BH 3

Overview of Emergency Childbirth Maneuvers and Postpartum Hemorrhage Management

In this detailed lecture, crucial techniques and guidelines for managing childbirth complications and postpartum hemorrhage (PPH) in emergency settings are discussed. The role of paramedics and the medical director in implementing advanced life support (ALS) principles are reviewed along with essential maneuvers and interventions.

BLS and ALS Context

  • The Bureau of Labor Statistics (BLS) indicated that Emergency Childbirth Management (ECM) needed to be included in Advanced Life Support (ALS).
  • As a result, a medical directive was established, but there are concerns about its clarity and effectiveness in practice.
  • Reference made to the previous year's MCME which included practical, hands-on experience regarding childbirth scenarios—highlighting the importance of practical training in addition to theoretical understanding.

Key Childbirth Techniques

Bimanual Compression
  • Definition: A technique to control bleeding by compressing the uterus between two hands to reduce blood loss.
  • Context: Not included in the medical directive but is found in a companion document. Expected to be utilized in specific complication scenarios.
  • Function: Important for managing certain cases when the patient experiences complications during delivery.
Nuchal Cord Management
  • Definition: A situation in which the umbilical cord is wrapped around the baby's neck.
  • Maneuvers:
    • Often can be managed by wrapping the cord around the baby's head during delivery.
    • If tightly wrapped, referred to as “smelly feet” maneuver:
      • Tuck the baby's head into the thigh of the leg towards which the baby is orientated during delivery and attempt to unwrap the cord as the baby is delivered.
    • If unsuccessful, as a very last resort, consider cutting and clamping the cord, bearing in mind that the baby will then no longer receive oxygen.
Shoulder Dystocia
  • Signs: Notable sign is turtling, where the baby’s head goes back in following contractions, indicating shoulder impaction.
  • Management:
    • Use the ALARM mnemonic: Ask for help; Hyperflex legs (knees to ears), apply supra-pubic pressure on the baby’s shoulders.
      • This increase in pelvic space and downward pressure has a high success rate (over 90%) in relieving shoulder dystocia.
    • If pressure does not relieve the dystocia, position the mother in Gaskins position (legs splayed) and attempt to extract one of the baby's arms if visible.
    • Repeat the ALARM maneuver twice before considering transport if necessary, switching providers to assess from different angles.
Breech Birth
  • General Advice: Hands off during breech delivery. Allow progression naturally.
  • Positioning: If toes are pointing upwards, facilitate turning the mother to ensure toes point downward for flexion during delivery.

Managing the Third Stage of Labor

Placental Delivery
  • Delayed Cord Clamping: Recommended post-delivery as long as the mother and baby are stable, ideally until the pulse in the cord ceases (often around 5 minutes).
  • Twins/Triplets: Only delay cord clamping on the last baby due to potential shared placentation.
  • If delivery is prolonged or complicated, consider en route delivery of the placenta if the mother is stable.
  • Oxytocin Use: Administer to aid placental delivery and control postpartum bleeding.
Postpartum Hemorrhage (PPH)
  • Definition: More than 400-500 mL blood loss classified as significant.
  • Management:
    • All patients who deliver receive oxytocin as per directive to manage bleeding.
    • Bimanual compression is utilized if the placenta is retained and cannot be delivered correctly.
    • Uterine Massage: For cases with the delivered placenta aimed at promoting uterine contraction. Should be vigorous and may be painful.
      • Effectiveness should be reassessed within several minutes; if ineffective, proceed to bimanual compression.
    • Contraindications for Uterine Massage: Retained placenta and in situations involving uncertain maternal stability.

Special Considerations

  • Oxytocin Administration: Must only be given when all babies are delivered; contraindicated if the mother is known to have preeclampsia or is experiencing seizures.
  • TXA in Trauma vs. PPH: TXA is not within the current guideline for PPH management outside of traumatic situations, as it has shown varying efficacy in different bleeding scenarios. Continued research is recommended.
  • Communication with Patients: It is vital to educate and communicate with mothers regarding interventions, especially regarding oxytocin and unnecessary delays during transport.

Conclusion

  • Effective management of childbirth and postpartum situations depends heavily on established techniques, timely interventions, and a thorough understanding of the medical directives and their respective limitations.