Female Reproductive System: Anatomy and Physiology

• As an EMT, decisions on assisting with delivery or patient transport must be made.

Anatomy and Physiology of the Female Reproductive System

• Ovaries area two glands on each side of the uterus, and are similar in function to male testes.
• Each ovary contains thousands of follicles, with each follicle containing an egg.
• Ovulation occurs approximately 2 weeks prior to menstruation.
• If fertilized, the egg implants in the endometrium which is the lining of the inside of the uterus.
• If the egg isn't fertilized within 36-48 hours after release, it dies, and the lining is shed as menstrual flow.
• Extending laterally from the uterus are the fallopian tubes, with one tube associated with each ovary.
• Fertilization usually occurs when the egg is inside the fallopian tube.
• The fertilized egg travels to the uterus where it develops into an embryo then a fetus, growing until birth.
• The uterus contracts during labor to push the fetus through the birth canal.
• The birth canal consists of the vagina and the lower third of the uterus, which is called the cervix.
• The vagina is the outermost cavity of the female reproductive system, forming the lower part of the birth canal.
• The vagina completes the passageway from the uterus to the outside world for the newborn.
• The perineum refers to the area between the vagina and the anus.
• In a pregnant woman, breasts produce milk carried through small ducts to the nipple for newborn nourishment.
• The placenta is a disk-shaped structure attached to the uterine wall that provides nourishment to the fetus.
• The placenta keeps the woman and fetus' circulation separate but allows substances to pass between them.
• Anything ingested by a pregnant woman can affect the fetus.
• The umbilical cord connects the woman and fetus through the placenta.
• The umbilical vein carries oxygenated blood from the placenta to the heart of the fetus.
• The umbilical arteries carry deoxygenated blood from the heart of the fetus to the placenta.
• The fetus develops inside of a fluid-filled baglike membrane called the amniotic sac.
• Amniotic sac contains 500-1,000 mL of amniotic fluid, that helps insulate/protect the floating fetus.
• The amniotic fluid is released in a gush when the sac ruptures, usually at the beginning of labor.
• Pregnancy is considered full term at 39 weeks, but has not gone beyond 40 weeks/6 days.

Normal Changes in Pregnancy

• Four body systems undergo major physiologic and anatomic changes during pregnancy, including: respiratory, cardiovascular, and musculoskeletal systems.
• Hormone levels increase in the reproductive system to support fetal development/prepare the body for childbirth.
• Pregnant women are at an increased risk for complications from trauma, bleeding, and certain medical conditions.
• Uterus is displaced out of its normally well-protected pelvic area position, increasing chance of direct fetal injury in trauma.
• Rapid uterine growth occurs during the second trimester of pregnancy.
• As the uterus grows, it pushes up on the diaphragm displacing it from its normal position.
• Respiratory capacity changes occur, with increased respiratory rates and decreased minute volumes.
• Overall blood volume gradually increases throughout the pregnancy, as much as 50% by the end of the pregnancy.
• The number of red blood cells also increases.
• The speed of clotting increases to protect against excessive bleeding during delivery.
• By the end of pregnancy, the pregnant patient's heart rate increases up to 20% to accommodate the increase in blood volume.
• Cardiac output is significantly increased by the end of the pregnancy.
• Pregnant women are at an increased risk for gastroesophageal reflux, nausea, vomiting, and potential aspiration.
• Weight gain during pregnancy is normal.
• The increase in body weight will eventually challenge the heart and impact the musculoskeletal system.
• Certain hormones affect the musculoskeletal system by making the joints "looser" or less stable.
• Changes in the body's center of gravity during the third trimester increase the risk of slips and falls.

Complications of Pregnancy

• Most pregnant women are healthy, but some may have preexisting medical conditions when they conceive or become ill during pregnancy.
• Oxygen delivery during pregnancy poses no harm to the fetus.
• Diabetes can develop during the second half of pregnancy in women who previously have not had it.
• Gestational diabetes resolves in most women after delivery.
• The treatment for gestational diabetes is the same as for any other patient with diabetes.

