1 OB Emergencies
Module 1 2016 CE- ECRN Condell Medical Center EMS System IDPH Site Code: 107200E-1216
PREPARED BY: DEBORAH SEMENEK RN, EMT-P MARK DZWONKIEWICZ FP-C, LI REVISED 7/11/16 OBJECTIVES 2 Upon successful completion of this module, the ECRN will be able to:
1. Differentiate the changes in assessment due to the patient’s pregnancy status as it relates to changes to the cardiovascular and respiratory systems. 2. Correlate findings in the assessment of the obstetrical patient with stages of labor. 3. Predict delivery complications based on the patient assessment. 4. Discuss presentation, assessment, and EMS intervention for antepartum bleeding, hypertensive emergencies, and maternal resuscitation. 5. Demonstrate appropriate actions to take for obstetrical delivery complications including breech birth, prolapsed cord, nuchal cord, presence of thick meconium, post partum hemorrhage. 6. Review selected Region X SOP’s as related to the topics presented. 3
7.Review case scenarios presented.
8. Review contents available in OB kit.
9. Review indications, complications, and the process of use of the meconium aspirator..
10. Successfully complete the post quiz with a score of 80% or better. Terminology of pregnancy 4
Prenatal period – time from conception until delivery of fetus Antepartum – time period prior to delivery Post partum – time interval after delivery Gravidity – number of times pregnant Parity – number of pregnancies to full term Fetus – a developing human in the womb Neonate – the first 30 days of life for the infant Estimated date of confinement (EDC) – estimated birth date Terminology cont’d 5
Placenta – temporary blood-rich structure; lifeline for the fetus Transfers heat Exchanges O2 and carbon dioxide Delivers nutrients Carries away wastes Bag of waters – amniotic sac; surrounds and protects fetus; volume varies from 500 – 1000ml Perineum – the skin between the vaginal opening and the anus Nuchal cord – cord wrapped around the fetal neck Physiological Changes During 6 Pregnancy
Pregnancy is a normal and natural process A woman’s body will undergo many changes in preparation for carrying another life Complications are uncommon but you must be prepared for them Pre-existing medical situations could be aggravated during pregnancy and develop into acute problems Physiological changes during 7 pregnancy:
Nausea and vomiting due to hormonal changes Delayed gastric emptying renal blood flow Kidneys may not be able to keep up with filtration and reabsorption Bladder displaced anteriorly and superiorly More likely to be ruptured in trauma Urinary frequency Loosened pelvic joints due to hormonal changes Physiological changes cont’d 8
oxygen demand and consumption Diaphragm pushed up by enlarging uterus = lung capacity cardiac output to 6-7 L/min by end of 2nd trimester Average in resting non-pregnant female is 4.9L/minute maternal blood volume by 45% Can sustain 30-35% total blood loss before change in vital signs are evident venous return to right atrium with gravid uterus compressing inferior vena cava Fetal blood supply 9
No direct link between mother’s blood and infant Mother’s blood flows to the placenta Placenta supplies blood to the fetus Placenta acts as a barrier protecting the fetus Some items cross the placental barrier and can affect the fetus: Alcohol Some medications – Valium Versed, oral diabetic meds, narcotics, some antibiotics, steroids Umbilical cord 10
A flexible, rope-like structure approx. 2 feet long Contains 2 arteries, 1 vein Transports oxygenated blood to fetus Returns relatively deoxygenated blood to placenta Fetus can twist and turn in the uterus and get wrapped up in cord Fetus can “tie umbilical cord into a knot” Normal pregnancy – 20 weeks & term 11 Antepartum Complications 12
Vaginal bleeding Ectopic pregnancy Placenta previa Placenta abruptio Hypertensive disorders Preeclampsia, eclampsia Supine Hypotensive Syndrome Vaginal Bleeding 13
May occur at anytime during the pregnancy If early, patient may not even realize they are pregnant In the field, exact etiology cannot be determined Keep heightened suspicion that vaginal bleeding may be related to patient being pregnant This could prove to be an emotional time for the patient and family Being supportive is important in this patient population Ectopic Pregnancy 14
Fertilized egg has implanted outside the normal uterus Patient often presents with abdominal pain that starts diffuse and then localizes to lower quadrant on affected side Patient may not even be aware that they are pregnant If in fallopian tube and tube ruptures, maternal death due to internal hemorrhage is a real possibility Abdomen becomes rigid with pain Often referred shoulder pain on affected side Placenta previa 15
Abnormal implantation of placenta on lower half of uterine wall Cervical opening partially or completely covered Placenta can start pulling away from attachment starting at 7th month Painless bright red vaginal bleeding Uterus usually soft Potential for profuse hemorrhage Definitive treatment is cesarean section delivery Abruptio placenta 16
