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  1. 1. OB Review
  2. 2. Question How many days are there between ovulation and the start of the menstrual cycle?
  3. 3. Question What is the term for the premature separation of the placenta from the uterine wall?
  4. 4. Question Where should the umbilical cord clamps be placed?
  5. 5. Question Name some risk factors for OB patients?
  6. 6. Paramedic Care: Principles & Practice Volume 5 Special Considerations/ Operations
  7. 7. Topics General Pathophysiology, Assessment, and Management The Distressed Newborn Specific Neonatal Situations
  8. 8. Introduction Neonate – Birth to 1 month Newborn – A baby in the first few hours of its life, also known as newly born infant BABY
  9. 9. C A D B
  10. 10. Epidemiology Approximately 6% of field deliveries require life support The incidence of complications increases as the birth weight decreases Approximately 80% of newborns weighing 1500 g (3 pounds, 5 ounces) at birth require resuscitation
  11. 11. Risk Factors
  12. 12. Pathophysiology To prepare it for extrauterine life, the respiratory system must suddenly initiate and maintain respirations
  13. 13. Conversion from Fetal to Neonatal Circulation
  14. 14. Major Circulatory Changes in Newborn Circulation
  15. 15. Pathophysiology Ductus Arteriosus – After closure, becomes ligamentum arteriosum – If hypoxia or severe acidosis occurs it may reopen Result in persistent fetal circulation
  16. 16. IMPORTANT ! ! ! Paramedic should support the first few breaths to prevent hypoxia and acidosis
  17. 17. Pathophysiology Infants are susceptible to hypoxemia – Primary apnea Simple stimulation and oxygen delivery will reverse bradycardia – Secondary apnea Infant becomes unresponsive to stimulation and will not spontaneously resume respiration Ventilation, oxygenation, and compressions may be necessary
  18. 18. Congenital Heart Anomilies Classifications – Increase pulmonary blood flow Patent ductus arteriosus Septal defect Atrial septal defect Ventricular septal defect
  19. 19. Septal Defects Atrial and Ventricular
  20. 20. Congenital Heart Anomilies Transposition of great vessels
  21. 21. Tetralogy of Fallot
  22. 22. Congenital Heart Anomilies Classifications (cont.) – Obstruction of Blood Flow Coarctation of the aorta Narrows the aorta Mitral stenosis, pulmonary stenosis, or aortic stenosis Valve problem causes obstruction Hypoplastic left heart syndrome Usually fatal within 1 month if not corrected Left side of heart is under developed
  23. 23. Congenital Heart Anomilies
  24. 24. Other Congenital Anomalies Diaphragmatic hernia – BVM ventilations may distend the abdominal contents into the thoracic cavity Meningomyelocele – Spinal cord or associated structures exposed Omphalocele – Abdominal contents in the umbilicus
  25. 25. Diaphragmatic Hernia Management – Positioning Head elevation – Do not use BVM May inflate abdominal organs – Intubate, if necessary
  26. 26. Omphalocele
  27. 27. Neural Tube Defects
  28. 28. Assessment Assess the newborn immediately after birth Normal respiratory rate is 40–60 per minute – Ventilate as necessary Normal heart rate is 150–180 at birth – A pulse less than 100 indicates distress – Evaluate skin color as well Use the APGAR score
  29. 29. APGAR Scale Know it….. Love it……. – 7 to 10: active and vigorous newborn – 4 to 6: moderately distressed newborn – < 4 requires immediate resuscitation
  30. 30. APGAR Scale
  31. 31. Treatment Begins prior to delivery Vast majority of term newborns require no resuscitation beyond suctioning of the airway, mild stimulation, and maintenance of body temperature
  32. 32. Establishing an Airway Critical step in caring for the newborn Suction the baby’s mouth first, then the nose, to avoid risk of aspiration
  33. 33. Establishing an Airway For lots of secretions, use a DeLee Suction Trap If meconium is present: – Do not stimulate or suction….use meconium aspirator – Will require intubation and suctioning
