Drill of the Month Drill of the Month Developed by Gloria Bizjak Assessing and Assisting Childbirth.

Drill of the MonthDrill of the Month

Drill of the MonthDrill of the MonthDeveloped by Gloria BizjakDeveloped by Gloria Bizjak

Assessing and Assisting Assessing and Assisting ChildbirthChildbirth

22Drill of the MonthDrill of the Month


Student Performance Objective:Student Performance Objective:

Given information, resources, and opportunity Given information, resources, and opportunity for discussion and practice, EMTs will be able to:for discussion and practice, EMTs will be able to:• List and define childbirth structures and termsList and define childbirth structures and terms• Describe the stages of laborDescribe the stages of labor• List the steps of evaluationList the steps of evaluation•Describe potential complications and Describe potential complications and emergenciesemergencies•List and demonstrate steps of labor and List and demonstrate steps of labor and delivery delivery EMTs will follow acceptable Maryland medical practice EMTs will follow acceptable Maryland medical practice and Maryland Medical Protocols for Emergency Medical and Maryland Medical Protocols for Emergency Medical Providers.Providers.



OverviewOverview Anatomical Structures and TermsAnatomical Structures and Terms Stages of LaborStages of Labor Steps of EvaluationSteps of Evaluation Labor and DeliveryLabor and Delivery Complications, Emergencies, and Complications, Emergencies, and

ManagementManagement Post Natal CarePost Natal Care


Anatomical Structures and Anatomical Structures and TermsTerms

StructuresStructures– Fetus: The developing babyFetus: The developing baby– Uterus (womb): A muscular organ in Uterus (womb): A muscular organ in

which the fetus developswhich the fetus develops– Amniotic sac: A membranous “bag of Amniotic sac: A membranous “bag of

waters” with 1—2 quarts of fluid in waters” with 1—2 quarts of fluid in which fetus floatswhich fetus floats Cushions and protects the fetus from injuryCushions and protects the fetus from injury Maintains a constant fetal body tempMaintains a constant fetal body temp Ruptures during laborRuptures during labor



StructuresStructures– Cervix: Narrow neck of uterus; dilates Cervix: Narrow neck of uterus; dilates

(widens or effaces) to allow infant’s head (widens or effaces) to allow infant’s head to emergeto emerge

– Mucous plug (bloody show): Like nasal Mucous plug (bloody show): Like nasal mucousmucous Forms at the neck of the cervixForms at the neck of the cervix Discharges as the cervix dilates and may go Discharges as the cervix dilates and may go

unnoticedunnoticed Usually tinged with blood as cervical vessels Usually tinged with blood as cervical vessels

rupturerupture

– Vagina: Birth canalVagina: Birth canal



StructuresStructures– Perineum: Area between vagina and anus; Perineum: Area between vagina and anus;

may tear during birthmay tear during birth– Placenta: Exchange organPlacenta: Exchange organ

Carries oxygen, nutrients, other ingestions Carries oxygen, nutrients, other ingestions (meds, drugs, alcohol) to fetal circulation from (meds, drugs, alcohol) to fetal circulation from mothermother

Carries carbon dioxide, wastes from fetal Carries carbon dioxide, wastes from fetal circulation to maternal circulation through cordcirculation to maternal circulation through cord

– Afterbirth: Placenta, amniotic sac, tissuesAfterbirth: Placenta, amniotic sac, tissues– Umbilical cord: Connects placenta to fetus; Umbilical cord: Connects placenta to fetus;

contains two arteries, one veincontains two arteries, one vein



TermsTerms– Dilation: Cervical widening measured in Dilation: Cervical widening measured in

centimeters (0—not dilated; 10—fully centimeters (0—not dilated; 10—fully dilated)dilated)

– Labor: Process of delivery in 3 stages of Labor: Process of delivery in 3 stages of contractions and dilation, birth, afterbirthcontractions and dilation, birth, afterbirth

– Meconium: First feces, greenish-black to Meconium: First feces, greenish-black to light brown, odorless, tarry; normally light brown, odorless, tarry; normally discharged a day or two after birthdischarged a day or two after birth

– Meconium staining: Fetal defecation in Meconium staining: Fetal defecation in uteroutero



TermsTerms– Delivery presentation: Fetal position in Delivery presentation: Fetal position in

birth canal, usually head firstbirth canal, usually head first– Crowning: Infant’s presenting part at Crowning: Infant’s presenting part at

vaginal opening—usually the headvaginal opening—usually the head– Cephalic presentation: Normal, head-first Cephalic presentation: Normal, head-first

presentationpresentation– Breech presentation: Feet or buttocks; Breech presentation: Feet or buttocks;

single foot: true emergencysingle foot: true emergency


Anatomical Structures and Anatomical Structures and TermsTerms TermsTerms

– Shoulder presentation (transverse lie): Shoulder presentation (transverse lie): Shoulder presents first (about 0.3%); true Shoulder presents first (about 0.3%); true emergencyemergency

