Assisting with Birth
If you are a person who may be helping a mom with the birth of her baby in an emergency situation, this information will help you stay calm and let birth happen naturally.
Looking at the anatomy of the female reproductive system.
Baby – fetus
Uterus – Organ baby is growing in
Birth canal (vagina) -
Cervix (opening at the end of the uterus) -
Bloody show – pink tinged mucus and maybe some blood mixed. Not a cause for concern. Not an emergency.
Perineum – area between the vagina and the anus. This is the area that the baby’s head will be bulging through. If birth is immanent you may see some of the baby’s head at this point. Mom will be actively pushing.
Placenta - A thick disk, about the size of a plate. Baby is hooked to cord. Cord is hooked to placenta. Placenta stuck to inside of uterus. The placenta feeds the baby oxygen and nourishment from the mother’s blood. Mom’s blood and baby’s blood do not usually mix. Nourishment and oxygen are exchanged in the placenta and where it hooks to mom. Once baby is out, placenta detaches from the wall of the uterus. Usually preceeded by a normal gush of blood of around ½ cup, or maybe a little more
Amniotic sac – bag of waters about 500 – 1,000 ml of fluid. Insulates and protects baby from bumps. The gush of water one might see is a normal part of labor and the lack of it inside will not harm the baby. Baby will be able to come out just fine, whether water has broken and or not.
Normal vitals for mom:
BP - should be under 140/90 and not too low
Temp – (usually a little higher while pushing) 98.6
Pulse – 60 – 90 (if working hard)
Oxygen stats – normal
Normal vitals for baby:
FHT – 120 – 160
Color of emerging head (best indicator of how baby is doing) – pinkish, or pinkish- purple…white not good, dark blue not good.
Respirations (after born) 120 – 160
Any questions?
Time line of pregnancy:
Normally 36 – 40 weeks. Before 37 weeks is too early to be born at home.
In Montana, 42 weeks is waiting too long to have a birth at home, unless a doctor is supervising.
Pregnancy is divided into 3 trimesters.
1st Trimester – 2nd Trimester - 3rd Trimester, 3 months each
Labor is divided into 3 stages:
Look at “What moms look like in labor” chart
1st Stage – chart
From start of contractions to full dilation. For first time moms usually takes average of 16 hours. Usually you will have time to transport a first time mom if she is in first stage still and not pushing. Multigravida (or mom who has had more than one baby) may only labor 8 hours or much less, depending on how may babies she has had and the labor pattern.
Onset of labor: water breaks (sometimes)
Bloody show (sometimes)
Contractions last about 30 – 60 seconds and getting longer and stronger. Uterus will stand up and change shape with each contraction and stay fairly hard between contractions.
2nd Stage – chart
Begins when cervix is fully over the top of the head and the head slips through into the birth canal and ends when baby is out.
It is during this stage that you need to make a decision about whether to transport.
Signs: Mom feels a lot of pressure on her bottom, like she has to have a huge bowel movement. She will probably have an intense urge to push. If not, the uterus is capable of pushing the baby out without help from mom. If you do not want a mom to push, simply have her say pa-pa-pa, or shallow breathe in the top of her chest. Demonstrate breathing technique and get eye contact with her.
If the perineum is pushing outward and baby’s head is showing, just relax and get ready to catch.
3d Stage – chart.
Starts when baby is born and ends with the delivery of the placenta. This may take up to 30 minutes. Usually you will not transport the mother during that time. Be sure to follow BSI precautions, as this is the messiest part.
Emergencies Before Baby if born.
You get a call to respond to a mom who is feeling very sick, is bleeding or in a lot of pain with her pregnancy…
Options:
Pre-eclampsia – or pregnancy induced hypertension. Moms will be over 20 weeks along (usually only found in 1st time moms)
Cause: Liver/metabolism overload.
End result if not cared for could be: seizures, comma, death of baby and mom
Symptoms:
Headache, pretty severe
Seeing spots
Swelling in hands and feet (not just in feet, but usually both)
Anxiety
High Blood Pressure (way over 140 / 90)
Supine Hypotensive Syndrome: – Not an emergency in itself
Cause: mother lies on her back, baby compressing inferior vena cava.
