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Emergency And Acute Medicine – Uncomplicated Delivery
Basics And Etiology
Emergency department delivery is uncommon, and the true incidence in the United States is unknown. It occurs more frequently in health care systems where patients have limited or no prenatal care. Most ED deliveries fall into three common scenarios. These include multiparous patients with a history of rapid labor, nulliparous patients who fail to recognize labor symptoms, and patients with limited prenatal care, lack of transportation, or premature labor.
Diagnosis – Signs And Symptoms
True labor is defined by regular uterine contractions occurring at least every five minutes and lasting 30–60 seconds. Significant vaginal bleeding during labor requires immediate evaluation for placenta previa or placental abruption. Patients may report abdominal or pelvic cramping, rupture of membranes that may feel like urinary incontinence, an urge to push or defecate, and bloody show due to loss of the mucous plug.
History
Key historical elements include last menstrual period and estimated gestational age, recent infections, pregnancy history and complications, prior cesarean delivery, and adequacy of prenatal care.
Physical Examination
Signs of imminent delivery include a fully effaced and dilated cervix, approximately 10 cm in a term pregnancy, palpable fetal parts, bulging of the perineum, and widening of the vulvovaginal opening. Fetal position and presenting part should be assessed by abdominal palpation when possible.
Essential Workup
A sterile bimanual pelvic examination is the most important assessment tool to evaluate labor and imminent delivery. Cervical dilation, effacement, and fetal station should be assessed. Patients should not push until full dilation is confirmed. Pelvic examination should be deferred in patients with vaginal bleeding until ultrasound excludes placenta previa. Fetal heart tones should be obtained using Doppler.
Diagnosis Tests And Interpretation
If the patient is in active labor, laboratory evaluation should include complete blood count, blood type, and Rh screen. If an Rh-negative mother delivers an Rh-positive infant, Kleihauer-Betke testing should be performed and Rh immunoglobulin administered within 72 hours. Urinalysis may be obtained if urinary tract infection or preeclampsia is suspected. Imaging is not required for uncomplicated vaginal delivery. Third-trimester vaginal bleeding requires emergent ultrasound to assess for placenta previa or placental abruption. If time allows, ultrasound may assist in determining placental location.
Differential Diagnosis
Consider Braxton Hicks contractions, which are irregular and do not cause cervical dilation or effacement. Other considerations include musculoskeletal low back pain, round ligament pain, ovarian torsion, appendicitis, and nephrolithiasis.
Treatment – Prehospital Care
Patients should be placed in the left lateral recumbent position. Emergency medical services personnel should be properly trained and equipped for obstetric emergencies. Transport of high-risk obstetric patients prior to delivery is associated with lower neonatal morbidity and mortality compared with post-delivery neonatal transport. Air transport is safe when necessary, though supplemental oxygen should be provided to mitigate fetal hypoxia from altitude exposure.
Initial Stabilization And Therapy
A sterile pelvic examination should be performed promptly if there is no vaginal bleeding. Patients in active labor should be transferred to labor and delivery unless birth is imminent. If the cervix is fully dilated and fetal parts are visible at the perineum, preparation for ED delivery is required.
Emergency Department Treatment And Procedures
Notify obstetrics, pediatrics or neonatology, and the neonatal intensive care unit. Prepare for neonatal resuscitation. Position the patient supine or in Sims position, establish IV access with normal saline or D5NS, provide supplemental oxygen, and place the patient in lithotomy position. Assemble an obstetric delivery kit including bulb syringe, sterile clamps, scissors, and umbilical clamp. If time allows, cleanse the perineum with povidone-iodine.
During delivery, guide the fetal head in a controlled manner as crowning occurs. Routine episiotomy is not required but may be performed if uncontrolled tearing occurs. After delivery of the head, suction the nasopharynx and assess for a nuchal cord. If present and loose, reduce it over the head; if tight, double clamp and cut before completing delivery. Apply gentle downward traction to deliver the anterior shoulder, followed by the posterior shoulder and body. Hold the infant at the level of the uterus, suction again, clamp and cut the cord, and initiate warming, drying, and stimulation. Provide oxygen or neonatal resuscitation as indicated.
The placenta typically delivers spontaneously within 20–30 minutes. Monitor closely for postpartum hemorrhage. Uterine massage promotes placental separation and uterine contraction. Avoid traction on the umbilical cord to prevent uterine inversion or cord rupture. If the placenta does not deliver and bleeding is severe, emergent operative management is required. After placental delivery, inspect it for completeness and examine the uterus, vagina, and perineum for lacerations. Persistent bleeding without laceration suggests uterine atony.
Medication Management
Routine medications are not required after uncomplicated delivery. If uterine atony persists despite massage, administer oxytocin intravenously. Continued bleeding may require methylergonovine intramuscularly, followed by carboprost tromethamine if refractory.
Follow-Up And Disposition
All women who deliver in the emergency department should be admitted to labor and delivery or a postpartum unit for monitoring, even if the delivery is uncomplicated. Neonatal consultation and NICU admission are required for infants with respiratory distress, gestational age less than 36 weeks, low birth weight, low Apgar scores, or other complications. Term infants without complications may be admitted to the nursery or remain with the mother in a combined unit. If post-delivery transfer is required, consider separate ambulances for mother and infant.
Key Clinical Lessons And Common Errors
Be prepared for obstetric emergencies such as cord prolapse, shoulder dystocia, and breech delivery. Always remember that after delivery, there are two patients requiring care—the mother and the newborn.
