Emergency childbirth

Normal Stages of Labor

Emergency childbirth is the birth of an infant in places or situations other than what was planned. In most cases the location of childbirth is planned ahead of time and may be at home, a hospital, medical facility or birthing center. In other situations, the birth occurs on the way to these facilities. Oftentimes, no trained medical personnel are present, other times there may be police or other first responders. Emergency measures are indicated when childbirth is imminent.

Background

Each year more than 250,000 women around the world die from complications due to childbirth or pregnancy, with bleeding and hypertension as the leading causes. Many of these deaths are preventable by emergency care, which include antibiotics, drugs that stimulate contraction of the uterus, anti-seizure drugs, blood transfusion, and delivery of baby with assistance (vacuum or forceps delivery) or C-section.

In 2012, 1.36% of births took place outside of a hospital, and this number has been increasing over the last 30 years. This is likely a combination of more home deliveries and deliveries at birth centers, with 66% occurring at home and 29% in birthing centers. In a study of home deliveries in the US and Canada, about 12% of attempted home deliveries required urgent transport to hospital for more specialized care. Reasons for transfer include failure of labor to progress, maternal exhaustion or need for more pain medication, or maternal/fetal complications (see below).

Preparation

Pregnant women usually seek medical care throughout pregnancy and plan for the birth of a baby with a healthcare team. In an emergency childbirth situation, it is recommended to seek further education and make a plan.

Early Preparation

Many childbirth education classes cover emergency birth procedures. Parents are trained to learn the signs of early labor or other indications that may require assistance. Caregivers can take a class on infant and child life support. Some recommend having a kit of emergency supplies in the home such as: clean towels, sheets, clean scissors, sterile gloves, sanitary pads, diapers, and instructions for infant-rescue breathing.

Late Preparation

Additional help may be found by calling 911 (in the United States) or an applicable number to get emergency medical services or nearby medical staff.

A vehicle driven safely toward medical care may be considered an acceptable option during the first stage of labor (dilation and effacement). During the second stage of labor (pushing and birth), a vehicle is usually stopped unless imminently arriving at a medical facility. If a vehicle is taken, additional occupants can support the mother and baby should assist in delivery. The mother and baby are kept warm throughout.

If unable to reach a medical facility, a safe building with walls and a roof are sought that will provide protection from the environment. A warm and dry area with a bed is preferable.

Supplies are collected for both the mother and the baby. Possible supplies may include blankets, pillows, towels, warm clean water, warm water bottles, soap, clean towels, baby clothes, sheets, sterile gloves, sanitary pads, diapers, identification tags for mother and baby, and instructions for infant-rescue breathing. A bed may be prepared for the baby with a basket or box lined with a blanket or sheets. Items are needed to clamp or tie the umbilical cord in two places. Shoestrings or strips of a sheet folded into narrow bands may be used. These items can be sterilized by boiling (20 minutes) or soaking in alcohol (up to 3 hours). Scissors or a knife are needed to cut the umbilical cord and may be sterilized with the same procedure.

Evaluation

A background obstetric history should be obtained: how many prior births has the patient had (if this is not her first birth, the patient's labor could be short), how many weeks along is she or what is her estimated date of delivery, any special concerns related to this pregnancy such as being told she has twins, being told she has a complication, or even if she has received regular prenatal care. Any other relevant medical history, allergies, drugs, recent signs of infections (fever) should be asked.

Signs and Symptoms

• Any gush of fluid (rupture of membranes)? This would indicate that labor will probably begin soon if the patient is near term.
• Any vaginal bleeding? Could indicate a bloody show, a small amount of bloody discharge prior to labor, or if large amounts of bleeding occurred it could indicate potentially life threatening complications.
• How frequent are her contractions? One common recommendation is the patient may be in active labor if contractions are 5 minutes apart for one hour (if rupture of membranes has not occurred).
• Ask if she feels the urge to push with her contractions? This is an indication delivery is soon. 

Physical Exam

If time permits and if trained: one should obtain vital signs to include maternal heart rate, respiratory rate, blood pressure, temperature and oxygen rate.

The patient should be draped with available blankets for privacy.

Examine and use your hand to feel the patient's abdomen for the presence of contractions. Note the intensity, frequency, and length of contractions.

With permission and privacy, perform an exam of the pelvic area:

• Inspect to see if there is any presenting part of the baby, their head will feel hard versus their buttocks will feel soft.

• If the baby's head is presenting out of the vagina (crowning), then delivery will be happening soon and you should prepare to deliver the baby now.
• Trained physicians would conduct a manual cervical exam to determine the patient's cervical dilation.