– Placenta previa: Placenta attaches low in Placenta previa: Placenta attaches low in womb (before infant)womb (before infant) May cover cervical opening and ruptures, bleeds May cover cervical opening and ruptures, bleeds

painlessly as cervix dilatespainlessly as cervix dilates

– Placenta abruptio: Premature, sudden Placenta abruptio: Premature, sudden (abrupt) separation of placenta from uterus (abrupt) separation of placenta from uterus (1%)(1%) Serious complication; common cause of late Serious complication; common cause of late

bleedingbleeding

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Anatomical Structures and Anatomical Structures and TermsTerms TermsTerms

– Braxton Hicks contractions: Rhythmic Braxton Hicks contractions: Rhythmic uterine clenching lasting 30—60 secondsuterine clenching lasting 30—60 seconds Occurs in some about mid—to—end of Occurs in some about mid—to—end of

pregnancypregnancy Different from labor contractionsDifferent from labor contractions

– Eclampsia: Causes seizures, sometimes Eclampsia: Causes seizures, sometimes coma, usually after 20coma, usually after 20thth week week Follows pre-eclampsia of high blood pressure, Follows pre-eclampsia of high blood pressure,

swelling of hands, feet, and protein in urineswelling of hands, feet, and protein in urine

– Fontanel: Soft (unossified) areas of Fontanel: Soft (unossified) areas of infant’s skull: anterior, posterior, medialinfant’s skull: anterior, posterior, medial

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Stages of LaborStages of Labor First stage (dilation stage)First stage (dilation stage)

– Begins: Regular contractions, cervical Begins: Regular contractions, cervical dilationdilation Contractions about 30 minutes apart; near Contractions about 30 minutes apart; near

birth—3 minutes apartbirth—3 minutes apart Mucous plug discharges with “bloody show” Mucous plug discharges with “bloody show” Amniotic sac breaks; EMTs may have to tearAmniotic sac breaks; EMTs may have to tear

– May break hours before (but body continues to May break hours before (but body continues to produce fluid) or after crowning/head deliveryproduce fluid) or after crowning/head delivery

– Fluid usually clear; staining indicates fetal defecationFluid usually clear; staining indicates fetal defecation

Ends: Fully dilated cervix, more frequent Ends: Fully dilated cervix, more frequent contractions, more severe labor painscontractions, more severe labor pains

Pressure on rectum—feel need to move bowelsPressure on rectum—feel need to move bowels

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Stages of LaborStages of Labor Second stage (Birth stage)Second stage (Birth stage)

– Begins: Infant enters birth canalBegins: Infant enters birth canal Decide whether to transport or stay and Decide whether to transport or stay and

deliverdeliver If birth appears imminent, prepare for If birth appears imminent, prepare for

deliverydelivery

– Ends: Birth of infantEnds: Birth of infant

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Stages of LaborStages of Labor Third stage (Afterbirth stage)Third stage (Afterbirth stage)

– Begins: After infant is bornBegins: After infant is born Contractions resume shortly after birthContractions resume shortly after birth Contractions continue until placenta and Contractions continue until placenta and

other tissue deliverother tissue deliver Contractions are usually milder than laborContractions are usually milder than labor

– Ends: Delivery of afterbirth: placenta Ends: Delivery of afterbirth: placenta and cord, amniotic sac, uterine liningand cord, amniotic sac, uterine lining May take 10—20 minutesMay take 10—20 minutes

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Steps of EvaluationSteps of Evaluation On arrival: Size up the sceneOn arrival: Size up the scene Approach and perform initial Approach and perform initial

assessmentassessment– Mental statusMental status– Airway, breathing, circulation (heart Airway, breathing, circulation (heart

rate, bleeding)rate, bleeding)– DisabilityDisability– ExposureExposure– Clinical priority (1, 2, 3, or 4)Clinical priority (1, 2, 3, or 4)– Disposition (mode, status)Disposition (mode, status)

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Steps of EvaluationSteps of Evaluation Perform history and physical Perform history and physical

assessmentassessment– General questionsGeneral questions

Name, age, due dateName, age, due date First pregnancy?First pregnancy?

– Labor for first pregnancy: 16—20 hoursLabor for first pregnancy: 16—20 hours– Labor for subsequent pregnancies progresses Labor for subsequent pregnancies progresses

more quicklymore quickly

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assessmentassessment– Questions about labor (help determine Questions about labor (help determine

transport or stay and deliver)transport or stay and deliver) How long having labor pains?How long having labor pains?

– Several hours (possibly prepare to deliver)Several hours (possibly prepare to deliver)– Couple of hours (possibly transport)Couple of hours (possibly transport)

How often are pains? (Most mothers time How often are pains? (Most mothers time them)them)

– Far apart (transport)Far apart (transport)– Frequently (prepare to delivery)Frequently (prepare to delivery)

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assessmentassessment– Questions about laborQuestions about labor

Has water broken?Has water broken?– If so, how long ago?If so, how long ago?– Response may not affect delivery or transport Response may not affect delivery or transport

decisiondecision

Bleeding or bloody show?Bleeding or bloody show?– Response may not affect delivery or transport Response may not affect delivery or transport

decisiondecision

Straining or feeling urge to move bowels?Straining or feeling urge to move bowels?– If so, infant’s head is in birth canal (prepare to If so, infant’s head is in birth canal (prepare to

deliver)deliver)– If no, transportIf no, transport

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Examine mother for bleedingExamine mother for bleeding– Some bleeding is normal with dilationSome bleeding is normal with dilation– If excessiveIf excessive

