Obstetrical Emergencies (Emergency Childbirth)

Although it is far from an ideal situation, you may be faced with a situation requiring you to assist with an unplanned, emergency childbirth. This situation, which can be stressful, painful, or scary in the best of environments, may be greatly intensified by a fear of the unexpected  or the possibility that something may go wrong.

Childbirth is a natural process in which things rarely go wrong. According to the American Red Cross, thousands of children all over the world are born each day, without complications, in areas where no medical assistance is available.

By following a few simple steps, you can effectively assist in the birthing process. This page provides information and references regarding childbirth, how to assist with the delivery of the baby, and how to care for both the mother and newborn.

Note: Many of the links on this page are from www.babycenter.com, an excellent Web site for pregnancy, delivery and early childhood development. Check it out! Click the link in this sentence to see pregnancy and childbirth videos on babycenter.com.

Normal Pregnancy

Pregnancy begins with fertilization, when a sperm cell penetrates the mature egg after ovulation. Changes begin occurring immediately: the protein coating around the egg changes to prevent other sperm from entering, the genetic makeup of the child is established, and the sex is determined by whether the sperm is X (for girl) or Y (for boy). Within 24 hours, the fertilized egg (or zygote) begins subdividing into cells as it passes from the fallopian tubes to the uterus (or womb). The developing cells are called an embryo for the first 8 weeks and then a fetus after 8 weeks until birth.

The placenta begins to develop inside the uterus after the egg attaches itself to the uterine wall. Its purpose is to deliver oxygen and nourishment to the fetus and to remove waste products. The fetus develops in the uterus, surrounded by amniotic fluid. The uterus is made up of smooth muscle and blood vessels that allow it to enlarge significantly and to forcibly contract during labor. The ability of the uterus to produce strong contractions helps pass the baby from the uterus into the birth canal. Strong contractions also help the uterus constrict blood vessels to prevent hemorrhage, and to help the uterus return to its previous size.

The cervix (lower end of the uterus) forms the start of the birth canal from the uterus into the vagina. During birth, the cervix dilates, causing a mucous plug at the base of the cervix to be expelled, and the fetus to be passed into the vagina.

The duration of a full-term pregnancy is approximately 9 months (about 38 weeks from the time in which the embryo becomes implanted into the woman’s uterus). The due date is usually calculated as 40 weeks from the woman’s last menstrual period. Pregnancy is broken down into trimesters, each approximately 3 months in length.

  • The first trimester involves implantation and rapid development of the embryo. This usually takes place without symptoms although slight bleeding may occur. Morning sickness affects about 70% of pregnant women during the first trimester, subsiding by the second trimester.
  • During the second trimester, the pregnant woman feels re-energized and begins to show (putting on weight with the growth of the fetus). The movements of the fetus can be felt my the mother, and the fetus develops sufficiently so that it is possible to determine whether the baby will be male or female.
  • The mother gains the most weight during the third trimester when the fetus grows more rapidly. This growth can cause discomfort for the mother, including hernia, weak bladder, and backache. The fetus moves to a head down position in anticipation of birth (called dropping).

Labor

Pregnancy culminates in labor (also known as the birth process). Labor has 3 or 4 distinct stages:

  1. Rhythmic contractions of the uterus that cause the cervix to dilate
  2. Delivery of the baby
  3. Delivery of the placenta
  4. Stabilization of the mother (sometimes not included as a stage)

For first-time mothers, delivery of the baby (stage 2) can last 12 to 24 hours; subsequent deliveries usually require less time.

Assessing labor in a prehospital setting

If you are asked to assist a pregnant woman outside of the hospital, you first need to determine whether she actually is in labor. Braxton Hick contractions are false labor contractions that may cause the patient to think they are about to have the baby. Ironically, an increase in false labor contractions can signal the onset of real labor. Other signals of impending labor are:

  • Rhythmic contractions 2 minutes apart or less and lasting 60 to 90 seconds
  • A bloody show (that occurs when the mucous plug falls out of the opening in the cervix
  • A sudden gush or trickle of amniotic fluid from of the vagina (the patient’s “water breaking“)
  • The patient’s strong urge to bear down
  • The patient feels the infant’s head moving down the birth canal or crowning in the vaginal opening
Preparing for delivery

When a pregnant woman experiences the signals of impending labor, call for advanced medical personnel immediately. Conduct primary and secondary assessments. The SAMPLE history can easily be adapted to this situation. For example:

  • Signs/symptoms: How far apart are the contractions? Did your water break? Do you feel the baby’s head moving down?
  • Allergies: Do you have any allergies, especially strong reactions?
  • Medications: Are you taking any medications?
  • Pertinent history: Is this your first pregnancy (usually takes longer)? What is your due date? Are you having a boy/girl/twins (twins come faster)? Did the doctor inform you of any complications to expect? Have you experienced complications during your pregnancy or in your previous childbirths, if any? Do you have any other medical conditions that we should be aware of?
  • Last intake: When did you last eat or drink?
  • Events: What were you doing when you started experiencing symptoms of labor? How long ago did your water break, etc.?

