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Obs and Gynae - Vaginal delivery

Indications

Precipitous delivery (rapid labour)

and

Child’s head is crowning (visible or causing bulging of the perineum)

or

Serious illness unsuitable for labour ward transfer (eclampsia, SBP >170, haemorrhage)

Contraindications (absolute in bold)

None

Alternatives

Transfer to birthing unit

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

or

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Intrapartum:

Nuchal cord (cord around neck)

Shoulder dystocia

Breech position

Post-partum:

Foetal compromise

Post-partum haemorrhage

Cervical, vaginal, perineal lacerations

Retained placenta

Procedural hygiene

Standard precautions

PPE: surgical mask, protective eyewear, sterile gloves, sterile surgical gown

Area

Resuscitation bay with neonatal equipment

Staff

Obstetric and paediatric support

Maternal: birthing assistant (ideally obstetrician or midwife) and nurse assistant

Foetal: clinician to receive the baby (ideally paediatrician or neonatologist) and nursing assistant

Scribe

Equipment

Resuscitaire attached to gas source and with warmer on

Doppler (for assessing foetal heart rate)

Bedside ultrasound (for assessing foetal heart rate and singleton vs multiple pregnancy)

Arterial forceps or haemostats x 2

Clamps for the cord x 2

Sterile scissors

Suction

Clean pad

Sterile drape

Warm towels

Positioning

Comfortable position for the woman

Ideally supine with hips and knees flexed (dorsal lithotomy)

Sterile drape underneath the buttocks

Clean pad over anal area

Medication

Oxytocin 10 units IM (for use after delivery of the shoulders)

Sequence (assessment)

Examine externally to look for presenting part and vaginal loss (clear or bloody)

If baby’s head is not visible or causing bulging of the perineum, transfer to birthing unit for delivery

If baby’s head visible or causing bulging of the perineum (crowning), prepare for imminent delivery

Sequence (delivery of baby)

Once head visible, support the inferior perineum with one hand

Support the foetal head with the other hand, applying gentle pressure preventing uncontrolled delivery

Encourage mum to breathe through contractions (pant) rather than pushing (bearing down)

Once the head has delivered, it will turn to face one side (restitution) - do not twist or pull on the head

Palpate neck for the presence of a nuchal cord (25-35%)

Once restitution has occurred, with the next contraction, the shoulders should deliver spontaneously

If the shoulders do not deliver, provide downwards traction to deliver the anterior shoulder

Once the anterior shoulder visible, guide the foetus upward delivering the posterior shoulder

Administer oxytocin 10 units IM after delivery of the shoulders

Clamp the umbilical cord with two umbilical clamps 3cm from the umbilical insertion and cut in between

Dry baby and wipe away secretions from nose and mouth with warm towels (providing stimulation)

Transfer baby to mother or Resuscitaire for further assessment if required

Sequence (delivery of placenta)

Clamp the cord near the introitus using haemostat/arterial forceps

Observe for signs of placental separation (lengthening cord, bleeding, rising firm fundus)

Maintain gentle counterpressure on the uterus with the non-dominant hand (to prevent uterine inversion)

Apply controlled cord traction with contractions (consistent, downward traction on the haemostat or forceps)

Cease traction on the cord when the contraction stops

Once the placenta has been delivered, massage the uterus to encourage contraction

Managing complication

Sequence: nuchal cord (cord around neck)

Seek urgent senior help (midwife, obstetric registrar and consultant)

Try to unwrap the cord from the neck once the head has delivered

If this is not possible, deliver the baby completely, then unwrap the cord

Avoid clamping and cutting the cord prior to delivery (associated with morbidity and mortality)

Sequence: shoulder dystocia (anterior shoulder impaction)

Diagnosis: no head restitution (turning to turning to the side after head delivered), pulling into perineum

Seek urgent senior help (midwife, obstetric registrar and consultant) and drain bladder

Attempt the following manoeuvres below in McRoberts position

McRoberts: hyperflex thighs towards abdomen, apply suprapubic pressure with a fist over the anterior shoulder

Rubin II: fingers on posterior aspect of the anterior shoulder, pushing towards the foetal chest (narrows diameter)

Woods corkscrew:fingers on anterior aspect of posterior shoulder, pushing towards the foetal back (with Rubin II)

