AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• DIFFERENTIALS
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• DIFFERENTIALS
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Few events cause more stress for an emergency physician than a pregnant woman at full term who is ready to deliver in the ED.

For more information, see Medscape's specialty Ob/Gyn & Women's Health and Medscape's Pregnancy Resource Center.

Pathophysiology

Pregnancy and delivery are natural processes that have been occurring for millennia. Physicians have become involved only in the relatively recent past. Therefore, attendance to the natural course is mandatory; interventions are indicated only in the event of deviations from the natural or expected course.

Frequency

United States

The precise incidence of ED deliveries of pregnant full-term patients is unknown. In 2005, 14 births occurred per 1000 total population. Fertility rates (births per 1000 women aged 15-44 y) decreased to 66.7. Approximately 80% received prenatal care in the first trimester.¹

Mortality/Morbidity

The infant death rate for 2004 was 6.78 per 1000 live births.¹ The maternal death rate in 1997 was 7.7 per 100,000 births (37.1 in 1960).²

Race

The numbers of members of racial groups who receive prenatal care differ and are correlated to the probability of their seeking care in the ED.

• In 2005, 57% of all mothers sought care in the first trimester.¹
• The percentage of white mothers seeking any prenatal care was 99.5%, with the percentage of black mothers close behind at 98.7%.¹

Age

Fertility rate statistics have 15 years as the lower cutoff point. However, laboratory testing should be performed to rule out pregnancy when any female capable of reproduction (potentially as young as 9 y) presents with abdominal complaints and when pregnancy cannot be ruled out at physical examination.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• DIFFERENTIALS
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

The history often is enough to raise suspicion of pregnancy as the cause of a patient's complaints. However, seemingly virginal patients can be pregnant, and denial of the pregnancy is not uncommon. Claims of regular menstrual periods and/or lack of sexual involvement do not rule out pregnancy.

• General signs of pregnancy include the following:
• • Cessation of menses
  • Morning sickness (eg, nausea, vomiting)
  • Urinary frequency
  • Breast enlargement and/or engorgement
  • Abdominal enlargement
  • Quickening and lightening (ie, settling of the fetus)
  • Uterine consistency changes (Goodell and Hegar signs), uterine enlargement, change in uterine shape, and uterine contractions
  • Mucosal changes (Chadwick sign)
• Gestation is defined as 280 days. The estimated date of confinement (EDC), or due date, is calculated by taking the first day of the last normal menstrual period (FDLMP), subtracting 3 months, and adding 1 week. Hand-held wheels aid this calculation.
• Typically, lightening (settling of the infant, head down, into the true pelvis) occurs several weeks before labor.
• Braxton Hicks (false labor) contractions (irregular rhythmic uterine tightening) may occur. The onset of these contractions is earlier with each succeeding pregnancy.
• Labor presentation may be classic or with variations. The onset of true labor may be gradual, abrupt, or catastrophic. In the first stage of labor, regular uterine contractions cause the cervix to dilate. The second stage consists of descent of the presenting part and delivery. The third stage of labor is delivery of the placenta.
• Signs of imminent delivery should be noted.
• • Bloody show, the expulsion of the mucus plug from the cervix
  • Breakage of the amniotic sac (bag of waters).  Determine the appearance of the fluid expelled. Clear fluid is normal, thin fluid is meconium (fetal intestinal contents consisting of the remains of swallowed amniotic fluid mostly composed of sloughed digested skin cells) stained, and thick pea-soup fluid is heavy meconium .
  • The sensation of impending defecation or an urge to push
• For a patient in labor, obtain the following minimal data set:
• • Last menstrual period (LMP), EDC, and prenatal care (including plans for delivery)
  • Pregnancy history, written as "(gravida, para, X-X-X-X)," where gravida is the total number of pregnancies (including the present one), para is the number of deliveries after 20 weeks of pregnancy, and X-X-X-X is the number of full-term infants-number of preterm infants-number of abortions-number of living children
  • Problems during this or previous pregnancies
  • Prior ultrasonographic examinations and results, and bleeding during pregnancy or labor (If findings are positive, be alert for placenta previa.)
  • Past medical and surgical history, medications, and allergies

Physical

Physical examination of the abdomen and pelvis is an invaluable tool in diagnosing labor as the cause of a woman's abdominal complaints.

