CLINICAL PRACTICE GUIDELINES HPCSA

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Abbreviations,ACS Acute Coronary Syndromes,AEA Ambulance Emergency Assistant. AFEM The African Federation for Emergency Medicine. AHA American Heart Association,ALS Advanced Life Support. ANT Ambulance Emergency Technician,BAA Basic Ambulance Assistant. BEMC Bachelor s in Emergency Medical Care,BLS Basic Life Support. CCA Critical Care Assistant,CEBHC Centre for Evidence based Health Care.
COPD Chronic Obstructive Pulmonary Disease,CPG Clinical Practice Guideline. CPR Cardiopulmonary Resuscitation,EC Emergency Care. ECSSA Emergency Care Society of South Africa,ECA Emergency Care Assistant. ECP Emergency Care Practitioner,ECT Emergency Care Technician. EM Emergency Medicine,EMSSA Emergency Medicine Society of South Africa.
ENSSA Emergency Nurses Society of South Africa,Epinephrine Adrenaline. HPCSA Health Professions Council of South Africa,ICU Intensive Care Unit. ILCOR International Liaison Committee on Resuscitation. ILS Intermediate Life Support,IM Intramuscular Intramuscularly. IMD Invasive Meningococcal Disease,IO Intraosseous Intraosseously. IV Intravenous Intravenously,ND EMC National Diploma in Emergency Medical Care.
NICU Neonatal Intensive Care Unit, NIV NPPV Positive Pressure Non Invasive Ventilation. NSTEMI Non ST Elevation Myocardial Infarction,PaCO2 Partial Pressure of Carbon Dioxide. PBEC Professional Board for Emergency Care,PR Per Rectum. STEMI ST Elevation Myocardial Infarction,SVT Supraventricular Tachycardia. TCA Tricyclic Antidepressant,VF Ventricular Fibrillation.
VT Ventricular Tachycardia,Recommendations, The following depicts the purpose of the various text boxes. Practice point Aims to guide clinicians in how to perform the. recommendation in practice, Implementation point Clarifies the context of a recommendation. Cross reference Identifies other useful recommendations sections. Definitions, Clinical advice seeking consultation with providers of an individual an individual registered as. an Emergency Care Practitioner Emergency Medicine Physician or appropriate healthcare. professional specialist,1 Obstetrics Gynaecology, There were no evidence based clinical practice guidelines addressing obstetric issues from a. purely pre hospital emergency services perspective Despite this there were many high quality. recommendations from in hospital and other types of health facilities e g midwife run delivery. units which are directly applicable to pre hospital management of obstetrics The delivery and. birth process will ideally not occur in the pre hospital environment but every practitioner needs. to be able to manage a delivery and to intervene where necessary within the limits of their. scope of practice,1 1 Normal Delivery, A normal birth is defined by the WHO as spontaneous in onset low risk at the start of labour.
and remaining so throughout labour and delivery The infant is born spontaneously in the vertex. position between 37 and 42 completed weeks of pregnancy After birth mother and infant are. in good condition World Health Organization 1996 The role of the EMS practitioner is to. provide comfort and support for the mother and newborn and to monitor and assist where. necessary while transferring to the appropriate health facility However an apparently low risk. normal delivery can complicate without warning at any stage so the definition is often applied. retrospectively, Healthcare professionals and other staff caring for women in labour should establish an. empathetic relationship with women in labour and ask them about their expectations and. needs so that they can support and guide them being aware at all times of the importance of. their attitude the tone of voice used the words used and the manner in which care is provided. Australian Resuscitation Council 2011, The first stage of labour begins from the onset of labour onset of regular labour pains until the. second stage of labour During the first stage lasting on average 5 8 hours mothers require. reassurance comfort and support hydration and appropriate pain relief where necessary The. second stage of labour is usually faster commencing when the cervix is fully dilated and the. foetus is expelled The initial passive phase precedes the active phase where there are. expulsive contractions maternal pushing and the foetus becomes visible During the active. phase mothers should be encouraged to push and the foetus supported as it emerges. In the presence of foetal distress it may be appropriate to expedite delivery by encouraging. the mother to push earlier than the recommended active phase at the end of the second stage. Foetal distress during labour is suspected when the foetal heart rate is. abnormally high or low It should be managed as follows pre hospital. Explain the problem to the woman,Place the woman in the left lateral position. Stop oxytocin infusion if applicable, Give oxygen by face mask at 6 L min for 20 30 minutes. Start an intravenous IV infusion of Ringer s lactate to run at 240. mL hour for 1 2 hours unless the woman is hypertensive or has. cardiac disease, Consider transferring the patient to a facility with the capability.