Hypertensive Disorders

• Gestational hypertension is the presence of high blood pressure without other systemic effects.
• A systolic blood pressure higher than 140 mm Hg and a diastolic blood pressure higher than 90 mm Hg defines gestational hypertension.
• Considered severe when systolic blood pressure is higher than 160 mm Hg and/or diastolic pressure is higher than 110 mm Hg.
• Preeclampsia, or pregnancy-induced hypertension, can develop after the 20th week of gestation, and be characterized by: severe hypertension, severe/persistent headache, visual abnormalities, swelling in the hands and feet (edema), upper abdominal or epigastric pain, dyspnea and/or retrosternal chest pain, anxiety, and altered mental status.
• Eclampsia is characterized by seizures that occur as a result of hypertension.
• To treat seizures: Lay the patient on her left side; maintain her airway; administer supplemental oxygen if necessary; suction the airway if vomiting occurs; provide rapid transport; and call for an ALS intercept.
• Transporting the patient on her left side can also prevent supine hypotensive syndrome.
• Supine hypotensive syndrome is from the pregnant uterus compressing the descending aorta and inferior vena cava when the patient lies supine.

Bleeding During Pregnancy

• Internal bleeding may signify an ectopic pregnancy, when an embryo develops outside the uterus, most often in a fallopian tube.
• Suspect ectopic pregnancy consideration if sudden onset of severe abdominal pain and vaginal bleeding in the first trimester of pregnancy.
• Suspect ectopic pregnancy in a woman who has missed a menstrual cycle and complains of sudden, severe, usually unilateral pain in the lower abdomen.
• Serious vaginal hemorrhage may occur before labor begins.
• In early pregnancy, may be from spontaneous abortion, or miscarriage.
• In later stages, vaginal hemorrhage may indicate: abruptio placenta (placenta separates prematurely from the uterus caused by hypertension/trauma), or placenta previa (placenta develops over/covers the cervix).
• Any bleeding from the vagina in a pregnant woman is a serious sign requiring prompt hospital treatment.
• Treat for shock if signs are present; place a sterile pad/sanitary pad over the vagina and replace as necessary; do not put anything into the vagina to control bleeding.
• Spontaneous abortion is pregnancy loss before 20 weeks of gestation without preceding surgical/medical intervention.
• Can use term interchangeably with miscarriage.
• Induced abortion refers to the elective termination of a pregnancy prior to the time of viability.
• Bleeding and infection are the most serious complications from an abotion.
• If the woman is in shock, treat/transport her promptly to the hospital.
• Bring any tissue that passes through the vagina to the hospital without pulling any tissue out of the vagina.
• Pregnant women have increased chance of being victims of domestic violence/abuse.
• Abuse during pregnancy increases the chance of spontaneous abortion, premature delivery, and low birth weight.
• Abuse places the woman at risk from bleeding, infection, and uterine rupture.
• Pay attention to the environment for any signs of abuse.
• Pregnant patients who are abused are often scared/dishonest about how injuries occurred, so talk to the patient in a private area, away from the potential abuser.

Substance Abuse

• Effects of substance addiction to the fetus include: prematurity, low birth weight, severe respiratory distress, and death
• Fetal alcohol syndrome describes the condition of infants born to women who abused alcohol.
• Pay special attention to safety when handling a delivery of a drug- or alcohol-addicted woman.
• Clues indicating an addicted patient may include: presence of drug paraphernalia, empty wine/liquor bottles, or statements made by family/bystanders/patient herself.
• The newborn may need immediate resuscitation.

