Are you ready to deliver a baby in your ED?
When a woman in labor comes to your ED, there are three possibilities, says Jay Kaplan, MD, FACEP, chairman of the department of emergency medicine at Saint Barnabas Medical Center in Livingston, NJ. "Labor may be early and birth is not imminent, in which case the woman can be transported to labor and delivery in a timely fashion, but with no rush. Or there could be an impending obstetric emergency, calling for stat transport to [labor and delivery] L&D. Or, birth is imminent and you prepare for delivery in the ED. You do not want to have to deliver babies in elevators."
It’s rare to deliver a baby in the ED, but you need to be ready for it, says Kaplan. "It’s a challenge because it doesn’t very commonly happen," he notes. "Also, there is heightened anxiety. You go from having two patients in one body to two patients in different bodies, and you need enough resources to take care of both the mom and baby."
The most common scenario leading to emergency delivery is a woman who presents with a full-term pregnancy, says Karen B. McGee, CNM, MSN, director of Nurse-Midwifery Associates at University Hospital in Cincinnati, OH. "She has not adequately evaluated the situation or she has no one to help her out with other children or transportation," she explains. "She may have had several children and has had little pain warning her of the imminent delivery."
This is challenging for the ED nurse because there is no time to prepare, notes McGee. "It requires a quick assessment, call for help, and attending to the mother with whatever equipment is available. Sometimes it may be your bare hands and a coat or sweater, which recently happened to me outside the admission door!" she says.
Another scenario is an accident where there has been trauma to the mother, McGee says. "Labor is stimulated and the mother is unable to recognize the uterine activity due to distraction from other injuries," she explains. "This may be a preterm situation which may fulminate and the baby is born very quickly."
The key to a successful delivery in the ED is preparation, stresses Renee Holleran, RN, PhD, chief flight nurse and clinical nurse specialist at University Hospital in Cincinnati, OH. "There is probably not any ED that is immune to the potential for a delivery," she says. "When people are anxious, they will present to any hospital whether you have obstetrical services or not. No matter what type of ED you work in, protocols and equipment should be in place to appropriately respond to an emergency delivery."
Here are things to consider when facing an emergency delivery:
Know appropriate interventions. "If the mother says the baby is coming, it usually is," says McGee. "Attention is needed in delivering the baby, not in starting an IV or rushing her through the halls to labor and delivery." Usually, it is impossible to stop the baby from coming, nor should you, but you can verbally encourage gentle pushing and flex the head for slow delivery of the head, she explains.
The first provider at the imminent delivery should call for the delivery kit, help the mother into a comfortable and safe position, put on gloves, support the baby as it is being born, reassure the mother, and protect her privacy if at all possible, says McGee. "As the baby is being born, it is important to use the bulb syringe correctly, dry the baby off, stimulate breathing after a clear airway is assured, and place the baby on the mother’s abdomen," she explains.
Assure adequate ventilation by stimulation to the feet with a gauze 4´4 or gentle rubbing of the back, says McGee. It is also important to keep the baby warm and dry. "Place the hat on the baby’s head and the identification bands on the mother and baby," she advises.
There will be a small gush of blood when the placenta is ready to deliver, says McGee. "Strong traction on the cord is unnecessary and may lead to a broken cord," she notes. "Once the placenta and membranes are delivered, usually within 10-30 minutes after birth, the uterus will need to be evaluated. It should be firm and low in the pelvis and there should be no gushing of blood from the introitus."
Know what to look for in physical exam. "Examine the perineum for any bulge during contractions. Also look for bloody show or leakage and the color of amniotic fluid," says Kaplan. "It’s also important to check fetal heart tones, which should be in the 120 to 160 range."
Check the position of the baby’s head. If the presenting part is anything other than the head, one has to be concerned about an obstetric emergency, says Kaplan. "Ninety percent of vaginal deliveries at term occur with the head as the presenting part, and 3-4% of those deliveries are breech," he notes. "Check to see if the membranes are intact, since labor usually goes more quickly if membranes are ruptured. Do a bimanual exam to check how far the baby’s head has come down the birth canal."
