OB Transport Chuck Gipson MA NRP / CCP

Quality / Education Manager

MEDIC EMS

Objectives

To safely Transport OB Patients

Discussion of OB concerns

Overview of OB medications

Neonatal care equipment

Baby delivery

Know your Protocols

When to stay

When to go

When to call for help

When to panic

Fetal Development

Lets travel through time

1st Lunar Month

Foundations form for the skin, bones, lungs, GU System and Nervous system

Arm and leg buds begin to develop

Eyes, nose, and ears begin to develop

2nd Lunar Month

Brain development

Gender differentiation begins

Bones begin to ossify

3rd Lunar Month

Fingers and toes are distinct

Placenta is completely formed

Fetal circulation is complete

4th Lunar Month

Gender is differentiated

Kidneys secrete urine

Heartbeat is present

Nasal septum and palate are formed

5th Lunar Month

Fetal movements are felt by mother

Heart sounds detectable with a Doppler

6th Lunar Month

Skin appears wrinkled

Eyebrows and fingernails form

7th Lunar Month

Skin is red

Pupillary membrane disappears from the eyes

Considered viable if born

8th Lunar Month

Eyelids open

Fingerprints are set

Vigorous movement

9th Lunar Month

Subcutaneous fat develops and fills out skin

Amniotic fluid begins to decrease

10th Lunar Month

Skin is smooth

Eyes are uniformly slate colored

Bones of the skull are ossified and nearly together at the sutures

Develops antibodies

10th Lunar Month????

Yes 10 lunar months

They are only 28 day months

40 weeks = 280 days /7days

Physiologic Changes

During pregnancy

Cardiac output increases 30%

Pulse increases 15-20 BPM

BP increases 10-15 mmHg

Tidal volume increases 30-40%

Blood cells increase 30% plasma volume increases 50%

Psychologic Changes

Anyone want to go there?

Knowledge of problems

Pre-eclampsia / Eclampsia

Placenta Previa

Placental Abruption

Gestational diabetes

Premature rupture of membranes /

Preterm labor

Pre-Eclampsia / Eclampsia

Pregnancy induced hypertension

About 5% of pregnancies

Increased risk of teenage and >35 yo

Defined by a systolic increase of 35 mmHg or a diastolic of 15 mmHg

140/90 If no baseline

Eclampsia Assessment

Hypertension

Peripheral edema

Headache

Visual disturbances

Pulmonary edema

Seizures

Most common in last 10 weeks

Eclampsia Treatment

IV Large bore

Oxygen

If seizure Versed 5 mg IV

If seizures immanent give Magnesium 2-5 gm diluted in 100ml NS slow IV

(usually need an order)

Placenta Previa

Abnormal implantation of placenta over cervical opening

Generally appears 7th month or after

1 of every 250 pregnancies

Multi parity, previous previa, increased age

Previa Assessment

Vaginal bleeding

May be at onset of labor

Never do a vaginal exam

Placental abruption

Pulling away of placenta from cervical wall

1 of 120 pregnancies

Results in 20-30% fetal mortality

Maternal mortality rare

Abruption Assessment

Vaginal bleeding without pain in a peripheral abruption

Sudden sharp tearing pain without bleeding but with a rigid abdomen in a central abruption

Severe bleeding and maternal hypotension in a complete abruption

Gestational Diabetes

Diabetes with onset during pregnancy

4 of 100 pregnancies

First 20 weeks of gestation

Blood sugar may be increased or decreased

Can be diet controlled

Treat as any other diabetic patient

Premature rupture of membranes

Rupture of membranes prior to 38 weeks

Could be caused by placental problems, multiple gestations, excessive amniotic fluids, trauma, maternal chronic medical problems.