  34. 34. Establishing an Airway Drying and suctioning produce enough stimulation to initiate respirations in most newborns – Stimulate the newborn as required by flicking its feet or rubbing its back
  35. 35. Prevention of Heat Loss Heat loss can be life threatening to newborns Most heat loss results from evaporation Core temperature can quickly drop 1° Celsius from its original temp
  37. 37. Dry the newborn immediately Maintain room temperature at 74–76 degrees Close all windows and doors Swaddle the infant – In colder areas, use water bottles or rubber gloves filled with warm water Prevention of Heat Loss
  38. 38. Kangaroo Care
  39. 39. Newborn Swaddling 101
  40. 40. Cutting the Umbilical Cord Perform after you have stabilized the patient’s airway and minimized heat loss Keep newborn at level of mother to avoid transfusion of blood
  41. 41. Cutting the Umbilical Cord Place the first clamp approximately 10 cm (4 inches) from the newborn Place the second clamp about 5 cm (2 inches) farther Cut and inspect for bleeding periodically
  42. 42. The Distressed Newborn
  43. 43. The Distressed Newborn Presence of fetal meconium at birth indicates that fetal distress has occurred – Particulate meconium – Meconium staining Aspiration of meconium can cause significant respiratory problems
  44. 44. Meconium Aspiration
  45. 45. The Distressed Newborn Most common problems experienced by newborns of life involve the airway – Ventilation and oxygenation Fetal heart rate is the most important indicator of neonatal distress – Hypoxia leads to bradycardia – If heart rate < 60, begin compressions
  46. 46. The A’s and B’s Apnea – leads to Bradycardia Sometimes babies need to be reminded to breathe.
  47. 47. Resuscitation The vast majority of newborns do not require resuscitation beyond stimulation, maintenance of the airway, and maintenance of body temperature EMS units should carry a neonatal resuscitation kit
  48. 48. Inverted Pyramid for Resuscitation
  49. 49. Resuscitation Step 1: Drying, Warming, Positioning, Suctioning, Tactile Stimulation
  50. 50. Newborn Assessment Parameters Respiratory Effort – Rate and depth should increase immediately with tactile stimulation – Ventilate if necessary Heart Rate – If heart rate > 100 and respirations present, continue with assessment – If heart rate < 100 initiate positive pressure ventilations
  51. 51. Newborn Assessment Parameters Color – If central cyanosis present, administer supplemental oxygen APGAR – Unless it is necessary to resuscitate, obtain APGAR at 1 and 5 minutes
  52. 52. Resuscitation Step 2: Supplemental Oxygen – Blow oxygen across the newborn’s face – Will not cause toxicity – Do not withhold oxygen
  53. 53. Resuscitation Step 3: Ventilation – Ventilate if: HR < 100 bpm Apnea Persistent central cyanosis – Ventilate at 40-60 breaths per minute – Pop-off valve on BVM may need to be disabled
  54. 54. Resuscitation Intubate for the following conditions: – The bag-valve-mask unit does not work – Tracheal suctioning is required (such as in cases of thick meconium) – Prolonged ventilation will be required – A diaphragmatic hernia is suspected – Inadequate respiratory effort is found
  55. 55. Resuscitation Step 3: Chest Compressions – Initiate compressions if: The heart rate is less than 60 beats per minute – Compress lower half of the sternum Rate of at least 100 compressions per minute 30:2 compression/ventilation ratio – Reassess every 30 seconds
  56. 56. Chest Compressions
  57. 57. Intubation Considerations Always use an uncuffed endotracheal tube – 3.0 for normal newborn – 2.5 for premie Intubation bypasses glottic function and eliminates PEEP – Administer PEEP of 2–4 cm/H2O when ventilating Gastric Distension – Place oro or nasogastric tube – Oxygenate first
