Introduction to Emergency Medical Care 1

Introduction to Emergency Medical Care 1
Advance Preparation Prepare anatomy models for demonstration. Research related multimedia links for illustration purposes. Invite an obstetrician or labor and delivery nurse to class. Invite a law enforcement officer or sexual assault nurse to class. Prepare an OB kit for demonstration purposes. Invite assistant instructors and programmed patients to assist with psychomotor sessions.

OBJECTIVES 34.1 Define key terms introduced in this chapter. Slides 17, 22, 25, 34, 36, 39, 51, 60, 65–69, 74– Identify the anatomy of the female reproductive system and fetal development. Slides 16– Explain the physiology of pregnancy. Slide 21 continued

OBJECTIVES 34.4 Explain and describe measures to prevent or correct supine hypotensive syndrome. Slide Describe the three stages of labor. Slides 25– Discuss the assessment of a patient in labor, including history and physical examination. Slides 31–33 continued

OBJECTIVES 34.7 Discuss how to decide if delivery is imminent or if the patient in labor should be transported to a medical facility for delivery. Slides 33– State findings that may indicate the need for neonatal resuscitation. Slides 35–36 continued

OBJECTIVES 34.9 Discuss the role of the EMT in normal childbirth, including preparation and delivery. Slides 39–43, 45– Describe the normal steps in care of the neonate. Slides 51–53 continued

OBJECTIVES 34.11 Explain the indications and procedures for neonatal resuscitation, following the inverted pyramid order of priorities. Slides 55– Discuss after-delivery care of the mother, including delivery of the placenta, controlling vaginal bleeding, and providing comfort to the mother. Slides 59–62 continued

OBJECTIVES 34.13 Describe and discuss the special care required for complications of delivery, including: breech presentation, limb presentation, prolapsed umbilical cord, multiple birth, premature birth, and meconium. Slides 65–70 continued

OBJECTIVES 34.14 Describe and discuss the special care required for emergencies in pregnancy, including: excessive prebirth bleeding, ectopic pregnancy, seizures in pregnancy, miscarriage and abortion, trauma in pregnancy, stillbirths, and accidental death of a pregnant woman. Slides 72–81 continued

OBJECTIVES 34.15 Describe and discuss the special care required for gynecological emergencies, including: vaginal bleeding, trauma to the external genitalia, and sexual assault. Slides 85–87

MULTIMEDIA Slide 29 Information About Childbirth Video
Slide 82 Information About Preeclampsia Video Slide 83 Ectopic Pregnancy Video These videos appear later in the presentation; you may want to preview them prior to class to ensure they load and play properly. Click on the links above in slideshow view to go directly to the slides.

Anatomy and physiology of the female reproductive system
Physiologic changes in pregnancy Care of the mother and baby during labor and childbirth Care of the neonate Post-delivery care of the mother continued

Complications of delivery
Emergencies in pregnancy Gynecological emergencies

Topics Anatomy and Physiology Physiologic Changes in Pregnancy
Labor and Delivery Patient Assessment Normal Childbirth The Neonate Care After Delivery Planning Your Time: Plan 180 minutes for this chapter. Anatomy and Physiology (30 minutes) Physiologic Changes in Pregnancy (20 minutes) Labor and Delivery (20 minutes) Patient Assessment (20 minutes) Normal Childbirth (15 minutes) The Neonate (15 minutes) Care After Delivery (20 minutes) Childbirth Complications (20 minutes) Gynecological Emergencies (20 minutes) Note: The total teaching time recommended is only a guideline. continued

Topics Childbirth Complications Gynecological Emergencies

Anatomy and Physiology
Teaching Time: 30 minutes Teaching Tips: Use anatomic models and multimedia graphics to illustrate anatomy and physiology. Anticipate the changes in pregnancy. Discuss briefly how these organs might change with fetal development. Discuss menses in the context of the reproductive cycle.

Point to Emphasize: The ovaries, fallopian tubes, uterus, and vagina are the female reproductive organs. Each organ has specific functions with regard to the production and development of a fetus. Class Activity: Have students label the major structures of the female reproductive system on a blank diagram. Critical Thinking: Given the anatomical differences in their reproductive systems, what risks might women have that men do not? For what injuries/illnesses do these anatomical differences pose a risk?

Female Genitalia External Internal Labia Perineum Mons pubis Vagina
Ovaries Fallopian tubes Talking Points: A woman’s external genitalia consists of three major structures: the labia, the perineum, and the mons pubis. The vagina is the birth canal made up of smooth muscle. It connects the uterus to the outside world. Ovaries are small round organs located on either side of most women’s lower abdominal quadrants. Fallopian tubes are also called oviducts. They connect to the uterus. Discussion Topic: Describe the location and function of the following female reproductive organs: ovaries, fallopian tubes, uterus, vagina. Knowledge Application: Have students work in groups. Assign each group a specific organ or structure associated with female reproduction. Have groups present to the class and discuss function.

