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INTRODUCTION

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Babies have been born for millions of years without EMS intervention. This is one “emergency” that almost always turns out well. The CDC reported that, in 2009, there were 4,130,665 births in the United States (a birth rate of 13.5 per 1000 population), with 1.1% delivered out-of-hospital. The percent born preterm (<37 weeks' EGA) was 12.2%, and the percent born at a low birth weight (<2500 g) was 8.2%. In the United States, the overall infant mortality was 6.9 per 1000 live births, but 183.2 per 1000 babies born prior to 32 weeks' EGA.1

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PROCEDURES

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  • Assessment of prehospital delivery likelihood

  • Delivery (uncomplicated)

  • Complicated delivery

    • Shoulder dystocia

    • Breech delivery

    • Umbilical cord prolapse

    • Uterine inversion

    • Postpartum hemorrhage (PPH)

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ASSESSMENT OF PREHOSPITAL DELIVERY LIKELIHOOD

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Ascertain the obstetric history (gravida and parity) using the GNPTPAL numbering system. N is the total number of pregnancies; T is the number of term births (multiples, eg, twins only count as one birth); P is the number of preterm births (<37 weeks); A is the number of abortions (<20 weeks), and L is the total number of children who lived at least 28 days. Next, determine the estimated gestational age (EGA) of tis fetus in weeks—most accurately by a previous ultrasound, by dates from LMP, or distance from the symphysis to the fundus in centimeters (modestly accurate in the 20- to 36-week range; inaccurate in case of multiples, poly- or oligohydramnios).

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Ascertain the presence of contractions (ctx), their time of onset, duration, and interval frequency. Stage 1 (from onset of labor to full cervical dilation) in a primiparous woman takes an average of 10 hours (95% complete by 25 hours); for a multiparous woman, the mean is 8 hours (95% by 19 hours). Stage 2 (full cervical dilation to delivery of the neonate) for a primiparous woman takes an average of 33 minutes (95% by 118 minutes); for a multiparous woman, a mean of 9 minutes, with 95% delivered by the end of 47 minutes. Primiparous women are likely to deliver when contractions are 3 to 5 minutes apart and last 40 to 90 seconds, increasing in strength and frequency for at least an hour. Delivery is imminent if contractions are 2 minutes or less apart, especially for a multiparous woman.2

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Assess anticipated difficulties with prehospital delivery and/or need for neonatal resuscitation: preterm (<37 weeks' EGA; 12.18% in 2009), multiples (In 2009, twins occurred 33.2 times per 1000 births, triplet and higher order multiple birth rate was 1.53 per 1000 births), anticipated abnormal presentation/lie, lack of adequate prenatal care (none or first visit at >3 months' EGA; 6.6% of desired pregnancies, 14.5% of mistimed or unwanted pregnancies in 2002),3 placenta previa (2.8 cases per 1000 singletons, 3.9 cases per 1000 twin pregnancies),4 poly- or oligohydramnios, the presence of a cerclage, or the anticipated need for Cesarean section. A cerclage is a stitch that holds the cervix closed. It is commonly placed in a woman who has a weak (incompetent) cervix that tends to dilate. The stitch works to hold the cervix closed, thus keeping dilation from occurring and preserving the pregnancy. Cervical cerclage is temporary and is removed before delivery of the infant. If labor progresses with it present, the stitch can cause cervical lacerations and hemorrhage. Rarely, a transabdominal cerclage is placed—this is permanent and all infants must be delivered via C-section. The cesarean delivery rate in 2009 was 32.3% of all births. Half of the women aged 40 and older (49.5%) delivered by cesarean compared with less than one in four women under age 20 (23.1%). This is also the case among women having singleton births (older women have higher rates of multiple births, which are more likely to be delivered by cesarean.

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