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EMERGENCY CHILDBIRTH Susan Lafaver RNC BSN C-EFM Nurse Manager Labor and Delivery Birth Place St Josephs Hospital Health Center
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EMERGENCY CHILDBIRTH
Susan Lafaver, RNC, BSN, C-EFM Nurse Manager, Labor and Delivery/Birth Place
St. Joseph’s Hospital Health Center
Review anatomy and physiology of pregnancy Describe steps in assisting in a normal childbirth
delivery List priorities of care during transport of the
mother and infant Describe the most important components of
neonatal resuscitation Discuss treatments for common obstetrical
complications
HAS ANYONE BEEN PART OF A DELIVERY OUTSIDE THE
HOSPITAL?
Emergency personnel may be called to assist with the birth of a child Remember: childbirth is a natural
process; you are there simply to assist First – remain calm!
Normal perinatal mortality
is 0.04%
Ovaries: Produce eggs Uterus: Holds fertilized egg as it develops Fallopian tubes: Connect ovaries and uterus Birth canal (vagina): External opening
(1 of 2)
Fetus: Developing baby Umbilical cord: Delivers nutrition and removes
waste products from developing infant Placenta: Draws nutrients from uterus which
are then transported through umbilical cord
(2 of 2)
Stage one Initial contractions occur,
water breaks, bloody show occurs, but no crowning visible
Stage two Involves actual delivery of baby
Stage three Involves delivery of placenta
(afterbirth)
Have you had a baby before? Prenatal care? When are you due? Any complications with this pregnancy or any prior
pregnancy?
Patients generally know if they have any serious pregnancy related conditions unless NPC (placenta previa, breech)
When did the contractions begin? How far apart are the contractions? Have you had any bleeding? Has the bag of waters broken? Color of fluid? Do you feel an urge to move your bowels? Is the baby’s head coming out (crowning)? (Look)
(1 of 2)
No prenatal care Due date or gestational age Prior or present complications Contraction history Vaginal bleeding Color of amniotic fluid Urge to have a bowel movement Head crowning
DO YOU HAVE EMERGENCY DELIVERY KITS ON YOUR RIGS?
ARE YOU FAMILIAR WITH THE CONTENTS?
Gloves Bulb syringe Umbilical cord clamp Scissors Towels or blankets for
baby for drying Blanket for mom AND
baby for covering
Explain process in a calm, encouraging voice Wash your hands thoroughly and put on gloves
Place a towel or sheet under the woman
Have plenty of towels on hand
Place her in as comfortable a position as possible
REMAIN CALM!!! THE GOAL IS A GENTLE
DELIVERY
Have the woman lie on her back with her knees drawn up and apart
Tell the mother to breathe rapidly as the baby’s head emerges
Place one palm gently over the advancing head to prevent an explosive delivery
Suction the mouth first, then the nostrils Do not cut the cord unless it is tight around the neck If the cord is around the neck , try to slip it over the head
If it is too tight, place two clamps about 2 inches apart on the cord. Cut the cord between the clamps with sterile scissors (not trauma scissors)
(1 of 3)
One shoulder is then delivered with the next contraction
The upper shoulder usually passes first with gentle downward pressure on the head
The lower shoulder can then be delivered with gentle
upward pressure on the head You should never exert traction on the infant’s head
or neck in order to facilitate delivery Once the shoulders are delivered, the baby will slide
out Watch out – babies are slippery!
(2 of 3)
In a normal birth, the baby will turn to its side by itself after the head emerges.
(3 of 3)
Ready or Not!
OOPS! - Place baby skin to skin with mom Cut the cord only if necessary
The ABC’s of neonatal stabilization/resuscitation are the same as those applied to adults:
AIRWAY
▪ Clear? Gurgling?
BREATHING
▪ Good respiratory effort, chest moving? Need stimulation? What is the normal RR of a newborn?
CIRCULATION
▪ Assess heart rate-what is the normal HR of a newborn?
▪ Assess color-what is normal?
“The successful transition from intrauterine life to extrauterine life is dependent upon significant physiologic changes that occur at birth. In almost all infants (90%!) these changes are successfully completed at delivery without requiring an special assistance. However, about 10% of infants will need some intervention , and 1% will require extensive measures at birth.” Neonatal Resuscitation Instructor Manual, 2012
Vigorously dry infant with towel Clear mouth and nose Place the newborn SKIN TO SKIN on the mother’s
chest to keep warm Place baby on mom’s belly with head turned to side Cover newborn’s head and body with a fresh, dry,
warm blanket/towel Stimulate as needed
The newborn infant should:
Begin crying right after birth (may need stimulation)
Breathe spontaneously at a rate greater than 40 breaths per minute
Have a pulse greater than 100 beats per minute
Assess APGAR Score at 1 min and 5 min
Best score is 10 Measure at 1 and 5 minutes Score of 6 or less, increase assessment
Suctioning the mouth Suctioning the nose
If needed, suction at delivery of the head. Can suction once delivery is completed
Why suction the mouth first? Can it be harmful? What about meconium? Does every baby need bulb
suctioning? How will I know when to suction?
