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Pneumogravita patients can have labor lasting up to 24 hours. Urinary contractions become more regular and closer together. Braxton Hicks contractions are false labor and do not increase in intensity or frequency. True labor contractions start in the back and wrap around. Signs of imminent childbirth include contractions less than 5 minutes apart, inability to talk during contractions, urge to push, and bulging at the perineum. The third stage of labor involves delivering the placenta, which can take up to 30 minutes. If delivery is imminent and unable to reach the hospital, prepare to deliver and use the OB kit. Position the patient with legs up and provide privacy. Use towels or sheets for cleanliness. Support the head, neck, and upper back. Pneumogravita patients could have a labor as long as 24 hours. Urinary contractions become more regular and last about 30 to 60 seconds each. So what happens is they become closer together, they start at 30 minutes, then 28, then 24, then 20, then 15, and they kind of get stronger and stronger until they're about 2 to 3 minutes apart. Increase in frequency and intensity. Labor is generally longer in the Pneumogravita than in the Multigravita patient. Women may experience preterm or false labor called Braxton Hicks contractions. That's just a doctor that identified that. You just put a name to it. So Braxton Hicks contractions. Contractions are not regular and do not increase in intensity or frequency. They come and go. True labor, once it starts, it ain't stopping. Pain and contractions start and stay in the lower abdomen. True contractions, they start at the back and they wrap around because the uterus is contracting this way, pushing down. Physical activity or change of position may alleviate pain and the contraction. Now, if I sit this way, I feel better. Not real contractions because it doesn't matter what position you sit. They're going to pain no matter what. Brownish show if anything is present. A bloody show if present is brownish. What happens is that mucus plug will actually, you'll pass that mucus plug. It looks almost like a bloody snot and many times it ends up in the underwear. Of course, it might come on in the toilet when somebody urinates or something like that. If you have that bloody snot, that's a sign of the mucus plug has been released. Whereas sometimes it's just a little bit of blood during the labor phase that gets released. Leakage of fluid usually occurs. This is urine and it smells like urine. Remember, amniotic fluid is colorless and odorless so it shouldn't smell like urine. Someone may experience premature rupture of the amniotic sac. They may or may not go into labor, supportive care and transport to the hospital. If a water breaks, the woman should go to the hospital and get evaluated. They'll probably put you in the hospital and put you on bedrock. The head of the fetus descends into the woman's pelvis as the physician's for delivery. This is called lightening. Sometimes babies should turn and head down. Sometimes babies don't and they can end up in what we call a breech mutation. The second stage begins when the fetus begins to encounter the birth canal and ends when the baby is born. Uterine contractions are usually closer together and last longer. The perineum will bulge. This is called crowning. The way you can tell active labor. If a woman's contractions are less than five minutes apart. They last 30 to 60 seconds. Mom can't breathe, can't talk while she's having the contractions because it hurts so much. She feels like she's going to have a bowel movement or needs to have a bowel movement. She feels the urge to push. And when you look in the vaginal opening during a contraction, you see a bulging at the perineum. Those are all signs of imminent childbirth. That means the baby should come in, drop trowels, set up shop, it's time to deliver. Those are the things we're looking for. The third stage begins with the birth of the baby and ends with delivering the placenta. The placenta must completely separate from the uterine wall to come out. And so it gets pushed out by the contractions. It can take up to 30 minutes. So if you have been waiting for 30 minutes in the house for the placenta, you're wrong. Take your baby, transport to the hospital to deliver it. The placenta will deliver by itself. You want to take the delivery. There's actually in the OB kit, there is a plastic bag, a specimen bag. You can put the placenta in the bag. The hospital wants it. The pathology will check it, make sure it's all there, make sure there's no issues with it. But you want to take it with you, but you don't necessarily wait for it to be delivered. Mom will just deliver. She'll have contractions and it'll just come out. So consider delivery as seen when. Delivery is imminent. It will occur within a few minutes with all those signs and symptoms I told you about. A natural disaster, inclement weather, or other environmental factors making it possible to reach the hospital. You're injured and your ambulance won't start. It's a hurricane. You're stuck in an elevator. Whatever the case may be. To determine if delivery is imminent, ask the patient, how long have you been pregnant? How long have you been pregnant? If she says more than 38 weeks, it'll be coming. When are you due date? If she says within two weeks, it'll be now. Is this your first baby? If she says no, I'm multi-para, I guarantee it's probably coming. Are you having contractions? Yes. How far apart? Less than five minutes? They last for a minute, 30 seconds to a minute. I can't talk when they're happening because it hurts so much. All right. I