Labor and Childbirth 

Assessment

History:	Signs & Symptoms:	Differential:
□ Due date of LMP  □ Time contractions started & how often  □ Rupture membranes  □ Time / amount of any vaginal bleeding  □ Sensation of fetal activity  □ Past medical and pregnancy/delivery history  □ Medications  □ If known high risk pregnancy	□ Episodic pain  □ Vaginal discharge or bleeding  □ Crowning of urge to push  □ Meconium  □ Urge to defecate	□ Abnormal presentation:  □ Buttock  □ Foot  □ Hand  □ Prolapsed cord  □ Placenta previa  □ Abruptio placenta  □ Premature labor

Clinical Management Options

EMT-B

• High Flow Oxygen to all mothers with imminent childbirth  • Always check for nuchal cord once the head has been delivered • Reference complications of delivery maneuvers  • Wipe the face and mouth clean with a clean towel • If there is evidence of meconium (brown/yellow amniotic fluid) suction the mouth than nostrils. • If baby is not in distress, consider delayed cord clamping for up to 60 seconds.   • Skin to skin contact for mother and baby and encourage infant to breast-feed.  • If post-partum hemorrhage, then fundal massage.  • See Clinical Procedures for Birthing and Position Complications

Paramedic

• Vascular access with Isotonic Crystalloid titrated to effect for vaginal hemorrhage  • For hypotension due to significant hemorrhage following delivery or delayed placenta delivery, Tranexamic Acid and Calcium

Pearls

• Document all times (delivery, contraction frequency, and length). Record APGAR at 1 minute and 5 minutes after birth. 
• If maternal seizures: refer to the Obstetrical Emergencies Guideline. Eclampsia can occur up to 2 months post-partum. 
• After delivery, allowing child to nurse and massaging the uterus (lower abdomen) will promote uterine contraction and help to control postpartum bleeding. 
• Post-partum hemorrhage defined as blood loss > 1000mL or > 500mL with signs/symptoms of hypotension. The perineum should be checked for bleeding from vaginal tears. Bleeding should be controlled by direct pressure over the laceration. 
• The most common cause of post-partum hemorrhage is uterine atony due to prolonged labor, or multiple gestations.

Complications of Delivery Maneuvers

Most deliveries proceed without complications – If complications of delivery occur, the following are recommended: 

1. Shoulder dystocia – if delivery fails to progress after head delivers, quickly attempt the following 
   1. Hyperflex mother’s hips to severe supine knee-chest position 
   2. Apply firm suprapubic pressure to attempt to dislodge shoulder 
   3. Apply high-flow oxygen to mother 
   4. Transport as soon as possible 
   5. Contact direct medical oversight and/or closest appropriate receiving facility for direct medical oversight and to prepare team 
2. Prolapsed umbilical cord 
   1. Placed gloved hand into vagina and gently lift head/body off cord 
      1. Assess for pulsations in cord 
      2. Maintain until relieved by hospital staff. 
   2. Consider placing mother in prone knee-chest position or extreme Trendelenburg  
   3. Apply high-flow oxygen to mother 
   4. Transport as soon as possible 
   5. Contact/transport to closest appropriate receiving facility for direct medical oversight and to prepare team 
3. Breech birth 
   1. Place mother supine, allow the buttocks and trunk to deliver spontaneously, then support the body while the head is delivered 
   2. If head fails to deliver, place gloved hand into vagina with fingers between infant’s face and uterine wall to create an open airway 
   3. Apply high-flow oxygen to mother 
   4. Transport as soon as possible 
   5. Contact direct medical oversight and/or closest appropriate receiving facility for direct medical oversight and to prepare team 
   6. The presentation of an arm or leg through the vagina is an indication for immediate transport to hospital 
   7. Assess for presence of prolapsed cord and treat as above 
4. Nuchal Cord
   1. Once the baby’s head as been delivered, check an umbilical cord around the neck
   2. If the cord is loose, pull over the head
      1. It is essential not to break the cord, do not pull hard
   3. If the cord is tight, clamp the cord and cut. Then have the mother push to deliver the baby quickly
      1. Anticipate need for oxygen and resuscitation if the cord is cut prior to delivery.