Upon completion of this module, you should be able to: Define terms associated with female

reproductive anatomy; define terms associated with the process of labor; discuss cultural

values affecting pregnancy; identify special considerations of adolescent pregnancy; summarize

the normal physiology of pregnancy; list and describe signs and stages of labor; list components

of assessment for an obstetrical patient; identify the contents of an obstetrics kit;

state indications of an imminent delivery; list steps for a normal delivery; discuss

initial care of the newborn; summarize neonatal resuscitation procedures; describe complications

of pregnancy, labor, delivery, and postpartum; discuss gynecological emergencies; and, describe

the age-related variations for pediatric and geriatric assessment and management of the

female patient. You should also be able to appreciate the

emotions that a sexual assault victim may be experiencing.

Lastly, as a portion of a subsequent classroom lab, you should be able to: Demonstrate the

steps to assist in the normal delivery of a baby; demonstrate the steps to assist in

complicated deliveries; demonstrate infant neonatal procedures; demonstrate post-delivery

care of an infant; demonstrate the post-delivery care of the mother; demonstrate the steps

in management of the mother with excessive bleeding; and, demonstrate completing a prehospital

care report for patients with obstetrical or gynecological emergencies.

A women�s external genitalia, referred to as the vulva, consists of four major structures:

the labia minora, labia majora, clitoris, and vaginal vestibule or orifice.

The labia minora consists of two thin inner folds of skin within the vestibule of the

vagina. The labia majora is comprised of the outer

folds of skin and adipose tissue surrounding the vaginal opening; this structure defines

the lateral boundaries, if you will, of the external female genitalia.

The clitoris is a small, elongated erectile organ located anteriorly on the vulva.

The vaginal vestibule or orifice is the opening to the vagina. The opening is protected by

the labia minor and majora. These structures are all contained within

an area known as the perineum. The perineum is a diamond-shaped area corresponding to

the outlet of the pelvis. Both men and women have a perineum. In women, the area encompasses

the vulva as well as the anus. It is bounded by the coccyx posterior, the pubic arch anterior,

and the inside of the thighs laterally. Also located within this are is the urethra,

a membranous tube that extends from the urinary bladder to the exterior of the body for the

voiding of urine. Moving to the internal female reproductive

organs, the uterus is a muscular, hollow organ located along the midline in most women�s

lower abdominal quadrants. The organ is designed for implantation of a fertilized egg where

it can develop into a fetus. During the final stages of pregnancy, the uterus is also responsible

for labor and muscular contractions for expulsion of the baby.

Ovaries are small, round organs located on either side of most women�s lower abdominal

quadrants. These organs are responsible for producing ova (eggs) for conception. The ovaries

also produce many of the hormones necessary for the process of reproduction.

The ovaries and uterus are connected via fallopian tubes. When an egg is released from an ovary,

it travels down the fallopian tube into the uterus. If fertilization of an egg occurs,

it commonly does so while in a fallopian tube. In a normal pregnancy, the fertilized egg

will continue its journey down the fallopian tube into the uterus for implantation and

continued development. Given a pregnancy, the woman is carrying a

fetus and other supportive structures. The fetus is simply the developing baby within

the uterus. At eight weeks of development, the fetal stage officially begins. From that

point, until delivery, the developing baby is referred to as a fetus.

The placenta is attached to the wall of the uterus and exchanges oxygen, nutrients, and

wastes between the mother and the fetus through the umbilical cord.

The umbilical cord contains blood vessels that carry blood containing oxygen and nutrients

to the baby, as well as vessels that transport blood with fetal waste products back to the

placenta and the mother. Some additional terms and definitions as they

relate to labor and delivery are as follows: Labor is the process of having (or delivering)

a baby. While various resources define labor as consisting of either three or four stages,

it is commonly held to begin with the first uterine muscle contraction and it ends once

the placenta is expelled from the woman. Bloody show is mucus and blood that may be

expelled from the vagina as labor begins. Presenting part is the body part of the baby

that exits the labor canal first. While this is commonly the head, given a typical delivery,

it can also be an arm, leg, or buttocks. Crowning is the appearance of the fetal scalp

at the vaginal orifice during delivery. Spontaneous abortion, also known as a miscarriage,

is the delivery of the product of conception early in pregnancy (before the 20th week).

