The thought of a woman presenting to the ED in active labor is justifiably a cause for anxiety—the emergency physician must contend not only with the often rusty recollection of the stages of normal delivery, but also with the knowledge that there are serious and even fatal complications associated with labor. Maternal and fetal survival may depend on the ability to successfully manage pre-eclampsia, eclampsia, hemorrhage, shoulder dystocia, malpresentation, cord prolapse, breech delivery, or fetal distress. Every ED should be prepared to take care of a woman in active labor. Tools include a basic delivery kit, an infant warmer or isolate, and medical supplies and equipment for neonatal resuscitation (see chapter 108, "Resuscitation of Neonates" and Tables 101-1 and 101-2). Show
TABLE 101-1Equipment and Supplies for Emergency Delivery View Table||Download (.pdf) TABLE 101-1 Equipment and Supplies for Emergency Delivery Sterile gloves Sterile towels and drapes Povidone-iodine (Betadine) to cleanse the perineum Sterile lubricant gel Sterile scissors Kelly clamps Cord clamps Rubber suction bulb Towel or blanket for the infant Gauze sponges (4×4) Syringes (10 mL) and needles (22–24 gauge) Placenta basin Suture (3-0 chromic and 2-0 Vicryl) and needle driver TABLE 101-2Medications for Emergency Delivery and Indications for Use View Table||Download (.pdf) TABLE 101-2 Medications for Emergency Delivery and Indications for Use
Out-of-hospital births occurred in 1.36% of births in 2012, and out-of-hospital births in the United States had a lower risk profile than in-hospital births, so that fewer teen, preterm, low-birth-weight, and multiple births occurred out of hospital.1 Occasionally, planned home deliveries experience medical complications and require rapid transport to the ED to assist with labor and delivery. In a prospective study of home births in the United States and Canada, nearly 12% of 5400 women who had planned a home delivery ultimately required urgent transfer to a hospital during the course of labor. The majority of intrapartum transfers were performed for failure to progress, need for pain management, and maternal exhaustion. Postpartum transfers encompassed a variety of obstetric and/or neonatal complications such as maternal hemorrhage, retained placenta, or newborn respiratory distress.2 Out-of-hospital deliveries may also occur due to inadequate or nonexistent prenatal care, transportation difficulties, remote setting, or the onset of premature labor. Occasionally, a woman may also attempt to avoid the hospital/physician fees associated with pregnancy until the delivery of her child, presenting to a hospital for the first time when in active labor. The development of obstetric centers for high-risk pregnancy has led to a significant decline in neonatal mortality in the United States, and transports to specialized units have increased. The most common reasons for transport include preterm labor (41%), premature rupture of membranes (21%), hypertensive disease (16%), and antepartum hemorrhage (13%).3 Other indications for transport include eclampsia or pre-eclampsia, fetal distress, multiple gestation, fetal anomalies, and maternal health problems, including traumatic injuries. EMS units transporting an actively laboring patient should carry sterile delivery packs, relevant medical supplies (Table 101-1), and appropriate medications (Table 101-2). The transport team should be trained to assist in the precipitous delivery of an infant. Prehospital protocols regarding the complications of labor and delivery should be reviewed regularly to ensure that EMS personnel are adequately prepared for both normal delivery and potentially catastrophic pregnancy-related events. For deliveries in an austere environment or in a disaster zone, the United Nations Population Fund provides a vaginal delivery kit for use during disaster relief, which includes a plastic sheet to lay on the ground, soap for washing hands and the perineum, string and a razor blade to tie and cut the umbilical cord, and a blanket to protect the newborn baby.4 RUPTURE OF MEMBRANESDetermining rupture of membranes predicts not only the likelihood of imminent labor, but also the potential for complications, such as infection or cord prolapse. Spontaneous rupture of membranes occurs during the course of active labor in the majority of patients, although it also happens prior to onset of labor in approximately 8% of third-trimester patients.5 Fifty percent of women who experience premature rupture of membranes deliver within 5 hours, and 95% give birth within 28 hours of this event.6 The history of spontaneous rupture of membranes typically involves report of a gush of clear or blood-tinged fluid. Occasionally, patients recount continued leaking or dampening of their underwear on standing or with a Valsalva maneuver. Thick greenish brown fluid suggests the presence of meconium in amniotic fluid. Rupture of membranes may be confirmed by using nitrazine paper to test residual fluid in the fornix or vaginal vault while performing a sterile speculum examination. Amniotic fluid has a pH of 7.0 to 7.4 and will turn nitrazine paper a dark blue. Vaginal fluid, on the other hand, typically has a pH of 4.5 to 5.5; the nitrazine strip, thus, remains yellow. False-positive results may occur, however, in the presence of blood, lubricant, Trichomonas vaginalis, semen, or even cervical mucus. Another test that confirms rupture of membranes is ferning, which is the observation of sodium chloride crystals on a microscope slide as amniotic fluid dries (Figure 101-1). FIGURE 101-1. Typical ferning of dried amniotic fluid.
