heart rate, and location of the placenta.

MEDICAL DECISION MAKING

Delivery of a fetus is best done by obstetricians in a labor

and delivery unit. If time allows, the emergency physician

should attempt to transfer the patient to an appropriate

setting. In a hospital with no obstetric services, a precipitously delivering mother must be delivered by the emer ­

gency physician. If delivery is not imminent, the patient

may be transferred. If a patient needs to be transferred to

another hospital, she should be sent by an advanced life

support-equipped ambulance, as a patient in labor is c onsidered medically unstable (Figure 46-1).

Gravid fema le

with contractions

Prepare for

emergency del ivery

Partia lly di lated

and Obstetrician

in the hospital

.AFigure 46-1 . Emergency del ivery diagnostic algorithm.

CHAPTER 46

TREATMENT

If the decision is made to deliver the child in the ED, call

for obstetric and pediatric support if available. Large-bore

intravenous (IV) access should be obtained and fluids

started. Oxygen by nasal cannula is given to the mother,

especially if there are any signs of fetal distress. The infant

radiant warmer should be set up and in the room. Delivery

equipment should be set up including cord clamps,

scissors, suction, forceps, and neonatal resuscitation

equipment.

The mother is placed in the dorsal lithotomy position,

and the perineum is cleaned with povidone-iodine solution. Time permitting, the physician should be dressed in

gown, sterile gloves, hat, and mask. When the mother is

fully dilated, and the head is at + 3 station, the examiner

uses a towel and supports the perineum by gently putting

pressure on the fetal chin. The other hand is used to control the fetal occiput (Figure 46-2A). Slight pressure on the

occiput ensures a smooth delivery of the fetal head and

reduces tearing.

Once the fetal head is delivered, the physician should

suction the nose and mouth and check for a nuchal cord.

The mother should stop pushing at this point. If a nuchal

cord is present, it is pulled over the fetal head. If unable to

pull the cord over, it should be clamped in two places and

cut in the middle.

Next, the anterior shoulder is delivered by guiding the

head inferiorly with gentle traction. The posterior shoulder

is delivered next by traction upwards. This will also deliver

the rest of the infant (Figures 46-2B and 46-2C). If the

shoulders are not easily delivered, the physician should

consider shoulder dystocia as a complication. Once the

infant is delivered, the cord is clamped in 2 locations and

cut in the middle. The infant is wrapped, cleaned, and

taken to the infant warmer for evaluation.

Ideally, a second physician or experienced practitioner

can care for the newborn while the delivering physician

Figure 46-2. A. Del ivery of the head while putting pressure over the peri neum. B. Del ivering the anterior

shoulder. c. Del ivery of the posterior shoulder is performed with gentle upward traction, while su pporting the

head. Reprinted with permission from VanRooyen MJ, Scott JA. Chapter 1 05. Emergency Del ivery. In: Tintina IIi

JE, Stapczynski JS, Ma OJ, Cline OM, Cyd ulka RK, Meckler GO, eds. Tintinolli's Emergency Medicine: A

Comprehensive Study Guide. 7th ed. New York: McGraw-Hill, 201 1.

EMERGENCY DELIVERY

Table 46-1 . APGAR scoring.

Sign 0 Points

Activity Absent

Pulse Absent

Grimace No response

Appearance Blue-gray or pale

Respiration Absent

treats the mother. The newborn should be warmed, given

oxygen, and stimulated. The APGAR is performed at 1 and

5 minutes (Table 46- 1). Neonatal intubation should be

considered for poor tone, shallow respirations, and cyanosis. Once the infant is assessed, attention is directed back

to the mother, to deliver the placenta. The placenta should

deliver spontaneously, but it can be assisted with uterine

massage while pulling gently on the umbilical cord.

Pulling too forcefully can result in uterine inversion.

Complications of delivery include postpartum hemorrhage, shoulder dystocia, and breech presentations.

Although rare, these complications generally require the

assistance of an obstetrician.

Postpartum hemorrhage can occur immediately after

delivery or up to a few hours after delivery. The physician

should check for retained products, uterine atony, uterine

inversion, or vaginal lacerations that are contributing to the

blood loss. In the case of uterine atony, oxytocin can be given,

20 units in 1 L of Lactated Ringer's solution. Additionally,

misoprostol 1 mg can be given per rectum.

Shoulder dystocia is present when the fetus's anterior

shoulder becomes caught under the mother's pubic bone.

It is more common in diabetic mothers, obesity, and postmaturity of the fetus. The first clue to the physician that

shoulder dystocia is occurring is a retraction of the fetal

head toward the vagina immediately after it is delivered.

This is called the "turtle sign." In the event of a shoulder

dystocia, the mother's legs are flexed to a knee-chest position (McRobert maneuver). This rotates the pubic bone

over the anterior fetal shoulder. Second, an assistant provides firm suprapubic pressure to further disengage the

1 Point

Arms and legs flexed

<100 bpm

Grimace

Normal, except extremities

Slow, irregular

2 Point

Active movement

> 1 00 bpm

Sneeze, cough, pulls away

Normal over entire body

Good, crying

anterior shoulder. If this does not resolve the dystocia, an

episiotomy should be performed to enlarge the opening

and provide access to the posterior shoulder.

Breech presentations are ideally delivered by cesarean

section. Rapid bedside ultrasound can determine whether

the fetal head or another part is presenting. Breech presen ­