PREHOSPITAL CHILDBIRTH

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PREHOSPITALCHILDBIRTH

• Jim Pointer, MD
• Medical Director
• Alameda County EMS

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Goals for Todays Lecture

• Identify need for prehospital delivery
• Mechanics of normal delivery
• Manage complications of delivery
• Normal neonatal resuscitation

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Disclaimer

• The following presentation includes graphic
  depictions of

nudity,
blood,
and slippery newborns.
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General Concepts

• First - take your own pulse
• Mom is more important
• Normal perinatal mortality 0.04
• ED perinatal mortality 8?
• Dont be a hero

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Treating Mom

• Always use supplemental O2
• Left lateral decubitus position
• 2 large-bore IVs

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Labor

• False labor
• Lower abdomen
• Irregular
• Mild
• Treat with hydration
• Braxton-Hicks contractions

• True labor
• Upper abdomen, radiating
• Regular
• Severe

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Signs of Imminent Delivery

• Rectal pressure
• Strong urge to push
• Crowning
• (sometimes you gotta look)
• Multiparity

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Physical Examination

• Fundal height
• Umbilicus 20 weeks
• Add 1cm per week to 36 weeks (costal margin)
• Assessing progression of labor
• Effacement
• Dilation
• Station
• Minimize number of vaginal exams

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Delivery - Preparation

• Bulb suction
• Dry towel/blanket
• Cord clamps
• Scissors

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Crowning

• Thin the perineum
• Support head/perineum with two hands
• Coach on pushing

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Head is Out

• Stop pushing!
• Suction mouth and nose
• Check for nuchal cord
• present in 25
• reduce or clamp

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Deliver the Shoulders

• Gentle downward then upward pressure on head
• Mom pushes again
• Shoulder dystocia

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Clamping the Cord

• 2 clamps
• 10cm from baby
• 4 - 5cm apart
• Cut between
• Umbilical stump can be used for access in the
  hospital

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The Baby is Slippery!
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Placenta

• Delivery preceded by gush of fluid/blood
• No rush 20 minutes OK
• Do not use much traction
• Bring to hospital

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From Start . . .
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. . . To Finish
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Postpartum Care

• Watch for hemorrhage
• Massage uterine fundus (this hurts!)
• Beware the surprise twin

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Basic Neonatal Resuscitation

• Respiratory
• Respiratory
• Respiratory
• Hypothermia
• Hypoglycemia

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Neonatal ABCs

• Dry
• Warm
• Position
• Suction
• Stimulation

• Oxygen
• Ventilation
• Chest compressions
• Meds

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Neonatal ACLS

• Chest compressions indicated
• for HRlt80
• Rate 120/minute, ½ - ¾ inch
• Medications
• Epinephrine
• Narcan
• Glucose (administer as D10)
• Dopamine

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Common Complications

• Breech presentation
• Cord prolapse
• Shoulder dystocia
• Bleeding

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Breech Basics

• Only deliver these if necessary
• Do not touch baby until you can see umbilicus
• Easy to cause intrabdominal injury
• If head stuck, do episiotomy

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Pull some cord free
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Rotate to Deliver Arms
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Finger in Mouth to Flex Neck and Deliver Head
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Episiotomy if Stuck Breech
Ouch!
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Umbilical Cord Prolapse

• Never push it back in!
• Hand in vagina to push up on babys head
• Mom in Trendelenburg
• Drape cord with soaked gauze
• Transport
• Needs immediate C-section

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Shoulder Dystocia

• Pull knees back far
• Pressure over bladder
• Twist babys torso (not the head) intravaginally

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Bleeding at Term

• Bloody show
• Placenta previa
• Abruptio placentae (abruption)
• Postpartum
• Massage that uterus!
• Consider retained products

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In Summary

• Consider possibility of prehospital delivery
• Calm down and get ready
• Look for complications
• Breech - let body deliver and then get head out
• Neonate dry, warm, respiratory care

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