Best Practices: Emergency Delivery

Emergency delivery or precipitous delivery in the emergency department (ED) occurs infrequently and can be stressful for an emergency physician who may be unpracticed in the procedure of a standard vaginal delivery. If the fetal head is visible with contractions or the cervix is fully dilated and/or effaced, consider calling obstetrics to the ED versus risking delivery during transportation. However, the emergency physician may have to deliver the infant if a medical practitioner skilled in obstetrics is not immediately available. Image courtesy of Mark Brady, PA-C.

If a pregnant patient cannot be transferred immediately to the Labor and Delivery department, vital signs—including assessment of fetal heart rate—should be obtained and supportive therapy started with intravenous access and hydration. If available, fetal monitoring should be initiated to evaluate for signs of fetal distress. Image courtesy of Wikipedia Commons.

The steps of a standard cephalic delivery of a full-term fetus in occiput anterior position are described here. As the head emerges, perineal support should be provided by gently applying pressure with the thumb and index finger on each side of the inferior aspect of the vagina to help prevent perineal lacerations. Slight counterpressure should be applied to prevent rapid expulsion, which increases the risk for high-degree lacerations. Additionally, gentle downward pressure should be applied to the occiput to guide the head away from anterior structures to prevent urethral tears.

As the head delivers, allow restitution where the head will turn to one side or the other. At this time, check for a nuchal cord. If a loose nuchal cord is encountered, reduce over the infant’s head before delivering the anterior shoulder. If there is a tight nuchal cord, apply 2 clamps and transect between to allow delivery.

To deliver the anterior shoulder, apply gentle and steady downward traction. Take care not to pull forcefully, which can put the infant at risk for brachial plexus injuries. Be aware of the potential complication of shoulder dystocia in larger infants or mothers with gestational diabetes. Special maneuvers for shoulder dystocia are mentioned later.

Once the anterior shoulder is delivered, gentle upward traction should be applied to deliver the posterior shoulder, after which the torso will be rapidly expelled. Take care to support the infant by cradling the head in one hand and supporting the lower body with the other.

After delivery, the head should be held below the heart to facilitate clearance of secretions. At this time, the infant can be cradled in one arm and the nose and mouth should be suctioned with a bulb suction to promote spontaneous respirations. The infant should be dried and stimulated. The Apgar score should also be assessed (as detailed later).

A double clamp should be applied approximately 3 cm to distal the insertion of the umbilicus and the cord transected with sterile scissors. If meconium aspiration is suspected, the cord should be immediately clamped after delivery and the infant transferred to a warmer for airway assessment and deep suctioning. Image courtesy of Wikipedia.

After delivery and stabilization of the infant, attention can be turned to the delivery of the placenta. Gentle, steady traction should be applied while the placenta is allowed to detach and deliver spontaneously to avoid tearing of the cord or incomplete delivery and retained portions of placenta. Gentle suprapubic pressure should be applied with the nondominant hand to prevent uterine inversion. The placenta usually takes 10-30 minutes to delivery.

After delivery of the placenta, gentle fundal massage should be performed. Clots can be manually removed from the vaginal vault. Oxytocin, 10 units IM, should be given to facilitate uterine contraction. If significant postpartum hemorrhage occurs, give additional oxytocin or other contractile agents and continue bimanual massage.

Many emergent complications of labor and delivery exist of which the emergency physician should be aware. First, umbilical cord prolapse occurs when the cord prolapses through the cervix and possibly vagina. The cord can potentially be compressed by the presenting part of fetus. The prolapsed cord may only be palpable on bimanual exam. If encountered, the examiner’s hand should elevate the presenting part to reduce cord compression and should remain in the vagina until the patient can be transported for delivery by Caesarean section. Do not attempt to reduce the prolapsed cord.

Other complications include shoulder dystocia, in which the anterior shoulder becomes lodged behind the pubic symphysis (arrow), typically in larger babies. When routine downward traction fails to deliver the posterior shoulder, the McRoberts maneuver can be applied in which the patient’s legs are sharply flexed onto the abdomen while suprapubic pressure is applied. In many cases, this maneuver is sufficient to free the impacted shoulder.

If the McRoberts maneuver is not effective, the Rubin maneuver may be applied. In this method for delivering the shoulder, the fingers of one hand are inserted behind the posterior aspect of the fetal shoulder in order to rotate the fetal trunk into the (wider) oblique plane.

