Below umbilicus (fetus unlikely viable if delivered)
At umbilicus (~22wk)
Above umbilicus
Prolapsed cord visibleunassessed
Cord prolapseObstetric emergency — nearest obstetric unit or nearest ED if severe, pre-alert immediately.
Imminent Birth?
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JRCALC
Signs of Imminent Birth
Stay & prepare to facilitate birth on scene if: regular contractions (1–2 min intervals) AND (urge to push/bear down OR head visible & advancing through vaginal entrance — consent + observe during a contraction).
Regular contractions, 1–2 min intervalsunassessed
Urge to push / bear downunassessed
Head visible & advancing (may recede between contractions — normal)unassessed
Birth imminent
Stay on scene. Proceed to Birth Management. Call for help — at least one paramedic clinician should be present per local procedure. Consider critical care escalation if high-risk pregnancy.
Birth not imminent
Any patient with contractions requires fetal monitoring — recommend conveyance by ambulance. If planned home birth, request midwife per local guidelines.
Continuous Dynamic Assessment
If staying on scene with no progress (same amount of presenting part visible) after 10 minutes → prepare to extricate, time-critical transfer to nearest obstetric unit, pre-alert.
10-minute progress check
10:00
Not started
Birth becomes imminent en-route
Pull over and stop the ambulance. Follow Birth Management below. Call for additional resources per local guidelines. Consider critical care if high risk. It is not necessary to wait for the placenta before continuing conveyance — proceed to nearest appropriate destination, pre-alert.
Birth Management
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JRCALC
Initial Steps
Call for help — enough resources per local procedure; ≥1 paramedic present
Consider critical care escalation if high-risk pregnancy
PPE applied, universal precautions
Team introduced, rapport established with patient/family
Lead clinician identified — for patient and for each expected baby
Midwife requested if planned home birth (per local guidelines)
Ambient temp as high as possible (aim 25°C) — windows/doors closed, heating on max
Newborn life support area prepared — firm, flat, off the floor, same room; airway adjuncts & newborn masks available
JRCALC
Supporting the Birth
Head visible — hands poised to receive baby
At crowning — encourage patient to pant, slow the birth of the head
Restitution — head turns to side between/during next contraction
Rest of baby born during next contraction — support shoulders/body, lift baby to patient's abdomen. Do not pull.
Shoulder dystocia flaggedExternal reference — see Shoulder Dystocia guideline (not built into this tool). Obstetric emergency.
Cord around neck/body — unlooped if present (no need to remove routinely, baby can be born with cord in place)
Newborn & Cord
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JRCALC
Initial Newborn Assessment
Baby onto patient's abdomen, dry & stimulate. Assess over first 60 seconds with cord intact, providing thermoregulation.
Colourunassessed
Toneunassessed
Breathing rateunassessed
Heart rate (stethoscope)unassessed
Colour normalcentrally perfused mucous membranes
Colour abnormalcentral cyanosis >1 min post-birth
Tone normalflexed
Tone abnormalfloppy
Breathing normal30–60/min
Breathing abnormal<30/min
HR normal100–160/min
HR abnormal<100/min
Abnormal finding — start Newborn Life Support
Clamp & cut cord and begin NLS. External guideline — Newborn Life Support not built into this tool
Defibrillator
Do NOT use a defibrillator at any point for monitoring or for Newborn Life Support.
JRCALC
Thermoregulation
Windows/doors closed, heating on max (aim 25°C)
>32 weeks: thoroughly dry with towels, remove wet towels
≤32 weeks: place UNDRIED in clear plastic bag onto heat source extreme preterm detail incomplete — see note below
Hat applied to dry head
Patient's abdomen kept dry when baby lying on it
Thermal mattress applied
Additional warming aids applied (insulating wrap etc.)
Target newborn body temperature: 36.5–37.5°C.
JRCALC
Optimal Cord Management
Keep cord intact ≥60 seconds post-birth — reduces morbidity/mortality (~1/3 of baby's blood volume is in the placenta at birth).
Clamp cord immediately if:
Cord snapped (if at baby's abdomen — apply pressure, time-critical conveyance, pre-alert) · Cord prevents effective NLS · Further babies still to be born (Multiple Pregnancy — external guideline)
Baby well — keep cord intact until it has gone white (clamp/cut at 60s if cord too short to allow holding)
Clamp ~5cm from baby, second clamp ~5cm further along
Cut between clamps with cord scissors — minimise baby exposure time
Parent/birth partner offered opportunity to cut cord (assisted safely)
CautionKeep newborn's fingers/genitals clear of scissors. Bodily fluid exposure risk from cord blood spurting.
Third Stage
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JRCALC
Placenta Delivery
Active management (uterotonics, controlled cord traction) is midwife-only — not within ambulance clinician scope.