Female Reproductive Cycle
Menstruation Stimulated by estrogen and progesterone Ovaries release ovum Uterus walls thicken Fallopian tubes move egg (peristalsis) Uterine walls expelled (bleeding 3–5 days) Points to Emphasize: The monthly reproductive cycle produces predictable changes to the reproductive organs in anticipation of fetal implantation and development. If fertilization does not occur, the reproductive cycle ends with menses. Talking Points: After a woman reaches puberty, approximately every 28 days her uterus goes through changes to prepare for implantation of the fertilized egg. Peristalsis is a wave of muscular contraction. Fertilization typically occurs in the fallopian tube. Without fertilization, the thickened inner walls of the vagina slough off and are expelled through the vagina. Knowledge Application: Create a matching exercise. Have students match organs and structures to their functions. continued

Female Reproductive Cycle
Fertilization Sperm reaches ovum Ovum becomes embryo Embryo implants in uterus Fetal stage begins Talking Points: The embryonic stage occurs roughly from the point of fertilization through the first 8 weeks of pregnancy. From this point until delivery, the developing baby is referred to as the fetus, which will develop over the next 32 weeks (a typical pregnancy lasts about 40 weeks). Discussion Topic: Describe the reproductive changes that occur during the female reproductive cycle.

Physiologic Changes in Pregnancy
Teaching Time: 20 minutes Teaching Tips: Consider using an anatomic model to better illustrate the fetus, placenta, and uterus. Compare and contrast normal abdominal anatomy to the anatomy of a full-term pregnancy. Discuss the changes that occur. Invite a pregnant female to class. Describe external changes and illustrate changes in vital signs.

Changes in the Reproductive System
Points to Emphasize: A growing fetus creates massive changes to the reproductive system. Most important, the uterus gets larger. Pregnancy increases oxygen demand, increases maternal blood volume, puts pressure on the GI system, and causes ligaments to stretch. Talking Points: Other changes occur elsewhere in the woman’s body. In later stages of the pregnancy, the fetus can put pressure on the woman’s diaphragm, decreasing the volume of air in the lungs. Pressure on the stomach and intestine can slow digestion. Nausea and vomiting are common in pregnancy. Discussion Topics: Describe the major changes that occur during pregnancy. Specifically comment on the following: reproductive system, cardiovascular system, musculoskeletal system, respiratory system. Discuss the pathway that the fetus takes to reach the outside world. Describe how the fetus obtains oxygen and nutrients while inside the uterus. What role does the placenta play? Knowledge Application: Have students work in small groups. Assign each group a system and ask that group to research and present on the changes that take place during pregnancy.

Supine Hypotensive Syndrome
Placenta, infant, and amniotic fluid total 20–24 lbs. When supine, mass compresses inferior vena cava Cardiac output decreases Dizziness and drop in blood pressure Point to Emphasize: Supine hypotensive syndrome causes late-term pregnant females’ blood pressure to drop when they lie flat. EMTs can prevent this by positioning them in a lateral recumbent position. Talking Points: This is also referred to as vena cava compression syndrome. The body begins to compensate when it senses a drop in blood pressure by contracting the uterine arteries, redirecting blood to the major organs. Class Activity: Assess a pregnant female. Discuss external changes and changes in vital signs. Knowledge Application: Have students work in small groups. Have each group position one of its members so as to avoid supine hypotension syndrome. Consider a seated patient, a supine patient, and a patient on a backboard. Critical Thinking: How might the changes of pregnancy make a woman more vulnerable to trauma?

Think About It How does the development of the fetus affect other body systems? Talking Points: The development of the fetus has immediate physical effects on neighboring body systems as well as making other systems in the body work harder to sustain the growing fetus.

Labor and Delivery Teaching Time: 20 minutes
Teaching Tips: Use multimedia graphics to illustrate the progression of labor. Explain why the changes occur. Discuss how structures must change to allow for delivery of the fetus. Discuss the stages of labor, using real-life examples. Discuss how these stages might be recognizable from assessment findings.

First Stage Talking Point: First stage of labor starts with regular contractions and thinning and gradual dilation of the cervix. It ends with the cervix fully dilated. This occurs over several days or weeks and leads to Braxton-Hicks contractions, which are usually irregular and not sustained. In actual labor, the uterus will contract regularly and the cervix will dilate. As this happens the fetus’s head moves downward. Contractions are timed from the start of one contraction to the beginning of the next. Discussion Topic: Describe the first stage of labor. Discuss the changes that occur.

Second Stage Talking Points: The second stage is when the EMT must make the decision to stay on scene or to transport. It begins with full dilation of the cervix. During this time contraction becomes more frequent and labor pains more severe. As the baby’s head moves down, the mother will feel the urge to push and move her bowels. This stage ends when the baby is born. Discussion Topic: Describe the second stage of labor. Discuss the changes that occur.

