All skills Flashcards
NPA
contraindications
none
NPA
Precuastions
Facial fracture or suspected basal skull fracture
- possibility of cerebral intrusion (only insert if necessary to maintain airway)
TBI/nTBI
- stimulating a gag reflex can significantly worsen intracranial pressure (only use if necessary)
NPA
How to
- Select size by measuring from the corner of the nose to the earlobe
- lubricate the distal end
- Push the tip of the nose gently upwards
- inset NPA into the widest nostril, 90degress to patient’s face, with gentle rotations if required (if resistance try other nostrils)
- remove if the patient gags (look for subtle movement in the neck)
- suction with a Y-suction catheter can be passed down the NPA to suction the pharynx if required
OPA
indications
- support airway patency in the unconscious patient
- bite block in intubated patient
NPA
indications
- support airway patency in the unconscious patient (preferred in patients with trismus, gag reflex, and oral trauma in addition to other adjuncts to optimise airway patency)
OPA
contraindications
- trismus
- gag reflex
- TBI/nTBI with adequate ventilation/oxygenation (stimulating gag reflex can worsen intracranial pressure)
OPA
How to do
- select size by measuring from the angle of the jaw to the middle of incisor (front teeth)
- hold OPA by the flange and insert it upside down until halfway in (to clear the tongue to prevent pushing it back into the airway)
- rotate 180 degrees over the tongue while continuing to insert (if patient gags immediately remove)
- insert until flange resting against lips
- remove if the patient gags
SGA
indications
- unconscious Pt without gag reflex
- ineffective ventilation with BVM and basic airway management (Mx)
- <10 minutes assisted ventilation required
- unable to intubate
SGA
contraindications
- intact gag reflex or resistance to insertion
- strong jaw tone or trismus
- suspected epiglottis or upper airway obstruction
SGA
precautions/side effects
- inability to prepare the Pt in the sniffing potions
- Pts who require high airway pressure
- Paediatric Pts who may have enlarged tonsils
- vomit in the airway
side-effects
- correct placement does not prevent passive regurgitation or gastric distension
SGA
size
Size 1
- 2-5 kg and not max side of gastric tube
Size 1.5
- 5-12 kg and max size of gastric tube it 10
size 2.0
- 10-12 kg and max size gastric tube 12
size 2.5
- 25-35 kg and max size of gastric tube 12
size 3.0
- 30-60 kg and max size of gastric tube 12
size 4.0
- 50-90 kg and max size of gastric tube 12
size 5.0
- 90+ kg and max size of gastric tube 14
SGA
How to do
- Don gloves, respiratory mask, eyewear.
-Assess consciousness and airway reflexes.
-Choose the appropriate size of LMA/i-gel® for the patient’s body weight.
-Open packaging, maintaining hygiene. If using i-gel®, remove from protective cradle.
-Lay out LMA/i-gel® and other airway resuscitation equipment on a clean surface. - Place the patient supine with head in neutral anatomical or sniffing position.
- Ensure any foreign material is cleared from airway before inserting LMA.
- Lubricate back, sides and tip of distal LMA/i-gel® mask with water-based gel.
- Perform chin lift to open mouth sufficiently wide to allow mask insertion.
- Hold stem firmly. Introduce tip into mouth. Gently direct upwards along mouth roof, away from the tongue.
- Once clear of tongue, continue pushing posteriorly, following palate curve into pharynx. If tongue cannot be cleared or resistance is encountered, gently rotate left and right to continue progress.
- Gently apply sufficient force to seat tip of device in oesophagus until no further progress can be made.
- Ensure no airway reflex is triggered by placement.
- Attach BVM resuscitator. Ventilate patient appropriately.
- Once confident of LMA placement and effectiveness, by observing chest rise and fall
Secure in place, using adhesive tape attached to face and device or cloth tape tied off. Maintain LMA midline in the mouth, with incisors on the integral bite block. - When convenient, insert appropriate size of duodenal tube through gastric port (if device has one) into stomach. This may require slight initial lubrication applied to the port first. Withdraw air/gastric content using 50/60 mL catheter tip syringe.
Triple airway manoeuvres
indications
Pt requires airway management
Triple airway manoeuvres
contraindications
none
Triple airway manoeuvres
how to do
- Assess for suspected spinal injury
- head tilt: place hands on either side of the patient’s head and gently tilt it back
- Jaw thrust: with fingers placed behind the mandibular angle and thumbs on the chin, lift the jaw upwards. maintain this position
- Open mouth: use both thumbs to open the mouth and visualise the oropharynx (looking for obstruction)
- avoid pressure on the sub-mandibular soft tissues as this may contribute to airway obstruction
Suction
indications
suspected fluid observation in the airway or airway device
Suction
contraindications
none
Suction
precautions
- epiglottitis - extreme caution (stimulation of the epiglottic may precipitate complete airway obstruction)
- croup (may require suction if swelling and distress is worsened)
Suction
how to do
- Don gloves, respiratory mask, eyewear.
- Position head in sniffing position.
