# Obstetrics



## yay4stress (Mar 19, 2008)

I can clearly remember the instructing medic telling us in the obstetrics portion of class how glad he was that he's never had to deliver a baby.  Every Medic I've ever run with has made it very clear that since obstetrics is classified as BLS in PA, that if we get an obstetrics call, I will be in back delivering the kid.

Well, it had been a long while, but no obstetrics calls.  I guess people want to have their kids in a hospital, not a moving truck.

A few days ago though, we got paged lights and sirens to an unknown location for a possible childbirth.  They give us the aproximate location, and my ambulance, along with 3 others from different services start cruising the area to find this car with the delivering woman.  Well, dispatch gets back in touch with the husband, and they're now about half a mile from teh previous location.

This guy never pulled over!  We drive for 10 minutes tryign to find them, and even though he called 911 for assisstance, HE NEVER PULLED OVER HIS CAR!  I didn't have to deliver a baby though, cuz the dumb-arse made it out of our service area and into the hospital parking lot before anyone could find him.  if he had stayed put, we would have been there sooner than it took for him to make it to the hospital.

Who calls 911 and then doesn't wait for help?  Hero dad....  WE all got a good laugh about it though, and my hands didn't have to get sticky.


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## EMTgurl911 (Mar 20, 2008)

What an Idiot, its like saying then why the hell did you call us for if you drove to the hospital anyways...:wacko:


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## yay4stress (Mar 20, 2008)

Exactly!  His wife was probably none to happy with him what with the speeding and lack of comfortable seeting arrangement in what was called in as a 2 door sedan.


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## yay4stress (Mar 20, 2008)

And that is my only small bit of comfort in a 20 minute waste of time that I had to do a trip sheet on anyway.


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## reaper (Mar 20, 2008)

You have to write a report, with no pt found? That sucks.


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## Ridryder911 (Mar 20, 2008)

Wow! What a general assumption! O.B. calls are basic ? Obviously your state, and even instructor have little to no experience in obstetrics and gynecology. 

The reason many do not have experience delivering a kid is because about 80% of mothers have prenatal care. They have been told approximate time of delivery, problems have been taken care of prior to delivery or placed in a hospital after the first sign of phase I labor. 

I guess your instructor never heard or seen the undiagnosed "high risks".. You know the ones that call EMS? The ones without prenatal care. Such as gestational diabetics, preeclampsia, preterm, abruptio placenta, wrong fetal placement such as foot/limb presentation, breech? 

This is not even considering other high risks such as the mother that have taken meth/crank (which is very common to induce labor in prostitutes), smokers,  HTN mothers (yes, CVA is common in deliveries), what about multi births such as twins. 

All of these are very common in O.B. calls in EMS. Remember, those that usually have taken care of themselves, that have been worked up, deliver in a nice sterile environment.. not usually in the back of an EMS unit.  

Now considering after delivery you now have two patients. Preterm infants that are common on respiratory arrests, mother may have complications as well.  

I suggest your state take their head out of the sand and re-think things. As a Basic I would definitely be scared sh*tless! Some of the worst calls I have been on is active delivery. Even as an RN & Paramedic with great experience of obstetrics, these are the calls I have the most concerned over. Remember, the action of the delivery is ? The infant. Is BLS okay to deliver care to a premi or infant that is already addicted to narcotics?


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## JPINFV (Mar 20, 2008)

reaper said:


> You have to write a report, with no pt found? That sucks.


Why? It's not exactly that long of a narrative anyways and most of it can be filled out (regardless of if there's a patient or not) on the way to the call anyways (times, unit #, crew members, run number, etc).


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## EMTgurl911 (Mar 20, 2008)

Yeah well in my class they told us pregnancy were BLS calls too and ALS should only be needed in case the baby needs advanced care...


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## Topher38 (Mar 20, 2008)

reaper said:


> You have to write a report, with no pt found? That sucks.




In my state we have to write a report regardless, Refusals as well.


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## emtwacker710 (Mar 20, 2008)

Topher38 said:


> In my state we have to write a report regardless, Refusals as well.



yea we do the same thing here in our area, refusals we have to fill out a refusal form and have them sign in 3 million places then fill out the pt. info part of the PCR and thats about it..


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## Jon (Mar 20, 2008)

Around here, imminent delivery is ALS, while general "labor pains" are BLS, unless there are other complications. When I've heard of deliveries, ALS has always been involved, because there always seem to be complications in the field.

