How to Safely Transport a Mother and Breech Baby in Prehospital Emergencies

While most childbirths occur in hospitals, emergency medical services (EMS) are sometimes required for deliveries outside of these facilities. These situations can range from unexpected births to planned home births with complications. In these critical moments, the immediate priority is the safe and rapid transportation of both mother and, if already born, the baby to a hospital for expert medical care. EMS professionals must be adept at quickly assessing the gestational age, recognizing imminent delivery, and managing potential complications that may arise, including breech presentations.

Prehospital care during delivery focuses on ensuring a controlled birth, managing postpartum bleeding in the mother, and providing essential newborn care until hospital transfer is possible. It’s crucial to acknowledge that out-of-hospital births are statistically linked with a higher risk of perinatal mortality compared to hospital deliveries. Therefore, comprehensive knowledge of prehospital delivery procedures, immediate postpartum care for both mother and newborn, resuscitation techniques, and the management of delivery complications, particularly breech births, is vital for EMS practitioners.

This resource aims to enhance the competency of healthcare professionals in managing prehospital deliveries, with a specific focus on the complexities of transporting mothers with breech presentations. It provides updated knowledge, skills, and strategies for prompt complication identification, effective intervention implementation, and improved care coordination, ultimately aiming to improve patient outcomes and reduce maternal and fetal morbidity in emergency transport scenarios involving breech births.

Objectives:

• Recognize situations requiring prehospital delivery and identify the signs of imminent birth, including breech presentation.
• Evaluate pregnant patients in prehospital settings to determine labor stage, maternal and fetal well-being, and fetal presentation, specifically breech.
• Implement appropriate prehospital obstetric protocols for managing labor and delivery, including specific techniques and considerations for breech deliveries in emergency transport.
• Collaborate effectively with EMS teams and hospital staff to ensure seamless care for mothers and newborns, especially in complicated presentations like breech.

Introduction

Prehospital delivery, often termed “birth before arrival” (BBA) or unplanned out-of-hospital birth, refers to an unintentional birth outside a hospital. Unlike planned home births, these scenarios lack preparation and immediate access to healthcare professionals and necessary equipment. EMS teams are sometimes called upon to transport patients from planned home births when complications arise. [1]

When EMS is dispatched to assist a woman in active labor, the primary goal is to transport her swiftly to a hospital equipped with obstetric services. These facilities are staffed with trained obstetric clinicians and have the resources to manage potential complications effectively. The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) advocate that hospitals and accredited birth centers are the safest environments for childbirth. [2] However, transport may not always be feasible before delivery occurs. EMS professionals are frequently called when birth is precipitous, imminent, or occurs en route to the hospital, sometimes involving complicated presentations like breech. [3]

Unplanned prehospital deliveries are associated with increased risks of perinatal mortality and morbidity for both the newborn and the mother. [4], [5], [6], [1] This increased risk is often attributed to inadequate EMS training in managing emergent deliveries and intrapartum complications, including breech presentations, as well as potential delays in providing recommended neonatal resuscitation. [3], [7], [3] Therefore, EMS practitioners must be proficient in delivery techniques, immediate postpartum assessment, and management for both mother and newborn, with specific protocols for complicated scenarios such as breech births during transport.

Anatomy and Physiology

Pelvic Girdle

The bony pelvis forms the birth canal through which the fetus must pass during delivery. The dimensions and shape of the maternal pelvis, combined with fetal size and position, significantly influence the ease of delivery. In a small percentage of deliveries, the anterior fetal shoulder can become lodged behind the maternal pubic bone, leading to shoulder dystocia, a critical obstetric emergency. [8], [9]

Uterus

The uterus, a muscular, pear-shaped organ in the female pelvis, houses the fetus, placenta, and amniotic fluid during pregnancy. Labor contractions, powerful rhythmic muscular actions of the uterus, propel the baby through the pelvic outlet and vagina. [9]

Cervix

The cervix, a fibromuscular canal, is the lower part of the uterus connecting to the vagina. During labor, uterine contractions push the fetal head against the cervix, causing it to dilate (open) and efface (thin), allowing fetal passage from the uterus into the vagina. [9]

