OB's - Paramedics Checking Dilation

[Ridryder 911]

I've performed perineal massage or "stretching" to help prevent tearing, especially on brow presentations. The mother could care less at the time if I had my fingers or my foot, as long as she was not being ripped apart.

The same on breech deliveries as well. This is one of those issues, if to reoccur again, I make a call to the Doc, get a verbal order (if there is time) and do what you need to do.

R/r 911

[Dustdevil]

Interesting things are said at paramedic schools taught inside of medical schools. Many of the lecturers are MD specialists in the respective discipline that have no real knowledge or understanding of paramedic practice. Consequently, they don't know how in depth to get with us, and they tend to lecture to us as if we are residents.

In that setting, I've heard at least three OBs lecturing to paramedic classes advise them to perform episiotomies if the tear appears imminent, and then go on to explain and illustrate the procedure. It's always priceless to see the look on the instructor's face about this time -----> :shock:

In the same rural system where we were to do dilatory checks, episiotomies were also allowed, but none of us ever did one in the several years I was there.

[tniuqs]

Intrapartal assessment skills were mandated in Alberta as part of Gap Training, this generated MUCH contraversy, the point being that understanding the procedure and practice on plastic "models" was advantagious not a negative, can't see how more education is somehow frowed upon, I have had the good fortune of delivering 8 last count, never really needing this skill as of yet:

It can be very dependant on the circumstances surrounding the specific mat call and this may indicate a need for advanced skill sets. For example: a response by air to remote nursing station, maybe a greater that a 2 hour flight to a receiving facility. So does one subject the expectant mother (dilated to 6 cm) to a rather harsh enviroment of a medivac and - 30 C instead of staying in the realative security of a well lighted, warm enviroment.

So I believe there should "not" be a hard and fast rule as not all Paramedics have the luxury afforded to them of a 20 minute transport time...

cheers

[FireMedic65]

only if she is hot! jk

but really.. i dont see any reason why it should be checked... if the baby is coming, it's coming... you aren't gonna stop, check, and wait until its 9cm or whatever and deliver...

[tniuqs]

only if she is hot! jk

but really.. i dont see any reason why it should be checked... if the baby is coming, it's coming... you aren't gonna stop, check, and wait until its 9cm or whatever and deliver...

If I were an EMT working in a urban environment I must absolutely agree, this is NOT a skill that should even be considered, hot or not....good grief man.

But, I think you are missing my point, by taking an appropriate mat history i.e. primagravid vs. multi, prenatal care, socioeconomic status, even race can become serious considerations as well (when considering the above senario).

Therefore if a MAT patient is 4 vs. 6 cm dilated this may be very good indicator(s) that you should/or should not transport the individual perhaps just have coffee and wait to deliver in a FAR more controlled environment, with more helping hands, there are RNs in nursing stations .... first off do no harm my friend, do no harm.

The major point here is do you rip down the road at high speed and bounce both patients around in the back of a flying cigar tube or truck, just to get that mom to a hospital ?

This MAY NOT be the most prudent or intelligent thing to do, after all pregnancy is not a disease..... after all more kids are born in the back of a cab than in the back of an ambo.

cheers

[whit72]

I dont know about you all. I think I looked under a pregnant womans dress once in my whole career, thats because there was a head sticking out.

I note severity, contraction time, gravida/para and move along. Nothing good can come from looking up a pregnant womans dress.

[katbemeEMT-B]

While we are on the OB subject, lets say no dilation checks in the field for most, but what about episiotomies? To assist a tough delivery should they be allowed? Yes I realise that it is better most times to allow the baby to come out on its own, to even allow the perineum to tear. But at times I have had some women not tear and we assist stretching as much as possible but babys head sets stuck just inside and episiotomy could free the baby quicker helping avoid airway compromise of the baby.

I understand that your ultimate concern is getting the baby out quickly and safely, but as a childbirth instructor and doula, I can also tell you that even OB docs are moving away from episiotomies. They are finding that woman heal faster from a tear than an episiotomy, and some woman have torn even after the episiotomy. I know of several that tore all the way into the anal tissue. Once the external folds of tissue are cut, they tear much easier because of the stretching. Perineal message and a slow, controlled delivery is the best bet. If you want to slow the delivery process, have the mom lay flat on her back, bringing her legs up to her chest as much as possible. It makes for an uphill climb for the baby. If you want to speed things up, have mom sitting up up much as possible with legs drawn up towards the side of chest while still allowing you access to the vaginal area. Some times changing positions ( lay on left or right side) helps also, as babys do get hung up on the pelvis or the woman may not be equally dilated.

I am thankful I have never had a delivery in the ambulance. I would imagine the space restraints suck, along with the constant bouncing.

[spenac]

only if she is hot! jk

but really.. i dont see any reason why it should be checked... if the baby is coming, it's coming... you aren't gonna stop, check, and wait until its 9cm or whatever and deliver...

Obviously somebody hasn't done many OB calls. Nothing hot and nothing sexual about a vagina covered with all sorts of pre-birth goo(hows that for a medical term).

Another poster mentioned having only looked under 1 OB's dress. If you do many OB calls that will bite you in the rear. Speaking from experience, the quite calm girl saying she has no pain will all of a sudden have something screaming from between her legs. Our policy is all OB's are naked patients. IMHO if you have not at least done a visual exam you can not say you have given proper care. Some woman cannot feel that the cord, an arm, etc is protruding.

tniuqs thanks for posting about rural EMS. People in the citys just cannot seem to grasp that you are the only medical care available for more than an hour.

As far as delivery for those that have not done it. 90% of the time the worst part is the clean up. I always choose to catch the baby and do patient care leaving my partner to clean all the goo(hey theres that medical term again) from the cot, the wall, ceilings, cabinets, and floor. Of course we actually keep lots of towels, sheets, and blankets. We if time allows cover everything so clean up is easier. People always laugh saying our ambulance looks like a linen truck because one big cabinet is full of linens, but when I have helped on their trucks they find out why real quick. Now those more rare cases where things go wrong, it takes it's toll on everyone.

I do think in rural areas the options I have posed in this topic could really benefit number 1 the mother and unborn child and secondly the EMS crew.

[jsadin]

Spenac, where the heck to you work? 6 live births in the ambulance this year? I know medics with 20yrs in the field (in busy systems) who haven't delivered any babies. Holy guacamole...

[Dustdevil]

Spenac, where the heck to you work? 6 live births in the ambulance this year?

None speaking English, none with prenatal care, and none over eighteen either!