Steps to Take In an Emergency Child Birth Situation
EVALUATING THE MOTHER
As a general guideline, there are three cases in which you should not try to transport the mother to a hospital or doctor:
1.When you have no transportation available.
2.When the delivery of the baby can be expected within five minutes.
3.When the hospital or doctor cannot be reached (due to a natural
disaster or some other kind of catastrophe). Imminent delivery
can best be determined by simply talking to the mother. Open
lines of communication and good rapport with the mother are
necessary for a successful delivery. The mother is naturally
nervous and apprehensive, since she expected to have her baby in
the well-controlled environment of a hospital delivery room —
not in the street or at home. When you arrive at the scene and
find a woman in labor, you will first need to determine whether
you have adequate time to transport her to the hospital. To make
this decision, ask the mother certain questions:
- Has the mother had a baby before?
Labor during the first pregnancy is usually slower than in later
pregnancies, allowing more time for transport. If this is a
first child, you will have time to transport unless the mother’s
vagina is bulging and you can see the crown of the baby’s head
in the birth canal. In women who have had several children,
there may not be much time. Previous deliveries cause most of
the structures used in the birth process to stretch, permitting
easier delivery.
- How
frequent are contractions? Contractions more than five minutes apart generally allow enough
time to get the mother to a nearby hospital. Contractions less
than two minutes apart, especially in a woman who has had more
than one pregnancy, signal impending delivery and do not allow
enough time for transport. False contractions, or “false
labor,” may begin as early as three or four weeks
before actual delivery. These contractions, part of the natural
stretching process that begins early in pregnancy, allow the
uterus to grow with the development of the fetus. As the fetus
grows and the uterus enlarges, these contractions become more
and more evident. They are usually confined to the lower part of
the abdomen and groin but do not increase in intensity. True
labor contractions are felt in the lower back and extend in a
gird like fashion from the back to the front of the abdomen.
There is a definite pattern to the rhythm and a gradual increase
in intensity, frequency, and duration. False labor pains are
irregular and are usually relieved by walking. In true labor,
the intervals between contractions are regular and do not cease
with exercise. During labor, the interval between contractions
gradually diminishes from ten minutes in early labor to two or
three minutes in the second stage. The duration of the
contractions is usually forty-five to ninety seconds. For the
woman bearing her first child, the total length of labor can be
up to eighteen hours. For women who have had several children,
eight hours is not uncommon. However, remember that no two women
are alike.
- Has the mother’s amniotic sac (bag of waters) ruptured, and if
so, when? If rup- ture occurred many hours before, the
likelihood of fetal infection is increased, and the hospital
staff should be alerted.
- Does the mother feel as though she has to move her bowels? This
sensation is caused by the baby’s head in the vagina pressing
against the rectum and indicates that delivery is imminent.
Under no circumstances should you allow the mother to sit on the
toilet. Excessive bearing down by the mother will cause early
delivery and may result in the death of the child.
- Examine
the mother to see whether the crown of the baby’s head (or
whichever part of the baby comes out first) is bulging out of
the vagina. If so, the baby is about to be born, and you will
not have time to go to the hospital before delivery. This can
only be determined by direct examination. Communication with the
mother is crucial at this point; you must have gained the
mother’s trust and confidence. A simple explanation about the
necessity for examination should suffice for the mother and or
father. Every step of the examination should be carefully
explained in simple, easily understandable terms. If you think
that you have plenty of time for a trip to the hospital,
transport the mother in the following manner:
- Keep her lying down, and remove any underclothing that might
obstruct delivery.
- If
possible, place a stretcher underneath the mother during
transport.
- Place a folded blanket, sheet, or other clean object underneath
her buttocks and lower back.
- Have the mother bend her knees and spread her thighs apart so
that you can watch for the fetal crowning (appearance of the
crown of the baby’s head in the birth canal) .
- If the father or someone else is present, ask that person to
reassure the mother and to talk to her during this part of the
examination, since it can be embarrassing for both parties.
- Do not allow the mother to go to the toilet.
- Never ask the
mother to cross her legs or ankles, and never tie or hold her
legs together in an attempt to delay delivery. Never try to
delay or restrain delivery in any way, since this causes undue
pressure and may result in death or permanent injury to the
infant.
