Case of JANUARY

header-title-decorationCase of JANUARY

CASE OF THE MONTH — January 2022

Case presentation

childbirth

EMS responds to the home of a 34-year-old female complaining of sudden onset abdominal pressure. The patient states the pressure started two hours prior to calling 911 and is worsening. As paramedics attempt to help her from her bed, she experiences a gush of clear fluid from her vagina. She exclaims that she feels an intense urge to push. She states she cannot remember the date of her last menstrual period. Exam notes an obese female in moderate distress clutching her lower abdomen. Initial vitals are BP 109/67, HR 108, RR 18, O2 Sat 98% on room air.

This patient presents in labor with a severe urge to push. An urge to push is often an indication that the fetal head is engaged in the pelvis and exerting pressure in the perineal region and is a sign of an imminent delivery. Her primary provider impression is Childbirth (Mother) (BRTH) since delivery is imminent. She should be managed in accordance with TP 1215, Childbirth (Mother).

In a normal pregnancy, the entire process of labor may last anywhere from hours to days as the cervix thins and dilates. Factors associated with a shorter labor time include multiparity (i.e. having previously given birth). During labor, the provider may use the time between contractions to gather valuable information regarding time to delivery or if delivery is imminent. Pregnant patients without an imminent delivery can be treated as per TP 1218, Pregnancy Labor. If contractions last more than 60 seconds or are less than 2 minutes apart, the provider should be prepared for imminent delivery following TP 1215, Childbirth (Mother). Crowning, urge to push, and presentation of a presenting part are all indicators of an imminent delivery as well.

If gestational age is unknown, as in this case, one way to estimate is via abdominal exam through palpation of fundal height (i.e. top of the uterus). As a general rule, if the fundus rises to the level of the umbilicus, this equates to approximately 20 weeks gestational age. If the fundus rises to the level of the xiphoid, this equates to approximately 38 weeks gestational age. A pregnancy is considered full term after 37 weeks. Any pregnancy with an imminent delivery should be considered a provider impression of “Childbirth – (Mother)” if suspected to be after the first trimester (13 weeks or greater) and managed in accordance with TP 1215, Childbirth (Mother) in coordination with base hospital guidance. Generally, pregnancies less than 20-weeks gestation are considered non-viable and resuscitation of the newborn in the field may not be indicated. However, it is important to consider that dates are often incorrectly estimated or unknown.

In the prehospital setting, an external vaginal exam is indicated when a patient is experiencing an urge to push or in active labor with frequent contractions. Providers should assess for a bulging amniotic sac, crowning, or a presenting fetal part. Any of these findings indicate that delivery is imminent. Of note, both male and female providers alike should seek to have a chaperone (i.e., second provider) during the external vaginal exam.

The EMS providers complete a full assessment including an external vaginal exam. A firmness is palpated halfway between the xiphoid and umbilicus and the apex of the fetal head is visualized within the vaginal canal. The frequency of contractions is noted once every two minutes and lasting approximately 70 seconds. Vital signs remain the same. The patient also states that she has had five prior pregnancies that were delivered vaginally.

Crowning is defined as one of the last stages of childbirth when the large part of the fetal head is visualized at the vaginal opening. If the patient is found the be crowning, delivery is imminent.

In this case, delivery is imminent based on the frequency of contractions and crowning noted on exam. Given that this is a multiparous patient, she is also more likely to rapidly progress through the final stages of labor to delivery which in some cases, may be on the order of seconds to minutes. In situations where delivery is not imminent, expedited transport is optimal for patients in labor where delivery can occur in a controlled, sterile setting. However, if delivery is imminent, EMS personnel should remain on scene and prepare for delivery. The patient should be placed in supine or semi-fowlers position with knees to chest or feet planted on the surface beneath her and an obstetrics (OB) kit should be located and opened. If time and resources allow, a sterile sheet should be placed under the mother’s hips and a space for neonatal resuscitation should be cleared. Providers should also consider calling in additional units to assist with neonatal resuscitation. Finally, providers may defer establishing vascular access in favor of focusing on a controlled delivery or expedited transport.

Potential complications during delivery (see accompanying videos)

Complication

Presentation Field Management
Breech delivery A presenting part other than the head is present (e.g., foot, buttocks) Support the presenting part and allow the newborn to deliver.  Place a gloved hand inside the mother and form a “V” with fingers on baby’s face to flex the head and facilitate delivery.
Prolapsed umbilical cord Exam notes an umbilical cord in the birth canal. Do not attempt to replace the cord into the uterus. Place a hand in the birth canal and attempt to elevate the fetal part that is compressing the cord. The providers hand should remain in the birth canal elevating the fetal part during transport.
Nuchal Cord As the head is delivered, the umbilical cord is found to be wrapped around the neck. Options for management:

·         Attempt to reduce cord by sliding 1 finger under it and lifting it off the neck and over the head.

