Emergency Labour & Delivery PDF

Introduction You may be faced with a situation that requires you to assist with emergency labour and/or delivery. Take comfort in knowing that things rarely go wrong. Childbirth is a natural process. Thousands of children are born all over the world each day, without complications, in areas where no...

Introduction You may be faced with a situation that requires you to assist with emergency labour and/or delivery. Take comfort in knowing that things rarely go wrong. Childbirth is a natural process. Thousands of children are born all over the world each day, without complications, in areas where no medical assistance is available during labour and delivery. By following a few simple steps, you can effectively assist in the labour and delivery process. Key Content Pregnancy................................ 302 The Birth Process..................... 302 Assessing Labour.................. 302 The Labour Process.............. 303 Preparing for Delivery............ 304 Assisting with Delivery........... 304 Caring for the Neonate and Mother................................. 306 Care and Assessment for the Neonate............................. 306 Caring for the Mother......... 308 Midwives and Home Births.... 309 Complications During Pregnancy............................. 309 Spontaneous Abortion........ 310 Premature Labour................ 310 Ectopic Pregnancy................ 310 Third Trimester Bleeding..... 311 Complications During Childbirth............................. 311 Prolapsed Cord..................... 311 Breech Birth.......................... 312 Limb Presentation................ 312 Multiple Births..................... 313 PREGNANCY, LABOUR, AND DELIVERY 16 Pregnancy, Labour, and Delivery 301 PREGNANCY Placenta Umbilical cord Pregnancy begins when an egg (ovum) is fertilized by a sperm, forming an embryo. The embryo implants itself within the mother’s uterus, a pearshaped organ that lies at the top of the pelvis. The embryo is surrounded by the amniotic sac. This is a fluid-filled sac also called the bag of waters. The fluid within the amniotic sac is constantly renewed and helps to protect the embryo from injury and infection. As the embryo grows, its organs and body parts develop. After approximately 8 weeks, the embryo is called a fetus. In order to continue developing properly, the fetus must receive nutrients. The fetus receives these nutrients from the mother through a specialized organ attached to the uterus called the placenta. The placenta is attached to the fetus by a flexible structure called the umbilical cord. The fetus develops for approximately 40 weeks (about 9 months), at which time the birth process begins (Figure 16–1). PREGNANCY, LABOUR, AND DELIVERY THE BIRTH PROCESS 302 The birth process begins with the onset of labour, which is the final phase of pregnancy. Labour begins with a rhythmic contraction of the uterus. As these contractions continue, they cause the cervix to dilate. The cervix is a short tube of muscle at the upper end of the birth canal that serves as the passageway from the uterus to the vaginal opening. When the cervix is sufficiently dilated (approximately 10 cm), it allows the baby to travel from the uterus through the birth canal. The baby passes through the birth canal and emerges from the vagina, at which point it is referred to as a neonate. Assessing Labour If you are called to assist a pregnant woman, you will want to determine early in your assessment whether she is in labour. If she is in labour, you should determine how far along she is in the birth process and whether she expects any complications. The following questions and some quick observations can help you to determine these factors: Fetus Uterus Cervix Vagina Figure 16–1: Mother and fetus at 40 weeks. Is  this your first pregnancy? The first stage of labour often takes longer with first pregnancies than with subsequent ones. Are you under a physician’s care for any factors that make this as a high-risk pregnancy? Has the amniotic sac ruptured? When this happens, fluid flows from the vagina in a sudden gush or a trickle, which may be confused with loss of bladder control. People often describe the rupture of the sac as the water breaking. Note that labour often begins without the amniotic sac rupturing. What are the contractions like? Are they very close together? Are they strong? The length and intensity of the contractions will give you valuable information about the progress of labour. As labour progresses, contractions become stronger, last longer, and are closer together. Is there a bloody discharge? This thick, pink or light red discharge from the vagina is the mucous plug that falls from the cervix as it begins