- Lay out Magill’s forceps. Attach Yankauer sucker to the suction tubing. Ensure all suction system components attached, including collection bottle. (If available, fill a cup/container with water. Test suction function by dipping tip into water and occluding top hole.)
- Insert laryngoscope until tip is located in vallecular. Identify glottis or FBAO.
- Grasp Yankauer sucker in right hand. Depending on preference, hold device so either thumb or index finger can cover top hole. Progress the sucker inwards along length of laryngoscope blade until it reaches the fluid.
- When sucker tip is in position, cover top hole to commence suction. Sweep laryngoscope tip left and right, with sucker tip following, until pharynx is clear and glottis visible. Attempt should take <10 seconds.
- Either discard and replace the used sucker or place it into clean, isolated container. If further suction is necessary, repeat the process. If fluid occludes suction hose, dip sucker tip into clean water briefly, under suction, to clear it.
- Visualise airway clarity before exiting.
- Provide oxygenation/assisted ventilation as necessary.
CPAP
Contraindications
- Inability to manage own airway (alter conscious state, active vomiting or excessive secretions)
- upper airway obstruction
- Hypoventilation (patient must have adequate spontaneous respirations)
- untreated tension pneumothorax (must be treated before considering CPAP)
- Haemodynamic instability (severe hypotension, ventricular arrhythmias - should all be treated before considering)
- Injuries that preclude mask application
CPAP
precautions
- hypovolemia
- post chest decompression (closely monitor)
- COPD (monitor for deterioration)
- Hypotension
CPAP
Indications for it to be removed
- Cardiac/respiratory arrest
- Pt agitation/intolerance
- No improvements after 1hr
- HR <50
- SBP <90
- GCS <13
- Decreasing SpO2
- Loss of airway control
- Copious secretion
- Active vomiting
- Paramedic judgement of Pt deterioration
CPAP
How to do
- Wears appropriate personal protection, including eyewear and respiratory mask
- Acknowledges therapy can be fitted from beside or behind patient
- Positions patient sitting upright
- Reassure the patient and explain the procedure
- Suctions froth or fluid from the airway if necessary before applying mask and beginning therapy.
- Connect CPAP mask to filter and then to CPAP valve/oxygen tubing - including PEEP valve if included
- Attached CPAP mask to oxygen source and set flow to 10L/min (Inspects device for correct functioning for use)
- Place mask against patient’s face (Holds face mask over patient’s nose and mouth, positioning it to gain an effective seal. If necessary, fits mask against one cheek first, then over bridge of nose, then onto other cheek) - constant encouragement and reassurance
- Allows the patient to become accustomed to mask. Provides reassurance and explanation.
- Apply and adjust the head harness (applies head harness evenly to maintain effective seal)
- Adjust oxygen flow meter to ensures airflow is constant and desired pressure (10cm of H2O) reading is attained - a flow rate of 12-14 L/min will typically be required (DO NOT exceed 10cm H2O of pressure
- Reassesses patient continuously to monitor effectiveness of therapy, including consciousness and pulse oximetry.
- If patient’s condition deteriorates due to respiratory failure or life-threatening complications, removes therapy and responds appropriately.
Valsalva Manoeuvre
Indications
- atrioventricular re-entry tachycardia (AVRT)
- AV node re-entry tachycardia (AVNRT)
Valsalva Manoeuvre
contraindications
- systolic blood pressure <90 mmHg
- unstable or rapidly deteriorating patient
- atrial fibrillation or atria flutter
Valsalva Manoeuvre
precautions
none
Valsalva Manoeuvre
how to do
- Don PPE as required
- Attached to patient to cardiac monitor and position monitor so that it can be viewed by all paramedics
- get 10ml Syringe and open a new one and ensure the barrel is able to move freely in and out
- Reassure patient and explain the procedure
- Gain consent and check contraindications
- Consider inserting an intravenous cannula
- Position patient in the appropriate position (Modified Valsalva (Semi-Recumbent)
Standard Valsalva (Supine Position)) - Hand the Syringe to the patient with barrel left pushed inward
MODIFIED VALSALVA
- position patient semi-recumbent
- press the snapshot button to record cardiac rhythm
- Encourage the patient to exhale forcefully into the syringe for approximately 15 seconds with enough pressure to push the syringe plunger outward, followed by normal breathing
- Immediately lay the patient flat and raise the patient’s legs to approximately 45 degrees for 15 seconds
- lower the patient’s legs and return them to a semi-recumbent position
- press end snapshot
STANDARD VALSALVA
- position the patient supine
- press snapshot button to record cardiac rhythm
- have the patient take one normal breathe and hold it
- encourage the patient to exhale forcefully into the syringe for approximately 15 seconds with enough pressure to push the syringe plunger outward, followed by normal breathing
- patient remains in supine position
- press end snapshot
Reassess the patient to confirm cardiac rhythm and reassess Pt vital signs
Intravenous Access
indications
when intravenous medication administration is required
Intravenous Access
contraindications
none
Intravenous Access
precautions
- if there is evidence of contamination (e.g dirt, blood or burns)
- if the patient has renal failure in the same arm as their arteriovenous fistula if one is present in the limb
Intravenous Access
how to do
- Dons appropriate PPE
- Discusses procedure. Obtains informed consent and allergies if any
- Exposes limb and arranges it in a supported dependent position.
