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Emergent delivery
From WikEM
Contents
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
- 4th stage of labor - 1st hour after placental delivery
- Period of time with highest risk for postpartum hemorrhage
6 Cardinal Movements of Fetal Descent[2]
- Engagement
- Flexion
- Descent
- Internal rotation
- Extension
- External rotation
Clinical Features
- Abdominal pain
- Rupture of membrains
- Crowning
Differential Diagnosis
- Emergent delivery
- Umbilical cord prolapse
- Breech delivery
- Shoulder dystocia
- Perimortem cesarean delivery
Evaluation
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
Management
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
Emergent Delivery Instructions (2nd Stage)
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
- See newborn resuscitation for complications
Emergent Delivery Instructions (3nd Stage)
- 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-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
Postpartum Emergencies
- Amniotic fluid embolus
- Chorioamnionitis
- Eclampsia
- Postpartum endometritis
- Postpartum headache
- HELLP syndrome
- Postpartum hemorrhage
- Mastitis
- Peripartum cardiomyopathy
- Preeclampsia
- Retained products of conception
- Uterine rupture
See Also
References
- ↑ Cunningham, F., Leveno, K., Bloom, S., Spong, C., Dashe, J. Williams Obstetrics, 24th Ed. McGraw-Hill Education, 2014. Chapter 47.
- ↑ 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.
- ↑ 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.
- ↑ Del Portal DA et al. Emergency department management of shoulder dystocia. J Emerg Med. 2014 Mar;46(3):378-82.
