Child Birth Emergencies: Assess the Mother, Deliver Baby & Handle Breech Birth Guide

Objectives:

1. List the eight steps to assess the mother.
2. List the seven steps for preparing the mother before the hospital.
3. List the ten steps for delivering a baby.
4. Identify three complications during pregnancy.
5. Identify six complications during delivery.
6. Show how to treat a breech presentation and a wrapped umbilical cord around the neck.

Anatomy of Pregnancy

Amniotic sac:

A sac of fluid in which the fetus develops during pregnancy.

Cervix:

The neck of the uterus in which the unborn infant passes into the vagina.

Fetus:

The unborn developing baby in the uterus.

Placenta:

A disk-shaped organ on the inner lining of the uterus. Rich in blood vessels, it supplies nourishment and oxygen to the fetus during pregnancy. It also absorbs waste from the fetus into the mother’s bloodstream.

Umbilical cord:

An extension of the placenta through which the fetus receives nourishment while in the uterus.

Uterus:

The organ that contains the developing fetus or unborn infant. A special arrangement of smooth muscles and blood vessels in the uterus allows for great expansion during pregnancy and forcible contractions during labour and delivery.

Vagina:

Channel through which the infant passes to reach the outside.

Stages of Labour

Patient’s position for childbirth

First stage (dilation):
Begins with the mother’s contractions and ends when the infant enters the birth canal. During this first and longest stage, the cervix becomes fully dilated (expanded).

2) Second stage / expulsion:

Begins the moment the infant moves into the birth canal. When the baby’s head appears at the opening of the birth canal, it is called “crowning.” The second stage ends with the birth of the infant.

3) Third stage (placental):

The placenta separates from the uterine wall. It is usually then spontaneously expelled from the uterus.

3. Assessment of the Mother

Use universal precautions and secure the scene.

1. Conduct initial assessment.
2. Verify prenatal care, get doctor’s information, ask about any difficulties with pregnancy, and whether delivery is to be normal.
   • Ask when her due date is.
3. Ask the patient if it is her first pregnancy.
   • If so, the labour process will usually last close to 18 hours. The duration of labour is considerably shorter with each subsequent birth (approximately 2-3 hours).
4. Determine when contractions began and if the amniotic sac (water bag) has ruptured.
5. Ask the patient if she feels any pressure being applied to the pelvis or the urge for a bowel movement.
   • Do not allow patient to sit on the toilet.
6. Determine the frequency and duration of contractions.
   • Use a gloved hand on the patient’s abdomen to feel for the involuntary tightening of the uterine muscles.
7. Visual evaluation:
   • Check for crowning or bulging in the vaginal area. If no crowning, move to the next step. If either the head or other part of the body is visible, prepare to deliver at the scene.

8) Determine if delivery will be at the scene or if there is time for transport:

• If contractions are less than 2 minutes apart, prepare to deliver the baby at the scene.
• If contractions are between 2 and 5 minutes apart, make a decision on several factors, such as whether this is the first pregnancy, if the patient feels an urge for a bowel movement, traffic and weather conditions, or other complications.
• If contractions are 5 minutes or more apart, the mother usually has time for transport.

CAUTION:
Do not allow the mother to cross or hold her legs together to delay delivery. Death or permanent injury may occur.

4. Pre-hospital Preparation of the Mother

Use universal precautions and secure the scene. Make sure to use full personal protective equipment.

1. Ensure privacy for the patient (select an appropriate area).
2. Have the mother lie on her back with knees bent and legs spread. Elevate the buttocks. Inspect the vaginal area but do not touch it except during delivery of the baby.
3. Have O.B. (obstetrical) kit ready and opened.
4. Place a sheet or clean towel under the patient’s buttocks, another under the vaginal area, and another covering the legs and abdomen.
5. Evaluate the frequency and duration of contractions.

6. Check for crowning.
7. Comfort and reassure the mother.
   Encourage her to keep breathing slowly and comfortably. Stress the importance of relaxing between each contraction.

8) Determine if delivery will be at the scene or if there is time for transport:

• If contractions are less than 2 minutes apart, prepare to deliver the baby at the scene.
• If contractions are between 2 and 5 minutes apart, make a decision on several factors, such as whether this is the first pregnancy, if the patient feels an urge for a bowel movement, traffic and weather conditions, or other complications.
• If contractions are 5 minutes or more apart, the mother usually has time for transport.

CAUTION:
Do not allow the mother to cross or hold her legs together to delay delivery. Death or permanent injury may occur.

4. Pre-hospital Preparation of the Mother

Use universal precautions and secure the scene. Make sure to use full personal protective equipment.