to dilate, signalling the onset of labour. This sign is often referred to as bloody show. Do you have an urge to push? If the expectant mother expresses a strong urge to push, this signals that delivery is imminent. Is the baby crowning? If the baby’s head is visible, the baby is about to be born. Note that these are general guidelines only: Every patient (and every birth) can be different. A patient may have contractions for hours without her amniotic sac rupturing, for example, or may have a much longer second birth than her first. The Labour Process The labour process has four distinct stages. The length and intensity of each stage varies from patient to patient and from birth to birth. The duration of the entire process ranges from just a few hours to several days, but generally the process takes between 12 and 24 hours. First-time mothers typically have longer labours. Second and subsequent births are often shorter, but this is a guideline, not a rule. STAGE ONE—PREPARATION In the first stage, the mother’s body prepares for the birth. This stage covers the period of time from the first contraction until the cervix is fully dilated. A contraction is a rhythmic tightening of the muscles in the uterus. It is like a wave: It begins gently, rises to a peak of intensity, and then drops off and subsides. The muscles then relax, and there is a break before the next contraction starts. As the time for delivery approaches, the contractions become closer together, last longer, and feel stronger. Normally, contractions that are less than 3 minutes apart signal that childbirth is near. When timing the space between contractions, time from the beginning of a wave to the beginning of the next wave, not just the time between the contractions. To prepare for delivery, create a comfortable, clean (preferably sterile) area for the mother. Help her into a position of comfort, and respect her privacy as much as possible. Keep unnecessary bystanders away unless the mother requests their presence. Ensure that necessary equipment is ready for use and close by. If you have an obstetrics kit, it will contain the necessary equipment. Note the spacing of the contractions: When contractions are less than 3 minutes apart, childbirth is imminent. Watch for any signs of complications, and allow the woman’s body to progress naturally. Figure 16–2: When crowning begins, birth is imminent. The woman’s emotional state and stress levels have a direct impact on the ease of the labour process. Create a calm, supportive, and professional atmosphere, and respect the woman’s requests as much as possible (e.g., she may want to turn off bright lights) as long as they do not interfere with care. STAGE TWO—DELIVERY OF THE BABY The second stage of labour involves the actual delivery of the baby. It begins once the cervix is completely dilated and ends with the birth of a neonate. The baby’s head will become visible as it emerges from the vagina. When the top of the head begins to emerge, it is called crowning (Figure 16–2). When crowning occurs, birth is imminent, and you must be prepared to receive the baby. STAGE THREE—DELIVERY OF THE PLACENTA Once the neonate has fully emerged from the birth canal, the third stage of labour begins. During this stage, the placenta usually separates from the wall of the uterus and exits through the birth canal. This process normally occurs within 20 minutes of the delivery of the baby. If the placenta does not emerge fully, or if pieces are torn loose during delivery, this is a serious complication that requires rapid transport. STAGE FOUR—STABILIZATION The final stage of labour involves the initial recovery and stabilization of the mother PREGNANCY, LABOUR, AND DELIVERY While not impossible, it is extremely rare for a woman to go into labour and give birth so quickly that it creates an emergency situation. This is a popular plot device in television and movies, but in reality, the onset of labour is usually gradual and steady. 303 after childbirth. Normally, this stage lasts for approximately 1 hour. During this time, the uterus contracts to control bleeding, and the mother begins to recover from the physical and emotional stress of childbirth. PREPARING FOR DELIVERY Preparing Yourself Assisting with delivery can be a daunting task. Responders may alternate between feelings of excitement and fear. Childbirth is also messy, involving a discharge of watery, sometimes bloody fluid during stages one and two of labour and what appears to be a rather large loss of blood after stage two. Try not to be alarmed by the loss of blood; it is a normal part of the birth process. Only bleeding that cannot be controlled after the neonate is born is a problem. Take a deep breath and