National Registry Paramedic Exam: Gynecological Emergencies, Obstetrics, and Newborn Resuscitation

Objectives
- Describe the anatomy and physiology of the female reproductive system and the changes a pregnant woman’s body undergoes during pregnancy. 
- Identify and describe the cardinal movements of labor, the events associated with the 3 stages of labor, and complications associated with abnormal deliveries.
- Differentiate, assess, and treat various gynecological emergencies.
- Identify the steps for newborn resuscitation in any newborn and components of the APGAR score.
- Differentiate, assess, and treat emergencies related to the newborn.

This guide will encompass all of women’s health, reproduction, and care and resuscitation of the newborn during and after birth. Female reproductive anatomy and physiology will be presented first, which will be followed by the gynecological conditions with which the paramedic should be familiar. The next section will cover conception, fetal development, and birth. It also will cover possible problems a woman may encounter during gestation, birth, and following birth. Finally, the guide discusses the newborn child and resuscitation of the child under normal circumstances as well as during an emergency.

1. Female Reproductive Anatomy
Female reproductive anatomy is both external and internal. The external anatomy is collectively known as the vulva. Working posteriorly from the mons pubis, which overlies the symphysis pubis of the pelvis, the first specific structure of the vulva is the clitoris, which is a mass of erectile tissue and nerve fibers that is covered with the prepuce and becomes engorged with blood during sexual arousal. Dividing laterally and posteriorly from the prepuce are the labia. The labia majora are the most lateral and are immediately visible. The labia minora are thinner and lie medial to the labia majora.

The area between the 2 labia minora is known as the vestibule. At the anterior fold of the labia minora and within the vestibule is where the urethral opening, which drains urine from the bladder, is found. At the posterior end of the vestibule is the vaginal opening. The vagina serves 3 purposes: 
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Within the vagina are 2 openings for the Bartholin glands. These glands secrete lubricant into the vagina during intercourse. Finally, posterior to the vaginal opening and anterior to the anus is the perineum. The perineum can tear during normal vaginal deliveries. A thin membrane called a hymen may cover or partially cover the vaginal opening.
The internal anatomy includes the vagina, the uterus, the fallopian tubes, and the ovaries. The vagina extends from the vestibule outside the body superiorly and ends at the inferior opening of the uterus called the cervix. The opening of the cervix is called the os. The uterus is a very muscular organ in which the fetus develops from conception to birth. The walls are almost entirely muscle, sometimes called the myometrium, and are internally lined with highly vascular tissue called endometrium, which sloughs off during menstruation. The uterus is responsible for contractions during birth.


Figure: External Female Anatomy and Internal Female Anatomy (Source: Cleveland Clinic)

Extending laterally from the superior portion of the uterus on the right and left are the fallopian tubes. The fallopian tubes connect the ovaries with the uterus and serve as a passageway for the egg, or ovum. The end of the fallopian tube nearest the ovary is open to the abdominal cavity; the ovaries and the fallopian tubes are not directly connected. Fertilization of the egg with sperm will likely occur in the fallopian tubes, which will then travel to and implant in the endometrium within the uterus. The ovaries lie within the lower abdominal quadrants, one on each side. In each ovary are thousands of follicles, each of which can mature to become an oocyte and be released as an ovum.

Ovulation and Menstruation
The ability to reproduce is under hormonal control. Prior to puberty, the hypothalamus restricts the production of gonadotropin-releasing hormone (GnRH). At the start of puberty, this restriction is lifted as the hypothalamus releases
pulses of GnRH, which then triggers the anterior pituitary gland to synthesize and release follicle- stimulating hormone (FSH) and luteinizing hormone (LH). These hormones trigger the production of other sex hormones that develop and maintain
the reproductive system.

Female Sexual Development
The ovaries, which are derived from the same embryonic structures as the testes, also are under the control of FSH and LH secreted by the anterior pituitary gland. The ovaries produce estrogens and progesterone.

Estrogens are secreted in response to FSH, and they result in the development and maintenance of the female reproductive system and female secondary sexual characteristics (breast growth, widening of the hips, and changes in fat distribution). In the embryo, estrogens stimulate development of the reproductive tract. In adults, estrogens lead to the thickening of the lining of the uterus (endometrium) each month in preparation for implantation of a zygote.

Progesterone is secreted by the corpus luteum—the remnant follicle that remains after ovulation—in response to LH. Interestingly, progesterone is involved in the development and maintenance of the endometrium but
not in the initial thickening of the endometrium, which is the role of estrogen. This means that both estrogen and progesterone are required for the generation, development, and maintenance of an endometrium capable of supporting a zygote. By the end of the first trimester of a pregnancy, progesterone is supplied by the placenta, and the corpus luteum atrophies and ceases to function.

Menstrual Cycle
During the reproductive years (from menarche to menopause), estrogen and progesterone levels rise and fall in a cyclic pattern. In response, the endometrial lining will grow and be shed. This is known as the menstrual cycle and can be divided into 4 events: the follicular phase, ovulation, the luteal phase, and menstruation.


Figure: (a) FSH facilitates the maturation of a single ovum. (b) The peak of LH around day 14 marks ovulation, the release of the oocyte from the follicle. (c) The endometrial lining of the uterus reaches its peak in the luteal phase and is shed at the beginning of the next cycle.

Follicular Phase
The follicular phase begins when the menstrual flow, which sheds the uterine lining of the previous cycle, begins. GnRH secretion from the hypothalamus increases in response to the decreased concentrations of estrogen and progesterone, which fall off toward the end of each cycle. The higher concentrations of GnRH cause increased secretions of both FSH and LH. These 2 hormones work in concert to develop several ovarian follicles. The follicles begin to produce estrogen, which has negative feedback effects and causes the GnRH, LH, and FSH concentrations to level off. Estrogen works to regrow the endometrial lining, stimulating vascularization and glandularization of the decidua.

Ovulation
Estrogen is interesting in that it can have both negative and positive feedback effects. Late in the follicular phase, the developing follicles secrete higher and higher concentrations of estrogen. Eventually, estrogen concentrations reach a threshold that paradoxically results in positive feedback, and GnRH, LH, and FSH levels spike. The surge in LH is important; it induces ovulation, the release of the ovum from the ovary into the abdominal (peritoneal) cavity.

Luteal Phase
After ovulation, LH causes the ruptured follicle to form the corpus luteum, which secretes progesterone. Remember that estrogen helps regenerate the uterine lining, but progesterone maintains it for implantation. Progesterone levels begin to rise, but estrogen levels remain high. The high levels of progesterone again cause negative feedback on GnRH, FSH, and LH, preventing the ovulation of multiple eggs.

Menstruation
Assuming that implantation does not occur, the corpus luteum loses its stimulation from LH, progesterone levels decline, and the uterine lining is sloughed off. The loss of high levels of estrogen and progesterone removes the block on GnRH so that the next cycle can begin.

Pregnancy
On the other hand, if fertilization has occurred, the resulting zygote will develop into a blastocyst that will implant in the uterine lining and secrete human chorionic gonadotropin (hCG). This hormone is an analog of LH, meaning that it looks very similar chemically and can stimulate LH receptors. HCG maintains the corpus luteum and is critical during first trimester development because estrogen and progesterone secreted by the corpus luteum keep the uterine lining in place. By the 2nd trimester, hCG levels decline because the placenta has grown to a sufficient size to secrete progesterone and estrogen by itself. The high levels of estrogen and progesterone continue to serve as negative feedback mechanisms, preventing further GnRH secretion.

Menopause
As a woman ages, her ovaries become less sensitive to FSH and LH, resulting in ovarian atrophy. As estrogen and progesterone levels drop, the endometrium also atrophies, and menstruation stops. Also, because the negative feedback on FSH and LH is removed, the blood levels of these 2 hormones rise. This is called menopause. Profound physical and physiological changes usually accompany this process, including flushing, hot flashes, bloating, headaches, and irritability. Menopause usually occurs between the ages of 45 and 55 years.

General Gynecological Assessment
Assessment of the patient with a gynecological problem can be a sensitive issue. On the part of the paramedic, it requires asking some personal questions that may result in emotional answers. Maintaining the most professional and sensitive manner possible is essential to being able to complete a thorough and appropriate assessment. In such cases, the paramedic is a stranger asking about the patient’s sexual history. It is easy to ask these questions with an unintentional air of judgment, so be sure to preface them with why the information is needed. The answers to these questions can be used to rule out problems that could impact immediate treatment, such as the administration of certain medications. It could be to ensure that the patient is taken to an appropriate facility. It also could simply be medically necessary. Whatever the reason, good communication about it can make for a better experience for the paramedic and the patient.
Any patient deserves dignity and respect, especially the gynecological patient. The teenage patient likely will not want to answer such sensitive questions in the presence of her parents, for fear of getting into trouble, for example. Questions such as those that follow should be asked in privacy after ensuring the patient understands why they are being asked. Rarely are such patients such a dire emergency that the sensitive history and physical cannot wait until the patient is in the relative privacy of the ambulance.
If the patient is a minor, the paramedic may ask the questions away from a parent; however, he or she must share the information with the parent as part of informed consent for any treatment the paramedic determines is needed unless the patient is pregnant and this has been confirmed. Once the patient is pregnant, or has been pregnant, the patient is considered legally emancipated and is capable of making her own decisions regarding healthcare without the usually requisite approval from a parent or guardian. In addition, the parent or guardian may not be informed about the treatment or condition without written consent from the emancipated minor; he or she is permitted all the same privacy concerns as any other competent adult.
As with any patient, a thorough SAMPLE and OPQRST as appropriate should be completed. However, this may leave some important questions unanswered, particularly for the gynecological and potentially pregnant patient. Following that, as part of the history of present illness interrogation, more direct questions need to be asked and answered. What follows are some specific questions or question types that should be asked of any known or suspected gynecological patient, along with a brief explanation about why they should be asked.

Menstruation Questions

- When was your last menstrual period? Are your periods regular? Together, these questions can help guide the paramedic whether the patient is or could be pregnant. A menstrual period that was previously occurring at regular, predictable intervals that is now >2 weeks late could mean that the patient is pregnant.
- Was your last period’s flow typical of your regular periods? A patient who notes that her most recent period was considerably lighter than usual—either producing less blood or bleeding for fewer days—could have had what is known as breakthrough bleeding. Breakthrough bleeding occurs when the fertilized ovum, now called a zygote, implants in the endometrium. This generates some bleeding usually at about the time the patient would be expecting her period. In each case, if the periods were regular and are now late or the most recent period had lighter than usual flow, more investigation is needed into possible pregnancy.
- Have you had any pain with menstruation? This could indicate a host or issues discussed later in this guide.

Sexual History Questions

- Could you be pregnant? Many patients will answer no to this question, appropriately. However, many people do not realize the most probable time for a woman to become pregnant is to have unprotected intercourse approximately 14 days after the start of the previous menses, with most literature indicating the highest time being 12 to 17 days after the start of menses. Many will also answer no because they are on some variety of birth control and believe that such products or devices will eliminate all possibility of pregnancy. If the woman is of childbearing age, the next question should be an automatic follow-up:-
- Have you had unprotected intercourse with multiple partners? This could indicate the possibility of the patient having an sexually transmitted disease (STD), especially if the patient has an associated complaint of vaginal discharge.

Vaginal Discharge

- What is the texture? Is there an odor associated with it? Women are much more susceptible to getting a sexually transmitted infection than are men, and because of the dark, wet internal environment, the female is more likely to have a significant infection that can have a symptom that includes a vaginal discharge.
- Was it bloody? This could indicate problems other than infection, including cancer and trauma.

During the physical examination, rarely is direct observation or evaluation of the vulva necessary for a paramedic’s assessment to be considered thorough. In most cases palpation of the lower quadrants of the abdomen can provide enough information about the internal anatomy of the gynecological patient, especially when combined with a good history of the present illness. In addition, do not omit the rest of a physical examination just because the complaint is gynecologic in nature; there could still be systemic effects, as will soon be seen.

2. Gynecological Conditions and Emergencies
This guide will list various conditions and discuss first their pathophysiology. Next, any specific assessment points needed for that particular issue will be discussed. Finally, each subsection will conclude with recommended treatments that are beyond basics. For gynecological emergencies and transports to the hospital, the basic treatment includes the following:

- Maintain the patient’s dignity and provide emotional support if needed.
- Transport the patient in the position of comfort, which can include transporting the patient in the captain’s chair or on the bench seat if she is stable. Never transport a patient in the cab of the ambulance.
- If the patient is unstable or may be unstable, provide low-flow oxygen via a nasal cannula to maintain a pulse oximetry rating >95%.
- The patient should be able to be transported to the hospital of choice in most circumstances.

