Section 13 - Emergency Preparedness for Childbirth
Purpose: This section is presented under the supposition that all hospitals need to recognize the potential for receiving obstetric patients during a disaster and appropriately plan for obstetric mass care. In a disaster event, the following may occur:
- Obstetric patients might present to ANY hospital.
- Transfer of patients to specialized hospitals might not be feasible.
All hospitals and all providers must be prepared to deliver care to obstetric patients during disasters. It is likely that the Emergency Department will become saturated with patients who are critically or moderately ill or injured during a disaster. Therefore, obstetric patients ready to deliver may be transferred to other units in the hospital.
This section is intended to serve as a general guide to staff who may need to assist/perform uncomplicated deliveries outside the Emergency Department or on a nursing unit in a facility, which does not usually provide obstetric services.
- General Guidelines
- Emergency Obstetric Package for Hospitals that do not Provide Delivery Services
- Urgent Maternal History
- Guidelines for Uncomplicated Deliveries
- The Baby
- The Umbilical Cord
- What if the Baby is Coming Bottom First?
- The Placenta or Afterbirth (Third Stage)
- Care of the Mother
- Psychosocial Considerations
- Pregnant women have unique needs in a disaster, often experiencing greater risk for health complications associated with pregnancy, such as premature labor, premature birth, birth of low birth-weight infants, and neonatal and infant deaths.
- In emergencies, pregnant women may experience additional stress. Stress, in conjunction with lack of appropriate hydration and nutrition, can result in premature labor and delivery.
- Emergency situations can disrupt transportation and access to the planned delivery environment. This can result in both physical and psychological implications.
- Treatment of women and infants can also be complicated by lack of access to medical records, as well as lack of access to necessities, such as diapers, formula, baby bottles and clothing.
- Without appropriate supports, there is the possibility of increased morbidity and mortality. Each hospital should be aware and contact the Regional Perinatal Center (RPC) in their area. The RPCs can provide telephone guidance in case of emergency. In addition, each hospital should keep a recent edition of one of the standard obstetrics and pediatric texts conveniently located in the ER.
Emergency Obstetric Package for Hospitals That Do Not Provide Delivery Services
The following supplies will help your facility be prepared for birth:
Basic supplies for childbirth:
- 3 curved Kelly clamps
- 2 Mayo scissors
- 1 sponge stick
- 1 needle holder
- 1 large basin or 1 large kidney basin (for placenta)
- 1 10-pack sterile gauze sponges
- 1 Holister cord clamp (If no cord clamp, may use sterile gauze to tie off cord)
- Suction catheters
- 1 bulb syringe
- 4 sterile towels
For perineal laceration repair:
- 1 11.2-inch 20-gauge needle
- 1 10-cc syringe
- 1% lidocaine
- Chromic "000" or Vicryl "000" suture
- Betadine solution
Medication for Mother:
- 2 10-unit vials Pitocin (oxytocin injection)
- Rhogam [Rho(D) Immune Globulin (Human)], if necessary
Medication for Infant:
- Erythromycin 1% eye ointment
- Phyponadione 1.2cc for injection (vitamin K)
Note: Preassembled kits are available commercially. However, these kits do not necessarily include clamps and scissors.
Due to lack of continuous fetal monitoring equipment, neonatal resuscitation must be available and ready to be implemented at every delivery. (See Appendices 13-1 through 13-4 at the end of this section for a review of newborn resuscitation.) Resuscitation equipment should be prepared and checked prior to delivery of the infant. This includes suction catheters (8F or 10F) for suctioning of meconium, and other emergency equipment noted later in this toolkit.
The following PDF link contains excerpts from Giving Birth "in Place": A Guide to Emergency Preparedness for Childbirth (American College of Nurse-Midwives, 2003) and is reprinted in this modified version with permission: (http://www.midwife.org/siteFiles/education/giving_birth_in_place.pdf).
Urgent Maternal History:
The first step in developing a plan for managing obstetric patients by a hospital that does not typically handle obstetric patients is to determine how pregnant and laboring women will be triaged and cared for, which may be required during a pandemic influenza outbreak. The following questions may prove helpful in making those determinations.
Note: This is not a complete obstetric history. Rather, this is an abbreviated 'urgent maternal history' to help make triage decisions.
Determine how pregnant laboring women will be triaged and cared for.
- Is the baby more than 4 weeks early?
- What is your due date?
- What baby is this for you?
