Labour Birth ER Sep2009

7/30/2019 Labour Birth ER Sep2009

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Labour and Birth in the Emergency Room:

Guidelines for Assessing Labour, Facilitating Imminent Delivery, andInitiating Transfer when Possible

Revised: September 2009


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Table of Contents

Introduction 3Roles of the Emergency Team.. 4

Assessment of Maternal and Fetal Well-Being................................ 5o Key questions 5o Auscultation of fetal heart tones 6o Signs and symptoms of labour.. 6o Signs and Symptoms of Imminent Birth 7

Plan for Care.. 8 Maternal Assessment Quick Reference..... 9

When Birth is Imminent.. 10Delivery Step-by-Step. 11Assessment and Care Following Birth... 16

Neonatal Assessment.. 18Keeping Baby Warm. 20Neonatal Resuscitation Overview................................................... 21Transfer 22Active Maternity Service Directory... 23Equipment... 25Medications for Obstetrical Emergencies and Routine Birth:Recommended for Stock in Emergency Rooms.. 26Laboratory Tests... 32Documentation.................................................................................... 33References................................................................................. 34

Appendix A (Samples of standard documentation for labour and birth) 35Appendix B (Reference Guide and Equipment List for NRP). 45

Photographs and illustrations not specifically referenced have all beenobtained via Google Images (2009)


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Introduction

The majority of women in Nova Scotia give birth in a hospital with an active maternity service.Occasionally, pregnant women arrive in active labour in the emergency or outpatient area ofa facility where a maternity service is unavailable. Health care professionals must be able to

accurately assess these situations to determine the safest and most effective way to care forthese women. In some cases the assessment may indicate that a transfer to the nearestfacility with an active maternity service is possible. When it is possible that the birth will occurbefore completing a transfer, physicians and nurses at the local site should support thewoman and her family through labour and birth to optimize a healthy outcome for bothmother and infant. Transfer should not be attempted if it is suspected that birth may occur enroute.

The following document has been developed to support health care professionals in thosefacilities where an active maternity service is not available. It is intended to provide guidanceand support to safely and effectively care for childbearing women who present in labour to

these facilities. Included are guidelines for:

Assessment of the labouring woman and her fetus Indications for transfer and transfer process, including a directory of all facilities

within the province who provide a maternity service Care and documentation during labour and birth when transfer is not possible Basic neonatal resuscitation skills Assessment and care following birth Equipment Medications to keep in stock for obstetrical emergencies and routine birth Laboratory tests


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Roles of the Emergency Team

The value of multidisciplinary assessment and care by the emergency room team shouldnever be underestimated. It is, however, the responsibility of the physician to make the final

decision regarding the womans care. Where time and circumstances permit, it is alwaysadvisable to seek support and advice from a referral center or from the transport team.

It is important that nurses in ambulatory care or outpatient/emergency departments take allopportunities to learn the skills of assessing maternal and fetal progress and well being. Skillsrequired to complete a comprehensive assessment, and provide reassurance to the womanand her family, include:

Assessing labour in terms of frequency, strength and duration of contractions Assisting women with regard to decision-making in early labour and the

potential need for travel or transfer to the most appropriate facility for labourand birth

Auscultating the fetal heart with a fetoscope or Doppler Recognizing a normal fetal heart rate, or abnormal fetal heart rate Providing initial stabilization when necessary in consultation with referral center

colleagues until transfer of mother and/or baby Recognizing signs of rapidly progressing labour and birth Assisting pregnant women during labour and birth

Providing appropriate maternal and newborn assessment and care in theimmediate post partum period, including initial breastfeeding.

Emergency Health Services Lifeflight 1-800-743-1334


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Assessment of Maternal and Fetal Well-Being

The best source of information about a womans pregnancy history and presenting concernsis the woman herself. Many women, particularly after 36 weeks gestation, will have a copy oftheir Nova Scotia Prenatal Record with them, which will provide valuable information about

her pregnancy. In addition to the information gained from this record the woman can verballyprovide her own history when prompted with key questions.