- In case of vomiting, turn the mother’s head to one side and
clean out her mouth, either manually or by suction.
PREPARATIONS FOR A NORMAL DELIVERY
1.
Assist the patient to lie on her back with her knees bent and
separated as far apart as possible and her feet flat on the
surface beneath her. A hard surface is best for the mother
— it can be softened a little with folded sheets or towels or
blankets (you can even use newspapers if you have nothing else)
— and it is easier for you if the surface can be elevated. Most
of the time, the mother will be in her own bed or some other bed
in the house. Try placing chairs underneath the bed legs to
elevate the bed, and make it firmer by putting a solid object
(such as a piece of plywood, an ironing board, or table leaves)
between the mattress and the box springs. If the mother is in
her bed, try to protect the mattress from the blood and amniotic
fluid. Use a waterproof sheet, if one is available, or keep a
thick layer of newspapers next to the mattress. If possible,
place a stretcher underneath the mother on the bed. It will make
transport easier, and you will not have to disturb the mother.
It will also protect her bed while providing a firmer surface.
Lift the mother’s buttocks about two inches off the surface with
a pad of folded sheets, blankets, or towels. Position the mother
so that at least two feet of surface extend beyond her vagina.
This surface will support the slippery baby. If the mother is in
an automobile and lying down on the seat, have her place one
foot on the floorboard.
2.
Remove any constricting clothing, or push it above the mother’s
waist. 3. Have the best possible light directed toward the
mother’s genital area. Watch for gapping of the vagina and
bulging of the skin between the vagina and the anus. With each
contraction, the baby’s head may be visible as the labia (lips
of the vagina) open wider.
4.
If equipment is available, place it on a table next to the
mother; keep it away from the birth canal so that it will not be
contaminated by the gush of amniotic fluid. Cleanse your hands
with germicidal wipes. Place the pack where it will be
convenient for you to use, and open it. Remove one sheet,
touching only the corners. Between contractions, when the mother
can concentrate on what you are telling her to do, ask her to
raise her hips. Place one fold of the sheet well underneath her
hips, and unfold it toward her feet. If time permits, use a
second sheet to cover the mother’s abdomen and legs, leaving the
birth canal area uncovered. If you do not have sheets, use a
sterile towel.
5.
Do not touch the vagina at any time. 6. Put on sterile gloves if
you have them. 7. Watch for the emergence of the top of the
baby’s head at the vagina. Be prepared to support the baby’s
head as it emerges.
DELIVERY OF THE BABY
1. As
the baby’s head is born, it normally faces down; it then usually
turns so that its nose is toward the mother’s thigh.
2.
As soon as the baby’s head is visible, support the head with one
hand and pick up the rubber bulb syringe. Compress the syringe
BEFORE you bring it to the baby’s face. When it is compressed,
insert the tip of the syringe about 1 to 1.5 inches into the
baby’s mouth. Then slowly release the bulb to allow mucous and
water to be drawn into the syringe. Remove the syringe and
discharge the syringe contents onto a towel.
3.
When the head is born, check to see if the umbilical cord is
around the baby’s neck. if it is, use two fingers to slip the
cord over the shoulder; or clamp, cut, and unwrap the
cord.
4.
To help the lower shoulder out, support the head in an upward
position. As the shoulders emerge, be prepared for the rapid
appearance of the rest of the baby’s body — the head and
shoulders are the widest parts and take the longest to emerge.
5.
As the abdomen and hips emerge, place your other hand under
these areas. You should now have two hands supporting the
baby.
6.
No attempt should be made to pull the baby from the vagina. If
the amniotic membranes cover the head after the baby emerges,
the sac should be torn with a clamp, the fingers, or with
forceps to permit the escape of amniotic fluid. Move the sac
away from the baby’s face to enable the baby to breathe. Avoid
touching the mother’s anus during delivery. When born, the baby
will be bluish and covered with a whitish, cheesy, slippery
substance known as the vernix caseosa.
7.
Use a sterile towel (or the cleanest cloth available) to receive
the baby. If possible, note and record the time of birth.
8.
As soon as the baby is completely delivered, pick it up to allow
mucous and fluid to drain from its nose and mouth. Be sure that
you have a firm hold, because a newborn baby is very slippery.
