The Quick and Dirty Guide to Childbirth

Calls to EMS for OB emergencies especially, those where the patient is full term and in possible labor, are some of the scariest but, rewarding calls we face as medical professionals. It is important to have a thorough understanding of the development of the fetus as well as, emergencies that may arise for the newborn infant and/or mother during the pregnancy and delivery. In Childbirth I, we will concentrate on a normal delivery.

In the Beginning

When a normal pregnancy begins; during ovulation the female ovary releases an ovum (egg) and begins its journey through the uterine tube. While in the uterine tube, sperm from the male, fertilizes the ovum to form a single-celled zygote. After a few days of rapid cell division, a ball of cells called a morula forms. The murola forms a hollow ball of cells called a blastocyte and implantation occurs, fetal development begins immediately. The normal duration of pregnancy is 40 weeks from the first day of the patients last cycle.
Pregnancy is often described in trimesters, with each trimester lasting 13 weeks, or three calendar months.

The first trimester is comprised of months 1 - 3, or weeks 1–15
The second trimester consists of months 4 - 6, or weeks 16–27
The third trimester includes months 7 - 9, or weeks 28–40

As Time Marches On

Placenta

The placenta is formed about fourteen days after ovulation, it is a disc-like organ composed of interlocking fetal and maternal tissues, it is the organ of nutrient exchange between the mother and the fetus. The placenta is crucial for fetal development and is responsible for the following:

1. Transfer of gases: The diffusion of oxygen and carbon dioxide through the placental membrane and is similar to the same diffusion that occurs in the lungs. Dissolved O2 in the maternal blood diffuses into the fetal circulation. Carbon dioxide then diffuses from the fetal blood back into the maternal blood.

2.Transfer of nutrients: The other metabolic substances that the fetus needs, diffuse into fetal blood in the same manner as O2. The placenta also actively absorbs some nutrients from maternal circulation. These substances include:

Glucose
Fatty acids
Potassium
Sodium
Chloride

3. Excretion of waste: Waste products diffuse from fetal to maternal circulation and are excreted with the mothers waste. These waste products are:

urea
uric acid
creatinine

4. Hormone Production: The placenta becomes a temporary endocrine gland by secreting estrogen and progesterone. This helps prepare the mothers body and the fetus for delivery.

5. Formation of a Barrier: The placenta forms a barrier from harmful substances and chemicals in the mothers circulation. The placenta is selective and only protects the fetus from some harmful substances, others can cross the barrier easily.

Umbilical Cord

The umbilical cord connecting the placenta to the fetus consists of one umbilical vein and two arteries and is present from the sixth week of pregnancy through delivery. The vein carries oxygenated blood toward the fetus; the arteries return the blood from the fetus to the mother.

Amniotic Sac

While the placenta provides nutrients to the fetus and assists with the removal of wastes, the amniotic sac, which consists of membranes that cover the fetus, provides protection. The amniotic sac fills with amniotic fluid that is designed to protect the fetus and to provide an environment that is optimal for fetal development. A volume of up to one liter of amniotic fluid is maintained by the fetus's excretion of urine, as well as its swallowing of the amniotic fluid.

Delivery

Your main objective when evaluating a pregnant patient is to determine if her complaints are related to active labor and if so, is delivery imminent?

Don Proper BSI and prep OB kit
Examine for crowning
Feel for uterine contractions
Take baseline vital signs

The Stages of Labor/Delivery

Stage I: (Dilation) Regular contractions, thinning and gradual dilation of cervix, ends with fully dilated cervix (10 cm); Lasts: 12-16 hrs. primipara, 5-7 hrs. multipara
Stage II: (Expulsion) Fully dilated; The time from when the baby enters the birth canal until he is born. Stage lasts 80 min. primipara, 30 min. multipara
Stage III: (Placenta delivery) The time between birth and afterbirth; average time 5 to 30 min.
"Bloody show" begins with the loss of the mucus plug and continues through out the delivery.

While assessing the patient for the obvious signs and symptoms of labor, be sure to ask the right questions:

1. Get her full name and age, for the receiving facility
2. What is her expected due date?
3. Is this the first pregnancy?
4. Has she had prenatal care during the pregnancy?
5. When did labor pains start?
6. Has there been a rush of water or is there any"bloody show" present?
7. Does the patient feel the urge to push?
8. Does the patient feel the need to have a bowel movement?

