Health care systems in which patients have little prenatal care tend to have greater incidence of ED deliveries.
ED deliveries usually occur in 1 of the following 3 scenarios:
Multiparous patient with history of prior rapid labor
Nulliparous patient who does not recognize symptoms of labor
Patients with lack of prenatal care, lack of transportation, or premature labor
Diagnosis
Signs and Symptoms
True labor presents as uterine contractions occurring at least every 5 min and lasting 30-60 sec.
Significant vaginal bleeding with labor demands immediate assessment for placenta previa or abruption.
History
Last menstrual period and estimated gestational age (EGA)
Recent infections
Pregnancy history, complications
Prior C-section
Prenatal care
Abdominal/pelvic cramping
Ruptured membranes (amniotic sac)
May report incontinence
Urge to push or have a bowel movement
Bloody show-loss of mucous plug
Physical Exam
Signs of imminent delivery:
Fully effaced and dilated cervix (~10 cm in term infant)
Palpable fetal parts
Bulging of perineum
Widening of vulvovaginal area
Try to determine fetal position and presenting part by palpation of the uterus
Essential Workup
Sterile bimanual pelvic exam is the most useful tool to assess presence of labor and possibility of imminent delivery:
Assess dilation, station, and effacement
No pushing until full dilation
Bimanual exam should not be done with vaginal bleeding until ultrasound (US) can rule out placenta previa.
Fetal heart tones (FHTs) should be obtained by Doppler
Diagnosis Tests & Interpretation
Lab
If patient is in active labor, CBC, blood typing, and Rh screen should be sent:
Kleihauer-Betke testing should be ordered after delivery if Rh-negative mother gives birth to Rh-positive child
Rh immunoglobulin can be administered to mother within 72 hr of delivery
Urinalysis if there is concern about urinary tract infection or preeclampsia
Imaging
Imaging studies are not needed for uncomplicated vaginal deliveries
3rd-trimester vaginal bleeding should have emergent US to evaluate for placental abruption or placenta previa
If time permits, US can help locate the position and anatomy of the placenta
Differential Diagnosis
Braxton Hicks contractions:
Irregular uterine contractions that do not result in cervical dilation or effacement
Muscular low back pain
Round uterine ligament pain
Other causes of abdominal pain, such as torsion of the ovary, appendicitis, nephrolithiasis
Treatment
Pre-Hospital
Place patients in left lateral recumbent position
Emergency medical services (EMS) personnel should be adequately trained and have proper equipment available for delivery
EMS transportation of high-risk obstetric patients before delivery:
Lower neonatal morbidity and mortality
Faster and less expensive when compared with transportation of neonate after delivery
Use of air transport for obstetric patients has been shown to be safe and effective:
Altitude during flight can result in hypoxia for fetus; pregnant patients should be placed on supplemental oxygen
Initial Stabilization/Therapy
Immediate sterile pelvic exam to assess for cervical dilation, effacement, station, or presenting parts (if no vaginal bleeding)
Patients in active labor should be transferred to labor and delivery immediately unless delivery is imminent
If patient is completely dilated and fetal parts are on perineal verge, prepare for ED delivery
Ed Treatment/Procedures
Obstetrician should be notified that delivery will be occurring in ED
Pediatrician or neonatologist and NICU should be notified
Prepare for neonatal resuscitation
Place patient in supine position or Sims position
Begin IV saline or D5NS and supplemental oxygen, and place patient in lithotomy position
Assemble obstetric (OB) pack:
Bulb syringe
2 sterile Kelly clamps
Sterile Mayo scissors
Umbilical clamp
Neonatal resuscitative equipment should also be available
If time permits, sterilize vaginal area with povidone-iodine (Betadine)
Uncomplicated vaginal delivery should occur as follows:
As crowning occurs, deliver head in controlled fashion, guiding it through introitus with each contraction.
