1. Chapter 37
Emergency Childbirth

2. Overview Anatomy Review Normal Childbirth Emergency Childbirth
Special Delivery Scenarios
Post-Delivery Care

3. Anatomy Review During pregnancy, the uterus enlarges
The fetus obtains all nutrients from the placenta
The umbilical cord connects the fetus to the placenta; both are enclosed in the amniotic sac
Effacement and cervical dilation begin as the pregnancy comes to an end
The woman’s body undergoes many changes throughout pregnancy. The developing fetus grows and obtains nutrients from the placenta. As pregnancy nears an end, the woman’s body prepares to expel the fetus.

5. Normal Childbirth Stage 1 of labor Fetal head moves into pelvis
Cervix thins and dilates
Uterus begins to contract
Can take from a few to up to 30 hours
The amniotic sac ruptures
The first stage of labor can take quite some time. This is the stage at which the body prepares to expel the fetus by thinning and dilation of the cervix. The head of the fetus moves into position and contractions of the uterus push the head further down into the pelvis.

6. Normal Childbirth Stage 2 of labor Forceful uterine contractions
Increasing vaginal pressure
The head becomes visible
Mother begins to push
Fetus exhibits the cardinal movements of labor
The newborn is delivered
Usually 30 to 60 minutes
The second stage of labor generally progresses more quickly than the first. The uterine contractions become more forceful, pushing the fetus further into the birth canal. The head becomes visible and the mother begins to push. The fetus progresses through several movements, positioning itself for birth. This stage of labor ends with the birth of the newborn.

7. Normal Childbirth Stage 3 of labor Uterus decreases in size
The placenta separates from the uterus and is expelled
Generally within 30 minutes of delivery
In the third stage of labor the uterus begins to decrease in size, which forces the separation of the placenta from the uterine wall. The placenta is then expelled from the uterus. The placenta should be placed in a bucket or bag and transported with the mother and child to the hospital.

8. Stop and Review
What are the normal anatomical changes that occur during pregnancy?
Describe the three stages of labor.
1. During pregnancy, the woman’s body undergoes many changes. Her uterus enlarges as the infant grows, her blood volume increases to reflect new demand, the breasts enlarge in anticipation of breastfeeding, and the hormones circulate throughout the body.
2. During the first stage of labor, the woman’s contractions start, preparing for eventual childbirth. In this stage, the mucous plug stopping the cervix is often discharged and a bloody show alerts the mother to impending delivery. During the second stage, the cervix dilates and thins and the infant is born. During the third and final stage, the placenta is delivered as the uterus continues contractions and returns to a more normal size.

9. The Process of Birth

10. Emergency Childbirth History What is the due date?
Have there been any complications with the pregnancy?
Note the color of the amniotic fluid
When did contractions begin and how far apart are they?
Note the number of pregnancies and the number of live children
The current and past history of the pregnancy can be helpful in the plan of action for management of the delivery.
Knowing the due date will allow the EMT to prepare for a premature birth.
Identifying complications during the course of pregnancy will alert the EMT to possible complications during birth.
The presence of meconium in the amniotic sac tells the EMT to address respiration concerns when the infant is delivered.
Noting the beginning and timing of contractions will allow the EMT to estimate how far labor has progressed.
Knowing the woman’s past history of pregnancies and births will give the EMT an idea of how fast the labor may progress.

11. Emergency Childbirth Assessment Initial assessment and vital signs
Look for signs of crowning or abnormalities
Maintain privacy and perform assessment in the presence of another EMT
Only repeat examination if patient’s condition changes
As with all patients, the assessment begins by monitoring the ABCs and taking a set of vital signs.
If the mother complains of pressure, examine the vaginal opening for signs of crowning.
Be sure to maintain the mother’s privacy during this exam.
If delivery is not imminent, prepare the patient for transport. The assessment need not be done again unless the patient’s symptoms change.

12. Emergency Childbirth Preparation for delivery Don appropriate PPE
Prepare supplies
Contact medical control
Two EMTs should facilitate delivery: one to tend to the mother and one to tend to the newborn
If delivery is imminent, prepare quickly for it. The EMT should don gloves, gown, mask, and eyewear since he will be exposed to a large amount of bodily fluids during the birth process. It is a good idea to contact medical control to alert them to the pending birth and arrival of the mother and child. The physician may also want to monitor the call in the event that complications arise.

13. Emergency Childbirth Normal delivery
Since field delivery is rare, EMTs may want to review these steps frequently
Most deliveries are completed without complications
Review the steps involved in delivery of an infant frequently, since it is not encountered in the field on a regular basis.

14. Special Delivery Scenarios
Prolapsed umbilical cord
A cord lodged between the birth canal and the fetus’ head
Can be life threatening
The cord is visible on examination of the vaginal opening
Place mother on 100% oxygen and place in head down, buttocks raised position
Push the fetus away from cord
As the fetus moves through the birth canal, the umbilical cord can sometimes become lodged in between the fetus and the birth canal.
This can cause a decrease in the blood supply to the fetus, threatening her life if undetected.
The EMT must visually inspect the vaginal opening for signs of presentation of the cord.
If the cord is presenting and a pulse is not felt in it, the EMT should provide the mother with 100% oxygen and position her in the head down, buttocks up position.
The EMT should also insert a gloved hand into the vagina and push the fetus away from the umbilical cord. The mother should be transported in this manner.