Vaginal Bleeding
Vaginal bleeding can occur for a variety of reasons, many of which the paramedic will not be able to thoroughly evaluate or assess. In patients of childbearing age, vaginal bleeding could be related to their menses.

Alterations of menstruation include hypermenorrhea, polymenorrhea, dysmenorrhea, and metrorrhagia. Hypermenorrhea, also known as menorrhagia, is abnormally heavy bleeding during a period that lasts longer than usual or contains a larger amount of blood than usual. Polymenorrhea refers to a condition where a woman has a period more frequently than once every 24 days and is usually brought on by physical or mental stress. Dysmenorrhea is painful menses that can be so bad as to interfere with daily life. In dysmenorrhea, the patient experiences lower abdominal pain and cramping similar to that of childbirth. Primary dysmenorrhea occurs early in life shortly after menarche, which is a girl’s first menses. Secondary dysmenorrhea occurs later in life after previously normal relatively painless menses. It often indicates a genuine gynecological problem. Metrorrhagia is spotting that occurs in between periods and often is related to hormonal problems or can be a harmless part of ovulation.
Vaginal bleeding that is spontaneous, unrelated to the menstrual cycle, or does not stop is always an abnormal finding. It could indicate cervical or uterine cancer, a new pregnancy, or a serious infection. Vaginal bleeding that presents during a known pregnancy is very ominous and likely indicates a spontaneous abortion if the gestational age is <20 weeks. After 20 weeks, it could still indicate spontaneous abortion, but it also may indicate placenta previa, or abruption placenta (see below).

Assessment of the patient who complains of vaginal bleeding is highly dependent on history taking. 
- With empathy, determine whether the patient knows if she is pregnant. Reassure her that just because there is vaginal bleeding does not mean that the pregnancy is terminating, though it could negatively impact it. 
- If the patient is not pregnant but of childbearing age, determine if this is in relation to her menses. 

You can evaluate blood loss without requiring the patient to undress by asking about how many pads she has used in the past hour or past 24 hours.
The basic treatment discussed earlier applies here. If the patient is not currently wearing a pad, offer her a 5x9 dressing or allow her to place a pad before transporting the patient. Encourage the patient not to place a tampon or anything else into the vagina. Evaluate the vital signs, as for any patient, and treat hypotension with volume expansion of 500–1,000 mL.

Endometritis Endometritis is an inflammation of the inner uterine lining, the endometrium. It is most commonly caused by an STD, specifically chlamydia and gonorrhea. Symptoms include lower abdominal pain and pelvic pain. Pain can increase on palpation of the lower abdomen. If the swelling is bad enough, it can lead to constipation and abdominal distension. The patient also will have malaise, fever, and lethargy. Basic gynecological care applies.

Endometriosis Endometriosis is a condition where the endometrial lining, normally confined to the uterus, grows outside the uterus on the ovaries and abdominal organs. In rare cases, it can even be found in the lungs and other parts of the body as well. It responds to hormones in much the same way that regular endometrium does, so during menstruation, it sloughs off and bleeds in much the same way. Without a clear path out of the body, it causes pain because of the irritation it causes to the peritoneum, called peritonitis.
Although it is painless in some women, it can be excruciatingly painful in others. In patients who complain of symptoms, the most common complaint is generalized lower abdominal pain that sometimes spreads around to the back and into the pelvis. Other patients may complain of painful intercourse and bowel movements. Some patients may have increased pain on palpation of the lower quadrants and also have rebound tenderness. Treatment includes basic gynecological care. Pain can be so intense that it may need to be managed with intravenous analgesics if medical control approves.

Ectopic Pregnancy
A pregnancy that occurs anywhere other than within the uterus is called an ectopic pregnancy. The most common location for an ectopic pregnancy is within 1 of the fallopian tubes, with >95% of them occurring within the tube. The other locations include the abdominal cavity and sometimes even on the surface of the ovary. Patients who have had pelvic inflammatory disease (PID), tubal ligation reversal, or previous ectopic pregnancies are at greatest risk. This population of patients is at risk because of scar tissue that may be present in the tubes, blocking the passage of the fertilized oocyte to the normal implantation location in the uterus. The patient may know she is pregnant because all of the usual changes associated with pregnancy occur, including increased progesterone, a positive pregnancy test, and sore and swollen breasts.
Patients will complain of unilateral lower abdominal pain that gradually worsens over a couple days. The pain may come from the stretching and eventual rupture of the fallopian tube or the spontaneous abortion of the fetus. The patient also may have vaginal bleeding. Blood may accumulate in the abdominal cavity, causing rebound tenderness and diffuse abdominal pain. If the bleeding is excessive in the abdomen, the patient also may have the Cullen sign or the Grey Turner sign.
Patients will very likely need emotional support as well as medical treatment. After performing a complete assessment and ensuring the ABCs are secure, initiate cardiac monitoring and an intravenous line. Administer fluid as needed if hypotension is present. Consult medical control for pain management. Keep the patient warm and treat for shock.

Pelvic Inflammatory Disease
Pelvic inflammatory disease (PID) is an infection of the internal reproductive organs, specifically the uterus, fallopian tubes, and ovaries that occurs almost exclusively as a result of a sexually transmitted infection (STI) in women who are sexually active. The most common organisms causing PID are chlamydia, gonorrhea, candidiasis, and bacterial vaginitis; they infect the lining of the organs and can cause long-lasting reproductive problems such as infertility or scarring in the fallopian tubes, thus increasing the likelihood of an ectopic pregnancy. PID itself is rarely life threatening unless sepsis occurs and the patient goes into shock. Risk factors include frequent sexual activity with multiple sexual partners.
Patients most often will complain of diffuse bilateral lower quadrant achy pain. The patient often will note that the pain gets worse with walking and possibly with intercourse. Patients may state that they have vaginal discharge, fever, chills, and pain or burning on urination. An infection that has spread outside the reproductive tract and into the abdominal cavity may be characterized by rebound tenderness. Treatment includes the basic gynecological care mentioned earlier and symptomatic treatment for pain and hypotension. Septic shock is possible, so be prepared to treat for shock.

Vaginitis Vaginitis, an inflammation of the vagina, can be caused by 2 organisms. Candida albicans is a fungus that often causes vaginal yeast infections which can lead to vaginitis as the pH increases (becomes more basic). The chances of getting vaginitis increase if the patient is taking oral contraceptives, or if she is menstruating, pregnant, or has unprotected intercourse. If the patient is infected with Candida, she will complain of a burning and itchy feeling in her vagina as well as pain and soreness during intercourse. She also may note a vaginal discharge that resembles cottage cheese.
Bacterial vaginitis most often is caused by bacteria in the genus Gardnerella, which normally inhabits the vagina. Patients may get this after a recent course of antibiotics because the antibiotic can kill off the good bacteria of the vagina, allowing the Gardnerella to grow uninhibited. This can happen regardless of age and can happen in children for the same reasons; it is not exclusively tied to intercourse or sexual activity. Patients with Gardnerella will complain of a fishy smelling vaginal discharge and an itching, burning sensation.
Treatment for both forms of vaginitis is beyond the scope of the paramedic. Routine transport to a physician would be recommended. There is seldom any emergency associated with these infections.

Sexually Transmitted Diseases
The following are some of the common STIs that a person may be infected with. The paramedic will, in most cases, not diagnose or treat any of these specifically, although a general understanding could prove helpful. Infections that cause PID are most concerning to the paramedic and include chlamydia, gonorrhea, and bacterial vaginitis.

- As 1 of the most common STIs, chlamydia can be treated with antibiotics. Chlamydia also can cause infections of the eye and urethra.
- Herpes, a  viral infection, can affect different parts of the body. Genital herpes is characterized by sores and blisters in the area of the body that is infected—genitals, mouth, buttocks, or anus. Sores can come and go with outbreaks. Transmission is possible though much less likely in the absence of the sores when the virus is dormant (not active).
- Gonorrhea: These bacteria love to grow in warm, dark, moist places and, as a result, can cause an infection in the anus, vagina, and penis as well as the mouth, throat, and eyes. Women are generally asymptomatic until the infection spreads to other organs, particularly when it causes symptoms consistent with PID in addition to painful intercourse and urination. Painful vaginal burning and itching is accompanied by a yellow-green discharge that can sometimes be bloody.
- Genital warts, caused by the human papilloma virus (HPV), is by far the most common STD. A vaccine is now available for 4 of the known strains of virus; 2 of the 4 strains are responsible for >70% of genital cancers in both men and women. HPV can be passed from the mother to the infant during birth.
- Syphilis is an infection with the bacterium Treponema pallidum, and  while it can be spread in nonsexual ways it most often is spread during sexual activity. Syphilis can occur in stages. 
Syphilis can be treated with a single injection of penicillin G at any time during the first 2 stages.

Toxic Shock Syndrome
Toxic shock syndrome is a form of septic shock that can affect both men and women; however; it is most common in women who use tampons during menses. The sepsis is associated with infection with either Streptococcus pyogenes or Staphylococcus aureus. Women were believed to get this more often because tampons would leave behind fibrous pieces in the vagina and invite infection. This problem has become much less common since tampon manufacturers improved their products to not leave fibers behind.
Patients will complain of a wide array of complaints, including syncope, fever, sore throat, vomiting, diarrhea, and headache. The patient’s condition could quickly deteriorate to shock if antibacterial treatment is not initiated quickly. Kidney and liver failure and DIC are all possible courses for the untreated patient. The patient with toxic shock syndrome must be managed aggressively and treated for shock, including fluid resuscitation and treating any cardiac dysrhythmias that are present.

Ruptured Ovarian Cyst and Ovarian Torsion
Ovarian cysts are formed on a regular basis and house the developing oocyte before it is released during ovulation. Occasionally, these cysts do not rupture and release the ovum; these cysts disappear spontaneously and rarely cause an issue. Occasionally, however, after normal ovulation, the now empty cyst fills with blood and begins to stretch. This stretch will cause a dull achy pain on one side of the lower abdomen. As the cyst stretches, pressure builds up, leading to rupture. When an ovarian cyst ruptures, sudden, intense pain quickly follows. This pain starts in a lower abdominal quadrant and can radiate throughout the abdomen and to the back. It also may be accompanied by rebound tenderness from blood in the peritoneum as well as nausea and vomiting.
Ovarian torsion occurs when an ovary twists on the ligament to which it is attached. This can cause pain and symptoms similar to that of a ruptured ovarian cyst and is usually caused by an ovarian cyst that has not ruptured.
Treatment for each condition is primarily aimed at pain relief and making the patient comfortable. This often is described as the worst pain a woman has felt, so fentanyl or morphine are appropriate treatments. Initiate an intravenous line on the patient for medication administration, but fluids are not likely to be needed. Because nausea and vomiting are common symptoms with both conditions, 4 mg ondansetron can be administered. The patient should be transported in a position of comfort if one can be found.

Prolapsed Uterus
A prolapsed uterus is not a particularly common condition, but it occurs when the uterus drops from its normal position and sometimes becomes visible outside the body. Women who have had multiple vaginal births are at risk for this condition. Elderly women are at risk for this condition regardless of birthing history because the ligaments that hold the uterus suspended in the abdomen weaken over time.
The patient may complain of feeling as if something is bulging in her vagina or may complain of lower abdominal pressure, particularly upon standing. A visual genital examination (a rare occurrence for a paramedic) should be performed; evaluate the vaginal opening for anything protruding from it. If there is tissue present, do not attempt to replace it or push it back into the vagina. Instead, lightly cover the tissue with moist sterile dressings and transport the patient to the hospital. If the patient is in severe pain, contact medical control for orders on administering analgesia.

Sexual Assault
Sexual assault can occur to any person, not just a woman, of any age at any time. The most common type of assault is rape. Children and the elderly represent some of the most common targets. Sexual assault can involve more than just penetration of the patient’s body and often involves injuries to the rest of the body beyond just the genitalia.

