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This fit begins with restlessness, the face twitches and the eyes roll. This stage is followed by a tonic phase where the body goes completely rigid, the jaw is clenched, the head thrown back, the eyes turn up and the back arches. Due to the spasm of the respiratory muscles, respiration is stopped.

The tonic stage is followed by rapid convulsions that affect the whole body. The convulsions usually only last two or three minutes, after which the patient will subside into coma. Due to the fact that the patient is unconscious during the fit they may be incontinent.

During the fit, the patient should be prevented from hurting themselves, not by restraint, but by guiding the limbs and head away from harmful objects. The patient should not be moved during this time, although this may be necessary if danger is imminent.

Once the convulsive stage is over the patient must be kept warm, quiet and away from bright lights, as these things can provoke another fit.

The patient should only be moved on the authority of a doctor. If this is not possible, then movement should be extremely careful and not rushed. Oxygen therapy can be administered if available


Postpartum haemorrhage

what is it

Postpartum haemorrhage

This excessive bleeding, up to 24 hours after the birth, can vary from patient to patient and from as much as half a litre in a large woman to just a little from a smaller woman. In any event the outcome will be signs of shock and eventual collapse.

Bleeding after this time is known as secondary postpartum haemorrhage.

Normal bleeding is controlled by the contractions and retraction of the uterine muscles, coupled with contractions of the arteries themselves, clotting of blood in torn vessels and opposition of the anterior and posterior walls of the uterus.

It is only when these natural processes are hindered, eg not all the placenta has been expelled from the uterus, that postpartum haemorrhage occurs.


What kinds of haemorrhage can happen with pregnancy

Accidental haemorrhage

This usually occurs as a result of toxaemia, but can be caused by strenuous exercise, stress or falling. It is more common in hypertensive (high blood pressure) patients and in multiparae (those who have had more than one pregnancy).

It can be divided into three main types:

Revealed haemorrhage
This is when all the blood passes via the vagina - it is the least dangerous type.


Concealed haemorrhage
This is the most dangerous condition, the only symptoms being sudden severe pain, shock and collapse. The womb is very hard and tender, there is no vaginal bleeding and the pulse is thready and rapid.

Combined haemorrhage
This is bleeding that starts out as concealed, but later becomes revealed. This too is a very serious cond

Unavoidable haemorrhage

Sometimes called placenta praevia and exists when the placenta develops in the lower uterine segment, partially covering the internal os.

As the lower uterine segment stretches in the later weeks, the placenta is prematurely separated from the uterine wall.

There is no pain and the only symptom is vaginal bleeding and a history of bleeding during pregnancy



Sometimes called miscarriage, abortion is the termination of the pregnancy before the 24th week of development. It can be threatened, incomplete or complete abortion.

The actual haemorrhage of an abortion usually stems from the decidua but ends up as revealed haemorrhage via the vagina



How does the female reproductive system work

Fallopian tubes

Fallopian tubes

There are two fallopian tubes extending from either side of the uterus. They are around 10cm long and lie in the upper margin of the broad ligament. The outer end of each tube is trumpet like and enters the peritoneal cavity where the fimbrae on the end surround the ovaries. The fimbrae collect the ovum as it is released from the ovary.

The tubes have muscular walls continuous with that of the uterus. The outer coat is of peritoneum and the inner is of ciliated epithelium. The cilia wave back and forth in order to move the ovum along the length of the tube until it reaches the uterus.

The fertilisation of the ovum with spermatozoa usually takes place within the fallopian tubes


How does the female reproductive system work



The uterus is a pear-shaped organ that is approximately 8cm long and 5cm wide. The organ lies between the bladder and the rectum. The uterus receives its blood supply from the following arteries:

Ovarian arteries - branches off the abdominal aorta

Uterine arteries - branches off the internal iliac artery

The accompanying veins drain back into the inferior vena cava.

Although the uterus does receive some stimulus from the sympathetic nervous system, its own individual stimulus means that it can contract totally independently of both spinal and sympathetic systems.

The uterus has several major functions:

To receive fertilised ovum and retain and nourish the foetus throughout pregnancy

To expel the foetus at full term by muscle contraction

To play a part in menstruation


How does the female reproductive system work



This is the canal that leads downwards and forwards from the cervix to its lower orifice in the vulva. It is lined by a thin type of skin that is thrown into a number of folds and is kept moist by the secretion of the mucous glands that are present in the cervix.

This secretion is slightly acid due to lactic acid.