Apply sanitary padsApply sanitary pads Treat for shockTreat for shock Consider ALSConsider ALS Rapid transportRapid transport Notify receiving facilityNotify receiving facility

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Examine mother for crowningExamine mother for crowning– Explain what you will do before visually Explain what you will do before visually

inspectinginspecting– Prepare for deliveryPrepare for delivery

If presenting part is visible, mother is crying If presenting part is visible, mother is crying out, straining, and wanting to move bowelsout, straining, and wanting to move bowels

– For first delivery with no straining or crowning, For first delivery with no straining or crowning, transporttransport

Transport rapidly if there is a single limb Transport rapidly if there is a single limb presentationpresentation

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Feel abdomen for uterine contractionsFeel abdomen for uterine contractions– Explain what you will doExplain what you will do

Place gloved hand over navalPlace gloved hand over naval Time duration of contractionTime duration of contraction Time frequencyTime frequency

Take vital signsTake vital signs

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Labor and DeliveryLabor and Delivery Labor (first stage)Labor (first stage)

– Normal labor painsNormal labor pains Begin with ache in lower backBegin with ache in lower back Become stronger in lower abdomenBecome stronger in lower abdomen Come at regular intervals lasting 30 seconds Come at regular intervals lasting 30 seconds

to a minuteto a minute

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Labor and DeliveryLabor and Delivery Labor (first stage)Labor (first stage)

– ContractionsContractions Uterus contracts causing pain; relaxes Uterus contracts causing pain; relaxes

relieving painrelieving pain May start and last for a while, stop and start May start and last for a while, stop and start

againagain CharacteristicsCharacteristics

– Contraction time: beginning of uterine contraction Contraction time: beginning of uterine contraction until relaxationuntil relaxation

– Contraction interval (frequency): start of one Contraction interval (frequency): start of one contraction to start of nextcontraction to start of next

Contractions times of 30 seconds to 1 Contractions times of 30 seconds to 1 minute, intervals of 2—3 minutes: delivery is minute, intervals of 2—3 minutes: delivery is imminentimminent

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Labor and DeliveryLabor and Delivery Delivery (second stage)Delivery (second stage)

– Preparation: Assemble itemsPreparation: Assemble items Personal protective equipmentPersonal protective equipment Towels and sheetsTowels and sheets Gauze padsGauze pads Bulb syringeBulb syringe Clamps/hemostats/cord tapeClamps/hemostats/cord tape ScissorsScissors Baby blanket/towelsBaby blanket/towels Sanitary padsSanitary pads Plastic bag or containerPlastic bag or container

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– Preparation: Evaluate and prepare Preparation: Evaluate and prepare mothermother History: name, age, due date, first History: name, age, due date, first

pregnancy, attended by physician?pregnancy, attended by physician? Current condition: when labor pains started, Current condition: when labor pains started,

how often, bleeding/bloody show, straininghow often, bleeding/bloody show, straining Evaluate: examine for crowning, feel Evaluate: examine for crowning, feel

abdomen and time contraction frequency, abdomen and time contraction frequency, duration, take vital signsduration, take vital signs

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– Decision to transport or stay and deliverDecision to transport or stay and deliver Transport: first delivery, no straining, no Transport: first delivery, no straining, no

crowningcrowning Stay and deliver: not a first delivery and/or is Stay and deliver: not a first delivery and/or is

straining, needing to move bowels, straining, needing to move bowels, contractions 2 minutes apartcontractions 2 minutes apart

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Labor and DeliveryLabor and Delivery Delivery (second stage): Stay and Delivery (second stage): Stay and

deliverdeliver– Ensure privacy; remove clothing (waist Ensure privacy; remove clothing (waist

down) position and drape motherdown) position and drape mother– Position on left side with signs of supine Position on left side with signs of supine

hypotension syndromehypotension syndrome– Elevate buttocks with bedding or towelsElevate buttocks with bedding or towels– Knees bent, legs apartKnees bent, legs apart

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deliverdeliver– Have someone at mothers headHave someone at mothers head

Partner: monitor vital signs, vomitingPartner: monitor vital signs, vomiting Family for comfort, emotional supportFamily for comfort, emotional support

– Position selfPosition self To view vaginal areaTo view vaginal area To assist birth with supplies close byTo assist birth with supplies close by

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deliverdeliver– Deliver infantDeliver infant

Hands at vaginal opening when head Hands at vaginal opening when head appearsappears

Spread fingers, avoid pressure on fontanelsSpread fingers, avoid pressure on fontanels Support emerging headSupport emerging head

– Apply slight pressure to prevent explosive birthApply slight pressure to prevent explosive birth– Keep clear of anal area, dischargesKeep clear of anal area, discharges

Place pressure on perineum to prevent Place pressure on perineum to prevent tearingtearing

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deliverdeliver– Unbroken amniotic sac: tear and peel Unbroken amniotic sac: tear and peel

from facefrom face Amniotic fluid should be clearAmniotic fluid should be clear Staining indicates fetal feces—suction Staining indicates fetal feces—suction

immediately, repeatedly: mouth then noseimmediately, repeatedly: mouth then nose Provide ventilations/compressions as neededProvide ventilations/compressions as needed Rapid transportRapid transport

