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EMS Crew Delivers Breeched Infant

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At 2205 hours, Rescue-102 is called to a private residence for a young female complaining of abdominal pain. On arrival, the EMS providers determine that the patient is 24 weeks pregnant and is having contractions. She’s conscious, alert and oriented.

While one crew member assesses vital signs, the lead paramedic begins establishing the medical history. Although a language barrier and dim lighting increase the difficulty of the assessment, the medic is able to determine that this is her first pregnancy.

The patient is in obvious distress due to continuous contractions, but it’s unclear whether her water has broken. No crowning is noted, so the lead paramedic decides to quickly move the patient to the stretcher and place her into the ambulance.

Once the patient is loaded into the unit, she begins to have severe contractions. The crew members prepare for a possible delivery, and another unit is requested to respond.

A second check for crowning reveals a breech presentation. Despite the buttocks presenting first, the patient rapidly delivers after only a brief period of pushing (see Figure 1 above and Figure 2, p. 31). One crew member attends to the mother while the other two care for the female newborn, who has an initial Apgar score of 2. Fortunately, two other units in close proximity to the scene quickly arrive. One of the arriving EMS providers took over care for the mother who was in stable condition. Oxygen had been applied, and an IV was already established by the caregiver attending to the mother.

The second-arriving crew assisted in care for the newborn, which included warming, drying, suctioning and tactile stimulation. The cord was clamped and cut.

When the baby didn’t adequately respond, positive-pressure ventilations were established via bag-valve mask. Despite these interventions, the baby’s cardiac and respiratory status remained severely depressed. Chest compressions were started due to significant bradycardia coupled with clear signs of inadequate perfusion. A size 3 endotracheal tube (ET) was placed on the first attempt. Only five minutes had elapsed since birth, but it seemed like a lifetime to the EMS crew who now determined that the Apgar score was only 4.

The combined EMS crews continued their resuscitative efforts while en route to the hospital with only marginal improvement in the newborn’s condition. On arrival at the emergency department, patient care was transferred to the receiving staff after the lead physician verified that the ET tube was properly positioned in the trachea.

The heart rate had risen to 140 bpm, and the neonate began spontaneous respirations. The baby survived and was doing well at the time this article was written.

Discussion
Many lessons can be learned from this case. First, the old adage “expect the unexpected” remains a strong piece of advice for EMS personnel. A call for a female with abdominal pain can range from an upset stomach to domestic violence to an ectopic pregnancy—and all points in between.

Some lessons aren’t as clear during initial EMT or paramedic training as they are when viewed through the lens of experience. As crew members enter a scene, they can miss many clues that are readily apparent. Does the patient appear in distress? Are fluids on the ground? Is there an obvious level of urgency at the scene?

Second, recognizing imminent birth should trigger crew members to rapidly prepare for delivery. Although it may be a wish to hurry up and get to the hospital, sometimes the crew must accept that the birthing process won’t wait.

This scene involved a home not conducive to welcoming a child into the world, which is why the lead medic opted to move into the unit—in a clean environment in which all supplies were readily available and the lighting was markedly improved. Despite the fact that this was the first pregnancy for this patient, crew members also considered and prepared for imminent birth.

Third, it’s important to recognize that the birthing process immediately creates a scenario with two patients. If possible, calling for additional help early will distribute the work between crew members. This case involved additional challenges given the premature age of the newborn, the breech presentation and the rapid delivery. Consider how the scene could have become more difficult if the mother also experienced significant hemorrhage. The standard treatments of allowing the baby to be with the mother or providing uterine massage become impossible when the newborn is severely distressed and in need of care.

Lastly, care for the infant delivered with an Apgar of 2 requires focus on the basics as a paramount concern. Positioning, warming, suctioning and tactile stimulation are important steps.1 The initial assessment must be performed simultaneously.

Clamping and cutting the cord facilitates better access to the patient while also preventing blood volume problems by either having the newborn too low or too high in comparison with the mother.

Ensuring good air exchange either through the neonate’s own efforts or via positive-pressure ventilation is a high priority. Assess pulse oximetry values early, and administer oxygen as protocols dictate. (Controversy still exists over the need to initially resuscitate with room air vs. using oxygen.)2,3

Remember that current American Heart Association Guidelines outline the need to perform chest compressions if the newborn’s heart rate is below 60.1 You should also consider how you’ll obtain access for administering fluids. Is an intraosseus cannulation feasible? Is it preferable to cannulate the umbilical cord? Is an IV possible? The sooner access can be obtained, the easier it will be to have a point for medication administration or delivery of fluids. The case noted here involved a fairly short transport time, which made the decision-making process easier for the caregivers.

Summary
Our profession requires that we rapidly adapt to any number of unique situations. It’s our skill, training and experience that provide the greatest chance for a favorable outcome. When we share stories with each other, our ability to prepare for similar cases through the sharing of lessons learned makes us all better providers. JEMS

References
1. Kattwinkel J, Perlman JM, Aziz K, et al. Part 15: Neonatal resuscitation: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 Suppl 3):S909–S919.
2. Davis PG, Tan A, O’Donnell CP, et al. Resuscitation of newborn infants with 100% oxygen or air: A systematic review and meta-analysis. Lancet. 2004;364(9442):1329–1333.
3. Rabi Y, Rabi D, Yee W. Room air resuscitation of the depressed newborn: A systematic review and meta-analysis. Resuscitation. 2007;72(3):353–363.
4. Gabbe SG, Niebyl JR, Simpson JL. Obstetrics: Normal and problem pregnancies, 4th ed. Churchill Livingstone: New York, 2002.

This article originally appeared in January 2012 JEMS as “Breech Birth: Not your average abdominal pain call.”



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