Assessment
Sexual assault is a crime; consequently, the patient is essentially a crime scene. Questioning of the patient should be done only as the patient allows. Very often, the patient will not want to recount what just happened. Focus the assessment on what hurts and what the patient needs treated. As in any gynecologic emergency, professionalism, support, and empathy are of the utmost importance. Early in the patient contact, ask the patient if he or she would feel more comfortable with a male or female provider in the back of the ambulance with the patient; the patient may not feel comfortable with a person of the same sex as the assailant. Make every effort to make this happen. In addition, it is recommended that there be >1 person in the back of the ambulance with the patient who is not associated with the patient. This precaution is to prevent the patient from implicating EMS or police in the assault as a result of his or her fragile emotional state.
For multiple reasons, the physical assessment of the genitals is not recommended. First, any examination may remove valuable evidence from the perpetrator. Second, this is generally a sensitive spot for any assessment to take place, and the assault only compounds that fact. Third, there often is nothing different that the paramedic will do after assessing this area. Only in cases of impaled objects and life-threatening bleeding should this area be evaluated on any patient, male or female. The remainder of the assessment should be completed as time allows and should be thorough so that other medical or traumatic findings are not missed.
Treatment for the patient who has been assaulted centers on providing comfort and addressing pain and anxiety. Deciding to treat pain and anxiety should be left to the discretion of the medical control physician because these medications can possibly alter the patient’s ability to recall events accurately in the near term when the investigation is in the most critical stage.

Crime Scene Preservation
In a sexual assault, as with any assault, stabbing, or gunshot wounds, victims of a crime and the scenes in which they are found need to be preserved and documented. This way, law enforcement can still do their important investigation while EMS provides care to the victims. With this in mind, EMS providers should always follow the direction of law enforcement, even if it makes on scene care more difficult. The goal on any crime scene is to carefully gather the patient and get off the scene as swiftly as possible. This goal will help prevent the providers from leaving something behind or inadvertently having evidence cling to them as they move about the scene.
The patient’s body is essentially a crime scene and should be treated that way. Employ the following measures to help preserve evidence for collection at the hospital.

- Prevent the patient from washing his or her hands or any part of the body because this can eliminate evidence.
- Remove any clothing cautiously and deliberately. If clothes need to be removed as part of the normal course of critical patient treatment, avoid cutting through any holes, especially those that could have resulted from a bullet or a knife. Avoid cutting or contacting blood or semen stains. Try to stay near a normal seam.
- Any clothing that is removed should be placed in paper bags and held for evidence. Plastic bags should not be used because these will allow mold to grow and possibly destroy trace physical evidence.
Documentation
Document anything that is observed or experienced on the scene or with the patient. The EMS providers will likely be called to provide testimonial evidence during a trial if it occurs. Testimonial evidence is evidence that witnesses provide from oral documentation or facts. It is helpful to incorporate such evidence into the patient care chart clearly and factually, free from embellishment or opinion. Anything the patient tells you during the transport should be documented; use quotes whenever possible and avoid paraphrasing.
Any treatment conducted on the patient needs to be clearly documented, especially intravenous attempts, intramuscular or subcutaneous medication administration, and any medication given. Any missed and successful intravenous location should be documented clearly because, if this patient does not survive, the coroner may mistake the hole the paramedic put in the patient as a place where an assailant injected a medication to facilitate the assault.
Any medication you give should be accurately documented as well, especially sedatives and narcotics, because a perpetrator can use these on their victims to make them easier targets. It is for this reason that a medical control physician is not likely to order these types of medications to be given until blood can be legally drawn to test for drugs in the patient’s system prior to arrival at the hospital.

3. Obstetrics
This section will cover everything related to birth. It begins with a discussion on conception and fetal development, including fetal circulation. Maternal changes during pregnancy will be discussed along with medical issues that can go along with these changes. Next will be preterm emergencies associated with pregnancy. This section will then conclude with a review of the stages of labor during normal deliveries. Since the APGAR Score is determined before the conclusion of the third stage of labor, it is included in this section as part of the continuum of perinatal care.

Pregnancy Anatomy and Physiology
As the ovum passes through the fallopian tubes, if it encounters sperm within approximately 24 hours of ovulation, fertilization may occur. Fertilization of the ovum usually occurs in a fallopian tube. After fertilization, the fertilized ovum, now called a zygote, continues to travel down the fallopian tube and implants in the endometrial lining somewhere within the uterus where it will grow and develop into an embryo and then into a fetus. Implantation happens about a week after fertilization.
By the time of implantation, the zygote has undergone multiple rounds of cellular division and is now called a blastocyst. What was once a single cell, by the time of implantation has features that will become the fetus, placenta, and amniotic sac. Implantation can cause some spotty painless bleeding that may be alarming to the mother who does not yet know she is pregnant or dismissed easily as early, light menstruation. 
Implantation causes a cascade of changes in the mother as well. Shortly after implantation, the union of the blastocyst with the endometrial lining signals the lining to begin to release hCG, which simulates the corpus luteum in the ovary to continue to release progesterone. Progesterone is responsible for maintaining the endometrial lining throughout pregnancy. Within 10 days from implantation (<3 weeks after conception), the embryo has developed a placenta, an umbilical cord, and an amniotic sac, and the rudiments of a heart have already begun to beat rhythmically.
By the end of the 3rd week of pregnancy, the circulatory system is complete with some vasculature, a heart, and red blood cells. The neurological system is beginning to develop, and distinct areas of the brain can be differentiated. By the end of the 4th week, extensive folding of a previously basically flat embryo has given rise to the cranial vault, spinal cord, and the chest and abdominal cavities. The digestive tract also begins to develop, oriented by the location of the brain. The brain is essentially complete with all the distinct features it will have in simply smaller versions; growth will continue in the brain to enlarge itself for several weeks to come. Limb buds also begin to appear once the spinal cord is complete.
Over the next several weeks, development will continue at an alarming rate. The digestive system with all the accessory organs is visible and essentially complete by the end of the 6th week. The eyes have begun to take shape and orient themselves near the brain. The kidneys will be completely formed and functioning by the end of the 6th week, and glucagon is being produced by the fetal pancreas. From about the 8th week on, the structures critical to life outside the womb have developed, and the musculoskeletal system continues to develop bone, cartilage, tendons, and muscles. The fetus will not be capable of survival outside the womb for about another 4 months, however, because it is still too small. After the 28th week of gestation, the fetus is said to be viable if it is born prematurely, although it still requires extensive care.
The infant floats in a watery fluid called amniotic fluid or amnion, which is contained within the amniotic sac and serves to provide an essentially weightless environment in which the infant will develop. Later on, the fetus will consume the amnion and pass wastes into the fluid, so it also serves an excretory function.
The umbilical cord and placenta connect the fetus to the mother. The fetus gets all its O2 and nourishment from the mother via these 2 structures. Nearly everything the mother consumes can pass across the placental barrier, including sugar, protein, water, alcohol, and most illicit and prescription drugs. Though drugs of any kind are a concern throughout pregnancy, they are most dangerous during the rapid development that occurs between the 3rd and 8th weeks. During these weeks in particular, drugs can interfere with proper formation of the circulatory and nervous systems in particular but also the digestive and endocrine systems.

Fetal Circulation
The fetal circulation is different from that of the independent person. The veins carry oxygenated blood away from the placenta and toward the fetus, whereas the arteries carry deoxygenated blood toward the placenta and away from the fetus. A way to remember this is that the Arteries carry blood Away from the fetus and therefore are Anoxic (without O2).
Within the fetus, circulatory differences also are present. Because the lungs of the fetus are not responsible for oxygenation of the blood until after birth, it is energetically favorable to the newborn to largely bypass the pulmonary circuit. Blood that enters the right atrium of the heart has already been oxygenated from the placenta and can pass as expected into the right ventricle, but it also can pass through the foramen ovale directly into the left atrium. The blood that goes directly into the left atrium is then eventually pumped to the rest of the body through the aorta as normal. 
The blood that entered the right ventricle also has 2 options. Some blood will, in fact, go to the lungs to nourish the cells of the lungs themselves, but some blood will pass from the pulmonary artery directly into the aorta through the ductus arteriosus. This bypasses the pulmonary circuit and helps deliver the most blood to the body as possible with each beat. Within 30 minutes after the neonate takes its first breath after delivery, the ductus arteriosus and foramen ovale will close, establishing adult circulatory pathways. Pay particular attention to the areas that blood has a choice of direction.


Figure: Chart of Fetal Circulation


Figure: (a) Systemic fetal circulation. (b) Enlarged view of fetal circulation highlighting the 3 fetal shunts.

Maternal Changes During Pregnancy
The gravid female also experiences many physiologic and anatomic changes during pregnancy to be able to carry and metabolically support the growing fetus. Changes occur in the circulatory system, the urinary system, and the digestive system.

Circulatory Changes
Blood volume increases by approximately 50% during the course of pregnancy, increasing the volume from about 4.5 L to approximately 7 L. This increase is necessary to meet the perfusion needs of the fetus as well as maintain the perfusion of all maternal organs, particularly the kidneys. Furthermore, this prepares the mother for delivery, where the mother can lose in excess of 500 mL of blood during a normal spontaneous vaginal delivery (NSVD) and sometimes as much as 1,000 mL during a cesarean section. This excess volume allows for an autotransfusion of blood from the uterus as it contracts back to maternal circulation.
Red and white blood cell counts increase during pregnancy. The red blood cell count increases by nearly 35%, which is why most women take prenatal vitamins or, more recently, simply an iron-containing multivitamin. The increased rate of erythropoiesis makes an iron supplement essential; without it, pregnant women can suffer from pregnancy-related iron-deficiency anemia. White blood cell counts typically triple during the course of the pregnancy.
The maternal heart actually increases in size to be able to handle the polycythemia and increased circulating volume by anywhere from 10% to 15%. This increases overall cardiac output about 40% from about the 22nd week of pregnancy through the end. Helping increase the cardiac output, the heart rate also increases to a new normal resting rate about 20 beats per minute higher than before the mother was pregnant.

Respiratory Changes
The respiratory system experiences stress as well and for a variety of reasons. First, a lot more blood is circulating that needs to be oxygenated. Second, the mother’s overall O2 demand has increased to meet her increased metabolism as well as the fat metabolism of the developing fetus. Third, as the fetus develops and the uterine fundus pushes superiorly, it will push the abdominal contents against the diaphragm. This is initially compensated, limiting the ability of the mother to expand her chest cavity. This results in an overall decrease to the tidal volume in late stages; however, early on, the tidal volume and minute volume increase, each by as much as 50%.

Urinary System Changes
The kidneys increase in size by up to 30%, and the ureters can actually increase in diameter to accommodate the increase in urinary output. Consequently, the mother increases the amount of urinary output volume, therefore increasing the frequency of urination. Complicating the increased urine volume produced is a marked decrease in the volume of the urinary bladder. This is why pregnant women feel as if they are constantly urinating!

GI and Metabolic Changes
The GI system experiences decreased motility because of increased progesterone levels, which can lead to heartburn and belching. It also can exacerbate vomiting if food stays in the stomach for too long. The weight of the fundus on the lower intestines, coupled with decreased overall motility, can lead to constipation. The combined metabolism of the mother to accommodate the weight gain and structural changes as well as provide for the fetus’s metabolic needs often can lead to an increase in carbohydrate intake. Women can become diabetic during pregnancy, called gestational diabetes, as a combined result of increased carbohydrate intake and cellular decline in insulin sensitivity despite an increase in insulin production in the pancreas.

General Assessment of the Pregnant Patient
First, let’s clarify some pregnancy-specific terminology.

- Gravidity. The number of times a person has been pregnant, regardless of outcome of the pregnancies. If a patient is pregnant with multiple fetuses, she is still pregnant only once.
- Parity. The number of births the patient has had. This does not change if an infant is stillborn.
- Abortions. The number of spontaneous or elective abortions a patient has had. Spontaneous abortions are any fetal deaths that occur at <20 weeks of gestation; elective abortions can occur at any gestational age.
- Living. The number of live children the mother has born. This is strictly an infant who had any pulse or respiratory activity. It does not change if the infant was not able to survive. The number increases only if the infant was born after 20 weeks.

Using this GPAL shorthand method, a patient who was currently pregnant with 1 child and had viable twins from a previous pregnancy with no prior elective abortions would be G:2, P:2, A:0, L:2. Once this hypothetical mother has the child from her current pregnancy, the numbers would change to G:2, P:3, A:0, L:3. Some physicians may break down the parity number further to clarify term and preterm. Preterm would be any infant born prior to 36 weeks of gestation.

