Assist in Vaginal Delivery


TERMINAL LEARNING OBJECTIVE:  Given a scenario involving a pregnant female who is in labor discuss terms, treatment procedures and complications associated with vaginal delivery IAW Emergency Care, Brady.


INTRODUCTION:  Birth is a time of joy, fear, expectation and possibly sorrow.  It is usually a smooth, natural process.  Medical intervention is seldom required beyond supportive care.  When you are called to assist and transport a mother who is in labor, you must be prepared for any situation.


Anatomy and Physiology of the Female Reproductive System


a.   Terms and Definitions


     (1)  Uterus - the hollow muscular organ in which a fetus grows, responsible for labor and expulsion of infant


     (2)  Cervix - the neck or opening of the uterus through which the baby passes during the birth process


     (3)  Vagina - lower part of the birth canal


     (4)  Fetus  - a developing baby in the uterus


   (5) Placenta - an organ of pregnancy attached to the wall of the uterus where oxygen, nutrients, and waste exchange takes place between the mother and fetus


     (6)  Umbilical cord - fetal structure that connects the fetus to the placenta.  Contains two arteries and one vein to provide blood flow between the fetus and placenta.


     (7)  Amniotic sac - fluid-filled sac in which the fetus develops - Sometimes called a "bag of waters"


     (8)  Perineum - the surface area between the vagina and anus in females; between the scrotum and the anus in males


    (9)  Bloody show - a watery, bloody discharge of mucus which forms in the cervix and is expelled at the beginning of labor


     (10)  Crowning - the bulging-out of the vagina which is opening as the baby's head or presenting part presses against it


     (11)  Contraction - the shortening and tightening of the uterus which results in the dilation and effacement of the cervix


     (12)     Antepartum - the period spanning conception and labor



     (13)     Postpartum - after childbirth


     (14)     Gravida - a pregnant woman - Used with a numeral to indicate the number of pregnancies (i.e., gravida 3=3 pregnancies)


     (15)     Para - a woman who has produced a viable infant (over 500 grams/20 weeks gestation).  Used with a numeral to designate number of children (i.e., para 3=3 pregnancies carried to the stage of viability).


     (16)     Term infant  - infant born between 38 and 41 weeks gestation


b.      Review of the anatomy and physiology of the female reproductive system


     (1)   Identification of specific body parts


            (a)    External genitalia (vulva)


                1) Mons pubis


                2) Labia


                3) Urinary meatus


                4) Vaginal orifice


                5) Perineum


                6) Anus


            (b)    Internal genitalia


                1) Vagina


                2) Cervix


                3) Uterus


                4) Fallopian tubes


                5) Ovaries


      (2) Normal physiology


            (a)    Menstruation


                1) Normal discharge - blood, mucous, cellular debris from uterine mucosa



                2) Approximately every 28 days


                3) Absent during pregnancy


            (b)    Ovulation


                1) Egg (ovum) released from ovary following breaking of follicle


                2) Usually occurs 14 days after the beginning of the menstrual cycle


Stages of Labor


a.   First stage


     (1)  Begins with the onset of regular contractions


            (a)    Contraction time - the span of time from the beginning of a contraction of the uterus to when the uterus relaxes


            (b)    Interval time - the span of time from start of one contraction to the start of the next contraction


      (2) Rupture of amniotic sac


WARNING:     "Meconium staining" - amniotic fluid that is greenish or brownish-yellow rather than clear, is an indication of possible fetal distress during labor.


      (3) Appearance of bloody show


      (4) Ends with the full dilation and effacement of the cervix


NOTE:     In order for a vaginal delivery to occur, the cervix must both thin out (efface) to 100% and open up (dilate) to 10cm (3-4 inches).


