The physiological process by which the fetus, placenta and membranes are expelled through the birth canal.
- Spontaneous onset between 37 and 42 weeks gestation.
- The progress of labour is within acceptable time limits.
Signs of imminent birth
- Increasing frequency and severity of contractions (3-5 contractions in a 10-minute period)
- Urge to push or open bowels
- Bulging perineum/anal pouting
- Crowning/presentation of part of the baby
- Spontaneous rupture of membranes can occur during the 1st or 2nd stage of labour
- 1st Stage from the start of labour until the cervix is fully dilated (several to many hours).
- 2nd Stage full dilation of the cervix until the birth of the baby (few minutes to 2 hours).
- 3rd Stage after birth of the baby until the placenta and membranes have delivered (few minutes to an hour).
- 4th Stage the first few hours after birth
- Consider vehicle for back-up.
- Be prepared to stop the vehicle for delivery.
- Fentanyl is not recommended if the mother is in active labour, and may cause respiratory depression in the newborn.
- Suction is not routinely recommended with newborns and may cause bradycardia and airway damage. Only suction if there is a clear indication for its use (e.g. meconium or blood clots in airway). Refer to Airway Suction clinical skill.
- Primary Survey
- Offer continuous support and reassurance
- Position patient appropriately in a position of comfort (avoid supine positioning due to aortocaval compression)
- Perform maternal vital sign survey
- Consider oxygen if indicated as per CPG
- Apply cardiac monitor if trained and authorised
- Consider pain relief; methoxyflurane is not contraindicated in labour, and should only be withheld if the mother gets too drowsy
- Consider anti-emetic
- Exclude cord prolapse
- Assess stage of labour, if birth imminent, prepare for delivery guidelines adjacent, and as per Childbirth clinical skill
- Do not attempt delivery of malpresentation unless imminent
- Do NOT pull on the cord
- Prepare for newborn resuscitation
- Monitor patient persistently, recording full observations every 10 minutes (or 5 minutes if time critical)
- Transport Priority 1 if patient time critical, pre-notifying receiving facility
- Apply cardiac monitor
- Establish vascular access
- Consider pain relief; methoxyflurane is not contraindicated in labour, and should only be withheld if the mother gets too drowsy
- Consider anti-emetic
- Exclude cord prolapse
- Assess stage of labour, if birth imminent, prepare for delivery guidelines adjacent, and as per Childbirth clinical skill
- Do not attempt delivery of malpresentation unless imminent
- Do NOT pull on the cord
- Prepare for newborn resuscitation
- Monitor patient persistently, recording full observations every 10 minutes (or 5 minutes if time critical)
- Transport
- Priority 1 to nearest obstetric unit if patient time critical
- To booked obstetric unit if patient stable
- Pre-notify receiving facility in both circumstances
- As per Advanced Care guidelines
Management of active labour
1st Stage Labour
- Observe all maternal vital signs
- Assess stage of labour, if birth imminent, prepare for delivery as per Childbirth clinical skill
Care of the Newborn
- Record time of delivery
- If the amniotic sac remains intact, gently break it open with your fingers. Allow the baby to deliver in the sac completely before breaking, as this can stimulate the baby to breathe early.
- Stimulate the baby to induce crying e.g. rubbing towel on the baby’s back.
- Place the baby onto the mothers abdomen and encourage skin to skin contact.
- Place a dry towel on top and allow the baby to suckle to assist with the release of oxytocin and delivery of the placenta
- Assess APGAR at 1 minute, 5 and 10 minutes after birth
- The cord does not need to be cut in the prehospital setting, unless the baby or mother requires immediate intervention. Delayed cord clamping can improve the baby's blood volume and reduce the risk of anaemia. Maximum benefits have been achieved by 3-4 minutes.
- Should immediate intervention be required, clamp and cut the umbilical cord with two cord clamps. Place the first clamp 4 fingers from the baby’s body, place the second 2 fingers from the first clamp. Wait for the cord to stop pulsating and cut the cord in between the 2 clamps. If bleeding present, apply a third clamp.
- Refer to Newborn Life Support CPG.
3rd Stage Labour
- Apply pad to vagina and ensure no excessive blood loss has occurred. Refer to CPG Post Birth Complications
- Suckling of the newborn will induce the delivery of the placenta. The mother will experience the same contractions as with delivery of the baby
- Do not try to deliver the placenta, and never pull the cord
- Encourage the mother to push when she feels the need to birth the placenta
- If the placenta delivers spontaneously, place in a biohazard bag and transport with the mother
- Do not delay transport for delivery of placenta - it is normal for the placenta to take up to 1 hour to deliver after the birth
- Cover mother and keep warm
- Monitor mother and baby en route to hospital
- Newborns are at risk of hypothermia, skin to skin contact is strongly recommended. Ensure the baby is kept warm with blankets and the van heating is turned on. Consider baby bonnet if available
APGAR:
| Sign | 0 Points | 1 Point | 2 Points | |
|---|---|---|---|---|
| A | Appearance (Skin Colour) | Blue-gray, pale all over | Normal, except for extremities | Normal over entire body |
| P | Pulse | Absent | Below 100 bpm | Above 100 bpm |
| G | Grimace (Reflex Irritability) | No Response | Grimace | Sneeze, cough, pulls away |
| A | Activity (Muscle Tone) | Absent | Arms and Legs Flexed | Active Movement |
| R | Respiration | Absent | Slow, irregular | Good, crying |
Potential complications:
- Haemorrhage during pregnancy
- Pre term labour
- Pre-eclampsia/Eclampsia
- Shoulder dystocia
- Breech presentation
- Cord prolapse
- PPH
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