When the patient goes into labor, the cervix will be 2-3 cm dilated. "It has to be 10 cm before it’s completely dilated, and the cervix has to efface or thin out completely before it will slide over the baby’s head so that the baby can be delivered," says Kaplan.
Prepare for complications if the baby isn’t coming down headfirst. "The diameter of the baby’s head (which dilates the cervix) is bigger than the buttocks, so what potentially can happen is that the body comes out, but the head gets caught by the cervix," Kaplan notes.
Shoulder dystocia involves the baby’s shoulder getting caught underneath the pubic symphysis, Kaplan explains. "If that happens, one of the first things you can do is to roll a woman on her side, so the baby’s bottom shoulder is not pressing into the bed, and then press down directly over the pubic bone," he says. "This occurs in 0.13-2.0% of all vaginal deliveries."
Treat the process as normal. "In the ED, we mostly see diseases or illnesses, but this is a normal process. Neither doctors nor nurses nor EMTs deliver babies, mothers do. So our primary role is to help the mother as she delivers the child and be prepared if complications arise," says Kaplan.
The process may be easier than you expect, says Kaplan. "Quick babies are often good babies. When babies come more quickly than anyone expects, the woman thinks she’s going to have a long, hard labor, but some don’t have much labor at all," he notes.
Assess the mother’s emotional state. "The more in control a woman is, the better the delivery will go," says Kaplan. "There needs to be a cooperative relationship. It’s imperative for the physician and nurse to remain as calm as possible."
Make direct eye contact with the woman, says Kaplan. "Establish a partnership with the woman as quickly as possible, so you become a team working together. Tell her, Keep looking in my eyes and I’m going to talk to you, we’ll work together on this.’ Otherwise a woman will close her eyes and she’ll get lost in the pain."
If the delivery appears imminent (the baby is crowning), place the mother in a position of comfort so that she may assist you with the delivery process, says Holleran. "Someone needs to coach’ the mom. A good inservice may be to review the stages of labor and the breathing exercises that accompany them," she recommends.
In an emergency, you do not need a delivery table. "Ninety percent of the births I assisted involved the woman giving birth in the left lateral position, says Kaplan. "An assistant holds up the woman’s right leg and the doctor or nurse gets positioned between the legs to catch the baby. That is quick and comfortable, and you can do that on any stretcher."
Have a delivery pack on hand. Equipment should include an emergency delivery tray composed of a bulb syringe, umbilical cord clamp, scissors, and a scalpel, says Holleran. "A neonatal resuscitation bag, something to place on the baby’s head to help retain heat and an infant face mask should also be included with the tray," she notes. "There needs to be an issolette (if possible) or some type of method to keep the infant warm. If you do not have one, skin-to-skin contact with the mother may be used in a pinch."
Know what supplies are needed. "In an absolute emergency, all you need is a couple sterile drapes, gowns and gloves, two kelly clamps and a pair of scissors, availability of oxygen, and a bulb suction device," Kaplan says.
Understand that women do not need to push during contractions. "There is a misconception that women have to push babies out,’ says Kaplan. "The fact is that once the baby’s head comes way down, the contractions of the uterus can push it out. It is important to control the delivery of the baby. So women should push in between contractions, or let the contraction itself push the baby out."
As the baby [emerges], support the head and place it in a dependent position, Holleran says. "Clear the airway with the bulb syringe," she adds. "As the rest of the child presents, be sure the baby is in a safe position and will not fall or be dropped."
Give oxygen. "Oxygen in the short term will do no harm to either the mother or the baby," says Kaplan. "If you get signs of fetal distress, such as the baby’s heart rate is less than 120, roll the woman on her left side if she’s been on her back and give her oxygen. That way, the weight of the baby and uterus are not lying directly on the aorta and inferior vena cava, decreasing venous return to the heart, cardiac output, and placental flow. Oxygen will then more easily get to the baby."
You don’t have to cut the umbilical cord right away. "In an emergency, one of the best positions for the baby is lying across the mother’s abdomen with the head in a dependent position. The umbilical cord can remain intact," says Kaplan. "That gives the baby a bit of transition time, until the uterus contracts again and shears the placenta off the wall of the uterus, the baby is still getting oxygenated blood from the mother."
