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OB Emergencies. November 2010 CE Condell EMS System Objectives by Jeremy Lockwood, FF/PM Mundelein Fire Department Packet prepared by Sharon Hopkins, RN, BSN, EMT-P. Objectives. Upon successful completion of this module, the EMS provider will be able to:

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Ob emergencies l.jpg

OB Emergencies

November 2010 CE

Condell EMS System

Objectives by Jeremy Lockwood, FF/PM Mundelein Fire Department

Packet prepared by Sharon Hopkins, RN, BSN, EMT-P


Objectives l.jpg
Objectives

Upon successful completion of this module, the EMS provider will be able to:

  • 1. Identify appropriate standard precautions in the OB delivery setting.

  • 2. Identify progression of a normal pregnancy.

  • 3. Describe assessment of an obstetrical patient.

  • 4. Identify predelivery complications.

  • 5. Describe indications and signs of imminent delivery.

  • 6. Identify the stages of labor.


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Objectives cont’d

  • 7. List the contents of the OB kit

  • 8. Describe how to use the contents of the OB kit.

  • 9. Describe the steps in assisting delivery of the newborn.

  • 10. Describe care of the newborn baby.

  • 11. Describe APGAR scoring.

  • 12. Describe when and how to cut the umbilical cord.

  • 13. Describe the delivery of the placenta.

  • 14. Describe post delivery care of the mother.


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Objectives cont’d

  • 15. Describe abnormal deliveries and procedures.

  • 16. Identify and describe delivery complications.

  • 17. Describe meconium staining and its implication to the newborn.

  • 18. Review documentation components for discussed conditions.

  • 19. Given a manikin, demonstrate use of the OB kit.

  • 20. Demonstrate use of the meconium device.


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Standard Precautions

  • Anticipate the exposure to a large amount of blood and body fluids

  • Full protection is recommended

  • Don’t assume the absence or presence of disease just by appearances of the patient or situation


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Standard Precautions

Handwashing-

still most

effective

control

measure

around


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Just Protect Yourself!!!

  • Do what you can


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Normal Pregnancy Development

  • Ovulation and what follows

    • Release of an egg from ovary

    • Egg travels down fallopian tube toward uterus

    • Intercourse within 24-48 hours of ovulation could result in fertilization

    • Fertilization occurs in the fallopian tube

    • Fertilized egg will implant in the uterus and pregnancy begins


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Prenatal Development cont’d

  • Placental development

    • Approx 3 weeks after fertilization

    • Blood rich structure for the fetus

      • Transfers heat

      • Exchanges oxygen and carbon dioxide

      • Delivers nutrients

      • Carries away waste products

      • Endocrine gland

        • Secretes hormones for fetal survival

        • Secretes hormones to maintain pregnancy


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Placental Development cont’d

  • Protective barrier

  • Connected to the fetus via the umbilical cord

    • Flexible, rope-like structure

    • 2 feet in length; ¾″ diameter

    • Contains 2 arteries, 1 vein

      • 2 arteries return relatively deoxygenated blood to the placenta

      • 1 vein transports oxygenated blood to fetus



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Amniotic Sac

  • “Bag of waters”

    • Thin-walled membranous covering holds the amniotic fluid

      • Surrounds and protects fetus

      • Allows for fetal movement during development

  • Volume varies from 500 ml to 1000 ml

    • 500 ml = 1 pint = 2 cups

      • Premature rupture increases risk of maternal and fetal infection that could be life threatening


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Physiological Changes of Pregnancy

  • Due to:

    • Altered hormone levels

    • Mechanical effects of enlarging uterus

    • Increased uterine blood supply

    • Increasing metabolic demands on the maternal system


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Physiological Changes to the Systems

  • Reproductive system

    • Uterus becomes larger

    • Contains 16% of the mother’s blood during pregnancy

  • Respiratory system

    • Increase in oxygen demands

    • 20% increase in oxygen consumption

    • 40% increase in tidal volume

    • Slight increase in respiratory rate

    • Diaphragm pushed upward


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Physiological Changes to the Systems

