Emergent delivery

Background
  • 4 million deliveries per year in the US
  • Highest pregnancy rates seen in 25-29 year old females[1]

Stages of Labor
Stage Info Image
1st: Dilation
  • Latent
    • Passage of cervical mucous plug
    • Slow dilation to 3 cm
  • Active
    • Rapid cervical dilation from 3 cm to 10 cm
  • ~8 hours in primiparous and ~5 hours in multiparous

2nd: Birth
  • Cervix fully dilated
  • Urge to push
  • Expulsion of infant
  • ~20 - 50 minutes

3rd: Placental delivery
  • ~20 minutes

4th: Post-placental delivery

6 Cardinal Movements of Fetal Descent[2]
  1. Engagement
  2. Flexion
  3. Descent
  4. Internal rotation
  5. Extension
  6. External rotation

Clinical Features
  • Abdominal pain
  • Rupture of membranes
    • Pooling of fluid in the vaginal vault
    • Ferning pattern when fluid is allowed to dry on microscopic slide
    • pH testing with nitrazine paper turning blue
  • Crowning

Differential Diagnosis

Evaluation
Stage 2: Birth

Cervical Dilatation
  • Diameter of the internal cervical os increases as labor progresses
  • 0 cm (closed/fingertip) to 10 cm (complete/fully dilated)
    • Measure with index and middle fingers of examining hand
    • Use sterile gloves, sterile lubrication, and sterile speculum

Effacement
  • Assessment of the cervical thinning
  • Percentage of normal 3-4 cm long cervix
    • 4cm cervix = 0%
    • 0cm (thin) cervix = 100%
      • Fully effaced cervix feels paper-thin

Station (-5 to +5)

Distance of the presenting body relative to the maternal ischial spines

  • -3 = beginning of second stage of labor
  • 0 = in line with the plane of the maternal ischial spines
  • +3 = impending delivery
  • +4 to +5 = crowning

True versus False Labor
  • False labor is defined as uterine contractions that do not produce cervical changes.
    • Braxton-Hicks contractions: Brief contractions, irregular in both duration and intensity
  • True labor is characterized by regular contractions that lead to cervical changes, gradually increasing in intensity and duration

Management

Preparation
  • Position patient in the dorsal lithotomy position[3]
  • Put on personal protective equipment
  • Prepare suction, airway equipment, and warmer for infant
  • Call for OB, NICU, pediatrics
  • Call for additional staff members
  • Divide team into maternal team and infant team (to receive infant after delivery)

Emergent Delivery Instructions (2nd Stage)

Perineal inspection
  • Infant's head bulges the perineum
  • If prolapsed cord is present, elevate the presenting fetal part, place patient in Trendelenburg position, and call OB stat
  • Gentle digital stretching with a lubricated finger may prevent tears and lacerations
  • Support the perineum with a sterile towel and place the other hand over the occiput to promote fetal head extension

Slowly deliver the head
  • Check for nuchal cord
    • If present, slip finger between infant's neck and cord and attempt to reduce cord by pulling over infant's head
      • If unable to reduce cord, clamp or cut cord if infant's face can be cleared from perineum with immediate suction

Deliver anterior shoulder
  • Position hands on either side of the head and exert a gentle downward force[4]

Deliver posterior shoulder
  • Maintain position of hands and apply a small amount of upward traction

Delivery of the body
  • Controlled expulsion helps to prevent perineal lacerations

After delivery of infant
  • Hold the infant securely
  • Position in a manner that facilitates the flow of blood from the placenta to the infant
  • Stimulate and dry the infant
  • Clamp then cut the umbilical cord 3cm distal to insertion at umbilicus with sterile scissors, wait 1-3 minutes following delivery
  • If uncomplicated delivery with clear airway and good respiratory support, mother may hold child immediately (skin to skin)
  • If mother or infant is unstable, pass infant to receiving team
    • Place infant in a warm incubator
    • Check APGAR scores at 1, 5, and 10 minutes after delivery
    • See newborn resuscitation for complications

Emergent Delivery Instructions (3nd Stage)
  • Placental delivery
  • Maintain manual suprapubic pressure
  • Provide gentle cord traction and allow spontaneous placental separation
  • Placenta usually delivers within 10-30 minutes
    • Avoid excessive cord traction to prevent uterine inversion
    • Signs of placental separation
      • Abrupt lengthening of cord
      • Sudden gush of blood
      • Cephalad migration of uterus
    • Inspect for missing placental segments and normal cord insertion and vessels
      • Normal cord should have 3 vessels
      • If placenta is not intact, there may be retained products of conception in the uterus requiring manual or surgical removal
  • Start oxytocin 20U-40U in 1L NS at 200-500 mL/hr or give oxytocin 10U IM in a patient without IV access
    • Administering oxytocin prevents 40% of PPH

Emergent Delivery Instructions (4th Stage)
  • 1st hour after placental delivery
  • Palpate abdomen and check for the achievement of uterine firmness and contraction
  • Period of time with highest risk for postpartum hemorrhage (>500 mL blood)

Disposition
  • Admit

Complications

3rd Trimester/Postpartum Emergencies

See Also

References
  1. Cunningham, F., Leveno, K., Bloom, S., Spong, C., Dashe, J. Williams Obstetrics, 24th Ed. McGraw-Hill Education, 2014. Chapter 47.
  2. Tintinalli, Judith E., J. Stephan Stapczynski, O. John Ma, David M. Cline, Rita K. Cydulka, Garth D. Meckler, The American College of Emergency Physicians. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7th Ed. The McGraw-Hill Companies, Inc. 2011. Chapters 103-105.
  3. Marx, John MD, Hockberger, R. MD, Walls, R. MD. Rosen’s Emergency Medicine-Concepts and Clinical Practice 8th Ed. Elsevier, 2013. Chapters 34, 37, 178, 179.
  4. Del Portal DA et al. Emergency department management of shoulder dystocia. J Emerg Med. 2014 Mar;46(3):378-82.
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