9

The main ideas from this information are: - Hands-only CPR is not recommended, ventilation is necessary. - The Apgar score is used to assess the status of newborns. - Breach deliveries require special care and can take longer. - Limb presentations and prolapsed cords require immediate medical attention. - Spina bifida and multiple gestations are less common but require specific care. Do not do hands only CPR, you must ventilate. That's what we're doing, two thumbs in a circle and hands. Three to one, three compressions to one breath. So you and your partner are gonna have to work really well. When you ventilate, just until chest rise, you might squeeze this, but maybe all you do, just enough to get chest rise. As the colon is standing as present, quickly suction the newborn mouth and nose and provide rescue ventilation. Baby's puffed, baby's swallowed. Unless the baby's breathing well, baby's gonna need ventilation. So the AFGAR score is a standard scoring system used to assess the status of the newborn. Oh no, another pneumonic, oh yeah. And know it, learn it, live it, you will see it again. Wait, wait, wait, hang on to me, hang on to me. Appearance of post-tumor activity or respiration. Five is a scale of zero to two. 10 being a perfect score, zero being really bad. And it is set at one minute and five minutes. Not at birth, it's at one minute and five minutes. You must record the AFGAR score on your PCR. One minute and five minutes. Okay, I'll tell you right now. Appearance, post-tumor activity and respiration. So, appearance, if the entire baby is pink, it's a two. That's good. If the body is pink but the hands and feet remain blue, that's a one, most babies are born this way. If the entire baby is blue or extremely pale, that's a zero, bad. Pulse, more than 100 is a two. That's good. Fewer than 100 is a one. That's not, that doesn't happen very often. No pulse, that's bad. Grimace or irritability. Newborn cries and tries to move the foot away when you flex the soles of the feet. He's pissed off and he's letting you know it. That's a two. Newborn gives a weak cry, very light response to stimulus. That's a one, but some. Baby does not react to stimulus. It is lethargic or limp. That's bad. Activity and muscle tone. What you do is you take the legs and you open the legs and you try and straighten the legs and open them. So you're gonna take the legs and you're gonna pull open, pull them straight and open them, just gently. Not yanking them, you know, just gently. But if the baby has a good strong resistance, then that's a two. If the baby has weak resistance, like very little resistance, that's a one. If the baby's limp, no muscle tone, zero. Respirations. Rapid respirations, greater than 30 breaths per minute. That's a two. Slow respirations, less than 30 breaths per minute. That's a one. No respirations is a zero. So we add them up, they should go from zero to 10. Most babies are born at eight or nine. Usually there's some pink there and like there's either a weak cry or weak activity. Or sometimes a pulse rate less than 100. So eight to nine is fairly common for newborn at one minute. At five minutes, they should be 10. So if it's five minutes and you do your secondary AFCAR score and they're not 10, there's a problem. You need to do some resuscitation, okay? And this is table 34-4, so it's in your book too. So assessing a newborn, calculate the AFCAR score at one minute. Stimulation should result in immediate increase in respirations. If the newborn is breathing well, assess the pulse. It's all about pulse. It's all about pulse rate. That's what the pulse and scan, that's what's gonna tell you if the baby's doing well or not. Assess oxygenation via pulse oximetry. You're not gonna use one of those thumb probes or finger probes, it's gonna be too big. You'd have to have a special pulse oximetry for infants. Observe for the cyanosis. Request the second unit if the newborn is in distress and require resuscitation because remember you got mom. Babies should be a two-person resuscitation attempt. In situations where assisted ventilation is required, use the newborn. We have newborn masks. They're very small, round masks. So newborn BBMs and newborn masks. If the newborn does not require breathing, it does not begin breathing on his or her own, it does not have an adequate heart rate, CPR, ventilation, CPR, rapid transport, and three-to-one ratio. So some different types of delivery. So this is a breach delivery. What happens if the patient did not do lightening? Occasionally, most infants will go ahead first, but sometimes I think one in 30 births are breached or one in 40 births are breached, something like that. It's called a breach presentation. It's not uncommon. This, although it is an abnormal birth, it is a standard feel birth. You can deliver that. Breach deliveries usually take longer, so you often have, if you know that the baby is breached, you've got time to transport. So if you see bulging at the perineal opening and when you look, you see like a