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In some countries, people give birth at home instead of in a hospital. Obstetricians handle pregnancies and births, while gynecologists handle reproductive issues. When a pregnant woman can't get to the hospital or there's a medical emergency, a decision must be made on whether to deliver the baby on scene or transport to the hospital. Ovaries release eggs for pregnancy, and fertilization usually occurs in the fallopian tubes. The uterus pushes the baby out through the birth canal, which includes the vagina and cervix. The placenta attaches to the uterus and connects to the baby through the umbilical cord. The amniotic sac surrounds the baby and contains amniotic fluid. The umbilical cord carries oxygenated blood from the placenta to the baby. The placenta separates from the uterus after delivery, and the umbilical cord is the lifeline of the fetus. The amniotic sac ruptures when the water breaks. in a hospital, right? And that's what we do in developed countries, but in other countries people have babies all the time. My ex-partner I used to work with here in Gardner, I'm a gardener, he delivers both of his infants and his children in the bathtub. So, people do have homes for birth. It's actually more common now than it used to be. Obstetrics is a pregnant woman. An obstetrician is somebody who handles a pregnancy. So a gynecologist handles female reproductive issues, an obstetrician handles babies, the pregnancies and birth, and then a pediatrician handles the baby after they're born. Occasionally the pregnant woman is unable to get to the hospital or there might be a medical emergency, something outside of what they expect. This is when you need to decide whether to assist with the delivery on scene or transport to the hospital. Do we have time? That's the big question. You do not want to deliver a baby in a moving ambulance. I'll deliver a baby in a stopped ambulance all day, but not in a moving ambulance. So the ovaries are two glands, one on each side of the uterus, similar function to the nal testes, they release that egg or that ovum that we use for pregnancy. Ovulation occurs approximately two weeks prior to menstruation during the ovulation phase and the release of FSH, folliculostimulating hormone. The pulmonary tube extends out laterally from the uterus with one end associated with each ovary. Fertilization usually occurs when the egg is inside the pulmonary tube. 90% of fertilization happens in the pulmonary tube. The egg continues to travel down the pulmonary tube into the uterus, adheres to the uterine wall, and begins to develop. The uterus is a muscular organ that includes the protective agent as it grows. It produces contractions during labor. That's actually what pushes the baby out. The muscular uterus pushes the baby out in this direction and kind of pushes the baby this way and out. The birth canal is made up of the vagina and the uterus. And so there's the cervix right there, that muscular, almost like a sphincter-like muscle there. This is the baby. Notice how the baby's head down. This is a term called lightening. We'll talk about L-I-G-H-T-E-N-I-N-G, lightening, where the baby is most of the time upright or on its side. And during the last two to three weeks of pregnancy, the baby will shift and go into a head down position, which is what we have right here. So this would be almost like a ready to deliver. Yeah, unless he turns the other way. What's that? Unless he turns the other way. Yeah, it's a breach. Correct. You can see this is the fundus, or the head of the uterus, which kind of ends up up here during pregnancy. The placenta and, of course, the umbilical cord into the baby. And the baby is surrounded inside a sac called the amniotic sac, with the amniotic fluid. It can be anywhere from a half a liter to two liters of fluid. And as you can see, as the baby's born, it literally pushes out through here. This is kind of anatomically incorrect, but literally it's a big baby through a very small hole. And the baby pushes it out. But as you can see how the baby is born, as it comes out, the toilet puts pressure on the rectum, which is right here. And that's why women get the feeling that they kind of have a bowel movement, and they sit on the toilet and have a poop in a baby. That's why you don't allow a woman who is having abdominal pain to use the restroom. The vagina is the outermost cavity of the female reproductive system, and forms the lower part of the birth canal. Now, it completes the passage from the uterus to the outside world. The perineum is that tissue between the vaginal opening and the rectum. Breast milk, the