- Nulligravida. A female who has never been pregnant.
- Nulliparous. A female who has not given birth.
- Primigravida. A female who is pregnant for the first time.
- Multigravida. A female who has been pregnant more than once, regardless of outcome.
- Multiparity. Having given birth multiple times. 
- Grand multiparity. A female who has given birth more than 5 times.

The history of the pregnant patient is not materially different from that of any other adult patient. As with any other patient, investigate the chief complaint, independent of the pregnancy, while keeping in mind how this may all be affecting the fetus. Keep in mind during the assessment of any female of childbearing age that she may be pregnant.
Once it is confirmed that the patient is pregnant, specific pregnancy questions should be asked. First find the GPAL values for the patient and document any history of abortion of any kind. Higher numbers of pregnancies that concluded with vaginal deliveries could result in a precipitous delivery, meaning the infant could deliver remarkably fast. Determine how the previous pregnancies ended, paying particular attention to any cesarean section history, especially if vaginal delivery is imminent. Vaginal birth after cesarean can be complicated and carries an increased risk of uterine rupture. In addition, determine if the patient has had prenatal care of any kind and if the physician has any concerns about the pregnancy or delivery.

Antepartum Complications Related to Pregnancy
Many problems are unique to the pregnant population. This section will look at the conditions that a woman could face exclusively because she is pregnant. This will include any problem related to pregnancy, not problems related to delivery. Each section will contain pathophysiology and assessment points to identify the problem, using both interrogation and the physical examination, and treatment options for the paramedic to consider.

Supine Hypotension Syndrome
Because of the increasing size and weight of the fundus, the expanded uterus, patients who are in their 3rd trimester should not lie on their back. This can cause supine hypotension syndrome, which results from the fundus lying on and compressing the inferior vena cava and possibly also the aorta. This can materially interfere with blood returning to the heart from the lower extremities and abdomen, possibly leading the patient to pass out after about 5–7 minutes if left uncorrected. Maternal hypotension means the placenta, and by extension the fetus, will be hypoperfused. Extended hypoperfusion of the fetus could result in fetal demise.
Patients will start to show early signs of shock before they pass out, including anxiety, nausea, dizziness, and tachycardia. If the patient is supine, such as if she has to be confined to a backboard, suspect this as a cause. The condition can be remedied if the backboard is tilted toward the patient’s left, or if the patient is allowed to lie in the left lateral recumbent position. If patient condition does not improve after these maneuvers, consider fluid resuscitation.

Hyperemesis Gravidarum
Hyperemesis gravidarum is a condition where the patient has excessive vomiting episodes, often in excess of 4 times daily. The cause is unknown but seems to be related to particularly high hCG concentrations in the blood. Patients with this condition often are sensitive to smells that can trigger vomiting. This can be so bad as to affect electrolyte balances and pH and water balance in the body. Patients often are hypovolemic and may be hypoglycemic as well.
The assessment of these patients is a general assessment that should include orthostatic vital signs if the patient is capable. Assess the skin and mucous membranes for evidence of dehydration. In addition to preparing for more vomiting during patient contact—which could be projectile vomiting—transport the patient in a position of comfort and initiate ECG monitoring and an intravenous line of NSS. If the patient is hypotensive or tachycardic, consider administering 500 mL NSS. Check the blood glucose level and administer 25 g D50 if <60 mg/dL. To help control vomiting, administer 4 mg ondansetron intravenously and 50 mg diphenhydramine intravenously or intramuscularly if medical control permits.

Hypertensive Disorders
Hypertension in the pregnant patient is a significant cause for concern, particularly if it began while pregnant. If the patient was hypertensive prior to becoming pregnant, it is not necessarily an immediate threat as much as it would be if it is pregnancy-induced hypertension. Pregnancy-induced hypertension often is a sign of preeclampsia, a group of early warning signs that the patient may have eclampsia. The symptoms of preeclampsia include edema most often of the face, hands, and ankles; protein in the urine; and hypertension, all of which began or worsened after the 20th week of pregnancy. Preexisting renal problems, diabetes, and the African American race predisposes a patient to preeclampsia. A patient is diagnosed with eclampsia after the patient has a seizure in addition to these symptoms. Treatment for preeclampsia in the prehospital environment includes high-flow O2, especially if the SBP is >160 or the DBP is >105. Transport comfortably but quickly, preferably to the hospital of choice, possibly for emergent delivery.
First-line treatment of seizures from eclampsia is 4–6 g magnesium sulfate administered over approximately 15 minutes. Seizing will usually stop with just the loading dose. For extended transport times, a maintenance infusion of magnesium should be initiated at 1–2 g/hr and should be slowed if the patient shows a declining mental status. Although magnesium will likely control the seizure, if it persists, 4 mg lorazepam is the next line drug of choice. The blood pressure should be monitored and not treated prehospital because it needs to be slowly lowered to avoid fetal compromise. However, medical control may order 20–40 mg of labetalol every 15 minutes, or 5–10 mg of hydralazine every 10 minutes as needed to maintain an SBP between 140 and 160 mmHg and a DBP between 90 and 110 mmHg.

Gestational Diabetes Mellitus
As mentioned earlier in this section, the patient may become diabetic as a result of being pregnant. The patient may present similar to any diabetic who is not pregnant and may have high or low blood sugar levels. This can be assessed and managed as previously discussed.

Toxoplasmosis
Toxoplasmosis is a parasitic infection that women can get, most commonly from handling cat litter or ingesting food contaminated with the parasite. Pregnant women are encouraged to eat only thoroughly cooked meat and to not change cat litter boxes. This disease does not have any symptoms and is detectable only with a blood test. Newborns also do not show any specific symptoms, but they may develop learning, visual, and hearing difficulties later in life.

Vaginal Bleeding During Pregnancy
One of the major reasons for bleeding in the pregnant patient is the ectopic pregnancy. But several other conditions unique to the pregnant patient can involve spontaneous vaginal bleeding.

Abortion
Abortion is the expulsion and death of a fetus prior to being viable outside the uterus. Depending on the text, this can be at any time prior to 20 or 28 weeks of gestation. For consistency, this text will use 20 weeks as the cutoff. What follows is an explanation of the degrees of abortion the paramedic may encounter in the field.
In spontaneous abortion, the body ends the pregnancy without warning. This can be caused by chromosomal abnormalities in the fetus, from a failed implantation, or from failed maintenance of progesterone from either the corpus luteum or the placenta. Illicit drug use increases the possibility of spontaneous abortion. In most cases, a finite cause cannot be identified. Treatment is limited to emotional support and prevention of shock. If the patient has not already done so prior to EMS arrival on the scene, apply a pad to the vagina but do not pack the vagina.
Elective abortion is a type of abortion that is a conscious decision on the part of the mother to end the pregnancy. If carried out in a doctor’s office, hospital, or clinic, there are not nearly as many complications as when the mother takes it upon herself to elicit the abortion. Toxic herbal and chemical preparations can be taken that make the blood toxic to the fetus, which also may have negative effects on the mother. Desperation may lead a person to insert various instruments into the uterus in an attempt to forcibly detach the placenta from the endometrium, which can lead to profuse and life-threatening bleeding. When encountered with a patient who has had or attempted to perform an elective abortion, remember to be professional and not pass judgment on the patient.
For any of a variety of reasons, a patient may come close to having a spontaneous abortion, also known as a threatened abortion. These reasons can include dehydration or malnutrition, where the mother’s body needs to sacrifice the fetus for its own survival. Reversal of the causative problem often can halt the abortion, and the mother can carry to term or closer to it. Alternatively, a threatened abortion may proceed all the way to a complete abortion or become an incomplete abortion. Patients who have experienced a threatened abortion and still have a viable pregnancy (fetal heart tones are present, and the fetus is moving as before) are usually placed on near total bed rest to prevent such symptoms from happening again. In a threatened abortion, although the fetus’s viability is threatened, it remains alive, the cervix remains closed (this is not assessed by paramedics), and fetal and placental tissue has not been passed. Treatment is aimed at supportive care for any presenting symptoms and should include emotional sensitivity and professionalism on the part of the responders.
In an inevitable abortion, the cervix has dilated; vaginal bleeding often is profuse and contains clots and may contain endometrial, placental, or fetal tissue. In this case, the abortion is not yet complete but cannot be stopped or reversed. Treatment should include emotional support whenever possible, but aggressive fluid resuscitation and treatment of shock are priorities.
An incomplete abortion occurs when only a portion of the products of conception—fetus, placenta, and amnion—are expelled while some remain in the uterus. An inevitable abortion may conclude as an incomplete abortion and require medical care to become a complete abortion. A complete abortion is where none of the products of conception remain in the uterus. Treatment for an incomplete abortion cannot be done in the field, and a paramedic’s care is limited to emotional support and treatment of any other secondary symptoms, such as septic or hypovolemic shock.
On rare occasions, the fetus may die, but the body does not expel it. This is a missed abortion. Treatment for a missed abortion is dilation of the cervix and curettage, which is scraping of the endometrial lining.

Abruptio Placenta
Abruptio placenta occurs when the placenta begins to detach from the uterine wall prematurely, often long before the infant has actually been delivered. There are many causes for this condition, including drug and alcohol abuse and smoking, but the most common reason is maternal hypertension. External blunt trauma is the next most common reason. Abruptio placenta may result in slight, moderate, or profuse vaginal bleeding and should be considered in cases of vaginal bleeding in late-term pregnancies. It is possible for the patient to lose a lot of blood to the point of being hypotensive yet show no or minimal external bleeding. The placenta or amniotic sac can prevent the blood from actually escaping the vagina. Therefore, placental abruption should be considered whenever the pregnant patient in the 3rd trimester appears to be in shock.


Figure: Abruptio Placenta Presentations

Treatment for placental abruption is supportive and should include high-flow O2, intravenous fluid infused at a rate to maintain a SBP >100 mmHg, and rapid transport to a hospital capable of handling emergency deliveries.

Placenta Previa
Placenta previa occurs when implantation has occurred low in the uterus and the placenta develops over the cervical os, or opening. Placenta previa can be described as marginal, partial, or complete, depending on its relationship with the os. In a marginal placenta previa, the placental edge lies extremely close to the os and could impact NSVD. In partial placenta previa, the placenta does obstruct the os to a measurable degree. The placenta completely covers the os in complete placenta previa. 


Figure: (A) Normal placenta. (B) Marginal placenta previa. (C) Partial placenta previa. (D) Total or complete placenta previa.

This condition can be completely unknown to the mother who has not received any prenatal care and does not present a problem to either the fetus or the mother until delivery. In the patient who has had prenatal care, the mother will be scheduled for a cesarean section at about the 38th week of gestation to minimize the possibility of the body initiating natural childbirth. There is only 1 way out of the uterus naturally for the infant, and in the case of placenta previa, it is through its own blood supply. As the cervix starts to dilate in preparation for natural childbirth, vaginal bleeding will begin and remain constant or increase over time.
Treatment for the patient with placenta previa is the same as for abruption placenta: prepare for and treat for shock. In placenta previa, the paramedic should encourage the patient to breathe slowly and deeply through contractions to help the mother avoid pushing. Patients also may be transported in the knee-chest position, where the mother’s knees and chest are in contact with the stretcher, and her pelvis is the highest part of her body. This will temporarily help minimize the pressure of the infant on the placenta and “buy time” to get to the hospital without more bleeding.

Stages of Labor
Labor is the overall term for the process of delivering the fetus and the placenta and can be divided into 3 distinct phases.

The 1st stage of labor begins with the onset of contractions of the uterus, called labor pains. These pains begin as an achy feeling, often in the upper abdomen or back. Many women describe them as similar to that crampy feeling that a person would get with diarrhea. Initially, the contractions may be as far apart as about 15 minutes, but they tend to get closer together as labor progresses. The timing of these contractions is typically measured from the beginning of a contraction to the beginning of the next, and the duration of a contraction is how long the pain lasts before fully subsiding. It is important as part of the assessment of the pregnant patient with contractions to measure and report both how long they last and the time in between each.
As the uterus contracts, the infant is forced into the cervix and eventually the vagina. As this happens, 3 major changes happen to the cervix. First, the cervix shortens and becomes thinner, which is called effacement. As this is happening, the os of the cervix begins to dilate and gets larger in diameter, eventually achieving a diameter of about 10 cm. Neither of these measurements and assessment points are something the paramedic will measure because these measurements are internal and require extensive training; however, it may be reported to the paramedic during an interfacility transport. Delivery is imminent when the patient is fully dilated and 100% effaced. A fully dilated cervix signals the end of the 1st stage of labor and the beginning of the 2nd. It often is at a point prior to the presentation of the head that the bag of waters (i.e., amniotic sac) ruptures (breaks), releasing a gush of amniotic fluid.
The 2nd stage of labor begins when the head of the infant is visible with simple inspection of the vulva, essentially simultaneous with full dilation of the cervix. The presentation of the head is called crowning. Although any part of the infant can present, the head is by far the most common, with the buttocks presentation (breach) being the 2nd most common. If the head presents, it will generally be face down and flexed with the chin in contact with the chest. At this point, contractions are typically <3 minutes apart, the strongest they have been thus far during labor, and often last a full minute, making them seem nearly constant to the mother.
As the head begins to present, it is incumbent on the paramedic to remain calm and appear in control, even though he or she will only be assisting a completely natural process. It often is difficult to decide whether to transport the patient who presents with contractions or stay on scene and await delivery.

