1. Emergency Delivery and Newborn Stabilization

2. Objectives Discuss triage of the laboring patient. Outline the resuscitation-oriented history. Describe the steps for performing a vaginal delivery. Describe the steps in resuscitation of the newly born.

3. Case Presentation You are called to the scene of a 20-year-old woman in labor. ETA to scene: 5 minutes ETA from scene to nearest hospital with delivery service: 12 minutes

4. Prearrival Preparation Review en route: –Triage of laboring patient –Steps for a vaginal delivery –Steps in resuscitation of the mother and the newly born

5. What is your next step in the care of this patient? General Impression and Management Priorities You arrive on scene and find this presentation.

6. Key Concept: Triage of the Laboring Patient Two simple questions: –Is this your first delivery?  If not, how long was the labor of the first delivery? –Do you feel the urge to push?  If yes, delivery is within 30–60 minutes.

7. Key Concept: Triage of the Laboring Patient Brief physical assessment: –Is the child’s head crowning? –Is the head or scalp visible at the perineum during contractions?  If yes, delivery is imminent.

8. Key Concept: Breech Deliveries Four percent of deliveries are breech. Inspection of perineum shows a foot or buttock. Do NOT deliver a baby with breech presentation in the field; transport to ED.

9. Case Progression This is the woman’s second baby. She states that labor with her first baby was short (2 hours). She feels the urge to push.

10. Key Concept: Preparing for a Field Delivery Resuscitation-oriented history: 1. Are you having twins? 2.When are you due to deliver? 3.What color was the amniotic fluid?

11. Key Concept: Multiple Deliveries If twins or multiple newly borns are expected, prepare for more than one delivery. –Prepare extra equipment. –One provider resuscitates the first baby while the second provider delivers the second baby. –Consider calling for a second ambulance.

12. Key Concept: Premature Newly Born Prematurity is defined as less than 36 weeks gestation. Prepare appropriately sized airway equipment.

13. Key Concept: Meconium Greenish color of amniotic fluid is a sign of passage of fetal stool. If there is time, you may suction the baby’s mouth, then nose.

14. Case Progression The patient states she has only one baby. She is near term. The color of the amniotic fluid is clear. What equipment do you need for delivery?

15. Management Priorities: Position Mother for Vaginal Delivery Prepare an area for the baby, and keep the room warm. Supine PositionSims Position

16. Management Priorities: Position Mother for Vaginal Delivery Supine, positioned over the side of the bed. –Advantage: best positioning for suctioning the baby at the perineum. –Disadvantage: EMS professional must “catch” the baby.

17. Management Priorities: Vaginal Delivery Allow the mother to push the head out. Reduce nuchal cord. –50 to 60% of deliveries Guide the baby out; don’t pull — let the mother do the work!

18. Management Priorities: Vaginal Delivery Place a hand around the neck posteriorly to control delivery. As needed, pull the anterior shoulder downward to clear the mother's symphysis pubis.

19. Management Priorities: Vaginal Delivery Deliver the baby and keep the baby at the level of the vaginal opening. Tie the cord in two places and cut it.

20. Management Priorities: Vaginal Delivery Suction the baby’s mouth and nose. Begin resuscitation of the baby as needed. Delivery of placenta is nonemergent.

21. The baby is born limp and lifeless. No respiratory effort is noted. He is blue. What do you do now? Case Progression

22. Management Priorities: Immediate Care of the Newly Born Dry, warm, position, suction, and stimulate the infant. Clear the airway. Assess breathing. Assess heart rate. Assess color.

23. Key Concept: Oxygen Some evidence suggests that hyperoxia can be harmful to the newly born. –Do not give supplemental oxygen to the vigorous newly born. –Oxygen should be given to the compromised newly born or newly born with a low oxygen saturation.

24. The infant remains apneic after the initial steps. What do you do now? Case Progression

25. Management Priorities: Bag-Mask Ventilation Extend the head slightly on the neck. Position hands in “EC-clamp.” Ventilate at 40 breaths per minute.

26. Management Priorities: Assess Heart Rate Palpate a pulse at the base of the umbilical cord. –Count for 6 seconds and multiply by 10. If cord pulse cannot be palpated, listen for heartbeat with a stethoscope.

27. Management Priorities: Chest Compressions If the heart rate remains < 60 beats/min, after 30 seconds of bag-mask ventilation, begin chest compressions. –3:1 ratio. Pause to deliver a breath. –90 compressions and 30 breaths/min (120 “events” per minute)

28. Management Priorities: Chest Compressions in the Newborn

29. Management Priorities: Depressed Newly Born Resuscitation If heart rate is < 60 beats/min after another 30 seconds CPR, consider intubation. Prepare epinephrine. –The dose of epinephrine is 0.01 to 0.03 mg/kg (0.1 to 0.3 mL/kg of the 1:10,000 solution) ET/IV/IO. –The preferred route for epinephrine administration in the newly born is via the IV route. –If vascular access is not available, the ET route can be used. Consider administration of a higher dose (up to 0.1 mg/kg).

30. Management Priorities: BLS Shock Treatment for the Newly Born Shock symptoms: –Poor perfusion –Weak pulses –Poor response to resuscitation. Shock treatment: –Rapid transport.

31. Management Priorities: ALS Shock Treatment of the Newly Born Assure adequate oxygenation and ventilation. Obtain intravenous access: –Intravenous: first choice –Intraosseous: second choice –Umbilical venous: if trained and equipped 10 mL/kg normal saline or Ringer’s lactate, which may be repeated

32. Key Concept: The Inverted Pyramid

33. Case Progression After bag-mask ventilation for 30 seconds, the heart rate increases to 140 per minute. The baby becomes pink centrally with cyanosis only of the hands and feet. He begins to cry and you discontinue bag-mask ventilation. You wrap the baby in a dry blanket and hand him to his mother. You now focus on your second patient!

34. Key Concepts: Transport Considerations: The Vigorous Newly Born Infant restraint seat unavailable. – Place the baby in the mother's arms. – Allow mother to breastfeed. Infant restraint seat available. – Secure the baby in rear-facing position. – Secure the seat to the ambulance. – Keep the newly born warm!

35. Key Concepts: Transport Considerations: The Compromised Newly Born Secure to backboard. Provide airway management. Keep newly born warm! Monitor. Check glucose value. Transport.

36. Case Progression After delivery of the baby, there is no maternal hemorrhage. You prepare to transport the baby in mother’s arms. Restrain mother on the gurney.

37. ED Course At the hospital, you are directed to the postpartum unit where the mother and baby are admitted. They are discharged the next day.

38. Case Summary Although most field deliveries are normal, the rate of complications is higher for an out-of-hospital birth. Positioning, suctioning, and drying are the only interventions usually needed. In a depressed newly born, use a graded approach to management based on the baby’s heart rate and respiratory effort.

39. Summary Review the steps for vaginal delivery and newborn stabilization en route to scene. Proper triage decisions are vital. Childbirth is a natural act that usually needs only minimal intervention. In the depressed newborn, oxygenation and ventilation are the keys to successful resuscitation.