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deliverdeliver– After head delivers, ensure that After head delivers, ensure that

umbilical cord is not around infant’s umbilical cord is not around infant’s neckneck Cord around neck: tell mother to pant, not Cord around neck: tell mother to pant, not

pushpush Loosen cord with fingersLoosen cord with fingers Slip it from around neckSlip it from around neck Can’t remove cord: Clamp in two places, cut, Can’t remove cord: Clamp in two places, cut,

remove from neckremove from neck

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deliverdeliver– Infant usually presents face down, Infant usually presents face down,

rotates to siderotates to side Support head with one hand and wipe Support head with one hand and wipe

nose, mouth with gauze padsnose, mouth with gauze pads Use bulb syringe to suction mouth first, Use bulb syringe to suction mouth first,

then nosethen nose– Suction the mouth 2-3 times, inserting the Suction the mouth 2-3 times, inserting the

syringe 1 ½ inchessyringe 1 ½ inches– Suction the nose 2-3 times, inserting the syringe Suction the nose 2-3 times, inserting the syringe

½ inch½ inch

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deliverdeliver– Upper shoulder delivers first: guide Upper shoulder delivers first: guide

infant’s head downwardinfant’s head downward– Lower shoulder delivers; guide infant’s Lower shoulder delivers; guide infant’s

head upwardhead upward– Deliver torso and legs: Infant is slipperyDeliver torso and legs: Infant is slippery

Position on side, head slightly lower than Position on side, head slightly lower than body, same level as mother until cord stops body, same level as mother until cord stops pulsingpulsing

Suction mouth and nose againSuction mouth and nose again

– Record time of birthRecord time of birth

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Complications, Emergencies, Complications, Emergencies, ManagementManagement

Positional complications: Supine Positional complications: Supine Hypotensive SyndromeHypotensive Syndrome

– Occurs in the third trimester Occurs in the third trimester – Weight of uterus, infant, placenta, amniotic Weight of uterus, infant, placenta, amniotic

fluid compress inferior vena cavafluid compress inferior vena cava– Pressure on inferior vena cave reduces Pressure on inferior vena cave reduces

blood flow return to heart and cardiac blood flow return to heart and cardiac outputoutput

– Body compensates: contracts uterine Body compensates: contracts uterine arteriesarteries Dangerous to fetus; restricts blood to mother’s Dangerous to fetus; restricts blood to mother’s

organsorgans

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– Signs and symptomsSigns and symptoms Dizziness and a drop in blood pressure Dizziness and a drop in blood pressure

when the mother is in a supine positionwhen the mother is in a supine position Other shock signs and symptoms but are Other shock signs and symptoms but are

also related to laboralso related to labor

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– ManagementManagement Check vital signs and continue to monitorCheck vital signs and continue to monitor Position mother on left side to relieve Position mother on left side to relieve

weight on vena cavaweight on vena cava Treat for shock: elevating legs will not Treat for shock: elevating legs will not

relieve low blood pressure or reduce relieve low blood pressure or reduce constriction of vena cavaconstriction of vena cava

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Birth complications: Breech Birth complications: Breech presentationpresentation

– Most common abnormal presentation: Most common abnormal presentation: buttocks, both legsbuttocks, both legs

– Can deliver spontaneouslyCan deliver spontaneously Risk of birth trauma is highRisk of birth trauma is high Meconium staining is frequentMeconium staining is frequent Risk of prolapsed cord is increasedRisk of prolapsed cord is increased

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Birth complications: Breech Birth complications: Breech presentationpresentation

– ManagementManagement Check for crowning; do not pull on legsCheck for crowning; do not pull on legs Provide oxygenProvide oxygen Consider ALS; rapid transportConsider ALS; rapid transport Notify receiving facilityNotify receiving facility Assist delivery if necessaryAssist delivery if necessary

– Deliver and support torsoDeliver and support torso– Insert gloved fingers in V to form airway for infantInsert gloved fingers in V to form airway for infant– Prevent explosive delivery of headPrevent explosive delivery of head– Provide post-natal careProvide post-natal care

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Birth complications: Prolapsed cordBirth complications: Prolapsed cord– Common in breech births; cord is pressed Common in breech births; cord is pressed

between vaginal wall and infant’s head, between vaginal wall and infant’s head, cutting off oxygen to infantcutting off oxygen to infant

– ManagementManagement Position mother: head down, buttocks raisedPosition mother: head down, buttocks raised Provide oxygenProvide oxygen Care for cord: wrap and keep moist, insert Care for cord: wrap and keep moist, insert

gloved hand to lift infant from vaginal tissuegloved hand to lift infant from vaginal tissue—provides airway, keeps head off cord, —provides airway, keeps head off cord, maintains pulsations maintains pulsations

Consider ALS; rapid transport; notify Consider ALS; rapid transport; notify receiving facilityreceiving facility

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Birth complications: Single limb Birth complications: Single limb – Arm, more commonly—one leg usually Arm, more commonly—one leg usually

with prolapsed cord; cannot be with prolapsed cord; cannot be delivered in fielddelivered in field

