SJRH ED Rounds June 8 2021 By Dr Robin Clouston 1 Local context Sussex 45 min from Saint John St Stephen 1h 5 min from Saint John Inclement weather decreases ability to travel ID: 912858
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The Baby is Coming!
Unanticipated Birth in the Rural ED
SJRH ED RoundsJune 8 2021By: Dr. Robin Clouston
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Slide2Local context:Sussex 45 min from Saint JohnSt. Stephen 1h 5 min from Saint JohnInclement weather decreases ability to travelUnanticipated births:Sussex: approximately 3 per year
CCH: approximately 3 per yearSaint John: ?1 per year
Slide3Objectives:Discuss an approach to the pregnant patient presenting in query labour in a rural EDIncrease confidence in decision making re: transfer vs. care in placeReview the normal vaginal birth processPrepare for common delivery complicationsProvide resources for future learning3
Slide4The Case:
Erica, 24y G3P1A1, GA 40w3dPresents to Sussex ED at 18:45Reporting contractions for 2h
Initially irregularFor last 1h, contracting q 5 min, lasting 1 minYou are asked to assess her…what do you want to know?
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Slide55Burning questions…GPA status?Gestational age?How many babies?
Previous pregnancy history? (c-section? Labour complications?)Getting prenatal care?Present pregnancy history? Group B strep status?Cephalic presentation?Membranes intact or ruptured?Any bleeding or bloody show?Frequency, duration and strength of contractions?Fetal wellbeing? (Fetal movement, FHR)
Cervical dilation?
Slide66Burning questions…Is birth imminent? (“Time” vs “no time”)To Transfer or Not to Transfer?
If not transferring…what do I do?
Slide7Signs and Symptoms of Imminent Birth:Labouring patient says “The baby is coming!”Uncontrollable urge to pushBulging perineum or rectumPatient is panicking / will not settleCrowning of the fetal presenting partConsider: what is most important when birth is imminent?
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Slide8When birth is imminent:No time for a comprehensive history and examMost important to determine:How many babies?Gestational age (term or preterm?)Presentation (cephalic or breech?)Are membranes ruptured, if so any meconium?
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Slide9When birth is imminent:
What are you going to do?
Model a calm, comforting attitude for team
Remain with the patient at all times
Call for help + delivery supplies
Get gloves if time, a towel if time
Support perineum through delivery
Anticipate possible shoulder dystocia
Place baby skin to skin with mom
Delayed cord clamp x 60 sec
APGARs
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Slide10When birth is imminent:
“Birth is a natural process, and the vast majority of the time it is uncomplicated.”
– Unanticipated Birth Outside the Birthing Unit, Reproductive Care Program of Nova Scotia 2018
What are the goals?Protect health of laboring patientProtect the health of the infantSupport the normal birth processCreate a positive, lasting memory of the birth for the patient and her partner or support person
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Slide11When birth is NOT imminent“Transfer should not be attempted if it is suspected that birth may occur en route.”– Unanticipated Birth Outside the Birthing Unit, Reproductive Care Program Nova Scotia 2018Not just about the dilation…Strength, frequency, duration of contractionsMultiparous status
History of previous precipitous labourRupture of membranesCervical dilation and effacementNot sure call OB
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Slide12The Case:Erica, 24y G3P1A1, GA 40w3dTo Sussex ED 18:45pmCtx x 2hCtx q 5 min, lasting 1 min, x 1h
On assessment: MultiparousFirst baby: shoulder dystocia
No past hx of precipitous birthMembranes intactIn Sussex ED, ctx are palpated as strong, q3min lasting 1 min, she is breathing through them, asking for pain control.POCUS: cephalic
Cx: 6cm, 70% Would you transfer this patient?12
Slide13Routine vaginal delivery:
What do you do every time?13
Slide14Get familiar with your set up…
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Slide16Routine vaginal delivery: the preparationClearly communicate plan to team + patient and partner Call Obstetrician to inform / for supportCall 2nd doctor to attendPain control, i.e fentanyl, EntonoxMonitor FHR with intermittent auscultation by RNIntrapartum POCUS ?cephalicPosition laboring patient to promote delivery, ex: side-lyingConsider risk of shoulder dystocia, discuss with team and patientGet equipment ready
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Slide17POCUS to confirm fetal head position:- Place probe over pubis and identify fetal skull- If skull not visible in pelvis, check RUQ, LUQ for breech17
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Slide20Routine vaginal delivery: the birthWhen fetal head is near crowning:Don the sterile gown + glovesPrepare stretcherGentle pressure to support perineumLight pressure to baby’s headEncourage pushing with contractionsAs head crowns, advise panting and small, light pushes20
Simulated birth Part 1:
https://www.youtube.com/watch?v=VGRdy1cMXoo
Slide21Routine vaginal delivery: the birth21Simulated birth Part 2:https://www.youtube.com/watch?v=tf3P_DGEUic
