Birth Complications PDF - London Ambulance Service - 18 May 2023

Birth Complications Recognition of complicated births Management of obstetric emergencies Use of maternity tools to aid decision making Session objective Describe the possible complications of labour and how to support the lead clinician in assessment and management of the following com...

Birth Complications Recognition of complicated births Management of obstetric emergencies Use of maternity tools to aid decision making Session objective Describe the possible complications of labour and how to support the lead clinician in assessment and management of the following complications: Pre-term labour Cord prolapse Multiple births Breech birth Shoulder Dystocia London Ambulance Service NHS Trust 2 Pre-term labour London Ambulance Service NHS Trust 3 Pre-term labour Birth not imminent? Defined as: 20 – 37and Ascertain the gestation weeks gestation whether - transfer birth is imminent mother to nearest obstetric unit or ED with obstetrics onsite London Ambulance Service NHS Trust 4 Unknown gestation Concealed pregnancy or no antenatal care? As a general rule, if the woman appears visibly pregnant and/or the fundus is palpable at the umbilicus, the gestation is likely to be over 20 weeks. CONSIDER SAFEGUARDING Any pregnancy over 20 weeks without antenatal care requires safeguarding ref through EBS. London Ambulance Service NHS Trust 5 Signs of Pre-term labour Regular contractions or tightenings Period-type pain or pressure in vagina Membrane rupture (waters breaking) Backache May be accompanied by bleeding (>20 weeks RED FLAG) London Ambulance Service NHS Trust 6 Pre-term labour management Assess whether birth is imminent. Birth imminent? → Prepare for birth on scene Update EOC, request additional resources Prepare for NLS, warm environment ++ Signs of pre-term labour and birth not imminent→ Pre-Alert Reassess mother continuously en route London Ambulance Service NHS Trust 7  Survival Comfort focussed care care 21+ 6 weeks gestation and below  22 weeks gestation and above  Gestation unknown and eyes fused  Gestation unknown and eyes not fused  London Ambulance Service NHS Trust 8 Cord Prolapse London Ambulance Service NHS Trust 9 Cord Prolapse Defined as the umbilical cord prolapsing out of the vagina prior to birth Normally occurs with membrane rupture. More likely in pre-term labour, with breech presentation or multiple births. The cord may be visible at the vaginal opening, or may be felt by the woman. Inspection with consent is necessary to diagnose. London Ambulance Service NHS Trust 10 Risks associated with Cord Prolapse Causes fetal hypoxia (can lead to brain damage and/or death) by: Compression by the presenting part (head or buttocks) on the cord Vasospasm as the cord is exposed TIME CRITICAL EMERGENCY London Ambulance Service NHS Trust 11 Management of cord prolapse Pre-alert to nearest obstetric unit (unless birth is imminent, mother will require an emergency caesarean section). Minimise handling of the cord. Gently replace to the vulva using a clean dry pad. Do not re-insert the cord into the vagina. Walk to the ambulance and assist mother into an exaggerated SIMs position. London Ambulance Service NHS Trust 12  A- Knees-chest position can be used if any delay in transferring mother to the ambulance (not for conveying) B- Exaggerated SIMS position London Ambulance Service NHS Trust 13 Multiple Births London Ambulance Service NHS Trust 14 London Ambulance Service NHS Trust 15 Management of multiple births Have a lower threshold for conveyance (if birth is not assessed as imminent, aim to get to nearest obstetric unit as quickly as possible) If birth on scene, clamp cord of the 1st twin immediately Babies are likely to be pre-term/smaller- thermoregulation even more important Time between 1st baby and subsequent babies may be a few minutes- hours. Do not delay on scene. London Ambulance Service NHS Trust 16 Breech Birth London Ambulance Service NHS Trust 17 Breech birth Breech birth is when the buttocks or feet are presenting first. More common in pre-term births and multiple births (twins or triplets) The longer the time from the birth of the buttocks to complete delivery, the greater the risk of hypoxic injury. If the birth is slow, interventions are required. London Ambulance Service NHS Trust 18  Normal breech birth video https://vimeo.com/503806192 (No manouvres required) London Ambulance Service NHS Trust 19  Breech birth London Ambulance Service NHS Trust 20 Breech birth- take away points If the feet come out first, and are not immediately followed by the buttocks, this is an emergency and requires rapid transport to hospital (Footling breech) Use Maternity Action Tool checklist to guide management Prepare for NLS and/or PPH Call for help (2nd crew/ APP-CC/ CTM/ IRO) Hands POISED ready to intervene/receive the baby Set a timer- delay means intervention required London Ambulance Service NHS Trust 22 Shoulder Dytocia London Ambulance Service NHS Trust 23 Recognition of Shoulder Dystocia Definition- Shoulder Dystocia happens when the baby’s head has been born and the shoulders become stuck on the mother’s pelvic bone, preventing the birth of the baby’s body Diagnosis- Once the head of the baby is born, if the body is not born with the next 2 contractions we diagnose Shoulder Dystocia London Ambulance Service NHS Trust 24  Shoulder Dystocia London Ambulance Service NHS Trust 25 Axial Traction Axial traction: Steady pressure in a straight line (not upwards or downwards) London Ambulance Service NHS Trust 26 Shoulder Dystocia- take away points Use the Maternity Action Tool checklist to guide management Prepare for NLS and PPH Early pre-alert is essential Document time of delivery of the head and any manouvres performed Avoid encouraging the woman to push or upwards/downwards/excessive traction London Ambulance Service NHS Trust 28 Summary Birth complications can be difficult to predict- always call for help early in maternity Use the maternal assessment and obstetric emergencies cards on JRCALC+ to guide management Do not call a midwife during an obstetric emergency- this will delay care (unless the patient declines to be transferred) Datix all birth complications London Ambulance Service NHS Trust 29