emergency delivery chrisnel jean, d.o presented by: dr. donze 12/8/05

EMERGENCY EMERGENCY DELIVERYDELIVERYChrisnel Jean, D.OChrisnel Jean, D.O

Presented by: Dr. DonzePresented by: Dr. Donze12/8/0512/8/05

Evaluation of Pregnant PtEvaluation of Pregnant Pt

Initially, ED physicians must determine the condition of the mother and the fetus in any pregnant women that present beyond 20 wks gestation.

Evaluation of Pregnant PtEvaluation of Pregnant Pt• Must consider obtaining the following

info:

1. Medical history / Social history (drug use)

2. Obstetrical history• Parity (G0P1) • Gestational age (GA) – can be determined by the

following:– LMP (Pregnancy wheel)– Fundal height (cm = wks of GA +/- 2 wks) Falsely

elevated in obese pts – Ultrasound – detect congenital disorder / not an

accurate predictor of GA in 3rd trim (varies +/- 3 wks)• EDC can be determined by:

– Pregnancy wheel or Naegle rule = LMP+9months and 7days

FUNDAL HEIGHTFUNDAL HEIGHT

Evaluation of Pregnant PtEvaluation of Pregnant Pt

Other Obstetrical history:– Prenatal care / OBGYN – Midwives– PNV– Complications from this recent and past

pregnancy (Infection / Eclampsia / HELLP)

TRUE vs FALSE LABORTRUE vs FALSE LABOR• False Labor:

Uterine contractions that do not lead to cervical changes

Irregular (intensity / duration) confine to low ABD

Known as Braxton-Hicks

Tx with hydration / rest

• True Labor:Painful repetitive

uterine contractions increase steadily in intensity and duration leads to progressive effacement and cervical dilatation

Begins in fundus then radiate to pelvis.

leads to progressive descent of fetus into pelvis.

STAGES OF LABORSTAGES OF LABOR• Stage I

– Onset regular contraction to full cervical dilatation

– 2 phases: Latent / active (3 – 5 cm)

• Stage II– Full dilatation to

delivery

• Stage III– Delivery infant to

delivery placenta

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION• If pt present with no bleeding then do

sterile speculum and bimanual exam.(Lubricant false nitrazine test if no

PROM )

• Perform Ultrasound Prior to PE if pt present with bleeding to r/o placenta previa.

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION


• Should include the following:– Inspect / palpate ABD for fundal hgt.

– Cervix exam: • Effacement – thinning of the cervix (labor)• Dilatation – diameter of the internal cervical

os (indicates progression of labor)


• Station – the level that the fetus occupies in the pelvis with the reference point being the maternal ischial spine (palpable 4 and 8 o’clock in the vaginal canal)

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION• During PE of the pregnant pt, you

should attempt to determine the presentation of the child

(potential breech presentation or cord prolapse.)

This can be done by the following method:1. Leopold maneuvers2. Digital examination


1. Leopold Maneuvers:– Palpation of the fetus through the

maternal abd to determine fetus position and presentation.• Used for screening for malpresenation /

fetal weight. (sensitivity 28 – 88% / spec 94%)

PE: PE: Leopold ManeuversLeopold Maneuvers

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION2. Digital examination:

vertex presentation is best confirmed with palpation of the cranial sutures.

Palpation of feet / hands malpresentation

Note: verification of presentation is preferred by US

Spont. Rupture of MembraneSpont. Rupture of Membrane• During the PE of pregnant pt you

must evaluate for SROM • SROM determines and predicts

imminence of labor and potential for complications

• ”gush of clear or blood-tinged fluid”• The amount of fluid can be increase

by Valsalva / standing.

• SROM occur most commonly during active labor. Approx. 10% of 3rd trim will have SROM prior to labor

Confirmation of Spont. Confirmation of Spont. Rupture of MembraneRupture of Membrane

• The presence of Amniotic fluid (SROM) can be confirmed by the following:

1. Nitrazine test: Turns from yellow to dark blue in presence of Amniotic fluid

(Amniotic pH=7 – 7.4) Remain yellow color in presence of norm vaginal fluid (Vaginal

pH = 4.5 – 5.5) False positive can occur secondary to presence of blood,

lubricant, Trich, seman, or cervical mucus.

Confirmation of Spont.Confirmation of Spont. Rupture of Membrane Rupture of Membrane

2. Ferning /Microscopy NaCl crystals on a

slide as amniotic fluid dries.

Spont. Rupture of MembraneSpont. Rupture of Membrane• PE must include evaluation for

possible infection and presence of meconium:– Signs of chorioamnionitis

• Maternal fever• Fetal tachycardia• Fundal tenderness

• If membranes intact NO amniotomy in ED. Can lead to:

• Precipitous labor• Cord prolapse

PROM: Premature Rupture of PROM: Premature Rupture of MembranesMembranes

• PROM:• Rupture of amnion and chorion 1 hour or

more prior to onset of labor.