try to relax. Remember that you are only supporting the process; the expectant mother is doing all the work. Ask  her to focus on one object in the room while regulating her breathing. Remain calm, firm, confident, and encouraging. This can help reduce fear, apprehension, pain, and discomfort. The use of slow, deep breathing during labour can help by: Aiding in muscle relaxation. Providing distraction from the pain of strong contractions as labour progresses. Ensuring adequate oxygen to both the mother and the baby during labour. Attending a childbirth course is a common practice for expectant mothers. Course topics include expectations during labour and labouring techniques that include breathing and building a birth plan. The expectant mother may provide suggestions or make requests regarding comfort, cultural expectations, and personal needs. Wherever possible, try to fulfill as many of the mother’s and/or family members’ requests as possible, as long as they are safe for you, the mother, and the child. PREGNANCY, LABOUR, AND DELIVERY Supporting a Patient in Labour 304 Make sure the expectant mother understands that the baby is about to be born. Expectant mothers can display a wide range of emotions during the birthing process, from being completely calm and collected to being quite fearful or apprehensive. Common concerns include the pain, birth complications, and the condition of the baby. Labour pain ranges from discomfort similar to menstrual cramps to intense pressure or pain. Many women experience something in between. Factors that can increase pain and discomfort during the first stage of labour include: Irregular breathing. Tensing up because of fear. Not knowing what to expect. Feelings of loneliness and lack of support. To help the expectant mother cope with the discomfort and labour pain: Reassure her that you are there to help. Explain what to expect as labour progresses. Suggest specific physical activities that she can do to relax (e.g., regulating her breathing). ASSISTING WITH DELIVERY It is difficult to predict how much time you will have before the baby is delivered. Time the expectant mother’s contractions from the beginning of one contraction to the beginning of the next. You will recognize that delivery is near if contractions are less than 3 minutes apart. The expectant mother might say that she feels the need to push, or that she feels as if she has to have a bowel movement. You may also see that the baby is starting to crown. Any of these signs indicates that delivery is imminent. Assisting with the delivery of the baby can be a simple process. The expectant mother is doing all the work. Your job is to create a clean environment, help guide the baby from the birth canal, and minimize the possibility of injury to the mother and baby. Establish a clean environment for delivery. Use items such as clean sheets, blankets, or towels. To make the area around the mother as sanitary as possible, place these items over the mother’s abdomen and under her buttocks and legs (Figure 16–3). To add a level of privacy, you can also drape a clean sheet over the mother’s legs. Keep a clean, warm towel or blanket handy to wrap the neonate. Other items that can be helpful include a bulb syringe to suction secretions from the baby’s mouth and nose, gauze or sanitary pads to help absorb secretions and vaginal bleeding, a large plastic bag or towel to hold the placenta after delivery, and supplemental oxygen. Help the mother into a position of comfort: She will usually tell you which position is most comfortable for her. Figure 16–3: Place clean sheets, blankets, towels, or even clothes under the mother. As crowning occurs, place a hand on the top of the baby’s head and apply gentle, light counterpressure (Figure 16–4). This allows the baby’s head to emerge slowly, not forcefully, and helps prevent tearing of the perineum and injury to the baby. At this point, the expectant mother should be directed to stop pushing to allow for a controlled delivery of the head. Instruct the mother to concentrate on her breathing and try to avoid pushing. Panting and/or exhaling in slow, short breaths are two breathing techniques that may help her stop pushing: This helps to prevent a forceful birth. Figure 16–4: Place your hand on top of the baby’s head and apply light pressure. PREGNANCY, LABOUR, AND DELIVERY As the head emerges, the baby will turn to one side (Figure 16–5). This will enable the shoulders and the rest of the body to pass through the birth canal. Support the baby’s head and check to see if the umbilical cord is looped around the baby’s neck (a life-threatening condition referred to as a nuchal cord). If it is, gently slip it over the baby’s head. If this cannot