Once the head is born:Check for nuchal cord If present, gently loosen OR, if cannot loosen, may need to clamp and cut cord
Then allow baby’s head to spontaneously restitute to L or R
Slide22Routine vaginal delivery: the birthTo help shoulders deliver:Gently move hands downward with baby’s head to guide anterior shoulder under pubic arch. Never pull.If delayed = shoulder dystociaOnce the anterior shoulder is delivered:Gently guide baby’s body upward over the perineum 22
Slide23Routine vaginal delivery: Baby is born!23Place baby skin to skinGently dry with towelBaby should begin to cry vigorouslyDelay cord clamping x 60 secCollect sample of cord, cord bloodGive oxytocin 10 units IM or 5 units IV with birth of babyDocument APGARs at 1 min, 5 min
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Slide25Routine vaginal delivery: the placentaSigns of placental separation:Lengthening cordGush of bloodRising of uterus in abdomenVery gentle traction to cordPatient may push for placentaExamine placenta ?intact25
Slide26Routine vaginal delivery: the placentaAfter delivery of placenta:Massage the fundusOxytocin 10 units in 500mL over 4hExamine the perineum Active Management in the Third Stage
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Slide27Routine vaginal delivery: after delivery27Complete the delivery recordPromote mother and baby bonding + breastfeedingArrange transferReassure parentsThank the teamDebrief prn
Slide28Common complications of vaginal delivery:
What do you need to be ready for?28
Slide29Anticipate!Risk stratify: past obstetrical history + current pregnancy historyRisk of shoulder dystocia increased:Previous shoulder dystociaGestational diabetes, macrosomia, obesityProlonged second stageRisk of post partum hemorrhage increased:The Four T’s: Tone, Tissue, Trauma, ThrombinEx: Previous PPH, macrosomia, rapid labour
, high parity, retained placentaOther complications to consider (not discussed today):Preterm birth?Twins?Breech presentation?Previous cesarian section? risk of uterine rupture
Need for neonatal resuscitation?29
Slide30Shoulder dystociahttps://www.youtube.com/watch?v=jNmSJDbTARwDiagnosis: “turtle sign”First steps:Announce the shoulder dystociaMcRoberts Maneuver (hyperflex legs)Suprapubic pressure x 30 secMove through additional maneuvers70% of shoulder dystocias are relieved with a McRoberts maneuver, +/- suprapubic pressure
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Slide32Post partum hemorrhageIf risk factors, large bore IV for labourMonitor bleeding immediately postpartumBleeding should be no more than a full pad, or < 500mL in 1st hourIf excessive bleeding:Tone, Trauma, Tissue, Thrombin almost always TONETwo-handed fundal massage, straight cath
bladderEnsure oxytocin 10 units IV infusingSuture bleeding lacerationsIf ongoing bleeding:2nd large bore IV
Additional uterotonics:Misoprostol 800ug PRTranexamic acid 1000g IVCarboprost 0.25mg IMErgot 0.25mg IM Blood products32
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Slide34…back to the case:Erica, 24y G3P1A1, GA 40w3dTo Sussex ED 18:45pmCtx x 2hCtx q 5 min, lasting 1 min, x 1h
On assessment: MultiparousNo past hx of precipitous birth
First baby: shoulder dystociaMembranes intactIn Sussex ED, ctx are palpated as strong, q3min lasting 1 min, she is breathing through them, asking for pain control.POCUS: cephalic
Cx: 6cm, 70% Held in Sussex for delivery34
Slide35…back to the case:
Held in Sussex for delivery
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doctor called inBaby delivered 20:58pmNuchal cord, reducedShoulder dystociaRelived w McRoberts + suprapubic pressureNon-intact placentaPost partum hemorrhage of ~1LTreated with oxytocin, fundal massage, straight cath, misoprostol PRSutured bleeding laceration
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Slide36Take home points:
When birth is imminent focus on what matters (Singleton? GA? Cephalic? Meconium?)
To transfer or not to transfer?go beyond the cervix in your decision making
Anticipate shoulder dystocia and PPHPerform active management in the third stageAim to create a positive memory of the birth“Birth is a natural process, and the vast majority of the time it is uncomplicated.”
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Slide37Further learningOB Sim Day: June 30th 2021Further reading: Unanticipated Birth Outside the Birthing Unit, Reproductive Care Program of Nova Scotia 2018ALARM Course: https://www.sogc.org/en/content/events/alarm-courses.aspxALARM Virtual:https://
www.sogc.org/alarm-virtualNeonatal Resuscitation (NRP) coursehttps://www.cps.ca/nrp-prn
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Slide38Resources:Unanticipated Birth Outside the Birthing Unit, Reproductive Care Program of Nova Scotia 2018http://rcp.nshealth.ca/sites/default/files/clinical-practice-guidelines/Unanticipated%20Birth%2020180926.pdfALARM Manual 25th Ed. 2018J Borhart, K Voss. Precipitous Labour and Emergency Department Delivery. Emerg Med Clin N Am 37 (2019) 265-276A. Gupta, M Adler. Management of an Unexpected Delivery in the Emergency Department. Clinical Pediatric Emergency Medicine. June 2016.
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Slide39Questions?
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