7

If the placenta is aborted during childbirth, a procedure called dilation and deuteration is performed to remove excess tissue. Pregnant women are at risk of domestic abuse, which can lead to complications like spontaneous abortion and low birth weight. Substance abuse during pregnancy can cause birth defects and the baby may require resuscitation. Pregnant women are at risk of falling due to changes in balance. They also experience changes in blood volume and heart rate. Trauma can cause placenta abruption and cardiac arrest in pregnant women. CPR should be performed to save both the mother and baby. Cultural sensitivity is important when treating pregnant patients. Teenage pregnancy rates are high in the US and pregnant teenagers may not know they are pregnant or be in denial. Respect their privacy and assess their pain and age away from parents. What happens is, if the placenta is aborted either way, once the baby is removed, they have to do what they call a GNC, dilation and deuteration. They take these little sticks that are made of seaweed, made of pellets, and they insert them in the cervix, and it causes the cervix to dilate chemically. And they go in with a deuterate, which almost looks like a tiny ice cream scooper. This guy's sharp-edged. And they scrape the inside of the uterus to remove all the excess tissue. Because any fetal tissue that's left in there will rot, and it can lead to TTS, toxic shock syndrome, and the patient becomes septic and dies. So we want to get rid of that if we can, and that's what they usually do. So you might get a patient who has a spontaneous abortion, or an elective abortion, who's having bleeding, abdominal pain, and you could transport them to the hospital for that. Abuse. Pregnant women have an increased chance of being victims of domestic abuse and violence. The most common perpetrator against women is the baby daddy. Abuse increases the chance of spontaneous abortion, premature delivery, and low birth weight. This is one of those times where I've got a patient I suspect abused. I'll say to mom, okay, we're going to get you in the ambulance, I'll tell dad, sir, I want you to do me a favor and follow behind in your car, because when she gets discharged, you're going to have to take her home, so it's better to just bring your car now, and then we'll meet you at the hospital. Okay. Now you've got mom in the back of the ambulance, now you can say, hey, do you feel un... I see things that make me feel you're unsafe. Do you feel safe? In that case, you can have the police meet you at the loading dock. The woman is at risk for bleeding, infection, and uterine rupture. One of the most rapidly fatal pregnancy issues is uterine rupture. That's where the uterus actually tears, and when it does that, mom and baby die very rapidly. Pay attention to the environment for signs of abuse. Talk to the patient in a private area, away from the potential abuser and any other front ears. Substance abuse affects addiction on the fetus in uterine rupture, low birth weight, severe respiratory distress, and even death. Fetal alcohol syndrome, again, alcohol is one of the few things that can actually cause physical deformation. Unlike most of the other drugs, like cocaine and heroin and stuff, the baby will be born addicted to it, but they have low birth weight, but they generally don't have birth defects. Alcohol actually causes physical defects. You never want to deliver a baby to a substance abuser, somebody who's an IV drug user or somebody who uses... Don't deliver that in the field if you can. That's the last thing you want to do, because the baby's probably going to have to have significant resuscitative efforts when it's born. Narcan, ventilating, CPR, all kinds of stuff. So avoid that if you can. If you know you have a substance abuse patient and you know you're going to end up delivering it, call for ALS. Not just another drug, ALS. Pay special attention to your safety. Look for clues that you're dealing with an addicted patient. Newborn will probably need immediate resuscitation. And remember, that's a pretty messy scene, right? There's going to be a lot of blood there, a lot of fluids. Women have been known to have bowel movements. They urinate. There's about half a liter of blood in the aortic fluid. You've got all this fluid flying all over the place. Make sure you've got masks, goggles, gloves. Protect yourself. With the trauma-causing vomiting of pregnant women, you have two patients, the mother and the unborn fetus. I can't reach up inside to treat the baby, so I'm going to treat mom to the best of my ability, and her body will treat the baby. But always, never let a woman in her second or third trimester, hey, never take a refusal from them if you can do it. And we shouldn't even begin to avoid it. You're going to end up, you could very well end up with an issue if you take a refusal from them. Pregnant women also have an increased risk of falling. Loosened joints in the musculoskeletal system, increased weight of the uterus, and displacement of abdominal organs can affect balance, right? Everything's kind of forward, so they've got to walk it forward, right? Pregnant women have an increased amount of total blood volume, 48% more blood volume, 50% more red blood cells, and a 20% increase in heart rate. So if their heart rate's usually 70, then it's going to be close to 90. Or