WARNING:     There is usually time to transport the patient before delivery during this phase.


b.   Second stage- Feeling of or urge for bowel movement


     (1)  Begins when the baby enters the birth canal


     (2)  Contractions become stronger


     (3)  Presenting part appears


     (4)  Ends with the birth of the baby



CAUTION:      Transportation of the patient at this time should NOT BE CONSIDERED.  Delivery is imminent.


c.   Third stage


     (1)  Begins when delivery of baby is complete


(2)     Ends with the delivery of the placenta and umbilical cord


Care for Normal Delivery Outside the Hospital


a.  Evaluation of the mother


     (1)  Ask the mother the following questions


            (a)    How long have you been pregnant or expected due date?


            (b)    How long and how often she has been having contractions?


            (c)    If she has had any bleeding or bloody show?


     (2)  Check for signs and symptoms that indicate delivery will occur before transport is possible


            (a)    Head or other presenting part is visible (crowning)


            (b)    Mother tells you "The baby is coming", especially if she is a multiparous woman


            (c)    Mother feels as if she is having a bowel movement with increasing pressure in the vaginal area


            (d)    Mother feels the need to push


            (e)    Hospital is not accessible due to traffic or weather/disaster


            (f) Transportation will not become available before anticipated time of delivery


     (3)  If delivery is eminent with crowning, contact medical officer for decision to commit to delivery on site  If delivery does not occur within 10 minutes, contact medical officer for permission to transport.


b.   Predelivery preparation of the mother


     (1)  Ensure the mother's privacy


     (2)  Obtain and open emergency obstetric pack.  This will provide all the sterile supplies needed for care of the mother and infant before and after delivery.



     (3)  In absence of an emergency obstetric pack medic should collect clean sheets and towels, heavy sting or cord (shoelaces) to tie the cord, a towel or plastic bag to wrap the placenta, and clean unused rubber gloves and eyewear


    (4)  Put on gloves, mask, gown, and goggles for infection control precaution if the conditions permit/as time allows


     (5)  Position the mother and prepare work space for both delivery and care of the newborn


            (a)    Position mother lying with knees drawn up and spread apart.  Elevate the hips with a folded blanket or pillow.


            (b)    Create a sterile field around vaginal opening with sterile towels or paper barriers


            (c)    Have another individual monitoring the airway, render assistance if she should vomit, and provide emotional support


c.   Assist in delivery of the baby


     (1)  Encourage mother to breathe deeply through her mouth.  She may feel better if she pants.


   (2)  When the infant's head appears during crowning, place fingers on the bony part of skull and exert slight pressure to prevent an explosive delivery.  Use caution to avoid "soft spot" (fontanelle.)


   (3)  If the amniotic sac does not break, or has not broken, use a clamp or your finger to puncture the sac and push it away from the infant's head and mouth as they appear


   (4)  As the infant's head is being born, determine if the umbilical cord is around the infant's neck


         (a)    If the umbilical cord is around the infant's neck, slip it over the shoulder or clamp, cut, and unwrap


         (b)    Umbilical cord must be clamped and cut if it is wrapped too tightly around the infant's neck  (Brady Emergency Care 8th pg 463, fig 24-8)


   (5)  After the infant's head is born, support the head, suction the mouth first then the nostrils two or three times with a bulb syringe if available


CAUTION:  Use caution to avoid contact with the back of the mouth.


         (a)    Squeeze the bulb syringe before placing it in the mouth or nose


         (b)    Slowly release with withdrawal


         (c)    Squeeze again to expel contents before reinserting



   (6)  Continue to support the baby's head between contractions while waiting for the rest of the body to be delivered


WARNING:  DO NOT pull on the baby's head to assist with the delivery.


   (7)  As the feet are born, grasp the feet.  Wipe blood and mucus from mouth and nose again.


   (8)  Wrap the infant in a warm blanket and place on his side, with the head slightly lower than the trunk


WARNING:  Keep infant warm to prevent hypothermia, which can occur quickly.


   (9)  Keep infant level with vagina until the cord is cut


   (10)  Have your partner monitor and complete initial care of the newborn.


   (11)  The infant must be breathing on its own before clamping and cutting the cord.