When birth is imminent and there is little time to do a more comprehensive assessment it ismost important to assess the gestational age of the baby, whether or not the membraneshave ruptured, if the amniotic fluid or water is clear or colored yellow to green to brownfrom the presence of meconium (stool from the fetus), and the presentation of the baby(i.e. is the baby coming out head first or breech). The presence of meconium may impacthow the resuscitation of the baby is managed (refer to Delivery Step by Step). Thegestational age will impact the timing of the initiation of the transfer process and theidentification of the most appropriate referral center for transfer. A breech presentation may

indicate a need for a cesarean section if there is time.

Key Questions to Assess Maternal and Fetal Well-Being

Mother

When is your due date? How many weeks pregnant are you? (


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Has your water broken? (May be felt as a gush, trickle, or wetness.) When? Is it clearin color?

Is there any vaginal bleeding? (Note: amount, color, consistency, how long?)

Auscultation of Fetal Heart Tones

The fetal heart tones are most easily heard through the babys back. When unsure ofthe babys position, you may consider asking the mother on which side she mostfrequently feels the babys kicks. Assuming this to be the location of the babys limbs,you would auscultate on the opposite side of her abdomen, midway between theumbilicus and symphysis pubis. The fetal heart tones will be heard lower in theabdomen as the baby moves down into the pelvis as labour progresses.

Wi l l i a ms Ob s te t r i c s - 2 2 n d Ed . (2 0 0 5 )

Signs and Symptoms of Labour

Regular contractions and/or back pain not relieved with rest or other comfortmeasures

Pelvic or vaginal pressure

Increased vaginal discharge, including but not limited to bloody show

Ruptured membranes with or without contractions (this may be indicated by slow

leaking of fluid, wetness, popping sound accompanied by fluid, or a larger gush offluid)

Cervical change (someone who is skilled at cervical assessment can perform avaginal exam only after careful assessment, consideration, and consultationregarding gestational age and membrane status; or if birth is imminent)

Do not perform a vaginal exam if the pregnancy is less than 36 weeks gestation unless birthappears imminent or you have consulted with a physician from a regional or tertiary hospital.


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Signs and Symptoms of Imminent Birth

Mother states the baby is coming or the babys moving down

Uncontrollable urge to push

Bulging perineum and rectum

Uncontrollable passage of stool Mother may panic

Sudden nausea and vomiting

Crowning of the fetal head


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Plan for Care

Suspected labour, maternal or fetal concerns or other safety factors such as time,distance and travel conditions may influence your decision to:

Discharge home

Transfer to a referral center

Provide care in your facility

Guidelines for Discharge Home:

If appropriate assessment indicates that the woman is not in labour, or if she is in theearly/latent stage of labour, she may be offered the option of returning home ordriving to the hospital where she plans to deliver giving consideration to distanceand travel conditions. She should be advised of the signs of labour (p.6) andencouraged to return if she is unable to get to a facility with an active deliveryservice.

Guidelines for Transfer to a Referral Center:

Consult with physician on call at the appropriate referral center, or through LifeFlight

Maintain continuous support and assessment

Consider safety of conditions for transfer (adequate time before delivery, weather)

Ensure appropriate care providers are available to accompany mother during transfer

Reassess labour progress prior to transfer

If birth is imminent and the baby is preterm (


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Maternal Assessment: Quick Reference

Key Question orObservation:

IS THE BABYCOMING?

Maybe=

TRANSFER

YES!=

IMMINENT BIRTH

No=

DISCHARGEHOME

Consult LifeFlight(1-800-743-1334)

ornearest referral

centre

Maintaincontinuous support

and assessment

Make every effort toavoid delivery en

route;Always transferwhen

possible

Provide a safe,comfortable, private

environment withcontinuous support

Get help andprepare equipment

Consult referralcentre or LifeFlight(1-800-743-1334)

and initiate neonataltransport PRN

Provide informationre: signs/symptomsof labour or other

indications to seekmedical care

Advise woman ofnearest active

maternity service forfuture assessments

when possible


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When Birth is Imminent

Birth is a natural process and the vast majority of the time is uncomplicated, particularly whenthe pregnancy is at term (> 37 weeks). It is highly likely that most of the women who findthemselves giving birth in an emergency room will have had previous vaginal deliveries,hence the precipitous nature of the labour and inability to get to a facility with a maternityservice. This successful vaginal birth history gives a very good indication that this delivery will

go smoothly.

