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Unanticipated Birth

Guidelines for Labour Assessment,


Imminent Delivery, and Transfer

Revised: December 2012


For further information contact:

Reproductive Care Program of Nova Scotia


Telephone: (902) 470-6798
Fax: (902) 470-6791
Email: rcp@iwk.nshealth.ca
Address: 5991 Spring Garden Road, Suite 700
Halifax, NS B3H 1Y6

This publication can also be accessed electronically via the Internet at:
http://rcp.nshealth.ca

Suggested citation: Reproductive Care Program of Nova Scotia. Unanticipated


Birth: Guidelines for Labour Assessment, Imminent Delivery, and Transfer.
December 2012, Halifax, Nova Scotia.

Page 1 of 48
Table of Contents
Introduction .................................................................................................3
Roles of the Emergency Team ...................................................................4
Assessing Maternal and Fetal Well-Being ..................................................4
o Key questions ..................................................................................5
o Auscultation of fetal heart tones.......................................................7
o Signs and Symptoms of Labour .......................................................7
o Signs and Symptoms of Imminent Birth ...........................................8
Planning for Care........................................................................................8
Maternal Assessment Quick Reference ................................................10
When Birth is Imminent ............................................................................11
Delivery Step-by-Step ...............................................................................12
Maternal Assessment and Care Following Birth .......................................15
Neonatal Assessment and Care ...............................................................17
Keeping Baby Warm .................................................................................19
Neonatal Resuscitation Overview ..........................................................20
Transfer ....................................................................................................21
Active Maternity Service Directory ............................................................22
Equipment for Birth and Immediate Newborn Care ..................................23
Medications for Obstetrical Emergencies and Routine Birth:
Recommended for Stock in Emergency Rooms .......................................25
Laboratory Tests.......................................................................................31
Documentation .........................................................................................32
References ...............................................................................................34
Appendix A (Samples of standard documentation for labour and birth)....35
Appendix B (Reference Guide and Equipment List for NRP) ...................46

Photographs and illustrations not specifically referenced have all been obtained via
Google Images (2009)

Page 2 of 48
Introduction

Most women in Nova Scotia give birth in a hospital with an active maternity service.
Occasionally, women arrive in active labour in the Emergency or Outpatient area of a
facility where a maternity service is unavailable. Health care professionals must be able to
accurately assess these situations to determine the safest and most effective way to care
for labouring women. In some cases the assessment may indicate that there is enough
time to transfer the woman to the nearest facility with an active maternity service. When it
is likely that birth will occur, transfer may not be appropriate. Local clinicians must have
the basic knowledge and skills required to support labour and birth in order to optimize
healthy outcomes for both mother and infant. Transfer should not be attempted if it is
suspected that birth may occur en route.

This document has been developed to support health care professionals who do not
deliver babies as part of their usual practice. It is intended to provide guidance and
support to safely and effectively assess and care for laboring/birthing women. Included
are guidelines for:
Assessment of the labouring woman and her fetus
Indications for transfer and the transfer process, including a provincial
directory of all facilities offering a maternity service and details regarding
EHS LifeFlight

Care and documentation during labour and birth when transfer is not
possible

Basic neonatal resuscitation skills


Assessment and care following birth
Equipment
Medications to keep in stock for obstetrical emergencies and routine birth
Laboratory tests

Transfer should not be attempted if it is


suspected that birth may occur en route.

Page 3 of 48
Roles of the Emergency Team
The value of multidisciplinary assessment and care by the emergency room team should
never be underestimated. It is, however, the physicians responsibility to make a final
decision regarding the womans care. Where time and circumstances permit, it is always
advisable to seek support and advice from a referral centre or from the transport
team/EHS LifeFlight Medical Control Physician (MCP).

Emergency Health Services (NS) EHS LifeFlight 1-800-743-1334

Clinicians in ambulatory care or outpatient/emergency settings should be able to


recognize labour and perform basic assessments of maternal, fetal, and newborn well-
being. To complete a comprehensive assessment and provide reassurance to the woman
and her family, the following skills are required:
Assessing frequency, strength and duration of contractions
Helping women in early labour with decision-making; to consider the
potential need for travel or transfer to the most appropriate facility for labour
and birth

Auscultating the fetal heart tones with a fetoscope or Doppler


Recognizing a normal (or abnormal) fetal heart rate
Providing initial stabilization in consultation with referral centre colleagues
until mother and/or baby are transferred

Recognizing signs of rapidly progressing labour and birth


Assisting and supporting women during labour and birth
Providing appropriate maternal and newborn assessment and care in the
immediate post partum period, including supporting the initiation of
breastfeeding

Assessing Maternal and Fetal Well-Being


The woman herself is the best source of information about her obstetrical and medical
history and presenting concerns. Many women, particularly after 36 weeks gestation, will
carry a copy of their Nova Scotia Prenatal Record (PNR) with them; this will provide
valuable information about her pregnancy. In addition to the information gained from the
PNR, the woman can discuss and describe her own health history when prompted with
key questions.

Page 4 of 48
When birth is imminent and there is little time to do a comprehensive assessment, it is
most important to assess the gestational age of the baby, whether or not the amniotic
membranes have ruptured, and the presentation of the baby (i.e. is the baby coming
out head first or breech buttocks or feet). The gestational age will determine the
urgency of the transfer process and the most appropriate referral centre for transfer. It is
best not to artificially rupture the membranes unless 1) instructed to do so by an
obstetrician at the referral centre; or 2) the baby delivers. A breech presentation may
indicate a need for a cesarean section if there is time.

Key Questions to Assess Maternal and Fetal Well-Being

Questions regarding mothers status Consideration

Are you pregnant? Confirm pregnancy and that viability has been
achieved (> 20 weeks)

When is your due date? < 37 weeks = preterm


OR
How many weeks pregnant are you? Neonatal transport should be arranged as soon as
OR possible if birth is imminent and maternal transport
When is your baby due? is not an option.

Is this your first baby? If NOT, were her other deliveries vaginal or by
cesarean section?

NOTE: If she has had a previous vaginal birth,


expect a faster labour and delivery than she
experienced with her first birth. If she has had a
previous cesarean birth, this should be
discussed with the LifeFlight physician (MCP).

Do you have any health concerns? Some pre-existing health conditions (e.g. diabetes,
OR hypertension, obesity) may increase risk for
Do you have any medical conditions? adverse perinatal outcomes.