            (a)    Palpate the cord with your fingers to make sure it is no longer pulsating


            (b)    Use clamps or umbilical tape found in the obstetric kit


            (c)    Apply the first clamp about 8 to 10 inches from the baby


            (d)    Place the second clamp 2 to 3 inches below the first, approximately 4 fingers width from infant


            (e)    Cut the cord between the clamps or knots using sterile surgical scissors


CAUTION:        NEVER unclasp a cord once it has been cut, or attempt to adjust a clamp once it is in place.


   (12)  Observe for delivery of the placenta while preparing mother and infant for transport


   (13)  When the placenta is delivered, wrap it in a towel and put it in a plastic bag


   (14)  Place sterile pad over vaginal opening, lower mother's legs, help her hold them together.  Transport mother, infant, and placenta to hospital.


   (15)  Record the birth


            (a)    Document exact time of birth on the run sheet


            (b)    Make a double-backed tape bracelet with the time of birth and the mother's full name.  Apply to baby's wrist or ankle.


d.  Caring for the newborn



     (1)  Position, dry, wipe and wrap the newborn in a blanket and cover the head


            (a)    Place baby in a head-down position


            (b)    Repeat suctioning the mouth and nose as necessary


     (2)  Assessment of infant - normal findings


            (a)    The APGAR score may be used to evaluate the newborn's condition.  Perform as soon as the infant's born and 5 minutes later. 


            (b)    Evaluating the adequacy of a newborn’s vital functions immediately after birth


            (c)    Five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color


            (d)    Each parameter is given a score from 0 to 2


            (e)    Majority of infants are vigorous and have a total score of 7 to 10


                1) Appearance - note the infant's color.  Normal color is pink with some cyanosis of the extremities.


                2) Pulse - determine the infant's pulse rate.  The pulse rate should be greater than 100 per minute.


                3) Grimace - evaluate the infant's response to an irritable stimulus.  The infant should cry or react vigorously.


                4) Acitivity - how much is the infant moving?  Infant should have good motion in extremities.


                5) Respiration effort (breathing) - the infant should be breathing within 30 seconds after birth (breathing normal or crying)


     (3)  Stimulate newborn if not breathing


            (a)    A gentle vigorous rubbing of the baby's back should stimulate breathing, if that fails, snap your index finger against the sole of the feet


              (b)        DO NOT hold the baby upside down to slap its bottom


     (4)  Resuscitation of the newborn - after assessment, if signs and symptoms require either cardiac or pulmonary resuscitation, perform the following steps when appropriate


            (a)    If breathing effort is shallow, slow, or absent, provide artificial ventilations


                1) 40 to 60 per minute


                2) Reassess after 30 seconds



                3) If no improvement, continue artificial ventilation and reassessments


            (b)    If heart rate is less than 100 beats per minute, provide artificial ventilations


              1) 40 to 60 per minute


                2) Reassess after 30 seconds


                3) If no improvement, continue artificial ventilation and reassessments


            (c)    If heart rate is less than 80 beats per minute and not responding to artificial ventilations, start chest compressions


            (d)    If heart rate is less than 60 beats per minute, start compressions and artificial ventilations


                1) Chest compressions in the newborn should be delivered at a rate of 120 per minute, mid sternum


                2) Give compressions with two thumbs, fingers supporting the back, at a depth of 1/2 to 3/4 inch


CAUTION:  This is for newborns only.


            (e)    Color - if the infant exhibits cyanosis of the face and/or torso with spontaneous breathing and adequate heart rate.  Administer oxygen 10 to 15LPM using oxygen tubing held as close as possible, but not directly into the infant's face.


e.  Delivering the placenta.


    (1)  The placenta is normally expelled within minutes after the baby is born.  Never pull on the cord to facilitate delivery.


    (2)  Save the placenta in a container and place it in a plastic bag, or wrap it in a towel or paper and bring it with the mother and baby to the hospital


f.   Emergency care of mother post-delivery - place baby to mothers breast.