• Abdominal striae may be noted. They are due to the rapid expansion of the uterus.
• When the patient is seated, the epigastrium has a typical shelflike appearance that is created by settling of the fetus.
• Fetal movements may be observed.
• Dullness on percussion of the area from the pubic symphysis to several centimeters below the xiphoid is evidence of a full-term pregnancy (in the right setting).
• Careful listening with a standard stethoscope may reveal fetal cardiac activity. Fetal stethoscopes or Doppler probes are helpful but unnecessary at term. Listening in all 4 quadrants may reveal twins.
• Carefully performed, Leopold maneuvers reveal much information and prepare the emergency physician for complications.
• • Palpate the fundus. If the area is smooth, hard, and round, it is the head. If the tissue is irregular, it is some other part of the fetus body.
  • Palpate the sides. A smooth, long surface suggests the fetus back. If the contours are irregular, it is probably the front or side.
  • Grasp the part in the pelvis. If it is smooth, hard, and round, it is the head. If it is irregular, it is some other part of the body.
  • Rub along the back and down to the pelvis to see if the head is present. A shelf or an abrupt change in the angle of the palpated part when the head is encountered indicates that the head is in extension (face presentation, unfavorable). If the path is smooth, the head is flexed (favorable).
• The cervix effaces (thins).

Causes

Causes of pregnancy are both obvious (ie, sexual activity) and hidden (eg, lack of access to reliable birth control, low self-esteem, denial, poverty).

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• DIFFERENTIALS
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• DIFFERENTIALS
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Few laboratory tests are useful.
• Initial determination of the patient's hemoglobin level and Rh blood group status is required.
• If the patient has received prenatal care, other laboratory tests have been performed.
• Kleihauer-Betke testing can be ordered after delivery for Rh-negative mothers of Rh-positive infants. (One unit of Rh immunoglobulin per 15 mL fetal blood in the mother's circulation is administered intramuscularly within 72 h of delivery.)

Imaging Studies

• Generally, if sufficient time for imaging studies exists, time to transport the patient to the obstetrics ward exists.
• Ultrasonography may be useful, but it is not immediately available at most facilities. Additionally, many emergency physicians are not skilled at interpreting sonograms. However, if available, sonograms may be used to determine the following:
• • Fetal position
  • Number of fetuses and/or age of the fetus
  • Presence of cardiac activity
  • Fetal malformation (eg, CNS, developmental)
  • Quantity of amniotic fluid
  • Estimation of fetal weight
  • Hydatiform mole
  • Rh isoimmunization
• Radiography has a role in the emergency assessment of the pregnant patient.
• • It is available quickly at most facilities, and emergency physicians are skilled at independent interpretation of radiographs.
  • If areas other than the pelvis require radiographic evaluation, shield the abdomen; perform abdominal radiography only when it is absolutely necessary.
  • Plain radiographs of the abdomen may be used for pelvimetry to show the position and number of fetuses.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• DIFFERENTIALS
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

• Provide oxygen.
• Obtain intravenous access.
• Generally, transport the patient in the left lateral recumbent position; use this position especially if the expectant mother's blood pressure decreases (because of pressure on the vena cava, which reduces return to the heart).
• Prepare for field delivery, because little can be done to prevent the birth.

Emergency Department Care

If the baby is not crowning (ie, child's head bulging at the perineum), a brief vaginal examination performed with a sterile-gloved hand reveals if the cervix is dilated (to 10 cm) and/or effaced (thinned to about 1 mm). Additionally, determine the descent of the presenting part relative to the ischial spines (in centimeters and expressed as + when it is caudal to [above] the spines).

Identify the presenting part. A smooth surface with a Y configuration is the most favorable finding; this is the lambdoid suture, which indicates presentation of the flexed head. A + configuration indicates the bregmatic suture; this sign is less favorable, but sufficient time may exist to transport the patient to the obstetrics unit. Face, foot or feet, hand or arm, and breech presentations are obvious on palpation. These unexpected presentations can be problematic for delivery in the ED, because they require special expertise.

If the baby is not crowning, the mother is not yet completely dilated (or if she is, she is not feeling an urge to push), and no complications are noted (see Complications), the mother may be moved to the obstetrics ward.

