Standard

EMS 135 - Maternal/Child

Course Description

Emphasizes the study of gynecological, obstetrical, pediatric and neonatal emergencies.

Maternal/Child combines the unique relationships and situations encountered with mother and child. Provides a detailed understanding of anatomy/physiology, pathophysiology, assessment, and treatment priorities for the OB/GYN patient. Pediatric and neonatal growth and development, anatomy and physiology, pathophysiology, assessment and treatment specifics are covered in detail. Successful completion of a PLS/PALS course is required. This course provides instruction on topics in Division's 5 (Medical), Sections 13 (Obstetrics) & 14 (Gynecology) and 6 (Special Considerations), Sections 1 (Neonatology) and 2 (Pediatrics) of the USDOT/NHTSA Paramedic National Standard Curriculum.

Competency Areas		Hours
Anatomy and Physiology of the Female Reproductive System		Class	4
Pathophysiology of the Female Reproductive System		D. Lab	2
Anatomy and Physiology of the Pediatric and Neonatal Patient		P. Lab/O.B.I.	0
Pathophysiology of the Pediatric and Neonatal Patient		Credit	5
Assessment of the OB/GYN Patient
Assessment of the Pediatric and Neonatal Patient
Treatment Modalities of the OB/GYN Patient
Treatment Modalities of the Pediatric and Neonatal Patient
Successful Completion of either PALS and/or PLS

Prerequisite:	EMS 126, EMS 127, EMS 128, EMS 129
Corequisite:

Course Guide

Competency	After completing this section, the student will:	Hours
Competency	After completing this section, the student will:	Class	D.Lab	P.Lab/ O.B.I.
ANATOMY AND PHYSIOLOGY OF THE FEMALE REPRODUCTIVE SYSTEM

PATHOPHYSIOLOGY OF THE FEMALE REPRODUCTIVE SYSTEM

ANATOMY AND PHYSIOLOGY OF THE PEDIATRIC AND NEONATAL PATIENT

PATHOPHYSIOLOGY OF THE PEDIATRIC AND NEONATAL PATIENT

ASSESSMENT OF THE OB/GYN PATIENT

ASSESSMENT OF THE PEDIATRIC AND NEONATAL PATIENT

TREATMENT MODALITIES OF THE OB/GYN PATIENT

TREATMENT MODALITIES OF THE PEDIATRIC AND NEONATAL PATIENT

SUCCESSFUL COMPLETION OF EITHER PALS AND/OR PLS

UNIT TERMINAL OBJECTIVE

5-14 At the completion of this unit, the paramedic student will be able to apply an understanding of the anatomy and physiology of the female reproductive system to the assessment and management of a patient experiencing normal or abnormal labor.

COGNITIVE OBJECTIVES

At the completion of this unit, the paramedic student will be able to:

5-14.1 Review the anatomic structures and physiology of the reproductive system. (C-1)

5-14.2 Identify the normal events of pregnancy. (C-1)

5-14.3 Describe how to assess an obstetrical patient. (C-1)

5-14.4 Identify the stages of labor and the paramedic's role in each stage. (C-1)

5-14.5 Differentiate between normal and abnormal delivery. (C-3)

5-14.6 Identify and describe complications associated with pregnancy and delivery. (C-1)

5-14.7 Identify predelivery emergencies. (C-1)

5-14.8 State indications of an imminent delivery. (C-1)

5-14.9 Explain the use of the contents of an obstetrics kit. (C-2)

5-14.10 Differentiate the management of a patient with predelivery emergencies from a normal delivery. (C-3)

5-14.11 State the steps in the predelivery preparation of the mother. (C-1)

5-14.12 Establish the relationship between body substance isolation and childbirth. (C-3)

5-14.13 State the steps to assist in the delivery of a newborn. (C-1)

5-14.14 Describe how to care for the newborn. (C-1)

5-14.15 Describe how and when to cut the umbilical cord. (C-1)

5-14.16 Discuss the steps in the delivery of the placenta. (C-1)

5-14.17 Describe the management of the mother post-delivery. (C-1)

5-14.18 Summarize neonatal resuscitation procedures. (C-1)

5-14.19 Describe the procedures for handling abnormal deliveries. (C-1)

5-14.20 Describe the procedures for handling complications of pregnancy. (C-1)

5-14.21 Describe the procedures for handling maternal complications of labor. (C-1)

5-14.22 Describe special considerations when meconium is present in amniotic fluid or during delivery. (C-1)

5-14.23 Describe special considerations of a premature baby. (C-1)

