Subject: Emergency Child Birth
EVALUATING THE MOTHER
As a general guideline, there are three cases in which you should not try to transport the mother to a hospital or doctor:
1. When you have no transportation available.
2. When the delivery of the baby can be expected within five minutes.
3. When the hospital or doctor cannot be reached (due to a natural disaster or some other kind of catastrophe). Imminent delivery can best be determined by simply talking to the mother. Open lines of communication and good rapport with the mother are necessary for a successful delivery. The mother is naturally nervous and apprehensive, since she expected to have her baby in the well- controlled environment of a hospital delivery room -- not in the street or at home. When you arrive at the scene and find a woman in labor, you will first need to determine whether you have adequate time to transport her to the hospital. To make this decision, ask the mother certain questions:
1. Has the mother had a baby before? Labor during the first pregnancy is usually slower than in later pregnancies, allowing more time for transport. If this is a first child, you will have time to transport unless the mother's vagina is bulging and you can see the crown of the baby's head in the birth canal. In women who have had several children, there may not be much time. Previous deliveries cause most of the structures used in the birth process to stretch, permitting easier delivery.
2. How frequent are contractions? Contractions more than five minutes apart generally allow enough time to get the mother to a nearby hospital. Contractions less than two minutes apart, especially in a woman who has had more than one pregnancy, signal impending delivery and do not allow enough time for transport. False contractions, or "false labor," may begin as early as three or four weeks before actual delivery. These contractions, part of the natural stretching process that begins early in pregnancy, allow the uterus to grow with the development of the fetus. As the fetus grows and the uterus enlarges, these contractions become more and more evident. They are usually confined to the lower part of the abdomen and groin but do not increase in intensity. True labor contractions are felt in the lower back and extend in a gird like fashion from the back to the front of the abdomen. There is a definite pattern to the rhythm and a gradual increase in intensity, frequency, and duration. False labor pains are irregular and are usually relieved by walking. In true labor, the intervals between contractions are regular and do not cease with exercise. During labor, the interval between contractions gradually diminishes from ten minutes in early labor to two or three minutes in the second stage. The duration of the contractions is usually forty-five to ninety seconds. For the woman bearing her first child, the total length of labor can be up to eighteen hours. For women who have had several children, eight hours is not uncommon. However, remember that no two women are alike.
3. Has the mother's amniotic sac (bag of waters) ruptured, and if so, when? If rup- ture occurred many hours before, the likelihood of fetal infection is increased, and the hospital staff should be alerted.
4. Does the mother feel as though she has to move her bowels? This sensation is caused by the baby's head in the vagina pressing against the rectum and indicates that delivery is imminent. Under no circumstances should you allow the mother to sit on the toilet. Excessive bearing down by the mother will cause early delivery and may result in the death of the child.
5. Examine the mother to see whether the crown of the baby's head (or whichever part of the baby comes out first) is bulging out of the vagina. If so, the baby is about to be born, and you will not have time to go to the hospital before delivery. This can only be determined by direct examination. Communication with the mother is crucial at this point; you must have gained the mother's trust and confidence. A simple explanation about the necessity for examination should suffice for the mother and or father. Every step of the examination should be carefully explained in simple, easily understandable terms. If you think that you have plenty of time for a trip to the hospital, transport the mother in the following manner:
1. Keep her lying down, and remove any underclothing that might obstruct delivery.
2. If possible, place a stretcher underneath the mother during transport.
3. Place a folded blanket, sheet, or other clean obiect underneath her buttocks and lower back.
4. Have the mother bend her knees and spread her thighs apart so that you can watch for the fetal crowning (appearance of the crown of the baby's head in the birth canal) .
5. If the father or someone else is present, ask that person to reassure the mother and to talk to her during this part of the examination, since it can be embarrassing for both parties.
6. Do not allow the mother to go to the toilet.
7. Never ask the mother to cross her legs or ankles, and never tie or hold her legs together in an attempt to delay delivery. Never try to delay or restrain delivery in any way, since this causes undue pressure and may result in death or permanent injury to the infant.
