![]() This technique provides control of an explosive delivery, as well as avoidance of the high morbidity associated with fetal neck hyperextension. As soon as the head is accessible, continuous gentle countertraction should be administered to maintain it in a flexed position. When crowning occurs, the mother should be instructed to push along with the contractions, with the physician positioned in front of the introitus ready to accept the fetus. Positioning of the mother may require an approximate 10-degree tilt to the left to prevent uterine pressure on the inferior vena cava and associated hypotension. A radiant warmer and appropriate airway equipment should be available. A gynecologic bed with lithotomy position capability is ideal, and a resuscitation bay with greater accessibility and equipment is recommended. If delivery is imminent, the patient will have to remain in the ED. For the emergency physician, determination of dilation and effacement is the most important part of the examination-a fetus that is still contained within a closed and minimally effaced cervix will probably be transferred to obstetrics whether or not it is vertex (fetal head as the presenting part). This includes assessment of station (level of decent into the pelvis relative to the maternal ischial spines), effacement (degree of cervical thinning), and dilation of the cervical aperture. Once labor is confirmed, the goal is to evaluate the positioning (orientation in space relative to the maternal pelvis) and presentation (body part palpable at the cervix) of the fetus, along with the degree of change in the uterine cervix. For any patient with a complaint of passage of clear fluid from the vagina without other signs and symptoms of labor (bloody show and regular, progressing, often painful contractions), a sterile speculum examination should be performed before a gloved digital examination to evaluate for PROM. ![]() If shoulder dystocia is encountered, hyperflexion of the maternal hips and knees (McRoberts maneuver) and suprapubic pressure are first-line interventions that resolve most instances of dystocia.įor more information on the management of difficult labor, see After determination of hemodynamic stability, the next priorities are to determine whether true labor is occurring and the appropriate disposition to achieve optimal medical care. They should be used sparingly and typically only with complicated deliveries. Episiotomies are no longer recommended during routine pregnancies. Resuscitation equipment should be available immediately. If care requires out-of-hospital transfer, it is imperative to establish early and reliable contact with the treating obstetrician to facilitate a safe plan of care.Įven though multiple physical interventions may be necessary with an abnormal delivery, an uncomplicated one typically only requires measures that support smooth fetal passage. If care is available in-house, transfer can be accomplished at any point before crowning. The major point of triage is during stage I of labor.
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