AFFECTIVE OBJECTIVES

At the completion of this unit, the paramedic student will be able to:

5-14.24 Advocate the need for treating two patients (mother and baby). (A-2)

5-14.25 Value the importance of maintaining a patient’s modesty and privacy during assessment and management. (A-2)

5-14.26 Serve as a role model for other EMS providers when discussing or performing the steps of childbirth. (A-3)

DECLARATIVE

I. Introduction

A. Pregnancy results from ovulation and fertilization

1. Most pregnancies are uncomplicated

2. Complications can occur

a. Eclampsia/ pre-eclampsia

b. Diabetes

c. Hypotension/ hypertension

d. Cardiac disorders

e. Abortion

f. Trauma

g. Placenta abnormalities

B. Childbirth involves labor and delivery

1. Childbirth is a natural process, often only requiring basic assistance

2. Throughout the process, the paramedic is caring for two patients, not one

3. Complications can occur

a. Breech/ limb presentation

b. Multiple births

c. Umbilical cord problems

d. Disproportion

e. Excessive bleeding

f. Pulmonary embolism

g. Neonate requiring resuscitation

h. Preterm labor

II. Review of the anatomy and physiology of the female reproductive system

A. Normal events of pregnancy

1. Ovulation

2. Fertilization

a. Occurs in distal third of fallopian tube

3. Implantation

a. Occurs in the uterus

B. Accessory structures of pregnancy

1. Placenta

a. Transfer of gases

(1) Oxygen and carbon dioxide

b. Transport other nutrients

(1) Glucose

(2) Potassium, sodium, chloride

c. Excretion of wastes

(1) Urea, uric acid, creatine diffuse into maternal blood

d. Hormone production

(1) Placenta acts as temporary endocrine gland

(2) Secretes estrogen, progesterone, etc.

(a) Prevents menses

(b) Causes anatomical changes in preparation of childbirth

e. Protection

(1) Provides partial barrier against harmful substances

(2) Does not protect against steroids, narcotics, some antibiotics

2. Umbilical cord

a. Connects placenta to fetus

b. Contains two arteries and one vein

3. Amniotic sac and fluid

a. Membrane surrounding fetus

b. Fluid originates from fetal sources - urine, secretions

c. Between 500 and 1000 ccs of fluid after 20 weeks

d. Rupture of the membrane produces watery discharge

C. Fetal growth process

1. End of 3rd month

a. Sex may be distinguished

b. Heart is beating

c. Every structure found at birth is present

2. End of 5th month

a. Fetal heart tones can be detected

b. Fetal movement may be felt by the mother

3. End of 6th month

a. May be capable of survival if born prematurely

4. Approximately middle of 10th month

a. Considered to have reached full term

b. Expected date of confinement (EDC)

D. Obstetric terminology

1. Antepartum - before delivery

2. Postpartum - after delivery

3. Prenatal - existing or occurring before birth

4. Natal - connected with birth

5. Gravida - number of pregnancies

6. Para - number of pregnancies carried to full term

7. Primigravida - a woman who is pregnant for the first time

8. Primipara - a woman who has given birth to her first child

9. Multiparous - a woman who has given birth multiple times

10. Gestation - period of time for intrauterine fetal development

III. General assessment of the obstetric patient

A. Initial assessment

B. History of present illness

1. SAMPLE

a. Pertinent medical history

(1) Diabetes

(2) Heart disease

(3) Hypertension/ hypotension

(4) Seizures

2. Current health of patient

a. Pre-existing conditions

b. Prenatal care

(1) None

(2) Physician

(3) Nurse midwife

C. Obstetrical history

1. Length of gestation

2. Primipara or multiparous

3. Previous cesarean sections

4. Previous gynecologic or obstetric complications

5. Contractions

6. Patient states that "the baby is coming"

7. Anticipating normal delivery (versus multiple births, etc.)

8. Pain

a. OPQRST

9. Vaginal bleeding

a. Presence

b. Amount

c. Color

d. Duration

10. Vaginal discharge

a. Presence

b. Amount

c. Color

d. Duration

D. Physical examination

1. Comforting attitude and approach

a. Protect patient modesty

b. Maintain privacy

c. Be considerate of reasons for patient discomfort

2. Recognition of pregnancy

a. Breast tenderness

b. Urinary frequency

c. Amenorrhea

d. Nausea, vomiting (morning sickness)

