(Transcript is automatically generated).

Matt: [00:00:00] You know, for EMS providers, this is one of those calls that strikes a little bit of fear because they're so rare. 

Erik: I remember, um, a call on the radio from the charge nurse, get a gurney outside, she's given birth.

Narrator: You are listening to EMS with your hosts, Erik Axene and Matt Ball. 

Erik: Two. 

Matt: Part two. Yep. Took a little break, got some coffee. 

Erik: Should we talk about all the things to click again or do we just get into it? 

Matt: Uh, well if you're listening to the podcast, you didn't stop listening 'cause this is a continual thing, so. 

Erik: Oh, I see. I see. I'm glad you know what you're doing. 

Matt: No, that's fine. But yeah, this is unit two. If you're watching this for CE credit, this is unit two two, so you'll follow that. That's the separated one. But yeah, we talked about, well you just got done listening to unit one, so we won't review too much. Now we're gonna talk about some fun stuff. I don't know about fun stuff. 

Erik: Yeah, it's 

Matt: more detailed stuff. 

Erik: Just, well, I mean, as far as pregnancy goes, this [00:01:00] is like you're landing the plane now, right? So this is this, these are. This is, uh, the pregnancy related emergency. So we broke it up into three sections. 

Matt: Yep. 

Erik: Antepartum, intrapartum and postpartum 

Matt: or to speak EMS before, during, and after.

Erik: Good. 

Matt: Put it in layman's terms. 

Erik: I love that about you, Matt. You make things. It's so much more simple. 

Matt: That's because Matt has to make them simple so they make sense to Matt. 

Erik: I think that's why people like you is like you make things complicated topics easy to understand 

Matt: Well, and I think that's what makes us good instructors.

I know. 'cause I have to break it down to a super simple level so that I can understand it. Right, because that's just the way my brain works, right? Yeah. And, but a lot of people, I've always said it's like Michael Jordan teaching you how to play basketball. So much of that came so natural to him. He doesn't understand how somebody can't move like he does.

Or, you know, a lot of doctors don't under, well, why can't you understand this concept? I just explained the pathophysiology and I'm like, okay dude, because my brain doesn't work like yours. Yeah. I need to break it down to a third [00:02:00] grade level 'cause I'm a fireman and I need to understand it and then build upon that, you know?

But all of our brains work different. 

Erik: Well, I think those, that's my favorite part of of teaching is those aha moments. 

Matt: Oh yeah. 

Erik: That's what we all love as teachers. 

Matt: As a teacher and a student. 

Erik: Yeah. And a student, right? 

Matt: Yes. Yeah. When you're finally like, oh, this isn't as complicated as I thought it was as a student.

Yeah. And then on the giving end of that, when you're a teacher. Mm-hmm. And you can vis, that's one thing that I love about live teaching. Mm-hmm. Is that. You can see when the light bulb, sometimes yes, you can see when that light bulb goes off. Or you can see when somebody's really struggling. If you're a good instructor and you're reading faces and you're like, I've lost them here.

They're not. They're not. They're not with me. And then when you, okay, hang on. Let's pause. Let's not keep moving forward. 'cause I can tell some of you're lost. What, what's confusing you? And then you go back and then you're like, okay, well let's talk about it. And then it's like, oh, okay. That's a great feeling as a teacher. 

Erik: And I, and sometimes in the virtual environment, we have people come contact us through the website to tell us about how they learn something that treated a patient. [00:03:00] So if you're listening and you've learned something and impacted your patients. Gotta tell us. 

Matt: Yeah. Yeah.

And I think, like I said in the first part with with OB patients, because we don't get a lot of these patients, it's crucial that we're constantly doing, studying these type of patients. Yeah. Because you know, with a lot of patients, you're gonna learn through experience because you're doing it every day. 

Erik: Right.

Matt: But these are patients that are very rare. And so you really gotta know what you're doing and you're not gonna get that, um, you know, through experience. You're gonna have to get that through education. Yeah. Um, so. Before, during, and after pregnancy? 

Erik: Yeah. Antepartum before pregnancy or before partition is what antepartum would be.

Matt: There you go. Is that Latin? 

Erik: I think so. Well, it's probably, yeah, I think so. I think it's Latin. 

Matt: I don't know. 

Erik: Uh, but yeah. So before pregnancy, so as you're approaching pregnancy, the, there are certain pregnancy related emergencies that can occur. 

Matt: That's right. 

Erik: And the first one we're gonna talk about is preeclampsia.

Matt: Yes. 

Erik: So it's [00:04:00] that, um, that woman who's, uh, complaining of certain things that are associated with preeclampsia with high blood pressure. 

Matt: Yep. 

Erik: So, uh, one of the I guess common complaints would be headache. 

Matt: Headache. Yeah. Blurred vision. 

Erik: Blurred vision. Yep. Visual disturbances we would say. 

Matt: Yep. 

Erik: You can even have what's called a visual scotoma.

Sparkly lights. Yep. 

Matt: Yep. 

Erik: Blurry vision. Uh, those types of things can occur with the headache. And then, uh, the, they may complain subjectively of swelling. 

Matt: Mm-hmm. 

Erik: Uh, abdominal pain. Mm-hmm. Um. 

Matt: Typically like lower extremity swelling, 

Erik: correct. Yeah. Correct. Yeah. And it can be every, anywhere. It can be, 

Matt: but that's the most common place that they're gonna have pedal edema.

Erik: Correct? Yeah. This dang planet with gravity. It's just uh Exactly. All sorts of problems. Exactly. Did you know that gravity is the weakest force known to man? 

Matt: The weakest force known to man. 

Erik: Yeah. Isn't that an interesting perspective? 

Matt: Never thought about it. 

Erik: It takes, 

Matt: it's [00:05:00] interesting, 

Erik: it takes this giant rock we call Earth.

Mm-hmm. 

Matt: Third rock from the sun 

Erik: to hold me down right where I can still jump against its force. 

Matt: Okay, yeah. Makes sense. 

Erik: But it really is, gravitational force is the weakest force known to man. It's a very weak force. Takes a tremendous amount of mass to create that force. It's weak. You know, you think about it, the force you generate with your quadriceps can lift you up against it, right?

I mean, yeah, it's a very weak force. 

Matt: For context, last night we had our ACE Christmas party. 

Erik: We sure did. 

Matt: And. And, and I did a little roast of Dr. Axene. 

Erik: You did a roast of me 

Matt: and, and this was, uh, this is what we call Dr. Axene, chasing a squirrel as we're talking about antepartum pregnant patients, gravity. And all of a sudden we're talking about gravity.

And I think I said, well, as a matter of fact, I have it right here on the phone. 

Erik: Oh, no, 

Matt: no. I'm not gonna read the whole thing. But the one line that is applicable to exactly what we're saying is he's like a giant yellow lab that will knock you off your feet when he goes chasing his world. [00:06:00] But the good news is you're a yellow lab and everybody loves Yellow Labs.

Erik: Well, see, the thing I like about it though is like we, it may have been better time to do it later about gravity. No, I'm talking about 

Matt: Oh, oh, yeah. Yeah. 

Erik: But I view them as a brain break. Right. Oh, for sure. You talking? Oh, for sure. You know, it's like a, 

Matt: oh, it's fun. 

Erik: It's good to have a brain break. 

Matt: Yes. I just dunno how you keep all this knowledge in your head.

It's amazing. 

Erik: I love you like a brother. 

Matt: It's amazing to me. Yeah, 

Erik: no, we can't take ourselves too seriously, 

Matt: right? Oh, no, no, no, no. I love the, uh, Harley picture with me and Hailey, Jill Osmond and my cat, because I, can 

Erik: you pull those up and show them? 

Matt: Uh, 

Erik: we should pull them up. So 

Matt: I don't have I don't have 'em.

Erik: Oh, I'll give it to you. Oh, I'll give it to you. 

Matt: Yeah. Oh, oh, yeah. Oh yeah, yeah, yeah, yeah. You give 'em to me an output. 

Erik: It'd be kind of funny actually. 

Matt: Yes, yes. 

Erik: Um, anyway, uh, so yeah, gravity actually, uh, uh, that's why we have that dependent edema. 

Matt: Mm-hmm. 

