EMERGENCY CHILDBIRTH: ABNORMAL
- OBTAIN FOCUSED HISTORY (Refer to the OBSTETRICAL/GYNECOLOGICAL Guidelines):
- Estimated date of confinement (“EDC” or “due date”)
- Contractions: Frequency, duration, intensity
- Amniotic sac rupture (time and presence of meconium)
- Previous pregnancies and deliveries (especially multiple births, complications, vaginal or C-section)
- “AMPLE” history (especially hypertension, pre-eclampsia, diabetes, seizures, cardiac)
- Medications taken prior to labor, including over-the-counter
- Prenatal care (especially any identified pregnancy complications)
- Vaginal bleeding and/or abdominal pain
- ASSESS MATERNAL VITAL SIGNS & IMPLEMENT CONTINUOUS MONITORING:
- Heart Rate (HR), BP, Respiratory Rate (RR), SpO2, Temperature
- ECG and SpO2 monitoring
- Administer 100% oxygen by NRBM to the mother, and obtain IV/IO access, if time permits
- PREPARE FOR DELIVERY:
- Prepare delivery area and open OB kit: prepare bulb syringe, cord clamps, towels, newborn blanket
- Remove patient’s clothing and place clean pad under patient
- DELIVER THE NEWBORN – For additional specific guidance refer to the next page or contact BioTel:
- During contractions, urge patient to push (exception: cord prolapse)
- Deliver and support the emerging fetal presenting part, if not the head
- Recognize abnormal presentation requiring immediate care and immediate transport, e.g. prolapsed cord, hand/foot presentation, shoulder dystocia:
- Must be delivered by Emergency C-section: prolapsed cord, breech presentation when the head does not deliver within 3 minutes, shoulder presentation (“transverse lie”), cephalopelvic disproportion (“CPD” – fetal head is too large or woman’s pelvis is too small for normal delivery)
- Deliver legs and body, if possible and continue to support the fetus
- Deliver head
- If the fetal head is not promptly delivered, insert gloved fingers/hand into the vagina to establish a space for breathing and/or to relieve pressure on the umbilical cord:
- Special circumstances for inserting a gloved hand into the vagina during active labor:
- Breech presentation when the head does not deliver immediately to prevent suffocation
- Umbilical cord prolapse to lift the presenting part off the cord
- In both instances, this position must be maintained en route, until C-section delivery
- Assess for and document the presence of meconium
- Initiate rapid transport to an appropriate Obstetrical Specialty Care facility
- Deliver the shoulders, if not previously delivered
- Deliver the remainder of the body, if not previously delivered
- Place newborn on mother’s abdomen or level with the mother’s uterus
- Note the time of birth, and the delivery details (and the time of placenta delivery)
- Control maternal hemorrhage, if needed and document mother’s vital signs; continue continuous monitoring of both mother and fetus/newborn
- NEWBORN CARE – Refer to the NEONATAL CARE Guidelines:
- Continue to monitor maternal vital signs and fetal viability/newborn vital signs en route to an appropriate Obstetrical Specialty Care facility. (Refer to the DESTINATION Policy or contact BioTel.)
- For patient care considerations not covered by this procedure, consult BioTel.
EMERGENCY CHILDBIRTH: ABNORMAL
ADDITIONAL RESOURCES
- These abnormal conditions cannot be safely managed in the field and require immediate C-section:
- Cephalopelvic Disproportion (“CPD”): fetus’s head is too large or mother’s pelvis is too small
- Associations: Primigravida with prolonged, excessively strong contractions for a long time
- Risks: Uterine rupture, fetal demise
- Umbilical Cord Prolapse: fetal part compresses the cord, causing anoxia
- Associations: breech presentation, PROM, large fetus, multiple gestation, long cord, preterm labor
- Risk: Fetal anoxic brain injury
- EMS treatment different from normal childbirth:
- Position the mother with her hips elevated, or in Trendelenburg or knee-chest position
- Administer 100% oxygen via NRBM to the mother
- Instruct mother to “pant” with each contraction – instruct her NOT to bear down
- Apply moist, sterile gauze to the exposed cord: handle the cord carefully
- With a gloved hand, gently attempt to push the fetus back into the vagina and elevate the presenting fetal part off the cord
- If the cord spontaneously retracts, allow it do so without attempting to reposition it
- This position must be maintained en route, until emergency C-section can be performed
- Periodically reassess and document fetal viability (palpable pulse in the cord)
- Shoulder Presentation (“Transverse Lie”): fetal arm or shoulder may be the presenting part
- Associations: Rare, except in second twins
- These abnormal conditions may require C-section delivery and require immediate transport:
- Breech Presentation: If the head does not deliver within 3 minutes, the infant cannot be safely delivered in the field
- Three types:
- Most common: “frank” or “frontal” – hips flexed, legs extended, buttocks presentation
- 2nd most common: “incomplete” – foot presentation
- Least common: “complete” – both hips & knees flexed, buttocks presentation
- Associations: Multiple gestation, preterm labor
- EMS treatment different from normal childbirth:
- Contact BioTel for instructions, while permitting the fetus to deliver spontaneously up to the level of the umbilicus
- During delivery, ensure that the fetal face is turned away from the maternal symphysis pubis
- Avoid excessive traction or manipulation of the fetal head or spine
- If the head does not deliver immediately, take action to prevent suffocation:
- Insert a gloved hand into the vagina, palm towards the fetus’s face
- Form a “V” around the nose with the index and middle fingers
- Gently push the vaginal wall away from the fetal face until the head is delivered