be done, slip it over the baby’s shoulders as they emerge. The baby can slide through the loop. Wipe the baby’s mouth and nose when they become visible. Guide one shoulder out at a time. Do not pull the baby. As the baby emerges, he or she will be wet and slippery. If possible, use a clean towel to support the neonate and reduce the risk of accidentally dropping him or her. Figure 16–5: As the baby emerges, support the head. 305 Place the neonate on its side, between the mother and you. This allows you to safely perform a primary assessment. Document the time the neonate was born. Leave the cord in place and do not pull on or cut it. Clamp or tie the cord while waiting for the placenta to be delivered. Use clamps or sterile ties at two locations, 10 and 15 cm (4 and 6 in.) away from the neonate. Stillbirth is the birth of an infant after 20 weeks of pregnancy that died at some point during pregnancy or labour. The woman and the baby should be transported to a medical facility. If the baby dies during the delivery, he or she is not considered stillborn, and resuscitation may be effective. CARING FOR THE NEONATE AND MOTHER Care and Assessment for the Neonate CARING FOR THE NEONATE PREGNANCY, LABOUR, AND DELIVERY The first few minutes of the neonate’s life are a difficult transition from life inside the mother’s uterus to life outside. Your first priority is to see that the neonate’s airway is open and clear. Note that neonates breathe primarily through their noses. It is important to immediately clear the mouth and nasal passages. 306 You can do this by using your finger or a gauze pad to wipe around the nose and mouth. If the neonate is not actively crying or has evidence of meconium aspiration and respiratory distress, active suctioning with a bulb syringe is indicated (Figure 16–6). Squeeze the bulb, insert it into the nose or mouth, and then release the bulb to clean out the fluids. Squeeze the fluids out of the bulb syringe before attempting to suction up any other fluids. Most neonates begin crying and breathing spontaneously. Crying helps clear the neonate’s airway of fluids and promotes respiration. If the neonate has not made any sounds, stimulate him or her to elicit the crying response by flicking your Figure 16–6: A bulb syringe can be used to clear the neonate’s mouth and nose of any obvious secretions. fingers on the soles of the neonate’s feet and drying the neonate vigorously for 30 seconds. This is important, as the neonate requires stimulation in order to begin respiration. After your initial 30 seconds of care, assess the neonate’s respiration for 10 seconds. If respirations are absent or ineffective, begin assisted ventilations at a rate of 1 breath every 3 seconds (Figure 16–7). Using a neonate or pediatric BVM with room air, ventilate for 30 seconds, and then assess the neonate’s pulse. If the neonate’s heart rate is between 60 and 100 bpm, continue to ventilate for an additional 30 seconds with room air or supplemental oxygen. Continue to provide 30-second periods of ventilation followed by 10-second pulse assessments. If the neonate’s heart rate ranges from 0 to 60 bpm, perform chest compressions with ventilations at a rate of 3:1. If the heart rate increases to between 60 and 100 bpm, continue ventilations at a rate of 1 breath every 3 seconds. If the heart rate is greater than 100 bpm, continue with your primary assessment and routine care. Optimally, a neonate’s heart rate should be between 140 and 160 beats per minute (normal heart rate is 100 to 180 bpm). Begin CPR if the Stimulate to elicit crying response Active crying with stimulation > 100 bpm Continue with primary assessment and routine care Assess respiration Ineffective gasping/apnea Assess heart rate Ventilate (BVM) for 30 seconds > 60 bpm and < 100 bpm Ventilate (room air) for 30 seconds < 60 bpm Perform CPR at a ratio of 3:1 for 30 seconds Figure 16–7: Neonatal resuscitation. Once you have stabilized the neonate’s heart and respiration rate, your second priority is to maintain a normal body temperature. Because neonates can lose heat quickly, it is important to keep them warm. Dry the neonate gently but vigorously, and wrap him or her in a clean, warm towel or blanket. If possible, record an initial set of vital signs. Most important are breathing, heart rate, and skin colour. You can review vital signs in Chapter 5. ASSESSING THE NEONATE The APGAR score is a numerical system used to assess the condition of a neonate (Table 16–1). It evaluates the neonate’s heart rate, respiratory rate, muscle tone, reflex irritability, and colour. Each of these five categories is given a score of 0, 1, or 2, resulting in a total score between 0 and 10. The assessment is performed twice: first at 1 minute after birth, and again at 5 minutes after birth. The name APGAR is often used as an acronym to aid in remembering the five areas to be evaluated (Appearance, Pulse, Grimace, Activity, and Respiration). Assess each area as follows: PREGNANCY, LABOUR, AND DELIVERY neonate’s pulse rate is less than 60 bpm and the neonate is not responding to ventilations (see page 149). If the neonate’s heart rate is in the normal range but the neonate is showing cyanosis or signs of laboured breathing, blow by supplemental oxygen is indicated: Attach a section of tubing to the regulator and deliver oxygen at 4 litres per minute by holding the open end of the tubing near the neonate’s face. 307 TRANSPORTING A NEONATE Appearance (skin colour): Assess the infant’s skin colour, looking at both the torso and the extremities: Torso and extremities are pale and blue: 0 Torso is pink, extremities are blue: 1 Torso and extremities are pink: 2 Pulse: Assess the infant’s pulse using a stethoscope: No detectable pulse: 0 Pulse lower than 100 bpm: 1 Pulse of 100 bpm or higher: 2 Grimace (reflex irritability): Assess the infant’s response to stimulation, such as a gentle pinch: No response: 0 Some facial grimacing: 1 Grimacing and a cough, sneeze, or cry: 2 Activity (muscle tone): Manipulate the infant’s extremities and evaluate the tone of the muscles: Muscles are floppy, loose, and without tone: 0 Muscles have some tone, extremities show some flexion: 1 Muscles show active motion: 2 Respiration: Assess the infant’s respiration: No respiration: 0 Slow or irregular respiration: 1 Strong respiration, crying: 2 PREGNANCY, LABOUR, AND DELIVERY A score between 7 and 10 is considered normal, 4 to 6 is fairly low, and 0 to 3 is critically low. Note that scores of less than 2 in some areas are normal. A score of 10 is fairly uncommon, and a perfectly healthy neonate may have a score of 7 or 8. 308 Transporting a neonate safely requires skilled personnel and specialized equipment. Ideally, a neonatal transport team should be requested, but this may not be readily available. If you must transport a neonate, he or she must be placed on monitoring, and if any issues arise with the neonate’s heart rate, respirations, or temperature, interventions must be performed immediately. Caring for the Mother Balancing the needs of the neonate and the mother may be a challenge for the first few minutes after birth. If you are working in a team, one responder should address the needs of the neonate while another cares for the mother. If working alone, continue to check the mother’s condition frequently while you provide the initial care for the neonate. Once the neonate’s vitals are stable, encourage the mother to begin breastfeeding the neonate. Breastfeeding helps stimulate the uterus to contract, which helps slow bleeding, and provides a wide range of benefits for both the infant and the mother. After the delivery of the neonate, the placenta will still be in the uterus and attached to the neonate by the umbilical cord. Contractions of the uterus will usually expel the placenta within 20 minutes of delivery. Catch the placenta in a clean towel or container. Unless specifically directed to do so by local protocols or your medical director, do not separate the placenta from the neonate or cut the clamped/ tied umbilical cord. Instead, leave the placenta attached to the neonate and place it in a plastic bag or wrap it in a towel for transport to the hospital. TABLE 16–1: THE APGAR SCORE ELEMENT 0 1 2 Appearance (skin colour) Body and extremities blue and pale Body pink, extremities blue Completely pink Pulse Absent Below 100 bpm 100 bpm or above Grimace (irritability) No response Grimace Cough, sneeze, cry Activity (muscle tone) Limp Some flexion of extremities Active movement, flexed arms and legs Respiration Absent Slow and irregular Strong, crying Total Score = SCORE After childbirth, many new mothers experience shock-like signs or symptoms, such as shivering, slight dizziness, and cool, pale, moist skin. A supine position will help to compensate for these effects. Maintain normal body temperature and monitor her vital signs. POSTPARTUM BLEEDING While minor bleeding after birth is normal, postpartum bleeding is excessive bleeding after the birth (more than 500 mL or 17 oz.). It may be caused by the uterine muscles not contracting fully, pieces of placenta or membranes remaining in the uterus, or vaginal or cervical tears during delivery. Postpartum bleeding frequently occurs within the first few hours after delivery, but it can be delayed for up to 24 hours after delivery. If a woman experiences postpartum bleeding, care for any external bleeding from perineal tears as open wounds. Do not attempt