e. Uterine

3. Evaluating uterine size

a. Between weeks 12 and 16

(1) Visually and by palpation to be above the symphysis pubis

b. 20 weeks

(1) At the level of the umbilicus

c. At term

(1) Near the xiphoid process

4. Presence of fetal movements

a. By observation

b. By questioning the patient

5. Presence of fetal heart tones

a. Audible at approximately the 20th week

b. May be detected earlier with fetal doppler

c. Normal rate 120 to 160 beats per minute

6. Vital signs

a. Consider orthostatic

7. Genital inspection

a. When indicated

b. Visually inspect for crowning and/ or vaginal bleeding

IV. General management of the obstetric patient

A. Basic treatment modalities

1. Airway, breathing, circulation

2. Administer oxygen

a. High-flow, high-concentration PRN

3. Non-pharmacologic intervention

a. Position of comfort and care

(1) Left lateral recumbent after the 24th week, if not in active labor

b. Monitor cardiac rhythm

c. Evaluate the fetus status if possible

d. Treat for hypotension if necessary

4. Pharmacological intervention

a. IV access

(1) Large bore

(2) Volume expander

(3) Consider second line

b. Analgesia may be appropriate

(1) Consider the possibility of masking symptoms or a deteriorating condition

(2) Consider potential fetal impact

(3) Nitrous oxide is the analgesia of choice

5. Transport the patient emergently

6. Psychological support

a. Calm approach

b. Maintain modesty/ privacy

V. Specific complications of pregnancy

A. Trauma

1. Minor trauma common in the obstetric patient

a. Reasons

(1) Syncopal episodes

(2) Diminished coordination

(3) Loosening of the joints

2. Major trauma

a. Susceptible to a life-threatening episode due to increased vascularity

(1) May deteriorate suddenly

3. Abdominal trauma

a. Premature separation of the placenta

b. Premature labor

c. Abortion

d. Rupture of the uterus

e. Fetal death

(1) Death of the mother

(2) Separation of the placenta

(3) Maternal shock

(4) Uterine rupture

(5) Fetal head injury

B. Vaginal bleeding

1. Abortion/ miscarriage

a. Classifications

(1) Complete

(a) Uterus completely evacuates fetus, placenta, and decidual lining

(2) Incomplete

(a) Some placental tissue remaining in uterus after expulsion of fetus

(3) Spontaneous

(a) Occur before 20th week, due to maternal or ovular defects

(4) Criminal

(a) Intentional ending of pregnancy under any condition not allowed by law

(5) Therapeutic

(a) End pregnancy as thought necessary by a physician

(6) Threatened

(a) Vaginal bleeding during first half of pregnancy

(7) Inevitable

(a) Severe cramping and cervix effacement and dilation

(b) Attempts to maintain pregnancy are useless; changes are irreversible

b. Incidence

(1) Assume during first and second trimester of known pregnancy

c. Specific assessment findings

(1) Additional history

(a) Statement that she has recently passed tissue vaginally

(b) Complaint of abdominal pain and cramping

(2) Additional physical examination

(a) Evaluate impending shock - check orthostatic vital signs

(b) Presence and volume of vaginal blood

d0 Additional management

(1) Collect and transport any passed tissue, if possible

(2) Emotional support extremely important

2 Ectopic pregnancy

a0 Incidence

(1) Approximately 1 of every 200 pregnancies

(2) Most are symptomatic and/or detected 2-12 weeks gestation

b0 Cause

(1) Ovum develops outside the uterus

(a) Previous surgical adhesions

(b) Pelvic inflammatory disease

(d) Use of an IUD

c0 Organs affected

(1) Fallopian tube

d0 Complications

(1) May be life-threatening

(2) May lead to hypovolemic shock and death

e0 Specific assessment findings

(1) Severe abdominal pain, may radiate to back

(2) Amenorrhea - absence of monthly blood flow and discharge

(3) Vaginal bleeding absent or minimal

(4) Upon rupture, bleeding may be excessive

(5) Shock signs and symptoms

(6) Additional history

(a) Previous surgical adhesions

(b) Pelvic inflammatory disease

(d) Use of an IUD

(e) Previous ectopic pregnancy

(7) Additional physical examination

(a) Check for impending shock - orthostatic vital signs

(b) Presence and volume of vaginal blood

f0 Additional management:

(1) See "general management"

