1. Emergency Delivery and Newborn Stabilization
Although most deliveries in the field or home occur without complications, there are increased risks for perinatal morbidity and mortality in the out-of-hospital setting.
The probability of death or lifelong brain injury is higher when the child is born after a precipitous, out-of-hospital delivery compared with a controlled, in-hospital delivery.
When a perinatal complication occurs, the treatment during an infant's first few minutes after birth may make a great difference in the child’s functional outcome and quality of life.

2. Objectives Discuss triage of the laboring patient.
Outline the resuscitation-oriented history.
Describe the steps for performing a vaginal delivery.
Describe the steps in resuscitation of the newly born.
Read the objectives.

3. Case Presentation
You are called to the scene of a 20-year-old woman in labor.
ETA to scene: 5 minutes
ETA from scene to nearest hospital with delivery service: 12 minutes
Transport time issues are extremely important for women in labor. Understanding community resources for perinatal care will assist the prehospital provider in deciding when and where to transport a laboring patient.

4. Prearrival Preparation
Review en route:
Triage of laboring patient
Steps for a vaginal delivery
Steps in resuscitation of the mother and the newly born
Prearrival preparation includes review of triage of the laboring patient, steps for a vaginal delivery, and steps in the resuscitation of the newborn.
Emergency delivery and care of the infant in the first 24 hours (the child is termed the “newly born” during this vulnerable period) can be challenging to the prehospital professional.
The presence of more than one patient ― the mother and the newly born infant(s) ― adds another dimension to this challenge.

5. General Impression and Management Priorities
You arrive on scene and find this presentation.
The rapid triage history (short labor) and physical assessment (crowning) indicate that delivery is imminent.
Ask this question: “What is your next step in the care of this patient?”
What is your next step in the care of this patient?

6. Key Concept: Triage of the Laboring Patient
Two simple questions:
Is this your first delivery?
If not, how long was the labor of the first delivery?
Do you feel the urge to push?
If yes, delivery is within 30–60 minutes.
The safest place for the laboring mother and the baby is in a delivery room of a hospital. Sometimes, however, labor is fully in progress when is activated.
Emergency delivery in a moving vehicle is dangerous. When treating a woman in labor, the prehospital professional must first decide whether to transport the mother to an ED or to prepare for an out-of-hospital delivery.
If more than one baby is to be delivered, consider calling for a second ambulance.
In order to triage the laboring patient properly, ask two simple questions and then perform a brief physical assessment of the mother's perineum. This information will tell whether delivery is imminent.

7. Key Concept: Triage of the Laboring Patient
Brief physical assessment:
Is the child’s head crowning?
Is the head or scalp visible at the perineum during contractions?
If yes, delivery is imminent.
Next, perform a brief physical assessment of the perineum. Look for crowning ― the visible appearance of the fetal head at the vaginal introitus. Crowning is a sign that delivery is near.
Use the presence or absence of crowning to help decide whether to transport or prepare for delivery.
If the child's head is not immediately visible, inspect the mother's perineum during a contraction and note whether the head becomes visible. If the infant is crowning or if the baby's head is visible at the perineum with contractions, prepare for delivery unless the transport time is extremely brief (less than 5 minutes).

8. Key Concept: Breech Deliveries
Four percent of deliveries are breech.
Inspection of perineum shows a foot or buttock.
Do NOT deliver a baby with breech presentation in the field; transport to ED.
Four percent of term deliveries are breech deliveries.
Inspection of the perineum will not show a head crowning, but another anatomic part, such as the feet or buttocks, might be visible.
Breech deliveries carry a much higher risk to both the infant and mother than vertex deliveries.
Given the risk of complications and the potential need for an emergency cesarean section to deliver the baby safely, initiate transport to the hospital as soon as a breech presentation is identified, even if delivery appears imminent.