- Applies tourniquet over bicep or above limb where IV is to be inserted, ensuring pulse is palpable.
- Determines cannulation site, using visualisation, palpation or both, and cannula size for intended use.
- Places sharps waste container in convenient location.
- Lays out equipment on a clean surface, ensuring asepsis.
- Prepares site by swabbing in concentric circles, a 5cm by 5cm area for 10 seconds. Allows 30 seconds to dry. Do not re-touch.
- Holds cannula flashback chamber with dominant hand. Announces that sharp is in use. Removes protective cap and discards.
- Stabilises vein with distal traction using non-dominant hand (stretch skin local and distal)
- Places tip either directly on top of vein or immediately beside it, at appropriate angle for vein.
- Pushes tip through skin at appropriate angle (10-15°), with sufficient force to just enter the vein (if Pt conscious warn Pt)
- Observes for flashback. When flashback is observed, stops advancing trocar and flattens angle to skin.
- Advances trocar a few more millimetres until cannula is also in the vein.
- Either feeds off cannula with forefinger of dominant hand or continues to feed entire trocar further into the vein.
- Releases traction, then releases tourniquet.
- Compresses skin over cannula end with three fingers of non-dominant hand. Maintains pressure until cannula is capped.
- After warning others (SHARPS OUT), withdraws trocar from cannula and immediately drops into sharps waste container.
- Taking care to not dislodge cannula, gently flushes with 5–10 ml saline (pull back and then in). Looks for free flow and no tissue swelling.
- Attaches desired capping option to cannula end and twists in place.
- Covers hub with clear adhesive aseptic dressing.
- Secures capping device with tape and/or bandage.
- flush with 5mL of normal saline
- Clean up area around you, anything contaminated and be careful of sharps
- remove gloves and sanitise hands and put on fresh gloves
Maternity focused assessment
Questions
PRODROME
- any reported complaints over the past (week/days) 1/52 – nil pain, PV bleeding, illness, infection or trauma
PREVIOUS PREGNANCIES
- any/number of previous pregnancies?
- prior caesarean sections/interventions?
- complications/problems with previous pregnancies?
- length of previous labours?
CURRENT PREGNANCIES
- How many weeks pregnant are you?
- are you expecting a singleton or multiple pregnancies?
- Have your membranes ruptured? What was the colour of the amniotic fluid?
- are you having contractions? Assess frequency and duration
- do you have an urge to push?
- have you felt fetal movement? more/less or same as normal?
- hospital interventions (if any)?
- do you anticipate any problems/complications (baby/mother)?
- have you had any antenatal care?
- any current complaints? (vaginal bleeding/PV loss, high BP, pain, trauma, any other issues?
Maternity focused assessment
reproductive (signs of going into labour)
Imminent Delivery
- Active pushing/grunting
- Rectal pressure (urge to use bowels or bladder)
- Anal pouting
- Bulging perineum
- Urge to push
- Crowning (presenting baby’s head)
- mother’s statement “I am going to have the baby”
Maternity focused assessment
BP
minimal change - initial decrease in 1st and 2nd trimester normal in 3rd trimester
- SBP >140 mmHg and DBP > 110 mmHg is significant (look into)
Maternity focused assessment
HR
normal 80-110 bpm
increased by 15-20 bpm
Maternity focused assessment
Cardiac output
normal volume 6-7 L/min during pregnancy
increased by 30-40%
Maternity focused assessment
ECG
non-specific ST changed
Q wave - (leads III and EVF) atrial and ventricular ectopics (irregular heartbeat)
Maternity focused assessment
SVR
decreased due to progesterone and blood volume
Maternity focused assessment
RR
normal 14-19 breathe/minute at term
increases by 15% (2-3 breaths/minute)
Maternity focused assessment
Oxygen
increased by 15-20%
Maternity focused assessment
Blood volume
5500 mL at term
increased by 30-50% volume
Newborn resuscitation
what to do
Birthed, dried, skin to skin with mother
ASSESS
- Breathing
- muscle tone (flexed arms and legs)
BREATHING ADEQUATELY AND GOOD MUSCLE TONE
- vigorous newborn
manage as per the newborn baby’s CPG
APNOEIC OR GASPING OR NO MUSCLE TONE
- stimulate by drying (not more than 30 seconds)
- maintain warmth (blanket and beanie)
- place supine with head/neck in a neutral position with blanket under shoulders
- suction only if airway obstruction is suspected
ASSESS AGAIN
- breathing
- heart rate (auscultate or ECG)
HEART <100 AND/OR APNOEIC OR GASPING
- IPPV @ 40-60 per minute on room air
- pulse oximetry (right hand or right wrist)
- ECG monitoring if not already attached
- reassess after 30 seconds
ASSESS
- heart rate and breathing
- reassess every 30 seconds and change management accordingly
HR <60
CPR @3:1 ratio with oxygen (5 L/min)
- consult with PIPER for all infants with HR <60
HR 60-100
- IPPV @40-60 per minute
- ensure adequate mask seal, and airway position and increase ventilation pressure targeting chest rise
- if not increase in heart rate: IPPV with oxygen 5 L/min
HR >100, but SPO2 <90%
Breathing laboured
- IPPV at 4060 per minute
- titrate oxygen (1-5L/min) to meet target saturations
Breathing normally
- maintain warmth and treatment as per newborn baby CPG
- titrate oxygen 1-2 L/min via nasal cannula to meet target saturations
- discontinue oxygen where SpO2 >90%
normal newborn
weight
3.5kg
normal newborn
blood volume
80 mL/kg
normal newborn
HR
110-170
normal newborn
RR
25-60
normal newborn
temperature
36.5 - 37.5
normal newborn
BGL
2.6 - 3.2
normal newborn
Appearance
- Dusky and peripherally cyanosed in the first few minutes, with blue-ish/purple hands and feet are normal for the first 24 hours after birth
- Supplemental oxygen is generally not required where the newborn is breathing effectively and the HR is >100.
