ABSTRACT
Unplanned out-of-hospital birth is defined as a birth that occurs before arrival and without a planned midwife or medical doctor. The frequency of complications in mothers and babies is higher in unplanned deliveries out of hospital. Due to the shortness of the uterus and a history of bleeding at the 17th week, a 27-year-old mother who was administered betamethasone three times intermittently and her baby who was 22 weeks old were brought to the pediatric emergency service by ambulance, with the umbilical cord not separated from the clamped placenta between the legs of the mother. The baby was hypothermic at the first evaluation. The baby was immediately warmed up, the navel was clamped and separated from the placenta, and nasal oxygen therapy was initiated. While the body temperature was 35.5 °C at the 20th minute of birth; placed in a thermal bag, placed in a transfer incubator, connected to nasal continuous positive airway pressure, and admitted to the neonatal intensive care unit. On the 9th day of her follow-up, baby died due to apnea, desaturation, and resistant acidosis and hypotension. This case is presented in order to minimize the complications related to out-of-hospital delivery and to emphasize the necessity for the healthcare professionals to be adequately trained and equipped for delivery and neonatal resuscitation management, and to develop protocols between health and ambulance services.
Keywords: Out-of-hospital delivery, mortality, perinatal morbidity, newborn
Introduction
Unplanned out-of-hospital (OOH) births are the deliveries that occur without a midwife or doctor prior to arrival at the hospital.1 It is important for healthcare personnel working in ambulances as worse outcomes are reported for mothers and infants compared to in-hospital and planned home births.2 It has been reported that healthcare professionals working in ambulances are in the second rank among healthcare personnel who encounter childbirth.3
The annual incidence of out-of-hospital deliveries is reported as 0.08-1.99%, which is quite low.1,4 The frequency of complications in mother and baby is higher in out-of-hospital births than in-hospital births. Perinatal conditions and inadequate postnatal care have been reported to be the most common causes of out-of-hospital neonatal deaths.5 Due to hypothermia, prematurity, asphyxia, jaundice, tetanus, and problems in the management of the placenta and umbilical cord, hospitalization in the neonatal intensive care unit (NICU) and mortality rates are higher.6
With this case, the problems experienced in the pre-hospital management of a 22-week-old premature baby born in an ambulance were discussed. In addition, it is presented to minimize the complications related to OOH births and to emphasize the need for the healthcare professionals to be adequately trained and equipped in neonatal resuscitation management at birth, to develop protocols between health and ambulance services, to help clinical management of the protocols, referral, and destination decisions.
Case Report
The baby of the 27-year-old mother with antenatal follow-up and uterine shortening, who had been administered betamethasone three times at the 17th week due to a history of bleeding, was from her 22-week second pregnancy and was brought by ambulance between the mother’s legs. It was learned from the mother’s history that she had been hospitalized in an external center due to bleeding two days ago, followed up for two days with a five-centimeter cervical dilation, and discharged the day before. The baby was born in the ambulance approximately two minutes before the admission, and was brought with the umbilical cord clamped and not separated from the placenta. The first minute APGAR score was unknown. In the evaluation at the fifth minute of birth, the 5th minute APGAR score was 7, and the baby was started to be warmed, the umbilical cord was clamped and separated from the placenta, and nasal oxygen therapy was started.
In the physical examination, the baby’s general condition was moderate and he had groaning. The body weight was 470 grams (Picture 1). On arrival, his body temperature was 33.1 °C, heart rate was over 100/min, respiratory rate was 38/min, and oxygen saturation (SpO2) in room air was 99%. The lung examination revealed tachypnea, bilateral rales, subcostal, intercostal, suprasternal retraction, and nasal flaring. Cardiovascular system examination was normal, bilateral femoral artery pulses were taken. In the neurological examination, light reflex could not be evaluated and the baby was hypotonic. There were no sucking, searching and catching reflexes. The skin was bright red-purple, thin and immature.
The tenth minute body temperature was 35.1 °C, heart rate was 104/min, respiratory rate was 32/min, SpO2 was 99%. The 20th minute body temperature was 35.5 °C, heart rate was 150/min, respiratory rate was 32/min, SpO2 was 100%. The baby was wrapped in a thermal bag, placed in the transfer incubator, connected to nasal continuous positive airway pressure (CPAP), and admitted to the NICU.
In the blood gas taken from the umbilical vein, pH was 7.35, pCO2 was 27.9 mmHg, HCO3 was 15 mEq/L, lactate was 4 mmol/L, and blood glucose was 120 mg/dL, white blood cell was 10.310/mm3, platelet was 364,000/mm3, hemoglobin was 19.5 g/dL, hematocrit was 59.1%, C-reactive protein was 1.03 mg/L (normal range: 0-5 mg/L), interleukin 6 was 33.56 pg/mL (normal range: <7 pg/mL), procalcitonin was and 0.687 ng/mL (normal range: 0-0.5 ng/mL). Amikacin, penicillin-G, fluconazole and caffeine treatments were started for the case.