vaginal packing to control internal bleeding. You can encourage the mother to breastfeed the neonate, as this also stimulates the uterus to contract. Position the patient for shock and monitor her condition. Do not let the patient eat or drink anything. As always, a patient presenting with signs of shock should be in the rapid transport category (if she is not already). MIDWIVES AND HOME BIRTHS Registered midwives are health professionals who provide primary care to women and their babies during pregnancy, labour, birth, and the postpartum period. Midwives practise across Canada and are governed by provincial legislation. As primary care providers, midwives may be the first point of entry to maternity services, and they are fully responsible for clinical decisions and the management of care within their scope of practice. Midwives provide the complete course of low-risk prenatal, intrapartum, and postnatal care, including physical examinations, screening and diagnostic tests, risk and abnormal condition assessments, and normal vaginal deliveries. Midwives work in collaboration with other health professionals and consult with or refer to medical specialists as appropriate. Midwives attend births in hospitals, birth centres, and patients’ homes. Women expecting a normal vaginal delivery have the option of a home birth if they are under the care of a midwife. Women choose home births for a variety of reasons. Midwives regularly deliver babies at home. However, if a professional responder is called, there has likely been an unexpected complication that creates a medical emergency. Care for a woman or neonate should be a collaborative effort. The scope of practice for a midwife will be very different than yours as a responder. Provide support and interventions as per your scope of practice. Always follow your local protocols. COMPLICATIONS DURING PREGNANCY Many complications that can arise during pregnancy are difficult to differentiate. Because of the vulnerable state of a fetus in utero, it is important to err on the side of caution and place any pregnant patient with concerning signs or symptoms in the rapid transport category. Always provide reassurance and support to the patient. For a pregnant patient, you should be concerned with two important signs and symptoms: abdominal pain and vaginal bleeding. Any abdominal pain, persistent or profuse vaginal bleeding, or bleeding in which tissue passes through the vagina should be assessed by a physician as soon as possible to determine the cause. A pregnant patient exhibiting these signs and symptoms should be in the rapid transport PREGNANCY, LABOUR, AND DELIVERY Expect some additional vaginal bleeding when the placenta is delivered. Gently clean the mother using gauze pads or clean towels. Place a sanitary pad or towel over the vagina. Have the mother place her legs together. Do not insert anything into the vagina for any reason. Gently massage the lower portion of the abdomen, as this will stimulate the uterus to contract, helping to eliminate large blood clots and slowing bleeding. This may be done by the mother or her support person, or by a responder. 309 category. You should also monitor the patient closely and take steps to minimize shock. When transporting a woman in the third trimester of pregnancy, position her on her left side. Spontaneous Abortion Spontaneous abortion, often referred to as miscarriage, is the spontaneous termination of pregnancy from any cause before 20 weeks of gestation. Spontaneous abortion is relatively common, occurring in about 1 in 10 pregnancies. It is a common cause of vaginal bleeding in the first trimester of pregnancy. Signs and symptoms of spontaneous abortion include: Anxiety and apprehensiveness. Vaginal bleeding, which may be minor or profuse, and which may contain tissue. Cramp-like abdominal pain that is similar to the pain of labour or menstruation. During your patient interview, you should attempt to determine: The time of onset of the pain and bleeding. The approximate amount of blood lost. Whether any tissue was passed along with the blood. PREGNANCY, LABOUR, AND DELIVERY Should the woman feel an urge to go to the bathroom, ask her to call you in if she sees any tissue or clot-like matter after urinating. Collect and transport any tissue found to the hospital for analysis. 