Emergency Childbirth in the pre-hospital setting

1. Barry Kidd 2010 1
Emergency Childbirth

2. Barry Kidd 2010 2
Emergency Childbirth
Overview
 Childbirth is not an injury or a disease, but
a natural physiologic process
 Remember, you have two patients
 Ideally the patient will make it to the
hospital
 Most patients will require immediate
transport but skills for emergency
childbirth and recognition of complications
are essential

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The Pregnant Patient
 Increase in
extracellular fluid of 6-
8 L
 Increase in maternal
blood volume of 40%
 Cardiac output
responds to changes
in position

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LABOR?
 Rhythmic contractions
with cervical changes
 False labor
 Stage 1 (latent/active)
 Stage 2 (complete
dilatation  delivery)
 Stage 3 (placenta)
 Stage 4 (1 hour post
placental delivery)

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The Pregnant Patient in Labor
 ABC’s
 Keep the pt on her
LEFT side
 Administer oxygen
 Start IV fluids
 Transport if delivery
does not appear
imminent

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ASK:
 How many weeks are you?
 When are you due?
 Is this your first baby?
 Did you have prenatal care?
 Any fluid from your vagina?
 Any complications with this
pregnancy?
 What meds or drugs do you
take?
 Contractions? How far apart?
How long do they last?
 Do you feel like you need to
push?

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YES, IN ACTIVE LABOR
To Transport or Not
 Transport
 Abnormal presentation
 Prolonged rupture of
membranes
 Maternal or fetal
distress
 Meconium staining
 Heavy vaginal
bleeding
• Abruption (pain)
• Placenta previa
(painless)
 No Transport
 Imminent delivery
 Crowning
 Mom’s pushing

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DELIVERY IMMINENT
 Set up delivery area
 OB kit
 IV access
 Start IV fluids
 Administer
supplemental oxygen
 Don gloves, mask,
gown if available

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Imminent Delivery
 Prepare!
 3 towels/blankets
1 under her butt
1 folded between her legs, just
below her vagina
1 across her abdomen

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DELIVERY
Keep a Hand on the Perineum
 Head is the biggest part
 Control with PRESSURE
 No pulling, No pushing
 Avoid an explosion!

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Delivery of Head
 Once the head is
delivered, suction the
baby’s mouth and nose
 Head usually comes out
face down and will rotate
 This is the time to suction
 CHECK FOR
UNBILICAL CORD
AROUND NECK!!!

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Delivery
 Once the head is
delivered apply gentle
downward pressure to
deliver the anterior
shoulder
 Lift the baby gently to
deliver the posterior
shoulder
 Be careful – BABY IS
SLIPPERY!!

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Baby’s Out
 Keep baby at level of
vagina
 Clamp and cut
umbilical cord, clip
next to mom first
 Cut cord BETWEEN
the clips

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Immediate Post Delivery
 If breathing not spontaneous,
stimulate the infant BY
RUBBING THE BABY’S
BACK OR FLICK THE
BABY’S FEET
 Rub and dry baby with towel,
stimulate infant, resuction
mouth and nose, give blow-by
oxygen
 Keep baby warm and dry
 Lay infant with head down 15
degrees
 Note time of birth
 If infant’s breathing is
absent, shallow, or slow,
begin artificial ventilation at
40-60 ventilations per minute

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INITIAL ASSESSMENT OF INFANT
HEALTH
Apgar Score

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Apgar Scores
One Minute and Five Minutes of Life
Sign 0 1 2
 Heart Rate: Absent Slow (<100) >100
 Resp Effort: Absent Slow/Irreg Good/Cry
 Muscle Tone: Flaccid Some flexion Active motion
 Reflex: None Grimace Vigorous Cry
Irritability
 Color: Blue/pale Body Pink All Pink
Extremities Blue

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Now, Back to Mom
 Vagina will be oozing blood –
this is normal
 Don’t pull on umbilical cord
 Umbilical cord will suddenly
lengthen and delivery of the
placenta will follow
 Will usually occur within 30
minutes
 Mom can push to deliver
placenta
 Once delivered, check to see if
placenta is intact
 Place placenta in bag provided
in OB kit

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Now, Back to Mom
 Fundal massage
 Clean up patient
 Check for bleeding,
vaginal tears
 Remember vital signs
and ABCs

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Favorite Complications
 CEPHALOPELVIC
DISPROPORTION:
 Head too big
 Hips too small
 Treatment:
 Administer
supplemental oxygen
 Start IV, normal saline
 Transport, load-and-go

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More Favorite Complications
 ABNORMAL
PRESENTATION:
 Breech
 Best delivered at the
hospital
 Don’t pull on baby, just
support

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Still More Favorite
Complications
 PROLAPSED UMBILICAL
CORD
 Cord has fallen into the pelvis
and is compressed between
the fetus and bony pelvis,
shutting off fetal circulation
 Don’t push cord back in
 Put mom in Trendelenberg
position
 With a gloved hand, enter
vagina, push baby’s head
toward mother’s head
 Protect exposed cord with
moist saline dressings
 This patient requires an
EMERGENCY C-SECTION

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Even More Favorite
Complications
 MULTIPLE BIRTHS
 Remember baby,
baby, then placenta,
placenta
 Often second baby is
breech

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Least Favorite Baby
Complications
 SHOULDER DYSTOCIA
 Head delivers routinely
 Anterior shoulder gets
stuck under mom’s
symphysis pubis
 “Turtle Sign”, head retracts
slightly
 DO NOT PULL ON HEAD
 Try McRoberts Maneuver
• Hips down off edge of
bed, vigorously pull both
legs back toward chest
• Firm downward CPR-like
pressure with open hand
above symphysis pubis,
frees baby’s shoulder

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Least Favorite Baby Complications
Shoulder dystocia is a specific case of
dystocia whereby after the delivery of the
head, the anterior shoulder of the infantant
cannot pass below the pubic symphysis,
or requires significant manipulation to pass
below the pubic symphysis

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Least Favorite Baby Complications
The McRoberts Maneuver is employed in
case of shoulder dystocia during childbirth
and involves hyper flexing the mother's
legs tightly to her abdomen. This widens
the pelvis, and flattens the spine in the
lower back (lumbar spine). If this
maneuver does not succeed, an assistant
applies pressure on the lower abdomen
(suprapubic pressure), and the delivered
head is also gently pulled.

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Least Favorite Baby Complications
suprapubic pressure

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Shoulder Dystocia
McRobert’s Maneuver

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Maternal Complications
Post partum
hemorrhage
 Significant bleeding
from vagina
Treatment
 Two large bore IVs,
fluids (if you have the
protocol)
 Supplemental oxygen
 Treat for shock
 Load-and-go

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Summary
 Remember child birth is a natural, normal,
physiologic human event
 Most deliveries are routine
 Be prepared for complications

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Emergency Childbirth
Questions and Answers