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Labor and Delivery in the Emergency Department

Labor and Delivery in the Emergency Department. Ricardo R. Jim énez, M.D. Pediatric Emergency Medicine, Fellow Emory University School of Medicine Children’s Healthcare of Atlanta. Objectives. The risk of labor and delivery in the ED. Objectives. Approach to the pt in possible labor.

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Labor and Delivery in the Emergency Department

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  1. Labor and Delivery in the Emergency Department Ricardo R. Jiménez, M.D. Pediatric Emergency Medicine, Fellow Emory University School of Medicine Children’s Healthcare of Atlanta

  2. Objectives • The risk of labor and delivery in the ED

  3. Objectives • Approach to the pt in possible labor

  4. Objectives • Management on labor and delivery in a sub-optimal setting

  5. Objectives • Diagnosis of a complicated delivery

  6. Objectives • Management of the most common complicated deliveries

  7. Labor and Delivery in the ED • ED avoidance perspective on labor and delivery (L&D) • When possible the pts in labor should be triage and transfer to an obstetric facility • Birth in the ED are rare • When labor has progressed to fetal expulsion, the ED physician will become the obstetric provider • The ED physician must posses basic skills for intrapartum management of normal and abnormal deliveries

  8. Perinatal infant mortality in 0.04% Normal pregnancy Good prenatal care Delivery by an Ob Perinatal infant mortality for deliveries in the ED is 8% to 10% No prenatal care Unexpected complications Women with drug and alcohol abuse Victims of domestic abuse Denial or unaware of pregnancy Illegal aliens Labor and Delivery in the ED

  9. Labor and Delivery in the ED • Any delivery in the ED should be considered High Risk • Maternal mortality is also increase • The transfer of a pt in labor should be supported by clinical and medicolegal judgment • En route delivery can be fatal for fetus and mother

  10. Labor and Delivery in the ED • Consolidated Omnibus Reconciliation Budget Act (COBRA) of 1989 • Clearly identify labor as a condition unsuitable for transfer due to its unstable nature

  11. Limitations of the ED • Need for: • Experience personnel • Monitoring instruments • Tocodynamometry • U/s • Fetal scalp monitors • Vacuum extractors • Forceps • Prenatal hx • C-section is not an option in the ED

  12. Normal Delivery • Normal L&D would proceed, without physician intervention, to good outcome • Mother and fetus are very vulnerable • After 24wks any assessment must include both mother and fetus • Symptoms: • Abdominal pain • Back pain • Cramping • Urinary urgency • Vomiting • Anxiety

  13. Normal Delivery • False labor (Braxton Hicks contractions) • After 30wks the uterus becomes a contractile organ • Contractions are synchronous • Will not increase infrequency or duration • Non dilated cervix • Intact membranes • Relieved with mild analgesia

  14. Normal Delivery • True labor • Cyclic uterine contraction of increasing frequency, duration and strength • Cervical dilatation • Bloody show • Mucous plug expelled • Blood is dark and scant • Not a contraindication for cervical exam • Reliable indicator for onset of labor

  15. Normal Delivery • First Stage of Labor (Cervical Stage) • Ends when the cervix is fully dilated and effaced • Latent phase- slow cervical dilatation • Active phase- rapid cervical dilatation • Duration is close to 8hrs in nulliparous and 5hrs in multiparas • Most women that deliver in the ED arrive in active phase stage 1 or early stage 2

  16. Normal Delivery • First Stage of Labor (Cervical Stage) • Examination of the cervix (Sterile approach) • Effacement • Dilatation • Position • Station • Presentation

  17. Normal Delivery • First Stage of Labor (Cervical Stage) • Effacement • Refers to the thickness of the thinning cervical canal compared to the cervix • Paper thin is 100% effaced • Dilatation • Cervical opening in cm, complete is 10 cm • Position • Describes the relationship of the fetal presenting part to the birth canal

  18. Normal Delivery

  19. Normal Delivery

  20. Normal Delivery • First Stage of Labor (Cervical Stage) • Station • Indicates the relationship of the presenting parts to the ischial spines

  21. Normal Delivery • First Stage of Labor (Cervical Stage) • Presentation • Specifies the presenting anatomic part • 95% of all labors the presenting part is occiput or vertex

  22. Normal Delivery • First Stage of Labor (Cervical Stage) • Presentation • On palpation a smooth surface with 360 degrees of bony contours and suture lines should be found • 3 sutures will extend from the posterior fontanel and 4 from the anterior

  23. Normal Delivery

  24. Normal Delivery • Second Stage of Labor • Full cervical dilatation • Urge to bear down and push with uterine contractions • Position will advance to +3 with crowning • Contractions last 1 to 2min and recur after a resting phase of less than a min • Duration is close to 50 min in nulliparous and 20 min in multiparous

