emergent delivery

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Emergent Delivery Dan Stevens ED Registrar SCGH

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Page 1: Emergent Delivery

Emergent Delivery

Dan Stevens ED Registrar SCGH

Page 2: Emergent Delivery

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

Page 3: Emergent Delivery

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)

Page 4: Emergent Delivery

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

Page 5: Emergent Delivery

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

Page 6: Emergent Delivery

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

Page 7: Emergent Delivery

Assessment of Labour• Investigations• Ultrasound

• Assess lie• If longitudinal, type of presentation

• Cephalic• breech

• Fetal heart rate

• CTG – if expert available

Page 8: Emergent Delivery

Women in Labour

Page 9: Emergent Delivery

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

Page 10: Emergent Delivery

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

Page 11: Emergent Delivery

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

Page 12: Emergent Delivery

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

Page 13: Emergent Delivery

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

Page 14: Emergent Delivery

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!

Page 15: Emergent Delivery

Here it is in action….Video 1 Preparation

Video 2 Delivery

http://scghed.com/ed-orientation/obstetrics-orientation-resources/

Page 16: Emergent Delivery

Possible complications• Bleeding in 3rd trimester• Cord Prolapse• Shoulder Dystocia• Breech Presentation• Immediate PPH

Page 17: Emergent Delivery

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

Page 18: Emergent Delivery

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

Page 19: Emergent Delivery

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

Page 20: Emergent Delivery

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

Page 21: Emergent Delivery

Peri-Mortem C section• Indication• Equipment• Procedure

Page 22: Emergent Delivery

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

Page 23: Emergent Delivery

Equipment• Sterile Precautions• Scalpel (11)• Scissors (curved with blunt end)• Suction • Retractors (or assistants)• Packs• Cord Clamps• Sutures

Page 24: Emergent Delivery

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

Page 25: Emergent Delivery

If she can do it……