Unexpected or Precipitous Birth in the Absence of an Obstetric Provider
Jennifer G. Hensley
Elisabeth D. Howard
Skill Unit 1
Managing an Unexpected or Precipitous Birth
Objectives
After completion of this module, you will learn:
That remaining calm and attending to the woman is paramount, recognizing birth is a normal process and will occur whether or not you are anxious
Those situations that can result in an unexpected or precipitous birth before the obstetric provider arrives
Signs of an impending birth
What equipment should be ready and available (emergency birth pack)
How to deliver the baby, support natural birth, and help the newborn adapt to extrauterine life
What to do if another unexpected event occurs, that is, breech
What to do if there is meconium-stained amniotic fluid, difficulty delivering the baby’s shoulders, excessive uterine bleeding, overt or occult bleeding from lacerations, or a newborn with difficulty breathing
What should alert you to the possibility of excessive uterine or birth laceration(s) bleeding
Dangers of an improperly conducted unexpected or precipitous birth
Immediate care of the newborn
Immediate care of the mother
Information that must be charted on the hospital record
Key Terms
Upon completion of this module, you will be able to recall the meaning of the following terms and use them when consulting with other health professionals. Terms are defined in this module or in the glossary at the end of this book.
hematoma
“feather blow”
lochia
nasopharynx
nuchal cord
oropharynx
precipitous
restitution
turtle sign
shoulder dystocia
thermoregulation
uterine atony
Why is it important for you to be able to deliver a baby in the absence of an obstetric provider?
You, the maternity nurse have a responsibility to provide safe care for the mother and baby. If you make the assessment that a woman will give birth before her obstetric provider arrives, you must ask for help and be prepared to instruct and assist the woman while another nurse helps care for the newborn.
Comprehensive protocols addressing an unexpected or precipitous birth in the absence of the obstetric provider should be developed by each institution.
DO NOT WAIT TO PREPARE for the birth. You should be ready: call for help, prepare the woman and her support person that birth is imminent, and prepare the place of delivery.
Which women are at risk for delivery before the arrival of their obstetric provider?
Women who are at risk include those who:
Have had at least one vaginal birth
Have preterm labor (smaller baby)
Have a history of a rapid labor or a previous precipitous birth
Have made rapid progress during the current labor
Are in active labor and have travelled a great distance to the hospital
Have an unexpectedly small baby
The Delivery Process
Signs and Symptoms of an Impending Delivery
A woman having her second or subsequent baby who exclaims, “It’s coming!,” is probably correct. When the baby’s head crowns and the woman experiences the maximal perineal stretch, or “ring of fire,” you should stop what you are doing and attend to her. She needs you.
New-onset early decelerations noted on the fetal monitor tracing of a laboring woman with an epidural may indicate descent of the head as the cervix fully dilates.
A woman who has been comfortable with an epidural but suddenly feels pain or “pressure down there” may have rapidly progressed to the second stage.
Involuntary shaking of the lower legs in a woman having an unmedicated birth (no epidural) may occur as the presenting part descends, putting pressure on nerves.
Increased bloody show may be seen as the cervix completes dilation.
A strong urge to “push” or to bear down (rectal pressure), or actual involuntary pushing with contractions may occur (“Ferguson’s reflex”).
Separation or parting of the labia may be seen as the presenting part emerges (Fig. 9.1).
 FIGURE 9.1 Labial separation |
Increased fullness and pressure against the perineum may be seen (bulging perineum) (Fig. 9.2).
 FIGURE 9.2 Bulging perineum |
Relaxation and bulging of the anus, with or without loss of stool, may also be seen (Fig. 9.3).
 FIGURE 9.3 Bulging of anus |
The Nurse’s Role
What must you do to assist with the birth for consistency?
If the obstetric provider is not yet present, you should:
Relax and stay calm. Help the mother and her support person prepare for the imminent birth. Remember, women have been birthing for centuries and birth is a natural process. It will happen whether or not you are in the room.
Birth is a clean, not a sterile event. Put on gloves, but do not waste time finding the correct size sterile gloves if they are not readily available.
It is not necessary to scrub the perineum with an antiseptic, this wastes time. Do wipe away stool with an x-ray detectable sponge.
Do not vigorously bulb suction the baby’s oronasopharynx on the perineum. This can stimulate the vagus nerve and cause bradycardia. Wipe excess secretions away with an x-ray detectable sponge.
Allow the umbilical cord to stop pulsating before clamping and cutting. This allows the baby to receive extra blood.
Place the baby on the maternal chest/abdomen while drying him/her off. This should be sufficient stimulation to assist with spontaneous respirations. Cover both mother and baby with warm blankets.
It is not necessary to deliver the placenta immediately.
Calmly call for assistance. Have another nurse in the room to help with the care of the mother and newborn.
If chart information is not available, obtain pertinent information with a 30-second history:
Which baby is this for you?
When is your due date?
Did you have prenatal care?
Have you had any problems with the pregnancy?
Do you have any health problems?
Inform the woman and her support person that the birth is about to take place.
Reassure the woman that she will be assisted and will not be left unattended.
DO NOT LEAVE THE ROOM. Send her support person for help if necessary.
Instruct the woman to “feather blow” with each contraction, unless told to push.
Open the emergency birth pack at the bedside or on the bed. It should contain the following items:
A package of x-ray detectable sponges
Absorbent towels
A soft bulb syringe (use only if necessary)
A small drape or sterile field barrier
Two clamps, such as Kelly or Rochester (use only if necessary)
A cord clamp or umbilical tape
Scissors
Baby blankets
Gloves
Put on gloves (sterile preferred, but not essential), place the sterile barrier under the woman’s hips, and prepare for birth of the baby. Do not take your eyes off the perineum.
