Emergency Childbirth + Endotracheal and Tracheostomy Suctioning/Reinsertion Flashcards
Emergency Childbirth Medical Directive
What are the INDICATIONS?
What are the emergencies that we prepare for?
Pregnant patient experiencing labour
OR
post-partum patient immediately following delivery and/or placenta
Shoulder dystocia
Breech delivery
Prolapsed cord
Emergency Childbirth Medical Directive
What are the CONDITIONS for delivery?
What are the CONTRAINDICATIONS?
Childbearing years
Second stage labour
AND/OR
Imminent birth
AND/OR
Breech delivery
AND/OR
Prolapsed cord
N/A
Emergency Childbirth Medical Directive
What are the CONDITIONS for Umbilical cord and management?
What are the CONTRAINDICATIONS?
Childbearing
Cord complications
OR
if neonatal or maternal resuscitation is required
OR
Due to transport considerations
N/A
Emergency Childbirth Medical Directive
What are the CONDITIONS for External Uterine Massage?
What are the CONTRAINDICATIONS?
Childbearing years
Post-placental delivery
Placenta not delivered
Emergency Childbirth Medical Directive
What are the CONDITIONS for Ocxytocin?
What are the CONTRAINDICATIONS?
Childbearing years
SSBP Less than 160mmHg
Post-partum delivery
AND/OR
Placental delivery
Allergy or sensitivity to oxytocin
Undelivered fetus
Suspected or known pre-eclampsia with current pregnancy
Eclampsia (seizures) with current pregnancy
GREATER/EQUAL to 4h post placenta delivery
Emergency Childbirth Medical Directive
What are the 7 potential treatment plans for emergency childbirth?
the ‘consider’s”
- Delivery
- Shoulder dystocia delivery
- Breech delivery
- Prolapsed cord delivery
- Umbilical cord management
- External Uterine Massage
- Oxytocin
What are the Signs of 2nd stage labour?
What are the signs of labour? Primps vs Multips
Contractions every two to three minutes, lasting 60-90 seconds
Contractions associated with maternal urge to push or to move the bowels
Heavy red show visible at the vaginal opening
Presenting part or bulging membranes visible at vaginal opening
or perineumbulging with contraction
Crowning or other presenting part is visible
In primips, presenting part is visible during and between contractions, maternal
urge to push or bear down, and contractions are less than two (2) minutes apart
In multips, contractions five minutes apart or less and any other signs of second stage labor present.
Emergency Childbirth Medical Directive
What is the TREATMENT PLAN for delivery?
What is the TREATMENT PLAN for shoulder dystocia delivery?
Position the pt and deliver neonate
Perform ALARM twice on scene. If successful; deliver neonate
If unsuccessful;
transport to closest appropriate facility
Emergency Childbirth Medical Directive
What is the TREATMENT PLAN for breech delivery?
What are you considering?
What is the TREATMENT PLAN for prolapsed cord delivery?
HANDS OFF the breech. Allow neonate to deliver to umbilicus; consider carefully releasing the legs and arms as they are delivered; otherwise hands off
Once hairline is visible AND/OR 3 mins has passed since umbilicus was visualized attempt the Mauriceau Smellie-Veit maneuver
If successful; deliver neonate. If unsuccessful; transport to closest appropriate facility
If a cord prolapse is present, the fetal part should be elevated to relieve pressure on the cord.
Assist the patient into a knee-chest position or exaggerated Sims
position
insert gloved fingers/hand into the vagina to apply manual digital pressure to the presenting part which is maintained until transfer of care in hospital
Emergency Childbirth Medical Directive
What is the TREATMENT PLAN for umbilical cord management?
What are you considering?
What is the TREATMENT PLAN for external uterine massage?
If a nuchal cord is present and loose, slip cord over the neonate’s head. Only if a nuchal cord is tight and cannot be slipped over the neonate’s head, clamp and cut the cord, encourage rapid delivery
Following delivery of the neonate, the cord should be clamped and cut immediately if neonatal or maternal resuscitation is required. Otherwise, after pulsations have ceased (approximately 2-3 minutes), clamp the cord in two places and cut the cord
Post placental delivery
Emergency Childbirth Medical Directive
What is the ROUTE and TREATMENT PLAN for oxytocin?