8. In case of vomiting, turn the mother's head to one side and clean out her mouth, either manually or by suction.
Prep for a normal delivery
1. Assist the patient to lie on her back with her knees bent and separated as far apart as possible and her feet flat on the surface beneath her. A hard surface is best for the mother -- it can be softened a little with folded sheets or towels or blankets (you can even use newspapers if you have nothing else) -- and it is easier for you if the surface can be elevated. Most of the time, the mother will be in her own bed or some other bed in the house. Try placing chairs underneath the bed legs to elevate the bed, and make it firmer by putting a solid object (such as a piece of plywood, an ironing board, or table leaves) between the mattress and the box springs. If the mother is in her bed, try to protect the mattress from the blood and amniotic fluid. Use a waterproof sheet, if one is available, or keep a thick layer of newspapers next to the mattress. If possible, place a stretcher underneath the mother on the bed. It will make transport easier, and you will not have to disturb the mother. It will also protect her bed while providing a firmer surface. Lift the mother's buttocks about two inches off the surface with a pad of folded sheets, blankets, or towels. Position the mother so that at least two feet of surface extend beyond her vagina. This surface will support the slippery baby. If the mother is in an automobile and lying down on the seat, have her place one foot on the floorboard.
2. Remove any constricting clothing, or push it above the mother's waist. 3. Have the best possible light directed toward the mother's genital area. Watch for gapping of the vagina and bulging of the skin between the vagina and the anus. With each contraction, the baby's head may be visible as the labia (lips of the vagina) open wider.
4. If equipment is available, place it on a table next to the mother; keep it away from the birth canal so that it will not be contaminated by the gush of amniotic fluid. Cleanse your hands with germicidal wipes. Place the pack where it will be convenient for you to use, and open it. Remove one sheet, touching only the corners. Between contractions, when the mother can concentrate on what you are telling her to do, ask her to raise her hips. Place one fold of the sheet well underneath her hips, and unfold it toward her feet. If time permits, use a second sheet to cover the mother's abdomen and legs, leaving the birth canal area uncovered. If you do not have sheets, use a sterile towel.
5. Do not touch the vagina at any time. 6. Put on sterile gloves if you have them.
7. Watch for the emergence of the top of the baby's head at the vagina. Be prepared to support the baby's head as it emerges.
Delivery of the Baby
1. As the baby's head is born, it normally faces down; it then usually turns so that its nose is toward the mother's thigh.
2. As soon as the baby's head is visible, support the head with one hand and pick up the rubber bulb syringe. Compress the syringe BEFORE you bring it to the baby's face. When it is compressed, insert the tip of the syringe about 1 to 1.5 inches into the baby's mouth. Then slowly release the bulb to allow mucous and water to be drawn into the syringe. Remove the syringe and discharge the syringe contents onto a towel.
3. When the head is born, check to see if the umbilical cord is around the baby's neck. if it is, use two fingers to slip the cord over the shoulder; or clamp, cut, and unwrap the cord.
4. To help the lower shoulder out, support the head in an upward position. As the shoulders emerge, be prepared for the rapid appearance of the rest of the baby's body -- the head and shoulders are the widest parts and take the longest to emerge.
5. As the abdomen and hips emerge, place your other hand under these areas. You should now have two hands supporting the baby.
6. No attempt should be made to pull the baby from the vagina. If the amniotic membranes cover the head after the baby emerges, the sac should be torn with a clamp, the fingers, or with forceps to permit the escape of amniotic fluid. Move the sac away from the baby's face to enable the baby to breathe. Avoid touching the mother's anus during delivery. When born, the baby will be bluish and covered with a whitish, cheesy, slippery substance known as the vernix caseosa.
7. Use a sterile towel (or the cleanest cloth available) to receive the baby. If possible, note and record the time of birth.
