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HWN Suggests

Clamp the Cord: Emergency Department Deliveries – Part 1

Apply gentle pressure with a sterile towel using your dominant hand to support the perineum, easing the pressure of head descent to prevent vaginal tears. Apply gentle pressure with your non-dominant hand to the head with slight flexion to the infant’s neck as the mother gives small pushes.

The infant will restitute and rotate to face the maternal thigh after the head is delivered. Now is the time to check for a nuchal cord by running your finger around the neck.

To deliver the anterior shoulder, place your palms on the infant’s cheeks and apply gentle downward traction. Oxytocin 10 units IM should be administered after delivery of the anterior shoulder. Use gentle upward…

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Articles of Interest

Asynchrony EM: The Difficult Delivery

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.)

Back to the Basics: Emergency Spontaneous Vaginal Delivery

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)

Management of an Unexpected Delivery in the Emergency Department

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.

Precipitous delivery in the ED

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...

Precipitous Labor & Delivery: Free Shipping

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.

The Difficult Delivery: Breech Presentation

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?

The Difficult Delivery: Shoulder Dystocia

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.

The Difficult Delivery: Umbilical Cord Prolapse

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.

US - Pregnancy The LABUR protocol: Ultrasound of the Month

The LABUR protocol quickly evaluates the featus (number, presentation, heart rate), amniotic fluid (presense, quantity), and placenta (location) in late gestation.

Resources

International Emergency Medicine Education Project

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.

WikEM

Gentle digital stretching with a lubricated finger may prevent tears and lacerations.