Occurs in 7-10% of pregnancies

Braxton-Hicks contractions

Intermittent uterine contractions starts as early as 13 weeks

Called false labor

No cervical effacement

As they become more frequent and regular is considered true labor

Non-differentiated from true labor

Act of stopping labor is Tocolysis

1. Use sedation Narcotics (Morphine or Fentanyl), Benzodiazepines (Lorazepam, Diazepam)

2. 1,000 ml fluid bolus reduces the production of ADH secreted by the pituitary gland(same place oxytocin is produced) Oxytocin = uterine contraction

3. Beta agonist (Terbutaline, Magnesium sulfate) inhibit smooth muscle contractions

Research is looking at Calcium Channel Blockers

Transport on Meds

Must have physician’s order

Know the meds actions, side effects, precautions, end points, therapeutic modalities

Must monitor Cardiac rhythm

Two IV’s preferable

Ave radio or phone contact

Breech DeliveryPresenting part is the buttocks or legs.

Breech delivery is usually slow, giving you time to get to the hospital.

Prolapsed cord

Pain Management

Nitrous oxide preferred

Narcotics (Morphine, fentanyl) OK

Narcotics may cause hypotension of respiratory depression

Position for transport

Left lateral recumbent, especially after 24 weeks

Position of comfort

Avoid supine hypotensive syndrome

Why?

Questions to ask

Number of pregnancies?

Number of live births?

Prenatal care?

Complications?

Contractions? How many/ How far apart?

Urge to push?

Membranes ruptured?

Stages of labor

First- onset of labor to full cervical dilation

Second- full cervical dilation to delivery

Third- baby delivery to placental delivery

Temperature

If you aren’t sweating its too cold

Keep them covered up

Equipment

OB Kits

Bulb syringe

Cord clamps

Scalpel / scissors

PPE

APGAR scoring tool

Equipment

Broselow bag

Suction

Airways

Meconium aspirator

Warmth

Multiple Births

PLAN B,C,D

Extra crews

Extra equipment

Where are we going

What can they handle

Surroundings

Already born

Have to deliver

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Prepare for delivery

You gotta look

What do you see?

Delivering or driving?

Gravida Para #?

Water broken?

Contractions? Frequency and duration?

After delivery

Keep warm

Maintain altitude

Baby to breast

Clamp and cut cord

Transport

Summary

Have knowledge of OB related problems

Know how to care for an OB patient

If all else fails drop back punt and play defense!

Be prepared for delivery

Know how to deliver

Pediatric TraumaChuck Gipson

MA, NRP / CCP

Motor Vehicle Crashes are the number one cause of mortality in children under the age of one.

In the 0-14 year olds age group

5% of all fatalities

9% of all injuries

8% of all vehicle occupant injuries

In a 30 MPH head on crash the forward lateral force is 30 times the weight of an object.

Ex: a 150 pound person becomes 4500 pounds of forward force.

If ejected from a crash the chances of fatality are 13 times greater than if the occupant remains in the vehicle.

Car Seat Safety Timeline

1968 First seatbelts in American cars

1970 First protective infant seats

1978 First state mandatory child restraint law

1981 First car seat standard test

1985 Child restraint laws in all 50 states

1990 Child restraint use 40%

1999 Tethers implemented

2002 LATCH mandatory

Iowa has an 80% child restraint compliance rate and a 81.6% misuse rate.

Laws

Most parents will follow the law but will not go above and beyond.

SO WHAT ARE THE LAWS?

321.446 Child restraint devices.

1. a. A child under one year of age and weighing less than twenty pounds who is being transported in a motor vehicle subject to registration, except a school bus or motorcycle, shall be secured during transit in a rear-facing child restraint system that is used in accordance with the manufacturer’s instructions.b. A child under six years of age who does not meet the description in paragraph “a” and who is being transported in a motor vehicle subject to registration, except

a school bus or motorcycle, shall be secured during transit by a child restraint system that is used in accordance with the manufacturer’s instructions.2. A child at least six years of age but under eighteen years of age who is being transported in a motor vehicle subject to registration, except a school bus or

motorcycle, shall be secured during transit by a child restraint system that is used in accordance with the manufacturer’s instructions or by a safety belt or safety harness of a type approved under section 321.445.

