Normal Vaginal Deliveries
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Most women in labor present directly or are triaged to an obstetric unit so births occurring in the prehospital or emergency department (ED) setting are rare. Deliveries that do occur in the ED are associated with increased risk of neonatal and maternal morbidity and mortality.1
The overall perinatal mortality rate in the United States for births at 28 weeks’ gestation or greater has remained steady at 0.6% (6 deaths per 1,000 births) for almost a decade.2
Data on prehospital and ED deliveries are limited; however, the rates of perinatal mortality are reported to be as high as 8% to 10%.3
A study of accidental deliveries in the prehospital setting demonstrates neonates are more likely to require admission to the neonatal unit and have a higher perinatal mortality rate than controls (51.7 vs. 8.6/1,000 deliveries, respectively).4
The high-risk epidemiology of ED deliveries is multifactorial but primarily due to psychosocial factors. Data indicate that women who have unplanned deliveries in the prehospital or ED setting are more likely to be from low socioeconomic status.5
There is also evidence that these mothers have higher rates of smoking, illicit drug use, and poor or absent prenatal care.6
Women who have substance use disorder, who are victims of intimate partner violence, who are undocumented, or who are otherwise without access to routine medical care are overly represented in the population of women who deliver in the prehospital and ED setting.
Emergency medicine (EM) providers must be able to identify when a woman is in labor as well as determine if delivery is imminent and be prepared to manage that delivery while anticipating myriad potential complications. Providers must be able to manage both normal and complicated deliveries as well as maternal and neonatal resuscitation if required. It is critical that the ED has all necessary equipment for delivery of the fetus (Table 21.1
), resuscitation of the newborn, and aftercare of the mother. Ideally, this equipment is in a preassembled precipitous vaginal delivery kit that is ready to use when needed.
When a patient presents to the ED with suspected labor, the provider should obtain a focused history and physical examination to determine the stage of labor and whether delivery is imminent, as well as identify any risk factors for potential complications.
The initial history should include maternal parity, gestational age, due date, whether there was prenatal care during the pregnancy, duration and frequency of uterine contractions, and whether the patient feels the urge to push. Determining the approximate gestational age is paramount both to
assess potential fetal viability and to anticipate possible neonatal resuscitation needs in the event of a preterm delivery (defined as occurring at <37 weeks’ gestation). The patient should be asked about the presence and timing of rupture of membranes, presence of vaginal bleeding, complications with this pregnancy, history of prior complicated or precipitous deliveries, as well as any symptoms of infection. Clinicians should also obtain a basic medical and surgical history, list of current medications and allergies, and inquire about substance abuse.
TABLE 21.1 Basic Vaginal Delivery Kit Equipment Lista
Sterile gloves and gown
Sterile towels and a large sterile drape
4 × 4 sterile gauze sponges
Rubber suction bulb
Two umbilical cord clamps
Clean towels or blankets to dry and swaddle the infant
A red top tube (for collecting fetal blood from the placental end of the cut umbilical cord)
A basin for the placenta
Two sterile Kelly clamps
18 gauge and 20 gauge needles (for injecting lidocaine if needed)
5 cc and 10 cc syringe (for injecting lidocaine if needed)
Biohazard bags with ties (for wet/bloody clothing and sheets)
aStandard neonatal resuscitation equipment should also be available including neonatal warmer.
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