- Good muscle tone (flexing arms and legs)
- Spontaneous regular breathing
normal newborn
targeted SpO2
- minutes post-birth
- where to put the oximeters
- 1 minutes: 60 - 70%
- 3 minutes: 70 - 90%
- 5 minutes: 80 - 90%
- 7 - 10 minutes: >90%
The newborn baby
What to do
birthed, dried, skin to skin with mother
ASSESS
- breathing
- muscle tone
APNOEIC OR GASPING OR NO MUSCLE TONE
Non-vigorous newborn
- manage as per newborn resuscitation CPG
BREATHING ADEQUATELY AND GOOD MUSCLE TONE
- continue to dry (especially the head)
- maintain warmth (skin to skin, blankets and beanie for the baby)
- routine suction is not recommended
- monitor HR (auscultation), breathing, tone and colour
- If vital signs deteriorate or the airway is obstructed at any stage, manage as per newborn resuscitation CPG
NORMAL NEWBORN: RESUSCITATION NOT REQUIRED
- cut the cord once the cord has stopped pulsating (approx 1-2 minutes) unless parental preference is to remain attached
- note APGAR when practicable
TRANSPORT
>36 weeks gestation, uncomplicated delivery, stable vital signs
- Tx to appropriate maternity service (pre-booked hospital)
32 - 36 weeks gestation AND stable vital signs
- Tx to a level 2 hospital (paediatrics and midwife on-site 24/7) in consultation with PIPER
<32 weeks gestation, or unstoppable vital signs
- Tv to tertiary centre in consultation with PIPER
Rural Victoria
- Tx to the nearest base hospital or hospital with maternity service and contact PIPER
Normal birth
how to do
Imminent normal birth
- maternity history
- labour progression
Opioid analgesics are C/I in late second-stage labour
NORMAL BIRTH - NOT IMMINENT
- reassure
- monitor regularly for change
- Tx to the appropriate maternity service facility using a left lateral tilt position
- provide analgesia as per CPG
IMMINENT NORMAL BIRTH - PREPARATION
- reassure including cultural considerations
- prepare equipment for normal birth
- provide a warm and clean environment
- provide analgesia as per pain relief CPG
NORMAL BIRTH - BIRTH OF HEAD
- as the head advances, encourage the mother to push with each contraction
- if the head is birthing too fast, ask the mother to pant with an open mouth during contractions instead
- place fingers on baby’s head to feel the strength of descent of the head
- apply gentle pressure to the perineum to reduce the risk of perineal tears
- if precipitous (moving to fast), apply gentle backward and downward pressure to control sudden expulsion of the head - DO NOT HOLD BACK FORCIBLY
- not the time once the head is delivered
NORMAL BIRTH - UMBILICAL CORD CHECK
- following the birth of the head, check for an umbilical cord around the neck
- IF LOOSE and wrapped around the neck: slip over baby’s head with appropriate traction
- IF TIGHT: mother should be encouraged to push and if baby doe snot decent and cord still cannot be loosened, clamp and cut cord
NORMAL BIRTH - HEAD ROTATION
With the next contraction, the head will turn to face one of the mother thighs (restitution)
- this indicates internal rotation of the shoulders in preparation for the birth of the body
NORMAL BIRTH - BIRTH OF THE SHOULDERS AND BODY
- may be passive or guided
- hod baby’s head between hands and if required apply gentle downward pressure to deliver the anterior (top) shoulder
- once the baby’s anterior is visible, if necessary to assist the birth, apply gentle upward pressure to the birth posterior should - the body will follow quickly
- support the baby
- note time of birth
- place baby skin to skin with mother on her chest to maintain warmth unless the baby is not vigorous/requires resuscitation
- treat the vigorous baby as per newborn baby CPG
- treat the non-vigorous newborn as per newborn resuscitation CPG
- if the body fails to deliver in >60 seconds after the head, treat as per shoulder dystocia CPG
- following delivery of the baby, gently palpate the abdomen to ensure the second baby is not present
NORMAL BIRTH - CLAMPING AND CUTTING THE CORD
- There is no immediate urgency to cut the cord. Wait for the cord to stop pulsating, which commonly takes one to two minutes. Allow the birthing partner to cut the cord if they wish. Ideally, cord-cutting should be undertaken prior to extrication
- to cut the cord, apply the first clamp 10cm from the baby and the second clamp a further 5cm from the first, then cut between the two clamps
- for uncomplicated births, a parental birth preference where more and baby are transported to the hospital still attached is permissible (allowed)
NORMAL BIRTH - BIRTHING PACENA(THIRD STAGE)
Passive
- allow placental separation to occur spontaneously without intervention
- this may take from 15 minutes up to 1 hour
- position the mother sitting or squatting to alow gravity to assist expulsion