It is important to remain calm and provide both emotional and physical support to the womanand her family. The goal of care should be to prevent or minimize trauma to the woman andher baby by supporting the normal processes and movements of birth and to create apositive lasting memory of the birth for the woman and her family. A nurse should fulfillseveral fundamental roles:

remain with the woman at all times

ensure help is available to prepare for delivery

provide support and care to the mother and her family

provide care for the newborn baby.

Ideally, a separate room should be available for the woman giving birth. All equipment shouldbe kept in an area known to all staff and readily available for an imminent delivery. The roomshould be warm to minimize potential heat loss for the baby. In addition to increasing thetemperature of the room, be sure to close windows and keep the baby away from windows,outside walls, or any other potential sources of cold. A copy of standard provincialdocumentation for labour and delivery will help prompt you with regard to care; a sample ofthese are appended to this document (Appendix A) and can be photocopied or obtained fromthe RCP by calling 470-6798.


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Delivery Step by Step

Sound Confident and Reassuring

Close up eye contact

Touch her shoulder Speak in a quiet confident voice

Call her by name

Minimize the distraction and noise in the room, provide privacy

Position to Promote Delivery and Prevent Tissue Trauma

Encourage leaning back against a person, wall, or bed.

Flex knees or encourage her to pull back on her knees during contractions.

She should not lie flat on her back; left side-lying or a tilt to the left with the support ofa pillow under her right side is the best position to promote circulation and properlyoxygenate the baby.

Discourage forceful Valsalva pushes. Encourage her to push with her natural urges. Wash hands and wear gloves.

Get equipment ready.

Delivery of the Head

If the amniotic membranes have not yet ruptured and are bulging through theperineum break them with your fingers or use an instrument (e.g. Allis clamp) tobreak the water. Note the color, quantity and odour of the fluid.

Hold a towel or sponge between the vagina and the anus and apply gentle pressure tosupport the perineum and to encourage continued flexion of the fetal head.

Encourage light panting and gentle pushes as the head emerges to prevent theforceful expulsion of the head.

Maintain flexion with light pressure on the back of the babys head.


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Check for Cord

Once the head is born, encourage the woman to stop pushing for a moment while youcheck for the umbilical cord around the neck.

You will have time before the next contraction to sweep your fingers around bothsides of the neck, feeling for the cord.

If you feel cord gently try to loosen it and bring it out over the babys head, sweepagain in case it is looped twice.

If you cannot loosen it you will have to clamp it with two clamps, cut between theclamps, and unwind the cord.

If you have had to clamp and cut the cord you will have to quickly deliver the baby.


Suction

It is no longer recommended that babies be suctioned while on the perineum (NRP2006).

.

Restitution

Allow the babys head to spontaneously turn to face the mothers leg.

Let the uterus do the work of turning the baby through the pelvis once the head isborn.

As the baby restitutes, the shoulders are lining up to move through the pelvic bones The upper (anterior) shoulder passes under the pubic bone first

With a helper on each side support both legs helping the woman to flex her hips asshe pushes with the next contraction


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Support the Head

Both hands are placed on either side of the babys head for support.

The pushing power comes from the woman and her uterus, not from the assistantpulling.

The assistants hands move downward with the babys head as the upper shoulderpasses under the pubic arch.

The assistant uses a gentle downward motion, but never pulls.


Guide the Body

It is important to continue to protect the perineum at this point by not using forceful

movements while guiding the babys body out. Gently guide the babys body in an upward direction without pulling.

Feel the contraction pushing the baby out with the help of a steady easy push fromthe mother (this can be encouraged with panting or easy grunting).

Encourage the woman to gently help the baby along to prevent the forceful expulsionand injury to the vagina.


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Babys Out!

Keep the baby below the level of the umbilical cord until the cord is clamped toprevent blood loss from the baby.

As you gently dry the baby with warm towels he/she should begin to cry vigorously.