if it's 90, it's going to be close to 110. And their blood pressure's probably going to drop by 10 to 20 points. So if they're normally in 120s, they'll be in the 110s to 100s. They experience significant blood loss before you see signs of shock. Again, they could lose a liter of blood and it wouldn't even affect them. It's going to affect the baby. Fetus, if you see shock in mom, fetus is already in distress. Mom, the fetus will be in distress before mom even shows any signs. When a pregnant woman is involved in motor progression, mere hemorrhage may occur from the uterus. It is not uncommon for a woman to go into labor after a motor vehicle crash. A significant one. Airbag deployment, hits the steering wheel, T-bone, and causes the woman to go into labor. It's not an uncommon thing to happen. Trauma is one of the leading causes of placenta abruption, which causes that can be significant hemorrhage. Common symptoms include vaginal bleeding and severe abdominal pain, like a tearing abdominal pain, because the placenta literally tears away from the uterine wall. The possibility of a C-belt can result in injury to the pregnant woman and the fetus. Carefully assess the pregnant woman's abdomen and chest. The C-belt marks previous and obvious trauma. So that C-belt is not supposed to be worn here. It's supposed to be worn under. Cardiac arrest your focus is on, as with other patients, you're going to do CPR. You may have to put your hands up a little higher. You may have to displace the abdomen. But CPR is CPR. Your job is to do the best CPR you can to save both mom and baby. Mom doesn't, there have been many stories where mom didn't make it, but the baby did, because it was good CPR. So you save one out of two anyway. Not uncommon for women to die and the baby to be saved. They'll do a caesarean section, emergency caesarean section, right in the ED and deliver the baby. Notify the receiving facility that you're en route with a pregnant trauma in cardiac arrest. So you're just en route to. And if you have a patient in cardiac arrest, you're going to do mass, even if the woman is pregnant. If it's trauma, you're going to do mass. Even if the woman is pregnant. If it's trauma, it goes to UMass. If it's anything else, after 20 weeks, it goes to Memorial. Anything before 20 weeks can go to any hospital. Does that make sense? Traumas always go to UMass no matter what. We'll take these. Assessment and management, your focus is on the woman. Suspect shock based upon the mechanism of injury. Be prepared for vomiting aspiration. Now you can attempt to get the gestational age. So ask mom how many weeks long is she, when's her due date. And they can calculate that pretty well. They start by the menstrual cycle when the last period was. But then they also want to do the skull count. They can tell by the size literally of the feet. They measure the femur, the skull, the diameter of the skull, the femur, and something else. They can tell within a week the gestational age and when the due date is. It's very accurate. But the other way you can do it is called measuring the fundal height. You need a tape measure for this that has centimeters. But you put the tape measure from the umbilicus up to where the uterus meets the chest. Where it kind of meets, right? Where it kind of goes up. And you take that tape measure and you measure to that point. And the number of centimeters is the number of weeks of pregnancy. So if you have 35 centimeters from here to here, then it's 35 weeks of pregnancy. And it's very accurate too. We call it measuring the fundal height. So follow these guidelines when treating a pregnant trauma patient. Open the airway, hypo-oxygen, ensure adequate ventilation, assess circulation and transport. And the left side, the left lateral recumbent position to avoid that supine hypertensive disorder. Cultural value considerations. Cultural sensitivity is important. There are women where you cannot remove their clothes. You can't even talk to them. You Sharia Muslims and you're traditional Asians. You can't do anything to the woman unless the patriarch of the family says so. So what do you do for a pregnant woman who's in labor? And maybe she's out. What do you do? You have to respect their cultural sensitivity. It is what it is. And, you know, that also, you know, some women's cultures affect the choice of how they handle themselves during pregnancy and how they plan the childbirth process. That's not your place to judge. Your place is to do the best you can with what you have. Improvise, adapt, overcome. Some cultures may not permit the male, again, to accept the female to respect the differences on the face of the question. Teen pregnancy in the United States is one of the highest teen pregnancy rates in the developed world. Pregnant teenagers may not know they're pregnant or may be in denial. It's possible they don't even know. My sister had dysmenorrhea, which meant that she had irregular periods. She would be amenorrheic for six months. A means none. So she'd go six months, seven months without a period. She could be pregnant during that time and not know it because she would go seven months without a period. It wouldn't be unreal for her. So respect the teenage privacy and assessment of pain and her age to away from parents. Well, a woman, a girl, even if she's 12, if she's sexually active or she thinks she's pregnant