- breast-feeding may assist in separation or expulsion
DO NOT PULL ON CORD - WAIT FOR SIGNS OF SEPARATION (lengthening of cord - uterus becomes rounded, firmer, smaller - trickle of gush or blood from the vagina - cramping/contractions return)
- The placenta and membranes are birthed by maternal effort. ask mother to give a little push
- use two hands to support and remove the placenta using a twisting ‘see-saw’ motion to ease membranes slowly out of the vagina
- not time of delivery of placenta
- place placenta and blood clots into a container and transfer
- inspect placenta and membranes for completeness
- inspect the fundus is firm, contracted and central
- continue to monitor fundus though do not massage once firm
- if fundus is not firm or blood loss >500 mL treat as per primary postpartum haemorrhage CPG
Primary postpartum haemorrhage (PPH)
how to treat
PPH - blood loss >500 mL in first 24 hours from birth
ASSESS
- fundus tone
- visible blood loss
- perineal/vaginal laceration
FUNDUS FIRM
Palpable firm, central and compacted fundus
- high flow O2 therapy
- analgesia as required as per pain relief CPG
BP <90 mmHg
- consider normal saline IV (max 40 mL/kg) titrated to patient response
- consult for further fluid, if consult unavailable repeat normal saline 20 mL/kg IV
Treat ant lacerations with a dressing and firm pressure
FUNDUS NOT FIRM
- manage as per fundus firm (O2, normal saline and pain relief)
- normally the fundus will not become firm and contracted until the placenta is delivered (avoid fundal massage prior to placental delivery and continue checking for PV bleeding and observing vital signs)
- massage fundus until firm and blood loss reduces (use a cupped hand and apply firm pressure in a circular motion)
- encourage the mother to empty her bladder if possible
- encourage baby to suckle breast
FUNDUS REMAINS NOT FIRM
- oxytocin 10IU IM
- repeat oxytocin 10 IU IM after 5 minutes if bleeding continues
- tranexamic acid 1 gram IV over 10 minutes
DO NOT ATTEMPT DELIVERY OF PLACENTA DUE TO RISK OF UNTERINE INVERSION (the placenta fails to detach from the uterine wall, and pulls the uterus inside-out as it exits)
INTRACTABLE HAEMORRHAGE (nothing is working)
Perform external abdominal aortic compression
- locate point of compression just above the umbilicus and slightly to the left
- apply downward pressure with a closed fist directly through the abdominal wall
- effectiveness of compression may be evaluated by assessing palpable femoral pulse with pressure applied
Antepartum Haemorrhage
what to do
Antepartum Haemorrhage
ASSESS
- perfusion status
- external bleeding
- Patient Hx
- Abdominal pain
- >20 week gestation
NO CLINICAL SIGNS OF ALTERED PERFUSION
Antepartum Haemorrhage
- place Pt in the left lateral position
- transfer to the appropriate obstetric hospital
ANY CLINICAL SIGNS OF ALTERED PERFUSION
Internal bleeding may greatly exceed visible external bleeding and signs of poor perfusion may present late and are always significant
- Place the patient in the left lateral tilt position
- Transport to the appropriate obstetric hospital with notification in all cases
LESS THAN ADEQUATE PERFUSION
- consider normal saline IV (max. 40 mL/kg) titrated to the patient’s response
- consult for further fluid, if consult unavailable repeat normal saline 20 mL/kg
Treat pain as per pain relief CPG
Pre-eclampsia/eclampsia
what to do
ASSESS
- hypertension
- pre-eclampsia S/S
- seizure activity
- gestation >20 weeks
NORMAL BP
- consider other causes of complaint
- manage symptomatically
SIGNIFICANT HYPERTENSION
SBP 140-170 mmHg
DBP 90-110 mmHg
- basic care
- left lateral tilt
SEVERE HYPERTENSION
SBP >170 mmHg
DBP >110 mmHg
pre-eclampsia S&S
- consult with PIPER to manage hypertension
SEIZURE ACTIVITY - ECLAMPSIA
- treat as per seizures
- left lateral position
- high flow O2
POST SEIZURE
- assess for aspiration and treat symptomatically
- manage precipitous (possibly dangerous/fast) delivery as per normal birth CPG
- manage placental abruption as per antepartum haemorrhage CPG
Breech birth
what to do
ASSESS
- stage of labour and birth imminent
- buttocks or both feet presenting first
- one foot or hand/arm presenting first
STOP
- opioid analgesia is C/I in second-stage labour
- do not attempt delivery of on foot or hand/arm presentation
- only proceed with delivery if birth is imminent
NON IMMINENT BIRTH
- general maternal care
- transport to booked appropriate maternity service unit with notification
ONE FOOT, HARD OR ARM PRESENTING
- do not attempt to deliver
- transport to an appropriate maternity service unit with notification
- consult with PIPER for advice
IMMINENT BREECH BIRTH - BUTTOCKS OR BOTH FEET PRESENTING