If meconium is present and the baby is not vigorous (depressed respiratory rate,

depressed muscle tone, and/or a heart rate > 100 bpm), suction the baby as wellas possible. A team member competent and confident in neonatal intubation cangently insert a laryngoscope and, using a 10F or 12F suction catheter, suction themouth and posterior pharynx. An endotracheal tube connected to a suction source(and meconium aspirator, if one is available) is used for deeper suctioning.Delaying stimulation while suctioning occurs facilitates this.In the absence of intubation skills, use a large-bore catheter to suction secretionsfrom the mouth, then nose, as required. Follow with stimulation to initiate breaths.

Lift the baby onto the womans abdomen where she can see and hold her baby.

Keep the baby warm by placing the baby with the mother skin-to-skin.

Cover both with warm, dry blankets.

Give 10 units of oxytocin IM or 5 units IV to the mother. Remember to record the time of birth!

Congratulations!

Be sure to congratulate the woman and praise her efforts.

Dont forget to clamp and cut the cord.

Cord blood gases should be obtained if possible. Immediately after the delivery thecord is double clamped and a specimen is drawn into a heparinized syringe andsent to the laboratory for blood gas analysis. Alternatively, the cord blood may beplaced in a preheparinized syringe and placed on ice, refrigerated, and later

analyzed at a variable time up to 60 hours postpartum. Analysis of a pH, pO2,pCO2 and base deficit should be performed in the same way as blood gasanalyses are done for other hospital departments.

Waiting for the Placenta

Ideally, someone can observe the baby while another assesses bleeding andplacental delivery.

It is normal to see a small trickle of bright blood after the baby is born but before theplacenta is delivered.

You may see small tears in the skin or vaginal tissue; not all will need repair.

The placenta should come within a few minutes.

Signs of placental separation include:o Lengthening cordo Gush of bloodo Rising of the uterus in the abdomen

Do not massage the fundus (top of the uterus) or apply pressure in an attempt toassist the delivery of the placenta


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Very gentle traction can be applied to the cord with the other hand supporting theuterus just above the pubic bone.


You may apply gentle traction with ring forceps to the amniotic membranes if they aresomewhat adherent to the uterine wall.


Massage the fundus as soon as the placenta is delivered; it should be firm andpalpable around the level of the umbilicus.


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Assessment and Care Following Birth

Maternal Assessment

Vital signs, bleeding, fundal height and tone, bladder fullness, and perineum should bechecked every 15-20 minutes for the first hour after birth, every hour for the next four hours,and then once a day until discharge.

Bleeding

Lochia will be red (rubra) and moderate to heavy within the first hour after delivery. Itshould not exceed the saturation of a pad within the first hour.

If the mother has had a post partum hemorrhage in the past it is recommended thatan IV be started as she is at higher risk to have one again.

If the bleeding is excessive the fundus should be massaged. You may wish toconsider starting an oxytocin infusion; add 20-40 units of oxytocin to 1 litre ofRingers Lactate or NaCl and run at a rate of 100-125 cc/hour. This rate can beincreased if necessary.

If a continuous infusion or bolus of oxytocin IV and fundal massage does not controlthe bleeding consider the administration of an alternate uterotonic such asErgonovine maleate, Misoprostol, or Carboprost. Consult with a physician at yourreferral centre for advice.


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Vital Signs

BP

Pulse

Respirations Temperature

Pain

Fundal Height and Tone

The fundus should be firm and palpated at the level of the umbilicus and in the midlineof the abdomen.

If fundus is above the umbilicus or off from the midline this may be an indication thatthe bladder is full. The woman should be encouraged to void or be catheterized ifshe is unable to void on her own, particularly if the fundus is not firm and bleeding

is excessive. The flat of the hand should be used to palpate the fundus, while supporting the lower

portion of the uterus with the other hand.

Bladder

The bladder should not be palpable.

A distended bladder can interfere with uterine contractility leading to uterine atony andincreased post partum bleeding.

If the bladder is distended and the mother is not able to void on her own it isappropriate to catheterize to prevent or control post partum bleeding.

Perineum

Perineal lacerations causing excessive bleeding should be repaired; small, minimaltears generally heal well.


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An ice pack is recommended to reduce swelling.

