WHO COMES FIRST?
September 7, 2012
By Jeff Clawson, M.D.
Dr. Clawson: We have all but completed a review of most of our processes and policies. Within a previous draft the following was included:
In the event that both mother and child suffer cardiac arrest prior to the arrival of the ambulance crew, Pre-Arrival Instructions (PAIs) must be relayed in the first instance to the newborn baby before the mother.
Could you point me in the direction of any evidence base for this, if it remains a current recommendation? I have been through Chapter 8 of Principles of EMD and was not able to locate this directive. It may have been a locally-defined decision. Many thanks, Helen Rees Senior Nurse Practice & Service Development NHS Direct Wales Welsh Ambulance Services NHS Trust
Helen: I have forwarded your question to Brett Patterson, IAED Academies and Standards associate and Research Council chair, for his clarification. Dr. Clawson
Helen: I have done a few ethical searches on this topic but there isn’t much available since healthcare providers generally have enough staff to attempt resuscitation on both patients. Most of the ethical literature is about when to take the baby (crash C-section) or when to discontinue life support for the mother.
However, in my opinion, one point is clear—there are too many potential factors to make a blanket statement, i.e., gestation of fetus, health of fetus, cause of maternal arrest, time since maternal arrest, time since delivery, etc. Different situations warrant different approaches. For example, traumatic arrest of the mother associated with head trauma and delivery of full-term fetus might suggest working the baby, while an unknown cause of maternal arrest, with delivery of premature fetus with known potentially life-threatening defects, might warrant resuscitation of the mother.
My suggestion is to develop an internal policy that considers various scenarios, but I am still going to defer to Dr. Clawson on this one.
IAED Academics & Standards Associate Chair,
Council of Research
Helen: I think Brett has covered the waterfront well on this by listing the variables that might make either the mother or the baby the best candidate for resuscitation. Another aspect to throw in, and there are many, is if the mother bled out from a uterine tear, etc., and the baby is suffering a respiratory-caused arrest—in this case the baby would come first, as the mother would likely be irretrievable outside of a hospital.
I don’t recall us (in Principles of EMD textbook or at the Academy) ever taking a position on this. This center must have made this one up locally. For the father, who could likely be the caller, this would be unbelievably hard to witness, much less, handle. Really a “Bad Day at Blackrock” as we used to say.
Onward through the ethical fog. . .
Brett: Wow, what a nightmare scenario to even consider. I can’t really think of anything you left out. The problem depends on what caused mom to arrest and the gestational age/condition of the baby. That would determine who you resuscitated first. Is the baby a 30-week preemie that doesn’t have a high chance in the field with a mom who is having a SVT arrhythmia-type of issue and just needs to be converted? Did mom get shot in the chest and spontaneously delivered a healthy baby at 39 weeks? We had a baby in our unit whose parents got in a car accident on the way to the hospital. Mom didn’t put on her seatbelt because it was too annoying while she was laboring. Mom was mostly brain dead on arrival and the baby did fine after just a few days in intensive care. I just don’t know how to qualify this in an e-mail. This is definitely a “sit around the table with the high risk team and talk about it” issue.
Sorry not to be more help on this one.
Robin Ayers Chair, High Risk Delivery Standards Committee