Erik: For somebody laying in bed, you actually have dependent edema along the whole backside.

Matt: Right. 

Erik: Um, that's 

Matt: why blood pools and dead people. Exactly. Yeah. 

Erik: So [00:07:00] gravity's pulling that blood down to the lower extremities, right? And that edema is part of the diagnostic kind of picture of a person in preeclampsia, right? Technically the blood pressure 140 over 90 or higher is that number that really clues us in.

But like we talked about in the lecture, you don't have to have high blood pressure to have preeclampsia. You wanna really look for these signs and symptoms that we've been describing. 

Matt: And two, don't forget of the power of asking questions, right? 

Erik: Oh yeah. 

Matt: Ask your patient. Have you had any issues with your blood pressure?

Have you been diagnosed with preeclampsia? Has your doctor said anything? Talk to your patient and ask 'em these questions. Yeah, because that can take a lot of the mystery at, oh yeah, he said I need to be watching my blood pressure. Okay, now you've kind of confirmed that you've got this issue going on.

Like that's, uh, taking that whole approach of patient assessments, not just with your vitals. Talk to your patient. Ask them 

Erik: right, it's okay to cheat, get 

Matt: that's not cheating. That's being a good paramedic. That's being exactly, being a good clinician. Is using every bit of info. I tell my students all the time that being a [00:08:00] paramedic is like being a medical detective.

Yeah. Right. And so you don't just go in right. As a detective if you're trying to solve a crime and just look at the clues. Yeah. That's just one part of it. 

Erik: Yeah. 

Matt: What else do you do? You bring people in and you investigate witnesses, you investigate potential suspects, you investigate the, or you talk to the victims, right?

Yeah. You get their side of the story and you take all of the information, the clues that you see. Mm-hmm. You know, whatever the, the, the interviews that you did to paint a picture of what happened. Yeah. It's exactly what you're doing as a paramedic or a physician. 

Erik: That's right. 

Matt: Right. And so one part of that is talking to your patient.

To your patient. Yeah. Sorry. 

Erik: Yeah. My doctor and I, we've been working on this high blood pressure issue. He's concerned about me getting preeclampsia again. 

Matt: Yes. 

Erik: Yeah. Every pregnancy I have it. Yes. Wait a minute. Okay. 

Matt: We just solved the problem. Yeah, this is, yeah, 

Erik: but don't anchor on it 'cause it could be something else, right?

That's right. Yes. But keeping your mind up. But you're right though. I mean, talk to a patient. 

Matt: Well, and, and if I have a, a pre-eclamptic patient, right? 

Erik: Mm-hmm. 

Matt: My next main goal is, are they going to go eclamptic? Yes. Because there's a pre in front of [00:09:00] that. Yeah. And obviously if they go Eclamptic, I'm preparing that this patient could very easily seize on me.

Erik: Correct. 

Matt: And so I am mentally preparing, okay, what do I need to have an IV access. Yeah. I need to probably have my mag out and ready to go, what's my dose? Check all that. Have it ready to go. That way if this patient starts seizing, I can. 

Erik: Yep. 

Matt: Do my thing. 

Erik: Right. 

Matt: Or even call your medical control if they don't allow that. Yeah. Like our current protocols that I work under do not allow that. However, if I have an, well, I shouldn't say that. If their pressure's high enough, I can do that. 

Erik: Yeah. 

Matt: But, um. Yeah, 

Erik: because Yeah, 

Matt: call med control. 

Erik: Yeah. 

Matt: Yeah. And ask permission.

And you know what? You're a medical control doctor, right? I'm a paramedic. 

Erik: Uhhuh. 

Matt: If I call you as one of your paramedics and say, Hey Doc, I know this isn't in our protocols, but I've got a 28-year-old female. Blood pressure is 150 over 90 Uhhuh. She's got blurred vision and a extreme headache.

I'd like to give her two grams of mag uhhuh so that she doesn't go eclamptic on me. Are, are you okay with that? What would you think? 

Erik: Give four. 

Matt: Okay. There you [00:10:00] go. Yeah. And so that's, but you, what would you think about me as a paramedic or that paramedic that's calling you? 

Erik: Uh, they're thinking 

Matt: exactly.

Erik: You're thinking Exactly. And it's like, um, you're not just following a a, a recipe book protocol. Right. Exactly. You're thinking, you're thinking of, you know what, I think I might need to do more. 

Matt: Yes. 

Erik: And go for it. 

Matt: Yes. 

Erik: Um, you know, you can, you get somebody into seizures, your hand's gonna be forced. Yes. Let's try to prevent it.

Matt: Yes. 

Erik: Um, and get 'em to where they need to go. Because the cure for this, if they do become eclamptic, which is the next thing we're gonna talk about, which is basically everything we just said, plus seizures. Right. The mag. 

Matt: Yeah. 

Erik: Uh, follow your protocols, but given that Mag IV, um, is gonna be the first line treatment for it.

Matt: Yes. And if your protocols still have benzos as your first line treatment, just squirt it out the window and give the mag No, I'm just kidding. Don't do that. 

Erik: Yeah, that's right. 

Matt: No, but I mean, that's something to bring up. 'cause we, I've had this conversation, you've had this conversation with lots of people.

'cause I've worked with protocols that, you know, it was benzos first. And then the mag. Yeah. And we've had a lot of conversations over, no, give the mag [00:11:00] first. 

Erik: Yeah. 

Matt: But so maybe talk to your medical director. Yeah. Get their viewpoint on it. Certainly don't argue with the medical director, but, 

Erik: well, there could be other causes though.

We've talked about this before too, right? There's overdoses, withdrawal, uh, you know, a subarachnoid hemorrhage, meningitis, 

Matt: epilepsy. 

Erik: Epilepsy, right. There could be a lot of things at play here. Yes. Again, pregnant women can get lots of other diseases too, right? 

Matt: All of all of the other diseases. Yeah. 

Erik: But with the headache, yes.

The edema, 

Matt: the context, 

Erik: the abdominal pain, the whatever, all this stuff pressure together and then they start seizing with the, the high blood pressure, um, you know. Like if it barks like a duck. Isn't that what they say? 

Matt: If it barks like a duck, then yeah, it's a dog duck. 

Erik: Duck. Yeah. Right. Whatever it is. So treating it 

Matt: walks like a duck, quacks like a duck, it's probably a duck. Yeah. 

Erik: Now you give the mag and the mag doesn't work. 

Matt: Mm-hmm. 

Erik: Benzos may have a place. Right. Absolutely. Follow your protocols. But, and even ketamine potentially for, for those seizures that are just not [00:12:00] treated by other conventional therapies, 

Matt: the important thing is, is to be thinking ahead.

Erik: Yeah, 

Matt: always, regardless of what your patient is, always be thinking. What could happen with this patient? 

Erik: Yep. 

Matt: What could I, what should I be prepared for with this preeclamptic patient, with this pregnant patient, with this trauma patient, this cardiac patient? Mm-hmm. Putting the pads on somebody that's having a massive stemi.

Erik: Yeah. 

Matt: That's thinking ahead. Because 

Erik: each time you have a chest pain patient, we should be putting the pads on these patients. Yeah. 

Matt: Yes. Yes. 

Erik: Well, in this case, it's actually reminds me of the case we had in the last hour that preeclamptic that went into cardiac arrest. Mm-hmm. Um, you gotta think about these things and potential problems that could occur. Um, uh, preeclampsia, uh, sorry. Eclampsia is not a benign thing. No. It's life threatening. 

Matt: Yes. 

Erik: So mag first, benzos maybe. 

Matt: Yep. Oxygen, like we said, 

Erik: always, 

Matt: always on oxygen. Always. Yep. Yep. 

Erik: No, that's good. So eclampsia and don't forget those other things that can cause. A presentation that may be similar to what you might think is a seizure from a [00:13:00] eclampsia.

Matt: Yes. 

Erik: Don't forget those other causes. Even hypoglycemia is something we should, 

Matt: yes, please always check your blood sugar. Yeah. 

Erik: Now, one of the scariest pre or antepartum or a. Pre, what did you call it? 

Matt: Before, during and after? 

Erik: Before the before Emergencies, uh, is an ectopic pregnancy. 

Matt: Mm. 