Premature Rupture of MembranesRupture of the amnion and chorion prior to the onset of labor is called premature or prelabor rupture of membranes. If rupture of membranes occurs prior to 37 weeks of gestation, it is termed preterm premature rupture of membranes. Prolonged rupture of membranes transpires if delivery does not take place within 18 hours of rupture of membranes. It is important to understand the difference between and management of premature and preterm premature rupture of membrane as these patients may present to an ED for an initial evaluation.7 Risk factors related to both premature rupture of membranes and preterm premature rupture of membranes include infection, history of trauma, multiple gestation, fetal anomalies, abruptio placentae, and placenta previa. Obtain emergency obstetrics consultation for preterm premature rupture of membranes. CERVICAL DILATATIONCervical dilatation describes the diameter of the internal cervical os and indicates the progression of labor. The index and middle fingers of the examining hand are used to estimate the diameter, which is expressed in centimeters (from closed to 10 cm). Ten centimeters indicates full dilatation. As labor progresses, the cervix also undergoes thinning, known as effacement, which is described in terms of a percentage (%) of normal cervical length. Unfortunately, this estimate is poorly reproducible among examiners. Station indicates the level that the fetus occupies in the pelvis. The maternal ischial spines serve as the reference point and are palpable on either side of the vaginal canal (located at 4 and 8 o'clock). If the presenting fetal part remains above the ischial spines, the station is described as negative. Once the presenting fetal part has reached the level of the ischial spines, the station is 0, with further descent into the pelvis described as +1 or +2. Therefore, a +3 station corresponds to visible scalp at the introitus, indicating a fetal position consistent with impending delivery. TRUE VERSUS FALSE LABORDistinguishing true from false labor is an important initial step in the management of the pregnant patient (Table 101-3). False labor is defined as uterine contractions that do not produce cervical changes and is characterized by irregular, brief contractions that are usually confined to the lower abdomen. Commonly known as Braxton Hicks contractions, they are irregular in both intensity and duration. False labor may persist for several days and is commonly treated with hydration and rest. TABLE 101-3True Versus False Labor View Table||Download (.pdf) TABLE 101-3 True Versus False Labor
True labor, on the other hand, is characterized by painful, repetitive uterine contractions that increase steadily in both intensity and duration and result in cervical effacement and dilatation. Specifically, true labor pains typically commence in the fundal region and upper abdomen and radiate into the pelvis and lower back. True labor leads not only to cervical dilatation and effacement, but also to the progressive descent of the fetus into the pelvis, in preparation for delivery. STAGES OF LABORThere are three stages of labor (Table 101-4). The first stage commences with the onset of regular uterine contractions and ends with full cervical dilatation. The first stage can be subdivided into two phases: latent and active. The latent phase is characterized by moderately uncomfortable uterine contractions that are infrequent and irregular, resulting in gradual cervical changes. In this preparatory phase the uterus orients to contractions and the cervix undergoes both effacement and softening. The active phase is typically noted to arise once the cervix has dilated to 3 to 4 cm, and results in cervical dilatation at an average rate of 1.2 cm/h in nulliparous and 1.5 cm/h in multiparous women. The second stage of labor commences at full dilatation and ends with the delivery of the infant.8 The mean length of the second stage of labor is 20 minutes for multiparous women and 54 minutes for nulliparous women.9 The third stage of labor starts after the delivery of the infant and ends with the delivery of the placenta. The third stage usually lasts less than 10 minutes, and active intervention is usually not required until after 30 minutes, unless hemorrhage occurs. TABLE 101-4Stages of Labor View Table||Download (.pdf)
TABLE 101-4 Stages of Labor
