Child Birth.pdf

CHILDBIRTH PHASE I: LABOR 1. Obtain history and determine if there is adequate time to transport to a hospital with OB services Gravida (# of pregnancies) | Para (# of live births) Number of miscarriages, stillbirths, ab...

CHILDBIRTH PHASE I: LABOR 1. Obtain history and determine if there is adequate time to transport to a hospital with OB services Gravida (# of pregnancies) | Para (# of live births) Number of miscarriages, stillbirths, abortions or multiple births Gestational age in weeks: Due date (EDC) or last menstrual period (LMP) Onset, strength, duration & frequency of contractions (time from beginning of one to the beginning of the next) Length of previous labors in hours | any delivery complications? Status of membranes ("bag of waters") - intact or ruptured If ruptured, inspect for prolapsed cord & evidence of meconium | Note time since rupture Presence of vaginal bleeding/discharge ("bloody show") High-risk concerns: Lack of prenatal care, SUD, teenage pregnancy, mom ≥ 35 yrs; PMH diabetes, HTN, CV and other pre-existing diseases that may compromise mother and/or fetus; pre-term labor (< 37 wks); previous breech or C-section, or multiple fetuses 2. IMC special considerations: Maintain eye contact; coach mom to pant or blow during contractions If hypotensive or lightheaded: Turn on side; O2 12-15 L/NRM; NS IVF boluses in 200 mL increments up to 1 L 3. for S&S imminent delivery: Contractions ≤ 2 min apart; bulging/crowning during contraction, involuntary pushing, urgency to move bowels DELIVERY NOT IMMINENT: Allow pt. to assume most comfortable position; transport to hospital w/ OB services DELIVERY IS IMMINENT: - Do not attempt to restrain or delay delivery unless prolapsed cord is present - Provide emotional support; mom is in pain and may not cooperate - Position semi-sitting (head up 30°) w/ knees bent or on side on a firm surface, if possible - Wash hands w/ waterless cleaner | Put on FULL BSI | Remove clothing below her waist if able - Open OB pack; maintain content cleanliness; place absorbent materials beneath perineum and drapes over abdomen and each leg | Prepare bulb syringe, cord clamps, scalpel, and Chux to dry and warm infant | Ready neonatal BVM, NRM, resuscitation equipment, O2 supply | Prepare warmer if available PHASE II: DELIVERY 1. HEAD: Allow head to deliver passively Control rate of descent by placing palm of one hand gently over occiput Protect perineum with pressure from other hand If amniotic sac still intact, gently twist or tear the membrane 2. After head is delivered: No meconium: Do not suction during delivery to avoid Vagal stimulation and fetal bradycardia Meconium present: Gently suction mouth then nose w/ bulb syringe Anticipate need for resuscitation of a nonvigorous infant after delivery Feel around neck for the umbilical cord (nuchal cord) | If present, attempt to gently lift it over baby's head If unsuccessful, double clamp and cut cord between the clamps Support head while it passively turns to one side in preparation for shoulders to deliver 3. SHOULDERS: Gently guide head downwards to deliver upper shoulder first Support and lift the head and neck slightly to deliver lower shoulder If shoulder dystocia: Gently flex mother's knees alongside her abdomen Attempt to rotate anterior shoulder under symphysis pubis 4. The rest of the infant should deliver quickly with next contraction Firmly grasp infant as it emerges | Baby will be wet and slippery 5. Note date and time of delivery | Proceed to POST-PARTUM CARE NWC EMSS 2022 SOP 67 Rev. 3-11-24  NEWBORN AND POST-PARTUM CARE NEWBORN 1. Care immediately after delivery: Rapidly dry | Place healthy baby who does not require resuscitation on mom's abdomen for skin to skin contact Term gestation? Good tone? Breathing or crying? Breathing should begin in 30-60 sec. | If breathing well/crying: should not need tactile stimulation or suctioning If no breathing: Suction mouth, then nose using bulb syringe to clear airway | Gently rub back or