breast-produced milk is carried through the ducts to the nipple, which provides nourishment to the newborn once it's born. Early sign of pregnancy in the breast includes increased size and tenderness. My wife knew she was pregnant for my son, and she said, my breasts hurt. They feel bigger. I'm pregnant. And sure enough, she was. She knew. Women know. During the last week or two of pregnancy, before a baby is born, what happens is the milk begins to travel from the mammary glands down to the nipple, the ducts, and that's called letting down. A placenta attaches to the uterus wall and connects to the fetus by the umbilical cord. Okay, so what we have is the placenta attaches. It can attach anywhere along here. It can attach anywhere inside the uterus. And it attaches to the inside wall, and then it travels through the, the umbilicus travels through the umbilical, the amniotic sac into the baby. There are two umbilical vein arteries and one umbilical vein. The umbilical arteries take blood from the baby's heart, and it goes to the placenta. Remember how I told you that all arteries carry oxygenated blood? The only arteries that don't is the pulmonary arteries. Remember that? Because the pulmonary arteries take blood from the heart and go to the lungs? I lied. Because the umbilical arteries also carry the oxygenated blood. Because they go from the body through those arteries to the placenta to get oxygenated, get rid of its waste product, get all the nutrients, and then it comes back through the umbilical vein. Two umbilical arteries go out, one umbilical vein coming back. Remember how I told you that the pulmonary veins are the only veins in the body that carry oxygenated blood? I lied again. Because the umbilical vein returns oxygenated blood to the baby. And we use, we can use that. The umbilical vein, we can use that. If a baby is born and needs IV fluid, we can actually, we can cannulate that. We can put a needle inside the umbilical vein and give the patient, or give the infant nourishment with that. Or fluid through that. Surrounded by a sac called the umbilical, the amniotic sac with about one-half to two liters of the amniotic fluid. Amniotic fluid should be colorless and odorless. If there's a color and an odor to it, there's a problem. Could be infection. If it's greenish-tinged, the first baby bowel movement is called meconium. The first couple of them. If you've never seen it, it's like a green tarry poop. Right? And what happens is that's usually digested amniotic fluid and it's the process of the digestion as the baby's developing. During a stressful birth, during fetal distress, a baby can have a bowel movement inside that amniotic fluid. Well, where's that amniotic fluid going? Into the lungs. In the mouth, in the nose, in the eyes, in the ears? Well, the problem is meconium aspiration. They actually get that into the lungs, and that can be very serious. So we always want to identify mis-colored or foul-smelling amniotic fluid. Is that usually just during birth? Because my niece was over seven months old, because she had them, she oscillated. Yeah, it could be stress to the mother. It doesn't have to be during birth. It can be any time. Yeah, it can be any time. It can be in the heart. Yeah, yeah. And then what they have to do is they have to literally go inside with bronchoscopy, clean it out, and then they have to treat you with high-dose antibiotics. It was funny that the mother had to go up and down the hospital. She had a depression. Oh, that's even worse. Yeah. After delivery, the placenta separates from the uterine wall and delivers. Usually within 15 minutes, but it can take as long as 30 minutes, the uterus is contracting and pushing the baby out. And then the baby comes out, and the amniotic fluid is still against the wall of the uterus. So the amniotic fluid keeps contracting. It pushes the placenta off the uterine wall and closes off those blood vessels so that mom doesn't bleed to death. That's why we never pull on the umbilical cord. We allow the umbilical cord to come out on its own. We don't put any stress on the umbilical cord because we don't want to rip it away from the uterus because it will bleed very significantly. The umbilical cord is the lifeline of the fetus. One umbilical vein carries oxygenated blood from the placenta to the fetus, and two umbilical arteries carry deoxygenated blood from the fetus to the placenta. Well, it's really more than that. It's the oxygenated blood and the waste products, and then it brings oxygen and nutrients too. And what happens is it's funny because the uterus, the placenta attaches to the uterine wall, but the mama and baby's blood