FETAL DISTRESSFetal distress may occur during active labor. Thus, evaluate for signs of fetal status frequently. Indicators of fetal distress include fetal bradycardia or tachycardia, or late decelerations in fetal heart rate, which are defined as persistent drops in fetal heart rate both during and more than 30 seconds after a contraction. A physician or nurse trained in fetal monitoring can identify fetal distress (Figure 101-2). Doppler measurement of fetal heart tones is not reliable to detect decelerations. If decelerations are suspected, obtain emergency obstetrics consultation, and try to increase maternal blood flow by positioning the patient in the left lateral position, provide IV hydration, and administer oxygen. Further information is provided in the Advanced Life Support Course for Obstetrics (see later section "Useful Web Resources"). FIGURE 101-2. Fetal heart rate variability and uterine contraction patterns. A. Good variability. B. Good variability with brief accelerations. Fetal heart rises above baseline and quickly returns to normal. A reassuring pattern. C. Poor variability. May be due to fetal hypoxia. D. Variable decelerations. No relationship to uterine contractions. May represent cord compression. E. Late deceleration. Occurs at onset of contraction and slow return to baseline after contraction ends. Signifies uteroplacental insufficiency and fetal hypoxia. [Reproduced with permission from Pearlman MD, Tintinalli JE, Dyne PL (eds): Obstetric and Gynecologic Emergencies: Diagnosis and Management. McGraw-Hill, Inc., 2003. Figs. 10-9 and 10-10, pp. 131 and 132.]
When a patient >20 weeks' gestation presents to the ED with signs of labor, immediately obtain both maternal vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation, temperature) and the fetal heart rate. Doppler US can be used to measure fetal heart rate; a normal fetal heart rate is generally 120 to 160 beats/min, bradycardia is defined as less than 110 beats/min, and tachycardia is greater than 160 beats/min.10 A persistently slow fetal heart rate indicates fetal distress and requires emergency obstetric consultation. As part of the initial evaluation, obtain IV access, procure baseline laboratory studies including blood type, and send a urinalysis. HISTORYAsk about the onset and frequency of uterine contractions, fetal membrane status, presence or absence of vaginal bleeding, and presence or absence of fetal movement. The obstetric history should include parity, history of complications with prior deliveries, history of precipitous deliveries, prenatal care during this pregnancy, and estimated date of delivery. Obtain a medical and surgical history, a list of current medications, and allergies, and ask the patient about substance abuse. Inquire about symptoms of infection, such as fevers, chills, or foul-smelling vaginal discharge. Gestational AgeIf the patient knows the first day of her last menstrual period, the estimated date of delivery can be calculated by adding 9 months and 7 days to that date (Nägele's rule). Fundal height also provides a rapid estimate of gestational age and is measured in centimeters (cm) from the pubic symphysis to the top of the fundus (cm = weeks of gestation ± 2 weeks). Fundal height may be falsely overestimated in the obese patient. Bedside US also provides a useful assessment of gestational age in the third trimester, but estimated age can vary by ± 3 weeks. PHYSICAL EXAMINATIONMonitor vital signs for evidence of maternal fever, tachycardia, or elevated blood pressure. Assess fetal heart tones for bradycardia or tachycardia. Do not keep the pregnant woman flat on her back for a prolonged time period; compression of venous return by the gravid uterus can lead to hypotension in the mother, which in turn results in decreased blood supply to the fetus. So, place the patient in the left lateral position following the physical examination. On abdominal examination, determine fundal height, abdominal or uterine tenderness to palpation, and presence of uterine contractions. Examine the perineum for perineal lesions, such as those caused by herpes simplex virus, which might be a contraindication for a vaginal delivery. PELVIC EXAMINATIONPatients with vaginal bleeding should be evaluated with bedside US prior to speculum or bimanual examination, in order to rule out placenta previa. Patients without vaginal bleeding should be evaluated first with a sterile speculum examination to determine if membranes have been ruptured, to note cervical dilatation and effacement, and to determine fetal station and presentation. If rupture of membranes is suspected, perform a sterile speculum examination (do not use lubricant because lubricant may produce a false-positive nitrazine test), but do not perform a digital examination because even one digital examination increases the risk of infection.11 Also avoid digital examinations in the preterm patient in whom the