ICU Basics

Prehospital and transport

Field Delivery and Newborn Care Algorithm

Controlled birth, the first minute, then mother: dystocia and cord prolapse branches

Reviewed by Alex G, BSN, RN, CEN, CCRN, CMC, NREMT-P · From the Reference tab of the app

Each step lists what to do, then the choices that lead on. In the app the algorithm is tapped through one decision at a time.

1 Is birth imminent?

  • Signs: crowning or a part visible, urge to push or to move the bowels, the mother feels birth is coming (NASEMSO V3)
  • Ask: weeks of pregnancy, number of babies, prenatal care, bleeding, fluid color, drugs
  • Open the OB kit; prepare a warm area, towels, hat, bag-mask with a newborn mask, and suction

Crowning or pushing → step 2Labor, but birth not imminent → step 3Cord seen or felt before the baby → step 4A single arm or leg presenting → step 3

2 Controlled delivery

  • Support the head with gentle counterpressure so it does not pop out (NASEMSO V3)
  • Feel for a nuchal cord: slip it over the head; if too tight, double clamp and cut between the clamps (NASEMSO V3)
  • Do not routinely suction during delivery, even with a bulb (NASEMSO V3)
  • Guide the head down to deliver the anterior shoulder, then up for the posterior shoulder; deliver the body slowly and hold on: newborns are slippery
  • Breech: hands off until the trunk delivers, then support the body and never pull; if the head sticks, two fingers on the cheeks make a V to keep an airway (NASEMSO V3)

Head out, shoulders will not deliver → step 5Baby delivered → step 6

3 Transport now

  • Hypotensive before delivery: left lateral position, or manual left uterine displacement if she is supine (NASEMSO V3)
  • An arm or leg through the vagina means immediate transport to the hospital (NASEMSO V3)
  • Notify medical direction for breech, limb presentation, bleeding, or transport over 30 minutes (NASEMSO V3)

Birth becomes imminent → step 2

4 Cord prolapse

  • Gloved hand in the vagina: lift the presenting part off the cord and hold it there until hospital staff take over (NASEMSO V3)
  • Feel for cord pulsation; wrap the exposed cord in moist sterile gauze (NASEMSO V3); do not push it back
  • If that fails: prone knee-chest position, or steep Trendelenburg with hips raised (NASEMSO V3); high-flow oxygen for the mother (NASEMSO V3)
  • Emergent transport with prenotification

Birth happens anyway → step 6

5 Shoulder dystocia

  • Call for help; high-flow oxygen for the mother; notify the receiving hospital (NASEMSO V3)
  • McRoberts: hyperflex her hips, knees to chest (NASEMSO V3)
  • Firm suprapubic pressure, often by a second clinician; it allows delivery in up to 75% of cases (NASEMSO V3)
  • Angle the head toward the floor, but never pull on it; continue normally once the anterior shoulder is out

Shoulders delivered → step 6Still stuck: repeat and go → step 3

6 Term, good tone, breathing or crying?

  • Note the time of birth
  • While the cord is attached, keep the baby level with or below the mother, not higher (NASEMSO V3)
  • About 1 in 10 to 20 newborns needs help to transition (AHA 2025)

Yes to all three → step 7No to any → step 8

7 Routine care: skin to skin

  • Dry, cover the head, skin to skin on the mother, covered with dry linen
  • Defer cord clamping at least 60 seconds (AHA 2025: class 2a at term, class 1 under 37 weeks); then clamp twice about 5–6 inches from the abdomen and cut between (NASEMSO V3)
  • Keep the temperature 36.5–37.5 °C (AHA 2025)
  • APGAR at 1 and 5 minutes once stable; it does not guide resuscitation (NASEMSO V3)

Care for the mother → step 9

8 Warm, dry, position, stimulate

  • Dry, warm, keep the head covered; sniffing position; stimulate if breathing is ineffective (AHA 2025, 2a)
  • Suction mouth then nose only if the airway looks obstructed (NASEMSO V3); no routine suctioning, whether the fluid is clear or meconium-stained (AHA 2025, 3: No Benefit)
  • Cord, per protocol: intact cord milking may be reasonable in a nonvigorous baby of 35 weeks or more (AHA 2025, 2b); NASEMSO V3 clamps at once, or resuscitates first and clamps at 1 minute
  • Apneic, gasping or HR under 100 despite these steps: ventilation should start within 60 seconds of birth (AHA 2025, class 1)

