LEARNING OUTCOMES
After completing this module, the paramedic will be able to:
- Assess a pregnant woman and diagnose potential labour
- Know when and when not to move the woman in potential labour
- Assist with the birth
- Manage the third stage of labour
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Births attended by the ambulance service are generally those where the mother has been caught off guard and labour has progressed particularly rapidly or where the mother has been unaware of her pregnancy. There are also calls to cases where home births are planned and midwives are concerned and require a transfer, or where it is feared the midwife will not arrive before the baby and an ambulance is sent to assist in the interim.
Prehospital birth can cause great anxiety in paramedics, as they lack training and exposure to maternity in general. The fear of the unknown due to the lack of exposure and training in clinically significant events, and concerns about ‘what if something goes wrong?’ often cloud judgement (Heys et al, 2022).
When faced with an imminent birth, clinicians should use their existing assessment skills and must be able to assist with the birth of the baby. This involves identifying if the birth is about to happen, reassuring the woman, assisting with birthing the baby and ensuring both mother and child are safe and well following the birth.
The information needed for the clinician to gain a history and decide whether transportation or preparation for the birth is required has to be acquired quickly and accurately, but preferably not directly from the labouring woman. Establishing the history from her supporters if any are present will enable the woman to focus on her breathing and control of her contractions (Downe, 2008). The history should include (Association of Ambulance Chief Executives (AACE), 2019):
- Number of weeks' gestation
- Multiple or single pregnancy
- Number of previous pregnancies and births
- Any medical conditions
- Any complications in the current pregnancy
- Any complications in previous pregnancies
- Whether the waters have broken. If yes, what time? What colour?
- Whether there is any bleeding, If yes, what consistency? Is the woman still bleeding?
There needs to be a decision made as to whether the birth is imminent or if there is enough time to make it to the woman's booked unit. Several factors will influence this decision. These include:
- Number of weeks' gestation
- Presentation: is there a known breech presentation?
- Location: how far away from the unit you are?
- Weather conditions: is it icy and not safe to travel?
- Time of day: is it rush hour and are delays possible?
- Is this a planned home birth and can a midwife get to you?
- How difficult will extraction from the property be?
- Any home/environmental factors: are you in a property with no light or heat?
- Is the room clean and warm enough?
How can a paramedic tell whether the birth is imminent? This is a difficult question and, when the birth progresses rapidly, there is often little warning. Generally, the woman will instinctively start to bear down with the contractions and, once she starts to push, there are several key signs that can be observed and classed as birth imminent.
Signs of this in the woman include (Marshall and Raynor, 2020):
- Change in behaviour: she may become more withdrawn or more vocal
- She will be experiencing expulsive contractions because of the Ferguson reflex
- She will instinctively start to push and bear down
- She may become very vocal, especially when pushing.
External signs that may be visible include (Marshall and Raynor, 2020):
- Bulging of the perineum
- Anal dilation because of the pressure of the foetal head on the rectum
- Vaginal gaping when pushing
- Presenting part becoming visible: this is when the baby's head is first visible, not the crowning. Crowning is the widest part being born, as it looks as if the baby is wearing a crown
- Rupture of the membranes.
Do not get too focused on the pattern of contractions, especially when it comes to assessing an imminent birth. Contraction patterns are not always uniform and clinicians can often be caught out watching for the 1:2 pattern (one contraction occurring every 2 minutes) (Chapman and Charles, 2018; National Institute for Health and Care Excellence (NICE), 2022). If other signs are present, do not ignore these.
Reflection 1
Reflecting on the last birth or maternity case you attended, how did you feel?
Preparations for birth
Hopefully, there will be enough time to allow you to prepare the area for the birth. If there is no time, catching the baby is of the utmost importance to prevent them from falling to the ground and sustaining an injury.
A few key tasks need to be carried out to ensure the birth is as safe as possible for all involved:
- Call for back-up: informing the control centre and ensuring back-up is coming is vital
- Ensure that lighting is adequate for you to see safely: it is not necessary to have every light in the house on but there needs to be enough for you to see safely
- Warm the room as much as possible
- Collect some towels and warm them where possible
- Encourage the mother into a comfortable position: if she is standing, suggest she kneels or goes on all fours as this is not as high off the floor (Huang et al, 2019)
- Set up your maternity pack and newborn life support (NLS) station; the NLS station should preferably be off the floor to prevent the baby becoming cold or in being a draught
- Take out your guidelines (JRCALC or local guidance action card): have the algorithms to hand to check that this situation is progressing normally and to ensure no deviation
- Ensure there is an exit strategy in case you need to move quickly.
Consider how many practitioners are needed to catch a baby. If two crews have responded, you may end up with six members of staff on scene. It is not necessary for every member of staff to be in the same room staring as a woman who is half naked attempting to give birth. In an emergency situation, there is obviously a need for extra hands but, at a normal birth, the paramedic should think at this point: ‘Am I needed in here or can I wait until I am required?’ There are more women in the UK with post-traumatic stress disorder from birth trauma than ever before.
