1. Don appropriate PPE.
2. Gather all required equipment
3. Explain procedure and expected outcome to patient.
4. Obtain consent.
5. Provide warmth and adequate lighting (as much as possible).
6. Position the patient supine on a firm surface with her head and shoulders slightly raised, legs flexed and abducted at hips and knees.
7. Visualize the perineum.
8. Place plastic sheet/bag/towel/drape under patient’s buttocks.
9. Observe for rupture of membranes (if not already ruptured) and note colour of fluid if possible.
10. With non-dominant hand guard the perineum with a 4x4
11. Deliver the head in a controlled fashion.
    • Apply gentle pressure to vertex (neonate’s head) to control delivery of the head.
12. Once head is delivered; allow restitution of head to occur naturally.
13. Observe for nuchal cord
    • If cord is present and loose, slip cord over baby’s head.
    • Only if nuchal cord is tight and cannot be slipped over baby’s head, clamp and cut the cord.
14. Encourage patient to push with next contraction (or sooner if restitution has occurred and patient ready to push).
15. Provide gentle lateral flexion, followed by gentle upward flexion to deliver shoulders and body.
16. Place newborn directly onto the patient’s abdomen, prone with head to the side allowing airway to drain (skin to skin for warmth).
17. Dry, stimulate newborn, and assess for tone, breathing and crying.
18. Note the time of delivery.
19. Cover newborn with new blanket/towel to maintain warmth. (Do not re-use towel/blanket used to dry newborn.)
20. Allow cord to pulse before clamping and cutting cord (at least 2 minutes) unless neonatal resuscitation is required or multips are known or suspected.
21. Clamp the umbilical cord in two places approximately 15 cm from the infant’s abdomen and approximately 5 cm apart.
22. Cut the umbilical cord using sterile (disposable) scissors
23. Assess for placental detachment.
    Placental Delivery:
24. Guarding the uterus; place a hand on the lower portion of the abdomen, just above the symphysis pubis in a cupped position (supporting the lower portion of the uterus).
25. With other hand apply gentle controlled cord traction (working with patient’s contractions) using up and downward motion; when membrane trail is seen; ask patient to cough or laugh and gently tease out membranes in an up and down motion, until completely delivered.
26. Perform external uterine massage (see procedure list).
27. Place placenta into provided plastic bag and transport with Mom and newborn. Label bag with patient’s name and document time of delivery.

1. Don appropriate PPE.
   Gather all required equipment.
2. Gain consent to inspect perineum for prolapsed cord.
3. Explain procedure and expected outcome to patient.
4. Consider extrication strategy.
5. As soon as possible assist patient into knee-chest position or exaggerated Sims position
6. Encourage, if cord has not retracted into the patient to breathe through contractions
7. Keep patient informed of your actions (you will feel me touch you…you will feel pressure etc.).
8. Gently cradle cord in hand and replace cord into the vagina; insert finger(s)/hand into vagina until you feel presenting part and apply manual digital pressure lifting it off the cord (this will be maintained until transfer of care at hospital. Ideally, do not remove hand until instructed to do so)

1. Don appropriate PPE.
2. Gather all required equipment
3. Explain Procedure and expected outcome to patient.
4.  Assess for signs of imminent shoulder dystocia birth.
5. Inform patient, support person(s) and second paramedic of the emergency situation.
6. Explain procedure and expected outcome to patient.
7. Obtain consent.
8. Position the patient supine on the edge of a firm surface (if possible).
9. Note time of baby’s head delivered:
   • You have 8 MINUTES to complete delivery from time head is delivered.
10. Perform ALARM manoeuvers.
11. If first ALARM unsuccessful:
    • Paramedic partner performs ALARM manoeuvers.
12. If second ALARM unsuccessful: Transport immediately.
    • Perform ALARM en route to the hospital (as safely as possible).
13. If successful delivery of baby:
    • Assess and monitor adult patient and newborn for Shoulder Dystocia Delivery complications.
    • Provide newborn care in accordance with the current BLS and ALS PCS.
    • Address complications in accordance with the current BLS and ALS PCS.