Breech delivery is yet another potential complication of emergency delivery for which Cesarean delivery is recommended. In case of breech delivery, the emergency physician should call an experienced obstetrician immediately and allow delivery to occur spontaneously to the point the infant’s umbilicus appears. Details of a breech delivery are beyond the scope of this presentation.

The Apgar score was devised in 1952 as an easy way to quickly assess the health of a neonate immediately after birth. The Apgar score uses five criteria, with scores ranging 0 to 10. It is typically measured at 1 and 5 minutes immediately after delivery. A score of ≤3 is considered to be critical, 4-6 is concerning, and 7-10 is generally normal. The test can be repeated as necessary if the score remains low and is used to determine whether a neonate requires medical attention.

After a precipitous delivery, the neonate should be vigorously dried and placed in a warmer for evaluation and resuscitation if necessary. The nose and mouth should be suctioned with a bulb syringe if not done so at the perineum after delivery. If meconium aspiration is suspected, the infant should be mechanically suctioned with an 8F catheter. An Apgar score should be calculated. ABCs should be evaluated and PALS protocol followed. If an infant remains bradycardic with heart rate <60 beats per minute after 30 seconds of assisted ventilation, chest compressions should be initiated.

If immediate transfer to Labor and Delivery is not feasible, fetal monitoring should be initiated in the ED. Normal fetal heart rate (FHR) is between 120-160 beats per minute. Acceleration is an increase of more than 15 beats per minute above the baseline lasting more than 15 seconds; it is considered to be a reassuring sign of fetal well-being.

Early deceleration (shown) is a deceleration that is a mirror image of the contraction, with a slow onset coinciding with start of the contraction and a slow return to baseline. Early decelerations are caused by fetal head compression during uterine contraction and are not considered to be a sign of fetal distress.

Variable deceleration (shown) is characterized by an acute fall in the FHR with rapid downslope and variable recovery phase. It is caused by cord compression. Persistent variable decelerations can lead to acidosis and hypoxia.

Late deceleration (shown) is associated with uteroplacental insufficiency provoked by uterine contractions. It is characterized by a symmetric fall in FHR that begins after the peak of the contraction (pink dotted line). A pattern of late decelerations is not reassuring.

Perimortem cesarean delivery (C-section) is a consideration for women who suffer cardiac arrest, ideally completed within 5 minutes. First, estimated gestational age (EGA) should be determined either based on history or fundal height. In general, the uterus reaches the level of the umbilicus at 20 weeks and grows approximately 1 centimeter for every week thereafter. A fetus can be considered for perimortem C-section if the EGA is >23 weeks, but consideration should be made to resources available for neonatal resuscitation. Bedside ultrasound may be used to assess fetal viability if it does not cause delay. If fetal cardiac activity is absent, perimortem C-section is not indicated.

Perimortem cesarean delivery uses a midline incision from the level of the fundus to the pubic symphysis to gain exposure to the uterus with the use of retractors. Blunt dissection should be performed until the peritoneum is entered. A vertical incision is then made from the fundus inferiorly towards the anterior bladder reflection. When the uterine cavity is first entered, middle and index finger should be inserted to lift the uterine wall away from the infant while the incision is extended preferably with scissors. The infant should then be delivered through the hysterotomy and immediately handed to someone skilled in neonatal resuscitation while the cord is clamped. The placenta should be removed before closure and maternal resuscitative efforts continued. Image courtesy of Wikipedia Commons.

EMS personnel should be trained to recognize and manage labor and to assist in an emergency delivery in the prehospital setting if delivery occurs during transport. Additionally, a precipitous delivery kit should also be assembled and ready in the ED, including at a minimum the items shown. Transport of the actively laboring patient should include placement of a large-bore intravenous (IV) line and administration of IV fluids. Vital signs should immediately be assessed to evaluate for abnormalities such as hypoxia or significant hypertension that could indicate preeclampsia.

Administration of high-flow oxygen should be started immediately if the patient is hypoxic or if fetal bradycardia is detected on Doppler evaluation of fetal heart tones. The patient should be put in left lateral decubitus position to alleviate pressure of the gravid uterus on the inferior vena cava, which can cause decreased venous return to the heart. Near-term patients should never be placed in the flat, supine position for prolonged periods of time for this reason. Image courtesy of Wikipedia Commons.