Emergency Department Care

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:

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.
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.
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.
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).
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.
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.
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.