Delivery in the ED

The majority of spontaneous vaginal deliveries require minimal medical intervention and a supportive approach is all that will be required^1,2. However, as ED deliveries are an infrequent occurrence it is worthwhile preparing for the worst.

Location

• Resus (Ensure 2 spaces available: for mother and baby)

Equipment

• Towels + Gauze
• Sterile gloves
• Umbilical cord clamps (or surgical clamps) x 2
• Surgical scissors
• Entonox (50:50)
• Large plastic/metal bowl (for placenta)
• Female urinary catheter 
• Birthing partner (if possible) 
• Resuscitaire/Neonatal resuscitation equipment

Personnel

• Maternal team: Comprising ED +/- midwives +/- obstetrics
• Neonatal team: Comprising ED +/- Paediatrics 
• ITU/anaesthetics

Management of the active second stage of labour 

For the purpose of this section, we will cover some specific advice for managing delivery in the ED. If you would like to watch a simulation of a normal vaginal delivery, please follow this link.

• Position: Support the mother however possible, and allow her to adopt whatever position is comfortable without adding distress.
• Analgesia with Entonox (50:50) is recommended by NICE and is readily available in an ED setting³. Other analgesic methods (including opioids) are unlikely to be suitable in the ED and may cause harm to mother or baby³.
• Guard the perineum! Precipitous deliveries are associated with a higher degree of perineal trauma than non-precipitous due to higher velocity of delivery¹. Once the baby is crowning, place a gloved hand at the perineum and gently squeeze the two sides together to provide support and reduce the chance of perineal tearing^1,3. Routine episiotomy is not indicated, but may be indicated in some circumstances (See complications below).
• Suctioning of the foetal oropharynx is not recommended routinely³.
• Fundal pressure may be provided once the anterior shoulder has been delivered, however it is best avoided prior to this due to risk of shoulder dystocia⁵.
• Avoid brachial plexus injury by applying gentle axial traction when pulling the babys head and neck (Depending on the mothers position this may be more difficult)¹.
• Uterotonic agents should ideally be administered after delivery of the anterior shoulder, and before clamping of the cord, to reduce the risk of Postpartum Haemorrhage (PPH)^3,8. NICE and RCOG guidelines recommend the use of Oxytocin 10 units (iU) via intramuscular injection^3,8.While other agents are available (Ergometrine, Syntometrine) there is limited evidence of superior efficacy compared to Oxytocin and they can be associated with higher rates of nausea and hypertension³.

Once the baby is delivered, immediately dry them with towels to stimulate them to breathe. If there is respiratory effort (crying) and minimal concern, then the baby can be placed on the mothers chest to provide skin-to-skin contact¹. Any concern about the baby should be managed with the allocated Neonatal Resuscitation team to facilitate rapid assessment and management following established neonatal resuscitation guidelines.

Management in the third stage of labour

Active management of the third stage of labour is associated with a reduced rate of PPH compared to physiological management and may therefore be preferred in an ED delivery^3,6. Active management consists of:

• Cord clamping and dissection
• Uterotonic agents +/- uterine massage
• Umbilical cord traction to deliver the placenta

Cord clamping can, in most cases, be delayed for 1-2 minutes post-delivery (or until pulsation of the cord ceases) to allow delivery of oxygenated blood to the newborn from the placenta^3,6. If there is concern for the wellbeing of the newborn, the cord may be clamped and dissected to allow for transfer to a neonatal resuscitation space¹.

In order to dissect the cord, place 2 clamps approximately 7-10cm along the umbilical cord from the baby (spaced roughly 5cm apart) and use surgical scissors to cut the cord between the clamps¹.

To prepare for delivery of the placenta, wrap the placental portion of umbilical cord in gauze and prepare the vessel for the placenta and membranes (plastic/metal bowl). Placental delivery will usually occur 5-15 minutes after foetal delivery¹ (if >30 minutes despite active management this would be considered delayed ³ and will require urgent Obstetrics input). Await signs that the placenta has started to separate from the uterine wall. Using a gloved hand, apply gentle, intermittent traction to the gauze-wrapped portion of cord (avoid excessive, prolonged force as this may cause uterine inversion).

Monitor (and if possible, measure) vaginal blood loss to assist in the management of PPH.

Once the placenta and membranes have been delivered, carefully inspect to ensure they are complete and that no products of conception (POC) have been retained. Inspect the perineum/genitalia to assess for trauma which may require surgical intervention.