Manage as per normal birth CPG except for:
- request urgent assistance
- reassure including cultural considerations
- prepare obstetrics equipment
- provide a warm and clean environment
- provide analgesia as per pain relief CPG
- allow the birth to occur spontaneously
- position mother with buttocks to bed edge and legs supported to allow gravity to assist
- HANDS OFF THE BREECH
- the birth of the buttocks/feet will occur slowly
BUTTOCK FIRST PRESENTATION - BACK UPPERMOST -DELIVERY OF BODY/LEGS
- this is the most common presentation
- DO NOT ATTEMPT TO PULL THE BABY OUT
- encourage mother to push hard with contractions
- feet and legs should spring free
- await further decent
- keep the body warm by wrapping it in a towel or bubble wrap if needed
- the body will further descend to the clavicle and arms should swing free
- let baby’s hang until the nape of the neck is visible
- the baby should face downward
- assist the birth of the head using modified mauriceau smellie veit manoeuvre
BUTTOCK FIRST PRESENTATION - BACK UPPERMOST - DELIVERY OF HEAD MODIFIED MAURICEAU SMELLE VEIT MANOEUVRE
- place the index finger and ring finger of the non-dominant hand on the baby’s shoulders and the middle finger on the occiput to assist with flexion of the head
- place the dominant hand under the baby to support the body with the ring finger and index fingers on the baby’s cheekbones
- slowly lift the baby straight up in a circle onto the mother’s abdomen, allowing the head to birth slowly
- an assistant can aid flexion of the head by applying direct pressure behind the pubic bone
BUTTOCKS FIRST - BACK NOT UPPERMOST
- The baby’s back needs to remain uppermost
If legs are delivered and the back is not uppermost
- gently hold the baby by placing thumbs on bone sacrum with fingers around thighs
- DO NOT squeeze the abdomen
- rotate/turn baby uppermost between contractions taking care of baby’s spine
- take great care to NEVER pull the baby
BUTTOCKS FIRST PRESENTATION - LEGS DON’T BIRTH SPONTANEOUSLY
If extended legs (think Frank)
- slip one hand along the leg of the baby lying anteriorly
- place a finger behind the baby’s knee and deliver it by flexion and abduction
BUTTOCK’S FIRST PRESENTATION - ARMS DON’T BIRTH SPONTANEOUSLY LOVESETT’S MANOEUVRE
- hold the baby by the sacrum
- turn baby 90 degrees so that one shoulder is in the anterior-posterior diameter
- insert the finger into the brachial plexus and sweep the arm down over the baby’s chest
- turn baby 180 degrees so that the opposite shoulder is in the antero-posterior diameter
- repeat the finger manoeuvre
- turn the baby 90 degrees again so that the back is uppermost
- await further descent
DO NOT PULL OR APPLY TRACTION
Preterm labour
what to do
uterine contraction present @ 20 - 37 weeks
ASSESS
- ruptured membranes
- check for cord prolapse
- stage of labour
CORD PROLApSE
- manage as cord prolapse CPG
BIRTH IMMINENT
- consider other causes of complaint
- manage symptomatically
BIRTH NOT IMMINENT ≥ 34 WEEKS
- basic care
- reassure
BIRTH NOT IMMINENT <34 WEEKS
contraindications as per GTN medicine monograph including:
- bleeding in pregnancy
- BP <100 mmHg
50mg GTN patch (0.4 mg/hr) applied to the abdomen
- a further 50mg GTN patch *0.4 mg/hr) may be added after 1 hour if contractions persist (max 20 mg/24 hours)
Cord prolapse
what to do
Umbilical cord visible at vulva with ruptured membranes
ASSESS
- cord visible at vulva
- ruptured membranes
- stage of labour
BIRTH COMMENCING
- instruct mother to push
- assist in delivery
- prepare for newborn resuscitation
- magage as normal birth CPG
- manage as per newborn resuscitation CPG
BIRTH NO IMMINENT - MANAGEMENT OF MOTHER
- position the patient semi-prone with hips elevated over folded towels
- provide explanation and reassurance
- high flow O2 therapy
BIRTH NOT IMMINENT - MANAGEMENT OF CORD
- minimise cord handling
- keep cord warm and moist. Use two fingers to gently place the cord in the vagina
- if unsuccessful cover with warm saline packs (if possible)
BIRTH NOT IMMINENT MANAGEMENT OF PRESENTING PART
- if there is pressure on the cord by the presenting part insert fingers into the vagina and push presenting part (head) away from the cord
- maintain pressure until birth commences or advised to release
Shoulder dystocia
what to do
Possible shoulder dystocia
ASSESS
- normal birthing procedure fails to accomplish delivery
- prolonged head to body delivery time >60 seconds
- difficulty with birth of face and chin
- baby’s head retracts against the perineum (turtle sign)
- failure of baby’s head to restitute
- failure of shoulders to descend
- difficulty reaching NECK when attempting to check for a cord around the neck
- baby’s head colour turns purple then black