Some factors to consider in making this decision are as follows:

- The number of previous births the patient has had
- The duration of the contractions
- The interval of the contractions
- The mother feeling as if she needs to have a bowel movement
- Presentation of the head
- Whether the mother has had prenatal care
- If the patient is considered a high-risk pregnancy

Contractions of a frequent interval and long duration signal an imminent birth. If a mother has had multiple births prior to the current pending delivery, this delivery often will by much faster—on the order of minutes rather than a couple hours that is typical of nulliparous patients. If the patient says that she needs to have a bowel movement, do not allow her because this reflex is caused by the infant pressing on the rectum similar to feces preceding a bowel movement. If the patient is considered at high risk or has not had meaningful prenatal care, unless delivery is imminent, it may be worth attempting to get to a hospital capable of high-risk deliveries rather than stay on scene.
If any of these are present, it is highly recommended to stay at scene and perform an emergency delivery. Establish a clean, preferably sterile, area around the patient but particularly under the mother’s buttocks and between her legs and prepare the OB kit every ambulance should have.

The following are the steps and events that occur during the 2nd stage of labor:

- Position the mother in a semifowlers position with her knees drawn up to her chest. Have other personnel assist with this and prop her back up against something firm or have her partner or spouse support her. In addition, it is worth having another ambulance crew on scene with you because once the child is delivered, there will be 2 patients. If there is time, don gloves, mask, eye shield or goggles, and a gown. This will not be a clean event.
- Once the infant has crowned, apply gentle pressure on the newborn’s head during any contraction and attempt the mother makes to push. The goal here is to prevent an explosive delivery, which could lead to vaginal tears. During the intermission between contractions, encourage the mother to rest and catch her breath. During this time, keep the labia moist.
- As the head begins to emerge, it will naturally turn, typically toward the mother’s left. Support the head as it comes out and do not resist this turn. If the bag of waters has not ruptured by this time, carefully tear it with your fingers, or with the forceps or the scalpel from the OB kit to allow the amniotic fluid to drain.- Still with only the head of the infant out, and using the bulb syringe in the OB kit, suction the infant’s mouth then nose, making sure to get in the pockets of the cheeks when suctioning the mouth. Always suction them in alphabetical order: mouth then nose. Accomplish this by squeezing the bulb outside the infant and then insert the tip with the bulb compressed. After the tip is in the desired location, let go of the bulb, allowing it to reinflate and suck up the mucus and amnion in the mouth and nose.
- On the next contraction, guide the infant’s top shoulder out of the mother by applying gentle traction downward, being careful to not push too hard on the infant’s head, which could cause nerve damage to the infant. Once that shoulder is free from its likely hang-up on the pubic bone, lift up on the infant’s head, still during the contraction. This should free the lower shoulder from the perineum.
- Once the shoulders are free, the torso, pelvis, and legs will deliver quite rapidly. Be prepared to hold the infant as it emerges. Remember, it is very slippery and wet. Set the newborn down on the area between the patient’s legs. It is essential to keep it at the same level or lower than the vagina until the cord is cut.
- If the paramedic is comfortable and it has not already been done, now is the time to clamp the cord and cut it between the clamps once it has stopped pulsing. One clamp should be placed at about 7 inches from the neonate and the other about 10 inches from the neonate whenever possible. If the paramedic is not comfortable cutting the cord, leave the newborn at this level to prevent flow of blood out of the infant and into the placenta.
- Suction the mouth and nose again if needed. Dry the infant and wrap him or her in a dry blanket to preserve body heat. Place the neonate on the mother’s belly if she is able to hold the newborn.
- Proceed with newborn resuscitation guidelines from later in this guide if needed.

The delivery of the child concludes the 2nd stage of labor.
The 3rd stage of labor begins once the neonate is fully delivered and concludes with the delivery of the placenta. The placenta will be approximately the size of a dessert plate. Do not tug on the remainder of the umbilical cord in an attempt to accelerate this process. Within about 30 minutes, the placenta should deliver with a few more contractions. If after an hour the placenta has not yet delivered, transport the patient to the hospital because this may indicate a problem. Place the placenta in a plastic bag and bring it to the hospital; the physician will check it to ensure that the entire placenta has been expelled. Placenta retained in the uterus can lead to a lethal postpartum hemorrhage.

APGAR Scoring
The Apgar score is an assessment tool that assigns a numerical value to each assessment point. The score is calculated officially at 1 and 5 minutes of life, although the tool can be used at any time to evaluate the vitality of the newborn. For each section, assign the best score for the neonate from 0 to 2 and total the score for the 5 sections. Normal infants score 7 and higher. 

The Apgar Score
 

4. Perinatal Complications of Labor
Some issues may come up during the process of labor that the paramedic needs to be able to recognize and treat. These issues often are not predicted through ultrasounds available with prenatal care and can crop up in any patient.

Premature Rupture of Membranes
Premature membrane rupture occurs when the bag of waters ruptures more than an hour prior to the onset of labor. There are several possible outcomes to this condition. First, it may heal, and the pregnancy will continue as if nothing happened. Second, this could lead to infection if labor cannot proceed, which could later result in loss of the pregnancy. Finally, and most commonly, labor will either begin naturally or through medicinal induction within about 48 hours. This is not something that will affect the delivery overall; the paramedic should be aware that rupture of membranes does not, by itself, predict delivery.

Meconium Staining
Meconium is the infant’s first bowel movement. This ordinarily happens after birth; however, when the infant is under duress, it will pass this stool into the amnion as part of its panic. Ordinarily, the amniotic fluid is clear to a slight pale yellow. Meconium stained amniotic fluid that represents fetal distress is foul smelling, sticky, and greenish black. Fetal distress can be caused by any number of conditions, including nuchal cord, fetal developmental problems, trauma, hypoxia, and abruptio placenta.
The infant, for the entire time it is in the uterus, inhales the amnion, and this will include the meconium-stained amnion. If the mother has passed meconium-stained amniotic fluid, the paramedic must prepare for the potential delivery of a very sick infant. The infant may not be breathing or may be breathing ineffectively and require extensive support to survive. More will be covered on the topic of newborn resuscitation later.

Uterine Rupture
Uterine rupture may occur during delivery, particularly if the patient has any kind of scar tissue in the uterus, such as what may occur from a previous cesarean section. This could prove to be lethal to both the infant and the mother because of the inability to expel the infant and extensive bleeding from the uterus and possibly the placenta. If this happens while in the paramedic’s care, the patient may be able to relate that she once had strong contractions, but recent contractions have felt weaker. This is proceeding in the wrong direction; contractions should get stronger as they progress toward delivery. Patients also will appear in shock with pale, sweaty skin. All patients presenting with imminent delivery should get an intravenous fluid infusion, and it is even more important for this patient to receive.

Preterm Labor
Preterm labor is any labor that begins after 20 weeks of gestation and before the start of the 37th week of gestation. If the due date is still remote, the hospital course may be to try and curtail the contractions and preserve the pregnancy. Neonates are not viable outside the uterus until about the 20th week, and most physicians consider viability to be after the 28th week of gestation, although some intrepid neonates have survived births earlier than 28 weeks.

Precipitous Labor
Precipitous labor begins and ends with delivery in <3 hours. This may happen most commonly in multigravida and multipara mothers. In this situation, the contractions are stronger and more effective, increasing the chances that the patient tears as a result of a fast birth. It is important that the paramedic coach the mother through the delivery and encourage her to breathe through some contractions if needed.

Postterm Pregnancy and Labor
A normal term for a pregnancy is 40 weeks, so any pregnancy that lasts beyond 42 weeks is considered postterm. Although there is no direct threat to the mother for carrying beyond 40 weeks, the placenta may not be able to transfer enough nutrients and O2 to a child who has grown much beyond this time. Because fetuses may be larger than normal in this condition, there is an increased risk of delivery problems, including cephalopelvic disproportion and shoulder dystocia. Causes for retention of the fetus beyond 40 weeks are not well outlined.

Fetal Macrosomia
Fetal macrosomia represents an infant weighing >4,000 g (or 8 lb 13 oz) at birth, regardless of gestational age. Genetics and ethnicity play a significant role in predisposing a fetus to a high birth weight, with Hispanic patients being more likely to have a macrosomic child. Diabetes as a baseline or gestational diabetes also is a risk factor for a large infant. Male children also typically weigh more than female children, so they are disproportionately more likely to be macrosomic at birth.

Cephalopelvic Disproportion
Cephalopelvic disproportion is a situation where the size of the infant’s head exceeds that of the opening of the pelvis. Frequently, the mother knows this is a problem ahead of time if she has had sufficient prenatal care. It is not possible to deliver this child through normal vaginal delivery, and attempting to do so may cause massive uterine bleeding and life-threatening problems to the mother and infant.

Intrauterine Fetal Death
Intrauterine fetal death differs from an abortion of any kind because it happens after the 20-week threshold. Its causes often are difficult to determine and can vary from intrauterine umbilical cord strangulation to a complication of diabetes or eclampsia to intrauterine infection. Labor may not even occur naturally, and if it does, labor may not start for weeks after the fetus’ death. Upon expulsion from the uterus, the fetus may have blisters on the skin or skin actually sloughing off. It also may have already begun to putrefy and have dark discolorations depending on the degree of decomposition. The mother may or may not know that this has happened, and very little can prepare the mother or family for what the fetus will look or smell like. As a paramedic, try not to pass judgment and ensure professional behavior at all times. There is no need to attempt to resuscitate an obviously dead fetus.

5. Complications of Delivery
Although a vast majority of deliveries are completely normal and free of complications, paramedics must be prepared for delivery complications. This section will discuss the complications of delivery and the best treatment for each.

Prolapsed Cord
For fetuses with a prolapsed cord, the child is not yet visible, and crowning has not yet happened; however, the umbilical cord is visible, being looped outside the vagina. In most cases, though, the delivery process will continue to progress as if nothing is wrong. Yet this could prove problematic for the fetus as it will likely pinch off the umbilical cord too early, cutting off its own blood supply as it descends further and further into the pelvis. This presentation cannot be vaginally delivered in the field— or in the hospital, for that matter—and should not be attempted; this presentation will require Cesarean section.
Transport the patient in the knee-chest position, where the woman’s pelvis is the highest part of her, to have gravity help keep the child in the uterus. One paramedic should hold the cord for the duration of patient contact and ensure that it continues to have a palpable pulse. If the pulse should disappear, the fetus is likely beginning to press on it. Insert a gloved hand into the patient and gently but firmly push or lift the part of the fetus compressing the cord off it. This paramedic will then be committed to this patient in this position until a crash cesarean section can be accomplished and the fetus is delivered.

Multiple Gestations
Twins are not terribly complicated, typically. Twins often are smaller than single gestation infants born during the same week of gestational age. This low birth weight may predispose the neonate to needing some degree of resuscitative care after birth. The 2nd and any sequential neonates will be born about half an hour apart.
The procedure for birthing twins is not any different from single births; it just gets repeated. For twins, there will always be 1 umbilical cord for each neonate. The number of placentas may vary. If there are 2 umbilical cords attached to 1 placenta, then the twins are said to be identical. Conversely, fraternal twins each have their own placenta. As they are born, write the time and some kind of identifier on a piece of tape and wrap it like a bracelet around the ankle. Do not just apply the tape to the infant.

Cephalic Presentation
In normal, head-first deliveries, the crown or vertex of the head presents when the fetus’s head is flexed, with the chin touching its chest. Occasionally, the head can hyperextend, resulting in a face-first presentation. Even more rare is when the head presents, parietal area first, called the military presentation. Although field deliverable, it is one of the hardest cephalic presentations for the mother to deliver and can result in an arrested delivery or extreme pain for the mother.