After the physical exam and if the patient is not crowning, place the patient in the left lateral decubitus position (laying on her left side).

Delivery of term baby in normal position

Stages of labor

First stage of labor: dilation and effacement of the cervix; before the baby comes out

This stage of labor may last from 2 to 18 hours. Further care may be sought during this time.

1. Evaluation (above) is repeated, assessing for change in stage of labor.
2. The mother is encouraged to walk or sit in a comfortable position.

Second stage: cervix is dilated; the baby is coming out

This stage may last from 5 minutes to 3 hours.

1. Position. The mother is positioned in the lithotomy position, lying on her back, with her feet above or at the same level as the hips. The perineum (the space between the vagina and anus) is positioned at the edge of a bed.
2. Wash. The perineum is cleaned with antiseptic solution or soap and water. Any assistants will wash hands with soap and water and put on sterile or clean gloves.
3. Pushing. Pushing is encouraged during contractions.
4. Head. The head of the baby is delivered. Delivery of the head is controlled to prevent rapid expulsion. One hand is placed on the perineum while the other applies gentle pressure to the baby’s head as it comes out. Soft pressure can be applied to the baby’s chin through the perineum to help expel the head. Rapid expulsion is still prevented with soft head pressure.
5. Cord check. A check is made to look for the presence of an umbilical cord (nuchal cord) around the baby’s neck. If it is present, an index finger is used to attempt to pull it over the baby’s head. If this cannot be done, the cord is clamped/tied in two places. Then the cord is carefully cut, avoiding injury to the baby or mother.
6. Front shoulder. The front shoulder is delivered. This is the shoulder on the mother's front side, towards her belly. The assistant holds the baby's head with two hands and may need to apply slight downward pressure (towards her anus) to help the front shoulder out. Firm pressure can injure the baby. If the shoulder gets stuck this is called shoulder dystocia. See procedure for relief of shoulder dystocia (below).
7. Back shoulder. The back shoulder is then delivered by providing slight upward pressure (away from her anus).
8. Catch baby. The baby usually comes out right away after both shoulders. The baby is caught noting that babies are slippery. The assistant holds the baby at the level of the vagina.
9. Cut cord. The umbilical cord is clamped and cut. The cord is clamped in two places about 6cm to 8cm from the baby. The clamps or ties are tight in order to stop the blood flow. The cord is cut between the two clamps or ties. Sterilized scissors or a sterilized knife is used. Another assistant may help with this.
10. Dry baby. The baby is dried, wrapped, and kept warm. Appropriate neonatal care is provided or the baby is placed to the mother's breast. An identification band may be placed on the baby.

Third stage of labor: the delivery of the placenta

The baby is attached to the placenta by the umbilical cord. After the cord is cut, the placenta is usually still inside the mother. The placenta usually comes out in 2-10 minutes, but it may take up to 60 minutes.

1. Before the placenta is delivered there is a gush of blood as the cord gets longer.
2. The umbilical cord can be held taut, but must not be pulled with much force.
3. The placenta is delivered and is be inspected for completeness. The placenta should be stored in a bag for inspection by trained medical personnel.

Maternal complications

Complications of emergency childbirth include the normal complications of childbirth. Maternal complications include perineal tearing during delivery, excessive bleeding (postpartum hemorrhage), retained products of conception in the uterus, hypertension, and seizures.

Vaginal Bleeding and Shock

In a pregnant woman, 40% of the circulating blood volume is in the uterus, and approximately 4% of women have This creates a large bleeding potential and high risk of hemorrhagic shock ( low blood pressure from loss of circulating blood). For this reason, constant vigilance is important if any of the following occur if any of the following occur:

-      Vaginal bleeding early or late in pregnancy

-      Severe abdominal pain

-      Trauma (such as a fall or car accident) while pregnant

-      Uncontrolled vaginal bleeding after the baby is delivered

-      Inability to remove the entire placenta after the baby is delivered

First trimester bleeding

Causes of vaginal bleeding early in pregnancy include miscarriage (inevitable or incomplete abortion), embryo implantation and growth outside the uterus (ectopic pregnancy), and placenta attachment at the bottom of the uterus over the cervix (placenta previa), all of which can cause significant bleeding.

Bleeding after the first trimester and during delivery

Prior to and during delivery, bleeding can also occur from tears in the cervix, vagina, or perineum, sudden placental detachment (abruptio placenta) and placental attachment over the cervix(placenta previa), and uterine rupture.

