Basics of Birth for EMTs

    Notes from EMT Lecture Delivered by Midwife
    General Suggestions for Paramedics
    Estimating Blood Loss
    Meconium Recipe

    This information is recorded verbatim from a variety of sources, typically contributed by midwives practicing in a variety of settings.
    It is offered in a spirit of camaraderie to those who also work under high-pressure but rewarding circumstances.
    Thanks to all the EMTs/paramedics out there who have shared their information, training and good and bad times with midwives.
    If you've got suggestions for ways in which homebirth midwives can smooth interactions with EMS folks, please e-mail your comments to me, and I'll re-post them on the midwife lists and in the Midwife Archives.

    The baby needs to be warm in order to begin getting oxygen from breathing.  It is imperative to dry the baby, cover the head and keep the baby warm.  Baby will also be warmest and probably begin breathing best if laid on mom's belly, with the head slightly lower than the body to allow drainage of the airway.

    The baby continues to get oxygen through the umbilical cord for 5-10 minutes after the birth.  The umbilical cord is the baby's lifeline.  If it is loosely coiled around the baby's neck, simply lift it over the baby's head or widen the loop so the baby can be born through it.  If it is tight around the baby's neck and preventing the body from coming out, perform the Somersault Maneuver - tuck the baby's head up onto mom's thigh so the body can somersault out without requiring more length of cord.  You get big bonus points if you can do this while you support the perineum to prevent tears or have an assistant do this.


    Anatomy and Physiology:

    Uterus -  Organ of procreation; muscular bag of smooth muscle;  Begins as the size of a pear - at 9 months  encloses a 6 - 8 lb baby.

    Placenta - Disposable organ that feeds baby and removes waste.  Connects to baby by the umbilical cord - vein and 2 arteries

    Bag of waters - relatively tough membrane that encloses the baby.  May rupture as first sign of labor or just before or during birth.

    Average length of pregnancy - 9 calendar months or 40 weeks or 280 days.

    Average length of labor - 12 to 18 hours for primip, half that for multip

    EARLY LABOR:  cause of beginning of labor is unknown, thought to have several components---
    1.  urge of hollow organ to empty itself when it reaches a certain fullness
    2.  Aging of the placenta
    3.  hormonal changes
    4.  fetal hormone changes
    5.  combination of the above

    Early Signs of labor:
    Rhythmical contractions of the uterus
    blood or mucus show
    frequent urination and/or defecation
    menstrual like pelvic cramping
    trickle or gush of amniotic fluid

    Later signs of labor:
    Strong rhythmical uterine contractions
    Maternal anxiety and pain
    shaking or tremor of the limbs
    rectal pressure - urge to move bowels or pass gas
    confusion, restlessness
    increased bloody show
    trickle or gush of amniotic fluid

    Signs of Imminent delivery:
    Urge to bear down, move bowels, or push that is irresistible
    Increased bloody show
    Bulging of perineum
    Dilation of rectal sphincter

    Equipment needed for out of hospital delivery:
    Panic pack - usually contains several drapes, gloves, bulb syringe, cord clamps x 2, scissors or scalpel for cutting cord, peri pads.

    In addition, should have warm blankets or towels, oxygen with adult mask, warm environment, privacy

    Procedure for out of hospital delivery:

    One person takes charge, others play gofer as needed.
    Clear out non-helpful bystanders.
    Keep calm, keep voice low.
    Set up clean area that won't accidentally get messed up by mother.  Lay out all necessary equipment, set up oxygen.
    Wash hands and arms if there is time.
    Place clean drape under mother's buttocks (be prepared for gofer to clean away feces if necessary)

    Explain to mother what is happening, as it happens.

    As the perineum bulges, place hand gently but firmly over the introitus and the perineum, to prevent sudden uncontrolled expulsion of the fetal head.  Encourage the mother to pant or push very gently, explaining you want to avoid a tear.

    As the head emerges, keep firm gentle pressure on head and perineum until chin delivers.

    Feel for the cord behind the top ear.  If found, gently tug to see if it will slip over the head.  If tightly wrapped, clamp in 2 places and cut between.

