Precipitous delivery in the ED

A simplified approach to precipitous delivery in the emergency department

Case

You are chatting with your triage nurses on a slow night shift when a car pulls up to the front doors. A 34 year old woman G5P4 at 39 weeks gestation is wheeled up to triage by a slightly panicked appearing boyfriend. Her waters broke in the car on the way in and she feels the need to push. A quick exam after you get her through the doors reveals that she is crowning.

 

My approach

Call for help. Both obstetrics and pediatrics should be paged.

Call for equipment. Hopefully your ED will have an emergency delivery kit. At minimum you want sterile gloves, sterile towels, scissors, umbilical cord clamps, sterile 4×4 gauze, a needle driver, and sutures. You also must get the neonatal rewarmer and neonatal resuscitation equipment ready.

Get a very brief history: How many babies are in your belly? What is your due date? You can ask more if time permits.

If time permits, ultrasound to confirm head is presenting part. (If it’s not, see the post on breech delivery)

If time permits, clean and drape the perineum

Place 1 hand on the head to minimize uncontrolled movements. With the other hand provide gentle pressure on the perineum

Reassure mom. Have her push during contractions. Aim for 10 seconds of pushing, repeated 3 times for every contraction. When head presents, stop pushing and instead have mom breath through contractions.

When head is delivered, sweep neck for a nuchal cord

  • If cord present, slide over head
  • If cannot get over head, clamp x2 and cut between; deliver the baby  ASAP

Provide downwards (gentle) traction to deliver anterior shoulder. (If you cannot or the head “turtles” backwards – go to the shoulder dystocia algorithm)

Provide gentle upwards traction to deliver posterior shoulder

DON’T DROP THE BABY

Clamp the cord about 3cm from the abdomen x2 and cut. If the delivery was not ideally sterile, take the time to clean the umbilical stump (to prevent omphalitis)

Oxytocin 20units in 1 L NS, run at 250ml/hr

Stimulate baby, get apgars, congratulate mom

If neonatal resuscitation is required, get to it

 

Other FOAMed Resources

I didn’t find any. Let me know if I missed something, so I can add it.

References

Pope, Jennifer V. and Tibbles, Carrie D. (2012). The difficult emergency delivery. In: Winters, M.E. (Ed). Emergency Department Resuscitations of the Critically Ill. Dallas, Tx: ACEP.

VanRooyen MJ, Scott JA. Chapter 105. Emergency Delivery. In: Tintinalli JE et al eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com/content.aspx?bookid=348&Sectionid=40381574

Author: Justin Morgenstern

Community emerg doc, FOAM enthusiast, evidence junkie “One special advantage of the skeptical attitude of mind is that a man is never vexed to find that after all he has been in the wrong.” - William Osler

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