and shoulder; otherwise clamp cord in two
places, about 2 inches apart, cut cord between clamps.

• Assisting with the delivery (continued)
– If the airway is not clear and neonate is unable to clear
it, use bulb syringe to clear mouth and then nose.
– With next contraction, gently guide head downward to
facilitate delivery of upper shoulder; do not use force!
– Gently guide head upward to facilitate delivery of the
lower shoulder.

– Once baby completely emerges, keep level with vagina
until umbilical cord is clamped.
 Place an umbilical clamp about 10 cm (four inches) from the
baby and the second clamp about 5 cm (two inches) further
away from the baby.
– Cut between the two clamps.
– Wipe baby’s face to clean away blood and mucus.
– Dry baby gently; wrap in warm, dry blankets.
– Allow the mother to hold the baby.

– Record time of birth.
– Assign EMS provider to assess and care for baby;
obtain APGAR scores.
– Contractions will begin again after delivery to expel
placenta.

Scan 43-1 (1 of 8)
Assisting with Childbirth
1. Crowning.

Scan 43-1 (2 of 8)
2. Head delivers and turns.

Scan 43-1 (3 of 8)
3. Body delivers.

Scan 43-1 (4 of 8)
4. Grasp the newborn firmly as he is delivered.

Scan 43-1 (5 of 8)
5. Clamp and cut the umbilical cord.

Scan 43-1 (6 of 8)
6. Placenta delivers.

Scan 43-1 (7 of 8)
7. Clean and dry the newborn.

Scan 43-1 (8 of 8)
8. Administer blow-by oxygen if needed.

– Do not pull on umbilical cord to speed expulsion of
placenta.
– Place placenta in biohazard bag; transport it with
mother for inspection and disposal.
– If excess bleeding, perform fundal massage.

Figure 43-13
Fundal massage. To control excessive postpartum hemorrhage, support the body of the
uterus just above the pubic bone with one hand and massage the fundus with the other
hand.

– After delivery, inspect mother’s perineum for
lacerations. Place a sanitary pad over the perineum.
– Reassess vital signs; monitor amount of bleeding
during transport.

Complications of Labor and Delivery
(1 of 12)
• Preterm labor
– Onset of labor prior to 37 weeks’ gestation
– Complications related to immaturity of organ systems
and low birth weight
– Goal: stop preterm labor to allow fetus to develop as
much as possible before delivery
 Advanced EMTs do not administer tocolytics.
 Administration of IV fluids, with medical direction, may stop
premature contractions.

(2 of 12)
• Abnormal presentations―breech position
– Either buttocks or both feet presenting first in birth
canal
– Increases risk for maternal and fetal trauma, fetal
hypoxia, compressed or prolapsed umbilical cord
– Body usually delivered easily; shoulders or head may
be difficult to deliver
– Position mother for delivery with buttocks on edge of
bed, knees close to shoulders.

Figure 43-15
Breech presentation. Support the body as it delivers. If the head does not deliver
spontaneously and the fetus begins breathing, insert the index and middle fingers of your
gloved hand around the fetal nose and mouth to allow him to breathe.

(3 of 12)
(continued)
– In breech presentation, support legs and body as they
emerge, but do not pull on them.
– If head does not deliver but baby begins to breathe,
slide index and middle fingers into vaginal opening to
create “V” around baby’s nose and mouth to allow him
to breathe.

(4 of 12)
(continued)
– Rarely, arm or leg is presenting part (limb
presentation); cannot be managed in prehospital
setting.
– Transport without delay; request air medical transport,
if available.

Figure 43-16
A prolapsed umbilical cord.

(5 of 12)
• Prolapsed umbilical cord
– Umbilical cord emerges before presenting part of fetus
– Prehospital goal: prevent cord from being compressed
– Mother in knee–chest position; insert two fingers into
vagina and lift presenting part of infant off cord
– Apply oxygen by nonrebreather mask.
– Cover exposed cord with sterile, moist dressings;
transport without delay.