If the baby is crowning and none of the complications noted in Complications are present, the ED physician may need to deliver the baby.

• The general procedure for delivery is as follows:
• • Swab the perineum with povidone iodophor, and drape it with towels. Control the baby's head with the nondominant hand. If necessary to permit delivery of the baby, inject the midline perineum with lidocaine, and perform a midline incision down to (but not into) the rectal muscle. (Be aware there is no evidence that an episiotomy has any benefit.) Usually, the amniotic sac has broken; if not, open it now. Note the color and consistency of the amniotic fluid.
  • The lambdoid suture usually is anterior and at an angle of about 30° to the midline; it turns to the anteroposterior plane and emerges. The head turns to the coronal plane of the mother. Once the head emerges, suction the mouth and nose. Use a DeLee suction trap to suction the nose and deep hypopharynx if the amniotic fluid is not clear.
  • Check the neonate's neck for the umbilical cord; if it is wrapped around the neck, pull it gently over the head. If this is not possible (e.g., it is too tight or has too many loops), double clamp the cord and divide the cord between the clamps. Recheck the neck, because the cord may be wrapped more than once. Then deliver the child expeditiously.
  • Gentle traction toward the mother's posterior usually delivers the anterior shoulder; if this attempt is unsuccessful, try pressing down over the mother's bladder to move the anterior shoulder posteriorly. If this is unsuccessful, shoulder dystocia may be present. A number of options to address this exist: the ED physician may wait for the obstetrician; the ED physician also may deliver the posterior shoulder, rotate the anterior shoulder posteriorly, and then deliver that shoulder; or, the ED physician may use one of the more destructive moves, such as fracturing the anterior clavicle (a difficult maneuver at best).
  • Once the shoulders are out, the rest of the baby slips out quickly; however, be careful, because neonates are slippery. Keep the nondominant hand in place, controlling the baby's head, and slide the dominant hand under and along the baby as it emerges. Once the feet are out, rotate the baby 180° into a football hold. Suction the nose and mouth. Double clamp the cord 7-10 cm from the baby, and cut the cord between the clamps.
  • If the child starts breathing and moving and appears to be in good health, turn the baby over to nursing personnel. Make sure that the baby is vigorously dried, suctioned, and kept warm. If the birth is complicated by thick meconium (amniotic fluid that is thick and pea green), do not stimulate the baby to cry. Instead, use a 3.0 endotracheal tube, intubate the trachea, and suction it; then, stimulate the baby's breathing.
  • Do not unclamp the mother's side of the placenta until it is clear that only one fetus is present. Feel the uterus; if it is almost in the pelvis, probably only one fetus exists. Let the cord drain, collecting a clot tube for laboratory studies. Allow the third stage of labor, delivery of the placenta, to proceed slowly. Do not pull on the cord; guide the placenta out as it is expelled. Inspect the placenta to ensure that it is entirely expelled. Sending the placenta for pathologic evaluation is a good risk-management practice.
• If mother and baby are doing well and do not require resuscitation, the ED physician may perform vaginal and perineal repairs if he or she is comfortable doing so. Alternatively, it is generally acceptable to let the obstetrician or family practitioner finish this portion. Also, the mother and baby can be moved to the obstetrics ward for follow-up care.
• Apgar scoring is used to provide a rough estimate of the baby's immediate adaptation to extrauterine life. The score aids in determination of whether the baby is viable independently or needs help (resuscitation). Apgar scores should be documented at 1, 5, and 10 minutes in all neonates. If the 5-minute score is less than 7, continue scoring every 5 minutes for 20 minutes. However, if the child requires resuscitation, waiting to do a 1-minute score is not indicated. Assign scores in each of the following categories and total them for the Apgar score.
• • Appearance - 0 for blue or pale, 1 for body pink and limbs blue, and 2 for pink all over
  • Pulse - 0 for absent, 1 for less than 100 per minute, 2 for more than 100 per minute
  • Grimace - 0 for no response, 1 for some motion, 2 for crying
  • Activity - 0 for limp, 1 for some weak motion, 2 for active
  • Respiration - 0 for none, 1 for weak cry, 2 for strong cry

Consultations

Consult an obstetrician and/or a neonatologist as needed.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• DIFFERENTIALS
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Few drugs are needed in an uncomplicated delivery. If excessive bleeding occurs, first try massaging the uterus, because uterine atony is the most common cause of this complication. Do not try to push the uterus out the vaginal canal. Gently squeeze or compress the uterus to cause myofibrils to contract. This action compresses the vessels perforating the uterus. If this fails, try administering oxytocin (Pitocin), then prostaglandin F2.

