The novel coronavirus termed SARS‐CoV‐2 (COVID‐19) is a major public health challenge. Many maternity units around the country are currently considering management protocols for these patients. We report a case from a tertiary Australian hospital describing an uncomplicated vaginal birth in a COVID‐19 positive mother. To our knowledge this is also the first case described of a mother with COVID‐19 not separated from her infant. Management provided supports the current Royal College of Obstetricians and Gynaecologists and World Health Organization guidelines suggesting that it is possible to consider rooming in post‐delivery for COVID‐19 positive parents. Encouragement of breastfeeding appears possible and safe when viral precautions are observed.
Healthcare simulation has significant potential for helping health services to deal with the COVID-19 pandemic. Rapid changes to care pathways and processes needed for protection of staff and patients may be facilitated by a translational simulation approach-diagnosing changes needed, developing and testing new processes and then embedding new systems and teamwork through training. However, there are also practical constraints on running in situ simulations during a pandemic-the need for physical distancing, rigorous infection control for manikins and training equipment and awareness of heightened anxiety among simulation participants. We describe our institution's simulation strategy for COVID-19 preparation and reflect on the lessons learned-for simulation programs and for health services seeking to utilise translational simulation during and beyond the COVID-19 pandemic. We offer practical suggestions for a translational simulation strategy and simulation delivery within pandemic constraints. We also suggest simulation programs develop robust strategies, governance and relationships for managing change within institutions-balancing clinician engagement, systems engineering expertise and the power of translational simulation for diagnosing, testing and embedding changes.
Background: Fetal scalp lactate (FSL) is used when the cardiotocography (CTG) is not normal in an attempt to reduce the false-positive rate and the likelihood of unnecessary intervention. Whilst the test has almost a 100% negative predictive value, the positive predictive value of this test is very low. Aims: To measure the effect of introducing consultant obstetrician review of every abnormal CTG prior to the decision to perform FSL. Materials and Methods: A retrospective cohort study was performed using routinely collected de-identified data. Mode of birth outcomes for women who had a continuous CTG in labour were compared in two equal time periods, 12 months before and after a change in hospital policy. Change in hospital policy dictated that FSL was only performed on a pathological CTG after consultant obstetrician review of the CTG. Results: Consultant obstetrician review of CTG prior to FSL was associated with fewer FSL performed (1.7% vs 3.5%; P ≤ 0.01), fewer babies acidaemic at birth pH < 7.1 (0.8% vs 2.2%; P < 0.01), fewer caesarean sections for presumed fetal distress (CS for FD) (6.6% vs 8.1%; P = 0.05) and fewer instrumental births (17.6% vs 20%; P = 0.04). When adjusted for confounders, the change in policy was independently associated with a reduced likelihood of CS for FD (adjusted odds ratios = 0.78 (0.63-0.97); P = 0.03). Conclusions: A hospital policy whereby a consultant obstetrician reviews abnormal CTGs prior to performing FSL may help to increase the pretest probability and reduce the rate of CS for FD, as well as instrumental birth and unnecessary FSL.
A 31-year-old Jehovah's Witness, with a past history of a previous elective Caesarean section for breech presentation, was diagnosed with a major anterior placenta praevia in the current pregnancy. Blood product use was discussed and an advance health directive signed by the patient and consultant. The patient refused blood products, but consented to cell salvage, presurgical acute normovolaemic haemodilution, erythropoietin use and possible early recourse to hysterectomy.The patient was admitted at 27 weeks' gestation following a small bleed from the placenta praevia; steroids were prescribed to promote fetal lung maturity. Over the following weeks, the patient was seen by anaesthetic, haematology and paediatric staff. Erythropoietin therapy was commenced and her iron supplementation increased.From 30 weeks' gestation, the patient had repeated small antepartum haemorrhages. A plan was made to deliver her electively at the end of her 32nd week following preoperative acute normovolaemic haemodilution and intraoperative cell salvage.Five days prior to her scheduled operation, repeated small amounts of vaginal bleeding, associated with persistent uterine tightenings, forced the decision to undertake delivery at that time.Pre-operative acute normovolaemic haemodilution was performed prior to administering a general anaesthetic, giving a preoperative haemoglobin of 104 g/L (from 115 g /L). In view of the poorly formed vascular lower segment, a classical uterine incision was performed. The membranes were not ruptured on entry and the baby was delivered 'en caul' (i.e. with the membranes intact) as a breech. Apgar scores were 5 at 1 min, 8 at 5 min, cord pH was 7.36, and baseline neonatal haemoglobin was 135 g /L.Delivery of the infant en caul allowed the cell saver to be used without concern over amniotic fluid contamination; 400 mL autologous blood was re-infused to the patient via the cell saver. Although the estimated blood loss was 1.7 L, the haemoglobin concentration was 90 g /L on day 1. The woman made an otherwise uneventful recovery; the infant had mild respiratory distress syndrome, but was discharged at 23 days. DiscussionThe key issues in managing patients who refuse blood products are establishing a dialogue with the patient, optimising blood indices early, multidisciplinary input and occasionally intervening earlier to pre-empt disaster. 1 Cell salvage is used in surgery where heavy blood loss is anticipated 2 and involves the rapid collection, washing, and re-infusion of blood lost from the operative field. The procedure is relatively contra-indicated in obstetrics because blood contaminated with liquor could potentially cause an amniotic fluid embolism. Adequacy of the washing process to minimise this risk is difficult to assess. 2 Although 175 successful cases have been reported in the obstetric literature, 3 this is an inadequate number to quantify the risk of amniotic fluid embolism, with an incidence of up to 1:80 000 deliveries.This case describes a novel method to avoid cell saver contamination fro...
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