- Examine and explain the epidemiology of maternal, obstetric, and neonatal patients encountered in the pre-hospital setting.
- Appraise pharmacological and mechanical interventions used by paramedics for the management of maternal, obstetric, and neonatal patients.
- Implement the theoretical knowledge and clinical skills to assess and manage a maternal or neonatal patient in the pre-hospital setting.
The umbilical cord is known as the conduit between the fetus and the placenta which supplies blood from the placenta. The transportation of this oxygen and nutrition-rich blood from mother to baby. Its significance can be analyzed from the fact that around one-third blood of the growing fetus or baby is in the placenta. In the final phases of pregnancy umbilical cord also supply antibiotics so that the immune system of a baby can become stronger. However, as soon as the birth takes place there is no requirement for any such pathway. Thus, the naval string or umbilical cord is clamped immediately after birth (Argyridis, 2017).
At the time of birth umbilical cord pulsates for around 3-5 minutes and in this short duration also most of the blood stored is transfer to the new born. Usually most of the practitioners clamp or cut the cord within one or two minutes of the birth or before the pulsation of cord is ceased. According to Katheria and et.al., 2015, since this cord carry blood from the mother it is essential that after birth cord should by cut immediately so that severe bleeding and blood loss can be prevented in the mothers. The clamping of these blood vessels prevents blood flow from either direction so that risk to mother can be reduced.
However, many recent studies have suggested that instead of clamping umbilical cord immediately if it is left for few minutes then it can allow additional blood flow to new born and thus the risks such as iron deficiency, anemia can be reduced. It is also analysed that contrary to the earlier conceptions this practice of delayed clamping does not increase the health risk for mothers.
According to De Paco and et.al., 2016, delayed clamping is defined as the practice in which clamping of umbilical cord takes place only after delivery of placenta or after pulsations are ceased. The timing constraint in clamping procedure can bring considerable impact on the health of new born as well as mothers. The delayed clamping will allow transition of sufficient blood flow to neonatal so that outside womb also they can have healthy volume of blood cells, immune as well as stem cells.
The time delay in clamping procedure also enhances the interaction time between mother and neonatal and thus complexity and risk during delivery of placenta are also minimized. As per World health organisation also umbilical cord must be cord only after the circulation in these pulseless cord is ceased which have normal duration of 4-5 minutes. In support of this belief Focosi, 2014, explains that the immediate clamping can give rise to complexity in birth process and anatomy.
The blood and iron deficiency are the key results which can also cause irreversible neurodevelopment delay in the initial few months of neonatal. The early cord clamping can cause post- partum hemorrhage. As per the view of Katheria and et.al., 2017, the early clamping practices have been followed from long time and are essential to continue. To give evidence to this claim various researches are used which demonstrate that the delayed clamping can enhance the risk of jaundice in new born babies which is one of the leading health risk among neonatal.
As per the view of Fogarty and et.al., 2018, more mothers are now showing interest towards clinical practice of delayed cord clamping (DCC). Currently this practice is employed mostly with premature born babies because they have additional requirement of extra blood from umbilical cord. Contrary to this Katheria and et.al., 2015 argue that delayed clamping can has significant side effects and can increase certain risks in health of infants. Though strong medical researches have not validated completely to these beliefs but the issues cannot be neglected.
The hyperbilirubinemia has more probability to occur in new born children with DCC as a result of elevated iron storage. This is the prime cause of jaundice. However, some studies suggest that DCC does not make any difference in levels of bilirubinemia. The delayed clamping also increases the red blood cells in excess and thus polycythemia can occur in which breathing and circulation issues can cause hyperbilirubinemia. With polycythemia thickness of blood is increased which makes it hypervisocious.
It is argued by De Paco and et.al., 2016 that though there are no validated research studies suggesting the occurrence of above discussed issues but it cannot be ignored that delayed cord clamping increases the risk of postpartum hemorrhage. As discussed by Argyridis, 2017, additional few minutes in clamping process can be beneficial in neurodevelopment process few years later. It is suggested by Delayed Umbilical Cord Clamping May Benefit Children Years Later, 2015, that children with DCC tends to have higher social and motor skills. The increased iron storage by clamping within 5 minutes instead of initial 23-30 seconds leads to development of healthy brain. This excess blood help neonatal to easily cope up with the life exterior to the womb.
The maximum benefit from DCC is for the preemies. The delay helps them to manage their blood pressure effectively with less number of drugs to support them. The blood stored in umbilical cord is one of the effective source of blood stem cells which can be used in the treatment of blood diseases in children.
The cord blood can easily collect and stored from umbilical cord for the further use in bone marrow transplant and treatment for leukaemia and other diseases. Even if cord is clamp with delay then also there is plenty of blood left in the cord which can be used for banking purpose. In the view of Katheria and et.al., 2015 with the babies born through cesarean section it is not confirmed that DCC will provide the same benefits as provided in case of normal or vaginal delivery. The uterus contraction is not similar in C section and vaginal delivery. Instead, in C section before clamping less blood is pushed to neonatal.