Have there been any concerns with Conditions which have resulted in increased fetal or
this pregnancy? maternal surveillance (multiple gestations or
breech presentation) should be discussed with a
referral centre.

Page 5 of 48
Questions regarding babys status Consideration

Have there been any concerns with The LifeFlight MCP will collaborate with the referring
the babys health during this physician regarding decisions about transfer.
pregnancy?

Has your baby been more or less Further assessment is indicated to confirm fetal health
active today? (i.e. confirmation of a fetal heart beat via
AND auscultation or ultrasound)
When did you last feel your baby
move? If a compromised baby is anticipated and birth is
imminent, arrange neonatal transport immediately.
If birth is not imminent, arrange maternal transport.

Questions about labour Consideration

Describe what you are feeling now. Consider how the womans symptoms have changed
When did this start? over time and what made her decide to come to
hospital

Can you describe the pain? Frequency = time from beginning of one
Frequency contraction to beginning of next
Duration Duration = how long does the contraction last
Strength or intensity from beginning to end?
Constant or intermittent How firm is the uterus with contractions?
Location Can she rate her pain on a scale of 1 to 10?

Do you have any pelvic or vaginal Pelvic or vaginal pressure may indicate imminent birth
pressure? or less urgent conditions. Further assessment is
required (e.g. urge to push vs urinary frequency)

Has your water broken? May be felt as a gush, trickle, or wetness


If so, when?
Is it clear in colour? Inspect leaking fluid for presence of blood or
Is there a foul odour? meconium (babys first stool green or yellow-green)

Is there any vaginal bleeding? Note: amount, colour (bright vs dark), consistency
When did this start?

Page 6 of 48
Auscultation of Fetal Heart Tones

The fetal heart tones are most easily heard through the babys back. When unsure of the
babys position, you may consider asking the mother on which side she most frequently
feels the babys kicks. Assuming this to be the location of the babys limbs, you would
auscultate on the opposite side of her abdomen, midway between the umbilicus and
symphysis pubis. The fetal heart tones will be heard lower in the abdomen as the baby
moves down into the pelvis as labour progresses.

Williams Obstetrics - 22nd Ed. (2005)

Signs and Symptoms of Labour

Regular contractions and/or back pain not relieved with rest or other comfort
measures
Pelvic or vaginal pressure
Increased vaginal discharge, including but not limited to bloody show
Ruptured membranes with or without contractions (this may be indicated by slow
leaking of fluid, wetness, popping sound or sensation accompanied by fluid, or
a larger gush of fluid)
Cervical change (someone who is skilled at cervical assessment may perform a
vaginal exam only after careful assessment, consideration, and consultation
regarding gestational age and membrane status; or if birth is imminent)

Do not perform a vaginal exam if the pregnancy is less than 36 weeks gestation or if you
are unaware of placental location, unless birth appears imminent or you have consulted
with a physician from a regional or tertiary hospital.

Page 7 of 48
Signs and Symptoms of Imminent Birth

Mother states the babys coming or the babys moving down


Uncontrollable urge to push
Bulging perineum and rectum
Uncontrollable passage of stool
Mother may panic
Sudden nausea and vomiting
Crowning of the fetal head

Planning for Care


The presence or absence of labour, maternal or fetal concerns or other safety factors
such as time, distance and travel conditions will influence your decision to:
Discharge home
Transfer to a referral centre
Provide care in your facility

If in labour, transfer if possible.

Guidelines for discharge home:

If appropriate assessment indicates that the woman is not in labour, her symptoms are
not concerning, or if she is in the early/latent stage of labour, offer these options:
she may return home, OR
she may drive to the hospital where she plans to deliver, considering distance and
travel conditions. You may seek the recommendations of the delivering hospital.

Discuss with her the signs of labour (pg.9) as well as supportive care/comfort measures.
Encourage her to return if she is unable to get to a facility with an active delivery service.

Page 8 of 48
Guidelines for transfer to a referral centre:

Consult with physician on call at the appropriate referral centre, or call LifeFlight to
consult with the Medical Control Physician (MCP)

Maintain continuous support and assessment

Consider safety of conditions for transfer (adequate time before delivery, weather)

Ensure appropriate care providers are available to accompany mother during


transfer

Reassess labour progress prior to transfer

If birth is imminent and the baby is preterm (< 37 weeks) or if the baby is anticipated
to be compromised in any way, contact LifeFlight to mobilize the Neonatal Team

Guidelines for providing care in your facility:

If unable to safely transfer mother due to imminent delivery or poor travel


conditions, support the birth in your department

All Emergency Department staff should be familiar with the location and use of
equipment required to care for a woman giving birth

Provide a safe, comfortable, private environment with continuous support

Page 9 of 48
Signs and Symptoms of Imminent Birth:
Mom: The babys coming!
Maternal Assessment: A Quick Reference Uncontrollable urge to push
Bulging perineum and rectum
Uncontrollable passage of stool
Mother may panic
Sudden nausea and vomiting
Crowning of the fetal head

Key Question or Observation:


IS THE BABY COMING NOW?

Maybe YES! No
= = =
TRANSFER IMMINENT BIRTH Assess and/or treat
concerning symptoms
DISCHARGE HOME

Consult EHS LifeFlight Medical


Control Physician (MCP) Provide a safe, comfortable,
private environment with
(1-800-743-1334) continuous support
or the
consult further with MCP,
nearest referral centre
or provide woman with
information re:
signs/symptoms of labour, or
other indications to seek
Get help and prepare medical care
equipment
Maintain continuous support
and assessment

Consult referral centre or


EHS LifeFlight MCP
Make every effort to avoid (1-800-743-1334) and initiate
delivery en route; neonatal transport PRN
Always transfer when possible

Page 10 of 48
When Birth is Imminent
Birth is a natural process and the vast majority of the time is uncomplicated, particularly
when the pregnancy is at term (> 37 weeks). It is quite possible that most of the women
who give birth in an emergency room will have had previous vaginal deliveries, hence the
precipitous nature of the labour and inability to get to a facility with a maternity service. A
successful vaginal birth history gives a very good indication that this delivery will go
smoothly.