- If this is not your first baby, did you have any complications with your previous delivery?
- If the water has broken, what color was it?
- Are multiple births expected?
- What drugs/medications are you currently taking?
- Are you allergic to any medications?
- Have you used any narcotic drugs recently?
- Do you know your blood type?
- Have there been any complications during your pregnancy such as high blood pressure, swelling of the hands or feet, severe headaches, gestational diabetes or bleeding?
Guidelines for Uncomplicated Deliveries
Develop a plan for transferring high-risk deliveries or an alternate means of communication with a High Risk Obstetrician Specialist if transfer is not possible. The following are guidelines for an uncomplicated delivery:
During labor: First Stage
If the baby has been head down during the last weeks of pregnancy, chances are good that the baby will be head first at birth. This is the most common position for a baby. First labors can last for 12 hours or more while the next babies can come much faster.
- Keep the mother-to-be comfortable. It is good for her to walk, take a shower, get a massage and move, even if she is in bed. The mother-to-be may want to spend a lot of time in bed, or she may prefer to be on her feet or in a chair. Whatever feels best is OK.
- Be sure she drinks lots of fluids. Water, tea and juice are the best.
- Encourage her to go to the bathroom every hour.
- Maintain a calm and encouraging atmosphere.
- Use standard precautions.
- Wash hands often.
- Decide how to help other members of the family. Will they be present for the birth? What do they need to feel safe? Note: Anyone with any signs of flu should not be allowed into the delivery area. The mother-to-be should have at least one person who can be with her at all times, but other than that, it will be up to the hospital to decide how many can be present. Space may be an issue, and the mother-to-be should be made aware that she might not be able to have everyone present that she wants, due to the nature of flu and how easily it is spread.
- Reassure the mother-to-be that it is OK to make noise during labor and that this may actually help. Making groaning or crying noise during labor is OK. It can scare her helpers but they have to let her make the noise that helps her cope.
The urge to push: Second Stage
The longest part of labor is the time it takes for the cervix to open wide enough for the baby to pass into the birth canal or vagina (first stage). You can tell the cervix has opened all the way (fully dilated) when the mother has a very strong need to push (second stage). She cannot hold back that urge and may make sounds like she is going to the bathroom. Once she starts pushing, the baby can be born in a few minutes or a couple of hours. As birth gets closer, the area around the vagina begins to bulge out until the top of the baby's head is seen at the vaginal opening. The mother should be encouraged to push the baby's head out gently in any position that is comfortable for her. She does not have to lie on her back in bed; however, you will feel safer if she is lying down or squatting so the baby can slip gently onto a soft surface.
Put on your gloves and get in a place where you can see the baby come out. Remind the mother-to-be to push gently even when she wants to push hard. As the baby comes out, mom will feel a lot of burning around the vagina and this is when she may make a lot of noise. Support the baby's head by gently cradling it in your hands.
Remove cord if it is around the neck
After the head is born, determine if the cord is around the baby's neck. Reach behind the back of the baby's head, toward the back of the neck with your index finger. If you find a cord around the neck, this is not an emergency. Gently lift the cord over the baby's head, or loosen it so there is room for the body to slip through the loop of cord. If you are unable to unwrap it from around the neck, clamp it in 2 places and cut the cord between the 2 clamps. Otherwise, do not rush to cut the cord.
Cutting the umbilical cord
Continue to lightly cradle the baby's head between your hands. The baby's head will turn to one side and with the next contraction, the mother should push to deliver the body.
Gently support the body as it is born. Either bring the baby up to the mother and place her on the mother's chest
if the body does not come out, push firmly on the side of the baby's head to move the head down toward the mother's back. The shoulder will be born. The rest of the body should slip out easily followed by a lot of blood colored water.
If the head is born but the body does not come after 3 pushes, the mom must lie down on her back, put 2 pillows under her bottom, bring her knees up to her chest, have her grab her knees and push hard with each contraction. If the head still will not deliver, adopt a CPR Chest Compression Stance just above the mother's pubic bone, apply firm downward compressions, and encourage a strong push. This will release the shoulder that may be impinged behind the pubic bone.
After the baby is born, place her or him on the mother's chest and tummy, skin to skin, and cover both with towels. If the baby is not crying, rub her back firmly. If she still does not cry, lay her down so that she is looking up at the ceiling, tilt her head back to straighten her airway and keep rubbing. Not every baby has to cry, but this is the best way to be sure the baby is getting the air she needs. Use a bulb syringe to clear the airway by suctioning the mouth and both nares.
