emergent delivery
TRANSCRIPT
Emergent Delivery
Dan Stevens ED Registrar SCGH
Aims• Learn a bit about labour • Have an idea of how to deliver a baby• Know where relevant equipment is in this ED• Have an idea of what can go wrong and how to fix it• Discuss indications and process of perimortem C
section
Labour• Latent Labour
• Cervical effacement• ‘Show’• Dilatation to 4cm
• Active labour• Stage 1
• Further effacement to full dilatation (10cm)• Stage 2
• From full dilation to delivery of child• Stage 3
• From delivery of child to delivery of placenta• Stage 4
• 1st hour post delivery (highest risk of PPH)
Timeline….Stage Nulliparous Multiparous
1. Up to full dilatation 7 – 13 hours 5 – 8 hours
2. Full dilatation to delivery 50 mins 15 mins
3. Delivery of infant to delivery of placenta
5 mins 5 mins
4 immediate PPH 1st hour 1st hour
Assessment of Labour• History
• Previous obstetric history• Multi / nulli• previous complications• previous deliveries
• Current obstetric history• Due date• Pregnancy complications• Onset of contractions• Duration between contractions• Mucous show• Rupture of membranes• Vaginal bleeding
• Medical history
Assessment of Labour• Examination
• Abdominal exam• Gestational age
• > 12 weeks palpable in Abdomen• 22 weeks about level of umbilicus
• Lie• Oblique• Transverse• Longitudinal
• Vaginal exam• Assess dilatation• Possibly unnecessary in ED
• Risk of rupturing membranes. Introducing infection• Speculum
• More useful• Amount of dilatation• head visible• Cord prolapse
Assessment of Labour• Investigations• Ultrasound
• Assess lie• If longitudinal, type of presentation
• Cephalic• breech
• Fetal heart rate
• CTG – if expert available
Women in Labour
Normal Delivery• Stage 1 • Delivery of head
• Stage 2• Delivery of shoulders
• Stage 3• Delivery of body and legs
• Stage 4• Clamp and cut cord
• Stage 5• Delivery of placenta
1. Delivery of Head• Begins with Crowning• Aim is gradual, controlled delivery• Encourage pushing with contractions• One hand resting on infants crown • Other hand underneath, fingers exert upward pressure
on chin• Check for cord around neck and loosen if necessary• Once head delivers it restitutes
2. Delivery of Shoulders• Often deliver themselves with very gentle traction
• Anterior shoulder first with slight downward traction of head
• Posterior shoulder next with slight upward traction
3. Delivery of Body and Legs• Normally easily with gentle traction• Check the baby (or hand to colleague to check – should
have prepared for neonatal resus)• Wrap and stimulate• Wipe gunk from around infants mouth• Healthy baby
• Pink• Good tone• Strong resp effort (cry)• HR > 100
• Pass to mother
4. Clamp and Cut Cord• Place Kelly clamp 5cm from umbilicus• Place another clamp towards the placenta• Cut between the 2• Give syntocinon• Reduces risk of PPH
5. Delivery of Placenta• Happens 5 mins later• Warning signs that its imminent• Uterus becomes firmer and contracts• Gush of blood• Cord lengthens and protrudes
• Apply gentle traction and ask mum to bear down• Don’t use force!
Here it is in action….Video 1 Preparation
Video 2 Delivery
http://scghed.com/ed-orientation/obstetrics-orientation-resources/
Possible complications• Bleeding in 3rd trimester• Cord Prolapse• Shoulder Dystocia• Breech Presentation• Immediate PPH
Cord Prolapse• Occurs when cord bulges out after
rupture of membranes• Leads to fetal distress• Diagnosis made when cord seen on
speculum exam• Treatment = delivery of baby,
normally by C section• However, some temporising
measures….• Knee -> chest position (deep
trendelenberg)• Sterile gloved hand into vagina to
relieve pressure
Shoulder Dystocia • Impaction of shoulder after deliver of head• Occurs in 1% pregnancies• Many can be solved with
McRoberts Maneuver• Extreme lithotomy position• Assistant to apply suprapubic
pressure whilst you apply gentle downward traction on head
Immediate PPH• Causes• Uterine atony (most common)• Others: retained placenta
fragements, lacerations, uterine rupture• Uterine atony = soft, boggy
uterus• Blood• Oxytocin• Uterine massage• Through abdominal wall• bimanually
What to do at 2am• Make assessment• History • Examination external abdomen and speculum• Investigations Ultrasound
• Get help• Prepare for delivery (imminent head on view)• Delivery bundle box• Assign roles Delivery Vs neonatal resus• Gradual, controlled delivery (baby and placenta)
• Pat yourself on the back
Peri-Mortem C section• Indication• Equipment• Procedure
Indication• > 24 weeks pregnant
• Before this time infant chance of survival = 0• Effect of infant on maternal haemodynamics minimal
• Cardiac arrest• Aim for delivery in less than 5 mins from onset of cardiac
arrest• But if longer than 5 minutes don’t not do it
Equipment• Sterile Precautions• Scalpel (11)• Scissors (curved with blunt end)• Suction • Retractors (or assistants)• Packs• Cord Clamps• Sutures
Procedure• Vertical midline incision
• Umbilicus to symphysis pubis (follow linea alba line)• Skin subcutaneous tissue fascia rectus sheath peritoneum• Retract layers
• This should expose uterus• Make small vertical incision in lower uterine segment
• Should be gush of amniotic fluid• Extend the incision with scissors towards umbilicus• Grasp head and try to disengage it
• lift infant out• Fundal pressure from assistant may help
• Find placenta – separate it from the wall of the uterus and remove• Apply fundal pressure and uterine message• Close uterus then peritoneum then skin
If she can do it……
Resources• http://
broomedocs.com/wp-content/uploads/2012/10/TH-229-Post-Mortem-C-Section-perimortem1.pdf• http://
broomedocs.com/2012/10/perimortem-c-section-can-you-cut-it-in-obstetric-resuscitation/• https://
en.wikipedia.org/wiki/Self-inflicted_caesarean_section• Clinical Procedures in Emergency Medicine. Roberts
and Hedges 6th Edition• http://scghed.com/ed-orientation/obstetrics-orientatio
n-resources/