Figure 43-17
(A)
(B)
(A) Elevate the fetal presenting part off the umbilical cord. (B) Continue to elevate the
presenting part off the umbilical cord and transport the mother in knee-chest position.

(6 of 12)
• Shoulder dystocia
– Baby’s shoulders are larger than its head and become
lodged between mother’s pubic bone and sacrum
– Associated with very large fetuses
– Head delivers normally, then retracts back into birth
canal

(7 of 12)
• Shoulder dystocia (continued)
– Prepare for immediate transport; have mother lie with
buttocks at edge of bed, pull knees back as close to
shoulders as possible.
– Use your open hand to apply firm pressure just above
the pubic bone.
– If delivery does not occur, initiate transport without
delay.

(8 of 12)
• Precipitous delivery
– Occurs within three hours of onset of labor
– Risks: increased maternal and fetal trauma

(9 of 12)
• Multiple births
– Frequently premature; smaller than single-birth infants
– One presents in normal, head down position and the
other in breech presentation
– Deliver first infant; clamp and cut cord.
– Deliver second infant.
– There may be one or two placentas.

(10 of 12)
• Uterine rupture
– Tearing of uterus that may occur during labor or as
result of trauma
– Maternal and fetal mortality high
– Extreme abdominal pain; uterine contractions stop;
hypovolemic shock common
– Pain may decrease if rupture complete.

(11 of 12)
• Uterine inversion
– Occurs rarely; risk increased by pulling on umbilical
cord in attempt to speed delivery of placenta
– Uterus is turned inside out and pulled through cervix.
– Hypovolemic shock is likely; transport without delay.
– Cover exposed tissue with moist sterile dressings;
consult medical direction.

(12 of 12)
• Pulmonary embolism
– Can occur anytime during pregnancy or after delivery;
more common in patients who have had cesarean
section.
– Treat as you would any other patient with pulmonary
embolism.

Think About It
• Newborns easily become hypothermic without
signs and symptoms. Newborns do not shiver.
• Indications of hypothermia include irritability
(early), with lethargy in later stages, pale or
cyanotic skin, respiratory distress or respiratory
arrest, bradycardia.

Think About It
• Prevent heat loss by drying promptly and
wrapping in blankets. Do not unnecessarily open
ambulance doors. Keep temperature at minimum
of 75°F.
• Keep hypothermia in mind as a possible cause of
respiratory depression and bradycardia.

Assessment and Management
of the Neonate
• At birth, neonate wet and slippery, can easily
become hypothermic.
• Assess need for resuscitation; maintain body
temperature; improve respiration and heart rate if
needed.
• Routine care: suctioning excess secretions,
drying, keeping warm
• Tactile stimulation improves respiration.

Figure 43-18
An inverted pyramid represents the relative frequencies of interventions required in
neonatal resuscitation.

of the Neonate (1 of 3)
• Determining the need for resuscitation
– Do not require resuscitationL
 Full-term gestation
 Crying or breathing
 Good muscle tone
• If any of the three characteristics are not present,
what are the four steps that need to be taken?

Table 43-4
APGAR Scoring
A — Appearance
0 1 2
Cyanotic head, body, and Extremities Head and body pink, extremities
cyanotic
Completely pink
P — Pulse
0 1 2
Absent Less than 100 Over 100
G — Grimace
0 1 2
No reaction to stimuli Grimaces in response to stimuli Cries
A — Activity
0 1 2
Limp Some flexion of extremities Active Movement
R — Respirations
0 1 2
Absent Weak or irregular Strong cry

• APGAR score
– Most newborns score between 7 and 10.
– Score between 4 and 6: moderate distress
– Score 3 or less: severe distress that requires bag-
valve-mask ventilations with supplemental oxygen
– Heart rate below 60 and does not respond to
ventilations: start chest compressions
– Hypoxia is the most common cause of bradycardia in
newborns.