to perform a caesarean section, The third stage starts immediately after delivery of the baby and ends with delivery of the. placenta This would normally occur spontaneously within 30 minutes Australian Resuscitation. Council 2011, The active method of managing the third stage is recommended to. prevent excessive bleeding National Department of Health Republic of. South Africa 2015, Immediately after delivery of the baby ensure by abdominal. palpation that there is no previously undiagnosed second twin. even if antenatal ultrasound found a singleton pregnancy. If there is no second twin immediately give oxytocin 10 units. intramuscularly IM, Await uterine contraction for 2 3 minutes then feel for uterine. contraction every 30 seconds, Do not massage or squeeze the uterus with the placenta still.
When the uterus is felt to contract put steady tension on the. umbilical cord with the right hand while pushing the uterus. upwards with the left hand, Deliver the placenta by applying continuous gentle traction on. the umbilical cord, The fourth stage is defined as the first hour after delivery of the placenta The woman is at risk for. postpartum haemorrhage and must be observed National Department of Health Republic of. South Africa 2015, 1 1 1 Women in labour should be treated with the utmost respect and should be fully informed. and involved in decision making To facilitate this healthcare professionals and other. staff caring for them should establish an empathetic relationship with women in labour. and ask them about their expectations and needs so that they can support and guide. them being aware at all times of the importance of their attitude the tone of voice used. the words used and the manner in which care is provided Australian Resuscitation Council 2011. Evidence from non analytical studies such as case reports and case series or expert opinion or evidence. extrapolated from well conducted cohort or case and control studies with low risk of bias and a moderate. probability of establishing a causal relationship, 1 1 2 Women should be encouraged and helped to adopt any position they find comfortable. during the first stage and to be mobile if they wish following a check of motor and. proprioceptive block adapted, 1 1 3 Spontaneous pushing is recommended If there is no pushing sensation pushing should.
not be directed until the passive phase of the second stage of labour has ended Australian. Resuscitation Council 2011, Evidence from at least one meta analysis systematic review or clinical trial rated as high quality or well. 1 1 4 The perineum should be actively protected using controlled deflection of the foetal head. asking the woman not to push Australian Resuscitation Council 2011. Evidence from high quality systematic reviews of cohort or case and control studies cohort or case and. control studies with very low risk of bias and with high probability of establishing a causal relationship or. extrapolated evidence from high quality or well conducted meta analyses systematic reviews of clinical. trials or high quality clinical trials, 1 1 5 The duration of the third stage of labour is considered to be delayed if it is not complete. within 30 minutes after birth of the neonate with active management or within 60 minutes. with a spontaneous third stage Australian Resuscitation Council 2011. Evidence from non analytical studies such as case reports and case series or expert opinion or evidence. extrapolated from well conducted cohort or case and control studies with low risk of bias and a moderate. probability of establishing a causal relationship, 1 1 6 Active management of delivery is recommended Australian Resuscitation Council 2011. Evidence from at least one meta analysis systematic review or clinical trial rated as high quality or well. 1 1 7 Oxytocin should be used routinely in the third stage of labour Australian Resuscitation Council 2011. Evidence from at least one meta analysis systematic review or clinical trial rated as high quality or well. 1 1 8 The mother s expectations for pain relief during labour should be met as far as is possible. Australian Resuscitation Council 2011, Evidence from high quality systematic reviews of cohort or case and control studies cohort or case and. control studies with very low risk of bias and with high probability of establishing a causal relationship or. extrapolated evidence from high quality or well conducted meta analyses systematic reviews of clinical. trials or high quality clinical trials, 1 1 9 Inhaling nitrous oxide is recommended during labour as a pain relief method women.