Neonatal Assessment

First Impressions

If the baby is vigorous at birth place the baby on the mothers abdomen

Gentle massage while drying the infant with warm blankets is usually all that isrequired to stimulate regular respirations

Healthy newborns seldom require more than a clear airway and adequate warmth

If the baby has excessive secretions, it may be necessary to remove them by wipingthe mouth and nose with a towel or by suctioning with a bulb syringe (*rememberto depress the bulb before placing it in the mouth). Alternatively, you may considerusing a large-bore catheter to suction secretions from the mouth, then nose, ifrequired. Suction pressure should be set so that when the tubing is blocked, thenegative pressure reads approximately 100 mmHg. Be careful not to suctionvigorously or deeply as this can produce a vagal response. Brief, gentle suctioningwith a bulb syringe is usually adequate to remove secretions.

Apgar scores are assigned at 1, 5, and 10 minutes:


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Baby Assessment:

Appearance (color): blue to pinko Should turn pink very quickly, hands and feet may stay pale to bluish for up to

24 hourso Administer oxygen if the body does not turn pink within 90 seconds. This can

be done by cupping your hand as a mask over the babys nose and mouthwhile holding the oxygen tubing between your fingers.

Pulse (heart rate): 100bpmo Auscultate HR or feel cord pulseo Bag and mask ventilation if HR


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Keeping Baby WarmIt is essential for caregivers to provide warmth to newborn infants, as newborn hypothermiaand cold stress places a baby at increased risk for morbidity and mortality. For term babies,direct skin to skin cuddling with their mother is the preferred method to protect them from

cooling. For smaller or preterm infants it may be necessary to employ additional methods tomaintain a core temperature of 36.5 37.5 degrees Celsius.

Some facilities still have radiant warmers that were used when there was an active maternityservice on site. We recommend that these not be used. The risks of infant injury fromimproper use or poorly functioning equipment outweigh the benefits. Gel warming mattressesmay be used with caution to provide heat to prevent or treat cold stress in atrisk infantswaiting for or during transport. Blankets or IV bags should never be warmed in a microwaveto provide heat to an infant. Warm blankets may be found in a blanket warmer in anoperating room for those facilities with an OR service.

Other means of preventing heat loss from the baby:

Change wet blankets and replace with dry blankets that have been warmed, ifpossible.

Keep baby away from drafts.

Do not place baby on or near cold equipment, or walls and windows.


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Neonatal Resuscitation - Overview

Initial Steps

Place baby on a warm surface

Position with neck slightly extended

Suction mouth, then nose (as necessary)

Dry and stimulate

Remove wet linen from contact with baby

Reposition baby with neck slightly extended

Evaluate respirations, heart rate, and colour

PPV with room air at rate of 40-60/min. Ventilation is effective as demonstrated byHR>100 and pink colour

If after 90 seconds ventilation is ineffective, give supplemental oxygen as necessary

NRP algorithmNRP algorithm

Observational CareObservational Care

RoutineRoutine

CareCare

at 90 seconds

First30

seconds

CPS 2006


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Transfer

It is always ideal to transfer the labouring woman to a facility with an active maternity servicewhen possible. Furthermore, it is beneficial to transfer a baby in utero especially when theneed for special care is anticipated. Transfer should not be attempted if it is suspected thatbirth may occur en route.

Consult with an obstetrician at your regional centre or directly through LifeFlight about themanagement and/or transfer. If the infant needs special care and maternal transfer is not anoption, the neonatal transport team (through contact with LifeFlight) should be notified toenable their presence at the birth or as soon as possible thereafter to care for the infant. If itis necessary to transfer the baby after birth, family members will need information aboutparent rooms or courtesy rooms in the referral hospital. Staff should check with the receivingcentre to ensure the availability of a room, as space is sometimes limited. If a parent room isnot available, staff in the referring hospitals have information about alternateaccommodations for parents.

Some healthy mothers and babies may not necessarily need to be transferred after birth to areferral center depending on the distance to the referral center, maternal preference,availability of postpartum support for breastfeeding and skilled assessment of mother andbaby.

Regardless of where mother and baby are cared for in the postpartum period, the babyshould always remain in the room with the mother.