What is oxytocin?
ROUTE - IM
Dose - 10 units
Max. single dose - 10 units
Dosing Interval - N/A
Max. # of Doses - 1
a naturally occurring hormone controls uterine contractions therefore reducing the risk of postpartum hemmorhage
Emergency Childbirth Medical Directive
What if you see a limb presentation?
What do you do if the labour isn’t progressing?
Do not attempt to push the limb back into the vagina
discourage the patient from pushing
cover the limb using a dry sheet to maintain warmth
initiate transport as per the Load and Go Patient Standard of the BLS PCS
Paramedics should discourage the patient from pushing or bearing down during contractions and initiate transport
Emergency Childbirth Medical Directive
If delivery has not occurred on scene within approximately 10 minutes of
initial assessment, consider transport in conjunction with…?
Should placental delivery delay transport?
What do you do with the placenta?
Lack of progression of labour
Multiple births expected
Neonate presents face-up
Pre-eclampsia
Presence of vaginal hemorrhage
Premature labour
Primip
Distance to the closest appropriate receiving facility
NO
inspect it for wholeness
place in a plastic bag from the OBS kit
label it with the maternal patient’s name and time of delivery
transport it with the maternal or neonatal patient.
Emergency Childbirth Medical Directive
When should you cut/clamp the cord?
How do I control excess bleeding post-delivery?
Once the neonate is delivered - only if multiple gestation is suspected or neonatal or maternal resuscitation is required
Due to transport considerations - once cord has stopped pulsating approx. 3min
Perform an External uterine massage until bleeding stops
Do not pack the vagina to control bleeding
Administer oxytocin
Emergency Childbirth Medical Directive
What do you make the patient aware before preforming the external uterine massage?
What do you do if you’re not able to control post-delivery bleeding?
will be uncomfortable/painful for the mother when it is being performed correctly
Preform bimanual compression regardless of placental delivery
Emergency Childbirth Medical Directive
Where do you clamp and cut the umbilical cord?
Approximately 15 cm from the neonate’s abdomen and approximately
5-7 cm from the first clamp
Cut the umbilical cord between the clamps
Emergency Childbirth Medical Directive
When should a paramedic inspect the perineum?
4 occurances
History is suggestive of ruptured membranes or umbilical cord prolapse
The patient is in labor and reports an urge to push, bear down, strain or move
the bowels with contractions or reports that “the baby is coming”.
The patient is near term, level of consciousness is decreased, and history is
unavailable, inconclusive or indicates that labor was on-going prior to decrease
in/loss of consciousness
Vaginal bleeding is heavy and the patient is hypotensive or in shock
Emergency Childbirth Medical Directive
What does the “Childbearing age” for Delivery, Umbilical Cord Management and External Uterine Massage refer to?
Are we authorized to perform internal vaginal exams for cervial dilation
What could oxytocin induce?
14-50 years
NO
Vasoconstriction i.e. exacerbates hypertension
Exaggerated Sim Position desciption
What position is preferred and what is more effective?
The patient lies in left lateral position with left arm lying along the back and the right
knee drawn towards the chest with a pillow/wedge under the left hip/buttocks to raise the pelvis and use gravity to move fetus toward the fundus
Exaggerated Sims Position is preferred for safe transport
the knee chest
position is more effective at elevating the presenting part of the cord in the presence
of strong uterine contractions
Endotracheal and Tracheostomy Suctioning/Reinsertion Medical Directive
What are the INDICATIONS?
What is a tracheostomy tube?
Patient with endotracheal or tracheostomy tube
AND
Aiway obstruction or increased secretions
a catheter that is inserted into the trachea to establish and maintain a patent’s airway and to ensure the adequate exchange of oxygen and carbon dioxide
Endotracheal and Tracheostomy Suctioning/Reinsertion Medical Directive
What are the CONDITIONS for suctioning?
What are the CONTRAINDICATIONS?
N/A
N/A
Endotracheal and Tracheostomy Suctioning/Reinsertion Medical Directive
What are the CONDITIONS for emergency tracheostomy reinsertion?
