Overview of EMS Prehospital Deliveries
A prehospital delivery, also known as an unplanned out-of-hospital birth or birth before arrival, is when a baby is born outside a hospital without planning or preparation. Unlike a planned home birth, in these situations, there may be no healthcare professionals or medical equipment available. In some cases, emergency medical service (EMS) personnel may be called to help transport mothers who planned a home birth but encountered complications.
If EMS is asked to help a woman in active labor, the main goal is usually to get the mother to a hospital with childbirth services as fast as possible, if there’s enough time. These hospitals have doctors and nurses who specialize in childbirth and have the necessary equipment to deal with potential problems. Both the American Academy of Pediatrics (AAP) and the American College of Obstetrics and Gynecology (ACOG) agree that hospitals and accredited birth centers provide the safest environments for birth. However, if there’s not enough time to get to a hospital before the baby is born, EMS healthcare personnel are usually called to help when a fast delivery has happened or is about to happen, or if the mother gives birth during transportation.
Unplanned prehospital deliveries can increase health risks for the baby and the mother. This is often due to limited training among EMS staff for handling emergency deliveries and related complications, and a lack of appropriate newborn resuscitation. As such, it’s crucial that EMS professionals know the proper delivery techniques and how to assess and care for the mother and baby right after birth.
Anatomy and Physiology of EMS Prehospital Deliveries
The pelvis is a type of bone structure that forms a ring shape. When a baby is being born, it has to pass through this pelvis ring. How easy or difficult the delivery will be depends on the size and shape of the mother’s pelvis and the size and position of the baby. Sometimes, in rare cases (about 3% of the time), the baby’s shoulder might get stuck behind the mother’s pubic bone. This is called shoulder dystocia, which is an emergency condition during childbirth.
The uterus is a part of a woman’s pelvis. It’s shaped like a pear and is a hollow muscle. During pregnancy, the uterus holds the baby, the placenta (which provides nutrients to the baby), and the amniotic sac that’s filled with fluid. The uterus also plays a pivotal role during childbirth. It contracts or tightens in a rhythmic manner, pushing the baby through the pelvis, and finally, out through the vaginal opening.
The cervix is a tube-like structure that forms the opening of the uterus and leads into the vagina. During childbirth, as the uterus contracts, it pushes the baby’s head against the cervix. This action helps the cervix to open (or dilate) and thin out (efface), creating a pathway for the baby to exit from the uterus and move into the vagina.
Doctors assess the cervix during labor to track its progress. This is done through a vaginal examination using a sterile technique. They measure how open the cervix is, which is expressed in centimeters, and how thin it has become, which is measured as a percentage. A fully dilated cervix measures 10 centimeters and when it’s 100% effaced, it is as thin as paper.
The fundus is located at the top of the uterus. You can feel it as a firm, rounded dome when you press on the abdomen. The distance from the top of the fundus to the top of the pubic bone is measured in centimeters, and this is known as fundal height. This measure helps estimate how far along the pregnancy is. For example, around 20 weeks of pregnancy, the top of the uterus aligns with the belly button.
After the baby is born, the uterus returns to its non-pregnant size by contracting. This also helps control bleeding after childbirth by sealing off small blood vessels in the uterine muscle. Massaging the top part of the uterus can help stimulate this contraction, which is helpful in controlling post-delivery bleeding.
The placenta is an essential organ that connects the mother and the baby, enabling the exchange of nutrients and gases. It is attached to the uterine wall on one side and faces the baby on the other side. The umbilical cord, in most cases, connects to the center of the placenta. This cord is no longer needed after the baby is born, so the uterus contracts further to detach and expel the placenta.
Childbirth is divided into 3 stages. The second stage involves the delivery of the baby. The first stage starts with the onset of regular contractions and changes in the cervix, and ends when the cervix is fully open. The exact speed of labor can vary widely but generally moves faster for women who have given birth before. The third stage begins immediately after the baby is born and ends with the delivery of the placenta. This typically happens within the first 9 minutes after the baby’s birth.
