Emergency Department Delivery of Newborn

Question 1

What should be done as soon as the head delivers?

Answer 1

Sweep with finger, check for nuchal cord

Question 2

How is a nuchal cord managed?

Answer 2

Gently loosen the cord and attempt to reduce over the head. If unable, clamp and cut the cord and deliver quickly.

Question 3

What medications should be given immediately after delivery?

Answer 3

Oxytocin 10 units IM after delivery of the placenta

Add Oxytocin 30 units to 500 or 1,000cc fluid and infuse as fast as needed to control uterine atony

Question 4

What are signs of shoulder distocia?

Answer 4

Turtle head

Failure to advance

Question 5

How is shoulder distocia managed?

Answer 5

McRoberts maneuver: flex hips with suprapubic pressure (only attempt for 30 seconds before trying something else)
Try sweeping the posterior arm across body and face and delivering the posterior shoulder first
Try corkscrew maneuver: push post. shoulder backwards and anterior shoulder forward and rotate body
Break clavicle
Put mom on all fours
C-section

Question 6

How is breech presentation delivered?

Answer 6

Allow the infant to advance UNASSISTED until at the level of the umbilicus (assisting increases the risk of getting the head stuck later)
Externally rotate each thigh to deliver the legs
Rotate the body to put each shoulder anterior and deliver each shoulder
Position the baby face down and use hands on maxilla to flex the baby’s neck, assistant provides suprapubic pressure and then deliver the baby by pulling on shoulders

Question 7

What supplies are needed for delivery?

Answer 7

Sterile gloves, towels, gown
Scissors, two clamps
4x4 gauze
Needle driver and sutures
Baby warmer and resuscitation supplies

Question 8

Head delivers and then seems to retract and further advancement is not happening. What next?

Answer 8

Check for nuchal cord
Drain bladder if can do <1 min
McRobert's
Wood's corkscrew
Deliver the posterior arm first
Do epesiotomy
Break the clavicle by pressing in the middle of the bone

Question 9

You are alerted that a pt in triage is delivering a baby. What are your next steps and what do you need to know?

Answer 9

Page OB and Peds and get supplies
Confirm baby position by exam or US
Ask: how far along, and how many babies?

Question 10

How is umbilical prolapse managed?

Answer 10

Raise presenting part and reduce the cord
Hand stays in vagina until delivery
Can maybe instill fluid into the bladder to help hold baby in
Get to OR for delivery
Mom on all fours to have gravity help
If delayed OR use tocolytic

Question 11

What are tocolytic agents and doses?

Answer 11

Terbutaline: 0.25 mg SubQ every 20min to 3 hours or 2.5-10 mcg/min IV holding for tachycardia >120
Nitroglycerine: 50-200mcg IV bolus, favor 50 at a time repeated if needed
Magnesium: 4g IV over 15 minutes then 1–4g/hr

Question 12

Basic technique for delivering baby

Answer 12

Hand on head to control speed
Supportive pressure on perineum to prevent tearing
Mom pushes with contractions until head delivers then no more pushing
After head delivers, sweep for cord and either reduce over head or clamp, cut, and deliver fast
Downward pressure to deliver anterior shouder first
Upward traction to deliver posterior shoulder
Clamp cord 3cm from belly and cut
Oxytocin 20 units in 1L NS at 250/hr or 10 units IM
Stimulate baby, get apgars, suction, etc.
Check for post partum hemorrhage

Question 13

What are some steps to prevent post partum hemorrrhage?

Answer 13

Start oxytocin immediately after anterior shoulder delivers

Uterine massage after delivery

Question 14

How can pain be relieved during/after delivery?

Answer 14

Small doses ketamine or fentanyl

Question 15

How can oxytocin be given for PP hemorrhage?

Answer 15

10u IM or 40 units in 1L wide open

Question 16

What are adjunctive meds for PP hemorrhage?

Answer 16

Misoprostol 800mcg orally or rectally
Methylergonovine 0.2mg IM (not if HTN or CVD)
Carboprost 250 mcg IM (repeat q15 min x8 doses, not in asthma)

Question 17

What are the potential causes of post partum hemorrhage?

Answer 17

4 T's
Tissue (placental or fetal tissue)
Trauma (laceration or rupture)
Tone (uterine atony)
Thrombin (coagulopathy)

Question 18

What labs do you want to work up PP hemorrhage?

Answer 18

Coag panel and DIC panel

Question 19

Pt has vWD and is bleeding. What is the treatment?

Answer 19

DDAVP

Question 20

What are potential therapies for different coagulopathies?

Answer 20

FFP and platelets
DDAVP vWD
Factor replacement for known deficiencies
Cryoprecipitate for DIC

Question 21

Mom just delivered and is bleeding profusely. You give oxytocin and confirm that the uterus has good tone. What next?

Answer 21

Send coag labs
Have good IV access and get blood coming or infusing
Exam for retained tissue and repair any lacs
Blunt removal of any retained tissue

Question 22

All interventions have been tried but patient continues to bleed. What are the last efforts that can be done?

Answer 22

External aortic pressure, try for tamponade with blakemore or multiple foley balloons or with packing?
Need OR or interventional radiology for uterine artery ligation or embolization

Question 23

How is uterine inversion managed?

Answer 23

Turn off any oxytocin-like meds
May need tocolytic: (nitro 50mcg, Terb 5mcg IV, Mg 1-4g)
Don’t remove placenta until uterus is reduced
May need OR to reduce due to pain
Try to reduce with manual pressure
Restart oxytocin and hold uterus in place until firm
Rapid transfusion of blood or fluids

Question 24

How is delayed bleeding managed?

Answer 24

Same as for post partum bleeding, just need to add antibiotics
Retained products and infection are most common causes