Special Considerations for Trauma and Pregnancy

• Trauma calls involving a pregnant woman require consideration for two patients: the woman and the unborn fetus.
• Pregnant women have an increased risk of falling compared with nonpregnant women.
• Hormonal changes loosen joints in the musculoskeletal system.
• Increased weight of uterus and abdominal organ displacement can affect the woman's balance.
• Pregnant women have an increased overall total blood volume and an approximate 20% increase in their heart rate by the third trimester.
• A pregnant trauma pt can have a significant amount of blood loss, showing signs of shock
• The fetus also may be in trouble well before signs of shock are present.
• Be alert to additional concerns in order to assess/manage unique types of injuries when responding to a pregnant trauma patient.
• The uterus is especially vulnerable to both penetrating trauma and blunt injuries due to rich blood supply
• Trauma injury to the pregnant uterus can be life threatening to the woman/fetus.
• Usually, the only chance to save the fetus is to adequately resuscitate the woman.
• Hemorrhage may result from injuries to the pregnant uterus in a motor vehicle crash/similarly violent mechanism of injury.
• Trauma is a leading cause of abruptio placenta.
• Suspect abruptio placenta when the MOI is blunt trauma to the abdomen accompanied by signs/symptoms suggestive of shock.
• Seat belt marks, bruising, and obvious trauma should be assessed during inspection.
• If a pregnant trauma patient goes into cardiac arrest, focus is the same as with other patients in cardiac arrest.
• Perform CPR and transport to the hospital according to local protocol.
• If a woman is in the last month/two of pregnancy, compressions may need to be applied a little higher on the sternum than usual.
• Focus is on the assessment and the management of the woman.
• Follow these guidelines when treating a pregnant trauma patient: maintain open airway; administer high-flow oxygen; ensure adequate ventilation
• Assess circulation: control external bleeding; maintain a high index of suspicion for internal bleeding and shock based on the MOI.
• Transport considerations: transport the patient on her left side; call for ALS early; transport to a specialty obstetric/trauma center if one is available.

Other Considerations

• Cultural sensitivity is important when assessing/treating a pregnant patient.
• Women of some cultures may have a value system that will affect how they care for themselves during pregnancy and how they have planned the childbirth process.
• Some cultures may not permit a male health care provider, especially in the prehospital setting, to assess or examine a female patient.
• The United States has one of the highest teenage pregnancy rates among developed countries.
• Pregnant teenagers may not know they are pregnant or may be in denial about it.
• As you begin to assess all female teenagers, remember that pregnancy is a possibility.

Patient Assessment

• Childbirth is seldom unexpected, but can become an emergency.
• Scene size-up requires standard precautions and considering additional or specialized resources.
• Mechanism of injury/Nature of illness requires knowledge of pregnant patients not in labor.
• Primary assessment requires forming a general impression; determining if in active labor/time to assess for imminent delivery; performing a rapid scan exam.
• Uncomplicated birth concerns for the woman's breathing are not usually an issue
• Other medical conditions may cause a life threat to exist, and, sometimes, result in a complicated delivery.
• Adequate airway management and high-flow oxygen may be required
• Blood loss after delivery is expected, but significant bleeding is not.
• Quickly assess for any life-threatening bleeding and begin treatment immediately.
• Shock treatment requires controlling bleeding, administering oxygen, and keeping the patient warm.

Transport

• If delivery is imminent, prepare to deliver at the scene.
• The ideal place to deliver an infant is in the security of your ambulance or the privacy of the woman's home.
• The area should be warm and private with plenty of room to move around.
• If delivery is not imminent, prepare the patient for transport, and perform the remainder of the assessment en route to the emergency department.
• Women in the second and third trimesters of pregnancy should be transported lying on the left side when possible.
• Rapid transport for pregnant patients is required for those with: significant bleeding and pain; hypertension; a seizure; or an altered mental status.