(2) Second large bore IV line

(3) Trendelenburg, if shock impending

(4) Emergency transport to nearest surgically capable facility

3 Placenta previa

a0 Incidence

(1) About 1 in 300

(2) Higher in preterm births

b0 Cause

(1) Placenta implantation in lower uterus; covering cervix opening

(2) Associate with increasing age, multiparity, previous cesarean sections, intercourse

c0 Organs affected

(1) Placenta, uterus

d0 Complications

(1) Placental insufficiency and fetal hypoxia

e0 Specific assessment findings

(1) Bright red blood flow without pain or uterine contractions

f0 Additional management

(1) Emergency transport to appropriate facility

(2) Definitive treatment is cesarean section

4 Abruptio placenta

a0 Incidence

(1) Occurs in up to 2% of pregnancies

(2) Occurs in 1 in 200 deliveries

(3) 1 out of 400 fetal deaths

(4) Typically a third trimester complication

(5) Associated with hypertension, preeclampsia, trauma, multiparity

b0 Cause

(1) Premature separation of placenta from uterus

c0 Organs affected

(1) Placenta, uterus

d0 Complications

(1) Fetal hypoxia and death

e0 Specific assessment findings

(1) Third trimester bleeding

(2) Acute alteration in the contraction pattern

(3) Uterus becomes tender

(4) Uterus becomes board‑like if hemorrhage retained

(5) Symptoms of shock inconsistent with amount of visible bleeding

f0 Additional management

(1) Assess fetal heart tones often

(2) Transport in LLR position unless Trendelenburg is indicated

(3) Emergency transport of patient to an appropriate facility

(a) Definitive treatment is a cesarean section

C0 Complications of pregnancy

1 Exacerbation of pre-existing medical conditions

a0 Diabetes

(1) May become unstable during pregnancy

(2) Higher incidence of coma

b0 Hypertension

(1) May be complicated by pre-eclampsia/ eclampsia

(2) More susceptible to additional complications

(a) Cerebral hemorrhage

(b) Cardiac failure

c0 Neuromuscular disorders

(1) May be aggravated by pregnancy

d0 Cardiac disorders

(1) Additional stress on the heart

(a) Cardiac output increases 30% by week 34

2 Medical complications of pregnancy

a0 Toxemia (pre-eclampsia/ eclampsia)

(1) Incidence

(a) Serious condition

(b) Pregnancy induced hypertension (PIH)

i Hypertension, with albuminuria and/ or edema

ii After the 20th week of gestation

(2) Cause

(a) Associated with first birth, multiple births, excessive amniotic fluid

(b) Pre-existing conditions

i Hypertension

ii Renal disease

iii Diabetes

(3) Organs affected

(4) Complications

(a) Convulsions seriously threaten the fetus by abruptio placenta

(5) Specific assessment findings

(a) Occurs in the last trimester of pregnancy

(b) Pre-eclampsia is non-convulsive state of toxemia

i Hypertension (B/P > 140/90 - acute systolic rise > 20 and diastolic rise > 10)

ii Fluid retention with excessive weight gain

iii Proteinuria

(d) Eclampsia includes convulsions

(e) Additional history

i Hypertension

ii Excessive weight gain with edema and/ or seizures

(f) Additional physical exam

i Headaches and/ or epigastric pain; possible seizure

ii Visual problems

(6) Additional management

(a) If a seizure has not occurred

i Keep patient calm and quiet

ii IV access

iii Darken ambulance

iv Position patient left lateral recumbent

v Transport gently

vi Minimize stimuli to avoid precipitating seizure

vii Consider magnesium sulfate

(b) If a seizure is occurring

i IV access

ii Consider the administration of 5 to 10 mg of diazepam IV push

iii Administer 2 to 5 grams of magnesium sulfate diluted in 50 to 100 ccs of D₅W, slow IV push

i Consider magnesium sulfate

(d) Definitive treatment is cesarean section

b0 Diabetes

(1) Can be caused by pregnancy

c0 Supine-hypotensive syndrome

(1) Incidence

(a) Occurs near term

(2) Cause

(a) Abdominal mass compresses the inferior vena cava

i Reduces pre-load, and thereby cardiac output

(3) Organs affected

(4) Complications

(5) Specific assessment findings

(a) Check to see if volume depletion is the problem

(b) Additional history

i Recent medical history including diarrhea, vomiting

ii Problem coincidental to supine positioning

i Orthostatic vital signs

ii Tenting of skin

(6) Additional management

(a) If not volume depletion

i Transport left lateral recumbent

(b) If possibility of volume depletion

i Consider 2 large bore IVs

ii Volume replacement

iii Transport left lateral recumbent as precaution

3 Braxton-Hicks contractions

a0 Incidence

(1) Benign phenomenon that simulates labor

(2) Usually occurs after the third month of pregnancy

b0 Specific assessment findings

(1) Contractions are generally painless and may be helped by walking

c0 Additional management

(1) None

4 Preterm labor

a0 Incidence

(1) Labor that begins prior to 38 weeks gestation

(2) Incidence varies with age, presence of multiple gestations and other risk factors

b0 Causes

(1) Physiologic abnormalities (multiple factors)

