1. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Childbirth Chapter 12

2. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Outline Review of A and P Labor Assessment Assisting with Delivery Special Considerations Review of A and P Labor Assessment Assisting with Delivery Special Considerations

3. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Out-of-hospital childbirth is an infrequent call for First Responders. Because the knowledge and skills needed to assist with delivery are seldom used, many EMS providers are anxious when confronted with an impending delivery.

4. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Review of A and P

5. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Terminology Fetus = From the end of the second month of pregnancy to birth Newborn = From birth to age 1 month Pregnancy normally lasts about 266 days (9 calendar months) Fetus = From the end of the second month of pregnancy to birth Newborn = From birth to age 1 month Pregnancy normally lasts about 266 days (9 calendar months)

6. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Can you define? Uterus Placenta Birth canal Umbilical cord Bloody show Labor Uterus Placenta Birth canal Umbilical cord Bloody show Labor

7. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

9. Labor

10. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Stages of Labor First Stage –Begins with first contraction –Contractions intensify throughout –Ends when the cervix is fully dilated First Stage –Begins with first contraction –Contractions intensify throughout –Ends when the cervix is fully dilated

11. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

12. Stages of Labor Second Stage –Begins when the cervix is fully dilated –Bulging occurs –Crowning occurs –Ends with delivery of baby Second Stage –Begins when the cervix is fully dilated –Bulging occurs –Crowning occurs –Ends with delivery of baby

13. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Stages of Labor Third Stage –Begins when the baby is born –Ends with delivery of the placenta Third Stage –Begins when the baby is born –Ends with delivery of the placenta

14. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Stages of Labor Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

15. Assessment

16. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Is the Birth Imminent? What is the due date? Is this a single birth or multiple birth? Has there been any bleeding or discharge, or has the water broken? Is the mother feeling pressure like a need to move her bowels? What is the due date? Is this a single birth or multiple birth? Has there been any bleeding or discharge, or has the water broken? Is the mother feeling pressure like a need to move her bowels?

17. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. It’s Time! If the mother is having frequent, strong contractions and feels the urge to move her bowels, you will need to check for crowning If crowning is present, prepare for delivery If the mother is having frequent, strong contractions and feels the urge to move her bowels, you will need to check for crowning If crowning is present, prepare for delivery

18. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Do not allow the mother to use the bathroom. The act of bearing down as the baby descends into the birth canal may cause the baby to be delivered into the toilet !

19. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Preparing for Delivery Use BSI (gloves, eye protection, gown) Do not touch the vaginal area except to control the head of the infant as it emerges Do not attempt to delay the delivery Have the mother lie back with her knees bent and legs apart Use BSI (gloves, eye protection, gown) Do not touch the vaginal area except to control the head of the infant as it emerges Do not attempt to delay the delivery Have the mother lie back with her knees bent and legs apart

20. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Preparing for Delivery Elevate the buttocks with a folded blanket or pillow covered with clean towels or blankets Open the delivery kit and have it within your reach Elevate the buttocks with a folded blanket or pillow covered with clean towels or blankets Open the delivery kit and have it within your reach Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

21. The contents of a delivery kit. Delivery Kit Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

22. Assisting with Delivery

23. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Assisting with the Delivery Apply gentle pressure with the palm of your hand on the infants head as it emerges This is important because it prevents trauma to the infant’s brain from sudden decompression as it leaves the birth canal If the amniotic sac has not broken, use your fingers to tear the sac away from the baby’s face and as the head is delivered Apply gentle pressure with the palm of your hand on the infants head as it emerges This is important because it prevents trauma to the infant’s brain from sudden decompression as it leaves the birth canal If the amniotic sac has not broken, use your fingers to tear the sac away from the baby’s face and as the head is delivered

24. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Normal Delivery When crowning occurs, apply gentle palm pressure to the infant’s head Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

25. Normal Delivery Examine the infant’s neck for the presence of a looped umbilical cord Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

26. Assisting with the Delivery As the head is born, check to see if the umbilical cord is wrapped around the baby’s neck If it is, gently attempt to slip the cord over the baby’s shoulder so that it is not around the neck You must prevent the cord from tightening around the baby’s neck as the shoulders are delivered After the head is completely born, support it in your hands As the head is born, check to see if the umbilical cord is wrapped around the baby’s neck If it is, gently attempt to slip the cord over the baby’s shoulder so that it is not around the neck You must prevent the cord from tightening around the baby’s neck as the shoulders are delivered After the head is completely born, support it in your hands

27. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Normal Delivery Support the infant’s head as it rotates from shoulder presentation Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

28. Normal Delivery Once the head is delivered, suction the mouth then the nose Compress bulb syringe before placing it in the baby’s mouth Once the head is delivered, suction the mouth then the nose Compress bulb syringe before placing it in the baby’s mouth Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

29. Normal Delivery Guide the infant’s head toward the anterior shoulder Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

30. Assisting with the Delivery Use bulb syringe to suction the baby’s mouth and nose Support baby, as baby will be slippery Do not pull on the baby to deliver it Keep the baby at the level of the vagina until the umbilical cord has been clamped or tied Use bulb syringe to suction the baby’s mouth and nose Support baby, as baby will be slippery Do not pull on the baby to deliver it Keep the baby at the level of the vagina until the umbilical cord has been clamped or tied

31. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Umbilical cord Fasten one clamp approximately 4 inches away from the infant’s belly Fasten the second clamp approximately 2 inches away from the first clamp With sterile scissors, cut between the two clamps and pat with sterile gauze Fasten one clamp approximately 4 inches away from the infant’s belly Fasten the second clamp approximately 2 inches away from the first clamp With sterile scissors, cut between the two clamps and pat with sterile gauze Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

32. Do not clamp or tie the umbilical cord until it has stopped pulsating!

33. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Assisting with the Delivery When the umbilical cord has stopped pulsating, tie a piece of roller gauze firmly around the cord about half-way between the mother and the baby Use a square knot to make sure the knot does not loosen Dry the infant with a receiving blanket Wrap the infant in a second blanket to keep him warm; the body and head should be covered, with only the face exposed. When the umbilical cord has stopped pulsating, tie a piece of roller gauze firmly around the cord about half-way between the mother and the baby Use a square knot to make sure the knot does not loosen Dry the infant with a receiving blanket Wrap the infant in a second blanket to keep him warm; the body and head should be covered, with only the face exposed.