A. Removal of secretions from mouth B. Removal of secretions from nose
Note the time the baby was born for the birth certificate.
At the time of birth, most babies are blue or dusky. Some cry right away and others do not. If the baby is not crying, gently stimulate by:
- Flicking 1 finger against the newborn's heel
- Lightly slapping the sole of the newborn's foot or rubbing the sole of the newborn's foot
- Gently rubbing the lower back
- If needed, repeat for 10 to 15 seconds only
Never hold the baby upside down, slap the buttocks, squeeze, shake, or immerse in hot or cold water. If the baby is still not breathing, begin resuscitation. (See review of newborn oxygenation/resuscitation in Appendices 13-1 through 13-4 at the end of this section.)
If the baby is gagging on fluids in her mouth and turning blue, use the baby blanket to wipe the fluids out of her mouth and nose. Position and suction the baby as pictured below by first positioning the airway with the head slightly lower than the body. Then, elevate the shoulders with a 1-inch pad, turn the infant's head to the side and suction the mouth first with the bulb syringe inserted 1 to 1.5 inches. Do this 2 to 3 times. Follow by suctioning the nose with the bulb syringe inserted 0.5 inches into the nostril. NOTE: If the nose was suctioned before the mouth, the newborn may be stimulated to breathe in, and may inhale any fluid or secretions in the mouth.
Once the baby starts to cry, her color will be more like her mother, but her hands and feet will still be blue. Now is the time to keep the baby warm. Dry and warm the baby quickly to prevent heat loss by working quickly and efficiently. Use gentle rubbing to dry the baby thoroughly. Discard the towels used for drying and wrap the baby in a clean, dry towel or blanket. Put a hat on the baby and place the baby on top of the mother. The mother can help keep the baby warm with her body heat. It is also acceptable to place the baby skin-to-skin and cover baby and mother with a blanket.
The Umbilical Cord
The first priorities are to dry, warm, suction and position the baby. There is no rush to cut the cord. All you have to do is keep the baby close to the mother so the cord is not pulled tight. There are no nerve endings in the cord so it does not hurt either the baby or the mother when it is cut. It is very slippery so take your time, as there is no rush. The baby will cry when she is uncovered because she is cold, not because she is in pain.
If you pick the cord up between your fingers, you can feel the baby's pulse. The cord should be tightly clamped or tied in 2 places. The first clamp or tie should be approximately 8 to 10 inches from the baby. The second clamp or tie should be approximately 1 inch from the baby. Cut between the 2 clamps when the pulse ceases which will stop within about 10 minutes. Remember the cord is connected to the placenta, which is still inside the mother. After it is cut, place the end of the cord that is still connected to the mother's placenta into the basin. Cover the baby again to keep her warm.
What if the baby is coming bottom first?
A few babies are born bottom first. You will probably not know this is the case until the mother-to-be pushes and you see a bottom or feet and not a head coming out. At that time, you must:
- Bring the mother's bottom to the edge of the bed and have her legs pulled up to her chest.
- Prepare a soft landing spot for the baby on the floor.
- Let the baby's body and arms come out without touching the baby. You will be looking at the baby's back. Yes, you have to let her little bottom hang down toward the floor even if you are afraid she will fall. If you have to touch something, grab another pillow for the landing zone.
- When the head slips out grab the baby under the arms and bring her up to the mom.
If the baby's arms are out but the head does not come with the next contraction , you should have the mother get out of bed, squat and push.
Put the baby to breast: Even if the mother did not plan to breastfeed, one of the safest things you can do for the baby is put the baby to breast. Breastfeeding the baby helps keep the mother from bleeding too much and gets the baby the food it needs right away. If the cord is too short to allow the baby to reach the breast, it is OK to wait until you cut the cord.
Once the baby is done nursing and you are awaiting the delivery of the placenta, you may wish to weigh the baby and obtain its length. This is also the time to administer the eye prophylaxis (erythromycin 1% ointment applied to each eyelid) and vitamin K (phyponadione 1.2cc IM injected into the infant's thigh muscle).
The Placenta or Afterbirth (Third Stage):
The placenta looks like a big piece of raw meat with a shiny film on one side. On the other side, it has membranes attached to the placenta (the membranes look like skin that has been peeled off). When the placenta is ready to come, you will see a gush of blood from the vagina and the cord will get a little longer. Put the bowl close to the mother's vagina and put more waterproof pads under her bottom. Ask the mother to sit up and push out the placenta into the basin.