Cervical dilation, measured in centimeters during a sterile vaginal exam, monitors labor progress. Full dilation is 10 centimeters. Effacement, expressed as a percentage, indicates cervical thinning; 100% effaced means paper-thin. [9] In active labor, before full dilation, the cervix feels like a rim of tissue around the presenting fetal part, usually the head. When fully dilated and effaced, the cervix recedes behind the fetal presenting part and is no longer palpable. Imminent delivery is indicated when the cervix is not palpable and the fetal head is visible at the vaginal opening. [9]

Fundal Height

The fundus, the upper rounded part of the uterus, is palpable abdominally. Fundal height, measured in centimeters from the top of the fundus to the pubic bone, estimates gestational age, particularly in later pregnancy. At the umbilicus, it suggests about 20 weeks gestation, with each centimeter above adding approximately one week. [8], [10], [8]

Post-delivery, the uterus should contract to reduce to its non-pregnant size. This contraction constricts blood vessels in the uterine muscle, minimizing postpartum bleeding. Fundal massage encourages contraction and is crucial in managing postpartum hemorrhage. [11]

Placenta and Umbilical Cord

The placenta is the vital organ connecting mother and fetus, facilitating nutrient and gas exchange. One side attaches to the uterine wall, the other faces the fetus, typically with the umbilical cord centrally attached. After birth, uterine contractions aid placental detachment and expulsion, signaled by a blood surge and umbilical cord lengthening. Premature placental separation or umbilical cord tearing can cause severe hemorrhage in both mother and baby. [11]

Stages of Labor

Labor progresses in three stages. Fetal delivery occurs in the second stage.

Indications

Indications of imminent delivery include:

• Strong, involuntary maternal urge to push or defecate [13]
• Intense, regular contractions, occurring every 2 minutes or less.
• Bulging perineum.
• Crowning of the fetal head (fetal head visible at the vaginal opening) or spontaneous separation of the labia by the presenting fetal part. [14], [15], [16]

Contraindications

There are few absolute contraindications to unplanned prehospital delivery. EMS professionals cannot stop or significantly delay spontaneous labor. If the hospital is very close, discouraging pushing might briefly delay delivery, depending on cervical dilation and prior births. In precipitous labor, contractions are involuntary and forceful enough for delivery with minimal maternal effort. A strong, irrepressible urge to push is usually present, meaning delivery may occur regardless of attempts to delay it. EMS must be prepared for delivery en route.

Relative contraindications for vaginal delivery that EMS clinicians should be aware of include umbilical cord prolapse and breech presentation, particularly footling breech. Umbilical cord prolapse, where the cord precedes the fetus, leads to cord compression and potential hypoxic brain injury and cerebral palsy. Immediate Cesarean delivery is typically necessary. Until surgical intervention, cord decompression should be attempted by manually elevating the fetal presenting part via vaginal examination and placing the mother in a steep Trendelenburg or knee-chest position. [17]

Breech presentations (frank breech – buttocks first, or footling breech – foot first) are more common in preterm pregnancies and carry higher complication risks than cephalic (head-first) presentations. Breech presentations frequently require Cesarean delivery. In prehospital settings, EMS personnel should not attempt traction or vaginal breech extraction. Mothers with breech presentation in advanced labor should be instructed to pant during contractions and transported immediately to the hospital. Specialized obstetric expertise is crucial for managing breech deliveries. [18], [19] In the context of prehospital transport, a known breech presentation, especially in a mother in active labor, is a critical factor emphasizing the need for rapid and safe transport to a facility capable of performing Cesarean sections and managing potential breech delivery complications.

Equipment

For most uncomplicated deliveries, minimal equipment is needed. Ideally, EMS units should carry equipment to clamp and cut the umbilical cord and a dry cloth to dry and stimulate the newborn, such as a towel. While comprehensive obstetric and gynecological equipment may not be available, the following items should be readily accessible:

• Personal protective equipment (PPE): mask with face shield, gown, booties, sterile gloves.
• Clean, dry towels or cloths.
• Blankets and infant hat.
• Two umbilical cord clamps or hemostats.
• Medical scissors or scalpel for cord cutting.
• Container for placenta.
• Bulb suction.
• Supplemental oxygen.
• IV access equipment and crystalloid fluids.
• Oxytocin.
• Infant ventilation bag or manometer for ventilation pressure monitoring. [7]