never meet. It's the placental baby barrier. So mom's blood and baby's blood never meet. That's why it's possible to deliver a baby to a mom who has AIDS or hepatitis because the blood never meets. What happens in those situations is they use cesarean sections and they take the baby out inside the umbilical sac, clean off the sac, and then remove the baby from the sac so the baby never touches mom's blood. The fetus develops inside a fluid filled bag, a bag-like membrane called the amniotic sac. It can be anywhere from 500 to 2 liters, really. It helps insulate and protects the fetus. The fluid will gush from the ruptured sac. That's where the water breaks. Somebody will be standing there and all of a sudden, oh, there will be a puddle on the floor or in the car or in bed. My wife, my first wife, her amniotic sac ruptured in bed. Once in bed and ruptured one in the car, and then my youngest son, she ruptured... I can shout. How many times can you rupture? Should be just once. Yeah, it should be just once because once that bag ruptures, all the fluid drains out. You said she ruptured twice. Two kids. Different children. Oh, okay, I thought you were talking about... Different children. I will tell you that it used to be when you ruptured your amniotic sac, you used to go in the hospital and they would try and deliver that baby within 24 hours because they were afraid of infection. They've learned from that now and realized that it's not necessary. My wife's water broke, but because she was at 31 weeks or 30 weeks, he was a little too small for them to deliver, so they let him cook another 17 days and then she delivered at 31 and some weeks. And he was about this big. He was three pounds. You could literally hold him like this. So many mobile changes occur in the body that are not all related to reproductive system. You have changes in respiratory, cardiovascular, and musculoskeletal. Well, first of all, I will tell you because as that uterus goes up, it puts pressure on the diaphragm, so the patient can't take a deep breath. By the third trimester, a woman is breathing more rapidly and more shallowly. She could actually breathe 20 to 22 pounds a minute, but more shallowly because the diaphragm can't push that down. Cardiovascular system, a woman will produce 48% more red blood cells and 50% more blood volume. No, 48% more blood volume and 50% more red blood cells, which means because she's feeding the baby. Understand that the baby is a parasite until about age 18. The baby is a parasite, and it will suck the life of mom to survive until shock. In distress to mom, in signs of shock, mom's blood will shunt blood from the baby to her to survive and sacrifice the baby. So when you're treating a mom, especially a mom in shock, realize that you can't reach up inside and treat the baby, so you have to treat mom. You treat mom properly, and mom's body will treat the baby. Does that make sense? Also remember that a woman has 48% more blood volume and 50% more red blood cells. So a liter of blood loss to a woman who's pregnant might not even notice it. I lose a liter of blood, and my heart rate's going to be in the 120s, and my blood pressure is probably going to be in the low 100s to high 90s, and I'm going to be altered, cool, pale, flabby skin. That same liter of blood loss for a woman who's pregnant in the third trimester, she might, my heart rate might be up a little bit. That's about it. Because she has extra blood to lose, because it's not going to come from her. Where's it going to come from? The baby. So remember that. That's one of the reasons why motor vehicle accidents, even minor ones, I don't take refusals. I don't take no for an answer when it comes to a pregnant woman, especially in the third trimester. Man, we really need you to just go get checked out. I don't trust it because of that fact. Musculoskeletal, the joints become weaker, and of course, a woman has a strange sense of gravity. Gravity is more forward, so women tend to walk more this way. It's the first thing through the door, and so they have weaker joints, more weight to carry. The weight is more over forward, so women are more likely to fall, or have falls during pregnancy. Not only that, but what do we have in the wintertime? Ice, snow, all that great stuff, right? Hormone levels increase to support the fetal development and prepare the baby for childbirth. This is one of the reasons why women develop morning sickness, right? And sometimes they can get it, usually it's most common during the first trimester, but some people can have it the entire pregnancy. My stepsister, she's the one that had the twins, Jennifer and Jillian. Jennifer