Susceptibility to cold stress
Increased heat loss
▪ Proportionally large head
▪ Body surface area-to-weight ratio
▪ Minimal subcutaneous fat
▪ Poor perfusion (transisiton)
Decreased heat production
▪ < 6 mos unable to shiver
▪ Preterm = diminished brown fat
Evaporation Loss of water from skin and respiratory tract
Radiation Heat transfer to cooler surrounding walls or hard surfaces
Conduction Heat transfer from direct contact with cooler surfaces
Convection Heat loss to ambient air
Replace wet linen with dry linen ASAP Turn the heat up Decrease drafts and close doors when possible Cover head and body with blanket or clothing Keep baby on mom’s belly!
After drying, stimulation, and assessment, further interventions may be necessary
REMEMBER: …about 10% of infants will need some intervention , and 1% will require extensive measures at birth.” Neonatal Resuscitation Instructor Manual, 2012
Slightly tilt the infant’s head (sniff position) Suction the mouth and nose if needed Begin mouth to mouth-and-nose breathing
(1 of 2)
Check HR at 30 seconds via stethoscope or palpate cord. If HR >100, continue respirations
HR <100, continue mouth-to-
mouth and nose HR<60 after 30 seconds of
mouth-to-mouth and nose, start compressions, ratio 3:1
Reassess every 30 seconds
The placenta usually delivers spontaneously within 10-15 minutes
THERE IS NO RUSH TO DELIVER THE PLACENTA
Do not pull on the cord! It looks like a LOT of blood- don’t forget it includes
amniotic fluid. Normal blood loss 300-500 cc Massage the uterus with one hand while placing
your other hand just above the pubic bone after the placenta delivers
Signs and symptoms of shock are subtle as the mother has a high tolerance for blood loss due to extra blood and fluid built up during pregnancy
Vital Signs
Observe mother and baby-for what?? Recheck vagina for excessive bleeding Recheck firmness of uterus Remove wet towels, etc. Cover vaginal opening if a peri pad is
available Keep mom & baby together
Prompt transport! Support the body as it is delivered Use your fingers to keep baby’s airway open
by forming a pocket over the infant’s nose and mouth
The last movement is an upward movement of the head to deliver the forehead first
Umbilical cord comes out of the vagina before baby is born
A serious emergency that
requires rapid transport ! Prop mother’s hips and legs
higher than rest of her body Gently displace baby’s head
with 2 fingers of a gloved hand Do not grab cord (causes
HR)
Characteristics: BP > 160/110 and /or severe headache, visual disturbances, acute pulmonary edema or upper abdominal tenderness
Most patients can state that they have pre-eclampsia during their pregnancy
Treatment is to transport ASAP
Eclampsia refers to the occurrence of one or more generalized convulsions and/or coma in the setting of preeclampsia and in the absence of other neurologic condition
How do we know it’s eclampsia? Treatment:
Magnesium Sulfate 4 gm in 50 ml NS over 15 min if able to establish IV
Can give Magnesium Sulfate 1gm IM mixed with 2cc NS in each buttock
Predelivery
Placenta Previa
Placental Abruption
Don’t confuse with bloody show
Post delivery
Post partum hemorrhage due to uterine atony
Cervical or vaginal lacerations
During pregnancy, the blood volume increases to about 50% more than before pregnancy. This is important as it is designed to meet the demands of a growing uterus. More blood in the system protects Mom and baby from harm when Mom lies down or stands up. The increase is also a safeguard for the blood loss during labor and delivery. The blood volume increase begins during the first trimester and the largest increase happens during the middle trimester and the increase tends to slow down in the final trimester. Red blood cells and plasma (composition of blood) both increase during pregnancy.
Can you see why it is important to know if there is a history of placenta previa? What is the consequences of a vaginal exam?
Can you always see a patient bleed with a placental abruption? How will you know?
UTERINE ATONY-requires fundal massage Cervical lacerations Vaginal lacerations Extension of tear into rectum Peri-urethral tears
WHAT TO DO?
Cover perineum
Transport as soon as possible
VCU Medical Center Video -- EMS with Childbirth
7:24