Whether you are there and caught the baby or you have walked in as the baby was being born, the following steps are important as physiologically the process is not complete (AACE, 2019):
- Once the baby has been born, use a dry towel to rub and stimulate them all over, then, as soon as possible, place the infant on the mother's bare chest. This is really important: first, skin-to-skin contact will help to keep the infant warm; second, the initial bonding that takes place in these first few moments is a significant process for the mother-baby dyad (Kahalon et al, 2022). Cover them both with at least one dry towel or blanket, preferably two. Ensure no parts of the baby's skin are exposed. The baby's head has the largest surface area and so should be well covered by the towel or a hat
- Leave the umbilical cord intact until it has stopped pulsating and and await signs of placental separation and delivery. Do not be tempted to interfere with the cord as this may cause vasoconstriction before the entire blood volume has been transfused (refer to next section on cord management)
- Undertake an initial assessment to determine the condition of the newborn
- Observe the infant for signs of the onset of respiration and try to note both the time of the birth and the time of the first breath. While most babies cry immediately or seconds after birth, it can sometimes take up to 3 minutes for breathing to become established. During this time, stimulation by rubbing the infant dry with a towel will often cause them to gasp, as will the colder temperature they are now experiencing
- If there are concerns about the condition of the baby (e.g. failure to establish adequate respirations) then begin neonatal resuscitation. Carefully and closely monitor the condition of the baby and perform regular observations
- Monitor maternal vaginal blood loss, which is typically 200–300 ml. Sit the mother comfortably, (skin to skin with the infant) and place a clean incontinence bed sheet under her bottom as well as a clean maternity or large sanitary pad between her legs so you can monitor post-partum blood loss
- Continue to provide pain relief to the mother as necessary and undertake a set of baseline observations on her.
Reflection 2
Contraction patterns are not always uniform and clinicians can often be caught out watching for the 1:2 pattern. What was the contraction pattern at the last birth you attended?
Reflection 3
Did you think about the impact of the woman's position for birth during your last maternity case?
Cord management
Once the cord has stopped pulsating and appears white in colour, you can clamp and cut it (cutting between the clamps). If there is still a pulse after 20 minutes and you need to move to hospital, it is permitted to clamp and cut at this point to safely permit transport.
How to clamp and cut a cord (AACE, 2019; Fawke et al, 2021):
- Place one clamp on the non-pulsating cord approximately 5 cm from the umbilicus of the baby
- Place another clamp approximately 5 cm from that clamp
- Cut between the two clamps. Ensure all fingers, toes and genitals are out of the way before cutting. You should clamp the cord immediately if:
- The cord is snapped; grab the baby's end to prevent foetal haemorrhage
- The attached cord prevents the clinician from undertaking effective newborn life support
- It is extremely short and prevents the baby from being held.
In regular situations, you should always wait until it has gone white and stopped pulsating.
The evidence into why we should ‘wait for white’ can be found on the waitforwhite.com website (Burleigh, 2024) and a summary is given below.
It increases:
- Haematocrit
- Haemoglobin
- Blood pressure
- Cerebral oxygenation
- Red blood cell flow
- Breastfeeding duration
- Stem cell volume.
It decreases:
- Risk of intraventricular brain haemorrhage
- Risk of necrotising enterocolitis
- Risk of late-onset sepsis
- Need for blood transfusions for low blood pressure or anaemia
- Need for mechanical ventilation
- Risk of umbilical infections.
Reflection 4
Did you observe the pulsating cord and wait for white in the last birth you attended? If you haven't previously attended a birth, will you do this for the next birth you attend?
Third stage of labour or the birth of the placenta
Following the birth of the baby, the placenta must be expelled. The longer the placenta remains in situ, the greater the risk of bleeding and infection (Marshall and Raynor, 2020).
Placentas are managed differently in hospital to prehospital settings without the presence of a midwife. As prehospital clinicians, paramedics perform physiological management and it is not always expected that the placenta will be expelled before transport to the receiving maternity unit (Marshall and Raynor, 2020).
The expected management of the third stage will use the woman's natural hormones to assist with the placenta shearing from the wall of the uterus and then its expulsion. Therefore, increasing the level of natural oxytocin will help with the contraction of the uterus. This can be assisted by (Marshall and Raynor, 2020):
- Skin-to-skin contact with the baby
- Encouraging breastfeeding (if the woman wishes)
- Keeping the woman warm and feeling safe
- Ensure an empty bladder
- Sitting the mother in an upright position so gravity will assist
- Minimising chatter
- Keeping the lights at a safe level in order to see but dimmed where possible.
Reflection 5
During the last birth you witnessed, how much blood was expelled? Did this give you cause for concern? Did you correctly respond to that blood loss?
Management after birth
The following management guidelines can be used following the birth (AACE, 2019):
- Observe the woman carefully; perform an initial set of observations after the birth and monitor regularly to observe for signs of deviation
- Monitor the mother for bleeding that is consistent and not slowing. Refer to JRCALC and/or local guidelines for management of postpartum haemorrhage if bleeding is excessive. There is a very low threshold to leave the scene at this point and, if bleeding becomes excessive or there are signs of haemodynamic instability, then extraction should be expedited
- Do not pull on the cord at any point. This could cause the placenta to tear and lead to products being retained
- Ensure the placenta and all items that contain blood are transported to the hospital, so blood loss can be more accurately measured. Place soiled items into a clinical waste bag but keep the placenta separate to ensure it is correctly checked.
- If the placenta is still in situ and has not been expelled 20 minutes after the time of birth, convey to the nearest obstetric unit. Dependent of the mother's haemodynamic stability, this may need to be a rapid emergency transfer.
Tip: expect bleeding
A key element to remember is that during the phase where the placenta is sheared from the uterine wall, there will be frank blood loss. This is to be anticipated. Approximately 200-300 ml of blood will accompany this process. It is potentially an alarming amount if it is unexpected and often a cause for clinicians to worry or panic.
Careful observation of haemodynamic stability must accompany this. If there is any sign of bleeding over 500 ml or signs of haemodynamic instability, then treatment for postpartum haemorrhage must be started (AACE, 2024).