NAEMSP 2019: 3rd Trimester, Births, Babies!

When was the last time you brushed up on your neonatal resuscitation skills? Joelle Donofrio, DO, FAEMS, asked the audience where this topic falls on their to-do list at the 2019 NAEMSP conference in Austin, Tex. during her session “3^rd Trimester, Births, Babies!”

“We have to change how we think so we know what to do in low-frequency, high-risk events,” said Donofrio. She focused on two educational concepts for consideration in her presentation: where to put neonatal resuscitation in EMS curricula, and the prehospital providers’ approach to postpartum hemorrhaging.

Part 1: Where to Put Neonatal Resuscitation

“Are your medics ready on how to resuscitate the newly delivered?” Donofrio asked, referencing the lack of thorough patient care instructions for OB/GYN emergencies in EMS textbooks. The ones that do cover this content have obstetrics and pediatrics sections separated despite the obvious correlation, and protocols for these patient cases differ between the east and west coasts of the U.S., calling for a need to establish more consistent guidelines for EMTs and paramedics to follow (even NASEMSO’s guidelines for these categories are covered in different chapters).

Donofrio said many OB/GYN emergencies consist of more than just taking care of mom post-delivery or during imminent delivery, noting that very few textbooks (only three in the U.S.) have neonatal resuscitation content near or within sections covering OB complications, making it easy to overlook considering it's an infrequently-used skill. Prehospital care instructions for neonates (defined as newly delivered babies up to 30 days old) provided in EMS textbooks contain good information for providers but mostly emphasize applying APGAR and PALS without discussing potential complications mothers also face.

This lack of comprehensive education on neonatal resuscitation is evidenced by a 2017 study “Safety Events in High Risk Prehospital Neonatal Calls” published in the journal Prehospital Emergency Care. The conclusion of the four-year study states that “High-risk neonatal calls are infrequent and prone to a high incidence of serious patient safety events.” Results indicated that of the 26 neonatal patients involved in the study (all of whom were transported with lights and sirens), safety events were found in 73% of the patients while severe safety events were found in 38% of them—54% of the patients were in their first 24 hours of life, highlighting the significance of the prehospital providers’ need to be well-trained in neonatal care. The majority of these safety events were related to errors in medication administrations, resuscitation, procedures, and clinical assessments and decision-making.

The takeaway from this study, said Donofrio, is to recognize that neonatal care and obstetrics are two distinct specialties and prehospital providers must be astute in both of them. When one patient becomes two, it’s a unique, low-frequency but high-risk event, which is why proper education is imperative to ensure better patient outcomes for both mom and baby. “You are the obstetrician and neonatologist on this call,” Donofrio said.

It’s important to recognize the resuscitation of the newly delivered is vastly different from other pediatric and adult patients. The neonate is like an alien, Donofrio said, as it’s been in a water-based environment its whole life. She provides these essential steps to follow during resuscitation to turn that water-based babe into an air-breather:
 

• Primary apnea upon delivery: Warm, dry, suction, and stimulate the neonate and provide blow-by oxygen if necessary.
   
• Secondary apnea: If the baby still isn’t breathing, it may be because it doesn’t think it’s in a safe environment. Provide oxygen via BVM if the heart rate is less than 100 bpm or they are gasping or apneic.
   
• Chest compressions should follow if the heart rate is less than 60 bpm.
   
• Epinephrine should be administered if the heart rate remains below 60 bpm despite chest compressions.
   
• Stop chest compressions when the heart rate is greater than 60 bpm; Stop BVM ventilation when the heart rate is greater than 100 bpm and there is good respiratory effort.
   
• In short, “The only thing to measure is: Is the baby breathing and is the heart rate greater than 60 or greater than 100?”

“Resuscitate early for apnea,” Donofrio said. In fact, she advised to aggressively resuscitate in the first few minutes of life, as this will significantly improve the baby’s chances of survival. Evaluate for an APGAR score after successful resuscitation to determine if the baby goes to mom’s breast or not—it’s a green light if the baby is full-term, crying and breathing, and has good muscle tone.
 

Prehospital professionals should be educated and trained for managing special OB/GYN scenarios. Donofrio observed positive results from this endeavor in one hospital that retrained their paramedics and trained their second class of paramedic students with classroom and hands-on skill sessions in OB/GYN emergencies. The medics and students trained with obstetricians in simulations combining different types of real-life delivery scenarios with various levels of neonatal distress.

Paramedics responded well to the training, providing commentary like, “Review this skill more frequently. It’s high-risk and low-frequency. We should drill on this a lot more,” and “Thank you for finally bringing the relationship between childbirth and neonatal resuscitation to the forefront of our minds!”

Part 2: Approach to Postpartum Hemorrhage

Postpartum hemorrhaging is the most lethal childbirth complication but it's easily treated. A study conducted by the Institute for Health Metrics and Evaluation and the Journal of Obstetrics and Gynecology found that the United States’ maternal mortality rate is significantly higher than most other wealthy nations and has been on the rise since 1990, reporting nearly 24 pregnancy-related deaths per 100,000 live births. The nation's counterparts, on the other hand, have seen declines in maternal mortality rates, ranging from 3 to 14 deaths per 100,000 live births in countries like Sweden, the U.K., Japan, and Germany.

To counter this rising trend, the state of California decided providers needed to approach postpartum bleeding like any other form of severe bleeding. 

“Massive bleeding is massive bleeding is massive bleeding,” said Donofrio. It’s like treating any other trauma patient, she said—you must stop the bleed. The Trauma Triad of Death occurs in all massive bleeding, including postpartum bleeding, which tends to fall to the wayside when providers think 'massive bleeding.'

Donofrio leaves the audience with these final points:

• Where are you putting neonatal resuscitation in initial and continuing education?
• Treat your postpartum bleeds like a massive trauma patient.

Valerie Amato is assistant editor of EMS World. Reach her at vamato@emsworld.com.