Premature separation of normally implanted placenta from uterine wall Life threat for mother and fetus 20-30% mortality for fetus Signs & symptoms depend on extent of abruption Can have sudden sharp, tearing pain and stiff, board like abdomen Vaginal bleeding could range from none to some Blood could be trapped between placenta and uterine wall Maintain maternal oxygenation and perfusion Pre-hospital Care of antepartum 17 bleeding
Maintain high index of suspicion Treat for blood loss Positioning – lay or tilt left Monitor for adequate oxygenation Providing supplemental oxygen is also for benefit of the fetus Maintain adequate perfusion Consider fluid challenge as needed Expedited transport; transport as soon as possible Early report to receiving facility Hypertensive disorder of pregnancy 18
Major cause of maternal, fetal and neonatal morbidity and mortality Morbidity – presence of a disease state Mortality – relating to death A common medical problem in pregnancy Includes gestational hypertension (hypertension that develops during pregnancy usually after the 20th week) and pre-existing hypertension (typically defined as a blood pressure > 140/90) Preeclampsia 19
Most common hypertensive disorder of pregnancy Increased risk in diabetics, those with history of preeclampsia, and those carrying more than one fetus Progressive disorder; most commonly seen last 10 weeks of gestation, during labor, or first 480 postpartum Have a 30 mmHg increase in systolic B/P and 15 mmHg increase in diastolic B/P over baseline Signs and symptoms pre-eclampsia 20
Elevated blood pressure Headache Visual disturbances – blurred vision, flashing before the eyes Severe epigastric pain Vomiting Shortness of breath Tissue edema related to third spacing with fluid shift into tissues Swelling of face, hands, and feet Eclampsia 21
Most serious side of hypertensive disorders of pregnancy Generalized tonic-clonic seizure activity Often preceded by flashing lights or spots before their eyes Epigastric pain or pain RUQ often precedes seizure Note grossly edematous patient with markedly elevated B/P High mortality rates for mother and fetus Definitive treatment is delivery EMS needs to provide support until delivery at closest appropriate facility Managing seizures during pregnancy 22
Positioning of patient To protect from harm, protect airway Maintain patent airway Potential need for intermittent suction Support ventilations Patient’s respirations altered during active seizure activity Will need supportive ventilations especially in presence of long lasting seizure activity Manage seizure with Versed 2 mg IN/IVP/IO every 2 minutes up to 10 mg (does cross the placental barrier; could depress fetus) Supine hypotensive syndrome 23
Usually occurs in 3rd trimester Gravid uterus compresses inferior vena cava when mother lies supine Mother may experience dizziness Evaluate for volume depletion versus positioning problem Place mother in left lateral recumbent position (“lay left”) for assessment, treatment, and transportation to prevent this problem Identifying imminent delivery 24
Mother entering the 2nd stage of labor Measured from complete dilation of cervix (10cm) to delivery of fetus Could last 50-60 minutes for first pregnancy Contractions strong lasting 60-75 seconds and 2 -3 minutes apart Membranes may rupture Has urge to push Perineum bulging Crowning evident when head or other presenting part is evident at vaginal opening during a contraction Ob kit contents 25 Cap Ob kit contents
ID bands EMERGENCY CHILDBIRTH LABOR: Region 10 SOP Review 26 1. Obtain history. Initiate Adult Routine Medical Care. Gravida (# of pregnancies) Length of previous labors Para (# of live births) Bag of waters (amniotic sac) Intact? Broken? Due date, Duration and frequency of contractions High risk concerns
2. Position patient and evaluate for: SIGNS OF IMMINENT DELIVERY-crowning, bulging, in voluntary pushing SIGNS OF COMPLICATIONS-prolapsed cord, profuse bleeding, meconium staining
3. If delivery is not imminent, transport on left side. DELIVERY: Region 10 SOP Review 27
1. If contractions are 2 minutes apart, or signs of imminent delivery are present, open OB pack and don sterile gloves as well as standard precautions. Drape mother’s abdomen and perineum. Prepare to assist the delivery. 2. Initiate Adult Routine Medical Care. 3. Protect perineum with gentle hand pressure while supporting the newborn’s head as it emerges from the vagina. Tear amniotic membrane if it is still intact at this point. 4. Check for nuchal cord (cord wrapped around the neck). 5. Clear airway, if necessary, with a bulb syringe. Suction mouth, then nose as soon as head is delivered. 6. To facilitate delivery of the upper shoulder, gently guide the head downwards. Support and lift the head and neck slightly to deliver the lower shoulder. The rest of the newborn should deliver with minimal assistance. Get a firm grasp on newborn. Note time of delivery and record on newborn’s PCR. NEWBORN and POST PARTUM CARE: Region 10 SOP Review 28 1. Spontaneous respirations should begin within 15 seconds after stimulating newborn by drying, rubbing back or flicking the soles of the feet. Do not shake newborn. Rapid assessment should include the following characteristics: term gestation, crying or breathing and good muscle tone.
