EM OB 2: Emergency Delivery, part 2 Flashcards
in emergency deliver, but if time allows, what preparations can you do?
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.
The first step in the management of a woman in active labor are
to measure vital signs and initiate supportive therapy
- obtain venous access
- provide IV hydration
- initiate maternal and fetal monitoring (if available)
Delivery is imminent if the pelvic examination reveals
complete cervical effacement and the fetus is at the introitus
remarks on transport to the delivery suite
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
6 cardinal movments of labor
- Engagement
- Flexion (?)
- Descent (?)
- Internal rotation
- Extension
- External rotation
As the infant’s head emerges from the introitus, support the perineum by
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
median vs mediolateral episiotomy
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)
anesthesia in episiotomy
inject 5 to 10 mL of 1% lidocaine solution with a small-gauge needle into the posterior fourchette and perineum
some points in doing episiotomy
- while protecting the infant’s head, make a 2- to 3-cm incision with scissors.
- a median incision must be supported with manual pressure from below.
Do not drop the baby. How?
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.
remarks on suctioning the newborn
Do not routinely suction the nose and mouth. Suctioning can cause fetal bradycardia and hypoxia
Describe the Essential Newborn Care
- Immediate drying
- skin-to-skin contact
- delayed cord clamping
- Non-separation of baby from mother and breastfeeding initiation
remarks on clamping the cord
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
What should you do when aseptic care is not available during cord clamping?
Antiseptic topical care of the umbilicus with chlorhexidine can be done.
This reduces the risk of omphalitis and neonatal mortality
Remarks on APGAR score
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
remarks on an uncomplicated delivery
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
remarks on delivering the placenta
- The placenta usually delivers 10 to 30 minutes after delivery of the infant.
- 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.
What to do after the placenta has been removed?
- Gently massage the abdomen at the level of the fundus to promote contraction.
- Give oxytocin (10 to 40 units in 1 L normal saline at 250cc/hour or 10 units IM) to sustain contraction.
The estimated blood loss during a vaginal delivery is
usually less than 500 mL
What to do in cases of uterine atony
Vigorous bimanual massage
Give additional oxytocin or another uretonic agent (e.g., methylergonovinge, carboprost, or misoprostol)
How to give oxytocin
20 units/ 1000 mL normal saline [at 250cc/hour]
or 10 units IM
How to give methylergonovine
0.2 mg IM or IV or PO;
may repeat at 2- to 4-hour intervals
C/I:
- hypertension, eclampsia, preeclampsia
How to give carboprost
25 mcg IM every 15-90 mins
total dose 2 mg
C/I: asthma
How to give misoprostol
1000 mcg PR, SL, or PO once
unlabeled use for PPH
Remarks on episiotomy complications
Delay episiotomy or laceration repair until an experienced obstetrician is available to close the laceration and inspect for frouth-degree perineal laceration.