  • Cardiovascular system

    • Cardiac output increases

    • Maternal blood volume increases by 45%

    • More plasma increase than red blood cells so relative anemia develops

    • Maternal heart rate increases by 10-15 beats

    • B/P decreases slightly 1st & 2nd trimesters

    • Supine hypotensive syndrome when mother lies supine

      • Especially by 5 months of pregnancy


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Physiological Changes to the Systems

  • Gastrointestinal system

    • Nausea & vomiting are common in 1st trimester

    • Delayed gastric emptying (due to slowed peristalsis)

    • Bloating and constipation common


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Physiological Changes to the Systems

  • Urinary system

    • Renal blood flow increases

    • More likely to have glucose spilling into urine

    • Bladder displaced anteriorly & superiorly increasing likelihood of rupture during trauma

    • Urinary frequency is common especially 1st trimester


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Physiological Changes to the Systems

  • Musculoskeletal system

    • Pelvic joints loosened causing waddling gait

    • Center of gravity shifts with enlarging uterus

    • Postural changes taken to accommodate for increased anterior growth

      • Increased complaints of low back pain


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Obstetrical Assessment

  • Need to determine if delivery is imminent or if there is time to transport

  • Remain calm (at least on the outside!)

  • Ask a few questions

    • Basically direct or closed ended questions – requiring a simple answer in few words

  • Perform a visual examination

  • Evaluate vital signs

  • Remain calm (at least on the outside!)


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OB Assessment Questions

  • Expected due date

    • The more premature, the smaller the birth weight and the less mature the lungs

  • Number of pregnancies

    • The higher the number, the quicker they tend to deliver

  • Length of labor

    • 1st pregnancies can take up to 16-17 hours

    • Subsequent deliveries tend to shorten from the 1st one


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OB Assessment Questions

  • If bag of waters have ruptured or are intact

    • Once ruptured, delivery tends to progress faster

    • Once ruptured, must be evaluated due to increase risk of infection especially if not delivered within 24 hours

  • Feeling of having to move their bowels

    • This is from pressure of the fetal head moving through the birth canal


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OB Visual Examination

  • Gain rapid rapport with the mother

  • Disrobe the under garments

  • Visually inspect the perineum

    • Check for crowning or bulging

      • The appearance of the presenting part at the vaginal opening

      • Prepare for imminent delivery if crowning

      • Best to check during a contraction

    • Check for blood loss

    • Check for other parts – fingers, toes, cord


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OB Assessment - Contractions

  • Place gloved palm on mother’s abdomen

  • Contraction duration

    • Time from the beginning of one contraction (uterus tightens) to the end (when uterus relaxes)

  • Contraction interval or frequency

    • Time from the start of one contraction to the beginning of the next one

    • Includes contraction and rest intervals


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OB Assessment – Vital Signs

  • Routine vital signs are taken

  • Remember physiological changes of pregnancy:

    • Blood pressure, after initial drop, is near normal in 3rd trimester

    • Heart rate up by 10-15 beats over normal

    • Only slight increase in respiratory rate


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Supine Hypotensive Syndrome

  • Caused by the weight of an enlarging uterus pinching off blood supply in the inferior vena cava

  • Decreases blood return to the heart

  • Decreases stroke volume pumping out of the heart

  • Especially after 5 months transport the mother tilted or turned preferably toward the left


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Imminent Delivery

  • Crowning is present

  • Contractions last 30 – 60 seconds and are 2 - 3 minutes apart

  • Mother has the urge to move her bowels or she says “I HAVE TO PUSH!!!”