Shoulder Dystocia
Shoulder dystocia occurs when the fetus’s shoulders are too broad to deliver and is a common complication of fetal macrosomia. It is diagnosed after the head delivers and the upper shoulder gets stuck on the pubic bone. The first sign of shoulder dystocia is what is called the turtle sign, which is where the fetus’s head pushes out during a contraction and pulls back into the mother somewhat, analogous to a turtle retracting its head. This often is an unexpected complication, even in the hospital, and becomes a threat to the survival of the fetus for 2 reasons. First, the cord often is compressed between the fetus and the woman’s vaginal wall. Second, the birth canal compresses the entire chest, reducing or eliminating the fetus’s ability to breathe.
The delivery needs to be completed most likely before transport to the hospital, so being familiar with maneuvers designed to relieve shoulder dystocia is necessary.

The mnemonic for remembering the order of the maneuvers is, appropriately, HELPERR:

- Help. Call for additional help.
- Episiotomy. The paramedic cannot do this.
- Legs. Flex the legs at the hip as far as they can possibly go, essentially almost putting the knees in the armpits. This is called the McRobert maneuver.
- Pressure. Exert suprapubic pressure straight down on the fetus’s anterior shoulder while the patient is being held in the McRobert maneuver. The goal is to disimpact the anterior shoulder.
- Entry Maneuvers. This first involves an attempt at internal rotation of the fetus to dislodge either the anterior or posterior shoulder.
- Remove Posterior Arm. In this maneuver, the paramedic attempts to identify the posterior forearm and hand, gently pulling it free of the birth canal.
- Roll the Patient. Place the patient on all fours to try and straighten the spine and dislodge the posterior arm of the fetus.


Figure: McRobert Maneuver and Suprapubic Pressure

If shoulder dystocia is encountered, call medical control as soon as possible and have the doctor on the phone help guide the processes. Make the decision to transport the mother in the knee-chest position.

Nuchal Cord
A nuchal cord is a cord that has been wrapped around the fetus’s neck as a result of his or her normal movements in utero. As discussed in the normal birth outline, as soon as the neonate delivers in a head-first delivery, slip a finger in between the cheek and shoulder of the neonate after it rotates into the side-facing position. If pulsing is felt, or the cord can be seen, attempt to loop the cord back over the head of the neonate if there is enough slack. If there is not enough slack, loosen enough cord to be able to clamp it in 2 places and then cut the cord between the clamps. This must happen so that the delivery can be completed, and the neonate does not die of strangulation.

Breech Presentation
Breech presentations occur when the buttocks is the presenting part and are more common in premature births. These presentations can be delivered in the field; however, they are not ideal. It is not uncommon for breech births to be harder deliveries for the mother and last longer. There also is the very real possibility for the infant’s head to become stuck in the birth canal despite the rest of the body successfully delivering. If the infant’s head gets stuck and the rest of the body has delivered, first attempt to free the child by carefully lifting the child’s ankles upward in a circle toward the abdomen. This maneuver should free the head. If it does not and the head remains stuck, the child is in serious danger of asphyxiation. In this case, gently but quickly slide 2 fingers between the vaginal wall and the infant’s face and push up on the infant’s cheeks with 1 finger on each cheek. This will create a small gap through which the infant should be able to breathe. The paramedic who does this will be committed in this position until the infant’s head is freed from the mother at the hospital. At no point in time should anyone forcibly yank on the infant to try to extricate the child.

Limb Presentation
On rare occasions, and for not clearly understood reasons, a limb of the infant may be the presenting part. This can be any of the 4 limbs, but most commonly it is a leg, although the infant may be lying transverse in utero, thus presenting an arm. This presentation is not field deliverable, and the patient will need a cesarean section. Transport this patient in the knee-chest position with the pelvis as the highest part of the mother, so that gravity can aid in keeping the child in. If both legs are the presenting part, the infant may be deliverable in the field in the same manner and with the same considerations as a breech presentation.

6. Postpartum Complications
As previously discussed, pregnancy alone can be hard on the mother’s body. Birth can come with its own set of problems, as well. After giving birth, the mother is still not fully in the clear. Problems associated with having given birth can present anywhere from hours to weeks after birth. As the uterus returns to its normal position in the pelvis and hormone levels return to prepregnancy levels, several problems can arise for the new mother after giving birth.

Pulmonary Embolism
A PE is by far one of the most serious complications of childbirth and is the most common cause of maternal cardiac arrest during the perinatal time frame. Air, thrombus, amniotic fluid, or water (after a water birth) may enter maternal circulation and lodge in the lungs. This will result in the sudden onset of chest pain and shortness of breath, tachycardia, and all the other PE symptoms described in this guide. Be prepared to aggressively manage this patient’s airway and provide 100% O2.

Uterine Inversion
Uterine inversions occur for unknown reasons and are therefore unpredictable, although they are believed to happen most frequently when there is strong traction (pulling tension) on the umbilical cord with a placenta that is attached to the uterine fundus (superior portion). It is fortunately relatively rare and is lethal in about 15% of patients who experience it. Uterine inversions are classified by the degree of inversion.

- A uterine inversion where the uterus inverts and stays within the uterine cavity and does not extend beyond the cervical os is called an incomplete inversion.
- A complete uterine inversion occurs when the fundus of the uterus extends beyond the os but remains within the body.
- A prolapsed inversion occurs when any portion of the uterus is visible beyond the vaginal opening.

Treatment for uterine inversion is supportive care and includes the provision of 100% O2 and at least 1 intravenous line with fluid delivery titrated to maintain blood pressure; fluid boluses may be required to maintain the pressure, especially in the presence of a postpartum hemorrhage (PPH). Oxytocin should be stopped and withheld once inversion is recognized. Magnesium sulfate or terbutaline can be administered on order from the medical control physician if needed.

Postpartum Hemorrhage
PPH is defined as any bleeding in excess of 500 mL during the first 24 hours after vaginal delivery or 1,000 mL after cesarean section. Early PPH occurs within the first 24 hours. Late PPH occurs within the first 6 weeks after delivery. Causes for PPH include the following:

- Retained placenta (A piece of the placenta remains in the uterus.)
- Placenta accreta (Blood vessels from the placenta burrow into the myometrium instead of remaining within the endometrial layer.)
- Lacerations
- Instrumental delivery
- Fetal macrosomia
- Uterine atony (a lack of muscle tone in part or all the uterus)
- Hypertensive disorders
- Induction of labor and augmentation of labor with oxytocin

Treatment in the field is rather limited. But take the following steps to treatment while rapidly transporting the patient to the hospital.

- Perform fundal massage. This is not gentle therapeutic massage that a person might get at a spa. This is more like kneading dense bread. Knead the uterus in circles.
- Encourage the mother to breastfeed, particularly if it is within 24 hours.
- Add 10 units of oxytocin, if available, to 1,000 mL NSS and infuse at about 20–30 mL/min.
- Initiate 2 large-bore intravenous lines and run crystalloid solutions wide open.
- Do not pack, internally examine, or insert anything into the vagina.

Now, we will focus on both considerations in traumatic events that are unique to the pregnant patient because of both changes in mother’s physiology and the fundus itself. Motor vehicle accidents and domestic violence are the primary causes of trauma in the pregnant patient. The focus then will be on the trauma with which the paramedic should be concerned during each trimester.
During the 1st trimester, the uterine fundus is still well within the pelvic girdle and therefore protected. The abdominal contents have not yet begun to shift, and circulation of the patient has not materially changed. Injuries and sequelae from abdominal trauma are largely unchanged from that of the nonpregnant patient.
During the 2nd trimester, rapid growth of the fundus occurs, often leading to balance issues for the pregnant female and increased falls. The uterus itself is protected early on, but during the course of the trimester, abdominal organs are pushed upward and backward while the abdomen protrudes. The urinary bladder is now more superior and anterior, meaning that it is more susceptible to rupture in blunt or penetrating trauma. The mother’s circulating volume has increased by nearly 50% by the end of the trimester. Consequently, it may take more bleeding to show typical signs of shock, and the mother’s body will sacrifice the baby to save itself during times of severe hemorrhage. Blunt trauma and deceleration injuries increase the chances of abruptio placenta and spontaneous initiation of delivery. All these concerns continue through the 3rd trimester as well.
The fetus through all this is rather well protected. It has the amnion to cushion it and slow its overall movements during rapid decelerations, such as what may happen during falls or motor vehicle accidents. Beyond that, layers of muscle, fat, and other connective tissue provide an added barrier. During penetrating trauma, such as gunshots and stabbings, the mother may actually fare a bit better because of the presence of the fetus. In such attacks, the fetus often bears the brunt of the injuries. During assessment, ask the mother if she has noted any fetal movement since the traumatic event. Ask her if there is any possibility of having ruptured her water or if there is any vaginal bleeding.
Treatment of the fetus is accomplished with excellent treatment of the mother. In trauma patients where the abdomen could have been involved, supplemental O2 is always recommended. O2 is a first-line treatment in all cases of potential fetal distress, abruptio placenta, maternal hypovolemia, or hemorrhage. If the patient’s condition requires a backboard, tilt the backboard to the patient’s left to minimize the chances of supine hypotension syndrome. The pregnant trauma patient can benefit from intravenous fluids, even if hemorrhage is not directly observed. If ventilations are required, breathing slightly faster and closely monitoring EtCO2 is recommended because of the pregnant patient’s normally increased respiratory rate and volume.
 

7. Newborn Resuscitation
In the previous sections, the normal birth of a newborn was presented, including initial care routines of suctioning, drying and stimulating the infant, keeping it warm, and positioning it on the mother’s belly whenever possible. Abnormal births and presentations also were presented, as well as risks for fetal distress. This section will focus on describing what to do if the neonate is not born vigorous and crying, as more than 90% of children are. The section concludes by discussing common problems and treatments of the infant during the first month of life.

Assessment
Infants who are not crying forcefully or who are not moving actively after birth will need to be resuscitated, to varying degrees. Meconium staining, perinatal vaginal bleeding, maternal trauma, premature membrane rupture, and any other problem identified during prenatal care all increase the chances of the newborn needing some resuscitation. Within 30 seconds of birth, even before the first Apgar score is obtained, the infant needs to be quickly assessed for the ABCs. The inverted triangle will help guide the paramedic’s stepwise planning to newborn resuscitation.

Inverted Triangle
The inverted triangle is a means of remembering the steps to newborn resuscitation. It is designed to indicate, at the top, the treatments and interventions every infant will receive. Descending down to the tip of the triangle illustrates the interventions that very few infants require to survive. Progression through the inverted triangle will be based on the infant’s response to each higher level. Children are incredibly resilient when it comes to treatments, but this is especially true of newborns. With this in mind, movement from one level to the next should be rapid, roughly every 30 seconds or so.


Figure: The Inverted Triangle of Newborn Resuscitation

Warm, Dry, Position, Suction, Stimulate
As mentioned in the previous section, upon delivery, every infant will receive these steps. Maintaining the body temperature of the infant is essential. In the back of the ambulance, if it is comfortable for the EMS crew, it is frigid for the newborn. The infant should be dried off from the blood and amnion covering him or her as best as possible. During these treatments, the infant should be positioned on his or her back. After each intervention is completed and the child is breathing and becoming increasingly pink, place the infant on the belly of the mother to aid in delivery of the placenta and minimize blood loss. Suction the mouth first and then the nose. Although this is done immediately after the head presents and rotates, it should be done again after full delivery to ensure that nothing was missed. Deeper suctioning should be performed if the amnion was meconium stained (more on this later). Stimulation most often is accomplished simply during the drying process. However, if this has not worked sufficiently, flick the soles of the feet or rub the child’s back. If, after all of this is completed or 30 seconds has passed and the infant is not yet lively and vigorous, move down the triangle to the next level: oxygenation.

