Labor and Delivery in the Emergency Department

Pregnancy and delivery are natural processes that have been occurring for millennia. For millennia, delivery of the pregnant woman was the province of nonmedical (such as there was) personnel. As medical care progressed, nurses began the systematic medicalization of prenatal, delivery, and postnatal care (nurse-midwifery). This transition began in Europe, eventually crossing the Atlantic.

In the United States, physicians have become involved only in the relatively recent past. Therefore, attendance to the natural course is mandatory; interventions are indicated only in the event of deviations from the natural or expected course.

Frequency

The precise incidence of US ED deliveries of pregnant full-term patients is unknown. In 2021, 3,659,289 births were registered in the United States. The fertility rate (births per 1000 women aged 15-44 y) was 56.6 births per 1000 women. Additionally, 10.48% of US births were preterm. The cesarean delivery rate rose in 2021, to 32.1% of all US births.[5]  The low birthweight (< 2,500 g) rate in the fourth quarter of 2021 was 8.51%.[6]

Age

Fertility rate statistics have 15 years as the lower cutoff point. However, laboratory testing should be performed to rule out pregnancy when any female capable of reproduction (potentially as young as 9 y) presents with abdominal complaints and when pregnancy cannot be ruled out at physical examination.

The history often is enough to raise suspicion of pregnancy as the cause of a patient's complaints. However, seemingly virginal patients can be pregnant, and denial of the pregnancy is not uncommon. Claims of regular menstrual periods and/or lack of sexual involvement do not rule out pregnancy.

General signs of pregnancy include the following:

• Cessation of menses

• Morning sickness (eg, nausea, vomiting)

• Urinary frequency

• Breast enlargement and/or engorgement

• Abdominal enlargement

• Quickening and lightening (ie, settling of the fetus)

• Uterine and cervical consistency changes (Goodell and Hegar signs), uterine enlargement, change in uterine shape, and uterine contractions

• Mucosal changes (Chadwick sign)

Gestation is defined as 280 days. The estimated date of confinement (EDC), or due date, is calculated by taking the first day of the last normal menstrual period (FDLMP), subtracting 3 months, and adding 1 week. Hand-held wheels aid this calculation.

Typically, lightening (settling of the infant, head down, into the true pelvis) occurs several weeks before labor.

Braxton Hicks (false labor) contractions (irregular rhythmic uterine tightening) may occur. The onset of these contractions is earlier with each succeeding pregnancy.

Labor presentation may be classic or with variations. The onset of true labor may be gradual, abrupt, or catastrophic. In the first stage of labor, regular uterine contractions cause the cervix to dilate. The second stage consists of descent of the presenting part and delivery. The third stage of labor is delivery of the placenta.

Signs of imminent delivery, as follows, should be noted:

• Bloody show, the expulsion of the mucus plug from the cervix

• Breakage of the amniotic sac (bag of waters). Determine the appearance of the fluid expelled. Clear fluid is normal, thin fluid is meconium (fetal intestinal contents consisting of the remains of swallowed amniotic fluid mostly composed of sloughed digested skin cells) stained, and thick pea-soup fluid is heavy meconium.

• The sensation of impending defecation or an urge to push

For a patient in labor, obtain the following minimal data set:

• Last menstrual period (LMP), EDC, and prenatal care (including plans for delivery)

• Pregnancy history, written as "(gravida, para, X-X-X-X)," where gravida is the total number of pregnancies (including the present one), para is the number of deliveries after 20 weeks of pregnancy, and X-X-X-X is the number of full-term infants-number of preterm infants-number of abortions-number of living children

• Problems during this or previous pregnancies

• Prior ultrasonographic examinations and results, and bleeding during pregnancy or labor (If findings are positive, be alert for placenta previa.)

• Past medical and surgical history, medications, and allergies

Physical examination of the abdomen and pelvis is an invaluable tool in diagnosing labor as the cause of a woman's abdominal complaints.

Abdominal striae may be noted. They are due to the rapid expansion of the uterus.

When the patient is seated, the epigastrium has a typical shelflike appearance that is created by settling of the fetus.

Fetal movements may be observed.

Dullness on percussion of the area from the pubic symphysis to several centimeters below the xiphoid is evidence of a full-term pregnancy (in the right setting).

Careful listening with a standard stethoscope may reveal fetal cardiac activity. Fetal stethoscopes or Doppler probes are helpful but unnecessary at term. Listening in all 4 quadrants may reveal twins.