Remember to observe universal precautions.
Why should you instruct the woman to “feather blow” rather than push with some contractions?
When a woman pushes, she uses abdominal muscles and increases intra-abdominal pressure. This enhances the expulsive action of the contracting uterus. “Feather blowing” helps the woman to control the urge to push. To protect maternal tissue and the baby from trauma (facial bruising or subconjunctival hemorrhages), delivering the baby after gradual stretching of the perineal tissue is desired. The baby can also be delivered in between contractions.
What aseptic techniques should be done in preparation before birth for consistency?
Remember that birth is a “clean” (not a sterile) procedure. Instruments, however, should be sterile.
If time, wash your hands and forearms thoroughly, then put on gloves (sterile or clean). Wipe away stool that appears as the woman pushes.
Is control of the head important?
Research has shown the “hands-on” or “hands-off” approach to delivery of the head results in the same number of perineal lacerations.1,2 The key is to talk to the mother, tell her when to “feather blow” and when to push. The mechanisms of labor can guide your hand maneuvers:
Flexion
Extension
Restitution
External rotation
Lateral flexion
Expulsion
Hand maneuvers include NEVER PULLING ON THE BABY’S HEAD!
“Hands-off”
Allow the head to birth on its own
Support the body of the baby as it is born
“Hands-on”
Maintain flexion of the fetal head with one hand by gently pushing downward
Allow slow, controlled extension of the head
With your other hand, gently ease the perineum over the baby’s face
Check for a nuchal cord by slipping one finger down the baby’s neck as the head emerges
If possible, gently slide the cord over baby’s head
Deliver the anterior shoulder in a downward fashion and then the posterior shoulder in an upward fashion
Support birth of the body by expulsion
Place baby skin to skin on mother’s chest or abdomen
Why is it important not to hold back the delivery of the baby’s head by pushing against it or crossing the mother’s thighs?
Once it is clear that birth is about to occur, preparation must be made toward a safe and satisfying birth experience. Pushing back on the head to prevent birth can traumatize the baby and maternal tissues.
You can use “hands-off” or “hands-on” to assist with the birth: use the pads of the thumb, index, and middle fingers (Fig. 9.4) OR the cupped palm of the hand (Fig. 9.5) to maintain flexion of the head and to provide control as the head delivers. Talk to the mother.
 FIGURE 9.4 “Hands-On” hand placement techniques |
 FIGURE 9.5 “Hands-On” hand placement techniques |
Never try to hold the head back from delivering!
What other safety measures must you take to protect the mother during an unexpected or precipitous birth?
Position the mother comfortably so that the perineum, to which you must have access, can easily be viewed. Putting towels or pillows under the mother’s hips can help provide downward traction when delivering the shoulders.
Semi-Fowler’s in the labor bed: on her back, with her head elevated to a 45-degree angle (Fig. 9.6).
Side lying in the labor bed: have the support person elevate the mother’s upper leg so the legs are separated.
Squatting in the labor bed or by the side of the bed: after the head is born, support the body of the baby.
Maintain asepsis (clean technique). Careful handwashing, gloves, and use of the sterile emergency birth pack will help reduce the possibility of infection.
Allow delivery of the placenta without manipulation as it may take 30 to 60 minutes for this to occur. There is no need to tug on the cord. Observe for signs that the placenta is separating: the cord lengthens, a gush of blood comes from the vagina as the placenta detaches from the wall of the uterus, and the fundus changes from a discoid shape (flat) to a globular shape as the placenta drops into the lower uterine segment.
 FIGURE 9.6 Position in the labor bed. |
REMEMBER: If you are observing the progress of the mother’s labor and watching closely for signs of an impending birth, the unexpected or precipitous birth can:
Be planned and conducted in such a way as to eliminate last-minute rushing about
Provide a safe and satisfying experience for the woman and her support
What safety measures should be taken to protect the newborn?
In addition to “hands-on” or “hands-off” delivery of the head, you should:
Inspect for a cord around the neck as the head emerges and gently slide it over the head.
If the cord is tight and will not slide over the head, try to gently push the cord over the anterior shoulder as it is born.
If the cord is twice wrapped around the neck and cannot be “reduced,” allow the baby to birth and unwrap the cord as soon as possible.
If the cord is so tight the body of the baby cannot be born, place two clamps on the cord (1 inch apart from each other) and cut, unwrapping the cord as soon as possible.
Wipe off the baby’s face and head, gently sweeping away excess mucus from the nose and mouth if necessary.
Gently (not vigorously) suction the oropharynx then nasopharynx with the bulb syringe only if the baby has excessive secretions and difficulty initiating respirations.
Place the baby on the mother’s chest or abdomen and allow the cord to stop pulsating.
Prevent loss of body heat by drying the baby, then covering both mother and baby with warm blankets (thermoregulation).
Managing Problems
Meconium-Stained Amniotic Fluid
Occurs more often in high-risk pregnancies3
May be found in the presence of uterine tachysystole (precipitous labor; Pitocin drip)
May be associated with maternal hypertension
Is seen more often when the woman has a biophysical profile (BPP) of less than 6
Occurs more often in postdate pregnancies
May be associated with fetal hypoxic episodes
May be found with decreased variability in the fetal heart rate baseline; late decelerations do not have to be present
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