Street Drugs Update
Region VIII EMS Systems
Street Drugs
The Old, The New, The What?
Chicago Gang / Cartel Involvement
• Sinaloa cartel controls ~
45% of entire US drug
market
• Biggest cash generator in
Chicago is heroin
• High grade, white heroin
• Much less expensive than a
few years ago
Street Drugs Overview 2015
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Heroin
Synthetic Cannabinoids
2M2B (2-methyl-2-butanol)
MDMA / Exctasy / LSD / Bromo Dragonfly
Bath Salts / a-PVP / Flakka
Methoxetamine (Mexxy)
Krokodil
Party Pills
Drug Types
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Alcohol
Antidepressants
Anti-anxiety
Barbiturates
Cannabis
Club / Street
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Dissociative
Hallucinogens
Inhalants
Narcotics
Steroids
Stimulants
Nicotine
WHAT’S HOT ON THE STREET?
The Hot Corner
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Synthetic Cannabinoids
Flakka (alpha-PVP)
Fentanyl
Opana
MDMA / PMMA
• Heroin
Opioids
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Derived from the poppy plant, which contains opium
Cheaper, purity hard to judge
Dozens of formulations, including cough syrup
Obtained by
– Scamming doctors
– Burglarizing pharmacies
– Smuggling drugs / syrup in from Mexico
• Narcan more available
• Police
• BLS first responders
• Families / friends of opiate users
Sorting
the
Opium
• Opium contains 12% morphine plus
other analgesic alkaloids such as
codeine
• Used as a painkiller since ancient times
• Rx derived from opium AKA narcotics
» Morphine
» Codeine
» Heroin
» Oxycodone
» Hydrocodone
» Hydromorphone
» Methadone
» Fentanyl
Opana
• Chemical name: 4,5a-epoxy-3,14dihydroxy17-methylmorphinan-6-one
• AKA: oxymorphone hydrochloride,
Numorphan, Nucodan, Paramorphan, Blue
Heaven, Blues, Mrs. O, Orgasna IR, Pink,
biscuits, The O Bomb
• Category: semi-synthetic opioid
• Similar to: Oxycontin, heroin
• Actions: binds to the opiate receptors in the
brain, CNS depressant, pain relief and euphoria
Fentanyl (-laced heroin)
• Chemical name: fentanyl
• AKA: Apache, China girl, China white, dance fever, friend,
goodfella, jackpot, murder 8, TNT, Tango & Cash, as well as >
• Category: synthetic opiate
• Similar to: morphine (100x stronger per mL)
• Actions: binds to the body's opiate receptors, highly
concentrated in areas of the brain that control pain and
emotions, causing euphoria and relaxation
Spike in the number of East Coast overdose
deaths from heroin laced with fentanyl in
February through early May of 2015.
Purple Drank
• Codeine + Sprite + Jolly Ranchers
• If codeine unavailable, DM
(dextromethorphan) cough syrup is
substituted
• Produces euphoria and causes
motor skill impairment
Synthetic
Cathinones
• Amphetamine-like stimulant
found naturally in the Catha
eldus (AKA “khat”) plant
• Chemically similar to
amphetamines and MDMA
Catha edulis is a flowering plant native to the
Horn of Africa and the Arabian Peninsula.
Among communities from these areas, khat
chewing has a history as a social custom
dating back thousands of years.
Bath Salts
• Typically white or brown
crystalline powder
• Sold in small plastic or foil
packages
• Marked “NOT FOR HUMAN
CONSUMPTION”
• Taken orally, inhaled or injected
• Hallucinatory effects
Alpha-PDP
• Chemical name: alphapyrrolidinopentiophenone
• AKA: Flakka, Gravel
• Category: Synthetic cathinone /
chemically similar to “bath salts”
• Effects Similar to: Crystal Meth
• Actions: Central nervous system
stimulant
Helpful Hint: when something is labeled “Not for Human
Consumption”, it usually is not for human consumption.
MDMA
•
•
•
•
Chemical name: 3,4-methylenedioxy-methamphetamine
AKA: ecstasy, Molly
Category: Synthetic, psychoactive drug
Similar to:
– Stimulant amphetamine
– Hallucinogen mescaline
• Actions: feelings of increased energy, euphoria, emotional warmth
and empathy toward others, and distortions in sensory and time
perception.
