1. Caring for the Newborn

2. State Standard
25) Recognize and manage life threats based on simple assessment findings for a patient with special needs while awaiting additional emergency response. Utilize rubrics from textbooks, National HOSA guidelines, or clinical standards of practice for the following special patient populations and situations: a. Vaginal bleeding in pregnant patients b. Signs of labor and delivery c. Steps if EMR needs to deliver d. Initial care of neonates e. Care of mother after delivery f. Pediatric respiratory distress, seizures, and Sudden Infant Death Syndrome (SIDS) g. Geriatric care h. Child, elderly, and domestic partner abuse

3. Objectives Students will be able to…
Determine assessment Apgar scores of sample newborns
Demonstrate clamping and cutting of the cord
Demonstrate measures to resuscitate an unresponsive infant
Determine potential complications and treatments for mother and baby.

4. Apgar Scoring
Apgar is a quick test performed on a baby at 1 and 5 minutes after birth. The 1-minute score determines how well the baby tolerated the birthing process. The 5-minute score tells the doctor how well the baby is doing outside the mother's womb.
The Apgar score is based on a total score of 1 to 10. The higher the score, the better the baby is doing after birth.
A score of 7, 8, or 9 is normal and is a sign that the newborn is in good health. A score of 10 is very unusual, since almost all newborns lose 1 point for blue hands and feet, which is normal after birth.

5. Apgar Scoring

6. 23.1.5 Carefully dry the baby, and cover him to conserve heat.
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7. 23.1.6 Assess breathing and pulse rate for the newborn.
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Once the cord has stopped pulsating, clamp it in preparation for cutting.
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9. 23.1.9 Expect delivery of the placenta within 20 to 30 minutes following the delivery of the baby.

10. Delivery Caring for the Baby Clear baby's airway.
Make certain baby is breathing.
Perform quick assessment.
Clamp or tie off cord if protocols allow.
Keep baby warm.
Place paper bracelet loosely around baby's wrist.
Teaching Tip: Use an infant manikin to demonstrate the steps of suctioning a newborn.

11. Figure 23.7 Algorithm for assessment of the newborn.

12. Figure Use a sterile pad or clean handkerchief to wipe blood and mucus from around the baby’s mouth and nose.

13. Figure 23.9 It may be necessary to stimulate the newly born baby to breathe.

14. Delivery Caring for the Nonbreathing Newborn Provide rescue breaths.
Do not use bag-mask device or airway adjuncts designed for older children or adults.
Be careful not to hyperextend head and neck of baby.
Class Activity: Using infant manikins, direct students to demonstrate stimulating a neonate to breathe and practicing rescue breaths with an appropriate barrier device.

15. Table 23.1 Care for the Nonbreathing Newborn

16. Figure Resuscitate the newly born baby with a bag-mask resuscitator that is an appropriate size.

17. Delivery Caring for the Non-breathing Newborn Blow-by oxygen
Holding mask or cup several inches from baby's face.
Do not blow a stream of oxygen directly into baby's face.
Withholding oxygen may be more damaging than delivering too much.
Class Activity: Using infant manikins and supplemental oxygen devices, direct students to practice blow-by oxygen administration.

18. Figure Use an oxygen face mask or similar object attached to oxygen, and hold it near the baby’s face to supply blow-by oxygen.

19. Delivery Umbilical Cord Use sterile clamps or umbilical ties.
Apply one tie or clamp to cord about six inches from baby's abdomen.
Place second tie or clamp about two inches farther from baby.
Cut between two ties or clamps.
Class Activity: Using lengths of synthetic cord for simulation, direct students to apply clamps and practice cutting the cord.

20. Figure 23.13 Cutting the umbilical cord.

21. Delivery Caring for the Mother Deliver placenta and birth tissues.
Control vaginal bleeding by gently but firmly massaging from the pubis bone at the front of the pelvis upward only toward the navel.
Make her as comfortable as possible.
Provide reassurance.
Class Activity: Using an OB manikin and kit, direct students to demonstrate the steps for preparing for and assisting with a field delivery.

22. Think About It
You respond to a home and find a 32-year-old female seated on the side of her bed. Her husband states that she awoke with intense labor pains and "her water broke." This is her third child and her contractions are two minutes apart.
How will you proceed?
Class Activity: In response to the given scenario, use an OB manikin and tell students to prepare for a delivery. Direct them to don appropriate personal protective equipment, complete an assessment, prepare equipment, conduct a delivery, and care for mother and newborn.

