DESIGNATION OF CONDITION

Determining imminent birth may include: regular contractions lasting 45 - 60 seconds at 1-2 minutes intervals; crowning occurs; patient feels the urge to bear down or feels she needs to have a bowel movement.

EMPHASIS ON PATIENT CARE

Pre-delivery: Treat the child by treating the mother.
Post delivery: Maintain warmth and adequate ventilations for the baby.

FIRST RESPONDER AND BASIC PRE-HOSPITAL MANAGEMENT
1. Initial Management - Assess airway, breathing and circulation and manage as indicated.
2. Focused H&P - History, physical exam, vital signs.

• Obtain medical and obstetrical history including:
• Due date (EDC).
• When did contractions start, how close, bleeding, and does she feel the need to push.
• Previous or present illness, cardiac problems, diabetes, etc.
• Number of pregnancies, live births, and miscarriages (gravida, para, and abortions).
  • Patient's age.
  • Last menstrual period (LMP).
  • Complications of prior pregnancies, deliveries, prior C-section.
  • Summary of prenatal care.
  • Use of drugs.
• If birth is imminent and the following conditions present, contact a physician (preferably one who does obstetrics) for delivery instructions:
  • Multiple births
  • Excessive bleeding.
  • Breech presentation.
  • Meconium.
• Consider rapid transport and ALS intercept for the following (see Emergency Childbirth Complications):
  • Limb presentations.
  • Transverse presentation.
  • Unlikely to deliver vaginally.

 CHILDBIRTH (Imminent Delivery) continued

3. If the birth is imminent in the pre-hospital setting:

• Reassure mother - encourage to not bear down between contractions, but to “pant”.
• Place slight pressure over the head with hand to prevent rapid delivery, but do not attempt to delay delivery.
• Once head delivers, instruct mother to stop pushing.
• Suction the mouth then the nose with bulb syringe as soon as the face is visible.
• Support body as delivery proceeds. Baby will be extremely slippery. DO NOT pull on baby.
• Suction mouth then nose again (serves as stimulation).
• Dry and wrap in blanket, cover head. Stimulate the baby to breathe/cry. If baby does not breathe spontaneously, continue stimulation efforts, apply oxygen and prepare to ventilate with BVM. Take baby’s pulse at the cord. If>100, observe and continue drying, warming and stimulating. Place on mother’s abdomen and encourage mother to nurse the baby. If<100 assist ventilations. Do APGAR scoring.
• Using clamps or hemostats, clamp the cord, 6-10 inches from baby, 2 - 3 inches apart, then cut between clamps.
• If bleeding occurs post delivery, gently massage mother’s abdomen/uterus.
• Wait for placenta delivery. If placenta is not delivered in 15 min. then begin transport. Do not pull on the umbilical cord (deliver birth products to ED).
• Place sterile pad over vaginal opening.
• Cover mother with clean and dry bedding.
• Record time of the birth.
• Do not let the neonate become hypothermic.

4. Transport mother and baby to the nearest hospital. Bring all blood soaked pads and passed tissue to hospital.
5. Monitor the mother and baby’s vital signs and APGAR every 5 minutes.

INTERMEDIATE PRE-HOSPITAL MANAGEMENT

6. If the mother continues to bleed, initiate an IV of isotonic solution and infuse at a flow rate to maintain adequate vital signs.

7. Do not establish the IV in the antecubital, hand, or wrist unless no other site is available. Use the forearm.

PARAMEDIC PRE-HOSPITAL MANAGEMENT

8. If the placenta has delivered, and heavy vaginal bleeding continues, administer OXYTOCIN [10 - 20 USP units in 500 ml Isotonic Solution] at a flow rate of 10-15 gtts/min.

CHILDBIRTH/COMPLICATIONS (all levels)

1. If the cord is wrapped around the baby's neck:

• Gently pull and slip over the head or shoulders.
• If it will not slip over either, clamp cord twice, and cut between clamps and proceed with delivery.

