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CLINICAL PRACTICE GUIDELINESTo All Registered Emergency Care ProvidersThis document serves to inform all emergency care providers that the below ClinicalPractice Guidelines (CPGs) and related capabilities and medications have beenadopted by the Professional Board for Emergency Care (PBEC) for use andimplementation by all registered emergency care providers.It is the responsibility of all registered persons to a.) familiarise themselves and b.) undergolearning/training activities related to the contents of the document. In addition tofamiliarisation, it is important that as far as possible, and where relevant, the relatedclinical practice guideline is used during all clinical encounters. Where not applicable,all reasonable, locally contextual standards of care apply to clinical encounters. Thedeadline for the adoption of the revised list of capabilities and medications byregistered persons is the 31st of December. It is, however, acknowledged that thelearning/training activities required to perform procedures and administer medicationsnot currently on the scope of practice, will extend beyond this deadline.Emergency care providers are directed to the revised list of capabilities andmedications which are attached as an Annexure to the guidelines. The revised list ofcapabilities and medications (read together with the requirements linked to theperformance and/or administration of such skills/medications) are applicable as per theabove-mentioned deadline date. It must, however, be noted that the medications notcurrently on the scope of practice await final regulatory approval. Furthercommunication will follow in relation to the approval of these medications. Emergencycare providers acting outside of the revised list of capabilities (and mandatory trainingto perform such procedures) will be considered to be acting outside of the relevantscope of practice.July

HPCSAICUILCORILSIMIMDIOIVND EMCNICUNIV, NPPVNSTEMIPaCO2PBECPRSTEMISVTTCAVFVT- Acute Coronary Syndromes- Ambulance Emergency Assistant- The African Federation for Emergency Medicine- American Heart Association- Advanced Life Support- Ambulance Emergency Technician- Basic Ambulance Assistant- Bachelor’s in Emergency Medical Care- Basic Life Support- Critical Care Assistant- Centre for Evidence-based Health Care- Chronic Obstructive Pulmonary Disease- Clinical Practice Guideline- Cardiopulmonary Resuscitation- Emergency Care- Emergency Care Society of South Africa- Emergency Care Assistant- Emergency Care Practitioner- Emergency Care Technician- Emergency Medicine- Emergency Medicine Society of South Africa- Emergency Nurses Society of South Africa- Adrenaline- Health Professions Council of South Africa- Intensive Care Unit- International Liaison Committee on Resuscitation- Intermediate Life Support- Intramuscular, Intramuscularly- Invasive Meningococcal Disease- Intraosseous, Intraosseously- Intravenous, Intravenously- National Diploma in Emergency Medical Care- Neonatal Intensive Care Unit- Positive Pressure Non-Invasive Ventilation- Non-ST-Elevation Myocardial Infarction- Partial Pressure of Carbon Dioxide- Professional Board for Emergency Care- Per Rectum- ST-Elevation Myocardial Infarction- Supraventricular Tachycardia- Tricyclic Antidepressant- Ventricular Fibrillation- Ventricular Tachycardia

3Recommendations

4UsageThe following depicts the purpose of the various text boxes:Practice point: Aims to guide clinicians in how to perform therecommendation 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 asan Emergency Care Practitioner, Emergency Medicine Physician or appropriate healthcareprofessional (specialist).

51. Obstetrics & GynaecologyThere were no evidence-based clinical practice guidelines addressing obstetric issues from apurely pre-hospital emergency services perspective. Despite this, there were many high-qualityrecommendations from in hospital and other types of health facilities (e.g. midwife run deliveryunits) which are directly applicable to pre-hospital management of obstetrics. The delivery andbirth process will ideally not occur in the pre-hospital environment, but every practitioner needsto be able to manage a delivery and to intervene where necessary within the limits of theirscope of practice.1.1Normal DeliveryA normal birth is defined by the WHO as: “spontaneous in onset, low-risk at the start of labourand remaining so throughout labour and delivery. The infant is born spontaneously in the vertexposition between 37 and 42 completed weeks of pregnancy. After birth mother and infant arein good condition” (World Health Organization, 1996). The role of the EMS practitioner is toprovide comfort and support for the mother and newborn, and to monitor and assist wherenecessary, while transferring to the appropriate health facility. However, an apparently low-risknormal delivery can complicate without warning at any stage, so the definition is often appliedretrospectively.Healthcare professionals and other staff caring for women in labour should establish anempathetic relationship with women in labour and ask them about their expectations andneeds, so that they can support and guide them, being aware at all times of the importance oftheir attitude, the tone of voice used, the words used and the manner in which care is provided(Australian Resuscitation Council).The first stage of labour begins from the onset of labour (onset of regular labour pains) until thesecond stage of labour. During the first stage (lasting, on average, 5-8 hours) mothers requirereassurance, comfort and support, hydration and appropriate pain relief where necessary. Thesecond stage of labour is usually faster, commencing when the cervix is fully dilated, and thefoetus is expelled. The initial passive phase precedes the active phase, where there areexpulsive contractions, maternal pushing, and the foetus becomes visible. During the activephase, 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 encouragingthe mother to push earlier than the recommended active phase at the end of the second stageof labour.

