Aehlert EMR OLC Updates

Chapter 8–Patient Assessment

DCAP-BTLS is a helpful memory aid to remember what to look and feel for during the physical exam:

  • Deformities
  • Contusions (bruises)
  • Abrasions (scrapes)
  • Punctures/penetrations
  • Burns
  • Tenderness
  • Lacerations (cuts)
  • Swelling

Chapter 10–Bleeding and Soft-Tissue Injuries

Additional information related to Figure 10-4, regarding elevation and pressure points:

The use of elevation and pressure points has been taught to help control extremity bleeding for many years. According to the 2005 Resuscitation Guidelines, “There is insufficient evidence to recommend for or against the first aid use of pressure points or extremity elevation to control hemorrhage.The efficacy, feasibility, and safety of pressure points to control bleeding have never been subjected to study, and there have been no published studies to determine if elevation of a bleeding extremity helps in bleeding control or causes harm. Using these unproven procedures has the potential to compromise the proven intervention of direct pressure.”Be sure to check your local protocols and learn about the approved methods of bleeding control in your area.

Chapter 12 –Childbirth

Complications of Delivery

Prolapsed Cord

A prolapsed cord is a serious emergency that endangers the life of the unborn fetus. A prolapsed cord occurs when a portion of the umbilical cord falls down below the presenting part of the fetus and presents through the birth canal before delivery of the head. With each contraction of the uterus, the cord is compressed between the presenting part and the mother’s bony pelvis (Figure A). Without blood flowing through the cord, the baby will suffocate. The pressure on the cord must be reduced or relieved as quickly as possible.

Figure A. Prolapsed umbilical cord.

A pulsating umbilical cord indicates the fetus is alive.

Quickly call for Advanced Life Support personnel if you have not already done so. Place the mother in the knee-chest position. To do this, position her on her hands and knees. Then ask her to lower her head and chest to the floor (Figure B). This will help lessen pressure on the cord in the birth canal. Insert a sterile gloved hand into the vagina and push the presenting part of the fetus away from the cord. Apply only enough pressure to the presenting part so that a pulse returns in the cord. Once this has been accomplished, leave your hand in place. Do NOT attempt to push the cord back into the vagina. With a wet gauze pad or cloth, cup the cord against the mother’s body to keep it moist. Administer oxygen to the mother if it is available and you have been trained to do so. Arrange for rapid transport of the patient to the closest appropriate medical facility. Keep pressure off the cord and monitor the cord pulsations while awaiting patient transport.

Figure B. The knee-chest position. The mother is positioned on her hands and knees. Her head and chest are then lowered to the floor.

Breech Birth

A breech birth occurs when the baby’s buttocks or feet come out of the uterus first (Figure C). A breech presentation is dangerous for the fetus because of the increased likelihood of delivery trauma or suffocation due to a prolapsed cord. A breech presentation is best managed in the hospital. As soon as you recognize the presenting part is the baby’s buttocks or leg, request Advanced Life Support personnel to the scene. Administer oxygen to the mother if it is available and you have been trained to use it. Place the mother in the knee-chest position or on her left side with her hips and legs elevated. These positions allow gravity to pull the baby away from the mother’s cervix.

Figure C. A breech presentation occurs when the baby’s buttocks or feet come out of the uterus first.

If delivery is about to occur, use body substance isolation precautions, including gloves, mask, eye protection, and a gown. Prepare the mother in the same way as for a head-first delivery. Position the mother and prepare the OB kit. Allow the buttocks and trunk of the baby to deliver on their own. Do not pull on the baby. Pulling may cause the mother’s cervix to clamp down tighter on the baby’s head. Once the legs are clear, support the baby’s legs and trunk. The head should deliver on its own. If the head does not deliver within 3 minutes of the time the trunk was delivered, place a gloved hand into the vagina with your palm toward the baby’s face. Spread your fingers and form a “V” with your index and middle finger on either side of the baby’s nose (Figure D). Push the vaginal wall away from the baby’s face and hold the baby’s mouth open slightly with your finger. This may allow air to enter the baby’s mouth and nose. You must continue this position until the baby’s head is delivered. For transport, place the patient on her left side.

Figure D. Assistance positioning for a breech birth.

Limb Presentation

A limb presentation occurs when an extremity of the infant protrudes from the vagina before the head (Figure E). This situation is a medical emergency because the baby cannot be delivered in this position. Arrange for transport as soon as you recognize a limb presentation. Administer oxygen to the mother if it is available and you have been trained to use it. Place the mother in the knee-chest position or on her left side with her hips and legs elevated to decrease pressure on the umbilical cord.

Figure E. A limb presentation occurs when an extremity of the infant protrudes from the vagina before the head.

Multiple Births

A normal pregnancy is considered 40 weeks.

A woman pregnant with twins (or more babies) usually goes into labor in her 37th week of pregnancy. The more babies a woman is expecting, the higher the risk of having a premature delivery. On average, most pregnancies involving one baby last 39 weeks; for twins, 36 weeks; for triplets, 32 weeks; for quadruplets, 30 weeks; and for quintuplets, 29 weeks. Premature babies (also called preemies) can have many health challenges, including serious infections and respiratory distress due to underdeveloped lungs.

Multiple birth babies are usually smaller than a single full-term baby and, if they are delivered vaginally, are easier for the mother to push out. However, complications can occur during delivery. For example, the umbilical cord may be compressed by one or more of the babies because the uterus is crowded. The first baby is often born head first, but the babies after that may be in a breech, transverse (sideways), or head-first position when they enter the birth canal.

Anticipate multiple births if the mother’s abdomen appears unusually large or if it remains large after the first infant is delivered. If the mother has had prenatal care, she will usually know if she is expecting more than one baby.

If multiple births are expected, call for assistance immediately. Be prepared to resuscitate more than one baby. The steps for the delivery of multiple babies are the same as with the delivery of one baby. Each baby may be attached to its own placenta, or they may all be attached to the same one. Clamp or tie the umbilical cord after the first baby is born. Cut the cord if your EMS system allows you to do so. If the second baby is not delivered within 10 minutes of the first, the mother and baby must be transported immediately for delivery of the second baby.