Birth within the community; paramedics, OCC & intact cord resuscitation

Susan Rhind - Paramedic and Lecturer at University of Cumbria

Please welcome Susan Rhind - an operational paramedic and lecturer at the University of Cumbria. Susan's passions centre on improving care within the emergency healthcare services, and this includes helping to educate and guide clinicians in order to facilitate positive patient experience.

She is particularly passionate about improving maternity care within the ambulance service. Many of the adverse incidences within obstetric related cases are avoidable (Ledger et al., 2018) and an increase in knowledge, skill and integrated professional education provide means to equip health professionals to improve clinical outcomes and experiences for women and children in our community.

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Multi-professional training

Allied Healthcare Professionals

Recently, we have seen the celebration of Allied Health Professionals (AHPs). AHPs have joined each other in appreciation of their individual roles and how they work together to improve lives of patients.

As a Paramedic and University Lecturer, I found myself holding an event bringing together midwives and paramedics to revisit the current practice surrounding emergency obstetric care in the community; the rationale to standardise knowledge and integrate care provided to women and babies following birth outside of hospital.

Multi-professional training is recognised by the Royal College of Obstetricians and Gynaecologists (RCOG, 2018), as a means to reduce mortality and morbidity during birth.

Midwifery Consultant, Amanda Burleigh was invited to the University of Cumbria to present the topic of optimal cord clamping, which has subsequently led to further discussion as to how this can be better facilitated by paramedics when supporting birth within the community.

Ambulance services have revisited guidelines surrounding cord-clamping following uncomplicated births and these guidelines are reflected in an update provided by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) in 2017, with a secondary extension published in 2018 providing additional resources on managing birth in the community.

Blood loss management

This approach isn’t unique; ambulance trusts have sought guidance from multiple sectors previously to inform clinical practice, and this can be seen with an inclusion of evidence to support practice around major trauma or extreme blood loss management, now considered an integral paramedic skill.

This aspect that has had multiple reviews in recent years, and it is well-recognised that the ability to prevent further blood loss is paramount to patient survival and that outcomes from blood loss remain poor (Panteli, et al., 2015). With this is mind, tourniquets were reintroduced, and subsequently haemostatic dressings are now standardised agents to manage heavy blood loss.

The importance of controlling bleeding is highlighted when the heavily indoctrinated ABCDE assessment approach was changed to include the priority of haemorrhage control in the first instance. cABCDE, now provides emphasis on haemorrhage control over airway or breathing (National Institute for Health and Care Excellence [NICE], 2016).

In some cases, blood products are also available as a resource to support life within the community by Air Ambulance colleagues.

Photo Credit: www.bucksfreepress.co.uk

Now..Imagine if we could do that for babies following a complicated birth. Imagine a world where we have just the right equipment to get blood into a baby, at the precise composition and exactly at the point that the baby needs this most?

JRCALC (2018) currently promote a delay in cord clamping unless resuscitation is required and this is in-line with the guidelines from the Resuscitation Council (UK, 2011) newborn life support guidelines.

The European Resuscitation Council (2010) recommendations states that “for babies requiring resuscitation, resuscitative intervention remains the priority”, but does this mean the cord has to be cut before resuscitation is initiated?

Challenging the clinical barriers to intact cord resus

Paramedics and Midwives working together to change practice

Within the community, there are no ergonomic constraints to bringing the resuscitative equipment to the baby, this approach is quicker and efforts to promote thermoregulation can be continued whilst resuscitation is established.

Clinicians may hold a reservation around undertaking resuscitative efforts beside the mother however, Thomas et al., (2014) report positive clinical experience where clinicians have chosen to adopt this approach. Ambulance clinicians already understand the importance of inviting relatives to be with family members during resuscitative events, affording the chance to improve communication with the family – however, practice of immediate cord clamping and immediate extrication of babies from the house to the hospital; has been routinely carried out.

Clinical uncertainty and the need to remove these precious patients to ‘definitive’ care seems to be the driving force to these clinical decisions. Decisions are made where the stakes are high, are influenced by human factors and decision making is marred by complexity.

Intact cord resuscitation could direct the focus on the other essential assessment criterion which can be carried out in the initial stages, additionally facilitating a potential >30% increase in blood volume to the baby, thereby increasing cerebral oxygenation and improve circulatory and respiratory function. Adopting an approach of a considered effort to provide effective resuscitative efforts with the cord intact, allowing effective communication and thermoregulation to maximize the chance of a positive outcome.

Progress#waitforwhite

Students embracing #waitforwhite

Ambulance services are doing a tremendous amount to improve the outcome of babies born in the community, the 2017 clinical updates promotes a longer wait to clamp the cord and the ‘Wait for White’ message is part of the educative rhetoric, efforts are being made to keep babies warm with the introduction of hats, blankets and nappies within maternity packs, and management of obstetric emergencies are being demonstrated and included in mandatory training.

Ambulance services now have maternity leads and have seen the introduction of midwives and consultant midwives working within ambulance services to promote better care to women and babies born within our communities – working together to enhance life, just like the placenta and the baby; working together for a better and healthier start.

As a paramedic and a lecturer, it is my job to look at the current best evidence and help to promote the progression of this amazing profession. I’m hopeful for a future which promotes bringing the ’resus to the baby’ and practising in a world I have only imagined before.

Follow Susan on Twitter: @SusanRhind1

References

Brown, S.N., Kumar, D., James, C., Mark, J. (Eds.), 2017. JRCALC Clinical Practice Supplementary Guidelines 2017. Bridgewater: Class Professional.

Ledger, S., Hindle, G. & Smith, T., 2018. Mind the Gap: An Investigation into Maternity Training for Frontline Professionals Across the UK, Coventry: Baby Lifeline Training Ltd.

Mansfield, A.,(Ed.), 2018. Emergency Birth in the Community. Bridgewater: Class Professional.

National Institute for Health and Care Excellence (NICE), 2016. Major Trauma: Assessment and initial management. Available at: https://www.nice.org.uk/guidance/ng39

Panteli, M., Pountos, I., Giannoudis, P.V., 2015. Pharmacological adjuncts to stop bleeding: options and effectiveness. European Journal of Trauma and Emergency Surgery, Volume 42, pp. 303-310.

Resuscitation Council (UK), 2011. Newborn life support—resuscitation at birth. 3rd edn.

Richmond S., Wyllie, J. (2010) European Resuscitation Council Guidelines for Resuscitation 2010: Section 7, Resuscitation of babies at birth. Resuscitation2010; Volume 81, Issue 10,pp. 1389–99.Available at: https://doi.org/10.1016/j.resuscitation.2010.08.018

The Royal College of Obstetricians and Gynaecologists, 2018. Each Baby Counts: Themed report on anaesthetic care, including lessons identified from Each Baby Counts babies born 2015-2017. London: The Royal College of Obstetricians and Gynaecologists.

Thomas, M.R., Yoxall, C.W., Weeks, A.D., Duley, L., 2014. Providing newborn resuscitation at the mother’s bedside: assessing the safety, usability and acceptability of a mobile trolley. BMC Pediatrics; Volume 14, Issue 1. Available at: https://doi.org/10.1186/1471-2431-14-135