Chapter 13 Childbirth Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 1.

Anatomy and Physiology of Pregnancy
Female reproductive anatomy includes: Ovaries Fallopian tubes Uterus Vagina Perineum Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Ovaries Pair of almond-shaped organs located in right and left lower quadrants of the abdomen Function to release eggs and hormones Once a month an egg is released from ovary and travels through fallopian tube to uterus Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

A & P of Pregnancy Fallopian tube Uterus Cervix
Extends from each ovary and acts as a path for egg to reach uterus Uterus Pear-shaped muscular organ that houses unborn infant Cervix Neck of uterus–lower portion where it enters vagina Contains mucous plug that acts as barrier between uterus and vaginal opening during pregnancy Once labor begins–mucous plug will separate and discharge from vagina–sometimes termed bloody show Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Vaginal/birth canal Sheath that encloses lower portion of uterus and extends down to vaginal opening Perineum Area between vaginal opening and anus Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

A fertilized egg Grows and develops in uterus Is linked to the mother via the placenta Placenta O2 and nutrients from mother’s blood pass through placenta and enter circulatory system of fetus through the umbilical cord Umbilical cord Fetus passes waste material back through umbilical cord and placenta to mother’s circulatory system to be eliminated Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Amniotic sac Fluid-filled sac that surrounds fetus during pregnancy Helps protect developing fetus Rupture of the membranes Amniotic sac will typically rupture before delivery of the fetus Some mothers refer to this as “My water has broken” Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

A & P of Pregnancy Fig. 13-2: A, The relationship of the fetus to the mother. B, The first stage of labor begins with the onset of contractions and ends with dilation of the cervix. C, The second stage of labor begins with the fully dilated cervix and ends with delivery of the infant. D, The third stage of labor begins with the delivery of the infant and ends with the delivery of the placenta. Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 9

Labor Process that occurs when woman is preparing to give birth
Can last from a few hours to many hours or days Length of labor depends on: Age of mother Whether it is first or subsequent pregnancy General health of mother Overall health of fetus Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Labor First stage (First contraction to fully dilated) Contraction
Hardening and tightening of uterus Muscular movement of uterus Occurs at regular intervals, shortens as fetus moves through birth canal Normally accompanied by pain Generally, begin at approximately 30 minutes apart and become closer and closer until they are less than 3 minutes apart Contraction time Interval time Normally accompanied by pain Pain and intensity of contraction increase as time to birth is more imminent Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 11

Labor Second stage Begins with full dilation (opening) of cervix
Ends with delivery of the baby Infant’s head enters vagina (birth canal) Increasing pain gives mother urge to bear down or feel need to move bowels Presenting part Part of infant that appears first at vaginal opening During normal delivery–head is presenting part Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Labor Third stage Starts after baby is delivered
Ends after placenta (afterbirth) is expelled from mother’s body Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Delivery First decide As birth nears:
Will you need to deliver baby at scene? Is there enough time for mother to reach hospital As birth nears: Contractions last longer (up to 90 seconds) and become more intense Shorter interval of time between contractions Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Delivery Indicators to help determine if delivery is imminent
Ask questions Are you bleeding or having other kinds of vaginal discharge (bloody show)? Do you feel like you need to have a bowel movement? Do you feel increasing pressure in your vaginal area? What is your due date? Is there any chance of a multiple birth? Is this your first pregnancy? How long have you been having contractions? How far apart are your contractions? Has your water broken? Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Delivery Indicators to help determine if delivery is imminent
If mother states any of the following, consider performing a visual inspection Needs to push Needs to have a bowel movement Has bloody show Amniotic sac has ruptured Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Delivery Visual inspection Have patient lie on back
Elevate hips with padding Knees should be bent and feet flat on floor Knees should be spread apart Protect patient’s modesty and privacy Check for crowning during contraction If you see bulging of vaginal opening or crowning Prepare for immediate delivery Have another emergency first responder present when you perform visual inspection Touch vaginal area only during delivery and only when your partner is present Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 17

Delivery Breech birth (limb presentation)
Occurs when baby’s head is not presenting part Complicated delivery – Call for transport unit! If birth is not imminent Provide emotional support Call for help Continue to monitor mother while waiting for EMS Position mother on left side Encourage mother not to push Do what you can to calm and reassure her Mother will be doing most of the work Provide emotional support and coaching throughout process of delivery Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 18

Delivery Breech birth (limb presentation) If birth is not imminent
Provide emotional support Call for help Continue to monitor mother while waiting for EMS Position mother on left side Position mother on left side Relieves pressure from the uterus and fetus on the mother’s circulatory system Fig. 13-4: Position a pregnant patient in the left lateral recumbent position. Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 19

Delivery Proper BSI Equipment Supplies for delivery
Commercially prepared OB kit includes: Gloves, gown, mask, and eye protection Clean, absorbent materials including sheets and towels Blankets Bulb syringe ● Fig 13-5: Contents of a delivery kit. Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 20

