1. Silver Cross EMS EMD CE November 2011
Emergency Childbirth
Silver Cross EMS
EMD CE
November 2011

2. What to ask?
What to do?

3. From an Emergency Responder’s point of view……
This presentation is set up as if you were on scene, assisting with a delivery.
You will go over the questions to ask, things to look for, possible complications and assisting with a delivery. Hopefully this will help you picture the scene and better understand why you are asking certain questions and give more effective instructions.
Your EMDPRS will be updated soon, with some new information and pre-arrival instructions.

4. Introduction Childbirth is a normal, natural part of life.
Your part of the process involves helping, guiding, and supporting the infant as it is born.
After the birth, you should ensure the infant is breathing adequately and being kept warm.
Two indicators of an impending birth:
Frequency of the contractions
Crowning
As you prepare to assist the mother in the delivery, keep two things in mind:
Calm the woman: Delivery is a natural process.
Calm yourself: You are there to help or coach.

5. WARNING!
This lecture has some graphic pictures of childbirth and emergency delivery. There will also be an option to click on a link to view an actual childbirth video. Viewer discretion advised.

6. Anatomy of Pregnancy
The external opening is called the birth canal (vagina).
The developing infant (fetus) is encased in an amniotic sac for support and floats in amniotic fluid.
The placenta is the organ of exchange between mother and child.
The umbilical cord connects the baby to placenta.
Opening of the Uterus is the Cervix.

7. Fetal Anatomy
Placenta – develops early in pregnancy & performs important functions
Exchanges respiratory gases
Transports nutrients from mother to fetus
Excretes waste
Transfers heat
Active endocrine gland produces several important hormones
Attached by umbilical cord
Amniotic sac – develops early in pregnancy
Consists of membranes that surround & protect developing fetus
Amniotic fluid cushions fetus & provides stable environment
Umbilical cord – attaches fetus to placenta
Contains one vein & two arteries
Vessels in umbilical cord similar to pulmonary circulation
Arteries carry deoxygenated blood
Veins carry oxygenated blood
Newborn cord is about two feet long

8. Stages of Labor
First stage of labor: the pregnant woman’s body prepares for birth
Characterized by these conditions:
Initial contractions occur.
The bag of waters breaks.
The bloody show occurs. (loss of protective mucous plug from cervix)
The infant’s head does not appear during contractions.
This is the longest stage but is shorter for each pregnancy.

9. Stages of Labor Second stage of labor: the birth of the infant
Contractions are close together, 2-3 minutes apart.
Mother will have the urge to push.
You will see the infant’s head crowning during contractions.
There is no time for transport, you will need to assist with delivery.

10. Stages of Labor
Third stage of labor: delivery of the placenta (afterbirth)
Mom will start to have contractions again and will usually delivery the placenta within minutes. Your focus should be caring for mom and newborn.

11. Is There Time to Reach the Hospital?
Is this the woman’s first pregnancy?
A woman experiencing her first labor will usually have more time to reach the hospital.
Has the woman experienced a bloody show?
Loss of mucous plug.
Has the bag of waters broken?
The bag of waters usually breaks toward the end of the first stage of labor.

12. Is There Time to Reach the Hospital?
How frequent are the contractions?
Contractions less than 2 minutes apart usually indicate that delivery will occur very soon.
Contractions are timed from the start of one to the start of the next.
Does the woman feel an urge to move her bowels?
When the infant’s head is in the birth canal, it presses against the rectum.
Do not allow her to go to the toilet.

13. Is There Time to Reach the Hospital?
Is the infant’s head crowning?
Head is visible in the birth canal
Is transportation available?
Is the ambulance responding?
How far is it to the hospital?
Will bad weather, a natural disaster, or traffic prevent prompt arrival of transportation?
? What additional information do you want to know?

14. Preparing for Delivery
You will not be able to maintain sterile conditions.
Attempt to be as clean as possible.
Wash your hands thoroughly.
If you do not have a sterile delivery kit, use household items to prepare for delivery.
Use shoestrings or strips of cloth to tie the cord.
Have plenty of clean towels ready.
There will be lots of fluids, so protect yourself.

15. Preparing for Delivery
Place the patient on a firm surface that is padded with blankets, folded sheets, or towels.
Elevate the woman’s hips 2" to 4" with pillows and blankets.
Place the woman on her back with knees bent and feet flat on the surface beneath her.
Remove clothing below the waist.

16. Assisting With Delivery
In a normal birth:
The infant will turn to its side by itself after the head emerges.
The rest of the body will be delivered spontaneously.
The infant will be wet and slippery.
Keep the infant’s head at about the level of the woman’s vagina.
Encourage the mother to breath deeply between contractions and push with contractions.