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Active Maternity Service Directory (Nova Scotia Area Code 902)

Emergency Health Services Lifeflight 1-800-743-1334

Tertiary Centres:

Halifax:IWK Health CentreBirth Unit 470-6670

Sydney: Cape Breton Regional Health Care ComplexLabour and Delivery Unit 567-7834

Regional Centres:

Amherst: Cumberland Regional Health Care CentreSwitchboard 667-5400

Ext. 6144

Antigonish: St. Marthas HospitalChildrens and Womens Health Unit 867-4200

Bridgewater: South Shore Regional HospitalMaternal/Child Unit 543-5214

Kentville: Valley Regional HospitalSwitchboard 678-7381

Ext. 3050

New Glasgow: Aberdeen HospitalSwitchboard 752-7600

Ext.2530

Truro: Colchester Regional HospitalMaternal/Child Unit 893-5545

Yarmouth: Western Regional Health CentreSwitchboard 742-3541

Ext. 130 or 363

TRANSPORT SERVICE LifeFlight (for maternal and newborn transfer)

1-800-743-1334


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Community Centres:

Glace Bay: Glace Bay Health Care FacilityObstetrics Unit 842-2844


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Equipment

Ideally, a warm separate area or private room should be available for the womangiving birth.

All equipment should be kept in an area known to all staff and readily available for an

imminent delivery. A copy of standard provincial documentation for labour and delivery will help prompt

you regarding assessments

A sterile emergency delivery tray should contain: 4 clamps (it is useful to have at least one pair of kochers or an Allis clamp to

rupture membranes if needed) 1 pair curved scissors 1 pair suture scissors Blood collection tube (to fit with a red top) 1 umbilical cord clamp

1 small bowl

1 towel 3 ml bulb suction 1 drape 1 large pad suitable to place under the mothers buttocks Sponges Gloves

* Disposable emergency delivery trays are available. These are often more practical in acommunity hospital that does not provide obstetric services.

You will also need:1. Several warmflannel blankets/towels to dry the infant. The infant should be placed

skin-to-skin with the mother and covered with clean, dry, warm blankets. The infantshould always be dried immediately; this can be done while skin-to-skin on themothers abdomen or chest. An alternative to this is bundling the infant in 2 or 3 warmblankets.

2. Warm, sterile water (to wash mothers perineum)3. Suction catheters (#6,8,10)4. Maternity pads5. Ice pack for perineum (provides comfort and prevents swelling; can be made and

stored ahead by soaking a peri pad in water and placing it in the freezer. They mustbe wrapped in a light cloth to protect the perineum from the direct contact with ice).

6. 2 heparinized syringes for cord gases7. Plastic bag for placenta8. Identification bracelets: 1 for mother, 1 for baby9. Folder with RCP chart form package & necessary hospital laboratory requisitions10. Newborn resuscitation equipment (See Appendix B)


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Medications for Obstetrical Emergencies and Routine Birth:

Recommended for Stock in Emergency Rooms

For Routine Birth

Drug Name /Level of Care Use Indications Contraindications Dosage Storage

Pot

ErythromycinEye Ointment

(All hospitals)

Topical Antibiotic prophylaxis forneonatalophthalmia dueto N gonorrhoeae

None known each eyelid should first bewiped gently with a sterilecotton ball to removeforeign matter and permitadequate eversion of thelower lid. A line of ointment1 to 2 cm long is placed ineach lower conjunctivalsac, if possible coveringthe whole lowerconjunctival area. After 1min, any excess ointmentshould be wiped gentlyfrom the eyelids andsurrounding skin with asterile cotton ball.

Roomtemperature

Mild to Mirritation

Oxytocin

(All hospitals)

Uterotonic; actson the smoothmuscle of theuterus tostimulatecontractions

- Active ThirdStagemanagement

Hypersensitivity toOxytocin

- Active Third Stagemanagement:10 IU IM or5 IU IV with the delivery oftheanterior shoulder orimmediately after the infantis delivered

Hypotenwater intchangesfollowingconcent

- After placentaldelivery to controlpostpartumbleeding andpreventhaemorrhage

- To control postpartumbleeding: Add 20-40 IU to1000 ml of Ringers Lactateor NS and infuse at 100-125 mL/hr.