ALARM MANOEUVERS
Use the following 5 interventions.
A - Ask for assistance

1. 1. Ask patient to lay flat, on a firm surface (if not already done).
   2. Ask spouse/family/other healthcare professional to assist during ALARM.\
   3. Ask Paramedic Partner to assist during ALARM.

L - Legs abduction (MCROBERT’S MANOEUVER)
Hyperflex hips by lifting legs and knees.
Aim to:

1. 1. Bring knees to ears.
   2. Form a squatting position.
      Best performed by 2 people holding legs.

A - Adduct Shoulder (SUPRAPUBIC PRESSURE)

1. 1. Apply suprapubic pressure before the next contraction (to be performed by paramedic partner).
   2. Maintain throughout entire contraction.
   3. Instruct the patient to push in this position.
   4. Apply gentle downward lateral flexion of the head.

R - Roll Over (GASKIN MANOEUVER)
Perform Gaskin manoeuver (hands and knees).

1. 1. Ask patient to change position, rolling over onto hands-and-knees position.Apply upward lateral flexion of the baby’s head to facilitate delivery of the body.

M - Manually release posterior arm.
If hand visible:

1. 1. Follow humorous.
   2. Sweep arm across fetal chest and out.
   3. Deliver the posterior arm.

1. Don appropriate PPE.
2. Gather all required equipment
3. Explain Procedure and expected outcome to patient.
4. Obtain consent.
5. Assess for signs of imminent breech birth.
6. Position the patient to allow gravity to birth the baby.
   • Assist patient into an upright or supported squat position; OR
   • Bring buttocks to edge of bed, place feet on chair (if possible).
7. Hands off the breech.
8. Consider manual delivery of legs (if possible/necessary);
   • Apply pressure to the popliteal fossa once visible; AND
   • Gently sweep foot down and out.
9. Note time baby delivered to umbilicus.
   • You have 4 MINUTES to complete delivery of the head after umbilicus is visible
10. Consider manual delivery of arms (if possible/necessary);
    • If hand or elbow visible on fetal chest gently sweep hand down and out
11. Allow baby to descent with gravity.
12. Hands off the breech.
13. Another paramedic may apply gentle suprapubic pressure to maintain flexion of the head
14. Hands off the breech
15. Initiate Mauriceau-Smellie-Veit (MSV) Maneuver once:
    • Hairline/nape of the neck is visible; OR
    • Head does not deliver within 3 MINUTES after the umbilicus is visible
16. If head does NOT deliver:
    • Maintain MSV Maneuver and transport.
17. Once head delivers:
    • Assess and monitor adult patient and newborn for Breech Delivery complications.
    • Provide newborn care as per the current BLS and ALS PCS.
    • Address complications in accordance with BLS and ALS PCS.

MAURICEAU-SMELLIE-VEIT (MSV) MANOEUVER

1. Discourage the patient from pushing during the manoeuvre.
2. Support baby with forearm, palm supporting the chest.
   • Place second and fourth fingers on the malar bones (cheekbones) (not in the mouth).
   • Exert pressure on cheekbones to increase flexion of the neck.
3. Place other hand on baby’s back
   • Two fingers hooked over the shoulders.
   • Middle finger pushing the occiput to aid flexion.
4. Once hairline/nape of neck is visible:
   • Lift the body in an arc.
   • Assist the head to pivot around the symphysis pubis.
   • Allow face to delivered.
5. Ensure controlled delivery of the head.

1. Don appropriate PPE.
2. Gather all required equipment
3. Explain procedure and expected outcome to patient.
4. Obtain consent.
5. Assist with placental delivery utilizing controlled cord traction when signs of placental separation are observed:
   • Lengthening of the cord;
   • Sudden gush/trickle of blood from vagina with uterine contraction.
6. Conduct external uterine massage once the placenta has been delivered if the fundus remains soft/’boggy’ or there is continuous bleeding:
   • Place one hand on the lower portion of the abdomen, at the level of the symphysis pubis in a cupped position supporting the lower portion of the uterus.
   • Place one hand at the top of the uterine fundus. The uterus should now be palpable between the hands.
   • Begin massaging with the upper hand using a circular motion. The lower hand should remain still, supporting the lower portion of the uterus.
7. Continue massaging until post-partum bleeding stops.
8. If bleeding continues, perform:
   • External bi-manual compression; (see procedure list)
   • Encourage the patient to empty bladder

1. Don appropriate PPE.
2. Gather all required equipment
3. Explain Procedure and expected outcome to patient.
4. Obtain consent.
5. If not already performed/attempted:
   • Encourage infant latching/nipple stimulation.
   • Encourage patient to void her bladder.