Erik: So this one's a little tricky because the, the pregnant, the, the patient may not know she's pregnant.

Right? Yes. That's usually how these will present. 

Matt: Yes. 

Erik: Yeah. I did miss my period. It is a little late 

Matt: for the last nine months, 

Erik: so you're gonna have that pain. 

Matt: Yeah. 

Erik: Uh, it doesn't have to be one side or the other, but, um, um, I guess maybe we should walk back and do this a little more sequentially, Matt. Okay.

What is, what is Ectopic pregnancy. 

Matt: Yeah. It's when the, the egg gets fertilized anywhere other than the, uh, uterus. 

Erik: I like it that you said it that way. 

Matt: Well, why, how is I supposed to say it? 

Erik: Well, 'cause you can act No. 'cause a lot of people will say it's, it's a pregnancy in the fallopian tube. 

Matt: Oh, okay.

Erik: Uh, but that's, that's usually what it is. 

Matt: Yes. Yeah. That's, yes. [00:14:00] In the, but it can be anywhere outside of the uterus. That is an ectopic pregnancy. It doesn't have to be the fallopian tube. 

Erik: You can literally have a baby, I mean, outside of the fallopian tube, outside of the uterus, in the abdominal cavity, potentially.

So 

Matt: rare. 

Erik: It's rare. Very rare. 

Matt: But, and typically an ectopic pregnancy is in the, uh, fallopian tubes. That's where it occurs. 

Erik: And that's the most dangerous place to have it. Yes. 'cause of that. That fallopian, um, artery there. Yes. Um, and you get a pregnancy that develops in that confined space, you rupture that artery, you can bleed.

Matt: Lots of bleeding. 

Erik: Yeah. Lots of bleeding. And, uh, that's what makes an ectopic pregnancy dangerous. And so in the ER, and I think in the pre-hospital environment, any woman complaining of abdominal pain of reproductive age sure. Is pregnant until proven otherwise we have to have that perspective. 

Matt: Yep. Yeah.

When I would, uh, when I was working as a nurse, as pre-op, post-op, you know, we do our nursing assessments and all that stuff beforehand. If you have not had a hysterectomy or you're not like 90 years old, you are getting a pregnancy [00:15:00] test every time. Yeah. Before you go into surgery. 

Erik: Yeah. 

Matt: I don't, if you're a 50-year-old female and you come in and you have not had a complete hysterectomy, you know.

You're getting a pregnancy test. Correct. Just 'cause we're gonna make double, triple Sure that you are not pregnant. 

Erik: I had a patient once that was, uh, was talking to this gentleman and was going through surgical history with him and, uh, he was actually, uh, he, it was not a man. Yeah, it was a woman, uh, beard with obviously hormone replacement therapy and all that stuff.

Did not look like a woman at all, but had the woman parts. 

Matt: Yeah. 

Erik: And uh, it's important to know those things. Uh, because 

Matt: it's very important from a medical perspective, 

Erik: absolutely 

Matt: to hold.

Erik: Cause those ovaries can twist. Yes. And this, the abdominal pain could be from the torsion. Torsion. So don't forget to, to really, really ask a detailed question.

And especially if. Today is that, uh, hormone 

Matt: an ovarian torsion would be a little bit different than a testicular torsion. It's, it'd be important to know the difference between the two. Yes. 

Erik: But in this day and age though, too, there's, there's more of the hormone replacement stuff [00:16:00] happening Yes. Both ways, right?

Yes. Yes. So getting a good history, um, is crucial, I think. Uh, but, but with ectopic pregnancies, um, the danger here is hemorrhage. 

Matt: Yes. Yes. And this usually happens in the first trimester, correct? 

Erik: Yep. First trimester. 

Matt: Yeah. So keep that in mind. But like you said, they, they may not know they're even pregnant and then all of a sudden they're calling you for abdominal pain, which is a call we get all the time.

Erik: That's right. 

Matt: How often do we have in our differential diagnosis? Oh, it's a 25-year-old abdominal pain. Oh gosh. Another poo poo pain call. Yeah. You know, like, oh, hang on, this could be something else here. 

Erik: Some of the sickest patients I've had have been ectopic pregnancies. Yeah. I've shared some stories with you, with just the, the, uh, the blood in the belly.

Yep. Liter of blood in the belly after just, just a slow bleed over time. Yes. And that, that that blood in the belly is extremely painful. Painful. 

Matt: Yep. 

Erik: So the, that abdominal exam is not a benign thing. 

Matt: No. 

Erik: You cannot send these people or let these people stay home. I mean, I guess legally you'd have to on a refusal [00:17:00] if they're A&O four GCS 15. 

Matt: And you better explain the risks that, hey, listen. 

Erik: That's right. 

Matt: You could be experiencing a life threatening emergency. 

Erik: Yep. 

Matt: You could be bleeding into your abdominal, into your stomach. Yeah. You don't have to get all technical. 

Erik: Yeah. 

Matt: You could be bleeding significantly into your stomach and you could die very quickly.

Erik: That's right. That is actually the key of the refusal, is making sure they understand those risks and benefits. 

Matt: And, you know, I, I get into this discussion, I'll say sometimes with, uh, with guys about. Well, they, they just don't want to go. And it's like, did you really try? Did you really try to get, really try?

Did you really explain to 'em? Because I'll tell you what, I've been doing this over 20 years. I have never one time had somebody that I was really concerned with. Like, I mean, yeah, I've gone, okay, yeah, they failed. They're fine. There's nothing here. They, yeah, I get it. You don't wanna go to the hospital. I get it.

Right? But then there's sometimes where you're like, oof. 

Erik: Mm-hmm. 

Matt: Yeah. There's something's going on, you're whatever. 

Erik: Yeah. 

Matt: I have never one time had somebody where I sat down and had a heart to heart with, I listen. This is what I'm saying. A hundred percent honesty. This is what I'm seeing [00:18:00] on your EKG. This is what I'm seeing with your physical exam.

This is what I think's going on with you. I'm telling you, you really need to come with me to the hospital, please. I've never had somebody be like, Nope, not doing it. When you tell 'em like you could die, you could be bleeding in your stomach and you could die. 

Erik: Yeah. 

Matt: I've never had, nah, I'm good. I'll just stay home.

Now. I'm not saying it doesn't happen. 

Erik: Yeah. 

Matt: I'm saying that a lot of times. Do we really like convince our patients and, and communicate that to our patients. And if you do and they refuse, put that in your narrative. 

Erik: Yep. Quote them. 

Matt: Sorry, we're getting off. 

Quote them. Yes. In quotes in your narrative. 

Erik: Most common med control call I get are refusals.

Matt: Yeah. 

Erik: And, uh, they. Oftentimes it is. It's like this EKG looks like it could be a STEMI. And they refuse. Yep. And they cannot. And I can talk till I turn blue and it won't change their mind. But if they are A&O four GCs 15, they can refuse and they understand and communicate the risks and benefits like we've talked about in our lectures.

They have the legal right, the autonomy to be able to make a decision, even if it seems medically unreasonable, certain situations and exceptions we're not gonna get into today. 

Matt: Right, 

Erik: right, 

Matt: right. [00:19:00] Yeah. Interesting question for you. 

Erik: Yeah. 

Matt: You go on a pregnant female? No, she knows she's 

Erik: pregnant. 

Matt: Okay. Okay.

And, uh, she is in 

Erik: how, how many weeks? 

Matt: Let's say she's 38 weeks pregnant and she has had 

Erik: non ectopic pregnancy, 

Matt: non ectopic. Nope, she's, but this is more of a legal question. 

Erik: Oh, legal. Go ahead. 

Matt: Yeah. Uh, tied into pregnancy. Uh, she wants to go to the hospital. She's having contractions. Mm-hmm. Which she believes are contractions.

They're several minutes apart, so nothing urgent. Mm-hmm. But she's having contractions. She wants to go to the hospital, but she's refusing to go to the hospital that you would like to transport her to? She wants to go to a hospital an hour away 'cause that's where her OB is. 

How do you handle that as a paramedic?

Erik: An hour away. 

Matt: Let's say an hour away. 

Erik: Yeah. I know. I, I, we cannot, 

Matt: she says, if you do not take me to my hospital with my doctor, I am not going 

Erik: with, well, what's her complaint? I mean, 

Matt: abdominal pain and having contraction. She thinks she's about to give birth. 