and she confides that to you, you can't pass that information along to the parents. It's the reproductive right of the child. So that's a law. So, that's why I always like to have the parents in the room when I talk to the child. That way, I don't have to hide anything. Everything's there. Now, if the child says, I don't really feel comfortable talking to you with my parents in the room, mom and dad, you gotta leave. Or we'll take the patient in the ambulance. This is what it is. No, you can't disclose. That's HIPAA. That's a HIPAA violation. This is a crime. You can disclose it in the presence of a crime if it's the presence of an emergency. Yeah, that's true. Childbirth is seldom an unexpected event, but there are occasions when it becomes an emergency. You know, a woman is in labor and the car won't start or it's a snowstorm or a hurricane, stuck in an elevator, that kind of thing. Who was it expecting, had a plan, didn't work. So, be safe. You take standard precautions. Gloves, eye protection. You might want to have a gown. In an emergency situation, you might not have time to put on a gown. But if you have time to put one on, I highly recommend it. People don't use gowns like we have a gown. If you have time, consider calling additional resources. Absolutely. Call at least an additional ambulance, ALS, if you can. Determine if there's a mechanism of injury and nature of illness. Do not, oh my God, she's got abdominal pain. It must be laxative. She's got abdominal pain. It must be active labor. Because maybe it's not. Maybe there's something else going on. Falls and the necessity for spinal mobilization must be considered. Is it possible to have trauma and have pregnancy and active labor at the same time? Absolutely. So, don't be afraid. Collars are cheap, easy, well-tolerated, and do the job. Your general practitioner should tell you whether the patient's in active labor or whether it's time to assess and address other possible life threats. Perform your rapid examination. When trauma or other medical problems are present, treat these first, right? Because pregnancy, labor is going to happen. It's not like I have to do anything for it. If it's going to happen, it's going to happen. I might be able to slow it down a little bit, but I'll never stop it. You don't want to stop it. Life-threatening conditions with the woman's airway and breathing are usually not an issue during childbirth. Most women are, you know, they're awake and they're conscious and screaming. So, you're going to have your partner support them. Let him get the punch in the face and scream that. And I'm just going to set up shop and get ready to deliver. Motor vehicle crashes, assaults, and medical conditions can cause life-threatening issues. So, we need to address those. Assess airway and breathing to ensure adequacy. External and internal bleeding are potential life threats and should be assessed early. Treat bleeding, obviously. Blood loss after delivery is expected. Women can lose up to a half a liter of blood during childbirth. We don't expect a significant blood loss before the actual labor. And we don't expect a significant blood loss after the placenta. But between birth and the placenta, a 500 milliliters or a half a liter of blood is not uncommon. Assess and treat for life-threatening bleeding. If you have a shock or pressure, control bleeding, call ALS, get oxygen, make sure you're warm. Transport decision. If delivery is imminent, prepare to deliver and see. Ideal place to deliver is in the ambulance or a woman's home. If delivery is not imminent, prepare for patients for transport. There is a... During a full-term pregnancy, the last week of pregnancy, the last two weeks, week to two of pregnancy, the casing develops on the baby. It's called the vernix caseosa. It's like a cheese-like coating that develops on the baby. It aids in birth of the baby. It lubricates the baby for birth. And this cheese-like coating makes them extremely slippery. They're slippery suckers. And doctors, nurses, paramedics, EMTs have dropped babies because it slips out of their hands. It'll never be me. So I'm going to deliver that baby as close to the ground as possible. Or I'm going to scoot her up on the stretcher and I'm going to deliver right onto the stretcher. I know doctors, they put the stirrups, the legs in the stirrups, and they stand up and deliver the baby like this over a three-foot drop. That's because they're lazy and they don't want to get on the ground. They want to stand up and deliver. Not me. No thank you. I don't want to drop that sucker. I don't want to be the one that dropped the baby. Do you deliver the baby on the same side like a sheet or something? Like a clean one? Instead of them falling and trickling from their hands? Somebody's got to hold the sheet while you're delivering the baby. How do you hold the sheet out so the baby comes in? It's better just to do it over a floor. You can do it over a baby on a floor, on a stretcher, on a bed. Anywhere where the baby can come out onto a surface and not drop the baby. How do you keep people with that in the room? Sometimes. Sometimes you do, sometimes you don't. Unless you're a BLS provider. Sometimes you do, sometimes you don't. Provide rapid transport for the pregnant patient who has significant pain or bleeding. Obviously not that cramping pain. Something else. Hypertensive, that