9. Case Progression This is the woman’s second baby.
She states that labor with her first baby was short (2 hours).
She feels the urge to push.
Typically, the time in active labor is longer for first-time mothers (primiparas) than for women who have had prior deliveries (multiparas). A history of short labor, as in this case, often indicates short labor with subsequent babies; be prepared to deliver the newborn.
This mother has an "urge to push." Most women experience this feeling at the end of labor. In general, if the mother has the urge to push, the delivery will take place within an hour in first pregnancies, but within 30 minutes in second, third, or later pregnancies.

10. Key Concept: Preparing for a Field Delivery
Resuscitation-oriented history:
1. Are you having twins?
2. When are you due to deliver?
3. What color was the amniotic fluid?
Many factors in the mother's medical history will affect the outcome of the baby and help predict any need for newly born resuscitation.
However, after the decision has been made to deliver on scene, a resuscitation-oriented history is taken (three questions) to determine management strategies needed to ensure the safety of the baby.

11. Key Concept: Multiple Deliveries
If twins or multiple newly borns are expected, prepare for more than one delivery.
Prepare extra equipment.
One provider resuscitates the first baby while the second provider delivers the second baby.
Consider calling for a second ambulance.
If twins or multiple births are expected, prepare for more than one delivery. This may mean finding extra equipment, preparing an additional warm environment, and planning the management of the first baby while delivering the second.
This usually requires calling for a second ambulance.

12. Key Concept: Premature Newly Born
Prematurity is defined as less than 36 weeks gestation.
Prepare appropriately sized airway equipment.
Emergency deliveries are more common for preterm babies (less than 36 weeks), and prematurity significantly increases the risk of early complications for the child.
Knowing the due date is important for preparing the right resuscitation equipment for airway management and breathing support.
Make sure that there are masks sized for preterm infants less than 30-weeks gestation. Have a size 0 laryngoscope blade and endotracheal tubes in sizes 2.5 and 3.0 ready as well.

13. Key Concept: Meconium
Greenish color of amniotic fluid is a sign of passage of fetal stool.
If there is time, you may suction the baby’s mouth, then nose.
Greenish color in the amniotic fluid is a sign of passage of meconium, which is fetal stool.
Meconium release by the fetus may indicate intrauterine stress, especially hypoxia.
Overly aggressive suctioning, however, may cause vagal stimulation and lead to bradycardia.

14. What equipment do you need for delivery?
Case Progression
The patient states she has only one baby.
She is near term.
The color of the amniotic fluid is clear.
What equipment do you need for delivery?
Read the case progression.
Ask this question: “What equipment do you need for delivery?”

15. Management Priorities: Position Mother for Vaginal Delivery
Prepare an area for the baby, and keep the room warm.
Supine Position Sims Position
Position the mother for delivery (three basic positions); prepare an area for the baby, and keep the room or ambulance warm.
Two delivery positions are illustrated on this slide and a third is illustrated on the next slide.
Supine (on her back) on one side of a bed: You may place a stack of folded towels to raise the buttocks. Suctioning the baby's mouth and nose before delivery of the body is difficult with the mother in this position because most infants are born face down.
Sims position, in which the mother lies on her side with her back toward the attendant and her knees drawn toward her chest. In this position, the infant's head is easy to reach for suctioning before delivery.

16. Management Priorities: Position Mother for Vaginal Delivery
Supine, positioned over the side of the bed.
Advantage: best positioning for suctioning the baby at the perineum.
Disadvantage: EMS professional must “catch” the baby.
A third position to consider, in situations where oropharyngeal suctioning is necessary, is with the woman lying supine and positioned over the side of the bed, with each foot on a separate chair and her perineum at the edge of the bed.
After the baby's head is delivered, this position provides enough space to suction the mouth and nose before delivering the body.
The disadvantage of this position is the lack of a supportive surface under the perineum so that the prehospital professional must actually "catch" the baby.