History Taking

• History taking involves a thorough obstetric history, including: her expected due date; any complications that she is aware of; if she has been receiving prenatal care; and a complete medical history
• History taking involves a SAMPLE history.
• Questions related to prenatal care include: any complications the patient may have had during the pregnancy or potential complications during delivery; the due date, fetal movements, frequency of contractions, a history of previous pregnancies and deliveries and their complications; whether there is a possibility of multiples and whether the woman has taken any drugs or medications
• If her water is broken, ask whether the fluid was green, green fluid is due to meconium (fetal stool).
• Presence of meconium can indicate newborn distress and make it possible for the fetus to aspirate meconium during delivery.
• Secondary assessment involves focused physical examinations and on contractions/possible delivery if patient is in labor.
• Check for crowning if delivery is imminent.
• Do not visually inspect the vaginal area if no imminent delivery.
• Obtain a complete set of vital signs and pulse oximetry.
• Watch for tachycardia, hypo- or hypertension
• Hypertension, even mildly elevated blood pressure, may indicate more serious problems.
• Reassessment focuses on patient's ABCs and vaginal bleeding after delivery
• Imminent delivery requires notifying the receiving hospital.
• Provide an update on the status of the woman and the newborn after delivery.
• For a pregnant patient with a complaint unrelated to childbirth, include the pregnancy status of the patient in the report.
• If delivery occurred in the field, prepare two patient care reports to complete.

Stages of Labor

• The stages of labor are dilation of the cervix, delivery of the fetus, and delivery of the placenta.
• The first stage begins with the onset of contractions and ends when the cervix is fully dilated, averaging 16 hours for a first delivery.
• Other signs of the beginning of labor are the bloody show and the rupture of the amniotic sac.
• The frequency and intensity of contractions in true labor increase with time.
• Labor is generally longer in a primigravida than in a multigravida.
• A woman may experience preterm or false labor, or Braxton-Hicks contractions.
• Some women experience premature rupture of the membranes, in which the amniotic sac ruptures too early and the fetus is not developed or ready to be born.
• The second stage of labor begins when the fetus begins to encounter the birth canal and ends with delivery of the newborn (spontaneous birth).
• Make a decision about helping the woman to deliver at the scene or providing transport to the hospital.
• Uterine contractions are usually closer together and last longer.
• The perineum will begin to bulge significantly, and the top of the fetus's head should begin to appear at the vaginal opening (crowning).
• The third stage of labor begins with the birth of the newborn and ends with the delivery of the placenta.
• During this stage, the placenta must completely separate from the uterine wall and may take up to 30 minutes.

Normal Delivery Management

• Delivery at the scene should be considered when delivery is imminent within minutes.
• Delivery at the scene should also be considered for natural disasters that makes it impossible to reach the hospital
• To determine if delivery is imminent, ask: How long have you been pregnant? When are you due? Is this your first pregnancy? Are you having contractions? Have you had any spotting/bleeding? Has your water broken? Do you feel as though you need to have a bowel movement? Do you feel the need to push?

Questions for Potential Complications

• Were any of your previous deliveries by cesarean section? Have you had problems in this or any previous pregnancies? Do you use drugs, drink alcohol, or take any medications? Do you know if there is a chance you will have multiple deliveries? Does your physician expect any complications?
• Prepare for delivery if the patient says she has to move her bowels or feels the need to push.
• Visually inspect the vagina to check for crowning, without touching the vaginal area until delivery is imminent.
• It is imperative to never attempt to hold the patient's legs together once the delivery process begins.
• Instead, reassure her that the sensation of needing to move her bowels is normal and that it means she is about to deliver.
• During delivery at the scene one is only assisting with the delivery.
• Assistance involves helping, guiding, and supporting the baby’s birth.
• Emergency vehicles are stocked with a sterile emergency obstetric (OB) kit.
• Patient positioning requires removing or pushing clothing above her waist while preserving privacy.
• Elevate the hips about 2" to 4" with a pillow or blankets.
• Support the head, neck, and upper back with pillows/blankets; have her feet flat with her knees spread apart.
• Put on a protective face shield and gown.
• Place towels or sheets on the floor around the delivery area to help soak up body fluids and to protect the woman and the newborn.
• Open the OB kit carefully so that the contents remain sterile, and use sterile sheets/drapes from the OB kit to make a sterile delivery field.
• A partner should be at the patient's head to comfort, soothe, and reassure her during delivery.
• If the patient will allow it, administer oxygen.
• Nausea during delivery is common.
• Perineal area should be watched at all times for precipitous labor/birth.
• Contractoins should be timed and tell patient to breather shor tquick breaths, and rest/breathe deep between contractions.
• Observe infant's head when it begins to exit vaginas to support its exit
• Use sterile gloved hand to control the exit of the head and its boney parts and continue to support head until it rotates.
• Amniotic sacs usually break on its own at the beginning of labor, they are punctured, and they may suffocate the baby if they do not get cut.
• If one does not rupture take it into the face with the clamp and tear and then suction and wipe out the baby's nose in mouth