• Assessing vital signs
– Ideal heart rate: 140 to 160
– Strong cry indicates adequate respirations.
– Respiratory distress: grunting; subcostal, intercostal, or
supracostal retractions; seesaw respirations
– Pulse oximetry recommended when resuscitation
anticipated.
– Temperature: 98°F to 100°F
– Dry newborn and wrap in blankets; cover head.
– If blood glucose level is below 60 mg/dL, consult
medical direction.

Considerations in Neonatal
Resuscitation (1 of 4)
• Oxygen administration
– Goal: SpO2 96%; Long-term administration of high
concentrations of oxygen can cause complications in
newborns.
– Hypoxia is the primary reason for neonatal
bradycardia.
– Use blow-by oxygen; do not administer oxygen directly
by mask or cannula.

• Airway management and ventilation
– Do not use battery-powered or fixed electric suction in
neonate.
– Consider neonatal oropharyngeal airway for prolonged
ventilation.
– Use laryngeal mask airway (LMA) if ventilation by face
mask is not effective.
– Use neonatal bag-valve-mask device.

• Chest compressions
– Initiate if heart rate less than 60 beats per minute and
has not improved after assisted ventilation with
supplemental oxygen for 30 seconds.
– Use compression-to-ventilation ratio of 3:1 at rate of 90
compressions and 30 breaths per minute.

Figure 43-20
Proper position for CPR in the neonate.

• Fluids and medications
– Medications rarely used in newborn resuscitation
– 2 mL/kg of 10% dextrose, IV or IO, may be indicated
during post resuscitation care.
– 10 mL/kg IV or IO fluid infusion; Avoid rapid infusion to
prevent brain hemorrhage with premature newborns.

Neonatal Complications and Defects
(1 of 5)
• Prematurity
– Neonate born prior to 37 weeks’ gestation
– Neonate is not considered viable until 24 weeks’
gestation and 450 grams in weight.
– Resuscitate any newborn delivered after 20 weeks’
gestation, unless death obvious.

(2 of 5)
• Prematurity (continued)
– Require specialized care in NICU.
– Lungs are underdeveloped.
– Fat deposits are inadequate to maintain body
temperature.
– Thermoregulatory mechanism is immature.
– Glycogen stores are inadequate.
– Brain is less protected.

Figure 43-21
(A)
(B)
(A) Cleft lip. (B) Cleft palate.

(3 of 5)
• Airway abnormalities
– Choanal atresia: rare defect; complete blockage of
both nares
– Cleft lip/cleft palate: airway management difficult
• Defects of the abdomen
– Congenital diaphragmatic hernia (CDH): abnormal
opening in diaphragm; allows abdominal contents to
migrate into chest

Figure 43-23
Myelomeningocele.

(4 of 5)
• Defects of the abdomen
– Gastroschisis: abdominal wall defect; abdominal
contents extrude through abdominal wall
– Omphalocele: organs contained within translucent sac
outside abdominal wall
– Myelomeningocele: form of spina bifida; meninges
exposed over lumbar spine; may or may not contain
portions of spinal cord

(5 of 5)
• Defects of the skin
– Ichthyosis: flaking and sloughing skin; may resemble a
burn
– Impairment of skin increases heat and fluid loss.

Chapter Summary (1 of 3)
• Complications can occur during pregnancy or
labor and delivery; require Advanced EMT to
assess and manage emergencies involving
pregnancy, childbirth, and care of newborn.
• Pregnancy complications: trauma, spontaneous
abortion, placental abruption, gestational diabetes,
hypertensive emergencies.
• Be prepared to provide reassurance and
emotional support to mother.

• Determine if delivery is imminent; decision to
transport or prepare for field delivery.
• If field delivery, ensure you have enough
personnel to dedicate to assessment and care of
both mother and neonate.
• In most cases, delivery uncomplicated and
neonate not distressed.

• Preterm labor, abnormal fetal presentations,
prolapsed umbilical cord, uterine rupture, or
distress in newborn can turn routine call into
critical situation; will call for quick thinking and
action.
• Manage airway, breathing, circulation for both
patients.
• Prepare for transport without delay; select
appropriate receiving facility.

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