310 Spontaneous abortions are typically upsetting for a patient but are rarely medical emergencies. Any woman who experiences a suspected spontaneous abortion should be examined by a physician to ensure that all tissue has passed out of the uterus: Otherwise, interventions may be necessary. Premature Labour Labour that begins between the 20th and 37th week of gestation is called premature or preterm labour and is a medical emergency. Many factors increase the chance of having a preterm birth, including a history of preterm births or spontaneous abortions, carrying multiple babies, and poor nutrition, as well as certain diseases and abnormalities. Any woman who goes into labour between the 20th and 37th week of pregnancy is experiencing premature labour. Assess the patient to determine whether rapid transport is necessary. A physician will determine whether labour has truly begun and whether any interventions are necessary. If necessary, assist with labour as usual. Infants born prematurely, especially before 34 weeks, have not fully developed and are at high risk of infection, injury, and complications. BRAXTON HICKS CONTRACTIONS Many women experience Braxton Hicks contractions towards the end of pregnancy. These are also referred to as practice contractions or false labour, as they mimic many effects of labour contractions but do not result in true labour and delivery. Unlike labour contractions, Braxton Hicks contractions do not increase in intensity or become closer together over time. Other signs and symptoms of labour are not present. Ectopic Pregnancy An ectopic pregnancy occurs when a fertilized ovum implants outside of the uterus (e.g., in the fallopian tubes) (Figure 16–8). There are numerous causes of ectopic pregnancy; however, most involve factors that delay or prevent passage of the fertilized ovum through the fallopian tube and into the uterus. Predisposing factors include previous surgery, previous ectopic pregnancy, and intentionally blocked tubes (i.e., tubal ligation as birth control). Ask questions about these factors when interviewing a pregnant patient. Because the ovum is not in the uterus, there is little space for it to expand. As it grows, it puts pressure on the surrounding tissues and can ultimately rupture. A ruptured ectopic pregnancy usually causes a severe hemorrhage and is the leading cause of maternal death in the first trimester. Most ruptures occur between 2 and 12 weeks of gestation. Because an ectopic pregnancy can be immediately life threatening, any woman experiencing severe abdominal pain and who could even possibly be pregnant should be placed in the rapid transport category. Because emergency surgery is often indicated for ectopic pregnancies, the patient should not eat or drink anything. Third Trimester Bleeding Third trimester bleeding occurs in a very small percentage of pregnancies and is not considered normal. The causes of third trimester bleeding include: Abruptio placentae: a partial or complete detachment of a normally implanted placenta after 20 weeks’ gestation. Placenta previa: a condition in which the placenta is attached in the lower uterus, encroaching on the opening of the cervix. Uterine rupture: a spontaneous or traumatic rupture of the uterine wall. This may be a result of prolonged or obstructed labour, a previous scar from a Caesarean birth, or trauma. The signs and symptoms of third trimester bleeding may include: Vaginal bleeding (may be sudden and/or painless). Uterine cramping. Back pain. A woman with third trimester bleeding should be in the rapid transport category, as she should be Embryo Ovary Uterus Cervix Vagina 16–8: An ectopic pregnancy. assessed by a physician immediately to determine whether emergency interventions are necessary. Depending on the cause of the bleeding, emergency surgery may be required, so she should not eat or drink anything. COMPLICATIONS DURING CHILDBIRTH The vast majority of births occur without complication. For the few that do have complications, delivery can be stressful and even life threatening for the expectant mother, the baby, or both. A patient presenting with any of the conditions listed here should be in the rapid transport category. The most common complication of childbirth is persistent vaginal bleeding. Other childbirth complications include: Prolapsed cord. Breech birth. Limb presentation. Multiple births. Prolapsed Cord A prolapsed cord occurs when a loop of the umbilical cord protrudes from the vagina while the PREGNANCY, LABOUR, AND DELIVERY The signs and symptoms of ectopic pregnancy include: Abdominal pain (especially sharp pain on one side). Referred pain to the shoulder. Vaginal spotting or bleeding (may be minimal or severe). Nausea or vomiting. Missed menstrual periods. Syncope. Signs of shock. Fallopian tube 311 Figure 16–9: A prolapsed cord. Figure 16–10: The knee-chest position will take pressure off the cord. baby is still in the birth canal (Figure 16–9). As the baby moves through the birth canal, the cord will be compressed between the baby’s head and the birth canal, and blood flow to the baby will stop. Without this blood flow, the