Erik: Okay. So we have an imminent delivery. 

Matt: Yes. 

Erik: How many pregnancies has she had?

Matt: Let's say it's her second. 

Erik: Second one. [00:20:00] Um, um, an hour away. Well, 

Matt: 30 minutes away. An hour away, 

Erik: that's gonna put her at risk. They'll put baby at risk. I think I would, um, I would get her to the closest facility 

Matt: she's refusing. She's like, I will not go with you if you take me 

Erik: to this hospital. 

You have to be an advocate for baby, not just mom.

Matt: Okay. 

Erik: And, um, but it's, it's, the maternal rights are different in different states. Um, and if there's literally only one hospital. Here or another one an hour away. 

Matt: Well, that's just where she wants to go because that's where her OB is there. There's numerous other options, but she wants to go there because that's where she's had all of her prenatal care.

And 

Erik: because see, I'm looking at our community now and I've taken a unit outta service for, for two or plus hours to go drive out there. I think that's something else. We have to be a good steward of our resources. Yep. We're not a transport service to, 

Matt: but right now, now she's your patient. She's your emergency.

Erik: [00:21:00] Yeah, 

Matt: which is what we teach our paramedics that. Don't worry about the next call. You're on this call focused on this one. 

Erik: If, if she's having an if, if she's really gonna have that baby like imminently, then I would not transport her. I would, I would, I would let her refuse. I would. 

Matt: She said, I'll just drive myself or have my mom drive me to where I want to go.

I don't want to go with you. If you're gonna take me over here, I'm not going, 

Erik: yeah. 

Matt: This was a mega code question that Uhhuh I've had direct me. Yeah. Which I told them, I'm like, this is not a fair question for a new pet paramedic to ask. 

Erik: Yeah. 

Matt: But in my mind, what I would, 

Erik: this is a reasonable call I could get is a 

Matt: hundred percent 

Erik: med control.

Matt: So this is what I told our paramedics to do, and this is what the medical director and I talked about is within your documentation you have a refusal paperwork. It's not just a refusal of transport. You also have a refusal of destination refusal assessment, uhhuh. So I will tell my paramedics. Before I leave.

I understand. Explain the risks to her. 

Erik: Yep. 

Matt: Okay. You understand the, you know, the risks of being taken here. Yep, yep, yep. Okay. Before I leave this house, you are going to sign that you were [00:22:00] refusing to allow me to take you to the the destination that I recommend, 

Erik: the appropriate facility 

Matt: and you wanna go here, the appropriate facility, she signs that obviously if nothing happens in route, we're covered.

Erik: Yeah. 

Matt: If something were to happen in route, we're immediately diverting to the closest facility, Uhhuh. Right. But now I'm having her sign that before I leave the house. So if something bad does happen, I am covered. You know, legally I am covered that, hey, I tried to do the right thing. I called in control. I checked off refusal of recommended destination.

She signs the paperwork. 

Erik: So this, I'm assuming then that, see, I, I would, if I've got the med control call from you mm-hmm. And I'm talking to her on the phone. Mm-hmm. I am going to, till I'm blue in the face, persuade her and to go to the closest facilities. 

Matt: This, this scenario was, she was adamantly refusing.

Erik: Absolutely refused. 

Matt: To go with you. She's like, I'll just have my mom take me where I want to go. And now you're wasting all this time on scene where you could have been around. Yeah. So it's like, you know, she needs to be transported by ambulance. That's her safest [00:23:00] bet. 

Erik: Yeah. 

Matt: Is that if something were to happen en route, you're there to help her.

Um, but you also have to legally be covered. Right. So like I said, yeah. Recommended a destination, have her sign. I refuse it. 

Erik: That's definitely a reasonable option. 

Matt: And then you document the snot out of that bef, you know? Mm-hmm. After the call. And like I said, if something were to happen in route, you immediately divert to the closest.

Erik: You have to consider the context of your, your whole healthcare delivery system too. 

Matt: For sure. 

Erik: I mean, if you're the only ambulance in your community, 

Matt: there's a lot of things to consider. Yeah. A lot of factors. 

Erik: You, um. Yeah, it's, it's interesting. 

Matt: But I mean, how is that any different than what if she was allowing you to go and the closest hospital's an hour away?

Erik: Yeah. 

Matt: Then you're going, 

Erik: yeah. 

Matt: You know, so there's a lot of fact, but just, it was an interesting question that, like I said, I, he used to give this. This case that brand new paramedics do in their mega codes. And I'm like, that's not a fair case to give to a brand new baby paramedic. 

Erik: It's good to see the thought processes though, for people maintaining Yes.

Patient autonomy. 

Matt: Yes. 

Erik: Considering your [00:24:00] resources. Considering your, 

Matt: yeah, 

Erik: yeah. You know, 

Matt: all the different factors. Yeah. Yeah. That come into play all. So egg topic, we talked about that. Life threatening. 

Erik: Life threatening and, and something you really can't fix. 

Matt: Yeah. Pre-hospital leave. 

Erik: No. No. And you won't, you know?

Now we do have ultrasound. Uh, now, uh, you can look for it of our agencies. I suppose you can, but again, you can't fix it. No. You gotta get 'em to the place where they can fix it. That's right. And this is something any ER doctor is trained and ready to, to, and handle. To handle. Yeah. So, um, now if there are. In, you know, hemorrhagic shock and their pale and diaphoretic and altered 

Matt: all the signs of hemorrhagic shock 

Erik: with all of this tenderness, distended abdomen.

Uh, you've gotta, you gotta go to the closest facility. 

Matt: Yes. 

Erik: Um, 

Matt: closest facility with blood. 

Erik: Yes. And a surgeon. Yeah. You know, they gotta get this thing out and fixed, so that's good. 

Matt: So pre-hospital management, oxygen, IV, uh, maybe some TXA if that's in your op, in your protocols. Maybe some [00:25:00] pain management.

Erik: Mm-hmm. 

Matt: Uh, 'cause these are pretty painful. 

Erik: Yeah. A lot of the opiates can really screw you over. I was 

Matt: gonna say, you gotta be managing that Ketamine, 

Erik: you know, ketamine might be good. 

Matt: Yep. Better option. But, 

Erik: but you gotta get 'em to a surgeon. You gotta get that ectopic pregnancy out. 'cause like you said earlier, it's, it's, it's a pregnancy that's developing where it shouldn't be.

Right. And then, um, that will be the ultimate fix. 

Matt: Yes. Right. 

Erik: Um, now there's some other antepartum emergencies outside of this version of hemorrhage, but the other ones we're gonna talk about here are also hemorrhage emergencies. Mm-hmm. With, with an ectopic pregnancy, you're, you're not gonna be having the vaginal bleeding.

Right. 'cause you're bleeding, you know, intra abdominally. 

Matt: Right. 

Erik: But with abruption and with previa, 

Matt: yes. 

Erik: Uh, these are associated with vaginal bleeding. Now, abrupt, you placenta or placental abruption. Yeah. Is a, is a painful vaginal bleeding. Whereas placenta previa is a painless 

Matt: Yes. 

Erik: Uh, vaginal bleeding.

Right. Both of them equally. Terrible. Both. I 

Matt: just think abruption is pain. Previa is [00:26:00] no pain. 

Erik: No pain. 

Matt: Yeah. Is the good way to An abruption Sounds so dramatic though. Abruption. 

Erik: Yes. Eruption. Like a volcano of blood. 

Matt: Yes. Yes. Which it can be. 

Erik: It really is. Yeah. Yeah. I've, I mean, we've had a number over the course of my career, a number of different times of vaginal bleeding causing a, a massive transfusion protocol.

Mm-hmm. I mean, it's significant. I mean, woman, you know, syncopal event from massive hemorrhage. 

Matt: Yeah. 

Erik: That's not, that's not, uh, benign. It's interesting the risk factor for these both, uh, cocaine. And it's something worth, you know, you hear a woman who's got vaginal bleeding and you're just in conversation.

You go through your normal history while you're transporting, right? Um, and she's, yeah, I, I do use cocaine, right? That big red flag for these things, it really wreaks havoc with the placenta 

Matt: smoking too, right? 