3. This section does not apply to the following:a. Peace officers acting on official duty. b. The transportation of children in 1965 model year or older vehicles, authorized emergency vehicles, buses, or motor homes, except when a child is transported

in a motor home’s passenger seat situated directly to the driver’s right. c. The transportation of a child who has been certified by a physician licensed under chapter 148 as having a medical, physical, or mental condition that prevents

or makes inadvisable securing the child in a child restraint system, safety belt, or safety harness.d. A back seat occupant of a motor vehicle for whom no safety belt is available because all safety belts are being used by other occupants or cannot be used due to

the use of a child restraint system in the seating position for which a belt is provided.4. A person who violates this section is guilty of a simple misdemeanor punishable as a scheduled violation under section 805.8A, subsection 14, paragraph “c”.

Violations shall be charged as follows:a. An operator who transports a passenger under fourteen years of age in violation of subsection 1 or 2 may be charged with a violation of this section.b. If a passenger fourteen years of age or older is unable to properly fasten a seatbelt due to a temporary or permanent disability, an operator who transports such

a person in violation of subsection 2 may be charged with a violation of this section. Otherwise, a passenger fourteen years of age or older who violates subsection 2 shall be charged in lieu of the operator.c. If a child under fourteen years of age, or a child fourteen years of age or older who is unable to fasten a seatbelt due to a temporary or permanent disability, is

being transported in a taxicab in a manner that is not in compliance with subsection 1 or 2, the parent, legal guardian, or other responsible adult traveling with the child shall be served with a citation for a violation of this section in lieu of the taxicab operator. Otherwise, if a passenger being transported in the taxicab is fourteen years of age or older, the citation shall be served on the passenger in lieu of the taxicab operator.

5. A person who is first charged for a violation of subsection 1 and who has not purchased or otherwise acquired a child restraint system shall not be convicted if the person produces in court, within a reasonable time, proof that the person has purchased or otherwise acquired a child restraint system which meets federal motor vehicle safety standards.

6. Failure to use a child restraint system, safety belts, or safety harnesses as required by this section does not constitute negligence nor is the failure admissible as evidence in a civil action.

7. For purposes of this section, “child restraint system” means a specially designed seating system, including a belt-positioning seat or a booster seat, that meets federal motor vehicle safety standards set forth in 49 C.F.R. § 571.213.84 Acts, ch 1016, §1; 86 Acts, ch 1069, §1; 2000 Acts, ch 1133, §11; 2001 Acts, ch 132, §11; 2001 Acts, ch 137, §5; 2004 Acts, ch 1113, §2, 3; 2005 Acts, ch 8, §32; 2008 Acts, ch 1088, §123; 2010 Acts, ch 1186, §8, 9

Subsections 2 and 3 amended

Subsection 4 stricken and rewritten

Iowa

All children under the age of 6 must be restrained in a proper child restraint in the back seat

Children between 6 and 18 must be restrained in a proper restraint per manufacturer guidelines.

And it is not a primary law.

For Now

Is it legal to ride in the bed of a truck or on a motorcycle?

Why Kids in the back even if not injured and riding along?

Airbags.

Air bags are deployed at approx125 MPH.

Second generation airbags are deployed at approx 100 MPH.

Both will cause significant injuries to children.

Don’t get too bogged down with all of this information. This is not a car seat technician class, just awareness of potential injuries that may be present for children.

Why do I need to know this?

Approximately six million children are transported in ambulances every year in the United States.

Ambulances are not standard passenger vehicles

How much training have you had in securing a child in an ambulance?

Do you have a policy on how and whento do this?

Do you carry the appropriate equipment to do the job right?

Current Federal regulations and testing requirements for child restraints do not apply to emergency ground ambulances.

Car seats in ambulances

Certain practices can significantly reduce the potential for injury.

The Do’s and Don’ts

Of child transportation in emergency vehicles

DO

Drive cautiously at safe speeds

Tightly secure all equipment

Ensure that all restraint systems are used by patients and crew

Try to transport non-patient children in other vehicles when possible

DON’T

Drive at high speeds with sudden acceleration and deceleration with sharp turns

Leave equipment unsecured in moving vehicles

Allow patients crew to ride unrestrained

Allow family to ride unrestrained

Allow the child to ride in the parents arms

Do you use the seat of the patient?

Car seats are only tested for one crash and they were just in it.

Child safety seats are not immobilization devices.

Traumatic children should be restrained in a traditional manner

Why is this important?

Questions?

Questions?

Thank You

Thank You!