Talking Points: This stage begins after the baby is born
Talking Points: This stage begins after the baby is born. The placenta detaches itself from the wall of the uterus and is expelled. The third stage usually lasts 10–20 minutes and ends as the placenta is delivered. Discussion Topic: Describe the third stage of labor. Discuss the changes that occur. Knowledge Application: Have students work in small groups. Assign each group a stage of labor. Ask the group to research and present on the physiology of that stage. Critical Thinking: Consider problems that might interfere with the progression of these three stages. How might these stages be interrupted? Third Stage

Think About It Why is childbirth such an exhausting ordeal for the mother? Talking Points: Far from involving just the reproductive system, childbirth involves the woman’s whole body. Not only is all her strength called for, but her body undergoes massive change in a very short time.

Information About Childbirth Video
Video Clip Information About Childbirth Discuss the stages of labor. What signs and symptoms may indicate an imminent birth? What equipment do you need to prepare for an imminent delivery? Describe the EMT’s role during delivery. Why should you save the placenta after delivery? Describe what the EMT should do following delivery. Click here to view a video on the subject of childbirth. Back to Directory

Patient Assessment Teaching Time: 20 minutes
Teaching Tips: The questions used in this assessment are additions to the traditional patient assessment. Remind students not to forget the primary and secondary assessments. There are no absolutes with birth. Remind students that findings only generally predict outcomes. EMTs always should be prepared for surprises. Practice makes perfect. Allow time for assessment practice.

Assessing the Woman in Labor
Assessment focused on imminent delivery Name, age, expected due date First pregnancy? Seen doctor about pregnancy? When did labor pains start? Point to Emphasize: Assessment of the woman in labor is designed to predict imminent delivery and to recognize likely resuscitation of the neonate. Assessment can also help indicate the level of resources necessary to deliver the baby. Talking Points: Assessing a woman in labor includes all of the elements of traditional patient assessment including ABC’s as well as vital signs and SAMPLE history. There are also a few elements specific to pregnancy. The average time of labor for a woman having her first baby is normally 16–17 hours. Prenatal care is important in regard to being aware of medical complications and multiple births. In addition to asking when labor pains start, ask how often the patient has the pain. Ask her if her water has broken. Discussion Topic: Describe the assessment steps necessary to identify imminent delivery. What are the most important findings? continued

Assessing the Woman in Labor
Feel the urge to push? Examine for crowning Feel for uterine contractions Take vital signs Point to Emphasize: The urge to push and crowning indicate imminent delivery. Transport typically should be deferred to ready for a delivery on scene. Talking Points: In addition to the urge to push, you should also ask the patient if she feels the need to move her bowels. Do not allow the mother to go to the bathroom even if she says she has to. It is best to transport an expecting mother unless you expect imminent delivery based on your evaluation. Class Activity: Have students write out a script of questions that they would add to their traditional assessment that might help them identify imminent delivery or neonatal resuscitation. Knowledge Application: Describe the signs and symptoms of a woman in labor. Ask the class if transport is indicated or if a home delivery is likely. Discuss the decision-making process. Critical Thinking: What equipment is necessary in normal childbirth? How might you proceed if standard equipment were not available?

Crowning Talking Points: The presenting part is defined as the part of the infant that is first to appear at the vaginal opening during labor. Usually, the presenting part of the baby is the head. The normal head-first birth is called a cephalic presentation. If the buttocks or both feet of the baby deliver first, the birth is called a breech presentation or breech birth. If part of the baby’s head or presenting part is visible with each contraction, then birth is imminent.

Findings Indicating Possible Need for Resuscitation
No prior prenatal care Premature delivery Labor induced by trauma Multiple births Point to Emphasize: A lack of prenatal care, premature labor, multiple gestation, and underlying conditions indicate a likelihood of neonatal resuscitation. Talking Points: The most important outcome of anticipating neonatal resuscitation is getting help. Discussion Topic: What questions might you ask to help predict neonatal resuscitation? What answers would indicate resuscitation? Knowledge Application: Have students work in small groups. Assign a finding that indicates a likelihood of resuscitation. Ask that group to research and present to the class on why that finding might indicate resuscitation. continued

Findings Indicating Possible Need for Resuscitation
History of pregnancy problems (especially placenta previa and breech presentation) Labor induced by drug use (especially narcotics) and alcohol Meconium staining when water breaks Talking Points: Meconium staining is a sign of fetal distress. Discussion Topic: Describe what additional resources might be necessary in the event of a home delivery or neonatal resuscitation. Knowledge Application: Use programmed patients to simulate assessment scenarios. Have teams of students practice assessment decision making.

Think About It How can you get necessary information from a patient who may be having uncontrolled pain from contractions? Talking Points: Interviewing a woman who is in the midst of delivery is not an easy task. It will be helpful to get information from family. If the mother cannot tell you how far apart contractions are, you may have to time a set yourself.

