Emergent delivery: Difference between revisions
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==Background== | ==Background== | ||
* | *4 million deliveries per year in the US | ||
*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> | |||
===Stages of Labor=== | ===Stages of Labor=== | ||
{| {{table}} | |||
| align="center" style="background:#f0f0f0;"|'''Stage''' | |||
| align="center" style="background:#f0f0f0;"|'''Info''' | |||
*'''3rd | | align="center" style="background:#f0f0f0;"|'''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 | |||
| | |||
[[Image:Stage 1.png|400px]] | |||
|- | |||
|'''2nd: Birth''' | |||
| | |||
*Cervix fully dilated | |||
*Urge to push | |||
*Expulsion of infant | |||
*~20 - 50 minutes | |||
| | |||
[[Image:Stage 2.png|400px]] | |||
|- | |||
|'''3rd: Placental delivery''' | |||
| | |||
*~20 minutes | |||
**>18 minutes increases risk of [[postpartum hemorrhage]] with >30 minutes conferring very increased risk | |||
| | |||
[[Image:Stage 3.jpg|400px]] | |||
|- | |||
|'''4th: Post-placental delivery''' | |||
| | |||
*1st hour after placental delivery | |||
*Period of time with highest risk for [[postpartum hemorrhage]] | |||
| | |||
|} | |||
===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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*[[Abdominal pain]] | *[[Abdominal pain]] | ||
*Rupture of membranes | *Rupture of membranes | ||
** | **Pooling of fluid in the vaginal vault | ||
**Ferning | **Ferning pattern when fluid is allowed to dry on microscopic slide | ||
**pH testing with nitrazine paper turning blue | |||
*Crowning | *Crowning | ||
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==Evaluation== | ==Evaluation== | ||
[[File:Bookmiller 1954 176.png|thumb|Stage 2: Birth]] | |||
===Cervical Dilatation=== | ===Cervical Dilatation=== | ||
*Diameter of the internal cervical os increases as labor progresses | |||
*0 cm (closed/fingertip) to 10 cm (complete/fully dilated) | *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=== | ===Effacement=== | ||
*Assessment of the cervical | *Assessment of the cervical thinning | ||
*Percentage of normal 3-4 cm long cervix | *Percentage of normal 3-4 cm long cervix | ||
**4cm cervix = 0% | **4cm cervix = 0% | ||
**0cm (thin) cervix = 100% | **0cm (thin) cervix = 100% | ||
***Fully effaced cervix feels paper-thin | |||
===Station (-5 to +5)=== | ===Station (-5 to +5)=== | ||
Distance of the presenting body relative to the maternal ischial spines | Distance of the presenting body relative to the maternal ischial spines | ||
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*+3 = impending delivery | *+3 = impending delivery | ||
*+4 to +5 = crowning | *+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== | ==Management== | ||
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*Put on personal protective equipment | *Put on personal protective equipment | ||
*Prepare suction, airway equipment, and warmer for infant | *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)=== | ===Emergent Delivery Instructions (2nd Stage)=== | ||
====Perineal inspection==== | ====Perineal inspection==== | ||
* | *Infant's head bulges the perineum | ||
*Gentle digital stretching may prevent tears and lacerations | *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 | *Support the perineum with a sterile towel and place the other hand over the occiput to promote fetal head extension | ||
====Slowly deliver the head==== | ====Slowly deliver the head==== | ||
*Check for nuchal cord, | *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==== | ====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. | *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. | ||
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*Position in a manner that facilitates the flow of blood from the placenta to the infant | *Position in a manner that facilitates the flow of blood from the placenta to the infant | ||
*Stimulate and dry the infant | *Stimulate and dry the infant | ||
*Clamp then cut the umbilical cord | *Clamp then cut the umbilical cord 3cm distal to insertion at umbilicus with sterile scissors, wait 1-3 minutes following delivery | ||
*Place infant in a warm incubator | *If uncomplicated delivery with clear airway and good respiratory support, mother may hold child immediately (skin to skin) | ||
*Check [[APGAR]] scores at 1, 5, and 10 minutes after delivery | *If mother or infant is unstable, pass infant to receiving team | ||
*See [[newborn resuscitation]] for complications | **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)=== | ===Emergent Delivery Instructions (3nd Stage)=== | ||
*Placental delivery | *Placental delivery | ||
*Maintain suprapubic | *Maintain manual suprapubic pressure | ||
*Provide gentle cord traction and allow spontaneous placental separation | |||
*Placenta usually delivers within 10-30 minutes | *Placenta usually delivers within 10-30 minutes | ||
**Avoid excessive cord traction to prevent uterine inversion | **Avoid excessive cord traction to prevent uterine inversion | ||
**Signs of placental separation | **Signs of placental separation | ||
**Inspect for missing placental segments | ***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 | *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 | **Administering oxytocin prevents 40% of PPH |
Revision as of 17:51, 4 October 2019
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 |
|
|
2nd: Birth |
|
|
3rd: Placental delivery |
|
|
4th: Post-placental delivery |
|
6 Cardinal Movements of Fetal Descent[2]
- Engagement
- Flexion
- Descent
- Internal rotation
- Extension
- 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
- Emergent delivery
- Umbilical cord prolapse
- Breech delivery
- Shoulder dystocia
- Perimortem cesarean delivery
Evaluation
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
- If present, slip finger between infant's neck and cord and attempt to reduce cord by pulling over infant's head
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
- Acute fatty liver of pregnancy
- Amniotic fluid embolus
- Chorioamnionitis
- Eclampsia
- HELLP syndrome
- Mastitis
- Peripartum cardiomyopathy
- Postpartum endometritis (postpartum PID)
- Postpartum headache
- Postpartum hemorrhage
- Preeclampsia
- Resuscitative hysterotomy
- Retained products of conception
- Septic abortion
- 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.