The Problem
“No buyer of
molly knows
exactly what
he or she is
getting”
http://nymag.com/daily/intelligencer/2015/03/molly-drug-tests.html
Molly isn’t always herself
• Article authors bought six
samples of purported MDMA /
Molly and tested them
• Sample A – “Source was recommended to
the buyer by a friend “who claims his guy
always has pure, good stuff.” – MDMA
• Sample B – “User reports a “fun
experience, laughing, talking,” but adds
that it didn’t produce the usual “empathy
thing,” which made him suspect it wasn’t
molly.” – Ethylone
• Sample C - “Never seen it look like this,” notes
the buyer, who obtained it last Halloween. He
adds that it was a “good experience, less
intense than some.” – MDA (sibling of MDA)
• Sample D – “A friend of the buyer’s who tried it
said it was the best stuff he’d ever done.” –
MDA with two extra ingredients
• Sample E – “A yellowish powder that came from
a seller known for prescription meds” – Ethylone
• Sample F – “represented as MDMA from San
Francisco, where (rumor had it) the supply was
said to be purer.” - MDMA
Pump-It Powder
• Enhanced plant vitamin
• Methylexanamine is the active
ingredient, similar to Geranamine found
in the geranium plant
• Amphetamine and decongestant effects
• Can be snorted, injected or smoked
• “High” is delayed, resulting in some
users double or triple dosing
Krokodil (desomorphine)
• Street Names
– Russian Magic
– Cheornaya
– Himiya
• What / How
– Injected opioid (codeine combined with
other substances, frequently household
chemicals)
• Effects / Symptoms
– Fast-acting kick
– 8x effect of morphine
– Shorter half-life (< 2 hours)
Methoxetamine
• New “designer research chemical
product”
• Taken for hallucinogenic and
dissociative effects
• Analog to Ketamine
• Packaging reads “research chemical”
and “not for human consumption”
• Delayed high results in double dosing
Cyclic Antidepressant
• Trade names: Amitriptyline, Amoxapine, Desipramine (Norpramin),
Doxepin, Imipramine (Tofranil), Nortriptyline (Pamelor), Protriptyline (Vivactil),
Trimipramine (Surmontil), Maprotiline. All are tricyclics except for
Maprotiline, which is tetracyclic.
• Category: Cyclic antidepressants also affect other
chemical messengers, which can lead to a number of side
effects.
• Actions: Cyclic antidepressants block the absorption
(reuptake) of the neurotransmitters serotonin and
norepinephrine, making more of these chemicals
available in the brain.
Cyclic Antidepressant Overdose / Toxicity
Toxic Effect
Mechanism
Prolonged QRS complex / AV Block
Cardiac sodium channel → slowed depolarization in
atrioventricular node, His-Purkinje fibers, and ventricular
myocardium
Sinus tachycardia
Cholinergic blockade, inhibition of norepinephrine uptake
Ventricular tachycardia – monomorphic
Cardiac sodium channel inhibition – reentry
Ventricular tachycardia – Torsades de Pointes
Cardiac potassium channel inhibition – prolonged repolarization
Ventricular bradycardia
Impaired cardiac automaticity
Hypotension
Vascular alpha-adrenergic receptor blockade, cardiac sodium
channel inhibition, impaired excitation-contraction
Wide Complex Mess
Rhythm ECG in tricyclic overdose. (From Souhami RL, Moxham J: Textbook of
medicine, ed 4, London, 2002, Churchill Livingstone.)
Calcium Channel Blocker
• Trade names: Verapamil, diltiazem, nifedipine, nicardipine,
amlodipine, bepridil, felodipine, isradipine, nisoldipine
• Category: Calcium channel blockers
• Actions: Calcium channel antagonists block the slow L-type
calcium channels in the myocardium and vascular smooth
muscle, leading to coronary and peripheral vasodilation. They
also reduce cardiac contractility, depress SA nodal activity, and
slow AV conduction.