Normal Childbirth Teaching Time: 15 minutes
Teaching Tips: This section lends itself well to video clips of birth. Use video to demonstrate the progression of labor. Discuss and demonstrate the personal protective equipment necessary during a delivery. Use an anatomic model to demonstrate checking the position of the umbilical cord. Describe the technique to rectify a nuchal cord. Demonstrate a bulb syringe. Use a manikin to demonstrate the steps of suctioning a newborn.

Cephalic Delivery Point to Emphasize: EMTs do not deliver babies; mothers do!

Imminent Delivery Control scene Proper PPE
Place mother on bed, floor, or ambulance stretcher Remove clothing obstructing vagina Position assistant and OB kit Point to Emphasize: Childbirth requires a high level of personal protective equipment. Talking Points: If delivery takes place in an automobile, place the mother flat on the seat, and arrange her legs so she has one foot resting on the seat and the other on the floor. Discussion Topic: Describe the personal protective equipment necessary for a delivery. Knowledge Application: Using a programmed patient or a manikin, prepare for a delivery. Don appropriate personal protective equipment; prepare equipment and organize the delivery field. Discuss.

Preparing Mother for Delivery
Point to Emphasize: Emotional support for the mother is important during childbirth. Talking Points: Control the scene so the mother has privacy. (Her birthing coach may remain.) Proper PPE for you and your partner: surgical gloves, gowns, face mask, and eye protection. Place the mother on bed, floor, or ambulance stretcher and elevate her buttocks with blanket or pillow. You will need about 2 feet of workspace below the patient’s buttocks to initially care for the newborn. Remove any restrictive clothing. Drape the patient as shown in the diagram with sterile sheets or sterile towels. Knowledge Application: Have groups of students use programmed patients to role-play a delivery. Concentrate on scene management and teamwork.

Preparing the OB Kit Talking Points: Position the kit near the mother; all items must be within easy reach. Although supplies will vary, all kits should include what is shown in the slide. Discussion Topic: Describe the necessary components of an obstetrics kit. Class Activity: Assemble an obstetrics kit. Have students compile the components and discuss the use of each component.

Off-Duty Delivery Supplies
Clean sheets and towels Heavy, flat twine or new shoelaces Towel or plastic bag (for placenta) Clean, unused rubber gloves and eye protection Talking Points: The lack of PPE in this situation may expose the EMT to contact with infectious diseases.

Think About It Are there legal/moral/ethical concerns for an off-duty delivery? Talking Points: Students should be conversant with local laws and regulations governing any work that EMTs do while not on duty. Are they covered by Good Samaritan statutes? Are they required to assist?

Delivering the Baby continued
Talking Points: Keep someone at the mother’s head to provide support, monitor vital signs, and be alert for vomiting. Position your gloved hand over the mother’s vaginal opening when the baby’s head starts to appear. Place one hand below the baby’s head as it delivers, remembering the baby’s head has soft spots. A slight, well-distributed pressure may help prevent an explosive delivery. Do not pull on the baby! continued

Talking Points: If the amniotic sac has not ruptured by the time the baby’s head has delivered, use your finger to puncture the membrane. Examine the fluid for meconium staining, which will be a green-black or mustard yellow color. Once the head delivers, check if the umbilical cord is around the neck. While doing this, ask the mother to pant. If you are unable to slip the cord over the baby’s head, you will have to cut it. Clamp the cord and be extremely careful as you cut between the clamps. As soon as the baby’s head is visible, support the head with one hand. Wipe the mouth and nose with a gauze pad. Then suction the mouth and nose with a bulb syringe. (Follow your local protocol.) Compress the syringe prior to inserting it into the baby’s mouth and insert 1–1½ inches. Discussion Topic: Discuss the steps that you must take as the baby’s head appears. Describe preventing an explosive delivery, assessing the umbilical cord, and suctioning. Knowledge Application: Using a manikin, demonstrate the steps involved in suctioning a newborn. Have students repeat. continued

Talking Points: The upper shoulder usually delivers with some delay, followed quickly by the lower shoulder. Support the baby throughout this process. Gently guide the baby’s head downward as the upper shoulder delivers, then gently upward as the lower shoulder delivers. continued

Talking Points: Support the baby throughout the entire process. Keep in mind that newborns are very slippery. continued

Delivering the Baby Talking Points: As the lower extremities are delivered, grasp them to have a good hold on the baby. Once delivered, lay the baby on his side with head slightly lower than the body to facilitate drainage of fluids from the mouth and nose. Keep the baby at the same level as the mother’s vagina until the umbilical cord stops pulsating. Dry the infant and wrap in a warm, dry blanket. Note the exact time of birth. Write the mother’s last name and the time of birth on a piece of tape, and attach tape to baby’s wrist. (Fold tape so adhesive does not touch baby’s skin.) Critical Thinking: How might cultural considerations affect the steps you take to assist with delivery? Are there cultures in which standard practice might not be acceptable?

