Emergency Delivery

first10em difficult delivery posts:

emcrit perimortem C-section:

http://emcrit.org/wee/peri-mortem-c-section/

Precipitous Delivery

Call for help: OB and NICU/peds/colleague/ancillary staff
Equipment: betadine, sterile gloves, towels, 2 clamps, scissors, newborn warmer and bag. “Born on Arrival” kit if available.
Apply pressure at perineum with left hand covered by a towel
Place right hand on occiput to control delivery of the head
Deliver the head and direct mother to stop pushing
Check back of neck for cord. If present, lift anteriorly over head. If unable, clamp and cut cord and deliver quickly
Exert downward pressure on head and neck to deliver anterior shoulder using “V” shape of index and middle finger of right hand
Exert upward pressure on head and neck to deliver the posterior shoulder using a “C” shape of thumb and index finger of left hand
Deliver rest of body with left hand around neck and right hand supporting body. Place baby on mother or warmer.
Clamp cord twice at least 5 cm from newborn’s abdomen and cut between clamps
Proceed with newborn resuscitation (warm, dry, stimulate)

Shoulder Dystocia (progress in stepwise fashion until delivery progresses)

Recognized by failure of delivery to progress past neck, “turtle sign” when head retracts back to perineum after pushing
McRoberts maneuver: Knee-chest position
Suprapubic pressure by assistant
Anterior shoulder sweep: rotate the anterior shoulder towards the baby’s face by pushing on scapula to unlock anterior shoulder from pubic bone
Rotate the posterior shoulder to anterior position using a similar shoulder sweep and then deliver that shoulder
Deliver posterior arm by passing the arm along the baby’s chest
Episiotomy or fracture the clavicles as a last resort

Breech Presentation

As the fetus begins to emerge, the hips will deliver
Avoid aggressive traction, which increases the risk for head entrapment or nuchal arm entrapment. Allow mother to push as far as possible.
Assist delivery of the legs.
When the scapulae appear under the symphysis, sweep the anterior shoulder to unlock it from the pubic bone. Deliver the anterior arm.
Rotate the shoulder girdle to facilitate delivery of the posterior arm.
Rest the fetal body on your dominant palm and forearm.
Place your dominant-hand index and middle fingers over the infant’s maxilla to maintain head flexion. Place non-dominant hand between the scapulae. Apply downward traction on the shoulders with non-dominant hand, then elevate the body of the fetus to deliver the head.

Prolapsed Cord

Prepare for an emergency cesarean section. If unable, temporize:
Place the mother in knee-chest or deep Trendelenburg (head-down) position
Minimize compression of the umbilical cord by inserting a sterile gloved hand and exerting manual pressure in the vagina to lift and maintain the presenting part away from the prolapsed cord
After manual elevation of the presenting part, instill 500 mL of saline into the bladder to raise the presenting part and maintain cord decompression.
Tocolytic therapy can be administered to decrease uterine contractions.

Perimortem C-section

Make a vertical incision through the abdominal wall from subxiphoid area to the symphysis pubis.
Manually retract the abdominal wall laterally in both directions to expose the anterior surface of the uterus and retract the bladder inferiorly.
Use a scalpel to make a small vertical incision through the lower uterine segment (lowest part of uterus).
Use bandage scissors (or trauma shears) to extend the incision vertically to the fundus.
Deliver the infant, suction the nose and mouth, and clamp and cut the cord.