How does the female reproductive system work



There are two ovaries, one attached to the posterior aspect of the broad ligament on either side of the uterus. They lie directly below each fallopian tube, as they form an arch over them. The ovary can be described as having a medulla in the centre, mainly of fibrous tissue, a cortex of epithelium, and a number of cystic sacks called graafian follicles. These contain the ova surrounded by a little fluid.

The graafian follicle gradually works its way to the surface of the ovary where it ruptures. After it has ruptured, the ovum is released into the peritoneal cavity , but is almost immediately captured by the fimbrae of the fallopian tubes. Fimbrae are fringe-like processes that surround the ovary. The ruptured graafian follicle then develops into a solid yellowish body called the corpus luteum, which is responsible for the secretion of progesterone.

If the ovum is fertilised, the corpus luteum continues to develop throughout the duration of the pregnancy.

Progesterone is responsible for sensitising the mucous membrane of the uterus in preparation for the reception of the fertilised ovum and also for restricting the growth of further graafian follicles during the pregnancy. If the ovum is not fertilised the corpus luteum continues to develop only until the next menstrual period, when it gradually disappears to be replaced by fibrous tissue.

The graafian follicles secrete oestrogen, which plays an important part in the regulation of menstruation


What should I know about child birth?

Child birth or labour can be divided into three stages:


Both right and left-occipito posterior, although still head-down positions, are classed as malpresentations, as more rotation of the baby is required to achieve a delivery and therefore complications may occur.

The most common is a delay in the second stage of labour


Foetal presentations
There are several ways that a baby can present itself

Normal presentation

The normal presentation, left-occipito anterior, or first vertex has the head as the presenting part, this is the most common presentation.

Right-occipito anterior is also considered to be a normal presentation



What should I know about child birth?

Breech Presentation

Breech presentation

Breech presentations occur when the baby has its buttocks instead of its head as the presenting part.

A complete breech means the baby has its knees bent.

A frank breech means that the baby's legs are straight, doubled back to its head.

A prolapsed leg or knee can accompany a breech.


What should I know about child birth

Face presentation

Face presentation

A face presentation is a head-down presentation but it is the face that presents instead of the occipital bone.

Persistent mento-posterior is again a head-down presentation, but the baby's chin lodges in the hollow of the maternal sacrum , therefore the head cannot be fully extended making a normal birth impossible.


What should I know about child birth

Brow presentation

Brow presentation

A brow presentation occurs when the head is in such a position that the widest diameter of the skull is presented as the baby enters the pelvic brim, a normal birth is most unlikely.


What should I know about child birth

Transverse lie presentation

Transverse lie

A transverse lie can be diagnosed by abdominal examination, as the uterus is very irregular.

There is no presenting part and early rupture of the membrane will occur, resulting in the impossibility of spontaneous delivery.

A prolapsed arm can also accompany a transverse lie, whereas a prolapsed leg or knee can accompany a breech.



umbilical cord prolapse

An umbilical cord prolapse may accompany any presentation and this is a dire emergency for the baby. A loop of umbilical cord will be visible at the entrance to the vagina. It is important to handle this as little as possible to reduce the possibility of spasm of the cord. The loop should be covered in a warm moist sterile dressing and re-inserted into the vagina. The mother should be placed in the left lateral position and urgently transported to hospital.


There are two more things to be aware of:

There are two more things to be aware of:

Obstetric shock, which is a condition of collapse that can follow a difficult delivery or haemorrhage

Eclampsia. This can occur in the last stage of pregnancy, in labour, or after the actual delivery. It is potentially life threatening for both mother and baby and takes the form of a fit followed by coma.


What do I need to know about child abuse

Battered or abused children are children who are the focus of deliberate injury by adults. The definition includes actual or likely physical injury (or suffering) to a child, including deliberate poisoning.

Child abuse can lead to serious mental and physical disabilities, and around 1 in 500 battered children actually die each year from their injuries. Child abuse is usually categorised under one of three headings; physical abuse, sexual abuse or mental cruelty.

It is highly likely that from time to time technicians and paramedics will deal with physically abused children. Although sexual and mental abuse is equally prevalent these children rarely need emergency ambulance procedures directly linked to the abuse. The Resource Centre links below will help you to find out more about different aspects of child abuse


Profile of child abuse

signs to look out for

Profile of child abuse

Statistics show that in the majority of child abuse cases it is usually the parent or guardian that is responsible - often a person who was themselves abused as a child. This individual tends to be poorly prepared for the task of bringing up a child. Sometimes a specific event will trigger the incident of abuse, for example marital difficulties, loss of a job, illness and overcrowding in the home can all be catalysts to child abuse.

