Babies have been born for millions of years without EMS intervention. This is one “emergency” that almost always turns out well. The CDC reported that, in 2009, there were 4,130,665 births in the United States (a birth rate of 13.5 per 1000 population), with 1.1% delivered out-of-hospital. The percent born preterm (<37 weeks’ EGA) was 12.2%, and the percent born at a low birth weight (<2500 g) was 8.2%. In the United States, the overall infant mortality was 6.9 per 1000 live births, but 183.2 per 1000 babies born prior to 32 weeks’ EGA.¹

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  Assessment of prehospital delivery likelihood

  
  
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  Delivery (uncomplicated)

  
  
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  Complicated delivery

  
  
  
  
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    Shoulder dystocia

    
    
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    Breech delivery

    
    
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    Umbilical cord prolapse

    
    
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    Uterine inversion

    
    
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    Postpartum hemorrhage (PPH)

  
  

Ascertain the obstetric history (gravida and parity) using the G_NP_TPAL numbering system. N is the total number of pregnancies; T is the number of term births (multiples, eg, twins only count as one birth); P is the number of preterm births (<37 weeks); A is the number of abortions (<20 weeks), and L is the total number of children who lived at least 28 days. Next, determine the estimated gestational age (EGA) of tis fetus in weeks—most accurately by a previous ultrasound, by dates from LMP, or distance from the symphysis to the fundus in centimeters (modestly accurate in the 20- to 36-week range; inaccurate in case of multiples, poly- or oligohydramnios).

Ascertain the presence of contractions (ctx), their time of onset, duration, and interval frequency. Stage 1 (from onset of labor to full cervical dilation) in a primiparous woman takes an average of 10 hours (95% complete by 25 hours); for a multiparous woman, the mean is 8 hours (95% by 19 hours). Stage 2 (full cervical dilation to delivery of the neonate) for a primiparous woman takes an average of 33 minutes (95% by 118 minutes); for a multiparous woman, a mean of 9 minutes, with 95% delivered by the end of 47 minutes. Primiparous women are likely to deliver when contractions are 3 to 5 minutes apart and last 40 to 90 seconds, increasing in strength and frequency for at least an hour. Delivery is imminent if contractions are 2 minutes or less apart, especially for a multiparous woman.²

Assess anticipated difficulties with prehospital delivery and/or need for neonatal resuscitation: preterm (<37 weeks’ EGA; 12.18% in 2009), multiples (In 2009, twins occurred 33.2 times per 1000 births, triplet and higher order multiple birth rate was 1.53 per 1000 births), anticipated abnormal presentation/lie, lack of adequate prenatal care (none or first visit at >3 months’ EGA; 6.6% of desired pregnancies, 14.5% of mistimed or unwanted pregnancies in 2002),³ placenta previa (2.8 cases per 1000 singletons, 3.9 cases per 1000 twin pregnancies),⁴ poly- or oligohydramnios, the presence of a cerclage, or the anticipated need for Cesarean section. A cerclage is a stitch that holds the cervix closed. It is commonly placed in a woman who has a weak (incompetent) cervix that tends to dilate. The stitch works to hold the cervix closed, thus keeping dilation from occurring and preserving the pregnancy. Cervical cerclage is temporary and is removed before delivery of the infant. If labor progresses with it present, the stitch can cause cervical lacerations and hemorrhage. Rarely, a transabdominal cerclage is placed—this is permanent and all infants must be delivered via C-section. The cesarean delivery rate in 2009 was 32.3% of all births. Half of the women aged 40 and older (49.5%) delivered by cesarean compared with less than one in four women under age 20 (23.1%). This is also the case among women having singleton births (older women have higher rates of multiple births, which are more likely to be delivered by cesarean.

Perform a rapid, focused physical examination. Confirm the estimated gestational age by noting the symphysis to fundal height in centimeters. Remove all clothing from the lower half of the patient, and assess for dilation, effacement, and crowning.