What are the CONTRAINDICATIONS?
Patient with an existing tracheostomy where the inner and/or outer cannula(s) have been
removed from the airway
AND
Respiratory distress
AND
Inability to adequately ventilate
AND
Paramedics are presented with a tracheostomy cannula for the identified patient.
Inability to landmark or visualize
Endotracheal and Tracheostomy Suctioning/Reinsertion Medical Directive
What is the TREATMENT PLAN for suctioning for a patient who is less than 1y?
What is the TREATMENT PLAN for suctioning for a patient who is ≥ 1 year but < 12 years?
Dose - 60-100mmHg
Max. single dose - 10sec
Dosing Interval - 1min
Max. # of Doses - N/A
Dose - 100-120mmHg
Max. single dose - 10sec
Dosing Interval - 1min
Max. # of Doses - N/A
What is the TREATMENT PLAN for suctioning for a patient who is greater than 12y?
What is the TREATMENT for Emergency tracheostomy reinsertion?
Dose - 100-150mmHg
Max. single dose - 10sec
Dosing Interval - 1min
Max. # of Doses - N/A
Max # of attempts - 2
Endotracheal and Tracheostomy Suctioning/Reinsertion Medical Directive
How do you manage suctioning/oxygenation, what should you do before hand (if possible)?
What is preferred with regards to cannula usage?
What is an attemp defined as?
Pre-oxygenate with 100% oxygen
Ask the patient to cough and clear their airway
A new replacement inner or outer cannula over re-using exisiting ones
the insertion of the cannula into the tracheostomy
Endotracheal and Tracheostomy Suctioning/Reinsertion Medical Directive
How do you minimize hypoxia and possible trauma?
What does starting at the lower end of suction pressures do for the pt?
What happens when you exceed the recommended suction pressures?
Don’t suction more than once/min
minimizes adverse effects
causes injury and swelling to the mucosal tissues of the airway and increases the risk of arrhythmia
Endotracheal and Tracheostomy Suctioning/Reinsertion Medical Directive
What do you do if all suctioning attempts have been made to clear the tracheostomy and you’re unable to oxygenate/ventilate using positive pressure ventilation?
What do you do in the event that the tracheostomy tube or inner cannula has been withdrawn and the patient is in respiratory distress?
The trach is then considered a FBAO (foreign body airway obstruction) and must be removed in order to gain access to the stoma for O2/PPV administration.
Utilize a family member or caregiver on scene (they are more knowlegable in the matter)
Endotracheal and Tracheostomy Suctioning/Reinsertion Medical Directive
What do you do If there is no family member/caregiver available who is knowledgeable in replacing the tracheostomy tube or inner cannula?
How do you optimize the insertion of the tracheostomy?
Prepare a new tracheostomy tube or inner cannula for reinsertion
If a new tracheostomy tube or inner cannula is not available, remove the inner cannula (if not already done), deflate the cuff (if present) and clean the current tracheostomy tube or inner cannula with saline or water
rinse.
put pt in a 30-90 degree sitting position
Endotracheal and Tracheostomy Suctioning/Reinsertion Medical Directive
Are you still able to insert the outer in the absence of an obturator?
Can the inner cannula be inserted during the inhalation phase?
What are paramedics recommended to utilize if a patient requires assisted ventilations, and there is no appropriate inner cannula available with a 15 mm adaptor?
YES - be cautious because the outer cannula may damage the
soft tissue of the trachea
Yes - it should be
an appropriate sized mask attached to a BVM to provide ventilation through the outer cannula ensuring an adequate seal
Endotracheal and Tracheostomy Suctioning/Reinsertion Medical Directive
What should paramedics do when a reinsertion fails?
What should paramedics do when occlusion of the stoma and attempts to ventilate the patient through the mouth and nose are unsuccessful or impossible?
occlude the stoma and attempt standard oral airway maneuvers and ventilation through the mouth and nose
paramedics should utilize an appropriate sized mask that can provide a seal around the stoma attached to a BVM to provide ventilation through the stoma ensuring an adequate seal