Behaviour patterns that have been recorded in individuals responsible for abuse include:

  1. A show of outright hostility towards the child
  2. Hostility towards the technician/paramedic in attendance
  3. Lack of concern over the condition of the child
  4. Haste in leaving the casualty without first ensuring the child's safety and well-being
  5. A neglected or abused child is rarely carried in an affectionate manner

The abuse of a child, is for most of us a distressing and emotional situation. You must maintain a non-judgmental attitude towards suspected abusers. The role of the ambulance person is to treat injuries and record the relevant information in a calm and responsible manner


Physical abuse

Physical abuse

Statistics state that in around two thirds of physical abuse cases the victims are under the age of three years. In families of more than one child, the abuse may not be targeted at all the children, it is often isolated to only one child.

The first clue to an incident of abuse may lie in the history of the injury. If there is more than one witness, try to interview each one separately, recording what is said. If the child is old enough and able to talk, ask the child how the injury happened while a colleague questions the adult(s). Any marked differences between versions of the same event is suspicious, as are any injuries found that do not correspond to the history of events. In summary you should look for:

Significant delay in seeking medical help
The majority of children who sustain accidental injury will be presented for treatment immediately.

  1. Major discrepancies in the history
  2. Discrepancy between the history and injuries
  3. Discrepancy between the history and child's capabilities
  4. History of regular trauma
  5. Vague and contradictory accounts of the accident

Signs and symptoms
An observation of the child's behaviour and general appearance may give the first indication of child abuse. Common observations in abused children include a general apathy towards the situation, without obvious signs of distress. The child may be withdrawn, quiet and may not cry. Often the child will not seek comfort from the adult(s).

On a head to toe survey, observe the skin for bruising and burns, noting the location and colour of any found. Children will often have bruises on bony prominences like elbows, knees, shins and foreheads, but are unlikely to accidentally bruise themselves on other areas. Sites of abused skin damage include:

Sides of the face

Behind the arm

The buttocks and lower back

The genitalia

Bruise patterns may outline an object used to inflict the injury. Hand printing bruising around the abdomen, neck, face, arms and legs is particularly suggestive. The age of a bruise can be approximately assessed by its colour and can be checked against the history:

Burns can also be suggestive. Circumferential burns caused by scalding with no sign of splash burning are unlikely to be accidental. Scald burns to the buttocks and soles of the feet and ankles are also more likely to have been inflicted - toddlers getting into a bath will get in one foot first and usually only injure one foot. These types of burns have usually been caused by "dunking" the child. Be suspicious of burns where skin folds in the injury area are burn free. Burns to the palm of the hand are common accidents but those to the back of the hand are not.

Other sources of skin damage include bites, pinches, kicks and bizarre marks:

Animal bites will normally result in puncturing, cutting and tearing of the skin by the carnivorous dentition. Human bites can cause breaches of the skin if very aggressive, but will normally result in crescent-shaped bruising in which individual tooth marks can be identified. Check that the size of the bruise impression is not too small to correspond to any animal involved in the injury.

Usually to the lower half of the body, these produce large, irregular shaped bruises occasionally reflecting the shape of the shoe.

Bizarre marks
Unusual bruises can occur when a child is struck through clothes, the pattern of the weave may appear. Puncture wounds (eg from nappy pins) and cord burns also produce unusual non-accidental marks.


Child abuse

Secondary survey

Secondary survey

Start with a careful examination of the head. In infants, look for bulging fontanels and in all small children be alert for signs of head trauma and increased intracranial pressure. Bald spots may be a sign of the hair having been yanked out.

Check for bruises around the mouth or lacerations of the oral mucosa, (can be caused by a feeding bottle or feeding spoon being forcibly jammed into an infant's mouth). Injury to the upper lip and its frenulum often follow forced feeding (tears to the frenulum do not rejoin and can be readily checked).

Feel the chest for tenderness and instability. Accidental rib fractures are rare in children but are common in cases of abuse. Abdominal internal injuries are the second most common cause of death (after head trauma) in cases of child abuse. Inspect the abdomen for distension, tenderness or rigidity.

Finally check the long bones for deformity. The location of fractures in long bones can be highly suggestive of child abuse. Outside of the hospital this sign is difficult and unreliable without the facility of an x-ray.