17. Assisting With Delivery

18. Assisting With Delivery
Support head with gentle pressure
Check and see if cord is wrapped around baby’s neck— attempt to loosen (more on that later)
Apply gentle downward pressure on shoulder & head
After anterior shoulder has delivered, apply gentle upward pressure. Once shoulders are out the rest of body will follow quickly.
Suction or wipe out mouth & nostrils (in that order) when head appears
Once delivered, stimulate infant if it does not breathe (info to follow)
Put two clamps on umbilical cord & cut 6 inches from navel between clamps, after the cord stops pulsating

19. Childbirth video
Follow this link to a childbirth video, starting with crowning and ending with stimulation of the infant and awaiting the afterbirth. This baby had Nuchal Cord.

20. Amniotic sac
During first stage of labor amniotic sac usually breaks, expelling amniotic fluid
If sac is still covering infant’s head when head appears, use a finger to pierce sac
Very tough membrane
Note color & character of amniotic fluid
Fluid can be clear or straw-colored (which is normal)
Tainted, discolored, thick or “pea soup-like” (which indicates meconium staining or a bad intra-uterine infection)
Baby could be in distress

21. Nuchal Cord
Once head delivers, have mother to stop pushing so you can check to see if the cord is wrapped around infant’s neck
If cord looks like it is wrapped tightly, you will need to loosen it
Gently slip cord over baby’s head by placing two fingers under cord at back of neck
Bring cord over shoulders & head
Cord is durable, but it can tear if handled roughly so don’t use excessive force
Too tight to loosen, clamp cord in two places two inches apart and cut cord between clamps

22. Continued Delivery Instructions
After the baby is out, remember to keep baby level with birth canal until the cord is clamped and cut
Position infant on it’s side for drainage
Re-suction or wipe out the baby’s mouth & nostrils
Dry & wrap baby in a warm blanket — cover its head
If baby is not breathing, try to stimulate it by
gently but vigorously rubbing the infant’s back with you fingertips or flick the soles of it’s feet
If no response
begin CPR

23. Stimulate baby

24. CPR - Two-Thumb Encircling Hands Technique
CPR technique for the infant that is not breathing, after stimulation
Place infant on a firm, flat surface
Find compression site which is just below nipple line on middle or lower third of sternum
Wrap your hands around upper abdomen with your thumbs on compression site
Use your thumbs to deliver gentle pressure against sternum, pressing ½ to ¾ inch into chest at rate of 100 per minute
30:2 compressions to breaths

25. Aftercare of the Mother and Newborn
Continue to observe the mother and infant and keep both warm.
Bleeding should stop after placenta delivers.
Observe mother for excessive bleeding and treat for shock
If baby is doing well and mother wants to breastfeed, this will help slow bleeding down by contracting uterus

26. Complicated Deliveries (a very small percentage)
Cord presentation
Limb presentation
Breech (buttocks or feet)
Shoulder Dystocia (stuck at shoulders)
Premature or Stillborn
Multiples
Drug or alcohol abuse
Underlying medical problems with mother or child
Can your questioning help identify possible problems and better prepare responders?

27. Complicated Deliveries
Most can not be delivered safely in the field. Elevate mother’s hips to relieve pressure on birth canal and advise her not to push. Have her focus on her breathing and wait for responders.

28. Pregnancy Complications
Any bleeding during pregnancy could be the sign of a serious problem Ectopic Pregnancy (outside uterus) Miscarriage Placenta problems Uterus rupture

29. More Problems
Some women develop diabetes during pregnancy (Gestational Diabetes)
Diabetics can have problems maintaining their blood sugar levels during pregnancy
Supine hypotensive syndrome occurs when increased weight of uterus compresses inferior vena cava while a patient is on her back
Position mother on her left side to avoid this

30. Pre-Eclampsia Variety of signs and symptoms including:
Hypertension
Abnormal weight gain
Edema
Headache
Protein in the urine
Epigastric pain
If untreated, preeclampsia can progress to eclampsia

31. Eclampsia
Eclampsia, also called toxemia, most serious manifestation of hypertensive disorders of pregnancy
Characterized by grand mal seizures
Often preceded by visual disturbances such as flashing lights or spots before the eyes
Eclampsia patients often experience swelling of hands & feet & markedly elevated blood pressure
If eclampsia develops, death of mother & fetus frequently results
Treat by lying mother on her side, maintaining airway and monitor until help arrives

32. Summary
Childbirth is a natural process with a small percentage of complications.
Follow your scripted protocol for imminent births.