Erik: Smoking 

Matt: another big risk. 

Erik: And older pregnancies too. Advanced age. Uh, 35 is the number. 

Matt: Yeah. 

Erik: Uh, pregnancy is over 30.

Matt: We're [00:27:00] not calling ladies over 35 old. 

Erik: No, we are not. 

Matt: Just to clarify. 

Erik: Absolutely not. 

Matt: No, we are just saying that there's some risks associated with having a pregnancy over the age of 35. 

Erik: If you're a woman listening. Whatever age you are, you're beautiful. 

Matt: Yeah, that's exactly right. Let's move on. Before we get ourselves in, 

Erik: we're in trouble.

There's this no nice way or good way to ask a woman, like, if you think she's pregnant, 

Matt: you just don't ask. Oh, I thought you were gonna say how old they are. I'm like, you just don't ask, ask. 

Erik: Well that too, right? 

Matt: Yeah. And you do not assume that they're pregnant because even if they are, they're gonna turn around and go, I'm not pregnant.

You never had them mess with you. 

Erik: Oh no. I, I, I, 

Matt: you just think she maybe drinks a lot or something? 

Erik: Dear friend who did that, the unthinkable asked when she was due and she was just not pregnant at all. 

Matt: Oh, 

Erik: and oh, how do you recover from that? 

Matt: You don't, no, you just go bury your head in the sand 

Erik: and if, and if you.

Don't ask about the pregnancy, 

Matt: then you're con no Uhuh. The risk. The risk [00:28:00] reward benefit is not there. 

Erik: Just don't say anything. 

Matt: Just don't say anything until somebody else confirms it and they'll be like, oh, that's great. I didn't know. You look amazing. You never 

Erik: really suits. You just don't even try. 

Matt: No, the risk for benefit is not there because the offensiveness will be 10 times worse than you not recognizing or knowing that she was pregnant.

Yeah, don't do that. 

Erik: Reminds me of that, uh, Michigan State story. I've told you before in the elevator. 

Matt: Oh yeah. 

Erik: There's just certain things you just, you can't get them back. You just 

Matt: toothpaste out of the tube, man. It's out there now 

Erik: just, it's just, there's nowhere to hide in an elevator. Oh my gosh. 

Matt: Especially.

Yeah. 

Erik: Anyway, that's funny. So now we've gone to the antepartum. Before birth. Now we're in birth now, right? Yes. Is that what you said? During, 

Matt: before, during and after. 

Erik: During. During birth? Yes. Yeah, during birth. I love that this is the intrapartum emergency. Yes. So now we're given, uh, we're, we're delivering baby.

Matt: Mm-hmm. 

Erik: So let's walk through the process of delivering a baby. 

Matt: Mm-hmm. [00:29:00]

Erik: So. Um, you know, hand on the head. 

Matt: Mm-hmm. 

Erik: A little bit of counter pressure. 

Matt: Right. 

Erik: Baby is usually facing down towards, 

Matt: first off, I think we should say this, pre preface it with this. 

Erik: Yeah. 

Matt: Is that, again, like we said in unit one, women have been having babies for thousands of years.

It's a natural process. 

Erik: I'm glad you said this. 

Matt: Mom is going to be delivering the baby, right? 

Erik: Yes. 

Matt: You are hopefully just gonna be like facilitating it. Mm-hmm. Right? Making sure everything goes. But mom's doing all the work. 

Erik: Yeah. 

Matt: Right. These are just things that as the provider you can do to help facilitate the delivery.

Erik: Correct. 

Matt: Right. You're not, you know, mom's pushing. Encourage, mom, stay calm. If you're in this situation, I, you're, I know you're gonna be scared. Especially if it's the first time you've ever, you know, you're gonna be nervous, you're gonna be scared. Stay calm. Yeah. Because you want mom calm. 

Erik: Yeah. 

Matt: So don't be freaking out.

Act like you've done this a million times. Be a professional and then follow these steps. But remember that. This is a natural thing. If mom's full term, everything's probably gonna be fine. 

Erik: Yep. And then if you know what's going to happen and what's typically occurring, you can, and you're ready for [00:30:00] it can help to facilitate it.

Yes. And you kind guide things. Yes. Knowing that as we'll get through this. 

Matt: Yes. 

Erik: We'll know where to hold and what direction to, to guide baby up and down. 

Matt: Yes. So 

Erik: rotations, you know, to expect. 

Matt: Yes. 

Erik: And then, then 

Matt: what's normal? What's not normal. 

Erik: Exactly. Yes. And then you'll also be able to identify certain emergencies you might be able to fix.

Yes. You know, one of the reasons why our, um. Uh, I guess life expectancy has gone up mm-hmm. Considerably in the last century is from maternal care. A large percentage of women and babies died, which really took the average life expectancy down. Yeah, sure. It's one of the major reasons it's come up. 

Matt: Yeah.

Erik: And that was really one of the big reasons why. In the Civil War era life, the, the average life expectancy was about 44 years. 

Matt: Mm-hmm. 

Erik: A lot of people would live to be over 44, of course. Right. But the average was brought down by the pretty significant maternal mortality rate. 

Matt: Yes. 

Erik: Now that we, 

Matt: that musket shots decreased the life [00:31:00] expectancy.

Erik: He's really interesting in prenatal care. Right. 

Matt: Here we go squirrel. 

Erik: Well it's related to this is using gloves. Which was actually a relatively recent discovery, which sounds ridiculous. I know. But use gloves. 

Matt: Imagine what we'll be doing in a hundred years from now. We'll be going those idiots back there.

Erik: I know. And then using sterile scissors to cut the cord. 

Matt: Mm-hmm. Yeah. Don't take out your raptor shears. Don't do that. 

Erik: And then recognizing some of these emergencies as being an emergency to recognize it, to know, wow. If we want to have baby live here, we need to get a C-section. We need to get some surgical help.

Matt: Yes. 

Erik: That hasn't always been available. Mm-hmm. So we really are in a unique position where we can identify some of the problems. Yeah. So let's walk through the delivery process. So now we got, 

Matt: so mom's pushing, you're put, putting a little back pressure. 

Erik: Yep. And, uh, just 

Matt: so, especially mom's been pregnant five times.

Erik: Well, let's back up a second actually and do this a little different. I think I would've taught the course differently if we would do it again. 

Matt: Okay. 

Erik: Chronologically, what problem could occur before you see the head? [00:32:00] Mm-hmm. Well, what if you see a butt? 

Matt: Yes. Right, right, 

Erik: right. What if you see a foot? 

Matt: Yeah. 

Erik: If you see a chord, right?

Matt: Yeah. Anything but a head. 

Erik: Yes. 

Matt: Is badness. 

Erik: So we'll talk about, we actually talked about this in the lecture. Mm-hmm. But I think this might be better time to talk about it. 

Matt: Okay. '

Erik: cause you want to elevate those presenting parts. 

Matt: Yes. 

Erik: I can't remember depression or something like that. I can't remember. Yeah. 

Matt: I don't remember.

Erik: Whatever. But push, elevate the presenting part. And so women can get into that position, uh uh, where they're basically up on their knees, butt up in the air. Mm-hmm. And baby now gravity. The weakest force known to man can help pull baby down and put pressure off that presenting part. Now, hopefully, is

Matt: this the, 

Erik: I'm sorry, that was for the nuchal cord?

Matt: Yeah. 

Erik: If it was a cord. 

Matt: Yes. Yeah, you're right. 

Erik: Sorry. Sorry. 

Matt: Which one's McRoberts. 

Erik: Uh, the McRoberts is the one's if you've got the, uh, shoulder dystocia. 

Matt: That's right. 

Erik: Yeah. 

Matt: We'll get to that. 

Erik: We'll get to that. Yeah. But anyway, so. You could have a presenting part is my point. Yes, 

Matt: yes. 

Erik: And you wanna elevate the presenting part and you can, by getting mom up in that position, you can [00:33:00]alleviate 

Matt: some And this is on her back?

Erik: This is on her back, 

Matt: yes. Her, yes. Knees up to her chest. 

Erik: Well that's, that's McRobert's. 

Matt: That's right, that's right. 

Erik: Sorry, the, 

Matt: I'm getting 'em confused. 

