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==Background==
==Background==
*Prolapsed cord
[[File:Bumm 123 lg - Copy.jpg|thumb|Estimated gestational age based on physical exam.]]
**Do NOT attempt to reduce
*4 million deliveries per year in the US
***Instead,elevate the presenting fetal part to reduce compression and transport to OR
*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>
*Breech presentation
**Try to let the delivery occur spontaneously without touching the fetus


==Physical Examination ==
===Stages of Labor===
===Digital Examination of the Vagina===
{| {{table}}
# Cervical Dilatation
| align="center" style="background:#f0f0f0;"|'''Stage'''
## 0 cm (closed/fingertip) to 10 cm (complete/fully dilated)
| align="center" style="background:#f0f0f0;"|'''Info'''
# Effacement
| align="center" style="background:#f0f0f0;"|'''Image'''
## assessment of the cervical length
|-
## percentage of normal 3-4 cm long cervix
|'''1st: Dilation'''
## 4cm cervix = 0%; 0cm (thin) cervix = 100%
|
# Station (-5 to +5)
*Latent
## (distance of the presenting body relative to the maternal ischial spines)
**Passage of cervical mucous plug
### -3 = beginning of second stage of labor
**Slow dilation to 6 cm
### 0 = in line with the plane of the maternal ischial spines
*Active
### +3 = impending delivery
**Rapid cervical dilation from 6 cm to 10 cm  
### +4 to +5 = crowning
*~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>===
#Engagement
#Descent
#Flexion
#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==
==Differential Diagnosis==
{{Postpartum emergencies DDX}}
{{Emergency delivery DDX}}
 
==Evaluation==
[[File:Bookmiller 1954 176.png|thumb|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==
==Management==
===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
*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<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 3cm distal to insertion at umbilicus with sterile scissors
**ACOG recommends delaying cord clamping until 30-60 seconds after delivery<ref>Committee on Obstetric Practice. ACOG Committee Opinion No. 684: Delayed umbilical cord clamping after birth. Obstet Gynecol. 2017;129(1):e5–10.</ref>
*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)===
[[File:Human placenta 02.jpg|thumb|Normal whole placenta (fetal side).]]
[[File:Human placenta 01.jpg|thumb|Normal whole placenta (maternal side).]]
*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==
{{Postpartum emergencies DDX}}


==See Also==
==See Also==
*[[Post-Partum Emergencies]]
*[[Vaginal Bleeding (Main)]]
*[[Infant_scalp_hematoma|Newborn Scalp Hematoma]]
*[[Apgar score]]
*[[Newborn resuscitation]]


==Source==
==References==
<references/>


[[Category:OB/GYN]]
[[Category:EMS]]
[[Category:OBGYN]]
[[Category:Procedures]]

Latest revision as of 19:38, 14 December 2022

Background

Estimated gestational age based on physical exam.
  • 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 6 cm
  • Active
    • Rapid cervical dilation from 6 cm to 10 cm
  • ~8 hours in primiparous and ~5 hours in multiparous

Stage 1.png

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

Stage 2.png

3rd: Placental delivery
  • ~20 minutes

Stage 3.jpg

4th: Post-placental delivery

6 Cardinal Movements of Fetal Descent[2]

  1. Engagement
  2. Descent
  3. Flexion
  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

Emergent delivery and related complications

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
    • ACOG recommends delaying cord clamping until 30-60 seconds after delivery[5]
  • 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)

Normal whole placenta (fetal side).
Normal whole placenta (maternal side).
  • 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.
  5. ↑ Committee on Obstetric Practice. ACOG Committee Opinion No. 684: Delayed umbilical cord clamping after birth. Obstet Gynecol. 2017;129(1):e5–10.
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