Emergent Delivery

Emergent Delivery

1. Emergent Delivery Dan S tevens ED Registrar SCGH

2. Aims Learn a bit about labour Have an idea of how to deliver a baby Know where relevant equipment is in this ED Have an idea of what can go wrong and how to fix it Discuss indications and process of perimortem C section

3. Labour Latent Labour Cervical effacement ‘Show’ Dilatation to 4cm Active labour Stage 1 Further effacement to full dilatation (10cm) Stage 2 From full dilation to delivery of child Stage 3 From delivery of child to delivery of placent a Stage 4 1 st hour post delivery (highest risk of PPH)

4. Timeline…. Stage Nulliparous Multiparous 1. Up to full dilatation 7 – 13 hours 5 – 8 hours 2. Full dilatation to delivery 50 mins 15 mins 3. Delivery of infant to delivery of placenta 5 mins 5 mins 4 immediate PPH 1 st hour 1 st hour

5. Assessment of Labour History Previous obstetric history Multi / nulli previous complications previous deliveries Current obstetric history Due date Pregnancy complications Onset of contractions Duration between contractions Mucous show Rupture of membranes Vaginal bleeding Medical history

6. Assessment of Labour Examination Abdominal exam Gestational age > 12 weeks palpable in Abdomen 22 weeks about level of umbilicus Lie Oblique Transverse Longitudinal Vaginal exam Assess dilatation Possibly unnecessary in ED Risk of rupturing membranes. Introducing infection Speculum More useful Amount of dilatation head visible Cord prolapse

7. Assessment of Labour Investigations Ultrasound Assess lie If longitudinal, type of presentation Cephalic breech Fetal heart rate CTG – if expert available

8. Women in Labour

9. Normal Delivery Stage 1 D elivery of head Stage 2 Delivery of shoulders Stage 3 Delivery of body and legs Stage 4 Clamp and cut cord Stage 5 Delivery of placenta

10. 1. Delivery of Head Begins with Crowning Aim is gradual, controlled delivery Encourage pushing with contractions One hand resting on infants crown Other hand underneath, fingers exert upward pressure on chin Check for cord around neck and loosen if necessary Once head delivers it restitutes

11. 2. Delivery of Shoulders Often deliver themselves with very gentle traction Anterior shoulder first with slight downward traction of head Posterior shoulder next with slight upward traction

12. 3. Delivery of Body and Legs Normally easily with gentle traction Check the baby (or hand to colleague to check – should have prepared for neonatal resus ) Wrap and stimulate Wipe gunk from around infants mouth Healthy baby Pink Good tone Strong resp effort (cry) HR > 100 Pass to mother

13. 4. Clamp and Cut Cord Place K elly clamp 5cm from umbilicus Place another clamp towards the placenta Cut between the 2 Give syntocinon Reduces risk of PPH

14. 5. Delivery of Placenta Happens 5 mins later Warning signs that its imminent Uterus becomes firmer and contracts Gush of blood Cord lengthens and protrudes Apply gentle traction and ask mum to bear down Don ’ t use force!

15. Here it is in action…. Video 1 Preparation Video 2 Delivery http://scghed.com/ed-orientation/obstetrics-orientation-resources /

16. Possible complications Bleeding in 3 rd trimester Cord Prolapse Shoulder Dystocia Breech Presentation Immediate PPH

17. Cord Prolapse Occurs when cord bulges out after rupture of membranes Leads to fetal distress Diagnosis made when cord seen on speculum exam Treatment = delivery of baby, normally by C section However, some temporising measures…. Knee -> chest position (deep trendelenberg ) Sterile gloved hand into vagina to relieve pressure

18. Shoulder Dystocia Impaction of shoulder after deliver of head Occurs in 1% pregnancies Many can be solved with McRoberts Maneuver Extreme lithotomy position Assistant to apply suprapubic pressure whilst you apply gentle downward traction on head

19. Immediate PPH Causes Uterine atony (most common) Others: retained placenta fragements , lacerations, uterine rupture Uterine atony = soft, boggy uterus Blood Oxytocin Uterine massage Through abdominal wall bimanually

20. What to do at 2am Make assessment History Examination  external abdomen and speculum Investigations  Ultrasound Get help Prepare for delivery (imminent  head on view ) Delivery bundle box Assign roles Delivery Vs neonatal resus Gradual, controlled delivery (baby and placenta) Pat yourself on the back

21. Peri -Mortem C section Indication Equipment Procedure

22. Indication > 24 weeks pregnant Before this time infant chance of survival = 0 Effect of infant on maternal haemodynamics minimal Cardiac arrest Aim for delivery in less than 5 mins from onset of cardiac arrest But if longer than 5 minutes don ’ t not do it

23. Equipment Sterile Precautions Scalpel (11) Scissors (curved with blunt end) Suction Retractors (or assistants) Packs Cord Clamps Sutures

24. Procedure Vertical midline incision Umbilicus to symphysis pubis ( follow linea alba line) Skin  subcutaneous tissue  fascia  rectus sheath  peritoneum Retract layers This should expose uterus Make small vertical incision in lower uterine segment Should be gush of amniotic fluid Extend the incision with scissors towards umbilicus Grasp head and try to disengage it lift infant out Fundal pressure from assistant may help Find placenta – separate it from the wall of the uterus and remove Apply fundal pressure and uterine message Close uterus then peritoneum then skin

25. If she can do it……

26. Resources http:// broomedocs.com/wp-content/uploads/2012/10/TH-229-Post-Mortem-C-Section-perimortem1.pdf http:// broomedocs.com/2012/10/perimortem-c-section-can-you-cut-it-in-obstetric-resuscitation/ https:// en.wikipedia.org/wiki/Self-inflicted_caesarean_section Clinical Procedures in Emergency Medicine. Roberts and Hedges 6 th Edition http://scghed.com/ed-orientation/obstetrics-orientation-resources /