23. COMPLICATIONS AND EMERGENCIES

24. Complications and Emergencies
Abnormal bleeding
Miscarriage
Breech delivery
Premature delivery
Multiple births
Stillbirths
Teaching Tip: Invite a midwife, OB physician, or OB nurse to discuss treating complications of delivery.

25. Complications and Emergencies
Risk of Complications
Younger than 18 years old or older than 35
First pregnancy or more than five pregnancies
Swollen face, feet, abdomen from water retention
High or low blood pressure
Diabetes
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26. Complications and Emergencies
Risk of Complications
Illicit drug use during pregnancy
History of seizures
Predelivery bleeding
Infections
Alcohol dependency
Injuries from trauma
Premature rupture of membranes
HOMEWORK: Assign each student a risk factor for complications during pregnancy. Direct them to use medical websites to research details about each one. Ask them to share their findings with the class.

27. Complications and Emergencies
Pre-delivery Emergencies
Miscarriage
Spontaneous natural loss of embryo or fetus before the twenty-eighth week.
Spotting
Normal discharge of blood during pregnancy
Critical Thinking: Why is it important to treat all lower-quadrant abdominal pain in a woman of childbearing years as a possible ectopic pregnancy?
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28. Complications and Emergencies
Pre-delivery Emergencies
Ectopic pregnancy
When fertilized egg implants somewhere other than uterus
Critical Thinking: Why is it important to treat all lower-quadrant abdominal pain in a woman of childbearing years as a possible ectopic pregnancy?

29. Figure 23.15 Position the patient to control excessive prebirth bleeding.

30. Complications and Emergencies
Emergency Care of Pre-birth Bleeding
Make sure the ambulance is on the way.
Take BSI precautions.
Place patient on her left side.
Provide for shock.
Monitor the airway.
Administer oxygen per local protocol.
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31. Complications and Emergencies
Emergency Care of Pre-birth Bleeding
Place a sanitary pad or bulky dressing over vaginal open.
Replace as needed.
Save all blood soaked pads and any fetal tissue in a biohazard bag for transport.
Monitor and reassure the patient while you wait for EMT or ALS personnel.

32. Figure 23.16 Algorithm for complications of childbirth.

33. Complications and Emergencies
Complications During Delivery
Meconium staining
Product of baby's first bowel movement
Inhalation of this fluid on first attempt to breathe may lead to aspiration pneumonia.
Breech birth
Buttocks or feet deliver first.
Critical Thinking: Why is immediate action so important during a breech birth?

34. Figure 23.17 Create and maintain an airway for the baby during a breech birth.

35. Complications and Emergencies
Complications During Delivery
Limb presentation
Presentation of arm or single leg
Prolapsed cord
Delivery of umbilical cord prior to delivery of baby
Compression of the cord obstructs oxygen flow.
Place wet dressings over the cord.
Critical Thinking: Why is a prolapsed cord dangerous to the fetus?

36. Figure Place the mother in the knee-chest position, which will help keep pressure off the umbilical cord in a limb-presentation birth.

37. Complications and Emergencies
Complications During Delivery
Multiple births
Not necessarily abnormal
Frequently involve premature delivery
Premature births
Any baby weighing less than 5.5 pounds at birth or born before the thirty-seventh week
Discussion Question: What risks are present with premature infants and are not present with full-term babies?
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38. Complications and Emergencies
Complications During Delivery
Stillborn
Fetus that is delivered dead
Discussion Question: What risks are present with premature infants and are not present with full-term babies?