- This position must be maintained en route, until emergency C-section
- Shoulder Dystocia: fetal shoulders blocked by maternal symphysis pubis, causing the head to deliver but then to pull back tightly against the mother’s perineum
- Associations: increased birth weight (e.g. infant of diabetic mother)
- Risks: brachial plexus injury, fractured clavicle, fetal anoxia from cord compression
- EMS treatment different from normal childbirth:
- Contact BioTel for instructions while positioning the mother on her back in a knee-chest position
- Avoid excessive traction on the fetal head or spine
- These conditions may complicate delivery – EMS Providers should prepare for immediate transport:
- Multiple Gestation: NOTE – women with no prenatal care may be unaware of multiple pregnancies
- Risks: prematurity, PROM, placental abruption, postpartum hemorrhage, abnormal presentation
- EMS treatment different from normal childbirth:
- 1st twin: identical to singleton with the same presentation
- Uterine contractions usually resume within 5 to 10 minutes
- Delivery of the 2nd fetus usually occurs within 30 to 45 minutes
- Both twins usually deliver before the placenta(s)
- BioTel may advise transport prior to delivery of the 2nd fetus
- Increased newborn risks after delivery: hypothermia, hypoxia, hypoglycemia, sepsis
- Postpartum maternal hemorrhage may be severe, requiring vigorous fluid resuscitation and uterine massage
- Precipitous Delivery: Rapid, spontaneous delivery within 3 hours of onset of labor
- Associations: Grand multipara (woman with 7 or more prior deliveries)
- Risks: fetal head trauma, fetal hypoxia, hemorrhage due to tearing of the umbilical cord
- EMS treatment different from normal childbirth:
- Apply gentle counterpressure to the fetal head, but do NOT attempt to detain fetal descent
- Examine the maternal perineum for tears or hemorrhage
- Control maternal perineal hemorrhage with firm pressure on gauze pads
- Pulmonary Embolism & Amniotic Fluid Embolism (“AFE”): Common causes of maternal mortality before, during, and after delivery
- Associations:
- Pulmonary Embolism: more common after C-section than after vaginal delivery
- AFE: Multiparous women in 1st stage of labor; maternal trauma; placenta previa, placental abruption, intrauterine fetal demise
- Risk: Maternal death
- Signs and Symptoms:
- Sudden, severe dyspnea; pleuritic, localized chest pain; tachycardia; tachypnea; hypotension; shock; cyanosis; cardiopulmonary arrest
- EMS treatment different from normal childbirth:
- Refer to relevant Treatment Guidelines for CARDIAC ARREST, SHOCK, DYSRHYTHMIA
- Continuous ECG, SpO2, and ETCO2 monitoring
- IV/IO at TKO rate
- 12-Lead ECG
- Abnormal Maternal Hemorrhage: Examples: placenta previa, placental abruption, multiple gestation, uterine rupture, uterine inversion
- Associations: Trauma
- Risks: Maternal and/or fetal death
- NOTE: Absence of vaginal bleeding does NOT exclude placental abruption
- Mandatory transport to an Obstetrical Special Care facility for any pregnant woman with abdominal pain after MVC or other trauma (Refer to DESTINATION Policy)
- EMS treatment different from normal childbirth:
- Continuous ECG, SpO2, and ETCO2 monitoring
- Large-bore IV/IO access and fluid resuscitation to treat hypovolemic SHOCK
- Uterine Inversion: uterus turns “inside out”
- #1 cause: personnel placing excessive traction on the cord or excessive pressure on the uterine fundus
- Other causes: Forceful uterine contraction; maternal cough or sneeze
- Two types: incomplete and complete
- Signs/symptoms: postpartum hemorrhage; sudden, severe lower abdominal pain; shock
- EMS treatment different from normal childbirth
- Monitor and resuscitate as for other causes of maternal hemorrhage
- Do NOT attempt to remove the placenta
- If the uterus is freshly inverted AND the placenta has already separated, apply pressure with gloved fingertips and palm, and push the uterine fundus upward through the cervical canal
- If this is ineffective, or if the placenta has NOT already separated, cover all protruding tissues with moist, sterile dressings and transport
- If the uterus has been inverted for a prolonged period, or if in doubt, cover all protruding tissues with moist, sterile dressings and transport
- Meconium Staining: Fetal stool in the amniotic fluid, indicative of fetal distress
- NOTE: Meconium staining cannot be determined until after rupture of fetal membranes, when delivery may be imminent
- Associations: Post-term delivery, small-for-gestational-age (SGA) infants
- Risks: perinatal mortality, hypoxemia, aspiration pneumonia, pneumothorax and Meconium Aspiration Syndrome (generally only with thick meconium)
- Signs and symptoms: spectrum from minimal symptoms to severe cardiorespiratory depression
- EMS treatment different from normal childbirth:
- During delivery, as the head delivers and before shoulder delivery, if possible:
- Clear the airway and suction the mouth, then pharynx, and then nose
- After delivery:
- Vigorous infant: remove residual meconium from the hypopharynx by suctioning under direct vision
- Depressed infant:
- Perform direct ET suctioning, using the ET tube as a suction catheter
- Quickly intubate the trachea, preferably before the infant takes 1st breath
- Apply suction to the ET tube, while withdrawing it
- Monitor HR
- If the HR drops below 100 BPM, ventilate with an infant BVM
- Repeat the intubation-suction for 3 seconds-extubation cycle until no further meconium is removed, as long as the HR remains at least 100 BPM
- If the HR remains above 100 BPM, do not ventilate between cycles
- If the ET tube occludes with meconium, replace it with a fresh tube
- Refer to the NEONATAL CARE Guidelines for resuscitation and other treatments