Emergent delivery: Difference between revisions
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*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>
*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>


==Preparation==
===Stages of Labor===
*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>
===1st stage of labor===
*Put on personal protective equipment
*Passage of cervical mucus plug to full cervical dilation and effacement
*Prepare suction, airway equipment, and warmer for infant
*8 hours in nulliparous and 5 hours in multiparous
*Place OB and NICU consults
 
===2nd stage of labor===
*Full cervical dilation to delivery of infant
 
==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


==Pregnancy Specific Physical Examination ==
==Pregnancy Specific Physical Examination ==
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#+3 = impending delivery
#+3 = impending delivery
#+4 to +5 = crowning
#+4 to +5 = crowning
==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<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>===
===6 Cardinal Movements of Fetal Descent<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>===
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#External rotation
#External rotation


==Management and Complications==
===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
===Normal (Emergent) Delivery Instructions===
===Perineal inspection===
===Perineal inspection===
*Infants head bulges the perineum
*Infants head bulges the perineum
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*Check APGAR scores at 1, 5, and 10 minutes after delivery
*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
==Management and Complications==
===Prolapsed cord===
===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>
*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>

Revision as of 15:33, 25 March 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]

Stages of Labor

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

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

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

6 Cardinal Movements of Fetal Descent[2]

  1. Engagement
  2. Flexion
  3. Descent
  4. Internal rotation
  5. Extension
  6. External rotation

Management and Complications

Preparation

  • Position patient in the dorsal lithotomy position[3]
  • Put on personal protective equipment
  • Prepare suction, airway equipment, and warmer for infant
  • Place OB and NICU consults

Normal (Emergent) Delivery Instructions

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[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 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

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]

Shoulder dystocia

3rd Trimester/Postpartum Emergencies

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. ↑ 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.
  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.
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