17. Management Priorities: Vaginal Delivery
Allow the mother to push the head out.
Reduce nuchal cord.
50 to 60% of deliveries
Guide the baby out; don’t pull — let the mother do the work!
Most babies deliver themselves without assistance. Although the prehospital professional may attempt to control the delivery, only minimal interference with this natural process is necessary in most cases.
Next, with one finger, feel the infant's neck for the umbilical cord.
If it is there, gently lift it over the baby's head. Do not pull hard on the cord because it may lead to avulsion of the cord with severe hemorrhage.
Allow the mother to push the head of the baby out.

18. Management Priorities: Vaginal Delivery
Place a hand around the neck posteriorly to control delivery.
Placing a hand around the neck posteriorly and one underneath the infant may help control the delivery.
On occasion, the infant's anterior shoulder may need to be pulled posteriorly to clear the mother's symphysis pubis (pubic bone). This can be accomplished by placing a hand on either side of the infant's head and gently pulling downward.
As needed, pull the anterior shoulder downward to clear the mother's symphysis pubis.

19. Management Priorities: Vaginal Delivery
Deliver the baby and keep the baby at the level of the vaginal opening.
Tie the cord in two places and cut it.
Keep the infant lying on the bed at the level of the vaginal introitus until the umbilical cord is clamped or tied.
Do not hold the baby higher than the uterus or womb before to clamping the cord because this may lead to transfusion of blood from the baby to the placenta (fetal placental transfusion), hypovolemia, and anemia.
Alternatively, holding the baby with an unclamped cord below the level of the uterus can lead to transfusion of blood from the placenta to the baby, leading to a dangerously high hematocrit.

20. Management Priorities: Vaginal Delivery
Suction the baby’s mouth and nose.
Begin resuscitation of the baby as needed.
Delivery of placenta is nonemergent.
The baby will be born face down. Suction the baby's mouth first and then the nose using a rubber bulb syringe.
Suctioning will help clear the airway of mucus and amniotic fluid and make the transition to breathing easier.
The last step in the delivery process is the delivery of the placenta. This generally occurs spontaneously 10 to 15 minutes after birth. Delivery of the placenta is not an emergency procedure and must not delay the transport of the mother and infant. Do not pull on the umbilical cord to hurry the process.

21. Case Progression The baby is born limp and lifeless.
No respiratory effort is noted.
He is blue.
What do you do now?
Read the case progression.
Ask this question: “What do you do now?”

22. Management Priorities: Immediate Care of the Newly Born
Dry, warm, position, suction, and stimulate the infant.
Clear the airway.
Assess breathing.
Assess heart rate.
Assess color.
Follow a well-organized plan for assessment and immediate care of all babies. Most term newly borns will not require any ALS interventions.
At birth, the baby is covered in amniotic fluid and can lose a lot of heat through evaporation unless immediately dried. Heat loss drastically increases the metabolic demand and oxygen consumption. Thoroughly dry every infant, healthy or depressed.
Remove wet towels or blankets from around the baby after drying and replace them with clean, dry ones. This will take no more than 5 to 10 seconds.
Clear the airway with nasopharyngeal suctioning.
If the baby is breathing but the HR is < 100, start bag-mask ventilation.
In this case, it is important to emphasize the need to quickly dry, stimulate, and clear the nose. If the baby remains apneic, airway management MUST proceed without delay.

23. Key Concept: Oxygen
Some evidence suggests that hyperoxia can be harmful to the newly born.
Do not give supplemental oxygen to the vigorous newly born.
Oxygen should be given to the compromised newly born or newly born with a low oxygen saturation.
Although controversial, there is evidence to suggest that too much oxygen may be harmful. Do not give supplemental oxygen to an active, vigorous baby.
Although there are negative effects of hyperoxia (high oxygen saturation) in the newly born, if the baby is distressed, the goal in the field should be to ensure adequate oxygenation through administration of supplemental oxygen and assist ventilation when needed.

24. Case Progression The infant remains apneic after the initial steps.
What do you do now?
Read the case progression.
Most babies will be crying, indicating adequate respiratory effort! Breathing effort may be slightly irregular in normal newly borns.
Gasping or grunting are signs of increased work of breathing and respiratory distress.
An apneic baby, with no visible respiratory effort, requires immediate treatment.