·         Clamp cord in 2 places and cut between clamps.

Shoulder dystocia The head is delivered normally, but then retracts slightly as the shoulder becomes stuck at the pelvis (most commonly the anterior shoulder under the pubic symphysis).

Place patient in supine position. Perform McRoberts Maneuver with suprapubic pressure.

·         Hyperflex hips to bring knees to chest.

·         Place firm suprapubic pressure to move anterior shoulder under pubic symphysis.

These complications during delivery represent true obstetrical emergencies. Should initial field management be unsuccessful, contact the base hospital and initiate immediate transport. It may also be advisable to tell the mother not to push during contractions in certain cases. Management of these complications should follow TP 1217, Pregnancy Complications.

McRoberts Maneuver with Suprapubic Pressure

Source: https://en.wikipedia.org/wiki/McRoberts_maneuver#/media/File:McRoberts_maneuver.svg

The patient experiences another strong contraction and the head begins to deliver. The paramedic places a hand on the top of the head to slow and control the delivery. The shoulders deliver next, followed immediately by the body and legs without complication. The newborn lets out a strong cry

In a normal vaginal delivery when the fetus is positioned head-down (i.e., not breech), the providers’ main role is to control the speed of the delivery to prevent rapid expulsion. If the patient is crowning and the amniotic sac is still intact, pinch and twist the sac to the rupture the membrane.

Delivery of the Newborn
Source: https://en.wikipedia.org/wiki/Childbirth#/media/File:2920_Stages_of_Childbirth-02.jpg

 As the head emerges from the vagina, the provider should place a hand on the top of the head to control the delivery of the head. As the head rotates to a neutral position from face down to the side, the provider should use two hands to gently guide the head at a slight downward angle to deliver the anterior shoulder and then at a slight upward angle to deliver the posterior shoulder. Excessive traction should be avoided. Once the shoulders deliver, the provider can assist the delivery of the rest of the body immediately after.

After delivery, steps should be taken to dry, warm, and stimulate the newborn. If the newborn appears vigorous and begins to cry, cord clamping can be delayed by 30-60 seconds to allow additional blood flow into the newborn. Do not delay cord clamping for more than 60 seconds. After the cord is clamped and cut, the baby should be placed skin to skin on the mother. Neonatal resuscitation should be in accordance with TP 1216-P, Newborn/Neonatal Resuscitation if indicated. In most cases, the placenta will deliver naturally within 30 minutes. In the field, it is not necessary to provide traction on the umbilical cord to expedite this process. Pulling on the umbilical cord may cause it to tear and retract, leading to an increased risk of uncontrolled hemorrhage.

Both the mother and newborn should be transported to a Perinatal Center with an Emergency Department Approved for Pediatrics (EDAP)

if the newborn is greater than 34-weeks gestation or a Perinatal Center with an EDAP and an NICU if less than 34-weeks gestation. Transport decisions can be guided by Ref No. 511, Perinatal Patient Destination and should be made in coordination with the base hospital.

On arrival to the emergency department, the mother and newborn were greeted by the emergency medicine, obstetrics and pediatrics teams. Fundal massage was initiated to promote uterine contraction and reduce post-partum hemorrhage. The placenta was delivered 15 minutes later without complication. The mother was started on an oxytocin drip to assist with uterine contraction and care was transferred to the obstetrical team. After discussion with the mother, the newborn was determined to be approximately 34 weeks at the time of delivery and was taken to the NICU.

Learning Points

  1. An approximate gestational age can be determined based on fundal height.
  2. When delivery is not imminent, transporting to an appropriate receiving facility where a controlled, sterile delivery can occur should be prioritized.
  3. Crowning occurs when the fetal head is visible at the vaginal opening and is a sign of imminent delivery that should occur on scene.
  4. Life-saving interventions must be performed when obstetrical complications like breech delivery, prolapsed cord, shoulder dystocia, and nuchal cord arise.

References

  1. Mistovich J, Karren K. Prehospital Emergency Care (11th Edition). Pearson. 2018
  2. Snyder S. Prehospital Childbirth, Part 1: Without Complications. 2013. https://www.emsworld.com/article/196634/prehospital-childbirth-part-1-without-complications
  3. Snyder S. Prehospital Childbirth, Part 2: Fetal Complications. 2013. https://www.emsworld.com/article/11192112/prehospital-childbirth-part-2-fetal-complications

Author: Jake Toy, DO