Grasp the baby at the ankles, slipping one of your fingers
between them, and support the baby’s shoulders with your other
hand, with your thumb and middle finger around the baby’s neck
and your forefinger supporting the baby’s head. You can place a
towel around the ankles to give you a better grip.
9.
Do not pull on the cord when picking up the baby. Raise the
baby’s hips slightly higher than its head for drainage, and lie
the baby on its side at the level of the birth canal or lower
(do not place the baby on the mother’s abdomen at this time). It
will probably breathe and cry almost immediately. Soon after
this cry, the cord will become limp and will no longer pulsate
— the blood flow ceases, since the baby no longer needs
it.
10.
Suction out the baby’s mouth several more times to clear it of
all mucous. Wipe away any blood and mucous from the nose and
mouth with sterile gauze or a gloved finger, maintaining a firm
hold to prevent the baby from slipping. Then use the rubber
syringe to suction the mouth and both nostrils. Be sure to
squeeze the bulb before inserting the tip, then place the tip in
the baby’s mouth or nostrils, and release the bulb slowly. Expel
the contents into a waste container, and repeat suctioning as
needed. Keep the baby’s head lowered when clearing mucous by
finger or syringe — do not attempt to support the baby in
midair while holding it only by its feet.
11.
If the baby does not breathe on its own at this point, stimulate
it by rubbing its back gently or by slapping the soles of its
feet. If you still get no response, start mouth to-mouth
ventilation, bearing in mind that babies are very little and
thus require very small puffs. Never use mechanical ventilation
devices on a newborn infant. If the baby begins breathing on its
own, administer oxygen by mask (four liters or less) until the
baby’s skin color is pink. If breathing is still absent,
however, and no pulse is present, begin cardiac compression, and
continue it until you arrive at the hospital. Keep the baby
wrapped in a blanket as much as possible.
12.
As soon as the baby is breathing and crying, wrap it in a
blanket (if you have one). If possible, the blanket should be
heated to about 90″ F. Wrap the baby so that only its face
is exposed. Do not pull on the cord, and do not tie the cord.
The cord will usually be long enough for you to place the baby
on the mother’s abdo- men; help her to hold the baby there in a
side-lying position.
13.
Unless it is policy in your area, do not worry about tying or
cutting the cord. When the baby first cries, the circulation
from baby to cord normally ceases, and clots form to seal off
the umbilical blood vessels. The cord must be cut under strict
antiseptic conditions because of possible infection, so you
should not cut it if you cannot do it antiseptically. Leaving
the cord and placenta attached to the baby may be a bit messy,
but it is safe. No harm will result, and this will prevent
improper tying and/or cutting of the cord. if it is necessary to
cut the cord, of if it is standard procedure in your area, place
two clamps on the cord about three inches apart, positioned
about six inches from the baby’s navel. About one inch from the
clamp that is closest to the baby’s body, tie the cord off (on
the baby’s side of the clamp) with the umbilical tape. Compress
the cord very slowly with the tape to avoid cutting through it.
(Never use string or thread — you will cut through the cord
immediately.) Tie the tape with a square knot. Cut the cord
between the two clamps, using the sterile surgical scissors.
Periodically check the ends of the cord for bleeding,
controlling any that may occur.
DELIVERY OF THE PLACENTA
1.
If there are no complications, and cutting the cord is accepted
local protocol, observe the appearance of the cord and its
location at the vagina. As the placenta separates from the
uterus, the cord will appear longer.
2.
Place one hand on the mother’s abdomen, and feel for a definite
contraction. The contracting uterus should feel like a hard
grapefruit-sized ball.
3.
Wait for the delivery of the placenta. The placenta is usually
delivered within ten minutes, but fifteen to twenty minutes may
elapse. Most will deliver within twenty minutes. Never pull on
the cord to check for separation of the placenta. As the uterus
contracts, encourage the mother to bear down to expel the
placenta and membranes. Some bleeding may be expected as the
placenta separates.
4.
When the placenta appears at the vagina, grasp it gently, and
rotate it. Do not pull, but slowly and gently guide the placenta
and the attached membranes (fetal sac) from the mother’s
body.
5.
Do not cut the cord unless it is necessary or unless you are
instructed to do so. Wrap the placenta in a sterile towel, and
place it next to the baby. Wrap the baby and the placenta
together in the third sterile sheet from the pack, and place
both in the mother’s arms.