In summary indications might be:

  1. Apathetic children that don't cry
  2. Children who don't turn to adults for comfort
  3. Poorly nourished or cared for children
  4. Multiple bruising around the face, trunk and buttocks
  5. The presence of old bruising in the above places
  6. Suspicious burns - cigarette burns, direct contact burns other than on the hands, scalds without splash marks on the buttocks or feet but sparing skin folds
  7. Injuries to and around the mouth
  8. Rib fractures


Management of abused children

Management of abused children

Give the appropriate treatment to the child at the scene and then transport them to casualty. If what you have seen or heard raises suspicions of child abuse, then report your findings to the casualty doctor.

It is not your responsibility to challenge the parents or guardians with any charge of child abuse. Be tactful and discreet in your dealings with these adults. When handing over the patient give a full and factual report on their condition and the circumstances leading up to the injuries.

It can be important not to let the adult(s) suspect that you do not believe their account of any incident. Do not allow your feelings to interfere with your management of the situation


Sexual abuse

Sexual abuse

Sexual abuse is the most common form of child abuse and the frequency is far higher in girls than boys.

When sexual abuse is going on within a family, it is unlikely that the parent, guardian or relative will allow the situation to come to the attention of the authorities, and so it is rare that the ambulance service become involved. It is more likely that ambulance personnel will come into contact with sexually abused children due to the rape of the child by a stranger. In this situation you will not only have to deal with a very distressed and frightened child, but also parents who will often translate their feelings of helplessness into anger.

Defuse the situation by remaining calm and professional, an understanding attitude is essential. Find out from your patient where the pain lies. Limit any physical examination to a check for major injuries that require stabilisation. A detailed examination will be highly distressing for the child, so only treat major injuries before transportation to hospital.

Document the history, your observations and any treatment carefully. In this situation, you will be called to give evidence in court and your documentation will form a legal document


What conditions might I see in geriatric patients?

What conditions might I see in geriatric patients?

Brain ageing and deterioration happens constantly, but although the neurones of the central nervous system have little or no properties of regeneration, no significant deterioration happens until we reach sixty. Even then the deterioration occurs at different rates in individuals.

The brain shrinks by approximately 10% in old age, but this can be due to many factors like diet, living conditions and of course neurone failure and disease.

Several factors contribute to the deterioration of neurones, one of which is a reduction in oxygen supply due to arteriosclerosis of the carotid and vertebral arteries. The reduced blood supply also results in a reduced supply of vitamins, minerals and glucose. The ageing brain cells begin to produce abnormal proteins that cause a build up of toxins. The toxins and a combination of all or some of the other factors will eventually result in dementia.


Parkinson's disease

Parkinson's disease

Nerve impulses are transmitted from one neurone to another via neurotransmitters. Two of these transmitters are acetocholine and dopamine. A balance of the two is essential for normal body movement, balance and function.

In a patient suffering from Parkinson's disease, some cells do not produce enough dopamine and an imbalance occurs, resulting in signs and symptoms like:

Muscle rigidity

Muscle tremor

Expressionless face

Postural disturbances

Difficulty starting and stopping a movement, eg walking

Loss of coordination


Cerebrovascular accident


Cerebrovascular accident

CVA in layman's terms is called a stroke, and in some instances, apoplexy. It is caused by one or more of the cerebral arteries becoming blocked, causing an infarct of necrosed tissue in the brain. This tissue will never regenerate and its specific function will be lost for good. It may be possible however, to retrain another part of the brain to perform the same function through laborious physiotherapy.

This blockage can be caused in any of three ways:

This type of CVA happens when a blood vessel suddenly bursts. Patients will normally have a history of hypertension and have been exerting themselves before the episode. The onset will be rapid and will usually result in unconsciousness. Consciousness will either return when the oedema surrounding the burst subsides, or will continue to deteriorate into death.


This type of CVA happens in patients who suffer hypotension or who take sedative drugs that cause a gradual build up of debris within the cerebral arteries. This debris limits the flow of blood impairing the function of the brain tissues, resulting in a slow onset of diminishing bodily and speech functions.


This type of CVA, like the haemorrhage type, has a rapid onset and can result in immediate death. An embolus , perhaps from a deep vein thrombosis, comes into the circulation and becomes lodged, usually in a bifurcation of a cerebral artery, causing an infarct, with the inevitable result of brain dysfunction and unconsciousness.

It is possible for either side of the brain to become injured as a result of any CVA, but it does seem that the right side of the brain is more often damaged. This results in the left side of the body showing the paralysis.

Always remember that a conscious CVA victim will be extremely frightened and frustrated at the lack of normal bodily movement.


The Three Stages of Labor:

The Three Stages of Labor:


Expulsion &