On the fourth day of the follow-up, it was switched from nasal CPAP mode to non-invasive intermittent positive pressure ventilation mode due to apnea. Chest X-ray was consistent with respiratory distress syndrome. Echocardiography showed patent foramen ovale. On the fifth day, the baby was intubated due to increased apnea frequency and desaturation. Respiratory acidosis was observed in blood gas. Antibiotic treatment of the patient who was found to have increased acute phase reactants after sepsis screening was rearranged.
In the transfontanel ultrasonography taken on the 5th day of the hospitalization, grade 1 hemorrhage and nodular appearance were observed in the left caudothalamic groove. On the seventh day of the follow-up, dopamine was initiated due to hyperglycemic resistant acidosis, high lactate, and hypotension. Then, because hypotension did not improve and peripheral circulatory disorder developed, dobutamine treatment was started. Repeated echocardiography revealed impaired systolic functions and an ejection fraction of 41%. The patient, whose hypotension did not improve, died on the ninth day of the hospitalization. Consent for the study was obtained from the family.
Discussion
Although pre-hospital unplanned deliveries are rare, perinatal mortality and neonatal morbidity rates are high. This risk increases even more in very premature (<32 weeks) and extremely premature (<28 weeks) deliveries.7 In this case, the delivery was unplanned and happened very early and with low birth weight in the ambulance while trying to reach the hospital. The patient, whose first interventions were made in the emergency room, was quickly admitted to the NICU.
The most common complication in out-of-hospital deliveries is hypothermia and is the most important risk factor for mortality. In infants with low birth weight, every 1 °C decrease in body temperature from birth to NICU causes a 28% increase in mortality.8 In a study examining rewarming methods in out-of-hospital deliveries, it was reported that the way to prevent heat loss during the period until the baby’s admission to the NICU was the training of personnel working in the pre-hospital management, the creation and use of a checklist, and improvement with continuous feedback. In the same study, it was also stated that the best method was the use of a transport incubator.8 Our case was hypothermic on arrival to the hospital, and it was thought that the intervention was insufficient due to lack of equipment. It is very important that health staff are trained to prevent possible complications.2 In studies in the literature, the knowledge of healthcare professionals about neonatal life support was found to be at moderate level.5 In a study, it was reported that there was a 75% reduction in face mask leakage with an increase in theoretical knowledge after a simulation-based training.5 In another study, it was reported that healthcare professionals had low self-confidence in OOH births and felt unprepared to manage these cases.9 In our case, we could not determine the level of knowledge of the paramedics in the ambulance about neonatal management. However, despite the fact that the patient was premature and had a low birth weight, the presence of spontaneous breathing during delivery and the absence of excessive bleeding in the mother was a great opportunity for patient management. Therefore, health personnel training is very important in OOH births.
Moreover, it is very important to have the necessary equipment support as well as the training of health personnel for birth.7
As in our case, the lack of appropriate resources at birth delays the ideal care. For this reason, having the necessary equipment for both prehospital transportation and emergency services for the management and transport of these babies will prevent the development of possible complications.
There are also major deficiencies in the intervention and documentation of out of hospital deliveries.2 In a study, it was found that approximately one-third of the cases had missing documents, which made it difficult to determine how patients were treated.10 In another study, it was reported that important information such as newborn evaluation, including APGAR scores, was lacking and documentation was scarce.11 All interventions applied in order to evaluate the effectiveness of the actions taken should be written completely and accurately. In this way, the deficiencies of the health personnel, the points where they are inadequate and the deficiencies in the materials can be determined and their supply and personnel training can be arranged.2
Conclusion
It is important to train health personnel at regular intervals due to the bad consequences of unplanned births for mother and baby. Complication rates can be reduced by providing the necessary materials for transport in both ambulances and emergency services.
Ethics
Informed Consent: Consent for the study was obtained from the family.
Peer-review: Externally peer-reviewed.
Authorship Contributions
Concept: S.T.G., O.D.G., Y.M.A., İ.F., Ö.Ç., Design: S.T.G., O.D.G., Y.M.A., İ.F., Ö.Ç., Data Collection or Processing: S.T.G., O.D.G., Analysis or Interpretation: S.T.G., O.D.G., Y.M.A., İ.F., Ö.Ç., Literature Search: S.T.G., O.D.G., Writing: S.T.G., O.D.G.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.