     (1)  Up to 500cc if blood loss is normal and well tolerated by the mother following delivery


    (2)  The soldier medic must be aware of this loss so as not to cause undue psychological stress on him or the new mother


     (3)  If there is excessive blood loss, massage the uterus


            (a)    Place fully extended fingers on lower abdomen above pubis and massage lightly with a circular motion over area



            (b)    If bleeding continues, check massage technique and transport immediately.  Provide oxygen and perform ongoing assessment.


    (4)  Regardless of estimated blood loss, if mother shows signs and symptoms of shock, treat as such and transport prior to uterine massage.  Massage the uterine fundus en route to the hospital.

Monitor for complications during labor


a.   Complications during labor: Meconium -  a greenish-black to light brown material that collects in the intestine of a fetus and forms the first stool of a newborn.


     (1)  Premature infants ("Preemie")


            (a)    Description


                 1)  An infant weighing less than 5.5 lbs. or born before the 37th week of gestation


                 2)  Smaller and thinner than a full-term baby


                 3)  The proportion of the head to the body is greater than a full-term infant


            (b)    Treatment and transport - same as for normal births


                 1)  Dry the baby thoroughly as soon as possible after birth


                 2)  Keep warm - absence of fully developed layer of fatty tissue allows rapid cooling and development of hypothermia


                    a)  Wrap completely, with face exposed


                    b)  Maintain temperature of room or ambulance at 90-100o


                 3)  Keep mouth and nose clear of mucus by suctioning frequently


                 4)  Provide ventilations and/or chest compressions based upon the baby's pulse and respiratory effort (see Annex F)


                 5)  Administer oxygen (humidified, if possible) by directing flow into an improvised tent over baby's face


                 6)  Watch the umbilical cord for bleeding.  Apply another clamp or tie closer to the abdomen to prevent excessive blood loss. 


                 7)  Prevent contamination.  Wear a gown/mask.  Keep bystanders at a distance.


                 8)  Handle gently while providing all care


                 9   Inform hospital of premature delivery



     (2)  Breech presentation


            (a)    Description


                1)   Presenting part is the buttocks or feet


                2)   Most common abnormal delivery


            (b)    Treatment and transport


                1)   Initiate rapid transport upon recognition of a breech presentation


                2)   Never attempt to deliver the baby by pulling on its legs


                3)   Provide high concentrations of oxygen


                4)   Place the mother in a head-down position with the pelvis elevated


                5)   If the body delivers, support buttocks and trunk and prevent an explosive delivery of the head


                6)   After delivery, care for the newborn, cord, mother, and placenta as in normal delivery.


     (3)  Prolapsed umbilical cord - a true emergency


            (a)  Description


                 1)   Umbilical cord presents first


                2)   Oxygen supply to baby is interrupted when the cord is squeezed between the vaginal wall and the presenting part


                3)   Commonly seen with breech deliveries or small babies (premature births/multiple births)


            (b)       Treatment and transport


                1)   Perform initial assessment


                2)   Place mother with her head down and elevate her hips with a blanket or pillow, this will lessen pressure on the birth canal


                3)   Provide a high concentration of oxygen


                4)   Gently push on the presenting part to keep pressure off cord, by inserting several fingers of your gloved hand into the vagina.  Maintain this position until relieved by the physician at the medical treatment facility.



                5)   Check the cord for pulses and keep it warm with a towel moistened with sterile saline and wrapped again with a dry towel


                6)   DO NOT attempt to push the cord back inside the mother


                7)   Transport immediately to a medical facility


                8)   Have your partner obtain baseline vital signs, AMPLE history, and physical exam en route to the hospital, if possible


     (4)  Limb presentation


            (a)       Description - arm or leg presents first


            (b)       Foot is the most common in a breach presentation


            (c)       Limb presentation cannot be delivered in the prehospital setting


            (d)       Treatment and transport


                1)   Place mother in a head down position with hips elevated


                2)   Administer a high concentration of oxygen


                3)   DO NOT attempt to place the limb back into the vagina


                4)   Transport immediately to a medical facility


     (5)  Multiple birth


            (a)       Description - more than one infant is being born (e.g., twins, triplets)


            (b)       Treatment and transport


                1)   Assist as in a single delivery


                2)   Clamp and cut the cord of first baby


                3)   Note time of first birth


                4)   Assist with subsequent births, cut and clamp each cord.  Note the time of each birth.