Assessing and treating umbillical cord

• After giving birth, use a finger to feel around the next in the umbilical cord because it can harm the baby if it still there
• Usually the cord can slide over the baby, but if it cannot it MUST be cut
• The head is the largest part of the baby so once it out the body usually follows with help
• Support the head and upper body as the shoulders deliver, but DO NOT put the baby out of the birth canal
• It feels slippery in some causes and may be had a cheesy substance on them called vernix caseosa

Post deliverty

• If the monther is stable and willing the baby should lay next to her immediately
• Clean and ensure the baby is warm with the top of their head covered
• Wipe any secretion from the babies mouth as need and keep the neck still
• Cut the cord after a minuet (60sec)

Placenta stage

• Placenta takes about 30 min and will deliver itself
• Place a sterile pad or towel over the vagina and move mothers legs to be straight
• Rub the abdomen to slow down the bleed and keep one hand on top of the pubic bone
• Keep track of the time of birth in the patient care report
• These are emergency cases:
• The placenta has not delivered itself in over 30 mins
• The bleeding is more thatn 500ml
• Their is significant bleeding after the placenta has delivered
• Take the monther and baby to the hospital right after

Assessment and Resuscitation of the baby

• The 'golden minuet' is the first minute of birth
• Airway, Suction, Positioning and Drying can preformed
• 30second of breathing should happen usually and their heart rate should be 100 or more
• If their heart beats are too low, they need stimulation to get the baby breathing
• Check Spontaneous Response, extremities movement, skin tone
• Heart rate can be felt at either the umbilical cord or in the brachial artery
• To two person compressio using the hand to encircle
• Mouth and then nose suction can assist if the amniotic fluid came out or if it is the after math of the water sac
• Apgar check after the the two minutes

The Apgar scores measures the five functions of babys

• Appearance
• Pulse
• Grimace or irritability
• Activity or muscle tone
• Respirations
• High possible sore is about 10
• Start stimulations to make repspirtations increase
• Start the ventilation if thier is not an increase
• If breathing well, check the heart rate by stethscope or with your hands
• The heart rate needs to be 100 or more
• Then assist them with central cyanosis, high flow oxygen and request help

Other complication deliveries

• Foot comes out fist is the body part that comes out
• Vertex is the where the head leads
• Breach is the butt and is a huge risk because of the umbilical cord and traums
• Most breach usually give you time to get to their hospital, but starts from their
• It is rare but limbs can show and limbs cannot get out
• Transport patient to hospital quickly
• Place on her back, with her head down and pelvis elevated
• Dont attempt to push the body back in, and cover with a towel
• Also the cord can wrap around so get in there to push the baby's head away and put oxygen

Spina Bifida

• Spinal cord can stick out and needs moist and sterile dressings and it can affect the core tempature
• Twins have about 30 days in between births and usually the smaller ones come out first
• 10 mind between births and it can take it out fast

Premature and Post Termination

• Less that 8 months or 36 weeks is premative labor
• Usually this requires lots of treatments and resusitation, but may only be small
• Post termination lasts for 41 weeks, and they can be over 10 pounds
• Labor and delivery is more difficult with bigger babies

Fetal Demise

• May have foul oder with interuterine infection
• With death babies ignore resusitations
• If the wound is exceeds 1000ml then it is excessive and contine to massage the uterus
• Fix the mother and the symthoms of shock

Pstpartum issues

• Uterus issues are caused by the muscles and can affect their potential life
• Use a sterile pad and adinister oxygen
• Check them for Venus Emblomsi, like pulmonary embolism