buttocks being delivered, you've got time to go to the hospital. That delivery's gonna take probably 20 or 30 minutes. If you see the head bulging, okay, baby's coming, but if you see buttocks, you've got a few minutes, you can take the chance and go to the hospital. If the buttocks has passed through the vagina, the delivery has begun. So once you see the buttocks at the hole and bulging through, you still got a little bit of time. Provide emergency care and call for ALS and consult medical controls. It's a good idea to be in contact with medical control because you can develop a complication to this. So preparing for a breach delivery is the same for a normal birth. Position the woman, prepare the OB kit, place yourself and your partner in a normal position, allow the buttocks and legs to deliver spontaneously. What happens is the hardest part to deliver is the shoulder and the head. So in a regular presentation, the head and the shoulders go and the body just goes boom and they're done. But this is backwards. So mama pushes out the buttocks, the legs and all the way up to the chest, but now the head and the shoulders are stuck. So sometimes mom pushes it up to get the shoulders out but not the head. She's like, I can't push it anymore. And you're like, don't stop now! And the head's stuck but the body's outside. What you have to do in that situation, if the head doesn't come out, you don't pull on the baby, you don't like it that, what you wanna do is take two fingers and push, insert them in the vagina and push the vaginal tissue away from the nose. As the baby's coming out, the baby's like this in the vaginal tissue, right? So now the shoulders are out, baby wants to take a breath, the chest expanded, but it can't because it's stuck like this. So you stick your two fingers in there and you push the tissue away from the baby's nose so the baby can breathe. Now if mom can't deliver that baby, that's the way you're gonna go all the way into the ED with your fingers in the vaginal opening like that, holding that tissue away from the baby's face. That's rare, but it can happen, so be prepared for that. One time that you'll insert your finger into your glove's finger inside of the vaginas. One reason you'll do that is you push the tissue away from the baby's face. If you don't do that, baby's gonna start coming back because remember the baby's pushing on the placenta, the umbilical cord is in that opening too, so it's being pressed on by the baby's head. So then the baby's not getting oxygen from the placenta. Ah, that's sad. A limb presentation. Remember how I told you that you don't want to put the legs together and have mom not push, right? Because it can cause uterine rupture. This is one of the times where you do. This is called a limb presentation with a limb post out. You do not want to deliver that because you'll split the baby in half, you'll rupture mom's uterus, and they'll both be dead in the back of your anus. So what you want to do is put a moist, like towel or dressing on the leg, keep it moist, have mom close the legs, please don't push, call ALS, and drive like it's stolen. The only way that can be delivered. You don't stuff that back inside and hope that it works. It doesn't work that way. Limb presentation. It's surgical, it's usually surgery, there are doctors who can do a special, I forgot what they call it. They flip, you know? Yeah, they can manipulate the baby, the Murphy procedure or something, but it is very painful, it can cause fetal distress, so we don't do it. Place the patient on her back with her head down and her pelvis elevated. Never try to push a poor baby. A prolapsed cord. If you see mom, and as the bulging of the head, if you see the umbilicus, you don't wanna try and deliver that either, because what'll happen is the umbilicus will be dragged with the head and it'll cause a placenta abruptio, and mom will probably bleed to death. So this is one of those times when we tell mom, ma'am, don't push, you put your hands up inside the vaginal opening and you push the head off of the umbilicus. Don't push in the pontineals, push in the bony part of it, but you wanna push off and then try and keep the head off of the umbilicus. We don't wanna try and stuff the umbilicus back in and hope that that works, because it doesn't work that way. I know it looks like there's a lot of space in there, but in real life there isn't that much. Let's call it a prolapsed umbilical cord. Sorry about that. Oh, this is the one. Place the pregnant woman supine with the foot of the cot raised higher than the head, have her elbows and her hips in a knee to chest position, right, and then put your finger inside and push, keep the head off of the umbilicus. Spina bifida, developmental defects in which a portion of the spinal cord and meninges may protrude outside the vertebrae. I think this happens in one of every 1,000 births or something like that, or 10,000 births. Cover that tissue with a moist sterile dressing. Do not lay the patient on that tissue. Keep