You don’t need an infant warmer. "The mother’s abdomen is a great warmer, as long as you dry the baby off and then put a fresh, dry blanket over the baby," says Kaplan.
Once the baby is born, wipe it clean, advises Holleran. "This will decrease the risk of hypothermia and stimulate the infant," she says.
Know the role of ultrasound. "If you are concerned about complications in the third trimester, such as a placenta previa or abruptio placenta, ultrasound can be useful," says Kaplan. "If a woman has excessive bleeding, it’s helpful to know where the placenta is. Placenta previa can be a life-threatening complication, in that the placenta is sitting over the cervix. Under those circumstances, you don’t want to do a bimanual exam because if you put your finger in the placenta, the woman can hemorrhage."
Estimate the gestational age of the baby. "In addition to the due date, look at the amount of vernix on the baby, and look at feet to see how many creases are on bottom," says Kaplan. "Very premature babies will have almost no creases and will be covered with vernix."
Avoid complications after birth. "You want to dry the baby off and maintain body temperature, because hypothermia can be a significant problem, as can hypoglycemia," says Kaplan. "If the heart rate is less than 100, one has to be concerned. The baby’s color is also important. If pale or blue, it is a major cause for concern."
If the child does not respond immediately, initiate resuscitation using the Neonatal Resuscitation Pyramid from the Pediatric Advanced Life Support Course, Holleran recommends. (See TABS procedure for newborn resuscitation on page 45.) "Protocols should be developed for complications such as a breech delivery or meconium staining," she says.
Obtain an APGAR Score. "It is a good idea to tape this information to the isollette or in a convenient area," Holleran says. "Most of us do not remember the components of the APGAR Score unless we use it routinely."
Evaluate whether the baby is in distress. The most common problems are low fetal heart rate, meconium, bleeding either before or after birth, shoulder dystocia, and the baby not breathing, notes McGee.
Assess the baby’s respiratory rate, heart rate, and color. "If the heart rate is below 100 and the baby is not making a good respiratory effort with persisting cyanosis, then initially use an infant ambu bag to ventilate the baby," says Kaplan. "If the heart rate is less than 80, and there is no rapid response to the blow by oxygen and ventilation, then begin chest compressions with the two finger method at rate of 120, with one-half to three-fourths inch depth of compression," says Kaplan.
If the fetal heart rate is taken and it is below 90 and the baby isn’t coming immediately, it is important to get obstetrical assistance, notes McGee. "If the water is greenish brown or very bloody, it is also important to get assistance from an experienced provider," she says.
Suction on the perineum when the head is delivered. "After delivery, a bulb is preferable, because other suction devices can lead to bradycardia," says Kaplan. "If there is a thick meconium, the baby should be intubated and suctioned below the cords."
Know differences in maternal physiology. "The more familiar you are with what is normal for a pregnant woman, the quicker one can recognize what is abnormal," says Kaplan. "A pregnant woman can lose 30-35% of her blood volume before she becomes hypotensive."
Fetal distress may be the first sign of impending maternal deterioration, Kaplan notes. "If the baby becomes bradycardic or is having late decelerations, then you have to ask yourself if something is going on with the mother. The vascular volume in pregnant women is increased by 40-50%, which means she can have significant blood loss without vital sign change."
A pregnant woman’s normal heart rate increases 15-20 beats to an average pulse of 95 by the third trimester, says Kaplan. "The blood pressure decreases to an average of 108 over 67 by third trimester, and cardiac output increases 40 percent."
The white blood cell count is elevated in the 12,000 range, and the red blood cell mass increases 33%, Kaplan notes. "But with plasma volume increasing 40-50%, it gives you a normal physiologic anemia. "There is delayed gastric emptying, which increases the risk of aspiration, and there is displacement of normal anatomic position of the organs, which changes the presenting physical findings of illness."
There is also the hyperventilation of pregnancy, notes Kaplan. "It’s mislabeled because the respiratory rate doesn’t change but the tidal volume increases. So if you’ve got a woman who has a rapid respiratory rate, don’t just assume it’s due to the pregnancy."