  58. 58. Resuscitation Step 4: Medications and Fluids – Vascular access can most readily be managed by using the umbilical vein 2 arteries 1 vein Vein is larger and thinner-walled – Other routes Endotracheal Peripheral veins Intraosseous – Fluid therapy should consist of 10 mL/kg bolus
  59. 59. The Umbilical Cord
  60. 60. Neonatal Resuscitation Drugs
  61. 61. Maternal Narcotic Use May complicate delivery Shown to produce low birth weight infants Such infants may demonstrate withdrawal symptoms: – Tremors, startles, decreased alertness, and respiratory distress Naloxone is the drug of choice – Within 4 hours of delivery – Avoid use in opiate addicted mother as acute withdrawal may occur
  62. 62. Neonatal Transport Distressed newborns should be transported on their side Transport to NICU from stabilizing facility may be required – If isolette unavailable, keep MICU warm and keep newborn warm © Ray Kemp/911 Imaging
  63. 63. Specific Neonatal Situations
  64. 64. Specific Neonatal Situations Meconium-Stained Amniotic Fluid Apnea Diaphragmatic Hernia Bradycardia Prematurity Respiratory Distress Hypovolemia Seizures Fever Hypthermia Hypoglycemia Vomiting Diarrhea
  65. 65. Meconium-Stained Amniotic Fluid Occurs in approximately 10–15% of deliveries Fetal distress and hypoxia can cause the passage of meconium into the amniotic fluid – Thick meconium is aspirated into the lungs in utero or with first breath – May produce respiratory distress Partial obstruction of some airways may lead to pneumothorax
  66. 66. Meconium-Stained Amniotic Fluid Intubation and suctioning may be necessary – Suction prior to stimulating newborn Suction at 100 cm/H2O or less – Repeat as necessary Ventilate following suction
  67. 67. Apnea Usually due to hypoxia or hypothermia; other causes include: – Narcotics or CNS depressants – Weakness of respiratory muscles – Septicemia – Metabolic disorders – CNS disorders Manage with tactile stimulation and ventilations, if necessary – Intubate if prolonged episode – Consider Narcan if suspected opiate involvement
  68. 68. Bradycardia Most commonly caused by hypoxia – Follow the procedures in the inverted pyramid Suctioning, positioning, administration of oxygen or ventilation, tracheal intubation, and maintain warmth Resist the temptation to treat bradycardia in a newborn with pharmacological measures alone – Epinephrine is drug of choice if unresponsive to measures above – NO ATROPINE
  69. 69. Prematurity An infant born prior to 37 weeks or weight ranging from 0.6 to 2.2 kg (1 pound, 5 ounces, to 4 pounds, 13 ounces) Greater risk of: – Respiratory suppression, head or brain injury caused by hypoxemia, changes in blood pressure, intraventricular hemorrhage, and fluctuations in serum osmolarity – Hypothermia
  70. 70. Prematurity Prematurity should not be a factor in short-term treatment Maintain airway and body temperature during transport
  71. 71. Respiratory Distress/Cyanosis Occurs most frequently in premature infants – Immature central respiratory control center – Easily affected by environmental or metabolic changes Assessment Findings – Tachypnea – Paradoxical breathing – Intercostal retractions – Nasal flaring – Expiratory grunt
  72. 72. Respiratory Distress/Cyanosis Management – Follow the inverted pyramid of treatment Pay attention to airway and ventilation Chest compressions, if indicated – Medications Sodium bicarbonate Dextrose – Maintain body warmth
  73. 73. Hypovolemia Leading cause of shock in newborns Signs of hypovolemia – Pale color – Cool skin – Diminished peripheral pulses – Delayed capillary refill, despite normal ambient temperature – Mental status changes – Diminished urination (oliguria)
  74. 74. Hypovolemia Management – Administer a fluid bolus and assess the infant’s response 10 mL/kg of an isotonic crystalloid solution Infant may often need 40–60 mL/kg of fluid – Do not use solutions containing dextrose
  75. 75. How much fluid was that?
