obstetrical emerg ecb-newborn

EMS SKILL EMS SKILL

OBSTETRICAL EMERGENCY / EMERGENCY CHILDBIRTH NEWBORN ASSESSMENT & MANAGEMENT

PERFORMANCE OBJECTIVES The examinee will demonstrate proficiency in assessing the newborn and performing initial care and interventions as necessary.

CONDITION The examinee will be requested to assess and perform the initial care of the newborn and intervene as necessary using a simulated patient. The newborn is full term with no major complications during pregnancy. The newborn was suctioned during the birth process, the cord clamped and cut and the baby is wrapped in a blanket. Required equipment will be in the room readily accessible.

EQUIPMENT Baby manikin with umbilical cord clamped, bulb syringe, baby blankets, oxygen tank with flow meter, oxygen tubing, neonatal oxygen mask, neonatal bag-valve-mask device, stethoscope, goggles, masks, gown, gloves.

PERFORMANCE CRITERIA 100% accuracy required on all items designated by a diamond ( ) for skills testing and must manage successfully all items indicated by

double asterisks (**). Documentation, identified by the symbol (§), must be practiced, but is not a required test item. Appropriate body substance isolation precautions must be instituted. • Ventilations and compressions must be at least at the minimum rate required.

PREPARATION

Skill Component

Key Concepts

Take body substance isolation precautions

• Mandatory personal protective equipment – gloves

Evaluate additional BSI needs

• Situational - goggles, masks, gown

Determine: Additional resources Specialized equipment

PROCEDURE

Assessment of the newborn is performed after the baby is dried, wrapped, airway cleared, and stimulated

Skill Component

Key Concepts

Assess and support body temperature:

Dry newborn completely - if not done previously Keep wrapped with head covered

Newborns become hypothermic very easy which can precipitate hypoglycemia, respiratory problems, increased oxygen demand and bradycardia.

Wrap the baby so only the face is exposed, they lose most of their heat from the head area.

Assess and support the airway:

Position on back or side with neck in a neutral position Suction with bulb syringe - if needed

Hyperextension or flexion of neck may cause an airway obstruction. To maintain in position, place a rolled blanket or towel under the neck and shoulders.

If copious secretions, place baby on the side with the neck slightly extended. This allows the secretions to collect in the mouth and not in the posterior pharynx.

When suctioning with a bulb syringe: - make sure that the bulb syringe is compressed first before placing

in the mouth and nose

- place the syringe approx. 1"-1 1/2” into the mouth and no more than 1/2” into nostrils, slowly release the bulb drawing fluid into the syringe and discharge contents onto a towel.

Prolonged or deep suctioning of the newborn’s oropharynx may cause bradycardia and/or apnea. Never suction longer than 3-5 seconds per attempt.

Obstetrical Emergency – Newborn Assessment & Management © 2001, 2004 of 5


Skill Component

Key Concepts

Assess breathing:

If adequate - continue with assessment

If respirations shallow or slow - administer oxygen and stimulate by: - vigorously rubbing back with a towel slapping or

flicking the soles of the feet

If gasping or respirations are inadequate - ventilate with bag-valve-mask at 40-60 breaths per minute

Ventilate baby with bag-valve-mask if no response to administration

of 100% oxygen and stimulation of 5-10 seconds.

Oxygen should be administered by:

- using a face mask with at least 5 Liters/minute, held loosely over the baby’s face

- blow-by with oxygen tubing at least 5 Liters/minute, held near the baby’s nostrils

For effective bag-valve-mask ventilations, the mask must be the appropriate size and have a tight seal.

Use only enough force to allow for good chest rise. Over-inflation causes gastric distention, which will affect tidal volume by elevating the diaphragm.

Assess circulation:

Heart rate If > than 120 beats/minute - continue assessment

If 100-120 beats/minute -administer oxygen

If < than 100 beats/minute - ventilate with bag-valve-mask device attached to 100% oxygen

If < 60 beats/minute - start CPR @ rate of 120 compressions/minute

Color If pink or peripheral cyanosis of hands and feet - no treatment indicated

If central cyanosis and good respirations and heart rate > 100 beats/minute - administer oxygen

If generalized pallor or cyanosis and no response to oxygen administration - ventilate with bag-valve-mask device attached to 100% oxygen

The heart rate is a reliable indicator of the newborn’s distress level.

Check pulse by one of the following: - palpate pulse at base of umbilical cord - palpate brachial or femoral pulse - auscultate apical pulse

Normal newborn heart rate is 120-160 beats/minute.

If ventilating with a bag-valve-mask device, or performing chest compressions the heart rate must be re-assessed every

30 seconds.

Compression to ventilation ratio is 3 compressions to 1 ventilation.

Color is the least important indicator of adequate circulation. The newborn must also be assessed for activity, grimace cry, heart rate and respirations.

DO NOT attempt to obtain an APGAR score if the newborn requires resuscitation measures.

APGAR score is determined at 1 minute and 5 minutes after birth. If the score is less than 7, it is repeated every 5 minutes for 20 minutes.

Los Angeles County does not required an APGAR score, nor is the APGAR score part of the National DOT Curriculum. However, EMT and Paramedic textbooks provide this information and many EMS systems use this score as part of the newborn assessment.

Assess umbilical cord for:

Bleeding - apply sterile dressing and direct pressure if indicated

Security of clamps or ties - use additional clamps or ties as indicated

Make sure clamps are secure and will not slip or the baby may

hemorrhage.

Use ties in case of an enlarged umbilical cord.

The mother and newborn should be transported to the same facility.