Basics And Etiology
Emergency department delivery is uncommon, and the true incidence in the United States is unknown. It occurs more frequently in health care systems where patients have limited or no prenatal care. Most ED deliveries fall into three common scenarios. These include multiparous patients with a history of rapid labor, nulliparous patients who fail to recognize labor symptoms, and patients with limited prenatal care, lack of transportation, or premature labor.
Diagnosis – Signs And Symptoms
True labor is defined by regular uterine contractions occurring at least every five minutes and lasting 30–60 seconds. Significant vaginal bleeding during labor requires immediate evaluation for placenta previa or placental abruption. Patients may report abdominal or pelvic cramping, rupture of membranes that may feel like urinary incontinence, an urge to push or defecate, and bloody show due to loss of the mucous plug.
History
Key historical elements include last menstrual period and estimated gestational age, recent infections, pregnancy history and complications, prior cesarean delivery, and adequacy of prenatal care.
Physical Examination
Signs of imminent delivery include a fully effaced and dilated cervix, approximately 10 cm in a term pregnancy, palpable fetal parts, bulging of the perineum, and widening of the vulvovaginal opening. Fetal position and presenting part should be assessed by abdominal palpation when possible.
Essential Workup
A sterile bimanual pelvic examination is the most important assessment tool to evaluate labor and imminent delivery. Cervical dilation, effacement, and fetal station should be assessed. Patients should not push until full dilation is confirmed. Pelvic examination should be deferred in patients with vaginal bleeding until ultrasound excludes placenta previa. Fetal heart tones should be obtained using Doppler.
Diagnosis Tests And Interpretation
If the patient is in active labor, laboratory evaluation should include complete blood count, blood type, and Rh screen. If an Rh-negative mother delivers an Rh-positive infant, Kleihauer-Betke testing should be performed and Rh immunoglobulin administered within 72 hours. Urinalysis may be obtained if urinary tract infection or preeclampsia is suspected. Imaging is not required for uncomplicated vaginal delivery. Third-trimester vaginal bleeding requires emergent ultrasound to assess for placenta previa or placental abruption. If time allows, ultrasound may assist in determining placental location.
Differential Diagnosis
Consider Braxton Hicks contractions, which are irregular and do not cause cervical dilation or effacement. Other considerations include musculoskeletal low back pain, round ligament pain, ovarian torsion, appendicitis, and nephrolithiasis.
Treatment – Prehospital Care
Patients should be placed in the left lateral recumbent position. Emergency medical services personnel should be properly trained and equipped for obstetric emergencies. Transport of high-risk obstetric patients prior to delivery is associated with lower neonatal morbidity and mortality compared with post-delivery neonatal transport. Air transport is safe when necessary, though supplemental oxygen should be provided to mitigate fetal hypoxia from altitude exposure.
Initial Stabilization And Therapy
A sterile pelvic examination should be performed promptly if there is no vaginal bleeding. Patients in active labor should be transferred to labor and delivery unless birth is imminent. If the cervix is fully dilated and fetal parts are visible at the perineum, preparation for ED delivery is required.
Emergency Department Treatment And Procedures
Notify obstetrics, pediatrics or neonatology, and the neonatal intensive care unit. Prepare for neonatal resuscitation. Position the patient supine or in Sims position, establish IV access with normal saline or D5NS, provide supplemental oxygen, and place the patient in lithotomy position. Assemble an obstetric delivery kit including bulb syringe, sterile clamps, scissors, and umbilical clamp. If time allows, cleanse the perineum with povidone-iodine.
During delivery, guide the fetal head in a controlled manner as crowning occurs. Routine episiotomy is not required but may be performed if uncontrolled tearing occurs. After delivery of the head, suction the nasopharynx and assess for a nuchal cord. If present and loose, reduce it over the head; if tight, double clamp and cut before completing delivery. Apply gentle downward traction to deliver the anterior shoulder, followed by the posterior shoulder and body. Hold the infant at the level of the uterus, suction again, clamp and cut the cord, and initiate warming, drying, and stimulation. Provide oxygen or neonatal resuscitation as indicated.
The placenta typically delivers spontaneously within 20–30 minutes. Monitor closely for postpartum hemorrhage. Uterine massage promotes placental separation and uterine contraction. Avoid traction on the umbilical cord to prevent uterine inversion or cord rupture. If the placenta does not deliver and bleeding is severe, emergent operative management is required. After placental delivery, inspect it for completeness and examine the uterus, vagina, and perineum for lacerations. Persistent bleeding without laceration suggests uterine atony.
Medication Management
Routine medications are not required after uncomplicated delivery. If uterine atony persists despite massage, administer oxytocin intravenously. Continued bleeding may require methylergonovine intramuscularly, followed by carboprost tromethamine if refractory.
Follow-Up And Disposition
All women who deliver in the emergency department should be admitted to labor and delivery or a postpartum unit for monitoring, even if the delivery is uncomplicated. Neonatal consultation and NICU admission are required for infants with respiratory distress, gestational age less than 36 weeks, low birth weight, low Apgar scores, or other complications. Term infants without complications may be admitted to the nursery or remain with the mother in a combined unit. If post-delivery transfer is required, consider separate ambulances for mother and infant.
Key Clinical Lessons And Common Errors
Be prepared for obstetric emergencies such as cord prolapse, shoulder dystocia, and breech delivery. Always remember that after delivery, there are two patients requiring care—the mother and the newborn.
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