PROLONGED HEAD-TO-BODY DELIVERY TIME >60 SECONDS
- note time of birth of head
- request urgent additional assistance
- explain to the mother and ask her to push with focused effect when required
- position mother with buttocks at bed edge
- apply gentle downward traction to deliver anterior shoulder
DELIVERY ACCOMPLISHED - NEWBORN
- manage per newborn resuscitation
- assess for clavicle injury and immobiliser if necessary
DELIVERY ACCOMPLISHED - MOTHER
- basic care
- reassure
DELIVERY NOT ACCOMPLISHED - AFTER 30-60 SECONDS
- alternate the following sequence until the baby is delivered
- manage as per delivery accomplished if successful at any time
AT NO TIME attempt to rotate the baby’s head - rotate shoulders using pressure on the baby’s scapula instead
DELIVERY NO ACCOMPLISHED AFTER 30-60 SECONDS
Hyperflexion of maternal hips (McRoberts manoeuvre) - knees to nipples
- place the mother in a recumbent position
- hips on the edge of the bed enabling better access for gentle downward traction
- assist the mother in grasping her knees and pulling her knees/thighs back as far as possible onto her abdomen (use the assistant to help achieve and maintain position)
DELIVERY REMAINS NOT ACCOMPLISHED AFTER 30 - 60 SECONDS
Suprapubic pressure whilst in Mc Roberts position
- Hands in CPR position behind the pubis, at 45-degree angle along baby’s back (trying to rotate baby forward)
- Apply 30 seconds of firm downward pressure, then 30 seconds of rocking motion to get the shoulder out from under the rim, at a rate of approximately 1 per second
DELIVERY REMAINS NOT ACCOMPLISHED AFTER 30-60 SECONDS
All fours (Gaskin) manoeuvre
- rotate mother to all fours
- hold baby’s head and apply gentle downward traction - attempting to dis-impact and deliver the posterior shoulder (now uppermost)
DELIVERY ACCOMPLISHED
- manage as above
- the newborn. is likely to require resuscitation
DELIVERY REMAINS UNACCOMPLISHED
- consult with PIPER regarding when to abandon maneuvers and treatment
- if unable to consult, transport with notification
- transfer in McRoberts’s manoeuvre position with 30 degrees left later tilt
Intra-muscular injection
Indication
medications requiring administration via the intramuscular route
Intra-muscular injection
contraindications
none
Intra-muscular injection
precautions
large volumes may be painful - avoid dilution unless indicated in relevant CPG
- if a large volume is anticipated (more than 2 mL0, consider splitting administration between more than one site
Intra-muscular injection
what to do
- Explain the procedure to the patient/carer and gain consent for medication administration
- Check allergies
- Check medication (double-check with a second person, if available. Visually inspect medication tampering, leakage or changes in expected appearance. Check expiry date)
- Check the 5 rights (right patient - right medication - right dose - right route - right time - right documentation)
- draw up medication
- Select a suitable needle size for injection (typically will be 23g needle, 25g may be required in smaller children or small adults)
- Place sharps container ready for use
- Perform hand hygiene
- Select the appropriate site (these being the posterior deltoid in the upper arm, the upper outer quarter of the gluteus medius of the buttock or the side of the thigh) - for time-critical patients the thigh is the quickest as it provides the most rapid absorption
- Wipe selected sit thoroughly with the swab using a circular motion (allow to air dry, don’t fan or blow-dry)
- verbalise “sharps out” and ensure others in the area are clear before removing the protective cap from the needle
- using free hand, stretch around the point of the anticipated entry
- insert the needle at a 90-degree angle (the depth of the needle depends on the subcutaneous tissue but is usually 2/3 depth of the needle length for IM)
- confirm needle position (with needle still in muscle, release skin stretch and grasp barrel of syringe)
- gentle pull back on the syringe plunger approximately 0.5mL and inspect for any blood flashback (blood flashback suggest placement into a blood vessel)
- If significant blood flashback appears, discard the syringe and repeat the procedure with a new syringe
- Administer medication (whilst holding barrel of syringe, push down on the plunger to slowly inject medication
- Withdraw needle (verbalise ‘sharps out’ and ensure others in the area are clear
- withdraw the needle quickly and immediately place the syringe into a suitable located sharps container
- post-injection care (cover wound with an adhesive dressing)
- document medication administration via VACIS
- observe for response to medication and requirement for repeated doses if indicated by relevant CPG
The maternity Pt