BLS units shall call for an ALS unit or transport to the most appropriate hospital as per Reference: - 511 - Perinatal Patient Destination - 808 - Base Hospital Contact and Transport Criteria.

ONGOING ASSESSMENT

Skill Component

Key Concepts

§ Repeat an ongoing assessment every 5 minutes:

Initial assessment Relevant portion of the focused assessment Evaluate response to treatment Compare results to baseline condition and vital signs

The initial and focused examination is repeated every 15 minutes for stable patients and every 5 minutes for priority patients.

Every patient must be re-evaluated at least every 5 minutes, if any treatment was initiated or medication administered, unless changes in the patient’s condition are anticipated sooner.

Priority patients are patients who have abnormal vital signs, signs/ symptoms of poor perfusion or if there is a suspicion that the patient’s condition may deteriorate.


DOCUMENTATION

Skill Component

Key Concepts

§ Verbalize/Document:

Time of delivery of baby Problems with this pregnancy Presence of meconium Integrity of the cord Condition of the baby

Documentation must be on either the Los Angeles County EMS

Report or departmental Patient Care Record form.

Time of delivery for the baby is the time when the baby’s body is delivered.

Developed 12/01 Revised 7/04


Supplemental Information DEFINITIONS: • Baby - name used to indicate newborn

• Newborn - neonate in the first minutes to hours after birth

• Neonate - infants in first month after birth (28 days)

• Infant - includes the neonate period to 1 year (12 months)

• Central cyanosis - bluish color on trunk and face

• Peripheral cyanosis - bluish color limited to hands and feet

• Meconium - fetal feces that is normally passed as the baby’s first bowel movement. However, during fetal or maternal stress, defecation may occur before birth

• Oxygen administration - administration of free-flow oxygen directly to baby’s face by either mask or blow-by method: - mask - at least 5 Liters/minute, held loosely over baby’s face - blow-by with oxygen tubing - at least 5 Liters/minute, held near the nostrils

INDICATIONS FOR BAG-VALVE-MASK VENTILATIONS: • Apnea, gasping, or inadequate respirations • Heart rate less than 100 beats/minute • Persistent central cyanosis unresponsive to administration of oxygen

INDICATIONS FOR CARDIOPULMONARY RESUSCITATION: • Pulseless • Heart rate less than 60 beats/minute

NOTES: • Newborns must make three rapid transitions to the out side world from their protected environment in utero: - Changing their circulatory pattern - Emptying fluid from their lungs and beginning ventilation - Maintaining body temperature

• Four main objectives in caring for the newborn: - Provide and maintain warmth. Important to dry and wrap baby with only face exposed, they lose most of their heat from the head

area. - Continually assess respirations, heart rate and color. - Maintain adequate respirations by positioning, suctioning, administration of oxygen, and ventilate with a BVM if indicated - Provide cardiac compressions for heart rate < 60

• The mother and newborn should be transported to the same facility.

• BLS units shall call for an ALS unit or transport to the most appropriate hospital as per Reference No. 511 and 808

• Signs of poor perfusion are: weak cry, bradycardia (heart rate < 100 beats/minute), inadequate respirations (< 40 breaths/minute), and cyanosis.

• Hyperextension or flexion of neck may cause an airway obstruction. To maintain in position, place a folded blanket or towel under the neck and shoulders.

• If copious secretions are present, position the baby on the side and slightly extend the neck. This allows the secretions to collect in the mouth and not in the posterior pharynx.

• When ventilating with a BVM, use only enough force to allow for good chest rise. Over-inflation causes gastric distention which will affect tidal volume by elevating the diaphragm

• If ventilating with a bag-valve-mask device, heart rate must be re-assessed every 30 seconds.

• Check pulse by one of the following: - auscultate apical pulse - palpate pulse at base of umbilical cord - palpate brachial or femoral pulse

• Normal newborn heart rate is 120-160 beats/minute.

• Compression to ventilation ratio is 3 compressions to 1 ventilation.

• APGAR score is not required in Los Angeles County and is not in the EMT-I DOT Curriculum, but is found in all ECB literature.


• APGAR score is assessed at 1 minute and 5 minutes and if the score is less than 7, it is repeated every 5 minutes for 20 minutes.


APGAR SCORE

Evaluation Factor Findings Score

Appearance (color) - cyanotic or pale - blue hands and feed with pink body

0 points 1 point

- extremities and trunk pink 2points

Pulse - no pulse - < 100/ minute

0 points 1 point

- > 100/minute 2 points

Grimace (reflex irritability) - no reflex to stimulation - slight reflex to stimulation

0 points 1 point

- grimace, cough, sneeze, or cry in response to stimulation 2 points

Activity (extremity movement, degree of flexion and resistance to straightening them)

- limp, no extremity movement - some flexion with no movement

0 points 1 point

- actively moving 2 points Respirations - no respiratory effort

- slow, irregular effort with weak cry 0 points 1 point

- good effort with strong cry

2 points 7-10 points = normal - provide routine care 4-6 points = moderately depress - provide stimulation and oxygen 0-3 points = severely depressed - provide CPR and BVM ventilations

• The inverted pyramid - reflects the frequencies for neonatal resuscitation without meconium stained amniotic fluid INVERTED PYRAMID STEPS

Step 1 - always needed 1 Step 2 - frequently needed 2

Step 3 - infrequently needed 3

Step 4 - infrequently needed 4

Step 5 - rarely needed 5 • Always assess and manage: Temperature (warm & dry) American Heart Association Pyramid Airway (position & suction) Breathing (stimulate to cry) Circulation (heart rate & color)


obstetrical emerg ecb-newborn

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