There will be a lot of blood and water coming after the placenta. Firmly rub the mother's stomach below her belly button while supporting her lower abdomen until most of the bleeding stops (see picture below). This will hurt but needs to be done. The heaviest bleeding should stop in a minute and then the bleeding will be more like a heavy period. If the bleeding increases again, very firmly rub the mother's lower belly until the bleeding slows. When it is firm, you will be able to feel a uterus, which is the size of a large grapefruit, in the lower belly. A firm uterus is a good thing as it will stop the mom from bleeding too much.
If the uterus will not stay firm and the bleeding is heavy, give 10 units Pitocin (oxytocin injection) IM in the mother's thigh or gluteal muscle. Continue to massage the uterus until the bleeding is under control. If the bleeding is not under control, then repeat Pitocin.
The mother's bottom and uterus may be sore. You may see places where the mother's skin has torn around her vagina. Most of these tears will heal without any problems. If the laceration is deep and the area below the vagina is visually open, repair the laceration by injecting 1% lidocaine into the edges of the laceration and repair with Chromic "000" or Vicryl "000" (whatever you have available). Cleanse the area with Betadine (povidone-iodine 10%). The mother will feel better when you put an ice pack on her bottom where the baby came out and then put the sanitary pad on top of the ice pack. She may want to take pain medication at this time.
After the mother has delivered the placenta and the bleeding has slowed down, give her a drink of juice, soup, or milk and something to eat like crackers and cheese or a peanut butter and jelly sandwich. Using standard precautions, change the bedding. Put a diaper and tee shirt or 'onesie' on the baby. Remember that the baby can be placed on the mother's chest for warmth.
- It is important for the mother to breastfeed the baby in the first hour after birth and at least every 2 hours until her milk comes in.
- Breastfeeding will keep the uterus firm and decrease bleeding.
- Colostrum, the liquid that is in the breast right after birth until the milk comes in, will give the baby all of the food she needs and it will help prevent infection.
- Even if the emergency continues for days, weeks or months, there will always be a ready supply of safe and perfect food for the baby.
Getting Started with Breastfeeding: A newborn will nurse best in the first hour after birth when she is awake and alert. The mother may be more comfortable if she lies on her side with pillows under her head. The mother and baby should be face-to-face and belly-to-belly. The baby will also nurse better if they are skin-to-skin.
The mother should place her nipple and breast against the baby's lips. The baby will lick and try to nurse. The mother needs to help by placing her nipple into the baby's open mouth. It may take a few tries before the baby can start sucking. If the baby is sleepy, rub her belly and back firmly to wake her up. If the baby is too sleepy, try uncovering her for a short time and rubbing the mother's nipple against the baby's lips. If the mother gets tired, take short breaks and start again. Once the baby nurses for the first time it gets easier.
What to Avoid
- Do not use a pacifier or a bottle to start the baby sucking. It confuses some babies because they do not suck the same on the mother's breast as on a bottle or pacifier.
- Do not separate the mother and baby for very long. The more they stay together, including when they sleep; the sooner breastfeeding will be well established. If a bassinet is not available, alternate sleeping arrangements for baby need to be considered as mentioned below:
- The baby can be placed in an approved crib, sleep surface or other improvised container with sides. In an emergency, a drawer or a bin may be used. There must be plenty of room between the baby and the sides of the container, so that the baby's face is in no danger of being pressed against the sides or mattress.
- Remove soft, fluffy and loose bedding and stuffed toys from the baby's sleep area. Always place the baby on his or her back to sleep, even for naps. Make sure the baby's face and head stay uncovered during sleep.
- Do not dress the baby too warmly. Do not let the baby get too warm during sleep.
- Make sure everyone who cares for the baby knows to place the baby on his or her back to sleep.
- When the baby and the mother are ready for discharge, review safe sleeping arrangements with the mother and stress that she should not let anyone smoke around the baby.
Care of the Mother
- The mother should go to the bathroom within 1 to 2 hours after the baby is born.
- If the room is cold, you can use hot water bottles to keep the baby warm. Just wrap the warm bottle in a blanket and place it next to the baby's back.
- After birth, women are usually offered Tylenol, Advil or another non-aspirin product for pain every 3 to 4 hours, as needed. This would be a good choice if the mother does not have an allergy to this medication.