was a SIDS baby to die. Jillian now has four kids. But she actually was sick during the entire pregnancy, and she actually lost weight in her pregnancy. She got really thin, and we don't know if that had something to do with the SIDS, but she just couldn't eat anything. She couldn't keep anything down. The uterus is the place from its protected place in the pelvis. Remember the uterus is the most protected organ in the human species, but as the mom gets pregnant, it kind of pokes its way out. It's the first thing to walk through the door. It's the first thing that gets hit. This increases the chance of direct fetal injuries. A good number of traumas to pregnant women come from children. The five-year-old jumps on mom's belly when she's lying in bed or on the couch, or the kid's playing and kicks her while she's lying down. Kids just don't know. They don't realize it, and it can be very serious. Animals. A big dog jumps on your belly. Rapid uterine growth occurs during the second trimester. So in the first trimester, this is where the baby begins to develop. This is the neurological development. So important in the first trimester. The second trimester is when the uterus really expands, preparing for the baby's growth in the third trimester. It's not that the baby grows and the uterus grows at the same time. The uterus expands, and then the baby grows inside it. So respiratory capacity changes, and with increased respiratory rate and decreased minute volume, so mom tends to, because of this rapid uterine growth, she tends to breathe more rapidly, more shallowly. Usually the first thing that develops is the neurological development of the baby, the nervous system. And then the internal organs develop, and then in the third trimester is when the baby starts putting on weight and developing muscle. And then the last thing to develop, usually within the last six weeks of pregnancy, is the respiratory system. That's the last thing that develops. Blood volume gradually increases to allow for adequate perfusion and prepare for blood loss during birth. Again, about 48% more blood and about 50% more red blood cells, which means a woman becomes polycythemic. She has a lot of red blood cells, which leads to potential for clotting. Women can develop blood clots. As a matter of fact, postpartum blood clots is not an uncommon cause of death in postpartum women. There was a fire chief who, I remember a few years ago, his daughter died. She had a baby. She was two weeks after birth, and she developed sudden shortness of breath and chest pain. They rushed her in, and she died in the ER, a pulmonary embolism, from a blood clot. Patient's heart rate increases by up to 20%. Blood pressure drops conversely. Changing the GI tract causes increased risk for GERD. What happens is that stomach gets pushed out of the way. It gets pushed by the uterus, and so it gets compressed. Women usually can't eat a full meal, and they usually get GERD because it pushes the acids back up through the cardiac sphincter and back up into the esophagus, and they get GERD. Also, women are at a higher risk for nausea and vomiting and possible aspiration because, again, any pressure on the abdomen is going to push on the stomach, leading to vomiting. Weight gain during pregnancy is normal. Weight gain will challenge the heart, impact the musculoskeletal system. Again, the joints become looser and less stable, more weight, change in the center of gravity. Women are more likely to vomit. Most pregnant women become healthy, but some are ill and become pregnant anyway. They don't realize it. They don't know it. Did you ever see the television show, I Didn't Know I Was Pregnant? That happens. Women go into the hospital because they have abdominal pain, and all of a sudden, the doctor says, congratulations, you're in labor. What? I didn't even know I was pregnant! Especially heavy women. It happens. It happens. More often than you think. Use oxygen to treat any heart or lung disease in a pregnant patient. Don't worry about giving oxygen. Oxygen will not affect the baby. It will not hurt the baby. Go ahead and give oxygen as necessary. Diabetes develops during pregnancy in many pregnant women who have not had it previously. Gestational diabetes usually resolves after delivery. So what happens is, gestational diabetes is the same diabetes as everybody else. Chemical changes cause either a reduced or a complete cessation of the production of insulin. So some women have to actually go on insulin during the pregnancy. Usually right after the baby is born, it's gone. Sometimes. Sometimes, like my aunt, it converts to type 1 diabetes, and you have it for