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Chapter 101: Emergency Delivery

Sarah Elisabeth Frasure

INTRODUCTION AND EPIDEMIOLOGY

The thought of a woman presenting to the ED in active labor is justifiably a cause for anxiety—the emergency physician must contend not only with the often rusty recollection of the stages of normal delivery, but also with the knowledge that there are serious and even fatal complications associated with labor. Maternal and fetal survival may depend on the ability to successfully manage pre-eclampsia, eclampsia, hemorrhage, shoulder dystocia, malpresentation, cord prolapse, breech delivery, or fetal distress. Every ED should be prepared to take care of a woman in active labor. Tools include a basic delivery kit, an infant warmer or isolate, and medical supplies and equipment for neonatal resuscitation (see chapter 108, "Resuscitation of Neonates" and Tables 101-1 and 101-2).

TABLE 101-1Equipment and Supplies for Emergency Delivery
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TABLE 101-1 Equipment and Supplies for Emergency Delivery

Sterile gloves

Sterile towels and drapes

Povidone-iodine (Betadine) to cleanse the perineum

Sterile lubricant gel

Sterile scissors

Kelly clamps

Cord clamps

Rubber suction bulb

Towel or blanket for the infant

Gauze sponges (4×4)

Syringes (10 mL) and needles (22–24 gauge)

Placenta basin

Suture (3-0 chromic and 2-0 Vicryl) and needle driver

Note: List excludes standard adult and neonatal resuscitation equipment.

TABLE 101-2Medications for Emergency Delivery and Indications for Use
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TABLE 101-2 Medications for Emergency Delivery and Indications for Use
Classification Medication Dosage Indication/Use Contraindications
Uterotonic Oxytocin 10–40 units/1000 mL normal saline or 10 units IM Stimulation of uterine contraction or as uterotonic for PPH Hypersensitivity
Misoprostol 1000 micrograms PR once Unlabeled use for PPH Hypersensitivity
Methylergonovine 0.2 milligram IM or IV or PO; may repeat at 2–4 h intervals PPH Hypersensitivity, hypertension
Carboprost 250 micrograms IM every 15–90 min (total dose 2 milligrams) PPH Asthma
Antihypertensive Hydralazine 5 milligrams IV, followed by 5- to 10-milligram boluses every 20 min Pre-eclampsia/eclampsia, hypertensive emergency Hypersensitivity
Labetalol 20 milligrams IV, followed by doubled doses up to 80 milligrams (20–40–80–80) every 10 min; maximum total dose, 220 milligrams Pre-eclampsia/eclampsia, hypertensive emergency Hypersensitivity, sinus bradycardia
Anticonvulsant Magnesium sulfate Loading dose of 4–6 grams IV over 15 min, followed by 2 grams/h infusion; can also give 5 grams IM in each buttock Seizure prophylaxis in pre-eclampsia/eclampsia Myasthenia gravis
Electrolyte supplement toxicity Calcium gluconate 1 gram IV over 5–10 min Magnesium toxicity Hypersensitivity, cardiac arrhythmia
Analgesic Lidocaine 1% 1–10 mL injected locally Local anesthetic Hypersensitivity
Fentanyl, 50 micrograms/mL 50 micrograms/mL Short-acting opiate analgesic Hypersensitivity
Opiate antagonist Naloxone 0.4–2.0 milligrams IV every 2–3 min as need up to 10 milligrams cumulative dose Narcotic overdose Hypersensitivity
Antiemetic Ondansetron 4 milligrams IV Nausea, vomiting Hypersensitivity

Abbreviation: PPH = postpartum hemorrhage.

Out-of-hospital births occurred in 1.36% of births in 2012, and out-of-hospital births in the United States had a lower risk profile than in-hospital births, so that fewer teen, preterm, low-birth-weight, and multiple births ...

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