Thus, it can be risky for the mother to wait for clamping because excessive blood loss need to be prevented by immediate cord clamping. The delayed cord clamping is used by service care providers so that transfusion of placental to neonatal can take place effectively and blood volume can be increased in the new born babies (What’s the Hurry? The Benefits of Waiting to Cut the Umbilical Cord After Birth, 2014).
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Pre-hospital settings of implementing DCC in health care centres: Though the concept has been endorsed by various medical regulations and authorities but still the pattern of DCC in premature babies in not accepted widely. The health organisations must include and implement a multidisciplinary educational concept. With this approach responsible authorities can motivate the stakeholders regarding the benefits, potential impact on the health of mother as well as new born, safety standards and concerns and DCC protocols. It will help mothers and the family members to take appropriate decisions that if they want delayed clamping or immediate clamping.
According to Argyridis, 2017, procedural practice planning is important for health organisations so that they can assess the effectiveness and preparedness of the hospital in adopting DCC protocols, participation of staff compliance and tracking of outcomes in the neonatal who underwent the procedures. The delay during clamping procedure can also increase anxiety and thus at that moment it can become difficult for the practitioners as well as patient to choose the method. The lack of clarity towards the impact of DCC can affect the decisions of health institutes to adopt this policy.
Though world health organisation, AAP, SOGC have developed guidelines which support the delay but still health service providers are not able to address the uncertainties related to DCC. It has been the prime factor which makes difficult for the hospitals to bring delay in clamping procedure. As per the discussion in De Paco and et.al., 2016 society or people who prefers instant services also avoid this delay clamping. Though the delay is small but people may not find it as essential area of their concern. The maternity and child health and well being are their only concern. Development of DCC protocols and implementation for the premature babies can be essential and beneficial. Thus, in order to implement pre-hospital setting for implementing DCC involves following stage.
Motivation recruitment: Multidisciplinary team including nurses, gynaecologists, obstetricians, pediatricians, midwives and neonatologist can give information to all aspects of DCC to the patients so that they can decide which cord clamping method they want to adopt.
Creation: The health service providers must develop protocols and consensus which can implement and describe DCC.
Implementation: The compliance must be monitored during practice and staff members must be trained to manage stress and complexity during delay.
The hospitals can perform DCC in the cases where obstetric complexities are observed. However, the infants who need additional interventions after delivery such as in case of pre mature babies there is less probability of giving DCC. When neonatal requires any additional care for the stabilisation then health professionals does not make any delay in clamping because their main concern is to provide immediate care to the child so that there are no complications.
During the process of DCC new born is placed below or at the placenta so that placental transfusion can be encouraged by the action of gravity. During the waiting time period for clamping procedure the health professionals must ensure that child must be provided skin to skin care. In the stages of early care of new born certain measures must be taken by the hospital so that clamping process can be done accurately and within time frame (Argyridis, 2017). These measures include drying, stimulation efforts for first cry or breathing and temperature controlling by skin contact.
If nurses feel that there is obstruction to the airways then, secretions must be cleared. In hospitals there must be availability of Apgar timers which can monitor the elapsed time and a time interval between birth and cord clamping can be facilitated. The hospitals must also take care that there must be no interference between clamping and active management of third stage of labor. It also includes the consideration of uterotonic agents for minimizing the bleeding in mothers after delivery.
The hospitals also consider the facts that in women with abnormal placentation, umbilical cord avulsion and abruption the delay is not considered as the healthy option. Thus, in these circumstance health professionals are advised to perform immediate clamping only (The Role of the Umbilical Cord, 2018). The effective decisions regarding time delay can be taken by carers and multidisciplinary team involved in the care services of mother and neonatal. The limited data and decision making approaches can give desired results when they are individualised.
DCC protocols: In order to ensure the homogeneity of the practices of delayed clamping standard treatment approach for DCC is recommended. To make the process accurate the clinical authorities must define consensus before delivery which describe that how much delay will be followed. The timekeeper must start immediately as the baby is delivered and thus must announce the time in predefined intervals.
To delay the clamping the infant is wrapped in a warm towel and when the delay interval is reached then clamping is performed in the standard fashion. The clinical practitioners and multidisciplinary group members must take care that during the delay no safety concerns are neglected. The health professionals are also required to monitor the infant during this phase. The delay is also recorded for the future reference.
The transition from immediate cord clamping to delayed version requires the support and motivation from the leaders as well as clinical environment. Though the process is simple but it requires additional resources and clinics and health organisations must assure the availability of t these resources. Direct application of the DCC it is suggested that hospitals first provide training based upon simulations so that important steps can be highlighted and are well understood by the care providers (What happens to baby’s umbilical cord after birth, 2018). The hospitals must also make proper documentation of the delay and its outcomes must be monitored to analyse the effectiveness and outcomes of the procedures.
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Books and Journals
Argyridis, S., 2017. Delayed cord clamping. Obstetrics, Gynaecology & Reproductive Medicine. 27(11). pp.352-353.
De Paco, C., Herrera, J., and et.al., 2016. Effects of delayed cord clamping on the third stage of labour, maternal haematological parameters and acid–base status in fetuses at term. European Journal of Obstetrics & Gynecology and Reproductive Biology, 207, pp.153-156.