Drug Category: Oxytocics

These agents are used to reduce postpartum bleeding.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• DIFFERENTIALS
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Transfer

• A specific body of law governs transfer of patients in labor. It is too large to review here. Please see the article on COBRA Laws and EMTALA. The original statute was passed as a part of a much larger bill, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). Consequently, the acronym COBRA was used frequently in medical literature when referring to the statute. This statute is also titled the Emergency Medical Treatment and Active Labor Act (EMTALA). Since the latter name is more specific and descriptive, it has become the preferred acronym for referring to the statute. The full text of the statute can be found in any public library's reference section under 42 U.S.C.A. Section 1395dd et seq.³
• When it is deemed necessary to transfer a patient in labor because of anticipated risks to the neonate, it is generally best to transport her before delivery. This will normally give the neonate the optimal environment pending arrival at the facility that has the needed equipment and personnel available.
• Stabilization must be achieved. Labor should usually be arrested (eg, terbutaline, magnesium sulfate, ritodrine). Care is coordinated with the receiving facility and physician.

Complications

• Several items, including the umbilical cord and placenta previa, can be felt at initial vaginal examination.
• • Umbilical cord compression: Have someone insert a sterile gloved hand into the vagina, into the cervix, and against the pelvic wall, while maintaining space between the index and middle fingers for the cord to pass uncompressed. This individual should accompany the patient and stay in this position until the operating surgeon or obstetrician directs otherwise.
  • Placenta previa: Copious vaginal bleeding usually heralds placenta previa. The mother may be aware of this condition prior to admittance to the ED. Do not perform a vaginal examination in a patient who is bleeding vaginally and in labor. Order an immediate ultrasonography, type and cross-match blood, and alert a surgeon and an obstetrician.
• Stillbirth may occasionally occur; despite everyone's best efforts, a child may be born without signs of life.
• • Psychological support for the parents is mandatory. Grieving occurs, with all of its potential for pathologic processes.
  • If available, a clergyperson should visit the parents.
  • Recommend a support group to the parents.

Prognosis

Childbirth is a natural process.

Patient Education

• For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center. Also, see eMedicine's patient education article Labor Signs.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• DIFFERENTIALS
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Volumes have been written about the legal problems of those in obstetrics. However, the vast majority of this information does not apply to the emergency physician. The emergency physician only should be concerned with delivering care commensurate with that of any reasonable emergency physician.
• Much concern is expressed regarding the use and interpretation of fetal monitor strips. Be aware of the following issues:
• • If sufficient time exists to use a fetal monitor, enough time exists to transport the mother to the obstetrics ward and/or to administer a tocolytic.
  • The use of fetal monitoring is a classic example of the application of technology based on an absolute dearth of information or proof that it makes any difference. Therefore, the American College of Obstetrics and Gynecology does not recommend the routine use of fetal monitoring.⁴

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• DIFFERENTIALS
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

1. National Center for Health Statistics. Vital Stats Births. Available at http://www.cdc.gov/nchs/datawh/vitalstats/VitalStatsbirths.htm. Accessed April 11, 2008.
2. CDC. Healthier mothers and babies. MMWR Morb Mortal Wkly Rep. Oct 1 1999;48(38):849-58. [Medline]. [Full Text].
3. Frew S. MedLaw. Available at www.medlaw.com.
4. ACOG Committee on Ethics. Innovative practice: Ethical Guidelines. Available at http://www.acog.org/from_home/publications/ethics/co352.pdf.
5. Danforth DN. Obstetrics and Gynecology. 4^th ed. Philadelphia, Pa: Harper and Row; 1982.
6. Mifsud AJ, Efstratiou A, Charlett A. Early-onset neonatal group B streptococcal infection in London: 1990-1999. BJOG. Sep 2004;111(9):1006-11. [Medline].
7. Willson JR. Atlas of Obstetric Technic. 2^nd ed. St Louis, Mo: Mosby; 1969.

Article Last Updated: Jul 17, 2008