Eric Van Dusen: OB Emergencies (3/28/25)

And here we are. So, good morning, Everybody. It is March 28th, it's Friday. It is a Florida EMS webinar. I'm filming from somewhere not in Florida, but I didn't want to miss today because Eric Van Dusen and I've gotten to know each other over the last several years. And we last met in Indiana in French Lick. If you haven't been to French Lick, you gotta go. We had the opportunity to break bread. I learned a lot about him. He is, you know, he hails from South Dakota from, I think I'm saying it right, Eric Yankton.

Yep. Currently in Yankton and Yankton.

EMS flight paramedic simulation expert. And when we got to talking, he says that he does a lot on OB emergencies. And I said, please come on the Florida EMS webinar because we really need this information. So without any further ado, Eric, if you want to make any further introduction.

Sure.

Please, my friend, take it away. I appreciate you coming.

I. I appreciate it. Thank you very much. And I. I'm grateful for the opportunity to be able to present today.

In South Dakota, we had a mobile simulation truck that actually traveled throughout the. We had three of them, and I was in charge of one. And I was the only person on the crew that really delved into wanting to do ob. And we not only did EMS fire based OB training, but also hospital based. And so I was working with obstetricians, realm of specialty. And when I had several of them make comments of I learn a truckload when you come, I'm like, that's kind of strange considering I'm just a medic. But from the flight world, we got to fly with the maternal team and NICU team. And we live in a very rural frontier environment. And so the chances of us encountering this stuff is high.

You know, but when you look at the demographics across the country, I also spent a year in Vegas working with training medics in the valley. About 50% of the deliveries were at home. And so when do we get called for ems? When things go sideways. And when things go sideways, we need to be really prepared for it. And so I was excited Peter asked me to present on this. And so we'll jump into it. And of course, my title is I always imagine this. I have a twisted sense of humor because I work in ems. Most babies technically head out. You got to remember, I'm a dad and I'm a grandfather, so I have bad dad jokes all the time.

And it's strange because I have a lot of folks are like, you're unique because you like to do OB training and number one, you're a male, number two, you're, you're a medic. And so I, I just try to dive in as know as much as I can about the subject matter. So I've also worked mainly hospital based which is going to tie the two pieces together because we're the front line of healthcare and so what can we do to bridge that gap to get our patients from the hospital environment to the hospital environment in safe conditions and prepare their team for what's coming in? Again, I've never had a baby. I usually challenge all my listeners when I'm doing talks. How many of you delivered a baby and hands go up. I'm like, you're a dude, you've never delivered a baby. We are there to assist with the delivery and that is our job is to be a coach and to assist with that process.

So I can't describe what it's like having a baby. I'm not going to pretend to. However, it's funny because it's so easy you can do in the back of a taxi and that's why there's so many babies born and there's so many that are born at home or on the way to the hospital or wherever the circumstances may be. About 90% of all deliveries go without any resuscitative efforts. Things go pretty naturally. Our job is just to show up when and watch for those signs and symptoms when things do go sideways. The number of deliveries I've been involved in, we only had one extensive resuscitation. It was a 23 weeker, 680 grams and we were able to resuscitate it. One of the most intense codes you ever run as I'm doing compressions and ventilations on this 680 gram kiddo. Very focused but very simplistic. Most of us have learned our sample history. The one thing I want to highlight here are the medications.

We actually had a stint of circumstances in South Dakota where through the hormonal changes of pregnancy, moms were being put on some antidepressants. And what we found out is.

Babies would come out with some respiratory compromise, respiratory suppression. And so if you happen to know on their medication list or history that they're on any antidepressants that you should be prepared that there's a chance the baby could come out with some respiratory compromise when we start talking about the illicit drugs. The study came out in 2020, last one I actually saw, they're saying one in six babies were born with neonatal absentee syndrome, that's one every 54 minutes, which is a little higher than we want to see. And being from the center of the country rule, we're still seeing that even in our neck of the woods as well. So nobody's really immune to it.

Most of the medics I ever dealt with, they wanted nothing to do with ob. Their theory was duct tape their legs together in diesel. Some things that you can do if you do not want to try to deliver in the back of the ambulance, give them a fluid challenge. Causes smooth muscle relaxation. It's very simplistic. It's in your skill set, easy to do. Have them do some breathing techniques. Some agencies have the tokolytics, if you remember the acronym. It's not my time. Endomethacin, nifedipine, mag sulfate, terbutaline. I used to work for an agency. We use terbutaline for both.

Respiratory compromise and ob. And I had to use a couple different times just because they were pre 37 weeks. And I'm just not comfortable delivering before 37 weeks because there's no surfactant baby's lungs yet and I don't want to have to work a baby in the back of the ambulance by myself.

Ectopic pregnancies, you got to keep in mind any female of childbearing age, and you're talking from the age range of 8, 9 up until mid-40s with abdominal pain, you have to have a thought process that there could be an ectopic pregnancy or OB relation to it. As you can see, there are several different areas in the diagram or in the picture there that cover the different.