6.
When the placenta is delivered, and if the cord has been cut,
place the placenta in a plastic bag to be taken to the hospital,
where it may be examined for completeness; retained pieces of
placenta will cause persistent bleeding.
7.
Check the amount of vaginal bleeding. A small amount (one or two
cups, or less than 500 milliliters) is normal.
8.
Examine the skin between the anus and the vagina for
lacerations, and apply pres- sure to any bleeding tears.
9.
Remove the soiled sheet. Save all evidence of blood loss
(stained sheets or towels) for the physician to examine.
10.
Place two sanitary napkins over the vaginal and perineal area
(the area between the vagina and the anus), touching only the
outer surface and placing the napkins from the vagina toward the
anus. Help the mother place her thighs together to hold the
napkins in place.
11. Elevate the feet if needed.
12.
Massage the mother’s lower abdomen to help contract the uterus.
Do this by feeling the abdomen until you note a
“grapefruit-size” object. This is the uterus. Rub in
this area, using a circular motion. This will help the uterus
contract, thereby controlling bleeding. If the mother desires to
nurse the baby, let her do so, because this will also help to
control the bleeding. If there is a tear in the tissue between
the vulva and the anus (perineum), let the mother know that this
is normal and that it will be taken care of at the hospital.
13.
Continue to give the mother lots of comfort and emotional
support. 14. Cover the mother and baby for warmth, but do not
overheat. Prepare both for transportation to the hospital.
Remember, complications are more likely to develop in a cold,
stressed infant.
IMPORTANT: PROTECT BABY AGAINST HEAT LOSS!
Complications in Birth
PRE & POST: DELIVERY EMERGENCIES
Major conditions may be present in a
pregnant woman who has not yet delivered:
1.
Convulsions. A pregnant woman may experience a seizure from any
usual reason (epilepsy, high fever, blow to the head, etc.) or
from toxemia. If a pregnant woman is having a seizure: · Place
her on her side. This will allow her to breathe easier, thus
supplying the baby with more oxygen. · Give oxygen if possible.
During a seizure, the mother’s body, hence the baby, will become
oxygen-deprived and will need additional oxygen. · When the
seizure subsides and the patient regains consciousness, elevate
her head and shoulders. This will allow her to breathe easier
and will make her more comfortable.
2.
Heart-Lung Complications. Though not common, it is possible for
a pregnant woman to experience breathing difficulties from
allergies, asthma, etc., or even to have a heart attack. If an
event of this type occurs: · Give emergency care for the
existing condition. · Administer oxygen. 3.
Hemorrhage. There are various reasons for a mother to bleed from
the vaginal opening. You should observe the external area of the
vagina but should not examine vaginally. A vaginal examination
can increase the hemorrhage. Give the following care: · Administer
a high concentration of oxygen immediately if available.
Maintain the patient’s body temperature with blankets.
Encourage the mother to lie on her side, which should allow the
mother to breathe easier, thence help to oxygenate the baby’s
blood more efficiently. A pneumatic counter pressure device (i.e., MAST) may be used only on the legs
if the emergency rescuer is trained in its use, if a physician
is contacted first (follow local protocol), and if the mother’s
condition warrants it.
UMBILICAL CORD AROUND THE NECK
If the umbilical cord is wrapped around the baby’s head
in the birth canal: 1. Try to slip it gently over the baby’s
shoulder or head.
2. if you cannot slip it over the baby’s head, and if it is
tight around the neck, place clamps or ties on the cord two inches
apart, and cut between them quickly; unwrap the cord from around
the neck.
3. Deliver the shoulders and body, supporting the head at all
times. Limb Presentation If an arm or a leg is first to emerge
from the vagina, you must transport the mother im- immediately to
the hospital. A limb presentation means that the baby has shifted
so much in the uterus that a normal delivery is impossible and
that the baby will have to be delivered by surgical technique.
Delay can be fatal. DO NOT attempt to pull on the baby by an arm
or leg.
WEDGED SHOULDERS
If the baby’s shoulders become wedged in place after the head
has been delivered:
1. DO NOT attempt to pull on the baby.
2. Suction the baby’s mouth and nose.
3. Make sure that the baby is breathing.
4. Transport mother and baby to the hospital.
5. Constantly monitor the mother and baby during the transport.
MULTIPLE BIRTHS
Multiple births generally present no problems, and twins are
delivered in the same manner as single babies, one after another.
