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While most deliveries take place in hospitals, there are cases where emergency medical services (EMS) are called to help with out-of-hospital deliveries, whether they are unexpected or planned but facing complications. In such situations, the initial priority is to swiftly transport both the mother and the infant, if the baby has already been delivered, to a hospital where they can receive appropriate care. Healthcare practitioners involved in these situations should possess the skills to assess the gestational age quickly, recognize if delivery is imminent, and be prepared to address any sudden issues that may arise. Prehospital delivery primarily involves ensuring a controlled and guided delivery of the infant, managing immediate postpartum maternal bleeding, and providing limited care for the newborn until the patient can be safely transferred to a hospital. It's important to note that studies have demonstrated a higher risk of perinatal mortality in deliveries occurring outside a hospital compared to those within a hospital setting. Consequently, healthcare practitioners must be well-informed about prehospital delivery procedures, immediate postpartum care for both the mother and newborn, resuscitation techniques, and the management of common delivery complications. The purpose of this activity for healthcare professionals is to enhance their competence when dealing with prehospital deliveries. It equips them with updated knowledge, skills, and strategies for promptly identifying complications, implementing effective interventions, and improving care coordination. Ultimately, this improves patient outcomes and reduces maternal and fetal morbidity. Objectives: Identify indications for prehospital deliveries and recognize when an imminent birth is occurring. Assess pregnant patients in the prehospital setting to determine the stage of labor and maternal and fetal well-being. Implement appropriate prehospital obstetric protocols for managing labor and delivery, including techniques for delivering a baby in emergent situations. Collaborate with other EMS personnel and healthcare providers to ensure seamless care for both mother and newborn. Access free multiple choice questions on this topic.

Prehospital delivery, often termed an unplanned out-of-hospital birth or birth before arrival, occurs when an infant is unintentionally born outside a hospital setting. In contrast to planned home births, these situations involve no prior preparations or access to healthcare practitioners and equipment. Sometimes, EMS personnel are summoned to transport planned home birth patients facing complications.[1] When EMS is called to aid an actively laboring patient, the foremost objective should be expeditiously transporting the mother to a hospital with obstetric services, if feasible. These facilities have obstetrically trained clinicians and the resources to handle potential complications. The American Academy of Pediatrics (AAP) and the American College of Obstetrics and Gynecology (ACOG) concur that hospitals and accredited birth centers offer the safest birthing environments.[2] However, sometimes there's insufficient time for transport before delivery. EMS healthcare practitioners are often summoned when a precipitous delivery has occurred or is imminent or the patient delivers en route.[3] Unplanned prehospital deliveries have been linked to elevated perinatal mortality and morbidity risks for both the neonate and the mother.[4][5][6][1] This is largely attributed to inadequate EMS obstetrical training in managing emergent deliveries and intrapartum complications, along with a failure to provide recommended neonatal resuscitation.[3][7][3] Hence, EMS practitioners must be well-versed in appropriate delivery techniques and immediate postpartum assessment and management for both the mother and neonate.

Obstetric Lacerations Lacerations are common after vaginal deliveries, especially with the first delivery. Lacerations may involve the perineum, vagina, vulva, periclitoral, or periurethral tissue. Perineal tears are the most common and are classified by degrees of severity as follows: First degree: laceration of the perineal skin only Second degree: extension of a laceration from the perineal skin to the perineal muscles Third degree: laceration involving the anal sphincter Fourth degree: laceration extending from the perineal skin through to the anal sphincter complex and anal epithelium [39] Nonperineal lacerations are often superficial and do not need to be repaired unless actively bleeding; however, if performed, repair of lacerations requires appropriate training, lighting, visualization, and pain control. ACOG recommends that the judgment of an obstetrically trained clinician be used to determine whether or not a first or second-degree laceration should be repaired.[39] Most second-degree lacerations are repaired, but no evidence supports surgical repair over expectant management. However, a trained obstetric clinician should surgically repair third- and fourth-degree lacerations. If significant bleeding from a laceration is identified, it typically can be conservatively managed by applying pressure until an appropriately trained clinician can evaluate and provide treatment as indicated.[39] Breech Delivery Breech presentations are the most common type of malposition encountered. Breech vaginal deliveries are associated with higher levels of neonatal morbidity and mortality.[40] This is because the fetal head, the largest and hardest fetal body part to move through the maternal pelvis, can become entrapped within the pelvis after the body delivers. During this time, the umbilical cord can become compressed as it runs alongside the fetal head, and the fetus is deprived of oxygen until the head is delivered. Whenever feasible, these patients should be taken to the hospital for delivery. Even if a fetal foot or buttock is visible at the vaginal opening, reaching a hospital facility for a safer delivery may still be possible. However, once the fetus has been delivered to the level of the neonatal umbilicus, a breech delivery is imminent, and the EMS clinician should be prepared for on-scene delivery.[10]

