Labor and Delivery in the Emergency Department

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Labor and Delivery in the Emergency Department

• Ricardo R. Jiménez, M.D.
• Pediatric Emergency Medicine, Fellow
• Emory University School of Medicine
• Childrens Healthcare of Atlanta

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Objectives

• The risk of labor and delivery in the ED

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Objectives

• Approach to the pt in possible labor

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Objectives

• Management on labor and delivery in a sub-optimal
  setting

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Objectives

• Diagnosis of a complicated delivery

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Objectives

• Management of the most common complicated
  deliveries

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Labor and Delivery in the ED

• ED avoidance perspective on labor and delivery
  (LD)
• When possible the pts in labor should be triage
  and transfer to an obstetric facility
• Birth in the ED are rare
• When labor has progressed to fetal expulsion, the
  ED physician will become the obstetric provider
• The ED physician must posses basic skills for
  intrapartum management of normal and abnormal
  deliveries

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Labor and Delivery in the ED

• Perinatal infant mortality in 0.04
• Normal pregnancy
• Good prenatal care
• Delivery by an Ob

• Perinatal infant mortality for deliveries in the
  ED is 8 to 10
• No prenatal care
• Unexpected complications
• Women with drug and alcohol abuse
• Victims of domestic abuse
• Denial or unaware of pregnancy
• Illegal aliens

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Labor and Delivery in the ED

• Any delivery in the ED should be considered High
  Risk
• Maternal mortality is also increase
• The transfer of a pt in labor should be supported
  by clinical and medicolegal judgment
• En route delivery can be fatal for fetus and
  mother

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Labor and Delivery in the ED

• Consolidated Omnibus Reconciliation Budget Act
  (COBRA) of 1989
• Clearly identify labor as a condition unsuitable
  for transfer due to its unstable nature

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Limitations of the ED

• Need for
• Experience personnel
• Monitoring instruments
• Tocodynamometry
• U/s
• Fetal scalp monitors
• Vacuum extractors
• Forceps
• Prenatal hx
• C-section is not an option in the ED

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Normal Delivery

• Normal LD would proceed, without physician
  intervention, to good outcome
• Mother and fetus are very vulnerable
• After 24wks any assessment must include both
  mother and fetus
• Symptoms
• Abdominal pain
• Back pain
• Cramping
• Urinary urgency
• Vomiting
• Anxiety

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Normal Delivery

• False labor (Braxton Hicks contractions)
• After 30wks the uterus becomes a contractile
  organ
• Contractions are synchronous
• Will not increase infrequency or duration
• Non dilated cervix
• Intact membranes
• Relieved with mild analgesia

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Normal Delivery

• True labor
• Cyclic uterine contraction of increasing
  frequency, duration and strength
• Cervical dilatation
• Bloody show
• Mucous plug expelled
• Blood is dark and scant
• Not a contraindication for cervical exam
• Reliable indicator for onset of labor

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Normal Delivery

• First Stage of Labor (Cervical Stage)
• Ends when the cervix is fully dilated and effaced
• Latent phase- slow cervical dilatation
• Active phase- rapid cervical dilatation
• Duration is close to 8hrs in nulliparous and 5hrs
  in multiparas
• Most women that deliver in the ED arrive in
  active phase stage 1 or early stage 2

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Normal Delivery

• First Stage of Labor (Cervical Stage)
• Examination of the cervix (Sterile approach)
• Effacement
• Dilatation
• Position
• Station
• Presentation

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Normal Delivery

• First Stage of Labor (Cervical Stage)
• Effacement
• Refers to the thickness of the thinning cervical
  canal compared to the cervix
• Paper thin is 100 effaced
• Dilatation
• Cervical opening in cm, complete is 10 cm
• Position
• Describes the relationship of the fetal
  presenting part to the birth canal

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Normal Delivery
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Normal Delivery
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Normal Delivery

• First Stage of Labor (Cervical Stage)
• Station
• Indicates the relationship of the presenting
  parts to the ischial spines

