Neonate Restraint Post-Delivery

How do you transport mom and baby in the same ambulance?

  • Mom holds baby while on cot with seatbelts.

    Votes: 3 37.5%
  • Baby is on cot in some sort of infant approved device, mom sits elsewhere.

    Votes: 0 0.0%
  • Baby is in provided car seat which is secured to probably the airway chair, mom is on cot.

    Votes: 2 25.0%
  • You call for a second unit.

    Votes: 3 37.5%
  • Following eval you allow mom or baby to go to POV.

    Votes: 1 12.5%
  • Other.

    Votes: 0 0.0%

  • Total voters
    8

Tigger

Dodges Pucks
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You deliver a baby, things are fine for both mom and baby. How are you going to transport the two of them in your ambulance?

Let's take away having a sick patient here, mom or baby. If at all possible, that warrants a two ambulance response.

So what do you do? Skin to skin contact is important, but let's be real, that does not provide for a restrained infant at all. Can your ambulance take a car seat if it's not on the cot? Can you put mom not on the cot? What sort of devices do you carry on the ambulance to facilitate whatever it is you do?

I've been mulling this for a great long while and I still do not have much in the way of a definitive answer. For those of you who have car seats built into the airway chair, remember that those are not rated for newborn infants. Also remember that anything besides a traditional three point safety belt will make securing a provided car seat quite difficult.
 

PotatoMedic

Has no idea what I'm doing.
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We have a "kangaroo" transport that straps baby to mom and mom gets strapped to gurney. I believe it does skin to skin.
 

NPO

Forum Deputy Chief
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We use the ACR (Ambulance Child Restraint). I know you said to not consider needing 2 ambulances due to them both being healthy, however, we send 2 ambulances and they're transported separately every time, not just if one is sick.
We have a "kangaroo" transport that straps baby to mom and mom gets strapped to gurney. I believe it does skin to skin.
We evaluated those, but they don't meet crash test standards. NHTSA says each patient needs their own seat.
 

Peak

ED/Prehospital Registered Nurse
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Specifically regarding kangaroo care it is only recommended in low risk, full term, uncomplicated deliveries. In my opinion no ED or EMS delivery is going to qualify, something went wrong if they are not delivering in hospital, a birth center, or at home with a qualified provider.

All high risk deliveries require assessment of the neonate, and only after reassuring assessment can mom hold. I guess the question is how many paramedics feel that they are adequately trained and experienced to fully examine a newborn.
 

hometownmedic5

Forum Asst. Chief
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Specifically regarding kangaroo care it is only recommended in low risk, full term, uncomplicated deliveries. In my opinion no ED or EMS delivery is going to qualify, something went wrong if they are not delivering in hospital, a birth center, or at home with a qualified provider.

All high risk deliveries require assessment of the neonate, and only after reassuring assessment can mom hold. I guess the question is how many paramedics feel that they are adequately trained and experienced to fully examine a newborn.
Since the origination of the species, women have been delivering their babies wherever they happen to be when the time strikes, for most of human history without the benefit of any variety of actual medical care or attendant. This is still happening to this day in the third world, probably since I started writing this. Nothing necessarily “went wrong”. Perhaps they just got caught short. I showed up almost a week early when my parents were at the company Christmas party. We made it to the hospital, but only just barely. Not a thing was “wrong”. They just didn’t have it planned for that day.

I disagree with your basic that any delivery that happens outside of a hospital is all of a sudden, based solely on geography, high risk. I also disagree with your basic premise that we aren't qualified to separate a sicker than poop infant from one that is breathing, crying, pink or pinking, moving all extremities etc. I’m not a neonatologist, but I absolutely feel comfortable assessing them for the basic characteristics of a living human being. A significant premie, sure. Not improving assessment, absolutely. A known or readily appreciable cause for concern, yup, all high risk; but a full term, low risk, uncomplicated delivery with a good assessment to me is not all of a sudden “high risk” simply because the baby was impatient.

ETA: Yes, sometimes things do go wrong. Breeches, stills, cord presentations and so on. We are talking about those here.
 

DrParasite

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We always tried to send two units for any prehospital delivery. typically 1 ALS unit and 1 BLS unit, but the majority of the time both patients were transported BLS / with just supportive measures, nice and easy, with no lights or sirens, in one truck, both properly secured

mom holding baby during the ride is a bad idea, plain and simple. yes, I'm sure it's been done in the past, but one crash, hard stop, or pothole, and that tiny poop machine becomes a tiny football.

if the baby is sick (not just early, but needs aggressive intervention), baby goes in a separate truck and treated appropriately, and is secured to the cot via the appropriately approved device, with towels as needed to take up any voice spaces.
 

