Imminent childbirth & APGAR

Recognize imminent delivery

• Prepare for field delivery when childbirth is progressing faster than safe transport to an emergency receiving center. Signs include a visible presenting part, contractions about 3 minutes or less apart, ruptured membranes with contractions, an urge to bear down or have a bowel movement, sudden vaginal bleeding with contractions, or prior vaginal birth with frequent active contractions.
• Request an ALS response if not already present. Reassure the mother, use standard precautions, free clothing from the birth canal, and allow a comfortable position with room for delivery.

Assist a controlled birth

1. Let the mother push with contractions when the urge is unavoidable. Support the perineal area with moderate pressure and control delivery of the head to reduce tearing.
2. Support the head as it emerges and allow natural rotation. If the cord is around the neck, slip a finger beneath it and move it over the head when possible.
3. Support delivery of the shoulders and body without pulling. Keep a secure hold on the newborn and support the head and neck.
4. Dry the newborn at the level of the vagina, wipe obvious fluid gently from the mouth and nose, and stimulate by drying. Do not routinely use bulb suction unless clearly needed for ventilation.
5. Wait more than 30 seconds after birth before clamping a stable newborn's cord. Place clamps about 4 and 6 inches from the newborn and cut between them. If the newborn is depressed, clamp and cut immediately to begin resuscitation.

Mother, newborn & placenta

• Place a dried, naked, stable newborn skin-to-skin on the mother's abdomen, wrap both warmly, and support feeding when appropriate. If clamps are unavailable, keep the newborn on the mother's chest above the abdomen and uterus during transport.
• Allow the placenta to deliver naturally; never pull on the cord. Package and transport the placenta for receiving-facility examination. Do not delay transport waiting for placental delivery.
• For continued postpartum bleeding, firmly massage the uterine fundus over the lower abdomen and continue while bleeding remains heavy. ALS care includes monitoring, oxygen as tolerated, IV fluid titrated to perfusion, and ALS escort.

APGAR at 1 and 5 minutes

• Score heart rate, respiratory effort, muscle tone, reflex response, and color from 0-2 each at 1 minute and again at 5 minutes. Resuscitation must not wait for APGAR scoring.
• Heart rate: 0 absent, 1 below 100, 2 at least 100. Respirations: 0 absent, 1 weak cry or hypoventilation, 2 strong cry. Tone: 0 limp, 1 slight flexion, 2 active flexion.
• Reflex response: 0 none, 1 some grimace, 2 cough or cry. Color: 0 blue/pale, 1 pink body with blue extremities, 2 completely pink.
• Total 7-10 suggests a healthy newborn, 4-6 a potentially sick newborn, and 0-3 a severely depressed newborn. At 5 minutes, a score below 7 requires constant monitoring and management as a depressed newborn.

Special presentations

• Prolapsed cord: elevate the mother's hips in left lateral or Trendelenburg position and use a gloved hand to keep the presenting part off the cord until hospital staff assume care; provide ALS escort to an obstetric-capable receiving center.
• Breech: do not pull on an extremity. B-060 directs avoiding touching or stimulating the newborn until the head delivers; PR-040 provides ALS maneuvers for arms or a trapped head. Follow the complete source and transport with ALS escort.
• A depressed newborn needs warmth, an open airway, stimulation, then BVM if not revived. If those steps fail and heart rate is below 60/min, begin compressions and give oxygen after about 5 minutes of compressions as directed by B-060.
• A maternal seizure during or after delivery is an extreme emergency: protect the newborn, manage the mother's airway, and immediately notify dispatch of the change in status.