Author:
Patricia DeMelo Panakos
IvetteMotola
Etiology
- Delivery in ED is rare:
- Incidence of ED deliveries in the U.S. is not known
- 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
Signs and Symptoms
- True labor presents as uterine contractions that occur at least every 5 min, last 30-60 s, and result in cervical changes
- Significant vaginal bleeding with labor demand s 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
- Vaginal bleeding
- Ruptured membranes (amniotic sac)
- May report incontinence
- Urge to push or have a bowel movement
- Bloody show—loss of mucous plug
- Onset and frequency of contractions
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 or via bedside US
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 in patients with vaginal bleeding until US can rule out placenta previa
- Fetal heart tones (FHTs) should be obtained by Doppler
Diagnostic Tests & Interpretation
Lab
- If patient is in active labor:
- CBC
- Type and screen
- Rh
- Rh immunoglobulin can be administered to mother within 72 hr of delivery
- Kleihauer-Betke testing should be ordered after delivery if Rh-negative mother gives birth to Rh-positive child
- Urinalysis if there is concern about urinary tract infection or pre-eclampsia
Imaging
- Imaging studies are not needed for uncomplicated vaginal deliveries
- Third-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
Prehospital
- 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 (OB) 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 OB 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
- In patients without vaginal bleeding, immediate sterile pelvic exam to assess for cervical dilation, effacement, station, or presenting parts
- 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 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:
- 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 of 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
- Tranexamic acid (TXA) reduces death due to postpartum bleeding:
- Should be given as soon as possible after bleeding onset
Medication
- Carboprost tromethamine (Hemabate): 0.25 mg IM q15-60min (up to 2 doses)
- Methylergonovine maleate (Methergine): 0.2 mg IM or IV
- Oxytocin: 20-40 units IV in 1 L of normal saline infused at 250-500 mL/hr IV
- Tranexamic acid: 1 g (100 mg/mL) at a rate of 1 mL/min