Emergency Delivery and Newborn Stabilization

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Emergency Delivery and Newborn Stabilization
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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.

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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

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Prearrival Preparation

• Review en route
• Triage of laboring patient
• Steps for a vaginal delivery
• Steps in resuscitation of the mother and the
  newly born

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General Impression and Management Priorities
You arrive on scene and find this presentation.

• What is your next step in the care of this
  patient?

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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 3060 minutes.

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Key Concept Triage of the Laboring Patient

• Brief physical assessment
• Is the childs head crowning?
• Is the head or scalp visible at the perineum
  during contractions?
• If yes, delivery is imminent.

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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.

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Case Progression

• This is the womans second baby.
• She states that labor with her first baby was
  short (2 hours).
• She feels the urge to push.

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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?

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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.

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Key Concept Premature Newly Born

• Prematurity is defined as less than 36 weeks
  gestation.
• Prepare appropriately sized airway equipment.

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Key Concept Meconium

• Greenish color of amniotic fluid is a sign of
  passage of fetal stool.
• If there is time, you may suction the babys
  mouth, then nose.

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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?

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Management Priorities Position Mother for
Vaginal Delivery

• Prepare an area for the baby, and keep the room
  warm.
• Supine Position Sims Position

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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.

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Management Priorities Vaginal Delivery

• Allow the mother to push the head out.
• Reduce nuchal cord.
• 50 to 60 of deliveries
• Guide the baby out dont pull let the mother
  do the work!

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Management Priorities Vaginal Delivery
Place a hand around the neck posteriorly to
control delivery.
As needed, pull the anterior shoulder downward to
clear the mother's symphysis pubis.
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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.

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Management Priorities Vaginal Delivery

• Suction the babys mouth and nose.
• Begin resuscitation of the baby as needed.
• Delivery of placenta is nonemergent.

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Case Progression

• The baby is born limp and lifeless.
• No respiratory effort is noted.
• He is blue.
• What do you do now?

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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.

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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.

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Case Progression

• The infant remains apneic after the initial
  steps.
• What do you do now?

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Management PrioritiesBag-Mask Ventilation

• Extend the head slightly on the neck.
• Position hands in EC-clamp.
• Ventilate at 40 breaths per minute.

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Management PrioritiesAssess 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.

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Management PrioritiesChest Compressions

• If the heart rate remains lt 60 beats/min, after
  30 seconds of bag-mask ventilation, begin chest
  compressions.
• 31 ratio. Pause to deliver a breath.
• 90 compressions and 30 breaths/min (120 events
  per minute)

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Management PrioritiesChest Compressions in the
Newborn
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Management Priorities Depressed Newly Born
Resuscitation

• If heart rate is lt 60 beats/min after another
  30 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 110,000 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).

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Management Priorities BLS Shock Treatment for
the Newly Born

• Shock symptoms
• Poor perfusion
• Weak pulses
• Poor response to resuscitation.
• Shock treatment
• Rapid transport.

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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 Ringers lactate, which
  may be repeated

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Key Concept The Inverted Pyramid
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Case Progression

• After bag-mask ventilation for 30
  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!

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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!

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Key Concepts Transport Considerations The
Compromised Newly Born

• Secure to backboard.
• Provide airway management.
• Keep newly born warm!
• Monitor.
• Check glucose value.
• Transport.

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Case Progression

• After delivery of the baby, there is no maternal
  hemorrhage.
• You prepare to transport the baby in mothers
  arms. Restrain mother on the gurney.

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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.

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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 babys heart rate and
  respiratory effort.

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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.