8. Nurse-attended emergency birth (precipitate birth). When woman presents without prenatal care to emergency department, may represent drug abuse.
   IMMINENT BIRTH
   1. Assessment: identify signs of imminent birth:
      1. Strong contractions.
      2. Bearing-down efforts.
      3. Perineal bulging; crowning.
      4. Mother states, “It’s coming.”
   2. Analysis/nursing diagnosis:
      1. Pain related to:
         1. Strong, sustained contractions.
         2. Descent of fetal head.
         3. Stretching of perineum.
      2. Anxiety/fear related to imminent birth.
      3. Ineffective individual coping related to circumstances surrounding birth; anxiety, fear for self and infant.
      4. Injury related to lacerations (vaginal, perineal).
      5. Fluid volume deficit related to:
         1. Lacerations.
         2. Uterine atony.
         3. Retained placental fragments.
      6. Impaired gas exchange related to intact membranes after birth.
      7. Risk for injury related to:
         1. Precipitate birth.
         2. Trauma.
         3. Hypoxia.
   3. Nursing care plan/implementation:
      1. Goal: reduce anxiety/fear-reassure mother.
      2. Goal: delay birth, as possible.
         1. Discourage bearing-down efforts.
         2. Encourage panting.
         3. Side-lying position to slow descent and allow for more controlled birth.
      3. Goal: prevent infection.
         1. Provide clean field for birth.
         2. Avoid touching birth canal without gloved hands.
         3. Support perineum (and advancing head) with sterile (or clean) towel.
      4. Goal: prevent, or minimize, infant hypoxia and perineal lacerations.
         1. If membranes intact as head emerges, tear at neck to facilitate first breath.
         2. Feel for cord around neck (if present, and if possible, slip cord over head; if tight, and sterile equipment at hand, clamp cord in two places, cut between clamps, unwrap cord). If unsterile environment, keep fetus and placenta attached-do not cut cord.
      5. Goal: facilitate/assist birth.
         1. Hold head in both hands.
         2. Apply gentle downward pressure to bring anterior shoulder under pubic symphysis.
         3. Gently lift head to ease birth of posterior shoulder.
         4. Support infant as body slips free of mother’s body.
      6. Goal: facilitate drainage of mucus and fluid -> patent airway.
         1. Hold infant in head-dependent position.
         2. Clear mucus with bulb syringe (if available), or use fingertip, wipe with towel.
      7. Goal: prevent placental transfusion-hold infant level with placenta until cord stops pulsating, clamp and cut.
      8. Goal: prevent chilling.
         1. Wrap infant in towel or other clean material.
         2. Place infant on side, head dependent, on mother’s abdomen.
         3. Dry head, cover with cap or material.
      9. Goal: stimulate respiration. If neonate fails to breathe spontaneously:
         1. Maintain body temperature-dry and cover.
         2. Clear airway
            1. Position: head down.
            2. Turn head to side.
         3. Stimulate.
            1. Rub back gently.
            2. Flick soles of feet.
         4. If no response to stimulation:
            1. Slightly extend neck to “sniffing” position (head tilt-chin lift method).
            2. Place mouth over newborn’s nose and mouth and exhale air in cheeks, saying “ho” (prevents excessive pressure).
      10. Goal: begin cardiopulmonary resuscitation (CPR) if no heart rate.
          1. Place infant on firm, flat surface.
          2. With two fingers on sternum depress ‘A-’A inch 100 times/min.
          3. Assist ventilation on upstroke of every fifth compression (5:1 ratio).
          4. Go immediately to emergency department.
      11. Goal: maintain infant’s body temperature.
          1. Wrap placenta with baby, if cord intact.
          2. Place infant in mother’s arms.
   PLACENTAL SEPARATION
   1. Assessment-third stage: identify signs of placental separation.
   2. Nursing care plan/implementation:
      1. Goal: avoid/minimize potential for complications (everted uterus, tearing of placenta with fragments remaining, separation of cord from placenta).
         1. Avoid traction (pulling) on cord.
         2. Avoid vigorous fundal massage.
         3. Discourage maternal bearing-down efforts unless placenta visible at introitus.
         4. With fundus well contracted, and placenta visible at introitus, encourage mother to bear down to expel placenta.
      2. Goal: prevent maternal hemorrhage (uterine atony).
         1. Encourage breastfeeding, or stimulate nipple.
         2. Gently massage fundus, support lower part of uterus, and express clots when uterus is contracted.
         3. Encourage voiding if bladder is full.
         4. Get to a medical facility.
      3. Goal: encourage bonding/stimulate uterine contractions. Encourage breastfeeding.
      4. Goal: legal accountability as birth attendant. Record date, time, birth events, maternal and fetal status.
   3. Evaluation/outcome criteria:
      1. Experiences normal spontaneous birth of viable infant over intact perineum.
      2. Uncomplicated fourth stage-status satisfactory for both mother and infant.
      3. Expresses satisfaction in management and result.