Morning Report: Extramural Deliveries in the Emergency Room

Dr. Corburn presents today’s Morning Report!

Emergency Room Extramural Deliveries: What can go right? What can go wrong?

What can go right?

-Is the infant descending head-first (not breech-buttocks or feet first): decide this based on examination and confirm by ultrasound

-Attempt to coach the mother in controlled pushing to avoid precipitous, uncontrolled delivery

-6 cardinal movements of labor:

1) Enagagement

2) Flexion

3) Descent

4) Internal rotation

5) Extension

6) External rotation

-During the process, if able, support the perineum by gentle digital stretching of the inferior perineum

-As the head is descending, place a sterile towel on the inferior perineum while supporting the head of the baby

-Use counter pressure against the perineum to prevent precipitous delivery (and high grade perineal injuries) and to avoid damage to anterior perineal structures

-As the infant’s head delivers, use gentle downward traction to deliver the anterior shoulder

-Be gentle to avoid brachial plexus injuries

-After the anterior shoulder is delivered, pull upward to delivery the posterior shoulder and the remainder of the baby

-Double clamp the cord 3cm distal to the umbilicus and cut with sterile scissors

Delivery of the placenta

-Within 10-30 minutes post delivery of baby

-Allow spontaneous delivery of placenta; over traction can cause damage, which can lead to excessive bleeding

-After delivery, fundal massage helps to promote contraction and hemostasis

-Average vaginal birth has blood loss around 500ml

-Greatest cause of maternal morbidity and mortality during delivery is from hemorrhage, most commonly caused by uterine atony

-Provide patient with oxytocin (10-40 units in 1L normal saline at 250ml/hr or 10 units IM) to also promote contraction and limit blood loss

What can go wrong during delivery?

1) Nuchal cord:

-Can complicate up to 25-35% of deliveries

-If loose, the cord can be reduced over the infant’s head

-If tight, clamp at 2 spots most accessible and cut the cord

2) Umbilical cord prolapse:

-When bimanual exam reveals pulsatile umbilical cord

-Compression of the cord (by the fetal presenting parts) can be life threatening to the undelivered baby

–Never attempt to reduce the cord

-Examiner’s hand should elevate presenting fetal part off of the cord while transporting patient to OR for emergency cesarean section

-Need early ob/gyn involvement

3) Shoulder Dystocia:

-Impaction of the anterior shoulder in the pelvis after delivery of the fetal head

-Risks to fetus include brachial plexus injuries, hypoxia, compromised fetal circulation, fetal death

-Some techniques to employ:

-Extreme lithotomy position for the mother (McRoberts’ maneuver)

-Drain bladder

-Episiotomy

-Suprapubic pressure (to attempt to push-out the shoulder from the pelvis)

-Woods corkscrew maneuver: rotate posterior shoulder of fetus into anterior shoulder position

-Delivery of posterior shoulder first

Resources:

VanRooyen, Michael J., and Jennifer A. Scott. “Chapter 105. Emergency Delivery.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. Eds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2011.n. pag. Access Medicine. Web. 20 Aug. 2015.