should be informed that its analgesic effect is moderate and that it can cause nausea. and vomiting somnolence and altered memories Australian Resuscitation Council 2011. Evidence from high quality systematic reviews of cohort or case and control studies cohort or case and. control studies with very low risk of bias and with high probability of establishing a causal relationship or. extrapolated evidence from high quality or well conducted meta analyses systematic reviews of clinical. trials or high quality clinical trials, 1 1 10 If parenteral opioids are chosen as analgesia patients should be informed that they have. a limited analgesic effect and can cause nausea and vomiting Australian Resuscitation Council 2011. Evidence from at least one meta analysis systematic review or clinical trial rated as high quality or well. 1 1 11 Anti emetics should be considered when IV or IM opioids are used adapted. 1 2 Newborn Care, For a foetus in distress requiring resuscitation there should be. immediate cord clamping to facilitate optimal resuscitation. Otherwise delayed cord clamping would usually be advocated. ie clamp the umbilical cord after the second minute or after it. stops pulsing Australian Resuscitation Council 2011. Assess the baby s Apgar score at 1 minute National Department. of Health Republic of South Africa 2015, To keep the baby warm he or she should be covered and dried. with a blanket or towel that has previously been warmed whilst. maintaining skin to skin contact with the mother Australian. Resuscitation Council 2011, The mother and baby should not be separated for the first hour. or until the first feed has been given During this period the. midwife should remain vigilant and periodically observe. interfering as little as possible in the relationship between the. mother and neonate checking the neonate s vital signs colour. respiratory movements tone and if necessary heart rate. Australian Resuscitation Council 2011, 1 2 1 Delayed clamping of the umbilical cord is recommended Australian Resuscitation Council 2011.
Evidence from at least one meta analysis systematic review or clinical trial rated as high quality or well. 1 2 2 Women should have skin to skin contact with their babies immediately after birth Australian. Resuscitation Council 2011, Evidence from at least one meta analysis systematic review or clinical trial rated as high quality or well. 1 2 3 Breastfeeding should be encouraged as soon as possible after birth preferably within the. first hour Australian Resuscitation Council 2011, Evidence from at least one meta analysis systematic review or clinical trial rated as high quality or well. 1 2 4 Systematic oropharyngeal and nasopharyngeal aspiration are not recommended for. neonates Australian Resuscitation Council 2011, Evidence from at least one meta analysis systematic review or clinical trial rated as high quality or well. 1 3 Abnormal Delivery,1 3 1 Shoulder Dystocia, In shoulder dystocia delivery of the baby s head is not followed by delivery of the rest of the. body because the shoulders are too broad and become stuck in the pelvis This usually happens. with large babies 3 5 kg National Department of Health Republic of South Africa 2015. There can be significant perinatal morbidity and mortality associated with the condition even. when it is managed appropriately Maternal morbidity is increased particularly the incidence. of postpartum haemorrhage 11 as well as third and fourth degree perineal tears 3 8. Brachial plexus injury BPI is one of the most important foetal complications of shoulder dystocia. complicating 2 3 to 16 of such deliveries Royal College of Obstetricians and Gynaecologists. clinical practice guideline is used during all clinical encounters Where not applicable all reasonable locally contextual standards of care apply to clinical encounters The deadline for the adoption of the revised list of capabilities and medications by registered persons is the 31st of December 2018 It is however acknowledged that the

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