History:

 

• Due date
• Medications/illicit drug use
• Prenatal care
• Gravida/para
• High risk pregnancy
• Time contractions started/how often
• Rupture of membranes
• Time/amount of any vaginal bleeding
• Sensation of fetal activity
• Past medical and delivery history

 

Significant Findings:

 

• Spasmodic pain
• Vaginal discharge/bleeding
• Crowning/urge to push
• Meconium

 

Differential:

 

• Abnormal presentation
  • Buttock
  • Foot
  • Hand
• Prolapsed cord
• Placenta previa
• Abruptio placenta
• Ectopic pregnancy

 

 Assess for crowning ?

 

• No

 

• • Monitor and reassess; document frequency and duration of contractions

 

• Yes

 

• • Position mother for birth

• • Oxygen

• • Initiate IV; infuse fluid at a rate sufficient to prevent hypovolemic shock

 

Check for:

 

• • Nuchal cord
  • Prolapsed cord
  • Breech Birth
  • Multiple Births

 

1. Gently press on perineum to prevent explosive birth and unnecessary tearing
2. Anterior shoulder normally delivers first followed by posterior shoulder
3. Suction mouth and then nose
4. Keep baby at level of the vagina until cord is cut
5. Clamp and cut cord
6. Record infant APGAR
7. Suction, warm and dry the infant
8. Deliver placenta

 

Excessive bleeding > 500 mL ?

 

• No

 

• • Notify receiving facility or contact Medical Control

 

• Yes

 

• • Perform uterine massage

 

• Oxytocin (Pitocin) 20 units (in 1,000 mL Normal Saline) slow IV administration titrate according to severity of bleeding.

• Facilitate breast feeding to increase uterine contraction
• Notify receiving facility or contact Medical Control

 

PEARLS:

 

• Position for birth: semi-fowlers with knees drawn up and apart with buttocks elevated.
• Create a sterile field around vaginal opening.
• If nuchal cord is present, attempt to slip cord around neck.  Clamp and cut if unable to remove cord.
• If prolapsed cord is present, do not attempt to place cord back into vagina. Instead, cover cord with a moist dressing and do not over- stimulate. If the baby is on the cord, insert two fingers into the vagina and attempt to lift the baby off the cord.
• In the case of a breech birth, attempt to prevent delivery. Have the mother blow hard and constant. If birth is imminent, place the mother semi-fowlers with her knees high to her chest. Do not pull the baby and let the delivery proceed naturally. If the baby's head does not deliver, insert two fingers into the vagina in the shape of a "V" in an effort to create an airway for the infant.
• Keep the infant warm! Dry infant, place infant on mother's chest (skin to skin); cover both infant and mother.
• Document all times (contraction frequency, length and delivery).
• Record APGAR at 1 minute and 5 minutes after birth.
• Consider transport prior to placenta delivery.