(2) Uterine or cervical anatomical abnormalities

(3) Premature rupture of membranes

(4) Multiple gestations

(5) Intrauterine infections

c0 Complications

(1) Premature delivery of infant

d0 Specific assessment findings

(1) Contractions that result in the progressive dilation or effacement of the cervix (not a field assessment)

(2) May be difficult to differentiate labor from Braxton-Hicks contractions (false labor)

e0 Additional management

(1) Requires transport for evaluation and treatment by an appropriate health care provider

(2) Consideration of tocolysis if not contraindicated

(a) Rest

(b) Fluids (IV or even PO in some cases)

(d) May require administration of a tocolytic at the receiving facility (magnesium sulfate, a beta agonist or indocin)

VI VI Normal childbirth

A0 Characteristics of labor

1 Discomfort in the back and/ or the abdomen

2 Contractions occurring at regular intervals

a0 Increasing frequency and intensity of contractions

b0 Time from the beginning of one contraction to the beginning of the next

B0 Stages of labor

1 Stage I (Dilatation Stage)

a0 Onset of regular uterine contractions to complete cervical dilation

b0 Average time

(1) 12.5 hours in primipara

(2) 7 hours in multipara

2 Stage II (Expulsion Stage)

a0 Full dilatation of the cervix to the delivery of the newborn

b0 Average time

(1) 80 minutes in a primipara

(2) 30 minutes in a multipara

3 Stage III (Placental Stage)

a0 Immediately following delivery of the baby until expulsion of the placenta

b0 Average time

(1) 5 to 20 minutes

C0 Progression of labor

1 First stage of labor

a0 Contractions

(1) Typically begin short and gently

(2) Occur at intervals of ten to fifteen minutes

b0 Effacement

(1) Thinning and shortening of the cervix

c0 Cervical dilation

(1) Stretching of the opening of the cervix to accommodate baby

2 Second stage of labor

a0 Contractions

(1) Stronger and longer

(2) Lasting 50-70 seconds

(3) Occurring at intervals of 2-3 minutes

b0 Amniotic sac typically ruptures

c0 Urge to bear down or push becomes very strong

d0 Crowning

(1) Largest part of the fetal head is visible

D0 Delivery process

1 The decision to transport

a0 Related to the imminence of delivery

(1) Number of pregnancies

(a) Labor is shortened with multiparity

(2) Frequency of contractions

(a) Two minutes apart may signal imminent delivery

(3) Maternal urge to push

(a) Desire to push signals imminent delivery

(4) Crowning of the presenting part

(a) Imminent delivery

b0 Related to the presence of complications

(1) Abnormal presentations

(2) Fetal distress

(3) Multiple births

2 Delivery of the newborn

a0 Prepare a delivery area

(1) Clean, adequate space

b0 Provide oxygen to the mother

(1) Nonrebreather or nasal cannula

c0 Establish an IV

(1) KVO/ TKO rate

d0 Position mother on her back and drape appropriately

e0 Monitor the fetal heart rate, if time allows

f0 Coach the mother in breathing patterns

g0 Encourage mother to push with contractions

h0 Establish body substance isolation practices

i0 Control the delivery of the fetal head

(1) Apply gentle hand pressure on the head

(2) Beware of fontanelle

(3) Support the head as it delivers

j0 Tear amniotic sac if it continues to cover the baby's head

(1) Permits escape of amniotic fluid

(2) Allows the newborn to start breathing

k0 Check for the presence of the umbilical cord wrapped amount the neck

(1) Carefully remove it

l0 Suction the neonate’s mouth and nose

m0 Provide support as the head rotates and the shoulders deliver

(1) Keep the neonate’s head above the level of the vagina

n0 Clamp the umbilical cord

(1) First clamp approximately 4 inches from neonate

(2) Second clamp approximately 6 inches from the neonate

(3) Cut the cord between the two clamps

o0 Support and evaluate the neonate following delivery

3 Delivery of the placenta

a0 Usually occurs 5-20 minutes after delivery of neonate

b0 Do not delay transport to wait for the delivery of the placenta

c0 If it delivers, place the placenta in a plastic bag

E0 Additional care

1 Care for the mother

a0 Excessive bleeding

(1) Perform fundal massage of the uterus

(a) Stimulates contraction

(b) Breast feeding stimulates contraction of the uterus

(2) Manage any perineal tears by direct pressure

b0 Observe and monitor the mother

(1) Signs of hemorrhage and stability of pulse and blood pressure

2 Neonate care

VII Routine care of the neonate (for more detail, see neonatology unit)

