Emergent delivery: Difference between revisions

No edit summary
No edit summary
Line 1: Line 1:
==Background==
==Background==
*Prolapsed cord
*There are 4 million deliveries per year in the US with the highest pregnancy rates seen in 25-29 year old females<ref>Cunningham, F., Leveno, K., Bloom, S., Spong, C., Dashe, J. Williams Obstetrics, 24th Ed. McGraw-Hill Education, 2014. Chapter 47.</ref>
**Do NOT attempt to reduce
 
***Instead,elevate the presenting fetal part to reduce compression and transport to OR
==1st stage of labor==
*Breech presentation
*Passage of cervical mucus plug to full cervical dilation and effacement
**Try to let the delivery occur spontaneously without touching the fetus
*8 hours in nulliparous and 5 hours in multiparous
==2nd stage of labor==
*Full cervical dilation to delivery of infant
 
===6 Cardinal Movements of Fetal Descent===
#Engagement<ref>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.</ref>
#Flexion
#Descent
#Internal rotation
#Extension
#Eexternal rotation
 
===Perineal inspection===
*Infants head bulges the perineum
*Gentle digital stretching 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 reduce the cord around neck or clamp and cut
===Deliver anterior shoulder===
*Position hands on either side of the head and exert a gentle downward force<ref>Del Portal DA et al. Emergency department management of shoulder dystocia.
J Emerg Med. 2014 Mar;46(3):378-82.</ref>
===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 6-8 cm distal to insertion at umbilicus with sterile scissors
*Place infant in a warm incubator
*Check APGAR scores at 1, 5, and 10 minutes after delivery
 
===3rd stage of labor===
*Placental delivery
*Maintain suprapubic fundal 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: cord lengthens, sudden gush of blood, and uterine fundus moves cephalad in abdomen
**Inspect for missing placental segments
*Start Oxytocin 20U in 1L NS at 10-20 mL/hr or give Oxytocin 10U IM in a pt without IV access
*Administering Oxytocin prevents 40% of PPH
 
===4th stage of labor===
*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
**[[Postpartum hemorrhage]] defined as loss of >500 mL blood after SVD
**Uterine atony is responsible for 80% of [[Postpartum hemorrhage]] cases
**Other causes include genital lacerations, uterine inversion, uterine rupture, coagulation abnormalities, and/or retained placental tissue
 
 
==Preparation==
*Position patient in the dorsal lithotomy position<ref>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.</ref>
*Put on personal protective equipment
*Prepare suction, airway equipment, and warmer for infant
*Place OB and NICU consults
 
==Pregnancy Specific Physical Examination ==
===Cervical Dilatation===
#0 cm (closed/fingertip) to 10 cm (complete/fully dilated)
===Effacement===
#Assessment of the cervical length
#Percentage of normal 3-4 cm long cervix
#4cm cervix = 0%; 0cm (thin) cervix = 100%
===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
 


==Physical Examination ==
===Digital Examination of the Vagina===
# Cervical Dilatation
## 0 cm (closed/fingertip) to 10 cm (complete/fully dilated)
# Effacement
## assessment of the cervical length
## percentage of normal 3-4 cm long cervix
## 4cm cervix = 0%; 0cm (thin) cervix = 100%
# 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


==Differential Diagnosis==
==Differential Diagnosis==
{{Postpartum emergencies DDX}}
{{Postpartum emergencies DDX}}


==Management==
==Management and Complications==
 
===Prolapsed cord===
*Do NOT attempt to reduce instead, elevate the presenting fetal part to reduce compression and transport to OR<ref>Holbrook BD. Umbilical cord prolapse. Obstet Gynecol Clin North Am. 2013 Mar;40(1):1-14.</ref>
===Breech presentation===
*Try to let the delivery occur spontaneously without touching the fetus<ref>Mercado J. Critical obstetric and gynecologic procedures in the emergency department. Emerg Med Clin North Am. 2013 Feb;31(1):207-36.</ref>
==See Also==
==See Also==


==Source==
==Source==
 
<references/>
[[Category:OB/GYN]]
[[Category:OB/GYN]]
[[Category:Procedures]]
[[Category:Procedures]]

Revision as of 02:21, 6 February 2015

Background

  • There are 4 million deliveries per year in the US with the highest pregnancy rates seen in 25-29 year old females[1]

1st stage of labor

  • Passage of cervical mucus plug to full cervical dilation and effacement
  • 8 hours in nulliparous and 5 hours in multiparous

2nd stage of labor

  • Full cervical dilation to delivery of infant

6 Cardinal Movements of Fetal Descent

  1. Engagement[2]
  2. Flexion
  3. Descent
  4. Internal rotation
  5. Extension
  6. Eexternal rotation

Perineal inspection

  • Infants head bulges the perineum
  • Gentle digital stretching 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 reduce the cord around neck or clamp and cut

Deliver anterior shoulder

  • Position hands on either side of the head and exert a gentle downward force[3]

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 6-8 cm distal to insertion at umbilicus with sterile scissors
  • Place infant in a warm incubator
  • Check APGAR scores at 1, 5, and 10 minutes after delivery

3rd stage of labor

  • Placental delivery
  • Maintain suprapubic fundal 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: cord lengthens, sudden gush of blood, and uterine fundus moves cephalad in abdomen
    • Inspect for missing placental segments
  • Start Oxytocin 20U in 1L NS at 10-20 mL/hr or give Oxytocin 10U IM in a pt without IV access
  • Administering Oxytocin prevents 40% of PPH

4th stage of labor

  • 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
    • Postpartum hemorrhage defined as loss of >500 mL blood after SVD
    • Uterine atony is responsible for 80% of Postpartum hemorrhage cases
    • Other causes include genital lacerations, uterine inversion, uterine rupture, coagulation abnormalities, and/or retained placental tissue


Preparation

  • Position patient in the dorsal lithotomy position[4]
  • Put on personal protective equipment
  • Prepare suction, airway equipment, and warmer for infant
  • Place OB and NICU consults

Pregnancy Specific Physical Examination

Cervical Dilatation

  1. 0 cm (closed/fingertip) to 10 cm (complete/fully dilated)

Effacement

  1. Assessment of the cervical length
  2. Percentage of normal 3-4 cm long cervix
  3. 4cm cervix = 0%; 0cm (thin) cervix = 100%

Station (-5 to +5)

Distance of the presenting body relative to the maternal ischial spines

  1. -3 = beginning of second stage of labor
  2. 0 = in line with the plane of the maternal ischial spines
  3. +3 = impending delivery
  4. +4 to +5 = crowning


Differential Diagnosis

3rd Trimester/Postpartum Emergencies

Management and Complications

Prolapsed cord

  • Do NOT attempt to reduce instead, elevate the presenting fetal part to reduce compression and transport to OR[5]

Breech presentation

  • Try to let the delivery occur spontaneously without touching the fetus[6]

See Also

Source

  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. ↑ Del Portal DA et al. Emergency department management of shoulder dystocia. J Emerg Med. 2014 Mar;46(3):378-82.
  4. ↑ 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.
  5. ↑ Holbrook BD. Umbilical cord prolapse. Obstet Gynecol Clin North Am. 2013 Mar;40(1):1-14.
  6. ↑ Mercado J. Critical obstetric and gynecologic procedures in the emergency department. Emerg Med Clin North Am. 2013 Feb;31(1):207-36.
Retrieved from "https://www.wikem.org/w/index.php?title=Emergent_delivery&oldid=30909"