25. Management Priorities: Bag-Mask Ventilation
Extend the head slightly on the neck.
Position hands in “EC-clamp.”
Ventilate at 40 breaths per minute.
Begin bag-mask ventilation as per the technique described in the slide.
The index finger and thumb form a “C.”
The long finger is placed on the bony surface of the chin—do not push on the soft tissues—this hand position is called the EC-Clamp.
Avoid pressing down too hard with the mask onto the baby’s face; this can cause bradycardia through the trigeminal reflex. Instead, lift the baby’s jaw into the mask with the EC clamp technique.
The head is slightly extended on the neck—overextension results in obstruction.
Ventilate at 40 times per minute—state “squeeze, release, release.” This will help you maintain an appropriate rate of bagged breaths and allow adequate expiratory time.

26. Management Priorities: Assess Heart Rate
Palpate a pulse at the base of the umbilical cord.
Count for 6 seconds and multiply by 10.
If cord pulse cannot be palpated, listen for heartbeat with a stethoscope.
In the newly born, a low heart rate is usually due to hypoxia, not primary cardiac disease. The crying, active baby usually has an adequate heart rate. Assess the heart rate carefully in a baby who is not active or who requires assisted ventilation.
This is most easily accomplished by palpating a pulse at the base of the umbilical cord.
Count the number of beats over 6 seconds, and multiply this number by 10. Sometimes the umbilical vessels are constricted so that the pulse is not palpable.
Therefore, if a pulse cannot be felt, listen for the heartbeat over the left side of the chest using a stethoscope.

27. Management Priorities: Chest Compressions
If the heart rate remains < 60 beats/min, after 30 seconds of bag-mask ventilation, begin chest compressions.
3:1 ratio. Pause to deliver a breath.
90 compressions and 30 breaths/min (120 “events” per minute)
After 30 seconds of bag-mask ventilation and a heart rate < 60 beats/min, begin chest compressions.
3:1 ratio. Pause to deliver a breath.
90 compressions and 30 breaths/min (120 “events” per minute).

28. Management Priorities: Chest Compressions in the Newborn
The hand encircling technique may be best to deliver effective compressions.
Compress at a rate of 120 compressions per minute.
With the delivery of breaths at a 3:1 ratio, you will actually deliver 30 breaths and 90 compressions per minute.

29. Management Priorities: Depressed Newly Born Resuscitation
If heart rate is < 60 beats/min after another seconds CPR, consider intubation.
Prepare epinephrine.
The dose of epinephrine is 0.01 to 0.03 mg/kg (0.1 to 0.3 mL/kg of the 1:10,000 solution) ET/IV/IO.
The preferred route for epinephrine administration in the newly born is via the IV route.
If vascular access is not available, the ET route can be used. Consider administration of a higher dose (up to 0.1 mg/kg).
Check the heart rate after 30 seconds. If it is less than 60 beats/min, prepare for administration of epinephrine: 0.01 to 0.03 mg/kg of 1:10,000 (0.1 to 0.3 mL/kg).
If vascular access is not available, consider administration of ET epinephrine (up to 0.1 mg/kg of the 1:10,000 solution, because the endotracheal route may be associated with lower blood levels of the drug).
There is no evidence that the use of a higher concentration of epinephrine results in a better outcome.
Continue chest compressions, and give repeated doses of epinephrine every 3 to 5 minutes until the heart rate is above 60 beats/min.

30. Management Priorities: BLS Shock Treatment for the Newly Born
Shock symptoms:
Poor perfusion
Weak pulses
Poor response to resuscitation.
Shock treatment:
Rapid transport.
Shock at birth is most commonly due to severe hypoxia (in the womb or during delivery) and acidosis.
Blood loss during delivery caused by umbilical cord avulsion or fetal/placental transfusion is an uncommon cause of shock in the newly born. Signs and symptoms of shock, whatever the cause, include abnormal appearance (lethargy, hypotonia), abnormal color (pallor, mottling), tachycardia, and prolonged capillary refill time. Hypothermia may also mimic these findings.