life. The thing with gestational diabetes, it makes very big babies. So if it's not properly treated, it's not uncommon to have a baby at nine months full term, that's 10, 11 pounds. It's just like delivering a watermelon. Do you have diabetes before type 1 in your whole life? Can you look at that? If you have type 1 diabetes, some women find that the diabetes gets better during pregnancy. It becomes more regulated. I don't know what it is. It's funny because during pregnancy, I think we talked about this, but like anti-psychotic medications. They're teratogenic. They will kill the baby. So you can't take them when you're pregnant. But a lot of women who get pregnant end up very reduced psychiatric issues during the pregnancy. Same with diabetes. Women have severe diabetes, they get pregnant. Sometimes it kind of fixes the problem temporarily. It's weird. Treatment is the same for any patient with diabetes. They just don't watch it. You'll have to check your blood sugar, watch what you eat. Gestational hypertension. The presence of high blood pressure in the absence of other systemic issues. We call this preeclampsia. Preeclampsia. Preeclampsia is hypertension of pregnancy. Now this says the total blood pressure of 140 over 90. Remember, a woman's blood pressure should go down by the third trimester, right? So her blood pressure, if it's normally 120, should be like 110 or maybe lower. Maybe 100. And now she's at 140. That is significant hypertension. And that's what we get, what we call preeclampsia. The problem with preeclampsia, we call it pregnancy-induced hypertension. It's usually proteins that cause it. It can happen any time after 20 weeks. Usually if you have severe preeclampsia, you're going to be bedridden for the rest of your pregnancy. Signs include severe hypertension, well over 140 millimeters of mercury. Severe or persistent headache. That increased intracranial pressure causes a headache. Visual abnormalities. They'll see dizziness, diplopia, double vision. They'll see spots in front of their eyes. Swelling of the hands and feet, nosebleeds, anxiety. This used to be called toxemia of pregnancy. And it's proteins within the blood that cause it. Now it's called preeclampsia. And the problem with preeclampsia, if it's not treated, it leads to eclampsia, which is seizures in pregnancy. Seizure activity in pregnancy. Eclampsia, the problem with eclampsia, it's seizures in fact. Hypertension-induced seizures. The problem with eclampsia is what? Is a seizure in and of itself bad for mom and baby? No. No. The electrical activity, right? No. What does it do, though? What is the problem with it? The lack of oxygen to breathe. Mom's not breathing, so baby's not getting oxygenation. So that's the problem. That's why we don't want pregnant women to be seizing. We can give patients, pregnant women, we can give them what we call MagSulfate. It's two to four grams. Two to four grams, we can give MagSulfate, and that usually helps to, and there's a way we remember it. I don't know if I should tell you about the dose. It's funny to me. We all learn the dose. One to two for me and you. Three to four for the friggin' four. That's how we learn the dose. I'm not saying it's right. I'm just saying that's the way we learn it. You never forget it after that. So a patient with pregnancy, lie them on their left side. Now it's a little bit of trivia, but that's the way an ambulance is designed. If you look at that ambulance, now imagine a patient laying on their left side. We call it left lateral recumbent, almost left fetal position. She's looking this way. I'm sitting at that bench looking at her, so I'm constantly in contact with her watching her airway. That's kind of the way the ambulance is set up. So we always put a woman in the left lateral position. There's another reason why we do it. Not just to keep the patient looking at me. We're going to cover it in a minute. Lay them on their left side. Maintain their airway. Supplemental oxygen, absolutely. Don't worry about it. Give it. If vomiting occurs, have suction available. They'll be laying on their left side so they won't aspirate from the vomit and for rapid transport call the ALS. Now I will tell you that baby delivery is a BLS call all day. We call ALS for a second hand, for a second set of hands is reason why. But you might get a BLS ambulance. Baby delivery is a BLS thing. So transporting on the left side, this is the other reason for transporting a patient on the left side. If I have a four to eight pound baby, maybe 10 pounds of fluid, 12 pounds of fluid, and then the additional mass of the placenta and the uterus, I could have 20, 25, 30 pounds of extra