Overdose Effects
• Verapamil has the deadliest profile, combining severe myocardial
depression and peripheral vasodilation
• Verapamil and diltiazem act on the heart and blood vessels
• Dihydropyridines such as nifedipine cause primarily vasodilation
and subsequent reflex tachycardia
• Calcium antagonists have negative effects on heart rate,
contractility, conduction, and vascular tone
– Except for nifedipine which tend to result in tachycardia even in severe
toxicity
Clinical Presentation / Manifestations
Organ System
Manifestations / Effects
Cardiovascular
Hypotension, sinus bradycardia, sinus arrest, AV block, AV dissociation, junctional
rhythm, asystole (1)
Pulmonary
Respiratory depression, apnea, pulmonary edema, ARDS
Gastrointestinal
Nausea, vomiting, bowel infection (rare)
Neurologic
Lethargy, confusion, slurred speech, coma, seizures (uncommon), cerebral
infarction (rare)
Metabolic
Lactic acidosis, hyperglycemia (mild), hyperkalemia (mild)
Dermatologic
Flushing, diaphoresis, pallor, peripheral cyanosis
Beta Blocker
• Names: Acebutolol (Sectral), Atenolol (Tenormin), Betaxolol
(Kerlone), Bisoprolol/hydrochlorothiazide (Ziac), Bisoprolol
(Zebeta), Carteolol (Cartrol), Metoprolol (Lopressor, Toprol XL),
Nadolol (Corgard)
• Category: Beta-Adrenergic Blocking Agents
• Actions: Decreased chronotropic and inotropic action, lowers
blood pressure and cardiac workload
Overdose Effects
• Beta-adrenergic antagonist (ie, beta-blocker) toxicity can
produce clinical manifestations including bradycardia,
hypotension, arrhythmias, hypothermia, hypoglycemia,
and seizures.
• The presentation may range from asymptomatic to shock.
Beta Blocker Co-Ingestion
The outcome is significantly worse when these agents
are co-ingested with psychotropic or cardioactive
drugs. This is true even if the amount of beta-blocker
ingested is relatively small. The co-ingestants that most
markedly worsen prognosis include calcium channel
blockers, cyclic antidepressants, and neuroleptics.
These co-ingestions are the most important factor
associated with the development of cardiovascular
morbidity and mortality.
http://emedicine.medscape.com/article/813342-overview#aw2aab6b2b4
Clinical Presentation / Manifestations
Organ System
Manifestations / Effects
Cardiovascular
Bradycardia, hypotension
Neurologic
Decreased level of consciousness, seizures (cellular hypoxia from decreased
cardiac output), coma
Respiratory
Bronchospasm (more likely in patients with bronchospastic disease like asthma),
pulmonary edema (secondary to heart failure), respiratory arrest
Synthetic Cannabinoids
• Chemical name: Gosh only knows what is in these
(dried, shredded plant material with chemical additives)
• AKA: Spike, K2, fake weed, Yucatan Fire, Skunk, Moon
Rocks, Bliss, Black Mamba, Bombay Blue, Genie, Zohai
• Category: Psychoactive (mind-altering)
• Similar to: Cannabis
• Actions: Users report experiences similar to those
produced by marijuana—elevated mood, relaxation, and
altered perception—and in some cases the effects are
even stronger than those of marijuana. Some users
report psychotic effects like extreme anxiety, paranoia,
and hallucinations.
Dabs (BHO)
• Chemical name: Butane hash oil
(THC)
• AKA: BHO, Dabs, Wax
• Category: Psychoactive
• Similar to: Marijuana
• Actions: A drop or two is said to be
as potent as a joint, and can keep a
person high for more than a day
Transdermal Patches
• Legal or illegal patches which contain
medication or substances absorbed
transdermally
• Narcotics and analgesics
• Cannabinoids / THC
• Undiscovered patches can continue to
infuse medication during EMS contact
• Extreme situations seen where patients
chew patches to extract the substance
THC Puppy Chow
• Chemical name: THC
• AKA: Muddy Buddies, Marijuana-laced
foodstuffs
• Category: Psychoactive
• Actions: Similar to other cannabinoids
except the user may not know the food is
spiked
Pharm / Pharming / Punchbowl Party
• Attendees must bring pills to add to mix
• Most common among teens
• They bring whatever they can pilfer from
parents, grandparents, siblings,
neighbors
• Random handful = random effects
• Never quite sure of what you took
Assessment
Davidson's Principles and Practice of Medicine. Thomas, S.H.L.; White, J.. Published January 1, 2014. Pages 205-230. © 2014.