Placenta In:

1. 1. Attempt to deliver the placenta; guarding the uterus use gentle controlled cord traction during contraction with the patient pushing.
   2. If the delivery of the placenta is unsuccessful and patient is exhibiting signs of post-partum hemorrhage; ensure resuscitative measures are in place and perform external bimanual compression as described below.

External Bi-Manual Compression:

1. 1. Place one hand on the lower portion of the abdomen, at the level of the symphysis pubis; cup hand, supporting the lower portion of the uterus.
   2. Place the other hand at the top of the uterine fundus. (The uterus should now be palpable between the hands.)
   3. Compress the uterus between each hand continuously compressing the uterus (perform for as long as possible; this may require rotation of providers) until post-partum hemorrhage stops.

Placenta Out:

1. 1. Perform external uterine massage (EUM).
   2. If EUM is unsuccessful, perform external bi-manual compression as described above

PREPARATION:
If Administering Medication via Syringe - NO Injection Port (includes preloads):

1. Remove the dust cap of the vial, or use a gauze/ampule cracker to safely crack the
   ampule and dispose of the top into a sharps container.
2. If using a vial, clean the top of the vial with an alcohol swab.
3. Attach a blunt tip needle to an appropriately sized syringe.
4. Fill the syringe to the desired volume, ensuring there is no air in the syringe. Be
   cautious of any medication overflow/spray.
5. Remove the blunt tip needle and dispose into a sharps container.
6. If the medication requires dilution, draw up the required amount of saline using an
   aseptic technique with a new blunt-tip needle.
7. Perform a medication cross-check with your partner, if available.
8. Dispose of the ampule/vial into a sharps container.

PROCEDURE:
If Administering Medication via Syringe - NO Injection Port (includes preloads):

1. Pre-oxygenate patient.
2. Remove ventilation adjuncts from ETT.
3. Inject medication directly into the ETT.
4. Re-attach ventilation adjuncts and continue with positive pressure ventilation (PPV).
5. Dispose of the preload or remaining medication into a sharps container.

If Administering Medication via Syringe - WITH Injection Port (includes preloads):

1. Continue oxygenation throughout the procedure.
2. Clean the injection port with an alcohol swab.
3. Inject medication directly into the injection port.
4. Dispose of the preload or remaining medication into a sharps container.

PREPARATION:

1. Locate the appropriate site: Proximal tibia site- located approximately 2 cm below the tibial tuberosity on the anteromedial aspect of the leg along the flat aspect of the tibia.
2. Clean the site with an aseptic technique.
3. Select the appropriate gauge needle:
   • < 1 year (appropriate gauge as per manufacturer) 18g.
   • > 1 year (appropriate gauge as per manufacturer) 16g.
4. Stabilize the bone with the non-dominant hand-index finger and thumb on either side of the tibia. In addition, it may be required to place a towel roll or sheet under the knee to assist with stabilization.
5. As a safety precaution, do not place your hand under the site to stabilize.

PROCEDURE:

1. Insert IO at 90 degrees through the skin.
2. Direct caudally away from the epiphyseal plate, begin a twisting motion with medium pressure.
3. Stop insertion once a loss of resistance is felt (tactile pop); this signifies the needle is within the marrow.
4. Remove the stylet and twist down the stabilizer (if needed). The catheter should feel firmly seated in the bone (1st confirmation of proper placement).
5. Attach the prefilled saline lock (optional) with a 10 ml syringe filled with saline to IO.
6. Aspirate for bone marrow.
7. If bone marrow is not aspirated, then attempt confirmation of intraosseous insertion by other means (flushes with no extravasation, IO needle at an appropriate depth, and inserted well into bone).
8. Flush with 8-10 ml NS in a syringe
9. Secure IO catheter in place.
10. Connect the IV set with the pressure infuser.
11. Fluid administration may be provided under a pressure infuser of 300 mmHg maximum or by a syringe to bolus for a more accurate method.

