9-1-1; What Is Your Emergency?

Wednesday, February 25, 2015

Childbirth & the EMD: Instructions on Talking a Mother or Bystander Through Baby Delivery

Taken from Public Safety Communications Magazine, February 2015
Written by Stephen H. Reichman, Sr., involved in emergency communications since 1986.  He is currently superintendent of training at Bucks County Emergency Communications, located in the southeastern corner of Pennsylvania.  He has been an adjunct instructor for the APCO Institute for more than 11 years, is a contributing editor for the APCO CTO 4th and 5th edition curriculum and was in the first APCO EMD Instructor class in the early 1990s.

The birth of a child is a joyous event in the lives of new parents or parents of multiple children.  For the Emergency Medical Dispatcher (EMD), it can also be one of the most challenging, eventful and satisfying calls to handle.

After successfully verifying the location and dispatching responders, much of the call involves following the childbirth guidecards, as well as coaching the caller and those at the scene.  It is possible that the caller my be the mother who is about to give birth, or it could be a bystander(friend, family member, etc.) who will be responsible for following the telecommunicator's instructions.

Your agency has approved childbirth protocols to help you guide the caller through each step.  Adherence to the protocols will minimize confusion and create an environment where you can smoothly guide the process and maintain reasonable safety at the scene.  Understanding some background information about pregnancy and childbirth will enhance your ability to process this type of incident with proficiency.

Childbirth: A Momentous Event
Many people have faced an unexpected childbirth scenario, whether because the baby arrived prematurely or because the arrival was so sudden as to prevent the mother from safely being transported to a hospital.  The EMD is an integral part of this event to assist in the various aspects involved in emergency childbirth.

The reality in any childbirth event is that the mother does all of the hard work, but she needs the help of those around her for support and to help her work through one of the most difficult situations in her life.  The EMD and family member(s) or bystander(s) must work together to provide emotional support as well as basic first aid for the mother and baby.  The EMD's primary job is to get the whole team working together.

Verify the Location
One can never overstate the need for properly verifying the location of an emergency call, and this is the EMD's first order of business when responding to an emergency childbirth.  Obtaining the incident location is 95% of our job, and we have a stated need to get the right person, in the right type of response vehicle, in the right response mode, to the right place.  Any pre-arrival instructions (PAIs) we provide are just the icing on the cake.

If the telecommunicator fails to pay attention to location details, then help will be sent to the wrong location.  It is vital that we keep our guard up when verifying the location of the incident with the caller.  Always get verbal verification and make sure it matches up with your technology resources.  Identifying the location properly saves time and lives.  It is such a small step in the process, but it is the most important.

Additionally, the EMD needs to obtain the exact location of the mother and facilitate good scene management by getting the caller next to the mother in preparation for PAIs.  Doing this early on minimizes time delays caused by restaging the caller later, and puts the caller in a better position to visualize the situation for you.

Dispatch Criteria Determines Response Level
Remember that you need only one criterion to initiate a dispatch, but you will need to determine if the situation requires Advanced Life Support (ALS) or Basic Life Support (BLS).  Your local EMD/EMS protocols should be followed in each case.

As a simple guideline, verify the current status of:

  • ABC: If anything adversely affects the mother's Airway, Breathing and/or Circulation, dispatch ALS.
  • LOC: Any decreased, diminished or lowered Level of Consciousness indicates an underlying medical issue and requires the dispatch of ALS.
  • MOI: If there is significant Mechanism of Injury caused by some kind of trauma such as a motor vehicle accident, a fall, assault/violence, etc., dispatch ALS.
Pregnancy Trimesters
Pregnancy is a life condition, not an illness, and should be treated as such.  The medical events that occur during this  life event are what the EMD responds to and assists the mother with.  Pregnancy is a nine-month period divided into three, three-month phases referred to as trimesters.  Months 1-3 are the first trimester, months 4-6 are the second trimester and months 7-9 are the third trimester.  Our discussion revolves around the final stages of the third trimester.

As mother and baby advance through the trimesters, the severity of possible complications increases.  In addition, many factors come into play that can allow for early childbirth or imminent and precipitous childbirth situations, the two most common of which are miscarriage and premature birth.

Miscarriage is a spontaneous expulsion of the non-viable developing baby due to trauma or an unknown issue.  This can happen at any point in any of the three trimesters and has various levels of risk depending upon how far into the pregnancy the miscarriage occurs.

Premature births are births that occur before the baby's body is fully developed for birth at the normal time.  Doctors determine viability for premature births as those that have reached at least 24 weeks of gestation.  Premature birth requires intensified care to assist the baby in reaching physical maturity outside of the womb.  Specialized neonatal (newborn) care is vital for the baby's survival.

Active Labor & Transition
When a mother's body is readying for the delivery of the baby, the uterine muscles contract and relax at intervals that will cycle at quicker rates as labor progresses.  Increasingly intense pain accompanies the contractions.  The muscle contractions will periodically cease, which gives the mother time to regroup her strength for the next set of contractions.