  • Bag of waters has ruptured


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Stages of Labor

  • 3 stages of labor

  • 1st stage – dilatation stage

    • Begins with onset of true labor contractions

    • Ends with complete dilatation (10 cm/4″) & effacement (100%) of the cervix

      • Is manually confirmed in the hospital setting, not field

    • Stage can last approximately 8-10 hours for first labor to about 5-7 hours in multipara


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1st Stage of Labor cont’d

  • Contractions

    • Early in this stage are usually mild

      • Duration of 15-20 seconds

      • Frequency every 10-20 minutes apart

    • Increase in intensity as labor progresses

      • Duration of 60 seconds

      • Frequency every 2-3 minutes

  • Care is supportive at this point in time

    • Allow husband/significant other to time contractions

      • Keeps them busy, involved, and out of the way


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Timing Contractions

  • Duration

    • Timed in seconds

    • Timed from the beginning of the contraction to the end the contraction

    • Contractions lasting 60-90 seconds indicate imminent delivery

  • Frequency

    • Timed in minutes

    • Timed from the beginning of one contraction to the beginning of the next contraction

    • Contractions coming every 2-3 minutes indicate imminent delivery


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2nd Stage of Labor – Expulsion Stage

  • Begins with complete dilatation of cervix

  • Ends with delivery of fetus

  • Can last 50 – 60 minutes for the first delivery

  • Can last 30 minutes for future deliveries

  • Contractions strong, uncomfortable

    • Duration is 60-75-90 seconds

    • Contraction every 2 – 3 minutes


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2nd Stage of Labor cont’d

  • Mother has urge to bear down

  • Mother has back pain

  • Crowning is evident on visual inspection

  • Membranes usually rupture now

  • OB kit should be open by now

  • Be ready to support mother in delivery


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OB Kit

  • May be supplied in a variety of packaging

  • If extra supplies are needed, where are they kept?

  • Always anticipate using the OB kit

    • Better to have it available and not need it / use it than need it and not have it

  • Kits are usually packaged with disposable products

  • Practice Standard Precautions

    • Goggles, mask, gloves, gown



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Cord Clamps

  • FYI

    • If not used for a period of time, it has been reported that the OB clamps become brittle and can break

    • There is no hurry to clamp and cut a cord

    • If you transport the mother and baby with the cord intact, so be it

      • The hospital will take care of clamping and cutting the cord


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Delivery of the Newborn

  • As soon as the head and neck emerges, check for nuchal cord and begin to suction mouth then nose with bulb syringe

    • Depress bulb first before insertion of mouth, then nose

  • To facilitate delivery of upper shoulder, gently guide head downward

  • Support and lift head and neck slightly to deliver lower shoulder

  • Rest of infant delivers passively and very quickly


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Newborn At Delivery

  • They’ll grow into being a Gerber baby!


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Care of the Newborn cont’d

  • Hold on tight

    • Infant is slippery due to cheesy covering and amniotic fluid

  • Note time of delivery and record on the infant’s run report

  • Stimulate the infant

    • Suctioning, rubbing the back, flicking at the soles of the feet, drying off


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Suctioning the Newborn

  • Suction mouth then nose always in that sequence

  • Infant’s are obligate nasal breathers

  • Want to clear the airway before stimulating them to take a breath

  • Always depress bulb syringe and THEN place into infant’s mouth, then nose


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Care of the Newborn

  • Continue to suction mouth then nose

  • Spontaneous respirations should begin within 15 seconds after stimulation

  • If no respirations, begin BVM support at 30-40 breaths per minute

  • If pulse < 60 or between 60-80 and not improving, begin CPR

  • Obtain 1 minute APGAR (ie: record as 9/10)


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APGAR Score

  • Assesses newborn adjustment to extrauterine life

  • 1 minute score indicates need for resuscitation

  • 5 minute score predicts mortality and neurological deficits

  • Order of importance

    • Heart rate

    • Respiratory rate

    • Muscle tone

    • Reflex irritability

    • Finally color – least helpful; most visible/obvious



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Care of the Umbilical Cord

  • Clamp and then cut the cord after pulsations have stopped & cored is limp

    • Clamps placed 8″ from infant’s navel 2″ apart

    • Watch the end of the cord for leakage of blood

    • If leaking, add additional clamps moving toward the infant’s navel



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FYI – What About Cord Blood?