Breech presentations are the most common type of malposition encountered. Breech vaginal deliveries are associated with higher levels of neonatal morbidity and mortality.[40] This is because the fetal head, the largest and hardest fetal body part to move through the maternal pelvis, can become entrapped within the pelvis after the body delivers. During this time, the umbilical cord can become compressed as it runs alongside the fetal head, and the fetus is deprived of oxygen until the head is delivered. Whenever feasible, these patients should be taken to the hospital for delivery. Even if a fetal foot or buttock is visible at the vaginal opening, reaching a hospital facility for a safer delivery may still be possible. However, once the fetus has been delivered to the level of the neonatal umbilicus, a breech delivery is imminent, and the EMS clinician should be prepared for on-scene delivery.[10] For the delivering clinician to perform the maneuvers of a breech delivery, the mother should be placed in the semi-recumbent position. The infant should be allowed to deliver spontaneously, without any assistance from the EMS clinician, to the level of the neonatal umbilicus. The EMS clinician can then hook their fingers around the infant's hips and apply downward traction; additionally, if not already facing down, the infant should be rotated so that its spine is facing up. As the fetal body continues to deliver, the delivering clinician may support the fetal body on their forearm and deliver the legs, 1 at a time, by grasping the thigh and sweeping the leg up and out while flexing the knee.[10] When the scapulas are visible, the neonate should be rotated 90 degrees to face 1 of the maternal thighs. The EMS clinician should then sweep their fingers over the anterior arm, bending at the elbow and moving it down and across the infant's chest until the arm is out of the vagina. The infant should then be rotated 180 degrees to the other side, and the process should be repeated to deliver the second arm.[10]

For the delivering clinician to perform the maneuvers of a breech delivery, the mother should be placed in the semi-recumbent position. The infant should be allowed to deliver spontaneously, without any assistance from the EMS clinician, to the level of the neonatal umbilicus. The EMS clinician can then hook their fingers around the infant's hips and apply downward traction; additionally, if not already facing down, the infant should be rotated so that its spine is facing up. As the fetal body continues to deliver, the delivering clinician may support the fetal body on their forearm and deliver the legs, 1 at a time, by grasping the thigh and sweeping the leg up and out while flexing the knee.[10] When the scapulas are visible, the neonate should be rotated 90 degrees to face 1 of the maternal thighs. The EMS clinician should then sweep their fingers over the anterior arm, bending at the elbow and moving it down and across the infant's chest until the arm is out of the vagina. The infant should then be rotated 180 degrees to the other side, and the process should be repeated to deliver the second arm.[10] To deliver the head, the infant should be placed so that it is lying on the forearm of the delivering clinician with the fetal legs straddling the forearm. The clinician should use the other hand to grasp the shoulders and apply downward traction until the back of the head is visible. At this point, the index and middle fingers of the bottom hand should be placed on the infant's face to apply downward pressure to the infant's maxilla while an assistant applies firm maternal suprapubic pressure. These maneuvers should allow the fetal head to flex and move under the pubic bone. Keeping downward pressure on the face and suprapubic pressure on the maternal abdomen, the delivering clinician elevates the infant's body straight up into the air toward the maternal abdomen, with the infant held between the clinician's 2 forearms, allowing the face and the entire head to deliver.[10] Shoulder Dystocia