15. Activity: Divide the class into groups of four to five students and have them read and prepare the questions related to the case “Delivery” in textbook Chapter 37. Bring the groups back together and have each group report on their responses.
Suggested Responses:
1. The classic sign of an impending childbirth is the urge to push. Other signs include frequent labor pains, crowning, and rupture of the bag of waters.
2. The history of the pregnant woman should include her expected date of delivery (EDD), if she has had any complications during her pregnancy, history of prenatal care, previous pregnancies, and how these deliveries went. The physical examination should include timing contractions and then, if the contractions are two minutes apart, looking for crowning.
3. The EMT should have equipment for the mother, oxygen and the like, as well as a fully stocked obstetrics kit.
4. If the umbilical cord presents first (a prolapsed cord), the EMT should apply 100% oxygen to the mother, ask her to assume the knee-to-chest position (Sims), and transport immediately while contacting medical control en route.
5. The EMT’s management of a breech, footling, or buttock presentation is the same as for a prolapsed cord.
(suggested responses continued on next notes page)

16. “Delivery” Suggested Responses (continued):
6. Green-tinged amniotic fluid may indicate infant meconium. If the meconium is thin and watery, the EMT should suction the oropharynx. If the meconium is thicker, like pea soup, the EMT should suction the oropharynx and consider ALS assistance for more invasive procedures.
7. Whenever multiple births are anticipated, the EMT should prepare a similar number of childbirth kits.
8. The EMT should prepare for the imminent birth of a premature infant. This may include requesting ALS assistance to the scene as well as contacting medical control. As premature infants are prone to hypothermia, the EMT should warm the room and prepare heated blankets.
9. After delivery of the baby, the EMT should place the infant on the mother’s breast. This encourages maternal bonding and stimulates hormones that aid in the delivery of the placenta.
10. Immediately after childbirth, the EMT needs to dry, warm, and stimulate the infant’s breathing. An Apgar score should also be obtained at the 1- and 5-minute marks.

17. Special Delivery Scenarios
Breech presentation
Fetus may present buttocks first or limbs first
Increases fetus’ risk of injury
Place mother on 100% oxygen and position head down with pelvis elevated
Immediately transport to nearest facility
Call medical control
Beech presentation occurs whenever the presenting part is not the fetus’ head.
A breech delivery can increase the fetus’ risk of injury during delivery and can cause further complications. Physicians may often choose to deliver via a cesarean section in these cases.
If a breech presentation is encountered, the EMT should place the mother on 100% oxygen and position her head down with pelvis elevated.
Transport should be immediate to the closest facility.
Medical control should be called.

19. Special Delivery Scenarios
Meconium
Aspiration can be harmful to the fetus
Can result in infection and injury to the lung tissue
The thicker it is, the more dangerous to the fetus
Suction the nose and mouth to remove the meconium
Transport immediately and call for ALS backup
Aspiration of meconium can result in infection and damage to the newborn’s lung tissue. The presence of meconium can be noted in the amniotic fluid. The EMT should be prepared to slow the delivery down and allow time to suction the newborn’s nose and mouth to remove the meconium. The newborn should be transported immediately and ALS should be called for backup.

20. Special Delivery Scenarios
Multiple gestation
Delivery of two or more newborns
Usually premature
Second is often in breech presentation
Transport immediately
The more babies to deliver, the greater the risk for complications. Multiple births are often delivered prematurely, and the second baby may not be in the proper presenting position.

21. Special Delivery Scenarios
Premature delivery
Early delivery of the newborn
Underdeveloped pulmonary system
Prone to injury and requires extensive resuscitation
Transport as soon as possible and alert the hospital you are en route
Delivery of the premature infant is not recommended in the field. The premature infant will present with an underdeveloped pulmonary system and most likely require intensive resuscitative efforts. Transport should be initiated as soon as possible and the receiving hospital should be alerted to the situation.

22. Post-Delivery Care Mother Newborn Monitor for bleeding
Stimulate contraction of the uterus via massage
If bleeding is excessive, treat for shock
Newborn
Initial assessment and resuscitation if required
After delivery, the EMT has two patients to care for. One EMT should tend to the mother’s needs. The mother should be monitored for bleeding, and treatment for shock should begin if necessary. A second EMT should tend to the newborn. The initial assessment should be done and resuscitation begun if required.

23. Stop and Review What are the signs of a pending delivery?
Why is the predelivery history important?
Describe the assessment and management of the following:
Prolapsed umbilical cord
Breech presentation
Multiple births
Meconium
1. The classic signs of impending delivery include an urge to push and crowning at the vaginal opening. Other symptoms can be the bloody show, rupture of the bag of waters, and more frequent labor contractions.
2. The predelivery history alerts the EMT to any potential complications that the mother may experience. This history will help guide the questions the EMT will ask medical control. 3.
If the umbilical cord presents first (a prolapsed cord), the EMT should apply 100% oxygen to the mother, ask her to assume the knee-to-chest position (Sims), and transport immediately while contacting medical control.
The EMT’s management of a breech, footling, or buttock presentation is the same as for a prolapsed cord.
Whenever multiple births are anticipated, the EMT should prepare a similar number of childbirth kits.
Green-tinged amniotic fluid may indicate infant meconium. If the meconium is thin and watery, the EMT should suction the oropharynx. If the meconium is thicker, like pea soup, the EMT should suction the oropharynx and consider ALS assistance for more invasive procedures.