feel like I need to push. If you want to have a bowel movement, these are all signs. It's coming. Have you had any spotting or bleeding? Has your water broken? If she says yes, another reason. Do you feel as though you need to have a bowel movement or are you in need to push? So, were any of your previous deliveries by cesarean section? Because if they were, ask, are you supposed to have a baby delivered vaginally? Because if not, I don't want to do it here. Have you had any problems with this or any previous pregnancy? Any complications? Do you drink? Do you use drugs? Drink alcohol or take any medications? Especially things like blood thinners and beta blockers. Is there any chance of multiple deliveries? Let me know now. And does your physician expect any complications? If the patient says she's about to deliver and she has to have movement of the bowels or feels the need to push, you should prepare to deliver. Take your cues from mom. Especially if she's already had a baby and she tells you, I feel like I need to push. She knows. Visually inspect the vagina for crowning. Do not touch the vaginal area unless delivery is imminent. Once delivery is imminent, you're going to put on a set of surgical gloves. Now, surgical gloves are not like these. These are exam gloves. These keep my stuff off of you and your stuff off of me. These are not really sterilized. Exam gloves are individually wrapped. Surgical gloves. We open them up, we remove them, put our hands inside them, and we don't touch anything but mom or baby. Once I have these on, I'm locked in. I'm with mom, I'm with baby, it's my job. The surgical gloves. Once labor has been done, it cannot be slow to stop. Never have mom hold your legs together. And I shouldn't say that because there are times we will do that, but they're very specific. We're going to talk about that. As a general rule, don't say, geez, I really don't want to deliver this baby. It's going to make a mess in the ambulance. Hold your legs together. We'll get you to the hospital. Don't do that. Don't let mom go to the bathroom because she can deliver the baby in the toilet. Remember, if you're delivering a cesarean, you are only assisting mom with the baby. You're a coach. Get your coach. Push him out. Shove him out. Way out. That's all we do. Women have been delivering babies since time immemorial. Native American women would go in the woods, deliver a baby, and come out with the baby in a buffalo bladder of water. Women deliver babies all the time. We're there as a coach, and we're there in case there is a complication. That's really what we're there for. So this is the OB kit. The OB kit will have some things in it that you really need to pay attention to. You should get to know the OB kit at your duty station when you get hired. Maybe you can open up an expired one at Secret Santa. You're going to have things like draping to drape over mom for privacy and modesty. You're going to have a hat, a beanie cap for the baby. You're going to have a scalpel. I hope you don't have a scalpel, and I'll tell you why I don't use them in a minute. You are going to have a cord clamp. You're going to have some 4x4s and 5x9s. Maybe a diaper. Maybe a bulb syringe and a couple other things. And these are all the things you're going to use for the baby and mom when we deliver. It's called an OB care center in case you don't carry two of them in your ambulance. So position the patient. You want to preserve privacy. I'll be honest with you. Most women are like, just get this baby out of me. I don't care. But what you're going to do is you're going to remove from the underwear down, from the pants down. You don't have to take off the shirt. You can leave the shirt on, but remove the pants and the underwear. And then you're going to have the woman sit up, but she's going to put her legs up. And I would recommend doing it over a flat surface. Don't do it overhang. Do it on the floor, or on a bed, or on the stretcher. Pull her legs as much as she can comfortably to her chest. That's what your partner can do. He can help her do that as well and coach her from behind as he's talking to her. You want to put blankets or sheets underneath their buttocks. Stack up four or five layers. You want to bring her pelvis up a couple of inches. And so what happens is, as the baby's being born, blood's going to come out. Mom might have a bowel movement. She might urinate. You might have the gush of water if she breaks her amniotic sac. So you want a clean feel to deliver the baby. So anything that comes out, you can roll up that sheet, move it away, and you've got a clean feel to deliver the baby. So that's why you stack four or five piles of sheets underneath her so you have a clean feel when the baby's born. Support the head, neck, and upper back. This is what your buddy's job for is so she can punch and bite him. Have her knees flex and have her feet flat and her knees spread apart. Place towels or sheets around the floor. You want to make it as clean of an environment as possible. Throw a sheet over the top of her just for privacy. Open the OB kit, put on the sterile gloves, and that's it. Once I do that, I touch nothing but mom and baby. Now, of course, as I said again, you don't have to remove the shirt or anything, but you've got to remove from the pants down. This is basically, you're going to set it up. You're going to have mom pull her knees back. What I do is this. The further my knees come back, the more of a straight shot it is for the baby to come out. It makes it easier. And again, I'm going to have multiple layers of sheets underneath this so I can have a clean feel for delivery. Your partner should be at the