To deliver the head, the infant should be placed so that it is lying on the forearm of the delivering clinician with the fetal legs straddling the forearm. The clinician should use the other hand to grasp the shoulders and apply downward traction until the back of the head is visible. At this point, the index and middle fingers of the bottom hand should be placed on the infant's face to apply downward pressure to the infant's maxilla while an assistant applies firm maternal suprapubic pressure. These maneuvers should allow the fetal head to flex and move under the pubic bone. Keeping downward pressure on the face and suprapubic pressure on the maternal abdomen, the delivering clinician elevates the infant's body straight up into the air toward the maternal abdomen, with the infant held between the clinician's 2 forearms, allowing the face and the entire head to deliver.[10] Shoulder Dystocia Shoulder dystocia occurs when the infant's shoulder becomes impacted behind the maternal pubic bone, causing the infant's body to get stuck in the birth canal. This complication is difficult to anticipate, but risk factors include macrosomia, maternal diabetes, maternal obesity, and fetal postdates. Recognizing and managing this complication quickly is crucial because prolonged dystocia can result in severe fetal morbidity (eg, asphyxiation, clavicle fracture, and brachial plexus injury).[41] Shoulder dystocia can be expected when, following the delivery of the fetal head, it either firmly retracts against the perineum or starts moving back into the vagina during the intervals between contractions. This is known as the turtle sign because it can appear like a turtle pulling its head back into its shell. This occurs because the fetal head is expelled as the mother pushes, but because the fetal shoulder is stuck behind the pelvic brim when the mother stops pushing, the head gets pulled back into the vaginal canal. The delivering clinician should call for additional help when this sign is observed.[42]

Shoulder dystocia can be expected when, following the delivery of the fetal head, it either firmly retracts against the perineum or starts moving back into the vagina during the intervals between contractions. This is known as the turtle sign because it can appear like a turtle pulling its head back into its shell. This occurs because the fetal head is expelled as the mother pushes, but because the fetal shoulder is stuck behind the pelvic brim when the mother stops pushing, the head gets pulled back into the vaginal canal. The delivering clinician should call for additional help when this sign is observed.[42] Several maneuvers can be used to resolve the dystocia. Before attempting maneuvers, the delivering clinician should check for a nuchal cord and remove it if possible. If a tight nuchal cord is noted, the cord can be doubly clamped and cut before the body delivers. This should be an option of last resort; the anterior shoulder should be delivered before clamping and cutting a tight nuchal cord to avoid neonatal asphyxia due to shoulder dystocia.[28]

Several maneuvers can be used to resolve the dystocia. Before attempting maneuvers, the delivering clinician should check for a nuchal cord and remove it if possible. If a tight nuchal cord is noted, the cord can be doubly clamped and cut before the body delivers. This should be an option of last resort; the anterior shoulder should be delivered before clamping and cutting a tight nuchal cord to avoid neonatal asphyxia due to shoulder dystocia.[28] The first maneuver to attempt should be the McRoberts maneuver.[43] To perform this maneuver, assistants should sharply flex the parturient's thighs up onto her abdomen/chest (resulting in hyperflexion at the hips). If no one is available to help, the mother can be instructed to "pull your knees up to your armpits" or "pull your thighs onto your chest." This position alters the angles within the pelvis, allowing more room for the shoulders to move through the pelvis.[44] Simultaneously with or immediately after a short trial in the McRoberts position, the assistant should be asked to apply pressure above the maternal pubic bone to help manually dislodge the impacted shoulder.[45] If both of these maneuvers are unsuccessful, the delivering clinician can reach their hand into the posterior vagina and attempt to grasp the posterior forearm of the fetus, flexing it at the elbow. Then, the clinician can sweep the arm up and across the fetal chest, delivering the posterior arm. This alters the angle of the shoulder girdle and is often enough to relieve the dystocia.[28][43] They can also attempt to rotate the fetus in the birth canal by pushing on the back side of the anterior fetal shoulder and rotating 30 degrees toward the fetal face.[28][43] If the infant still has not been delivered, the mother can be flipped onto her hands and knees, and these maneuvers can be repeated in the new position. Umbilical Cord Prolapse

The first maneuver to attempt should be the McRoberts maneuver.[43] To perform this maneuver, assistants should sharply flex the parturient's thighs up onto her abdomen/chest (resulting in hyperflexion at the hips). If no one is available to help, the mother can be instructed to "pull your knees up to your armpits" or "pull your thighs onto your chest." This position alters the angles within the pelvis, allowing more room for the shoulders to move through the pelvis.[44] Simultaneously with or immediately after a short trial in the McRoberts position, the assistant should be asked to apply pressure above the maternal pubic bone to help manually dislodge the impacted shoulder.[45] If both of these maneuvers are unsuccessful, the delivering clinician can reach their hand into the posterior vagina and attempt to grasp the posterior forearm of the fetus, flexing it at the elbow. Then, the clinician can sweep the arm up and across the fetal chest, delivering the posterior arm. This alters the angle of the shoulder girdle and is often enough to relieve the dystocia.[28][43] They can also attempt to rotate the fetus in the birth canal by pushing on the back side of the anterior fetal shoulder and rotating 30 degrees toward the fetal face.[28][43] If the infant still has not been delivered, the mother can be flipped onto her hands and knees, and these maneuvers can be repeated in the new position. Umbilical Cord Prolapse Umbilical cord prolapse is when a loop of the umbilical cord gets stuck below the head of the fetus. This is concerning because the fetal head can compress the cord as the delivery progresses, preventing oxygenated blood from getting to the baby. These patients should be taken to a facility capable of performing a cesarean delivery. If the EMS clinician feels a pulsating cord of tissue consistent with a prolapsed umbilical cord on the vaginal exam, the mother should be instructed to stop pushing and be placed in the Trendelenburg position. The delivering clinician should attempt to decompress the cord by placing their hand into the vagina and pushing the fetal presenting part, typically the head, back up into the vagina and holding it there until instructed to remove their hand by the delivering surgeon at the hospital.[18] The clinician elevating the head should be prepared to maintain that position with the patient in the operating room.[28]

Umbilical cord prolapse is when a loop of the umbilical cord gets stuck below the head of the fetus. This is concerning because the fetal head can compress the cord as the delivery progresses, preventing oxygenated blood from getting to the baby. These patients should be taken to a facility capable of performing a cesarean delivery. If the EMS clinician feels a pulsating cord of tissue consistent with a prolapsed umbilical cord on the vaginal exam, the mother should be instructed to stop pushing and be placed in the Trendelenburg position. The delivering clinician should attempt to decompress the cord by placing their hand into the vagina and pushing the fetal presenting part, typically the head, back up into the vagina and holding it there until instructed to remove their hand by the delivering surgeon at the hospital.[18] The clinician elevating the head should be prepared to maintain that position with the patient in the operating room.[28] Postpartum Hemorrhage Postpartum hemorrhage (PPH) is when the mother loses more than 500 mL of blood after a vaginal delivery.[46] It is one of the leading causes of pregnancy-related maternal death worldwide.[47] Much of the treatment involves getting the patient to a hospital that provides obstetric care. Still, there are several things the prehospital delivering clinician can do to assist in this situation.

Postpartum hemorrhage (PPH) is when the mother loses more than 500 mL of blood after a vaginal delivery.[46] It is one of the leading causes of pregnancy-related maternal death worldwide.[47] Much of the treatment involves getting the patient to a hospital that provides obstetric care. Still, there are several things the prehospital delivering clinician can do to assist in this situation. EMS personnel should take the patient's vitals, establish IV access, and administer fluids similar to any traumatic hemorrhage. EMS clinicians should communicate to the receiving hospital that postpartum hemorrhage is suspected so that preparations for management can be made (eg, massive transfusion protocol).[11] They should also attempt to identify the cause of the hemorrhage so they can attempt to stop the bleeding. The most common cause of PPH is uterine atony, which causes 70% to 80% of cases.[48] Usually, the uterus begins to contract spontaneously after the baby has been successfully delivered. Thus, the myometrium effectively clamps down on the hemorrhaging spiral arteries, preventing further blood loss. Vigorous massage of the uterine fundus can stimulate this uterine contraction. If this is insufficient, bimanual uterine massage can be done by placing 1 hand within the vagina and the other on the maternal abdomen over the uterine fundus and compressing the uterus between their hands, similar to putting pressure on a wound.[49] In a hospital setting, administering oxytocin immediately following the delivery of the infant is the most critical intervention for reducing the risk of PPH. For this reason, ACOG, the World Health Organization, and the American Academy of Family Physicians all recommend the universal administration of a uterotonic agent, usually oxytocin, following all births by obstetric clinicians.[48]

In a hospital setting, administering oxytocin immediately following the delivery of the infant is the most critical intervention for reducing the risk of PPH. For this reason, ACOG, the World Health Organization, and the American Academy of Family Physicians all recommend the universal administration of a uterotonic agent, usually oxytocin, following all births by obstetric clinicians.[48] Estimation of maternal blood loss (EBL) should be recorded. Typical vaginal deliveries have an EBL of less than 500 mL, and blood loss may be significantly less. (One standard soda can is approximately 300 mL.) Estimating blood loss can be difficult, as up to several hundred milliliters of amniotic fluid may be mixed with the blood. In general, bleeding should slow significantly within the first few minutes after delivery, especially after delivery of the placenta. If bleeding persists at a significant rate or if large blood clots, such as those the size of an apple, are observed, clinicians should be concerned about the possibility of a postpartum hemorrhage. Uterine massage should be continued until bleeding improves, or hospital clinicians can administer oxytocin. It can be administered intramuscularly (IM) or by slow IV infusion. IV bolus has been associated with cardiovascular collapse. A standard dosage is either 10 units administered IM or 5 to 10 units given as an IV bolus. It can be given at any time after the delivery of the infant's anterior shoulder, as there is no clearly defined optimal timing for its administration.[48][11] If the patient has IV access, up to 30 units can be added to 500 to 1000 mL of fluid and given as a continuous infusion.[48] In addition to uterine atony, other less common causes of PPH include heavy bleeding from lacerations, retained placental fragments or membranes, or an acute coagulopathy (eg, disseminated intravascular coagulation). Therefore, a careful pelvic exam and rapid transfer to a hospital with obstetric clinicians are also appropriate.[11] Neonatal Resuscitation

In addition to uterine atony, other less common causes of PPH include heavy bleeding from lacerations, retained placental fragments or membranes, or an acute coagulopathy (eg, disseminated intravascular coagulation). Therefore, a careful pelvic exam and rapid transfer to a hospital with obstetric clinicians are also appropriate.[11] Neonatal Resuscitation About 1% of infants struggle with the transition to extrauterine life and require some level of CPR beyond standard warming, drying, and stimulation (eg, rubbing the trunk).[50] Neonatal resuscitation is similar to standard CPR for a young infant. It may include positive pressure ventilation (PPV), endotracheal intubation and airway suctioning, chest compressions, and other interventions. Neonates should be assessed to determine if they require further resuscitative interventions within the first 60 seconds after birth. The following are indications that further resuscitation is required: a preterm neonate, absence of vigorous crying or effective breathing, and poor muscle tone. The following resuscitation protocol is recommended by the AAP, ACOG, the American Heart Association (AHA), and a 2022 international consensus for neonates demonstrating difficulty with birth transition.[50][32] Repeat initial resuscitation steps: Clear the airway (eg, suction with a bulb syringe). Bulb suction the mouth first, then the nose, to prevent aspiration if the neonate gasps during nasal suctioning. Avoid vigorous suctioning of the posterior pharynx. This may cause reflex bradycardia and damage the mucosa, which can interfere with feeding. Warm, dry, and stimulate the neonate by replacing wet towels or cloths and rubbing with a dry towel. If the infant demonstrates labored breathing or persistent cyanosis: Monitor blood oxygen saturation (SPO2). The target SPO2 increases with increasing minutes since birth. The target SPO2 at 1 minute of life is only 60% to 65%; this target increases by 5% every minute for up to 5 minutes. At that point, the SPO2 target is 80% to 85%; at 10 minutes of life, it is 85% to 95%. Consider continuous positive airway pressure.[32][50] If the infant's HR is <100 bpm, or if the infant is gasping or apneic: Initiate PPV. Most term babies do not require supplemental oxygen with PPV.

Monitor blood oxygen saturation (SPO2). The target SPO2 increases with increasing minutes since birth. The target SPO2 at 1 minute of life is only 60% to 65%; this target increases by 5% every minute for up to 5 minutes. At that point, the SPO2 target is 80% to 85%; at 10 minutes of life, it is 85% to 95%. Consider continuous positive airway pressure.[32][50] If the infant's HR is <100 bpm, or if the infant is gasping or apneic: Initiate PPV. Most term babies do not require supplemental oxygen with PPV. Supplemental oxygen should be used judiciously and guided by pulse oximetry readings and target SPO2 levels. Adequate ventilation alone is usually enough to restore HR in newborn infants. Monitor SPO2 with pulse oximetry. Consider electrocardiography (ECG) monitoring. If the HR stays <100 bpm despite PPV, check ventilation and consider intubation.[32][50] If the infant's HR is <60 bpm: Start chest compressions, coordinated with PPV. Perform neonatal intubation if not done already. Give 100% oxygen. Perform ECG monitoring. If there is no response after 45 to 60 seconds of effective compressions, give epinephrine 0.1 to 0.3 mL/kg of 1:10,000 solution IV, equaling 0.01 to 0.03 mg/kg.[32][50] Neonatal Hypothermia Neonatal hypothermia is associated with increased mortality, and this risk increases as the neonate's temperature drops further from 97.7 °F (36.5 °C).[51] This risk is even more pronounced in premature infants. Hypothermia may also be associated with intraventricular hemorrhage and neonatal respiratory issues. Additionally, the temperature of infants (without asphyxiation) on admission strongly predicts morbidity and mortality. The AHA 2022 CPR guidelines recommend maintaining infant temperatures between 97.7 °F (36.5 °C) and 99.5 °F (37.5 °C) for optimal outcomes.[50] The best options for maintaining normal temperatures include the following: Skin-to-skin contact, covered by a blanket with healthy neonates. Use of a radiant warmer, if available. Placing the infant in a clean, food-grade plastic bag up to the neck level, swaddling them, and holding them against the warm bodies of appropriate adults (eg, parent, EMS personnel) may be beneficial in highly low-birth-weight infants. Getting the baby into a warm, temperature-controlled room or increasing the temperature in the room to ≥78.8 °F (23 °C).[50]

When responding to a call for assistance during labor, the initial priority should be to swiftly transport the mother to a hospital equipped with obstetric care. It's essential to notify hospital clinicians, including emergency, neonatologists, obstetric physicians, and nurses, before the patient's arrival so they can prepare the necessary equipment, such as infant warmers, and be ready for treatment if required. In a hospital setting, trained obstetric professionals can conduct the delivery in a controlled environment, equipped to handle any potential complications.[8][10] However, circumstances may not always allow sufficient time to transport the mother to the appropriate facility. In such cases, EMS practitioners must be well-versed in the proper delivery techniques.[22][52] To optimize patient outcomes, it is essential to maintain detailed documentation of the EMS team's interventions and ensure sound clinical care to facilitate effective communication between healthcare professionals. This is crucial because the delivery circumstances and the newborn's initial condition can influence how physicians or other advanced practitioners manage these patients upon their transfer to the hospital. Additionally, EMS clinicians should be capable of providing a verbal report when transferring patients to hospital-based clinicians.