Obstetrics, Neonatal,

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Obstetrics, Neonatal, Pediatrics

• Condell Medical Center EMS System
• March 2003 Continuing Education

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Obstetrics

• deals primarily with the care of women throughout
  pregnancy
• pregnancy is a normal, natural process
• complications are not common

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Specialized structures

• placenta
• umbilical cord
• amniotic sac

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Placenta

• disk-shaped organ
• develops 3 weeks after fertilization
• gas, nutrient waste transfer/transport
• hormone production
• protective barrier between mom baby
• some medications easily cross the barrier

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Umbilical cord

• flexible, rope-like cord
• approximately 2 feet long
• allows blood flow from fetus to placenta
• fetal circulation independent of mothers

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Umbilical cord

• 2 umbilical arteries carry deoxygenated blood
• umbilical vein carries oxygenated blood

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Fetal blood flow
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Fetal blood flow

• supply-side circulation
• oxygenated blood from placenta gt umbilical vein
  with oxygenated blood gt fetal liver gt inferior
  vena cava gt right atrium gt shunted into left
  atrium (bypassing the nonfunctional lungs) gt left
  ventricle gt systemic circulation

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Fetal blood flow

• return-side circulation
• mostly deoxygenated blood from superior vena cava
  gt right atrium gt right ventricle gt pulmonary
  artery gt shunted to descending aorta gt 2
  umbilical arteries gt placenta for oxygenation

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Newborn blood flow

• circulatory shunts
• constrict, close collapse at birth in most
  infants
• circulation develops into normal circulation

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Fetal heart tones

• auscultated by 22 weeks
• can be as early as 16 weeks
• auscultate by flat, stethoscope diaphragm by 22
  weeks
• normal heart rate 120-160 beats/minute
• HR gt 160 or lt 120 early sign of fetal distress
  or maternal hypoxia

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Amniotic sac

• thin-walled fluid-filled sac
• surrounds protects embryo
• after 20th week, volume 500-1000 cc
• cushions protects fetus
• allows for fetal movement within uterus

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Terminology

• prenatal period conception to delivery
• postpartum after delivery
• gravidity - of times woman has been pregnant
• parity - of pregnancies carried to full term
• G before P 1st have to be pregnant before you
  can deliver
• document G then P on run report (G2 P1)

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Maternal pregnancy changes

• ? uterine size
• more vulnerable to injury during trauma
• reaches level of umbilicus by 4th month
• displaces pelvic, abdominal eventually thoracic
  organs
• cardiovascular system
• cardiac output ? 30
• HR ? 15-20 bpm late in 3rd trimester

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Maternal pregnancy changes

• blood volume ? 30, plasma volume ? 50
• BP ? 10-15 mmHg in 2nd trimester
• BP normal by term
• ? venous return to heart due to wt of uterus on
  inferior vena cava (supine hypotensive syndrome)
• left lateral recumbent
• ? hemoglobin concentration (O2 carrying capacity)
  more plasma than RBCs

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Maternal pregnancy changes

• respiratory system
• ? maternal oxygen demand
• only slight ? in RR
• uterus pushes ? diaphragm ? lung capacity
• center of gravity changed due to enlarging uterus
• unsteadiness in ambulation
• ? potential for falls

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Stages of labor

• pre-labor
• dilation stage (1st stage)
• expulsion stage (2nd stage)
• placental stage (3rd stage)
• length of 3 stages vary patient to patient
• primagravida (1st pregnancy) usually longer labor
  than multigravida patient

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Stages of labor

• pre-labor
• several weeks before active labor
• cervix begins to soften, thin dilate
• full dilation means complete cervical dilation of
  about 10 cm or 4-5 in
• characterized by descent of fetus
• relieves pressure in upper abdomen
• increases pressure in the pelvis
• mucous plug may be expelled

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Dilation stage (1st stage)

