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Green Fluid, Imminent Delivery, 25 Minutes From Anywhere

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Green Fluid, Imminent Delivery, 25 Minutes From Anywhere

You are dispatched to a rural home 25 minutes from the nearest hospital. A 31-year-old woman at 39 weeks says her water broke 20 minutes ago and she feels like she needs to have a bowel movement. She is on her bed on her hands and knees and says the baby is coming. She has had two previous vaginal deliveries. On examination you see the baby's head crowning and thick greenish-black staining of the fluid on the sheets. Her contractions are about 2 minutes apart and she is pushing involuntarily. She is alert, blood pressure 128/78, pulse 100. The ambulance is outside and you are the only EMS crew on scene.

1. Do you package and drive, or do you stay and prepare to deliver? Defend your answer.

Read the worked answer

You stay and prepare to deliver. Driving is not an option.

The reasoning:

  • The head is crowning. Delivery is minutes away, not 25 minutes away.
  • She is a multip with two prior vaginal deliveries - later babies come faster, and the urge to push is involuntary.
  • Contractions 2 minutes apart plus the urge to have a bowel movement is the classic description of a baby on the perineum.

If you load her, you deliver in a moving ambulance with no room to work and no extra hands - a worse environment for mother and newborn than a bed with light and space.

Preparation instead:

  1. Call for a second crew or ALS - do this early, even though they will arrive late. Say crowning and meconium on the radio.
  2. Gloves, eye protection, towels, bulb syringe, cord clamps, blankets, a hat for the baby.
  3. Position her however she is comfortable - hands and knees is acceptable; side-lying or semi-sitting also works.
  4. Support the perineum and let the head deliver slowly with her pushes. Do not pull on the head.
  5. Keep the room warm and the baby warm - newborns lose heat fast.

Plan to transport mother and baby together after delivery.

2. What does the greenish-black fluid mean, and how does it change what you do at the moment the head delivers?

Read the worked answer

It is meconium-stained fluid - a sign the baby passed stool before birth.

Why it matters:

  • The baby may have inhaled meconium. Meconium is sticky and irritating and can block small airways, so the baby may need help clearing it and may not breathe well at birth.
  • It changes a normal delivery into a delivery that needs a suction-ready, airway-focused approach.

What changes at delivery of the head:

  1. Do not rush the delivery of the body. Let the head deliver, then wipe the face and suction the mouth first, then the nose, with a bulb syringe - mouth before nose so the baby does not gasp through the nose and inhale more.
  2. Suction gently and only what you can see near the airway. Do not probe deeply - that causes swelling and vagal slowing.
  3. Do not stimulate or dry vigorously before the airway is cleared.
  4. Check for a nuchal cord - if the cord is wrapped around the neck and loose, slip it over the head; if tight, leave it and deliver the body, then deal with it.
  5. After delivery, dry, warm, stimulate, and assess breathing. If the baby is not breathing effectively, begin newborn support with a BVM and request the highest level of help available.

Expect a baby who needs more airway attention than a clear-fluid delivery, and tell the receiving facility about the meconium on arrival.

3. The head delivers, but with the next contraction the shoulders do not come out and the head appears to retract. What do you do?

Read the worked answer

This is a shoulder dystocia. Do not pull on the head - that is the one thing that causes harm here.

What you are seeing: the head delivered but the shoulders are stuck behind the pubic bone, and the head retracting against the perineum is the classic sign.

Actions, in order:

  1. Tell her to stop pushing. Pushing drives the shoulders harder into the blockage.
  2. McRoberts position - bring her knees up and back toward her chest, flattening the bed if you can. This alone resolves many cases.
  3. Suprapubic pressure - one rescuer presses firmly on the lower abdomen just above the pubic bone, angled to dislodge the shoulder. Never press on the fundus (the top of the uterus).
  4. Do not pull on the head or twist the neck. Support it and let it be.
  5. Call for help and get moving toward definitive care as soon as the baby is out. Shoulder dystocia is an obstetric emergency with a short clock.
  6. Keep talking to her. She will be frightened and may be told to push by people around her - your voice needs to be the one she follows.

If the maneuvers fail, you keep the position, keep the pressure, and get the patient to a delivery room as fast as is safe. Document the time the head delivered and the maneuvers used.