Symptoms: low blood pressure, feeling faint, weak
Transport lying on left side
Hemorrhage – Any heavy, bright red bleeding from the vagina, in a pregnant woman is a serious sign. Treat for possible shock (left side lying only, high-flow oxygen, blanket, etc… Place sanitary napkin so hospital can measure how much blood is lost and replace as necessary. Save all pads and all tissue. Do not put anything in the vagina to avoid infection.
Causes:
Miscarriage – bleeding, sometime very heavy, cramping. Mom may be in shock from lack of blood.
Ecoptic pregnancy – A pregnancy that develops outside the uterus, most often in the fallopian tube. This complication is the one that develops into internal hemorrhage following rupture.
Symptoms: Missed menstrual cycle
Sudden stabbing, unilateral, pain in lower abdomen
Placenta abruption – placenta separates prematurely from the wall of the uterus.
Symptoms: Rock hard uterine contractions, no break in between, very painful. Heavy, bright red, bleeding, unless baby is crowing and blocking vaginal opening. bleeding. Mom may be in shock.
Placenta previa – placenta grows over cervix and blocks baby’s exit from uterus. Symptoms: Heavy, bright red, bleeding, unless baby is crowing and blocking vaginal opening. bleeding. Mom may be in shock. Baby may be in distress or….?
Accidents – Pregnant woman who have received heavy injuries may be experiencing severe internal hemorrhage. Treat for shock, support airway. Put small wedge or rolled towel under a mother’s hip or somehow be mindful of avoiding supine hypotension if mom is advanced in her pregnancy.
Preparing for Delivery.
You are called to the scene of a mom who is giving birth to her 5th baby. She is obviously in heavy labor… How do you determine whether delivery is going to occur within the next few minutes?
Consider proceeding with the birth at the scene if:
Delivery is within a few minutes.
A natural disaster, bad weather or some other problem makes it impossible or safe to get to the hospital.
When no transportation is available.
How do you know whether baby is about to say hello to the world?
Ask mom questions: (or someone that can talk for her). A woman in heavy labor may not be able to communicate coherently to a barrage of questions.
How long have you been pregnancy (or when is your due date)?
Is this your first baby?
How far apart are contractions? How long do they last?
Do you feel like you have to push (have a big bowel movement)?
Any spotting or bleeding?
Water broken, or water gushing with contractions?
Was your previous child delivered cesarean?
If mom has given birth before, she may be able to tell you whether the baby is about to be born. If she says yes, get ready. (Put your catcher’s mitt on, knees slightly bent, leaning forward… and get ready!)
Observe: Is mom’s abdomen rock hard?
Is she grunting, straining, or pushing with contractions?
Do you see perineal bulging or head crowning?
Is she obviously having a hard time coping with each contraction?
A woman in transition (the past part of 1st stage) may be having a hard time coping with each contraction and feel a sense of panic.
A woman in early labor say she is in pain with each contraction, but can talk during and between contractions quite well.
A woman is active labor 5 – 7 cm will not talk during a contraction, nor will she feel like chatting between. She will be leaning over a bit and her abdomen will be very hard (stand up and change shape) with contractions.
A woman with active pushing is not usually in extreme pain. She is making a lot noise, maybe even swearing, but she should not in terrible pain.
To Do:
Once labor is well underway, there is no stopping the program (A lot of mom’s wish they could!)
Do not hold mom’s legs together.
Do not pry her legs open. Ask mom to relax and let her legs go so you can observe her perineum if she is pushing.
Do not let her use the toilet, or be alone in the bathroom or bedroom.
If you do decide to deliver at the scene:
Your part: Help, guide, and support baby as it is born. Stay calm, talk firm, comforting words, and protect modesty while setting her in a semi-sitting position.
Mom’s part: Side-lying - If baby is coming fast, have mom assume a left side-lying position with one leg supported up. This takes the pressure off the baby’s head. Encourage her to be in control, make low sounding birth noises (not high pitched screaming) and to listen to your directions.
Semi-sitting, Fowler’s position: Mom should be sort of sitting up (not lying flat on her back). Use pillows or blankets to support her.