Timing between the contractions helps to identify if the birth is imminent of not.  The active contractions phase is called "active labor."  When the mother's body has adjusted the baby into position for delivery, the muscles will contract at a heightened level with intense pain so as to encourage the mother to push and complete the delivery of the baby.  During this time, mothers are often close to the edge of their willingness to participate in the process and need to be encouraged and coached through this phase, which is called "transition" (i.e., the transition from labor to delivery).  During transition, positive reinforcement; calm, clear, respectful and sometimes firm tone of voice; and repetitive persistence will be the strategies of choice.

Complications by Trimester
In addition to active labor and delivery, telecommunicators should be prepared for a number of complications that can occur unexpectedly throughout pregnancy.  First and second trimester complications include:
  • Miscarriage: bleeding and other complications may indicate miscarriage and may not present as something related to the pregnancy.  If there appears to be no relationship between the bleeding and pregnancy, or the caller's chief complaint differs from pregnancy, use the appropriate guidecard.  The EMD determines severity, dispatches the appropriate response and provides PAIs accordingly.
  • Vaginal bleeding and other gynecological complaints should be handled by using the appropriate guidecard.  Again, determine severity and dispatch the appropriate response vehicle providing any necessary PAIs.
Third Trimester complications may include:
  • Imminent or precipitous birth: Imminent birth involves labor pains less than two minutes apart.  Precipitous birth means that the birth comes extremely fast; that is common for women who have had multiple children.
  • Arms, hands or feet presentations (breech): In this situation, the EMD should instruct the mother (or have a family member or bystander instruct the mother) to get into a position on her hands and knees to use gravity to maintain the baby's current position and remove some of the pressure off of the mother's lower back.  On her knees, the mother can also place her arms and head down on a pillow with her hips upright.  Instruct the mother to take slow, deep breaths to help her remain calm.  Instruct her not to push.
  • Umbilical cord presentation: If the baby's head or neck gets tangled in the umbilical cord during delivery, the EMD should instruct the caller to carefully remove the cord from around the baby's neck.  If the cord presents before the baby, instructions will be similar to those given in a breech situation.
  • Placenta previa: This is a condition in which the placenta has grown over the opening of the uterus.  When dilation occurs, it causes broken blood vessels and bleeding.  This is a true medical emergency and treatment for shock is paramount.  EMDs should instruct the caller to have the mother lay on her left side with her legs and feet elevated if possible.
The Roles of Those Involved in Emergency Childbirth
The mother and baby are the focal point of this event.  Together as a team they are working to bring new life into the world.  Whatever we do will be based upon what is best for 1)the mother, and 2) the baby.  Once delivery is complete, the EMD has two patients who will need to be cared for.  Never forget that the mother is doing all the hard work, we are just assisting.

If the caller is a bystander (not the mother herself), that person is your on-scene source of information and should be called upon to perform the actions necessary to assist and care for the mother and baby.  This caller must also work to ready the scene for the arrival of emergency responders.

It is not unheard of for a young child to call 9-1-1 for his or her mother while she is in labor.  Always be prepared for any type of caller.  Your ability to coach them through with encouragement will make the difference.  Make sure to clearly articulate your questions and your instructions and, if necessary, ask them if they are OK with the instructions to verify understanding.  Repeat a question or instruction to ensure you get things right.

The EMD is the primary response person -- the first person from emergency services to have contact with the scene.  Their primary responsibility is to ensure that EMS is dispatched to the correct location and provide updates on the incident.  Remote scene management is also a large part of the responsibility, ensuring the caller is with the patient and that emergency services can access the patient.  In addition, the EMD is the primary coach for the caller (family, friends or bystanders), providing vital PAIs to assist in caring for the mother and baby.

As well as helping the mother and baby, another skill that comes in to play is high-performance coaching.  The EMD assists the caller with emotional support through the use of effective verbal techniques, proper use of the guidecard and verbal encouragement while they are performing the basic skills to help the mother during the birth.  The EMD understands various caller emotional phases and overcomes them with the proper techniques.

The EMS responder and emergency room personnel round out this extraordinary team of people who will ensure the mother and baby are taken care of after the 9-1-1 call is complete.

Pre-Arrival Instructions for Childbirth
Your agency has developed PAIs and protocols that best work for your region and comply with the basic PAI standard.  The EMD should always stick to the guidecard and provide the information located there as necessary.  Appropriate voice tone and clarity of wording is important to properly deliver the instructions.  Some wording on APCO's childbirth guidecard is in bold typeface, which means this word should be emphasized and articulated clearly to the caller.

Childbirth PAIs are divided into three main sections: Labor; Imminent or Active Delivery; Complications; and Labor:Non-Imminent Delivery

Labor: Imminent or Active Delivery -- follow these instructions when contractions are less than two minutes apart, the mother has a strong desire to push, the caller reports crowning of the baby's head, etc.  Throughout the call, periodically encourage the caller or mother that help has been dispatched and that you will stay on the line.