Erik: No, well they are confusing. 

Matt: It's all tied together. Together in my head. 

Erik: So, so 

Matt: that's right. That's the, yeah. 

Erik: So the problem right now is we have something coming out of the vaginal canal that shouldn't be coming out.

Matt: Right. Right. 

Erik: Whether it's a head with a cord or a cord. Or a foot. Or a butt. 

Matt: Yeah. Yep. 

Erik: If you're in the breach position, you do not want deliver that thing. You want to, you want to coach mom on breathing, don't push. Yep. Contractions are gonna come. You can't stop that. Yeah. But, um, but then you want to get mom in that position.

Where she's got her butt up in the air. Mm-hmm. And then, uh, decreasing some of the pressure on that presenting part. 

Matt: Mm-hmm. 

Erik: And that, that, especially with a nuchal cord, right? 

Matt: Mm-hmm. 

Erik: Um, but anyway, yeah. So we got, uh, let's say there's no presenting, well, there's a head that's crowning the, 

Matt: the, the, what we want see 

Erik: what we wanna see.

Typically, babies facing posterior at least. Right. It's the looking towards [00:34:00] mom's 

Matt: Facing down. 

Erik: Facing down. Yeah. And counter gentle counter pressure on the head. Mm-hmm. And, uh, and during the contractions, you see some progress being made. Now, one thing we'll learn later and we can, I guess mention it now, is that if, if during contractions, the head is coming out, and then between contractions, the head pops back in and disappears, that's turtling or whatever.

Mm-hmm. That could be shoulder dystocia. Mm-hmm. And that might require you then to do that, the McRoberts maneuver, to try to get that anterior shoulder that can get stuck under the pubic bone. Mm-hmm. Mm-hmm. But let's just say like, no, like you said, most pregnancies. You know, just guiding baby. So head is emerging at some point.

Baby's gonna rotate now. Mm-hmm. And now gonna be facing one of mom's thighs one way or the other. And, and so we're gonna keep our hands on either side of the head 

Matt: just to support it. 

Erik: Yep. Just to support it. And then we're gonna guide it. Now, when you're initially guiding it, you want to guide [00:35:00] Posteriorly first.

Mm-hmm. So, as the head emerges, I'm gonna be gentle. Pressure posteriorly, 

Matt: which is gonna deliver the anterior shoulder. 

Erik: Exactly. And then once the anterior shoulder's clear, we want a little bit upward to get the posterior shoulder out. And at that point, 

Matt: baby's coming. 

Erik: Get ready. Baby's coming. 

Matt: Yeah. And a lot of fluid.

Erik: And a lot of fluid. 

Matt: So be ready. 

Erik: So why don't you take us through the, the last part of the procedure now. Um, baby is in your arms. Mm-hmm. We're gonna put it Skin to skin with mom on her belly. 

Matt: Well, first off, I'm gonna kind of stimulate baby, right? We're also, 

Erik: oh, sorry. 

Matt: Let's not, let's also not forget about delayed cord clamping.

Erik: We'll get there. Yes. So, yes. 

Matt: Well, we're, we're there, 

Erik: we're there 

Matt: baby's out. 

Erik: But, uh, but while we're waiting, while the cord, well, while we delay the cord clamping mm-hmm. Uh, we want to get baby on maternal skin as quick as possible. But you can't do that after you've stimulated, after you've 

Matt: done, but yeah, you can't lift baby up to mom.

Because then all the blood you get after 

Erik: Oh, true, true, true. Yes. 

Matt: Yeah, yeah, yeah. Yes. Just to be clear, I wanna make sure everybody understands. 

Erik: I see what you're saying. 

Matt: Baby has been delivered. Umbilical [00:36:00] cord is still attached. The placenta inside, mom. 

Erik: Yes. Right? Yes. Yes. 

Matt: We want that good nutrient rich blood from the placenta.

Erik: 30 to 60 seconds. 

Matt: Again, Uhhuh. Yes. Literally count it off. Set a timer for 60 seconds. Let that good nutrient, rich blood flow into baby, because if you pick baby up again, gravity, if, if baby is higher than the placenta. 

Erik: Yep. 

Matt: Now the blood is gonna rush out of baby and go into the placenta. We don't want that.

Erik: Correct. 

Matt: This can dramatically help you as the provider because it's better for your patient. Yes. 

Erik: So 

Matt: as, 

Erik: as soon as the cord is clamped, we can do all 

Matt: Yes. Just leave the baby down there for a minute. Right now, obviously if baby's coming out and having extreme issues and we need to handle that. 

Erik: Yeah. 

Matt: Then yes.

But. Normal birth, leave baby down there for about 60 seconds. Then clamp, cut the cord, and then 

Erik: I've been teaching 30 to 60 seconds. 

Matt: I know in the hospital, when I was going through nursing school, they literally had a timer. 

Erik: 60 seconds. 

Matt: For 60 seconds. Yep. They literally timed it the moment baby came out.

Hang on. I remember it was actually kind of funny. We had, I think I told this in the lecture, but it, we were watching a lady give birth. Mm-hmm. And it was this old [00:37:00] school OB, I mean, this is, this guy's probably been delivering babies for 30 years. 

Erik: Right. 

Matt: And that baby came out, you know, and he was just doing what he's done thousands upon.

Yeah. And he goes to pick the baby up and he's gonna clamp clamp cut. And the nurse is like, oh no, Dr. Axene, we need to remember delayed cord. Oh, that's right. And he sits there and he just held the baby and they, okay. 60 seconds. And they started a timer. So if you're doing it, 

Erik: I almost did the same thing.

Matt: Well, I mean, in the heat of the moment, you just. But I think if you're doing it 30 to 60 seconds mm-hmm. It's not nothing mandatory or magical, about 60 seconds. As long as you're not just immediately cutting it, that's the key. 

Erik: So, or clamping it. That. 

Matt: Or clamping. Yes. 

Erik: So when you clamp the cord, it's 10 centimes, 10 centimeters from the umbilical.

Uh. Uh, the umbilicus and then five centimeters from, from that. Mm-hmm. 

Matt: Cut and cut between, yeah. 

Erik: Yeah. 

Matt: Don't go clamp clamp. Yeah. 

Erik: Yeah. 

Matt: Common joke. Yeah. Yeah. And then stimulate baby. Yep. You know, you want to kind of I mm-hmm. Look at it like, piss baby off 

Erik: and dry, baby. 

Matt: You're not gonna make ba you're not gonna break baby.

Baby's bones are like rubber. Mm-hmm. You're not gonna break baby. 

Erik: And most of the time [00:38:00] everything's gonna go fine. That's right. Stimulate baby's crying. And then you, 

Matt: they're gonna be a little bit blue. You're not gonna have an APGAR score of 10 at one minute. That's not a thing. 

Erik: They never do that. 

Matt: They never do that.

And if you say that, everybody's gonna know you're stupid. So don't say that. Well, we literally just literally had a, a, a call with some midwives where mm-hmm. They had documented that the APGAR score was 10 and. And I'm like, that immediately just discredits you. It's like saying their heart rate's 70 and their blood pressure's going 20 over 80.

Like no, it wasn't, 

Erik: it's not quite as bad as a GCS of one 

Matt: Or zero. That was worse. Yeah. So yeah, they're at, but again, your your APGAR score, they're gonna come out, they're gonna be a little bit woo, usually in the extremities. That's one. 

Erik: We forgot a step. Something that we should do when we're delivering baby as the, as we were delivering as the head, as the baby rotated and the head emerges, you gotta sweep the neck just to make sure you don't have a nuchal cord. 

Matt: Oh. And wash. Like you can kind of wipe off mouth. But we don't suction mouth the nose anymore. Remember we don't do that anymore. 

Erik: That's right. Its not, not routine anymore. 

Matt: Yes, 

Erik: you [00:39:00] can do it 

Matt: if you see some meconium or some signs. 

Erik: No, not even with meconium.

Matt: Oh, okay. 

Erik: Yeah. Not even with meconium. I'm sorry. I, that's, that's a new thing. 

Matt: I, I was gonna say I, 

Erik: because we used to do that now follow your protocols, but 

Matt: Right, right, right. 