Roomtemperature

Vitamin K

(All hospitals)

necessary forsynthesis in the

liver of factor II(prothrombin),factor VII(proconvertin),factor IX(thromboplastin),and factor X.

prevention ofhaemorrhagic

disease of thenewborn

none known Within 6 hours of birth:Single IM dose of 0.5mg

(birthweight 1500 g or less)or 1.0 mg (birthweightgreater than 1500 g)

Roomtemperature

None knassociat


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Drug Name Use Indications Contraindications Dosage StoragePo

MagnesiumSulphate(MgSO4)

(All hospitals)

CNS depressant eclampsiaprevention ortreatment.

antepartumhaemorrhage,chorioamnionitis,hypocalcaemia, renalfailure, myastheniagravis

Should be administeredonly under the continuoussupervision of a healthcare professional familiarwith the proper dosage,monitoring parameters,and the use of the antidote,Calcium Gluconate.

Loading dose: 4 gm bolus

over 20 mins followed by acontinuous infusion of 2gm/hr. If solution is notpremixed, withdraw 80 mlfrom a 1000 ml bag of RL.

Add 40 mg (80 ml) MgSO450% to the bag. Theresultant concentration is

40 gm MgSO4 per 1000ml.

Roomtemperature

hyporefdepresshypotenhypocaledema, generalof moth

WinRho

(All hospitals)

Rho (D) immuneglobulin

prevention ofrhesus (Rh)alloImmunization

maternal Rh-positivestatus; maternal weakD (Du) status; paternalRh-negative statuswhen paternity is

certain

Postpartum nonsensitizedRh-negative womandelivering an Rh-postiiveinfant:300 g IV or IMwithin 72 hours of delivery.

Following miscarriage,threatened abortion,ectopic or partial molarpregnancy 12 weeks:300g IV or IM.

Store inrefrigerator;may need toobtain fromblood bank

Blood p


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Indomethacin(Indocid PDA)

(All hospitals)

non-steroidalanti-inflammatory;tocolytic

For women withpreterm labourin preparation fortransfer to LevelIII facility.

allergy to ibuprofen orother NSAIDs, history ofliver or kidney disease,blood or urineabnormalities

100 mg pr x 1 dose Roomtemperature

Matetightndepefeverdisturdeprelighthproblhivesthe sk

blackbleedpassipersisnauseconstoligurin urinFetalof duc

Penicillin GSodium

(All hospitals)

antibiotic;treatment ofGroup Bstreptococcal(GBS) disease

Treatment attime of labour orrupture ofmembranes: allwomen positive

by GBSscreening doneat 35-37 weeks;women withinfant previouslyinfected withGBS;documentedGBS bacteriuria;< 37 weeksgestation unlessthere is evidenceof negative GBSscreening in past5 weeks;maternal fever.

allergy to penicillin 5 million IU IV, then 2.5million IU IV q4h.

Women who are allergicand not at risk foranaphylaxis:substituteCefazolin 2 g IV then 1 gIV q8h.

Women who are allergicand at risk foranaphylaxis: substituteclindamycin 900 mg IVq8h or erythromycin 500mg IV q6h.

signsrash, edemanap


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Narcan

(All hospitals)

opioid antagonist Continuedrespiratorydepression afterpositive-pressureventilation hasrestored normalheart rate andcolour, AND ahistory ofmaternal narcotic

administrationwithin the past 4hours

suspected maternalnarcotic addiction orknown methadone use;newborn heart rate


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Laboratory Tests

TIP:Keep corresponding requisitions with the emergency maternity equipment and chartforms.

Cord Blood:

ABO, Rh and DAT (Direct Antiglobulin Test)

Following birth, collect at least 1 mL into a 10 mL clotted blood collection tube (pinkstopper).

Carefully label and refrigerate.

Forward to laboratory with the appropriate requisition as soon as possible.

Rh Positive mothers:

Healthy Rh-positive mothers do not require routine laboratory testing unless there arespecific indications (i.e. CBC related to blood loss, rubella or varicella titre ifimmunization status is unknown or unsure).

Rh Negative mothers or mothers with antibodies (alloimmunized):

ABO, Rh type & Antibody screen

Within twelve hours following delivery, collect and fill two 10-mL clotted blood tubes

(pink stopper) Complete appropriate requisition.