  • Obtained in the hospital within 10-15 minutes of delivery

  • Collected from umbilical cord after delivery and after care of newborn provided

  • Consists of stem cells that can transform into variety of healthy tissue

  • Useful to treat leukemia, lymphomas and other diseases

  • Fee charged for private donations and storage

  • NOT the same as embryonic stem cells


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Care of The Newborn cont’d

  • Continue to dry and wrap infant to preserve body temperature

  • Obtain 5 minute APGAR (ie: record as 10/10)

  • Continue to suction mouth then nose as needed

  • Keep infant in head downward position

    • Facilitates drainage from the airway

  • Assess vital signs of infant (is it time to retake mom’s?)


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Care of the Newborn

  • Infant in head down (and side lying) position

  • Hat placed to minimize heat loss

  • Cord clamped and cut


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3rd Stage of Labor – Placental Stage

  • Begins immediately after delivery of infant

  • Ends with delivery of placenta

  • Do not need to delay transport waiting for placenta to deliver

  • Signs of separation

    • Gush of blood from vagina

    • Change in size, consistency, shape of uterus

    • Lengthening of cord protruding from vagina


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Delivery of the Placenta

  • Allow to deliver spontaneously

  • May take up to 20 minutes after infant delivered to deliver the placenta

  • If delivered at the scene, collect and transport with the patient

    • Inspected for retained placental parts

  • For excessive external bleeding, apply dressings externally

  • For excessive vaginal bleeding, uterine massage AFTER placenta is delivered




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Post Partum Care of the Mother

  • What is post partum hemorrhage?

    • Loss of more than 500 ml of blood (1 pint; 2 cups)

    • To control, massage uterus AFTER delivery of placenta

      • Will feel uncomfortable to the mother

      • Massage until the uterus feels firm

      • Recheck every 5 minutes

      • Check your rate of IV fluids

      • Are you administering oxygen?


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Fundal Massage

  • Performed AFTER delivery of placenta

  • Uterus should be firm

  • Place one hand immediately above symphysis pubis

  • Place one hand on uterine fundus (top)

  • Massage with 2 hands


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Post Partum Care

  • Congratulate the new parents!

  • Inform them if it is a boy or girl

  • If possible, offer the mother a towel to wipe her face and hands

  • By holding the wrapped infant, the mother’s body heat will help maintain the body heat of the infant


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Abnormal Delivery Presentations

  • If you are prepared for the worst and get the best, hidden bonus!!!


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Breech

  • 4% of term deliveries

  • Head is not the presenting part!!!

  • Transport immediately to closest ED with OB capacity

  • Higher risk to infant and mother

  • Potential need for C-section


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To Facilitate Delivery of Breech

  • As soon as legs deliver, support infant’s body

  • If accessible, palpate cord for pulsations

  • Attempt to loosen cord to create slack

  • After torso & shoulders deliver, gently sweep arms down

    • If face down, gently elevate legs & trunk to facilitate delivery of head

    • DO NOT HYEREXTEND HEAD

    • DO NOT PULL ON INFANT


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If Head Does Not Deliver in 30 Seconds

  • Reach 2 gloved fingers into vagina to locate newborn’s mouth

  • Push vaginal wall away from newborn’s mouth

  • Keep fingers in place and transport immediately

  • Call report ASAP

  • Keep delivered portion of infant warm & dry

  • If infant delivers, anticipate distressed newborn

    • Anticipate maternal hemorrhage


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Footling Breech – Not a Field Delivery

  • If one foot is visible, wonder “where is the rest of the baby?”

