15 Things to Know Before Your Next Obstetrical Call

There’s something about the patient in labor that makes my palms sweat. I’m not alone. Most of us EMS folks get a little anxious at the idea of delivering a baby. Obstetrical calls can go very right and they can go very wrong. The stakes are high.

Here are a few things to consider before you run your next obstetrical call.

1) At full term, pregnant females have a heart rate 10-15 beats per minute faster than when they were prepartum. (Psst…Before they were pregnant.) They also have 25%-30% higher stroke volume and 30%-50% higher cardiac output.

2) Pregnant females will tolerate significant blood loss before they become symptomatic. Once they are symptomatic, they will decompensate rapidly.

3) The official obstetrical term for the mother’s water breaking is “rupture of membranes”. It can be documented with the abbreviation ROM.

4) Unlike the Glasgow Coma Score, you can’t just guess that a healthy baby gets an automatic 10 on the APGAR score. Most healthy babies are born with a score between 8 and 10. In some regions of the United States very few babies are ever scored a 10 at birth.

5) You won’t remember the APGAR score when you’re holding a newborn baby in your hands. Write it on your OB kit.

6) All things considered, moms tends to be the best judge of when labor is eminent.

7) In your EMT class we drilled on the idea that mom should be laid on her left side. More recent research has indicated that getting mom on her side is the important part. Whether she’s on her left side or right side makes no real difference.

8.) Designate the person with the least to do as the official time keeper. Make sure they have access to the most accurate clock available.

9) 600 ccs of blood pass between mom and baby every minute. Mom can loose 1,000-1,500 ccs of blood before she becomes symptomatic. Typical postpartum hemorrhage should be in the neighborhood of 500 ccs.

10) Delay transport if delivery is eminent. Don’t delay transport for delivery of the placenta. It can take hours. Once baby is out, package for transport.

11) Aggressive (uncomfortable) fundus massage is still the best method to slow postpartum hemorrhage.

12) Cut the cord between the clamps. (Seriously…it happens.)

13) When delivering twins, both babies will deliver first. Both placentas will deliver after. Any other ordering is an obstetrical emergency.

14) Fetal trauma cannot be ruled out in the prehospital setting. Lack of vaginal bleeding or pain on palpation does not rule out fetal trauma. Pregnant mothers who have suffered any significant mechanism to the abdomen should be transported for evaluation. (They will typically be observed for 12-24 hours.)

15) Don’t forget to prepare for two patients.

Now it’s your turn: What OB tips would you add to the list?

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  1. The fastest and easiest way to get warm blankets for a delivery at home is to have someone put several clean bath towels in the clothes dryer for a few minutes. Clean, absorbent and easy to wash later…

  2. Good one Linda. What else?

  3. Where does baby go as you drive?

  4. With the mom. Really?

  5. “With the mom” is arguably a violation of federal safety regs on buckling up. Which is not to say that it won’t or shouldn’t happen, especially given the question of where else to put the little grub, but it’s something to think about.

  6. Check the placenta over. I was on awful premature delivery call and quite literally missed a second child while bagging the placenta. This was overwhelmingly likely to have been a non-viable child, but it definitely still weighs on me heavily.

  7. Be sure you know where your OB kit is and what is in it. The time to find out is not when the head is presenting (crowning). Most kits are sterile including gloves, so try and use those. Maintain baby warmth.

  8. Haven’t had a birth yet. But witnessed a few with family members. Remember folks it will be bloody, it will look like that scene in Alien, and dont forget sometimes other bodily secretions may happen. If these other secretions happen CHANGE, have the partner switch up in there and get the stuff off and put on clean equipment.

    I have a question regarding the cord. Like I said I haven’t had a birth under my belt yet so…. I have heard folks on my squad that have had births that some leave the cord attached and just have the ED do the cutting. Something about stem cells and all. Is that a viable option in the prehospital setting or is it SOP to clamp and cut?

  9. Skibumleo says:

    My instructor taught me to put suction of the oral cavity on the list to prevent inspiration from the first cry. And if I feel confortable the baby feels cold.

  10. @Skibumleo

    Suction the oral cavity then suction the nares both when the head first delivers.

  11. In regards to points 1 and 2,

    In pregnant women, red blood cell mass increase about 25-30%, but plasma volume increases about 50% in single pregnancies and 70% in twins. This is known as the physiological anemia of pregnancy and is important since skin and renal profusion (to get rid of heat and metabolic waste respectively) doesn’t rely on RBCs. However, while cardiac output increases significantly, blood pressure actually drops about 6 mmHg systolic and 10mmHg diastolic during pregnancy due to decreased peripheral vascular resistance (Students: Physiology review. What’s the relationship between cardiac output, PVR, and systolic and diastolic blood pressures?).