weight here. So when I lie flat, that uterus presses on the major blood vessels in my thoracic cavity. Now the aorta is under pressure. It's not going to collapse. But the vena cava is mushy and pliable. It will. So if I lie down, that vena cava gets compressed and that reduces blood flow to the heart. Reduced preload means reduced afterload. The less that goes in, the less that comes out. So patients, pregnant women in their third trimester lie down and they all of a sudden get dizzy, they get nauseous because they have the reduced blood flow. So to fix that, they sit up. You'll see a pregnant woman in her third trimester, they'll sleep in a recliner. Or they'll sleep with five pillows almost sitting up to reverse that issue. And that's one of the reasons why that ambulance is set up that way so that the patient can lay on their left side. I can look at them, they can look at me and it removes the belly off the uterus, reversing supine hypotensive disorder, or supine hypotensive syndrome. Remember we talked about CPR? And if you have a patient lying flat, you can displace the uterus to the patient's left side and pull the uterus over and it gets the uterus off of the vena cava. You can pull the uterus for you. Ectopic pregnancy, we talked about that. And that's what happens. It starts growing, it starts stretching, and then it pops. And when it pops, the fallopian tube, the fallopian tube is very muscular, very vascular, and it constantly pulsates and it will continue to bleed and bleed and bleed. You can exsanguinate from an ectopic pregnancy rupture. May or may not have spotting. So consider an ectopic pregnancy in the presence of severe abdominal pain and vaginal bleeding during the first trimester. Consider the possibility in a woman who has missed a menstrual cycle and complains of sudden severe pain in the lower abdomen. It'll be all of a sudden, oh, that hurts, what is that? And they're going to have almost like a tearing feeling in their lower abdomen. Hemorrhage with a vagina that occurs before labor may be very serious. There's usually bleeding afterwards, but there should be no bleeding before. So a spontaneous abortion, those are actually different terms. A spontaneous abortion is a pregnancy that's lost after 20 weeks, or before 20 weeks. After 20 weeks, they call it a miscarriage because technically it's viable. They can actually work a baby 23, 24 weeks, believe it or not. My stepson, for my second marriage, he was born in a pound. Tiny, tiny guy. And now he's like 6'2", so I mean, you'd never be able to tell. So that's the difference. So you can have a spontaneous abortion, which means the body aborted it, usually before 20 weeks is spontaneous abortion, after 20 weeks is a miscarriage. And of course you can have an elected abortion, but that's a different thing. Then we have two conditions that can also lead to vaginal bleeding, and we call it placenta abruptio and placenta previa. So in abruptio placenta, or placenta abruptio, the placenta abruptly, he tears away from the uterine wall. So remember, that's all about blood vessels, because remember the blood is traveling through that and it's getting oxygenated? So when that tears away, the blood will come down and come out of the vagina. And the patient will have a tearing abdominal pain with spotting or bleeding. So the patient will have tearing, all of a sudden, oh my God, tearing abdominal pain. Usually with a history of some form of trauma, whether they were hit, kicked, they fell, car accident, something happened that caused trauma to the abdomen that caused that placenta abruptio. And the problem with that is both, not only is mom hemorrhaging, but the baby's not receiving blood flow either. And that patient has to go and get an ultrasound, and they may end up doing a cesarean section, depending on how far along the mom is. The next one is placenta previa. Placenta previa is the cause of painless spotting. This is where you get spotting during pregnancy, but there is no pain involved. And what happens is the placenta develops over the vaginal opening. And so as the baby moves around and presses on it, it actually causes bleeding, and you get painless bleeding during pregnancy. My sister had this with my niece, and they said she was going to end up having a c-section. And they actually scheduled one, and then about a month and a half before her delivery, they said, we don't have to give you a c-section anymore. So placenta actually migrated its way back up, and she delivered a vaginal. We're just thankful. So abortion is the pattish of the fetus on placenta before 20 weeks, spontaneous or elective. Afterwards, it's a miscarriage.