If the mother is in the bathroom, encourage her to stay off the toilet.  Instruct the mother to lay flat on her back on a bed or the floor and to try to relax by taking slow, deep breaths through her mouth.  Instruct the mother to remove her clothing below the waist and to bend her knees. (Keep in mind the environment the mother is in and try to ensure some amount of privacy is provided.)

Continue by having the caller or a bystander place a clean towel under her buttocks and have additional towels ready, if available.  Prepare the caller or birth assistant by letting them know what is going to happen:
  • The baby's head will deliver first, usually.  Careful support of the head is required as he or she is delivered.  Never pull on the baby, only support it.
  • If leg, arm, buttocks or umbilical cord is presented first, you will need to refer to the complications section of the guidecard.
  • If the umbilical cord is around the baby's neck, instruct the caller to carefully and gently slip the cord over the baby's head with their fingers.
  • Let them know there may be some water and blood with the delivery and that this is normal.  Excessive bleeding should be reported back to you.
  • The rest of the baby's body should deliver with the next few contractions.  Make them aware this could happen quickly and be ready to continue to support the baby.
Once the baby is delivered, instruct the caller to clean out the baby's mouth and nose with a clean, dry cloth to ensure a clear airway.  Then have them wrap the baby in a warm, dry blanket or towel.  Instruct them not to pull on or cut the umbilical cord.  If the baby is not breathing or crying on its own, they should rub its back or gently slap the bottoms of the baby's feet to stimulate a response such as breathing and crying.  If there is no response then you will need to go to the infant CPR guidecard for the appropriate PAIs.

If all is well, tell the caller to keep the baby warm and place the baby between the mother's legs.  This is lower than the placenta and mother's heart and will protect the baby's blood flow (the baby continues to receive blood flow from the mother when still connected to the placenta).  The mother may want to lie on her left side and have the baby lay next to her.  This is fine and helps to keep the baby below the mother's heart level and at or below the level of the placenta for proper blood flow.  Contractions may again start up when the placenta is delivered.  Again, this is normal and will also involve water and blood.  Always keep the baby at the same level as the placenta.

The EMD now has two patients, monitoring both for normal breathing is important.  If there is any excessive bleeding by the mother, have her lie on her left side and elevate her legs and feet slightly.

Complications -- as previously discussed, the instructions for complications are simply to encourage the mother to get up on all fours (hands and knees) and have her try to relax by taking slow, deep breaths.  Be sure to instruct her not to push.  Let the caller know that help is on the way and you are staying on the line.

Non-Imminent Delivery -- refer to this section of the guidecard if the caller does not indicate imminent birth (no crowning, contractions greater than five minutes apart, no urge to push, etc.).  Instruct the caller to have the mother lie in a comfortable position of her left side.  According to the online parenting resource KidsHealth, lying on one side eases stress on the mother's heart because it keeps the baby's weight from applying pressure to the large vein -- the inferior vena cava -- that carries blood back to the heart from the feet and legs.

Some doctors specifically recommend that pregnant women sleep on their left side throughout pregnancy.  Because the liver is on the right side of the abdomen, lying on your left side helps keep the uterus off that large organ.  Sleeping on the left side also improves circulation to the heart and allows for the best blood flow to the fetus, uterus and kidneys.

Tips for Caller & Patient Care
Verbally indicating respect and exhibiting a calm, competent voice tone and demeanor is important on every 9-1-1 call, especially during a childbirth event.  Always remember to treat the caller and mother the same way you would like to be treated if you were in similar circumstances.  This seems to be universally understood, but you as the EMD need to actively make it happen.

For the mother, this whole experience revolves around her.  Create an environment that exhibits calm, action and confidence by encouraging the caller to communicate what is going on each step of the way.  Always emphasize that your instructions are "to help the mother with the delivery," "to do this for the mother" and that you are there in support and will stay on the line until medical responders take over.

The caller will need you to be patient and respectful, so speak articulately and clearly.  The caller's emotions could be just about anywhere on the emotional spectrum, so be ready to adjust to their emotional presentation.  You may need to be firm yet respectful, or you may just need to be direct by reading the PAIs directly from the card.  You may need to use calming techniques (i.e., have them pause and take a deep breath or two to reboot), including using repetitive persistence to provide instructions.

Once the baby is born, work with the caller to help you monitor both the mother and the baby, periodically checking to make sure they are breathing normally, etc.  Be a positive coach and tell them often they are doing a great job.  Have the caller also tell the mother she is doing a great job.  Keep the team energized with positive words and positive voice characteristics, and provide reassurance that help is on the way.

Childbirth events can be some of the most challenging yet satisfying calls the EMD may handle.  Understanding the basic information on pregnancy and childbirth will help prepare the EMD to handle the call with confidence.  The EMD role is central to a smooth handling of the 9-1-1 caller and managing the scene for the mother's and newborn's comfort and safety.  Adherence to the childbirth guidecard protocols in combination with positive and professional caller interaction will help to bring the event to a proper conclusion and a new life into the world.

No comments:

Post a Comment