31. Management Priorities: ALS Shock Treatment of the Newly Born
Assure adequate oxygenation and ventilation.
Obtain intravenous access:
Intravenous: first choice
Intraosseous: second choice
Umbilical venous: if trained and equipped
10 mL/kg normal saline or Ringer’s lactate, which may be repeated
Because hypoxia is the most common cause of depression in the newly born, initial resuscitative efforts should ensure adequate oxygenation and ventilation.
Volume resuscitation is rarely needed. In exceptional circumstances where hypovolemic shock is suspected, consider placing an IO line.
Fluid resuscitation should be limited to 10 mL/kg of normal saline to avoid precipitating congestive heart failure. This dose may be repeated if needed.

32. Key Concept: The Inverted Pyramid
Basic life support (BLS) is usually all that is required during deliveries and therefore comprises the largest area at the top of the inverted pyramid. In contrast, advanced life support (ALS) interventions such as intubation and medication administration are rarely required and comprise the smallest area at the bottom of the inverted pyramid.

33. Case Progression
After bag-mask ventilation for seconds, the heart rate increases to 140 per minute.
The baby becomes pink centrally with cyanosis only of the hands and feet.
He begins to cry and you discontinue bag-mask ventilation.
You wrap the baby in a dry blanket and hand him to his mother.
You now focus on your second patient!
Read the slide.

34. Key Concepts: Transport Considerations: The Vigorous Newly Born
Infant restraint seat unavailable.
Place the baby in the mother's arms.
Allow mother to breastfeed.
Infant restraint seat available.
Secure the baby in rear-facing position.
Secure the seat to the ambulance.
Keep the newly born warm!
The active term infant requires no intervention or electronic monitoring during transport. Be sure that the child is restrained as per local EMS system policy.
In some systems, it is acceptable to restrain the mother appropriately and allow her to hold the baby during transport. Encourage her to breastfeed the active infant if possible. This may prevent hypoglycemia and promote maternal/infant bonding, uterine contractions, and decreased uterine bleeding.
Provide a warm environment in the ambulance.

35. Key Concepts: Transport Considerations: The Compromised Newly Born
Secure to backboard.
Provide airway management.
Keep newly born warm!
Monitor.
Check glucose value.
Transport.
Hypothermia develops quickly in newly borns.
Oxygen demand triples when skin temperature drops by 1 degree. Signs of hypothermia are similar to those of shock.
Keep the baby warm during transport. Have a small knit cap available to cover the infant's head.
Turn the heat on in the ambulance even at the risk of discomfort to the mother and crew. Place the baby on the mother's bare chest (skin-to-skin contact), and cover both of them to maintain the infant's temperature.
The depressed newly born or prematurely delivered baby is at risk for hypoglycemia, but this complication is unlikely to develop in the first 30 minutes of life. If transport times are longer, measure a bedside glucose at approximately 30 minutes after birth or immediately in any baby who has a drastic change in responsiveness or perfusion. Treat if it is < 40 mg/dL.

36. Case Progression
After delivery of the baby, there is no maternal hemorrhage.
You prepare to transport the baby in mother’s arms. Restrain mother on the gurney.
Read the slide.

37. ED Course
At the hospital, you are directed to the postpartum unit where the mother and baby are admitted.
They are discharged the next day.
Read the slide.

38. Case Summary
Although most field deliveries are normal, the rate of complications is higher for an out-of-hospital birth.
Positioning, suctioning, and drying are the only interventions usually needed.
In a depressed newly born, use a graded approach to management based on the baby’s heart rate and respiratory effort.
Read the slide.

39. Summary
Review the steps for vaginal delivery and newborn stabilization en route to scene.
Proper triage decisions are vital.
Childbirth is a natural act that usually needs only minimal intervention.
In the depressed newborn, oxygenation and ventilation are the keys to successful resuscitation.
Read the slide.