• PPROM (Preterm PROM):• Rupture occurs prior to 37 wks gestation.

• Prolong ROM:• Occurs if delivery does not occur within 18 h

of ROM.

PROM / PPROMPROM / PPROM

• Possible causative factors include:Infectionh/o PPROMh/o traumaMultiple gestationsFetal anomaliesPlacental abruptionPlacenta previa

PROM / PPROMPROM / PPROM• OBGYN may use conservative

management in <34 wks gestation.

• More aggressive if:Signs of chorioamnionitis/fetal distress Maternal transport required - tocolytics Delayed delivery to initiate steroids for

lung maturation

• Noninfectious PPROM may be prolonged with antibiotics– Erythromycin and ampicillin

Fetal DistressFetal Distress

• Indicators– Decel in FHR, persistent

drop in FHR during contraction (lasting >30sec)

• Continue Fetal heart monitoring

• Doppler heart sounds - decelerations, episodic bradycardia >5min needs emergent C-sec

Fetal DistressFetal Distress

• Interventions:– Increase maternal blood flow– Increase maternal serum O2 conc.– Maternal positioning (L/R lateral,

knee/chest) – Fetal scalp stimulation– Terbutaline Injections (stop contract/

incr. Blood Flow)

Emergency DeliveryEmergency Delivery• Initial Step:

Obtain maternal VS, FHRInitiate supportive txVenous access, maternal and fetal

monitoringBefore transferring pt consider stage

of labor / pt’s parity

Emergency DeliveryEmergency Delivery Sterile Pelvic exam

(Degree cervical dilatation/effacement, crowning, √ for fetus in introitus)

Determine presenting part/position

Palpate for skull sutures / fontanel, buttock, or extremity

Process of Labor and DeliveryProcess of Labor and Delivery

Six Cardinal Movements:1. Engagement2. Flexion3. Descent4. Internal Rotation5. Extension6. External Rotation

Delivery StepsDelivery Steps1-3 Perineum

stretching /thinning allow passage of newborn Attempt to avoid Episiotomy

3-4 Control of fetal head to prevent large perineal tear and head / facial trauma to the newborn

4 Nose/mouth suctioning meconium?

4 Palpate neck for nuchal cord

4-6 Gentle traction avoid brachial plexus injuries (No jerky or forceful moves)

Delivery StepsDelivery Steps6-7 “Slippery infant”

9-11 Double clamp umbilical chord and cut

12 Wrap/dry/gentle stimulation

12 Determine APGAR at 1 / 5 min.

12 Initiate neonatal resuscitation if a cyanotic / apneic child is delivered with no response to stimulation.

APGARAPGAR

Good, cryingGood, cryingSlow, Slow, IrregularIrregular

AbsentAbsentRespirationRespirationRR

Normal over Normal over entire bodyentire body

Normal Normal except for except for extremitiesextremities

Blue-gray, Blue-gray, pale all overpale all over

AppearanceAppearanceAA

Sneeze,cough,Sneeze,cough,pulls awaypulls away

GrimaceGrimaceNo responseNo responseGrimaceGrimaceGG

Above 100 Above 100 beats/minbeats/min

Below Below 100beats/min100beats/min

AbsentAbsentPulsePulsePP

Active Active movementmovement

Arms and Arms and legs flexedlegs flexed

AbsentAbsentActivityActivityAA

2 points2 points1 point1 point0 points0 pointsSignSign

Cutting The Umbilical CordCutting The Umbilical Cord

Delivery of PlacentaDelivery of Placenta• Occurs in 15-20m after infant is

delivered• Allow spontaneous separation with

gentle traction.• Aggressive traction on the cord can

lead to:• Uterine inversion• Cord Tearing• Placenta disruption severe vaginal bleed

Delivery of PlacentaDelivery of Placenta

• Massage uterus after delivery of placenta (promote contraction)

• Oxytocin maintain uterine contraction (10–20u IV in 1 L NS at 250mL/h or 10u IM)

• Uterine atony excessive vaginal bleed – Oxytocin, Methylergonovine or carboprost tromethamine

• Delay episiotomy or laceration repair for OBGYN to perform.

