UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES

MEDICAL CENTER

PROCEDURE

 PROCEDURE:                                    126
EFFECTIVE:                                   9/94
REVISION:                                   1/00
APPROVED:                                8/05

PROCEDURE FOR UNEXPECTED VAGINAL DELIVERY IN THE CLINIC SETTING IN THE ABSENCE OF A PHYSICIAN

PURPOSE: To provide a standard for clinic nurses to perform a vaginal delivery in the clinic setting while waiting for an ambulance or physician to arrive

SUPPORTIVE DATA:

  1. In the event of a patient in labor with delivery imminent, 911 should be called to transport the patient (and infant if patient already delivered) to the hospital.

EQUIPMENT:

  1. BIB pack (2 absorbent towels, sterile drape, two kelly clamps, cold clamp, scissors)
  2. Doptone
  3. Sterile gloves, if time allows
  4. Sterile gown, if time allows
  5. Warm blankets, if available
  6. Bulb syringe
  7. 4 X 4" gauze sponges

NURSING ACTION:

PROCEDURE STEPS:

  1. If possible, put patient onto exam table with hips elevated or leave on floor, but elevate hips. Maintain patient privacy.

KEYPOINT: At the time of delivery there needs to be room for delivery of infant’s shoulders.
  1. Wash and glove hands. Place sterile barrier under woman’s hips and if possible cleanse perineum.

KEYPOINT: It is not necessary to provide totally sterile field, but cleanliness is important.
  1. Observe perineum for bulging of rectum.
    2.

KEYPOINT: Head is down in pelvis and crowning will occur soon.
  1. Have patient pant during contractions, maintaining flexion on baby’s forehead and control delivery of head. Support perineum with sterile towel or 4 X 4’s.

KEYPOINT: The urge to push is greater with contractions. It is easier to control delivery of baby’s head if she pants. Guarding perineum helps prevent laceration.
  1. Observe to see if bag of water is intact over baby’s head. Use fingers or kelly clamp if necessary to rupture membrane over the baby’s head or to tear away from baby’s face.

KEYPOINT: This prevents aspiration of fluid at birth.
  1. Check for nucal cord and if present, slide over baby’s head or double clamp and cut.

KEYPOINT: If present, this may impede progress.
  1. Following the birth of the baby’s head and prior to the delivery of the shoulders, wipe mucous from mouth and face and then suction baby’s mouth and nose.

KEYPOINT: Airways need to be clear to allow spontaneous respirations and crying.
  1. Observe for restitution of the baby’s head.

KEYPOINT: Baby’s head will turn in alignment with its back.
  1. Deliver anterior shoulder by holding baby’s head on either side with your hands and apply gentle downward traction while mother pushes. Once the anterior shoulder is delivered, gentle upward traction is applied to deliver posterior shoulder.

      KEYPOINT: Keeping the fingers out of baby’s face and off the neck reduces the risk of trauma to baby.
  1. After shoulders deliver, support baby with lower hand. As baby delivers, slide upper hand down the back to grasp the feet. Hold baby with head lower than feet to facilitate drainage of airway.

KEYPOINT: At delivery, babies are very slippery and wet; a firm hold must be maintained.
  1. Double clamp and cut cord.
  2. Quickly dry baby and wrap baby (including head) in warm blankets and place on mother's chest or abdomen. Check for spontaneous respirations and heart rate. Assure baby is well-oxygenated by observing pink color, spontaneous respirations and heart rate >100.

KEYPOINT: Keeping baby warm and dry is essential to avoiding temperature loss and cold stress.
  1. While waiting for placenta to separate, observe for any obvious tears and lacerations and if present, apply pressure with sterile gauze to control bleeding.
  2. Observe for signs of placental separation:
    1. Lengthening of the cord
    2. Sudden gush of blood
    3. Change in shape of the uterus

Do not massage the uterus prior to placental separation.

KEYPOINT: Placental separation may take up to thirty minutes. Forceful removal of the placenta prior to separation can cause incomplete separation and hemorrhage.

  1. Deliver placenta by having mother push gently (if she gets the urge) and apply gentle traction on the cord with one hand and cup the other hand above the symphysis pubis to "guard the fundus."

      KEYPOINT: During delivery of the placenta, the fundus is "guarded" to prevent the uterus from inverting.
  1. Following delivery of placenta, administer 10 units of Oxytocin into anterior thigh. (Requires physician's order.)

KEYPOINT: Pitocin contracts the uterus and thus controls bleeding.
  1. Observe perineum and labia for bleeding and tears. Apply sterile gauze and pressure.

KEYPOINT: The uterus will contract with adequate massage and reduce bleeding.

Special Considerations:

  1. During delivery, fetal heart tones should be monitored after every contraction.
  2. Mother’s blood pressure should be monitored q 15 minutes X 1 hour after delivery.
  3. If extra staff is available at delivery, time of birth of both baby and placenta should be observed.
  4. Baby’s heart rate, color, respiration, reflexes and tone should be noted at 1 minute and at 5 minutes. An Apgar score can be assigned later. The heart rate should be more than 100 bpm, but may be 160-180 bpm in the first 30 minutes. The respirations are frequently irregular and 60-80/min with brief moments of apnea.
  5. After delivery, mother’s pulse, respiration and blood pressure should be monitored every 15 minutes. Temp only once.

REFERENCES:

Delivery in the Absence of Primary Care Provider, Marjorie T. McManus, RN, MS, CNM

RESOURCE PERSON(S):   Joni Yarnell, RNP, CNM; Mary Lawrence, RN; Marie Patterson, RN, BSN, MA; Nancy Andrews, M.D.


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