34. Delivery of the placenta Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

35. Infants quickly lose heat, especially from the scalp. They may quickly become hypothermic, even in a relatively warm room.

36. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Assisting with the Delivery If necessary, wipe mucus from the nose and mouth with sterile gauze Place the infant on the mother’s abdomen Record the time of delivery Wait for additional EMS responders to arrive If necessary, wipe mucus from the nose and mouth with sterile gauze Place the infant on the mother’s abdomen Record the time of delivery Wait for additional EMS responders to arrive

37. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Special Considerations

38. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Multiple Births Will need to prepare for delivery of the second infant after caring for the first The delivery of subsequent infants is handled the same as the first Infants are usually smaller and born earlier Assess the newborns for breathing problems and keep them warm Will need to prepare for delivery of the second infant after caring for the first The delivery of subsequent infants is handled the same as the first Infants are usually smaller and born earlier Assess the newborns for breathing problems and keep them warm

39. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Abnormal Presentations Normally the infant’s head is the first part to be delivered If the feet, buttocks, or other body part present first, the delivery may be very complicated –Instruct the mother not to push –Notify incoming EMS responders of the situation –Reassure the mother that more help is on the way Normally the infant’s head is the first part to be delivered If the feet, buttocks, or other body part present first, the delivery may be very complicated –Instruct the mother not to push –Notify incoming EMS responders of the situation –Reassure the mother that more help is on the way

40. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Care of the Newborn Normally, infants will begin to cry at birth Normal vital signs: –Heart rate > 100/minute –Respiratory rate > 40/minute Normally, infants will begin to cry at birth Normal vital signs: –Heart rate > 100/minute –Respiratory rate > 40/minute

41. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Care of the Newborn Infant is not responding normally –Does not cry, is limp, and/or has cyanosis of the face or torso –Stimulate the feet by lightly flicking the soles of feet or rub the back If this does not improve the infant’s condition within one minute, further resuscitation is needed Infant is not responding normally –Does not cry, is limp, and/or has cyanosis of the face or torso –Stimulate the feet by lightly flicking the soles of feet or rub the back If this does not improve the infant’s condition within one minute, further resuscitation is needed

42. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Care of the Newborn Make sure the airway is open and clear of fluids Ventilate gently at 40-60 times per minute Reassess after one minute If the heart rate is ≤ 60 bpm, begin chest compressions Make sure the airway is open and clear of fluids Ventilate gently at 40-60 times per minute Reassess after one minute If the heart rate is ≤ 60 bpm, begin chest compressions

43. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Care of the Mother Observe for delivery of the placenta, which may take up to 30 minutes There will be vaginal bleeding as the placenta delivers If the placenta delivers, wrap it in a towel and keep it at the level of the infant Place a sterile pad over the vaginal opening and help the mother lower her legs Observe for delivery of the placenta, which may take up to 30 minutes There will be vaginal bleeding as the placenta delivers If the placenta delivers, wrap it in a towel and keep it at the level of the infant Place a sterile pad over the vaginal opening and help the mother lower her legs

44. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Care of the Mother 300 to 500 mL of blood loss is normal following delivery If vaginal bleeding excessive –You may need to massage the uterus –Treat for shock –Encourage breastfeeding 300 to 500 mL of blood loss is normal following delivery If vaginal bleeding excessive –You may need to massage the uterus –Treat for shock –Encourage breastfeeding

45. Uterine Massage Place the palm of one hand firmly on the abdomen, just above the pubic bone to support the uterus Use the palm of the other hand to firmly massage the abdomen below the belly button Place the palm of one hand firmly on the abdomen, just above the pubic bone to support the uterus Use the palm of the other hand to firmly massage the abdomen below the belly button Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

46. Uterine Massage Remember to communicate with the mother and keep her informed of what you are doing Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

47. Care of the Mother Monitor vital signs Replace bloody sheets under the mother with fresh ones while you are awaiting transport Monitor vital signs Replace bloody sheets under the mother with fresh ones while you are awaiting transport

48. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Summary The majority of births are uncomplicated and only some require special assistance. This is one of the few times EMS personnel have the opportunity to participate in a happy event. For the occasional complications arising from childbirth, the First Responder must remember the priorities of care: airway, breathing, and circulation. The majority of births are uncomplicated and only some require special assistance. This is one of the few times EMS personnel have the opportunity to participate in a happy event. For the occasional complications arising from childbirth, the First Responder must remember the priorities of care: airway, breathing, and circulation.

49. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Summary Other responding personnel must be notified of any complicating situations, such as a presenting part other than the head, umbilical cord protruding through the birth canal prior to the baby and excessive maternal bleeding. It is essential to remember that newborns have a special need to be kept warm, and must be wrapped in a blanket after birth, with only the face exposed. Other responding personnel must be notified of any complicating situations, such as a presenting part other than the head, umbilical cord protruding through the birth canal prior to the baby and excessive maternal bleeding. It is essential to remember that newborns have a special need to be kept warm, and must be wrapped in a blanket after birth, with only the face exposed.

50. Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Summary The key to success is to be knowledgeable and practice the skills ahead of time.

51. Questions? Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.