ob emergencies l.
Download
Skip this Video
Download Presentation
OB Emergencies

Loading in 2 Seconds...

play fullscreen
1 / 90

OB Emergencies - PowerPoint PPT Presentation


  • 426 Views
  • Uploaded on

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:

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'OB Emergencies' - oya


Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
ob emergencies

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
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.
objectives cont d
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.
objectives cont d4
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.
standard precautions
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
standard precautions6
Standard Precautions

Handwashing-

still most

effective

control

measure

around

normal pregnancy development
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
prenatal development cont d
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
placental development cont d
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
amniotic sac
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
physiological changes of pregnancy
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
physiological changes to the systems
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
physiological changes to the systems15
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
physiological changes to the systems16
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
physiological changes to the systems17
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
physiological changes to the systems18
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
obstetrical assessment
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!)
ob assessment questions
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
ob assessment questions21
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
ob visual examination
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
ob assessment contractions
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
ob assessment vital signs
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
supine hypotensive syndrome
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
imminent delivery
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
stages of labor
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
1 st stage of labor cont d
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
timing contractions
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
2 nd stage of labor expulsion stage
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
2 nd stage of labor cont d
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
ob kit
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
cord clamps
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
delivery of the newborn
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
newborn at delivery
Newborn At Delivery
  • They’ll grow into being a Gerber baby!
care of the newborn cont d
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
suctioning the newborn
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
care of the newborn
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)
apgar score
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
care of the umbilical cord
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
fyi what about cord blood
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
care of the newborn cont d45
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?)
care of the newborn46
Care of the Newborn
  • Infant in head down (and side lying) position
  • Hat placed to minimize heat loss
  • Cord clamped and cut
3 rd stage of labor placental stage
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
delivery of the placenta
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
post partum care of the mother
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?
fundal massage
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
post partum care
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
abnormal delivery presentations
Abnormal Delivery Presentations
  • If you are prepared for the worst and get the best, hidden bonus!!!
breech
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
to facilitate delivery of breech
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
if head does not deliver in 30 seconds
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
footling breech not a field delivery
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
prolapsed cord
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
prolapsed cord60
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
placenta previa
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
abruptio placenta
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
meconium staining
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
meconium aspiration equipment
Meconium Aspiration Equipment
  • Intubation equipment
    • Blade, handle
    • 2 ET tubes
  • Meconium aspirator
  • Suction
    • Suction turned down to 80mmHg
meconium aspiration procedure
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
meconium aspirator
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

multiple births
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
stressed newborn
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
documentation
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
case scenario 1
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
case scenario 171
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?
case scenario 172
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
case scenario 2
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
case scenario 274
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
case scenario 275
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
case scenario 3
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
case scenario 4
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
case scenario 5 documentation
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
case scenario 5
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
case scenario 580
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
case scenario 581
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
case scenario 6 documentation
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
case scenario 6
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
case scenario 684
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?
case scenario 8 acute mi st elevation ii iii avf
Case Scenario #8 – Acute MI ST Elevation II, III, aVF
  • Hold nitroglycerin until consult with Medical Control (hypotension a possibility with inferior wall MI)
hands on practice
Hands-on Practice
  • 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
bibliography
Bibliography
  • 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.