It is important to remain calm and provide both emotional and physical support to the
woman and her family. The goals of care should be to prevent or minimize trauma to the
woman and her baby by supporting the normal processes and movements of birth, and to
create a positive lasting memory of the birth for the woman and her family. Health care
professionals should:
remain with the woman at all times
ensure help is available to prepare for delivery
provide support and care to the mother and her family
provide care for the newborn baby

Ideally, a separate room should be available for the woman giving birth. All equipment
should be kept in an area known to all staff and readily available for an imminent delivery.
The room should be warm to minimize potential heat loss for the baby. In addition to
increasing the temperature of the room, be sure to close windows and keep the baby
away from windows, outside walls, or any other potential sources of cold (CPS 2011). A
copy of standard provincial documentation for labour and delivery will help prompt you
with regard to care; samples of these are appended to this document (Appendix A) and
can be photocopied or obtained from the RCP by calling (902) 470-6798 or requested via
the RCP website at http://rcp.nshealth.ca.

Page 11 of 48
Delivery Step by Step
Call for Assistance
There are at least two patients present at each delivery the mother
and the baby. Each will require a care provider.
Sound Confident and Reassuring
Close up eye contact
Touch her shoulder
Speak in a quiet confident voice
Call her by name
Minimize the distraction and noise in the room, provide privacy
Position to Promote Delivery and Prevent Tissue Trauma
She should not lie flat on her back; side-lying or tilted with the support of
a pillow under her side is the best position to promote circulation,
minimize trauma and optimally oxygenate the baby
If she prefers, she can lean back against a person, wall, or bed
Discourage forceful Valsalva pushes. Encourage her to push with her
natural urges
Flex knees or encourage her to pull back on her knees during
contractions
Wash hands and wear gloves
Get equipment ready
Delivery of the Head
If the amniotic membranes have not yet ruptured and are bulging
through the perineum break them with your fingers or use an
instrument (e.g. Allis clamp) to break the water. Note the color,
quantity and odour of the fluid
Hold a towel or sponge between the vagina and the anus and apply
gentle pressure to support the perineum and to encourage
continued flexion of the fetal head
Encourage light panting and gentle pushes as the head emerges to
prevent the forceful expulsion of the head and perineal trauma
Maintain flexion with light pressure on the back of the babys head.
Do not pull on the babys head

Check for the Cord


Once the head is born, encourage the woman to stop pushing for a
moment while you check for the umbilical cord around the neck
You will have time before the next contraction to sweep your fingers
around both sides of the neck, feeling for the cord
If you feel cord gently try to loosen it and bring it out over the babys
head, sweep again in case it is looped twice; OR
If you cannot loosen the cord, you may have to clamp it with two
clamps, cut between the clamps, and unwind the cord
Williams Obstetrics - 22nd Ed. If you have had to clamp and cut the cord, you will have to quickly
(2005) deliver the baby

Page 12 of 48
Restitution
Allow the babys head to spontaneously turn to face the mothers leg
Let the uterus do the work of turning the baby through the pelvis once
the head is born
As the baby restitutes (i.e. turns to one side or the other), the
shoulders are lining up to move through the pelvic bones
With a helper on each side support both legs helping the woman to
flex her hips as she pushes with the next contraction
Support the Head and Guide the Body
Place a hand on either side of the babys head for support
The pushing power comes from the woman and her uterus, not from
the assistant pulling
Move hands downward with the babys head as you guide the upper
(i.e. anterior) shoulder under the pubic arch
Use a gentle downward motion; never pull
Once the upper shoulder is delivered, gently guide the babys body
without pulling in an upward direction over, not through, the
perineum
Feel the contraction pushing the baby out with the help of a steady
easy push from the mother (you can encourage the mother to
gently help the baby along with panting or easy grunting). This
Williams Obstetrics - 22nd Ed. will help to prevent forceful expulsion and injury to the vagina and
(2005)
perineum
Babys Born!
Lift the baby onto the womans abdomen or chest where she can see
and hold her baby
Keep the baby warm by placing the baby with the mother skin-to-
skin (unless baby requires resuscitation see page 19)
As you gently dry the baby with warm towels, he/she should begin to
cry vigorously
If meconium is present and the baby is not vigorous (depressed
respiratory rate, depressed muscle tone, and/or a heart rate <
100 bpm), suction the baby as well as possible. Do not suction a
vigorous baby. A team member competent and confident in
neonatal intubation can gently insert a laryngoscope and, using a
10F or 12F suction catheter, suction the mouth and posterior
pharynx. An endotracheal tube connected to a suction source
(and meconium aspirator, if one is available) is used for deeper
suctioning. This is facilitated by delaying stimulation while
suctioning occurs.
In the absence of intubation skills, use a large-bore (10-12 F) catheter
to suction secretions from the mouth, then nose, as required.
Follow with stimulation to initiate breaths.
Cover both with warm, dry blankets
Give 10 units of oxytocin IM or 5 units IV to the mother
Remember to record the time of birth!

Page 13 of 48
Congratulations!

Congratulate the woman and praise her efforts!

Cord Bloods
Place two clamps on the cord and cut in between. If available, a
plastic cord clamp may replace the clamp used on the babys
cord stump. From the cord that is still attached to the placenta,
draw cord blood into a clotted blood specimen tube (pink top)
and label accordingly
If possible, obtain cord blood gases. Immediately after birth double
clamp the cord and draw up specimens into heparinized
syringes; send to the laboratory for blood gas analysis (Note: the
larger blood vessel in the cord is the umbilical vein, the two
smaller vessels are the umbilical arteries. Ideally, specimens
may be obtained from one of each). Alternatively, draw up the
cord blood into a preheparinized syringe and place on ice and/or
refrigerate; this may be later analyzed at a variable time up to 60
hours postpartum. Analysis of a pH, pO2, pCO2 and base deficit
should be performed in the same way blood gas analyses are
done for other hospital departments
Waiting for the Placenta
Ideally, someone is caring for the baby while another assesses
bleeding and placental delivery. The placenta should come
within a few minutes
It is normal to see a small trickle of bright blood after the baby is born
but before the placenta is delivered
You may see small tears in the skin or vaginal tissue; not all will need
repair
Signs of placental separation include:
Lengthening cord
Williams Obstetrics - 22nd Gush of blood
Ed. (2005) Rising of the uterus in the abdomen
Do not massage the fundus (top of the uterus) or apply pressure in
an attempt to assist the delivery of the placenta
Very gentle traction can be applied to the cord with the other hand
supporting the uterus just above the pubic bone
You may apply gentle traction with ring forceps to the amniotic
membranes if they are somewhat adherent to the uterine wall
Massage the fundus as soon as the placenta is delivered; it should
be firm and palpable around the level of the umbilicus

Page 14 of 48
Maternal Assessment and Care Following Birth
Check vital signs, bleeding, fundal height and tone, bladder fullness, and perineum:
every 15-20 minutes for the first hour after birth,
every hour for the next four hours, and then
once a day until discharge.