Why do People Need EMS Prehospital Deliveries
Signs that a baby is about to be born include:
* A strong, natural desire from the mother to push or feeling like she needs to go to the bathroom
* Very strong muscle tightening in the womb happening regularly, less than 2 minutes apart
* Bulging of the area between the vagina and anus, known as the perineum
* The baby’s head becomes visible at the opening of the vagina, also known as crowning. Alternatively, the mother’s vaginal lips may part naturally due to pressure from the baby’s presenting body part.
When a Person Should Avoid EMS Prehospital Deliveries
In some rare cases, an emergency health care worker may not be able to delay or prevent a baby’s birth, if it’s happening spontaneously. If the health worker is close to the hospital, they might ask the woman to try not to push which could delay the birth a little bit. This largely depends on how dilated (that’s how far her cervix has opened to let the baby come out) the woman is and how many babies she’s already had. During a very fast birth, a woman’s body often pushes the baby out without much help from her. She might not be able to stop this feeling of needing to push. So, the baby could be born no matter what she tries to do. In such cases, health care workers have to be ready to deliver the baby while on the way to the hospital.
Emergency health care workers should be mindful of two things that could stop a vaginal birth. One is called umbilical cord prolapse, where the baby’s umbilical cord comes out before the baby. This can squeeze the cord and cause problems like brain damage due to not enough oxygen (hypoxia), or cerebral palsy. A cesarean delivery (or c-section), which is surgery to take the baby out, is usually preferred. To help the situation, the health care worker can try to lift the baby away from the cord using 2 fingers or their whole hand, while positioning the mother in a way that helps until a doctor can perform the c-section in a hospital.
The second situation is called a frank breech or footling breech. This is when a baby comes out bum-first (frank breech) or foot-first (footling breech) instead of head-first. It is more common in premature births and can lead to more complications than a normal birth. Often, a c-section is needed. In this case, the health care worker shouldn’t pull at all, and should ask the mother to take short panting breaths during contractions until they reach the hospital for specialized help.
Equipment used for EMS Prehospital Deliveries
For most simple childbirths, only some basic equipment is needed. If you’re in a situation where you’re not in a hospital and medical professionals who come in an ambulance have to help with a birth, they should ideally have something to close off and cut the baby’s umbilical cord plus a dry cloth, say a towel, to dry and stimulate the baby. Sometimes, they won’t have all the equipment normally found in a delivery room, but they should try to have the following items:
- Personal protective equipment like a mask with a shield for the whole face, a gown, boot covers, and sterile gloves
- Towels or clean, dry cloths
- Blankets and a hat for the baby
- Two umbilical cord clamps or hemostats, which are clamps used in surgery
- Medical scissors or a sharp blade to cut the cord
- A container for the placenta
- A bulb syringe to gently suction mucus out of baby’s mouth and nose
- Supplemental oxygen
- Equipment to set up an intravenous (IV) drip and crystalloid fluid, which is a type of IV fluid used to replace fluids in the body
- Oxytocin, a medicine often used to help with contractions during childbirth
- Baby ventilation bags or a manometer, a device used to measure the intensity of inflating pressures during ventilation, which is the process of providing air to the lungs
These pieces of equipment should be easy for ambulance crews or their helpers to get to quickly. Typically, they would be kept in an ambulance as part of an emergency delivery kit. However, there’s only so much storage space inside an ambulance and some of the equipment might be too expensive to keep around all the time. On top of that, different ambulance services might stock different equipment
If there is no medical equipment available during delivery, clean clothing can be used to dry, stimulate, and warm the baby.
Who is needed to perform EMS Prehospital Deliveries?
If a baby needs to be delivered before reaching the hospital, the emergency medical service (EMS) personnel will have to do their best with the people they have on hand. Ideally, there should be at least one person assisting the medical professional who is delivering the baby. The team at the hospital, including emergency doctors, newborn baby doctors (neonatologists), and childbirth doctors (obstetricians), as well as nurses, should be told ahead of time that the patient is on the way. This allows them to get ready needed instruments and equipment, such as special heaters for the baby.
