Back to the Basics: Emergency Spontaneous Vaginal Delivery

Mon, 11/23/2020 - 10:19am
Editor: 
Alison Jaworski, MD

Emergency Spontaneous Vaginal Delivery 

Christine Collins, MD 

 

A young female presents in your ED waiting area in active labor. What steps are you going to take to safely delivery the baby and prevent fetal and maternal complications?  

 

Precipitous labor in the ED can occur because of social and/or physiologic challenges. Social factors include lack of access to routine prenatal care, lack of transportation to the hospital, or financial reasons. Physiologic factors include strong uterine contractions, lack of awareness of contractions, and low birth canal resistance. Patients may also come to the ED with a planned at-home delivery that resulted in complications requiring emergency care. 

 

When a woman presents in active labor, obtain maternal vital signs and establish IV access. Fetal heart tones can be measured with doppler (anything less than 110 is bradycardia, greater than 160 is tachycardia). If your facility has access to OB-GYN, initiate contact with specialists early. 

 

Important history questions:  

  • Gravity and parity 

  • Gestational age 

  • Any obstetric or medical problems 

  • Vaginal bleeding 

  • “Gush of Fluid”/rupture of membranes 

  • Feeling Contractions? 

  • Feeling Baby moving? 

 

Physical exam: 

  • Fundal height 

  • 12 wks: fundus below pubic symphysis  

  • 20 wks: fundus at umbilicus 

  • 36 wks: fundus at xiphoid process  

  • 37-40 wks: fundus will regress below the xiphoid process slightly 

  • Is the fetus visible? What is the presenting fetal part? Is the umbilical cord visible? 

  • Is there abdominal or uterine tenderness? Do you feel contractions? 

  • Examine the perineum for lesions such as HSV 

  • If the cervix is fully dilated/effaced/ or the fetal head is visible, avoid transporting the patient out of the ED due to risk of delivery during transportation. 

 

Delivery:  

  • - Gather equipment:  sterile gown, gloves, towels, and drapes, sterile scissors, kelly clamps, cord clamps, chlorhexidine to clean perineum, gauze, syringe and 22-24 gauge needles to collect fetal blood, container for placenta  

  • - Guide mother: instruct to push during contractions, with breaks in between to prevent maternal exhaustion 

  • - Place gentle pressure at the perineum to prevent rapid delivery and perineal tear. 

  • - Deliver the head: As the head emerges from the introitus place a sterile towel on the inferior aspect with one hand, while using the other hand to support the fetal head. Use one hand to support the fetal chin and the other to support the crown.  

  • - Restitution of the head: The baby’s head will begin to rotate 45 degrees, to a posterior lateral position. Feel for nuchal cord. If present and loose, slip it over the baby's head. If too tight to pull over the head, apply two clamps and cut the cord. (this occurs in 25-35% of deliveries) 

  • - Deliver the shoulders: gently push the head downwards to deliver the anterior shoulder under the pubic symphysis. Use an upward movement to deliver the posterior shoulder. 

  • - Deliver the body: hold onto the back of the head and buttocks as it delivers. Do not drop the baby. Place baby onto mother’s chest. 

  • - Delay clamping the umbilical cord for 1-3 minutes after birth. Double Clamp the umbilical cord 3 cm from umbilicus, and cut middle w/ sterile scissors.  

  • - Deliver the placenta after about 10-30 minutes. Use gentle traction while massaging the fundus to promote uterine contraction.  

  • - Assess for perineal lacerations that may need to be repaired by an obstetrician. Pack lacerations if no obstetrician is not immediately available.  

 

References:

1. Frasure SE, Kerrigan K. Emergency delivery. In: Tintinalli JE, Ma OJ, Yealy DM, et al., eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. New York, NY: McGraw-Hill; 2020:(Ch) 101.  

2. Barrs VA. Precipitous birth not occurring on a labor and delivery unit. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on October 27, 2020.)