– ManagementManagement Care for cord: wrap, keep moist, ensure Care for cord: wrap, keep moist, ensure

pulsation by keeping infant’s head off cordpulsation by keeping infant’s head off cord Position mother: head down, buttocks Position mother: head down, buttocks

raisedraised Provide oxygenProvide oxygen Consider ALS, rapid transport, notify Consider ALS, rapid transport, notify

receiving facilityreceiving facility

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Other possible birth events: MultipleOther possible birth events: Multiple– ConsiderationsConsiderations

Usually twins, uncomplicatedUsually twins, uncomplicated Second infant may deliver in breech Second infant may deliver in breech

positionposition Rapid transport if complications developRapid transport if complications develop

– Determine multiple birthDetermine multiple birth Mother informs youMother informs you Unusually large abdomen, which remains Unusually large abdomen, which remains

large after first birthlarge after first birth Strong labor pains, contractions resume Strong labor pains, contractions resume

after first birthafter first birth

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Other possible birth events: MultipleOther possible birth events: Multiple– Management (Call for additional Management (Call for additional

personnel)personnel) Assist with delivery of first infantAssist with delivery of first infant Clamp/tie cord before birth of second infant Clamp/tie cord before birth of second infant Assist with delivery of second infant (may Assist with delivery of second infant (may

deliver before or after placenta)deliver before or after placenta) Provide post-natal careProvide post-natal care Assist with delivery of placenta(s)Assist with delivery of placenta(s) Transport and ensure infants’ warmthTransport and ensure infants’ warmth

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Other possible birth events: Other possible birth events: PrematurePremature

– Infant weights < 5 ½ lbs at birthInfant weights < 5 ½ lbs at birth– Head is large proportionate to bodyHead is large proportionate to body– Mother provides due date informationMother provides due date information– Infant delivers prior to 28Infant delivers prior to 28thth week week

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Other possible birth events: Other possible birth events: PrematurePremature

– Management: Follow Universal Management: Follow Universal Algorithm for Newly Born, Inverted Algorithm for Newly Born, Inverted Pyramid of Neonatal ResuscitationPyramid of Neonatal Resuscitation Suction mouth and nose; provide blow-by Suction mouth and nose; provide blow-by

oxygenoxygen Keep warm and dryKeep warm and dry Monitor airway, continue suctioning as Monitor airway, continue suctioning as

neededneeded Protect from exposure: birth discharges, Protect from exposure: birth discharges,

other individualsother individuals Notify receiving facilityNotify receiving facility

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Pre-birth bleeding emergencies: Pre-birth bleeding emergencies: Vaginal bleedingVaginal bleeding

– Considerations: Serious gynecological Considerations: Serious gynecological emergency if not trauma or menstrual emergency if not trauma or menstrual relatedrelated Potentially life-threatening with abdominal Potentially life-threatening with abdominal

painpain Hypovolemic shock a serious complicationHypovolemic shock a serious complication

– ManagementManagement BSIBSI Ensure Airway, assess/treat for shock, oxygenEnsure Airway, assess/treat for shock, oxygen Rapid transportRapid transport

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Pre-birth bleeding emergencies: Pre-birth bleeding emergencies: Placenta previa (potentially life Placenta previa (potentially life threatening)threatening)

– Placenta forms or attaches low in uterus, Placenta forms or attaches low in uterus, close to or over cervix previous to fetusclose to or over cervix previous to fetus

– It lies between infant and cervical opening It lies between infant and cervical opening preventing deliverypreventing delivery

– Cervix dilates, tears placenta, which Cervix dilates, tears placenta, which bleeds profuselybleeds profusely

– Infant’s head presses on placenta, causing Infant’s head presses on placenta, causing further bleeding to torn placentafurther bleeding to torn placenta

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Pre-birth bleeding emergencies: Pre-birth bleeding emergencies: Placenta abruptio (potentially life Placenta abruptio (potentially life threatening)threatening)

– Placenta partially or completely Placenta partially or completely separates from uterine wall separates from uterine wall

– Signs and symptomsSigns and symptoms Possible obvious profuse bleeding with Possible obvious profuse bleeding with

complete abruptioncomplete abruption Possible little or no obvious bleeding with Possible little or no obvious bleeding with

partial abruption: blood is trapped between partial abruption: blood is trapped between placenta and uterine wallplacenta and uterine wall

Signs of shockSigns of shock Abdominal pain may or may not be presentAbdominal pain may or may not be present

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Pre-birth bleeding emergencies: Pre-birth bleeding emergencies: Ectopic pregnancy (potentially life Ectopic pregnancy (potentially life threatening)threatening)

– Problems occur early in pregnancyProblems occur early in pregnancy– Egg implants outside uterus usually in a Egg implants outside uterus usually in a

fallopian tube, grows, ruptures tube, fallopian tube, grows, ruptures tube, causes internal bleeding, paincauses internal bleeding, pain

– Signs and symptomsSigns and symptoms Shock: low blood pressure, rapid weak Shock: low blood pressure, rapid weak

pulse—late signspulse—late signs Abdominal painAbdominal pain

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Pre-birth bleeding emergencies: Pre-birth bleeding emergencies: Placenta previa, abriptio; ectopic Placenta previa, abriptio; ectopic pregnancypregnancy