8. As soon as the baby is completely delivered, pick it up to allow mucous and fluid to drain from its nose and mouth. Be sure that you have a firm hold, because a newborn baby is very slippery. Grasp the baby at the ankles, slipping one of your fingers between them, and support the baby's shoulders with your other hand, with your thumb and middle finger around the baby's neck and your forefinger supporting the baby's head. You can place a towel around the ankles to give you a better grip.
9. Do not pull on the cord when picking up the baby. Raise the baby's hips slightly higher than its head for drainage, and lie the baby on its side at the level of the birth canal or lower (do not place the baby on the mother's abdomen at this time). It will probably breathe and cry almost immediately. Soon after this cry, the cord will become limp and will no longer pulsate -- the blood flow ceases, since the baby no longer needs it.
10. Suction out the baby's mouth several more times to clear it of all mucous. Wipe away any blood and mucous from the nose and mouth with sterile gauze or a gloved finger, maintaining a firm hold to prevent the baby from slipping. Then use the rubber syringe to suction the mouth and both nostrils. Be sure to squeeze the bulb before inserting the tip, then place the tip in the baby's mouth or nostrils, and release the bulb slowly. Expel the contents into a waste container, and repeat suctioning as needed. Keep the baby's head lowered when clearing mucous by finger or syringe -- do not attempt to support the baby in midair while holding it only by its feet.
11. If the baby does not breathe on its own at this point, stimulate it by rubbing its back gently or by slapping the soles of its feet. If you still get no response, start mouth to-mouth ventilation, bearing in mind that babies are very little and thus require very small puffs. Never use mechanical ventilation devices on a newborn infant. If the baby begins breathing on its own, administer oxygen by mask (four liters or less) until the baby's skin color is pink. If breathing is still absent, however, and no pulse is present, begin cardiac compression, and continue it until you arrive at the hospital. Keep the baby wrapped in a blanket as much as possible.
12. As soon as the baby is breathing and crying, wrap it in a blanket (if you have one). If possible, the blanket should be heated to about 90" F. Wrap the baby so that only its face is exposed. Do not pull on the cord, and do not tie the cord. The cord will usually be long enough for you to place the baby on the mother's abdo- men; help her to hold the baby there in a side-lying position.
13. Unless it is policy in your area, do not worry about tying or cutting the cord. When the baby first cries, the circulation from baby to cord normally ceases, and clots form to seal off the umbilical blood vessels. The cord must be cut under strict antiseptic conditions because of possible infection, so you should not cut it if you cannot do it antiseptically. Leaving the cord and placenta attached to the baby may be a bit messy, but it is safe. No harm will result, and this will prevent improper tying andlor cutting of the cord. if it is necessary to cut the cord, of if it is standard procedure in your area, place two clamps on the cord about three inches apart, positioned about six inches from the baby's navel. About one inch from the clamp that is closest to the baby's body, tie the cord off (on the baby's side of the clamp) with the umbilical tape. Compress the cord very slowly with the tape to avoid cutting through it. (Never use string or thread -- you will cut through the cord immediately.) Tie the tape with a square knot. Cut the cord between the two clamps, using the sterile surgical scissors. Periodically check the ends of the cord for bleeding, controlling any that may occur.
Delivery of the Placenta 1. If there are no complications, and cutting the cord is accepted local protocol, observe the appearance of the cord and its location at the vagina. As the placenta separates from the uterus, the cord will appear longer.
2. Place one hand on the mother's abdomen, and feel for a definite contraction. The contracting uterus should feel like a hard grapefruit-sized ball.
3. Wait for the delivery of the placenta. The placenta is usually delivered within ten minutes, but fifteen to twenty minutes may elapse. Most will deliver within twenty minutes. Never pull on the cord to check for separation of the placenta. As the uterus contracts, encourage the mother to bear down to expel the placenta and membranes. Some bleeding may be expected as the placenta separates.
4. When the placenta appears at the vagina, grasp it gently, and rotate it. Do not pull, but slowly and gently guide the placenta and the attached membranes (fetal sac) from the mother's body.
