The Pre-hospital Delivery Dr Lisa Canavan ST5 Obstetrics & Gynaecology

 Delivery Imminent  Emergencies ◦ Shoulder dystocia ◦ APH/PPH ◦ Cord Prolapse ◦ Breech Delivery ◦ Eclampsia ◦ Maternal Collapse  Basic neonatal resuscitation

 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

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

 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

 Frequency of contractions  Pushing/expulsive noises  Rupture of membranes  Cervical show  Vaginal bleeding  Crowning

 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

 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 secs 3. Open the airway – neutral position 4. 5 x inflation breaths ◦ If no chest movement reposition and repeat 5. Chest compressions if HR <60 6. Ratio CPR 3:1 and reassess every 30 seconds

 Score 7-10 normal  4-7 might need some resus  <4 immediate resus needed  Scored at 1, 5 and 10 minutes

 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

 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

 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

 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

 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 

 Blood loss >500mls – can loose this in 1 minute!  Primary or secondary  5% deliveries major PPH Minor <1000mls Moderate mls Severe >2000mls Major

The 4 T’s Tone TraumaTissue Thrombin

HELP!ABCDEMedicalSurgical

Medical  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

 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

 Bhoopalam PS, Watkinson M. Babies born before arrival at hospital. BJOG (1):57-64  Unterscheider J et al. Born before arrival births: Impact of changing obstetric population. J O&G (8):  Home Birth and Born Before Arrival (BBA) Maternity Manual guideline Mid Cheshire NHS Trust Dec 2013  UK Ambulance Service Clinical Practice Guidelines (2006)