– ManagementManagement Obtain baseline vital signs and monitorObtain baseline vital signs and monitor Treat for shock: position, oxygenTreat for shock: position, oxygen Manage bleedingManage bleeding Replace and save soaked pads, expelled Replace and save soaked pads, expelled

tissuestissues Consider ALS, rapid transportConsider ALS, rapid transport Notify receiving facilityNotify receiving facility

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Pre-birth bleeding emergencies: Pre-birth bleeding emergencies: Miscarriage—spontaneous abortionMiscarriage—spontaneous abortion

– Fetus miscarries/aborts before 28Fetus miscarries/aborts before 28thth weekweek

– Signs and symptomsSigns and symptoms Moderate to severe bleedingModerate to severe bleeding Abdominal pain, crampingAbdominal pain, cramping Tissue dischargeTissue discharge Signs and symptoms of shockSigns and symptoms of shock

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– ManagementManagement Obtain baseline vitals and monitorObtain baseline vitals and monitor Provide care for shockProvide care for shock Manage bleedingManage bleeding Replace, save soaked pads, expelled tissuesReplace, save soaked pads, expelled tissues Provide emotional supportProvide emotional support Prepare for delivery if necessaryPrepare for delivery if necessary Notify receiving facility, rapid transport, call Notify receiving facility, rapid transport, call

ALS for neonatal intensive care of premieALS for neonatal intensive care of premie

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– ManagementManagement Obtain baseline vitals and monitorObtain baseline vitals and monitor Provide care for shock, manage bleedingProvide care for shock, manage bleeding Replace, save soaked pads, expelled tissuesReplace, save soaked pads, expelled tissues Provide emotional supportProvide emotional support Prepare for delivery if necessaryPrepare for delivery if necessary Notify receiving facility, rapid transport, call Notify receiving facility, rapid transport, call

ALS for neonatal intensive care of premieALS for neonatal intensive care of premie

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Seizures: Caused by eclampsiaSeizures: Caused by eclampsia– Occurs late in pregnancy or after Occurs late in pregnancy or after

deliverydelivery– May result in comaMay result in coma

Precursor is pre-eclampsiaPrecursor is pre-eclampsia Begins mid-way through pregnancyBegins mid-way through pregnancy

– Swollen hands and feetSwollen hands and feet– Increasing hypertensionIncreasing hypertension– Headaches Headaches

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Seizures: Caused by eclampsiaSeizures: Caused by eclampsia– Signs and symptomsSigns and symptoms

High blood pressure, rapid pulseHigh blood pressure, rapid pulse High temperatureHigh temperature Headache, dizziness, seeing spotsHeadache, dizziness, seeing spots Epigastric pain, nauseaEpigastric pain, nausea Puffy face, swollen hands, ankles, feetPuffy face, swollen hands, ankles, feet Excessive weight gainExcessive weight gain Seizures beginning with twitching of face, Seizures beginning with twitching of face,

arms, handsarms, hands ComaComa

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Seizures: Caused by eclampsiaSeizures: Caused by eclampsia– ManagementManagement

Check for and maintain patent airwayCheck for and maintain patent airway Administer oxygenAdminister oxygen Suction as neededSuction as needed Position and transport on left sidePosition and transport on left side Maintain body warmthMaintain body warmth Handle patient gentlyHandle patient gently Rapid transportRapid transport

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Trauma: TypesTrauma: Types– Falls (soft tissue injuries, fractures)Falls (soft tissue injuries, fractures)– Violence, e.g., beatings (soft tissue Violence, e.g., beatings (soft tissue

injuries)injuries)– External force blunt trauma, e.g. External force blunt trauma, e.g.

vehicle collisions (fractures, ruptured vehicle collisions (fractures, ruptured organs, soft tissue injuries)organs, soft tissue injuries)

– Penetrating injuries (soft tissue injuries)Penetrating injuries (soft tissue injuries)– Sexual assault (soft tissue injuries)Sexual assault (soft tissue injuries)

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Trauma: PhysiologyTrauma: Physiology– Fetus is relatively protected in first two Fetus is relatively protected in first two

trimesters: amniotic fluid, muscular trimesters: amniotic fluid, muscular uterusuterus

– Minor trauma poses no harmMinor trauma poses no harm– Vehicle collisions: grater magnitude of Vehicle collisions: grater magnitude of

forceforce Fetus: more likely injured in last trimesterFetus: more likely injured in last trimester Mother: injury w/shock, bleeding affects Mother: injury w/shock, bleeding affects

fetusfetus

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Trauma: PhysiologyTrauma: Physiology– Blunt trauma injuries in last trimesterBlunt trauma injuries in last trimester

Uterus: rupture, placenta abruptioUterus: rupture, placenta abruptio Rupture other organs: internal bleeding, Rupture other organs: internal bleeding,

difficulty breathingdifficulty breathing– Spleen, liver, diaphragmSpleen, liver, diaphragm

– Soft tissue injuries, fracturesSoft tissue injuries, fractures Massive bleeding, shockMassive bleeding, shock Affects mother and fetusAffects mother and fetus

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Trauma: ManagementTrauma: Management– Size-up scene for safety (collisions, violence)Size-up scene for safety (collisions, violence)– Check ABC’s, treat for shockCheck ABC’s, treat for shock– Patient history, specifically blunt force Patient history, specifically blunt force

traumatrauma Blows to abdomen, pelvis, backBlows to abdomen, pelvis, back Has water broken, vaginal/genitalia bleeding?Has water broken, vaginal/genitalia bleeding?