prolongation of gestation is desired. Using sterile vaginal examination, examine the cervix for dilatation, effacement, and station. Bedside US is the simplest method to verify presentation. Vertex presentation and lie can also be confirmed through palpation of the cranial sutures on digital examination. Palpation of small parts, such as feet or hands, often indicates malpresentation. If meconium is present on the examining finger, be prepared for neonatal resuscitation (see chapter 108). The first steps in the management of a woman in active labor are to measure vital signs and initiate supportive therapy. Obtain venous access, provide IV hydration, and initiate maternal and fetal monitoring (if available). Delivery is imminent if the pelvic examination reveals complete cervical effacement and the fetus is at the introitus. Labor can progress very rapidly, particularly in multiparous patients. Both the stage of labor and the parity of the patient should be taken into account when considering whether to transport a laboring patient to the labor and delivery suite or to another facility. If the cervix is fully effaced and dilated or the fetal head is visible during contractions, the obstetrician (if available) should come to the ED rather than risk a precipitous delivery during transport to the delivery suite. As the cervix fully dilates, effacement becomes complete, the fetus descends into the pelvis, and the patient will experience the urge to push. The cervix should be fully dilated before the patient begins to push in order to avoid cervical lacerations. Determine fetal presentation by palpating skull sutures and fontanelle or the buttock or extremity. Bedside US can confirm presentation. If time allows, prepare the perineum by washing it with mild soap and water and swabbing with povidone-iodine. Place drapes over the patient. Medical personnel attending to the patient should don gowns, masks, and gloves. Call for obstetric support. Six cardinal movements describe the process of fetal descent during labor and delivery: (1) engagement, (2) flexion, (3) descent, (4) internal rotation, (5) extension, and (6) external rotation (Figure 101-3). The following discussion describes delivery in the cephalic, occiput anterior position. As the fetus descends through the birth canal and reaches the introitus, the perineum bulges in order to accommodate the fetal head. Gentle digital stretching of the inferior portion of the perineum can aid delivery. The perineum undergoes gradual thinning and stretching to enable passage of the newborn. FIGURE 101-3. The movements of normal delivery for a vertex presentation. A. Engagement, flexion, and descent with vertex anterior. B. Internal rotation with occiput becoming anterior. C. Extension and delivery of the head. As the infant's head emerges from the introitus, support the perineum by placing a sterile towel along the inferior part of the perineum with one hand, and support the fetal head with the other hand. Ask the mother to breathe through contractions (rather than bear down) in order to deter rapid expulsion of the baby. Provide mild counterpressure for controlled extension of the fetal head. As the infant's head presents, use the inferior hand to control the fetal chin and keep the superior hand on the crown of the head, supporting the delivery. D. External rotation, bringing the thorax into the anteroposterior diameter of the pelvis. As the head delivers, palpate the infant's neck to assess for the presence of a nuchal cord. Nuchal cord is noted in approximately 25% to 35% of all term deliveries.13 If the cord is loose, move it over the infant's head, and allow delivery to proceed as usual. If the cord is wound tightly around the neck, however, apply two close clamps in the most accessible area, and then cut the cord. E. Delivery of the anterior shoulder. Once the head is delivered, it will turn to one side or the other. Grasp the sides of the head with both hands, and apply gentle downward traction (go with gravity) until the anterior shoulder is delivered. Jerky or aggressive traction may injure the brachial plexus. If you have not checked for a nuchal cord, do so now. As the head rotates, place the hands on either side of the head, providing gentle downward traction. This maneuver allows for the delivery of the anterior shoulder. F. Delivery of the posterior shoulder. Use an upward movement to deliver the upward shoulder. Do not apply traction. If meconium is present or the newborn is limp or poorly responsive, stimulate the baby and be prepared to begin the steps of neonatal resuscitation with ventilation and oxygenation14,15 (see chapter 108).