In urban settings, advanced medical care may be only a few minutes away. Try to keep the patient calm and in a position of comfort for her until more help arrive. If advanced medical care is delayed and birth seems imminent, you may have to assist with the delivery. The following are some great resources for out-of-the hospital emergency childbirth:

Assisting with delivery simply means to:

  • Establish a clean, comfortable environment for delivery using plastic over the mattress or padding and clean blankets or sheets over the plastic and under the mother
  • Position the mother in a way that is comfortable for her. She should not be flat on her back as this allows the uterus to compress the vena cava, which compromises blood flow from the legs to the heart and limits the effectiveness of contractions.
  • Place clean sheets or towels on the mother’s abdomen and upper legs; keep a clean towel ready to receive the baby
  • Because there can be spraying blood and body fluids, use disposable gloves, face shield or mask and eye wear, disposable gown or apron, and footwear, if available, after washing your hands and forearms.
  • Have other items on hand like oxygen, bulb syringes, pads and sponges, etc.
  • Help the mother with the delivery of the baby:
    • As the baby’s head crowns, apply light pressure to prevent forceful emergence.
    • Have the mother push gently with each contraction, and concentrate on breathing exercises and panting. Click to learn the differences between coached and spontaneous pushing.
    • As the baby’s head emerges, guide it out without pulling. The baby will turn to one side to allow the shoulders and the rest of the body to pass through the birth canal. Guide one shoulder out at a time and support the head at all times.
    • If the umbilical cord is wrapped around the baby’s neck, gently slip it over the baby’s head or around the shoulders.
    • Use a clean towel to receive and hold the baby. Note the time of the birth.
    • Clean the baby, especially around the nose and mouth. Make sure the baby is breathing.
    • Place the baby next to the mother with head slightly lower than body.

Caring for Baby and Mother

Even if the delivery of the baby occurs without complication, you will need to provide routine care for the newborn and the mother. As you provide this care, you should also monitor both patients for signs of more serious problems that rarely occur.

Caring for the Newborn

Caring for the newborn includes the following (to see a video description of these care steps, click here):

  • Cleaning the baby, especially the nasal passages and mouth – When the newborn is delivered, it will be slippery and wet, and sticky fluid may block the mouth and nose. Dry the newborn, particularly the head and use a bulb syringe to suction fluid from the nose and mouth. If a bulb syringe is not available, gently press down on each nostril to expel mucus and fluid and then wipe the material away from the mouth and nose using sterile gauze.
  • Maintaining warmth – Wrap the newborn in a clean, soft towel or small blanket. Support the head at all times. Click the link to learn how to swaddle a newborn. Here is a video demonstration of swaddling, and here is another with lots of great information.
  • Establishing and monitoring normal breathing – Most newborns begin crying spontaneously. If the baby does not make any sound after delivery, stimulate a crying reflex by flicking the soles of the feet with your finger or by rubbing the baby’s lower back.
  • Assessing the newborn – At the 1-minute and 5-minute marks, perform the APGAR score to determine how the newborn is doing and whether additional medical care is needed. Click this link to learn about APGAR. Let this score help to guide your care for this newborn, including resuscitation if necessary.
  • Resuscitating the newborn, if necessary – Begin positive-pressure ventilations and oxygen administration if the newborn’s respirations are less than 30 breaths per minute, the pulse rate is less than 100 beats per minute, and/or the APGAR score is 3 or less. If the newborn’s pulse rate falls below 60 beats per minute, start infant CPR.
  • Cutting /not cutting the umbilical cord – It is not necessary to clamp, tie, or cut the umbilical cord, and local protocols may prohibit you from doing so. The placenta will be delivered within 10-30 minutes of the newborn and it can remain attached until more help arrives.
Caring for the mother

Caring for the mother includes:

  • Receiving the placenta – Uterine contractions usually expel the placenta within about 30 minutes of the birth of the newborn. The mother may experience strong contractions, similar to childbirth, and may have to bear down to expel the placenta. When the placenta appears, slowly guide it out of the vagina without pulling and place it in a clean towel or container.
  • Controlling bleeding after birth – Expect some additional bleeding following the delivery of the newborn and the placenta. Place a sanitary pad over the vagina and have the mother place her legs together. Treat the patient for shock by maintaining normal body temperature, removing bloody sheets from the area, and keeping the patient comfortable and reassured.
  • Providing physical and emotional support – Keep the mother comfortable and in contact with her baby. Monitor the vital signs of both patients until advanced medical care takes over. Dry the mother’s face and give her sips of water if she is thirsty. For more information, read Emotional Health During Pregnancy and Recovering from Childbirth,

Complications

Complications, although rare, can occur during pregnancy and delivery. To read articles about pregnancy complications, click 7 pregnancy complications to watch out for. In addition to those 7 conditions, the patient may experience chronic hypertension, excessive amniotic fluid,  false labor, incompetent cervix, intrauterine growth restriction, and iron-deficiency anemia during the course of the pregnancy. The patient may report having a pregnancy complication during the SAMPLE history.

The most common complication surrounding delivery is postpartum hemorrhage (persistent vaginal bleeding). Other birth complications include: