6.1. POLICIES

Related titles

Childbirth, the birth of a child.

The purpose of the assistance

1. Recognizing the onset of labor.
2. Assistance in normal labor.
3. Recognize complications of childbirth.
4. Applying appropriate techniques in the event of complications in labor.

Patient description

Inclusion criteria

The beginning of labor, the birth of the fetal head.

Exclusion criteria

1. Vaginal bleeding at any stage of pregnancy (see the guideline “Emergency Conditions in Obstetrics and Gynecology”).
2. Emergencies in the first or second trimester of pregnancy (see the guideline “Emergencies in Obstetrics and Gynecology”).
3. Seizures in eclampsia (see the guidelines “Emergencies in Obstetrics and Gynecology” and “Eclampsia/Pre-eclampsia”).

Patient management

Condition assessment

Signs of impending labor:

a) contractions
b) appearance of the fetal head;
c) pushing
d) bowel movements;
e) rupture of the membrane;
e) discharge of the mucous plug.

Treatment and interventions

1. In case of labor and absence of pushing, transport the patient to a specialized admission unit.

2. The labor should be monitored to ensure a slow and controlled birth to prevent injury to the mother: support the fetal head (if possible).

3. Check for cord wrapping around the neck:

a) if available, remove it through the head;
b) if it is not possible to remove it, clamp the umbilical cord between two clamps and cut the umbilical cord between them.

4. Do not sanitize the infant’s airway (even with a syringe) during labor.

5. Place your hands around the fetal head behind the ears and gently push the head downward to allow the anterior shoulder to come out.

6. Gently point the head upward to ensure that the back shoulder emerges.

7. Slowly allow the other part of the baby’s body to appear.

8. After 1-3 minutes, clamp the umbilical cord at the level of 15 cm from the umbilical ring with two clamps; cut the umbilical cord between them; if resuscitation is necessary, cut the umbilical cord as soon as possible.

9. Record the APGAR score at the first and fifth minutes.
After the infant is born, resuscitation (including the use of a syringe) should only be performed if there are signs of airway obstruction or if continuous positive pressure ventilation is required (Follow the Neonatal Resuscitation guidelines for further care of the newborn infant).

10. Pat the newborn dry, cover with a blanket, and place it with the mother if resuscitation is not necessary.

11. The placenta will come out spontaneously, usually within 5-15 minutes after delivery:

a) do not forcefully remove the placenta, do not pull the umbilical cord;
b) collect the entire litter in a bag and bring it to the emergency room.

12. After delivery, uterine massage and breastfeeding will help to reduce uterine contractions and control bleeding:

a) Assess the amount of blood loss in the mother;
b) treat hypovolemia if necessary.

13. Transport the newborn baby in a safety seat (or incubator) if resuscitation is not required.

14. Keep the newborn warm during transportation.

15. Most births are uneventful. If complications occur, it is recommended:

15.1. Dystocia of the shoulders – in case of delayed birth after the head appears, quickly perform the following steps:

a) Bend the mother’s legs at the knee and pelvis and bring them toward the abdomen;
b) apply pressure over the womb to dislodge the shoulder;
c) Provide supplemental oxygen to the mother;
d) transport to a hospital as soon as possible;
e) contact medical management and/or the nearest emergency department for further instructions and to prepare the team to receive the patient.

15.2. Umbilical cord prolapse:

a) Insert a gloved hand into the vagina and gently pull the head/part of the body away from the umbilical cord:

• • • • assess the pulsation in the umbilical cord;
      • Keep the baby in this position until arrival at the hospital;

b) position the mother in the knee-chest position or Trendelenburg position;
c) provide high concentration supplemental oxygen to the mother;
d) transport to a hospital as soon as possible;
e) contact medical management and/or the nearest emergency department for further instructions and to prepare the team for patient admission.

15.3. Pelvic presentation:

a) Position the mother in a supine position, allow the fetus’ buttocks and trunk to push out on their own, and then support the body until the head is visible;

b) if the head cannot emerge, insert a gloved hand into the vagina and place your fingers between the baby’s face and the walls of the birth canal to ensure airway patency;

c) provide high concentration supplemental oxygen to the mother;

d) transport to the hospital as soon as possible;

e) contact medical management and/or the nearest emergency department for further instructions and to prepare the team to receive the patient;

e) prolapse of an arm or leg from the vagina is an indication for urgent transportation to the hospital;

f) assess for umbilical cord prolapse and provide care as described above.

а) Position the mother in a supine position, allow the fetus’ buttocks and trunk to push out on their own, and then support the body until the head is visible;
b) if the head cannot emerge, insert a gloved hand into the vagina and place your fingers between the baby’s face and the walls of the birth canal to ensure airway patency;
c) provide high concentration supplemental oxygen to the mother;
d) transport to the hospital as soon as possible;
e) contact medical management and/or the nearest emergency department for further instructions and to prepare the team to receive the patient;
f) prolapse of an arm or leg from the vagina is an indication for urgent transportation to the hospital;
g) assess for umbilical cord prolapse and provide care as described above.

15.4. Excessive bleeding during active labor may occur due to placenta previa:

a) Take a history from the patient;
b) placenta previa can prevent a vaginal birth;
c) if a cesarean section is necessary, transport her to the hospital immediately.

15.5. Cardiac arrest in the mother:

a) apply manual pressure to move the uterus from left to right;
b) Provide care according to the guideline “Cardiac arrest” (defibrillation and drug doses remain the same as in non-pregnant patients);
c) transport to the hospital as soon as possible if the gestational age is more than 24 weeks (a post-mortem cesarean section in the emergency room has the highest chance of success if performed within the first 5 minutes after the mother’s cardiac arrest);
d) contact the medical management and/or the nearest admitting department for further instructions and to prepare the team for the patient’s admission.

Patient safety

1. Postural hypotensive syndrome:

a) if the mother is hypotensive before labor, position the patient on her left side or manually shift the uterus to the left;
b) pressing the legs to the chest can be dangerous during high-speed transportation to the hospital.

2. Do not sanitize the infant’s airway (even with a syringe) during labor.

3. Newborn babies are very slippery, do not drop the baby.

4. Do not pull on the umbilical cord when the placenta is delivered.

Useful information for training

Key points

1. Obstetric anamnesis:

a) gestational age;

b) number of pregnancies;

c) number of live births;

d) number of stillbirths;

e) date of the last menstrual cycle;

e) gestational age;

f) prenatal care;

f) expected number of children;

h) use of medications by the mother.

a) gestational age;
b) number of pregnancies;
c) number of live births;
d) number of stillbirths;
e) date of the last menstrual cycle;
e) gestational age;
f) prenatal care;
f) expected number of children;
h) use of medications by the mother.

2. Notify medical management if available:

a) prenatal bleeding;
b) postpartum bleeding;
c) breech presentation;
d) leg presentation;
d) wrapping the umbilical cord around the neck;
e) prolapse of the umbilical cord.

3. A little bleeding is normal during any labor.
Large amounts of blood or bleeding are abnormal.

APGAR scale

Key elements of documentation

All time intervals (labor, frequency and duration of contractions).

Criteria for the effectiveness of assistance

1. Identification of complications.
2. Documentation of the APGAR score.
3. Reassessment of the mother’s condition.