BIRTH COMPLICATIONS

Pre-Term Labour

• Pre-term Labour is defined as birth between 20-37 weeks gestation.
• Assess gestation and whether birth is imminent.
• If birth is imminent, prepare for birth on scene and notify EOC.
• If birth is not imminent, pre-alert the nearest obstetric unit or ED with obstetrics onsite.
• If the mother is visibly pregnant or the fundus is palpable at the umbilicus, the gestation is likely to be over 20 weeks.
• Any pregnancy over 20 weeks without antenatal care requires safeguarding through EBS.
• Signs of preterm labour include: regular contractions, period-type pain or pressure in the vagina, membrane rupture, backache. Bleeding after 20 weeks is a RED FLAG.
• If birth is not imminent, reassess the mother continuously en route.
• Survival focused care: Applicable for gestation 21+6 weeks and below.
• Comfort care: Applicable for gestation 22 weeks and above, gestation unknown and eyes fused, gestation unknown and eyes not fused.

Cord Prolapse

• Cord prolapse is when the umbilical cord exits the vagina prior to birth.
• This commonly occurs with membrane rupture, especially in cases of pre-term labour, breech presentation, or multiple births.
• The cord may be visible at the vaginal opening or felt by the woman.
• Inspection with consent is necessary for diagnosis.
• Cord prolapse is a TIME CRITICAL EMERGENCY.
• Risks: The presenting part (head or buttocks) compressing the cord can cause fetal hypoxia, leading to brain damage or death.
• Management: Pre-alert the nearest obstetric unit, minimise handling of the cord, gently replace it to the vulva using a clean dry pad, avoid re-inserting the cord into the vagina.
• Assist the mother into an exaggerated SIMs position while transferring to the ambulance.
• If there's a delay in transferring the mother to the ambulance, consider the knees-chest position (not for conveying).

Multiple Births

• A lower threshold for conveyance is recommended if birth isn't imminent.
• If birth occurs on scene, clamp the cord of the first twin immediately.
• Thermoregulation is crucial due to the likelihood of pre-term/smaller babies.
• There may be several minutes to hours between the birth of the first baby and subsequent babies.
• Do not delay on scene.

Breech Birth

• Breech birth occurs when the buttocks or feet present first.
• It is more common in pre-term births and multiple births.
• The longer the time from the birth of the buttocks to complete delivery, the greater the risk of hypoxic injury.
• Interventions may be required if the birth is slow.
• If the feet come out first and are not immediately followed by the buttocks, this is an emergency (Footling breech) and requires rapid transport to hospital.
• Use the Maternity Action Tool checklist for management.
• Prepare for NLS and/or PPH, and call for additional support (second crew, APP-CC, CTM, IRO).
• Keep hands POISED, ready to intervene or receive the baby.
• Set a timer as a delay indicates intervention is required.

Shoulder Dystocia

• Shoulder dystocia occurs when the baby's head is born but the shoulders become stuck on the mother's pelvic bone, preventing the birth of the baby's body.
• It's diagnosed if, after the head is born, the body is not born within the next two contractions.
• Axial Traction: Apply steady pressure in a straight line (not upward or downward).
• Use the Maternity Action Tool checklist for management.
• Prepare for NLS and PPH.
• Early pre-alert is essential.
• Document the time of the head delivery and any maneuvers performed.
• Avoid encouraging the woman to push or apply upward/downward/excessive traction.

Summary

• Birth complications can be unpredictable, so call for help early in maternity cases.
• Utilize the maternal assessment and obstetric emergencies cards on JRCALC+ to guide management.
• Do not request a midwife during an obstetric emergency; this will delay care (unless the patient declines transfer).
• Datix all birth complications.