New Babies Born at Barnes in July 2019

Br Paramed J. 2019 Dec 1; 4(3): 43–48.

Babies born in the pre-hospital setting attended by ambulance clinicians in the n east of England

Graham McClelland

North E Ambulance Service NHS Foundation Trust: ORCID iD: http://orcid.org/0000-0002-4502-5821

Emma Burrow

North East Ambulance Service NHS Foundation Trust

Helen McAdam

North E Ambulance Service NHS Foundation Trust

Abstruse

Introduction:

The majority of births in the Great britain happen in hospital or at stand-solitary midwife led centres, or with the support of midwives in a planned manner exterior of hospital. The unplanned nascence of a baby in the pre-hospital setting is a rare event which may outcome in an ambulance beingness chosen, and then omnipresence at a birth is a rare event for ambulance clinicians. A service evaluation was conducted to study which clinical observations were recorded on babies born in the pre-infirmary setting who were attended past ambulance clinicians from the North E Ambulance Service (NEAS) over a one-year catamenia.

Methods:

A retrospective service evaluation was conducted using routinely collected information. All electronic patient care records covering a one-year period between 1 Oct 2017 and 30 September 2018 with a main impression of 'childbirth' were examined.

Results:

This evaluation identified 168 individual pre-hospital childbirth cases attended by NEAS clinicians during the evaluation timeframe. The bulk (85%) of babies were born to multiparous mothers with a median gestation of 39 weeks. Very few clinical observations were recorded on the babies (respiratory rate 23%, eye rate 21%, temperature x%, APGAR 8%, blood sugar one%) and no babies had all five of these observations documented. Only v% of babies had any complications documented.

Conclusion:

This written report showed that NEAS ambulance clinicians rarely attend babies built-in in the pre-infirmary setting and that complications were infrequently recorded. At that place was a lack of observations recorded on the babies, which is an issue due to the clear link between hands measurable characteristics such equally temperature and mortality and morbidity.

Keywords: ambulance, childbirth, pre-infirmary

Introduction

The bulk of births in the U.k. occur in infirmary or at stand-lonely midwife led centres, or with the pre-planned back up of midwives exterior of hospital. The birth of a infant in the pre-hospital setting is often unplanned and attendance at a birth is an uncommon event for ambulance clinicians. The rate of babies born before arrival (BBA) at hospital in the Britain was reported equally 0.5% (Loughney, Collis, & Dastgir, 2006). The rate of babies BBA in Commonwealth of australia (Thornton & Dahlen, 2018) and Ireland (Unterscheider, Ma'ayeh, & Geary, 2011) was similar to the United Kingdom, whereas in the United States the rate was higher at 1.iv% (MacDorman, Mathews, & Declercq, 2014).

Babies born in an unplanned fashion in the pre-infirmary setting have an increased risk of complications such as hypothermia, perinatal bloodshed, low birth weight and access to neonatal intensive care (Loughney et al., 2006; Thornton & Dahlen, 2018; Unterscheider et al., 2011). Despite these increased risks, the literature indicates that most pre-infirmary births require minimal interventions from ambulance clinicians (McLelland, McKenna, Morgans, & Smith, 2018).

A recent update to the Great britain Ambulance Service Clinical Practice Guidelines (Articulation Royal Colleges Ambulance Liaison Committee & Clan of Ambulance Chief Executives, 2017) revised the guidance for 'Care of the newborn' with specific mention of the risks of hypoxia, hypoglycaemia and hypothermia for newborn babies. Based on these guidelines, a minimum bones set of clinical observations that should be recorded on all newborns included pulse rate and respiratory charge per unit, both of which likewise feature in the APGAR (appearance, pulse rate, grimace, activity, respiration) score (Apgar, 1953), claret sugar (BM) and temperature.

The aim of this service evaluation was to study if these clinical observations were being fully recorded on babies built-in in the pre-hospital setting who were attended past ambulance clinicians from the Northward East Ambulance Service (NEAS). This evaluation was conducted equally the data describing the pre-infirmary care of these patients are scarce, to place areas for improvement and to support future research.