Clinical signs of poisoning by pharmaceutical agents and drugs of misuse.
Comprehensive
Exam of the
Poisoned
Patient
Davidson's Principles and Practice of Medicine.
Thomas, S.H.L.; White, J..
Published January 1, 2014. Pages 205-230. © 2014.
Zofran
MEDICATION OF THE MONTH
Zofran (ondansetron)
• Class – Antiemetic
• Dosage – 4 mg orally dissolving tablet, 4 mg / 2 mL
solution
• Action – Antiemetic, selective serotonin 5-HT3 receptor
antagonist, exact mechanism of antiemetic action not fully
understood
• Indications – Nausea, vomiting
• Contraindication – Hypersensitivity to ondansetron
• Side Effects – Diarrhea, headache, lightheadedness
Wide complex tachycardia caused by overdose (cyclic)
CARDIAC RHYTHM OF THE MONTH
Wide Complex Tachycardia
(sodium channel blockade)
http://lifeinthefastlane.com/ecg-library/basics/tca-overdose/
ZOFRAN IN THE NEWS
UNUSED MEDICATION DISPOSAL
ALS ENRICHMENT
Region VIII
• As of the time of this CE, the Region VIII EMS Medical
Directors have decided no change to standing orders at
this time
• If in doubt, contact Medical Control hospital prior to giving
Zofran to pregnant patients
What To Do With Unused Drugs
• Dr Phillips mentioned the probability that you have
unused medications in your medicine cabinet
• Where do you dispose of those in your area?
Alternative Birthing
Alternative Birth Movement
• Consumer reaction to medical obstetrical practices developed in the United
States early in this century.
• Settings developed as single labor- delivery rooms in the hospital or as free
standing birth centers
• Physician resistance based on maternal and infant safety
• Physicians fear economic competition and loss of control over obstetric
practices
History
• Until the 1930’s childbirth was truly dangerous
• High percentages of women and infants died during or soon after
childbirth
• Organized medicine began to take steps to lower mortality rate
• New medical specialty was founded called Obstetrics
• Prenatal care gained recognition for its benefits in preventing
death
History
• Childbirth moved from home to hospital with promise of more
controlled conditions
• Improvements in public health, public sanitation, and control of
chronic illness reduced dangers of childbirth
• 1940’s advances in antibiotics and blood banks
• 1950’s routine maternity care became very rigid in the hospital
setting
• 1960’s the natural childbirth movement began to gain momentum
History
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Mothers began to attend childbirth classes
Involved family members in birth process
Spent more time caring for their babies in the hospital setting.
1970’s saw the reemergence of the midwife as well as the use of
alternative settings for birth
• Hospitals began to offer more flexible family centered care and
more homelike rooms for birth
History
History
History
History
Current
Providers
• Obstetrician/Gynecologist
– Medical physician (MD/DO) who has completed residency in OB/GYN
• Certified Nurse Midwife
– Registered nurse who has completed graduate education/training in
midwifery and is an APN
• Direct-Entry/Certified/Professional Midwife
– Non RN who has completed education in midwifery
– Not licensed to practice midwifery in Illinois
Providers
• Doula
• Lay person (non-medical) who
provides physical assistance and
emotional support related to
childbirth
Certified Nurse Midwife
• Advanced Practice Nurse
– Registered Nurse
• Average of 2-4 years of nursing experience on OB/GYN, post partum,
or related area
– Graduate education (master’s or doctorate) and training in nurse
midwifery
– Certified by the American College of Nurse-Midwives Certification
Council
– Licensed in Illinois as APN
– Collaborate with OB-GYNs to care for women
Certified Nurse Midwife
• CNMs attend 10% of all spontaneous vaginal births in the United
States
– 7% of total births in United States
• 97% in hospitals
• 1.8% in freestanding birth centers
• 1% at home
• CNMs have been practicing in the United States since the 1920”s
Certified Nurse Midwife
• Scope of practice
– Primary Healthcare for women(adolescence to beyond menopause)
• Gynecologic, family planning services
• Preconception care
• Care during pregnancy, childbirth, and postpartum
– Monitor fetal development
– Manage acute and chronic illnesses of women
• Care of normal newborn during first 28 days of life
• Treatment of male partners for STD’s
Certified Nurse Midwife
• Scope of Practice
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–
–
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–
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Conduct physical examinations
Prescribe medications
May admit, manage, discharge patients from the hospital
Order, interpret laboratory and diagnostic tests
Order use of medical devices
Health promotion, disease prevention, wellness,
education/counseling
Certified Nurse Midwife
• Why nurse midwives
– Improved infant mortality rate in hospitals, birth centers for women
who are low risk
– Fewer C-section births for low-risk women
– Reduced use of unnecessary procedures
– Reduced healthcare costs
– Increases access to care
– Provides care to underserved,
– Rural areas, as well as urban
Certified Nurse Midwife
• Why nurse midwives?