Bleeding
Lochia will be red (rubra) and moderate to heavy within the first hour after delivery.
Bleeding should not exceed the saturation of a pad within the first hour.
If the mother has any known risk factors for post partum hemorrhage consider
initiating an IV prior to the birth.
http://www.sogc.org/guidelines/documents/gui235CPG0910.pdf
If the bleeding is excessive massage the uterine fundus. Consider starting an
oxytocin infusion; add 20-40 units of oxytocin to 1 litre of Ringers Lactate or 0.9%
NaCl and run at a rate of 100-125 cc/hour. This rate can be increased if
necessary.
If a continuous infusion or bolus of oxytocin IV and fundal massage does not
control the bleeding, consider giving an alternate uterotonic such as:
o Ergonovine maleate
o Carboprost tromethamine (Hemabate) or
o Misoprostol (Cytotec)
See Table (page 25) for recommended dosages and routes.

Consult with a physician at your referral centre for advice


.
if management of excessive bleeding is required

http://www.waybuilder.net/sweethaven/MedTech/ObsNewborn/default.asp?iNum=20215

Page 15 of 48
Vital Signs
BP
Pulse
Respirations
Temperature
Pain

Fundal Height and Tone


The fundus should be firm and palpated at the level of the umbilicus and in the
midline of the abdomen.
The flat of the hand should be used to palpate the fundus, while supporting the
lower portion of the uterus with the other hand.

http://www.waybuilder.net/sweethaven/MedTech/ObsNewborn/default.asp?iNum=20215

Bladder
The bladder should not be palpable.
If the fundus is above the umbilicus or off from the midline this may indicate that
the bladder is full. A distended bladder can interfere with uterine contractility
leading to uterine atony and increased post partum bleeding.
If the bladder is distended encourage the woman to void. If she is not able to void
on her own, it is appropriate to catheterize to prevent or control post partum
bleeding.

Perineum
Perineal lacerations causing excessive bleeding should be repaired; small, minimal
tears generally heal well.
An ice pack is recommended to prevent or reduce swelling.

Page 16 of 48
Neonatal Assessment and Care
First Impressions
If the baby is vigorous at birth (crying, good tone, and HR >100 bpm) place the
baby on the mothers abdomen or chest.
Gentle massage while drying the infant with warm blankets or towels is usually all
that is required to stimulate regular respirations.
Healthy newborns seldom require more than a clear airway and adequate warmth.
Routine suctioning is not recommended. If the baby has excessive secretions, it
may be necessary to remove them by wiping the mouth and nose with a towel or
by suctioning with a bulb syringe (*remember to depress the bulb before placing it
in the mouth). Alternatively, you may consider using a large-bore (10-12 F)
catheter to suction secretions from the mouth, then nose, if required. Suction
pressure should be set at 80-100 mmHg. Be careful not to suction vigorously or
deeply as this can produce a vagal response. Brief, gentle suctioning with a bulb
syringe is usually adequate to remove secretions.

Apgar scores are assigned at 1, 5, and 10 minutes:

















http://www.plasma-sy.com/node/4206

APGAR 0 1 2 1 min 5 min 10 min


On RCPs Birth Heart Rate Absent Below
100
Above
100
Resp. Absent Slow Good
Record, this is how effort irregular crying
Muscle Limp Some Active
Apgar scores are tone flexion motion
Reflex None Grimace Cough
recorded: Irritab.
Colour Blue Body Pink
sneeze
All Pink
Pale Blue extre.
Totals
Page 17 of 48
Baby Assessment for Apgar Scoring:

Appearance (color): blue to pink


Should turn centrally pink (lips, tongue, and central trunk) very quickly, hands and
feet may stay pale to bluish for up to 24 hours. You may need to distinguish
cyanosis from bruising.
If the baby is breathing but appears blue, administration of supplemental oxygen is
required. Attach a pulse oximetry probe on the babys right hand or wrist. If the
levels are low and not increasing, you may need to provide just enough
supplemental oxygen to help them achieve the targeted value for their age. This
can be done by cupping your hand as a mask over the babys nose and mouth
while holding the oxygen tubing between your fingers. Try to avoid oxygenation
that is either too high or too low either can be harmful.

Targeted Preductal
SpO2 After Birth
1 min 60% - 65%
2 min 65% - 70%
3 min 70% - 75%
4 min 75% - 80%
5 min 80% - 85%
10 min 85% - 95%
(CPS 2011)

Pulse (heart rate): <100bpm or >100bpm


Auscultate HR or feel pulse at base of cord
Bag and mask ventilation if HR <100bpm
Chest compressions if HR <60bpm after 30 seconds of effective bag and mask
ventilation.

Grimace (reflexes): no response facial grimace coughing or sneezing

Activity (tone): limp flexion of arms and legs

Respirations: none to irregular to vigorous crying


Stimulate if respirations are absent or gasping.
If there is no immediate response, initiate positive pressure ventilation (PPV) at 40-
60 breaths/min.

Page 18 of 48
Resuscitation
See page 18 for an overview of Neonatal Resuscitation, or Appendix B for the complete
NRP Flow diagram and equipment list.

Medications
Erythromycin eye ointment is administered to all babies (Note: delay the administration
of the eye ointment until after the mother has had a chance to breastfeed her infant within
the first hour of birth. The eye ointment may obscure the babys vision temporarily and
interferes with the ability to see their mother). (CPS position statement 2008)

Vitamin K 1mg IM (thigh) is administered to all babies within the first 4-6 hours after birth.
A dose of 0.5mg is appropriate for infants weighing less than 1500 g. (CPS position
statement reaffirmed 2012)

Keeping Baby Warm


It is essential for caregivers to provide warmth to newborn infants, as hypothermia and
cold stress place a baby at increased risk for morbidity and mortality. For term babies,
direct skin to skin cuddling with their mother is the preferred method to protect them from
cooling. For smaller or preterm infants it may be necessary to employ additional methods
to maintain a core temperature of 36.5o 37.5o Celsius (e.g. an incubator, if available,
with the air temperature set to 37o Celsius may be used for a preterm infant).