Peak

ED/Prehospital Registered Nurse
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Since the origination of the species, women have been delivering their babies wherever they happen to be when the time strikes, for most of human history without the benefit of any variety of actual medical care or attendant. This is still happening to this day in the third world, probably since I started writing this. Nothing necessarily “went wrong”. Perhaps they just got caught short. I showed up almost a week early when my parents were at the company Christmas party. We made it to the hospital, but only just barely. Not a thing was “wrong”. They just didn’t have it planned for that day.

I disagree with your basic that any delivery that happens outside of a hospital is all of a sudden, based solely on geography, high risk. I also disagree with your basic premise that we aren't qualified to separate a sicker than poop infant from one that is breathing, crying, pink or pinking, moving all extremities etc. I’m not a neonatologist, but I absolutely feel comfortable assessing them for the basic characteristics of a living human being. A significant premie, sure. Not improving assessment, absolutely. A known or readily appreciable cause for concern, yup, all high risk; but a full term, low risk, uncomplicated delivery with a good assessment to me is not all of a sudden “high risk” simply because the baby was impatient.

ETA: Yes, sometimes things do go wrong. Breeches, stills, cord presentations and so on. We are talking about those here.
But without modern care we had much higher maternal and infant fatality rates. Birth may have been happening, but women and newborns also died at a much higher rate.

Can you easily assess for PPHN?
 
OP
Tigger

Tigger

Dodges Pucks
Community Leader
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We use the ACR (Ambulance Child Restraint). I know you said to not consider needing 2 ambulances due to them both being healthy, however, we send 2 ambulances and they're transported separately every time, not just if one is sick.We evaluated those, but they don't meet crash test standards. NHTSA says each patient needs their own seat.
I have used the ACR system at other jobs and think it is effective. How did mom feel about not being in the same ambulance? Did you feel that you could spend enough time on scene with mom and baby if needed? I know in this thread we are told that we don't actually have the ability to assess these patients but literally every OB educator that's taught to our system has encouraged taking the time to get skin to skin contact and breastfeeding while on scene if vital signs, APGAR, and general presentation of both mom and baby are unconcerning.
Specifically regarding kangaroo care it is only recommended in low risk, full term, uncomplicated deliveries. In my opinion no ED or EMS delivery is going to qualify, something went wrong if they are not delivering in hospital, a birth center, or at home with a qualified provider.

All high risk deliveries require assessment of the neonate, and only after reassuring assessment can mom hold. I guess the question is how many paramedics feel that they are adequately trained and experienced to fully examine a newborn.
These patients are being transported to the hospital. Is the kangoofix adequate to transport a term delivery with normal vital signs and APGAR? I don't know, that's why I am asking. Perhaps we don't know enough, but that doesn't change the question I am asking, which is how would you transport the topic question?

We always tried to send two units for any prehospital delivery. typically 1 ALS unit and 1 BLS unit, but the majority of the time both patients were transported BLS / with just supportive measures, nice and easy, with no lights or sirens, in one truck, both properly secured

mom holding baby during the ride is a bad idea, plain and simple. yes, I'm sure it's been done in the past, but one crash, hard stop, or pothole, and that tiny poop machine becomes a tiny football.

if the baby is sick (not just early, but needs aggressive intervention), baby goes in a separate truck and treated appropriately, and is secured to the cot via the appropriately approved device, with towels as needed to take up any voice spaces.
How did you secure them in this case, specifically?
 

NPO

Forum Deputy Chief
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I have used the ACR system at other jobs and think it is effective. How did mom feel about not being in the same ambulance? Did you feel that you could spend enough time on scene with mom and baby if needed? I know in this thread we are told that we don't actually have the ability to assess these patients but literally every OB educator that's taught to our system has encouraged taking the time to get skin to skin contact and breastfeeding while on scene if vital signs, APGAR, and general presentation of both mom and baby are unconcerning.
Mom understood. When you explain to mom that there's no safe way to restrain her baby, they all understand.

As far as skin to skin, it's a great idea for in hospital, but it's not practical prehospital. I'm okay with staying on scene for a bit if they're both stable, but transport sooner than later will do them both some good. It's easy to keep baby warm in an ambulance without skin to skin, and a 20 minute transfer won't considerably change anything when waiting for skin to skin.

Safety is paramount. We debated this at length in committee, and we all agreed that we prefer skin to skin time, but not if it means transporting unsafely. We looked into the Kangaroo device for this reason, but it's lack of crash testing ruled it out for us.
 

Peak

ED/Prehospital Registered Nurse
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These patients are being transported to the hospital. Is the kangoofix adequate to transport a term delivery with normal vital signs and APGAR? I don't know, that's why I am asking. Perhaps we don't know enough, but that doesn't change the question I am asking, which is how would you transport the topic question?
For clarity when I say kangaroo care I’m referencing skin to skin and the associated cares, not a transport product.