– Assess based on mechanism of injuryAssess based on mechanism of injury Not significant: focused history, physical examNot significant: focused history, physical exam Significant: rapid trauma assessmentSignificant: rapid trauma assessment

– Check for bruised abdomen, vaginal bleedingCheck for bruised abdomen, vaginal bleeding

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Trauma: ManagementTrauma: Management– Take baseline vitals, monitor (Vital signs Take baseline vitals, monitor (Vital signs

may not indicate shock in a pregnant may not indicate shock in a pregnant woman)woman) Heart rate: 10—15 beats fasterHeart rate: 10—15 beats faster Blood volume: 48% higher; loses 35% blood Blood volume: 48% higher; loses 35% blood

volume before showing signs of shockvolume before showing signs of shock

– Treat for shock and watch for vomitingTreat for shock and watch for vomiting Have suction readyHave suction ready

– Provide emotional supportProvide emotional support

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Post Natal CarePost Natal Care Care of infant: Initial impression at Care of infant: Initial impression at

birthbirth– Breathing easilyBreathing easily– Heart beatingHeart beating– Crying vigorouslyCrying vigorously– Moving extremitiesMoving extremities– Hands and feet only are cyanoticHands and feet only are cyanotic

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Post Natal CarePost Natal Care Care of infant: APGAR check at 1 and Care of infant: APGAR check at 1 and

5 minutes after birth: 0—1—2 scale5 minutes after birth: 0—1—2 scale– Activity—muscle tone/movementActivity—muscle tone/movement– PulsePulse– Grimace—reflex irritability/reaction to Grimace—reflex irritability/reaction to

suction, flicking feetsuction, flicking feet– Appearance—color (hands/feet are Appearance—color (hands/feet are

cyanotic for a few minutes shortly after cyanotic for a few minutes shortly after birth)birth)

– RespirationsRespirations

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Post Natal CarePost Natal Care Care of infant: Universal Algorithm Care of infant: Universal Algorithm

for the Newly Born for BLS/Inverted for the Newly Born for BLS/Inverted Pyramid of Neonatal ResuscitationPyramid of Neonatal Resuscitation– Dry, warm, position, stimulate, suction Dry, warm, position, stimulate, suction

mouth/nose (multiple times mouth/nose (multiple times w/meconium)w/meconium) Position infant on side, suctionPosition infant on side, suction Ensure breathing after suctioning w/i 30 Ensure breathing after suctioning w/i 30

secondsseconds No breathing: rub back; still no breathing: No breathing: rub back; still no breathing:

snap finger against footsnap finger against foot

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for the Newly Born for BLS/Inverted for the Newly Born for BLS/Inverted Pyramid of Neonatal ResuscitationPyramid of Neonatal Resuscitation– If cyanotic: If cyanotic: Provide oxygenProvide oxygen– Apnea/gasping, heart rate ,100Apnea/gasping, heart rate ,100

Ventilate with neonatal BVM at 40—60/min Ventilate with neonatal BVM at 40—60/min or small puffs via mouth-to-maskor small puffs via mouth-to-mask

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for the Newly Born for BLS/Inverted for the Newly Born for BLS/Inverted Pyramid of Neonatal ResuscitationPyramid of Neonatal Resuscitation– Heart rate <60 after 30 seconds of BVMHeart rate <60 after 30 seconds of BVM

Provide chest compressions: 120/min at 3:1 Provide chest compressions: 120/min at 3:1 ratioratio

If no change, continue ventilations, If no change, continue ventilations, reassessmentreassessment

Heart rate > 100 but infant shows cyanosis Heart rate > 100 but infant shows cyanosis in face/torso, provide blow=by oxygen, 10—in face/torso, provide blow=by oxygen, 10—15 lpm15 lpm

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Post Natal CarePost Natal Care Care of infant: Cut the cordCare of infant: Cut the cord

– Before cuttingBefore cutting Ensure infant is warm and dryEnsure infant is warm and dry Ensure cord has stopped pulsatingEnsure cord has stopped pulsating

– Clamp/tie 10” and 7” from infantClamp/tie 10” and 7” from infant– Cut between two clamps/tiesCut between two clamps/ties

Do not unclamp/untie; add a second Do not unclamp/untie; add a second clamp/tie if bleeding continuesclamp/tie if bleeding continues

Protect placental end from exposure to Protect placental end from exposure to contaminantscontaminants

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Post Natal CarePost Natal Care Care of infant: Keep infant warmCare of infant: Keep infant warm

– Warmed towel and blanket or warmed Warmed towel and blanket or warmed bubble wrap and blanketbubble wrap and blanket

– Place wrapped infant on mother’s Place wrapped infant on mother’s abdomenabdomen