1. Ensure privacy for the patient (select an appropriate area).
2. Have the mother lie on her back with knees bent and legs spread. Elevate the buttocks. Inspect the vaginal area but do not touch it except during delivery of the baby.
3. Have O.B. (obstetrical) kit ready and opened.
4. Place a sheet or clean towel under the patient’s buttocks, another under the vaginal area, and another covering the legs and abdomen.
5. Evaluate the frequency and duration of contractions.

5. Delivery of the Baby

1. Apply very gentle pressure with the palm of your hand to prevent explosive delivery. Do not pull the infant from the vaginal opening.
2. If the amniotic sac (water bag) has not broken, tear it or pinch it open with your fingers and pull it away from the infant’s mouth and head. Do not delay this process. Never use a sharp instrument!
3. If the umbilical cord is around the infant’s neck, use two gloved fingers to slip the cord over the head. Only if you cannot dislodge the umbilical cord, attach two clamps three inches apart, and then cut between the clamps.

8) Determine if delivery will be at the scene or if there is time for transport:

• If contractions are less than 2 minutes apart, prepare to deliver the baby at the scene.
• If contractions are between 2 and 5 minutes apart, make a decision on several factors, such as whether this is the first pregnancy, if the patient feels an urge for a bowel movement, traffic and weather conditions, or other complications.
• If contractions are 5 minutes or more apart, the mother usually has time for transport.

CAUTION:
Do not allow the mother to cross or hold her legs together to delay delivery. Death or permanent injury may occur.

4. Pre-hospital Preparation of the Mother

Use universal precautions and secure the scene. Make sure to use full personal protective equipment.

1. Ensure privacy for the patient (select an appropriate area).
2. Have the mother lie on her back with knees bent and legs spread. Elevate the buttocks. Inspect the vaginal area but do not touch it except during delivery of the baby.
3. Have O.B. (obstetrical) kit ready and opened.
4. Place a sheet or clean towel under the patient’s buttocks, another under the vaginal area, and another covering the legs and abdomen.
5. Evaluate the frequency and duration of contractions.
6. Support the baby’s head. Wipe the mouth and nose with sterile gauze pads. Suction the baby’s mouth first, then the nose with a rubber bulb syringe. Compress the syringe every time before inserting it.

 

5. Continue to support the baby with both hands.

Gently guide the baby’s head downward to assist the mother in delivering the baby’s upper shoulder. If the lower shoulder is slow to deliver, assist the delivery by gently guiding the baby’s head upward.

Maintain open airway in the newborn

Suction newborn’s mouth then nose

9. Clamp and cut the umbilical cord when it stops pulsating.
   Do not clamp or cut the cord if it is still pulsating. Place two clamps on the umbilical cord, and then cut between the clamps using surgical scissors.
10. Record the date, time, and place of birth.

Newborn’s position in preparation for cutting umbilical cord

 

Cutting the umbilical cord

6. Delivery of the Placenta

Keep in mind that you have two patients in your care: not only the baby, but the mother as well. Care for the mother includes helping her deliver the placenta, controlling vaginal bleeding, and making her as comfortable as possible. The third stage of labour includes the delivery of the placenta with its section of umbilical cord, membranes of the amniotic sac, and some tissues lining the uterus. All of these together are known as the afterbirth.

1. Delivery of placenta will begin with a brief return of labour pains that stopped when the baby was born. You may notice a lengthening of the cord as this occurs.
2. Feel for contractions.
   Encourage the mother to bear down as the uterus contracts.
3. Slowly and gently guide the placenta from the vagina, but never pull. Save the placenta in a plastic bag and take it to the hospital.
4. Controlling vaginal bleeding after delivery.
   • Place a sanitary napkin or towel on the vaginal opening. Do not place anything inside the vagina.
   • Have the mother lower her legs and keep them together without squeezing. Elevate her feet.
   • Feel the mother’s abdomen below the navel until you feel a hard object the size of a grapefruit. This is the mother’s uterus. If bleeding appears to be excessive, massage the uterus using circular motions; this will cause the uterus to contract and control bleeding.
   • Consider initiating breastfeeding to stimulate uterine contractions.
5. Conduct ongoing assessment.

7. Complications of Pregnancy

There are several types of pre-delivery emergencies that may arise in the pregnant patient prior to labour or childbirth that are life-threatening to both the mother and the baby. In most cases, definitive treatment is beyond the MFR’s level of training and immediate transport is required.

Excessive pre-birth bleeding

One of several conditions that can cause excessive pre-birth bleeding is placenta previa, in which the placenta forms in an abnormal location (low in the uterus and close to or over the cervical opening) that will not allow for a normal delivery. As the cervix dilates during delivery, it causes the placenta to tear.
Another condition is abruptio placentae, in which the placenta separates from the uterine wall, either partially or entirely. Either type of complication may occur in the third trimester, and both are potentially life-threatening to the mother and fetus.