flick soles of feet Assess HR initially by auscultation and/or palpation If apnea, gasping; labored breathing; RR < 40; cyanosis; HR < 100 → Newborn Resuscitation SOP Prevent hypothermia: Maintain normal temp | Use infant warming device or wrap if available | Cover head with stockinette cap 2. Cord care: When pulsations stop clamp at 6" and 8" from infant's body; cut between clamps with sterile scalpel If no sterile implement available, clamp cord but do not cut; safely secure infant with mom for transport Check cord ends for bleeding 3. Obtain 1 and 5 minute APGAR scores: If ≤ 6 → Newborn Resuscitation SOP 4. Place ID tags on the mother and infant with the mother's name, delivery date and time, infant gender 5. Transport considerations: Transport baby in an infant car seat secured so the infant rides facing backward or in an approved commercial device for newborns per local procedure. Pad around infant prn Do NOT carry infant into ED or OB in rescuer’s arms due to risk of infection & trauma Transport mom & baby to a hospital with OB services (keep together if safe transport possible) Do not separate in two different ambulances unless absolutely necessary APGAR Assessment 0 1 2 Appearance (color) Blue or pale Blue hands or feet Entirely pink Pulse (heart rate) Absent < 100 ≥ 100 Grimace (reflex irritability) Absent Grimace Cough or sneeze Activity (muscle tone) Limp Some extremity flexion Active motion Respirations (effort) Absent Weak cry, < 40 Strong cry Infant’s patient care report - Document the following: 1. Date and time of delivery | gestation in weeks if known | delivery presentation (head or breech) 2. Presence/absence of nuchal cord | If present, how many times 3. Appearance of amniotic fluid, if known; especially if green, brown, or tinged with blood 4. APGAR scores at 1 minute and 5 minutes 5. Time placenta delivered and whether or not it appeared intact (if applicable) 6. Any infant resuscitation initiated and response MOTHER 1. Placenta should deliver in 20-30 minutes | If delivered, collect in bag from OB kit and transport for inspection Do NOT pull on cord to facilitate delivery of the placenta DO NOT DELAY TRANSPORT waiting for PLACENTA to deliver 2. Mother may be shivering; cover with a blanket 3. If perineum torn/bleeding: apply direct pressure with sanitary pads and have patient bring legs together Apply cold pack (ice bag) to perineum (over pad) for comfort and to reduce swelling 4. If blood loss > 500 mL: or S&S of shock / hypoperfusion: Time Sensitive Pt IV NS fluid challenges in 200 mL increments titrated to patient response up to 1 L Massage fundus until firm; breast feeding may increase uterine tone (Do not transport with baby breastfeeding) 5. If blood loss continues despite above with SBP < 90 (MAP < 65); transport ASAP; alert OLMC NWC EMSS 2022 SOP 68 Rev. 3-11-24  Time DELIVERY COMPLICATIONS sensitive pt BREECH BIRTH A footling/frank breech generally delivers in 3 stages: legs → abdomen | abdomen → shoulders | and head Dangerous times for the infant (risk of hypoxia): After delivery to the abdomen (cord can become compressed against the pelvic inlet as the head descends) and after delivery of the torso and shoulders, awaiting delivery of the head 1. IMC special considerations: IV NS; anticipate need for fluid challenges Obtain a quick pregnancy history per the Emergency Childbirth SOP Prepare for delivery per Emergency Childbirth SOP if birth is imminent 2. Prepare to transport with care enroute if only the buttocks or lower extremities are delivered Stay on scene for ONE contraction if the baby is delivered to the shoulders, while attempting delivery of the head If enroute, stop the vehicle to attempt delivery of the head Delivery Procedure 3. Legs delivered: Support baby's body wrapped in a towel / Chux If cord is accessible, gently palpate for pulsations | Do not manipulate cord more than necessary Attempt to loosen the cord to create slack for delivery of the torso / head 4. After torso and shoulders are delivered: Gently sweep down the arms If face down may need to lower body to help deliver head | Do not hyperextend the neck Apply firm pressure over mother's fundus to facilitate delivery of the head NEVER ATTEMPT TO PULL THE INFANT BY THE LEGS OR TRUNK FROM THE VAGINA May precipitate an entrapped head in an incompletely dilated cervix or it may precipitate nuchal arms 5. The head should deliver in 30 seconds (with the next contraction) If NOT, reach 2 gloved fingers into vagina to locate baby's mouth and pull chin down Push vaginal wall away from baby's mouth to form an airway Keep your fingers in place and transport immediately, alerting the receiving hospital of the baby's position Keep delivered portion of baby's body warm and dry 6. If head delivers: Anticipate neonatal distress | Refer to Newborn Resuscitation SOP as necessary 7. Anticipate maternal hemorrhage after the birth of the infant | Refer to Post-Partum Care of Mother Note: Single limb presentation (arm, leg) or other abnormal presentations may require C-section Do NOT attempt field delivery PROLAPSED CORD Check for a prolapsed cord whenever a patient claims her bag of water has ruptured 1. IMC special considerations: O2 12-15 L/NRM 2. Elevate the mother's hips | Instruct the patient to pant during contractions 3. Place gloved hand into vagina and place fingers between pubic bone and presenting part, with cord between fingers Apply continuous steady upward pressure on the presenting part 4. Avoid cord manipulation as much as possible | Cover with a moist dressing and keep warm 5. Transport with hand pressure in place UTERINE INVERSION 2. IMC special considerations: O2 12-15 L/NRM; IV NS titrated to patient response 3. Anticipate significant hemorrhage If only partially extruded: ONE attempt to replace uterus per protocol. Push fundus toward vagina with palm of hand. Apply saline moistened sterile towels or dressings around uterus. NWC EMSS 2022 SOP 69 Rev. 3-11-24  Time NEWBORN RESUSCITATION (APGAR = 6 OR LESS) sensitive pt Peri-viable birth (Delivery at 20 - 26 wks of gestation): Factors that influence survivability: gestational age; birth weight; gender (female), singleton birth, use of antenatal steroids Difficult to determine exact gestational age in the field. If any possibility that baby > 20 weeks gestation and has any of these: cyanosis with spontaneous ventilations, detectable slow heart beat by auscultation, or spontaneous movements: Keep warm; begin chest compressions; and transport immediately to a center with advanced levels of neonatal care (Level III NICU – see Hospital specialty designations in Appendix) “If a birth is at the lower limit of viability or involves a condition likely to result in early death or severe morbidity (severe congenital anomalies), noninitiation or limitation of neonatal resuscitation is reasonable after OLMC consultation and parental involvement in decision-making” (AHA, 2020) All births - General caveats: Majority of newborns require no resuscitation beyond drying, warming, mild stimulation, and airway suctioning Those that do my be critically ill and need expeditious transport to a hospital with OB capabilities Acrocyanosis: Peripheral cyanosis around mouth, hands & feet is often seen in healthy newborns Caused by peripheral vasoconstriction and increased tissue O2 extraction. Differentiate from central cyanosis. Central cyanosis: Caused by reduced arterial O2 sats; normal up to 5 to 10 min after birth when SpO2 should rise to 85%-95% (see chart) | Persistent central cyanosis is abnormal | Evaluate and treat promptly Apply cardiac monitor to all newborn infants requiring resuscitation [ALS] STEPS in RESUSCITATION 1. Assess RR/distress | motor tone | HR: Do not wait for APGAR score to begin resuscitating if obvious distress Connect to ECG monitor to assess HR [ALS] 2. Warm (maintain normal temp) | Dry | Stimulate by flicking the soles of the feet and/or rubbing the back 3. If weak cry, ineffective breathing, poor tone, or preterm: Position supine