Obstetrics 11: Imminent Delivery Portal
Birth is imminent if the mother, upon arrival at the hospital, is in labor with bulging of the perineum or crowning of the newborn’s head. Conduct the delivery in the nearest appropriate location where the needs of both the mother and baby may be addressed. The ED may be the preferred location if the labor and delivery rooms are not in close proximity.
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Place the mother on a cart and rapidly move her to an area where the baby can be delivered safely. Equipment must be available to resuscitate both the mother and the newborn. Team members should wear full, protective gear during delivery if possible. At least wear gloves and a protective facial shield.
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Identify the presenting part. Confirm that the presenting part is the occiput.
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Place your palm on the newborn’s head and encourage the mother not to push so expulsion is gentle. Do not attempt to hold the head in. With a sterile towel in your other hand, support the perineum.
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Feel for a loop of cord around the neck (nuchal cord). Slip it over the newborn’s neck if it is loose. If the loop is tight or there are multiple loops, divide the cord between clamps and unwind it.
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Aspirate the mouth and nostrils as soon as the baby is delivered. Intrapartum suctioning is no longer routine, especially if shoulder dystocia is anticipated. (Vol III—NRP3 Meconium Suctioning)
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Meconium-stained amniotic fluid has the potential to complicate delivery. If the infant is vigorous, endotracheal intubation and suctioning is probably not necessary. These infants display strong respiratory effort, good muscle tone, and HR > 100 bpm. Non-vigorous infants showing signs of distress need suctioning. These infants display poor respiratory effort and poor muscle tone, and HR < 100 bpm.
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Following active or passive head rotation, laterally place both hands on either side of the newborn’s head and lower it gently to facilitate delivery of the anterior shoulder under the pubis. A little suprapubic pressure by a team member may help in delivering this shoulder.
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Gently elevate the newborn’s head to allow for delivery of the posterior shoulder.
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Place one hand under the posterior shoulder and your other hand on the newborn’s head and guide the baby out. The baby is very slippery. Be careful. Dry the baby with a towel and take care not to lift it high or low. Place the baby on the mother’s abdomen in a blanket.
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Place a sterile clamp on the cord about 3 inches from the newborn. Apply an umbilical clamp proximal to the originally placed clamp (ie, double clamp) and divide the cord with sterile scissors.
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Allow the placenta to separate spontaneously from the uterus. Do not pull on the cord because uterine inversion may result, or the cord may tear. One may give 10 units of Pitocin IM as soon as the baby is delivered as it will help to separate and expel the placenta. This will minimize retained placenta and blood loss. Massage of the uterus after delivery of the placenta will cause the uterus to contract and stop uterine bleeding. If bleeding persists add more Pitocin or consider Methergine or Prostaglandin F2 alpha (Hemabate). Place the placenta in a basin and inspect for completeness. Take a tube of blood from the cord by unclamping and allowing blood to flow into the tube.
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If an episiotomy has been required, repair the incision. Use a running (3-0 vicryl or chromic) absorbable suture to repair the vaginal mucosa and a subcuticular stitch of absorbable suture to repair the perineal portion. Close any interrupted muscle layers with interrupted, absorbable sutures. Repair any tears that may be present. Observe the patient for continued bleeding. Gently insert fingers into the vagina to obtain proper exposure to examine for cervical and vaginal laceration.
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Transfer the patient to her hospital room if necessary and observe for potential postpartum complications. (Vol III—NRP5 Inverted Triangle/Apgar Score)