– Low risk pregnancies account for 60-80% of all pregnancies
– CNMs consult with and refer to obstetricians, perinatologists and
other healthcare professionals when patient is not low risk
– 20-40% could have potential complications
– Complicated pregnancies are referred to obstetricians or comanaged by physicians and CNMs in hospitals
Certified Nurse Midwife
• Referral from home to hospital
– 7-18% antepartum for OB reasons
• Placenta previa, pregnancy-induced hypertension, pre-term,
intrauterine growth restriction
– 8-12% intrapartum referrals
• Failure to progress, prolonged rupture of membranes, meconium
staining, fetal distress, bleeding, hypertension
Certified Nurse Midwife
• 1-2 % post- partum maternal referrals
– Retained placenta, post partum hemorrhage, laceration repair
• 1-2 % neonatal referrals
– Inability to establish normal respiration, congenital abnormality, low
birth weight, low apgar score, birth trauma, sepsis
• Urgent transfer 1/1000
Certified Nurse Midwife
• What to expect for EMS
– Report
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Vital signs
Description of reason for the call
Description of current patient condition
Description of all actions taken to stabilize patient
History
Last menstrual period
Estimated due date/ Mother’s medical history
Gravida and para
Certified Nurse Midwife
• What to expect for EMS
– CNM is an expert resource that can be utilized by EMS to assist
with patient care
– CNM cannot ask EMS to administer medication outside of their
SOP’s
– CNM cannot ask EMS to perform any procedure outside of their
scope of practice.
– Usually will accompany patient to the hospital to continue care
– Also trained to provide newborn care
Certified Nurse Midwife
• Ensure that provider is a certified nurse midwife
• Non-licensed individuals may refer to themselves as “midwives”
• If the situation is questionable, contact Medical Control
immediately
Doulas
• A doula, also known as a birth companion and post-birth
supporter, is a non medical person who assists a woman before,
during, and/or after childbirth, as well as her spouse and/or family,
by providing physical assistance and emotional support
Doulas
Doulas
•
•
•
•
DO
Assist and coach prior to,
during, and after labor
Provide emotional support
Physical support and massage
Assist with non labor related
needs
DO NOT
• Physically aid in delivering
baby
• Provide medical advice
• Examine, diagnosis, or treat
medically
Doulas
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•
•
•
Formal education not required
Can participate in a training program
May also learn through an apprenticeship or mentorship
Certification highly recommended (Certified Labor Doula (CLD)
Doulas
• CAPPA is an international certification organization for Doulas
• The labor doula works with families during pregnancy, during
labor, in the birth process and in the immediate post partum
phase
• They can be found working in the community, in private practice,
in cooperatives, as part of groups or agencies, as well as serving
in various community programs
Childbirth
• Childbirth has not changed but many things associated with
childbirth have
–
–
–
–
–
Women’s expectations
Pain management options
Economics of childbirth
Healthcare system
Technology used during pregnancy and birth
Birthing Methods
• Birth practices have changed in the past 100 years
• The Cesarean section rate is approaching 30% in the United
States
• Labor induction is becoming more common. An estimate of 40%
of all women are induced
Birthing Methods
• Vaginal birth
– Most common method
– Can be done with/without pain medication
• Cesarean section
– Surgical method requiring incision in abdomen and uterus
– Longer recovery
– Best for women at risk for complications, birth defects, multiple
fetuses, or women with certain health conditions
Birthing Methods
• Home Birth
– Allows for birth in familiar surroundings
– Home birth not suitable for women with high blood pressure, heart
problems, or diabetes