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Normal Delivery

• First Stage of Labor (Cervical Stage)
• Presentation
• Specifies the presenting anatomic part
• 95 of all labors the presenting part is occiput
  or vertex

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Normal Delivery

• First Stage of Labor (Cervical Stage)
• Presentation
• On palpation a smooth surface with 360 degrees of
  bony contours and suture lines should be found
• 3 sutures will extend from the posterior fontanel
  and 4 from the anterior

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Normal Delivery
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Normal Delivery

• Second Stage of Labor
• Full cervical dilatation
• Urge to bear down and push with uterine
  contractions
• Position will advance to 3 with crowning
• Contractions last 1 to 2min and recur after a
  resting phase of less than a min
• Duration is close to 50 min in nulliparous and 20
  min in multiparous

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Fetal monitoring

• After 24wks of gestation the fetus has to be
  asses just like the mother
• Uterine activity and Fetal cardiac activity
• Base line HR
• Maintained for 15 min in absence of contractions
• Single most important aspect of fetal monitoring
• Variability
• Indicator of fetal well being

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• Uterine activity and Fetal cardiac activity
• Acceleration
• Occur during fetal movement or umbilical cord
  compression
• Reflect and alert mobile fetus
• Deceleration
• More complicated and most be integrated into the
  clinical situation
• Three types
• Early
• Late
• Variable

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Fetal monitoring

• Uterine activity and Fetal cardiac activity
• Variability
• Decrease variability correspond to an inactive
  fetus
• Fetal acidemia
• Hypoxia
• Drugs use like alcohol, benzodiazepine,
  analgesics

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Fetal monitoring

• Uterine activity and Fetal cardiac activity
• Decelerations
• Early and variable are very common
• Represent physiologic responses to head
  compression by the birth canal or cord
  compression
• If persistent the delivery should be hasten if
  obstetric backup a c-section should be consider
• Late decelerations indicate uteroplacental
  insufficiency
• The lag, slope and the magnitute of the
  deceleration correlate with increase fetal
  hypoxia
• Immediate delivery should be perform

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Fetal monitoring

• Uterine activity and Fetal cardiac activity
• Sinusoidal traicing
• Low baseline HR and little variability
• Often a premorbid finding

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Fetal monitoring
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Fetal monitoring
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Fetal monitoring
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Fetal monitoring
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Normal Delivery

• Delivery ( Oh S what am I going to do? Stage)
• Equipment
• Radiant warmer
• Towels
• Umbilical clamps
• Scissors
• Airway management
• Adult and neonatal airway management
• Meconium suctioning tools
• Valium for you

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Normal Delivery

• Delivery
• Place the mother in dorsal lithotomy
• The vulva and perineum should be gently scrubbed
• Sterile cervical examination
• Digital stretching of the perineum
• Coach mother to sustain each push until crowning
• Once crowning occur coach so the delivery occur
  in a slow control manner

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Normal Delivery

• Delivery
• Coach mother to sustain each push until crowning
• Once crowning occur coach so the delivery occur
  in a slow control manner

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Normal Delivery

• Delivery
• Be calm
• Ask the mother to pant and not to push to slow
  the passage of the head and shoulders
• In a controlled delivery the performance of an
  episiotomy is not indicated

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Episiotomy

• The routine use of episiotomy has been challenged
• Increase maternal morbidity is associated with
  both medial and mediolateral approach
• Mediolateral approach is associated
• Less satisfactory cosmetic results
• Painful intercourse
• More pain
• Medial approach
• Serious perineal lacerations

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Episiotomy

• Should be performed only in shoulder dystocia or
  breech delivery
• Most authors recommend a mediolateral approach

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Normal Delivery

• Delivery
• Modified Ritgen maneuver facilitate most normal
  deliveries
• Once the head is delivered, it should be rotated
  to the mother thigh, mouth and nares should be
  bulb suction