A0 Care within first minute following delivery

1 Support

a0 Newborns are slippery

b0 Use both hands to support the head and torso

c0 Work closely to surface of the stretcher, bed, floor

2 Dry

3 Maintain warmth

a0 Hypothermia is a major concern

b0 Prevent heat loss by quickly drying and then covering the newborn, especially the head

4 Positioning

a0 Position the newborn on his/her side

b0 Place on warm clean object, such as sterile towels

5 Clear airway

a0 Repeat suction of the nose and mouth

b0 Wipe away secretions with sterile gauze

6 Tactile stimulation

a0 Usually adequately done through drying and clearing the airway

b0 Purpose to initiate respirations

c0 Slap or flick soles of feet or rub newborn’s back for additional stimulation

B0 Care following first minute

1 Evaluation

a0 Apgar scoring

(1) Completed at 1 and 5 minute intervals

(2) Based on assigning 0-2 values for 5 elements

(a Appearance (color)

i) Blue/ pale

ii) Pink body/ blue extremities

iii) Completely pink

(b Pulse

i) Absent

ii) Slow (< 100 bpm)

iii) Over 100 bpm

(c Grimace (reflex irritability to stimulation)

i) No response

ii) Grimace

iii) Cries

(d Activity (muscle tone)

i) Limp

ii) Some extremity flexion

iii) Active movement

(e Respiration

i) Absent

ii) Slow/ irregular

iii) Good strong cry

(3 Scores average 8-10

(4 Score of less than 6 requires resuscitation

(5 Do not delay any resuscitation efforts to assign APGAR scores

2. Resuscitation

a. Incidence

(1 Approximately 6% of hospital newborns require resuscitation

(2 Believed to be higher for out-of-hospital deliveries

b. Causes

(1 Premature birth

(2 Pregnancy and delivery complications

(3 Inadequate prenatal care

(4 Maternal health problems

c. Begun when tactile stimulation fails to initiate adequate respirations

(1 Do not need to wait to complete Apgar

d. Positive pressure ventilation

(1 Pediatric BVM and supplemental oxygen

(2 40-60 ventilations per minute

e. Assess heart rate

(1 Stethoscope

(2 Palpate brachial artery/ umbilical cord

f. Circulatory support

(1 Chest compressions if rate <80 bpm, and not responding to ventilations

g. Fluid and medication access

(1 Umbilical

(2 Peripheral IV

(3 Intraosseous

(4 Endotracheal (not for fluid administration)