The Neonate Teaching Time: 15 minutes
Teaching Tips: Neonatal resuscitation is an infrequently used skill that requires immediate action. Emphasize the need to learn and memorize the basic, immediate steps. Practice! Use video clips to demonstrate an actual neonatal resuscitation. Pause to underscore key components. Invite an OB or neonatal intensive care unit (NICU) doctor or nurse to review the steps of neonatal care. Use a manikin to demonstrate the immediate steps in caring for a newborn. Describe drying and stimulating. Use a manikin to demonstrate CPR on a newborn.

Assessing the Neonate Talking Points: Neonate is the term used for a baby from birth to one month old. The term infant is used for a baby in its first year of life. A neonate should be assessed as soon as its born. Pulse should be greater than 100/min. An APGAR score (appearance, pulse, grimace, activity, respiratory effort) is done one minute after birth and then again 5 minutes after birth. The total APGAR score is done on a scale of 0–10. Discussion Topic: List and describe the assessment findings that would indicate the need for artificial ventilations and CPR.

Keeping the Baby Warm Heat retention is high priority Dry baby
Discard wet blankets Wrap baby in a dry blanket (infant swaddler or “space blanket”) Cover head Point to Emphasize: The most important aspect of caring for a neonate is keeping the baby warm. Talking Points: Heat loss not only drops the neonate’s body temperature, but also drops glucose levels. Class Activity: Dry, warm, and stimulate. Pass a manikin among students. Have each student dry, warm, and stimulate the newborn. Emphasize key steps to prevent hypothermia. Knowledge Application: Have students work in small groups, using a manikin to practice the immediate care of a newborn. Provide different scenarios that require increased levels of intervention.

Cutting the Umbilical Cord
Talking Points: Do not tie, clamp, or cut an umbilical cord on a baby who is not breathing unless the cord is around the baby’s neck. Do not cut or clamp a cord that is still pulsating. Apply one clamp or tie about 10 inches from the baby. This leaves enough cord for paramedics and hospital staff to start IV lines. Discussion Topic: Describe the immediate steps necessary to care for a newborn. Include the steps necessary to cut the umbilical cord.

Think About It Why is it so important to stimulate the baby?
Talking Points: Babies are passive throughout birth, but should quickly become active (i.e., breathe), usually on their own. Stimulating babies ensures that they will start breathing on their own.

Neonatal Resucitation
Point to Emphasize: Neonatal resuscitation begins with stimulating the baby. If no breathing occurs, begin positive pressure ventilations. Talking Points: Few neonates require CPR or ALS interventions. Discussion Topic: Describe the steps required to ventilate a newborn appropriately. Skill Demonstration: Using a manikin, demonstrate the proper procedure for performing positive pressure ventilations on a neonate. Critical Thinking: You are called to respond to a mother who has delivered an extremely premature baby. You arrive and find that the baby was delivered at 15 weeks. It is extremely small and is not breathing. Do you begin resuscitation? What is the age of viability for a newborn? continued

Neonatal Resucitation
Talking Points: If heart rate is below 100 beats per minute, ventilate at a rate of 40–60/minute. If heart rate is below 60 per minute, then begin chest compressions at a rate of 120 per minute, as well. Discussion Topic: Describe the steps of CPR in a newborn. Knowledge Applications: Have small groups of students discuss how ventilations and compressions differ in a newborn when compared to adult CPR. Have students use a manikin to practice the assessment and treatment steps of neonatal resuscitation. Skill Demonstration: Using a manikin, demonstrate the proper procedure for performing CPR on a neonate.

Think About It What are the first steps in neonatal resuscitation?
What is central cyanosis? When is artificial ventilation required, and what is the rate of artificial ventilations? Talking Points: The first steps in resuscitation are drying, warming, positioning to keep the airway clear, suctioning, and tactile stimulation. Central cyanosis is blue coloration of the torso. If the heart rate is below 100 beats per minute, ventilations are provided at 40–60 per minute.

Care After Delivery Teaching Time: 20 minutes
Teaching Tips: Emphasize that the mother may be the more serious patient. Post partum hemorrhage can kill. Use previous discussions about shock to describe the treatment of a hemorrhaging mother. Advise students that uterine massage can be quite painful to the mother. Nonetheless, it is necessary in the event of excessive hemorrhage. Use video clips to illustrate the delivery of the placenta.

Caring for the Mother Mother at risk for serious bleeding, infection, emboli Deliver placenta Control vaginal bleeding Comfort Point to Emphasize: After delivery, there are two patients to care for: the infant and the mother. Although it is easy to make the baby the primary focus, there are many risks of childbirth for the mother. Knowledge Application: Use a programmed patient to create post-delivery scenarios. Practice assessment. Have students focus on identifying excessive bleeding and shock.

