The Pre-hospital Delivery Dr Lisa Canavan ST5 Obstetrics & Gynaecology.
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Born Before Arrival The Pre-hospital Delivery Dr Lisa Canavan ST5 Obstetrics & Gynaecology
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Transcript of The Pre-hospital Delivery Dr Lisa Canavan ST5 Obstetrics & Gynaecology.
Born Before Arrival
The Pre-hospital DeliveryDr Lisa CanavanST5 Obstetrics & Gynaecology
Delivery Imminent
Emergencies◦ Shoulder dystocia◦ APH/PPH◦ Cord Prolapse◦ Breech Delivery◦ Eclampsia◦ Maternal Collapse
Basic neonatal resuscitation
Objectives
BJOG 1991 (Birmingham)◦ 0.44% all deliveries BBA◦ Perinatal mortality rate 58.4/1000 vs. 10.1/1000
(RR 5.8)◦ Hypothermia commonest morbidity◦ Population - multigravid inner city Asians or young
unbooked white Europeans
J O&G 2011 (Ireland)◦ 0.36% BBA◦ Perinatal mortality 27.9/1000 vs. 8.5/1000◦ No difference in maternal morbidity or mortality
Is BBA a problem?
Equipment at planned homebirth
In the home•Entonox cylinder•Full O2 cylinder •Green O2 tubing •1 adult airway •Single use adult bag and mask •Adult pocket mask •3 infant airways •Single use neonatal bag and mask •Res-Q-Vac suction •2 Grey I.V. Cannulas •IV giving set •500mls Hartmann‟s •1 pair scissors
•Inco pads •2 Placenta bags •Sanitary towels •Nappy •Baby hat •Prolapsed cord kit •500mls normal saline •Foleys catheter •IV giving set •10mls water •spigot •Baby scales •Boy and Girl red book •Tape measures •Cot cards •Baby labels •Neopuff •Spare tubing•Spare facial mask•Entonox regulator •2 mouth pieces •2 face masks
Carried by midwife•Sonicaid and Pinard •Sphyg. and stethoscope •Thermometer •Tape measure •Delivery Pack/ Instruments •Gloves•Apron •Cord clamps •Gauze squares •Amnihook •2 Disposable Catheters •Lubricating jell •Hand cleansing rub •Assorted syringes/needles•Blood bottles •Cord blood stickers and forms •Towel •Needle holder •2 Vicryl Rapide 3/0 •2 Vicryl Rapide 2/0 •Sharps bin •Paperwork•2 clinical waste bag •2 large clear bags
First stage◦ Latent phase◦ Active phase◦ 2cm every 4 hours
Second stage◦ Passive descent◦ Active pushing
Third stage◦ Active◦ Physiological
Stages of Labour and Delivery
Catch!
If delivery not imminent move to booked maternity unit
If preterm or any complications move to nearest maternity unit
Request midwife and second vehicle
If any trauma or medical condition move to nearest ED
Be aware supine hypotension
Basic Principles
Frequency of contractions
Pushing/expulsive noises
Rupture of membranes
Cervical show
Vaginal bleeding
Crowning
How imminent?
Delivery
Delivery
Drape everything with inco pads – its messy! Keep temperature warm Lots of towels ready
As head delivers check for nuchal cord Deliver onto abdomen – beware they’re slippery Dry baby and discard wet towel
No need to clamp and cut cord Transfer to nearest unit or await midwife
Immediate Care
Birth is hypoxic event......but babies are designed to cope
1. Dry and cover baby – vigorously! 2. Assess need for intervention (APGAR)
◦ Tone, breathing and heart rate over 60-90 secs
3. Open the airway – neutral position4. 5 x inflation breaths
◦ If no chest movement reposition and repeat
5. Chest compressions if HR <606. Ratio CPR 3:1 and reassess every 30 seconds
Basic Neonatal Resus
Score 7-10 normal 4-7 might need some resus <4 immediate resus needed Scored at 1, 5 and 10 minutes
APGAR
Complications and Emergencies
Transfer all to nearest obstetric unit Minor/Moderate/Major
Placenta Praevia/Vasa Praevia Placental Abruption
◦ Be aware constant severe pain without bleeding Labour Post-coital Vaginal trauma/local causes Ruptured uterus esp. VBAC
Antepartum Haemorrhage
This is an EXTREME EMERGENCY Bony obstruction – anterior shoulder on symphysis
pubis Failure of head to deliver with routine traction on
next contraction Do not pull or twist baby’s head
Mc Robert’s postion Suprapubic pressure Rolling onto all fours Allow 2 attempts at delivery with each manoeuvre If not delivered immediate transfer to obstetric unit
Shoulder Dystocia
In hospital/trained provider
H – Help E – Episiotomy L – Legs into Mc Robert’s P – Pressure E – Enter manoeuvres R – Remove posterior arm R – Roll on all fours
Shoulder Dystocia
This is also an EXTREME EMERGENCY Replace cord gently in vagina Use pad to hold in place
◦ Or keep moist with saline soaked gauze Try to avoid use of chair Lie on side with padding under pelvis Elevates the hips Disimpacts fetal head Encourage not to push Direct to nearest obstetric unit
Cord Prolapse
If its not a head or a bum scoop and run!
Move mother to edge of bed or sofa to use gravity Support mother’s legs – looks a bit like McRobert’s position Do not touch body or umbilical cord until nape of neck visible Only exception – baby’s spine rotates to face the floor Gently hold the pelvis and rotate so back is facing upwards Do not clamp or cut cord until head is free Once baby born gently lift feet to aid delivery of head Take care not to over-extend baby’s neck
https://www.youtube.com/watch?v=MJbOxy1EDpI
Malpresentation/Breech
Blood loss >500mls – can loose this in 1 minute!
Primary or secondary 5% deliveries major PPH
Postpartum Haemorrhage
Minor <1000mls
Moderate1000-
2000mls
Severe>2000mls
Major
The 4 T’s
Tone
Trauma
Tissue
Thrombin
HELP!
ABCDE
Medical
Surgical
Management of atonyMedical
Bimanual compression
Empty bladder/Foleys
Syntocinon
Ergometrine
Misoprostol
Haemabate
Surgical
Balloon tamponade
Haemostatic Brace Suture
Uterine artery ligation
Uterine artery embolisation
Hysterectomy
Pre-eclampsia – hypertension and proteinuria Eclampsia – generalised tonic-clonic seizure
◦ 2.7/10,000 deliveries◦ Usually self-limiting◦ If seizure not stopped by 3 mins administer diazepam◦ In hospital treated with MgSO4
Symptoms – headache, visual disturbance, epigastric pain, muscle twitching, N+V, confusion
Complications – intracranial haemorrhage, renal failure, liver failure, liver capsule rupture, DIC
Pre-eclampsia/Eclampsia
Treat mother as first priority Special considerations
◦ Supine hypotension – can decrease cardiac output 40% Left lateral tilt or manually displace uterus
◦ Airway oedema◦ Increased risk aspiration◦ Perimortem caesarean to improve CPR by 5 minutes
Sepsis and VTE leading causes maternal death Manage as per underlying cause
Maternal Collapse
Bhoopalam PS, Watkinson M. Babies born before arrival at hospital. BJOG 1991 98(1):57-64
Unterscheider J et al. Born before arrival births: Impact of changing obstetric population. J O&G 2011 31(8): 721-3
Home Birth and Born Before Arrival (BBA) Maternity Manual guideline Mid Cheshire NHS Trust Dec 2013
UK Ambulance Service Clinical Practice Guidelines (2006)
References