Erik: But not anymore, not routine 

Matt: we used to suction, automatically suction every time 

Erik: we did. I know. 

Matt: Yes. But then it switched, you know, you just wipe, but then I still thought if there was meconium you would wanna suction.

So they took 

Erik: last I read, not even with meconium. The only time we would suction. It's just not suctioned routinely anymore. Right. But if after baby's delivered there's any sort of respiratory issue or distress suction obviously right away. Yeah. But even with meconium, not routine suctioning, um, based on what I read.

Mm-hmm. Um, 

Matt: and it's a vagal thing, right? Wasn't it? The suctioning was gonna stim, 

Erik: you know, I don't know. This is a good question. I should do some more reading on that. I don't, uh, but yeah, not routine anymore. That's a good, good point. 

Matt: Yeah. 

Erik: So we've delivered baby now. Yeah. Now let's talk about some situations.

You may encounter the nuchal cord, obviously. Oh, yeah. Uh, you, you [00:40:00] don't, you usually, if you do see a nuchal cord, it's loose and you can gently, gently pull it around baby's head that then everything's fine and just continue with what we talked about. Right? But if it's tight and impeding delivery, you may need to cut it or continue to try to deliver, 

Matt: clamp it first.

Erik: And actually what they recommend is to try to deliver that anterior shoulder first. Um, but either, 

Matt: but you might not be able 

Erik: to, if 

Matt: not be able to, if it's that tight, it could be giving them back pressure like you talked about with the turtle. 

Erik: That's exactly right. So, uh, this could be a bad situation.

Yeah. And this is, uh, you know, scary deal. Unfortunately, it's the reality of pregnancy. The delivery process can be dangerous and, um, uh, hopefully you're almost to the facility at this point. But, 

Matt: and the good thing is these are kind of rare. This isn't, 

Erik: they're rare, 

Matt: super common. Where, 

Erik: but you can, you can cut that cord or attempt to cut that cord or, uh, you know, if, if you have to, um, uh, that, that's a tough situation.

Yeah. But usually if you do encounter a nuchal cord, it's gonna be something that you could [00:41:00] loosely pull around, 

Matt: pop it around. 

Erik: Now, in delivery too, is, uh, if that, we talked about the, a presenting part, like a, if you're in breech position, you're not gonna. You're gonna coach mom, like we talked about, just to breathe.

Don't push during contractions until they get to the facility. They're probably gonna need a, uh, a c-section. 

Matt: Yep. 

Erik: Um, uh, let's see, what else have we missed? Uh, no, I think that's, I think 

Matt: that's, yeah, that's all for antepartum, 

Erik: I think, 

Matt: or, uh, 

Erik: I think the antepartum stuff. Yeah, that's it. So, uh, the, the key there.

I think the other concern would be, uh, um. Yeah. With breach delivery is shoulder dystocia. We mentioned that. Mm-hmm. That's the turtling thing. Mm-hmm. That's the other major kind of problem that you could encounter. Uh, we had shoulder dystocia issues with my son. 

Matt: Mm-hmm. 

Erik: He had trouble, uh, in the birth canal with my wife.

Matt: Big, huge Axene shoulders 

Erik: and a big head and all that. Yeah. Uh, but we, um. Anyway. And, and, uh, McRoberts [00:42:00] is that maneuver we talked about where the knees, you know, up into the chest can help to 

Matt: little pressure on the pubis. 

Erik: Exactly. 

Matt: Pop that shoulder 

Erik: and then pop it through and then, and then you continue as we talked about.

Matt: Mm-hmm. 

Erik: So, alright, that's the, um, and that's the shoulder dystocia, which is kind of a unique thing. Mm-hmm. Um, and the last period, now the postpartum. Mm-hmm. Now we're baby's out. 

Matt: Baby's out. 

Erik: You've cut the cord, you clamp the cord. Baby's, uh, hopefully gonna be on around a little bit. Skin to skin with mom.

Matt: Yep. Yep. 

Erik: Um, but one of the big issues, which is very common is uterine atony 

Matt: Mm-hmm. 

Erik: Postpartum problem. Squishy uterus. Squishy uterus. Yeah. Yeah. So what do we do to, to fix that? What? Uh, 

Matt: massages the fundus. 

Erik: Yeah. And aggressively. 

Matt: Yes. Yes, you do. 

Erik: It's not a 

Matt: it's not a soft Yeah. Sound 

Erik: like you're petting the table, 

Matt: guys this is the one time where you Yeah. You want to be 

Erik: aggressive. 

Matt: Yeah, fairly aggressive. I also heard like, and if I remember correctly, if memory serves from nursing school six years ago, breastfeeding. Can [00:43:00] help, uh, mom with bleeding. She's having some postpartum hemorrhage. Correct? 

Erik: That's right. It stimulates oxytocin.

At least from the posterior pituitary. 

Matt: Yep. 

Erik: That's absolutely right. 

Matt: So if you've got an issue with mom bleeding, maybe if she gets baby feeding 

Erik: Yep. While you massage, 

Matt: while you're massaging Yeah. It could be a natural way, right? 

Erik: Yep. 

Matt: To help, uh, some bleeding control. 

Erik: Now in our, uh, at our department, we have Pitocin, uh, which is an analog of oxytocin, what the body makes.

Right. And we can give that to hasten the contraction of the uterus. Well, that's really what it is, right? It's contraction of the uterus that helps to decrease the postpartum bleeding. Postpartum, bleeding's pretty normal. 

Matt: Yeah, 

a little bit. 

Erik: Yeah. 

Matt: Yeah. 

Erik: Now, if you, part of the process too, is delivering the placenta.

Matt: Mm-hmm. 

Erik: And if you've got placenta in there, it's. You're gonna have trouble getting it to relax. You gotta get everything out, so. 

Matt: Yep, yep, yep. 

Erik: And that may require something from the OB doctor in the operating room to get 

Matt: Yep. To get 

Erik: remnants out if we need 

Matt: Yep, yep, yep. 

Erik: If we need to. But you won't be able to do that in the, 

Matt: but yeah, make sure that, you know, like [00:44:00] dudes out there that aren't paying attention, there's gonna be two things coming out, the baby and the placenta.

So after you've delivered the baby, baby, there's something else that's gonna come out after that, so be ready for it. 

Erik: And then the third thing, 

Matt: and it's important to tell the doctors if that hasn't come out. 

Erik: Yeah. 

Matt: It's when you show up at the er, like, Hey, the placenta hasn't come out yet. So 

Erik: that's good.

Matt: Yeah. 

Erik: But the bleeding, the third thing that's coming, all that blood Yes. Is really, uh, it can be life threatening. Yes. Postpartum hemorrhage is no joke. 

Matt: No. 

Erik: And it's something that we have to, just like we talked about before with placental abruption and previa and all those is, uh, recognizing the signs of hemorrhagic shock.

Yeah. It's kind of one of those, this is something we have to be good at. Mm-hmm. It's so many. Whether it's a shark bite, a motor vehicle accident, 

Matt: a shark bite should be pretty obvious, but 

Erik: that's true. But it's all the same pathophysiology. Yes. Yes. We're bleeding from somewhere. We have to stop the bleeding. 

Matt: Yes.

Erik: If you're bleeding in your belly, it's really hard to stop that. Yeah. You gotta have, gotta give surgeon surgery potentially. So, so, uh, with, with uterine atony, um, or postpartum hemorrhage. Mm-hmm. If you have [00:45:00] Pitocin, give it, otherwise massage, maybe have the mom breastfeed. Mm-hmm. Those things can all help to decrease the risk of uterine atony.

And even if that uterus feels really firm when you're palpating it, the lower half, which is under the pelvis, can be 

Matt: super spongy. 

Erik: Really spongy or boggy. I think I like to use boggy. 

Matt: Yeah's probably a better word. 

Erik: Spongy is good. Boggy. Spongy. But anyway, um, and you can have that postpartum hemorrhage.

Mm-hmm. Even though the, the uterus feels just keep massaging, keep going. 

Matt: Yeah. It's not gonna hurt anything to 

Erik: Yeah. 

Matt: Massage it. Yep. 

Erik: Yep. So that's, that's really important. The other major postpartum issue, which is the last one we'll talk about is neonatal resuscitation. 

Matt: Hmm. The worst one. 