Delivery Supplies for delivery More OB kit items:
Sanitary napkins or bulky trauma dressings Scissors Gauze pads Rolled gauze, umbilical clamps Red plastic “medical waste” bags for soiled linen and disposable supplies Container for the placenta Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Delivery Delivery procedure Prepare for delivery Put on BSI
Prepare supplies and equipment to assist mother Provide reasonable privacy for mother by asking unneeded bystanders to leave or turn back and look away Have mother remove undergarments and lie on back with knees drawn up and spread apart Elevate mother’s hips Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Delivery Delivery procedure As baby moves down into birth canal:
Mother’s urge to push will be very strong Remind her not to arch her back Have her tuck her chin to chest, grab behind her knees, and curl body forward Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Delivery Delivery procedure As baby moves down into birth canal:
Encourage mother to hold her breath for 6-10 seconds as she bears down; pushing longer can cause Strain Rupture of blood vessels Exhaustion Tearing of perineum Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Skill 13-1: Normal Delivery
Prepare for delivery As the infant’s head appears, place the palm of your hand on top of baby’s head Step 1: To prepare for delivery, position mother on back with knees drawn up and spread apart. Elevate hips with pillow or folded blanket. Place clean, absorbent material under hips and place a sheet across each leg and mother’s abdomen. Step 2: As the infant’s head appears, place the palm of your hand on top of the baby’s head and exert very gently pressure to prevent an explosive delivery, in which baby’s head “explodes” through the birth canal quickly and causes extensive tearing at the vaginal opening. Step 3: If the amniotic sac is not yet broken, use your fingers to tear it away from infant’s head and mouth. The baby’s head is usually delivered face down. Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 25

Support baby’s head and check baby’s neck for presence of umbilical cord Support infant’s head as it rotates Step 4: Support baby’s head and check around baby’s neck for presence of umbilical cord. If cord is around neck, instruct mother not to push while you slide cord down over baby’s shoulder or slip it up over baby’s head. Step 5: Support the infant’s head as it rotates. Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 26

Suction baby’s mouth first and then baby’s nostrils two or three times with bulb syringe Step 8: Suction baby’s mouth first and then baby’s nostrils two or three times with bulb syringes. Hold the bulb syringe in your hand with your thumb on the large bulbous section so that it squeezes toward the narrow opening. Point the bulb syringe away from the patient, squeeze air out, and hold it. Place the narrow end in baby’s mouth first; then release your thumb pressure. Point bulb syringe away from patient and squeeze several times to eject contents. Baby’s mouth should be suctioned several times. Process is repeated with narrow end of bulb syringe placed in each nostril. Each nostril should be suctioned once or twice until reasonably clear. Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 28

If you do not have a bulb syringe, the mouth and then nose should be wiped with a gauze pad Support and assist in delivery of infant’s shoulders–rest of baby will be born very quickly Once infant is delivered keep the infant at or around level of vagina until umbilical cord has been cut Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

When umbilical cord stops pulsating–tie it with gauze between mother and newborn Wipe blood or mucus from baby's mouth and nose with sterile gauze and suction baby’s mouth and nose again Dry and wrap baby Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Stimulate baby to breath by rubbing its back or flicking the soles of its feet Position baby on side, with head slightly lower than trunk, or place baby on mother’s abdomen Record time of delivery Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

If there is a chance of multiple births, prepare for a second delivery Observe for delivery of placenta–could take up to 30 minutes Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

When placenta is delivered Wrap placenta and approximately ¾ of attached umbilical cord in towel and place them in plastic bag for transport to hospital Place bulky pad over vaginal opening Lower mother’s legs Encourage mother to hold her legs together Never place anything directly in vagina If not already done, clamp and cut umbilical cord If not possible–keep baby at level lower than placenta Prevents backward flow of blood from infant to placenta Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 33

Post-Delivery Postdelivery vaginal bleeding
Vaginal and perineal bleeding is normal during and after birth process Mother’s perineum tissue can tear during crowning and delivery of head causing moderate bleeding Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Post-Delivery Post-delivery vaginal bleeding
Normal to lose mL of blood (from inside uterus) after delivery Watch for signs that bleeding is excessive Anxiety Changing in level of consciousness or lethargy Rapid pulse Rapid respirations Bleeding that does not slow down or stop Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Post-Delivery To help control excessive postdelivery bleeding and minimize risk of shock: Control bleeding by massaging lower abdomen over uterus Control bleeding by massaging lower abdomen over uterus Place palm of your hand on lower abdomen above pubic bone Gently massage/knead area Mother may experience slight cramping and gush of blood as massaging contracts the uterus Fig. 13-6: To control postdelivery bleeding, you may need to massage the uterus. Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 36