You are going to need in your OB kit for the emergency vehicle:
Sterile umbilical scissors
Cord clamps and or tape
Small rubber bulb syringe
4 by 4 gauze
Sterile gloves
2 or 3 Infant blankets (one to wipe off, one to keep warm and another to change)
Sanitary napkins to measure blood
Infant size bag-valve-mask
Plastic bag for placenta
Any Quesitons?
Case study 1: So, you arrive at the home of a very pregnant mom lying on her big soft couch in heavy labor. Her husband is at work and on his way. She is not really communicating with you coherently to answer your 20 questions. 3 young kids are sitting on the floor with open-mouths, alternately staring at you and then her…. the neighbor lady arrives from next door and now it is time for you make a decision.
Let’s walk through some thoughts in your head.
What is the first thing crossing your mind?
What do we look for first?
How should we proceed if mom is pushing,
As time allows:
History and how it relates to present: she isn’t answering questions very well.
Physical exam: Perineum bulging, baby’s head can be seen about the size of a quarter. Mom grunting with each contraction. No blood, lots of pink tinged mucus.
Baseline vitals: no time
Initial assessment: prepare for birth
Action: Put Mom on floor --- kids on couch.
Put sterile towel or pad under mom
Open OB kit
Get sterile gloves on
Questions?
Case study 2: A man waves you down off the road, as your emergency vehicle arrives and parks at the side of the road. You are responding to a call from cell phone calling for 911. You get out and open their car door to find a woman with lots of fresh blood all over the seat under her. She said she feels like pushing, but she is also obviously in a lot of pain. She is distraught at having the baby in the car and with the sight of all the blood. She is breathing heavily and is pretty pale in the face.
What do you think?
History: First baby
Physical Exam: no bulging at perineum, lots of fresh blood
Baseline vitals: 90/ 65
Initial assessment: Danger for mom and baby with all the blood.
Action: Treat for shock. Transport immediately, even if birth is soon. (Probably won’t be, as this is a first time mom.)
Questions?
Delivering the Baby:
(Assuming that there are two of you responding.)
Mom’s needs: Assistant needs to be at mom’s head to comfort, soothe and keep her calm during delivery. She may appreciate someone’s hand to grip as she pushes. You can also have her pull her legs up, and hold onto her thigh’s from the outside as she pushes. She may be yelling or just quietly working hard to push that baby out.
Your job: Time contractions if there is time. (Abdomen will be very hard. We time from the start of one to the start of another one.)
Have mom breathe quick short breaths during pushing. Do not hold breath and puuuuuuuush! Deplete’s oxygen levels for baby.
Watch for crowning. Make mom comfortable. Keep eye contact with her and communicate with her. Important!
Birth:
1. Just as baby’s head is starting to crown, have mom stop pushing. Have her pant or say pa – pa – pa – pa . Let the head ease out. Put medium pressure on the top of the baby’s head to slow head coming so mom doesn’t tear. Let uterus bring baby’s head to crowning with next contraction.
2. As soon as baby’s head is out, have mom stop pushing. Suction mouth first and then the nose.
3. Side gloved finger down the back of the neck to feel for a cord wrapped around. If it is, gently pull some cord out, and pull it over the baby’s head.
4. Baby’s head will rotate to one side as it aligns with the shoulders again as they come under the pubis.
5. Hold the baby by the sides of the head and pull down gently to let the upper shoulder appear.
6. Support the head and upper body as the lower shoulder is born, pulling up.
7. Put baby on mom’s tummy and cover them both over with a blanket.
8. Do not cut cord, unless there is a need to remove baby from mother.
9. Allow placenta to deliver itself. Do not pull on cord. As placenta appears, twist, teasing membranes out in one piece. Can take up to 30 minutes.
Notes on Head Delivery:
What it looks like: Emerging brains. A baby’s skull plates fold over each other, to allow the head to fit through the birth canal. What you see is called molding. It is normal. The scalp wrinkles and looks like pushed together as it is first starting to crown.
Objective: Not to let the baby POP! out. Once baby is really starting to emerge, put gentle pressure on the top of the head pushing down to keep the baby’s chin tucked on his chest. Supporting the perineum at the top horizontally, with a 4 by 4, may prevent injury and a tear.