them on their side. Keep them warm and transport them to the hospital. Multiple gestations. Twins occur in one every 30 births or something like that. Triplets are one in every 300 births. Quadruplets are one in every 3,000 births. Pentuplets are one in every 30,000. It goes like that, right? The more babies, it exponentially gets higher. Twins are smaller than a single fetus and delivery is usually not difficult. About 10 minutes after the first birth, contractions will begin and the process will begin itself. The second one is usually born within 45 minutes of the first baby. It's usually eight to 10 minutes. So if you have babies that are born, I like a Sharpie, a black Sharpie, on the bottom of the foot. Don't do it on the forehead. On the bottom of the foot, just write number one and number two. And then on a piece of paper, number one, time of birth. Number two, time of birth. So is the birth for baby one? Is baby one, right? That's what you do. Because otherwise, you might get it mixed up. And I guess it doesn't really matter, but the procedure is the same as for a single fetus. Record the time of birth of each twin separately. Twins may be smaller, so they'll look pretty mature. A normal full-term single newborn weighs about seven pounds, anywhere between six and eight pounds. A newborn who delivers before eight months to 36 weeks or weighs less than five pounds at birth is considered premature. That's a preemie. And there's a preemie right there. You can see, see that little white stuff? That's the remnants of the vernix caseoca. This is caseosa, this is a full-term baby. This is a premature baby. You can see how much smaller it is. The head's proportionally larger, but the body's thinner. Sometimes these babies need significant respiratory stimulation or ventilation because they have, again, the last thing to develop in the last six weeks is objectation is the respiratory system. So sometimes they need that. They often require respiratory effort. For such case efforts, between four and seven is typically impossible. For such care, premature newborns as small as one pound are survived. And again, my, I hate to say ex-stepson, but he was born at a little over a pound and he's paramedic certified right now. Wouldn't even know the difference. Born at 26 weeks. Pregnancy, post-term pregnancy. Pregnancies last longer than 41 weeks. The babies are larger, usually 10 pounds or more. Large babies can lead to uterine rupture. It can lead to perineal tears. It can lead to fetal distress and even fetal demise. So they don't want that. So they want you to deliver between 38 and 41 weeks. They don't want you to over-cook. They don't want you to under-cook. Increased chance of injury to the fetus, increased likelihood of cesarean section. Woman at risk for perineal tears and infection. Can have meconium aspiration, infections in fetus stillborn. Fetal demise, you may deliver a fetus who died in the woman's uterus before labor. There have been doctors who have been known to, the baby dies and the doctor will let mom carry it to term. She'll carry the dead baby until she delivers it. Which would be obviously a very emotional thing for mom to deal with, so keep that in mind. If you deliver a baby, you'll either deliver a baby that looks viable or just a mass of tissue with skin swapping off and all that. If it looks viable, we work it. That's the rule of thumb. Remember, mom's watching. Do not resuscitate an obvious dead baby. If it's not resuscitative, if you can't find the airway, if it doesn't have a head, whatever the case may be, we're obviously not going to try and resuscitate an obvious dead baby. But if it looks viable, do resuscitation and transport to the hospital. If bleeding continues after delivery of the placenta, massage the uterus, massage the fundus. Make sure your hand placing is correct. Stimulate the nipples to put the baby to rest. Have mom put some towels between her legs, close her legs, elevate the buttocks. High priority transport, call ALS, the TXA, and IV fluid. Cover the vagina with a sterile pad. Change the pads as often as possible, change the pads as often as possible. Do not discard blood soak pads because we can count them and figure out how much blood loss, hypoxygen, and transport needed. Postpartum patients are at increased risk of an embolism. Remember how I told you that. They have a condition called polycythemia. They have more red blood cells. It takes about six weeks for the body to reabsorb those extra red blood cells. So in the six weeks postpartum, they have more red blood cells. They have a shorter clotting time, a faster clotting time, so they can actually develop these embolisms on their embolism. So when a woman complains of sudden difficulty breathing or shortness of breath, all of a sudden, status post less than six weeks after birth, sudden shortness of breath, chest pain, it hurts to breathe, maybe coughing up blood, that patient needs to go to a trauma center as they be because that's the sign of a pulmonary embolism.