Maternity
Pregnancy is considered to last approximately 40 weeks (280 days) from the last menstrual period (LMP), or 38 weeks (266 days) from the date of conception. However, a pregnancy is considered to have reached term between 38 and 42 weeks. Babies born before the 37 week mark are considered premature, while babies born after the 42 week mark are considered postmature.
During pregnancy, the mother undergoes many physiologic changes, be they cardiovascular, renal, haematological, metabolic or respiratory, changes that become very important in the event of complications.
- Plasma and blood volume increase by 40-50% to accommodate
the changes
- Results in overall vasodilation, increased heart rate (15 bpm), stroke volume, and cardiac output
- Diastolic blood pressure consequently decreases between 12-26 weeks, and increases by 36 weeks. If the blood pressure remains abnormal beyond 36 weeks, the mother should be investigated for preeclampsia, a condition that precedes eclampsia.
- Pregnant women often have the sensation of shortness of breath
First Stage of Labour
- This phase can take from 8 to 10 hours or longer if this is the first pregnancy.
- Show - mucous discharge from the vagina, which may be tinged with blood. Anything more than a tinge of blood be sure to get patient to hospital ASAP
- Contractions - coming at regular intervals and the cervix begins to dilate. Patient contractions will then gradually become stronger and more frequent, and last longer. While the experience of labour can vary widely, a typical one might start out with contractions coming every ten minutes, lasting 30 seconds each, and gradually increasing to every five minutes, lasting 40 to 60 seconds each.
- "waters breaking " refers to the rupture of the membranes surrounding the baby and the gush or the leaking of amniotic fluid through the vagina.
View 1st Stage of Labour Diagram
Management
Encourage mother to adopt a comfortable position, Entonox for pain relief, Transport to hospital as this might be your only opportunity
Second Stage of Labour
The second stage of labour starts when the cervix is fully open and ends when your baby is born. If this is a second pregnancy then this process can be very quick.
- This stage can last from 10 minutes to 2 hours.
- Contractions during this stage may be several minutes apart.
Management
- Contact control to ask for a midwife to attend,
- Prepare the stretcher with blankets and incontinence pads,
- Open maternity pack,
- Prepare warm blanket for the arrival of the baby,
- Reassure mother,
- Continue to offer pain relief,
- Patient comfort in a semi recumbent position,
- If enroute to hospital safely pull over and stop the ambulance.
N.B - Try to consider modesty with certain ethnic minorities. It could be extremely worrying for a women to be attended by a male crew. Try to minimise this anxiety and if possible allow a female member of staff to deal with the patient.
Delivery of the Baby
Click here to view stages of delivery
- Remind mother to try to pant, or only push very gently with the contractions.
- As the baby's head becomes visible, place your hand on the head and provide it with support to keep it from popping out (Do not apply pressure though). Getting mother to pant during this part will help prevent tearing of the perineum. (If tearing occurs and has not stopped after baby is born apply a pressure dressing)
- After the baby's head is completely out, dry her off with a clean towel and wipe her nose and mouth to clear away any mucus and blood.
- If necessary clear her airway with a mucus extractor, but only the oral cavity.
- If the rest of the body has not yet made its way out, her head should then be guided gently downward toward the floor to deliver the top shoulder. Then, to deliver her bottom shoulder, gently lift her body toward the ceiling.
- Once the shoulders are delivered, the rest of the body will be born fairly quickly. It is very important to be aware that the baby will be extremely slippery, so use extra caution in holding her.
- If the baby is not breathing or crying at this point, stimulate her to take her first breaths by firmly rubbing her back or by gently slapping the soles of her feet. Drying her off with a towel also can stimulate her and will prevent her from getting cold.
- If she is cyanosed then enrich the atmosphere with oxygen
- If the baby continues to not breathe, she may require rescue breathing.
- Dry off the baby as much as possible with clean, dry towels. Once she is dry, place her skin-to-skin on her mother's abdomen so that she can benefit from her mother's body heat. Cover mother and baby with a warm blanket
- Apply two cord clamps securely about 6 inches from the umbilicus and cut the cord between the clamps( Only if accepted by local protocols)
- If local protocols don't allow cord cutting, then if the cord is long enough, encourage the new mother to breastfeed her baby if she is willing. This will trigger additional uterine contractions, which will help to expel the placenta and reduce postpartum bleeding.
- Once the placenta is expelled, which can take anywhere from a few minutes to a half hour, it should be placed next to the newborn. You still do not want to cut the cord.
Third Stage of Labour
After the baby is born, the mother will continue to have contractions, but they will not be as uncomfortable as the contractions she experienced while she was in labour. The placenta will separate from the wall of the uterus. As this occurs, she may feel an urge to push as the placenta makes it's way into the birth canal, and the placenta will be delivered. Place the placenta into a bowl so that staff at the hospital can check it is intact. After the placenta has been delivered the mother may bleed a little but this should not be anymore than 200 - 300 mls. If the bleeding doesn't seem to be easing then gentle massage on the abdomen just above the umbilicus will start uterine contractions and the bleeding should begin to decrease.