If a neonate is well then ideally they are in a rear facing car seat that is correctly secured (I would think the airway chair in many ambulances would probably work well, the cot may work if you raise up the back).

If they are sick then then you need to balance the need for safety with the ability to provide care. A car seat may still be the best option considering the limited resources, however even a car seat can be hard to get a hold of.

Personally I don't like to use APGAR scores to judge how well or sick a newborn is. It isn't very well validated especially at altitude. It's value is also more so when you trend a 1, 5, and 10 minute score but really the assessment of the newborn should be much quicker and in depth. There is a good reason why we don't use APGAR scores as a routine part of evaluation in NRP.
 

DesertMedic66

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Unfortunately for my ground agency we only utilize the Ferno Pedi-Mate which is only good down to 10lbs. If family has a car seat, in my area they typically don't, then we will secure that. We are also in a system where getting 2 ambulances to child births is usually not an option at least initially.

For my flight company I ran into an issue where we were asked to fly a neonatal patient unfortunately due to our airframe we could not secure the car seat so we called for another airframe. This lead the company to acquire the Med-Kids Baby-board which goes down to like 2lbs. However that was a process since they were not certified for flight operations when we started looking into them. Before we started using them we were able to get them certified for flight.
 
OP
Tigger

Tigger

Dodges Pucks
Community Leader
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I have been fighting for anything besides mom holding baby forever and am finally getting traction hence the ask. I would prefer two ambulances but that has been difficult for us as of late ETA wise. I am not particularly comfortable transporting mom sitting (though I suppose it's possible) and our airway chair has a harness on it so getting a child seat in there is not possible. Which leaves so far as I can tell, two ambulances which is probably a necessity ETA notwithstanding if one patient is sick. Transport the sickest, leave the other on scene with the engine company until the second ambulance arrives. State EMS has ruled that this not abandonment either even if the engine is BLS.
 

Peak

ED/Prehospital Registered Nurse
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@Tigger I think part of the reason I would be particularly hesitant would be should the newborn become more sick or need more assessment that may not be possible with mom holding.

Do you have a picture of the airway chair? It may still be possible to buckle a basic car seat into it.
 

NPO

Forum Deputy Chief
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I have been fighting for anything besides mom holding baby forever and am finally getting traction hence the ask. I would prefer two ambulances but that has been difficult for us as of late ETA wise. I am not particularly comfortable transporting mom sitting (though I suppose it's possible) and our airway chair has a harness on it so getting a child seat in there is not possible. Which leaves so far as I can tell, two ambulances which is probably a necessity ETA notwithstanding if one patient is sick. Transport the sickest, leave the other on scene with the engine company until the second ambulance arrives. State EMS has ruled that this not abandonment either even if the engine is BLS.
We send 2 ambulances at the time of dispatch, to help reduce that issue of leaving a patient on scene. Also helps with resuscitation if needed.

Look into the ACR, or see if your agency is willing to retrofit the airway seat to be a seat with a built in child seat. Ours has a flip down back that then acts as a little booster with a car seat built in.

Still not optimal, but at least the child is restrained.
 
OP
Tigger

Tigger

Dodges Pucks
Community Leader
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@Tigger I think part of the reason I would be particularly hesitant would be should the newborn become more sick or need more assessment that may not be possible with mom holding.

Do you have a picture of the airway chair? It may still be possible to buckle a basic car seat into it.
Have tried, the buckle is too wide to pass through most bases or other attachments. It's a four point single buckle so there is a lot of material. I don't really want to use any sort of "affix to mom" type device, but given challenges with securing an infant seat it seemed worth considering. Suppose we could lay mom on the bench with the scoop and blankies but oof that sounds unpleasant.
We send 2 ambulances at the time of dispatch, to help reduce that issue of leaving a patient on scene. Also helps with resuscitation if needed.

Look into the ACR, or see if your agency is willing to retrofit the airway seat to be a seat with a built in child seat. Ours has a flip down back that then acts as a little booster with a car seat built in.

Still not optimal, but at least the child is restrained.
We do have built in child seats but ours (and most everyone's) are only good for 20 pounds and up.
 

Peak

ED/Prehospital Registered Nurse
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The base typically doesn’t add any real amount of safety over using the belt on the car seat directly if there is a slot for it.

For a short trip I'd rather have mom sitting up than laying on a back board. While we consider labor to conventially be something done laying down often a seated/squated or hands and knees position is actually more comfortable and efficacious for labor. Sitting versus laying is much less important than ensuring fundal tone, which can often be achieved in a seated position.
 

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