While EMS providers must be culturally sensitive in all patient interactions, calls involving

obstetrics and gynecology are even more critical in this regard. Women in all cultures have

a value system that will affect their pregnancy. This can include how the woman cares for herself

during the pregnancy as well as how they have planned the childbirth process. In some cultures,

for instance, it is not permissible for the woman to have a male healthcare provider assisting

in the delivery. These cultural differences may also involve social, psychological, and

emotional factors. In some cultures, being pregnant is associated with achieving status

and recognition within their family unit. For some women, on the other hand, being pregnant

results in a lower self-esteem. As an EMS provider, respect these differences and honor

the patient�s requests, remembering that any competent adult has the legal right to

refuse any part of assessment or care. Adolescent pregnancy is rampant in the United

States with UNICEF reporting in 2001 a birth rate of 52.1 per 1,000, the highest in the

developed world and more than twice the European average. As of 2011, the CDC has reported

a teen birth rate of 31.3. While this rate has decreased over the course of 10 years,

the CDC also recognizes a tremendous disparity in teen birth rates between racial and ethnic

groups with rates anywhere from approximately 10 to 50 per 1,000 based upon the race or

ethnicity of the group. In many instances, socioeconomic factors seem to be involved

and one reason why teen pregnancy is deemed socially undesirable is illustrated by the

CDC statistic that one-half of pregnant teenagers do not finish high school. The trickle-down

effect of that is an inability for the mother to find employment and earn a livable wage

without that basic level of education. Regardless the factors surrounding a teenage pregnancy,

the EMS provider assessing a pregnant teenage female must be professional and non-judgmental

at all times. Depending on the age of the patient, providing care may be complicated

by the level of physical and psychological maturity and development of the patient. Additionally,

a pregnant minor is still a minor, meaning that her parents may still have the legal

authority to authorize or decline healthcare for her. (Remember from the legal module of

this course that Wisconsin does not commonly recognize emancipated minors as other states

do.) It can also be common, depending on how long the patient has been pregnant, for her

to not know about the pregnancy, to be in denial about the pregnancy, or to have not

told her parents about the pregnancy. When assessing female patients, especially those

with gastrointestinal or abdominal complaints, always consider the possibility of the patient

being pregnant. Also keep in mind the patient�s need for independence and privacy. If possible,

it may be better for the teenage patient if any assessment is performed or history is

obtained away from her parents. If you have not covered it yet, one of the

modules within this course will discuss the legal obligation of an EMT to report to law

enforcement any suspected child abuse or neglect. This becomes pertinent when discussing adolescent

pregnancies because it is considered sexual abuse of a child in Wisconsin for a person

to have sex with a minor under the age of 16 (meaning 15 years of age or younger). If

the minor is either 16 or 17 years of age, the crime is a misdemeanor that is not considered

sexual abuse of a child and is not subject to the mandatory reporting requirements of

state statute 48 (sections 48.02 and 48.981). If the sex was nonconsensual, it is considered

sexual abuse of a child, regardless of the victim�s age. Remember as well that it takes

time for a pregnancy to show. Just because a pregnant female is 16, 17, or 18 years of

age at the time of an EMS contact does not mean she was that age at conception. The law

also does not consider the age of the individual who had sex with the pregnant female, so just

because the father is also a minor does not necessarily mean a crime did not occur.

If providing care to a pregnant, minor female, it is recommended that the EMT contact law

enforcement to report the incident and law enforcement can then make a determination

as to whether or not the statutory requirements for sexual assault of a minor were met.

For the woman who becomes pregnant, she is about to experience numerous, significant

changes to her body. Her reproductive system begins producing increased

hormones to support fetal development. These hormones will commonly impact the woman�s

emotional status. The respiratory system must begin handling

greater oxygen demand while pressure on the diaphragm from the developing fetus results

in a decreased minute volume. As a result, the mother�s respiratory rate is commonly

faster than it would be if she were not pregnant. The cardiovascular system must meet the demand

for oxygen and other nutrients for the fetus, which results in an increase in both blood

volume as well as the heart rate. The fetus commonly places pressure on the mother�s

vena cava, which can impact the effectiveness of circulation to her lower extremities and

clotting factor changes occur to accommodate the fetus.