Never allow a patient you feel may be in active labor to use the toilet

During labor, the mother will experience contractions of the uterus that help the patients cervix dilate and push the fetus out of the uterus into the birth canal. The contractions will occur at regular intervals, ranging from 30 minutes initially to 1 minute, as imminent labor approaches. Contractions or labor pains last between 30 seconds to 1 minute, if the pain is continuous or prolonged, consider other causes of OB pain.

If the signs and symptoms lead you to believe the patient may be in active labor

Expose the abdomen and genital area while being discrete, professional and calm. Contractions occurring within 2 minutes of each other should alert the EMT that delivery is imminent; preparations should be made, quickly. There is no set amount of time that the last stage of labor will last, every patient is different, especially patients that have had previous child births; be prepared for anything! Keep in mind though, a first time delivery usually lasts several hours. Mothers who have previously given birth, often know when they are ready to deliver. Labor tends to be shorter after the patients first child.
Consider transporting the mother if delivery does not occur within 20 minutes of experiencing contractions that are 2-3 minutes apart. Visually inspect for crowning, bleeding or other signs of emergency condition that may be causing the S&S.

When evaluating the mother, keep in mind the four signs of imminent delivery:

Crowning
Contractions < 2 minutes
Rectal Fullness (c/o needing to have bowel movement)
Feeling of having to push

Once you have determined that a field delivery is imminent, you should prepare as follows:

Request a paramedic unit
Don sterile gloves, gown, and eye protection
Position mother on her back, legs drawn up
Provide supplemental oxygen
Prepare OB kit
Prepare infant BVM

Presentations that are not able to be successfully delivered in the field:
Note: * Covered in Quick and Dirty Guide to OB Emergencies

A single limb presentation*
Prolapsed umbilical cord*

Presentations that can successfully be delivered in the field:

Normal Cephalic delivery (head first)
Umbilical cord around the fetuses neck *
Shoulder Dystocia *
Butt first *
Double footling *

Findings Indicating Possible Need for Newborn Resuscitation:

The patient has received no prior prenatal care
A Premature delivery
Labor induced by trauma
Multiple births
History of pregnancy problems (i.e., placenta previa and breech presentation)
Labor induced by illegal drug use (especially narcotics) and alcohol
Meconium staining when the patients amniotic sac ruptures (water breaks)

Meconium is the newborns first stool, it usually occurs well after birth. In some cases when the pregnancy has went past full term or the fetus becomes distressed during delivery then the fetus defecates and cause the meconium to mix with the amniotic fluid. If meconium staining is apparent in the fluid or noted on the newborns face/body, then immediate suctioning and airway control is crucial in preventing serious respiratory problems for the newborn.

OBGYN Emergencies and Childbirth Lecture

Assisting With Delivery

When assisting the mother to deliver her baby, it is important to remember that child birth is a natural event and in most cases, we are just there to "catch the ball".

If the patient has begun the first stage of active labor, the amniotic sac has usually ruptured, expelling the clear amniotic fluid that has protected the developing fetus throughout the pregnancy. The amniotic sac does not always rupture initially, the EMT can pierces it with a gloved hand when the head presents from the birth canal. Make sure to remove the sac from the newborns nose and mouth because for the first time, the baby will need them clear in order to breath.

Delivery Instructions

1. Encourage the mother to breath deeply between contractions and to push with contractions.

2. As the baby's head crowns, support it with gentle pressure over the perineum and gently support their head as the head delivers to avoid an explosive birth and prevent injury.

3. If the amniotic sac is still intact, rupture it with a finger to allow amniotic fluid to leak out.
Note the color and character of the amniotic fluid:
Normal fluid is clear or straw colored; Meconium in the fluid produces a tainted, discolored or thick, pea soup like color and should be recorded and kept.

4. As soon as the baby’s head appears, suction the mouth and nostrils with a bulb syringe. Squeeze air from the syringe before inserting, insert the syringe no more than one inch into the mouth and no more than ½ inch into each nostril.
NOTE: If you see signs of meconium staining, do not stimulate the infant before suctioning the mouth and nose. This is to avoid aspiration of fecal material that can cause pneumonia

5. If the umbilical cord is wrapped around the baby’s neck, gently slip it over the head DO NOT FORCE IT!. If the cord is too tight to slip over the head, apply umbilical cord clamps and cut the cord.
NOTE: Clamp and cut the umbilical cord only if he baby’s head has emerged and is in a position that lows you to manage the airway.

