Childbirth

Table of Contents

Aliases

Labor, delivery, birth

Patient Care Goals

  1. Recognize imminent birth
  2. Assist with uncomplicated delivery of term newborn
  3. Recognize complicated delivery situations
  4. Apply appropriate techniques when delivery complication exists

Patient Presentation

Inclusion Criteria

Imminent delivery with crowning

Exclusion Criteria

  1. Vaginal bleeding in any stage of pregnancy [see Obstetrical/Gynecological Conditions guideline]
  2. Emergencies in first or second trimester of pregnancy [see Obstetrical/Gynecological Conditions guideline]
  3. Seizure from eclampsia [see Obstetrical/Gynecological Conditions and Eclampsia/Pre-Eclampsia guidelines]

Patient Management

Assessment:

  1. Signs of imminent delivery:
    1. Contractions
    2. Crowning
    3. Urge to push
    4. Urge to move bowels
    5. Membrane rupture
    6. Bloody show

Treatment and Interventions

  1. If patient in labor but no signs of impending delivery, transport to appropriate receiving facility
  2. Delivery should be controlled so as to allow a slow controlled delivery of infant – This will prevent injury to mother
    1. Support the infant’s head as needed
  3. Check for cord around the baby’s neck
    1. If present, slip it over the head
    2. If unable to free the cord from the neck, double clamp the cord and cut between the clamps
  4. Do not routinely suction the infant’s airway (even with a bulb syringe) during delivery
  5. Grasping the head with hand over the ears, gently guide head down to allow delivery of the anterior shoulder
  6. Gently guide the head up to allow delivery of the posterior shoulder
  7. Slowly deliver the remainder of the infant
  8. After 1-3 minutes, clamp cord about 6 inches from the abdomen with 2 clamps; cut the cord between the clamps
    1. If resuscitation is needed, clamp cord and cut as soon as possible
  9. Record APGAR scores at 1 and 5 minutes
    1. After delivery of infant, suctioning (including suctioning with a bulb syringe) should be reserved for infants who have obvious obstruction to the airway or require positive pressure ventilation (follow Neonatal Resuscitation guideline for further care of the infant)
  10. Dry and warm infant, wrap in towel and place on maternal chest unless resuscitation needed
  11. The placenta will deliver spontaneously, often within 5-15 minutes of the infant
    1. Do not force the placenta to deliver; do not pull on umbilical cord
    2. Contain all tissue in plastic bag and transport
  12. After delivery, massaging the uterus and allowing the infant to nurse will promote uterine contraction and help control bleeding
    1. Estimate maternal blood loss
    2. Treat for hypovolemia as needed
  13. Transport infant secured in seat unless resuscitation needed
  14. Keep infant warm during transport
  15. 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 of cord
      2. Assess for pulsations in cord
      3. Maintain until relieved by hospital staff.
      4. Consider placing mother in prone knee-chest position or extreme Trendelenburg
      5. Apply high-flow oxygen to mother
      6. Transport as soon as possible
      7. 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. Excessive bleeding during active labor may occur with placenta previa
      1. Obtain history from patient
      2. Placenta previa may prevent delivery of infant vaginally
      3. C-Section needed – transport urgently
    5. Maternal cardiac arrest
      1. Apply manual pressure to displace uterus from right to left
      2. Treat per the Cardiac Arrest guideline for resuscitation care (defibrillation and medications should be given for same indications and doses as if non-pregnant patient)
      3. Transport as soon as possible if infant is estimated to be over 24 weeks’ gestation (perimortem Cesarean section at receiving facility is most successful if done within 5 minutes of maternal cardiac arrest)
      4. Contact direct medical oversight and/or closest appropriate receiving facility for direct medical oversight and to prepare team

Notes – Childbirth