  • Encourage mother to breath through a contraction so she does not add to the pushing

  • Keep infant’s extremity warm

  • Rapid transport

  • Early report


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Prolapsed Cord

  • Cord is delivering before the infant

  • Infant’s oxygen and blood supply will be compromised

  • Need to take pressure off the cord

  • Don’t want mother pushing with contractions

    • Have mother breath through the contractions


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Prolapsed Cord

  • True emergency

  • High fetal death rate

  • Must immediately recognize the emergency

  • Rapid transport

  • Place gloved fingers into vagina between pubic bone and presenting part

  • Cover exposed cord with moist saline dressing


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Placenta Previa

  • Abnormal implantation of placenta on lower half of uterine wall

  • Partial or complete blockage of cervical opening

  • Hallmark: Painless, bright red vaginal bleeding

  • Uterus usually soft


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Abruptio Placenta

  • Premature separation of normally implanted placenta from the uterine wall

  • 20-30% fetal mortality rate

  • Bleeding concealed

  • Sudden, sharp, tearing pain and stiff, boardlike abdomen

  • Life threatening OB emergency

  • Support mother’s oxygenation

  • Transport tilted or lying left


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Meconium Staining

  • Meconium is fetal stool

  • Release by the fetus may indicate intrauterine stress, like hypoxia

  • If observed, prepare for a distressed baby who may need ventilatory support

  • Fortunately, most meconium can be dealt with by using a bulb syringe


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Meconium Aspiration Equipment

  • Intubation equipment

    • Blade, handle

    • 2 ET tubes

  • Meconium aspirator

  • Suction

    • Suction turned down to 80mmHg


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Meconium Aspiration Procedure

  • Meconium aspirator connected to suction tubing

  • Intubate in usual manner

  • May not visualize landmarks due to meconium

  • Quickly connect aspirator to ET tube

  • Withdraw in twisting fashion while suctioning

    • Minimize suction time to 2 seconds or less

  • If time, repeat at least once more


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Meconium Aspirator

  • Time available to intervene is minimal

  • Must be prepared and move fast

While running

slide show,

left click

anywhere on

screen at right

to play video


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Multiple Births

  • Prepare for more than one delivery

  • Where is your extra equipment?

  • Expect smaller birth weight infants

    • Poorer ability to conserve body heat

    • Immature respiratory system

    • Need for the smallest equipment you carry


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Stressed Newborn

  • Infant flaccid, no muscle tone

  • Heart rate < 100

    • If < 60 begin chest compressions

  • Apneia or respiratory distress

    • Newborn respiratory rate 40-60 per minute

    • Support ventilations via BVM

      • One breath every 3 seconds

      • Just enough volume to make chest rise and fall


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Documentation

  • After delivery you have 2 patients

  • Complete run report for both the mother and the newborn

  • Include time of delivery

  • Note the one person who actually “caught” the infant at time of delivery

  • Keep mother’s information on the mother’s report; infant’s on the infant’s

  • Apply wristbands to both mother and newborn


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Case Scenario #1

  • You have arrived on the scene.

  • 27 year-old woman says she is in labor

  • What are the indications for imminent labor?

    • Urge to move bowels

    • Urge to push

    • Crowning

    • Ruptured bag of waters

    • Contractions every 2-3 minutes lasting 60-90 seconds


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Case Scenario #1

  • What questions do you need to ask specific to mother being in labor?

    • What number pregnancy is this?

    • What is her due date?

    • What are her contractions like?

    • Does she have the urge to push?

    • Is her bag of waters intact or broken?

    • Is she aware of any complications?


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Case Scenario #1

  • Describe the exam you need to perform

    • Visual inspection of perineum

      • Looking for crowning

      • Looking for abnormal presentation – fingers or toes, anything not expected

      • Looking for a prolapsed cord

      • Checking for blood loss

    • Evaluate contraction duration and frequency


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Case Scenario #2

  • You have responded to the scene of a 34 year-old mother in labor

  • Upon visual inspection, you note flecks of meconium in the leaking amniotic fluid

    • What does this indicate?

      • Anticipate a distressed infant

      • The infant will need gentle, aggressive airway care with the bulb syringe and possibly the meconium aspirator


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Case Scenario #2

  • What equipment is necessary?

    • Bulb syringe

    • Intubation equipment

      • Blade

      • Handle

      • ETT – 2 available (if the first one is clogged with meconium)

      • Stylet

      • Suction tubing

    • Meconium aspirator


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Case Scenario #2

  • What adjustment needs to be made with the suction when using the meconium aspirator?

