Emergency Delivery Summary

Initial Management

  • Large-bore IV access & fluids
  • Left lateral position
  • High-flow oxygen if needed
  • Vital signs monitoring
  • Obstetrics consultation

Fetal Monitoring

  • Normal FHR: 120-160 bpm
  • Accelerations: Reassuring
  • Early decels: Head compression
  • Variable decels: Cord compression
  • Late decels: Placental insufficiency

Delivery Steps

  • Perineal support during crowning
  • Check for nuchal cord
  • Gentle downward traction for anterior shoulder
  • Upward traction for posterior shoulder
  • Support infant head and body

After Delivery

  • Suction mouth/nose
  • Dry and stimulate
  • Assess Apgar score
  • Clamp cord (3cm from insertion)
  • Deliver placenta (10-30 min)

Medications

  • Oxytocin 10 units IM after placenta
  • Fundal massage
  • Additional oxytocin for hemorrhage

Complications

  • Umbilical cord prolapse
  • Shoulder dystocia
  • Breech presentation
  • Postpartum hemorrhage

Emergency Maneuvers

  • McRoberts for shoulder dystocia
  • Rubin maneuver if McRoberts fails
  • Elevate presenting part for cord prolapse
  • Bimanual massage for hemorrhage

Emergency Delivery

Management of precipitous delivery in the emergency department

Overview

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.

Preparation: Ambulance staff should be trained to recognise and manage labour 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.

Initial Management

Patient Assessment

  • Place large-bore intravenous (IV) line
  • Administer IV fluids
  • Assess vital signs immediately
  • Evaluate for hypoxia or significant hypertension (preeclampsia)

Positioning & Oxygen

  • Left lateral decubitus position
  • Prevents vena cava compression
  • Avoid prolonged supine position
  • High-flow oxygen if hypoxic or fetal bradycardia

Decision Point: 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.

Fetal Monitoring

If available, fetal monitoring should be initiated to evaluate for signs of fetal distress.

Interpretation of Fetal Monitoring

Pattern Description Significance
Normal FHR 120-160 beats per minute Reassuring
Acceleration Increase >15 bpm for >15 seconds Reassuring sign of fetal well-being
Early Deceleration Mirror image of contraction Fetal head compression - not concerning
Variable Deceleration Acute fall with rapid downslope Cord compression - can lead to acidosis
Late Deceleration Symmetric fall after contraction peak Uteroplacental insufficiency - concerning

Performing Delivery of Infant

The steps of a standard cephalic delivery of a full-term fetus in occiput anterior position are described below.

Delivery Procedure
  1. Head Emergence: Provide perineal support with thumb and index finger on each side of inferior vagina to prevent lacerations
  2. Control Delivery: Apply slight counter pressure to prevent rapid expulsion and gentle downward pressure on occiput
  3. Restitution: Allow head to turn to one side and check for nuchal cord
  4. Nuchal Cord Management:
    • Loose cord: Reduce over infant's head
    • Tight cord: Apply 2 clamps and transect between
  5. Anterior Shoulder: Apply gentle, steady downward traction (avoid forceful pulling)
  6. Posterior Shoulder: Apply gentle upward traction
  7. Infant Support: Cradle head in one hand and support lower body with other

Shoulder Dystocia Alert: Be aware of potential complication in larger infants. Do not apply excessive traction.

After Delivery of Infant

Immediate Newborn Care

  • Hold head below heart to clear secretions
  • Suction nose and mouth with bulb suction
  • Dry and stimulate infant
  • Assess Apgar score at 1 and 5 minutes
  • Evaluate ABCs and follow PALS protocol

Umbilical Cord

  • Apply double clamp 3 cm from umbilical insertion
  • Transect with sterile scissors
  • For meconium: Immediate clamping and transfer to warmer for deep suctioning

Placental Delivery

Placental Management
  1. Apply gentle, steady traction while allowing spontaneous detachment
  2. Apply gentle suprapubic pressure with non-dominant hand to prevent uterine inversion
  3. Placenta usually delivers in 10-30 minutes
  4. After delivery: Perform gentle fundal massage
  5. Manually remove clots from vaginal vault
  6. Administer Oxytocin 10 units IM to facilitate uterine contraction

Postpartum Hemorrhage: If significant bleeding occurs, give additional oxytocin or other contractile agents and continue bimanual massage.

Potential Complications

Many emergent complications of labour and delivery exist of which the emergency physician should be aware.

Umbilical Cord Prolapse

  • Cord prolapses through cervix and possibly vagina
  • Cord may be compressed by presenting fetal part
  • Management:
    • Elevate presenting part to reduce compression
    • Keep hand in vagina until C-section delivery
    • Do NOT attempt to reduce prolapsed cord
    • Immediate transport for Caesarean section

Shoulder Dystocia

  • Anterior shoulder lodged behind pubic symphysis
  • Common in larger babies
  • Management Sequence:
    • McRoberts maneuver: Sharply flex legs onto abdomen + suprapubic pressure
    • Rubin maneuver: Insert fingers behind posterior shoulder to rotate trunk
    • Avoid excessive traction to prevent brachial plexus injury

Breech Delivery

  • Caesarean delivery recommended
  • Emergency Management:
    • Call experienced obstetrician immediately
    • Allow spontaneous delivery to umbilical appearance
    • Do not pull on the fetus
    • Support spontaneous delivery

Postpartum Hemorrhage

  • Major cause of maternal mortality
  • Management:
    • Bimanual uterine massage
    • Oxytocin administration
    • Additional uterotonics if needed
    • Fluid resuscitation
    • Consider tranexamic acid

Emergency Delivery Kit

Every ED should have a prepared emergency delivery kit readily available.

Category Essential Items
Delivery Supplies Sterile gloves, drapes, gowns, umbilical clamps, cord scissors, bulb syringe
Medications Oxytocin, emergency medications for mother and newborn
Newborn Care Warm blankets, hat, neonatal resuscitation equipment, Apgar timer
Monitoring Fetal Doppler, blood pressure cuff, pulse oximeter
Documentation Delivery record, consent forms, Apgar scoring sheet