Some facilities still have radiant warmers that were used when there was an active
maternity service on site. We recommend that these not be used. The risks of infant injury
from improper use or poorly functioning equipment outweigh the benefits. Gel warming
mattresses may be used with caution to provide heat to prevent or treat cold stress in at
risk infants waiting for or during transport. Blankets or IV bags should never be warmed in
a microwave to provide heat to an infant. Warm blankets may be found in a blanket
warmer in an operating room for those facilities with an OR service.

Other means of preventing heat loss from the baby:


Change wet blankets and replace with dry blankets that have been warmed, if
possible.
Keep baby away from drafts.
Do not place baby on or near cold equipment, or near walls or windows.
A cap fashioned out of stockinette may be used.
Plastic wrap or a bag may be used for very preterm infants to prevent heat loss
through evaporation.
Page 19 of 48
Neonatal Resuscitation An overview
Initial Assessment

Term gestation?
Breathing or crying? If yes to all, baby stays with mother.
Good tone?

If no to any of these, baby may require the following measures:

A Airway (30 seconds)


Provide warmth
Position the head to open the airway
Suction mouth, then nose (as necessary)
Dry and stimulate, reposition head to maintain an open airway

B Breathing (30 seconds)


Evaluate respirations and heart rate
If apneic or HR<100 bpm, provide PPV with room air at rate of 40-60/min.
Ventilation is effective as demonstrated by HR increasing to >100 bpm
If HR< 60 bpm, start chest compressions and provide oxygen with PPV

C Circulation
Coordinate effective chest compressions and PPV (3:1)
Use pulse oximeter and titrate oxygen to achieve target SpO 2 levels
Discontinue chest compressions when HR > 60 bpm
Discontinue PPV when HR > 100 bpm and baby is breathing spontaneously

Page 20 of 48
Transfer
When possible, it is ideal to transfer the labouring woman to a facility with an active
maternity service. Furthermore, it is beneficial to transfer a baby in utero, especially when
the need for special care is anticipated. Transfer should not be attempted if it is
suspected that birth may occur en route.

Consult with an obstetrician at your regional centre or directly through LifeFlight about
management and/or transfer. If the infant needs special care and maternal transfer is not
an option, the neonatal transport team (through contact with LifeFlight) should be notified
to enable their presence at the birth or as soon as possible thereafter to care for the
infant. If it is necessary to transfer the baby after birth, parents will need information about
parent rooms or courtesy rooms in the referral hospital. Staff should check with the
receiving centre to ensure the availability of a room, as space is sometimes limited. If a
parent room is not available, staff in referring hospitals can provide information about
alternate accommodations for parents.

Some healthy mothers and babies may not necessarily need to be transferred to a
referral centre after birth depending on the distance to the referral centre, maternal
preference, and availability of postpartum support for breastfeeding and skilled
assessment of mother and baby.

Regardless of where mother and baby are cared for in the postpartum period, when they
are both stable the baby should always remain in the room with the mother.

Page 21 of 48
Active Maternity Service Directory (Nova Scotia area code 902)

Emergency Health Services EHS LifeFlight 1-800-743-1334


(For Maternal and Newborn Transfer)

Tertiary Centres:

Halifax: IWK Health Centre


Birth Unit 470-6670
Sydney: Cape Breton Regional Health Care Complex
Labour and Delivery Unit 567-7834

Regional Centres:

Amherst: Cumberland Regional Health Care Centre


Switchboard 667-5400 Ext.6144

Antigonish: St. Marthas Hospital


Childrens and Womens Health Unit 867-4200

Bridgewater: South Shore Regional Hospital


Maternal/Child Unit 543-5214

Kentville: Valley Regional Hospital


Switchboard 678-7381 Ext. 3050

New Glasgow: Aberdeen Hospital


Switchboard 752-7600 Ext. 2530

Truro: Colchester Regional Hospital


Maternal/Child Unit 893-5545

Yarmouth: Western Regional Health Centre


Switchboard 742-3541 Ext. 130

Community Centres:
Glace Bay: Glace Bay Health Care Facility
Obstetrics Unit 842-2844
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Equipment
Ideally, a warm separate area or private room should be available for the woman giving
birth.
Keep all equipment in an area known to all staff and where it is readily available for
an imminent delivery.
A copy of standard provincial documentation for labour and delivery will help
prompt you regarding assessments.

Sterile emergency delivery tray contents:


4 clamps (it is useful to have at least one pair of kochers or an Allis clamp to

rupture membranes if needed)
1 pair curved scissors
1 pair suture scissors
Blood collection tube (to fit with pink top)
1 umbilical cord clamp
1 small bowl
1 towel
3 oz bulb suction
1 drape
1 large pad suitable to place under the mothers buttocks
Sponges
Gloves
* Disposable emergency delivery trays are available. These are often more practical in
a community hospital that does not provide obstetric services.

You will also need:


1. Several warm flannel blankets/towels to dry the infant. The infant should be placed
skin-to-skin with the mother and both covered with clean, dry, warm linens. The infant
should always be dried immediately; this can be done while skin-to-skin on the
mothers abdomen or chest. You may also bundle the infant in 2 or 3 warm
blankets/towels.
2. Warm, sterile water (to wash mothers perineum)
3. Suction catheters (#6,8,10)
4. Maternity pads
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5. Ice pack for perineum (provides comfort and prevents swelling; can be made and
stored ahead by soaking a peri pad in water and placing it in the freezer. They must
be wrapped in a light cloth to protect the perineum from the direct contact with ice).
6. 2 heparinized syringes for cord gases
7. Plastic bag for placenta
8. Identification bracelets: 1 for mother, 1 for baby
9. Folder with RCP chart form package & necessary hospital laboratory requisitions
10. Newborn resuscitation equipment (Appendix B)

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Medications for Obstetrical Emergencies and Routine Birth:
Recommended for Stock in Emergency Rooms