EPISIOTOMYRoutine episiotomy for a normal spontaneous vaginal delivery varies with practitioner, institution, and country. Episiotomy may be necessary to expedite a delivery in cases of fetal distress or shoulder dystocia or if forceps or vacuum devices are used (Figure 101-4).12 The episiotomy can be performed in the midline or mediolaterally (45 degrees from the midline). Median episiotomy is easy to perform, but mediolateral episiotomy has a lower risk of extension to the anal sphincter (third-degree extension) or to the rectum (fourth-degree extension) than median episiotomy. If an episiotomy is clinically necessary, first inject 5 to 10 mL of 1% lidocaine solution with a small-gauge needle into the posterior fourchette and perineum. While protecting the infant's head, make a 2- to 3-cm incision with scissors in order to extend the vaginal opening, either at the midline or 45 degrees from the midline. A median incision must be supported with manual pressure from below. Take care to prevent extension of the incision into the rectum. FIGURE 101-4. Methods for episiotomy.
COMPLETION OF DELIVERYDo not drop the baby. The combination of amniotic fluid, blood, and vernix generates a very slippery infant. Before delivering the rest of the body, place your posterior hand underneath the axilla of the infant. Use the anterior hand to grasp the ankles of the infant with a firm grip. Following delivery, keep the infant warm and provide gentle stimulation. Do not routinely aspirate the nose and mouth. Gently bulb aspirate only if there are obvious obstructions from secretions. If delivery is uncomplicated, and the infant has responded well to initial stimulation with a clear airway and good respiratory effort, the mother may hold the child immediately while the cord is cut. Apgar scores are calculated at 1 and 5 minutes after delivery. Scoring parameters include general color, tone, heart rate, respiratory effort, and reflexes (Table 101-5). TABLE 101-5Apgar Scoring for Newborns View Table||Download (.pdf) TABLE 101-5 Apgar Scoring for Newborns
For an APGAR score of <7 refer to the chapter 108. Provide positive-pressure ventilation for all newborns with a heart rate <100 beats/min or who are gasping or apneic after 30 seconds. Do not clamp the umbilical cord of term or preterm infants for at least 1 to 3 minutes after birth. Delayed cord clamping increases neonatal iron stores. Double-clamp the umbilical cord 3 cm distal to its insertion at the umbilicus and transect with sterile scissors. In delivery settings where aseptic care is routine, there is no clear benefit to any additional topical care of the umbilicus. When aseptic care is not available, however, antiseptic topical care of the umbilicus with chlorhexidine reduces the risk of omphalitis and neonatal mortality.16 Once the umbilical cord is cut, dry the infant and either give the infant to the mother or place it in a warming unit. The placenta usually delivers approximately 10 to 30 minutes after delivery of the infant. Allow the placenta to separate spontaneously and provide only gentle traction. Aggressive traction on the cord can lead to uterine inversion, tearing of the cord, or even disruption of the placenta, all of which can result in severe vaginal bleeding. After the placenta has been removed, gently massage the abdomen at the level of the fundus to promote contraction. Give oxytocin (10 to 40 units in 1 L normal saline at 250 mL/h or 10 units IM) to sustain uterine contraction. The estimated blood loss during a vaginal delivery is usually less than 500 mL. Uterine atony, however, which occasionally follows a precipitous delivery, can lead to excessive vaginal bleeding. In that case, give additional oxytocin or another uterotonic of choice (see Table 101-2). As contractile agents are administered, provide vigorous bimanual massage.17 Delay episiotomy or laceration repair until an experienced obstetrician is available to close the laceration and inspect for fourth-degree perineal lacerations. UMBILICAL CORD PROLAPSEUmbilical cord compression is life threatening to the fetus. Obtain immediate obstetric assistance, as emergent cesarean delivery is indicated. Should the bimanual examination reveal a palpable, pulsating umbilical cord, elevate the presenting fetal part to reduce