Equipment should be easily accessible to EMS providers. Emergency delivery kits are often stored in ambulances. However, ambulance storage space is often limited, and equipment stocking can vary between EMS systems. [8], [7] Clean clothing can be used to dry, stimulate, and warm the infant if medical equipment is unavailable. [7]

Personnel

In prehospital delivery, EMS providers work with available personnel. Ideally, at least one assistant should be available to the delivering EMS professional. Hospital staff (emergency, neonatology, and obstetrics physicians and nurses) should be notified of the patient’s arrival to prepare necessary equipment like infant warmers. [8], [10]

Preparation

History and Physical Examination

Initial EMS assessment of a laboring patient determines transport stability. Patients showing signs of imminent delivery are considered unstable, and field delivery may be necessary before transport to the hospital. Upon arrival, EMS should quickly gather focused history and perform a physical exam to decide on the best course of action. [20], [13] Important historical information includes:

• Estimated due date and gestational age, if known. Last menstrual period can be used to calculate if the due date is unknown. [8]
• Number of pregnancies and prior vaginal and Cesarean deliveries.
• Pregnancy complications in current or past pregnancies.
• Onset and frequency of contractions.
• Membrane rupture (water breaking): time and fluid color.
  • Clear yellow: normal.
  • Bloody: possible placental abruption or placenta previa.
  • Green: meconium-stained, increasing neonatal respiratory risk. [8]
• Prenatal care received.
• Number of fetuses (singleton or twins) and fetal movement.
• Non-obstetric health issues, allergies, and medications.
• Known fetal position from recent assessments (e.g., ultrasound). [8]

Maternal vital signs should be taken, and fetal heart tones auscultated with a Doppler if available. [10] A rapid fundal height assessment estimates gestational age. Diagnosing active labor is generally beyond EMS scope. Transport to a facility with obstetric capabilities is the priority unless delivery is imminent. Imminent delivery is assessed by perineal inspection for rectal pressure, urge to push, or contractions less than 2 minutes apart. Signs like perineal distention by the presenting fetal part or fetal head emergence indicate impending delivery, requiring field delivery preparation. [13] Crucially, determining fetal presentation is vital during assessment. If breech presentation is suspected or confirmed during prehospital assessment, it significantly elevates the urgency for rapid transport.

Unless indicated by breech presentation or umbilical cord prolapse, sterile digital vaginal exams are usually deferred until hospital triage. Hospital clinicians will assess cervical dilation and effacement, fetal presentation, and station. [13] Vaginal exams should be avoided if vaginal bleeding is present until placenta previa is ruled out. [10] Perineal examination is best performed with the patient in the dorsal lithotomy position (supine with flexed hips and knees). [21]

Patient Positioning

Common Western delivery positions include left-tilted dorsal lithotomy or semi-Fowler’s. Safe delivery is possible in various positions: left lateral decubitus, kneeling, squatting, or hands and knees. EMS should prioritize maternal comfort, provider access, and a secure area for the baby to prevent neonatal falls. [22], [21]

Pregnant patients should not lie flat on their backs due to potential aortocaval compression, which can reduce uteroplacental blood flow. If supine, use a rolled towel under the left hip to tilt the patient or place them in a semi-reclined position at a 45-degree angle. [21] For transport, especially with a breech presentation, maintaining a left lateral tilt can optimize uteroplacental blood flow and may be beneficial.

Technique or Treatment

The goals for the delivering clinician are to minimize pelvic floor trauma for the mother, provide initial newborn support and resuscitation, and manage maternal and neonatal complications to optimize outcomes. If only one EMS provider is present, assistance from family, friends, or non-clinical bystanders may be necessary. [15] Delivery supplies or the emergency kit should be readily accessible. For semi-recumbent or left-tilted dorsal lithotomy positions, instruct the mother to flex hips and legs to open the pelvic inlet. [9] Drape the perineum and buttocks area with clean towels. If time permits, cleanse the perineum and vaginal area with povidone-iodine solution. [10] In breech presentations, these general preparations still apply, but the emphasis shifts to rapid transport while providing supportive care and preparing for potential complications en route.

