Obstetrics Pediatric Care Anatomy Review Ovaries Produces eggs

Obstetrics & Pediatric Care

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

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 - 1000 mls of fluid – Helps insulate and protect fetus

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

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

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

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

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

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

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

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

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

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?

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

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

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 o 2 – Less than 60 CPR call for ALS

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

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

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

Pediatric Emergencies

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

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

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

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

Pediatric Respiratory Rates

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

Pediatric Pulse Rates

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

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

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

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

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

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

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

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

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.

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.

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

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.

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