Obtain and prepare equipment for delivery (see Table 61-1). Calmness is first requirement of any delivery. Ninety-five to ninety-seven percent of all deliveries are vertex presentations—there is great probability the delivery will be uncomplicated. You will assist the mother—she will deliver the child. Cleanliness is second, and control is the third requirement. The cardinal movements are engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion of the baby.

Essential Equipment

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  PPE

  
  
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  Plastic-lined under pad

  
  
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  Drape sheet

  
  
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  Towels

  
  
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  Receiving blanket

  
  
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  Two umbilical clamps or ties

  
  
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  Scissors or scalpel

  
  
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  Plastic bag for placenta with tie

  
  
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  Cold pack

Technique

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  Step 1: Encourage the mother to take deep, slow breaths. Pain can be controlled to different extents through mental relaxation and by concentrating on deep breathing.

  
  
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  Step 2: Guide pushing, especially with crowning. Push between contractions (not at their peak) to attempt to slow down the birth. Have the mother blow out through her mouth at the peak of each contraction to help resist the urge to push. Stretching external vaginal opening with lubricated fingers may help decrease the likelihood of a tear.

  
  
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  Step 3: If the amniotic membrane is still intact and obstructing the delivery, pinch it to break a hole, and then tear it open.

  
  
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  Step 4: Place your hand on the advancing fetal head to control rate of expulsion, and support the baby’s head as it emerges. Never pull or twist the head, as this can cause CNS injury.

  
  
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  Step 5: When the head has delivered, check for nuchal cord. If present, gently lift the cord over the baby’s head or loosen it carefully so the baby can slip through the loop created by the cord (Figure 61-1).

  
  
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  Step 6: The baby’s head will rotate to one side spontaneously. Gently guide the side of the baby’s head downward so that anterior shoulder emerges with the next push (Figure 61-2).

  
  
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  Step 7: Lift the body upward gently to deliver the posterior shoulder, and the rest of the baby will follow very quickly—catch the feet between your fingers. (Figure 61-3) If the head comes out and the rest of the body does not after three pushes, have the mother pull her knees to her chest and push hard with each contraction. Consider an episiotomy as a last resort. (Figure 61-4)

  
  
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  Step 8: Hold delivered baby with both hands, slightly head down, at the level of the perineum. Dry and stimulate the child, noting the color, vigor of cry, and response to stimulation. Routine bulb suctioning of the oral and nasopharynx is no longer recommended unless airway obstruction is present. It is usually unnecessary and may result in vagal stimulation, causing apnea or bradycardia.

  
  
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  Step 9: Cord clamping should be delayed for at least 1 minute. Benefits of this additional blood flow include improved iron status, higher blood pressures after stabilization, and lower incidence of intraventricular bleeds.

  
  
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  Step 10: Ascertain the APGAR score (Table 61-1) at 1 and 5 minutes for the medical record, but resuscitation, if needed, should begin promptly and not awaiting the 1-minute score. Term babies should initially be resuscitated with room air and, when indicated, the administration of supplementary oxygen regulated by blending oxygen and air, if available. Chest compressions are started for a heart rate under 60. If the baby remains bradycardic after 90 seconds of resuscitation, increase the oxygen concentration to 100% until a normal heart rate is achieved.

  
  
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  Step 11: If oximetry is available, preductal measurements can be obtained from the right wrist or palm. At 1 minute, most babies will have an O₂ sat of 60% to 65%. It may take up to 10 minutes for a newborn to achieve normal preductal saturations of 85% to 95%.⁵

  
  
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  Step 12: When the child is stable, lay it on the mother’s abdomen for warm skin-to-skin contact. There is no need to wait for the delivery of the placenta before beginning transport to the hospital. The placenta typically delivers about 15 minutes after the baby. Do not pull on the umbilical cord to hasten the expulsion.

  
  
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  Step 13: Uterine massage will help decrease postpartum hemorrhage, and an ice pack applied to the perineum will ease the pain and swelling.