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Susan Lafaver, RNC, BSN, C-EFM

Nurse Manager, Labor and Delivery/Birth Place
St. Josephs Hospital Health Center

Review anatomy and physiology of pregnancy

Describe steps in assisting in a normal childbirth
List priorities of care during transport of the
mother and infant
Describe the most important components of
neonatal resuscitation
Discuss treatments for common obstetrical



Emergency personnel may be called

to assist with the birth of a child

Remember: childbirth is a natural
process; you are there simply to
First remain calm!
Normal perinatal mortality
is 0.04%

Ovaries: Produce eggs

Uterus: Holds fertilized egg as it develops
Fallopian tubes: Connect ovaries and uterus
Birth canal (vagina): External opening

(1 of 2)

Fetus: Developing baby

Umbilical cord: Delivers nutrition and removes
waste products from developing infant
Placenta: Draws nutrients from uterus which
are then transported through umbilical cord

(2 of 2)

Stage one
Initial contractions occur,

water breaks, bloody show

occurs, but no crowning visible

Stage two
Involves actual delivery of baby

Stage three
Involves delivery of placenta


Have you had a baby before? Prenatal care?

When are you due?
Any complications with this pregnancy or any prior
Patients generally know if they have any serious pregnancy

related conditions unless NPC (placenta previa, breech)

When did the contractions begin?

How far apart are the contractions?
Have you had any bleeding?
Has the bag of waters broken? Color of fluid?
Do you feel an urge to move your bowels?
Is the babys head coming out (crowning)? (Look)
(1 of 2)

No prenatal care
Due date or gestational age
Prior or present complications
Contraction history
Vaginal bleeding
Color of amniotic fluid
Urge to have a bowel movement
Head crowning



Bulb syringe
Umbilical cord clamp
Towels or blankets for
baby for drying
Blanket for mom AND
baby for covering

Explain process in a calm, encouraging voice

Wash your hands thoroughly and put on gloves

Place a towel or sheet under the woman

Have plenty of towels on hand

Place her in as comfortable a position as possible


Have the woman lie on her back with her knees

drawn up and apart
Tell the mother to breathe rapidly as the babys
head emerges
Place one palm gently over the advancing head to
prevent an explosive delivery
Suction the mouth first, then the nostrils
Do not cut the cord unless it is tight around the neck
If the cord is around the neck , try to slip it over the head
If it is too tight, place two clamps about 2 inches apart on the cord. Cut

the cord between the clamps with sterile scissors (not trauma scissors)
(1 of 3)

One shoulder is then delivered with the next

The upper shoulder usually passes first with gentle

downward pressure on the head

The lower shoulder can then be delivered with gentle
upward pressure on the head

You should never exert traction on the infants head

or neck in order to facilitate delivery
Once the shoulders are delivered, the baby will slide
Watch out babies are slippery!

(2 of 3)

In a normal birth, the baby will turn to its side by

itself after the head emerges.
(3 of 3)

Ready or

Cut the cord only if necessary

OOPS! - Place baby skin to skin with mom

The ABCs of neonatal stabilization/resuscitation are

the same as those applied to adults:
Clear? Gurgling?

Good respiratory effort, chest moving? Need
stimulation? What is the normal RR of a newborn?
Assess heart rate-what is the normal HR of a newborn?
Assess color-what is normal?

The successful transition from intrauterine life to

extrauterine life is dependent upon significant
physiologic changes that occur at birth. In almost
all infants (90%!) these changes are successfully
completed at delivery without requiring an special
assistance. However, about 10% of infants will
need some intervention , and 1% will require
extensive measures at birth. Neonatal
Resuscitation Instructor Manual, 2012

Vigorously dry infant with towel

Clear mouth and nose
Place the newborn SKIN TO SKIN on the mothers
chest to keep warm
Place baby on moms belly with head turned to side
Cover newborns head and body with a fresh, dry,
warm blanket/towel
Stimulate as needed

The newborn infant should:

Begin crying right after birth (may need

Breathe spontaneously at a rate greater than 40
breaths per minute
Have a pulse greater than 100 beats per minute

Assess APGAR Score at 1 min and 5 min

Best score is 10
Measure at 1 and 5 minutes
Score of 6 or less, increase assessment

If needed, suction at delivery of the head. Can suction once

delivery is completed

Suctioning the mouth

Suctioning the nose

Why suction the mouth first?

