Download Chapter 31

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 - 1000mls 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
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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
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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
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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 o2
– Less than 60 CPR call for ALS
APGAR
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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
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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)
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Does not require equipment
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Does not require you to touch the patient
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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
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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.