2. Suctioning with the bulb syringe should be reserved for a newborn with obvious obstruction to spontaneous breathing. If meconium is present and the newborn is not vigorous (decreased RR, decreased muscle tone, HR <100) use meconium aspirator for direct tracheal suctioning a. If still no respirations, begin ventilating at 40-60 breaths/minute. After 30 seconds of ventilation and if pulse < 60 begin chest compressions at a ratio of 3 compressions to 1 ventilation. Refer to Resuscitation of the Newborn/Neonate protocol.
3. Obtain 1 minute APGAR SCORE.
4. Keep newborn level with the vagina until the cord is double-clamped. The cord should be clamped 8 inches from the newborn’s navel with 2 clamps placed 2 inches apart. Cut the cord between the two clamps.
5. Continue to dry the newborn and wrap in a dry blanket to provide and maintain body warmth. Wrap the newborn in silver swaddler or blanket, ensuring the head is covered. If the newborn is cyanotic, but breathing spontaneously, place infant NRB mask next to newborn’s face and run OXYGEN at15 liters/minute. Region 10 SOP Review NEWBORN and POST PARTUM CARE: Cont. 29
6. Obtain 5 minute APGAR score. 7. Allow placenta to deliver spontaneously. Do not delay transport while waiting for placenta to deliver. Do not pull on cord to facilitate placental delivery. When delivered, collect placenta in plastic bag, bring to hospital and document time of placental delivery. 8. Check perineum for tears. If torn and bleeding, apply direct pressure with sanitary pads, and have patient bring legs together. 9. Observe for excessive vaginal bleeding (more than 500 mL). a. IV FLUID CHALLENGE in 200 mL increments. Titrate to desired patient response. b. Following delivery of the placenta, massage fundus of uterus until firm. Check every five (5) minutes for firmness and massage as necessary. 10. Utilize identification tags for mother and newborn, must include mothers name, gender of newborn, time of delivery. 11. Every reasonable attempt should be made to secure the mother and the newborn for transport Steps to take during delivery 30
Try for a private area if out in public Place patient on her back with room to flex knees and hips Prepare equipment – OB kit Coach mother to breath between contractions and to push with contractions once crowning is evident Support head as it emerges Check for nuchal cord If necessary clear the airway with a bulb syringe. Delivery cont’d 31
Gently guide baby’s head downward Facilitates delivery of upper shoulder Then gently guide baby’s body upward Facilitates delivery of lower shoulder Rest of baby quickly delivers Be prepared! Infant will be slippery! Note time of delivery – when baby totally out Keep baby in head down position Use of bulb syringe 32
Routine suctioning is no longer recommended Suctioning has been associated with bradycardia and other problems Suctioning is limited to necessity If performed, suction MOUTH, then nose Suctioning the nose is the stimulus to breath Want the airway clear prior to stimulation to take a breath Infant will not start to breathe until their chest clears the birth canal and can then expand Delivering the baby 33 Normal appearance of a new born 34
Infants will be wet and slippery Covered with a cheesy like substance that wears off shortly after delivery Hands and feet may be cyanotic longer than other parts of the body Extremities should be actively moving Newly born appearance 35
Risk for blood and body fluid contamination during all deliveries Have high regard for use of appropriate PPE’s! Drying off preserves heat and acts as a stimulus by the rubbing activity Initial assessment of newborn 36
Begin steps of inverted pyramid as you are assessing newborn Begin to dry infant; change to dry towel as needed Cold infants can deteriorate quickly Infants have difficult time generating & maintaining body heat; they cannot shiver to generate heat Suction with bulb syringe only when secretions are present Assess newborn as soon as possible after birth Normal respiratory rate averages 30-60 breaths per minute Normal heart rate ranges from 100 – 180 beats per minute Inverted pyramid Routine suctioning removed in 2015 AHA Guidelines 37
(Always needed)
(Infrequently needed) Apgar score 38
Developed in 1953 by Dr. Apgar, a surgeon turned anesthesiologist An assessment is taken at 1 and 5 minutes after birth The 1 minute score reflects how well the infant tolerated the birthing process and indicates need for early intervention The 5 minute score reflects how well the infant is tolerating being outside the womb as well as response to interventions provided The higher the score (closer to 10), the better the infant’s transition Early duskiness of distal extremities is common often leading to a 1 minute score of 9 The score does NOT predict the future health of the child APGAR cont’d 39