- When a new mother gets out of bed for the first time, she may feel dizzy. It is important that the mother is not holding the baby as she tries to get up. She can leave the baby on the center of the bed or place the baby in a crib, if one is available.
- Have her get up slowly.
- Have her sit up on the side of the bed to see how she feels.
- Have an adult take her to the bathroom and wait to be sure that she is not feeling faint.
- If she says she is going to faint BELIEVE HER and have her lie down on the floor.
- Do not attempt to walk her back to bed.
- You have about 10 seconds to get her down on the floor before she passes out and bangs her head on the way down.
- Once she is down flat, she will wake up and feel better. Just wait a few minutes and then carefully help her back to bed.
- In a couple of hours, the mother may want to take a shower. Be sure she has had something to eat and is not dizzy when she gets up. It is good to have someone close by as dizziness can return quickly.
The hours and days after a birth occurs are considered very important in the future psychological and physical growth of the infant. Maternal bonding with the infant usually begins to occur during the pregnancy, strengthened by the feeling of fetal movement, the visualization of the infant through sonography, and for the infant, developed through the familiarity with the mother's voice and heartbeat while in-utero. Ideally, the process of childbirth also reinforces this bond.
What happens around the time of birth and in the first few hours afterwards may affect the formation of a strong emotional bond between the mother and the infant. Situational factors such as a traumatic birth situation, stress, lack of social support, and the feelings and behaviors of the partner may also affect the bonding experience. Touch, response and mutual gazing are felt to increase the feeling of emotional connectedness. Physiologically, the production of oxytocin during lactation, causing an increase in parasympathetic activity, is also felt to decrease anxiety and increase the opportunity for strong emotional attachment to the infant.
When it comes to bonding, it is not a 'now or never' or 'instant mother love or never' situation. While the experiences immediately following childbirth may provide an important 'head start,' bonding can develop later. It is possible to catch up if the baby and mother are separated due to prematurity or a cesarean birth. Bonding also is not something that cements the parent-infant emotional relationship forever.
Following the birth, caregivers should consider to:
- Postpone routine procedures that will interfere with the immediate post-birth bonding period. Putting ointment in baby's eyes or administering the vitamin K injection can wait so that the infant can clearly visualize the parents and the parents can see into the infant's eyes.
- Let the baby stay connected with the mother. Put the baby on the chest or abdomen of the mother immediately after birth or after suctioning and the cutting of the cord unless medical intervention is needed that would preclude this.
- Encourage touching and gentle massaging of the infant. Allow skin-to-skin contact. While the infant is making the transition to breathing air, stroking will stimulate the infant to breathe more rhythmically.
- Encourage the mother to coo and talk to the infant. Studies show that mothers have a unique cadence and tone to their voices to which infants respond. The baby will be familiar with the mother's voice after hearing her speak while in-utero.
- Position the infant at a distance of 8 to 10 inches to optimize gazing. This is the usual nipple-to-eye distance. Encourage the mother to gaze at the infant and look into the infant's eyes. Let the baby breastfeed right after birth. Nipple stimulation increases oxytocin production and increases the contraction of the uterus, which lessens the risk of post-partum hemorrhage. Early nipple stimulation also stimulates the release of prolactin, which supports initiation of mothering behaviors. Some babies will be content to simply lick the nipple, while others will have a strong suck immediately after birth.
- Let the baby room in with the mother whenever baby and mother's health allows. The opportunity for tactile, visual, auditory and olfactory input for the mother will increase the opportunity for a strong emotional attachment to form between mother and infant.
- Allow the mother opportunities to discuss her feelings, if she wants to. Her feelings may cover a gamut from loving the glow of motherhood and love at first sight, to excitement, to a feeling of achievement, to relief the birthing is over. Some may want to be left alone for a while, as well. Some may want the opportunity to shower and pull their self together.
- Be sensitive and encouraging. Women who have not been able to carry through on their birth plan may have some feelings of guilt or discontent. It may be helpful to point out the positives of the situation. In addition, mothers may be encouraged to know you have faith in their abilities to meet the baby's needs and to mother well.
- Appendix 13-1: Overview of Newborn Resuscitation (PDF, 65KB, 1pg.)
- Appendix 13-2: Provide Supplemental Oxygen (PDF, 89KB, 1pg.)
- Appendix 13-3: Assisted Ventilations (PDF, 108KB, 1pg.)
- Appendix 13-4: Cardio Pulmonary Resuscitation (CPR) (PDF, 104KB, 1pg.)