Women who are not able to easily access medical

care are not good candidates for outpatient management.

SUGGESTED READING

American College of Obstetricians and Gynecologists. Committee

on Practice Bulletins-Obstetrics. Diagnosis and management of

preeclampsia and eclampsia. Obstet Gynecol. 2002;99:1 59-167.

Echevarria MA, Kuhn GJ. Emergencies after 20 weeks of preg -

nancy and the postpartum period. I n: Tintinalli JE, Stapczynski

JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD. Tintinalli's

Emergency Medicine: A Comprehensive Study Guide. 7th ed.

New York, NY: McGraw-Hill, 201 1, pp. 695-702.

Sibai BM. Diagnosis and management of gestational hypertension and preeclampsia. Obstet Gynecol. 2003;1 02:1 8 1-192.

Sibai BM. Diagnosis, prevention, and management of eclampsia.

Obstet Gynecol. 2005;105:402-4 10.

E mergency Delivery

jessica Sime, MD

Key Points

• Assemble sufficient staff and supplies to care for both

the mother and newborn.

• When vaginal bleeding is present, defe r the pelvic

exami nation until placenta previa has been excluded.

INTRODUCTION

Less than 1% of all deliveries are in the emergency

department (ED) because most women in labor are

quickly triaged to the labor and delivery unit. However, if a

woman is going to precipitously deliver, or the hospital has

no obstetric services, it is up to the emergency physician to

be prepared to deliver the infant.

Moreover, deliveries in the ED are more likely to be

considered high risk. Women who deliver in the ED

more often have had little or no prenatal care, may have

substance abuse problems, do not know they are pregnant,

or have been victims of domestic violence. These women

may have higher frequencies of complications such as

premature rupture of membranes (PROM), preterm labor,

malpresentation, umbilical cord prolapse, placenta previa,

abruptio placentae, or postpartum hemorrhage. The

emergency medicine physician must be prepared to manage

these complications.

CLINICAL PRESENTATION

� History

Past medical, surgical, gestational age, and obstetric history

should be obtained, as well as history of prenatal care. It is

important to inquire about vaginal bleeding during labor.

Scant, mucoid bleeding is usually termed bloody show and

• Util ize bedside ultrasound to check feta l presentation.

• Be prepared for complications such as postpartum hemorrhage, shoulder dystocia, and breech

presentation.

occurs when the cervical mucus plug is expelled. Heavy

vaginal bleeding is a worrisome sign and can represent

placenta previa (painless vaginal bleeding from the placenta covering the cervical os) or abruptio placentae (painful bleeding owing to placental separation from the uterus).

The physician should also determine whether the patient

has had a spontaneous rupture of membranes (SROM).

Clear, blood-tinged, or meconium-stained vaginal fluid

suggests rupture of membranes.

� Physical Examination

As always, vital signs are the first step in examination.

Fetal heart rate can be assessed with handheld Doppler

or with electronic fetal monitoring, if available. The

abdomen should be palpated for tenderness and fundal

height. Gestational age can be estimated if the mother is

unsure. At 20 weeks' gestation, the uterus is at the umbilicus, and it grows approximately 1 em every week until

36 weeks.

Pelvic examination should begin with inspection of

the perineum to determine whether the delivery is imminent (crowning). If the patient reports vaginal bleeding,

examination should be deferred until an ultrasound can be

performed. It is important to identify placenta previa first,

as the bimanual and speculum examination can exacerbate

the bleeding.

1 92

EMERGENCY DELIVERY

The bimanual examination determines the position of

the fetus and readiness of the cervix. Sterile gloves should

be used to prevent infection. A normal cervix is thick, only

open at the entry to fingertip, and is firm to touch.

Gradually the cervix thins; this is termed effacement.

Dilation of the cervix progresses from closed to fully open

(10 em). Station indicates the location of the presenting

part relative to the ischial spines. A presenting part at the

ischial spines is at 0 station. If the presenting part is at the

introitus, it is at + 3 station. Position describes the relationship of the presenting part to the birth canal. Usually the

fetal occiput is anterior.

Speculum examination can help identify spontaneous

rupture of membranes. Pooling vaginal secretions should

be tested with Nitrazine paper to determine pH. A dark

blue color correlates to a pH of 7.0-7.4 and indicates the

presence of amniotic fluid. Normal vaginal secretions have

a pH of 4.5-5.5. Next, the cervical os is inspected. The

examiner should identify whether it is open slightly, has

bulging membranes, a visible fetal head, or other presenting part. If the examiner sees a prolapsed umbilical cord,

he or she should keep a hand in the vagina and elevate the

presenting part to prevent cord compression, while an

assistant contacts obstetric services for an emergency

cesarean section.

DIAGNOSTIC STUDIES

� Laboratory

If a patient is about to deliver, no laboratory studies are

necessary. A complete blood count, type and screen,

prothrombin time/partial thromboplastin time are useful

in the event of postpartum hemorrhage. Rh type should be

sent to determine the need for RhoGAM.

� Imaging

Bedside ultrasound is used to determine the fetal position,