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Normal Delivery

• Delivery
• Downward pressure will help deliver the anterior
  shoulder and subsequent upward motion will
  deliver the posterior shoulder

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Normal Delivery

• Delivery
• Keep the infant low to promote blood flow from
  the placenta
• Clamp the cord 4 to 5 cm apart, with the proximal
  clamp 10 cm from the infant, and then cut

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Normal Delivery

• Third Stage of Labor (Delivery of the Placenta)
• Signs of placental separation
• Uterus becomes firm and globular
• Sudden gush of blood
• Umbilical cords protrudes further out of the
  vagina
• Uterus is displaced upward the abdomen

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Normal Delivery

• Third Stage of Labor (Delivery of the Placenta)
• Usually occurs between 5 to 10 min after
  delivery, but may be delayed up to 20 min
• Beyond 25 min is abnormal

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Normal Delivery

• Third Stage of Labor (Delivery of the Placenta)
• If excessive bleeding or prolong placental
  expulsion uterine massage may be indicated
• Puling on the cord or trying to express the
  placenta before it separates is contraindicated

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Normal Delivery

• Fourth Stage of Labor
• First hr after delivery of the placenta
• Highest risk for hemorrhage
• Examine cervix and vagina for any lacerations

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Normal Delivery
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Complicated Delivery

• Breech Presentation
• 4 of all deliveries
• Three types
• Frank
• Complete
• Incomplete
• Buttocks do not cause enough wedge to dilate the
  cervix
• The head becomes trapped
• Cord commonly prolapse

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Complicated Delivery

• Breech Presentation
• 4 of all deliveries
• Three types
• Frank
• Complete
• Incomplete
• Buttocks do not cause enough wedge to dilate the
  cervix
• The head becomes trapped
• Cord commonly prolapse

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Complicated Delivery

• Breech Presentation
• 4 of all deliveries
• Three types
• Frank
• Complete
• Incomplete
• Buttocks do not cause enough wedge to dilate the
  cervix
• The head becomes trapped
• Cord commonly prolapse

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Complicated Delivery

• Breech Presentation
• 50 of term infants who die as neonates are
  products of breech deliveries
• Deaths are associated to
• Asphyxia secondary to cord entrapment
• Neck and head trauma

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Complicated Delivery

• Breech Presentation
• The presentation to the ED may be increasing b/c
  of OB are now trying more breech deliveries

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Complicated Delivery

• Breech Presentation
• Diagnosis
• Leopolds maneuvers
• Cervical exam
• Ultrasound

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Complicated Delivery

• Breech Presentation
• Management
• The goal is to maximize the size of passage
• If possible keep membranes intact b/c it
  increases wedge
• Generous episiotomy or episioproctomy

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Complicated Delivery

• Breech Presentation
• Management
• Knee flexion and sweep out the legs
• After the umbilicus clears the perineum pull out
  10 to 15 cm of the cord
• Use the bony pelvis to hold the neonate
• Mauriceau maneuver

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Complicated Delivery

• Breech Presentation
• Management
• Mauriceau maneuver
• Use the fetal mouth to flex the neck and bring
  the chin in
• Fetal neck extension is associated to 70 cord
  injuries and worse dystocia

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Complicated Delivery

• Shoulder Dystocia
• Shoulders at vertical axis
• Second most common presentation
• 1/300 live births
• Incidence my be higher in the ED deliveries
• It will be diagnosed intrapartum

• Most commonly seen
• Diabetic mothers
• Obese mother
• Prolong second stage of labor
• Macrosomic neonates
• Postmaturity
• Erythroblastosis fetalis

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Complicated Delivery

• Shoulder Dystocia
• Complications include
• Asphyxia
• Brachial plexus injuries
• Humeral and clavicular fractures
• Diagnosis
• Turtle sign- fetal head retracts toward the
  perineum
• Traction on the head will extend and abduct the
  shoulders increasing the bisacromial diameter