h. Common medications and fluids

(1 Epinephrine

(2 Naloxone

(3 Volume expanders

(a Normal saline/ lactated Ringers

C. Continued care

1. Neonatal transport

a. Manage airway, breathing, circulation

b. Maintain warmth

VIII. Abnormal deliveries

A. Breech presentation

1. Incidence

a. Most common in premature births and uterine abnormalities

2. Assessment

a. Feet or buttocks are presenting part

3. Management

a. Shoulders, not the head are normally the difficult part to deliver

b. If delivering

(1 Allow neonate to deliver to the umbilicus

(2 With the legs clear, support the body in palm

(3 Extract approximately 4-6 inch loop of umbilical cord

(4 Rotate neonate for anterior-posterior shoulder positioning

(5 Apply gentle traction until axilla visible

(6 Guide neonate upward and deliver posterior shoulder

(7 Guide neonate downward to deliver anterior shoulder

(8 Ease the head out, do not apply excessive manipulation

c. If head does not deliver

(1 Form “V” with fingers on sides of neonate’s nose

(a Creates airway

B. Umbilical cord presentation

1. Incidence

a. Approximately 1 in 200 pregnancies

b. Suspect when fetal distress present

c. Contributing factors include breech birth, multiple births, large fetus

2. Assessment

a. Portion of cord visible, protruding through vagina

3. Management

a. Position mother with hips elevated

(1 Trendelenburg

(2 Knee-chest

b. Mother should pant with contractions to avoid bearing down

c. Use gloved hand to hold fetus in vagina

d. Keep pressure off cord

C. Limb presentation

1. Incidence

2. Assessment

a. Limb presents through vagina

3. Management

a. Emergency transport

b. Cesarean section delivery

D. Multiple births

1. Incidence

a. Twins occur in about 1 in every 90 births

b. Approximately 40% of twin deliveries are premature

2. Assessment

a. Mother may not know

b. First sign may be additional contractions and need to push

3. Management

a. Deliver in same manner as individual delivery

b. Need additional supplies

E. Cephalopelvic disproportion

1. Incidence

a. Small pelvis

b. Fetal abnormalities

c. Mother often primigravida

2. Assessment

a. Lack of progress through stages of delivery

b. Frequent, prolonged contractions

3. Management

a. Cesarean delivery necessary to avoid uterine rupture

b. Oxygenation, ventilation, circulatory support

c. Emergency transport

F. Meconium staining

1. Incidence

a. Between 8 and 30% of deliveries

b. Increased perinatal mortality

c. Meconium in amniotic fluid

(1 Could be aspirated

2. Assessment

a. Color varies from yellow, light green, or dark green (“pea soup”)

b. The thicker and darker the fluid, the higher the risk of morbidity

3. Management

a. Prepare for intubation

b. Clear airway/ thoroughly suction

(1 Mouth, pharynx, nose

(2 Direct visualization and suction of hypopharynx

c. Intubate

(1 Suction proximal end of endotracheal tube

G. Maternal complications of labor and delivery

1. Postpartum hemorrhage

a. Incidence

(1 Loss of more than 500 ccs of blood immediately following delivery

(2 May be caused by

(a Lack of uterine tone

(b Vaginal or cervical tears

(c Retained pieces of the placenta

(d Clotting disorders

b. Assessment

(1 History to include

(a Large infant

(b Multiple births have occurred

(c The patient has had placenta previa

(d The patient has had abruptio placenta

(e The patient has had prolonged labor

(2 Physical examination

(a Treat the patient The paramedic must rely on the patient’s clinical appearance and vital signs

(b The uterus feels soft on palpation

(c Inspect the external genitalia for injury resulting in excessive bleeding

(d Observe signs and symptoms of hypovolemic shock

c. Management

(1 ABCs

(2 High flow, high concentration oxygen

(3 Place the infant at the mother's breast if just delivered

(4 Provide uterine massage

(5 Consider 2 large-bore IVs for volume replacement

(6 Administer oxytocin per physician's order

(a Indications

i) To stimulate immediate postpartum contraction of the uterus and to control postpartum uterine bleeding, especially if uterine massage is ineffective or the patient is in shock

(b Administration - injectable oxytocin contains 10 USP units (20mg) per milliliter

i) IV dosage

a) Ten to twenty USP units in 1000 ccs crystalloid (normal saline)

b) Flow rate of 100-125 cc/hr., titrated to the severity of hemorrhage and uterine response

ii) IM dosage

a) Ten USP units (1 ml) IM

b) Only if unable to start an IV

(7 Do not attempt to force delivery of the placenta

(8 Do not pack the vagina

(9 Emergent transport of the patient

2. Uterine rupture

a. Incidence

(1 Rare, but serious

(2 Extremely high mortality for mother and fetus

(3 Most common after labor onset

(4 Associated with previous cesarean, operative scar, obstructed labor, fetal abnormalities

(5 Partial or complete

b. Assessment

(1 Severe, sudden, shearing pain during strong contraction

(2 Absent fetal heart tones or movement

(3 Complete rupture - pain subsides

(4 Uterus palpated as hard mass next to fetus

(5 Rapid shock onset

(6 Minimal external bleeding do to concealed bleeding

c. Management

(1 Treat for shock

(2 Emergency transport

3. Uterine inversion

a. Incidence

(1 Infrequent, but serious

(2 1 in approximately 2100 deliveries

(3 Turning the uterus inside out

(4 Occurs following contraction or with abdominal pressure

(a Coughing, sneezing

(b Improper fundal massage

(5 Occurs as a result of umbilical cord traction

(6 Protrusion of uterine fundus beyond cervix

b. Assessment

(1 Profuse postpartum bleeding

(2 Severe, sudden lower abdominal pain

c. Management

(1 Oxygenation, ventilation, circulatory support

(2 Emergency transport

(3 Do not attempt to deliver placenta

(4 Cover protruding tissue with moist, sterile dressings

(5 Replace protruding tissue upward into cervix

(a Discuss with medical direction physician

UNIT TERMINAL OBJECTIVE

5-13 At the end of this unit, the paramedic student will be able to utilize gynecological principles and assessment findings to formulate a field impression and implement the management plan for the patient experiencing a gynecological emergency.

