Neonatal Resuscitation & Emergency Childbirth Medical Directives

Question 1

Newborn Resuscitation Medical Directive: Indications

Answer 1

newborn patient

Question 2

Newborn Resuscitation Medical Directive: Conditions

Answer 2

1. PPV: Age <24h, HR <100 BPM
2. CPR: Age <24h, HR <60 BPM; Other: after 30 seconds of PPV using RA

Question 3

Newborn Resuscitation Medical Directive: Contraindications

Answer 3

1.Both PPV and CPR: obviously dead as per BLS, presumed gestational age <20weeks

Question 4

Newborn Resuscitation Medical Directive: Contraindications

Answer 4

1.Both PPV and CPR: obviously dead as per BLS, presumed gestational age <20weeks

Question 5

Newborn Resuscitation Medical Directive: Treatment

Answer 5

1. Consider PPV as per tx flowchart
2. Consider CPR as per current HSF guidelines

Question 6

Target preductal SpO2, on which hand?

Answer 6

Right Hand

1 min: 60-65%
2 min: 65-70%
3 min: 70-75%
4 min: 75-80%
5 min: 80-85%
10 min: 85-95%

Question 7

Newborn Resuscitation Medical Directive: Clinical Considerations

Answer 7

1. If newborn resus is required, initiate cardiac monitoring and R hand pulse ox monitoring
2. Infants born between 20-25 weeks gestation may be stillborn or die quickly, initiate resuscitation and transport as soon as feasible
3. If gestational age cannot be confirmed, initiate resuscitation and rapid transport
4. If newborn <20 weeks gestation, resuscitation is futile. Provide newborn with warmth and consider patching to BHP for further direction

Question 8

Emergency Childbirth Medical Directive
Indications

Answer 8

Pregnant pt experiencing labour OR postpartum patient immediately following delivery and/or placenta

Question 9

Emergency Childbirth Medical Directive
Conditions & Contraindications

Answer 9

Delivery:
* Age: Child bearing years (roughly 14-50 years)
* Other: 2nd stage of labour AND/OR imminent birth AND/OR shoulder dystocia AND/OR breech delivery AND/OR prolapsed cord
* Contraindications: n/a

Umbilical Cord Management:
* Age: Child bearing years
* Other: Cord complications OR if neonatal or maternal resus is required OR due to transport considerations
* Contraindications: n/a

External Uterine Massage:
* Age: Childbearing years
* Other: post-placental delivery
* Contraindications: placenta not delivered

Oxytocin:
* Age: Childbearing years
* SBP <160mmHg
* Other: postpartum delivery AND/OR placental delivery
* Contraindications: allergy/sensitivity to oxytocin, undelivered fetus (beware of twins, multi-gestation pregnancies), suspected/known pre-eclampsia w/ current pregnancy, eclampsia (seizures) with current pregnancy, ≥4 hours post placenta delivery

Question 10

Emergency Childbirth Medical Directive
Treatment

Answer 10

Individual flashcards for specifics

1) Consider delivery
2) Consider shoulder dystocia/breach delivery/prolapsed cord delivery
3) Consider umbilical cord management
4) Consider external uterine management
5) Consider oxytocin (where authorized and available)

Question 11

Emergency Childbirth Medical Directive
Treatment: Consider delivery

Answer 11

Position patient and deliver neonate (as per usual)

Question 12

Emergency Childbirth Medical Directive
Treatment: Consider shoulder dystocia delivery

Answer 12

Perform ALARM twice on scene. If successful, deliver neonate. If unsuccessful, transport to closest appropriate facility.
* A: Ask for help
* L: Lift legs, hyperflex thighs (McRobert’s maneuver)
* A: Adduct shoulder (apply suprapubic pressure)
* R: Roll over (Gaskin maneuver)
* M: Manual delivery of posterior arm (if visible at perineum)

IMPORTANT: not to direct the patient to push outside of a contraction to allow restitution of the head

Question 13

Emergency Childbirth Medical Directive
Treatment: Consider breech delivery

Answer 13

1. HANDS OFF the breech. Allow neonate to deliver to umbilicus; consider carefully releasing the legs & arms as they delivered; otherwise hands off.
2. Once hairline is visible AND/OR 3 mins has passed since umbilicus was visualized, attempt the MSV maneuver
3. If successful; deliver neonate. If unsuccessful, transport to closest appropriate facility

Question 14

Emergency Childbirth Medical Directive
Treatment: prolapsed cord delivery

Answer 14

If a cord prolapse is present, the fetal part should be elevated to relieve pressure on the cord. Assist the patient into a knee-chest position or exaggerated Sims position, and insert gloved fingers/hand into the vagina to apply manual digital pressure to the presenting part which is maintained until transfer of care in hospital.

CTAS 1

Question 15

Emergency Childbirth Medical Directive
Treatment: Umbilical Cord management

Answer 15

• If nuchal cord is present and loose, slip over neonate’s head
• If nuchal cord is tight and cannot be slipped over head, clamp & cut cord, encourage rapid delivery
• Following delivery or neonate, cord should be clamped & cut immediately if neonatal or maternal resus is required. Otherwise, after pulsations have ceased (~2-3 min) clamp cord in two places and cut cord.

Question 16

Emergency Childbirth Medical Directive: Treatment: Consider Oxytocin

Answer 16

Route: IM
Dose: 10 units
Max single dose: 10 units
Dosing interval: n/a
Max # of doses: 1

Question 17

Emergency Childbirth Medical Directive: Clinical considerations

Answer 17

1. If pt presents with limb presentation, DO NOT ATTEMPT TO PUSH LIMB BACK INTO VAGINA, discourage pt from pushing, cover limb using dry sheet to maintain warmth, and LOAD AND GO CTAS 1
2. If labour is failing to progress, discourage pt from pushing or bearing down during contractions
3. If delivery has not occurred on scene within ~10 min of initial ax, consider transport in conjunction with the following:
   * Patient ax findings: lack of progression of labour, Multiple births expected, Neonate presents face up, Pre-eclampsia, Presence of vaginal hemorrhage, Premature labour, Primip
   * Distance to closest appropriate receiving facility
4. When placenta is delivered, check for wholeness, place in plastic bag from OBS kit and label it with mom’s name and time of delivery. Transport with mom or neonate. Delivery of placenta shall not delay transport considerations/initiation

Question 18

Are you administering oxytocin to all postpartum patients?

Answer 18

Yes (as long as they meet conditions & no contraindications)

Oxytocin can be used a PPH prophylaxis or with PPH! Placenta does not have to be out at time of administration
* Couple this with active management during 3rd stage of labour to decrease overall risk of PPH

Question 19

What are potential umbilical cord complications?

Answer 19

• Nuchal cord
• Cord prolapse
• Immediate/delayed cord clamping/cutting, etc.

Question 20

Why is external uterine massage contraindicated for pre-placental delivery?

Answer 20

Massage may cause trauma/premature separation and substantial hemorrhage if done with retained placenta

Question 21

What are the contraindications of oxytocin use and why?

Answer 21

1. Allergy/sensitivity to oxytocin
2. Undelivered fetus: pt is not “post-partum” yet so can’t use
3. Suspected or known preeclampsia w/ current pregnancy: Hemodynamic effects of oxytocin in this population may be less predictable (disturbances in oxytocin & vasopressin secretion/actions in preeclampsia)
4. Eclampsia (seizures) with current pregnancy (see above)
5. ≥4 hours post placenta delivery: uterus already contracted