EM OB 2: Emergency Delivery, part 2

Question 1

in emergency deliver, but if time allows, what preparations can you do?

Answer 1

Wash the perineum by washing it with mild soap and water and swabbing with povidone-iodine.
Place drapes over the patient.
Medical personnel attending to the patient should don gowns, masks, and gloves.

Question 2

The first step in the management of a woman in active labor are

Answer 2

to measure vital signs and initiate supportive therapy
- obtain venous access
- provide IV hydration
- initiate maternal and fetal monitoring (if available)

Question 3

Delivery is imminent if the pelvic examination reveals

Answer 3

complete cervical effacement and the fetus is at the introitus

Question 4

remarks on transport to the delivery suite

Answer 4

If the cervix is fully effaced and dilated or the fetal head is visible during contractions, the obstetrician (if available) should come to the ED rather than risk a precipitous delivery during transport to the delivery suite

Question 5

6 cardinal movments of labor

Answer 5

1. Engagement
2. Flexion (?)
3. Descent (?)
4. Internal rotation
5. Extension
6. External rotation

Question 6

As the infant’s head emerges from the introitus, support the perineum by

Answer 6

placing a sterile towel along the inferior part of the perineum with one hand and supporting the fetal head with the toher hand.

gentle digital stretching of the inferior portion of the perineum can aid delivery

Question 7

median vs mediolateral episiotomy

Answer 7

median episiotomy
- easy to perform
- hass maternal discomfort during recovery

mediolateral episiotomy
- lower risk of extension to the anal sphincter (3rd degree) or rectum (4th degree)

Question 8

anesthesia in episiotomy

Answer 8

inject 5 to 10 mL of 1% lidocaine solution with a small-gauge needle into the posterior fourchette and perineum

Question 9

some points in doing episiotomy

Answer 9

1. while protecting the infant’s head, make a 2- to 3-cm incision with scissors.
2. a median incision must be supported with manual pressure from below.

Question 10

Do not drop the baby. How?

Answer 10

The combination of amniotic fluid, blood, and vernix generates a very slippery infant.

Before delivering the rest of the body, place your posterior hand underneath the axilla of the infant.
Use the anterior hand to grasp the ankles of the infant with a firm grip.

Question 11

remarks on suctioning the newborn

Answer 11

Do not routinely suction the nose and mouth. Suctioning can cause fetal bradycardia and hypoxia

Question 12

Describe the Essential Newborn Care

Answer 12

1. Immediate drying
2. skin-to-skin contact
3. delayed cord clamping
4. Non-separation of baby from mother and breastfeeding initiation

Question 13

remarks on clamping the cord

Answer 13

Delay for at least 1-3 minutes after birth
Delayed cord clamping increases neonatal iron stores.

Double-clamp the umbilical cord 3 cm distal to its insertion at the umbilicus and transect with sterile scissors.
DOH: Put ties tightly around the cord at 2 cm and 5 cm from the newborn’s abdomen

Question 14

What should you do when aseptic care is not available during cord clamping?

Answer 14

Antiseptic topical care of the umbilicus with chlorhexidine can be done.
This reduces the risk of omphalitis and neonatal mortality

Question 15

Remarks on APGAR score

Answer 15

calculated at 1 and 5 minutes after delivery
For an APGAR <7, resuscitate.
Provide positive pressure ventilation for all newborns with a HR <100 or who are gasping or apenic after 30 seconds

Appearance (color)
Pulse (heart rate)
Grimace (reflexes)
- grimace is 1 point
Activity (tone)
- flexed arms and leg is 1 point
Respiratory effort
- slow, irregular respiration is 1 point

Question 16

remarks on an uncomplicated delivery

Answer 16

if delivery is uncomplicated, and the infant has responded well to initial stimulation with a clear airway and good respiratory effort, the mother may hold the child immediately while the cord is cut

Question 17

remarks on delivering the placenta

Answer 17

1. The placenta usually delivers 10 to 30 minutes after delivery of the infant.
2. Allow the placenta to separate spontaneously and provide only gentle traction.
   Aggressive traction on the cord can lead to uterine inversion, tearing of the cord, or diruption of the placenta, all of which can result in severe vaginal bleeding.

Question 18

What to do after the placenta has been removed?

Answer 18

1. Gently massage the abdomen at the level of the fundus to promote contraction.
2. Give oxytocin (10 to 40 units in 1 L normal saline at 250cc/hour or 10 units IM) to sustain contraction.

Question 19

The estimated blood loss during a vaginal delivery is

Answer 19

usually less than 500 mL

Question 20

What to do in cases of uterine atony

Answer 20

Vigorous bimanual massage
Give additional oxytocin or another uretonic agent (e.g., methylergonovinge, carboprost, or misoprostol)

Question 21

How to give oxytocin

Answer 21

20 units/ 1000 mL normal saline [at 250cc/hour]
or 10 units IM

Question 22

How to give methylergonovine

Answer 22

0.2 mg IM or IV or PO;
may repeat at 2- to 4-hour intervals

C/I:
- hypertension, eclampsia, preeclampsia

Question 23

How to give carboprost

Answer 23

25 mcg IM every 15-90 mins
total dose 2 mg

C/I: asthma

Question 24

How to give misoprostol

Answer 24

1000 mcg PR, SL, or PO once
unlabeled use for PPH

Question 25

Remarks on episiotomy complications

Answer 25

Delay episiotomy or laceration repair until an experienced obstetrician is available to close the laceration and inspect for frouth-degree perineal laceration.