Preparing for EMS Prehospital Deliveries
Emergency services (EMS) first assess a woman in labor to check if she can safely be transported to the hospital. If signs indicate she might give birth very soon, she may need to deliver the baby before reaching the hospital. The EMS team will quickly gather information and check the patient to decide. Key details include the baby’s expected birth date and age, which can be estimated from the first day of the woman’s last period if she doesn’t know the due date.
The EMS personnel will also need to know the number of previous pregnancies and deliveries, any complications during this or earlier pregnancies, when contractions started and how often they occur, and whether the woman’s water has broken. The color of the fluid is significant; normal is clear yellow, bloody could mean issues with the placenta, and green could indicate a risk of breathing problems for the baby. It’s also necessary to know about any healthcare the woman has had, whether she’s expecting single or multiple babies, any other health issues, allergies, medications, and the baby’s position, if known.
If the baby hasn’t been delivered when EMS arrive, they will check the woman’s vital signs and, if possible, listen to the baby’s heartbeat. They’ll quickly measure the height of the woman’s abdomen to estimate how old the pregnancy is. If there’s time, they’ll take her to a hospital with special facilities for childbirth unless birth is imminent. This can be assessed by examining the woman’s perineum area if she feels a desire to push, feels pressure in the rectum, or is having contractions less than two minutes apart. If the baby’s head is visible or the perineum area is stretched by a part of the baby, it means delivery is likely soon, so the EMS team should prepare for a delivery in the field.
Usually, in the field, EMS don’t need to perform a sterile digital examination of the vagina, where a clean finger or tool is inserted to feel for the baby’s position. This is generally left until the woman is in the hospital, where a specially trained clinician can check the progress of labor by assessing changes in the cervix and the baby’s descent. However, if there’s a problem such as the baby being positioned feet first, the EMS team may have to do this examination. If there’s bleeding, it’s important to wait until a condition called placenta previa, where the placenta is blocking the baby’s exit, can be ruled out as a cause. This check is easiest when the woman is on her back with her legs bent at the hips and knees.
For delivery, the woman can be in many positions, including on her side, kneeling, squatting, or on hands and knees. The important things are her comfort, accessibility for healthcare personnel, and a safe place for the baby to prevent falls. However, the woman should not lie flat on her back, as this can reduce the blood flow to the fetus. If she is lying on her back, a towel can be used to tilt her to the left, or she can sit in a semi-reclining position at a 45-degree angle.
How is EMS Prehospital Deliveries performed
When a woman is giving birth, the healthcare professional’s goal is to ensure the mom and baby stay healthy. This involves lessening any potential harm to the mother, making sure the baby gets immediate support, and managing any complications that might come up. If there is only one trained medical professional present, they can ask family members, friends, or another non-medical person to assist with the birth and provide the mother with support.
In preparation for delivery, any necessary supplies or the emergency delivery kit should be within easy reach. The woman can choose to deliver in a semi-reclined or left-tilted dorsal lithotomy position (a lying down position where their hips and legs are flexed) to open up their pelvis. Clean towels can be spread around the mother’s buttocks and the area between her legs, known as the perineum. If time permits, this area should be quickly cleaned with a povidone-iodine solution, an antiseptic used to prevent infection.
When the baby’s head is close to coming out, the mother will likely experience the urge to push down. The health care provider will encourage her to push when she feels a contraction begin. It’s also important to allow the mother to breathe in a natural way and push in the way she prefers, offering support and encouragement throughout the process.
In the majority of deliveries attended by EMS personnel, the birth is relatively straightforward. Their main role is to help guide the baby’s birth safely to prevent any harm to the mother or the baby. Once the baby’s head is out, the provider will carefully check to see if the umbilical cord is wrapped around the baby’s neck (a condition known as a nuchal cord). If the cord is wrapped around the neck, it should be carefully loosened over the baby’s head. If it’s too tight, the cord may need to be clamped and cut to allow the baby to be delivered. This is only typically done if absolutely necessary.