Delivering the Placenta
Afterbirth: placenta with umbilical cord, amniotic sac membranes, and tissues lining uterus Placental delivery starts with labor pains May take 30 minutes or longer Begin transport in 10 minutes (do not wait to deliver placenta) Point to Emphasize: Typically it is not necessary to delay transport as the placenta is delivered. EMTs should retain the delivered placenta for examination at the hospital. Talking Points: Avoid putting pressure on the abdomen over the uterus to hasten delivery. If mother and baby are doing well, and there are no respiratory problems or significant uncontrolled bleeding, transportation to the hospital can be delayed up to 20 minutes while awaiting delivery of the placenta. The attending physician will want to examine the placenta and other tissues for completeness, since any afterbirth tissues remaining in the uterus pose a serious threat of infection and prolonged bleeding. Try to catch the afterbirth in a container. Label this material “placenta” and include the name of the mother and the time the tissues were expelled. Discussion Topic: Describe the delivery of the placenta. How would you know that this stage of labor has begun?

Controlling Vaginal Bleeding
Point to Emphasize: Excessive post partum bleeding can lead to shock. Assess and treat accordingly. Talking Points: Controlling vaginal bleeding for the mother is a priority. If the placenta hasn’t delivered in 20 minutes, transport mother and neonate. Blood loss is not usually more than 500 cc, but it may be profuse. Have mother lower her legs after placing a sanitary napkin over the vagina. Have her squeeze legs together. Elevate her feet. Massaging the fundus of the uterus (felt as a grapefruit-sized object) will be painful to the mother, but it controls bleeding. Nursing the baby also helps control bleeding. Discussion Topics: Describe how you might differentiate the normal bleeding that is associated with delivery from excessive bleeding. Discuss the steps used to treat excessive bleeding after delivery. Knowledge Application: Have students work in small groups to describe the steps used to control excessive hemorrhage after delivery. Critical Thinking: You deliver the placenta, but it looks like only a piece of the placenta. The mother is still bleeding heavily. What are the potential problems if part of the placenta remains inside the uterus?

Providing Comfort to the Mother
Take vital signs frequently Acts of kindness will be appreciated and remembered Wipe face and hands with damp washcloth Replace blood-soaked sheets and blankets Point to Emphasize: Talking to the mother and paying attention to her new baby are part of total patient care. A good rule to follow is to treat the patient as you would wish a member of your family to be treated. Talking Points: Dispose of all items that have been in contact with blood or body fluids in a biohazard container. Discussion Topic: Discuss emotional care. If there are mothers in the class, ask them to discuss how they would like to have been treated following childbirth.

Think About It What are your responsibilities in caring for the mother? What is considered to be the usual blood loss? Give examples of acts of kindness toward the mother. Talking Points: Responsibilities include delivery of the placenta, controlling vaginal bleeding, and making the mother as comfortable as possible. Some EMS systems recommend transport without waiting for delivery of the placenta. You can always stop the ambulance en route if the placenta begins to crown. Blood loss during delivery is considered to be normal in the amount of 500 cc. Acts of kindness include wiping the mother’s face and hands with a damp washcloth and then drying them, clearing away blood-soaked linens, and so on.

Childbirth Complications
Teaching Time: 20 minutes Teaching Tips: This section lends itself well to a multimedia presentation. Use graphics to illustrate umbilical prolapse, placenta previa/abruptio placentae, and breech presentations. Emphasize that the steps necessary to treat a prolapsed cord or a difficult breech delivery need to be undertaken immediately. Relate this to your previous discussions about neonatal CPR. How many ventilations of a newborn are lost with just a minute’s delay? Consider inviting a midwife, OB physician, or OB nurse to discuss treating complications of delivery. Discuss fetal development to better explain the challenges of prematurity. Focus on lung development and thermal regulation.

Breech Presentation Point to Emphasize: Breech presentations occur when the head is not the first presenting part of the baby during birth. Breech presentations can spontaneously deliver successfully, but the complication rate is high. Talking Points: Initiate rapid transport. Never attempt to deliver by pulling on legs. Provide high-concentration oxygen. Place mother in head-down position with pelvis elevated. Insert gloved hand and form V on either side of the baby’s nose to lift away from the vaginal wall. Discussion Topic: Describe the steps necessary to provide an airway to a complicated breech delivery. Why is immediate action so important? Knowledge Application: Have students work in small groups. Assign each group a specific complication of delivery. Have the group research and report on pathophysiology and immediate treatment priorities.

Limb Presentation Talking Points: Place mother in head-down position and give high-concentration oxygen by non-rebreather mask. Initiate rapid transport.

Prolapsed Umbilical Cord
Talking Points: The oxygen supply to the baby may be totally interrupted due to the cord being pinched. Elevate the mother’s hips and give her high-concentration oxygen. Keep the cord warm by wrapping it in a moist, sterile towel, and check for pulsation. Do not attempt to push the cord back inside. Insert gloved fingers into the mother’s vagina to keep pressure off the cord by pushing up on the baby’s head and buttocks. Transport to hospital, continuing pressure on the baby’s head. Discussion Topic: Describe a prolapsed umbilical cord. Why is this dangerous to the fetus? Describe the immediate actions necessary to treat this complication.