patient's head to soothe, comfort, reassure, or take the punch. If your patient will allow it, apply oxygen. You don't necessarily need it, but sometimes it helps. Continually check for crowning. You're watching for that bulging. And watch out for precipitous labor. Many women, especially women who've had multiple births, they can go from push to delivery in like three minutes. And the baby comes out. And it can happen. A friend of mine, my wife's cousin, she had her first baby and the baby came out like it was a three-minute labor. Like literally, she started pushing and the baby just popped right out. We call that a precipitous labor. Be prepared for that. It can happen. Position yourself so that you can see the perineal opening at all times. I'm sitting right there. Eyes on the perineal opening. Ready. Texas, knit me in. Break. Time the patient's contractions. Remind the patient to take short... You know, you've got to do that with mom's breathing. Push. Push. What happens if she kicks? In between? I'm going to get kicked in the face. That's what's going to happen. Between contractions, encourage the patient to rest and breathe deeply through her mouth. Do not try and keep up with her breathing. You will pass out, I promise. So, we're going to talk about how the baby's going to deliver now. This is the easiest way for me to do it is just kind of explain it then use the slides. So, what happens is the baby's coming down, passing through the birth canal. The head most likely will be facing, the face will be facing toward the rectum. Facing down most of the time. Remember, the head is this way. Mom's vagina is shaped this way. So, it's not going to go through this way. It's going to go through this way. So, the baby's going to turn so the head goes through the narrow way most of the time. Sometimes babies are born face up most of the time they're face down. So, as mom's pushing, you're going to put your hand on the baby's head. Don't poke your fingers in the fontanels or put your hand on the baby's head. And what you're doing is you're preparing for a precipitous labor. You don't want the baby to come shooting right out at you. You want to have a little, don't push it in but just give it a little support. So, as the head's coming out, mom's pushing, pushing, you start seeing the back of the head or maybe the face and then the head's completely out and then the neck. And you say, mom, stop pushing for a second. Don't push for one second. And you're going to run your finger along the neck. You're looking for what they call a knuckle cord which is a cord wrapped around the baby's neck. Now, if you see a knuckle cord which happens once in every hundred births or something, you just gently try and unwrap it. Don't pull on it. Don't yank on the cord to get extra slack. Just try and unwrap it. If you can't unwrap it, you want to clamp it and cut it. You put two clamps and cut it in between and that's why I don't have the scalpel in the OB kit. I'm taking out my trauma shears, I'm cleaning with alcohol and I'm cutting that sucker with that. I'm not going near a baby's neck with a scalpel. I will tell you that an umbilical cord is not like cutting through a hot dog. It's actually pretty stiff. It's like cutting through a garden hose. It's actually pretty hard to cut through so it's not going to cut through. So just keep that in mind because it's not going to be easy to cut. But anyway, I clamp it, cut it and then unwrap it. But remember, once you clamp and cut that cord, baby's not getting any more oxygenation. You need to deliver that baby right away to get that baby breathing again. So at that point, you've checked for an awful cord, you've fixed it if there was one or maybe there wasn't one. You say, okay mom, keep pushing. And what happens is the baby's head is going to turn to the left or turn to the right. Most commonly, they turn to the right. Because what happens is the shoulders are going to come out. So my head goes this way. My shoulder's not going to come out this way. I've got to turn so I go this way. So I'm going to turn and the shoulders are going to start coming out. And what we do is we gently guide, we don't pull, we don't yank, we don't push. We gently guide the head down to deliver Once the top shoulder comes out, we gently guide the baby up to deliver the posterior shoulder and then the rest of the body just kind of goes and comes right out. Make sure you get a hand on it. Make sure you don't just let the baby flop. Make sure you get a good hand on it. And then what we do is after the baby's born, we take towels that we have wrapped around. We wrap up the baby. We do tactile stimulation. We dry him. We rub him. Hey baby, baby, what's your baby's name? Hey Bobby, we dry him off and wrap him up. Do not cut the umbilical cord until it stops pulsating. It's usually within a minute or two. They used to say, you'll see doctors, they'll just clamp it and cut it right away. They're saying now it's actually better for the baby to allow that to stop pulsating on its own because then the baby gets the full umbilical blood. Until it becomes white. Yeah, it'll stop pulsating, it'll become white but you'll be able to feel it. You'll see that it stops pulsating. Then you clamp it. What you do is take two inches from the baby, clamp it, go another inch from that, clamp it again and cut in between. Just make sure you've got a good clamp because you don't want that blood to leak out. Everybody get, anybody, can you picture that? Let me picture how it goes. It's not that difficult. We really love the actual picture of it. They've got a picture of it. Um, so, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um, um,