BABY'S IN CHARGE
January 14, 2016
Editor’s Note: The following CDE is based on “The Birds and the Bees of Childbirth,” presented by Cassie Stavros and Sharon McCool at NAVIGATOR 2015, and revisions to the Medical Priority Dispatch System (MPDS) version 13.0.
My wife is having a baby,” the caller tells EMD Cassie Stavros, Lead Communication Specialist, Central Lane Communications, Eugene, Ore.
She turns to Protocol 24: Pregnancy/Childbirth/Miscarriage, and when she asks Case Entry Question 1—How many weeks (or months) pregnant is she?—the father is quick to reply, “She’s giving birth. That’s how far along. You need to get me an ambulance.”
Stavros has been through this before during her two years in calltaking prior to transferring to dispatch and working as lead specialist at the center in Eugene. She’s on the line with an anxious father, a mom in audible pain and fear, and a baby who’s not waiting for a drive to the hospital. This call, however, adds dimensions, testing Stavros on other levels becoming more apparent during each stage of the delivery.
The mother is on the “totie,” which Stavros doesn’t recognize as his word for the “toilet.” She repeatedly tells dad to calm down. He is apprehensive, mom’s voice is growing more pitched, and the baby doesn’t seem to budge past its head, even after three contractions.
Stavros moves to Panel 16 of Protocol F: Childbirth-Delivery and instructs the father to lay her flat. He’s hesitant.
“She can’t lay on the ground,” the father said. “There’s not enough space [in the bathroom] to lay her down.”
Stavros repeats directives to “calm down.”
“Take her to another room,” Stavros recommends. “Have her lie down in the hallway if you have to.” Stavros continues, providing instructions to place two pillows under his wife’s bottom; the mother is to grab her knees, pull them to her chest, and then push hard to get the baby out.
Mom follows the instructions relayed by her husband. Stavros provides instructions for her to push twice. Mom does and, again, the baby does not emerge beyond its head. Stavros goes to Panel 17 and tells dad to position his hand just above her pubic bone. He does. She moves to Panel 18 and dad follows instructions to push down and hold for three seconds.
“The shoulders are out,” the dad exclaims. “The baby’s out.”
A weak cry alerts Stavros to a possible breathing problem. She tells the dad to rub the baby’s back with a towel.
Paramedics arrive at the door.
Stavros critiqued the call almost immediately after she disconnected the line. She had assumed mom was on the floor and had misunderstood his use of the word “totie.” She faulted herself for repeatedly telling him to calm down.
“I never say that anymore, ‘calm down,’” she said. “It doesn’t help. I now say, ‘Take a deep breath’ and ‘I’m here with you.’”
There were also good things, such as the lifesaving recognition that comes from experience and training and the advancing nature of Protocol 24 and its increasing number of PAIs added to help EMDs direct the caller and patient through potential complications of childbirth and delivery.
“It was a good call,” Stavros said.
And it was a call helped by her military background in delivering instructions and keeping her emotions in check.
“I was able to focus and get into the zone,” she said.
Protocol 24: Pregnancy/Childbirth/Miscarriage
Protocol 24 is the most evolving protocol in the MPDS, according to Brett Patterson, IAED™ Academics & Standards Associate and Medical Council of Standards Chair.
“We started with instructions for a normal delivery and over the years have added instructions to cover more and more complications,” Patterson said. “Some are highly unlikely to happen but, according to our obstetrics council, even though they may seem a bit invasive, the consequences of not providing them are potentially fatal, so it’s better to include them for the rare chance they do.”
MPDS v13.0 continues the protocol’s progression with multiple modifications to Protocol 24 and the PAIs in Protocol F, including the addition of another possible delivery complication “cervical cerclage (stitch),” a new Key Question (KQ) 4 “(< 6 months/24 weeks) Does she have abdominal pain?” and coordinating 24-C-3 Determinant Code “Abdominal pain/cramping (< 6 months/24 weeks and no fetus or tissue),” and new Axioms, definitions, and DLS Links. PAIs for miscarriage are also now provided on a new Protocol G (Panels 1–9).
New and assumed complications
Cervical cerclage (stitch) is a surgical procedure involving a strong suture that prevents dilation of the cervix and, therefore, premature labor. It is a high-risk complication that involves positioning and encouragement not to push since the stitch must be removed before birth (Axiom 3). For this reason, the EMD is directed to the breech positioning pathway. This pathway is also used when the caller reports presentation of the cord, hands, feet, or buttocks first, which is a dire prehospital emergency that often must be handled at the hospital for the survival of the baby (Axiom 2).
The addition of cervical cerclage brings the number of potential childbirth complications addressed in the protocol to almost 12, without taking into account different complications related to one anomaly. For example, the failure to progress during end-stage labor could be due to shoulder dystocia or the size of the baby’s head obstructing passage through the mother’s pelvis.
During the call highlighted earlier in the article, Stavros realized that the baby’s inability to emerge beyond its head might be a sign of complication in the baby’s positioning.
That should send an alarm to the EMD, said Sharon McCool, EMD-Q®, Central Lane Medical Educator and EMD Regional Instructor. “After the head comes out, the rest of the baby should come flying out,” she said. “If that doesn’t happen, the dispatcher must do all she or he can do to get mom to deliver that baby.”
