In the prehospital realm, childbirth is defined as the unplanned delivery of a newborn outside of a hospital, which may or may not require resuscitation.  “Imminent delivery” is defined as the moment when the head, buttocks, or legs, of the baby become visible at the vaginal opening between contractions.  This is also known as crowning, and signals that delivery will occur within minutes.

Childbirth is a natural process, and only a small number of cases will require aggressive intervention.  The successful transition from intrauterine to extrauterine life depends on significant physiological changes that occur at birth, and although most newborns make this transition successfully, a small but significant number will require additional support, including resuscitation; paramedics must, therefore, prepare for the case where acute care and intervention are required.  It is critical to remember that maternity cases involve at least two patients, and both require assessment.

• Labour consists of 3 stages:
  • 1st stage: Dilation of cervix by regular and painful contractions.  This stage may last up to 12 hours.
  • 2nd stage: Birth of the infant.  This stage may last between 2 and 3 hours, but can also be much shorter in subsequent deliveries.
  • 3rd stage: Delivery of the placenta.  This stage may last up to 1 hour.
• Signs of imminent and inevitable delivery include the following:
  • Delivery imminent when contractions are less than 2 minutes apart and very strong.
  • Delivery is inevitable if the perineum is bulging, the head is crowning or the patient complains of an urge to “push”, “bear down”, or “have a bowel movement”.
• Uncomplicated/normal birth:
  • See Adult Childbirth - Imminent Delivery Algorithm in Additional Treatment section
  • The uncomplicated delivery
    • Term gestation with breathing and crying infant with good tone
    • Infant stays with mother, skin to skin, continued observation and maintain warmth
  • Complicated/high risk birth:
    • → L08: Complications of Delivery (malpresentation, shoulder dystocia, cord prolapse)
    • → L07: Preterm Labour
    • → L09: Postpartum Hemorrhage

• Multiples: Ensure that sufficient resources are assigned to each patient. Note that multiples (twins, triplets, etc) often deliver early. Review CPG L07: Preterm Labour for additional information.

• Cord clamping: It is now accepted and preferred practice to delay cord clamping at least 30 to 60 seconds, or longer. The practice is appropriate for healthy vigorous infants without birth complications.  If resuscitation is required, the cord should be clamped immediately to facilitate the care of the neonate.
• In the event that neonatal resuscitation is required, follow the NRP principles

• Patient assessment considerations
  • Consider known malpresentation of fetus (e.g., breech, shoulder dystocia).
  • Consider seeking consultation and additional resources as necessary
• Provide supplemental oxygen as required to maintain SpO₂ ≥ 94%
• Consider establishing IV access if further treatment is required
• General principles for managing the delivery of the child:

• Delivery should be controlled so as to allow a slow controlled delivery of the infant
• Support the infant’s head as needed
• Check the umbilical cord around the neck.  If it is present, slip it over the head.  If unable to free the cord from the neck, double clamp the cord and cut between the clamps.
• Grasping the head with hands over the ears, gently pull down to allow delivery of the anterior shoulder
• Gently pull up on the head to allow delivery of the posterior shoulder
• Slowly deliver the remainder of the infant
• Clamp the cord 2 inches from the abdomen with 2 clamps and cut the cord between the clamps
• Calculate and record APGAR scores at 1 and 5 minutes

• Refer to NRP guidelines for neonatal assessment and resuscitation. See CPG M09: Neonatal Resuscitation for additional details.
• General principles for care of the mother:
  • The placenta will deliver spontaneously, usually within 5 minutes of the infant.  Do not force the placenta to deliver.

• Massaging the fundus may decrease bleeding by facilitating uterine contractions after delivery of the placenta
• Consider tranexamic acid in uncontrolled vaginal bleeding
• Consider manual in utero pressure and packing
• Consider nitrous oxide for pain control.  Narcotics should be reserved as a last resort
• Midwives may give oxytocin or misoprostol for uncontrolled post-partum bleeding due to uterine atony

• All patients in labour should be transported to the nearest hospital unless delivery is imminent, or the patient’s primary care provider (i.e., midwife) is advising otherwise.
• Patients under the care of a midwife may refuse transportation to a hospital following a delivery.  This is a discussion to have with all parties present with a goal of family centered decisions and care.

• The APGAR score is the tool most commonly used to assess neonates.  The APGAR should be performed at 1 and 5 minutes of life.

Childbirth

Childbirth/Post Natal Mother Care

Newborn Care