COGNITIVE OBJECTIVES

At the completion of this unit, the paramedic student will be able to:

5-13.1 Review the anatomic structures and physiology of the female reproductive system. (C-1)

5-13.2 Identify the normal events of the menstrual cycle. (C-1)

5-13.3 Describe how to assess a patient with a gynecological complaint. (C-1)

5-13.4 Explain how to recognize a gynecological emergency. (C-1)

5-13.5 Describe the general care for any patient experiencing a gynecological emergency. (C-1)

5-13.6 Describe the pathophysiology, assessment, and management of specific gynecological emergencies. (C-1)

AFFECTIVE OBJECTIVES

At the completion of this unit, the paramedic student will be able to:

5-13.7 Value the importance of maintaining a patient’s modesty and privacy while still being able to obtain necessary information. (A-2)

5-13.8 Defend the need to provide care for a patient of sexual assault, while still preventing destruction of crime scene information. (A-3)

5-13.9 Serve as a role model for other EMS providers when discussing or caring for patients with gynecological emergencies. (A-3)

PSYCHOMOTOR OBJECTIVES

At the completion of this unit, the paramedic student will be able to:

5-13.10 Demonstrate how to assess a patient with a gynecological complaint. (P-2)

5-13.11 Demonstrate how to provide care for a patient with: (P-2)

4. Excessive vaginal bleeding

5. a. Abdominal pain

6. b. Sexual assault

DECLARATIVE

IX. Introduction

A. Disorders in the female reproductive system can lead to gynecological emergencies

B. Etiology

1. Acute or chronic infection

2. Hemorrhage

3. Rupture

4. Ectopic pregnancy

C. Some conditions can be life-threatening without prompt intervention

X. Review of the anatomy and physiology of the female reproductive system

A. Identification and physiology of specific body parts

1. External genitalia (vulva)

a. Mons pubis

b. Labia

(1 Majora

(2 Minora

c. Prepuce

d. Clitoris

e. Vestibule

f. Urinary meatus

g. Orifice of urethra

h. Vaginal orifice

i. Hymen

j. Perineum

k. Anus

2. Internal genitalia

a. Vagina

b. Cervix

(1 Cervical canal

c. Uterus

(1 Fundus

(2 Body

(3 Uterine cavity

(4 Endometrium

(5 Myometrium

d. Fallopian tubes

e. Ovaries

(1 Corpus luteum

(2 Follicles

(3 Oocytes

B. Normal physiology

1. Menstruation

a. Normal discharge

(1 Blood, mucous, cellular debris from uterine mucosa

b. Approximately every 28 days

c. Menarche

(1 Initial onset occurring during puberty

d. Menopause

(1 Cessation of ovarian function

(2 Cessation of menstrual activity

(3 Average age late 40s

2. Ovulation

a. Egg (ovum) released from ovary following breaking of follicle

b. Usually occurs 14 days after the beginning of the menstrual cycle

3. Menstrual and ovarian cycles

a. Proliferative phase

(1 Increase in endometrium thickness

(a Stimulated by estrogen increase

(2 Anterior pituitary hormones released

(a Stimulates cells producing estrogen

(b Initiates ovarian cycle

(3 Phase maintained by increased estrogen production

b. Secretory phase

(1 Follows ovulation

(2 Influenced by estrogen and progesterone

(3 Prepares the endometrium for gestation

(a Gestation - period from fertilization until birth

c. Menstrual phase

(1 Occurs when ovum is not fertilized

(2 Discharge lasts on average 4-6 days

(3 Flow averages 25-60 ml

(4 Absent during pregnancy

XI. General assessment findings of the patient with a gynecological emergency

A. History of present illness

1. SAMPLE

a. Associated symptoms

(1 Febrile

(2 Diaphoresis

(3 Syncope

(4 Diarrhea

(5 Constipation

(6 Urinary cramping

2. Check for pain or discomfort

a. OPQRST

b. Abdominal

c. Dysmenorrhea - painful menstruation

d. Aggravation

(1 During ambulation

(2 Dyspareunia - pain during intercourse

(3 Defecation

e. Alleviation

(1 Positioning

(2 Ceasing activity

3. Present health

a. Note any preexisting conditions

Standard

Course Description

Hours

Course Guide

D.Lab

ASSESSMENT OF THE OB/GYN PATIENT

TREATMENT MODALITIES OF THE OB/GYN PATIENT

UNIT TERMINAL OBJECTIVE

COGNITIVE OBJECTIVES

PSYCHOMOTOR OBJECTIVES

COGNITIVE OBJECTIVES

AFFECTIVE OBJECTIVES

PSYCHOMOTOR OBJECTIVES

DECLARATIVE