2. If the delivery is breech, but imminent, attempt to establish contact with a physician (who does obstetrics) for delivery instructions:

• Support infant’s body until the upper back appears.
• Grasp the iliac wings and apply gentle downward traction. DO NOT apply traction to the infant's legs or back, as this may cause dislocation of the back or adrenal hemorrhage.
• Swing the infant's body in the direction of least resistance, either to the right or to the left. By alternate swinging, both shoulders should deliver posteriorly. Keep the infant in the face down position.
• By splinting the humerus and applying gentle traction with two fingers, the arms can be delivered.
• Gentle abdominal compression of the mother's uterus will engage the infant's head. Swing the infant's head upwards until the body is in a vertical position.
• When the head delivers, suction and wrap the baby.
• Clamp the umbilical cord with two cord clamps and cut the cord between the clamps with sterile scalpel.

3. If there is a limb presentation:

• Place the mother in knee-chest position.
• Administer oxygen at a moderate concentration. Ventilate as needed.
• Transport immediately.

4. If the cord is prolapsed:

• Place a moist sterile dressing over cord.
• Place mother in knee-chest position.
• Administer oxygen at a moderate concentration. Ventilate as needed.
• Insert gloved hand into vagina and gently push baby’s head away from the cord until it pulsates.
• Transport immediately.

5. If the patient is experiencing pre-eclampsia (BP > 130/90 & edema):

• Keep patient in a left lateral recumbent position and keep away from intense stimulus (i.e. bright lights, loud noises, etc.). Headache, visual problems, abdominal pain or BP > 160/100 indicate more severe disease.
• Secure the airway and administer OXYGEN titrated to patient condition. For
  Intermediate and Paramedic level, initiate IV of an isotonic solution TKO.
• Anticipate seizures. If they occur, at the Paramedic level, consider MAGNESIUM SULFATE [4 gms] slow IVP or IM and DIAZEPAM [2-10 mg] slow IVP or rectally.
• For Magnesium Sulfate toxicity, administer CALCIUM PREPERATION [5-10 ml] slow IVP. (Do not exceed 2ml/min.)
• Unless delivery is imminent, transport immediately.

6. If Meconium staining is present:

• Suction the baby's mouth first, and then nose extensively before the first breath. Use bulb-syringe or DeLee suction.
• Consider endotracheal intubation. Bag-valve-mask ventilation is necessary, but ineffective.
• Tracheal suctioning is required for aspiration of thick, particulate meconium.
• Prolonged positive-pressure ventilation is necessary.

7. If the patient experiences excessive bleeding: For all patients, initiate an IV of an isotonic solution and infuse at a flow rate to maintain adequate vital signs (Intermediate and Paramedic levels only).

• Pre-delivery: Consider possible placental abruption, especially if associated with trauma or Cocaine use. If unstable vital signs (or fetal heart tones <100), notify emergency department of possible need for c-section.
• Post-delivery: Most likely uterine stretching, especially after delivery of the placenta. Massage fundus of the uterus (located suprapubically) vigorously. If bleeding continues administer OXYTOCIN [10 - 20 USP units in 500 ml Isotonic Solution] at a flow rate of 10-15 gtts/min. • Initiate rapid transport.

8. If shoulder dystocia (fetal shoulders impact the symphysis pubis) occurs:

• Position the mother on her left side in a dorsal-knee-chest position to increase the diameter of the pelvis.
• Attempt to guide the infant's head downward to allow the anterior shoulder to slip under the symphysis pubis. Avoid excessive force or manipulation.
• Gently rotate the fetal shoulder girdle into the wider oblique pelvic diameter. The posterior shoulder should deliver without resistance.
• After the delivery, continue with resuscitative measures as needed.

9. Miscarriage

• May result in profuse vaginal bleeding.
• Provide emotional support to mother, and treat her immediately for shock.
• Save all expelled tissues, and transport with patient.