CHILDBIRTH

1 NOTES

• When the cord is cut be aware that supply of oxygenated blood to the baby has been terminated

• Do not delay delivery after the nuchal cord has been cut

• Encourage active delivery once the nuchal cord has been cut

1. Manage airway and assist ventilations as necessary

2. Administer O2 as per Oxygen Therapy Protocol (Pg 44)

3. Request ACP intercept if available

4. Examine patient and determine if crowning2 present (Pg 75)

• If NO crowning – place in left lateral recumbent position, discourage patient from bearing down, and initiate transport

• If crowning present – place supine and prepare for imminent delivery

IMMINENT DELIVERY AND POST-PARTUM CARE

 1 NOTES

• When the cord is cut be aware that supply of oxygenated blood to the baby has been terminated

• Do not delay delivery after the nuchal cord has been cut

• Encourage active delivery once the nuchal cord has been cut

1) Call for second crew or additional resources, if available

2) Warm ambient temperature and prepare equipment

• Neonatal resuscitation equipment

• Warm blankets

• Clamps and scissors to cut umbilical cord

• Bag for placenta

3) Apply gentle pressure to the perineum (skin stretched between the vagina and rectum) using a cupped hand and encourage a controlled (non-explosive) delivery

4) Upon delivery of the head sweep your finger around the newborn’s neck to determine if the umbilical cord is wrapped around the neck (a nuchal cord) If nuchal cord present:

• Discourage pushing and attempt to guide the loop of cord over the newborn’s head prior to delivery of the shoulders

• If the cord is tight and you are unable to guide over the head, double clamp the cord approximately 2.5 cm apart and cut the cord1

5) Gently guide the delivery of the anterior shoulder (shoulder up against the pubic bone) followed by the posterior shoulder (shoulder directed towards the rectum)

6) As the delivery proceeds keep the newborn below the level of the cord

7) Upon delivery of the newborn clamp the umbilical cord approximately 8 cm from the newborn and cut between the clamps

8) Proceed immediately with the Neonatal Assessment and Resuscitation Protocol (Pg 78)

• If full-term, breathing or crying spontaneously, and with good tone, wrap the newborn and place on the mothers chest to encourage skin to skin contact and reduce risk of hypothermia

9) Calculate APGAR Score at 1 and 5 minutes (Pg 98)

10) Prepare for delivery of placenta

• Do not pull on umbilical cord. Allow placenta to deliver without being forced.

• Upon delivery of the placenta, place in a plastic bag along with the umbilical cord

11) Perform uterine fundal massage3 (Pg 75)

CHILDBIRTH

 • If NO crowning – 

CROWNING

• The phase at the end of labor in which the fetal head is seen at the opening of the vagina

1 NOTES

• When the cord is cut be aware that supply of oxygenated blood to the baby has been terminated

• Do not delay delivery after the nuchal cord has been cut

• Encourage active delivery once the nuchal cord has been cut

place in left lateral recumbent position, discourage patient from bearing down, and initiate transport

CHILDBIRTH

• If crowning present – 

CROWNING

• The phase at the end of labor in which the fetal head is seen at the opening of the vagina

1 NOTES

• When the cord is cut be aware that supply of oxygenated blood to the baby has been terminated

• Do not delay delivery after the nuchal cord has been cut

• Encourage active delivery once the nuchal cord has been cut

UTERINE FUNDAL MASSAGE

 1 NOTES

• When the cord is cut be aware that supply of oxygenated blood to the baby has been terminated

• Do not delay delivery after the nuchal cord has been cut

• Encourage active delivery once the nuchal cord has been cut

• Place one hand horizontally across the abdomen, just above the Symphysis Pubis (Pubic bone)

• Cup the other hand across the top of the uterus (Fundus).

• Using a kneading or circular motion, massage the uterus between your two hands

POST-PARTUM HEMORRHAGE

This protocol is intended for persistent and heavy vaginal bleeding post-vaginal delivery that is estimated to be greater than 500 mL and is refractory to conservative measures including firm uterine fundal massage.

1. Manage airway and assist ventilations as necessary

2. Administer O2 as per Oxygen Therapy Protocol (Pg 44)

3. Continuous cardiac, SpO2, and BP monitoring

4. IV access

5. Apply pressure to any bleeding perineal tears or lacerations of the perineum

6. Perform immediate uterine fundal massage1

7. Initiate fluid bolus as per Adult Fluid Therapy Protocol (Pg 43)

8. Request ACP Intercept if available

COMPLICATIONS OF DELIVERY

SHOULDER DYSTOCIA

• Place patient in semi-fowler’s position and perform McRoberts Maneuver1

• Have assistant stand beside the patient and facing the feet, use the heel of their hand to apply downward suprapubic pressure (just above pubic bone) to encourage the anterior shoulder (shoulder up against the pubic bone) to slip beneath pubic bone

• During contraction, encourage mom to push while assistant continues application of suprapubic pressure – attempt to deliver the anterior shoulder from under the pubic bone

• If all methods fail to deliver the newborn then initiate rapid transport and notify receiving hospital 

COMPLICATIONS OF DELIVERY

BREECH PRESENTATION (BUTTOCKS FIRST)

If delivery not imminent:

• Discourage pushing and initiate rapid transport and notify receiving hospital immediately

If delivery imminent:

• Place patient in semi-fowler’s position and perform McRoberts Maneuver1

• Sweep out legs and allow the buttocks and trunk to deliver spontaneously

• Support the body with your dominant forearm positioned under the newborn’s torso and attempt to guide head from beneath pubic bone

