Obstetrics & Pediatric Care

1. Obstetrics & Pediatric Care

2. Anatomy Review • Ovaries • Produces eggs • Fallopian Tubes • Funnels egg toward uterus • Usually where fertilization takes place • Uterus • Muscular organ where the fetus grows • Endometrium/ Lining thickens to prepare for implantation monthly • Cervix • Neck of uterus that leads into birth canal • Contains a mucous plug to seal uterine opening during pregnancy • Vagina

3. Structures of Pregnancy • Placenta • A disk-like structure that serves as a source of nutrients, oxygen and removal of wastes from developing fetus • Umbilical Cord • Attaches fetus to placenta • Amniotic Sac • Fluid filled bag that contains 500 - 1000mls of fluid • Helps insulate and protect fetus

4. Changes in Pregnancy • Hormone levels increase to support pregnancy • Rapid uterine growth • Exposes fetus to risk of injury • Impedes respiratory system • Increased respirations • Decreased minute volumes • Cardiovascular system • Blood volume increases up to 50% • Heart rate increases • Red blood cells increase • Weight Gain / Center of Gravity Changes

5. First Stage Of Labor • Dilation of Cervix • Longest stage can last up to 16 hours • Stretches and thins to become large enough for fetus to pass through • Bloody show / mucous plug is released • Amniotic sac ruptures / water breaks • Primigravida (first pregnancy) longer labor • Multigravida (has had previous pregnancies) shorter labor • Mother may report lightening, fetus descends into pelvis easing respiratory discomfort

6. Second Stage of Labor • Fetus enters birth canal and ends with delivery of infant. • Decision time? • Deliver on scene or head to hospital. • Signs of imminent birth • Mothers urge to push • Bulging of perineum • Crowning

7. Third Stage of Labor • Begins with birth of infant • Ends with delivery of placenta • May take up to 30 minutes • Contractions continue to detach placenta and close blood vessels to reduce blood loss. • Don’t delay transport waiting for placenta delivery

8. Complications of Pregnancy • Hypertensive disorders • Preeclampsia or pregnancy induced hypertension • Headache • Seeing spots • Edema hands and feet • Anxiety • High BP • Eclampsia • Seizure • Treatment • Place pt on left side (supine hypotension Syndrome) • Maintain airway • ALS intercept

9. Complications of Pregnancy • Bleeding • Ectopic Pregnancy • Miscarriage (spontaneous Abortion) • Abruptio Placenta (painful bleeding) • HTN and Trauma • Placenta Previa (painless bleeding) • Cervix dilation • Any bleeding is of concern and should be transported promptly with ALS intercept

10. Complications of Pregnancy • Diabetes • Care for as any other diabetic patient • May only be gestational diabetic • Check glucose levels and treat accordingly

11. Trauma and Pregnancy • Uterus susceptible to blunt force or penetrating trauma • Maternal death = fetal death • Supine hypotensive syndrome concern when immobilizing • Joints are weaker and looser due to increased hormone levels • Increased heart rate and blood volume delays symptoms of shock

12. Teenage Pregnancy • Physical and psychological development may be an issue in addition to pregnancy concerns

13. Normal Delivery Management • How long have you been pregnant? • When are you due ? • Is this your first baby ? • Contractions, how far apart, how long do they last? • Do you feel like you have to have a BM? • Any bleeding or spotting? • Has water broken? • Any previous C-sections? • Have you had problems with a previous pregnancy? • Do you use drugs, alcohol or take any medications? • Multiple births? • Prenatal care?

14. Delivery • Position patient supine knees bent • Drape pt to provide privacy • Open sterile OB kit • Be alert for precipitous delivery • Coach patient and reassure • Deliver head suction and guide for shoulder delivery • Body delivers (Use caution baby will be slippery.) • Keep baby at level of vagina until cord cut • Clamp 4 fingers from baby then another clamp 2 - 4’’ from first • Cut cord between the clamps

15. Delivery • When head delivers if amniotic sac not ruptured must remove it. • Feel around babies neck for cord if wrapped around neck unwrap before body continues to deliver

16. Post-Delivery Care • Stimulate baby by drying and warming • Assess APGAR score at this time • Wrap baby up covering head and allow mother to hold. • Heart rate • Greater than 100 warm dry and transport • 60-100 assist ventilations with BVM and o2 • Less than 60 CPR call for ALS

17. APGAR • Perform at 1 min and 5 min • Appearance • Pulse rate • Grimace • Activity • Respiratory Rate • Score is 0 - 1 - 2