Things to look out for:
Unruptured Amniotic Sac – Remove from baby’s face so baby can breathe. Puncture the sack with a clamp away from baby’s face, holding a towel. Suction baby’s mouth and nose immediately. If water has a bad odor, or is dark green, make a note to report to doctor.
Umbilical Cord around neck – Nucal cord. One that is wound tightly, several times needs to be released from the baby’s neck quickly after the head is out so baby can breathe.
Note: If you find the cord around the baby’s neck simply hold baby’s head towards the way he is facing to the mother’s thigh and as the baby’s body is born, let him summersault through the cord. WHY? If you cut the cord, and the baby does not deliver right away, due to stuck shoulders or? Then baby’s oxygen supply is cut off. Baby will deliver with short cord, unless it is wrapper around many times. Usually a cord is impeding decent is wrapped around an arm or the body and there is nothing that can be done about it.
Have to quickly cut the cord: Healthy cords are really tough to cut through and will spurt blood. Unhealthy placentas and cords may cut easily.
1. Place a clamp on the cord. Put another one about 2 inches away. Cut cord.
2. Unwrap cord from neck. If cord is around the neck several times, just cut once and unwrap.
3. Suctioning the baby: squeeze bulb syringe first, then place in cheek, towards back of baby’s mouth. Let go and aspirate mucus. Discard fluid on towel.
Do the same for each nostril, if baby seems to need help breathing because of stuff in the nose.
Notes on Delivering the Body:
Let mom push the rest of the baby out. Upper shoulder and then lower one. Once head is born, the rest usually delivers quite easily, unless baby is large. Don’t pull on the baby from the birth canal. The abdomen and hips appear, grasp the feet as they are born, holding onto the infant, well supported with both hands. Baby will be slippery and have vernix, a white cheesy-looking substance.
Notes on Postdelivery
As soon as the baby is born, stimulate baby with a dry towel and then put baby on its side on mom’s tummy. Cover both with another towel or blanket. Put hat on baby. Keeping baby from getting chilled is really a concern in cooler weather.
Clamp cord once it has stopped pulsing and then cut. Best to wait until cord stops pulsing. (Feel cord placing it between the sides of two middle fingers to avoid feeling your own pulse.)
Delivery of Placenta:
By now baby should be pinking up and breathing well. He may be crying or just plain looking around. No pulling on the cord, unless you can see the placenta at the opening of the vagina. A normal gush of blood will precede the placenta delivering.
Twist the placenta as it delivers, to tease out the membranes and avoid tearing them out.
Put placenta in a towel and then in a plastic bag for physician to examine to see if it is complete.
Help slow bleeding AFTER placenta is born by massaging the uterus. It will feel like a hard ball inside the abdomen. If not, massage the abdomen, until it does get firm. A soft uterus is going to bleed. Keep that uterus firm.
Emergency situations:
•More than 30 minutes goes by and there is no sign of placenta.
•More than 500 mL of blood BEFORE delivery of placenta
•Significant bleeding after delivery of placenta… slow trickle that will not stop or spurting or gushing with heart beat. Use 4 by 4 and put firm pressure on bleeding vessel.
If bleeding will not stop after keeping uterus firm, treat for shock and transport mom and baby to hospital. Never put anything into vagina.
Baby is born:
How is he doing?
Baby should begin breathing by himself within 15 to 20 seconds after birth. If not, rub baby’s back or flick baby’s feet to stimulate breathing. If baby does not begin breathing begin resuscitation efforts.
APGAR score:
Appearance: skin should be pink, Blue fingers and toes are O.K. Palms should be pink. Blue skin all over or blue around the mouth signal central cyanosis.
Pulse: Measure infant pulse in umbilical cord. If no pulse, begin CPR.
Grimace: Grimacing, crying or withdrawing in response to stimuli is normal and indicate that he is doing O.K. Flick bottom of foot.
Activity or muscle tone: Degree of oxygenation determines activity. Normally the hips and knees are flexed at birth. Pull his arm out and see that he recoils it back quickly. Baby should not be floppy or limp.
Respirations. Normally newborns should have regular and rapid breathing, with a good strong cry. If baby is labored in breathing or slow and shallow baby may need help with ventilations.
