Precipitous Birth in the ED

Procedure, instructions and discussion

Precipitous delivery in the Emergency Department.

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Instructions

Indications

Precipitous delivery (rapid labour)

AND

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

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

Contraindications (ABSOLUTE/relative)

None

Alternatives

Transfer to birthing unit

Consent

VERBAL – IF HAS CAPACITY

Simple procedure with a low risk of complications

NOT REQUIRED – IF LACKS CAPACITY

Emergency procedure to prevent serious injury or death
Brief verbal explanation of the procedure is still recommended

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

Infection Control

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

Area

Resuscitation bay
Including Neonatal equipment

Staff

Obstetric and paediatric support

MATERNAL

Birthing assistant (ideally obstetrician or midwife)
Nurse assistant

NEONATAL:

Clinician to receive the baby (ideally paediatrician or neonatologist)
Nursing assistant
Scribe

Equipment

Resuscitaire
Attached to gas source
Warmer on
Doppler (foetal heart rate)
Bedside ultrasound (foetal heart rate)
Arterial forceps or haemostats x 2
Clamps for the cord x 2
Sterile scissors
Suction
Sterile gloves
Warm towels

Position

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
(After delivery of the shoulders)

Sequence (Assessment)

Examine externally to look for presenting part and vaginal loss (clear or bloody)
Examine perineum for visible head or bulging of perineum (crowning), if presenting part not visible
Perform a digital vaginal exam (with sterile gloves), palpating for presenting part
If presenting part is not visible, there is no bulging of perineum and presenting part not palpable, birth is not imminent and you can arrange transfer to birthing unit for delivery
If presenting part is visible, there is bulging of perineum or presenting part not palpable, birth is imminent, prepare for delivery in the emergency department

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
Place the baby on mother’s chest, drying and stimulating the baby
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
Rotate the placenta as it is delivered to aid expulsion of membranes
Once the placenta has been delivered, massage the uterus to encourage contraction (fundal rub)
Inspect the placenta for trauma, a displaced cotyledon can prevent uterine contraction and lead to post-partum haemorrhage

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 or incomplete
Estimated blood loss volume
Apgar scores at 1, 5 and 10 minutes

MATERNAL CARE

Inspection of the perineum looking
(haemorrhage, skin tears and haematoma)
Regular observations and assessment of bleeding
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 is not a normal delivery. It is a precipitous delivery and has high risk of complications. It can be a stressful scenario. You should immediately request obstetric and neonatal support. If your hospital has obstetric and neonatal emergency numbers, you should activate as soon as you identify that birth is imminent and the patient cannot be transferred to the delivery suite.

Once you have identified a precipitous delivery, set up a resuscitation bay and neonatal equipment and attempted to obtained help, taking a few moments to complete an initial evaluation:

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

EXAMINATION

Uterine fundal height (Umbilicus = 20 weeks)
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

CONSIDER ULTRASOUND

Presenting part
Singleton vs multiple pregnancy
Estimated gestation

References

Borhart J, Voss K. Precipitous Labor and Emergency Department Delivery. Emerg Med Clin North Am. 2019 May;37(2):265-276.
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