– Should be prepared for possible transfer to a hospital should
complications occur
Water Birth
• Process of giving birth in a tub of warm water
• 25 U.S. Hospitals and 70% of all birth centers support water birth
• Water birth said to reduce anxiety, relax muscles, and speed up
labor, more holistic experience
• Reduces tearing of delicate tissues
• Emerged as widespread practice in Europe in 1980’s and 1990’s
Water Birth
• Water immersion in labor
• Water birth mother remains in the water during the pushing phase
and actual birth of baby
• Risk of infection concern of physicians
• Not recommended for breech births, twins or pregnancies with
risks of complications
• In 2014 the American College of Obstetricians and Gynecologists
and the AAP released a statement rejecting water births
Water Birth
• Breathing reflex in healthy
newborn babies does not kick
in until the baby’s face, nose
and mouth have been
stimulated by exposure to air
Hypnobirth
Hypnobirthing
• Self hypnosis in childbirth has been around for centuries
• Birthing women and their support partners are taught non
pharmacological strategies
Hypnobirth
• Hypnosis and self hypnosis during childbirth lead to:
–
–
–
–
–
Decreased average length of labor
Lower cesarean section rates
Decreased use of pain relief medication such as epidurals
Increased ease and comfort of labor and birth
Babies born under hypnosis tend to be calmer, more alert and better
sleepers and eaters
Acupuncture
• Acupuncture and acupressure alternatives to medical intervention
during labor
• Recommended to begin in the 36th or 37th week of pregnancy
leading up to birth
• Treatments help prepare uterus, pelvis, cervix for birth
encouraging efficient labor
• Pre birth acupuncture found women 35% less likely to be induced
and 31% less likely to have epidural
Acupuncture
Acupuncture
•
•
•
•
Acupuncture can be used in labor as well
Helps to increase and sustain contractions
Stimulates cervical dilation
Increases endorphin release (body’s natural coping mechanism
for pain)
• Acupressure can also be used to achieve similar results during
labor
• Also utilized post partum to promote healing, can decrease need
for pain medication post- partum
Birth Centers
• Home like facility, existing within a healthcare system with a
program of care designed in a wellness model of pregnancy and
birth.
• Birth centers are guided by principles of prevention, sensitivity,
safety, appropriate medical intervention and cost effectiveness
• They provide family centered care for healthy women before,
during and after normal pregnancy
Birth Centers
• Offers gynecologic and maternity care in safe, comfortable
environment
• Designed for healthy low risk mothers and healthy babies
• Involves the entire family in the pregnancy and birth
• Relaxed atmosphere
• Offers privacy
Birth Centers
• Women are encouraged to drink instead of routine IV’s
• Mother’s are not tied to electronic fetal monitoring
• Baby’s heartbeats are checked with handheld dopplers at regular
intervals
Birth Centers
•
•
•
•
•
Nurse Midwife is with mother throughout labor
Mother choses most comfortable position to give birth
Birth centers promote breastfeeding
No separation of mother and baby
All infant care done in front of family
Birth Centers
• Birth center is part of a medical care system
• If mother or baby develops a problem patient is transported to the
closest appropriate hospital
• Midwife may accompany mother to the hospital
• EMS should follow appropriate SOP’s
Birth Centers
• Low overall intrapartum and neonatal mortality rate
• Focus on creating healthy pregnancies and minimizing
interventions during labor
• No maternal mortality
• Neonatal mortality of 1.3/1000 births
• C-Section rate averages 4.4 percent compared to national
hospital average of 26%
OBSTETRICAL COMPLICATIONS
BLS/ALS
1. Initial Medical Care SOP, p. 4
2. HIGH FiO2 or VENTILATION
 ALS: If altered mental status or signs of hypoperfusion, IV FLUID BOLUS IN
200 mL increments titrated to patient response.