Table 20 – 1 has how to calculate the APGAR score. Perfect score is a 10.
Baby is crying, breathing well and has great color from his hands to his feet. Good muscle tone. Take one at 1 minute. Take one at 5 minutes. Take on at 10 minutes.
Case study 3.
You arrive on the scene and mom is semi-sitting up on the bed with baby between her legs, cord still attached. Baby is moving, but not crying. Dad is grabbing a blanket to cover baby. Mom is relieved and reaching down to touch baby.
History: Second baby
Physical Exam: baby just born, some fresh blood, lots of black meconium, baby is not crying yet, but is moving slightly.
Baseline vitals: There are now two persons to attend to:
Baby heart tones: above 100, respirations above 40 -60 breaths per minut Mom’s heart rate 55 – 85, respirations normal.
Initial assessment: Baby is slightly blue, put pinking up and stable. Mom is stable, watch for placenta coming and look for hemorrhage.
Action: Wrap baby in blanket and stimulate. Put baby on mom’s tummy to keep warm. Prepare to assist in delivery of placenta. Watch for hemorrhage. Fast delivery often precedes a uterus that says “all done” and then will not stay firm. Cut cord.
Case Study 4:
At the nearby motel a call comes in for help. Mom has delivered a baby unexpectedly and the baby is not breathing. You arrive and rush in to find a white baby, lying quietly and still.
History: no time
Physical exam: whitish blue baby, bluer head
Baseline: not breathing
Initial assessment: there is a heart beat, but baby needs help to breathe.
Action: quickly cover infant’s mouth and nose with mask and begin ventilations with a high-flow oxygen at a rate of 40 – 6- breaths/ minute. Make sure you have a good seal. Using gentle pressure, make the chest rise with each breath.
After 15 to 30 seconds of ventilation, check for heart tones: Heart beat 50 beats a minute. Start chest compressions. 90 compressions to 30 ventilations.
1. Put two thumbs side by side on the chest, with fingers circling the back. Place thumbs one finger width below an imaginary line drawn between the nipples in the middle third sternum.
2. Press the two thumbs gently against the sternum, using only enough force to compress the sternum ½ to ¾ inch.
BVM vent is done during the pause after every third compression. Deliver a total of 120 ventilations and compressions per minute. That seems pretty fast and it is. Ventilation is absolutely crucial to that baby breathing!
Don’t stop until baby takes a breath and starts to pink up. Don’t stop until you reach the hospital and baby is pronounced dead by Dr. Don’t give up! Many babies have survived without brain damage after a long time of effective CPR.
Delivery Complications:
Breech Delivery: Baby coming bottom first, foot first.
Baby is more likely to need NNR. A cord can also be presenting with feet or bottom more often. Breeches are usually slower to emerge, and so there is time to get mom to hospital.
If baby’s bottom has already come out, then let legs and bottom emerge. Wrap body and legs in a towel so you can hang onto the baby more carefully.
Let legs dangle to the side as you support the body. Head should be face down. Wait for head to come out to the hair line. Lift up on body and legs to deliver the face. As head is delivered keep baby’s airway open, by pressing the vaginal mucosa out of the way of the emerging nose and mouth.
Limb Delivery: You cannot successfully deliver a baby emerging with an arm or leg coming out first. Transport.
Don’t push it back in or pull on it. Wrap with a clean, warm towel. Put mom on her back, with head down and pelvis elevated, in case the cord is also protruding to cut baby’s oxygen supply off. High flow oxygen, as mom is probably pretty stressed and so is baby.
Prolapse of Umbilical Cord: Cord is coming out of the vagina ahead of the baby. Situation is dangerous and mom must be transported immediately. The baby’s head will compress the cord, cutting off the oxygen. Don’t attempt to put the cord back. Usually occurs early in labor as membranes rupture, so there is time to get mom to hospital.
Put mom in a knee-chest position. Carefully insert your gloved hand inside mom’s vagina and gently push the head off the cord. Wrap a sterile, moistened with saline solution around the cord. Give mom high-flow oxygen and transport quickly.
Excessive Bleeding: Some blood occurs with most deliveries. Blood that exceeds 500 mL is considered excessive. Although up to 500 is tolerated, you should continue to massage that uterus to keep it firm.