compression on the cord. Keep your hand in the vagina while the patient is transported and prepared for surgery to prevent further compression of the cord by the fetal head. Place the mother in the Trendelenburg position. Do not try to reduce the prolapsed cord.18 SHOULDER DYSTOCIAShoulder dystocia is the impaction of fetal shoulders at the pelvic outlet after delivery of the head. Typically, the anterior shoulder is trapped behind the pubic symphysis and prevents delivery of the rest of the infant.19,20 Complications of shoulder dystocia include fetal brachial plexus injury (due to overaggressive traction), clavicle fracture, fetal hypoxia (due to impaired respirations and/or compression of the umbilical cord), postpartum hemorrhage, and fourth-degree perineal lacerations. Prior to delivery of the head, the head may retract between contractions. Shoulder dystocia then becomes evident when routine downward traction fails to deliver the anterior shoulder once the head has been delivered. After the infant's head is delivered, the head retracts tightly against the perineum (turtle sign; Figure 101-5).21 Several steps can be used to relieve shoulder dystocia (Table 101-6). Immediately place the mother in the extreme lithotomy position, with her legs sharply flexed up to the abdomen and the knees held as widely apart as possible (McRoberts maneuver; Figure 101-6). Either the mother or an assistant should keep the legs held widely apart. Simultaneously apply suprapubic pressure. If a second assistant is available, he or she should place their hands in a CPR position, and apply downward pressure just above the pubic symphysis for 1 to 2 minutes to disimpact the anterior shoulder. Do not apply pressure to the uterine fundus, as this maneuver can further impact the shoulder. Suprapubic pressure serves to rotate the shoulder under the pubic symphysis.21 The combination of the McRoberts position and suprapubic pressure relieves about 50% of shoulder dystocias. TABLE 101-6Steps to Relieve Shoulder Dystocia View Table||Download (.pdf) TABLE 101-6 Steps to Relieve Shoulder Dystocia
FIGURE 101-5. Clinical appearance of shoulder dystocia. The infant's head is impacted against the perineum. [Reprinted with permission from Buckley RG, Knoop KJ: Gynecologic and obstetric conditions, in Knoop KJ, Stack LB, Storrow AB (eds): Atlas of Emergency Medicine, 2nd ed. New York, McGraw-Hill, 2002, Figure 10.46.]
FIGURE 101-6. McRoberts maneuver. Sharply flex the thighs up onto the abdomen, as shown by the horizontal arrow, and keep the knees spread widely. Simultaneously provide suprapubic pressure (vertical arrow). [Adapted with permission from Cunningham FG, Leveno KL, Bloom SL, et al: Williams Obstetrics, 22nd ed. New York, McGraw-Hill, 2005, Figure 20-14.]
The Gaskin maneuver (Figure 101-7) can also be employed. It is a simple maneuver, but with IVs and monitors in place or with an exhausted mother, it can be difficult to achieve. Place the patient on all fours. Exert gentle downward traction on the infant's head. In order to remember the direction of traction, remember to "go with gravity." In 80% of cases, this maneuver allows the posterior shoulder to successfully deliver.22 FIGURE 101-7. Gaskin maneuver for shoulder dystocia.
Should the previous maneuvers fail, rotational maneuvers, which move the shoulders into an oblique position, can be performed. Allow 2 minutes for these maneuvers. The maneuvers typically require an episiotomy. For the Rubin maneuver, place fingers behind the anterior fetal shoulder, and push the shoulder with your fingertips toward the baby's chest. This may reduce the dimension of the shoulder girdle and allow for delivery. For the Woods corkscrew maneuver (Figure 101-8), keep fingertips behind the anterior shoulder, and with the opposite hand, apply pressure to the back of the posterior shoulder, and rotate the shoulder girdle clockwise into an oblique position, allowing delivery. The reverse corkscrew maneuver is in the opposite direction. Place your fingers in front of the posterior shoulder and behind the anterior shoulder, and apply pressure counterclockwise.23 FIGURE 101-8. Corkscrew maneuver. A. Place fingertips behind anterior shoulder and in back of posterior shoulder. B. Then gently rotate clockwise until shoulder delivers.
