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INTRODUCTION

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Precipitous delivery in an emergency setting can be a source of significant anxiety for an emergency physician. While emergency delivery is a relatively uncommon occurrence, careful preparation and education can help in avoiding serious complications, and result in a positive outcome for the mother and child.

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CLINICAL FEATURES

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Any pregnant woman who is beyond 20 weeks’ gestation and appears to be in active labor should be evaluated expeditiously. Initial evaluation should include complete maternal vital signs and fetal heart monitoring. A persistently slow or fast fetal heart rate (less than 110 beats/min or greater than 160 beats/min) is an indicator of fetal distress. History includes frequency and time of onset of contractions, leakage of fluid, vaginal bleeding, estimated gestational age, and prenatal care. A focused physical examination should include an abdominal examination evaluating fundal height, abdominal or uterine tenderness, and fetal position. A bimanual or sterile speculum examination should be performed if no contraindications exist such as active vaginal bleeding. After the exam, place the patient in the left lateral decubitus position to prevent maternal hypotension.

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False labor is characterized by irregular, brief contractions usually confined to the lower abdomen. These typically painless contractions, commonly called Braxton–Hicks contractions, are irregular in intensity and duration. True labor is characterized by painful, regular contractions of steadily increasing intensity and duration leading to progressive cervical dilatation. True labor typically begins in the fundal region and upper abdomen and radiates into the pelvis and lower back.

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DIAGNOSIS AND DIFFERENTIAL

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Patients without vaginal bleeding should be assessed with sterile speculum and bimanual examinations to evaluate the progression of labor, cervical dilation, and rupture of membranes. Patients with active vaginal bleeding require initial evaluation with ultrasound to rule out placenta previa. Spontaneous rupture of membranes typically occurs with a gush of clear or blood-tinged fluid. If ruptured membranes are suspected, a sterile speculum examination should be performed and amniotic fluid obtained from the fornix or vaginal vault. Amniotic fluid is alkaline, will stain Nitrazine paper dark blue and will “fern” if dried on a slide. The presence of meconium in amniotic fluid should be noted. Avoid digital examinations in the preterm patient in whom prolongation of gestation is desired as even one examination increases the chance of infection.

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EMERGENCY DEPARTMENT CARE AND DISPOSITION

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If the cervix is dilated in a woman experiencing active contractions, further transport, even short distances, may be hazardous. Preparations should be made for emergency delivery. Assess fetal position by physical examination, and confirm by ultrasound, if possible. Place the patient in the dorsal lithotomy position. Notify an obstetrician, if one is available.

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Emergency Delivery Procedure (Fig. 62-1)

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FIGURE 62-1

Movements of normal delivery. Mechanism of labor and delivery for vertex presentations. A. Engagement, flexion, and descent. B. Internal rotation. C. Extension and ...

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