PROCEDURE:

1. Don appropriate PPE.
2. Gather all required equipment
3. Explain procedure and expected outcome to patient/guardian.
4. Obtain consent (if possible)
5. Locate and prep the appropriate site using aseptic technique: As authorized by local Base Hospital.
6. Select appropriate gauge needle and attach to drill:
   • EZ-IO® 45 mm Needle Set (yellow hub) should be considered for proximal humerus insertion in patients ≥40 kg or patients with excessive tissue over any insertion site.
   • EZ-IO® 25 mm Needle Set (blue hub) should be considered for patients ≥3 kg.
   • EZ-IO®15 mm Needle Set (pink hub) should be considered for patients 3-39 kg.
7. Attach needle to driver.
8. Insert needle.

Proximal Tibia – Adult and Pediatric <12 years of age

Pediatric:

1. Landmark anteromedial aspect of tibia, approximately 1 cm medial to the tibial tuberosity, or just below the patella (approximately 1 cm) and slightly medial (approximately 1 cm), along the flat aspect of the tibia
2. Gently drill, immediately release the trigger when you feel the loss of resistance as the needle set enters the medullary space.
3. Remove stylet from the catheter in a counter clockwise motion. The catheter should feel firmly seated in the bone (1st confirmation of proper placement).
4. Dispose of stylet into a sharps container.
5. Apply stabilizer (if available) over catheter and attach the primed extension to the catheter hub by twisting clockwise.
6. Aspirate for bone marrow (2nd confirmation of proper placement).
   • If bone marrow is not aspirated then attempt confirmation of intraosseous insertion by other means (flushes with no extravasation, IO needle at appropriate depth, site and inserted well into bone).
7. Flush the device with 10 ml normal saline checking for extravasation.
8. If no extravasation, attach primed line and secure arm in place across the abdomen.
9. Initiate infusion of appropriate fluid/drugs based on patient condition:
   • Use a pressure bag inflated to 300 mmHg for fluid infusion.
   • Discontinue infusion if extravasation occurs.

1. Assesses patient, donning appropriate PPE.
2. Identifies need for treatment. Patient meets indications for treatment under one or more Medical Directives.
   • Airway control AND
   • Other airway management is inadequate or ineffective
3. Confirms that conditions for treatment are satisfied
   • Lidocaine Spray – orotracheal intubation
   • AND that there are no contraindications to treatment
   • Lidocaine Spray – allergy or sensitivity to lidocaine, unresponsive patient
   • Age <50 years AND current episode of asthma exacerbation AND not in a near cardiac arrest.
4. Performs airway assessment using: LEMON
   • Look externally (facial trauma, large incisors, beard or moustache and large tongue).
   • Evaluate the 3-3-2 rule (incisor distance < 3 fingerbreadths, hyoid/mental distance < 3 fingerbreadths, thyroid-to-mouth distance < 2 fingerbreadths).
   • Mallampati (mallampati score > 3).
   • Obstruction (presence of any condition that could cause an obstructed airway)
   • Neck mobility (limited neck mobility).
5. Checks if patient has a gag reflex by oral airway insertion .
6. Suctions and clears the airway as required.
7. Pre-oxygenates. BVM with 100% O2 for 30-60 seconds.
8. Prepares ETT:
   • Chooses appropriate size
   • Checks for cuff leaks (injects maximum volume)
   • Deflates cuff
   • Lubricates distal end of ETT, if required
9. Precaution: C-Spine.
10. Inserts the ETT:
    • Pays attention to teeth for trauma
    • Identifies vocal cords
    • Depth of insertion adequate
    • Proper use of B-U-R-P maneuver
11. Confirms ETT placement using at least 2 primary methods:
    • ETCO2
    • Auscultation
    • AND one secondary method
    • EDD
    • other
12. Secures Endotracheal tube: SET protocol.
    • Placement / No displacement
    • Tube fixation
    • C-spine collar & Backboard
      • Clear/Plan/Command each patient movement
      • Verification after each patient movement
      • Documentation of ETT confirmation after each patient movement.
13. Troubleshooting ETT.
    • BVM and transport as initial back-up or after 2 ETT attempts
    • 2 attempts are defined as insertion of the laryngoscope into the mouth