Management
- Do not pull on the cord but to allow natural delivery of placenta
- Deliver into a bowl for hospital staff to inspect
- Massage abdomen at point of umbilicus. As you massage the uterus should start to harden and begin to ease bleeding.
Apgar Score
The Apgar score was devised in 1952 by Virginia Apgar as a simple and repeatable method to quickly and summarily assess the health of newborn children immediately after childbirth.
The Apgar score is determined by evaluating the newborn baby on five simple criteria on a scale from zero to two and summing up the five values thus obtained. The resulting Apgar score ranges from zero to 10.
The five criteria of the Apgar score:
| Score 0 | Score 1 | Score 2 | |
|---|---|---|---|
| Heart rate | absent | <100 | >100 |
| Respiration | absent | weak or irregular | strong |
| Muscle tone | none | some flexion | active movement |
| Reflex irritability | no response to stimulation |
grimace/feeble cry when stimulated |
sneeze/cough/pulls away when stimulated |
| Skin color | blue all over | blue at extremities | normal |
The test is generally done at 1 and 5 minutes after birth, and may be repeated later if the score is, and remains, low. Scores below 3 are generally regarded as critically low, with 4 – 7 fairly low and over 7 generally normal.
Complications
Several complications can arise throughout pregnancy. In the first trimester, the two major potential problems are miscarriage and ectopic pregnancy.
- "Miscarriage" (up to 24 wks) is the lay term for
the natural or accidental termination of a pregnancy at a
stage where the foetus is incapable of surviving. The medical
term for it is "abortion"; when the abortion is not
deliberately induced, it is termed a "spontaneous abortion".
- Threatened Miscarriage - Light bleeding with little or no pain
- Inevitable Miscarriage - Increased pain with bleeding. (Dilated cervix)
- Incomplete Miscarriage - When some of the placenta is retained. Severe bleeding and infection are common
- In a normal pregnancy, the fertilized egg enters the
uterus and settles into the uterine lining where it has
plenty of room to divide and grow. In a typical ectopic
pregnancy, the egg does not reach the uterus, but instead
adheres to the wall of the Fallopian tube. As the embryo
grows, the tube becomes stretched and inflamed, causing
extreme pain in the pregnant woman. If left untreated, the
affected Fallopian tube will likely burst.
- The most common symptoms and signs of ectopic pregnancy include:
- Patient of child bearing age
- Sharp pain in the abdomen or pelvis
- Signs of early pregnancy
- Vaginal bleeding
- Tender abdomen
- Dizziness or fainting and generally not feeling well
- The most common symptoms and signs of ectopic pregnancy include:
- Just because a woman is experiencing these pains it doesn't mean they have an ectopic pregnancy but bear in mind the possibility.
Management of Miscarriage/Possible Ectopic event
Reassurance, rest and gentle treatment, Entonox for pain relief, treatment for shock if necessary.
ASHICE (Consider)
Transport to Hospital (Bring all of patients pregnancy notes if available)
Professional Handover
Antepartum Haemorrhage (after 24 weeks)
Placenta praevia is characterised by the implantation of the placenta over or near the top of the cervix. Bright red blood is lost
Abruptio Placenta is separation of the placenta (the organ that nourishes the foetus) from the site of uterine implantation before delivery of the foetus. Blood is darker in colour and patient is likely to be in severe pain.
Management of Antepartum Haemorrhage
Reassurance, rest and gentle treatment, Entonox, treatment for shock if necessary.
ASHICE (Consider)
Transport to Hospital (Bring all of patients pregnancy notes if available)
Professional Handover
Eclampsia
It describes one or more convulsions occurring during or immediately after pregnancy as a complication of pre-eclampsia.
Before they suffer an eclamptic convulsion, most women have signs of pre-eclampsia, most notably high blood pressure and/or protein in the urine, Swollen hands and feet. Often there are one or more warning symptoms - such as restlessness, shakiness, intense headache, upper abdominal pain or visual disturbances - before the fit occurs, although these are very common, non-specific symptoms which are usually perfectly benign
Management
Reassurance, High concentrations of O2,Monitoring vital signs. Loosen tight clothing, Do not attempt to restrain patient, Do not put anything in patients mouth, Deal with any injuries sustained during attack. Consider paramedic backup
ASHICE (Consider)
Transport to Hospital
Professional Handover
Resuscitation During Pregnancy
If you happen to attend a female pregnant patient who is in cardiac arrest carry out CPR in the regular way. The only modification that you'll have to do is to tilt the Patient onto their left lateral side if they are in the later stages of pregnancy. This is done to avoid vena cava compression and to aid venous return back to the heart. Elevate the right hip by 10-15 cms and this should completely relieve vena cava compression.
Even in the case of a fatal RTC remove the PT and carry out CPR in the usual way. The unborn child may still be alive so doing CPR will give the child the oxygen it greatly needs until the child can be delivered on arrival to hospital