The musculoskeletal system must adapt to changes in the woman�s center of gravity given the

addition of a developing fetus, which can result in back pain, leg pain, and fatigue,

especially in the later stages of fetal development. The body also must prepare for the process

of delivery and the joints loosen, especially in the hips, which can cause instability for

the mother. The gastrointestinal system is also impacted

by the pregnancy. Digestion slows, which can lead to nausea and vomiting. The fetus also

places pressure on the bladder and intestines, which results in increased need to urinate

and possible incontinence. For the purposes of providing emergency medicine,

it is important to understand the timeline associated with conception and fetal development

as medical emergencies associated with pregnancy can vary in terms of type and severity over

the duration of a pregnancy. The process begins with ovulation in which

the ovaries discharge an egg. Fertilization occurs if a male sperm is introduced to the

female egg. Once the egg is fertilized, it must then implant itself into the lining of

the uterus. (If this implantation takes place someplace else, an ectopic pregnancy will

result. This type of medical emergency will be discussed a little later in this module.)

The next stage is called the embryonic stage, which is the period of time from fertilization

to about eight weeks afterward. The last stage is the fetal stage, which begins approximately

eight weeks after fertilization (after the embryonic stage) until delivery, approximately

40 weeks after fertilization. Before discussing the delivery of a baby,

the EMT must be able to recognize the signs of labor.

Lightening, also referred to as the baby dropping, is a sensation of pressure caused by the descent

of the uterus into the pelvic cavity. This occurs as the fetus changes position within

the uterus to prepare for delivery. In first-time mothers, this is commonly noticeable a few

weeks prior to delivery. For women who have delivered before, this sensation may not be

noticeable until just prior to delivery. Braxton Hicks contractions are sporadic uterine

contractions that occur during pregnancy. These can start as early as six weeks into

the pregnancy for some women. Typically, most women will not notice them, even if they are

occurring, until sometime in the mid- to late-second trimester. As the delivery date nears, Braxton

Hicks contractions may increase in frequency, becoming rhythmic and relatively close together.

They may also produce pain, which can lead some women to believe they are entering labor.

The difference between Braxton Hicks contractions and true labor contractions is that these

false labor contractions do not grow consistently longer, stronger, and closer together. If

the woman has not reached her 37th week yet and the contractions are becoming more frequent,

rhythmic, or painful, that may be a sign of preterm labor. If the woman is past 36 weeks,

contractions that last longer than a minute and occur within five minutes of each other

for at least an hour may be indicative of the start of labor.

Cervical dilation begins to occur as the woman nears labor. Because the cervix cannot be

visualized by the EMT, knowledge of dilation is commonly not an assessment finding unless

the pregnant female recently had a physician�s examination and was told at that time that

her cervix is dilating. (Dilation of zero to three centimeters is considered to be latent.

Active labor usually begins at four centimeters.) What may be noticeable as a result of cervical

dilation, however, is the appearance of a mucous discharge from the vagina. During pregnancy,

the opening of the cervix is blocked by a thick mucus plug to prevent bacteria from

entering the uterus. As the cervix dilates, this plug will loosen and may be passed as

one piece or as a mucus discharge from the vagina. Not all women will notice this discharge,

however. Bloody show can commonly accompany the passing

of the mucus plug. This is a light bleeding from the vagina that will make the mucus discharge

appear tinged pink, red, or brown. Rupture of membranes occurs when the amniotic

sac ruptures. Given the subsequent release of amniotic fluid, this rupture is commonly

known as �breaking the water.� Wisconsin Administrative Rule TRANS 309 governs

ambulance requirements within the state and one such requirement pertinent to the subject

of childbirth and delivery (at least at the time of creation for this presentation) is

that the ambulance carry a obstetrical kit containing sterile gloves, scissors or disposable

scalpels, two umbilical cord clamps, sterile dressings, towels, plastic bags, blanket or

other heat-reflective material large enough to cover a newborn, and a bulb syringe.

We will soon be discussing labor and delivery in the field by an EMT. It is important to