• onset of regular contractions to full cervical
  dilation
• average time primapara (1st delivery) 12-15
  hrs, multipara (2 deliveries) 7 hrs
• contractions cramp-like, radiating to small of
  back
• early stage contractions averaging 10-20 min
  apart lasting 15-20 sec
• late 1st stage averaging 2-3 min apart lasting
  60-90 sec

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Timing contractions

• duration how long each contraction lasts
• frequency how often contractions occur
• beginning of 1 contraction to beginning of next

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Expulsion stage (2nd stage)

• full dilation to delivery of newborn
• average time primapara (1st delivery) 50 min,
  multipara (2 deliveries) 20 min

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SS of imminent delivery

• contractions 2-3 min apart lasting 60-90 sec
• patient may be diaphoretic, tachycardic
• urge to push, bear down, move bowels
• crowning evident
• best checked during contraction
• ? bloody show (blood tinged mucous)
• more substantial bleeding NOT normal, should be
  evaluated

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OB kit

• should make sure these additional items are in
  your kit
• hat
• ID bracelet
• APGAR score sheet

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Placental stage (3rd stage)

• immediately after delivery of infant until
  expulsion of placenta
• average 5-20 min
• classical signs of placental expulsion
• gush of blood from vagina
• change in size, shape, consistency of uterus
• lengthening umbilical cord
• urge to push again
• bring placenta to hospital for inspection

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Field delivery process

• most common presentation is head first face
  down
• BSIs face shield, gown, gloves
• head delivers face down, begins to turn toward
  one of the mothers thighs
• use gentle pressure against the head to prevent
  explosive delivery

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Field delivery process

• check for nuchal cord
• cord wrapped around infants neck
• if present, slip cord over head
• if too tight, clamp cut now
• guide mother to control breathing through her
  mouth
• easy breaths in out
• no breath holding which may encourage pushing

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Field delivery process

• suction mouth then nose with bulb syringe
• suctioning nose first stimulates breathing
• need to clear airways before stimulus

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Field delivery process

• support guide head downward as the top
  (anterior) should delivers
• support guide infants head upward to deliver
  posterior should
• remainder of infant quickly delivers

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Field delivery process

• clear the airway
• dry infant to minimize heat loss
• position head downward to facilitate secretion
  drainage

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Field delivery process

• provide gentle tactile stimulation to initiate
  respirations
• rubbing back
• tapping soles of infants feet

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APGAR scoring

• helps distinguish between newborn that needs
  routine care from those needing greater
  assistance
• performed at 1 5 minutes after birth
• most APGARs at birth are 7-10
• change in score from 1 5 min is useful
  indicator of effectiveness of resuscitation

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APGAR scoring
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Cutting the cord

• no hurry to cut the cord
• never milk the cord
• may cause blood cell abnormalities to infuse into
  the infant
• keep baby below vaginal opening
• 3 min delay, additional avg of 80 ml of blood
  shifted from placenta to infant
• manage cord after clearing securing airway
  after drying/warming/stimulating

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Cutting the cord

• clamp cord 5-6 in (10-15 cm) away from newborn
• place another clamp 2-3 in (5 cm) farther away
• cut between the 2 clamps

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Cutting the cord

• observe cut ends of newborns cord for oozing
• if oozing/bleeding, place another clamp proximal
  (closer to newborn) to 1st clamp
• leave 1st clamp in place

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Post-partum hemorrhage

• gt 500 ml (1 pt or 2 cups) of blood
• usually from ineffective, incomplete uterine
  muscle contractions
• management
• O2, IV, monitor
• control external hemorrhage direct pressure
• massage fundus of uterus until firm
• encourage breast-feeding
• rapid transport

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Neonatal resuscitation
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Neonatal resuscitation

• prevent heat loss avoid hypothermia
• HR lt 100 unresponsive to stimulation, primary
  concern is to establish adequate ventilations
• meconium
• in amniotic fluid, deliver the head suction the
  meconium from the hypopharynx
• in hypopharynx, direct tracheal suctioning

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Neonatal resuscitation

• HR lt 60 despite adequate ventilations with 100
  O2 for 30 sec, provide chest compressions
• CPR ratio 31 with compression rate of 120/min
  1 breath every 2-3 sec
• 100 compressions/min 30 breaths/min
• slightly faster than traditional infant CPR