Post-Delivery To help control excessive postdelivery bleeding and minimize risk of shock: Treat for shock Provide mother with O2 Maintain mother’s normal body temperature by covering her with blankets Encourage breast feeding Stimulates contraction of uterus and may help control rate of bleeding Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Post-Delivery Postdelivery care of mother
After mother has delivered you should: Continue to monitor mother’s breathing and pulse Make mother comfortable and monitor her for bleeding by replacing blood-soaked sheets, blankets, and pads with clean, dry ones Maintain contact with mother while awaiting her transport to hospital Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Newborn Care Initial care of newborn
During delivery–clear baby’s airway Once baby delivered–stimulate baby to breathe Babies are bluish in appearance when first born and “pinken up” as their breathing becomes more regular Fig. 13-7: After the baby is born you should stimulate breathing if necessary by rubbing the infant’s back or flicking the soles of the feet. Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 39

Newborn Care Dry the baby Dry infant completely
Keep infant warm by wrapping infant in dry, warm blanket Cover head to reduce heat loss Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Newborn Care Clear airway
Once delivered, position infant on side with head slightly lower than body Wipe mouth and then nose with gauze pad Use bulb syringe to suction mouth and then nose Fig. 13-8: Compress the bulb before inserting it into the mouth or nose. This removes air from the syringe so that it can remove the secretions. Do not compress the bulb while it is in the infant’s mouth or nose or secretions will be expelled back into the mouth or nose. Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 41

Newborn Care Check for breathing
Provide stimulation for infant to breathe within first 30 seconds of life Once infant begins breathing: Check that infant is taking >40 breaths/minute and is awake and alert Crying is normal for newborns Check for breathing Provide stimulation for infant to breathe within first 30 seconds of life Rub infant’s back in vigorous yet gentle manner If rubbing back does not stimulate breathing – flick the soles of infant’s feet Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 42

Newborn Care Check for breathing
If newborn does not begin to breathe or continues to have breathing difficulty: Ensure an open airway Provide ventilation with mouth-to-mask or bag-mask technique at a rate of breaths/minute for approximately 30 seconds Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Newborn Care Check circulation
Monitor pulse of umbilical cord or pulse at brachial artery Pulse rate should be >100 beats/minute Baby should be “pinking up” in color If no pulse: Begin CPR Chest compressions should be performed at rate of 120/minute, and three compressions should be given for every one ventilation If there is a pulse, the action taken depends on the heart rate Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 44

Newborn Care Newborn should be assessed continually for first few minutes after delivery APGAR scoring system most commonly used Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Complications Miscarriage/spontaneous abortion
For unknown reasons, mother’s body rejects developing fetus and expels products of pregnancy Usually occurs before week 20 of pregnancy Be prepared to offer comfort and psychological support in addition to physical care Signs and symptoms Bleeding Abdominal cramps or pain Passing of pregnancy and fetal tissue Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 46

Complications Miscarriage/spontaneous abortion Treatment
Support mother’s airway, breathing, and circulation Save any passed blood or tissue for transport to hospital Provide O2 Arrange for transport Provide psychological support Support mother’s airway, breathing, and circulation Watch for bleeding and provide treatment for shock Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 47

Complications Multiple births
Watch each infant closely for breathing difficulties and rapid cooling Things to remember Mother is often not at full term when she goes into labor Labor may not last as long Babies often are smaller than full-term baby Each baby typically weighs less than or equal to 5½ pounds Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 48

Complications Prolapsed cord
Occurs when umbilical cord is presenting part in delivery Cord become pinched between baby’s head and mother’s birth canal blocking delivery of O2 to baby Do not attempt to push cord back into birth canal Fig. 13-9: Prolapsed cord. Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 49

Complications Prolapsed cord Position mother in a knee-chest position
Place wet dressings over exposed umbilical cord Provide psychological support to mother Provide mother with O2 Immediate transport necessary Fig : The knee-chest position. Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 50

Complications Breech birth Occurs when head is not the presenting part
If buttocks emerges first labor and delivery may proceed normally Be prepared to support the infant during delivery Fig : During a breech birth you may need to create and maintain an airway for the infant. Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 51

Complications Breech birth
If head does not appear shortly after rest of body create an airway for the baby Support baby’s body on your forearm Do not pull on baby to deliver head Using same hand that is supporting baby’s body, slide two gloved fingers into mother’s vagina and place them on each side of baby’s mouth Give mother O2 Using same hand that is supporting baby’s body, slide two gloved fingers into mother’s vagina and place them on each side of baby’s mouth Rest fingertips slightly to create an air space for baby as it tries to breathe Enrich delivery area with blow-by O2 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 52

Complications Breech birth If presenting part is an extremity
Delivery will probably not occur out of hospital Remain calm Comfort and reassure mother Position mother in knee-chest position Place mother on O2 Provide psychological support while waiting for her to be transported to hospital Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 53

Chapter 13 Childbirth Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 1.

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Chapter 13 Childbirth Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. 1.

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