BREECH PRESENTATIONBreech presentations occur in 3% to 4% of term pregnancies. Risks of breech presentations include umbilical cord prolapse, trauma, hypoxia, and fetal distress. Breech presentations occur most frequently in the delivery of premature infants; approximately 25% to 30% of all preterm infants (<28 weeks' gestation) present in breech position.24 Given the increased perinatal/neonatal morbidity and mortality associated with vaginal breech deliveries, cesarean section is recommended in breech presentations.24 Head entrapment is a major concern in a breech delivery. In a normal cephalic delivery, the larger head dilates the cervical canal, which ensures that the rest of the infant's body can follow. In a breech delivery, however, the head emerges last and may become stuck in an incompletely dilated cervix. In frank and complete breech deliveries, the buttocks dilate the cervix almost as effectively as the fetal head; therefore, delivery may proceed in an uncomplicated fashion. In these cases, allow the delivery to proceed spontaneously (Figure 101-9). The emergency physician subsequently places the index and middle fingers over the infant's maxillary bones (not in the infant's mouth) to help keep the head flexed, allowing the mother to expel the infant. It is important to refrain from pulling on the fetus, because this may impact the head in the pelvis or even entrap the extended fetal arm. Footling and incomplete breech positions are not safe for vaginal delivery due to the risk of cord prolapse or incomplete dilatation of the cervix. In any breech delivery, obstetric consultation should be obtained immediately. FIGURE 101-9. Breech delivery. A. Grasp the thigh to allow delivery of the leg. B. Grasp the other leg to allow its delivery. C. Grasp the feet at the ankles and rotate the sacrum anteriorly. D. The sacrum is rotated anteriorly. Maternal efforts deliver the baby to the level of the umbilicus. Wrap the trunk and legs in a towel. E. Maternal efforts further deliver to the level of the scapulae. Apply steady, gentle traction until scapulae come into view. F. Once the axilla is visible, the shoulder can be delivered. Rotate counterclockwise to deliver the anterior shoulder. (It does not matter which shoulder is delivered first.) G. Delivery of the anterior arm. When the scapulae appear, gently rotate the baby until one humerus can be followed down, rotated across the chest, and swept out. Then turn the baby clockwise to allow delivery of the other arm. H. Deliver the vertex of the skull by placing fingers at the maxillary process, and keep body parallel to the horizontal. Do not pull. Do not lift above the parallel to avoid neck hyperextension. Apply suprapubic pressure to aid delivery of the head.
PRETERM DELIVERYThe incidence of preterm delivery is approximately 12% and contributes substantially to perinatal morbidity and mortality.25 Preterm labor is also a major cause of precipitous delivery in EDs. Preterm infants present more frequently in the breech position. The delivery maneuvers are similar to those described above. Be prepared to initiate neonatal resuscitation. The decision as to whether to initiate resuscitative efforts in the ED is often difficult because patients may deliver an extremely premature fetus of unknown gestational age. Survival of the newborn increases significantly for each completed week from 21 weeks of gestation (0% survival) to 25 weeks of gestation (75% survival).26 When gestational age is known, initiate resuscitation of newborns 22 weeks of gestation or older. It is justified to cease resuscitative efforts after 10 minutes, and certainly, after 15 minutes of asystole. Acknowledgment The author gratefully acknowledges the contributions of Michael J. VanRooyen, Jennifer A. Scott, and Kimberly B. Fortner, coauthors of this chapter in the previous editions. 2. Johnson KC, Daviss BA: Outcomes of planned home births with certified professional midwives: large prospective study in
North America. BMJ 330: 1416, 2005. 3. Jony L, Baskett TF: Emergency air transport of obstetric patients. J Obstet Gynaecol Can 29: 406, 2007. 5. Mercer BM: Preterm
premature rupture of the membranes. Obstet Gynecol 101: 178, 2003. 6. Hannah ME, Ohlsson A, Farine D et al.: Induction of labor compared with expectant management for prelabor rupture of the membranes at term. TERMPROM Study Group. N Engl J Med 334: 1005, 1996.
7. Dare MR, Middleton P, Crowther CA et al.: Planned early birth versus expectant management for prelabour rupture of membranes at term. Cochrane Database Syst Rev 1: CD005302, 2006.