For Routine Birth


Drug Name / Potential Adverse
Use Indications Contraindications Dosage Storage Reference
Level of Care Effects
Topical Antibiotic prophylaxis for None known each eyelid should first be Room Mild to Moderate symptoms of Canadian Paediatric
Erythromycin neonatal wiped gently with a sterile temperature irritation. Society: Position
Eye Ointment ophthalmia due to cotton ball to remove Statement ID02-03
N gonorrhoeae or foreign matter and permit (Jan 2009)
(All hospitals) Chlamydia adequate eversion of the
trachomatis lower lid. A line of ointment
1 to 2 cm long is placed in
each lower conjunctival sac,
if possible covering the
whole lower conjunctival
area. After 1 min, any
excess ointment should be
wiped gently from the
eyelids and surrounding
skin with a sterile cotton
ball.
Uterotonic; acts - Active Third Hypersensitivity to - Active Third Stage Room Hypotension, tachycardia, Advanced Life
Oxytocin on the smooth Stage Oxytocin management: 10 IU IM or 5 temperature water intoxication, and ECG Support in
muscle of the management IU IV with the delivery of the changes have been observed Obstetrics (ALSO)
(All hospitals) uterus to anterior shoulder or following the administration of Canadian Edition,
stimulate immediately after the infant concentrated solutions. (2010); SOGC
contractions is delivered (2009)

- After placental - To control postpartum


delivery to control bleeding: Add 20-40 IU to
postpartum 1000 ml of Ringers Lactate
bleeding and or 0.9% NaCl and infuse at
prevent 100-125 mL/hr.
haemorrhage
necessary for prevention of none known Within 6 hours of birth: Room None known other than pain Canadian Paediatric
Vitamin K synthesis in the haemorrhagic Single IM dose of 0.5mg temperature associated with injection Society: Position
liver of factor II disease of the (birthweight 1500 g or less) Statement FN97-01
(All hospitals) (prothrombin), newborn or 1.0 mg (birthweight (Feb 2009)
factor VII greater than 1500 g)
(proconvertin),
factor IX
(thromboplastin),
and factor X.

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For Obstetrical Emergencies and Other Indications
Drug Name / Potential Adverse
Use Indications Contraindications Dosage Storage Reference
Level of Care Effects
Anticonvulant - to control or known hypersensitivity Room Maternal: dose-dependent Compendium of
Benzodiazepine Anxiolytic - prevent seizure to benzodiazepines; temperature CNS side effects: dizziness, Pharmaceuticals
Hypnotic - activity myasthenia gravis; drowsiness. and Specialities,
(All hospitals) Sedative breastfeeding Fetal: hypotonia, lethargy, online version (e-
sucking difficulties CPS) 2012

Corticosteroid; When preterm Allergies to Betamethasone 12 mg IM Room Maternal: Fluid retention and Advances in Labour
Betamethasone used to promote birth between 23 corticosteroids; q 24h x 2 doses. Should temperature increased blood pressure; and Risk
(Celestone) maturation of and 33 weeks' systemic fungal only be administered in potential for increased serum Management
preterm infants. gestation is infections consultation with an blood glucose. (ALARM) course
It is clinically expected within 7 obstetrician or Fetal: transient reduction in manual, 19th Edition
(Regional and proven to reduce days, neonatologist fetal heart rate variability (2012-2013)
tertiary) perinatal betamethasone and fetal movement. Because
mortality and the is given to the of insufficient scientific data
incidence of IVH mother to affect from randomized clinical trials
and RDS in fetal maturation. regarding efficacy and safety,
infants born repeat courses of
prematurely. corticosteriods should not be
used routinely.

prostaglandin For the treatment Cardiovascular, 0.25 mg deep IM or Refrigerate at Nausea, vomiting, diarrhea, Advanced Life
Carboprost F2Uterotonic of postpartum pulmonary, renal, or intramyometrial; may 2 to 8 C elevated B/P, pyrexia, Support in
(Hemabate) haemorrhage hepatic disease; repeat every 15 minutes headache, flushing, Obstetrics (ALSO)
due to uterine known hypersensitivity for a total dose of 2.0 mg diaphoresis, restlessness Canadian Edition,
(Regional and atony which has to the preparation (8 doses) (2010); SOGC
tertiary; with not responded to Clinical Practice
option to conventional Guideline #235
transport to methods of (2009)
community site management
prn)

Uterotonic For the treatment hypertension, Supplied in different Refrigerate at peripheral vasospasm, UpToDate August
Ergonovine of postpartum preeclampsia, fomulations; refer to 2 to 8 C; hypertension, nausea, 2012; e-CPS 2012;
maleate haemorrhage hypersensitivity to package insert and give as Stable 60 vomiting SOGC Clinical
(Ergometrine) due to uterine drug directed. days without Practice Guideline
atony which has refrigeration #235 (2009);
(All hospitals) not responded to Advanced Life
conventional Support in
methods of Obstetrics (ALSO)
management Canadian Edition,
(2010)

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Drug Name / Potential Adverse
Use Indications Contraindications Dosage Storage Reference
Level of Care Effects
vasodilator - treatment of drug allergy; systemic Initial dose 5 mg via slow Room hypotension, tachycardia, Advanced Life
Hydralazine antihypertensive severe pre- lupus; severe IV injection; may repeat IV temperature palpation, anginal symptoms, Support in
(Apresoline) eclampsia or tachycardia; dose 5-10 mg q15-30 flushing, headache, Obstetrics (ALSO)
eclampsia myocardial minutes for total dose of 20 gastrointestinal disturbances, Canadian Edition,
(All hospitals) insufficiency due to mg IV. Dosage must be proteinuria, abnormal liver (2010); SOGC
mechanical individualized and titrated function tests Clinical Practice
obstruction; cardiac according to patient's blood Guideline #206
failure; aortic pressure and fetal (2008)
aneurysm response; close monitoring
of B/P and FHR is
essential.
non-steroidal For women with allergy to ibuprofen or 100 mg pr x 1 dose Room Maternal: SOB, wheezing, Advanced Life
Indomethacin anti- preterm labour other NSAIDs, history temperature tightness in chest; dependent Support in
(Indocid PDA) inflammatory; in preparation for of liver or kidney edema, malaise, fever, loss of Obstetrics (ALSO)
tocolytic transfer to Level disease, blood or appetite, visual disturbances, Canadian Edition,
(All hospitals) III facility. urine abnormalities confusion, depression, (2010); SOGC
dizziness, lightheadedness, Policy Statement
hearing problems; skin rash or #165 (2005)
hives, yellow discoloration of
the skin or eyes: bloody or
black tarry stools, rectal
bleeding or discomfort when
passing stools, vomiting or
persistent indigestion, nausea,
stomach pain, constipation or
diarrhea; oliguria, dysuria, or
change in urine colour.
Fetal/neonatal: constriction of
ductus arteriosus

antihypertensive- treatment of pre- drug allergy; Start with 20 mg IV; repeat Room Maternal: hypotension, SOGC Clinical
Labetalol and -blocker eclampsia or uncontrolled 2080 mg IV q30min, or 1 temperature headache, fatique, dizziness Practice Guideline
(Trandate) eclampsia congestive heart 2 mg/min, max 300 mg in Fetal/neonatal: neonatal #206 (2008);
failure; asthma; 24 hours (then switch to bradycardia Advanced Life
(All hospitals) history of obstructive oral). Support in
airway disease; > 1 Obstetrics (ALSO)
AV block; cardiogenic For severe hypertension, Canadian Edition,
shock and states of BP should be lowered to (2010)
hypoperfusion; sinus <160 mmHg systolic and
bradycardia <110 mmHg
diastolic.