Bleeding after delivery (postpartum hemorrhage)

After delivery of the baby, a uterus that is not contracting (atonic uterus), ruptured uterus, remaining parts of placenta or baby or infected remaining parts of placenta or baby can cause severe bleeding. Postpartum bleeding is usually managed preventatively by massaging the lower abdomen (fundal masage), which increases contraction of the uterus and stops bleeding. Additionally, steady traction is applied to the cord to prevent trauma, cord avulsion, uterine inversion and retained placental products, all of which can increase blood loss and can increase risk of infection.

Postpartum hemorrhage is defined by loss of >500 mL blood within 24 hours after delivery. It is difficult to predict with few known risk factors and occurs in 3% of women, leading to ~150,000 annual deaths worldwide. Once uncontrolled bleeding occurs, management can be manual (fundal massage from the outside, packing the uterus, tamponading bleeding from the inside with balloon or condom catheter), and pharmacological (with oxytocin, ergotamine, misoprostol). Alongside these treatments, shock should be addressed with IV fluids or blood transfusions as discussed below.

Severe blood loss leading to shock

In shock, you may see cold clammy skin, pale skin (especially around eyes, mouth, and hands), sweating, anxiousness, and loss of consciousness. You may note fast heartbeat (110 beats per minute or more), low blood pressure (90mm Hg systolic or less), and decreased urine output.

The woman should be laid on her left side, with legs and buttocks elevated to encourage blood flow back to the heart with gravity. If available, IV fluids ( Ringer’s lactate or normal saline) should be started with monitoring of the heart rate, blood pressure, and appearance. If available, two large bore needings (16-guage or largest available) should be used to rapidly infuse 1L in 15-20 minutes, with a goal of giving 2L in the first hour. If unable to start IV and the woman is able to drink and is conscious with no recent convulsions, give 300-500 mL of fluid by mouth. If woman is unable to drink, is unconscious or has recently had convulsions, fluid can be given rectally with an enema bag or can. Fill enema with 500mL IV fluid, clamp end of tube and insert 10 cm (3-4inches) into the rectum. If filling enema, run water slowly or cramping can occur, pushing the water back out.

Convulsions (Seizures)

Convulsions (Seizures) in pregnancy can be caused by pregnancy specific causes of seizures such as Eclampsia and by normal causes of seizures such as epilepsy. Warning signs that may lead to convulsions include pre-eclamsia, which is a condition that pregnant women can get after 20 weeks of pregnancy that is characterized by new onset high blood pressure, headaches, blurry vision, trouble breathing from fluid in lungs, protein in urine from kidney failure, and elevated liver enzymes from liver dysfunction, and possibly coagulation defects from platelet dysfunction.

If a pregnant woman begins to have convulsions, shout for help, do not restrain, but do lie down on left side and check the airway (mouth, nose, throat). Turning on side decreases risk of breathing in vomit and spit.  If available, magnesium sulfate is the preferred treatment for seizures in pregnant women, starting with a dose of 4mg IV over 5 minutes. A sensation of warmth during infusion is normal, however, there is also a risk of stopping breathing with magnesium sulfate use, which would indicate the dosage is too high. If this occurs, calcium gluconate can be used to reverse the effects (1g IV over 10 minutes, often in solution). In general, make sure the breathing rate is at least 16 breaths per minute and the knee jerk reflex is still intact before giving more magnesium sulfate. If magnesium sulfate is unavailable, diazepam can be used to treat convulsions in pregnancy. The first dose, the loading dose, should be 10mg of diazepam IV given over 2 minutes. After this, the loading dose can be repeated. The maintenance dose is 40mg of diazepam in 500mL IV fluids. The amount of diazepam used should never be more than 100mg in 24 hours and it should be dosed in order to keep the woman awake, rousable, and breathing rate above 16 breaths per minute

Fetal care

Almost 10% of newborns require some resuscitative care. Common complications of childbirth that relate to the baby include breech presentation, shoulder dystocia, infection, and umbilical cord wrapped around the baby's neck (nuchal cord).

Evaluation

The newborn is evaluated at 1 and 5 minutes after birth using the Apgar score, which assigns points based on appearance (color), pulse, grimace (cry), activity (muscle tone), and respiration (breathing effort), with each component scored from 0 to 2. Scores below 7 generally require further care (see resuscitation below).

Routine care

After initial evaluation, babies who are doing well with good Apgar scores are dried and rubbed, any obstruction of breathing is cleared, and warmed either with skin-to-skin contact with the mother or under a heat source.