Carefully performed, Leopold maneuvers reveal much information and prepare the attendant for complications. Palpate the fundus. If the area is smooth, hard, and round, it is the head. If the tissue is irregular, it is some other part of the fetus body. The image below illustrates uterine fundal size and relative position on abdomen throughout gestation.

Uterine fundal size and relative position on abdomen throughout gestation.

Palpate the sides. A smooth, long surface suggests the fetus back. If the contours are irregular, it is probably the front or side. Grasp the part in the pelvis. If it is smooth, hard, and round, it is the head. If it is irregular, it is some other part of the body. Rub along the back and down to the pelvis to see if the head is present. A shelf or an abrupt change in the angle of the palpated part when the head is encountered indicates that the head is in extension (face presentation, unfavorable). If the path is smooth, the head is flexed (favorable).

The cervix effaces (thins).

Generally, if sufficient time for imaging studies exists, time to transport the patient to the obstetrics ward exists.

Ultrasonography may be useful and is immediately available at most facilities as FAST tools become increasingly available. Depending on the sophistication of the equipment and personnel available, sonography may be used to determine the following:

• Fetal position

• Number of fetuses and/or age of the fetus

• Presence of cardiac activity

• Fetal malformation (eg, CNS, developmental)

• Quantity of amniotic fluid

• Estimation of fetal weight

• Hydatiform mole

• Rh isoimmunization

Radiography has a role in the emergency assessment of the pregnant patient. It is available quickly at most facilities, and emergency physicians are skilled at independent interpretation of radiographs.If areas other than the pelvis require radiographic evaluation, shield the abdomen; perform abdominal radiography only when it is absolutely necessary. Plain radiographs of the abdomen may be used for pelvimetry to show the position and number of fetuses.

If the baby is not crowning (ie, child's head bulging at the perineum), a brief vaginal examination performed with a sterile-gloved hand reveals if the cervix is dilated (to 10 cm) and/or effaced (thinned to about 1 mm). Additionally, determine the descent of the presenting part relative to the ischial spines (in centimeters and expressed as (+) when it is caudal to [above] the spines).

Identify the presenting part. A smooth surface with a Y configuration of the skull suture lines is the most favorable finding; this is the lambdoid suture, which indicates presentation of the flexed head. A + configuration indicates the bregmatic suture; this sign is less favorable, but sufficient time may exist to transport the patient to the obstetrics unit. Face, foot or feet, hand or arm, and breech presentations are obvious on palpation. These unexpected presentations can be problematic for delivery in the ED, because they require special expertise.

If the baby is not crowning, the mother is not yet completely dilated (or if she is, she is not feeling an urge to push), and no complications are noted (see Complications), the mother may be moved to the obstetrics ward.

If the baby is crowning and none of the complications noted in Complications are present, the ED attending may need to deliver the baby.

The general procedure for delivery is as follows:

1. Swab the perineum with povidone iodophor, and drape it with towels. Control the baby's head with the nondominant hand. If necessary to permit delivery of the baby, inject the midline perineum with lidocaine, and perform a midline incision down to (but not into) the rectal muscle. (Be aware there is no evidence that an episiotomy has any benefit.) Usually, the amniotic sac has broken; if not, open it now. Note the color and consistency of the amniotic fluid.

2. The lambdoid suture usually is anterior and at an angle of about 30° to the midline; it turns to the anteroposterior plane and emerges. The head turns to the coronal plane of the mother. Once the head emerges, suction the mouth and nose. Use a DeLee suction trap to suction the nose and deep hypopharynx if the amniotic fluid is not clear.

3. Check the neonate's neck for the umbilical cord; if it is wrapped around the neck, pull it gently over the head. If this is not possible (e.g., it is too tight or has too many loops), double clamp the cord and divide the cord between the clamps. Recheck the neck, because the cord may be wrapped more than once. Then deliver the child expeditiously.

4. Gentle traction toward the mother's posterior usually delivers the anterior shoulder; if this attempt is unsuccessful, try pressing down over the mother's bladder to move the anterior shoulder posteriorly. If this is unsuccessful, shoulder dystocia may be present. A number of options to address this exist: waiting for the obstetrician; delivering the posterior shoulder, rotating the anterior shoulder posteriorly, and then delivering that shoulder; or, using one of the more destructive moves, such as fracturing the anterior clavicle (a difficult maneuver at best).