Clean incontinence sheet placed under buttocks to monitor bleeding
Regular observations at scene / en-route
Supported to pass urine / skin-to-skin / breastfeeding / upright position offered (aid placenta delivery)
Do not pull on the cord at any point
20-minute placenta timer (from time of birth)
20:00
Not started
Placenta still in-situ at 20 minutesTime-critical conveyance to nearest obstetric unit, pre-alert.
JRCALC
PPH Monitoring
Monitor for excessive bleeding: ≥500mL, or any blood loss causing signs of hypovolaemic shock.
Signs of PPHunassessed
PPH suspectedExternal guideline — Management of PPH not built into this tool.
Placenta + all blood-containing items transported to hospital (for blood loss measurement)
If patient wishes to keep placenta — transported with them, reassured maternity staff will return it after examination
Examining the placenta/membranes for completeness is not within ambulance clinician scope.
Skin-to-Skin & Feeding
Skin-to-skin (if desired) — baby prone, wrapped together with warm adult, face exposed, airway optimised (head turned to side), continuously monitored
Additional warming — hat + thermal mattress
Breastfeeding offered if desired, unless clinical need to convey overrides
Need to transport takes priority over infant feeding. Breastfeeding guidance is not within ambulance clinician scope.
Destination
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JRCALC — Maternity Care
Destination Decision
Nearest ED — cardiac arrest / airway / eclampsia / severe bleeding
Nearest full obstetric unit — other obstetric emergencies
Booked unit / birth centre — low risk, not imminent
Selected destination
Birth/standalone midwifery centres have no resident obstetricians, anaesthetists, neonatologists, or specialist neonatal facilities. Consider accessibility (out-of-hours, locked doors, corridors, lifts). Use SBAR for handover to maternity clinicians. Ensure mother conveyed to same hospital as baby (separate ambulances if either has concerns — clear compassionate communication, non-birthing parent may travel with baby). Preterm/newborns needing support should not travel in a car seat or skin-to-skin. ID band applied with mother's name + postcode.
JRCALC — Maternity Care
Health Inequity — At-Risk Ethnic Groups
MBRRACE-UK data: Black women are 4x more likely to die during pregnancy than White women; mixed-ethnicity women 3x; Asian women 2x. Use professional interpreters (not family members) where needed. Document condition-worsening safety-net advice given and understood.
JRCALC — Maternity Care
FGM
Types 3/4 can obstruct labour — infibulated (Type 3) cannot birth unassisted without de-fibulation. Increased risk of prolonged/obstructed labour, tearing, PPH.
FGM identifiedunassessed
FGM identifiedIf not known to maternity services and antenatal care absent: early recognition, rapid conveyance to nearest obstetric unit, information call to receiving unit ahead of arrival. Do not delay transportation. Safeguarding considerations apply — refer to Safeguarding Adults/Children guidance.
Waterbirth
Attending/managing planned waterbirths is outside ambulance clinician scope. Request patient leave the water. If they decline: explain risks (no waterbirth training, no training to resolve obstetric emergencies in water, no water-temperature monitoring equipment), involve birth partner, seek clinical advice + request midwife per local procedure, document discussion.
Room warmed, lights on, towels/maternity pack/NLS area prepared
Continuous reassessment — advise exit if birth/head not advancing, meconium, or fresh bleeding
Shoulder dystocia in water → ask patient to stand & exit pool immediately (obstetric emergency) — hands poised, standing may release baby. Baby born underwater → bring head above water surface immediately (lift baby yourself if patient cannot). Clamp/cut cord, move baby from water, assess + thermoregulate + NLS if required, ideally two separate clinicians for mother/baby. Third stage happens out of the water.
Preterm Labour/Birth
JRCALC
Babies born <37 completed weeks. High risk of morbidity/mortality if born out of hospital — time-critical conveyance to nearest obstetric maternity unit for preterm contractions. May present atypically: back pain, period-type pain, urinary symptoms, mild abdominal pain. Birth support approach is the same as term (see Birth Management). If imminent and advancing — stay, prepare for birth, urgently seek clinical advice per local procedure.
Preterm (<37 weeks)unassessed
⚠ Source gap — extreme preterm (≤32wk) management
The source text you provided cuts off mid-sentence at the start of the extreme-preterm section (referenced as "section 12.3 — altered approach"), so detailed guidance for ≤32-week births beyond the plastic-bag thermoregulation step above hasn't been built in. Send me that section and I'll add it.
Summary / PRF
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Event Log
No events logged yet
Documentation Checklist
SBAR handover given to receiving unit
Time of birth documented
Two sets of observations — mother and baby — documented
Newborn temperature recorded (thermometer, ASAP + during transport + on arrival)