                5)   Make certain to identify each child and order of birth (1 and 2 or A and B)


                6)   Provide care for each infant, mother, umbilical cord, and placenta as with a single delivery



     (6)  Meconium staining


            (a)       Description


                1)   Greenish or brownish-yellow amniotic fluid.  A result of fecal material released from the baby's bowels before birth.


                2)   Occurs when the infant is distressed due to cord compression, trauma, or other complications while inside the amniotic sac


CAUTION:  Appearance of meconium in amniotic fluid is a sign that the infant has a potentially serious problem.  Aspiration of meconium by the infant during delivery can cause severe respiratory complications.


            (b)       Treatment and transport


                1)   Suction the baby's mouth and then nose BEFORE stimulating the baby to breathe.  This is to avoid aspiration of amniotic fluid with meconium particles.


                2)   Continue to monitor the airway


                3)   Transport immediately


                4)   Notify hospital of the presence of meconium in the fluid


Predelivery Emergencies


a.  Terms and definitions


     (1)  Miscarriage - spontaneous termination of a pregnancy before 20 weeks gestation


     (2)  Abortion - spontaneous or elective termination of a pregnancy before the fetus has developed enough to survive on it's own


     (3)  Ectopic pregnancy - abnormal pregnancy in which the fertilized egg implants outside the uterine cavitiy


b.  Predelivery emergencies


     (1)  Miscarriage/spontaneous abortion - fetus and placenta may deliver before the 20th week of pregnancy


            (a)       Signs and symptoms


                 1)   Moderate to severe vaginal bleeding

                2)   Abnormal cramping

                3)   Discharge of tissue, blood, and/or blood clots from the vagina



            (b)       Emergency care steps


                 1)   Perform initial assessment


                 2)   Obtain SAMPLE history and baseline vital signs


                 3)   Initiate and maintain IV with Normal Saline


                 4)   Treat for shock if indicated


                 5)   Administer high concentration oxygen


                 6)   Place sanitary pad over the vagina.  Save all used pads.


                 7)   Save all expelled tissue


                 8)   Provide emotional support


                 9)   Transport immediately


     (2)  Ectopic Pregnancy


            (a)       95% of all ectopic pregnancies occurs in a fallopian tube


            (b)       Usually referred to as a "tubal pregnancy“


            (c)       Most likely to occur when the fallopian tube is scarred from infection (PID) or previous abdominal/gynecological surgeries


            (d)       Signs and symptoms


                 1)   Abdominal pain initially localized to one side or the other of the lower abdomen


                 2)   Initially pain is "crampy“ and intermittent in nature


                 3)   As pregnancy progresses, the fallopian tube ruptures and pain becomes constant and diffuses throughout the abdomen


                 4)   Patient may experience shoulder pain, which suggests a large hemoperitoneum


                 5)   Patient may or may not have vaginal bleeding


                 6)   Patient usually has an absence of menstruation.


                 7)   Rapid and weak pulse


                 8)   Low blood pressure



            (e)       Emergency care and treatment


                 1)   Maintain airway

                 2)   Administer oxygen

                 3)   Keep patient supine

                 4)   Initiate a large bore IV and administer IV fluids

                 5)   Keep NPO (nothing by mouth)

                 6)   Transport immediately to definitive care facility



     (3)  Pre-eclampsia (toxemia of pregnancy)


            (a)       Signs and symptoms


                1)   Hypertension

                2)   Proteinuria - protein in the urine

                3)   Elevated blood pressure

                4)   Excessive weight gain

                5)   Swelling (edema) of the face, hands, ankles, and feet


            (b)       Emergency care steps

                1)   Notify medical officer immediately

                2)   Perform initial assessment

                3)   Obtain SAMPLE history and baseline vital signs

                4)   Treatment based on signs and symptoms

                5)   Transport patient on her left side


     (4)  Eclampsia


            (a)       Signs and Symptoms


                 1)  Headaches

                 2)  Visual disturbances

                 3)  Epigastric pain

                 4)  Massive swelling (edema) especially of the face and hands

                 5)  Proteinuria (protein in the urine)