Can it be harmful?
What about meconium?
Does every baby need bulb

How will I know when to suction?

Susceptibility to cold stress

Increased heat loss
Proportionally large head
Body surface area-to-weight ratio
Minimal subcutaneous fat
Poor perfusion (transisiton)
Decreased heat production
< 6 mos unable to shiver
Preterm = diminished brown fat

Loss of water from skin and respiratory tract

Heat transfer to cooler surrounding walls or hard surfaces

Heat transfer from direct contact with cooler surfaces

Heat loss to ambient air

Replace wet linen with dry linen ASAP

Turn the heat up
Decrease drafts and close doors when possible
Cover head and body with blanket or clothing
Keep baby on moms belly!

After drying, stimulation, and assessment,

further interventions may be necessary

REMEMBER: about 10% of infants will need

some intervention , and 1% will require
extensive measures at birth. Neonatal
Resuscitation Instructor Manual, 2012

Slightly tilt the infants head (sniff position)

Suction the mouth and nose if needed
Begin mouth to mouth-and-nose breathing

(1 of 2)

Check HR at 30 seconds via

stethoscope or palpate cord.
If HR >100, continue

HR <100, continue mouth-tomouth and nose

HR<60 after 30 seconds of

mouth-to-mouth and nose,
start compressions, ratio 3:1

Reassess every 30 seconds

The placenta usually delivers spontaneously within

10-15 minutes
Do not pull on the cord!
It looks like a LOT of blood- dont forget it includes
amniotic fluid. Normal blood loss 300-500 cc
Massage the uterus with one hand while placing
your other hand just above the pubic bone after
the placenta delivers
Signs and symptoms of shock are subtle as the
mother has a high tolerance for blood loss due to
extra blood and fluid built up during pregnancy
Vital Signs

Observe mother and baby-for what??

Recheck vagina for excessive bleeding
Recheck firmness of uterus
Remove wet towels, etc.
Cover vaginal opening if a peri pad is
Keep mom & baby together

Prompt transport!
Support the body as it is delivered
Use your fingers to keep babys airway open
by forming a pocket over the infants nose and
The last movement is an
upward movement of
the head to deliver the
forehead first

Umbilical cord comes out of

the vagina before baby is born
A serious emergency that

requires rapid transport !

Prop mothers hips and legs

higher than rest of her body
Gently displace babys head
with 2 fingers of a gloved hand
Do not grab cord (causes

Characteristics: BP > 160/110 and /or

severe headache, visual disturbances,
acute pulmonary edema or upper
abdominal tenderness
Most patients can state that they have
pre-eclampsia during their pregnancy
Treatment is to transport ASAP

Eclampsia refers to the occurrence of one or more

generalized convulsions and/or coma in the setting
of preeclampsia and in the absence of other
neurologic condition
How do we know its eclampsia?
Magnesium Sulfate 4 gm in 50 ml NS over 15 min
if able to establish IV
Can give Magnesium Sulfate 1gm IM mixed with
2cc NS in each buttock

Placenta Previa
Placental Abruption

Dont confuse with bloody show

Post delivery
Post partum hemorrhage due to uterine atony
Cervical or vaginal lacerations

During pregnancy, the blood volume increases to about 50%

more than before pregnancy. This is important as it is
designed to meet the demands of a growing uterus. More
blood in the system protects Mom and baby from harm
when Mom lies down or stands up. The increase is also a
safeguard for the blood loss during labor and delivery. The
blood volume increase begins during the first trimester
and the largest increase happens during the middle
trimester and the increase tends to slow down in the final
trimester. Red blood cells and plasma (composition of
blood) both increase during pregnancy.

Can you see why it is important to know if there

is a history of placenta previa? What is the
consequences of a vaginal exam?

Can you always see a patient bleed with a

placental abruption? How will you know?

UTERINE ATONY-requires fundal massage

Cervical lacerations
Vaginal lacerations
Extension of tear into rectum
Peri-urethral tears


Cover perineum
Transport as soon as possible

VCU Medical Center Video -- EMS with Childbirth