    Suction the baby's mouth and nose.  This is mainly important if the amniotic fluid is green or brown colored.  Otherwise it's probably not a vital step and can actually cause breathing problems. [Note - It is important to suction the mouth before the nose.  "The mouth is suctioned first to ensure that there is nothing for the infant to aspirate if he or she should gasp when the nose is suctioned." [From the AAP/AHA Textbook of Neonatal Resuscitation, rev. 3/95, p. 2-12.]

    After head rotates to face mother's thigh, gently press down on head to encourage the top shoulder to deliver.

    When you can see the baby's top armpit crease, lift up on the head to deliver the bottom shoulder.  The rest of the baby should follow.

    Suction the baby's mouth and nose.

    Dry the baby vigorously, then DISCARD WET TOWELS and wrap the baby in dry warm clothes or blankets.

    Administer oxygen at 5 liters 1 1/2 inch from baby's face until trunk is pink and hands and feet less blue.  Some cyanosis of extremities is expected. Keep rest of baby's trunk and head well covered while administering oxygen as the draft will chill the child.

    If not expected to get to the hospital soon, clamp and cut the cord 10-15 minutes after the birth. (clamp the cord about 3 inches from the abdomen, then 2 inches beyond that, and cut between the 2 clamps.)

    Place the baby on mother's chest, with head lower than feet to allow gravity to assist the baby in clearing the airway.

    Watch for sudden gush of blood and lengthening of cord.  This means placenta has detached and is ready to be born.  Provide gentle traction on the cord.  Placenta will usually be pushed out easily by mother.  If it doesn't, get to hospital as soon as possible.  Normally, approximately one cup of blood is generally lost with the delivery of the placenta.

    After placenta born, immediately press fingers slowly and gently into abdomen at umbilicus - you'll feel the top of the uterus.  It may be somewhat spongy or slightly firm or rock hard if she's having a contraction.  Do slow and gentle circular massage to encourage contraction of the uterus.  This is extremely important, especially if there's a constant flow of blood.

    Expedite transport to hospital ASAP.

    Questions for Discussion and Review

    You have been called to the home of a friend who is pregnant. Describe what you would do in the following situations, including information you would call in to the hospital:

    When you arrive, the woman is having contractions 2 minutes apart, and the contractions are lasting 60 to 70 seconds each time.  She states that this is her 3rd baby and the last one only took 1 hour. She says with the last contraction she "sorta felt like pushing."

    When you arrive, the young woman says this is her third baby and the contractions are 5 minutes apart and lasting about 30 to 45 seconds.

    When you arrive, you are shown into the bedroom where there is a large crowd of concerned relatives hovering over a woman obviously in the second stage of childbirth.  Several are crying and upset, and the woman is screaming as she is pushing.

    When you arrive, you find a young woman sitting on the kitchen chair with 2 blood-soaked towels between her legs.  She says she is 8 months pregnant and has "spotted" a couple times this pregnancy but one hour ago she started PAINLESS bleeding from the vagina.

    The baby got there before you did.  It is lying screaming between the mother's legs....

    When you arrive, the woman is lying on the bed crying.  On questioning, she says that she and her man got in a fight and she got kicked in the stomach...and she's 6 months pregnant.

    General Suggestions for Paramedics

    Whatever happens, all persons attending a birthing Mom must stay incredibly calm and reassuring .  Unless there are obvious serious problem, reassure Mom that she is ok and baby ok.  So much is going on within her body, especially with rapid contractions, and a precipitous birth can scare the hell out of a Mom.  One of my Moms was unintentionally birthing #2 at home alone and a neighbor (male) stopped by, called 911.  Police came first, saw the crowning baby and ran out .  He was just telling the paramedic to hurry and get in there, but Mom got a serious fright that something was dreadfully wrong .  She recounts this story vividly even 15 years later.

    I do refresher courses for parameds and EMT's and one of the things I like to stress is that emergency childbirth is seldom an emergency. It's usually just a birth that is not happening where the mother planned.  I stress that this is still one of the most important events in her life, and how you behave will greatly influence how she will remember it, so make it nice.  Keep her covered from prying eyes.  Lots of the men will say at this point "she won't care at this point who sees her" and I tell them "but she will tomorrow."