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Drug Name / Potential Adverse
Use Indications Contraindications Dosage Storage Reference
Level of Care Effects
CNS depressant eclampsia antepartum Should be administered Room hyporeflexia, respiratory SOGC Clinical
Magnesium prevention or haemorrhage, only under the continuous temperature depression/arrest, maternal Practice Guideline
Sulphate treatment. chorioamnionitis, supervision of a health hypotension, maternal/fetal #206 (2008);
(MgSO4) hypocalcaemia, renal care professional familiar hypocalcemia, pulmonary Advanced Life
failure, myasthenia with the proper dosage, edema, cardiac arrest, Support in
(All hospitals) gravis monitoring parameters, generalized CNS depression Obstetrics (ALSO)
and the use of the antidote, of mother/fetus Canadian Edition,
Calcium Gluconate. (2010)

Loading dose: 4 gm bolus


over 20 mins followed by a
continuous infusion of 2
gm/hr. If solution is not
premixed, withdraw 80 ml
from a 1000 ml bag of RL.
Add 40 mg (80 ml) MgSO4
50% to the bag. The
resultant concentration is
40 gm MgSO4 per 1000 ml.
Prostaglandin E1 For the treatment use caution with 600-1000 mcg per rectum, Room Nausea; vomiting; diarrhea; SOGC Clinical
Misoprostol analog; of postpartum history of PO, or sublingual temperature pyrexia; shivering Practice Guideline
(Cytotec) Uterotonic haemorrhage cardiovascular #235 (2009);
due to uterine disease Dosage and route may Advanced Life
(All hospitals) atony which has vary depending on Support in
not responded to experience of prescriber Obstetrics (ALSO)
conventional Canadian Edition,
methods of (2010)
management

opioid antagonist Continued suspected maternal 0.1 mg/kg IV or IM Room seizures, acute withdrawal CPS/AHA/AAP
Naloxone respiratory narcotic addiction or temperature symptoms with maternal Neonatal
(Narcan) depression after known methadone narcotic use. Resuscitation
positive-pressure use; newborn heart Textbook, 6th
(All hospitals) ventilation has rate <100 bpm despite edition (2011)
restored normal effective ventilation
Newborn heart rate and and/or chest
Resuscitation colour, AND a compressions;
history of newborn cyanosis or
maternal narcotic hypotonia despite
administration normal heart rate and
within the past 4 adequate rate and
hours depth of respiration.

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Drug Name / Potential Adverse
Use Indications Contraindications Dosage Storage Reference
Level of Care Effects
antihypertensive treatment of allergy to nifedipine, 510 mg capsule to be Room vasodilatory effects; angina, SOGC Clinical
Nifedipine - calcium severe pre- extreme bradycardia, bitten and swallowed, or temperature congestive heart failure, Practice Guideline
(Adalat) channel blocker eclampsia or severe congestive just swallowed, every 30 pulmonary edema, #206 (2008)
eclampsia heart failure and/or min tachycardia, bradycardia,
(All hospitals) severe left ventricular excessive hypotension, skin
dysfunction; 10 mg PA tablet every 45 rashes; arthritis and transient
concomitant use of min to a maximum of 80 blindness
drugs known to affect mg/d
cardiac conduction, 2
or 3 heart block
antibiotic; Group Treatment at allergy to penicillin 5 million IU IV, then 2.5 signs of sensitivity include: SOGC Clinical
Penicillin G B streptococcal time of labour or million IU IV q4h. rash, urticaria, chills, fever, Practice Guideline
Sodium (GBS) disease rupture of edema, arthralgia, #149 (2004);
prophylaxis or membranes: all Women who are allergic anaphylaxis. SOGC Clinical
(All hospitals) treatment women positive and not at risk for Practice Guideline
by GBS anaphylaxis: substitute #276 (2012)
screening done Cefazolin 2 g IV then 1 g
at 35-37 weeks; IV q8h.
women with
infant previously Women who are allergic
infected with and at risk for anaphylaxis:
GBS; substitute clindamycin 900
documented mg IV q8h or erythromycin
GBS bacteriuria; 500 mg IV q6h.
< 37 weeks
gestation unless
there is evidence
of negative GBS
screening in past
5 weeks;
maternal fever.

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Drug Name / Potential Adverse
Use Indications Contraindications Dosage Storage Reference
Level of Care Effects
Rho (D) prevention of maternal Rh-positive Postpartum Store in Blood product reactions SOGC Clinical
WinRho immune rhesus (Rh) status; maternal weak nonsensitized Rh- refrigerator; Practice Guideline
globulin alloImmunization D (Du) status; paternal negative woman may need to #133 (2003)
(All hospitals) Rh-negative status delivering an Rh-postiive obtain from
when paternity is infant: 300 g IV or IM blood bank
certain within 72 hours of
delivery.

Following miscarriage,
threatened abortion,
ectopic or partial molar
pregnancy <12 weeks:
120 g IV or IM.

Following miscarriage,
threatened abortion,
ectopic or partial molar
pregnancy >12 weeks:
300 g IV or IM.

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Laboratory Tests
TIP: Keep corresponding requisitions with the emergency maternity equipment and chart
forms.

Cord Blood:
ABO, Rh and DAT (Direct Antiglobulin Test)
Following birth, collect at least 1 mL into a 10 mL clotted blood collection tube (pink
stopper).
Carefully label and refrigerate.
Forward to laboratory with the appropriate requisition as soon as possible.

Cord Blood Gases:


From a separate section of cord and using preheparinized syringes, draw up a
specimen from the umbilical artery (smaller blood vessel) and the umbilical vein
(larger vessel); label accordingly and send for blood gas analysis. Alternatively
these specimens may be placed on ice for later analysis.

Rh Positive mothers:
Healthy Rh-positive mothers do not require routine laboratory testing unless there
are specific indications (i.e. CBC related to blood loss, rubella or varicella titre if
immunization status is unknown or unsure).