with 1" pad under back/shoulders to align head & neck in a neutral position | Suction mouth then nose with a bulb syringe | Monitor HR 4. If dusky| RR > 40 & adequate effort | HR ≥ 100: Place neonatal NRM 1" from the baby's face | blow-by O2 10 L 4. If apneic| RR < 40 or ineffective breathing | HR ≥ 100 Target SpO2 after birth PPV/neonatal BVM at 40-60 BPM (inspiratory time 1 s or less) on ROOM AIR 1 min 60%-65% 2 min 65%-70% Do not exceed peak inflation pressures of 20-25 cm H2O (if measurable via BVM) 3 min 70%-75% First breath will require a little more pressure (30-40 cm H2O) to begin lung inflation 4 min 75%-80% Assess adequacy of ventilation by a rise in HR and, less reliably, chest expansion. 5 min 80%-85% Apply peds SpO2 to right upper extremity (wrist or medial aspect of palm) 10 min 85%-95% BRADYCARDIA (HR < 100) (Titrate O2 delivery to SpO2 readings if possible) 5. If apneic/labored | RR < 40 | central cyanosis | HR 60-99: PPV as above at 40-60/neonatal BPM + 15 L O2 6. If HR 94% for adequate fetal oxygenation) Anticipate significant bleeding/shock. If AMS or signs of hypoperfusion: Warm NS IV fluid challenges in 200 mL increments up to 1 L titrated to patient response Permissive hypotension is contraindicated in pregnant women | Maintain SBP ≥ 90 (MAP ≥ 65) Obtain pregnancy history per Emergency Childbirth SOP Ask about the onset, provocation, quality, region, radiation, severity, and duration of abdominal pain 2. Complete serial abdominal exams per OB Trauma SOP 3. Note type, color, amount, and nature of vaginal bleeding | Collect/transport any tissue that is passed with patient 4. See notes on bleeding / shock in OB Trauma SOP GESTATIONAL HYPERTENSION | PRE-ECLAMPSIA | ECLAMPSIA Gestational HTN: Non-severe: SBP ≥ 140 and/or DBP ≥ 90 (in at least 2 readings taken at least 15 min apart by EMS) who had normal BP prior to 20 weeks and has no proteinuria | Severe HTN: SBP ≥ 160 and/or DBP ≥ 110 mmHg PRE-ECLAMPSIA: New onset of HTN and proteinuria or the new onset of HTN and significant end-organ dysfunction with or without proteinuria after 20 wks gestation or within 6 weeks postpartum May have any of these: Mod-severe fluid retention / edema, rapid wt gain (> 10 lbs in one week), new-onset and persistent headache not accounted for by alternative diagnoses and not responding to usual doses of analgesics; visual symptoms (blurred vision, flashing lights or sparks, diplopia, photophobia); pulmonary edema, confusion, irritability, AMS, severe, persistent RUQ/epigastric pain; nausea/vomiting 1. IMC special considerations: GENTLE HANDLING, quiet environment Position patient on side if > 20 wks gestation | Manually displace uterus to the side Obtain BP while patient is positioned on side Obtain pregnancy history per Emergency Childbirth SOP; monitor FHTs if possible If AMS: Assess glucose level | Rx per Glucose Emergency SOP Minimal CNS stimulation | Do NOT check pupillary light reflex Lights and sirens may be contraindicated: Contact OLMC for orders 2. Anticipate seizures; prepare suction MAGNESIUM (50%) 2 g in16 mL NS (slow IVP/IO) or in 50 mL NS (IVPB) over 10 min | Max 1 g / 5 minutes Begin on scene, continue enroute | Cover IV site with cold moist gauze or cold pack to relieve burning ECLAMPSIA: Generalized tonic-clonic seizure during pregnancy with no other known cause 3. MAGNESIUM (50%) 2 g in16 mL NS (slow IVP/IO) or in 50 mL NS (IVPB) over 10 min | Max 1 g / 5 minutes If patient received 2 g for preeclampsia prior to experiencing a seizure, may give an additional 2 g to Rx seizure 4. If seizure persists after magnesium: MIDAZOLAM 2 mg increments IVP/IO q. 30-60 sec (0.2 mg/kg IN) up to 10 mg IVP/IO/IN titrated to stop seizure If IV/IO unable and IN contraindicated: IM dose 5-10 mg (0.1-0.2 mg/kg) max 10 mg single dose All routes: May repeat to max total dose of 20 mg prn if SBP ≥ 90 (MAP ≥ 65) unless contraindicated If chronic dx (HF); and/or on opioids or CNS depressants: ↓ total dose to 0.1 mg/kg NWC EMSS 2022 SOP 71 Rev. 3-11-24