blood pressure greater than 140. A patient having a seizure or an inpatient with altered mental status. You might want to transport them hyperactive. Obtain a thorough obstetric history. Ask about her expected due date. When are you due? Any complications that she's aware of. Good time to ask, are you having multiple births? Are you having twins, triplets, quadruplets? You don't want those things coming out at you, right? If she has received any prenatal care and a complete medical history. Also ask if she's had a caesarean section and does the doctor recommend caesarean. If a woman has a caesarean scheduled, you probably don't want to do a caesarean. There are two ways they can cut you when you have a caesarean. My first wife and my third wife both have them cut in different ways. When my first son was born, I told you he was born like he was born. His head was too big for a pelvis and he was born like a conehead. It was kind of an emergent, he was in fetal distress. It was an emergent delivery. They cut her this way longitudinally, right? They cut her this way, opened her up and took the baby out. When they stitched her back up, she could never have another vaginal delivery because of the potential to rip a uterine rupture. My other son was born with a bikini cut. They cut you this way and they take the baby out. If you have a bikini cut, it is possible to have a vaginal delivery. It depends on what the doctor desires. They don't really like to do caesarean sections because they are expensive and you open up the body for risk of infection. What you want to do is deliver the baby vaginally. If a woman has a caesarean section, ask, are you slated to have a vaginal delivery or are you going to have a caesarean? Did the doctor tell you you can have a vaginal delivery? If the doctor says, no, no, no, you have to have a caesarean, I don't want to deliver it. That is a good piece of information to have. Get your sample history. Your history should include questions related to prenatal care. Have you been to a doctor regularly? Have you had an ultrasound recently? Do you have gravida parastatus? Determine the due date, frequency of contractions. The contraction is when the uterus contracts. When that happens, the uterus wraps around down and it pushes this way and it kind of pushes the baby out. They will start out at about 30 minutes apart and they will be very mild. Slowly over time, they will progress and get worse. They don't wax and wane, they just slowly get worse until the point where they are like two minutes apart. Mom can't talk when she is having a contraction. She feels like she is having a bowel movement and you can see the baby's head bulging at the perineal opening. That is time to drop her out. Baby is coming. That is I am delivering now. We will talk about that. Previous history of pregnancies and deliveries to include the history of C-sections. Possibility of multiple births. Has she taken any drugs or medications? Has she been drinking? If the water is broken, ask if the food was green. That is meconium staining. We want to know that because it is potential for meconium aspiration. Assess the major body systems as needed. How do we assess major body systems? What do we do? How do we assess their major body systems? What do we do? Vital signs. That is another way to say take vital signs. It is trying to sound cool. Emphasize the chief complaint, whatever it is, pain. Assess fetal movement. Yes, and mom, do you feel the baby moving? If you have a good stethoscope like a litman, you might be able to hear a heartbeat if you are close. If the patient is in labor, focus on contractions and possible delivery. If you expect delivery, expect for frowning. Frowning is when you see bulging in the vaginal opening. Up to low. Obtain vital signs, complete set, and pulse oximetry be alert for tachycardia and hyperhypotension. Those are bad things. Hypertension, even mild, may indicate the potential for seizure activity. So even mild. Repeat your primary assessment. Constantly talk to your patient. Obtain a set of vital signs. Check for innovations in treatment. Your patient will probably be talking, probably yelling, probably obscenities, all kinds of good stuff, and that's perfectly fine. That helps. If delivery is imminent, notify staff at the receiving facility. I would call the radio and I would let them know that we are in the process of childbirth. We will be delivering on scene. I'll be calling for an additional ambulance as well. Provide an update on the status of mother and newborn after delivery. If delivery does not occur after 30 minutes, provide rapid transport. I'm looking at it. I've got contractions less than three minutes apart. They last more than a minute. Mom can't talk during. She feels like she's having a bowel movement. Then I'm going to assume that delivery is imminent. We're going to set up for delivery, and then if 20 or 30 minutes has gone by and the baby hasn't delivered, we're going to start transport by priority. For a pregnant patient with complaints unrelated to childbirth, be sure to include the pregnancy pattern. Remember that you may end up at Memorial. You might end up for trauma at UMass or St. Peter's. If delivery occurs in the field, you'll have two PCRs. We'll be able to drill for two patients. So stages of labor. Usually I break here, so why don't you take a break, five minutes.