Areas of that. Let me high out laser pointer, not highlighter. 70% of them are ampullary. And then the rest of them drop off dramatically. And then you can see off to the right side of it some of the causes that cause ectopic pregnancy. And Peter and I had a conversation about DEs, or they call it Stilbestrol. I was a medication used from 1948 to 1971. And so this, this is actually going to come out of my slide deck at some point in time because no one's ever going to hear about this. It was the very first drug scandal in the United States. They were giving it to pregnant moms trying to minimize the risk of ectopic pregnancies and spontaneous abortions or miscarriages. And it actually increased the chances of having ectopic pregnancies and having complications. And so they've stopped using it. However, the children of these Parents. And so if your parents were, you know, having kids in the early late 60s, early 70s, there's a chance that their kids would have childbearing complications as well. So at some point in time, it's just not something you're ever going to hear about again.

Cord complications. One of the few times that we can interject.

We want to try to keep the, the baby's head from compressing the cord in there. Sometimes we can see the cord coming out of the vaginal canal. We've always been taught you place a gloved hand in there, trying to prevent the baby from engaging into the pelvic girdle, which is good.

We can. Bladder emptying is more of a hospital setting. It's not something we typically do in the EMS world. We can give tocolytics like the terbutaline and nifedipine and things like that, if you have those. But we want to try to protect the cord and we want to try to avoid palpation of the cord because sometimes it can cause some vasoconstriction, which is going to cause a little bit of compromise with baby. But basically, we need to get into the hospital. This becomes one of those, you need to get diesel. So they can go in and do a C section. The funnest scenario I ever did, I had five physicians that I was running them through, and they had to push the pregnant mom with the baby prolapse cord all the way through the hospital down to the surgical suite and slide her over. And they had no nursing staff to help out. And all the nurses are watching me follow them, go down the hallway with these physicians and are like, you must be pretty powerful, dude, to be able to get these physicians to do this. I'm like, no, they're. They're playing the game and they're playing it well. It's kind of fun to see.

One of the things that we also talk about extensively in the pre hospital setting when it comes to OB is placenta previa. I always talk about taking a latex balloon, drawing a smiley face on it and blowing it up. And as you blow it up, yes, the face gets bigger. But sometimes that face shifts with depending on where you draw it at. As the placenta starts to develop in the uterus and the uterus grows through the weeks, that placenta can migrate. And so if they've had prenatal care and they've had partial placenta previa, it can migrate up out of the way, and they can have a normal vaginal birth without a lot of Complications. Now, I want to talk about this just briefly because placenta previa. I was always taught that you have bright red bleeding and no pain. And the difference between that and placenta abruption is you have pain and no bleeding.

That's not necessarily true. And I want to point it out in the next slide deck or in the next couple slides here for you. But you can see here, this is where we would talk about a normal placental where it attaches to the decidua basalis.

Down here. Placental preview. This is a complete. We're not going to do anything with this in the field, but they're going through the laboring process. We need to get them to the hospital and let them know kind of what we're seeing. For signs and symptoms. You can see this partial placenta previa. If we give this another couple weeks, this placenta may actually migrate up and out of the way, but you may still see some bleeding with that. And so something to keep in mind.

Other placental complications. Placental abruptions. The.

Decidual basalis is actually the point. There's four different deciduas within the uterine cavity, but this is actually where the fertilized egg attaches and it's the weakest point. And I'm going to talk about that with another complication coming up.

But it becomes weakened. It detaches from the uterine wall and starts to collect blood. And as that weight starts to increase, it starts causing more of the placenta to tear away from the uterine wall, and you can end up with complete placenta abruption. Again, this is typically seen with no external bleeding. They do have extreme pain with it, but depending on where the placenta has attached to the uterine wall, you can end up with bleeding. So the two differentials is placenta previous, typically painless placenta abruption. They're going to have pain. There's four different classifications for placental abruptions, asymptomatic and mild. You're really not going to see anything. All their vital signs are within normal limits. Typically babies doing fine. So it kind of falls in line with your different classifications of shock. And then you hit your class two and three, which are your most severe. And we've got to be stepping infection, getting them going where we need to go. This will also tie into postpartum hemorrhage, which we'll talk about coming up as well.

Cuvilar uterus, also known as utero placental apoplexy, is associated with placental abruption. So I wanted to throw this in There. One of my maternal nurses actually flew for a gal and she had this. What's interesting is when you start looking at the statistics on cuvilar uterus, they typically will tell you it's benign, there's nothing super significant about it, there's no complications. However, 1% of the cases are life threatening and mom will need a total hysterectomy to offset this. The maternal nurse that I was working with had flown for a gal and she started to massage the fundus. And because they delivered baby, there were some complications with it. And as she was massaging the fundus, her entire abdomen started to turn black and blue. And I know that they get a little aggressive with massaging the fundus, but this is, that's not normal. And so actually it creates bleeding and ecchymosis throughout the entire uterus, creates leading complications, creates a breakdown on clotting cascade, if you will. And so they can either have massive hemorrhages or they can increase a risk for a pulmonary embolism. So something to keep in mind, watch out for your respiratory drive on your patients.

Talked about abruption a little bit, talked about the decidual basalis. I'm just going to jump into this one because this is something that was never taught in paramedic school to me. So you can see that a normal placenta will attach to the endometrium here. Placenta accreta will actually grow through the endometrium and start to attach itself to it. And then you can actually get placenta increta where it starts to grow into the myometrium, which is going to be a complication that you're not going to end up delivering this placenta pre hospital.