BLS Childbirth

It is very rare for a pregnant woman to call for emergency services to assist with childbirth unless there are unusual circumstances, such as going into labor in an unusual place, or not having the ability to get to the hospital in time. For this reason, the unfamiliarity, as well as the possible complications, can be stressful for the EMS provider. Remember, however, childbirth is a natural process and usually only requires the facilitation of what is already happening. Often, delivery in the field occurs in uncontrolled environments, so it is important to have a good understanding of the delivery process and any possible complications.

History

Obtaining a thorough history and doing a proper assessment are important when treating an obstetric patient. You want to first establish the patient's chief complaint or reason for calling 9-1-1. Like any emergency call, ask SAMPLE and OPQRST questions to investigate. 

     You will want to know how many times the patient has been pregnant (gravida) and how many times she has given live birth (para). If it is the woman’s first pregnancy, labor will likely be slower and longer and there may be time to transport the patient to the hospital. Ask about gestation length and her projected due date. If this is not her first pregnancy or live birth, ask if she has had any complications with previous births or if her physician has any projected concerns about this pregnancy or delivery. You will also want to know if the patient has had any vaginal bleeding, and if so, how much?

     If the patient is currently in labor, ask if her water has broken. If she has the urge to push or move her bowels, it is likely that the baby’s head is pushing against the rectum, which means delivery is imminent. Find out what her contractions are like and how far apart they are. If the contractions are more than 5 minutes apart, there may be time to transport her to the hospital. If the contractions are less than 2 minutes apart, delivery is likely imminent.

     Obtaining the patient's history should give a good indication if there is enough time to transport her to the nearest hospital, or whether to prepare for a field delivery. To confirm, inspect the patient for crowning (appearance of the baby), which indicates the baby needs to be delivered immediately.

Stages of Labor

Labor is the process by which the fetus and placenta are expelled from the uterus and through the birth canal. It is important to understand the stages so that if you arrive at a patient in labor, you know how far along they are in the process. There are 3 stages of labor:

Stage 1: This stage is known as the dilation stage because it lasts until the cervix is fully dilated. It can last up to (or over) 12 hours (especially if it’s the patient's first pregnancy) or up to 8 hours if the patient has had previous deliveries (however, these are not exact and it is not unheard of for the dilation phase, regardless of previous births, to fall outside these windows). In this stage, the patient experiences crampy abdominal pains and contractions that occur in 5 to 15-minute increments. The cervix dilates to 10 cm and the woman begins to feel the urge to push. Towards the end of this stage, the amniotic sac ruptures and fluid pours out of the vagina. This is known as the “water breaking”.

Stage 2: This stage is known as the expulsion stage as it ends with the delivery of the fetus. The patient will have contractions every 2-3 minutes and the urge to push with each contraction. The cervix becomes fully dilated and the presenting part of the fetus (usually the head) begins coming out of the vaginal opening. This stage lasts about 1-2 hours for first-time deliveries and about 30 minutes if the woman has delivered before (though again, do not rely too heavily on these times as they are known to vary regardless of past deliveries).

Stage 3: This stage is known as the placental stage because it involves the separation and delivery of the placenta. 

Delivery

When preparing for delivery, you may only have a few minutes. Gather the OB kit, don the appropriate PPE and position the patient in the position of most comfort. Usually, this is the semi-fowlers position with the legs spread apart. Delivery consists of 3 parts: delivery of the head, delivery of the shoulders, and delivery of the body and legs. After the baby is delivered, the umbilical cord must be cut and the placenta delivered.

     Delivery of the head begins with crowning as the top of the head is visible through the vaginal canal. When delivering the head, the role of the EMS provider is to prevent rapid delivery. This can be controlled by placing the palm of the hand on the occipital lobe of the baby and applying gentle pressure as the mother pushes. The face will usually present facing downward. If the umbilical cord is wrapped around the baby’s neck (nuchal cord), attempt to loosen it and pull it over the baby’s head. If you are unable to release the cord, immediately clamp it and cut it to proceed with the delivery.

     After the head has been delivered, the shoulders may deliver on their own. If not, gently guide the newborn's head downward, pulling traction until the anterior shoulder presents. Then gently pull upward on the newborn's head until the posterior shoulder presents.

     Delivery of the body and legs does not occur immediately. You can assist with the delivery of the rest of the body by providing light traction on the neonate or applying light pressure to the uterine fundus. Once the newborn is delivered, maintain its body at the same level as the vagina to prevent draining blood from the umbilical cord. Suction the newborn's nostrils if necessary to clear the airway.

     Once the newborn has been delivered and is breathing, you will need to cut the umbilical cord as it is no longer necessary for the baby’s survival. Apply a clamp about 6-8 inches from the newborn, and another 2 inches from the first. Cut between the 2 clamps using a scalpel. Once the cord is cut, dry the baby, wrap it in a blanket and give it to the mother so they can bond. 

APGAR Score

The APGAR score is a test that is used to determine the newborn's physical condition and see if the baby needs immediate medical attention. The test has 5 parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each one is given a score from 0-2 at the 1-minute and 5-minute marks after delivery.