    • Suction needs to be turned down to 80 mmHg

      • Suction generally set at 300 mmHg for the adult population

    • Limit suctioning to less than 2 seconds


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Case Scenario #3

  • You are on the scene for a 17 year-old in labor

  • Upon visual inspection, you note a prolapsed cord

  • What interventions do you take?

    • Immediately place gloved fingers into the vagina to take pressure off the cord

    • Place the mother in the knee-chest position

    • Provide rapid transport with early report

  • End of this case discussion; move to next case


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Case Scenario #4

  • You are on the scene of a 2 car collision

  • One of the patients is 16 years-old and is 6 months pregnant

  • What would be the recommended position if transported?

    • Lying or tilted left to keep pressure off vena cava

  • Can this patient sign a release if she wants to?

    • She is emancipated and can sign a release

    • If she remains the parent after delivery, she remains emancipated

  • End of case discussion; move to next case


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Case Scenario #5 - Documentation

  • What’s right? What’s wrong/missing?

  • MVC –this is what’s provided:

    • Deformity to steering wheel; windshield starred

    • Extrication took 15 minutes

    • Patient complained of back pain; able to move upper extremities

    • Swelling noted to left upper quadrant


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Case Scenario #5

  • What’s right regarding documentation?

    • Description of damage to car

    • Need and length of time for extrication

    • Patient complaints listed

    • Visual inspection result to abdomen


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Case Scenario #5

  • What’s wrong/missing?

    • Is there any other information from the accident available or not?

      • Speed; what was hit or what hit car

      • Location of occupant in car

    • More descriptive of head to toe assessment

      • Distal CMS with back pain

      • Movement of lower extremities

      • Palpation results of abdomen


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Case Scenario #5

  • What does SMV’s stand for?

    • Sensation, movement, vascular

  • What does CMS stand for?

    • Circulation, motor, sensation

  • How do you test for them (yes, they are the same)?

    • Feel for pulses

    • Ask the patient to move a distal digit

    • Ask the patient if they can feel a touch that they are not staring at


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Case Scenario #6 - Documentation

  • What’s right? What’s wrong/missing?

  • 78 year-old with chest pain – this is what’s provided

    • Onset at 0800 while watching TV

    • Not relieved with rest or 2 Nitroglycerin tablets

    • 8/10 pain scale

    • EKG sinus rhythm

    • 12 lead done

    • IV, O2, Aspirin and nitroglycerin given


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Case Scenario #6

  • What’s right regarding documentation?

    • Onset – what patient was doing

    • Palliation/provocation

    • Severity

    • Time of onset

    • Care provided

    • Rhythm strip results

    • 12 lead obtained

    • Interventions appropriate


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Case Scenario #6

  • What’s wrong/missing?

    • OPQRST not complete

      • Missing quality of chest pain in patient’s own words

      • Missing if the pain radiates or not

    • Was any ST elevation observed on 12 lead?

    • Was 12 lead faxed to Medical Control?



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Case Scenario #7 – Acute MIST Elevation I, aVL, V2, V3, V4, V5, V6



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Case Scenario #8 – Acute MI ST Elevation II, III, aVF

  • Hold nitroglycerin until consult with Medical Control (hypotension a possibility with inferior wall MI)


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Hands-on Practice II, III, aVF

  • Practice with contents of OB kit

  • Practice positioning newborn in head down position

  • Practice using the bulb syringe to clear first the mouth then the nose

  • Paramedics to use the meconium aspirator

    • Practice in pairs to become most efficient with time


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Bibliography II, III, aVF

  • American Academy of Pediatrics. Pediatric Education for Prehospital Professionals 2nd Edition. 2006.

  • American Academy of Pediatrics. Neonatal Resuscitation. 2000.

  • Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles and Practices. Prentice Hall. 2009.

  • Limmer, D., O’Keefe, M. Emergency Care 10th Edition. Brady. 2005.

  • Region X SOP, March 2007; amended January 1, 2008.


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