Active Pushing

As the fetal head emerges, the mother will feel an urge to push due to rectal pressure from the descending fetal head. Encourage pushing with contractions. [15] Encourage natural breathing, including open glottis pushing (moaning or screaming) rather than closed glottis (Valsalva) pushing. Parturient-driven pushing is as effective as coached pushing. [23] Clinician empathy and interpersonal skills are as important as clinical skills for a positive birth experience. Verbal encouragement helps keep the mother calm and focused during pushing. [24], [25]

Approach to Delivery

Most EMS-assisted deliveries are quick and uncomplicated vaginal births. The EMS clinician’s primary role is to guide and manage delivery safely, preventing harm to mother and newborn. [10], [9] Traditionally, one hand is placed on the emerging fetal head for gentle counter pressure, preventing rapid expulsion, while the other hand supports the perineum. However, studies show no added benefit over a hands-off approach. [26], [10], [9] Routine episiotomy is not recommended and should not be performed. [27], [9]

Typically, the fetal head emerges facing the maternal rectum or abdomen. As the body moves through the pelvis, restitution occurs, where the head rotates to face a maternal thigh, usually within seconds.

Once the head is delivered and restitution occurs, check for a nuchal cord (umbilical cord around the neck). If present, gently try to reduce it by slipping it over the head, taking care not to tear or avulse it. Repeat until all loops are removed. [10], [9] If too tight to slip over the head, leave it if it doesn’t impede delivery and remove it once the body is delivered. If a tight nuchal cord prevents delivery, double clamp and cut it before body delivery as a last resort. Attempt anterior shoulder delivery first to avoid neonatal asphyxia in case of shoulder dystocia. [28]

After head delivery and restitution, the shoulders deliver. With the head facing a maternal thigh, grasp both sides of the head. Apply gentle downward traction (towards maternal rectum) to guide the anterior shoulder under the pubic bone. Then, guide the infant upwards (towards maternal abdomen) to deliver the posterior shoulder. The rest of the body should follow quickly. Hold the neonate firmly and place it gently on the mother’s abdomen. [10], [9]

Delayed Umbilical Cord Clamping

There is no need to rush cord clamping in prehospital settings. Unless the infant needs immediate CPR, delay cord clamping until pulsation stops, about 30-60 seconds post-delivery, or up to 3 minutes as recommended by some organizations. [29], [30] Delayed clamping allows autotransfusion of up to 100 mL of oxygenated blood in the first 3 minutes, particularly beneficial for preterm infants. [29] Initial care (airway, drying, stimulation, warming) and newborn assessment (respiratory effort, tone, HR) can be done before clamping.

To cut the cord, place two clamps and transect between them. Place the proximal clamp about 10 cm from the umbilicus to allow space for a potential umbilical catheter in the hospital. Place the second clamp 5 cm beyond the first for safe cutting with sterile scissors or scalpel. [10], [9]

Keep the cord clean and dry. If sterile technique was used for cutting, antiseptics are usually not needed for the stump. However, antiseptics may be considered if sterile equipment is unavailable or if contamination occurs, depending on the delivery environment. [31]

Immediate Postpartum Neonatal Evaluation

The AAP and other international societies recommend immediate newborn care: drying, stimulating, clearing airway, ensuring respiration, and keeping warm. After delivery, gently wipe the infant’s nose and mouth to clear mucus while placing skin-to-skin on the mother’s chest or abdomen. Bulb suctioning is not routinely needed. [32], [33] Dry and vigorously rub the infant within 60 seconds of birth with a clean towel to stimulate breathing and crying, clearing lungs of amniotic fluid. Most infants will breathe well after this. Wrap the dry baby in a warm towel or cloth. Skin-to-skin contact promotes bonding and warmth if a cloth is unavailable. [32] A food- or medical-grade, heat-resistant plastic bag can be used if skin-to-skin contact is not possible. [32]

Assess the infant on the mother’s abdomen within 30-60 seconds for resuscitation needs, considering:

• Heart rate: Normal newborn HR ≥100 bpm, assess by auscultation or umbilical cord palpation.
• Respiratory effort: Vigorous crying or unlabored breathing (40-60 breaths/min).
• Color: Assess for cyanosis. Central cyanosis (trunk or lips) indicates cardiorespiratory issues. Peripheral cyanosis (blue hands/feet) is common initially and usually resolves quickly.
• Tone: Active limb movement and normal muscle tone, not limp.
• Reflex irritability (grimace): Spontaneous grimace, cough, sneeze, or cry to stimulation. [34], [35]

APGAR scores, assessing HR, respiration, color, tone, and reflex irritability, should be done at 1, 5, and 10 minutes of life. Document findings for hospital clinicians. [34], [35] Infants breathing well with good tone usually need no further intervention. About 10% need additional stimulation beyond drying (rubbing trunk/back, gentle foot slaps). Infants with breathing difficulty or HR <100 bpm require neonatal resuscitation. [34], [35] See Complications section.

After initial assessment and stabilization, encourage breastfeeding to help maintain infant blood glucose. High-risk infants for hypoglycemia (mothers with diabetes, large or small for gestational age) need blood sugar checks within the first hour and close monitoring for the first few days. [34], [35]

Reassess the infant every 30-60 minutes for the first 4-8 hours and perform a full assessment within 24 hours. Neonates from unplanned prehospital deliveries should be transferred to clinicians trained in newborn care. [34], [35]

Delivering the Placenta

Placental delivery usually occurs 5-15 minutes after the infant, but can take up to 30 minutes. Transport mother and newborn even if the placenta hasn’t delivered by this time. If undelivered after 30 minutes, obstetric assistance is needed for possible abnormal implantation and bleeding risk. In most cases, the placenta delivers spontaneously with maternal effort. [36]

While gentle cord traction is used by trained birth attendants to aid placental delivery and reduce postpartum hemorrhage risk, it can also cause cord avulsion and uterine inversion, though rare and potentially morbid. [37], [38] Due to these risks and limited benefits, controlled cord traction for placental delivery is not generally recommended for prehospital deliveries by non-obstetric clinicians without specific training. [38] EMS clinicians should never pull on the cord. Placental detachment should be natural with uterine contractions.

If placental separation signs occur, the mother can bear down to deliver it. Separation signs include:

• Uterus becomes firmer.
• Sudden vaginal blood gush.
• Umbilical cord lengthening. [37]

When the placenta is visible at the vaginal opening, grasp it by the cord as the mother pushes and gently guide it out. Inspect the placenta for completeness to prevent retained products, which can cause bleeding or infection. [36] Keep the placenta in a container for hospital staff evaluation by obstetric clinicians.

Complications

Obstetric Lacerations

Lacerations are common after vaginal delivery, especially the first. They can involve the perineum, vagina, vulva, periclitoral, or periurethral tissue. Perineal tears are most common, classified by severity:

• First-degree: perineal skin only.
• Second-degree: perineal skin and muscles.
• Third-degree: anal sphincter involvement.
• Fourth-degree: perineal skin through anal sphincter complex and anal epithelium. [39]

Nonperineal lacerations are often superficial and may not need repair unless actively bleeding. Repair requires training, lighting, visualization, and pain control. ACOG recommends obstetrician judgment for first or second-degree laceration repair. [39] Most second-degree lacerations are repaired, but evidence doesn’t strongly support repair over expectant management. Third- and fourth-degree lacerations require surgical repair by trained obstetricians. Significant bleeding from lacerations can usually be managed with pressure until specialist evaluation and treatment. [39]

Breech Delivery

Breech presentations are the most common malposition. Vaginal breech deliveries have higher neonatal morbidity and mortality. [40] The fetal head, the largest part, can get trapped after body delivery, compressing the umbilical cord and causing fetal hypoxia. For breech presentation, rapid transport to a hospital capable of Cesarean delivery is paramount. Even if a foot or buttock is visible, hospital transport for safer delivery may still be possible. However, once the fetus is delivered to the level of the umbilicus, breech delivery is imminent, and EMS should prepare for on-scene management. [10] During transport of a mother with a breech presentation, constant monitoring of maternal and fetal status is crucial. Position the mother to optimize blood flow (left lateral tilt) and avoid any maneuvers to expedite delivery en route unless absolutely necessary.