COMPLICATIONS OF DELIVERY

LIMB PRESENTATAION

• Place patient in semi-fowler’s position and perform McRoberts Maneuver1

• Keep prolapsing limb warm and moist (cover with saline towel or gauze)

• Discourage mother from pushing with contractions

COMPLICATIONS OF DELIVERY

PROLAPSED CORD

• Place patient in supine position and perform McRoberts Maneuver1 with the hips elevated

• Avoid unnecessary manipulation of the cord

• Digitally elevate presenting part off the umbilical cord in order to maintain pulsation

• Cover exposed cord with moist, sterile dressing (saline soaked gauze)

• Initiate rapid transport and notify receiving hospital immediately

MCROBERTS MANEUVER

• Place mother positioned supine or semi-sitting

• With knees bent and out to the side, have patient pull knees towards her shoulders

• Have assistant push on the bottom of the feet to bring knees as high as possible to increase the anterior-posterior diameter of the 

NEONATAL ASSESSMENT AND RESUSCITATION

1. Determine gestational age and proceed with Neonatal Resuscitation Algorithm (Pg 80) and in accordance with General Guidelines outlined below

2. Request ACP intercept if available

3. Employ strategies to prevent hypothermia in term or pre-term newborns1

GENERAL GUIDELINES

NEONATAL CPR (VENTILATIONS AND COMPRESSIONS)

• Use a two-thumb, encircling the chest, technique

• Ensure high quality CPR

o Minimize interruptions in CPR

o Allow full recoil of the chest between compressions

o Deliver each breath over 1 second

o Deliver only enough volume to produce visible chest rise

Compressions : Ventilation Ratio  ---  3:1

1/3 chest depth

Depth -- 90 compressions / minute

Rate -- 30 breaths / minute

GENERAL GUIDELINES

NEONATAL ASSISTED VENTILATION (WITHOUT COMPRESSIONS)

• To be provided if newborn demonstrates ineffective or absent spontaneous respirations without need for chest compressions

• Rate: 40-60 breaths / minute

• Deliver each breath over 1 second

• Deliver only enough volume to produce visible chest rise

• Avoid excessive ventilation

TEMPERATURE CONTROL IN THE JUST-BORN PRETERM PATIENT (LESS THAN 37 WEEKS)

• Hypothermia will have significant harmful effects on the preterm patient

• Warm ambient temperature in anticipation of delivery (above 26ºC where possible)

• Dry the newborn

• Cover newborn, from the neck down with plastic “wrap” (non-circumferential)

• Wrap newborn a warm blanket or place skin-to-skin with mother and cover both mother and newborn with a warm blanket

Contact OLMC if BGL between 2.6 and 4 mmol/L in the populations indicated above to discuss need for intervention and management options

BLOOD GLUCOSE MEASUREMENT AND HYPOGLYCEMIA IN THE JUST BORN PATIENT

• Patients that have just been born will typically have blood sugars below normal adult values

• Routine measurement of BGL in the just born patient is not recommended

INDICATIONS FOR BGL MEASUREMENT IN THE JUST-BORN PATIENT

• BGL measurement is required ONLY if the patient is:

1) Pre-term

OR

2) Full-term AND requiring intervention or resuscitation beyond routine post-natal supportive care

• If BGL is less than 2.6 mmol/L – administer dextrose 10% 5 mL/kg SIVP

INDICATIONS FOR 12 LEAD ECG

12 lead acquisition is required in any patient presenting with:

• Chest pain

• Jaw pain

• Left arm pain

• Epigastric pain

• Non-traumatic back pain

• Shortness of breath

• Syncope

• Palpitation

• Weakness

• Nausea or vomiting

• Altered LOC

• Toxic ingestion or overdose

• Suspected electrolyte disturbance

• Dysrhythmia on 3 lead ECG

• Irregular pulse

• Diaphoresis disproportionate to environment

In addition to the indications listed above a 12 lead ECG should be performed any time the paramedic feels it is indicated

SERIAL 12 LEAD ECGs

If the initial 12 lead does not show evidence of ST elevation in a patient experiencing chest pain serial 12 lead ECGs must be performed as outlined below:

 NOTES

• Acquiring a 12 lead ECG should not prolong scene time or transport more than 2 minutes

• 12 lead acquisition should be performed concurrent with other assessment and care and should not interfere with treatment protocols

• Any time a 12 lead has been acquired a copy of the 12 lead must be attached (stapled) to the PCR to be left at the receiving facility and labeled with the patient’s surname and MCP number. A second copy of the 12 lead ECG must be attached (stapled) in an identical manner to the copy of the PCR to be kept by the ambulance service provider.

• You must document the device interpretation of the 12 lead ECG in the narrative portion of the PCR

1) In ambulance just prior to transport

2) Every 15 minutes during transport (if transport time greater than 30 minutes)

3) Just prior to arrival to receiving health care facility

4) Any time patient condition or ECG rhythm changes

If the initial 12 lead demonstrates evidence of ST elevation MI serial 12 leads are not required unless there is a change in patient condition or ECG rhythm changes

12 LEAD ECG ACQUISITION TECHNIQUE

Procedure

1. Place the patient in a supine or semi-sitting position

2. Expose chest enough to acquire a 12 lead ECG. Take all steps necessary and possible to protect the patient’s dignity and privacy

3. Prep the skin with alcohol or other wipe. Remove excess chest hair where needed for good contact. If patient is large breasted or obese, be sure to place leads correctly.

4. Attach the four limb and chest leads to the patient

5. Reduce causes of artifact. Stop patient movement. If en route to hospital, stop ambulance to acquire ECG.