International Journal of Healthcare Simulation

Background:

Childbirth can be unpredictable in its timing and clinical course. Low-risk pregnant women can choose to deliver their infants at home, with 1 in 50 women in England and Wales choosing a home birth [1]. However, for those giving birth for the first time, there is an increased risk of adverse perinatal outcomes when compared to an obstetric unit – 5 in 1000 for a hospital birth compared to 9 in 1000 for a home birth [1], and 45% of nulliparous women are transferred to an obstetric unit [2]. Obstetric emergencies can occur and infants are born in poor condition. In these cases, every minute matters to reduce morbidity and mortality. Expertise and resources are also limited in the community; midwives and paramedic crews must work synergistically to achieve the best outcomes. Our aim was not only to show ideal clinical management of a combined neonatal and obstetric emergency but also to explore multidisciplinary team working, communication, and human factors of these complex situations.

Methods:

The simulation involved a low-risk term pregnant woman who has chosen to have a home birth. It was filmed in a house for authenticity. In attendance were a community midwife and maternity assistant. The baby was born in poor condition: floppy, pale with no respiratory effort, and bradycardic. Neonatal life support was given up to and including chest compressions with good recovery of heart rate but no spontaneous breathing, therefore, requiring supraglottic airway insertion. The handover was given to the paramedics and the infant was conveyed to the neonatal unit. The scenario then unfolded with the mother also having a postpartum haemorrhage requiring oxytocin, syntometrine, misoprostol, tranexamic acid, and fluid resuscitation, utilising a second paramedic crew and transfer.

Results:

The simulation was recorded as exemplary management of this situation. It will be used to deliver training to West Midlands Ambulance Service and community midwives; aiding as a discussion point for clinical management, communication strategies, team leadership, roles, and delegation. We will collate written feedback on its impact on both paramedic and midwifery confidence levels. The community midwife, midwifery assistant, and paramedics who attended stated how much it had increased their confidence in managing a dual emergency, and affirmed their roles and responsibilities in such cases.

Conclusion:

We expect that with increased staff education and confidence, the outcomes of babies born in the community in unexpectedly poor condition will improve.

References

1. NHS. (Reviewed 2021) Where to give birth: the options. https://www.nhs.uk/conditions/pregnancy-and-baby/where-can-i-give-birth/ [Accessed on 27/06/2022]

2. Brocklehurst P, Puddicombe D, Hollowell J, Stewart M, Linsell L, Macfarlane AJ, McCourt C. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. British Medical Journal (BMJ). 2011;343:d7400.