Complications

With United States home births as an estimate, neonatal complications are common, with cord wrapped around the head 12-37% of the time (nuchal cord), insufficient oxygenation (birth asphyxia) 9% of the time, pulselessness 6% of the time, and breech presentation 3% of the time

Breech Presentation

Frank Breech Presentation (buttocks first) is the most common type of breech presentation

Normally, the head is the first part of the body to present out of the birth canal, however, other parts, such as buttocks or feet can present first, which is referred to as breech presentation. Risk for breech presentation may increase with multiple pregnancies (more than one baby), when there is too little or too much fluid in the uterus or if the uterus is abnormally shaped. Babies in breech presentation can be delivered vaginally depending on the experience of the provider and if the fetus meets specific low risk criteria, however Caesarian section is recommended if available. Ideally, vaginal breech delivery should not be performed without the availability of nearby emergency Caesarian section capabilities.

Pre-term labor

Incidence of preterm delivery is approximately 12%, and preterm births are a significant contributing cause of unplanned emergency delivery . Pre-term labor is defined as occurring before 37 weeks. The same principles of term emergency delivery apply to emergency delivery for a preterm fetus, however the baby will be at higher risk of other problems such as low birth weight, trouble breathing, and infections. The newborn will need additional medical care and monitoring after delivery and should be taken to a hospital providing neonatal care, which will likely include antibiotics.

Shoulder dystocia

In shoulder dystocia, the shoulder is trapped after the head is delivered, preventing delivery of the rest of the baby. The major risk factor (other than prior history of shoulder dystocia) is the baby being too large (macrosomia), which can result from the mother being obese or gaining too much weight, diabetes, and the pregnancy lasting too long (post-term pregnancy). Shoulder dystocia can lead to further fetal complications such as nerve compression and injury at the shoulder (brachial plexus), fracture of the collarbone, and low oxygen for the fetus (whether due to compression of the umbilical cord or due to inability of the baby to breathe). Shoulder dystocia is often signaled by retreat of the head between contractions when it has already been delivered ("turtle sign"). Treatment includes the McRoberts maneuver, where the mother flexes her thighs up to her stomach with her knees wide apart as pressure is applied on her lower abdomen, and Woods' screw maneuver, where the deliverer inserts a hand into the vagina to rotate the fetus. If all maneuvers fail, then C-section would be indicated.

Prolapsed Cord

Umbilical Cord Prolapse

A prolapsed cord refers to an umbilical cord that is delivered from the uterus while the baby is still in the uterus and is life threatening to the baby. Cord prolapse creates a risk of decreased blood flow (and oxygen flow) to the baby as delivery will cause cord compression. However, if the cord delivers before the baby, the cord should not be placed back into the uterus through the cervix since this increases risk of infection. Emergent obstetric care for C-section would be indicated, and in the meantime, one should elevate the foot of the bed if possible to attempt to keep the baby above the level of the cord. If no specialized care is available, one may attempt to reduce pressure of the cord manually and continue delivery, but also being prepared to clamp and cut the cord if needed.

Nuchal Cord

After the baby crowns, the umbilical cord may be found to be wrapped around the neck or body of the baby, which is known as nuchal cord. This is common, occurring in up to 37% of term pregnancies, and most do not cause any long-term problems. This wrapped cord should be slipped over the head so it is not pulled during delivery. If the wrap is not removed, it can choke the baby or can cause the placenta to detach suddenly which can cause severe maternal bleeding and loss of blood and oxygen to the baby. The cord may also be wrapped around a limb in breech presentation, and should similarly be reduced in these cases.

Resuscitation

If the baby is not doing well on its own, further care may be necessary. Resuscitation typically starts with warming, drying, and stimulating the newborn. If breathing difficulty is noted, the airway is opened and cleared with suction and oxygen is monitored; if necessary, one may consider using an positive airway pressure ventilator (which gives oxygen while keeping the airway open) or intubation. If the heart rate is below 60 beats per minute, CPR is started at 3:1 compression to ventilation ratio, with compressions given at the lower breastbone. If this fails to revive the newborn, epinephrine will be given.

Resuscitation is not indicated for newborns below 22 weeks of gestation and weighing below 400 grams. Resuscitation may also be discontinued if the baby's heart does not start after 10-15 minutes of full resuscitation (including breathing treatments, medications, and CPR).

In culture

The reports of emergency childbirth are typically of general interest. A mobile app was developed in Ethiopia that guides users through the procedures of assisting with an emergency birth.

References

Using Wikipedia for Research