5. Do not cut the cord unless it is necessary or unless you are instructed to do so. Wrap the placenta in a sterile towel, and place it next to the baby. Wrap the baby and the placenta together in the third sterile sheet from the pack, and place both in the mother's arms.
6. When the placenta is delivered, and if the cord has been cut, place the placenta in a plastic bag to be taken to the hospital, where it may be examined for completeness; retained pieces of placenta will cause persistent bleeding.
7. Check the amount of vaginal bleeding. A small amount (one or two cups, or less than 500 milliliters) is normal.
8. Examine the skin between the anus and the vagina for lacerations, and apply pres- sure to any bleeding tears.
9. Remove the soiled sheet. Save all evidence of blood loss (stained sheets or towels) for the physician to examine.
10. Place two sanitary napkins over the vaginal and perineal area (the area between the vagina and the anus), touching only the outer surface and placing the napkins from the vagina toward the anus. Help the mother place her thighs together to hold the napkins in place.
11. Elevate the feet if needed.
12. Massage the mother's lower abdomen to help contract the uterus. Do this by feeling the abdomen until you note a "grapefruit-size" object. This is the uterus. Rub in this area, using a circular motion. This will help the uterus contract, thereby controlling bleeding. If the mother desires to nurse the baby, let her do so, because this will also help to control the bleeding. If there is a tear in the tissue between the vulva and the anus (perineum), let the mother know that this is normal and that it will be taken care of at the hospital.
13. Continue to give the mother lots of comfort and emotional support. 14. Cover the mother and baby for warmth, but do not overheat. Prepare both for transportation to the hospital. Remember, complications are more likely to develop in a cold, stressed infant.
IMPORTANT: PROTECT BABY AGAINST HEAT LOSS!
PRE & POST: DELIVERY EMERGENCIES
Major conditions may be present in a pregnant woman who has not yet delivered:
1. Convulsions. A pregnant woman may experience a seizure from any usual reason (epilepsy, high fever, blow to the head, etc.) or from toxemia. If a pregnant woman is having a seizure: · Place her on her side. This will allow her to breathe easier, thus supplying the baby with more oxygen. · Give oxygen if possible. During a seizure, the mother's body, hence the baby, will become oxygen-deprived and will need additional oxygen. · When the seizure subsides and the patient regains consciousness, elevate her head and shoulders. This will allow her to breathe easier and will make her more comfortable.
2. Heart-Lung Complications. Though not common, it is possible for a pregnant woman to experience breathing difficulties from allergies, asthma, etc., or even to have a heart attack. If an event of this type occurs: · Give emergency care for the existing condition. · Administer oxygen. 3. Hemorrhage. There are various reasons for a mother to bleed from the vaginal opening. You should observe the external area of the vagina but should not examine vaginally. A vaginal examination can increase the hemorrhage. Give the following care: · Adminster a high concentration of oxygen immediately if available. Maintain the patient's body temperature with blankets. Encourage the mother to lie on her side, which should allow the mother to breathe easier, thence help to oxygenate the baby's blood more efficiently. A pneumatic counterpressure device (i.e., MAST) may be used only on the legs if the emergency rescuer is trained in its use, if a physician is contacted first (follow local protocol), and if the mother's condition warrants it.
Umbilical Cord Around the Neck
If the umbilical cord is wrapped around the baby's head in the birth canal: 1. Try to slip it gently over the baby's shoulder or head.
2. if you cannot slip it over the baby's head, and if it is tight around the neck, place clamps or ties on the cord two inches apart, and cut between them quickly; unwrap the cord from around the neck.
3. Deliver the shoulders and body, supporting the head at all times. Limb Presentation If an arm or a leg is first to emerge from the vagina, you must transport the mother im- mediately to the hospital. A limb presentation means that the baby has shifted so much in the uterus that a normal delivery is impossible and that the baby will have to be delivered by surgical technique. Delay can be fatal. DO NOT attempt to pull on the baby by an arm or leg.