1. Even if the mother is unaware of the fact, you
may suspect a multiple birth if the abdomen is still very large
after one baby is delivered; there are more strong uterine
contractions, and the baby’s size is out of proportion to the
mother’s abdomen. Labor contractions start again about ten minutes
after the first baby is born.
2. When the first baby is born, clamp and cut the cord (as
described earlier) to prevent hemorrhage to the second baby.
Contractions will continue, and the second and subsequent babies
should be born within minutes. Handle the baby as you would for a
single birth.
3. If the second baby has not been delivered within ten minutes of
the first, transport the mother and the first baby to the hospital
for delivery of the second twin. After the babies are delivered,
the placenta or placentas will be delivered normally.
4. Keep the infants warm. Twins are often born early and may be
small enough to be considered premature. Special precautions
should be taken to prevent a fall in temperature.
PREMATURE BIRTHS
A premature baby is one that weighs less than five and one-half
pounds or one that is born before seven months (twenty-eight
weeks) of gestation. You can judge by the baby’s appearance or
from the history given by the mother whether or not the baby is
premature. Premature babies are more susceptible to respiratory
diseases and infection and must be given special care. Thinner,
smaller, and redder than a full-term baby, a premature baby also
has a larger head in proportion to his body. Take these steps to
care for a premature baby:
1. Keep the baby warm. Wrap him in aluminum foil as an
outer wrapping for extra insulation if you have no other
facilities to heat him.
2. Keep the baby’s nose and mouth clear of fluid by gentle
suction with a bulb syringe.
3. Prevent bleeding from the umbilical cord; a premature
infant cannot tolerate loss of even minute amounts of blood.
4. Give oxygen into a tent above the infant’s head; do not
blast the oxygen directly into the baby’s face.
5. Prevent contamination. Premature infants are highly
susceptible to infection. Keep your breath from the baby’s face,
and have other people stay back.
6. If you have the facilities in your vehicle, you can warm
the baby during transport by placing covered hot water bottles in
the bottom and along the sides of a crib. Make sure that you wrap
the baby securely and that the bottles are covered completely,
since the skin of a premature infant burns easily .
EXCESSIVE BLEEDING AFTER DELIVERY
Internal bleeding can result when placental products are left
in the uterus, when uterine contractions are inadequate, or when
the mother develops clotting disorders. If bleeding is profuse,
continue uterine massage, and put the baby to the mother’s breast.
If bleeding persists, transport the mother
rapidly to the hospital while giving her care in the usual way for
shock. Avoid vaginal examination or packing of the vagina.
Continue gentle uterine massage during transport. External
bleeding from tears in the skin between the vagina and the anus
can be managed with firm pressure. It may be necessary to open the
labia to lay packs at the bleeding site.
BREECH BIRTH
Breech birth refers to a delivery in which the baby’s buttocks
appear first instead of the head. All efforts should be made to
get the mother to the hospital, but when transport is not
possible, follow these rules:
1. Position the mother as usual, and prepare her for delivery
as usual.
2. Let the buttocks and trunk of the baby deliver on their own.
3. Place your arm between the baby’s legs, and support the
baby’s back with the palm of your hand. Let the baby’s legs dangle
astride your arms. The head should follow on its own.
4. If the head takes longer than three minutes to deliver after
the waist and trunk have delivered, you must take steps to prevent
the baby from suffocating, since the baby’s head will compress the
umbilical cord inside the vagina and cut off circulation. · Place
your middle and index fingers along the infant’s face with your
palm toward his face. · Reach into the vagina to the baby’s
nose. Form an airway as you push the vagina away from the
baby’s face until its head is delivered slowly. Put your finger in
the baby’s mouth so that he can breathe.
5. Do not try to pull the baby. Never attempt to pull the baby
from the vagina by his legs or trunk.
6. When the head has been delivered, give the mother and infant
normal post delivery care.
7. If the head does not deliver within three minutes, transport
the mother to a medical facility either with her buttocks elevated
or in a knee-chest position. Maintain the baby’s airway throughout
transport.