    For point 9, just a pure nitpick, but technically no blood is supposed to pass directly between the mother and fetus, or else really bad things happen immunologically (Students: look up hemolytic disease of the newborn).

  12. Steve Whitehead says:

    @Max, David and Brandon, The fact that we have no real good, DOT compliant way to transport newborns is a dirty little secret of EMS. I’ve always kept babies with mom. And asked the driver to drive very safe.

  13. Steve Whitehead says:

    I’m sorry that happened to you Tom.

  14. Steve Whitehead says:

    @Jim Thanks for those Jim

    @skibumleo Actually, current research suggests that mouth or nose first isn’t terribly important. If there’s a bunch of junk in the nose, suction that first. If the mouth is junky…suction that. This is different from everything we’ve learned, I know!

  15. Steve Whitehead says:

    @Joe, thanks for all of those…even the nitpick. Good point.

  16. I haven’t even finished my EMT-B course yet. But we just got to the subject of Obstetrical Births. I was initially nerve wracked at the idea of assisting a mother and her newborn. Actually, I think I still am and will be even the day of said occasion. I’m still quite young and trying my best. I just want to thank the writers and those knowledgeable individuals that shared their brilliant observations. It kinda smooths things out and makes the whole process a bit clearer.

    The whole physiology of it all is something I am still very foggy about however. *worried*

  17. #11 – leave the fundus alone unless there is a hemorrhage, otherwise you can actually cause one. Similarly, do not pull on the cord when the placenta is attached; you can cause a hemorrhage. (In both instances, etiology would be partial separation of the placenta.)

    Jude, yes, leaving the cord intact is preferable for the baby unless the baby needs to be separated from mom to be worked on (or vice versa). At birth, up to 1/3 the baby’s blood volume is still in the cord and placenta; once you can’t feel the cord pulsing, you know the baby has gotten its blood volume, so that’s a more preferable time to clamp and cut if no emergencies present. (Dads catching the baby at home before EMS arrival should not be using a shoelace and house scissors, yuck.) Nicholas Fogelson MD put together an excellent post on this subject: http://academicobgyn.com/2009/12/03/delayed-cord-clamping-should-be-standard-practice-in-obstetrics/

    I like your note about suctioning first where there’s a bunch of junk. I would expand it to say only suction if there’s enough goop to interfere with breathing or if there’s meconium in the amniotic fluid. Part of the physiological transition from fetus to baby is clearing the fluid from the mouth, nose, and lungs. They tend to do it quite well. Intervene only as warranted.

    Shirt, just remember that birth works most of the time. Otherwise we wouldn’t have made it as a species before the invention of bulb syringes and cesareans. Of course, know the interventions you’re taught to help when things go awry. Be prepared for and watch for the worst, but in the case of birth, anticipate the best. Remember that it’s not a medical emergency – it’s a normal yet extraordinary physiological event that can sometimes have a medical emergency arise. Respect it as such and you’ll do great.

    One more note:

    If you get called to a planned home birth with a professional midwife in attendance, remember that she is an expert at facilitating birth and knows her patient well. Remember that you and she are both medical professionals with different areas of expertise. Ask her what her patient needs – both from you and from her. Let her ride with her patient; she has knowledge, skills, and equipment you don’t that could save her patient’s life even as she needs your knowledge, skills, and equipment to help her do so. Work together with respect. It can make all the difference.

    I’ve just recently found your blog and have been greatly enjoying it.

  18. administrator says:

    @Meg Thanks for all the great feedback on this one. The OB nurse who helped me put this list together strongly disagreed with you on the point of fundus massage. That’s medicine I guess.

    I also really like your note about using the professional midwife as a resource. Every EMS caregiver knows what it’s like to show up at the emergency room and be ignored by the staff. We ofter do the same thing to professional caregivers in the home.

  19. I know that this is an old post, but thought I would leave a comment anyways. As a student homebirth midwife, I was at first very hesitant about reading this post – but soon realized how great a job you did in writing this!
    I especially appreciate the comment regarding working with a midwife… THANK YOU SO MUCH!! That is SO invaluable to us when providing safe care to our clients!
    Thank you for this fabulous blog- I have been using it as an invaluable resource while completing my training!