Assisting in a Normal Delivery

In the event of a field birth where an EMS provider is present, it is important to remember that the mother and father (if present) are the ones who are technically "delivering" the baby. The goal of the EMS professional in this situation is to support the mother through the process and address any potential complications until a higher level of care can be sought. 

Pre-Delivery

It is advisable to have an IV or at least a heparin lock in place as a "route in" for fluids and medications, as pregnancy can be a normal condition that can deteriorate rapidly.

During Delivery

If the baby's head is seen at the vaginal opening, known as crowning, delivery will occur soon.

1. Someone should be positioned by the mother's head for support.
2. EMTs should wash their hands and don personal protective equipment. There is considerable risk for contact with physiologic fluids before, during, and after childbirth, specifically, amniotic fluid and blood.
3. The head of the baby should be supported as it is delivered. Control of the head's expulsion (without actually pushing back against it) will help prevent tears in the mother's vagina and labia.
4. If the umbilical cord is around the baby's neck, slip it gently over the head.
    
   If it is double (or more) looped, only slip it (them) over the head if it can be done gently. If not, a tight multi-looping can be separated by clamping and cutting, but only after delivery of BOTH shoulders. (Cutting the cord, of course, should only be done when delivery is guaranteed--that is, when both shoulders are out.)
    
5. Support the baby through its natural rotation as delivery unfolds and the first shoulder presents.
6. The upper shoulder should deliver next as the head is guided downward.
7. At this point (with BOTH shoulders delivered), if there is a tight double loop of umbilical cord that prevents further delivery, it is OK to apply two clamps and cut the cord between them. (At this point, the cord is compressed anyway, and if delivery is imminent via BOTH shoulders out, there is no harm.)
8. The rest of the body and feet should deliver quickly after that.
9. After the newborn's head is delivered, keep it slightly lower to aid fluid drainage. Suction the mouth and nose with a bulb syringe only if there's visible obstruction to clear the airway for breathing. Newborns often begin crying spontaneously, which is beneficial for lung expansion and oxygen exchange.
10. The birth time should be noted and transmitted to dispatch if at all possible.
11. The baby should promptly be dried well with a towel (newborns are super slippery!) and may be placed on the mother's chest for skin-to-skin contact and be kept warm, but ensure additional blankets/towels are given for warmth.
12. The cord will naturally decrease in pulsatile blood flow as the baby breaths, but it can take up to 10 minutes for it to stop pulsing post-delivery. There is a lot of evidence for delayed cord clamping (DCC) and its benefits for the baby (read more below). (Pending you did not have to cut the cord sooner due to delivery issues.)
13. Prepare for the delivery of the placenta and ensure it is complete. Any portions of the placenta that do not deliver can cause toxic shock syndrome if it is not recognized and remains inside the mother. If it is incomplete, notify the destination facility and be sure to convey clearly to the staff upon your arrival that the placenta was not delivered completely.
14. Keep mother and baby warm! Hypothermia can be detrimental to both, especially the baby. You may be hot and sweating in the back of your ambulance, but so long as they stay warm, that's what matters. 

Post-Delivery

Delayed cord clamping (DCC) has gained support from many groups in recent years, including the American College of Obstetrics and Gynecology (ACOG). A recent (2023) journal article listed on the National Library of Medicine website details this and many other evidence-based practice guidelines specifically for prehospital providers and can be found here. The article details the following about DCC: 

Evidence shows that except for infants requiring immediate cardiopulmonary resuscitation (CPR), the umbilical cord should not be clamped until it has stopped pulsating, approximately 30 to 60 seconds following delivery. Some professional organizations recommend waiting up to 3 minutes. Delayed cord clamping allows for the autotransfusion of up to 100 mL of oxygenated blood within the first 3 minutes after birth and is especially beneficial for preterm infants. Therefore, in most cases, the initial care (eg, clearing the airway, drying, stimulating, and warming the infant) and assessment of the newborn (eg, respiratory effort, tone, and heart rate [HR]) may be performed before clamping the cord.    

Beaird DT, Ladd M, Jenkins SM, Kahwaji CI. EMS Prehospital Deliveries. 2023 Oct 26. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 30252252.

Cutting the cord: The umbilical cord should only be cut if sterile equipment is available. After pulsation stops, place the first clamp 6 inches from the infant's abdomen, followed by the second clamp 9 inches from the infant. This standardized placement ensures adequate cord length remains attached to the infant while providing sufficient space between clamps for a clean cut. The 6-inch cord length that remains attached to the infant is particularly important if complications arise, as it provides Neonatal Intensive Care Unit (NICU) or critical care personnel easy access to obtain laboratory studies and administer fluids to the neonate. After both clamps are properly placed, cut between them using sterile scissors. Throughout this process, continuously monitor both mother and baby's airway, breathing, and circulation. A modified observation of the traditional Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score should be used to determine the well-being of the newborn:

• Is the baby's color good? and
• is the baby crying?

Although the hands and feet may be blue, as long as the trunk and face are pink, the airway and breathing are assumed to be good; if the baby is active in movement, these can be assumed to continue remaining good. A heart rate below 100 bpm indicates trouble ahead.

One of the biggest risks to the newborn is hypothermia. The brisk act of drying the baby may be enough to make a limp baby respond. Most of the heat is lost from the scalp, so wrapping the baby and covering the head is important, especially if complete medical care is some time away.

The afterbirth (placenta) should be delivered within twenty minutes after the birth of the baby and should be collected. Don't be surprised by a gush of blood right before--this is normal.

After delivering a baby, some bleeding is normal. A sanitary pad should be placed over the vaginal opening, and the uterus should be massaged in a continuous circular motion. The mother should be allowed and encouraged to nurse the baby as this will start hormonal changes that help the uterus to contract and stop bleeding. The baby can be unwrapped for skin-to-skin contact while nursing. The mother should be comforted and kept warm.

What about "bulging membranes"?

If the amniotic sac (the "membranes") remains intact through delivery, it can present ahead of the fetal head--called "bulging membranes" or a "bulging bag of water." Rupturing the membranes may result in precipitous delivery with (otherwise preventable) tears/lacerations. An intact amniotic sac can be your best friend if you're trying to arrive at your destination with the mother undelivered:

Intact membranes may not delay delivery, but they just might!

CAUTION: if there is an umbilical cord floating in the fluid of the amniotic sac ahead of the head, rupturing the membranes will cause the fetal head to slam against it, causing a prolapsed cord complication and the clock is ticking on the fetal hypoxia. Therefore, there is no need and even a risk to rupturing membranes. (Don't worry, if the baby's head does deliver with intact membranes (called "being born with a caul"), they're easily stripped or wiped away from the newborn's mouth and nares."