18. Delivery Complications • Breech presentation (butt first) • Can have normal delivery but at risk for injury • Limb presentation • Prompt transport, surgical delivery required • Prolapsed umbilical cord • Position patient in Trendelenburg • Use gloved hand to relieve pressure from cord and transport

19. Complications • Spina bifida • Birth defect with lumbar portion of spine exposed • Cover with sterile moist dressing • Abortion • Termination of pregnancy before 20 weeks gestation • Multiple births • Abuse • Substance abuse • Premature vs post-term • Fetal demise • Postpartum hemorrhage

20. Pediatric Emergencies

21. Introduction • Pediatric patients are not little adults • Many providers have a level of discomfort responding to and caring for pediatrics • Pediatric patients respond differently to stressful events and that response will differ based on developmental levels • Common problems in adults do not occur in children • Communication with child and caregiver is paramount • Remain calm, professional and sensitive • A calm parent contributes to a calm child

22. Growth and Development • Infancy – First year of life • Toddler – 1-3 years • Preschool Age – 3-6 years • School age – 6-12 years • Adolescence – 12-18 years

23. Anatomical Differences • Airway is smaller in diameter and shorter • Lungs are smaller • The occiput is larger and rounder • Tongue is proportionally larger

24. Anatomical Differences Cont. • Cartilage rings on trachea less developed • Children have an oxygen demand double that of an adult • Gastric distension can interfere with air movement • If SOB muscles fatigue easily resulting in respiratory failure • Respiratory issues are leading cause of cardiac arrest in pediatric patients

25. Pediatric Respiratory Rates

26. Circulatory System • Pulse rates differ from adults • Children have ability to constrict blood vessels and increase heart rate to compensate for poor perfusion • A small amount of blood loss can lead to shock. May be in shock despite normal BP

27. Pediatric Pulse Rates

28. Nervous System • Pediatric nervous system is immature, underdeveloped and not well protected • Head to body ratio larger • Brain tissue and vasculature are fragile and prone to bleeding form shear forces • Pediatrics brains require higher blood flow, oxygen and glucose • Secondary brain damage from hypotension and hypoxia more likely • Spinal injuries are less common in pediatric patients

29. Gastrointestinal • Liver spleen and kidneys are larger in proportion and situated more anteriorly and organs are closer to each other • Multiple organ injury is a higher risk • Liver and splenic injuries are more common in pediatric patients • Large amounts of bleeding can occur without signs of shock • Be alert for signs of shock • Altered Mental Status • Tachypnea • Tachycardia • Bradycardia

30. Musculoskeletal Injuries • Growth plates on bones allow for growth • Make bones flexible • More prone to stress factures • Injuries to growth plates can alter bone growth • Immobilize all strains sprains or injury complaints

31. Skin • Skin is thinner • Skin burns more easily and deeper • Higher ratio of body surface to body mass • Results in larger fluid and heat losses • More prone to hypothermia • Keep them warm

32. Primary Assessment • Form a general impression • Use pediatric assessment triangle (PAT). • 15- to 30- second structured assessment tool

33. Pediatric Assessment Triangle (PAT) • Does not require equipment • Does not require you to touch the patient • Three steps: - Appearance - Work of breathing - Circulation

34. Pediatric Assessment Triangle (PAT) • Appearance • Note LOC, muscle tone, interactiveness. • TICLS mnemonic helps determine if patient is sick or not sick. • Tone • Interactiveness • Consolability • Look or gaze • Speech or cry

35. Pediatric Assessment Triangle (PAT) • Work of breathing • Increases body temperature • May manifest as tachypnea, abnormal airway noise, retractions of intercostal muscles or sternum

36. Pediatric Assessment Triangle (PAT) • Circulation to the skin • Pallor of skin and mucous membranes may be seen in compensated shock. • Mottling is sign of poor perfusion. • Cyanosis reflects decreased level of oxygen.

37. Pediatric Assessment Triangle (PAT) • Stay or go • From PAT findings, you will decide if the patient is stable or requires urgent care. • If unstable, assess ABCs, treat life threats, and transport immediately. • If stable, continue with the remainder of the assessment process.

38. History • Investigate chief complaint • How long have they been sick • Any fever • Eating drinking and urine output • Activity • Vomiting diarrhea • Rashes

39. Secondary Assessment Infants, toddlers, and preschool-aged children should be assessed started at the feet and ending at the head. School-aged children and adolescents should be assessed using the head-to-toe approach.

40. Transport Safety • Use a restraint system appropriate for patient age, unless treatment of patient precludes that.