Methods

A retrospective service evaluation was conducted using routinely collected information to make up one's mind what clinical observations were recorded on babies born in the pre-hospital setting who were attended past NEAS clinicians over a ane-year period.

Setting

NEAS is the regional ambulance provider for around ii.5 million people in north e England, covering Northumberland, Tyne and Clothing, County Durham, Darlington and Teesside. NEAS employs effectually 1200 ambulance clinicians (paramedics and other clinical roles) who work out of 56 stations across the region (North E Ambulance Service NHS Foundation Trust, 2019).

Information collection, extraction and analysis

All electronic patient care records (ePCRs) covering a one-year period between 1 Oct 2017 and xxx September 2018 with an ambulance clinician recorded primary impression of 'childbirth' were requested from the NEAS informatics team.

The ePCRs were then filtered based on the following inclusion and exclusion criteria:

Inclusion:

• Baby born in the pre-hospital setting

Exclusion:

• Baby built-in in hospital

• Midwife in omnipresence at pre-hospital nascency

• Miscarriage or still nascency

The post-obit data were manually extracted from the ePCRs by the authors:

• Relevant timings (phone call to hospital, on scene time, nativity to hospital)

• Destination hospital

• Age of female parent

• Parity (baby number)

• Gestation

• Clinical observations recorded on the baby (temperature, BM, heart rate, respiratory rate, APGAR)

• Complications and interventions performed

These items were selected by the authors every bit existence relevant to care of the newborn, available in the pre-hospital setting and included in national ambulance guidelines (Joint Royal Colleges Ambulance Liaison Committee & Association of Ambulance Chief Executives, 2017).

All data are presented in a descriptive fashion forth with the number of cases where data were bachelor. Summary statistics are presented using median, interquartile range (IQR) and range. Complications and interventions were identified and extracted from the narrative and treatment sections of the ePCR and are presented in an amass fashion due to the pocket-sized number of patients involved.

Results

There were 236 ePCRs with 'childbirth' recorded as the impression between ane October 2017 and 30 September 2018. The ePCRs were filtered using the inclusion and exclusion criteria, which resulted in 168 individual childbirth cases being included in this service evaluation.

From the original 236 ePCRs identified, 68 cases were excluded for the following reasons: baby transported prior to crew's arrival (n = 1); babies born and cared for by midwives (north = 2); duplicate cases (n = 24); miscarriages (n = 6); not childbirth (n = 5); even so nascency (northward = ane); transported to hospital for nascence (n = 29).

Relevant timings

The median call to hospital time (n = 146) was 65 minutes (IQR 51–86, range 25–194). The median on scene time (due north = 149) was 30 minutes (IQR 22–41, range 8–113). The median birth to infirmary fourth dimension (n = 138) was 55 minutes (IQR 39–72, range 10–192).

The times when the calls leading to the pre-hospital birth were received past the ambulance service were examined (northward = 154), with 23% of calls in office hours (0900–1700) and 63% overnight (2000–0800).

Destination hospital

Ane hundred and threescore-six babies were transported to ten different hospitals across the due north e; ii babies were not transported as midwives arrived later the babies were born and stood the ambulance crews down.

Age of female parent

The median age of the mother (north = 166) was 28 years (IQR 24–32, range 15–43).

Parity

Parity was recorded in 110 cases, with the median value of second baby (IQR 2–three, range 1–10; Figure 1).

Effigy 1. Parity of mothers attended by ambulance clinicians.

Gestation

The median gestation menses (n = 78) was 39 weeks (IQR 38–twoscore, range 19–42).

Clinical observations recorded on the baby

Xviii (10%) babies had a temperature recorded. In 14 of these cases a single temperature was recorded and in four cases two temperatures were recorded. The median temperature was 36.three°C (IQR 35.five–36.five, range 34.8–37.5). The location where the temperature was taken from was recorded in xiii cases: axillary (n = 2); temporal (n = 2); tympanic (north = 9).