                6)   Seizures - occurrence of seizures clearly marks transition of pre-eclampsia to eclampsia


              (b)                                                Emergency care and treatment


                 1)  Position on left side.  Keep patient quiet and in a darkened room, if possible

                 2)  Administer high flow oxygen

                 3)  Initiate and maintain intravenous line

                 4)  Transport to hospital as gently and quickly as possible

                 5)  Anticipate seizure activity.  Have suction readily available.

                 6)  Pharmacological interventions as directed by MD/PA



     (5)    Ante partum Hemorrhage (bleeding before delivery)


            (a)       Three main causes


                (1)  Abruptio placenta - premature separation of the placenta from the wall of the uterus during the last trimester of pregnancy.  Patient will experience sudden onset of severe abdominal pain with or without vaginal bleeding.  Fetal movement/fetal heart tones are usually absent.  The abdomen will be tender and the uterus rigid to palpation.


                (2)  Placenta previa - painless vaginal bleeding.  Usually bright red.  Occurs as the cervix begins to dilate in preparation for delivery and the placenta covers all or part of the cervical canal.  Fetal movement continues and fetal heart tones are audible.  Uterus is soft and non-tender.


                (3)  Uterine rupture - usually occurs during labor.  Women at risk are multiparous or have had a previous c-section.  Vaginal bleeding may or may not be present.  Contractions will have lessened or stopped.  Patient will exhibit obvious signs of shock.


            (b)       Emergency care and management


                 1)  Regardless of cause of third trimester bleeding, management and treatment are the same.


                 2)  Position on left side


                 3)  Administer high flow oxygen


                 4)  Initiate and maintain at least two large-bore IV's


                 5)  Treat for shock


                 6)  Notify MD/PA Immediately


                 7)  Evacuate/transport to definitive care facility



     (6)  Trauma in pregnancy


            (a)       Three major causes


                 1)  Motor vehicle crashes


                 2)  Falls


                 3)  Penetrating injuries (i.e. gun shot wounds)




            (b)       Anatomic changes of pregnancy


                1)   Compression of abdominal contents into upper abdomen results in a higher incidence of abdominal trauma in association with chest trauma


                2)   Bladder is displaced upward and forward so it is outside the pelvic cavity and is at increased risk for injury


                 3)  The obviously enlarged uterus is at risk for injury/rupture



            (c)       Physiologic changes of pregnancy


                1)   Vascular volume increases to support the perfusion of two circulations (patient and fetus)


                2)   Increase in cardiac output to pump increased volume - resting heart rate increases to 15-20 BPM's


                 3)  Redistribution of blood volume with as much as a tenfold increase in blood flow to the pelvic region


                4)   Respiratory changes include an increased need for oxygen due to a higher basal metabolism - increased minute volume


                5)  Tidal volume increases along with minute volume to rid the body of the increased CO2 from the patient and fetus


                6)   All of the physiologic changes make it difficult to assess for signs and symptoms of shock and to adequately ventilate the patient


            (d)       Emergency care and management


                 1)  Treat the mother first


                 2)  Maintain adequate airway


                 3)  Administer high flow 02 - oxygen needs are 10 -20% higher than normal


                 4)  Assist with ventilations as needed - remember to provide higher minute volume


                 5)  Control external bleeding


                6)   Position on left side - lying on the left side will shift the weight of gravid (pregnant) uterus off the vena cava.  If immobilized on backboard, tilt board 30 degrees to the left.


                 7)  Initiate and maintain IV


                 8)  Transport/evacuate to definitive care facility




Remember, the soldier medic’s major role in the birth process is normally supportive.  Knowing the normal sequences of the process and helping the mother prepare for the birth enables the soldier medic to perform this supporting role effectively.  However, when complications develop, the soldier medic must be prepared to swiftly and properly assess, treat, and transport the patient(s).