Oxygenation
Hypoxia is the most likely cause for any respiratory or cardiac depression found in the newborn. Transient hypoxia occurs in every newborn because of compression of the umbilical cord between the vaginal wall and the infant during a normal delivery; therefore, addressing this hypoxia is of highest importance. The assessment here needs to focus on respiratory and heart rates. The rates should be >30 (with the infant having a strong cry) and >100. Cyanosis of the hands and feet under these conditions is considered normal, and the infant does not require any further treatment; simply monitor the child and be alert for an unlikely decline in status.
Central cyanosis when the heart rate is still >100, however, requires blow-by O2 because there may be another reason for the continuing cyanosis of the trunk or mucous membranes. O2 can be delivered with O2 tubing blowing a stream of air across the infant’s face or with a simple non-rebreathing mask. In most cases, the infant will “pink-up” after just a few minutes of supplemental O2. If O2 is used for more than a few minutes, it should be humidified. O2 should be discontinued if cyanosis of the trunk and mucous membranes resolves because excessive O2 administration to a newborn can be harmful to the eyes.

Positive Pressure Ventilation
If the infant is apneic for a period of 20 seconds or more at any point in time after birth, or the pulse rate is found to be <100 beats per minute, positive pressure ventilation should be initiated immediately. This should be continued until the heart rate improves to >100 beats per minute. Other signs that indicate the likely need for positive pressure ventilation include nasal flaring, grunting, and retractions. The retractions may be intercostal, subcostal, or supraclavicular. Breathing may appear so labored: the belly puffs out and the chest depresses with each inhalation, then vice versa during exhalation. This phenomenon is called see-saw respirations.
Because infant chests vary in diameter, O2 should be delivered in sufficient quantity to see the chest rise, typically about 3–6 mL/kg of O2 or about 1/10 the volume of an infant BVM. Ventilating a newborn may take more force than may otherwise be expected because the lungs have not fully inflated or there may not be enough surfactant in the lungs for them to inflate easily and fully. Blow-off valves often found on infant BVMs may release at a pressure lower than that required to adequately inflate a newborn’s lungs, particularly those of premature newborns. After the first few breaths after delivery, the pressure needed to obtain chest rise should lessen, and breaths should continue to be delivered to a volume needed for chest rise at a rate of 40–60 per minute.
Oral airways are rarely used on newborns. In fact, if they can be avoided, they should be because the hard plastic may cause trauma to the soft tissues of the palate if the airway is improperly inserted. If required, airways should be inserted using a tongue depressor and slid into position rather than rotated as in an adult. An oral airway can be life saving in the following conditions:

- Bilateral Choanal Atresia. A bony or membranous obstruction in the nasopharynx prevents airflow through the nose. This can be fatal.
- Pierre Robin Sequence. This sequence is a series of developmental anomalies that result in a small chin and a tongue positioned more posterior than normal. These often result in airway obstruction that an airway will definitely alleviate. Less invasively, placing the infant prone also may alleviate this condition.
- Bradycardia. Children respond to periods of hypoxia by first becoming bradycardic. Whether the hypoxia is a direct result of a long delivery, respiratory distress after delivery, or periods of apnea, bradycardia is frequently present. In most cases, the bradycardia responds to ventilation and oxygenation. If bradycardia does not respond to ventilation, consider other possible causes, including acidosis and hypothyroidism. Vagal stimulation from suctioning; intubation; or motion of a placed orogastric tube, nasogastric tube, or ETT against the hypopharynx is possible. More will be discussed on the pharmacologic interventions for bradycardia later.

If, after about 30 seconds of BVM use, the heart rate or the respiratory rate of the child has not increased, move to the next stage of resuscitation: intubation.

Intubation
Most newborns are resuscitated to full activity and respiratory and heart rates with O2 or a few minutes of ventilation with a BVM. If ventilation takes more than a few minutes, intubation should be considered because it will protect the airway from aspiration and minimize the chances of gastric insufflation from aggressive ventilation. Intubation should be considered any time it is expected that positive pressure ventilation will be used for an extended time.
Intubation is indicated in the following conditions.

Meconium Staining
As noted previously, the fetus is consistently inhaling the amniotic fluid. If there is meconium in it, the fetus could inhale that as well. If the fetus then get this into the lungs, it will likely result in severe respiratory depression and infection, which are associated with a high morbidity. This leads to atelectasis and hypoxia. It also will prevent the newborn from inhaling and inflating his or her lungs, resulting in a condition known as persistent pulmonary hypertension of the newborn and continued shunting of the blood in the heart through the foramen ovale and ductus arteriosus.
Ordinarily, after the infant is born, he or she is dried, warmed, and stimulated, but these procedures are not recommended in the meconium-stained infant, especially if the amnion was black and particulate. Instead, when the amniotic fluid contains meconium, aggressive suctioning beyond what would normally be done for any other normal newborn should be performed first, before drying, warming, and so on. To adequately clear meconium cleared from the lower airways, suctioning is performed using an ETT as a suction catheter attached to a meconium aspirator, which is then attached to the suction tubing. Next, using a laryngoscope and the usual intubation technique, suction deep into the trachea until there is nothing left to suction. Remember to suction out the cheek pockets as well. Discard the ETT. If deep suctioning yielded meconium in the lower airways, intubate and ventilate at a rate of 40–60 per minute with sufficient volume to see the chest rise. This is warranted in most meconium-staining cases.

Congenital Diaphragmatic Hernia
A congenital diaphragmatic hernia is where the infant is born with its abdominal organs within the chest cavity. The stomach and perhaps some intestines have herniated through either the esophageal hiatus or another abnormal opening of the diaphragm, causing the mediastinum to shift to the opposite side of the hernia. This can be diagnosed on prenatal ultrasound, so the mother may be able to relay this information to the paramedic during the birth, allowing time for the paramedic to prepare. If there was no prenatal care, such a condition would not be known; however, assessment of the newborn can reveal clues. Instead of being round, the abdomen would be flat or even sunken because of the lack of abdominal organs. There may be bowel sounds in the chest cavity in addition to severe respiratory distress.
For any newborn who has severe diaphragmatic hernia, early intubation is recommended because BVM places the patient at unnecessary risk for gastric insufflation. Because the stomach is in the chest, gastric insufflation will only further diminish available lung capacity. Ventilating these newborns is something of a balancing act as far as the pressures needed to generate lung inflation are concerned. Such infants tend to have underdeveloped lungs as a result of ongoing pressure from the abdominal organs during gestation, making them more susceptible to barotrauma. On the other hand, higher pressures may be needed to get any air into the lungs for the same reason. If available, the newborn should receive an orogastric tube to relieve gastric distension. Rapid transport to a facility capable of emergency surgery on a newborn is recommended.

Pneumothorax
Positive pressure ventilation whether via BVM or intubation can cause a pneumothorax in a newborn. The pneumothorax also may be caused by damage to the lung form meconium aspiration. Relieve the pneumothorax in the same way as an adult, only with a smaller 22-gauge over-the-needle intravenous catheter inserted in the 2nd intercostal space just above the 3rd rib to avoid the vascular and nerve bundle that lies inferior to the 2nd rib. A newborn with a pneumothorax should be intubated to secure the airway and help monitor increasing airway pressure after initial relief of the pneumothorax.

Compressions
Chest compressions should be initiated in any child who is pulseless or has a heart rate of 60 or less after 30 seconds of effective positive pressure ventilation. In most cases, there also should have been 30 seconds of ventilation through a properly placed ETT or LMA as well as prior to beginning compressions. Compressions should be continued until the heart rate improves to >60 beats per minute. Compressions can be performed in 1 of 2 ways as recommended by the American Heart Association.
Compressing the sternum with 2 thumbs, with the hands encircling the chest so the fingers support the spine is the ideal way to compress the chest. But this can be done only if there are 2 paramedics: 1 paramedic performs the compressions, and 1 paramedic ventilates the child. The thumbs should be over the lower third of the sternum. The person performing the compressions is located at the head of the patient, whereas the person doing the ventilating is located to the side. This will allow yet another paramedic to cannulate the umbilical vein to acquire vascular access (more on this later). A 3:1 ratio of compressions to ventilations should be performed, and each set of 3:1 should be complete in about 0.5 seconds. This will ensure about 90 compressions per minute and 30 breaths per minute. Pulse or ECG rhythm checks should be performed only after about every minute of compressions and ventilations.
The alternative method should be done by placing 2 fingertips on the sternum and the 2nd hand behind the infant’s shoulders to support the spine. Ventilations are then delivered by a 2nd paramedic. Compressions and ventilations should be delivered at the same rate as above. Check the pulse after 60 seconds of well-coordinated compressions and ventilations.

Vascular Access
Traditional vascular access in a newborn is difficult and can be very time consuming. Cannulation of the umbilical vein provides an ideal site for fluid resuscitation and medication administration. Ideally, this is accomplished with an umbilical catheter; however, any intravenous catheter can be used as long as it is <4 cm in length and the diameter can fit the umbilical vein. The steps for umbilical catheterization are as follows:

- Clean the length of the umbilical cord from the infant to about 3 cm away from the skin with alcohol or, preferably, povidone-iodine. Keep the area as sterile as possible, ideally draping the area with sterile drapes and using sterile gloves.
- Attach a 3–5 mL prefilled syringe to a 3-way stopcock that is also attached to a 3.5–5 Fr umbilical catheter and flush saline through the catheter.
- Cut the cord between the infant and the first cord clamp about 1–2 cm from the infant while pinching it shut with a cord tie proximally.
- Insert the umbilical catheter into the umbilical vein. The umbilical vein will be the larger diameter vessel of the 3 options and will have a thinner wall compared with the other 2 arteries. This often is referred to as putting the catheter “in the mouth and not the eyes.”
- Advance the catheter about 2–4 cm into the vein until blood can be aspirated into the syringe. Do not advance beyond about 5 cm; further advancement could cause liver and heart cannulation.
- Flush the catheter and tape into place.

Medications
Medications are at the tip of the inverted triangle because they are rarely required for newborn resuscitation. In most cases of the obtunded newborn, they can be resuscitated with effective ventilatory support. Medications in the pediatric population are generally weight based, so an estimated weight will be needed. Full-term infants are generally between 3 and 4 kg, with 3 kg considered the weight used for full-term newborns. Preterm infants can weigh <1 kg. This section will focus on conditions primarily treated with medications.

Bradycardia
Continuing from the discussion earlier in this section, although bradycardia most often is remedied with effective ventilation and oxygenation, there are some occasions where medications may need to be given. The medication of choice in a newborn is 0.01–0.03 mg/kg intravenous piggyback followed by a flush to get the medication into central circulation. Higher doses are not recommended because of profound and counterproductive hypertension of the newborn. Administration of the epinephrine via the ETT and should be given at 10 times the intravenous dose or 0.1 mg/kg. Pulses should be checked about 1 minute after intravenous administration and about 3 minutes after ET administration.

Narcotics
Other sources of bradycardia may include the infant’s response to narcotics. If the mother was a chronic narcotic user, administration of naloxone is not recommended for respiratory depression or bradycardia in the infant because of the increased possibility of fatal seizures the sudden withdrawal can induce. Instead, the infant should be weaned off the narcotic during the first few days or weeks of life. Conversely, if the respiratory depression could be from perinatal short term, acute narcotic use, then 0.1 mg/kg naloxone to a maximum of 2 mg is recommended.

Hypoglycemia
Hypoglycemia in the newborn is defined as any blood glucose reading <45 mg/dL, although many infants do not show symptoms until the readings are <20 mg/dL for a significant amount of time. Most term newborns will have sufficient glycogen stores to survive 8–12 hours without becoming significantly hypoglycemic because they have spent much of the 3rd trimester storing glycogen in their heart, liver, lungs, and skeletal muscle. Premature infants, on the other hand, have not had the opportunity to create these stores, so they are more likely to become hypoglycemic after birth. Stressed newborns also are more likely to present or become hypoglycemic.
Because symptoms often are vague, including irritability, limpness, eye rolling, tremors, twitching, or seizures, evaluate the blood sugar level of every infant behaving unusually. Unlike in the adult or even the older child, perform a heel stick on the newborn instead of a finger stick. This will be less painful for the child and can more easily be milked for the adequate amount of blood. If the blood sugar level is <45 mg/dL, administer 2 mL/kg of a 10% dextrose solution intravenously or intraosseously. Maintain the temperature of the newborn because hypothermia places an added stress on the child.

Tip: A 10% dextrose solution may need to be made because it often is not carried on an ambulance. This can be accomplished by taking D50 and discarding 40 mL from the prefilled syringe. Then refill the syringe to a total of 50 mL. This will result in 5 g in 50 mL or a 10% solution.

Acidosis
Despite adequate ventilation, oxygenation, and chest compressions, bradycardia may be a result of acidosis. The treatment of choice in adults is sodium bicarbonate, but this is associated with increased morbidity of the newborn and should be avoided. Treatment instead focuses on volume expansion as if the patient is hypovolemic. This will help in clearing metabolic acids.