Complications of Delivery: 1.Cord ProlapseComplications of Delivery: 1.Cord Prolapse

• In Cord Prolapse:Bimanual reveals

palpable pulsating cord

Elevate fetal part reduce cord compression

Examiners hand should Remain in Vagina TransportSurgery C-sec is

indicated.Do not attempt to

reduce prolapsed cord

Complications of Delivery: Complications of Delivery: 2. Shoulder Dystocia2. Shoulder Dystocia

Impaction fetal shoulder on pelvic outletAnterior shoulder trapped behind pubic

symphysis

More common with large infant

Increased Morbidity / Mortality


Complications can include:

1. Brachial plexus injury (overaggressive traction)

2. Impaired respiration fetal hypoxia

3. Cord compression compromised fetal circulation


Downward traction will be insufficient to the deliver the anterior shoulder

Turtle sign – after delivering the infant’s head, it retracts tightly against the perineum

MacRoberts maneuver – position the mother in the extreme lithotomy position (legs sharply flexed up to the abd)


Drain bladder/Consider episiotomyShould apply suprapubic pressure to

disimpact the ant. shoulder from the pubic symphysis.

NEVER APPLY FUNDAL PRESSURE further impact the shoulder on the pelvic rim.

Attempt delivery of posterior shoulder first

Woods’ maneuverWoods’ maneuver• To deliver the impacted

anterior Shoulder, a corkscrew maneuver should be attempted first.

• Grasps the posterior Scapula of the infants with 2 fingers and rotate the shoulder girdle 180 degrees in the pelvic outlet

• This rotate the post shoulder into the anterior position

Complications of Delivery: Complications of Delivery: 3. Breech presentation3. Breech presentation

Occurs in 3-4% pregnancies

3 - 4 times higher morbidity

More common with prematurity

Head entrapment may occur secondary to incompletely dilated cervix. (normal cephalic delivery – the larger head dilates the cervical canal)


Associated with greater incidence of Fetal distress and cord entrapment

Classified as the following FrankComplete Incompletefootling


Factors to remember:1. Hands off let delivery occur spontaneously until

umbilicus appears2. Lateral force on medial thighs3. Rotate fetus sacrum anterior position 4. Wrap exposed parts in towel5. Follow the right humerus down6. Turn fetus counterclock wise keep head in flexed

position to deliver left arm7. No traction risk head / arm entrapment8. Footling and incomplete breach not safe for

vaginal delivery cord prolapse / incomplete dilation of the cervix.

9. In any breech delivery consult OBGYN immediately.

Complications of Delivery: Complications of Delivery: 4. Preterm Delivery4. Preterm Delivery

• Preterm deliveryMost common precipitous childbirthCommon cause for emergency deliveryGestational age may not be knownMore often in breech positionIncreased morbid and mortalityControl the delivery to reduce trauma to

fragile preterm infantMore likely to require resuscitation

??Questions????Questions??1. Placenta previa rarely causes bleeding before the 3rd

trimester. Any patient with vaginal bleeding in the 3rd trimester, especially if painless, should be presumed to have a previa until it is ruled out by __.

A. bimanual examination with sterile gloves B. CT scan C. x-ray D. ultrasound

??Questions????Questions??2. Treatment for fetal bradycardia (<120) during labor

includes all of the following except:

A. Maternal O2 and IV fluids to improve fetal oxygenation and placental perfusion.

B. Use maternal lateral positioning to relieve pressure on the inferior vena cava, improving venous return and placental perfusion.

C. For tetanic uterine contractions associated with fetal bradycardia in the absence of rapid progression of labor, terbutaline, 2.5 mg SQ may be used to relax the uterus.

D. Encourage more prolonged pushing to hasten delivery. E. Consider uterine rupture, particularly if contractions seem

to stop. F. Consider cord prolapse and placental abruption as possible

causes of fetal bradycardia.

??Questions????Questions??3. All of the following are true regarding abruptio placentae

except:

A. Clinical findings include painful third trimester vaginal bleeding, with a tense, tender uterus.

B. Delivery is indicated (vaginal or c-section) for severe bleeding, maternal or fetal instability or abnormal coagulation studies.

C. Risk factors include previous abruption, smoking, hypertension, multiparity, trauma.

D. Shock can be reliably predicted from the amount of external bleeding.

E. Maintain volume and Hct; monitor mother and fetus; type & cross-match.

??Questions????Questions??4. Contraindications to the inter-hospital transfer of the

gravida in labor include all of the following except:

A. Probability of delivery in transit. The acceptable amount of cervical dilation varies depending upon the circumstances, but in general a patient who is dilated >4-5 cm should not be transported.

B. Positive nitrazine or fern test. C. Maternal or fetal instability. D. Actively seizing

??Questions????Questions??5. The patient with postpartum fever may have any of the

usual types of infection, or may have fever related to the postpartum state. Causes of fever related to the postpartum state that should be considered include which of the following:

A. pelvic thrombophlebitis. B. endometritis. C. episiotomy infection. D. surgical wound infection after cesarean section. E. all of the above

ANSWERS: DDDBE

emergency delivery chrisnel jean, d.o presented by: dr. donze 12/8/05

Documents

srom srom

pe of pregnant pt

pregnant women

wks of ga

active labor

verification of presentation

fetus position

vertex presentation