APGAR was recorded for 13 (8%) babies, with one baby scoring 8, one baby scoring 9 and eleven babies scoring 10.

Two (1%) babies had a BM recorded (3.1 and 5.nine).

30-5 (21%) babies had a heart rate recorded. In 28 cases a unmarried heart charge per unit was recorded, in five cases two heart rates were recorded and two cases had four eye rates recorded. The median heart rate was 150 (IQR 136–160, range 100–200).

Xxx-8 (23%) babies had a respiratory rate recorded. In 30 cases a single respiratory charge per unit was recorded, in half-dozen cases 2 respiratory rates were recorded and in two cases four respiratory rates were recorded. The median respiratory rate was 38 (IQR 35–45, range 18–65).

The total number of observations included in the basic minimum prepare defined before (pulse rate, respiratory rate, APGAR, BM, temperature) documented on each baby is displayed in Figure two.

Figure 2. Total number of observations documented on babies.

Complications and interventions performed

Ninety-seven (58%) babies had some course of warming recorded involving combinations of blankets, clothing and hats, towels and foil/blizzard blankets.

Nine (5%) cases had complications documented including bug with the umbilical cord and concerns around animate. Six (4%) cases involved inflation breaths and/or oxygen assistants to the baby. Three (2%) cases had CPR or resuscitation documented.

Eight (5%) mothers received syntometrine, with i patient receiving tranexamic acid.

Give-and-take

Description of results

This service evaluation describes the clinical data recorded on babies born in the pre-hospital setting attended by NEAS and shows that very few observations, including those recommended in national guidelines, were documented. No babies had all five basic observations documented and 71% had none of these observations documented. Of pre-hospital births attended by ambulance clinicians, 93% had no complications or interventions recorded, so the omission of basic observations is hard to explain.

Results in context

The mothers described in this report were slightly younger than the national boilerplate which was reported as 30.five in 2017 (Part for National Statistics, 2017), simply were like in historic period to previous inquiry in the due north east which reported a mean historic period of 27.vi (Loughney et al., 2006). 3 quarters of calls leading to pre-hospital births occurred out of office hours, which replicates the findings of previous research (Javaudin et al., 2019; McLelland et al., 2018; Unterscheider et al., 2011). The reasons for the increased frequency of pre-infirmary births outside of office hours are unclear.

Previous research reporting babies' BBA (Javaudin et al., 2019; Loughney et al., 2006; McLelland et al., 2018; Unterscheider et al., 2011) described a similar blueprint to the data reported here in that multiparous women were more frequent than primiparous women and that babies were built-in at, or effectually, full term. Higher parity is known to be associated with more rapid labour (Gunnarsson, Skogvoll, Jonsdottir, Roislien and Smarason, 2017).

There was a depression rate of recording of all of the clinical observations reported. Only x% of babies had a temperature recorded and 72% (n = 13) of these were beneath 36.v°C, which is the lower limit recommended by the Globe Wellness System (Globe Health Organization & Maternal and Newborn Health/Safety Maternity, 1997) and the International Liaison Commission on Resuscitation (ILCOR) Neonatal Job Force (Perlman et al., 2015). A similar study by Flanagan, Lord and Barnes (2017) conducted in Australia reported that just 2% of babies delivered by paramedics had a temperature recorded and all of these were hypothermic (< 36.2°C).

The maintenance of normothermia (36.v–37.5°C) has been shown to be very important to newborns, and deviations from this range, particularly hypothermia, are linked to increased mortality and morbidity (Chitty & Wyllie, 2013; Lunze, Bloom, Jamison, & Hamer, 2013; Trevisanuto, Testoni, & de Almedia, 2018). Evidence suggests a direct relation between hypothermia and mortality, with every 1°C below 36.5°C increasing the risk of mortality by 28% (Perlman et al., 2015). A contempo study by Javaudin et al. (2019) using multi-variate logistic regression identified four factors which were predictive of neonatal mortality and morbidity: multiparity, prematurity, maternal pathology and hypothermia. This is important as hypothermia is the but modifiable condition in the pre-hospital setting.