Any score less than 7 merits an intervention Supplemental airway Clearing the airway Physical stimulation Rubbing the back Flicking the bottom of the foot Most low initial scores at 1 minute improve with the usual interventions listed at the top of the pyramid and by the 5 minute assessment, are usually at higher, acceptable scores Providing assessment/reassessment is key 40 Care of the cord 41
Do not pull on the cord Avoid cutting the cord prematurely Want the last kick of blood available to be delivered to the infant Once the cord has stopped pulsating and gone limp, can prepare to clamp and tie it Place one clamp 8 inches from newborn’s navel Place 2nd clamp about 2 inches further away Cut exposed cord between the clamps – it’s tougher than anticipated Continue to assess the newborn’s end of exposed cord for any bleeding Care of the cord 42
There is no rush to clamp and cut the cord You want to give enough time for all blood possible to infuse from mother to the placenta to the infant Infant's have a very limited blood volume to begin with (80 ml/kg) Preventing heat loss 43
Heat loss can be life threatening for the newborn Most heat loss is via evaporation while wet with amniotic fluid Can lose heat via convection depending on temperature of room and movement of air around newborn Can lose heat via conduction if in contact with cooler objects Can radiate heat to colder nearby objects Preserving the newborn’s body 44 temperature
Dry the newborn immediately after birth Maintain a warm ambient temperature Close all windows and doors Replace wet towels with dry Keep infant wrapped and head covered to prevent heat loss Mother holding the newborn transfers her body heat. Ensure Mother /Infant safety during transport. Newborn resuscitation 45
Additional efforts required when the respiratory rate is decreased, heart rate <100, or there is decreased muscle tone Attempt positive pressure ventilations via BVM Rate of 40-60 breaths per minute Watch that the volume is enough to make the chest rise and fall Reassess after 30 seconds IF heart rate is 60 -100 beats per minute Continue positive pressure ventilation IF heart rate is less than 60 Begin chest compressions at a ratio of 3:1; reevaluate every 30 seconds 3rd stage of labor – placental stage 46
Uterus continues to contract Cord appears to lengthen May have increase in bloody discharge If delivered, transport with mother to the hospital Complications – prolapsed cord 47
Umbilical cord visible prior to delivery Cord will be compressed if fetus passes through birth canal Goal Prevent mother from delivering vaginally Prolapsed cord 48
This is one of the complications you want to visually check for as quickly as possible once on the scene of an imminent delivery If the cord is visible protruding from the vagina Elevate the mother’s hips Instruct patient to pant during contractions or just keep her breathing during a contraction Place gloved hand into vagina between pubic bone and presenting part Monitor cord between fingers for pulsations Keep exposed cord moist with dressings and keep warm Transport with hand in place – DO NOT REMOVE YOUR FINGERS Meconium Staining 49
Occurs in approximately 10-15% of deliveries Meconium is dark green and can be of thin or thick consistency Fetal distress and hypoxia cause meconium to pass from the fetal GI tract into the amniotic fluid If infant is breech, meconium staining is anticipated and expected as the abdomen is compressed in the birth canal Meconium aspiration increases neonatal mortality rate If aspirated can obstruct small airways & cause aspiration pneumonia and lead to respiratory distress Normal meconium stool 50
Usually passed within 480 of birth Typically transitions to normal stool beginning by day 4 Meconium is thick, dark almost black stool normally found in the infant’s intestines Becomes a problem when aspirated or otherwise blocks the infant’s small airway AHA revised guidelines for 51 Meconium and Tracheal Suctioning
Suctioning Nonvigorous Infants Through Meconium-Stained Amniotic Fluid 2015 (Updated): If an infant born through meconium stained amniotic fluid presents with poor muscle tone and inadequate breathing efforts, the initial steps of resuscitation should be completed under the radiant warmer. PPV should be initiated if the infant is not breathing or the heart rate is less than 100/min after the initial steps are completed. Routine intubation for tracheal suction in this setting is not suggested, because there is insufficient evidence to continue recommending this practice. However, a team that includes someone skilled in intubation of the newborn should still be present in the delivery room.