Hypovolemia
Hypovolemia is difficult to detect in newborns because newborns react to just about every event with bradycardia, including hypovolemia. In persistent bradycardia, especially with cofactors including abruptio placenta, sepsis, or multiple births, hypovolemia should be considered. Treatment for this is 10 mL/kg NSS or Lactated Ringer's (LR) intravenous or intraosseous that can be repeated up to 3 times before switching to blood is recommended.

Other Conditions Requiring Acute Interventions in the Newborn
Until now, the assessment and treatment of problems that may present during birth or immediately after birth were addressed, specifically those relating to the newborn who is obtunded and distressed. This section will discuss those issues not directly related to the pregnancy or the act of delivery. This group of issues a newborn may face may not present for a few days to weeks after delivery.

Seizures
Seizures in an infant often are related to a significant underlying issue, although they may be difficult to discern from other activities of the newborn. The causes of seizures in newborns are listed below. Seizures that occur within the first 3 days of birth are most likely caused by 1 of the first 3 causes on the list, whereas the rest of the list may begin after 3 days after birth.

- Hypoxic ischemic encephalopathy
- Hypoglycemia
- Other metabolic disturbances
- Meningitis or abscess
- Epilepsy
- Intracranial bleeding
- Birth defects and encephalopathy
- Drug withdrawal

Hypoxic events during or around birth can lead to hypoxic ischemic encephalopathy and is the single most common reason for seizures in the newborn, often with the fastest onset after birth, with the 1st seizure occurring as soon as 12 hours after birth. Seizures from this cause frequently start off subtly and worsen during the first few days of life. The newborn seizure should be differentiated from jitteriness. This is easily accomplished by gently applying pressure to a limb or passively moving 1 or more extremities. This will halt jitteriness, but it will not have any impact on a seizure. Jitteriness is not associated with eye deviations.
Hypoglycemia is noted separately from “other metabolic disturbances” because it is by far the most common metabolic disturbance to lead to seizures. The other metabolic disturbances include the following:

- Electrolyte imbalances, especially hypocalcemia, hyponatremia (sodium), and hypomagnesemia
- Abnormalities of proteins and amino acids
- Increased ammonia levels from liver problems
- Toxins

Assessment of the newborn would be incomplete without asking the mother about the situation surrounding birth, including normal versus cesarean, meconium staining, a nuchal cord, or any other prenatal complications. Hypoglycemia should always be assessed and treated as noted in the hypoglycemia section. Phenobarbital and benzodiazepines should be administered only under the advice of a physician.

Vomiting
Anyone who has ever been around a newborn knows all too well that he or she vomits. Often. Most of the vomiting that newborns do is seldom a cause for concern. It becomes worrisome if the vomiting interferes with weight gain, causes weight loss or dehydration, or appears bloody or bilious. Any of these may indicate a pathologic problem that needs to be addressed relatively quickly. As with vomiting at any age, aspiration is always a concern; it is especially concerning in newborns because they are not able to adjust to empty their mouths or avoid it when lying on their backs.

The causes of vomiting include the following:

- Esophageal Atresia. Atresia is the failure of the esophagus to properly develop and connect to the stomach. It may or may not be associated with a fistula, or unnatural connection, between the upper esophagus and trachea. Frothing after birth, and vomiting and choking with feeding, likely indicate this issue.
- Infantile Hypertrophic Pyloric Stenosis (IHPS). In this condition, the pyloric sphincter at the distal end of the stomach has thickened, and the stomach is unable to empty normally into the small intestine. Consequently, the stomach contracts forcefully to try and force the chime (stomach contents) through it. Instead, this often manifests as projectile vomiting. Infants with this often also appear malnourished and dehydrated, and they possibly have hypoglycemia or other electrolyte imbalances.
- Intestinal Atresia or Stenosis. Atresia here refers to a malformation of the bowel; stenosis is a narrowing of the bowel. If this occurs in the upper portion of the gut that is proximal to the ileum, the patient may present with bile-stained projectile vomiting, which helps differentiate it from IHPS (the vomit is not bile stained). If it occurs in the ileum or the large intestine, the infant will avoid feeding, have a distended and often hard abdomen, and possibly have a reduced amount of bowel movements.
- Malrotation. In this condition, the intestines fail to coil properly during gestation, resulting in a 270° rotation of the intestines around the superior mesenteric artery, the major artery branch off the aorta that services the gut. This results in the small intestine being crowded into the right side of the abdomen, and the ascending colon ends up being in the epigastric region. The child often will have bilious, sometimes bloody, vomit. If it is significant, the vomit may even smell like feces. It can be found prior to birth, although it can be diagnosed at any age. Surgical procedures can correct it.
- Meningitis. The child will present with projectile vomiting in addition to a fever and nuchal stiffness. Because the plates of the skull are not yet fused, the child also may appear to have an oversized head.
- Drug Withdrawal. Vomiting can be a symptom of drug withdrawal (if the mother was a narcotic user).
- Meconium Plug. The failure of the last segment of the large intestine to relax and allow the meconium to pass results in a mechanical obstruction. This can cause abdominal distension and feeding avoidance similar to intestinal atresia.

Treatment for vomiting in the newborn will ultimately be related to the cause. Initially, manage the ABCs and attempt to establish intravenous access. Check the blood glucose level and treat if needed. Be prepared for further vomiting episodes and the need to suction or manage the airway. Dehydration may be indicated by sunken fontanels or skin tenting if the vomiting has been going on for more than 24 hours. A fluid bolus of 10 mL/kg is indicated in that case and can be repeated up to 3 times with the goal of a more active child. Antiemetics are not indicated in newborns.

Premature and Low Birth Weight Infants
Any infant born before the completion of the 37th week is considered premature or preterm. Often, there is no discernible reason for the child to have been born preterm; however, the following are some causes that may lead to prematurity:

- Maternal dehydration
- Infection
- Placental insufficiency
- Polyhydramnios (too much amniotic fluid)
- Preeclampsia
- Cervical incompetence (cervix opens too early)
- Abruptio placenta
- Multiple births
- Trauma

Preterm infants are not necessarily born with a low birth weight; however, it is the most common reason for a newborn to be of low birth weight. Low birth weight is any newborn of any gestational age weighing <2,500 g or 5.5 lb. An infant weighing <500 g is unlikely to survive overall, but the infant stands the best chance in a hospital with a neonatal intensive care unit.
The best treatment for any child born either preterm or low birth weight is to keep the child warm and provide respiratory support as needed during rapid transport to a hospital that is capable of taking care of high-risk infants. Respiratory support and oxygenation should be given only to ensure adequate breathing and heart rate and should not be provided simply as a matter of course. Although long-term O2 exposure can cause retinopathy of prematurity, which is abnormal development of the vasculature of the retinas, O2 should not be withheld from the infant who is hypoxic. This could essentially be sacrificing the brain to care for the eyes because the brain is much more sensitive to periods of diminished O2 supply.

Neonatal Jaundice
Infants often are born with a yellowish tint to their skin called jaundice. In the adult, jaundice can be caused by hepatitis or liver failure; however, in the infant, jaundice is the result of the liver being unable to conjugate bilirubin during the first week of life. Infants have a higher mass of red blood cells, and it is believed that the increased rate of erythrocyte destruction and metabolism exceeds the liver’s ability to conjugate the resulting bilirubin. Generally, this is not a cause for concern, and it is almost a rite of passage for the newborn because it is seen to some degree in so many newborns. That said, bilirubin is neurotoxic, so high levels of bilirubin need to be addressed. The paramedic will not be able to address or meaningfully treat neonatal jaundice except to know that it will likely be the reason for altered mental status in a newborn with yellowish skin. The paramedic can start an intravenous line on the infant to temporarily dilute the bilirubin and to help minimize long-term effects; however, transport to the hospital is ideal.

Thermoregulation in the Newborn
The newborn’s thermoregulation system is immature and does not respond as in older children or adults. Newborns do not sweat to release heat; they are not able to shiver to generate heat when they are cold. As a result, newborns can become overheated when bundled in a heated car or in direct sunlight or may even become cold when they are in an otherwise comfortably heated house. Newborns have a higher volume-to-surface-area ratio, which means that even under normal circumstances they will lose body heat faster, even in warmer temperatures.
Fevers in newborns are relatively rare and often are not the presenting feature of an infection. Newborns can actually become hypothermic during an infection and are at higher risk for hypoglycemia and metabolic acidosis because of the immune response. Neonates with illnesses often become somnolent, have a reduced appetite, and wet fewer diapers.
Hypothermic newborns are a cause for concern because this is more likely the presenting sign of illness. Hypothermia also leads to increased metabolic activity to try and generate heat because they cannot shiver, leading to hypoglycemia and possibly metabolic acidosis. As hypothermia progresses, they may slow their respirations or become irritable. They also may have acrocyanosis (cyanosis of the hands and feet) or become bradycardic. To rewarm the neonate, skin-to-skin contact is the best and can be used after drying the infant and placing the infant on the mother. Avoid using heated water bottles or heating pads, which can cause burns or hyperthermia.

Congenital Heart Diseases
A variety of congenital heart diseases (CHDs) are listed here, and the paramedic should have at least a working knowledge of them. Aside from the supportive measures mentioned throughout this guide, EMS will not be able to do much for the infant with these conditions. Fortunately, many are not immediately life threatening upon birth; however, most will require surgery, often within 6 months or so after birth. The conditions and the most common signs or symptoms are presented.

- Ventricular Septal Defect (VSD). VSD often is a malformation of the septum between the 2 ventricles, which results in a net movement of blood from the left ventricle to the right because of the significantly higher pumping pressure the left ventricle generates. This leads to pulmonary hypertension as a result of the increased flow and also may result in a decreased systemic blood pressure.
- Pulmonary Stenosis. The pulmonary valve is damaged and often no longer opens fully. This causes an outflow problem from the right ventricle. Consequently, the right ventricle hypertrophies because of higher pressures needed to move blood out, so blood flow to the lungs decreases. Patients often present with JVD and cyanosis, especially during feeding.
- Tetralogy of Fallot. This combines 4 (hence tetralogy) conditions into 1 comprehensive CHD. The 4 conditions are pulmonary stenosis, right ventricular hypertrophy, VSD, and an overriding aorta. The first 3 were described previously. An overriding aorta is caused by the position of the VSD in relation to the aorta. Because of this malformation, the aorta will receive some deoxygenated blood from the right ventricle. The degree to which the aorta is connected to the right ventricle will determine its degree of “override.” These result in a child who is often cyanotic throughout the day but especially when crying, eating, or active at all. Infants will have “tet spells,” where they become centrally blue and may even pass out as a result of working too hard to breathe and an overall lack of O2.

Figure: Tetralogy of Fallot

- Atrial Septal Defect. This results from the failure of the foramen ovale to close, so blood is able to shift between the atria. This causes mixing of the blood and can cause the patient to be cyanotic.
- Patent Ductus Arteriosus. This is failure of the ductus arteriosus to close as it normally does after birth. As it does prenatally, this shunts blood away from the lungs, resulting in low oxygenation systemically. If O2 is administered to a child and the pulse oximetry does not increase, patent ductus arteriosus may be the cause. It can lead to CHF in the infant.
- Truncus Arteriosus. A condition where the pulmonary artery and the aorta are a single vessel. These patients often have CHF caused by the massive increase of blood flow to the lungs. Surgery divides the trunk into vessels.
- Tricuspid Atresia. This is a frequently fatal condition in which the infant lacks a tricuspid valve that, in turn, results in an undersized or absent right ventricle. Patients will have significantly decreased or absent blood flow to the lungs. The Fontan procedure redirects the vena cava and the hepatic portal veins directly into the pulmonary arteries. The result is a dual-chambered heart with 1 ventricle and 1 atrium—the left in both cases—to pump blood systemically and to the lungs.
- Transposition of the Great Arteries. This condition results in the pulmonary artery being connected to the left ventricle and the aorta being connected to the right ventricle. This results in blood returning from the body going right back out to the body without ever being oxygenated, and blood returning from the lungs heads right back to the lungs. Often, the systemic hypoxia can cause the foramen ovale and the ductus arteriosus to remain patent, allowing some oxygenated blood to reach systemic circulation. A VSD also may be present in patients with transposition of the great vessels.


Figure: Transposition of the Great Vessels