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How to Manage Precipitous Delivery and Complications

November 22, 2023

Written by Julie Brown

Spoon Feed
Although infrequent, precipitous vaginal deliveries in the ED occur and are associated with higher rates of maternal and fetal complications. Here’s how you can be prepared to manage these deliveries and common complications.

Top things I don’t want to hear on shift…”She’s crowning in trauma room 3″
In the event of a precipitous vaginal delivery in the ED, it is important to be prepared. The authors list several items to keep stocked for these procedures:

  • Sterile materials: gown, gloves, towels
  • Delivery equipment: clamps, scissors, sutures
  • Medications: uterotonic agents (oxytocin)
  • Neonatal resuscitation equipment: blankets, suction bulb, baby warmer

The authors go on to discuss four obstetrical emergencies and management tips for the emergency provider.

  1. Shoulder Dystocia: initially attempt the McRoberts maneuver by performing hyperflexion the maternal hips and knees against the sides of the abdomen while an assistant applies oblique suprapubic pressure to internally rotate the fetal shoulder. If this fails, the provider may attempt further rotational maneuvers, deliver the posterior shoulder, or place the patient in an all-fours position prior to considering more invasive maneuvers.
  2. Nuchal Cord: reduce the cord over the fetal head or shoulders. If the cord is tight, it may be clamped and cut prior to fetal delivery.
  3. Cord Prolapse: elevate the presenting fetal part with a warm, moist towel before moving toward emergency cesarean delivery.
  4. Postpartum Hemorrhage: administer uterotonic agents (oxytocin) while performing bimanual uterine massage. Intramuscular medications (carboprost 0.25mg IM or methylergonovine 0.2mg IM) are likely more available, and tranexamic acid 1g IV (+/- misoprostol 400µg SL) can also be considered. Evacuate any retained placental fragments and apply direct pressure to lacerations or hematomas. If these initial steps fail, consider uterine tamponade with TXA-soaked gauze or balloon tamponade device until surgical interventions can be provided.

How will this change my practice?
This article serves as a reminder that in Emergency Medicine, we are called on to manage the emergent conditions of all medical specialties. Delivering a baby is one of these, and we should be proud of our capacity to skillfully care for precipitously delivering patients. To prepare for these events, I think every ED should have a “Baby Box” kit containing necessary equipment to assist in both the precipitous delivery and management of potential complications.

Another Spoonful
We made this video on Neonatal Resuscitation in Five Minutes to give you a quick NRP refresher!

Source
Just the facts: precipitous deliveries in the emergency department. CJEM. 2023 Oct;25(10):799-801. doi: 10.1007/s43678-023-00552-9. Epub 2023 Jul 12.

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