Intrapartum : Precipitous Delivery Simulation and Case Study

2. Intrapartum: Precipitous Delivery Simulation and Case Study Kelly Hicks MSN, RNC-OB

3. Objectives • Illustrate the proper manner of handling a nurse assisted precipitous delivery. • Examine alternative tools that can be used to perform a vaginal delivery outside of the hospital setting.

4. Precipitous Delivery Simulation

5. Nurse Assisted Precipitous Delivery Guide • This guide can be used to assist in things to include when doing a precipitous delivery simulation. • It can help you remember things to tell or have the students perform.

6. Nurse Assisted Precipitous Delivery Guide • Assessment • Assess for signs of immediate delivery • Strong uterine contractions • Client beginning to bear down • Perineum begins to bulge • Baby’s head begins to crown • Client yells out, “ The baby is coming!” Lagerquist, S. & McMillin, J. (2007)

7. Nurse Assisted Precipitous Delivery Guide • Nurse’s Role • Reassure mother to decrease her anxiety or feelings of losing control • If possible, delay delivery until MD arrival • Instruct client not to bear down • Turn client to the side • Have client pant or “blow out candles” • If these interventions are unsuccessful, prepare for delivery Lagerquist, S. & McMillin, J. (2007)

8. Nurse Assisted Precipitous Delivery Guide • Nurse’s Role cont. • Call for additional personnel to assist with delivery • Decrease risk of infection • Use sterile delivery table and set-up if possible, if not able to keep sterile, keep clean • Sterile gloves should be worn, if not wear clean gloves • Support perineum and fetal head with a sterile or clean towel Lagerquist, S. & McMillin, J. (2007)

9. Nurse Assisted Precipitous Delivery Guide • Facilitate Delivery • If ROM has not occurred, tear membranes as head emerges • Support head with both hands • Check for the presence of a nuchal cord • Slip cord over the head if present and loose • If present and tight, clamp cord in two places and cut, then unwrap cord from baby’s neck Lagerquist, S. & McMillin, J. (2007)

10. Nurse Assisted Precipitous Delivery Guide • Facilitate Delivery cont. • After restitution, apply gentle downward pressure to bring anterior shoulder under pubic symphysis • Lift head slightly and slowly to assist delivery of posterior shoulder • Support baby’s body as it delivers Lagerquist, S. & McMillin, J. (2007)

11. Nurse Assisted Precipitous Delivery Guide • Resuscitate baby • Hold baby head-dependent or head down • Use bulb syringe to suction out mouth first, then nose • Assess for presence of breathing/crying and need for further resuscitation • Dry baby off with sterile or clean towel to promote warmth and tactile stimulation Lagerquist, S. & McMillin, J. (2007)

12. Nurse Assisted Precipitous Delivery Guide • Prevent placental transfusion • Hold baby level with placenta, clamp and cut cord • Promote warmth and facilitate bonding • Place skin to skin with mother • APGAR scores • At 1 and 5 minutes • Monitor for complications while awaiting arrival of MD Lagerquist, S. & McMillin, J. (2007)

13. Case Study • A 28 year-old G5P4 is in Starbucks when she experiences SROM, after having irregular uterine contractions all day. She doubles over in pain and slowly sinks to the ground. In between contractions she yells “He’s coming, he’s coming!” Everyone looks to you as you are in line wearing your stork scrubs. The barista calls 911 as you prepare for an imminent precipitous delivery.

14. Questions • What items do you need to collect to prepare for delivery? • What can you use to clamp the cord? • What can you use to suction the baby’s mouth and nose?

15. Questions • How will you keep the baby warm as you await the arrival of EMS? • The woman’s placenta spontaneously delivers prior to the arrival of EMS. What can be done to promote involution of the uterus?

16. Questions with Answers • What items do you need to collect to prepare for delivery? • Towels, gloves, anything that can be used to dry the baby off and potentially keep the baby warm. Something to suction the baby’s mouth and nose. Something to cut the cord. This should stimulate conversation for students to come up with other things as well. • What can you use to clamp the cord? • A shoelace or twist tie. Anything else that will cut off the circulation. The students may become very creative here and come up with things you have not even thought of yet, but that will work. Due to the fact that the environment is not sterile, the cord should not be cut yet.

17. Questions with Answers • What can you use to suction the baby’s mouth and nose? • A straw can be used, but the mother or a family member will be the one to perform suctioning due to exposure of body fluids. This may also spark more discussion. • How will you keep the baby warm as you await the arrival of EMS? • The best thing that can be done to keep the baby warm, is to the baby skin to skin with the mother. Towels can be used as well. If the placenta delivers, the baby can be wrapped in a blanket with the placenta to facilitate warmth.

18. Questions with Answers • The woman’s placenta spontaneously delivers prior to the arrival of EMS. What can be done to promote involution of the uterus? • Massage the fundus to expel any clots. Then have the baby breastfeed to release oxytocin. Since the woman is now a G5P5, there is need to discuss the risk of postpartum hemorrhage. Discussion should lead toward the potential of this complication.

19. References • Ladewig, P.A., London, M.L., and Davidson, M.R. (2010). Contemporary Maternal- Newborn Nursing Care (7th ed.) New York: Pearson Education. • Lagerquist, S. & McMillin, J. (2007). ATI Nurses Notes Maternal-Newborn Core content at-a-glance. Kansas: Assessment Technologies Institute. • North Carolina Concept-Based Learning Editorial Board. (2011). Nursing: A Concept- Based Approach to Learning. Volume 1. Pearson Publishing.