Your community is experiencing a major snowstorm.All road and air transportation into and out of the community is cut off.Many residents are experiencing power outages.The snow is continuing to fall and temperatures have dropped in the past few hours.You have been swamped trying to keep up with the emergencies and M.V.As on nearly impassable roads.

At 21:00 hrs. you are dispatched to a private residence on the outskirts of the community.Dispatch reports you are to respond to a 36-year-old female in labor.Dispatch reports the husband phoned looking for help as he thought the baby was coming and he was unable to drive his wife to the hospital.As they were talking, the phone went dead and they have been unable to re-establish contact.

Road conditions have deteriorated and the drive, which would normally take 20 minutes, takes you 45 minutes.As you approach the residence, you see a male frantically waving to you and flashing the porch light.He tells you his wife is about to deliver.He reports she is one week overdue with their first child.

You find the patient lying propped up on pillows in the bedroom.She appears to be experiencing a contraction as you enter the room and is concentrating on the pain and breathing.When the contraction subsides, she reports she is one week overdue and has had no problems during the pregnancy.She has one miscarriage three years ago.This is her first full term pregnancy.She was on fertility drugs prior to conception.She has seen her doctor regularly throughout the pregnancy and last had an appointment five days ago.The doctor reported everything was fine at that time, with the baby in a good position.

She has been experiencing mild, irregular contractions since early in the morning (approximately 4 a.m.).Her water broke around 6 p.m. this evening.She spoke to her doctor who suggested they get to the hospital when they could.Her husband has been trying to dig the car out of the snow and get it running.Approximately one hour ago the contractions suddenly became strong and regular, with shortening intervals in between.Approximately 40 minutes ago she vomited and began feeling the urge to push.While you are assessing her vitals she experiences another contraction which appears very intense and reports she “has to push.”She begins to bear down.You can see slight crowning while she is pushing.The contraction lasts 60 seconds and is repeated two minutes later.

1. Given the patients presentation, you should: A)   attempt to transport. B)    Prepare for delivery. 

2. Full term gestation is considered to be: A)   36 weeks. B)    38 weeks. C)    40 weeks. D)   42 weeks. 

3. This patient would be correctly described as: A)   para 1 gravida 1. B)    para 0 gravida 2. C)    para 2 gravida 1. D)   para 2 gravida 0. 

4. This patient is in: A)   first stage labour B)    second stage labour. C)    Third stage labour. D)   Fourth stage labour. 

5. Multipara patients are more likely to progress quickly through labour and deliver compared to nullipara patients. A)   true B)    False 

6. Effacement: A)   occurs during the third stage of labour. B)    refers to thinning of the cervix. C)    Refers to the emergence of the neonate’s face and head. D)   A and B are correct. 

7. Placenta previa is characterized by: A)   Nausea and vomiting. B)    Scant vaginal bleeding. C)    Painless, bright red bleeding. D)   Painful uterine contractions. 

8. The patient’s report of vomiting is lively indicative of: A)   Placenta previa. B)    Problems with the fetus. C)    Transition into second stage of labour. D)   None of the above. 

9. When crowning occurs: A)   Gentle pressure should be applied to the infant’s head. B)    Pulling on the infant’s head will aid in delivery. C)    Push the head against the mothers pushes. D)   None of the above. 

10. In a “normal” delivery, the infants mouth and nose should be suctioned: A)   after "complete" delivery. B)    After the head appears. C)    During shoulder and chest delivery. D)   None of the above. 

11. If the cord is wrapped around the infant’s head you should: A)   Attempt to slip it over the infant’s head. B)    Clamp and cut the cord. C)    Wait until the shoulders deliver to cut the cord. D)   A or B are acceptable. E)    All of the above. 

12. The umbilical cord should be clamped: A)   6 to 9 inches from the infant’s body. B)    As close to the infant’s body as possible. C)    In three places. D)   After "milking" the cord. 

13. The placenta should deliver: A)   concurrently with the infant. B)    Within two minutes of the infant’s birth. C)    Within twenty minutes of the infant’s birth. D)   None of the above. 

14. More than 500mL of blood loss after delivery is considered postpartum hemorrhage. A)   True B)    False 

15. Apgar scores should be determined before any infant resuscitation is initiated. A)   True B)    False 

16. Pain relief for this patient’s pain could be administered: A)   In the form of Demerol IM. B)    In the form of Morphine IM. C)    Only after delivery. D)   As nitrous oxide. 

17. A delivery is considered “premature” before: A)   41 weeks gestation. B)    40 weeks gestation. C)    37 weeks gestation. D)   36 weeks gestation. 

18. An obstetric history should include: A)   Length of gestation. B)    Maternal drug and alcohol abuse. C)    Recent infectious diseases. D)   All of the above. 

19. Trauma induced hypovolemia during pregnancy may not be evident until significant blood loss occurs. A)   True B)    False 

20. Meconium staining: A)   Refers to fetal stool in the amniotic fluid. B)    Refers to maternal stool in the amniotic fluid. C)    Increases the risk if perinatal mortality. D)   A and C. E)    All of the above. 

21. Post partum hemorrhage may be treated by: A)   Vaginal packing. B)    Uterine massage. C)    Oxytocin. D)   All of the above. E)    B and C only. 

22. Seizure activity associated with eclampsia may be treated with: A)   Airway management. B)    Diazepam C)    Magnesium sulfate. D)   B and C only. 

23. Ectopic pregnancy: A)   is a cause for third trimester bleeding. B)    May cause signs and symptoms of shock. C)    Is caused by partial detachment of the placenta. D)   A and C are correct. 

24. Spontaneous abortion: A)   Usually occurs before the 12th week of gestation. B)    Is common called miscarriage. C)    May be caused by abnormal placenta placement. D)   All of the above. 

25. Ways to improve on obstetrical calls include: A)   Hospital rotation through the delivery room. B)    Regular in-service. C)    Keeping up to date on neonatal certification. D)   All of the above. 

References – American Academy of Pediatrics, 1994.Pediatric Advanced Life Support.American Heart Association.

Saunders, Mick J., 1995 Mosby’s Paramedic Textbook. Toronto. Mosby Lifeline.

The answers to these questions are industry standards and may not necessarily be correct according to your local protocol.If there is any discrepancy between these answers and local protocol, please follow the protocol from your area as set out by your Medical Director.

Heather MacKenzie-Carey is a paramedic with over 18 years of EMS experience in Nova Scotia and Alberta.She has a Bachelor of Science Degree in Health Education from Dalhousie University, a diploma in Paramedicime from Northern Alberta Institute of Technology, and a certificate of Social Work from the University of Waterloo.Heather is an instructor for the Paramedic Program at Southern Alberta Institute of Technology.She can be reached at geomac@cadvision.com or www.turningpointgroup.com.

This Article is reprinted by permission from the author (Heather MacKenzie-Carey) and the Canadian Emergency News.