How We Do What We Do: Regular Delivery

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Below are the steps that you need to know in order to facilitate getting baby out safely as well as protecting mom’s perineum from lacerations (namely 3rd and 4th degree tears).  This will be particularly helpful when you are working at a facility that doesn’t provide OB service.  Print out this post and have it next to you during the delivery.  Enjoy!

2nd stage of Delivery

  • Establish IV access and start IV fluids – increased fluids decreases the length of time for labor.
  • Place mom on Nasal Cannula as it is associated with a decreased incidence of low cord pH (350% actually)

 

  • Perform your focused H&P: which includes Gestational age, timing and regularity of contractions, rupture of membranes. Cervical exam should be done to ascertain the stage of labor as imminent . Patients who are fully dilated (10 cm) and 100% effaced should be performed in the Emergency Department by the Emergency Physician. 
    • Only one cervical exam should be performed every 2 hours to reduce the incidence of intra-uterine infections. 
    • If patient is not full dilated and effaced, try to help mom avoid pushing
  • Call your back up. This includes OB, Peds ED/NICU depending on the clinical conditions, as well as availability.
  • Know the location of your equipment. Get familiar with the location of the OB pack, as well as neonatal resuscitation equipment in your ED.
  • Identify a supporting person to the head (doula) of the bed. This person acts as a support for the mother, as well as been shown to improve outcomes.
  • Place Mom in the Dorsal Lithotomy Position (semi recumbent at 30 deg to vertical) to avoid aortovagal compression, improved fetal alignment and larger AP and transverse pelvic outlet. 
    • This will also achieve less pain, incidence of operative delivery and decrease incidence of blood loss >500cc.  
    • Make sure she is comfortable – use pillows and have people help hold her legs as needed.
    • The patient should be instructed to postpone pushing (delayed pushing) unless the urge to push is there as it will improve the efficiency of maternal pushing as well as decrease fatigue.
  • As the fetal head is presenting, place one hand on the head while crowning and the other hand on the perineum so as to protect it from severe tears.  Encourage the mother NOT to push while the head delivers to slow down the process. 
    • This has been shown in an educational intervention study decrease the incidence of 4th degree lacerations.
  • As the head delivers, feel for nuchal cord (25-35% of deliveries). 
    • If loose, it should be reduced over the infant’s head. 
    • If tightly wrapped, clamp the cord in two places. Then cut the cord to allow the baby deliver. Once the cord has been cut you have to expedite deliver as the baby’s oxygen supply has been cut off.
  • As the head rotates, the physician’s hands guide the head and provide gentle traction downward to deliver the anterior shoulder.
  • Once delivered, guide the fetus upward to deliver the posterior shoulder.
  • Place hand around one of the legs of the infant to avoid dropping the infant.
  • There is no evidence that suctioning the neonate at this time improves outcomes or stimulates respiration
  • After 1 minute if possible clamp the umbilicus 3 cm distal to insertion at the umbilicus, milk the cord then place another clamp 2-3 cm distally.  Prior to clamping begin the administration of Oxytocin (10 U IM + 20U in a bag of LR) prior to clamping. 
    • This promotes an auto-transfusion of blood to the neonate and helps decrease maternal bleeding (post-partum hemorrhage).
    • Clamping longer than 2 minutes shows only minimal neonatal benefit and promotes potential for PPH.  Transect the umbilicus with sterile scissors.  
  • Baby should be placed on the maternal belly.
  • Dry baby and wrap him trying to note APGAR score at 1 and 5 minutes. 
    • If baby is not breathing spontaneously make the prompt decision to immediately intubate.
    • If no response, begin neonatal resuscitation (1 breath: 3 compressions).

3rd Stage of Labor: Placental Delivery

  • Keep very gentle traction on the clamped umbilical cord.  AVOID EXCESSIVE TRACTION!!!

Too much may cause uterine inversion, tearing the cord or disruption of the placenta causing for severe vaginal bleeding).

  • After delivery, gently massage at the fundus to promote uterine tone.
  • Allow for 10-30 minutes for delivery of the placenta. Signs of placental separation include cord lengthening, a gush of blood, and upward displacement of the uterus.
    • If placenta has not been delivered in 30 min, gentle traction should be placed on the cord to aid in the detachment of the placenta from the uterine wall.
    • If mother is hemorrhaging, the physician should insert hand into the uterus and by using a raking motion remove the placenta from the wall.

 

Reference:

 Berghell, V, Baxter,JK, Chauhan, SP, Evidence-based labor and delivery Management, American Jounral of Obstetrics and Gynecolgy, 2008.

 VanRooyen, M & Scott JA, “Emergency Deliver”: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, Seventh Edition, 2011.

 Tuuli, MG et al., Immediate compared with delayed pushing in the Second Stage of labor – A systemic review and Meta-analysis, Obstet Gynecol 2012; 120:660-8.

 Laine, K et al., Decreasing the Incidence of Anal Sphincter Tears During Delivery, Obstet Gynecol 2008;111:1053-7.

 Albers, LL et al., Midwifery Care Measures in the Second Stage of Labor and Reduction of Genital Tract Trauma at Birth: A Randomized Trial, J midwifery Womens Health. 2005; 50(5):365-372.

 Gungor et al. Oronasalpharyngeal suction versus no suction in normal, term and vaginally born infants: A prospective randomized controlled trial., Australian and New Zealand Journal of OB and Gyn 2005; 45:45-6.

Author: Michael Meguerdichian, MD

Editors: Komal Bajaj MD, Cara Taubman MD

4 Comments

  • Andrew Shannon

    Not infrequently, if we’re delivering in the ED, all we have are the stretchers. If the patient is far up the stretcher enough to be semi-recumbent, there is no space to guide the baby “down” for the anterior shoulder. If they are far down the stretcher enough to have that space, raising the head of the stretcher just kinks their neck. Any value to the “upside-down bedpan” trick for giving you some “baby clearance?” Too uncomfortable? Sheets/blankets under mom’s buttocks instead? (I believe the Jacobi ED pillow is much like the Loch Ness Monster in terms of frequency of sightings and my belief in its existence…)

  • Sammy

    Hey Mike, I’ve heard from an OB that you want to deliver the placenta before giving Oxytocin. So as not to hinder delivery. In your literature search is this correct? It would seem to me that Oxytocin would clamp down on Uterine vessels and make placenta delivery easier. Which way is correct?

    • Jacobi

      From both my literature review as well as discussing with an OB, giving Pitocin is to be given between delivering the baby and the placenta. Giving Pitocin decreases postpartum hemorrhage significantly and helps with separation of the placenta avoiding the need to rake the placenta out.

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