    To make a point about sensitivity, when I review draping the mom for the birth, I pick the most macho looking guy in the place to come up and give me a hand. He comes up and helps me move the table into place (thinking his job is done), and then I ask him to hop up on it. I position him on his back with legs drawn up and his crotch toward the group, and proceed to demonstrate draping, getting a good view of the field, etc., and demonstrate a birth with my fetal model, put baby up on "mom"s chest, cover and dry baby, put on the baby hat, discuss keeping baby warm, delivery of placenta and applying perineal pad.

    After this is done, I ask my helper how that felt, to be in that position, etc. He'll usually say a little awkward, or vulnerable, and I remind him that: A) he knows these people and B) he still had his clothes on, so be sensitive to the mom's situation.

    These folks can relate to the fact that a homebirth midwife's experience is more relevant to their work than most docs because we do our work "in the field" as they do, so sometimes we spend some time talking about improvising with what you might find at home to make the mom more comfortable.   I also bring a placenta with me to demonstrate (save this for last, 'cause sometimes you lose someone here). I bring a bunch of gloves in case some want to take a closer look.

       Points I like to make:

    To make my point about keeping baby warm, I donate 2 receiving blankets and a baby hat in a ziploc bag to each local ambulance crew, with my card in it and a note saying they could return the card for replacement hats and blankets when they use them up.

    This is all in addition to a quick review of complications and what-ifs.

    Estimating Blood Loss

    The bottom line is that accurate estimate of blood loss is only marginally relevant; it's nice to chart reasonably accurately, but that doesn't always provide useful guidelines for treatment.  Some moms lose 4 cups of blood and are quite fine; some moms lose 1 cup of blood and seem shocky.  And without having been present at the labor, it's almost impossible to guess how much of the bloody fluid you're seeing is really blood-tinged amniotic fluid.

    After the placenta's out, the best approach is simply trying to control bleeding by gentle massage of the uterus and treating the mom for shock if she becomes shocky.

    One technique, which involves prep time, is to mix up strawberry jello, in various consistencies, and put it, in pre measured amounts on various items for the student to guess .  Some in pure liquid form, some in chunks for clots .  Can pour on pad, towels, sheets, and then see what it looks like .

    PS, just tell them to be patient, and go slow .  The last paramedic birth I saw was a real blow-out and could have probably been prevented with some control of the baby's head .  She was young and it was not fun to see her get repaired.

    Liquid red jello works well as does outdated packed red blood cells for seeing just how much red goes how far.

    I once took a course where the instructor made up red jello and then used it before it was totally congealed. It gives a good visual image of the spread of blood but I don't think it would soak in the way blood does.

    Pouring a beaker (500 cc) with red jello that is just barely starting to set on a sheet, on a territowel, on a woman's skirt and underwear are ways to show a lay person how much 500 cc blood is .  In a L&D unit when the nurses were tested, they underestimated .  Then we have of course amniotic fluid that can add to the weight, if the amniotic sac breaks as she is giving birth.

    Daphne Singing Tree did this at our conference. She uses Jello and that way she can let it thicken a bit like blood, form clots for estimation. Then she puts it on pads, in water (to mimic the toilet) on cloths, in puddles. You measure and then put it on the many things a mom could bleed on.

     We did this at a conference in NY and as the jello poured off the table in the beginning midwives class one student fainted. We figured midwifery might   not be the calling for her.

    Having been in charge of props for a Halloween Horror Hayride for 2 years,   I have done a lot of experimenting with recipes for fake blood. I used to have to make a gallon a night, (and 10 gallons of slime).  The one that has come the closest to realism for me is cornstarch cooked with water for the right consistency, and tempera for color. As I recall, it was about 1 cup of cornstarch for 1 gallon of water, you'll have to adjust this. Dissolve the cornstarch with a cup or more of cool water, and when the gallon comes to a boil, pour in the cornstarch/water solution, stirring constantly (or you'll get clots). Powdered tempera is good as the coloring agent because it has some opacity. Red tempera with just a touch of blue is about right for color. Be forewarned that this does stain. Best   plan is to make it a little thick and add water to adjust after it has   cooled. (It will thicken on cooling.) If you don't have to make large   amounts, gelatin and water cooked together with tempera for color works,   but you need to keep stirring it often to keep tempera from precipitating   out. If you live in a rural area, you may be able to get cow or pig blood   from a local farmer when he's slaughtering an animal.