  25. Fetal monitoring • After 24wks of gestation the fetus has to be asses just like the mother • Uterine activity and Fetal cardiac activity • Base line HR • Maintained for 15 min in absence of contractions • Single most important aspect of fetal monitoring • Variability • Indicator of fetal well being

  26. Uterine activity and Fetal cardiac activity • Acceleration • Occur during fetal movement or umbilical cord compression • Reflect and alert mobile fetus • Deceleration • More complicated and most be integrated into the clinical situation • Three types: • Early • Late • Variable

  27. Fetal monitoring • Uterine activity and Fetal cardiac activity • Variability • Decrease variability correspond to an inactive fetus • Fetal acidemia • Hypoxia • Drugs use like: alcohol, benzodiazepine, analgesics

  28. Fetal monitoring • Uterine activity and Fetal cardiac activity • Decelerations • Early and variable are very common • Represent physiologic responses to head compression by the birth canal or cord compression • If persistent the delivery should be hasten; if obstetric backup a c-section should be consider • Late decelerations indicate uteroplacental insufficiency • The lag, slope and the magnitute of the deceleration correlate with increase fetal hypoxia • Immediate delivery should be perform

  29. Fetal monitoring • Uterine activity and Fetal cardiac activity • Sinusoidal traicing • Low baseline HR and little variability • Often a premorbid finding

  30. Fetal monitoring

  31. Fetal monitoring

  32. Fetal monitoring

  33. Fetal monitoring

  34. Normal Delivery • Delivery ( Oh S* what am I going to do? Stage) • Equipment • Radiant warmer • Towels • Umbilical clamps • Scissors • Airway management • Adult and neonatal airway management • Meconium suctioning tools • Valium for you

  35. Normal Delivery • Delivery • Place the mother in dorsal lithotomy • The vulva and perineum should be gently scrubbed • Sterile cervical examination • Digital stretching of the perineum • Coach mother to sustain each push until crowning • Once crowning occur coach so the delivery occur in a slow control manner

  36. Normal Delivery • Delivery • Coach mother to sustain each push until crowning • Once crowning occur coach so the delivery occur in a slow control manner

  37. Normal Delivery • Delivery • Be calm • Ask the mother to pant and not to push to slow the passage of the head and shoulders • In a controlled delivery the performance of an episiotomy is not indicated

  38. Episiotomy • The routine use of episiotomy has been challenged • Increase maternal morbidity is associated with both medial and mediolateral approach • Mediolateral approach is associated • Less satisfactory cosmetic results • Painful intercourse • More pain • Medial approach • Serious perineal lacerations

  39. Episiotomy • Should be performed only in shoulder dystocia or breech delivery • Most authors recommend a mediolateral approach

  40. Normal Delivery • Delivery • Modified Ritgen maneuver facilitate most normal deliveries • Once the head is delivered, it should be rotated to the mother thigh, mouth and nares should be bulb suction

  41. Normal Delivery • Delivery • Downward pressure will help deliver the anterior shoulder and subsequent upward motion will deliver the posterior shoulder

  42. Normal Delivery • Delivery • Keep the infant low to promote blood flow from the placenta • Clamp the cord 4 to 5 cm apart, with the proximal clamp 10 cm from the infant, and then cut

  43. Normal Delivery • Third Stage of Labor (Delivery of the Placenta) • Signs of placental separation • Uterus becomes firm and globular • Sudden gush of blood • Umbilical cords protrudes further out of the vagina • Uterus is displaced upward the abdomen

  44. Normal Delivery • Third Stage of Labor (Delivery of the Placenta) • Usually occurs between 5 to 10 min after delivery, but may be delayed up to 20 min • Beyond 25 min is abnormal

  45. Normal Delivery • Third Stage of Labor (Delivery of the Placenta) • If excessive bleeding or prolong placental expulsion uterine massage may be indicated • Puling on the cord or trying to express the placenta before it separates is contraindicated

  46. Normal Delivery • Fourth Stage of Labor • First hr after delivery of the placenta • Highest risk for hemorrhage • Examine cervix and vagina for any lacerations

  47. Normal Delivery

  48. Complicated Delivery • Breech Presentation • 4% of all deliveries • Three types: • Frank • Complete • Incomplete • Buttocks do not cause enough wedge to dilate the cervix • The head becomes trapped • Cord commonly prolapse

  49. Complicated Delivery • Breech Presentation • 4% of all deliveries • Three types: • Frank • Complete • Incomplete • Buttocks do not cause enough wedge to dilate the cervix • The head becomes trapped • Cord commonly prolapse

  50. Complicated Delivery • Breech Presentation • 4% of all deliveries • Three types: • Frank • Complete • Incomplete • Buttocks do not cause enough wedge to dilate the cervix • The head becomes trapped • Cord commonly prolapse

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