For some unspecified reason, EMT’s and Paramedics are terrified of OB/GYN emergencies, particularly childbirth. They take a natural, normal process of human reproduction and increase the stress level both on themselves and the mothers and fathers (if present). I think part of the problem is lack of knowledge on the topic, and historically women do fair better than men do on NREMT test questions related to childbirth and gynecological emergencies.
So let’s begin with something that you may face in the field: CHILDBIRTH
But seriously, what can we do for a birthing mother? Almost nothing. The natural birth process is automatic and will proceed without intervention. With it running automatically, what is the big deal?
Many medics run lights and sirens to the hospital with a woman in labor, especially when she’s getting ready to deliver. Why? Is it anxiety about handling a live birth? A desire to avoid the clean up or not have to write another report? We are endangering lives running to the hospital in an emergency mode for a BLS call. Mom doesn’t really need an IV, she just needs to breathe and push.
So now that I’m off my soapbox, let me talk about the process itself. It starts with the rupture of membranes, or the water breaking. This signals the beginning of labor, usually starting within 24-48 hours (Bledsoe et al, 1537). If a woman calls and tells you her water broke over 2 days ago and she is not having contractions, she needs to evaluated urgently for two reasons: the child without that fluid is at a higher risk of trauma and that the birth will need to be induced to reduce the risk of infection. This signals the start of the actual birthing process known as peurperium.
The water breaks for many reasons, mainly mechanical. The cervix softens and dilates, causing the amniotic sac to fill the gap. The head then comes down into that bulge creating uneven pressure and forcing a rupture. This a pretty common reason, but there are dozens of other reasons and you can find them here on this page about pregnancy and childbirth.
Labor at this point comes into three separate stages. The first is the dilation stage, which is where the cervix effaces, softens and dilates in order to expel the baby. Effacement is a term that confused me, it simply means that the cervix thins out and elongates, and begins several days before the actual beginning of labor. As labor continues, the cervix dilates to 10 cm and contractions move from being mild around 10-20 minute intervals lasting 10-15 seconds, to being extremely strong lasting up to 60 seconds at 2-3 minute intervals.
The second phase is called the expulsion phase. This is the actual delivery phase where the baby will be pushed out by the uterus. This phase has extremely strong contractions lasting 60-80 seconds. This phase for nullipara, or mothers who have not previously given birth, this phase can last over an hour. For multipara, or mothers who have given birth previously, this can last half the time.
In a normal delivery, the baby will present out of the vagina head first, face down. If the contractions are at the 2-3 minute contractions and baby does not present within 20 minutes you should transport immediately. This may be an indication of breech birth and require immediate surgical intervention.
As the baby comes out, you will want to support the head and as the head rotates so the shoulders can deliver you can begin to suction the mouth first, then the nose. Most commercial OB kits will have a bulb syringe in it, but in a pinch you can use a powered unit, but you should be careful. Now that the baby is out, you can now worry about the cord. Hold the infant at the level of vagina and clamp the cord 10cm away from the infant’s body and place the other clamp 5cm from that one and cut in between. Commercial kits will once again have cord scissors or a hook scalpel.
Now dry the baby, place it on the mother’s chest, and encourage nursing. They used to advocate immediate swaddling, but the mother’s body temperature will actually increase to warm the newborn so you can hold off on immediate swaddling. The vagina will continue to ooze blood after this process and maternal blood loss can be around 1/2 L (500 mL). The cord will appear to lengthen several minutes after the birth.
Now here comes the really icky part. The placenta will deliver shortly after the neonate does. This is called, you guessed it, the placental stage. The placenta should be bagged and tagged and transported with the mother and newborn. Some hospitals will run pathologic tests on the placenta and some parents will want the cord blood contained within.
And that’s it, you have successfully assisted in a natural process bring new life into this world. Vaginal delivery is a stressful process for mother, baby, and care providers who do not normally handle these situations. Next time we will cover non-standard situations dealing with childbirth and neonatal care.
Bledsoe, Brian E et al. Essentials of Paramedic Care (13 March 2006). 2nd Edition. Prentiss Hall.