OB's - Paramedics Checking Dilation

[captainstandup]

You made about nine really good points dust. I'm getting that OB book down right now. I think the part of this I have failed to understand is the discussion pertains to quite lengthy transports. I have always taught students the key to adequate patient care is good protocols and the key to excellent patient care is the ability to process a myriad of information, relate it back to the patients current situation, properly apply the protocols, and have the intellect to be prepared for a change in condition. Our service isn't in "down town LA" but we are about 30 minutes from a level II Trauma center with NICU and PICU 24 hours per day. I thinks this clouds my reasoning when presented with a scenario like this.

I like to think of myself as the patron saint of thinking out of the box "no pun intended"around our service and am often told "paramedics just take people to the hospital". These folks will be around here until they are so broken down they cant work anymore or will be forced out as EMS actually becomes a profession requiring education and folks that can adapt to an ever changing environment of care.

I'll be back on this one when I am better prepared to open my mouth...............

[Dustdevil]

Sweet! To be sure that nobody misunderstands my position here, I am very definitely not saying that this is anything that EMS in general is ready for. In fact, even in Spenac's situation, if they do it -- even with protocols and training -- they will get sued. Right or wrong, that's the nature of OB these days. This not just another monkey skill to be thrown out there with an eight-hour merit badge. To set this thing up will require more than just huge educational changes in his system. It will require revolutionary changes in EMS educational changes as a nationwide standard to establish our jobs as a licensed, educated, professional practice with a legislated scope. It will require a complete and total change in how paramedics are perceived by the government, the medical community, the insurers, and of course, by the public we serve.

I never said any of this was easy. I just said that, in order to provide optimum care under the conditions that Spenac describes, this would be part of the practice. Optimum care is what I am all about.

[tniuqs]

Spenac, I agree with you that in your scenario, the ability to check for dilation may be helpful. But if you are using it to determine if a woman is in labor is not a quantifiable reason. A woman can dilate and not be in labor. A better way to do this is to rest your hands on the womans abdomen and feel for consistent hardening of the entire abdomen. There should be no soft spots. When you feel this, you begin timing these "contractions". I have used this on two non-English speaking patients. This avoids the risk of introducing any type of bacteria into the vagina and cervix. If after monitoring the patient for contractions you note that they are two minutes or less apart, then yes, a more internal check should be performed.

Some very good teaching points coming out of this thread, I do agree that Intrapartal assessment can introduce bacteria yet this is a very common procedure in the Mat wards, properly done (as clean as possible) the risk is decresed, this would be a note to add. I was very fortunate to work with a MidWife (from the UK) she was a most excellent preceptor and worked directly in a Mat Unit, determining position of the kid is not dificult to learn, engagement of head a biggy. ps Head is hard, Bum is soft.....this in itself can be very vauable information.

I would also like to respond to tniuqs. You asked how an OB can miss placenta previa. As has already been stated, they depend on ultrasound for an internal picture of the uterus. I do not know the exact details, as I did not ask the OB when it happened, but I do know that ultrasounds don't always show a clear picture of what is going on.

It is my experiance that reading of ultrasound is fairly accurate, the reason I comment is that I have had a few "stat" transports of Mat patients when a diaphragmatic hernia is observed, this has been lifesaving for the kid as rapid transport to a center capable of ECMO...that is a heart lung bypass preformed at birth to allow surgeons to repair, in the past was 100% death rate, now about ~ 80 % survive....this is directly due to an educated OB or DI imaging and correct Dx.

Often times, the placenta is initially attached low in the uterus and as the baby and uterus grow, the placenta rises to it's normal position.

I could be wrong here but once the placenta is implanted, migration would be rather difficult, I would think? If I remember correctly it is about 10 days after fertilization that implantation occures, the blastocyst stage of development if I recall ?

I also know that this OB does not do constant ultrasounds on his patients unless he has reason to believe there is something amiss.

Ultra sound here is a bit more routine as possibly the costs are lower? dunno, I think we are comparing apples and grapefruit, usually done routinely upon initial positive "kill the rabbit test" stage, although most likely looking for heart beating, not disgnostic and if for any other reasonable question, unexplained bleeding +++ decreased fetal movement stuff like that.

This patient was progressing normally during her pregnancy and subsequent labor. She did not exhibit the normal excessive bleeding associated with placenta previa. If anything, she bled less than normal. Maybe that should have been the tipoff. When she came in for delivery, her contractions were three minutes apart and the OB happened to be on the floor as he had just delivered another baby. He went in to check for dilation and that's when all hell broke loose. She ended up having an emergency cesarian. It does not take much force to rupture a placenta enough to excessively bleed. You have to remember, OBs are human, they are not machines that never make mistakes and they aren't going to catch everything.

WHAT are you saying....MDs are not Gods? I sure hope ERdoc does not see this ! :shock:

....... checking for dilation is not going to assist the provider or change their direction of care.

Sorry disagree here but 15 minutes transport is not even a consideration when flying in VERY remote areas....(look back at my senario if you wish) it can take up to 5 hours by aircraft to get to definative care center....oh yes indeed.

Now if a provider is placed ... edited for redundancy

Agreed, again good post.

cheers

[captainstandup]

In your crunching, have you been able to come up with a transport time of an hour or more, yet? If so, then this should be pretty self-explanatory, considering all that has already been said. If not, then please continue crunching. Many medical questions cannot be answered in "several minutes," once you begin to think above the DOT level.

To lead you in the right direction, ask yourself this; how could this information be so absolutely vital to the hospital staff, yet worthless to us? What are they getting from it that we would not, and why would it not benefit us?

If you are thoroughly educated and experienced in the L&D process, and aware of the significance of all that is learned from vaginal checks in both the full-term and pre-term pregnancy, but still don't think this is appropriate for EMS on any level, then we have a legitimate discussion on our hands. But if this is simply your way of saying, "I don't need to know all that" without even knowing what it is that you do not know, then we're wasting our time here.

I thought you would like to know I was wrong on this dilation issue! I had a patient last month, interfacility transfer for OB emergency, 32 weeks, ruptured membranes, dilated and effaced, anyway we made the 98 minute transport without delivery. I was a very happy boy too. Extremely complicated maternal history including pre eclampsia, GDM, Pregnancy induced hypertension and a history of meth and marijuana use. Anyway my friends in L&D and an OB specialist are assisting me with a better understanding of the technique and assessment pearls. Just though you might want to know.

[Dustdevil]

Wait, that's different.

I ain't puttin' my fingers in no crack mama! :puke:

[captainstandup]

Why dust, one you get past the odor, drainage, bug infestation and sores they are just like every other female, aren't they?

I didn't put mine in there either, but it did illustrate my need for better understanding of the procedure.

[spenac]

So it is possible that checking dilation, checking baby position could actually be beneficial in the descion making process especially on long transports. I agree with Dusts many months ago post that it would require much more education, which seems to be the theme on this site when we discuss making any progress in EMS.