Emergency Delivery Summary

Initial Management

  • Large-bore IV line & fluids
  • Left lateral position
  • High-flow O2 if hypoxic/foetal bradycardia
  • Call OB if head visible/cervix fully dilated

Foetal Monitoring

  • Normal FHR: 120-160 bpm
  • Acceleration: reassuring sign
  • Early deceleration: head compression
  • Variable deceleration: cord compression
  • Late deceleration: uteroplacental insufficiency

Delivery Steps

  • Provide perineal support
  • Allow restitution & check for nuchal cord
  • Gentle traction for anterior shoulder
  • Upward traction for posterior shoulder
  • Support infant head and body

After Delivery

  • Head below heart for secretions
  • Suction nose & mouth
  • Dry and stimulate
  • Assess Apgar score
  • Clamp cord 3cm from umbilicus

Complications

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

Placenta Delivery

  • Gentle traction, allow spontaneous delivery
  • Suprapubic pressure to prevent inversion
  • Usually takes 10-30 minutes
  • Fundal massage after delivery
  • Oxytocin 10 units IM

Shoulder Dystocia

  • McRoberts maneuver first
  • Then Rubin maneuver if needed
  • Avoid excessive traction

Emergency Delivery

Comprehensive guide to managing precipitous delivery in emergency settings

Introduction

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.

Key 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

IV Access & Monitoring

  • Large-bore intravenous (IV) line
  • Administration of IV fluids
  • Assess vital signs immediately
  • Evaluate for hypoxia or hypertension

Positioning

  • Left lateral decubitus position
  • Alleviates pressure on inferior vena cava
  • Prevents decreased venous return
  • Avoid prolonged supine position

Oxygen & Consultation

  • High-flow oxygen if hypoxic
  • Oxygen if foetal bradycardia detected
  • Call obstetrics if head visible or cervix fully dilated
  • Be prepared to deliver if OB not available

Foetal Monitoring

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

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

Performing Delivery of Infant

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

Delivery Technique
  1. As the head emerges, provide perineal support with thumb and index finger on each side of inferior vagina
  2. Apply slight counter pressure to prevent rapid expulsion
  3. Apply gentle downward pressure to occiput to guide head away from anterior structures
  4. Allow restitution (head turns to one side)
  5. Check for nuchal cord:
    • Loose cord: reduce over infant's head
    • Tight cord: apply 2 clamps and transect between
  6. Deliver anterior shoulder with gentle, steady downward traction
  7. Deliver posterior shoulder with gentle upward traction
  8. Support infant by cradling head and lower body

Important Considerations

  • Avoid forceful pulling to prevent brachial plexus injuries
  • Be aware of potential shoulder dystocia in larger infants
  • Never attempt to reduce a prolapsed cord

After Delivery of Infant

Immediate Newborn Care

  • Hold head below heart to facilitate secretion clearance
  • Suction nose and mouth with bulb suction
  • Dry and stimulate infant
  • Assess Apgar score
  • Evaluate ABCs and follow PALS protocol if needed

Cord Clamping

  • Apply double clamp approximately 3 cm from umbilicus
  • Transect with sterile scissors
  • If meconium aspiration suspected:
    • Clamp cord immediately
    • Transfer to warmer for airway assessment
    • Perform deep suctioning

Placenta Delivery

Placenta Management
  1. After infant stabilization, focus on placenta delivery
  2. Apply gentle, steady traction
  3. Allow placenta to detach and deliver spontaneously
  4. Apply gentle suprapubic pressure with nondominant hand
  5. Placenta usually delivers in 10-30 minutes
  6. After delivery, perform gentle fundal massage
  7. Manually remove clots from vaginal vault
  8. Administer Oxytocin, 10 units IM
  9. For significant hemorrhage: additional oxytocin, other contractile agents, 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
  • May be compressed by presenting part of foetus
  • If encountered:
    • Elevate presenting part to reduce compression
    • Keep hand in vagina until Caesarean delivery
    • Do not attempt to reduce the prolapsed cord

Shoulder Dystocia

  • Anterior shoulder lodged behind pubic symphysis
  • More common in larger babies
  • Management steps:
    • McRoberts manoeuvre: sharply flex legs onto abdomen while applying suprapubic pressure
    • If ineffective: Rubin manoeuvre - insert fingers behind posterior aspect of foetal shoulder to rotate trunk into oblique plane

Breech Delivery

  • Caesarean delivery recommended
  • Call experienced obstetrician immediately
  • Allow delivery to occur spontaneously to umbilicus