If the baby's shoulders become wedged in place after the head has been delivered:
1. DO NOT attempt to pull on the baby.
2. Suction the baby's mouth and nose.
3. Make sure that the baby is breathing.
4. Transport mother and baby to the hospital.
5. Constantly monitor the mother and baby during the transport.
Multiple births generally present no problems, and twins are delivered in the same manner as single babies, one after another.
1. Even if the mother is unaware of the fact, you may suspect a multiple birth if the abdomen is still very large after one baby is delivered; there are more strong uterine contractions, and the baby's size is out of proportion to the mother's abdomen. Labor contractions start again about ten minutes after the first baby is born.
2. When the first baby is born, clamp and cut the cord (as described earlier) to prevent hemorrhage to the second baby. Contractions will continue, and the second and subsequent babies should be born within minutes. Handle the baby as you would for a single birth.
3. If the second baby has not been delivered within ten minutes of the first, transport the mother and the first baby to the hospital for delivery of the second twin. After the babies are delivered, the placenta or placentas will be delivered normally.
4. Keep the infants warm. Twins are often born early and may be small enough to be considered premature. Special precautions should be taken to prevent a fall in temperature.
A premature baby is one that weighs less than five and one-half pounds or one that is born before seven months (twenty-eight weeks) of gestation. You can judge by the baby's appearance or from the history given by the mother whether or not the baby is premature. Premature babies are more susceptible to respiratory diseases and infection and must be given special care. Thinner, smaller, and redder than a full-term baby, a premature baby also has a larger head in proportion to his body. Take these steps to care for a premature baby:
1. Keep the baby warm. Wrap him in aluminum foil as an outer wrapping for extra insulation if you have no other facilities to heat him.
2. Keep the baby's nose and mouth clear of fluid by gentle suction with a bulb syringe.
3. Prevent bleeding from the umbilical cord; a premature infant cannot tolerate loss of even minute amounts of blood.
4. Give oxygen into a tent above the infant's head; do not blast the oxygen directly into the baby's face.
5. Prevent contamination. Premature infants are highly susceptible to infection. Keep your breath from the baby's face, and have other people stay back.
6. If you have the facilities in your vehicle, you can warm the baby during transport by placing covered hot water bottles in the bottom and along the sides of a crib. Make sure that you wrap the baby securely and that the bottles are covered completely, since the skin of a premature infant burns easily .
Excessive Bleeding After Delivery
Internal bleeding can result when placental products are left in the uterus, when uterine contractions are inadequate, or when the mother develops clotting disorders. If bleeding is profuse, continue uterine massage, and put the baby to the mother's breast. If bleeding persists, transport the mother rapidly to the hospital while giving her care in the usual way for shock. Avoid vaginal examination or packing of the vagina. Continue gentle uterine massage during transport. External bleeding from tears in the skin between the vagina and the anus can be managed with firm pressure. It may be necessary to open the labia to lay packs at the bleeding site.
Breech birth refers to a delivery in which the baby's buttocks appear first instead of the head. All efforts should be made to get the mother to the hospital, but when transport is not possible, follow these rules:
1. Position the mother as usual, and prepare her for delivery as usual.
2. Let the buttocks and trunk of the baby deliver on their own.
3. Place your arm between the baby's legs, and support the baby's back with the palm of your hand. Let the baby's legs dangle astride your arms. The head should follow on its own.
4. If the head takes longer than three minutes to deliver after the waist and trunk have delivered, you must take steps to prevent the baby from suffocating, since the baby's head will compress the umbilical cord inside the vagina and cut off circulation. · Place your middle and index fingers along the infant's face with your palm toward his face. · Reach into the vagina to the baby's nose. Form an airway as you push the vagina away from the baby's face until its head is delivered slowly. Put your finger in the baby's mouth so that he can breathe.
5. Do not try to pull the baby. Never attempt to pull the baby from the vagina by his legs or trunk.
6. When the head has been delivered, give the mother and infant normal postdelivery care.
7. If the head does not deliver within three minutes, transport the mother to a medical facility either with her buttocks elevated or in a knee-chest position. Maintain the baby's airway throughout transport.