5. Once the shoulders are out, the rest of the baby slips out quickly; however, be careful, because neonates are slippery. Keep the nondominant hand in place, controlling the baby's head, and slide the dominant hand under and along the baby as it emerges. Once the feet are out, rotate the baby 180° into a football hold. Suction the nose and mouth. Double clamp the cord 7-10 cm from the baby, and cut the cord between the clamps.

6. If the child starts breathing and moving and appears to be in good health, turn the baby over to nursing personnel. Make sure that the baby is vigorously dried, suctioned, and kept warm. If the birth is complicated by thick meconium (amniotic fluid that is thick and pea green), do not stimulate the baby to cry. Instead, use a 3.0 endotracheal tube, intubate the trachea, and suction it; then, stimulate the baby's breathing.

7. Do not unclamp the mother's side of the placenta until it is clear that only one fetus is present. Feel the uterus; if it is almost in the pelvis, probably only one fetus exists. Let the cord drain, collecting a clot tube for laboratory studies. Allow the third stage of labor, delivery of the placenta, to proceed slowly. Do not pull on the cord; guide the placenta out as it is expelled. Inspect the placenta to ensure that it is entirely expelled. Sending the placenta for pathologic evaluation is a good risk-management practice.

If mother and baby are doing well and do not require resuscitation, the ED attending may perform vaginal and perineal repairs if he or she is comfortable doing so. Alternatively, it is generally acceptable to let the obstetrician or family practitioner finish this portion. Also, the mother and baby can be moved to the obstetrics ward for follow-up care.

Apgar scoring is used to provide a rough estimate of the baby's immediate adaptation to extrauterine life. The score aids in determination of whether the baby is viable independently or needs help (resuscitation). Apgar scores should be documented at 1, 5, and 10 minutes in all neonates. If the 5-minute score is less than 7, continue scoring every 5 minutes for 20 minutes. However, if the child requires resuscitation, waiting to do a 1-minute score is not indicated. Assign scores in each of the following categories and total them for the Apgar score.

• Appearance - 0 for blue or pale, 1 for body pink and limbs blue, and 2 for pink all over

• Pulse - 0 for absent, 1 for less than 100 per minute, 2 for more than 100 per minute

• Grimace - 0 for no response, 1 for some motion, 2 for crying

• Activity - 0 for limp, 1 for some weak motion, 2 for active

• Respiration - 0 for none, 1 for weak cry, 2 for strong cry

Transfer

A specific body of law governs transfer of patients in labor. It is too large to review here. Please see the article on COBRA Laws and EMTALA. The original statute was passed as a part of a much larger bill, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). Consequently, the acronym COBRA was used frequently in medical literature when referring to the statute. This statute is also titled the Emergency Medical Treatment and Active Labor Act (EMTALA). Since the latter name is more specific and descriptive, it has become the preferred acronym for referring to the statute. The full text of the statute can be found in any public library's reference section under 42 U.S.C.A. Section 1395dd et seq.[7]

When it is deemed necessary to transfer a patient in labor because of anticipated risks to the neonate, it is generally best to transport her before delivery. This will normally give the neonate the optimal environment pending arrival at the facility that has the needed equipment and personnel available.

Stabilization must be achieved. Labor should usually be arrested (eg, terbutaline, magnesium sulfate, ritodrine). Care is coordinated with the receiving facility and physician.

Few drugs are needed in an uncomplicated delivery. If excessive bleeding occurs, first try massaging the uterus, because uterine atony is the most common cause of this complication. Do not try to push the uterus out the vaginal canal. Gently squeeze or compress the uterus to cause myofibrils to contract. This action compresses the vessels perforating the uterus. If this fails, try administering oxytocin (Pitocin), then prostaglandin F2.

Class Summary

These agents are used to reduce postpartum bleeding.

Oxytocin (Syntocinon, Pitocin)

Oxytocin produces rhythmic uterine contractions and can stimulate the gravid uterus; it has vasopressive and antidiuretic effects. Oxytocin can control postpartum bleeding or hemorrhage by increasing postpartum myometrial tonus.

Methylergonovine (Methergine)

Methylergonovine acts directly on uterine smooth muscle, causing a sustained tetanic uterotonic effect that reduces uterine bleeding and shortens the third stage of labor. Administer intramuscularly during puerperium, delivery of placenta, or after delivering the anterior shoulder. Methylergonovine may also be given intravenously, over at least 60 seconds, but it should not be administered routinely (may provoke hypertension or a stroke). Monitor blood pressure closely when administering intravenously.