baby will die within a few minutes from lack of oxygen. breath, he or she will also be unable to breathe because his or her face will be pressed against the wall of the birth canal. If you notice a prolapsed cord, have the expectant mother assume a knee-chest position, leaning to the left side (Figure 16–10). This will help take the pressure off the cord. Initiate rapid transport and administer oxygen to the mother if it is available. Breech Birth PREGNANCY, LABOUR, AND DELIVERY Most babies are born headfirst. However, on rare occasions, the baby is delivered feet- or buttocksfirst. This is commonly referred to as breech birth. If the patient has a known or presented breech birth and is in labour, she should be in the rapid transport category. 312 To help with a breech delivery, place the index and middle fingers of your gloved hand into the vagina next to the baby’s mouth and nose. Spread your fingers to form a “V” (Figure 16–11), and maintain this position until the baby’s head is delivered. Although this will not lessen the compression on the umbilical cord, it may allow air to enter the baby’s mouth and nose. Supplemental oxygen is indicated for the mother. Limb Presentation In most births, the baby’s head presents first and the rest of the body follows. Less frequently, the If you are supporting a woman during a breech delivery, support the baby’s body as he or she exits the birth canal while you are waiting for the head to emerge. Do not pull on the baby’s body. This will not help to deliver the head and can cause serious injury to the baby. After about 3 minutes, if the head has not delivered, you will need to help create an airway so the baby can breathe. Because the weight of the baby’s head lodged in the birth canal will reduce or stop blood flow by compressing the cord, the baby will be unable to receive any oxygen. Should the baby try to take a spontaneous Figure 16–11: During a breech birth, position your index and middle fingers to allow air to enter the baby’s mouth and nose. baby’s arms or legs may present first, preventing the possibility of a normal delivery (Figure 16–12). This kind of delivery can be fatal, and the patient requires rapid transport. Never pull on the baby’s arms or legs. Multiple Births Some births involve delivery of more than one baby (e.g., twins or triplets). If the mother has had prenatal care, she should be aware that she is going to deliver more than one baby. Multiple births should be handled in the same manner as single births. There may also be a separate placenta for each child, although depending on the type of pregnancy, this is not always the case. Multiple births increase the chance of breech presentation. Twins have a higher risk of premature birth, and even when born full-term, they may be small enough to be considered premature. Take extra precautions to guard against heat loss until they can be transported to the hospital. Figure 16–12: Limb presentation prevents the possibility of a normal birth and could be fatal. PREGNANCY, LABOUR, AND DELIVERY Clamp or tie the cord after the first neonate is born. Labour contractions should resume within 5 to 10 minutes of the first neonate’s birth. The second neonate should be born shortly after the first. 313 SUMMARY THE LABOUR AND DELIVERY PROCESS Stage 1— Preparation Ensure the mother’s comfort and privacy. Create a comfortable, clean/sterile space.  Have necessary equipment ready. Stage 2— Delivery of the Baby As crowning occurs, place a hand on the top of the baby’s head and apply gentle, light pressure. Direct the mother to stop pushing and support the baby’s head and neck as they emerge. Assess the neonate. Stage 3— Delivery of the Placenta Put the patient in the rapid transport category if: The placenta does not fully emerge. The placenta is damaged during delivery. Stage 4— Stabilization Ensure the initial recovery and stabilization of the mother post childbirth. Neonatal Resuscitation Flowchart Stimulate to elicit crying response Active crying with stimulation > 100 bpm PREGNANCY, LABOUR, AND DELIVERY Ineffective gasping/apnea Assess heart rate Ventilate (BVM) for 30 seconds < 60 bpm > 60 bpm and < 100 bpm Ventilate (room air) for 30 seconds Continue with primary assessment and routine care 314 Assess respiration Perform CPR at a ratio of 3:1 for 30 seconds Assessing the Neonate THE APGAR SCORE 0 Element 1 2 Activity (muscle tone) Limp Some flexion of extremities Active movement, fixed arms and legs Pulse Absent Below 100 bpm 100 bpm or above Grimace (irritability) No response Grimace Cough, sneeze, cry Appearance (skin colour) Body and extremities blue and pale Body pink, extremities blue Completely pink Respiration Absent Slow and irregular Strong, crying