Prehospital Childbirth

Anatomy of Pregnancy

Around 9 months fetus rotates so head is facing down with scalp at vaginal canal eventually rotating up

Pregnancy Respiratory Changes

- Impaired movement of diaphragm

- Increased oxygen demands

Pregnancy Cardiovascular Changes

- Increased pulse rate

- Increased blood volume (up to 30%)

Pregnancy Musculoskeletal Changes

Softening of pelvic ring

Pregnancy Gastrointestinal Changes

Stomach and intestines displaced increasing risk of aspiration

First Stage of Labor

- Dilation of cervix

- Longest stage of labor (prima: 12h, multi: 7h)

- Contractions of uterine wall to dilate cervix to about 10 cm

Primapara

A woman who is pregnant for the first time

Multipara

A woman who is pregnant not for the first time

Amniotic Sac

- Ruptures during first stage of labor

- "Water breaking"

- Should be clear, yellowish, maybe slightly pink, thin watery liquid

Second Stage of Labor

- Expulsion of neonate

- Contractions are more frequent (2-3 minutes apart) then period of relaxation

- Prima: 80 minutes, mutli: 30 minutes

Urge to push

Felt between beginning of first contraction to the beginning of next contraction

Timing contraction

From beginning of muscle contraction through rest until next contraction

Active Birth Management

- Pull sac away from airway to clear face

- Wipe any fluids from mouth and nose

- Head should rotate 90 degrees for delivery of first shoulder

- Crowning may happen then retract a little

Third Stage of Labor

- Delivery of placenta

- About 20 minutes

- DO NOT pull on umbilical cord

- Save placenta for examination

Meconium

- Baby stool in amniotic fluid

- Thick, brownish, greenish pea-soup appearance

- Suction mouth then nose (don't suction too far in mouth)

Inserting suction too far in baby

Stimulates vagus nerve and causes bradycardia

Breech Position

- Presenting part is something other than head

- Butt, both legs may be able to deliver

- Arms or single leg require a C-section

Placenta Previa

- Will know about if had pre-natal care (ultrasound)

- Abnormally low implantation of placenta, may completely cover cervix

- Presents as painless vaginal bleeding

Abruptio Placenta

- Premature separation of the placenta from the uterine wall limiting oxygen and nutrients to fetus

- May be complete or partial

- High fetal mortality, result of trauma

Uterine Rupture

- Uterine wall ruptures

- High fetal and maternal rate, from trauma or strong contractions

- High risk for women with prior C-sections (VBAC)

VBAC

Vaginal birth after C-section

Prolapsed Cord

- Umbilical cord 'washes out' with amniotic fluid

- Pressure from baby in brith canal compresses cord and compromises blood flow

- Can lead to severe hypoxia

Umbilical Vein

- Delivers oxygenated blood from the placenta to the fetus

- Easily compressed

Umbilical Artery

Carries waste and carbon dioxide from fetus to placenta

Prolapsed Cord Treatment

- Cover cord with moist dressing

- Put mom on knees with butt up in air, may compromise mom's ventilation

- Use gloved fingers to try and keep baby's head off cord

Nuchal Cord

- Cord tangled around baby, often around neck

- Baby may not be able to come out

Nuchal Cord Treatment

Used gloved fingers to try to slip cord over baby's head or clamp and cut cord if recommended by med control

Shoulder Dystocia

- Shoulder gets stuck up against the pubic symphysis

- Turtle sign and McRobert's position

Turtle Sign

Head retracts between contractions and doesn't go out any farther each contraction

McRobert's Position

- Moves pubic symphysis up and forward and sacrum backwards (grab a leg and bend back and out to create larger opening)

- Creating a larger opening for shoulders to pass through

Postpartum Hemorrhage (PPH)

- Excessive bleeding after childbirth

- Defined as a loss of 500 ml or more after a vaginal birth and 1000 ml after a cesarean birth

- Often from incomplete contraction of uterus or retained segments of placenta

Postpartum Hemorrhage Treatment

External uterine massage or nursing by neonate to stimulate more contractions

Assessment of Labor

- History of prior pregnancy, complications, length of labor/delivery

- Gravida and Para (G1P0 or G3P1)

- Prenatal care information (# of babies, complications)

- When did contractions start, how far apart, water broke (fluid color)?

Gravida

- Number of pregnancies

- Including current pregnancy

- Listed first

Para (parity)

- Number of live births a woman has had

- Listed last

G1P0

First pregnancy, no previous births

G3P1

Third pregnancy (now, and twice before), one viable birth

Transporting Pregnancy

- No one can hold baby

- One ambulance for outside patient and one ambulance for inside patient

- Baby can be secrued to stretcher harness to be skin to skin with mom

Physical Exam of Pregnancy

- Length of contractions (<2 mins)

- Urger to push or move bowels (baby's head puts pressure on rectum)

- Presenting part (crowning or other parts)

Prehospital Delivery

- BSI, gloves, mask, eye shield, gown

- OB kits with bulb syrigne, umbilical scissors, cord clamps

- Prepare delivery area in warm place with absorbent material

Active Birth

- Apply gentle pressure to bony area of skull to prevent explosive birth, support head

- SUCTION MOUTH FIRST THEN NOSE AS HEAD DELIVERS (obligate nose breathers)

- Support torso and legs

- Wait about 2-3 minutes to clamp and cut umbilical cord to leave 4 inches

Post Birth Care

- Keep baby warm and dry

- Allow baby to nurse once able

- Uterine massage for excessive post-partum bleeding

- Monitor

APGAR Score

- Assess at 1 minute and 5 minutes after birth

- Activity (muscle tone), Pulse, Grimace (reflex irritability), Appearance, Respiration

- Rated 0-10

APGAR 0-3

Severely depressed

APGAR 4-6

Moderately depressed

APGAR 7-10

Excellent condition

Activity

- 0 points: Absent

- 1 point: Arms and legs flexed

- 2 points: Active movement

Pulse

- 0 points: Absent

- 1 point: below 100 bpm

- 2 point: over 100 bpm

- Best place to measure is below umbilical cord

Grimace

- 0 points: Flaccid

- 1 point: Some flexion of extremities

- 2 points: Active motion (sneeze, cough, pull away)

Apperance

- 0 points: blue, pale

- 1 point: body pink, extremities blue

- 2 points: completely pink

Respirations

- 0 points: absent

- 1 point: slow, irregular

- 2 points: vigorous cry

Priority of care (first to last)

Dry warm position suction stimulate, then oxygen, then ventilation, then chest compressions, then medications

Normal Infant Pulse

120-140 bpm

Neonate Resuscitation

Should only need suction, warming, and drying to stimulate

- If Cyanotic and pulse >100 use blow by O2

If cyanotic and pulse >100

Use blow by oxygen

If pulse <100 and/or apneic or agonal breathing and/or cyanotic

Use BVM with ventilations 40-60 bpm (1 every second)

If pulse <60

Chest compressions and BVM (need ALS intercept)

Delivery of Placenta

- Usually delivers within 30 minutes after baby

- DO NOT PULL

- Save for hospital examination

- If multiple births, may be more than one placenta per baby

- DO NOT delay transport waiting for placenta