 Palpate abdomen to determine uterine tone and presence of contractions.
 Place mother on left side or raise right side of backboard 20-30°. Insert second
IV line if no response to initial fluids.
BLEEDING IN PREGNANCY
2. Note type, color and amount of bleeding and/or vaginal discharge. If tissue passes,
collect and bring to the hospital with the patient.
TOXEMIA IN PREGNANCY OR PREGNANCY INDUCED HYPERTENSION
2. HANDLE PATIENT GENTLY. Minimize CNS stimulation (avoid lights and siren).
DO NOT check pupil response. Seizure precautions.
3. ALS: If seizure occurs:
Administer VERSED (midazolam) 2 mg increments IV q 2 minutes up to 10 mg
total as necessary, titrated to control seizures.
Labor and Delivery Complications
• Premature rupture of membranes (PROM)
– Membranes rupture too early in pregnancy
– Exposes baby to high risk of infection
• Umbilical Cord Prolapse
– Cord can slip thru cervix after water breaks preceding baby thru birth
canal
– Blood flow becomes blocked
– Or stopped
Labor and Delivery Complications
• Cord stretches and is
compressed during labor
• Leads to decrease in blood
flow
• Can cause sudden drops on
fetal heart rate
• Occurs 1 in 10 deliveries
Labor and Delivery Complications
• Amniotic Fluid Embolism
–
–
–
–
–
Most serious complication of labor and delivery
Small amount of amniotic fluid enters mothers blood stream
Usually occurs during difficult labor or C-section
Fluid travels to lungs and causes arteries in lungs to constrict
Widespread blood clotting a common complication
EMERGENCY CHILDBIRTH
BLS/ALS
PHASE I: UNCOMPLICATED LABOR
1. Obtain history and determine if there is adequate time to transport
a. Gravida (number of pregnancies) and Para (number of live births).
b. Number of miscarriages, stillbirths, and multiple births.
c. Due date (expected date of confinement, “EDC”) or date of LMP (last menstrual
period).
d. Onset, duration, and frequency of contractions (time from beginning of one
contraction to beginning of the next).
e. Length of previous labors in hours.
f. Status of membranes, intact or ruptured. If ruptured, inspect for prolapsed cord
or evidence of meconium.
g. HIGH RISK CONCERNS:
o maternal drug abuse
o teenage pregnancy
o history of diabetes/hypertension/cardiovascular disease/other pre-existing
diseases that may compromise mother and/or fetus
o preterm labor (< 37 weeks)
o previous breech or C-section.
2. Inspect for bulging perineum, crowning, or whether patient is involuntarily pushing
with contractions. If contractions are two minutes apart with crowning or any of the
above are present, prepare for delivery. If delivery is not imminent, transport on left
side. DO NOT ATTEMPT TO RESTRAIN OR DELAY DELIVERY UNLESS
PROLAPSED CORD IS NOTED.
IF DELIVERY IS IMMINENT:
3. Initial Medical Care SOP, p. 4
a. If patient is hyperventilating, coach her to take slow deep breaths
b. ALS: If patient becomes hypotensive or lightheaded at any time:
 IV FLUID BOLUS in 200 mL increments
 HIGH FiO2 or VENTILATION
4. Position patient supine on a flat surface, if possible. Use standard precautions.
5. Open OB pack. Place drapes over the patient’s abdomen and beneath perineum.
EMERGENCY CHILDBIRTH (Continued)
PHASE II: DELIVERY
4. Control rate of delivery by placing palm of one hand over occiput. Protect perineum
with pressure from other hand.
5. If amniotic sac is still intact, gently twist or tear the membrane. Note presence or
absence of meconium.
6. Once the head is delivered, allow it to passively turn to one side.
7. Feel around the neck for the umbilical cord (nuchal cord). If present, attempt to gently
lift it over the head. If unsuccessful, double clamp and cut the cord between the
clamps.
8. To facilitate delivery of the upper shoulder, gently guide to head downward. Once the
upper shoulder is delivered, support and lift the head and neck slightly to deliver the
lower shoulder. Allow head to deliver passively.