After the baby’s shoulders have been delivered, the rest of the body should be delivered quickly. There is usually no immediate need to clamp the umbilical cord. Unless the newborn requires immediate medical attention, the umbilical cord should not be clamped until it has stopped pulsating, usually around 30 to 60 seconds after delivery. Delaying clamping the cord allows the baby to receive an extra 100ml of oxygenated blood, especially beneficial for preterm babies. Afterwards, two clamps will be placed on the umbilical cord and cut between them to separate the baby from the placenta. The remaining cord near the baby’s belly button should be kept clean to prevent any infection.
Possible Complications of EMS Prehospital Deliveries
Tears and cuts, medically referred to as “lacerations”, are common after normal childbirth, especially with the first delivery. These lacerations can happen in the areas around the vagina including the perineum (the area between the vagina and anus), vulva, the area around the clitoris, and the area around the urethra (where the urine comes out). Perineal tears are most common and are categorized into four levels of severity ranging from minor injury to the skin only, to severe cases where the cut extends into the muscles of the anus.
Non-perineal lacerations are usually not deep and may not need to be stitched up unless there is active bleeding. The American College of Obstetricians and Gynecologists (ACOG) suggests that a specialized clinician decide whether minor lacerations need to be stitched up. Second degree tears are mostly stitched up, but evidence seems to be unclear if this is the best option – it might be that letting these heal naturally is just as good. However, more severe tears should certainly be stitched up. If there is significant bleeding from a laceration, it should initially be managed by applying pressure until a specialized clinician evaluates and decides on the most suitable treatment.
“Breech presentation” is when the baby is positioned in a way that their bottom or feet would come out before their head. These deliveries are associated with more risks for the newborn and should ideally be carried out in a hospital. However, if the baby’s body has already come out to the level of their belly button, it means the birth is very close, and the baby will likely be delivered before arriving at the hospital. In such a case, the responding medical team should prepare for delivering the baby on the spot. There are specialized techniques to assist with this kind of birth, it should be noted that emergency medical responders are trained to do this safely.
A difficult situation may arise called ‘shoulder dystocia’ where the baby’s shoulder gets stuck behind the mother’s pubic bone during birth. Risk factors for this can be a larger than normal baby, or health complications with the mother such as diabetes or obesity. This is often a sudden problem that the clinician needs to manage as soon as possible for the baby’s safety. There are specialized techniques, like the McRoberts maneuver, where the mother bends her knees upward towards her chest which in turn can help create more space in the pelvis to help the baby to be born.
What Else Should I Know About EMS Prehospital Deliveries?
Emergency health workers, like those in ambulances, don’t usually deliver babies. However, it’s key that they understand the correct ways to handle labor. The best situation is for the mom-to-be to reach a medical center before delivering, where the right care for labor and newborn babies is available. But sometimes, there might not be enough time to travel and the baby is born either just as the ambulance arrives or during the journey.
Emergency deliveries (those that occur out of hospital) have been associated with greater risks for both the newborn baby and the mother. Often, the main reason for this is that the ambulance crew haven’t had sufficient training in dealing with sudden deliveries, managing common labor complications, and providing the needed initial care for newborns. It is crucial for these healthcare professionals to keep updating their expertise. They should know how to speedily spot problems, perform effective procedures, and arrange the right level of care. This helps ensure the ambulance staff stays calm during an out-of-hospital delivery and works towards the best outcome for the mother and baby.
Most of the time, uncomplicated births only need little assistance from ambulance personnel, such as giving support and performing basic checkups. Vital parts of the delivery process involve helping with the baby’s head and shoulder coming out and the initial steps of newborn care. Emergency health workers should also be prepared to deal with common issues during childbirth, like a baby’s shoulder getting stuck (shoulder dystocia), the umbilical cord dropping down (umbilical cord prolapse), heavy bleeding after birth (postpartum hemorrhage), and a newborn having difficulty breathing (neonatal respiratory distress). This continues until the patient can be transported safely to a hospital.