6Foetal distress during labour is suspected when the foetal heart rate isabnormally 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 240mL/hour for 1-2 hours, unless the woman is hypertensive or hascardiac disease. Consider transferring the patient to a facility with the capabilityto perform a caesarean section.The third stage starts immediately after delivery of the baby and ends with delivery of theplacenta. This would normally occur spontaneously within 30 minutes (Australian ResuscitationCouncil).The active method of managing the third stage is recommended, toprevent excessive bleeding: (National Department of Health, Republic ofSouth Africa) Immediately after delivery of the baby, ensure by abdominalpalpation 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 unitsintramuscularly (IM). Await uterine contraction for 2-3 minutes then feel for uterinecontraction every 30 seconds. Do not massage or squeeze the uterus with the placenta stillinside. When the uterus is felt to contract, put steady tension on theumbilical cord with the right hand, while pushing the uterusupwards with the left hand. Deliver the placenta by applying continuous gentle traction onthe umbilical cord.The fourth stage is defined as the first hour after delivery of the placenta. The woman is at risk forpostpartum haemorrhage and must be observed (National Department of Health, Republic ofSouth Africa).1.1.1Women in labour should be treated with the utmost respect and should be fully informedand involved in decision-making. To facilitate this, healthcare professionals and otherstaff caring for them should establish an empathetic relationship with women in labourand ask them about their expectations and needs, so that they can support and guidethem, 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)Evidence from non-analytical studies such as case reports and case series or expert opinion or evidenceextrapolated from well-conducted cohort or case and control studies with low risk of bias and a moderateprobability of establishing a causal relationship.

71.1.2Women should be encouraged and helped to adopt any position they find comfortableduring the first stage and to be mobile if they wish, following a check of motor andproprioceptive block.adapted1.1.3Spontaneous pushing is recommended. If there is no pushing sensation, pushing shouldnot be directed until the passive phase of the second stage of labour has ended. (AustralianResuscitation Council)*Evidence from at least one meta-analysis, systematic review or clinical trial rated as high quality or wellconducted.1.1.4The perineum should be actively protected using controlled deflection of the foetal head,asking the woman not to push. (Australian Resuscitation Council)Evidence from high quality systematic reviews of cohort or case and control studies; cohort or case andcontrol studies with very low risk of bias and with high probability of establishing a causal relationship orextrapolated evidence from high quality or well-conducted meta-analyses, systematic reviews of clinicaltrials or high-quality clinical trials.1.1.5The duration of the third stage of labour is considered to be delayed if it is not completewithin 30 minutes after birth of the neonate with active management, or within 60 minuteswith a spontaneous third stage. (Australian Resuscitation Council)Evidence from non-analytical studies such as case reports and case series or expert opinion or evidenceextrapolated from well-conducted cohort or case and control studies with low risk of bias and a moderateprobability of establishing a causal relationship.1.1.6Active management of delivery is recommended. (Australian Resuscitation Council) *Evidence from at least one meta-analysis, systematic review or clinical trial rated as high quality or wellconducted.1.1.7Oxytocin should be used routinely in the third stage of labour. (Australian Resuscitation Council)Evidence from at least one meta-analysis, systematic review or clinical trial rated as high quality or wellconducted.1.1.8The mother's expectations for pain relief during labour should be met as far as is possible.(Australian Resuscitation Council)Evidence from high quality systematic reviews of cohort or case and control studies; cohort or case andcontrol studies with very low risk of bias and with high probability of establishing a causal relationship orextrapolated evidence from high quality or well-conducted meta-analyses, systematic reviews of clinicaltrials or high-quality clinical trials.1.1.9Inhaling nitrous oxide is recommended during labour as a pain relief method; womenshould be informed that its analgesic effect is moderate and that it can cause nauseaand vomiting, somnolence and altered memories. (Australian Resuscitation Council)Evidence from high quality systematic reviews of cohort or case and control studies; cohort or case andcontrol studies with very low risk of bias and with high probability of establishing a causal relationship orextrapolated evidence from high quality or well-conducted meta-analyses, systematic reviews of clinicaltrials or high-quality clinical trials.1.1.10If parenteral opioids are chosen as analgesia, patients should be informed that they havea limited analgesic effect and can cause nausea and vomiting. (Australian Resuscitation Council)Evidence from at least one meta-analysis, systematic review or clinical trial rated as high quality or wellconducted.1.1.11Anti-emetics should be considered when IV or IM opioids are used. adapted

81.2Newborn Care 1.2.1For a foetus in distress requiring resuscitation, there should beimmediate 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 itstops pulsing (Australian Resuscitation Council).Assess the baby’s Apgar score at 1 minute (National Departmentof Health, Republic of South Africa).To keep the baby warm, he or she should be covered and driedwith a blanket or towel that has previously been warmed, whilstmaintaining skin-to-skin contact with the mother (AustralianResuscitation Council).The mother and baby should not be separated for the first houror until the first feed has been given. During this period themidwife should remain vigilant and periodically observe,interfering as little as possible in the relationship between themother and neonate, checking the neonate's vital signs (colour,respiratory movements, tone and if necessary heart rate)(Australian Resuscitation Council).Delayed clamping of the umbilical cord is recommended. (Australian Resuscitation Council)Evidence from at least one meta-analysis, systematic review or clinical trial rated as high quality or wellconducted.1.2.2Women should have skin-to-skin contact with their babies immediately after birth. (AustralianResuscitation Council)Evidence from at leas