Reverse Woods corkscrew: fingers on posterior aspect of posterior shoulder turning in the opposite direction

Delivery of the posterior arm:sweep the posterior arm forwards and over foetal chest, deliver the arm by the hand

Sequence: breech position (buttocks or feet positioned delivered first)

Seek urgent senior help (midwife, obstetric registrar and consultant)

If delivery is not imminent, transfer to theatre for urgent Caesarean section

Otherwise, optimise position (supine with hips and knees flexed)

Try to delay maternal pushing andstay hands off initially

Allow maternal effort to deliver the baby spontaneously to the umbilicus, then

Encouraged mother to push until the trunk becomes visible up to the scapula

Do not pull on the limbs or body, this can cause entrapment of the head

If the arms do not deliver, rotate the trunk until the anterior shoulder delivers

Rotate the trunk in the opposite direction to deliver the posterior shoulder

Deliver the head with a forearm under the body with one finger either side of the maxilla

Use other hand on the upper back with a finger on the occiput, flexing the head anteriorly

Lift the body in an up and outwards motion maintaining gentle downward traction on the shoulders and head

Post-procedure care

Documentation:

Birth of the head time

Birth of the body time

Clamping of the cord time

IM oxytocin administration time

Time of placental delivery

Whether the placenta is intact, ragged or incomplete

Estimated blood loss volume

Apgar scores at 1, 5 and 10 minutes

Maternal care:

Inspection of the perineum looking for haemorrhage, skin tears and haematoma

Regular observations and assessment of bleeding until transfer to ward

Massage the uterus to encourage contraction

Neonatal care:

Regular observations until transfer to ward

Oxygen saturations from right arm (pre-ductal)

Vitamin K and hepatitis B administration

Tips

Always seek urgent support when managing delivery in the emergency department

Ultrasound of the abdomen can be used to exclude the possibility of a second foetus

Discussion

Spontaneous vaginal delivery in the emergency department can be a stressful scenario. Taking a few moments to complete an initial evaluation will help minimise stress and enable a controlled environment.

Take a focused history:

Contractions: frequency and duration

PV loss: clear or bloody

Foetal movements

Antenatal history: previous deliveries, antenatal care (doctors clinic vs midwives and GP)

Estimated due date, LMP, recent ultrasound scans

Baseline examination:

Uterine fundal height (umbilicus equivalent to 20 weeks gestation)

Strength, duration and frequency of contractions (palpate the uterus and time contractions)

A CTG can be used to assess the foetal heart, if there is someone qualified to interpret it

Bedside ultrasound can be useful to assess:

Presenting part

Singleton vs multiple pregnancy

Estimated gestation

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Carusi DA. The gynecologic history and pelvic examination. In: UpToDate. Waltham (MA): UpToDate. 2019 December 16. Available from: https://www.uptodate.com/contents/the-gynecologic-history-and-pelvic-examination

McKee-Garrett TM. Overview of the routine management of the healthy newborn infant. In: UpToDate. Waltham (MA): UpToDate. Viewed December 2019. Available from: https://www.uptodate.com/contents/overview-of-the-routine-management-of-the-healthy-newborn-infant

Barss VA. Precipitous birth not occurring on a labour and delivery unit. In: UpToDate. Waltham (MA): UpToDate. 2019 April 8. Available from: https://www.uptodate.com/contents/precipitous-birth-not-occurring-on-a-labor-and-delivery-unit

Royal Australia and New Zealand College of Obstetricians and Gynaecologists. Provision of routine intrapartum care in the absence of pregnancy complications. 17pp. East Melbourne: RANZCOG; 2017 Jul. Available from: https://ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Provision-of-routine-intrapartum-care-in-the-absence-of-pregnancy-complications-(C-Obs-31)review-July-2017.pdf?ext=.pdf

NSW Agency for Clinical Innovation. Childbirth in the ED. Sydney: ACI; 2017 Sept. Available from: https://aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/clinical-tools/obstetrics-and-gynaecology/childbirth-in-the-ed

Borhart J, Voss K. Precipitous labor and emergency department delivery. Emerg Med Clin North Am. 2019;37(2):265-276. doi:10.1016/j.emc.2019.01.007

© Agency for Clinical Innovation 2021