I've not had to deliver a child yet... but it will happen. Closest I ever came was working hospital security... On the weekend opposite mine, they had a woman deliver in the ED entranceway. I always joked about it with the nursing staff... becuase they knew me as an EMT before I started working security. I was all about pushing the paitent to L&D as fast as possible.... but it always seemed that I was playing EMT along with Security when someone with BIG problems came through the front door. ("hold pressure on this", "he's unconscious" etc).



As for tripsheets... if we respond, we do a tripsheet.


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## yay4stress (Mar 20, 2008)

WE have to write a report everytime we take the ambulence out for a call.  If it's cancelled, if the pt refuses, we always have to do a report.

and Obstetric calls are BLS here.  Talk about assumptions Rid.  Obstetrics aren't basic, but the skills for delivery are filed away under BLS skills.  So I'm an EMT-B, but I have to know how to deliver a baby.  If gestational diabetes is an issue, than yes, a medic (who also knows BLS I might add) will ride in back instead of an EMT if it becomes a problem.  For things like a prolapsed cord, EMT-Bs are trained to handle it.  Placenta Preva however, means we turn on the lights and sirens and get to a stabilizing facility, because not even a medic is going to do much good.

A good healthy dose of assumptions all around, eh Rid?


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## akflightmedic (Mar 20, 2008)

No, I do not think any false assumptions were made.

I have quite a few pre-hospital deliveries under my belt and not all of them ended with favorable outcomes.

Yes, women have been delivering since the dawn of man on their own with no medical intervention, but remember a lot used to die as well.

When you have a delivery call, you have to remember your patient load just doubled. You now have two patients. Actually you had two patients prior to delivery.

Very few basics know how to do a proper OB assessment. I can state this broad generalization because it also applies to paramedics. Some of the drivel you guys have stated in this thread as coming from other medics only reinforces that point.

Most have no clue where or how to asses FHTs (fetal heart tones), fetal positioning, nor would they even have the slightest clue about how to check or score cervical dilation. I am not advocating they should, as I consider this a more advanced skill that was necessary for me in my jobs, but I am just stating there is so much more to assess than just waiting for the baby to present.

As for OB being ALS or BLS, most pre-hospital deliveries will have some sort of ALS element involved. This is because as Rid stated, 80% or more have had prenatal care, have been to childbirth education, or know/expect the signs of delivery and go to a hospital well within the time limits.

The ones that go into active labor at home are typically your drug users, illegal residents (who have had no prenatal care), young mothers (no prenatal care), mothers on the lower end of the socioeconomic scale, or the ones that have straight out medical complications such as breech, cord or limb presentation, or placenta previa or abruptia.

Tell me none of the above calls need ALS assessment or care...


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## yay4stress (Mar 20, 2008)

What is an ALS provider going to do (SPEAKING PURELY IN PREHOSPITAL TERMS) that a BLS provider isn't?  In my area, medics and techs are on the same footing for obstetrics.  assessment of OB calls is the same for BLS providers and ALS providers here.

Once you get to a hospital, all bets are off.  I'm speaking only prehospital.


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## skyemt (Mar 20, 2008)

reaper said:


> You have to write a report, with no pt found? That sucks.



anytime we get toned out, we need "paperwork"...

no pt found amounts to about 3 words...

what's the big deal.


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## el Murpharino (Mar 20, 2008)

yay4stress said:


> What is an ALS provider going to do (SPEAKING PURELY IN PREHOSPITAL TERMS) that a BLS provider isn't?  In my area, medics and techs are on the same footing for obstetrics.  assessment of OB calls is the same for BLS providers and ALS providers here.



Aside from the additional education and advanced assessment techniques and recognition of life-threatening birth presentations....IV & fluids, EKG Monitor, advanced airway management (if needed) to include ET suctioning/meconium suctioning, magnesium sulfate (for pre-eclampsia or eclampsia)...and that's not even considering a neonatal arrest situation - I'm sure I missed alot, but this is what I could think of quickly.  Leave your ego at the door and realize that in these situations you had better be calling ALS.  Just because you won't need their interventions doesn't negate the fact that they're needed.  I'd like to see your ALS protocols in regards to obstetric emergencies and neonatal resuscitation.