Erik: And it's kind of like delivery most of the time when you, uh, have a delivery, baby's gonna be fine.

After you stimulate, they're gonna be crying. They turn pink. Yep. And they're breastfeeding and you. 

Matt: Everything's good. 

Erik: And then you arrive to the ER and everybody's singing Happy Birthday. 

Matt: Yes, that's right. But occasionally, 

Erik: yeah, and occasionally it's not, but you know, [00:46:00] it's really cool for us. Let's simplify this, Matt.

99% of the time when you do have an emergency, it's related to respiratory, it's related to those alveoli collapse because of a lack of surfactant that that decreases the surface tension so they can open up. Mm-hmm. So most of the time. So most of the time this isn't gonna happen. You stimulate baby cries and everything's fine.

Mm-hmm. Every now and then you're gonna see some respiratory issues and maybe a little bit of cyanosis, and it's, you're a little bit scared that stimulation's gonna be okay. 

Matt: Yes. 

Erik: But a little bit of positive pressure ventilation, non-invasive positive pressure ventilation if you need it. 

Matt: Yep. 

Erik: Is gonna open up those alveolar sacs and it's going to get baby back to where it needs to be.

Matt: Yeah. 

Erik: And most of the biggest risk factor for these postpartum neonatal emergencies is preterm. Mm-hmm. And we've talked about this in our lectures, but it's pretty simple actually. Yeah. It's all usually related to, [00:47:00] um, respiratory. 

Matt: Yeah. And we don't get endorsed by any companies, but when we find something that works, 

Erik: please talk about this.

Matt: Yeah. The neotees. Yeah. If you've never heard of a neotee, N-E-O-T-E-E. It is an amazing little tool for these exact kind of calls. You've got a neonate, you just delivered. They're having problems oxygenating the alveoli will open up, this amazing little tool. You can set your pip, your peep. You don't have to have a ventilator.

You hook it up to an oxygen bottle and then you can sit there, put your finger, put your, it's an amazing, positive pressure tool for these situations. So look into that. I mean, they're not expensive. It's a great tool to have in your toolbox. Yeah. Uh, very useful. And for this exact case right here. 

Erik: Yes.

Matt: But yeah, neonatal resuscitation, respiratory, you gotta start bagging. And then we have some criteria on heart rate. 

Erik: Yep. 

Matt: As far as. When we do what. 

Erik: Yeah. And the other thing I would mention too is that oxygen saturations are pretty wonky. 

Matt: Yeah. That's gonna take some time. Look at your baby if your baby's blue 

Erik: look exactly, 

Matt: yeah.

Then you, 

Erik: you're gonna get freaked out if you look at the [00:48:00] numbers. 

Matt: Yes. 

Erik: I'm talking sixties. Yes. I mean initially, right? Yes. Eventually after about 

Matt: it takes time. 

Erik: 10 minutes. Yeah. You're gonna be a, a pseudo normal. 

Matt: They're literally oxygenating for the first time ever. 

Erik: Yes. 

Matt: So give it a minute. Yeah. Yeah, 

Erik: that's right.

Matt: So look at their color. If they're really blue, you need to be oxygenating, you know, if they have some extremities, that's kind of normal, but still, 

Erik: yeah, 

Matt: if they look like they're struggling, and then look at the heart rate. 

Erik: Yeah. 

Matt: Then we need to be doing more 

Erik: now. And again, like we talked about, 99% of deliveries are gonna be fine.

Mm-hmm. And of that minority of times, 99% of those are gonna be respiratory. 

Matt: Right? So we're talking a very small, small percentage. 

Erik: It's very small beyond that, where it could be cardiac. And actually that's, uh, you wanna consider even a, I mean a neonatal, you know, cardiac monitoring. Maybe you need EKG, but this is I mean, depending upon how long your transport times are, these are the rare, rare things 

Matt: I, and I would say probably most, unless we got critical care flight folks that have equipment like that, [00:49:00]most of your EMS fire department agencies aren't gonna have that. 

Erik: And, and what these are usually related to is cardiac anomalies.

Right. Things that you are, I mean. 

Matt: There's no way you're 

Erik: gonna 99% of the time when it doesn't go right, it's respiratory and you can do certain things to help with that. That's right. Even if it's intubation. 

Matt: That's right. 

Erik: Right. Ne neonatal intubation, like we practice together on that tiny little baby, remember?

Um, but when you're getting to there, there's a subset of patients with congenital cardiac anomalies. Right. Um, and these, some of these are, um, all they need is a medication. To keep that ductus arteriosus open and that, um, that, um, 

Matt: I always think of when I took critical care, they said it's like Harry Potter, ductus arteriosus.

Erik: Yeah. Okay. Yeah. 

Matt: Anyway. 

Erik: Well that's a key though. And I think, uh, the vast majority of these emergencies that are freaking you out, um, are respiratory. 

Matt: Mm-hmm. 

Erik: And we have a lot that we can do otherwise, 

Matt: UVCs, you know, if you have the ability to [00:50:00] UVCs, if you need to give meds and stuff, you can do that. 

Erik: Oh yeah, that's right.

Yeah. UVC, we didn't talk about that. 

Matt: Yeah, you got, uh, two, two arteries, one vein, uhhuh. So the big, it looks like a smiley face. The big hole, what you want to hate for. Mm-hmm. Uh, if you're doing a UVC catheterization, so. It's not really difficult. 

Erik: So let's, uh, I guess summarize, we've, we've had two hours of content.

Mm-hmm. The first hour we hit, kind of general considerations of emergencies a pregnant woman might be in and things that we need to think about with her anatomy and physiology. 

Matt: Yep. Yep. Vital sign ranges, common problems, 

Erik: trauma and sepsis. Yep. Things that, you know, require a different mindset when you're treating them.

Right. 

Matt: Yeah. 

Erik: So that was good. And then the second hour we got into some of the birth related. Before, during, and birth? Before birth, during and after birth. Yeah. Um, uh, the one thing I would like to, to re just to reinforce 

Matt: mm-hmm. 

Erik: Uh, would be before pregnancy. Remember that in an ectopic pregnancy, any woman of reproductive age, like we said, who's got abdominal pain, you've gotta think about a possible [00:51:00] ectopic pregnancy.

Matt: That's your most serious concern. 

Erik: Yeah. Yeah. And then in the postpartum period, the thing that I would remind you of is that that woman's body is still in that pregnancy physiology. Mm-hmm. And there are some emergencies, like preeclampsia that can occur six weeks after the baby's been delivered. That's right.

So you've gotta still think about some of these pregnancy related emergencies. Mm-hmm. So those would be the two things I would say. Early on, mom doesn't even know she's pregnant, but she's got an ectopic. Mm-hmm. Right. And then later on postpartum, you can still have pregnancy emergencies. That's right. So it's something to think about.

Matt: Yep. Yep. Yeah. Again, these are calls that, uh, you know, if you listen to podcasts, do your studying because they're, you know, low frequency. 

Erik: Yeah. 

Matt: Um, you'll be prepared to handle kind of any situation that comes along. But again, the, the comforting thing is that very small majority of these calls uh, are gonna be something seriously wrong with mom or baby.

We have to be ready for them, right? Yeah. But most of the time, if you're going on a run of the mill LB [00:52:00] call and mom's at, you know, almost full, just everything's gonna be fine. 

Erik: Yep. 

Matt: Calm down, relax. 

Erik: Yep. 

Matt: And. 

Erik: I think that's a good way to, what you just said is a great way to approach it. It's like, you know, this is probably gonna be fine.

Matt: Yeah. 

Erik: But we know 

Matt: Yeah. 

Erik: That we obviously hope for the best. Yes. But we've prepared for the worst. That's right. 

Matt: That's right. We know what to do if something's wrong with mom, we know what to do if something's wrong with baby, we know what to do. 

Erik: Yeah. 

Matt: Um, so yeah, it's, it's all about preparation. 

Erik: Awesome. Yeah.

Preparation and practice. And then hopefully with these assessment questions, if you're doing this for CE, you'll take them and 

Matt: yeah, take your assessment questions. If not, uh, we'll see you on the next one. 

Erik: Be safe out there.

Narrator: Thank you for listening to EMS, the Erik and Matt Show.