39. Complications and Emergencies
Other Emergencies
Supine hypotensive syndrome
Abnormally low blood pressure that results when mother is supine and fetus puts pressure on vena cava
Preeclampsia
Potentially life-threatening condition that affects mother during third trimester
Characterized by high blood pressure and fluid retention
Critical Thinking: How might you avoid causing supine hypotensive syndrome in a late-term pregnant patient?
Talking Point: Preeclampsia may also be referred to as toxemia. Ask the patient if she has been diagnosed with preeclampsia or toxemia if you note fluid retention and high blood pressure.
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40. Complications and Emergencies
Other Emergencies
Eclampsia
Life-threatening condition characterized by seizures, coma, eventually death of both mother and baby
Critical Thinking: How might prenatal care help prevent eclampsia?
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41. Complications and Emergencies
Other Emergencies
Trauma
Vital signs of a pregnant woman are different from woman who is not pregnant.
Heart rate normally increased by about 15 beats per minute
Blood pressure normally 10 to 15 mmHg lower
Critical Thinking: How might prenatal care help prevent eclampsia?
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42. Complications and Emergencies
Other Emergencies
A pregnant woman can lose almost 40 percent of her blood volume before she shows any signs of shock.
Blunt-force injuries
Common in falls, vehicle crashes, abuse, assaults
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43. Complications and Emergencies
Other Emergencies
Penetrating injuries
Result of gunshot wounds and stabbings or punctures from debris of auto wreckage
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44. Complications and Emergencies
Other Emergencies
Vaginal bleeding
Blunt force and penetrating trauma
Intercourse
Sexual assault
Reproductive organ problems
Abnormal pregnancy
Placental tears and uterine rupture
Critical Thinking: What key findings would indicate a life-threatening condition in these situations?
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45. Complications and Emergencies
Other Emergencies
Placenta previa
Placenta grows and develops over cervix.
Placenta abruptio
Can occur in trauma situation when force of trauma abruptly tears placenta partially or completely away from wall of uterus.
Critical Thinking: Why is it important to monitor vital signs carefully in these patients?
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46. Complications and Emergencies
Other Emergencies
Sexual assault or rape is a psychologically and physically traumatic experience.
Fetus is also victim in the assault.
Injuries that the fetus receives may be direct from blows to abdomen, or indirect as result of injuries to mother.
Critical Thinking: Why is it important to NOT clean the vaginal area a patient who is a victim of sexual assault or rape? Why should you tell her not to wash or go to the bathroom?

47. Think About It
You respond to an apartment to find a 17-year-old female presenting with intense contractions and a prolapsed umbilical cord. You update EMS, but the ambulance is delayed due to a snowstorm.
What steps must you take while awaiting transport?

48. Activity ***We have now covered all of our objectives
We will now be demonstrating post delivery care of a newborn, delivery of the placenta, cord clamping, and care of the unresponsive infant.
Exit ticket/ Individual work: Read and complete The Call: Emergency Delivery scenario with questions under the birth and newborn care worksheets.
Turn these into the box.

49. SUMMARY

50. Summary
Normal gestation period for a human fetus is 40 weeks, or approximately nine months.
Infant considered premature if delivered prior to thirty-seventh week of gestation
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51. Summary Labor is a normal process the body uses to deliver a baby.
Average labor is 16 hours.
Can be much shorter or much longer
Labor has three stages.
First begins with onset of labor and ends with full dilation of cervix.
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52. Summary Labor has three stages.
Second stage begins with dilation of cervix and ends with delivery of baby.
Third stage begins after delivery of baby and ends with delivery of placenta.
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53. Summary Signs of imminent delivery
Contractions are two to three minutes apart.
Mother has urge to push.
Crowning at vaginal opening
When signs of imminent delivery are obvious, prepare for delivery at the scene.
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54. Summary Upon delivery of head, check for umbilical cord around neck.
If present, gently slip it over baby's head.
Suction mouth first then nose prior to delivery of baby.
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55. Summary After delivery, stimulate baby by drying with clean dry cloth.
Baby should begin breathing on own.
If breathing or pulse is inadequate, provide appropriate care immediately.
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56. Summary
Immediately call for ALS back up for any delivery that appears abnormal or complicated, such as breech presentation or prolapsed cord.
Place mother in knee-chest position and provide high-flow oxygen if available.
Follow local protocols.

57. REVIEW QUESTIONS

58. Review Questions Describe the function of the following:
Amniotic sac
Birth canal and cervix
Placenta and uterus
Umbilical cord
What is the purpose of each of the items in a typical field obstetrics (OB) kit?
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59. Review Questions
What are the three stages of labor and when do each begin and end?
What are the signs of an imminent delivery?
What are the steps for preparing and assisting with a field delivery?
What are the priorities of care for the newborn following a field delivery?
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60. Review Questions
What are the priorities of care for the mother following a field delivery?
What are the common complications related to a field delivery and how would you properly care for each?
What are the common causes of vaginal bleeding during the first trimester?
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61. Review Questions
What are the common causes of vaginal bleeding during the third trimester?
What is the appropriate care for a pregnant patient with vaginal bleeding?
What are the signs and symptoms of supine hypotensive syndrome?
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62. Review Questions
What is the appropriate care for a patient with signs and symptoms of supine hypotensive syndrome?
What are the signs and symptoms of preeclampsia?
What is the appropriate care for a patient with signs and symptoms of preeclampsia?