a birth that occurs accidentally or precipitously in or out of the hospital, without standard obstetric preparations and procedures. Signs and symptoms of impending delivery include increased bloody show, frequent strong contractions, the mother's desire to bear down forcibly or her report that she feels as though she is going to defecate, visible bulging of the bag of waters, and crowning of the baby's head at the vaginal introitus.
method If time permits, equipment is readied, but the delivery is not delayed for such preparations. Useful equipment includes sterile gloves, towels, bulb syringe, receiving blankets, scissors, two Kelly clamps, cord clamp or tie, and a basin for the placenta. The mother's vital signs are taken, and the fetal heart sounds are listened to if time permits and if equipment is available. The mother is reassured that emergency deliveries are usually simple and that all procedures and events will be explained. Despite her compelling urge to push and to deliver quickly, the mother is encouraged to ease the baby out slowly by not pushing and by blowing air forcibly out through pursed lips as she feels the strength of the urge building. As the head emerges, it is supported but allowed to rotate naturally. A check is made immediately to determine whether or not the umbilical cord is wound around the neck. If it is, a gentle attempt is made to slip it over the baby's head; if it is too tight, it is immediately clamped with two Kelly clamps placed 2 or 3 inches apart, cut between the clamps, and unwound from the neck. If the baby does not deliver immediately, mucus and fluid in the nose and mouth are sucked out with a bulb syringe. The shoulders are delivered one at a time by guiding the head downward to deliver the anterior (upper) shoulder under the symphysis pubis, and then upward to deliver the posterior (lower) shoulder over the perineum. The rest of the baby is quickly born. If the membranes of the amniotic sac are intact, the sac is snipped or torn behind the baby's neck and peeled away from the face so that the baby can breathe. If necessary, the nares, nasopharynx, and mouth may be suctioned with the bulb syringe, taking care not to slow the heart rate by stimulating the vagus nerve with the tip of the syringe on the back of the throat. The baby is kept warm and held with the head lower than the chest; it may be laid skin-to-skin on the mother's abdomen. The baby may thus be positioned, observed, and warmed in one place as the nurse or other helper covers the mother and baby with a dry blanket or towel and continues to provide emergency care as necessary through the third stage of labor. There is no urgent need to cut the cord or to deliver the placenta. When it is desired, the cord may be cut by clamping it in two places several inches from the baby and cutting it between the clamps with sterile scissors. The cord clamp may be put on later. If possible, an Apgar score is taken first at 5 minutes of age, then at 10. The placenta is ready to be delivered when the cord is seen to advance a few inches, the uterus becomes firmer and rises in the abdomen, and a small gush of bright red blood emerges from the vagina. The mother may help expel it by bearing down. The placenta is lifted out of the vagina slowly, with care, so that all of the membranes are drawn out with it. The placenta and membranes are kept for further evaluation. The uterus is massaged to ensure that it is well contracted, and the baby is put to breast if the mother wishes. The uterus is palpated frequently, and it is massaged when necessary. The baby is kept with the mother and observed for warmth, color, activity, and respiration. After delivery of the placenta, the perianal area is rinsed with warm sterile water and dried with a clean towel or cloth, and an ice pack and a sanitary pad or small towel are applied in such a way that the mother can hold them in place by drawing her legs together.
outcome criteria Almost all births are normal and do not constitute true medical emergencies. If a mother is healthy and is not bleeding, if her vital signs are normal, and if the fetal heart sounds are normal, there is no immediate cause for alarm, even if the birth is imminent. Emergency care is directed to ensuring that the newborn breathes well and is kept warm, that the mother is protected from hemorrhage, and that the mother's privacy is maintained. The nurse is likely to be the person who must initially evaluate the situation and decide whether to attempt to transfer or transport the mother or to prepare for emergency delivery. If a mother says the baby is coming, the attendant is advised to believe her and to act accordingly. Throughout the delivery and the third stage of labor, the nurse works to help the mother to feel calm, confident, and well cared for.