Apnea, gasping or HR under 100 → step 10Labored breathing or persistent cyanosis → step 11Breathing well, HR 100 or more → step 7

9 Mother: placenta and fundus

  • The placenta usually delivers within 5–15 minutes; never pull on the cord; bag it and bring it (NASEMSO V3)
  • Fundal massage at about the umbilicus and early breastfeeding help the uterus contract (NASEMSO V3)
  • Oxytocin per protocol after the placenta: 10 units IM, or 10–40 units in 1,000 mL IV titrated to tone, max 40 units per 1,000 mL (Pitocin label)
  • Estimate blood loss; vital signs; transport mother and baby secured, keeping the baby warm

Heavy bleeding or a soft, boggy uterus → step 12

10 Positive pressure ventilation

  • Rate 30–60/min, inflation 0.5–1 second, peak pressure 20–30 cm H₂O, PEEP if available (AHA 2025)
  • Start with 21% oxygen at 35 weeks or more, 21–30% at 32–34 weeks, 30–100% under 32 weeks (AHA 2025)
  • Pulse oximeter on the right hand; ECG is the fastest accurate heart rate (AHA 2025)
  • A rising heart rate is the best sign the breaths are working; recheck the heart rate after 30 seconds of breaths that move the chest

HR 100 or more and breathing → step 11HR not rising or chest not moving → step 13HR under 60 after 30 seconds of ventilation that moves the chest → step 14

11 Labored breathing or cyanosis

  • Pulse oximeter on the right hand as soon as possible (AHA 2025, class 1; NASEMSO V3)
  • Oxygen only to reach the target: 2 min 65–70%, 3 min 70–75%, 4 min 75–80%, 5 min 80–85%, 10 min 85–95% (AHA 2025 algorithm)
  • Consider CPAP (AHA 2025 algorithm); keep warm; check glucose if resuscitation continues or the mother has diabetes (NASEMSO V3)

Apnea, gasping or HR under 100 → step 10Stable: care for the mother → step 9

12 Postpartum bleeding

  • Firm fundal massage; empty the bladder if possible
  • Two large-bore IVs, fluids for hypovolemia; blood products if approved by medical direction (NASEMSO V3)
  • Oxytocin if not given; consider TXA per protocol (NASEMSO V3; doses in the Postpartum Hemorrhage algorithm)
  • Emergent transport with prenotification; look for tears and retained placenta

End of this path.

13 Ventilation corrective steps

  • Reposition the head; adjust the mask or use a 2-handed mask hold (AHA 2025)
  • Suction mouth and nose; open the mouth
  • Raise the peak pressure within 20–30 cm H₂O (AHA 2025), avoiding excess pressure (3: Harm)
  • Alternative airway: laryngeal mask at 34 weeks or more (AHA 2025: 2a as an alternative to intubation, 2b as the first interface), or intubation per scope

Chest moving, HR rising → step 10HR under 60 after 30 seconds of ventilation that moves the chest → step 14

14 Compressions, 100% oxygen, epinephrine

  • Ventilate through an ETT, or a laryngeal mask at 34 weeks or more if a tube is not possible; 100% oxygen during compressions (AHA 2025)
  • ECG for heart rate; two-thumb encircling hands on the lower third of the sternum, above the xiphoid, one third of chest depth (AHA 2025)
  • 3 compressions to 1 breath (AHA 2025), 90 compressions and 30 breaths a minute (NASEMSO V3); switch compressors every 2–5 minutes at a heart rate check (AHA 2025)
  • HR still under 60 despite optimized ventilation and compressions: epinephrine 0.01–0.03 mg/kg UVC or IO with a 3 mL saline flush (AHA 2025, class 1), or 0.05–0.1 mg/kg by ETT while access is placed; repeat every 3–5 minutes (AHA 2025)
  • Still under 60: think hypovolemia (saline or blood 10–20 mL/kg, AHA 2025) and pneumothorax

HR 60 or more: stop compressions, keep ventilating → step 10HR still under 60 → step 14

Drugs in this algorithm

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