For breech delivery management, position the mother semi-recumbent. Allow spontaneous delivery to the level of the umbilicus. Then, hook fingers around the infant’s hips, apply downward traction, and rotate the infant spine-up if not already. Support the body on your forearm and deliver legs one at a time by grasping the thigh, flexing the knee, and sweeping the leg up and out. [10] When scapulas are visible, rotate the neonate 90 degrees to face a maternal thigh. Sweep fingers over the anterior arm, bending at the elbow and moving it down and across the chest to deliver the arm. Rotate the infant 180 degrees to the other side and repeat for the second arm. [10]

For head delivery, position the infant on your forearm, legs straddling it. Grasp shoulders and apply downward traction until the back of the head is visible. Place index and middle fingers on the infant’s face to apply downward pressure on the maxilla while an assistant applies firm suprapubic pressure. These maneuvers should flex the head under the pubic bone. Maintain downward facial pressure and suprapubic pressure, then elevate the infant’s body straight up towards the maternal abdomen, holding the infant between forearms, allowing face and head delivery. [10] However, given the complexities and risks of breech delivery, EMS focus should remain on rapid transport to a hospital setting where these maneuvers can be performed by experienced obstetricians if vaginal delivery becomes unavoidable.

Shoulder Dystocia

Shoulder dystocia occurs when the anterior fetal shoulder impacts behind the maternal pubic bone, obstructing body delivery. Risk factors include macrosomia, maternal diabetes, obesity, and post-term pregnancy. Rapid recognition and management are critical due to potential fetal asphyxiation, clavicle fracture, and brachial plexus injury. [41]

Suspect shoulder dystocia if, after head delivery, it retracts against the perineum or moves back into the vagina between contractions (“turtle sign”). Call for help immediately upon observing this sign. [42]

First, check for and remove a nuchal cord if possible. If tight, double clamp and cut it as a last resort, only after attempting anterior shoulder delivery to avoid neonatal asphyxia. [28]

The McRoberts maneuver is the first intervention. [43] Have assistants sharply flex the mother’s thighs onto her abdomen/chest (hip hyperflexion). If alone, instruct the mother to “pull knees to armpits”. This position changes pelvic angles. [44] Simultaneously or immediately after McRoberts, have an assistant apply suprapubic pressure to manually dislodge the shoulder. [45] If unsuccessful, reach into the posterior vagina to grasp the fetal posterior forearm, flex it at the elbow, and sweep the arm across the chest to deliver it. [28], [43] Rotation of the fetus by pushing the back of the anterior shoulder 30 degrees towards the fetal face can also be attempted. [28], [43] If still undelivered, flip the mother to hands and knees and repeat maneuvers.

Umbilical Cord Prolapse

Umbilical cord prolapse occurs when a cord loop descends below the fetal presenting part, risking compression and fetal hypoxia. Immediate transport to a Cesarean-capable facility is critical. If a pulsating cord is felt during vaginal exam, instruct the mother to stop pushing and place her in Trendelenburg. Decompress the cord by manually elevating the fetal presenting part (usually head) vaginally and holding it up until instructed otherwise in the hospital operating room. [18] The clinician elevating the head must be prepared to maintain this position until Cesarean delivery. [28]

Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is blood loss exceeding 500 mL after vaginal delivery. [46] It is a leading cause of maternal death worldwide. [47] Treatment primarily involves hospital transfer, but prehospital EMS can take several steps.

Take maternal vitals, establish IV access, and administer fluids as for any traumatic hemorrhage. Notify the receiving hospital of suspected PPH to prepare for management (e.g., massive transfusion protocol). [11] Identify and address the cause of hemorrhage. Uterine atony is the most common cause (70-80%). [48] Vigorous uterine fundal massage stimulates uterine contraction, clamping down on bleeding spiral arteries. If insufficient, perform bimanual uterine massage: one hand in the vagina, the other on the abdomen over the fundus, compressing the uterus. [49]

In the hospital, oxytocin administration post-infant delivery is crucial for PPH prevention. ACOG, WHO, and AAFP recommend universal uterotonic use, usually oxytocin, after all births by obstetric clinicians. [48]

Estimate maternal blood loss (EBL). Typical vaginal delivery EBL is <500 mL, often less. Estimating blood loss is difficult due to amniotic fluid mix. Bleeding should slow significantly within minutes post-delivery, especially after placental delivery. Persistent significant bleeding or large clots (apple-sized) are concerning for PPH. Continue uterine massage until bleeding improves or hospital oxytocin administration. Oxytocin can be given IM or slow IV infusion (IV bolus can cause cardiovascular collapse). Standard dose: 10 units IM or 5-10 units IV bolus. Timing is not critical, can be given any time after anterior shoulder delivery. [48], [11] For IV access, add up to 30 units to 500-1000 mL fluid for continuous infusion. [48]

Other less common PPH causes include laceration bleeding, retained placenta/membranes, or coagulopathy (e.g., DIC). Pelvic exam and rapid transport to obstetric clinicians are also necessary. [11]

Neonatal Resuscitation

About 1% of newborns need CPR beyond warming, drying, and stimulation. [50] Neonatal resuscitation is similar to infant CPR, potentially including positive pressure ventilation (PPV), endotracheal intubation and suctioning, chest compressions, etc. Assess neonates within 60 seconds for resuscitation needs. Indications: prematurity, absent vigorous cry/breathing, poor muscle tone. AAP, ACOG, AHA, and international consensus guidelines recommend the following protocol for neonates with birth transition difficulties: [50], [32] (See original article for detailed resuscitation steps).

Neonatal Hypothermia

Neonatal hypothermia increases mortality risk, especially below 97.7 °F (36.5 °C), particularly in preterm infants. It can also be associated with intraventricular hemorrhage and respiratory issues. Infant temperature on admission is a strong predictor of morbidity and mortality.

AHA 2022 CPR guidelines recommend maintaining infant temperature between 97.7 °F (36.5 °C) and 99.5 °F (37.5 °C). [50] Best methods:

• Skin-to-skin contact, covered by a blanket for healthy newborns.
• Radiant warmer, if available.
• Clean, food-grade plastic bag up to neck level for very low birth weight infants, swaddling, and holding against warm adult bodies (parent, EMS).
• Warm, temperature-controlled room ≥78.8 °F (23 °C). [50]

Clinical Significance

Prehospital deliveries, while infrequent for EMS, require strong understanding of delivery techniques and emergency complication management. Ideally, transport laboring patients to obstetric and neonatal care facilities before delivery. However, transport time may be insufficient, resulting in delivery upon EMS arrival or en route. [3]

Unplanned prehospital deliveries are linked to higher perinatal mortality and morbidity for both mother and newborn. [4], [5], [6], [1] This is often due to inadequate EMS training in emergent deliveries, intrapartum complications, and basic neonatal resuscitation. [3], [7] Therefore, continuous updates in knowledge, skills, and strategies for complication identification, effective interventions, and care coordination are crucial. This ensures EMS composure during prehospital deliveries and the best possible outcomes for mother and newborn, especially in complex situations such as breech presentations requiring careful transport.

Uncomplicated deliveries require minimal EMS intervention, mainly support and basic assessments. Key aspects include guiding fetal head and anterior shoulder expulsion and initial neonatal resuscitation steps. EMS should manage common childbirth complications like shoulder dystocia, umbilical cord prolapse, postpartum hemorrhage, and neonatal respiratory distress until hospital transport.

Enhancing Healthcare Team Outcomes

For labor assistance calls, the initial priority is rapid transport to an obstetric-equipped hospital. Notify hospital staff (emergency, neonatologists, obstetricians, nurses) in advance to prepare equipment like infant warmers and treatment readiness. Hospital obstetric professionals can manage delivery in a controlled environment with resources for complications. [8], [10]

However, transport time may be insufficient. EMS practitioners must be proficient in delivery techniques. [22], [52] Detailed documentation of EMS interventions and sound clinical care are essential for effective communication between healthcare professionals, especially in cases involving breech presentation where transport decisions and en-route management are critical. Delivery circumstances and newborn initial condition impact hospital management. EMS clinicians should provide verbal reports upon hospital transfer.

Review Questions

(Review questions are present in the original article, but not included here as per instructions)

References

(References are identical to the original article and are included below for completeness)

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