Rh Negative mothers with Rh positive or Rh unknown baby:

Kleihauer

Within twelve hours following delivery, collect sample using one 4 mL EDTA tube(purple stopper).

Complete appropriate requisition

Laboratory technologist typically collects sample

PRN Bloodwork: CBC

Rubella and/or varicella titre if immune status is unknown

Newborn Bloodwork:Laboratory screening tests routinely done for full term healthy newborns include metabolicand endocrine screening (e.g. PKU screening), and a screen for bilirubin level. Bloodsamples are typically collected at 24-48 hours of age.


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Documentation

Documenting the events of an unexpected delivery in an emergency room or outpatientarea can be overwhelming during the moments of the birth. Even for experiencedcaregivers who routinely attend deliveries it can be challenging to maintain accurate andcontemporaneous documentation. Much of the documentation of the birth can be doneafter the delivery has occurred and mother and baby are assessed to be healthy and safein the immediate postpartum period. Noting and remembering the time of birth is oneimportant aspect of care and can be documented on the birth record as soon as

circumstances permit.

Keeping a small stock of RCP forms for use during unexpected births can help promotethe best care possible. These forms can help prompt caregivers to initiate appropriateassessments and treatments such as the timing of routine maternal and neonatalassessments and the administration of routine medications. While some of the formsmay not be applicable, depending on the duration of stay of the mother and newborn,the maternal assessment forms, partogram, birth record, and newborn assessmentforms will be helpful and necessary to use for any birth even if a transfer is indicatedshortly thereafter.

RCP maternal and newborn chart forms in order of their chart form number (forordering purposes) are:1. Physicians Maternity Assessment2. Maternal Assessment3. Partogram4. Birth Record5. Record of Parent Teaching/Mother-Baby Flow sheet6. Breast/Bottle Feeding Record7. Maternal Newborn Progress Notes8. Physician Newborn Examination9. Newborn Nursing Assessment10. Newborn TPR11. Newborn Weight Graph12. Atlantic Newborn Growth Chart

Refer to Appendix A to see sample RCP chart forms.


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References

Canadian Paediatric Society (2006). Neonatal Resuscitation Textbook(5th ed.).Ottawa,Canada.

Cunningham, F. G., Hauth, J. C., Leveno, K. J., Gilstrap, L., Bloom, S. L., & Wenstrom,K. D. (2005). Williams Obstetrics(22nd ed.). McGraw-Hill Companies, Inc. Retrievedfrom IWK Health Sciences Library database.

Soll, R. F. (2008). Heat loss prevention in neonates. Journal of Perinatology,28, S57-S59.


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Appendix A:

Samples of Standard Documentation for Labour and Birth


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Appendix B:

Canadian Paediatric Society (www.cps.ca) 2009


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Appendix B: Equipment for Neonatal Resuscitation

Item Community Site Regional Site

Infant warmer Means to keep baby warm in lieu of skin-to-skin contact (e.g. gel warming mattress oraccess to warm blankets)

Oxygen supply

Assorted neonatal masks Neonatal bag and tubing to connect to anoxygen source

O2 blender (or means to blend air with O2;e.g. Y-connector)

Manometer Endotracheal tubes (2.5-4) Tape and scissors Laryngoscope (0 and 1 sized blades) withextra bulbs and batteries(*requires specific training to achieve andmaintain competency)

T-piece resuscitator (e.g. Neopuff InfantResuscitator)

CO2 detector Laryngeal Mask Airway (LMA) size 1(*requires specific training to achieve andmaintain competency)

Bulb syringe Regulated mechanical suction Suction catheters (6F, 8F, 10F, 12F) Suction tubing and canister Feeding tube (8F catheter) Syringe, catheter tipped, 20 mL Meconium aspirator IV catheters (22 g) Tape and sterile dressing material D10W Isotonic saline solution Syringes, assorted (1-20 mL) Epinephrine (1:10,000) Sodium bicarbonate (0.5 mEq/mL)

Umbilical catheters (2.5F, 5F) Chest tube (10F catheter) 20 g IV catheter with 3-way stopcock (in lieuof chest tube)

Sterile procedure trays (eg, scalpels,hemostats, forceps)

Documents

Labour Birth ER Sep2009