Pre-hospital treatment for pre-birth bleeding

1. Place the patient on her left side.
2. Treat for shock.
   Elevate the patient’s legs.

3. Place a sanitary napkin or towel at the vaginal opening but do not place anything inside the vagina. Replace any blood-soaked napkins but do not discard them. All blood-soaked items should be taken to the hospital for examination.
4. Monitor all vital signs.

Transport the patient.

Spontaneous Abortion

For a number of reasons, the fetus and placenta may deliver before the 20th week of pregnancy, generally before the baby can live on its own. This occurrence is called an abortion. When it happens naturally, it is called a spontaneous abortion or miscarriage. An induced abortion results from deliberate termination of the pregnancy, in either a legal or criminal setting.

Signs and symptoms of spontaneous abortion

• Vaginal bleeding, ranging from moderate to severe
• Pain in the lower abdomen, similar to menstrual cramps or first stage labour pain
• Noticeable discharge of tissue from the vagina

Pre-hospital treatment for spontaneous abortion

1. Treat for shock.
   Provide oxygen per local protocol.
2. Place a sanitary towel or something similar on the opening of the vagina. Do not place anything inside the vagina.
3. Keep all the bloodstained towels and any expelled tissue for examination.

Transport the patient.

Ectopic Pregnancy

In a normal pregnancy, the fertilized egg will eventually implant on the wall of the uterus. In an ectopic pregnancy, the fertilized egg implants in an oviduct, in the abdominal cavity, or outside the uterus. These areas are not able to contain or support the growing embryo.

Signs and symptoms of ectopic pregnancy

• Acute abdominal pain, usually on one side
• Vaginal spotting or bleeding
• Signs of shock

Pre-hospital treatment for ectopic pregnancy

1. Treat for shock. Provide oxygen per local protocol.
2. Keep all the bloodstained towels and any expelled tissue for examination.

Transport the patient.

8. Complications of Delivery

Although most babies are born without difficulty, complications may also occur during delivery. As with complications of pregnancy, these can also be life-threatening to both the mother and the baby; and in many cases, definitive treatment is beyond the MFR’s level of training.

Breech Birth

This type is the most common abnormal delivery. A breech birth involves a buttocks-first or both-feet-first delivery. In addition, there is an increased risk of a prolapsed umbilical cord. Whenever possible, the mother should be transported to a hospital immediately for birth.

Pre-hospital treatment for breech birth

1. Position and prepare the mother for normal delivery.
2. Allow the buttocks or legs to deliver on their own — never pull.
3. Support the baby with the palm of your hand. The head should follow within three minutes.
4. If the head fails to deliver, maintain infant airway and transport immediately.
   Place the middle and index fingers of your gloved hand alongside the infant’s face. Your palm should be toward the baby’s face. Form an airway by pushing the vaginal wall away from the infant’s face. With a finger, hold the baby’s mouth away from its chest so that the baby can breathe.

Prolapsed Umbilical Cord

This is a situation where the umbilical cord presents first in the vaginal opening during delivery, and pressure from the baby’s head compresses the cord. This can cut off oxygen to the baby, making it a life-threatening condition. The mother must be transported immediately to a hospital for delivery.

Pre-hospital treatment for prolapsed umbilical cord

1. Help the patient into the knee-to-chest position.
   Alternatively, place her on her back with her hips elevated on pillows or blankets.
2. Provide oxygen per local protocol.
3. Wrap the exposed cord with a clean moistened towel.
4. Insert a gloved hand into the vagina to gently push the baby’s head away from the umbilical cord. Keep your hand in place and monitor the cord’s pulse throughout transport to ensure the baby is receiving blood flow.

Transport the patient immediately.

Limb Presentation

A limb presentation is a situation in which an arm or leg of the baby presents first through the vaginal opening during delivery. This type of delivery cannot be performed in the field, and the mother must be transported immediately to the hospital. Monitor the mother’s vital signs en route and provide emotional support.

Pre-hospital treatment for limb presentation

1. Place the mother in the knee-to-chest position.
2. Do not try to place the limb back into the vagina.

Multiple Births

Multiple births are when more than one baby is born during a single delivery. After one baby is delivered, the uterus will contract again, and the next baby will follow. Prepare for additional newborn care, including resuscitation, if needed.

Pre-hospital treatment for multiple births

1. Clamp or tie the cord of the first baby before the second baby is born.
2. The second baby may be born before or after the placenta is delivered.