Editors

KatiTihtonen

AnitaVirtanen

KatjaOvaskainen

Management of Delivery Outside Hospital

When a baby is born unexpectedly outside hospital (at home, in a car, or at a primary care centre), the delivery is usually quick and uncomplicated. The baby is delivered spontaneously often without any special assistance for shoulders needed.

Do not hesitate to contact a maternity hospital and, as necessary, ask for advice.
Provide the mother as natural a position as possible and a warm space.
Clean underlay
Necessary equipment in clean condition (suction, haemostatic clamp)
Hand hygiene
Slow down the coming out of the presenting part (head) by supporting it with a hand, and at the same time, the other hand should support the perineal area.
In breech presentation, manual assistance not until only the shoulders and the head are undelivered

Dry the child. Remember to keep the child warm.
- Wipe the child with a soft cloth or towel as quickly as possible.
- The baby can be put on the mothers bare belly.
- Cover the baby with a blanket to keep it warm. Do not forget to observe the colour and the breathing rate (normally 40-70 times per minute).
Check the airways and clean them only if necessary by using suction under visual control. Routine airway suctioning is not recommended even for a newborn in poor health.

Limbs in good flexion, good muscle tone
Reacts immediately to stimulation.
Begins to breathe spontaneously or cries within 1 minute of birth.
- If required, respiration may be stimulated by lightly tapping the child's soles and by lightly rubbing the child's back along the spine.
The heart beats more than 100 times per minute.
The skin colour is reddish or only slightly bluish.

See table T1.
The scores are usually assessed at the age of 1 and 5 minutes. As necessary, the score is assessed at the age of 10 minutes and later if there is any abnormality in the newborn's condition.

Features evaluated	0 Points	1 Point	2 Points
Heart rate	0	<100	>100
Respiration effort	Apnoea	Irregular, shallow, or gasping respiration	Vigorous and crying
Colour	Pale, blue	Pale or blue extremities	Pink
Muscle tone	Absent	Weak, passive tone	Active movement
Reflex irritability	Absent	Grimace	Active avoidance

The umbilical cord is clamped with two sterile Kocher or equivalent instruments and cut using sterile scissors. The umbilical cord may also only be closed e.g. with a sterile thread and leave the cutting to be performed at hospital.
The stump is swabbed with antiseptic solution (e.g. chlorhexidine containing alcohol) and closed with rubber or plastic clamps in hospital. Outside hospital clean string or thread can be used.
For analysis of thyrotropin (thyroxin stimulating hormone, TSH), try to take a sample of umbilical blood from a umbilical vessel on the placental side with a syringe to a test tube or by letting the blood run directly into the tube after cutting of the umbilical cord.

If the child does not begin to breathe, is pale and limp, and if the pulse rate is less than 100 per minute on auscultation, resuscitation is needed.
- In the majority of cases ventilation with a mask (using air) is sufficient.
- Ventilation-compression ratio = 1 : 3
- Compress with two fingers perpendicularly towards the sternum at the level of the mamillae.
- Monitored with a pulse oximeter, the target oxygen saturation is 90-95%.

After delivery of the baby the mother is given 5 IU of oxytocin Prophylactic Oxytocin to Prevent Postpartum Haemorrhage intravenously or intramuscularly in order to stimulate uterine contraction and avoid excessive bleeding. If oxytocin is not available, it is important to support and rub the uterus by pressing on the fundus to suppress bleeding during transportation.
If the mother does not bleed there is no urgency to deliver the placenta, it can be delivered later by a midwife in hospital, as necessary.
If the placenta has been delivered and the mother is still bleeding, she is given more oxytocin Uterotonic Agents for Firstline Treatment of Postpartum Haemorrhage and the rubbing of the uterus is continued. An ice bag can be placed on the mother's abdomen.
If misoprostol tablets (200 µg) are available, contractions of the uterus can be enhanced by administering 4 tablets rectally.
Transfer to the hospital
- Call the hospital to ask for advice and to inform about your arrival.

[Resuscitation (newborn)]. Current Care Guideline. Working group appointed by Finnish Medical Society Duodecim, Finnish Perinatological Society's Subdivision of Neonatologists and Finnish Resuscitation Council. Helsinki: Finnish Medical Society Duodecim 2022 (accessed 18 Jan 2023). Available in Finnish at: http://www.kaypahoito.fi/hoi50065.
Ovaskainen K, Ojala R, Tihtonen K, et al. Unplanned out-of-hospital deliveries in Finland: A national register study on incidence, characteristics and maternal and infant outcomes. Acta Obstet Gynecol Scand 2020;99(12):1691-1699.