In this case, shoulder dystocia was causing the delay. After delivery of the fetal head, the baby’s anterior shoulder gets stuck behind the mother’s pubic bone. The head emerges and seemingly gets sucked back into the birthing canal at the end of a contraction when the pelvic muscles relax.
“Basically, the baby is bone to bone,” McCool said. “It’s something more likely to happen for post-term babies or tiny moms giving birth to large babies.”
Shoulder dystocia is relatively uncommon—occurring in about 20,000 U.S. births each year—but poses serious harm to the baby and mom if birth is unduly delayed. Shoulder dystocia is not scripted as a potential complication in the MPDS, but it is a type of complication assumed when the baby fails to deliver following three contractions in the final stages of active labor, Patterson said. If the same occurs in the hospital setting, the mother will be instructed to change positions, similar to the position described in Protocol F: Panel 16.
“If that doesn’t work in the hospital, and the baby is still not out after several more pushes, the doctor will reach in and break the clavicle in an effort to fold the shoulder,” Patterson said. “That’s obviously nothing we’re going to advise in the EMD setting.”
McCool emphasized the importance of checking on the baby’s breathing status once the shoulder is released and the baby delivers.
“This has been a long, hard birth for the baby,” McCool said. “The baby is going to be sluggish, and you’ve got to focus on whether that baby is breathing.”
New Key Question
A second call played during the presentation highlights a surprise birth—mom didn’t know she was pregnant—compounded by breech presentation. EMD Daniel Wegscheider of Leitstelle Tirol, Austria, was the calltaker that was featured when named Euro NAVIGATOR Dispatcher of the Year 2013.
According to the call, abdominal pain that morning was the first indication that mom might be pregnant; the pains progressed, and, by the time she made the 112 call, the baby was on its way but in a legs-first breech position. Although mom was alone, she was able to follow Wegscheider’s instructions, including preparing a spot that was clean and soft for the baby to land.
“Abdominal pains are contractions until proven differently, even if the mother doesn’t recognize the contractions as labor,” McCool said.
The addition of KQ 4 on Protocol 24 identifies abdominal pain and cramping, which at any time during pregnancy “should be considered contractions until proven otherwise” (Rule 2). The new KQ 4 also complements changes to the Pre-Question Qualifiers on KQs 2 and 3 from “(≥5 months/20 weeks)” to “(≥6 months/24 weeks).”
Patterson said the ranges were adjusted based on the likelihood of fetal survival outside the womb in the prehospital setting.
A mother alone also raises other issues, McCool said.
“It’s very unsettling for the mom, forcing the EMD to prioritize,” McCool said. “You have to make decisions based on what this mom can do. You don’t want that mom getting up and walking around looking for a pin, shoelace, or string. The towel, however, is essential, she said.
Patterson said the towel—or comparable item for wrapping the baby—is necessary for warmth and, when indicated, to stimulate breathing. New language and formatting added to Protocol F, Panel 8 directs the EMD to confirm each action to make sure each is done before moving to the next.
“The baby is wet and without much of a fat layer; it’s going to lose body temperature rapidly,” he said. “Hypothermia is a strong possibility, so it’s important to wrap up the baby as soon as possible.”
According to widespread recommendations, the instructions for tying off the umbilical cord in Panel F-9 have been modified to first wait three minutes to monitor the baby, unless complications arise with the mother or baby. This delay is associated with neonatal benefits when the infant is placed at the level of the placenta.1
Patterson said the issue of a delay in tying off the cord, potentially allowing a final transfusion of blood to the newborn, has been pushed in the U.K., but less so in the U.S. While the Academy has now embraced the three-minute delay in protocol, a new Rule 6 on Protocol 24 provides an exception: “The umbilical cord should be tied immediately (F-9) if the mother or baby develops complications after delivery.”
That’s not all
Protocol 24 and Protocol F include several other modifications, a few of which include the following:
- The new suffix “M = Multiple birth” allows for more specific datacollection and differentiation of local response.
- The patient conditions “Placenta abruption” and “Placenta previa” have been added to the “HIGH RISK Complications” list and can be defined and authorized by local medical control; Axioms 4 and 5 provide EMDs with information to better understand these conditions.
- A new Protocol G, in conjunction with Protocol F, handles MISCARRIAGE situations. (This Protocol appears as a pullout behind Protocol 24 in the cardset.) These Panels include instructions to “Evaluate MISCARRIAGE,” “Wrap Fetus (and Afterbirth),” “Suprapubic Pressure,” “Fundal Massage,” and “Wait and Monitor.”
- POSTPARTUM Hemorrhage has been defined (“Vaginal bleeding ≤8 weeks after delivery”) for clarification and, by Rule, should be handled on Protocol 21 when delivery of the baby and the placenta is complete and bleeding is the only complaint. New protocol additions specifically address this condition.
“It’s a different kind of call to handle,” McCool said. “We’re not going to wait until help arrives. We’re here to help mom. The baby’s in charge.”
1 McDonald SJ, Middleton P. “Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes.” Cochrane Database of Systematic Reviews. 2008; April 16. http://www.ncbi.nlm.nih.gov/pubmed/18425897 (accessed Oct. 27, 2015).