Patient-Centred Care & Ethics
Historically, out-of-hospital obstetric care has sometimes resulted in poor experiences for mothers due to paramedics not listening to their wishes or applying unnecessary clinical interventions. A key foundation of normal delivery management is respecting the birthing woman's autonomy.
Avoiding Routine Interventions
Refrain from routine interventions (like inserting IV cannulas or mandating a specific birthing position) unless clinically indicated. Honour birth plans where safe to do so. Remember the patient quote from the literature: "I felt very violated... I didn't understand why I had a drip because all my births had been natural."
Obstetric History & Assessment
Gravidity and Parity
A standard way to communicate reproductive history:
- Gravidity (G): The number of times a woman has been pregnant, regardless of the outcome.
- Parity (P): The number of pregnancies carried to a viable gestational age (typically 20-24 weeks), regardless of whether the child was born alive or stillborn.
The "CCLUE" Assessment
Use this mnemonic to thoroughly assess a patient presenting in labour:
- C - Contractions: Presence, frequency (start of one to start of the next), and duration (how long one lasts).
- C - Complications: History of pre-term deliveries, previous Caesarean sections, placenta praevia, gestational diabetes, or hypertension.
- L - Leaking: Rupture of membranes (colour of fluid?), "show" (mucus plug), or vaginal bleeding.
- U - Urge: Does she have the urge to push, urinate, or use her bowels? (Strong indicator of imminent birth).
- E - Expected Delivery Date (EDD): Determines gestation and potential need for premature neonatal resuscitation.
The Stages of Labour
First Stage: Cervical Dilation
From the onset of regular, painful contractions to full cervical dilation (10cm). This is often the longest stage. The cervix effaces (thins) and dilates.
Second Stage: Expulsion of the Foetus
From full cervical dilation to the complete birth of the baby. Contractions are strong and expulsive. The mother will typically experience an uncontrollable urge to push.
Third Stage: Placental Delivery
From the birth of the baby until the complete expulsion of the placenta and membranes, and control of bleeding.
Managing an Imminent Delivery
Signs of Imminent Birth (Stay & Prepare)
- Contractions < 2 minutes apart and lasting > 60 seconds.
- Uncontrollable urge to push or use bowels.
- Crowning or bulging perineum.
- Anal pouting.
Second Stage Management
- Positioning: Encourage a position of comfort for the mother (semi-recumbent, all-fours, side-lying). Avoid flat supine.
- Environment: Ensure privacy, a warm environment (to prevent neonatal hypothermia), and prepare the maternity kit.
- Crowning & Head Delivery: Encourage gentle, controlled pushing ("pant-pant-blow") as the head crowns to minimize perineal tearing. Support the perineum as per local guidelines (hands on vs. hands poised).
- Restitution: Once the head delivers, it will naturally rotate (restitution) to align with the shoulders. Do not pull.
- Shoulders & Body: With the next contraction, guide the head gently downwards to deliver the anterior shoulder, then gently upwards to deliver the posterior shoulder. The rest of the body will follow easily.
- Immediate Care: Note the time of birth. Place the baby immediately on the mother's bare chest for skin-to-skin contact and cover them both with a warm, dry blanket.
Third Stage & Neonatal Assessment
Neonatal Assessment (APGAR)
Assess the neonate at 1 minute and 5 minutes post-delivery. Do not delay resuscitation to calculate an APGAR score if the baby is non-vigorous.
| Indicator | 0 Points | 1 Point | 2 Points |
|---|---|---|---|
| Appearance (Colour) | Blue, pale all over | Pink body, blue extremities (Acrocyanosis) | Pink all over |
| Pulse (Heart Rate) | Absent | < 100 bpm | > 100 bpm |
| Grimace (Reflex Irritability) | No response | Grimace / weak cry | Strong cry, active avoidance |
| Activity (Muscle Tone) | Limp / flaccid | Some flexion of arms/legs | Active motion, well flexed |
| Respiration | Absent | Slow, irregular, weak cry | Good, strong cry |
Third Stage Management
- Cord Clamping: Delay clamping for 1-3 minutes (or until cord stops pulsating) to allow placental transfusion, unless the baby requires active resuscitation away from the mother.
- Placental Delivery: Wait for signs of placental separation (lengthening of cord, gush of blood, firming of fundus). Ask the mother to push when she feels a contraction. Keep the placenta in a bag for hospital inspection.
- Post-Partum Haemorrhage (PPH) Check: Monitor blood loss carefully. A normal loss is usually under 500mL. Palpate the fundus to ensure it is firm and contracted.
Obstetric Handover
Ensure your handover includes maternity-specific details:
- Patient Name, Age, Gravidity (G), and Parity (P)
- Estimated Date of Delivery (EDD) or Gestation weeks
- Time of birth, Baby's Gender, and 1 & 5 minute APGAR scores
- Completion of the 3rd stage (Placenta delivered? Intact?)
- Estimated maternal blood loss (EBL)
- Vital signs and paramedic management provided