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Meconium staining

• passage of fetal stool (meconium) into the
  amniotic fluid
• dark, green, thick substance found in digestive
  tract of full-term newborns
• occurs in about 10-15 of all deliveries
• indicates an episode of fetal hypoxia
• hypoxia gt ? fetal peristalsis relaxation of
  sphincter gt meconium passing into fluid gt ?
  risk of aspiration of foreign material

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Increased newborn hazards

• ? prenatal mortality
• hypoxemia
• aspiration pneumonia
• pneumothorax from atelectasis (collapse of lung
  tissue)
• pulmonary HTN

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Meconium staining

• If light yellow to green to light green is thin,
  bulb syringe suction is usually adequate
• worst/more significant cases are dark green or
  pea soup appearing material usually require
  more aggressive resuscitation (meconium
  aspirator)
• usually seen in breech deliveries

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Assessment management

• normal infant
• signs
• meconium is thin, light-colored
• normal respiratory effort
• normal muscle tone
• HR gt 100
• intervention
• use bulb syringe to gently clear airway in normal
  manner

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Assessment management

• depressed/distressed infant
• signs
• meconium present
• depressed respirations
• depressed muscle tone
• HR lt 100

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Assessment management

• depressed/distressed infant
• equipment
• O2 tubing
• BVM
• laryngoscope blade handle
• ET tubes
• meconium aspirator
• suction tubing suction source

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Assessment management

• depressed/distressed infant
• intervention
• insert laryngoscope blade and use 12F catheter to
  clear mouth posterior pharynx
• attach meconium aspirator to end of ET tube and
  then attach to suction tubing
• suction 100 cm H2O
• insert ET with aspirator into trachea
• apply suction as ET is withdrawn
• repeat as necessary until little meconium is
  recovered or HR indicates resuscitation needed

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Assessment management

• depressed/distressed infant
• supplemental oxygen
• must be administered during use of non-bulb
  suction always during use of aspirator
• allow 100 O2 directed toward nose via mask or
  tubing held by rescuer
• can be withdrawn gradually once the newborn pinks
  up can remain pink on room air

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Meconium staining

• meconium baby (QuickTimeTM)

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Remember the basics!
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Other OB complications

• breech presentation
• buttocks or both feet present first
• interventions
• if infant starts to breath with its face pressed
  against vaginal wall, form a V and push vaginal
  wall away from infants face
• continue during transport

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Other OB complications

• prolapsed cord
• umbilical cord precedes fetal presenting parts
• interventions
• elevate hips, adminster O2, keep warm
• if cord is seen in vagina, insert 2 gloved
  fingers to raise fetus off cord
• wrap cord in sterile, moist towel
• transport immediately
• do NOT attempt delivery

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Broselow? tape

• guideline tool to help provide information during
  ped resuscitation
• size of equipment
• drug calculations
• diazepam, naloxone furosemide only listed in
  mg, not ml
• not in any specific order or protocol
• you need to know your protocol
• based on length of child

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Broselow? tape

• measure head (marked on tape) to feet
• use information in colored section at feet
• if between two sections, use one past feet

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Shaken Baby Syndrome

• serious form of child abuse
• describes injuries to infants after they have
  been violently shaken
• usually preceded by inconsolable crying
• rough movement causes neurological damage
• most commonly seen in infants lt 1 year

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Neurological damage

• cerebral contusions
• subdural hematomas
• intracranial hemorrhages
• diffuse swelling
• brain damage
• blindness
• paralysis
• death
• neck spine injuries also possible

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Signs symptoms

• irritability
• altered level of consciousness
• vomiting
• full, bulging fontanel (inspected when child at
  rest not crying)
• seizures
• unequal pupils
• finger bruises around upper arm or rib cage

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Shaken Baby Syndrome

• often no outward evidence of trauma
• objective documentation
• describe what you see, not what you think
• interventions based on presentation assessment

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