Keep education current. ED nurses need hands-on experience in labor and delivery as part of an annual competency program, McGee recommends. "They need to attend a continuing education program that teaches nurses to safely deliver babies in an urgent care setting," she says. "Nurses can perform mock deliveries and utilize training models to learn skills. Nurse-midwives can teach ED nurses to apply basic principles of emergency delivery through regularly scheduled learning labs and clinical preceptor programs."
For more information about emergency delivery in the ED, contact the following:
• Renee Holleran, RN, PhD, University of Cincinnati Medical Center, P.O. Box 670736, Cincinnati, OH 45267. Telephone: (513) 584-7522. Fax (513) 584-4533. E-mail: HollerRE@Healthall.com
• Jay Kaplan, MD, Saint Barnabas Health Care System, Department of Emergency Medicine, Mobile Intensive Care Unit, 94 Old Short Hills Road, Livingston, NJ 07039. Telephone: (973) 322-5127. Fax: (973) 322-8055.
• Karen B. McGee, CNM, MSN, Nurse-Midwifery Associates at The University Hospital, 234 Goodman Avenue, The University Hospital, Cincinnati, OH, 45267-0754. E-mail: email@example.com
6 questions to ask a woman in labor
"If you need to do a rapid evaluation on a patient in labor, you need to know what are the key questions you need to ask," says Jay Kaplan, MD, FACEP, chairman of the department of emergency medicine at Saint Barnabas Medical Center in Livingston, NJ. Those key questions include the following:
1. What number baby is this? "Is this a first baby or has the woman delivered one or many babies before?" says Kaplan. "That gives you some sense of the timetable you’re dealing with, because first babies generally come more slowly than the second or third."
2. What is the due date? "If you are within three weeks of the due date on the short side, or two weeks on the long side, then, by and large, there will be fewer complications with the baby," says Kaplan.
"Before the 37-week period you have to be concerned about respiratory difficulty, and, after the 42 weeks, you have to be concerned about post maturity with issues such as hypoglycemia or difficulty with temperature regulation," explains Kaplan. "Rather than being premature, they get malnourished, because the placenta loses its ability to keep up with the baby’s needs for nourishment."
3. Did the water break and if so, when? "If you have an intact membrane, then labor generally occurs more slowly, and babies are more protected," says Kaplan. "Fetal distress is less common with an intact bag of water than with ruptured membranes."
4. What is the color of the amniotic fluid? "If the color is yellowish white and clear, by and large you do not have a distressed baby. If it is greenish, that indicates the baby has had distress at some point during pregnancy. If it’s thick and green, like pea soup, you may well have an actively distressed baby and have to prepare for the worst," Kaplan says.
5. Has there been any bleeding? "Some bloody show is normal, but you want to try and quantify that, because you want to make sure you’re not dealing with the possibility of placenta previa," says Kaplan.
6. How often are the contractions? "You also want to know if there an urge to push," says Kaplan.
TABS Procedure for Newborn Resuscitation
Dry and cover the neonate as soon as possible to prevent heat loss. Place in a heated environment as soon as possible.
Suction the mouth first and then the nose. A neonate with fetal distress in utero may have meconium present. Suction early, when the head is delivered, with a suction trap. If the airway cannot be cleared, the neonate should be endotracheally intubated and suctioned.
B (beats [heart rate])
If significant bradycardia is present (< 80 beats/min) and does not improve with ventilation, initiate chest compressions. A brachial pulse should be palpable with compressions. Continue ventilating the neonate.
Consider pharmacologic support with drugs such as epinephrine, atropine, naloxone, dextrose, and sodium bicarbonate.
A blood glucose level < 40 mg/dL is a critical level in a neonate. When glucose is given, administer a 25% solution at 0.5 g/kg (or 2 mL/kg of a 25% solution).
Source: Sheehy’s Emergency Nursing: Principles and Practice, Fourth Edition. Lorene Newberry, Ed. St. Louis, Missouri;Mosby-Year Book, Inc.; 1998.