8. Dystocia and the augmentation of labor. ACOG Practice Bulletin Number 49, December 2003. Obstet Gynecol 102: 1445, 2003. 9. Kilpatrick SJ, Laros RK Jr: Characteristics of normal labor. Obstet Gynecol 74: 85, 1989. 10. ACOG Practice Bulletin No. 106. Clinical Management Guidelines for Obstetrician-Gynecologists (Replaces Practice Bulletin Number 70, December 2005). Intrapartum fetal heart rate monitoring. Obstet Gynecol 114: 192, 2009. 11. Alexander JM, Mercer BM,
Miodovnik M et al.: The impact of digital cervical examination on expectantly managed preterm rupture of membranes. Am J Obstet Gynecol 183: 1003, 2000. 13. Schaffer L, Burkhardt T, Zimmermann R, Kurmanavicius J: Nuchal cords in term and postterm deliveries—do we need to know? Obstet Gynecol 106:
23, 2005. 14. Vain NE, Szyld EG, Prudent LM et al.: Oropharyngeal and nasopharyngeal suctioning of meconium-stained delivery of their shoulders: multicenter, randomized controlled trial. Lancet 364: 597, 2004. 15. American Heart Association: 2010 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric basic life support. Pediatrics 126: e1400, 2010. 16. Mullany LC, Darmstadt
GL, Khatry SK et al.: Topical applications of chlorhexidine to the umbilical cord for prevention of omphalitis and neonatal mortality in southern Nepal: a community-based, cluster-randomised trial. Lancet 367: 910, 2006. 17. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76,
October 2006: postpartum hemorrhage. Obstet Gynecol 108: 1039, 2006. 18. Kahana B, Sheiner E, Levy A et al.: Umbilical cord prolapse and perinatal outcomes. Int J Gynaecol Obstet 84: 127, 2004. 19. Gherman RB: Shoulder dystocia: an evidence-based evaluation of the obstetric nightmare. Clin Obstet Gynecol 45: 345, 2002. 20. Bennett BB: Shoulder dystocia: an obstetric emergency. Obstet Gynecol Clin 26: 445, 1999.
21. ACOG Practice Bulletin: Shoulder dystocia. Number 40, November 2002. Int J Gynaecol Obstet 80: 87, 2003. 22. Bruner JP, Drummon SB, Meenan AL et al.: All-fours maneuver
for reducing shoulder dystocia during labor. J Reprod Med 43: 439, 1998. 23. Poggi SH, Spong CY, Allen RH: Prioritizing posterior arm delivery during severe shoulder dystocia. Obstet Gynecol 101: 1068, 2003. 24. Su M, Hannah WJ, Willan A et al.: Term Breech Trial Collaborative Group. Planned caesarean section decreases the risk of adverse perinatal outcome due to both labour and delivery complications in the Term Breech Trial. Br J Obstet Gynaecol 111: 1065, 2004. 26. Lemons
JA, Bauer CR, Oh W et al.: Very low birth weight outcomes of the National Institute of Child health and human development neonatal research network, January 1995 through December 1996. NICHD Neonatal Research Network. Pediatrics 107: e1, 2001. Which intervention would the nurse initiate when a fetal heart pattern signifying?During a client's labor the fetal monitor reveals a fetal heart pattern that signifies uteroplacental insufficiency. What is the nurse's priority intervention? Assisting the client to turn to the side-lying position will improve uterine blood flow, and fetal oxygenation will increase.
Which complication would the nurse assess for in a client who has had a spontaneous abortion?Some of the complications associated with spontaneous abortions include disseminated intravascular coagulation (DIC), increases in terms of the maternal thromboplastin levels and fetal autolysis.
Which complication occurs as a result of ineffective breathing patterns?When the breathing pattern is ineffective, the body will likely not get enough oxygen to the cells. Respiratory failure may be correlated with variations in respiratory rate, abdominal and thoracic patterns.
Which intervention ordered for a client with Cephalopelvic disproportion would the nurse question?A client who is having a difficult labor is diagnosed with cephalopelvic disproportion. Which medical orders should the nurse question? oxytocin (Pitocin) at this time may result in fetal compromise and uterine rupture.
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Which intervention would the nurse initiate when a fetal heart pattern signifying Uteroplacental insufficiency occurs?
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