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Complicated Delivery

• Shoulder Dystocia
• Management
• Successful delivery is possible with a sequential
  approach to each maneuver
• Increase the AP diameter of the passage
• Episiotomy or episioprotoctomy
• Draining the bladder
• McRoberts maneuver

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Complicated Delivery

• Shoulder Dystocia
• Management
• Suprapubic pressure
• Rubins maneuver- push the shoulders toward the
  chest

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Complicated Delivery

• Shoulder Dystocia
• Management
• Woods corkscrew
• Push the accessible shoulder to the chest, put a
  finger under the axilla and slid the other hand
  along the spine and grab the fetal hips
• Rotate 180º
• Delivery of posterior arm via a episioprotoctomy
• The posterior hand is sweep across the chest and
  brought to the chin
• Splint the humerus to prevent fractures and
  brachial plexus injury
• The hand is then pulled across the face to
  deliver the posterior shoulder

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Complicated Delivery

• Shoulder Dystocia
• Management
• HELPER Mnemonic
• Help
• Episiotomy
• Legs flexed- McRoberts maneuver
• Pressure- Suprapubic and shoulder pressure
• Enter vagina- Rubins maneuver or corkscrew
• Remove posterior arm from the canal

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Complicated Delivery

• Umbilical Cord Prolapse
• The umbilical cord precedes the fetus presenting
  part
• Develops during the second stage of Labor
• 50 occur with malpresentation
• Associate to PROM
• 8.6 to 49 perinatal mortality

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Complicated Delivery

• Umbilical Cord Prolapse
• Management
• With a viable fetus the preferred method of
  delivery is C-section
• To preserve umbilical circulation
• Knee to chest position on Trendelenburg
• Digitally elevate the presenting part from the
  cord
• Place a Foley and instill 500 to 700ml of NS
• Perinatal mortality decreases to 5 with
  C-section done within 10 min

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Complicated Delivery

• Umbilical Cord Prolapse
• Management
• What if C-section is not an option?
• Knee to chest position on Trendelenburg
• Digitally elevate the presenting part
• Gently pull the cord above the presenting part
• Rapid delivery
• Prepared to resuscitate the distressed infant

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Complicated Delivery

• Cord Entanglement
• Associated to fetal movement early in pregnancy
• Associated to 4 to 5 of stillbirths
• Cords knots can persist without fetal distress
  until they are pulled tight during delivery
• Management
• The only choice is rapid delivery and avoid
  further cord traction

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Complicated Delivery

• Cord Fetal Entanglement
• Common around neck and chest
• Multiple loops can be present
• Rarely cause fetal distress
• Management
• Loose coils can be reduced at the perineum by
  slipping them forward over the head
• Tight coils that impede delivery should be clamp,
  cut and rapidly deliver the fetus

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Summary

• Labor and Delivery in the ED is rare, but it will
  happen in your lifetime as a PEM

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Summary

• Labor and Delivery in the ED is rare, but it will
  happen in your lifetime as a PEM
• Deliveries in the ED are all High risk

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Summary

• Labor and Delivery in the ED is rare, but it will
  happen in your lifetime as a PEM
• Deliveries in the ED are all High risk
• Labor is unsuitable for transfer

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Summary

• Labor and Delivery in the ED is rare, but it will
  happen in your lifetime as a PEM
• Deliveries in the ED are all High risk
• Labor is unsuitable for transfer
• Call OB early if possible pt in labor

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Summary

• Labor and Delivery in the ED is rare, but it will
  happen in your lifetime as a PEM
• Deliveries in the ED are all High risk
• Labor is unsuitable for transfer
• Call OB early if possible pt in labor
• Concentrate in basic delivery skills and
  diagnosis of complications

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Summary

• Labor and Delivery in the ED is rare, but it will
  happen in your lifetime as a PEM
• Deliveries in the ED are all High risk
• Labor is unsuitable for transfer
• Call OB early if possible pt in labor
• Concentrate in basic delivery skills and
  diagnosis of complications
• At the end of the day might have save two lives

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Questions?