If mom is in shock, transport, massaging uterus en route.
Give mom high flow oxygen.
Place pad at vagina to catch blood to estimate blood loss
Monitor vitals frequently
Don’t hold legs closed and don’t pack the vagina with pads.
Miscarriage or Abortion:
Delivery of baby before 20 weeks is called an abortion or miscarriage. Most are unknown cause, although self-induced abortions by the mom or someone else may occur. Most serious complications are bleeding and infection. Bleeding can be the result of baby or parts of placenta stuck inside.
Bring to hospital any tissue and any surrounding bloody towels or pads in a plastic bag.
In rare instances, massive bleeding and severe hypovolemic or hemorrhage may occur.
Treat for shock and transport immediately.
Twins:
Always be prepared for more than one resuscitation and call for assistance.
If twins are present, the second will deliver before or after the first placenta. Second baby should be born before 45 minutes, after the first one was born.
Delivering an infant from an addicted mom:
No prenatal care.
Pay special attention to your own safety.
Wear goggles and gloves at all times.
Clues to dealing with a drug addicted mom:
Presence of drug paraphernalia
Empty wine or liquor bottles
Statements made by mom or neighbors
Transport mom and baby to hospital, as baby will probably be depressed and need some help getting going.
Premature Baby:
Normal baby weighs about 7 lbs. and is born after 37 weeks. A baby who is born before 8 months and is less than 5 lbs at birth is considered premature.
A preemie is smaller and thinner than a term infant. Head is proportionately larger. Vernix caseosa will be missing on the premature baby. Less body hair.
Premature babies need extra care to survive. Often requiring resuscitation, and should be done unless impossible. Babies 1 lb have survived and developed normally.
1. Keep baby warm. Very important. Dry baby and keep close to someone’s bare skin. 90 – 95 degrees. Book says to keep inside of ambulance at 90 degrees.
2. Keep mouth and nose clear of mucus and airway open
3. Carefully observe the cut end of the cord. Even a couple drops of blood lost in a preemie can be very serious.
4. Give oxygen. Make a tent over baby’s head, don’t direct oxygen into babies mouth and nose. Use a blanket or piece of foil.
5. Do not neglect baby. Protect from contamination. Do not breathe on baby.
6. Notify hospital that you have a preemie en route, if your hospital does not have a neo natal intensive care unit..
Fetal Demise:
Giving parents support and encouragement during this time is a true gift. They may be distraught, they may even be hostile. If the baby is premature, labor should progress normally. If infection has caused the baby to die, note the bad odor from the fluid.
What does a dead baby look like? Infant may have skin blisters, skin peeling or sloughing off, and a dark, mottled discoloration. Head will be soft and perhaps quite deformed looking, as it is squeezed through the birth canal.
Don’t attempt to resuscitate a baby who is obviously very dead.
Do attempt to resuscitate a baby who is experiencing cardiopulmonary arrest. They may also look white and blue mottled looking. You must attempt to help a normal –looking baby, even if they appear to not be breathing.
Delivery without Sterile Supplies
No OB kit? Hopefully you have gloves. Carry out the delivery as usual, using clean sheets and towels. If no sheets and towels are available, use newspapers that are clean.
As soon as the baby is born, wipe the inside of the babies mouth with your gloved finger to clear away blood, meconium and mucus. Do not cut the cord. Just carry the placenta with the baby and mom to the hospital. Keep the baby and placenta at the same level, so the blood does not drain from the baby back into the placenta. Keep baby warm.
Keep an eye open for odor, and color of the amniotic fluid.
Sexual Assault:
Do not examine the genitalia of a victim of sexual assault unless obvious bleeding is occurring that requires you to apply a dressing to stanch the flow.
Tell then not to wash, douche, urinate or deficate until after a Dr. has examined them. This will help preserve evidence of the crime.
If oral penetration has occurred, advise the patient not to eat, drink, brush teeth, or use mouthwash until he or she has been examined.
Perform limited physical exam. Provide treatment quickly, quietly, and calmly as possible. Take care to shield the patient from on-lookers.
Record all facts in detail in writing, even if the victim refuses transport.