Delivery, Uncomplicated, Emergency Medicine

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)