This is a very personal story, and one that is still raw in many ways after all of this time. I share it because I hope others can benefit from these lessons learned. These apply not only to precipitous deliveries, but also to other crises and unexpected situations.
In this post, we will explore postpartum hemorrhage and resuscitative hysterotomy...
Emergency Room Extramural Deliveries: What can go right? What can go wrong?
Complicated deliveries are infrequently performed, high-stress procedures. Call for OB and neonatology early, in addition to extra ED team members. Make sure someone prepares to care for the neonate.
It's all terrifying. Even more so if you wind up working somewhere where OB isn't in house 24/7. And the delivery doesn't even need to be 'difficult' per se -- any unexpected delivery in the ED is a pulse-quickening event (and we'll discuss normal deliveries, too.)
Deliver the head: As the head emerges from the introitus place a sterile towel on the inferior aspect with one hand, while using the other hand to support the fetal head. Use one hand to support the fetal chin and the other to support the crown. Restitution of the head: The baby’s head will begin to rotate 45 degrees, to a posterior lateral position. Feel for nuchal cord. If present and loose, slip it over the baby's head. If too tight to pull over the head, apply two clamps and cut the cord. (this occurs in 25-35% of deliveries)
First, take a deep breath and remember that 90%
of babies require no assistance at birth and
transition to the extrauterine environment appropriately all on their own.
Place 1 hand on the head to minimize uncontrolled movements. With the other hand provide gentle pressure on the perineum
Reassure mom. Have her push during contractions. Aim for 10 seconds of pushing, repeated 3 times for every contraction. When head presents, stop pushing and instead have mom breath through contractions.
When head is delivered, sweep neck for a nuchal cord...
Is the fetus visible and beginning to emerge from the vagina? This indicates delivery is imminent within minutes (median time is 30 minutes for the 2nd stage of labor in nulliparous women; 12 minutes in multiparous women).
If you see a breech (3% of all deliveries) or if the amniotic sac is visible, do not touch. Frank breeches (butt first), and footling breeches (single or both legs are extended into the canal), are both difficult to manage (the latter being a nightmare) and are outside the scope of this review. Breech deliveries should never deliver with traction.
You examine the patient, and sure enough she appears to be crowning, but something looks funny. That is a weird looking head. Oh wait, its a bum! How to you deal with a breech delivery?
As soon as shoulder dystocia is recognized, ask mom to stop pushing.
Check for a nuchal cord. If present slide over the head. If you cannot get it over the head, clamp x2 and cut between; deliver the baby ASAP. If it can be accomplished within 1 min, insert a foley catheter to drain the bladder.
The first step is called McRobert’s maneuver: an assistant is directed to push mom’s thighs as close to her chest as possible. A second assistant then applies suprapubic pressure.
As soon as the examining hand reveals an umbilical cord, the hand is used to elevate the presenting part and reduce compression of the cord. This hand remains in the vagina until baby is delivered by emergency c-section. Position the mother to reduce cord compression: either knee to chest position or left lateral with head down and pillow under mom’s hip.
The LABUR protocol quickly evaluates the featus (number, presentation, heart rate), amniotic fluid (presense, quantity), and placenta (location) in late gestation.
Although the incidence of performing ED deliveries is low, the stakes are much higher. The following list outlines the increased rates of various complications: Infant resuscitation → 25%. Infant mortality → 9%.
Nuchal cord → 9%.
Postpartum hemorrhage → 6%.
Shoulder dystocia → 3%.
Cord prolapse → 1%.
During delivery of the head, gentle upward pressure with a sterile towel or drape to prevent anal contamination on the perineal area helps elevate the presenting part and decrease the pressure the fetal chin exerts on the perineal skin.
Immediately following delivery of the head, palpate the fetal neck to inspect for umbilical cord encircling the neck. This cord needs to be reduced over the fetal head before delivery can continue.
Gentle digital stretching with a lubricated finger may prevent tears and lacerations.