Multiple Birth Have appropriate resources
Clamp or tie cord of first baby Assist with delivery of second baby Placenta and cord care are same as single delivery Keep babies and mother warm Discussion Topic: Describe the assessment findings that might indicate multiple births.

Premature Birth Keep baby warm Keep airway clear
Provide ventilations and chest compressions Watch umbilical cord for bleeding Oxygen (blow by) Call ahead to emergency department Point to Emphasize: By definition, a premature infant is one who weighs less than 51/2 pounds at birth, or one who is born before the 37th week of pregnancy. Discussion Topic: Discuss the hazards of prematurity. What risks are present with premature infants that are not present with term babies? Knowledge Application: Assign small groups different weeks of fetal development. Have groups research and present. Focus on fetal development at that week and the potential challenges posed if the baby were to be delivered at that stage of development. Discuss.

Meconium Don’t stimulate infant before suctioning
Suction mouth, then nose Maintain open airway Provide ventilations and/or chest compressions

Think About It Why is it important to have your partner or another person (birthing coach or other adult acceptable to the mother) observing as you help the mother through childbirth? Talking Points: Besides watching the mother for distress or turning her head if she needs to vomit, having an observer guarantees that there will be no doubt about the professional nature of your treatment of the mother.

Emergencies in Pregnancy
Excessive prebirth bleeding Ectopic pregnancy Seizures in pregnancy Miscarriage and abortion Trauma in pregnancy Stillbirths Accidental death of pregnant woman

Excessive Prebirth Bleeding
Main sign is unusually profuse bleeding Abdominal pain may or may not be felt Assess for signs of shock High-concentration oxygen and transport Place sanitary napkin over vagina Talking Points: It’s normal for a pregnant woman to have spotting or a light discharge of a small amount of blood. continued

Excessive Prebirth Bleeding
Point to Emphasize: Placenta previa and abruptio placentae are common causes of excessive prebirth bleeding. Talking Points: Placenta previa is a condition in which the placenta is formed in an abnormal location and does not allow for normal delivery. As the cervix dilates, the placenta tears. The similar abruptio placentae is a condition in which the placenta separates from the uterine wall. This can be partial or complete. Discussion Topic: Describe the pathophysiology of placenta previa and abruptio placentae. Describe how these disorders might injure the mother and baby.

Ectopic Pregnancy Point to Emphasize: One-sided abdominal pain in a woman of childbearing years should be assumed to be an ectopic pregnancy. Talking Points: Low blood pressure is a late sign of ectopic pregnancy.

Seizures in Pregnancy Existing preeclampsia Elevated blood pressure
Excessive weight gain Excessive swelling to face, ankles hands, and feet Altered mental status or headache

Miscarriage and Abortion
Cramping, abdominal pains Bleeding: moderate to severe Discharge of tissue and blood from vagina Talking Points: Treat for shock. Knowledge Application: Have students work in small groups. Have them rehearse death and dying situations associated with spontaneous abortion.

Trauma in Pregnancy Pulse 10–15 beats faster than non-pregnant women
Blood loss may be 30%–35% before signs/symptoms appear Ask patient if she received blows to abdomen Talking Points: Because of slowed digestion and delayed gastric emptying, there is a greater risk that the patient will vomit and aspirate. Have suction ready. continued

Trauma in Pregnancy Critical Thinking: Discuss the causes of trauma during pregnancy. What portion of the trauma can be accounted for by domestic violence?

Stillbirths Do not resuscitate if it is obvious the baby died some time before birth Resuscitate if baby is born in cardiac or respiratory arrest Prepare to provide life support Emotional support for family Talking Points: Keep accurate records of the time of stillbirth and care rendered for fetal death certificate. Resuscitative efforts should be withheld from stillborn babies who have been obviously dead for some time.

Accidental Death of Pregnant Woman
Chance to save unborn child Begin CPR on mother immediately Continue CPR until emergency cesarean section can be performed or you are relieved in emergency department Class Activity: Describe a complication. Have students discuss the immediate necessary actions. Discuss treatment in general.

Information About Preeclampsia Video
Video Clip Information About Preeclampsia What is preeclampsia? What are some signs and symptoms associated with preeclampsia? What are some possible complications of preeclampsia? What are some factors that can increase a patient’s risk of developing preeclampsia? Click here to view a video on the subject of preeclampsia. Back to Directory

Ectopic Pregnancy Video
Video Clip Ectopic Pregnancy What is an ectopic pregnancy? Where can an ectopic pregnancy occur? Discuss the risks of having an ectopic pregnancy. With what signs and symptoms might a patient with an ectopic pregnancy present? Click here to view a video on the subject of ectopic pregnancy. Back to Directory

Gynecological Emergencies
Teaching Time: 20 minutes Teaching Tips: Teach that vaginal bleeding is another form of internal bleeding and can have the same level of risk. Sexual assault is a difficult situation for EMTs. Recruit expert help for your presentation. Many domestic violence/sexual assault advocacy groups have professional educators who are willing to lend a hand. Invite a law enforcement officer or sexual assault nurse to class to discuss evidence collection and crime scene preservation.