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## Ridryder911 (Mar 20, 2008)

yay4stress said:


> WE have to write a report everytime we take the ambulence out for a call.  If it's cancelled, if the pt refuses, we always have to do a report.
> 
> and Obstetric calls are BLS here.  Talk about assumptions Rid.  Obstetrics aren't basic, but the skills for delivery are filed away under BLS skills.  So I'm an EMT-B, but I have to know how to deliver a baby.  If gestational diabetes is an issue, than yes, a medic (who also knows BLS I might add) will ride in back instead of an EMT if it becomes a problem.  For things like a prolapsed cord, EMT-Bs are trained to handle it.  Placenta Preva however, means we turn on the lights and sirens and get to a stabilizing facility, because not even a medic is going to do much good.
> 
> A good healthy dose of assumptions all around, eh Rid?



Again, why there is a debate between basics and medical knowledge. Sorry, your lost. 

Anyone knows how to deliver a baby, since the mother is really the one that delivers. They have been doing it since the creation of time. Really, again in comparison they teach it in advanced first aid/EMT courses. 

So you know how to perform the Leopold's maneuver, check fetal heart tones to detect distress or to detect deceleration, and to treat preeclampsia before it turns into eclampsia, or that IV bolus can stop premature labor? Sorry, I will NOT allow a first aider/EMT to treat my O.B. patients, I would be held negligent. They can assist me in care, otherwise according to the law I would be giving the patient to a lower trained person thus abandonment. I can assure you if something would occur, the patients attorney would think the same. I hope you & your partner have great malpractice insurance. 

If your Paramedics have not been taught anymore than BLS assessment on O.B.'s then their programs need to be revised. One can perform a better assessment through history, external examination (without checking dilatation) and checking fetal heart tones (surely you have a doppler on your unit for heart tones for PEA, right?). Get a O.B. nurse to give an inservice and your medical director to write better protocols, the patient(s) deserve better. 

I am not even discussing post delivery of neonatal problems. Let me guess, your Paramedics are not NRP certified either, right?

R/r 911


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## ffemt8978 (Mar 20, 2008)

I've always considered OB/childbirth calls to be ALS for a couple of reasons.

#1 - I refuse to change the census in my ambulance, so dying and multiplying happen on scene or at the hospital.  

#2 - I'm not going to clean up the mess afterwards.


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## JPINFV (Mar 20, 2008)

Ridryder911 said:


> surely you have a doppler on your unit for heart tones for PEA, right?



Nope. Dopplers aren't even listed as optional for the paramedic units where I grew up.


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## Ridryder911 (Mar 20, 2008)

That is a shame, since it is a standard device and treatment in checking for peripheral pulses on cardiac arrest with PEA as well as assessing for distal perfusion on crushing injuries or those with DVT etc . Nothing like telling the ER Doc there is no pulse and there is. 

Almost all the EMS units that I have worked upon it was standard equipment and really is not that costly as well. Not all ALS units have them but majority of them have them or is a priority to purchase. 

Fetal head can be placed upon them to detect FHR. Which is so simple.. (check mom pulse and the fetus will be heard differently, count the number of heart beats in one minute.. wallah! FHR! ) 

R/r 911


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## JPINFV (Mar 20, 2008)

Well, with EMS based fire suppression in Kalifornia, the emphasis is on buying more fire engines to run to medical calls than for equipment, training, or education.


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## Outbac1 (Mar 20, 2008)

One of our medics at work has delivered two human babies and one fawn. 
All deliveries went well. 

  A delivery from a mother with good prenatal care is one thing. But as Rid said a delivery from a high risk mother,(still quite prevalent in many places), is not something you want to do outside the hospital. I've had a fair bit of OB training the last few years from the courses I've taken and I will happily pass on a high risk birth. Way to many complications for my liking. Especially when you consider how little of the proper equipment is carried on most ambulances.


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## Jon (Mar 21, 2008)

Outbac1 said:


> <snip.
> A delivery from a mother with good prenatal care is one thing. But as Rid said a delivery from a high risk mother,(still quite prevalent in many places), is not something you want to do outside the hospital. I've had a fair bit of OB training the last few years from the courses I've taken and I will happily pass on a high risk birth. Way to many complications for my liking. Especially when you consider how little of the proper equipment is carried on most ambulances.



Additionally... the high-risk mothers seem to wait and call 911 to get a ride to the hospital.... and they consider the ED doc their primary physician. The patients who are being followed with prenatal care tend to know what is happening and get driven to the hospital by their spouses/family.... not the AmbuTaxi!


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