6. Encourage the mother to push. Support the baby’s head as it delivers.
Caution, babies are slippery!

7. Let the baby come at its own rate; the only interventions that you may be required to do is to gently pull the baby’s shoulders down (one at a time) so that it can squeeze through the vaginal opening; however this shouldn’t be required during a normal birth. To assist in delivery of the anterior shoulder, apply gentle downward pressure on the shoulder while continually supporting the newborns head.

8. As soon as the anterior shoulder has delivered, apply gentle upward pressure to assist in the delivery of the posterior shoulder.

9. Once both shoulders have delivered, be ready for the remainder of the body to deliver quickly. Newborn babies are slippery so handle carefully.

10. Stimulate the newborn to breathe by tapping the feet, if necessary.

11. Once pulsations have stopped, clamp the cord by placing a clamp approximately 8-10 inches from the baby. Place a second clamp approximately 2 inches from the first, then cut the cord between the clamps.Do not cut or clamp a cord that is still pulsating. Apply one clamp or tie about 10 inches from the baby. This leaves enough cord for paramedics and hospital staff to start IV lines.
Note: Do not tie, clamp, or cut an umbilical cord on a baby who is not breathing unless the cord is around the baby's neck.

12. Re-suction the baby’s mouth and nostrils if the newborn is not breathing or is having respiratory distress.

13. Dry and wrap the baby in a warm blanket and cover its head. One of the greatest risks to a newborn baby is to become hypothermic and hypoglycemic as it attempts to keep warm.

14. Place the newborn on its side to facilitate drainage of secretions.

15. Perform an APGAR assessment at 1 minute and 5 minutes after delivery.

Normal Vitals for Newborns:

Vital signs:
- Temperature (able to maintain stable body temperature in normal room environment)
- Pulse (normally 120 to 160 beats per minute in the newborn period)
- Breathing rate (normally 40 to 60 breaths per minute in the newborn period)

NOTE:
For premature births, provide infant with oxygen by blowing oxygen across the infant's face. Insulate the infant to maintain body temperature. Protect the infant from contact or exhaled breath of others who might transmit infections.

APGAR

APGAR Testing and Scoring is assigned in the first few minutes after birth to help identify babies that have difficulty breathing or have a problem that needs further care. The baby is checked at one minute and five minutes after birth for heart and respiratory rates, muscle tone, reflexes, and color.
Each section/category can have a score of 0, 1, or 2; with 10 points as the maximum. A total score of 10 means a baby is in the best possible condition. Nearly all babies score between eight and 10, with one or two points taken off for blue hands and feet because of immature circulation. If a baby has a difficult time during delivery, this can lower the oxygen levels in the blood, which can lower the Apgar score.

Note: Apgar scores of 3 or less often mean a baby needs immediate attention and care.

Care of the newborn after delivery:

Once the body has delivered the baby should begin breathing on its own within a few seconds but that may seem like an eternity, be patient and calm!. If breathing doesn't start spontaneously, you must stimulate it to begin by rubbing the newborns back or tapping your fingers on the soles of its feet. If the newborn does not start breathing effectively within 10 – 15 seconds of stimulation, use an infant BVM to deliver GENTLE PUFFS of air, just enough to cause the chest to rise. If after 30 seconds of assisted ventilation there is no response and the heart rate is < 60 beats/min, begin CPR and call for ALS assistance.
Keep the newborn warm by drying it and then wrapping it in warmed blankets. After the umbilical cord is clamped and cut, cover the baby's head to maintain body heat. Be careful because a wet baby is very slippery. Repeat suctioning of the nose and mouth, if needed.
Remember to check the APGAR score at 1 and 5 minutes.

Keep mother and baby safe and warm, place the wrapped baby on the mothers chest for warmth while transporting them to the nearest appropriate facility. Prepare for the delivery of the placenta about 20 minutes after the newborn is delivered.
It is important to realize that the mother may be the more serious patient following a normal delivery. Post partum hemorrhage can kill. Emphasize that the mother may be the more serious patient.
Post partum hemorrhage can kill!
Fundal massage over the mothers uterus can help stop post partum bleeding. It is painful for most mothers to experience directly after childbirth, but nonetheless, it is necessary in the event of excessive hemorrhage. If bleeding is excessive and fundal massage fails to slow or stop the bleeding, request ALS back-up so fluids and medications can be administered to help control blood loss.

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The Quick and Dirty Guide to Childbirth

In the Beginning