Rh Negative mothers or mothers with antibodies (alloimmunized):


ABO, Rh type & Antibody screen
Within twelve hours following delivery, collect and fill two 10 mL clotted blood tubes
(pink stopper)
Complete appropriate requisition.

Rh Negative mothers with Rh positive or Rh unknown baby:


Kleihauer
Within twelve hours following delivery, collect sample using one 4 mL EDTA tube
(purple stopper).
Complete appropriate requisition

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PRN Bloodwork:
CBC
Rubella and/or varicella titre if immune status is unknown

Newborn Bloodwork:
Laboratory screening tests routinely done for full term healthy newborns include
metabolic and endocrine screening (e.g. PKU screening), and a screen for bilirubin
level. Blood samples are typically collected at 24-48 hours of age.

Documentation
Documenting the events of an unexpected delivery in an emergency room or outpatient
area can be overwhelming. Even for experienced caregivers who routinely attend
deliveries it can be challenging to maintain accurate and contemporaneous
documentation. Much of the documentation of the birth can be done after the delivery
has occurred and mother and baby are assessed to be healthy and safe in the
immediate postpartum period. Noting and remembering the time of birth is one
important aspect of care and can be documented on the birth record as soon as
circumstances permit.

Keeping a small stock of RCP forms for use during unexpected births can help promote
the best care possible. These forms can help prompt caregivers to initiate appropriate
assessments and treatments such as the timing of routine maternal and neonatal
assessments and the administration of medications routinely used in maternal and
neonatal care. While some of the forms may not be applicable, depending on the
duration of stay of the mother and newborn, the maternal assessment forms, partogram,
birth record, and newborn assessment forms will be helpful and necessary to use for
any birth even if a transfer is indicated shortly thereafter.

RCP maternal and newborn chart forms in order of their chart form number (for
ordering purposes) are:
1. Physicians Maternity Assessment
2. Maternal Assessment
3. Partogram
4. Birth Record
5. Record of Parent Teaching/Mother-Baby Flow sheet
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6. Breast/Bottle Feeding Record
7. Maternal Newborn Progress Notes
8. Physician Newborn Examination
9. Newborn Nursing Assessment
10. Newborn TPR
11. Newborn Weight Graph
12. Atlantic Newborn Growth Chart

Refer to Appendix A to see sample RCP chart forms.

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References

Canadian Paediatric Society (2011). Textbook of Neonatal Resuscitation (6th ed.).


Ottawa, Canada.

Canadian Pediatric Society. Recommendations for the Prevention of Neonatal


Ophthalmia (2008).

Canadian Pediatric Society. Routine Administration of Vitamin K to Newborns (1997,


reaffirmed 2012). Retrieved August 1, 2012 from:
http://www.cps.ca/en/documents/position/administration-vitamin-K-newborns

Cunningham, F. G., Hauth, J. C., Leveno, K. J., Gilstrap, L., Bloom, S. L., & Wenstrom,
K. D. (2005). Williams Obstetrics (22nd ed.). McGraw-Hill Companies, Inc. Retrieved
from IWK Health Sciences Library database.

Society of Obstetricians and Gynaecologists of Canada (2009). Active management of


the third stage of labour: Prevention and treatment of postpartum hemorrhage. Journal
of Obstetrics and Gynaecology Canada; 31(10):980993.
http://www.sogc.org/guidelines/documents/gui235CPG0910.pdf

Society of Obstetricians and Gynaecologists of Canada (2004). The prevention of early-


onset neonatal Group B streptococcal disease. Journal of Obstetrics and Gynaecology
Canada; 26(9):82632.
http://www.sogc.org/guidelines/public/149E-CPG-September2004.pdf

Society of Obstetricians and Gynaecologists of Canada (2012). Management of Group


B streptococcal bacteriuria in pregnancy. Journal of Obstetrics and Gynaecology
Canada; 34(5):482486.
http://www.sogc.org/guidelines/documents/gui276CPG1205E.pdf

Society of Obstetricians and Gynaecologists of Canada (2003). Antenatal corticosteroid


therapy for fetal maturation. Journal of Obstetrics and Gynaecology Canada; 25(1):45
8.
http://www.sogc.org/guidelines/public/122e-co-janvier2003.pdf

Soll, R. F. (2008). Heat loss prevention in neonates. Journal of Perinatology, 28, S57-
S59.

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Appendix A

Samples of Standard Documentation for Labour and Birth

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Appendix B

Flow Diagram for NRP


Canadian Paediatric Society (www.cps.ca) 2011

Targeted Preductal
SpO2 After Birth
1 min 60% - 65%
2 min 65% - 70%
3 min 70% - 75%
4 min 75% - 80%
5 min 80% - 85%
10 min 85% - 95%

Page 46 of 48
Equipment for Neonatal Resuscitation

Item Community Site Regional Site


Infant warmer
Means to keep baby warm in lieu of skin-to-skin contact
(e.g. gel warming mattress, cap, warm blankets/towels)
Oxygen supply
Assorted neonatal masks
Self-inflating neonatal resuscitation bag and tubing to
connect to an oxygen source
O2 blender (or means to blend air with O2; e.g. Y-
connector)
Manometer
Endotracheal tubes (sizes 2.5 to 4)
Tape and scissors
Laryngoscope (0 and 1 sized blades) with extra bulbs
and batteries
(*Requires specific training to achieve and maintain
competency. Not to be used otherwise)

T-piece resuscitator (e.g. Neopuff Infant Resuscitator)


CO2 detector
Laryngeal Mask Airway (LMA) size 1
(*Requires specific training to achieve and maintain
competency. Not to be used otherwise.)

Bulb syringe
Regulated mechanical suction
Suction catheters (6F, 8F, 10F, 12F)
Suction tubing and canister
Feeding tube (8F catheter)
Syringe, catheter tipped, 20 mL
Meconium aspirator
IV catheters (22 g)
Tape and sterile dressing material

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Item Community Site Regional Site
D10W
Isotonic saline solution
Syringes, assorted (1-20 mL)
Epinephrine (1:10,000)
Sodium bicarbonate (0.5 mEq/mL)
Umbilical catheters (2.5F, 5F)
Chest tube (10F catheter)
20 g IV catheter with 3-way stopcock (in lieu of chest
tube)
Sterile procedure trays (eg, scalpels, hemostats,
forceps)

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