9. The rest of the newborn should deliver quickly with one contraction. Firmly grasp the
newborn as it emerges. Newborn will be wet and slippery.
10. Keep newborn level with vagina until cord stops pulsating and is double clamped.
PHASE III: CARE OF THE NEWBORN
NOTE: The majority of newborns require no resuscitation beyond maintenance of temperature,
mild stimulation, and suctioning of the airway. Transport is indicated as soon as the airway is
secured and resuscitative interventions, if needed, are initiated. If the APGAR score is < 6 at 1
minute or meconium is present, begin resuscitation.
BLS / ALS
1. Pediatric Initial Medical Care SOP, p. 74
2. Deliver head and body
3. Clamp and cut cord
4. Assess neonatal risk factors:
 Term gestation?
 Clear amniotic fluid?
 Breathing or crying?
 Good muscle tone?
5. Provide basic care:
 Provide warmth
 Position; clear airway as needed with bulb syringe or large bore suction catheter
 Dry the newborn, stimulate and reposition as needed
6. Check respirations:
 If apneic and meconium present, clear airway and provide deep suctioning of the
oropharynx. Begin positive pressure ventilation at rate of 40-60 per minute using
neonatal BVM.
 If apneic without signs of meconium, begin positive pressure ventilation at rate of 4060 per minute using neonatal BVM.
7. Check heart rate:
 If heart rate > 100 BPM, check color
 If heart rate 60-100 BPM, continue ventilations for 1-2 minutes, reassess heart rate.
 If heart rate < 60 BPM, administer chest compressions for 30 seconds at a ratio of
3:1 with ventilations, reassess heart rate.
 If heart rate remains < 60 BPM, continue CPR.
State of Illinois
Abandoned Newborn
Infant Protection Act
Background
• Safe Haven Laws:
• Statutes in the United States that decriminalize the leaving of unharmed
infants with statutorily designated private persons so that the child becomes
the ward of the state
– Also known in some states as:
– Baby Moses Law
– Safe Place
– Safe Surrender
Background
• Texas was first state to enact a “Baby Moses Law” in
1999
• Safe place originates in Mobile, Alabama
• By 2008, all 50 states had a form of safe haven law
• As of 2013 no one has used the law in the state of Alaska
Summary of Act
• The Abandoned Newborn Infant Protection Act allows the
parent or parents of unwanted infants, 30 days old or less
to relinquish the newborn to a Safe Haven
• Regardless of the age of the child, If there are signs of
abuse or neglect, proceed as if the child were abused or
neglected with appropriate care and transport to a
medical facility at which time a DCFS report must be filed
• If the child is obviously older than the 30 day-age covered
Definitions
Newborn
• 30-days old or less
• Safe Haven
• Any fire station, police station, hospital and emergency
medical care
facility that is staffed 24-hours a day where the relinquishing parent may take
an unwanted newborn
• This excludes free standing medical facilities
• If a designated Safe Haven is not staffed 24-hours a day, the sign must read
“Only When Staff Are Present”
Immunity
• Receiving personnel are immune from criminal or civil liability for
acting in good faith in accordance with this Act
Presumptions Allowed by the Act
• It is presumed that the relinquishing parent consents to the
termination of his or her parental rights
• It is presumed that the relinquishing parent is the newborn infant’s
biological parent
Consent and Treatment
• Consent for Medical Treatment of the Newborn
– the act of relinquishing the newborn infant serves as implied consent for
medical treatment if necessary
• Treatment and Transport of the Newborn
– Medical treatment will be provided as necessary
– Any abandoned newborn or infant will be transported to the hospital by
ambulance
Relinquishing Parent’s Rights
• The relinquishing parent has the right to anonymity providing there is no
evidence of abuse or neglect
– If abuse or neglect is suspected at the time of relinquishment
notify law enforcement
• The relinquishing parent may return to the Safe Haven within 72 hours of
relinquishment to reclaim the infant
– Upon request by relinquishing parent, the name and location of
the hospital that the newborn was transferred to must be
provided
• The relinquishing parent may petition the State within 60-days of the
relinquishment to reclaim the infant