© 2015 American Heart Association Meconium and Tracheal Suctioning? 52
Non-vigorous newborns with meconium-stained fluid do not require routine intubation and tracheal suctioning; however, meconium-stained amniotic fluid is a perinatal risk factor that requires presence of one resuscitation team member with full resuscitation skills, including endotracheal intubation.
Summary AAP/AHA 2015 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care of the Neonate Equipment for meconium aspiration 53
Suction tool Suction force turned down to 80 mmHg Meconium aspirator Intubation blade and handle 2 ETT of anticipated size Additional ETT sized below and above anticipated size to use Neonatal BVM Meconium aspirator 54
Connect small end of meconium aspirator to suction connecting tube Set suction down to 80 mmHg Endotracheal tube inserted using blade and handle Meconium may obscure your view Wider end of aspirator connected to proximal end of ETT Thumb placed over suction port while withdrawing ET tube within 2 seconds Discard ETT after 1 sweep and use new ETT if 2nd attempt made Supportive ventilation 55
Proper positioning is a small towel under the torso Volume is enough to make the chest rise gently Rate is 40-60 breaths per minute Do not flow oxygen into the infant’s eyes or put pressure over the eyes Newborns are sensitive to vagal stimulation and will respond with bradycardia Nuchal cord 56
Cord is wrapped around the infant’s neck Problem exists if the cord is too tight and prevents infant from delivering Remember: fetus is receiving their oxygen and blood supply via the cord If cord clamped and cut prematurely, infant needs to be delivered without delay to begin to ventilate on own Goal: If cord too tight for infant to deliver, then unwrap or clamp & cut Prevent mother from pushing until cord is unwrapped or cut Postpartum hemorrhage 57
Loss of more than 500 ml of blood immediately following delivery 500 ml = 2 cups = 16 oz = 1 pint = 1 pound by weight of soaked pad Most common cause is uterine atony – lack of uterine tone; failure of uterus to contract after delivery Occurs more frequently in multigravida and more common following multiple births or births of large infants Rely on clinical appearance of mother and vital signs Uterus often feels boggy on palpation Need to perform fundal massage Fundal massage – 2 handed technique58
Must NOT be performed until after delivery of the placenta Is a 2 handed technique Performed to get uterus to contract to minimize blood loss Need the uterus to firm up Should feel like a grapefruit or fist Fetal alcohol syndrome (FAS) 59
Life-long effects started from the womb When the mother drinks, alcohol crosses the placenta and passes to the fetus Alcohol affects neurons and the central nervous system (CNS) of the fetus Damages physical structures and growth Defects more pronounced as the child grows Crisis at birth 60
If FAS is suspected: Anticipate a small weight newborn Anticipate a newborn who may need some resuscitative efforts Assisted ventilations Extra attention to be kept warm due to typically a smaller birth weight SIDS 61
Sudden Infant Death Syndrome describes the unexplained sudden death of an infant Major cause of death in infant’s first month of life Most victims appear healthy prior to death There is still no cause of SIDS but theories do exist Stress in infant possibly from infection or other factors A birth defect Failure to develop A critical period of rapid growth Case scenario discussion 62
Review the following cases and determine what your general impression is Discuss what your intervention needs to be Refer to the Region X SOP’s as necessary Case scenario #1 63
EMS is called to the scene of a mother who is in labor What information should the ECRN collect from EMS early? Due Date Number of pregnancies Known complications Previous labor history if any If bag of waters are intact or broken The duration and frequency of contractions In given report, weeks of gestation should be provided and not the months Provides more precise picture of age of infant (i.e.: premature or not) Case scenario #1 64
What indicates that delivery is imminent?