Limitations and strengths

This evaluation is express past the retrospective nature of the data and the potential for observations and interventions to not accept been documented. The pocket-sized number of births could besides be a limitation of this report. Still, the total number of alive births in the north east in 2016 was 28,574 (Office for National Statistics, 2018). Applying a pre-infirmary birth rate of 0.5% to this figure and assuming there has been little change between 2016 and 2017/18, the expected rate of pre-hospital births would exist 143, then the population of 168 reported in this study appears plausible. The detailed case by case examination of the primary documentation is a strength of this study; all the same, the variation in how pre-hospital births were recorded meant that the data extraction involved some subjective interpretation.

Generalisability

There is no reason to believe that pre-hospital births in the northward eastward differ significantly from pre-hospital births beyond the Uk; therefore, the information from this service evaluation should be generalisable to other areas. However, a national audit or database of pre-hospital births, which would be beneficial for enquiry and development in this area, would be needed to prove or disprove this exclamation. NEAS clinicians are trained in a similar fashion and to a similar standard to other UK pre-hospital clinicians, and ambulance protocols beyond the United kingdom are based on national guidelines such every bit JRCALC (Joint Royal Colleges Ambulance Liaison Commission & Association of Ambulance Primary Executives, 2017); however, dissimilar ambulance trusts will interpret and implement protocols based on local needs, geography and expertise. In addition, different ambulance services use different formats of patient records, which may introduce variation into which data are recorded on pre-hospital births.

Controversies

The low rate of recording of basic observations is worrying and the reasons for this need to be explored. Possible explanations for this lack of recorded observations could exist: a lack of confidence in taking neonatal observations; thinking taking and/or recording the observations was unnecessary in babies that appear well; lack of equipment (e.g. saturation probes and blood pressure cuffs) designed for neonates; and other reasons.

Implications for do

The number of pre-hospital births can be used to estimate the exposure of ambulance clinicians to these events. If 168 births are evenly distributed between approximately 1200 clinicians (N Eastward Ambulance Service NHS Foundation Trust, 2019), so the exposure charge per unit would be 0.14 births per year per clinician. In do, the majority of clinicians piece of work on double crewed ambulances so the exposure charge per unit could be doubled to 0.28 per twelvemonth. This represents a very low level of exposure and concerns have been raised effectually skill maintenance and competency in other situations that clinicians are infrequently exposed to (Dyson et al., 2016).

Ambulance clinician education and training may need to reinforce the reasons why taking, recording and interim on observations such as temperature in a newborn baby are important in gild to change practice going forwards. In order to enable good exercise, equipment suitable for taking observations on newborn babies needs to exist available.

Implications for research

Farther research is needed to more comprehensively describe the clinical characteristics of babies built-in in the pre-infirmary setting. These data could potentially exist used to explore any links between pre-hospital birth, the initial clinical presentation of the baby, the demand for treatment in or out of infirmary and longer-term outcomes.

Conclusion

This report shows that NEAS ambulance clinicians rarely attend babies born in the pre-hospital setting, and when they are present the births are ofttimes uncomplicated and require few interventions. There was a lack of observations recorded on the babies which is an issue due to the clear link between easily measurable characteristics such as temperature and mortality and morbidity. More research is needed to constitute the barriers and facilitators to taking and recording observations on babies. Consistent recording of these information would allow areas for improvement to be identified and linking the pre-hospital information to hospital information would allow longer-term implications and outcomes to be explored.

Author contributions

All authors contributed to the study and read and approved the final manuscript.

Conflict of interest

None declared.

Contributor Information

Graham McClelland, North East Ambulance Service NHS Foundation Trust: ORCID iD: http://orcid.org/0000-0002-4502-5821.

Emma Burrow, North East Ambulance Service NHS Foundation Trust.

Helen McAdam, N E Ambulance Service NHS Foundation Trust.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783920/