  76. 76. 10 mL/kg
  77. 77. Seizures Usually indicate a serious underlying abnormality Types of Neonatal Seizures – Subtle – Tonic – Focal clonic – Multifocal – Myoclonic
  78. 78. Seizures Causes of neonatal seizures – Sepsis, fever, hypoglycemia, hypoxic-ischemic encephalopathy, metabolic disturbances, meningitis, developmental abnormalities, or drug withdrawal Management – Airway management and oxygen saturation – Anti-convulsant Benzodiazepine such as lorazepam (0.05 mg/kg) – Dextrose
  79. 79. Fever A rectal temperature of 38.0° C (100.4° F) or higher is considered fever – May be caused by life-threatening conditions such as pneumonia, sepsis, or meningitis Fever is the only sign of meningitis in the neonate Assessment Findings – Mental status changes (irritability/somnolence) – Decreased feeding – Skin warm to the touch – Rashes or petechiae
  80. 80. Petechiae
  81. 81. Fever Management – Ensure a patent airway and adequate ventilation – Administration of an antipyretic agent to a neonate is of questionable benefit
  83. 83. Hypothermia Common and life- threatening condition The increased metabolic demands can produce a variety of related conditions – Metabolic acidosis, pulmonary hypertension, and hypoxemia
  84. 84. Hypothermia Assessment findings – Pale color – Skin cool to the touch, particularly in the extremities – Acrocyanosis – Respiratory distress – Possible apnea – Bradycardia – Central cyanosis – Initial irritability – Lethargy in later stages
  85. 85. Hypothermia Management – Ensure adequate ventilations and oxygenation – Compressions, as necessary – Warm fluids through an IV fluid heater – Administration of Dextrose
  86. 86. Hypoglycemia More common in: – Premature or small-for-gestational-age (SGA) infants – The smaller twin – Newborns of a diabetic mother Infants with hypoglycemia may be asymptomatic – A blood glucose screening test of less than 45 mg/dL indicates hypoglycemia
  87. 87. Hypoglycemia Assessment Findings – Twitching or seizures – Limpness – Lethargy – Eye-rolling – High-pitched cry – Apnea – Irregular respirations – Possible cyanosis
  88. 88. Hypoglycemia Management – Management of the airway and ventilations – Compressions, if necessary – Administer dextrose (D10W or D25W) – Maintain warmth
  89. 89. Vomiting Uncommon during the first weeks of life – May be confused with regurgitation – Result of an abnormality Assessment Findings – Distended stomach, signs of infection, increased intracranial pressure, or drug withdrawal Management – Focus on ensuring a patent airway – Watch for bradycardia due to vagal stimulation
  90. 90. Diarrhea Can cause severe dehydration and electrolyte imbalances – Consider 5-6 stools a day normal Causes – Bacterial or viral infection – Gastroenteritis – Lactose intolerance – Phototherapy – Neonatal abstinence syndrome (NAS) – Thyrotoxicosis – Cystic fibrosis
  91. 91. Diarrhea Assessment Findings – Loose stools, decreased urinary output, and other signs of dehydration such as prolonged capillary refill time, cool extremities, and listlessness or lethargy Management – Maintenance of airway and ventilations, adequate oxygenation, and chest compressions – Consider fluid administration
  92. 92. Common Birth Injuries 2 to 7 of every 1,000 live births 2–3 percent of infant deaths Risk Factors
  93. 93. Common Birth Injuries Management – Protection of the airway, provision of adequate ventilation and oxygen, and, if needed, chest compressions – Newborns with birth injuries usually require treatment at specialized facilities
  94. 94. Cardiac Resuscitation, Post- resuscitation, and Stabilization The incidence of neonatal cardiac arrest is related primarily to hypoxia Risk factors include: – Bradycardia – Intrauterine asphyxia – Prematurity – Maternal drug use – Congenital diseases – Intrapartum hypoxemia
  95. 95. Assessment Findings – Peripheral cyanosis, inadequate respiratory effort, and ineffective or absent heart rate Management – Follow the inverted pyramid for resuscitation – Administer drugs or fluids according to medical direction – Maintain body temperature Cardiac Resuscitation, Post- resuscitation, and Stabilization
  96. 96. That’s It

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