What is the process
Pregnancy-related
ASSESS IF
- gestation
- in labour
- rupture of membranes
- presenting part on view
- baby born
OTHER MATERNITY PROBLEM
- trauma treatment per CPG
- cardiac arrest per CPG
BIRTH NOT IMMINENT
assess
- complicated or uncomplicated
UNCOMPLICATED
- basic bare
- pain relief CPG
- continue to monitor
- transport
COMPLICATED
- Manage per antepartum Haemorrhage
- manage per pre-eclampsia
BABY BORN
- newborn care as per newborn resuscitation CPG
Intrapartum care
- delivery as per normal birth CPG
- PPH as per CPG
BIRTH IMMINENT
assess
- complicated
- uncomplicated
UNCOMPLICATED
- delivery as normal birth
COMPLICATED
- Breech presentation
- preterm labour
- cord prolapse
- shoulder dystocia
Fundus massage
explain how to
FUNDUS NOT FIRM
- manage as per fundus firm
- normally the fundus will not become firm and contracted until the placenta is delivered (avoid fundal massage prior to placental delivery and continue checking for PV bleeding and observing vital signs)
- massage fundus until firm and blood loss reduces (use a cupped hand and apply firm pressure in a circular motion)
- encourage the mother to empty her bladder if possible
- encourage baby to suckle breast
aortic compression
how to do
INTRACTABLE HAEMORRHAGE (nothing is working)
Perform external abdominal aortic compression
- locate the point of compression just above the umbilicus and slightly to the left
- apply downward pressure with a closed fist directly through the abdominal wall
- effectiveness of compression may be evaluated by assessing palpable femoral pulse with pressure applied
Newborn resuscitation
what are we first assessing
Birthed, dried, skin to skin with mother
ASSESS
- Breathing
- muscle tone (flexed arms and legs)
Newborn birth
what are we first assessing
birthed, dried, skin to skin with mother
ASSESS
- breathing
- muscle tone
Normal birth
what are we first assessing
Imminent normal birth
- maternity history
- labour progression
Opioid analgesics are C/I in late second-stage labour
Primary postpartum haemorrhage (PPH)
what are we first assessing
PPH - blood loss >500 mL in first 24 hours from birth
ASSESS
- fundus tone
- visible blood loss
- perineal/vaginal laceration
Antepartum Haemorrhage
what are we first assessing
Antepartum Haemorrhage
ASSESS
- perfusion status
- external bleeding
- Patient Hx
- Abdominal pain
- >20 week gestation
Pre-eclampsia/eclampsia
what are we first assessing
ASSESS
- hypertension
- pre-eclampsia S/S
- seizure activity
- gestation >20 weeks
Breech birth
what are we first assessing
ASSESS
- stage of labour and birth imminent
- buttocks or both feet presenting first
- one foot or hand/arm presenting first
STOP
- opioid analgesia is C/I in second-stage labour
- do not attempt delivery of on foot or hand/arm presentation
- only proceed with delivery if birth is imminent
Preterm labour
what are we first assessing
uterine contraction present @ 20 - 37 weeks
ASSESS
- ruptured membranes
- check for cord prolapse
- stage of labour
Cord prolapse
what are we first assessing
Umbilical cord visible at vulva with ruptured membranes
ASSESS
- cord visible at vulva
- ruptured membranes
- stage of labour
Shoulder dystocia
what are we first assessing
Possible shoulder dystocia
ASSESS
- normal birthing procedure fails to accomplish delivery
- prolonged head-to-body delivery time >60 seconds
- difficulty with birth of face and chin
- baby’s head retracts against the perineum (turtle sign)
- failure of baby’s head to restitute
- failure of shoulders to descend
- difficulty reaching NECK when attempting to check for a cord around the neck
- baby’s head colour turns purple then black
Laryngoscope
what to do
- Position pat in the sniffing position
- Select the appropriate size blade and attach it to the handle ( place the blade from the top of the blade at the incisor to the mandible)
- place the laryngoscope alongside the left of the pt heads
- Place suction equipment don’t he right of the pt heads
- depending on which is your dominant hand (the dominant will lightly grip the laryngoscope near the base of the handle and the other hand support and steady the pt head
- open the mother
- insert blade down the righthand side of the mouth
- sweep the tongue to the left of the mouth `
- suction or remove foreign bodies as required
- slowly progress doesn’t the tongue visualise the epiglottis
- position the tip of the blade into the vallecula
- expose the vocal cords by exerting a lifting force up and along the axis of the handle, without angulation, to life the epiglottis
- If the vocal cords can not be seen, partly withdraw the blade from over the epiglottis and reinsert gently pointing the blade tip upwards into tongue to re-seek vallecula