Routine episiotomy is not necessary; however, if perineum is tearing, perform midline episiotomy by placing 2 fingers behind perineum and make straight incision toward (but not including) rectum with sterile Mayo scissors.
After fetal head is delivered, quickly suction nasopharynx, then feel around neck for nuchal cord:
If present, manually reduce over head
If nuchal cord is too tight, double clamp, cut cord, and deliver infant immediately
Apply gentle downward pressure on fetal head with uterine contractions:
Deliver anterior shoulder
Posterior shoulder and remainder of infant will rapidly deliver
After delivery, infant should be held at level of uterus and oropharynx suctioned again
Double clamp cord with sterile Kelly clamps and cut between them
Infant should be stimulated, warmed, and dried:
If cyanosis is present, infant should be given oxygen and resuscitated
Follow neonatal resuscitation protocols if necessary
Place umbilical clamp
Placenta will spontaneously deliver in 20-30 min:
Observe mother closely for postpartum hemorrhage
Uterine massage can aid in separation of placenta from uterus and limit uterine atony:
Avoid placing traction on umbilical cord because this can lead to inversion of uterus or rupture cord
If patient has severe bleeding and placenta is not passing spontaneously, patient should be taken immediately to operating room
After delivery of placenta, it should be examined for any irregular or torn areas suggestive of retained placental products
In uncomplicated delivery, use of drugs is not necessary:
Massage of uterus is all that is needed to facilitate cessation of bleeding after placenta has been delivered
Postpartum uterine bleeding is common:
Uterus, vagina, and perineum should be inspected for laceration
If no laceration is found, assume uterine atony
If uterus does not contract in response to uterine massage, administer oxytocin IV
Continued massage of uterus may be helpful if bleeding still persists; then give methylergonovine maleate (Methergine) IM
If bleeding is not responding to these measures, then carboprost tromethamine (Hemabate) can be administered IM
Medication
Carboprost tromethamine (Hemabate): 0.25 mg IM q15-60min (up to 2 doses)
Methylergonovine maleate (Methergine): 0.2 mg IM
Oxytocin: 20-40 U IV in 1 L of normal saline infused at 250-500 mL/h IV
Follow-Up
Disposition
Admission Criteria
All women with uncomplicated deliveries and no significant postpartum bleeding should be admitted to labor and delivery or postpartum unit for care and monitoring
Obtain pediatric or neonatal consultation and admit to neonatal ICU:
All infants with respiratory distress
Gestational age <36 wk
Weight <5 lb
Low Apgar scores
Term infants with none of above complications may be admitted to the nursery or with mother to combined maternal-fetal unit
If transferring the mother and infant after delivery, consider using 2 ambulances
Discharge Criteria
After adequate recovery from delivery, patient can be taken labor and delivery or postpartum unit
Patient should not be discharged home from ED
Pearls and Pitfalls
Be ready for complications such as cord prolapse, shoulder dystocia, breech delivery
Be prepared to treat 2 patients after delivery-mother and infant
Additional Reading
Enright K, Kidd A, Macleod A. Postpartum emergencies. Emerg Med J. 2009;26:310.
Marx JA, Hockberger RS, Walls RM, et al. Rosens Emergency Medicine: Concepts and Practice. 7th ed. St. Louis, MO: Mosby; 2009.
Mirza FG, Gaddipati S. Obstetric emergencies. Semin Perinatol. 2009;33:97-103.
Roberts JR, Hedges JR, Chanmugan AS, et al., eds. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, PA: Saunders; 2004.
Codes
ICD9
650 Normal delivery
661.30 Precipitate labor, unspecified as to episode of care or not applicable
V23.7 Supervision of high-risk pregnancy with insufficient prenatal care
ICD10
O09.30 Suprvsn of preg w insufficient antenat care, unsp trimester
O62.3 Precipitate labor
O80 Encounter for full-term uncomplicated delivery
SNOMED
177184002 Normal delivery procedure (procedure)
1031000119109 Insufficient prenatal care (finding)