Vaginal Bleeding Treat as potential life threat
Check for associated abdominal pain Monitor for hypovolemic shock Point to Emphasize: Vaginal bleeding that is not a result of direct trauma or a woman’s normal menstrual cycle may indicate a serious gynecological emergency. Talking Points: Asking the patient how many pads she has used to block bleeding may be helpful in assessing blood loss. Discussion Topic: Describe the assessment findings that would indicate life-threatening vaginal bleeding.

Trauma to External Genitalia
Observe MOI Look for signs of severe blood loss and shock Consider additional internal injuries Point to Emphasize: Consider assault a likely cause of any trauma to external genitalia. Talking Points: Caring for these injuries may be difficult due to patient modesty. Discussion Topic: Describe the treatment steps for external genitalia trauma. Knowledge Application: Using a programmed patient, simulate trauma and sexual assault situations. Have groups of students practice assessment and treatment strategies.

Sexual Assault Treat immediate life threats
Do not disturb potential evidence Examine genitals only if severe bleeding is present Discourage bathing, voiding, or cleansing wounds Fulfill mandated reporting requirements Points to Emphasize: Care of the sexual assault patient must include medical, legal, and psychological considerations. When treating sexual assault patients, EMTs should be professional, nonjudgmental, and conscious of personal space. EMTs should explain examinations and treatments beforehand and should be sensitive to fears and embarrassment. Talking Points: It may be necessary for you to stage your unit near the scene until it is rendered safe by police. Discussion Topic: Describe the priorities in caring for a sexual assault victim. Class Activity: Discuss the nonmedical priorities of caring for a sexual assault victim. Consider using a professional advocate/educator to lead this discussion. Critical Thinking: You are called for a sexual assault victim who is refusing evaluation and care. What steps should you take to deal with this situation? Might it be appropriate not to transport this patient?

Think About It When arriving at a crime scene, what are the key things to keep in mind as you respond?

Chapter Review

Chapter Review Although birth is a natural process that usually takes place without complications, involvement of EMS usually indicates something unusual has happened. The EMT’s role at a birth is generally to provide reassurance and to assist the mother in the delivery of her baby. continued

Chapter Review During normal delivery, determine if there should be immediate transport or if birth is imminent and will take place at the scene. If birth is to take place at the scene, have equipment ready and appropriate resources on hand. Always be prepared for resuscitation. continued

Chapter Review Complications of delivery are a true emergency. Be prepared to initiate rapid transport. There may also be pre-delivery emergencies or emergencies associated with pregnancy that you must be prepared to treat. continued

Chapter Review Stillbirth and death of the mother and sexual assault are difficult emergencies the EMT is occasionally called upon to manage. Emotional care for these issues may be as important as medical care.

Remember Female reproductive organs present new anatomy and specific potential emergencies. EMTs should recognize the different anatomy and be prepared to address reproductive emergencies. A growing fetus creates massive change to the mother’s body. All systems undergo major alterations. continued

Remember Assessment of the woman in labor is designed to predict imminent delivery and to recognize likely resuscitation. The urge to push and crowning indicate imminent delivery. Transport typically should be deferred for a home delivery. continued

Remember Lack of prenatal care, premature labor, multiple gestation, and underlying conditions indicate a likelihood of neonatal resuscitation. Childbirth requires a high level of personal protective equipment. continued

Remember The most important aspect of care for a neonate is keeping the baby warm. Resuscitation may be indicated by assessing breathing and heart rate. After delivery there are two patients to care for: the infant and the mother. continued

Remember EMTs should be familiar with the pathophysiology and emergency treatment of the various complications of childbirth. Care of the sexual assault patient must include medical, legal, and psychological considerations.

Questions to Consider What is the difference between abruptio placenta and placentae previa? How do you care for a prolapsed cord? What do you do if the bag of water is still intact during delivery?

Critical Thinking You are called to a pregnant woman in labor. During your evaluation you find that it is the woman’s first pregnancy, the baby’s head is not crowning, and contractions are 10 minutes apart. continued

Critical Thinking You ask the mother if she feels the need to move her bowels, and she says no. Do you prepare for delivery at the scene? Or do you transport the mother to the hospital?

Please visit Resource Central on www. bradybooks
Please visit Resource Central on to view additional resources for this text. Please visit our web site at and click on the mykit links to access content for this text. Under Instructor Resources, you will find curriculum information, lesson plans, PowerPoint slides, TestGen, and an electronic version of this instructor’s edition. Under Student Resources, you will find quizzes, critical thinking scenarios, weblinks, animations, and videos related to this chapter—and much more.

Introduction to Emergency Medical Care 1

Similar presentations

Presentation on theme: "Introduction to Emergency Medical Care 1"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Introduction to Emergency Medical Care 1

Similar presentations

Presentation on theme: "Introduction to Emergency Medical Care 1"— Presentation transcript:

Similar presentations

About project

Feedback