– Transport in warmed ambulanceTransport in warmed ambulance

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Post Natal CarePost Natal Care Delivery of afterbirth (third stage of Delivery of afterbirth (third stage of

labor)labor)– Include placenta, attached umbilical Include placenta, attached umbilical

cord, amniotic sac, uterine liningcord, amniotic sac, uterine lining– Delivery: brief, milder labor pains resumeDelivery: brief, milder labor pains resume

Usually w/i 20 min of delivery; longer—Usually w/i 20 min of delivery; longer—transporttransport

– May take 30 min to deliverMay take 30 min to deliver Save all tissues in container or towel, wrap in Save all tissues in container or towel, wrap in

plastic, labelplastic, label

– Transport decisionTransport decision Mother, infant stable: stay and deliverMother, infant stable: stay and deliver Mother, infant unstable: rapid transportMother, infant unstable: rapid transport

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Post Natal CarePost Natal Care Control bleedingControl bleeding

– Sanitary pads over vaginal opening; Sanitary pads over vaginal opening; nothing in vaginanothing in vagina

– Mother holds pads in place with legsMother holds pads in place with legs– Elevate legsElevate legs– Massage abdomen from pubis to Massage abdomen from pubis to

umbilicusumbilicus Helps contract uterus, control bleedingHelps contract uterus, control bleeding

– Allow mother to nurseAllow mother to nurse Helps contract uterus, control bleedingHelps contract uterus, control bleeding

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Post Natal CarePost Natal Care Care of motherCare of mother

– Take vital signs and monitorTake vital signs and monitor– Make comfortableMake comfortable

Wipe faceWipe face Cover and keep her and infant warmCover and keep her and infant warm Remove blood-soaked towels, drapesRemove blood-soaked towels, drapes Replace blood-soaked padsReplace blood-soaked pads

– TransportTransport

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Student Performance Objective:Student Performance Objective:Given information, resources, and opportunity Given information, resources, and opportunity for discussion and practice, EMTs will be able for discussion and practice, EMTs will be able to:to:• List and define childbirth structures and List and define childbirth structures and termsterms• Describe the stages of laborDescribe the stages of labor• List the steps of evaluationList the steps of evaluation•Describe potential complications and Describe potential complications and emergenciesemergencies•List and demonstrate steps of labor and List and demonstrate steps of labor and delivery delivery

EMTs will follow acceptable Maryland medical practice EMTs will follow acceptable Maryland medical practice and Maryland Medical Protocols for Emergency and Maryland Medical Protocols for Emergency Medical Providers.Medical Providers.

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Review:Review: Anatomical Structures and TermsAnatomical Structures and Terms

– List and describe the structures of pregnancyList and describe the structures of pregnancy– Name and define the terms of pregnancyName and define the terms of pregnancy

Stages of LaborStages of Labor– List and describe the beginning and endings of List and describe the beginning and endings of

the three stages of laborthe three stages of labor Steps of EvaluationSteps of Evaluation

– Describes the steps to take on arrival at the Describes the steps to take on arrival at the scenescene

– Describe the steps to take to evaluate the Describe the steps to take to evaluate the mothermother

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Review: Review: Labor and DeliveryLabor and Delivery Describe labor and EMT actions Describe labor and EMT actions

during laborduring labor List preparation steps for deliveryList preparation steps for delivery Explain decision to transport or stay Explain decision to transport or stay

and deliverand deliver Describe delivery process and EMT Describe delivery process and EMT

actions during deliveryactions during delivery

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Review: Review: Complications, Emergencies, and Complications, Emergencies, and ManagementManagement

Describe Supine Hypotensive Syndrome, Describe Supine Hypotensive Syndrome, list signs and symptoms and EMS carelist signs and symptoms and EMS care

Describe birth complications and Describe birth complications and managementmanagement– Breech presentationBreech presentation– Prolapsed cordProlapsed cord– Limb presentationLimb presentation

Describe other birth incidents and Describe other birth incidents and management management – Multiple birthMultiple birth– Premature birthPremature birth

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Review: Complications, Emergencies, Review: Complications, Emergencies, ManagementManagement

List pre-birth bleeding emergencies and List pre-birth bleeding emergencies and management management – Vaginal bleedingVaginal bleeding– Placenta previo and abruptionPlacenta previo and abruption– Ectopic pregnancyEctopic pregnancy– Miscarriage (spontaneous abortion)Miscarriage (spontaneous abortion)

Describe eclampsia, signs and symptoms, Describe eclampsia, signs and symptoms, management of seizuresmanagement of seizures

List types of trauma, physiological effects List types of trauma, physiological effects on mother and fetus, and managementon mother and fetus, and management

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Review: Post Natal CareReview: Post Natal Care Describe care of the newly bornDescribe care of the newly born

– Initial impressionsInitial impressions– APGAR scoringAPGAR scoring– Universal AlgorithmUniversal Algorithm– How to cut the cordHow to cut the cord

Delivery of afterbirthDelivery of afterbirth– List afterbirth tissuesList afterbirth tissues– Describe delivery process and EMT actions Describe delivery process and EMT actions

Describe care of motherDescribe care of mother

Drill of the Month Drill of the Month Developed by Gloria Bizjak Assessing and Assisting Childbirth.

Documents

Transcript of Drill of the Month Drill of the Month Developed by Gloria Bizjak Assessing and Assisting Childbirth.