Emergency Childbirth Medical Directive

Question 1

Emergency Childbirth Medical Directive

Answer 1

A Primary Care Paramedic may provide the treatment prescribed in this Medical Directive if authorized.

Note from Liz - I did my best, but honestly, just study this one from the book, the algorithm will be way clearer that way.

Question 2

Indications

Answer 2

Pregnant patient experiencing labour; OR

Post-partum patient immediately following delivery.

Question 3

Conditions - Delivery

Answer 3

Age: Childbearing years
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: Second stage labour and/or imminent birth

Question 4

Conditions - Umbilical Cord Management

Answer 4

Age: Childbearing years
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A
Other: Cord complications OR if neonatal or maternal resuscitation is required OR due to transport considerations

Question 5

Considerations - External Uterine Massage

Answer 5

Age: Childbearing years
LOA: N/A
HR: N/A
RR: N/A
SBP: N/A 
Other: Post-placental delivery

Question 6

Contraindications - Delivery

Answer 6

N/A

Question 7

Contraindications - Umbilical Cord Management

Answer 7

N/A

Question 8

Contraindications - External Uterine Massage

Answer 8

N/A

Question 9

Treatment

Answer 9

• Consider delivery
• Consider umbilical cord management
• Consider external uterine massage

Question 10

Consider delivery (algorithm)

Answer 10

Patient of childbearing years experiencing second stage labour and/or imminent birth
v
Position the patient supine on a firm surface, with her head and shoulders slightly elevated, legs flexed and abducted at hips and knees, feet flat and perineum clearly visible.
v
Complicated delivery?
No–> For head-first delivery, deliver the
head in a controlled fashion, allow spontaneous head rotation,
and deliver the neonate’s shoulders/body. Proceed to *
Yes:
Shoulder dystocia? Yes -> Attempt the McRoberts Manouevre
and apply suprapubic pressure.
Proceed to *.
No
v
Breach delivery? Yes -> ‘Hands off’ until the body has been
born to the umbilicus. Allow the head to
deliver spontaneously, or gently lift and
hold the neonate upwards and
backwards, while avoiding
hyperextension.
THEN If the head does not deliver
within approximately three minutes of
the body, attempt the Mauriceau-
Smellie-Veit Manouever.
Proceed to *
No
v
Nuchal or prolapsed cord? Yes -> Consider umbilical cord
management.
Proceed to *
No
v
*Assess maternal and neonatal patients, consider further umbilical cord manaagement, delivery of placenta, and external uterine massage.

Question 11

Consider umbilical cord management

Answer 11

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, and 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.
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.

Question 12

Clinical Considerations

Answer 12

If the patient presents with limb-presentation, do not attempt to push the limb back into the vagina; discourage the parient from pushing, cover the limb using a dry sheet to maintain warmth, and initiate transport as per the Load and Go Patient Care Standard of the BLS PCS.
If labour is failing to progress, dicourage the patient from pushing or bearing down during contractions.
If delivery has not occurred at scene within approximately ten minutes of initial assessment, consider transport in conjunction with the following:
a. Patient assessment findings:
i. Lack of progression of labour;
ii. Multiple births expected;
iii. Neonate presents face-up;
iv. Pre-eclampsia;
v. Presence of vaginal hemorrhage;
vi. Premature labour;
vii. Primip;
b. Distance to the closest appropriate receiving facility.
When the placenta is delivered, 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, and transport it with the maternal or neonatal patient. Delivery of the placenta should not delay transport considerations/initiation.