    Some of you may remember that a short while back I asked for your "placenta recipes" to go along with a physiology project I was doing   (making a placenta out of jello) .  Although I chickened out on including the recipes, I did come up with a fantastic-looking placenta that was quite realistic (complete with a licorice rope "umbilical cord" and plastic wrap "membranes", all set in a hand-made mold!) .  The recipe I came up with would also look great for your exercises in estimating blood loss.  It was raspberry jello and half water/half chocolate syrup (the cheap Hershey's kind) .  Turns out nice and dark-red, opaque, and sticky to boot!

    In a workshop the instructor used blue underpads and on each one poured different containers of a liquid that approximated the weight of blood(thinned down katsup or maybe you could actually get an outdated bag of blood or two) and poured varying amounts,100cc,240cc,360cc,500 and then we went around and felt the weight of the blue pads to get a good guesstimate .  This was a good tactile and visual example .

    You might suggest that they make red jello and then try pouring measured amounts on pads, towels, jeans, etc. so they know how different amounts look and feel.

    I've always thought I'd like to teach a class on this using red Kool-Aid® and chunks of red Jello®. Or liquid Jello and chunks of Jello (the chunks for clots).

    I find that people who don't put away food often have a problem estimating blood loss because they are not used to judging volume .  Different pads hold different amounts and different size pads hold different amounts .  If they take a pad and put as much of the Jello solution on it and feel how much it weighs in their hand and learn to judge it that way, it might be easier than saying, one pads holds "x" amount of blood.

    I don't know if this would be appropriate for paramedics, because they probably wouldn't have chux pads around in an emergency birth scenario, but this is how I was taught .  We use chux pads, so we would measure out different amounts of water mixed with some corn starch to thicken it (you can even add red food coloring if you want). And just heft the chux and 'feel' how heavy it it.  After a while you get a feel for it, and if you're using food coloring you can get a pretty good eye for it too.  But I always lift the chux, just to verify what my eye thinks it looks like. 

    When I was a midwifery school, the instructor used red jello, partially congealed in bowls and asked us to estimate the blood loss. She had premeasured the jello and had put some lap pads/abd pads in some of them to make the situation more realistic. Those who had been around blood loss got fairly close, but those who had not been around it were way off the mark.   Either too much or too little. It made a great lesson. I think she used 4 or 5 different bowls and amounts. From 200cc to 1000cc. I will never forget it.

    I am an 'old' EMT-RN, and I remember some paramedics saying it was really difficult to estimate blood loss.   My husband was also a paramedic and now is an ER nurse. According to him, the only thing in the ER that moves faster than the speed of light is a pregnant woman who says she has to push. I keep telling them at that point all they have to do is not let the baby hit the floor.

    Just make black cherry Jell-O and find & measure little round cups and make like regular Jell-O. For blood put twice as much water .

    When I set it up myself  I generally do several bowls of blood, one large bowl and one small bowl, with the same amount in it (trick question). Some more on Kotex's, and chux .

    Using food coloring added to water and a measuring cup, they can pour various amounts of colored liquid on various absorbent items (pads, towels, etc.) and quantify that way.  Also using eggs, the yolk with and with out the white to estimate the amount of blood lost in a clot.  Put the egg yolk alone in the measuring cup, then the whole egg, etc.  Weighing chux pads and converting gms to cc's is another method.

    Meconium Recipe

    On a similar thread, I made up some meconium also to teach paramedics .    Chocolate pudding, with some green food color mixed in. A demo for comparing a res-q-vac versus a de lee (try it) anyway, after the demo I brought the rest home, thinking I would practice some more, and kids thought it was just delicious!!!! They did mention the color was kinda *gross.*



Contact Ronnie Falcao, LM MS