Crowning Bulging of the perineum Contractions that are lasting 60-75 seconds and coming every 2-3 minutes Urge to push Feeling that she wants to have a bowel movement Case scenario #1 65
What is assessed with the APGAR score? A – appearance or coloring Fingers and toes often bluish for a few minutes P – pulse Best to have a pulse over 100 beats per minute G – grimace or reflexes Grimacing, coughing, sneezing are good to see A – activity or muscle tone Want to see flexed extremities R – respiratory effort Want to hear a strong cry Case scenario #1 66
What are the interventions listed at the top of the inverted pyramid that each newborn typically receives? Drying – to prevent heat loss by evaporation Warming the infant to stop the heat loss Stimulation by touching and rubbing the infant Flicking the bottom of the feet or rubbing the back if more tactile stimulation is required Keeping the newborn in a head down position to facilitate drainage from the lungs Case scenario #2 67
EMS has arrived on the scene and determined that they will need to deliver a newborn During assessment and in preparation of the event, EMS notices dark, thick greenish-black flecks of material in the leaking bag of waters What does this indicate? Evidence of meconium staining What does this mean? If not a breech delivery, the fetus may be in distress and require extra resuscitative efforts Review new AHA guidelines concerning the presence of meconium. Case scenario #3 68
EMS is on the scene and has just assisted a mother in delivering her 3rd child The infant is not as responsive to drying and stimulation as EMS feels they should be and extremities are dusky- What direction should you provide? You want to provide blow-by oxygen How would you deliver blow-by oxygen? Hold a source of oxygen next to the infant's nose and mouth and let the oxygen source “blow-by” Case scenario #3 69
The infant is not responding to the blow-by efforts The respiratory rate is low and the heart rate is less than 100 What is the next intervention? Begin positive pressure ventilations at 40-60 breaths per minute Ventilate with small puffs of air Reevaluate every 30 seconds Case Scenario #3 70
What intervention would you recommend if the pulse remained between 60 and 100? Continue positive pressure ventilations Reassess every 30 seconds What would intervention would you recommend if the pulse dropped below 60 in the newborn? Begin chest compressions 3 compressions to 1 ventilation Depress the sternum 1/3 the AP diameter of the chest on lower half of sternum Case Scenario #4 71
EMS is on the scene for a patient who fell Upon EMS arrival they note on report an unresponsive adult on the floor who is obviously pregnant This patient is in a tonic-clonic seizure What is your general impression? First thought is eclampsia Need to consider an epileptic seizure Need to be thinking possible hypoglycemia Need to determine presence of head injury Case Scenario #4 72
What is your recommended actions during this on- going seizure activity? Protect the patient from harm Maintain a patent airway Suction available Turn patient on left side Also avoids supine hypotensive syndrome Consider supporting ventilations via BVM 1 breath every 5-6 seconds (10-12 breathe per minute) Obtain any medical history available Case Scenario #4 73
What medication is used in the presence of seizure activity in the patient who is pregnant? Versed 2mg IN/IVP/IO May repeat every 2 minutes titrated to desired effect Maximum dose of 10 mg If seizure activity continues or reoccurs, contact Medical Control for additional orders of Versed up to an additional 10 mg Case scenario #4 74
What would be important to be relayed in face to face hand-off report with this case once at the hospital? Fact that Versed was administered
Versed crosses the placental barrier
If administered close to the time of delivery, may witness side effects in the newborn related to the Versed
Respiratory depression
Hypotension Would be important for OB to try to differentiate if signs or symptoms are due to the condition of the newborn or related to interventions performed 75
Double Knotted Cord – found on delivery – Healthy Baby! 76
Copy and paste the link below to view delivery video
https://www.youtube.com/watch?v=AgkCmJNbEwo&oref=https%3A% 2F%2Fwww.youtube.com%2Fwatch%3Fv%3DAgkCmJNbEwo&has_veri fied=1 Bibliography 77
Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4th edition. Brady. 2013. Mistovich, J., Karren, K. Prehospital Emergency Care 9th Edition. Brady. 2010. Region X SOP’s; IDPH Approved April 10, 2014. http://www.primehealthchannel.com/fetal-alcohol-syndrome-pictures-symptoms-statistics- and-treatment.html http://www.emedicinehealth.com/postpartum_depression/article_em.htm http://www.nlm.nih.gov/medlineplus/ency/article/003402.htm http://www.pphprevention.org/pph.php http://calsprogram.org/manual/volume1/Section4_Path/05- PATH4NeonatalEmergencies13.html Highlights of the 2015 AHA Guidelines Update for CPR and ECC CMC EMS System, April 2014 CE Module