OzEMedicine - Wiki for Australian Emergency Medicine Doctors

see labour; Mx of cord prolapse; ED Mx of 2nd stage of labour - emergency delivery;

• check antenatal & prenatal record for:
  • complications
  • estimated gestation
  • Rh gp & Abs
  • group B streptococcal culture on vaginal swab
    • ⇒ needs prophylactic IV penicillin during labour & to neonate

• consider admission for RIB, hydration, sedation & tocolytics

• uterine contractions < 10min or less apart but without progressive cervical change & often have irregular contractions which abate with sedation & hydration

• if present exclude placenta praevia BEFORE PV examination
• consider abruption & placenta praevia & Mx accordingly
• see Vaginal bleeding in pregnancy

• < 10% rupture membranes prior to spontaneous labor
• need to confirm as risk of:
  • maternal & fetal infection
    • ⇒ if < 37wks, avoid digital examinations (do sterile speculum) unless:
    • fetal bradycardia & ? cord prolapse
    • delivery appears imminent & need to assess Cx
  • Mx of cord prolapse
• note time of rupture, fetal movements, color (clear vs thin or thick green), amount & continued leakage
• DDx: urine leakage, vaginitis, normal physiologic discharge of pregnancy
• can confirm by:
  • nitrazine paper: pH > 7 (good specificity)
  • visualisation of fluid from os/vaginal pooling - excellent specificity (if no fluid, try Valsalva)
  • ferning on glass slide
  • decreased fluid on US (only fair to good specificity - oligohydramnios from other causes such as IUGR, fetal renal problems)

• see pre-eclampsia and eclampsia

• fetal heart rate assessment via CTG if indicated
• tachycardia > 160bpm:
  • fetal hypoxia, tachyarrhythmias, anaemia, heart failure
  • chorioamnionitis
  • maternal fever, hypothyroidism, beta adrenergic drugs
• bradycardia <120bpm:
  • NB. always check a bradycardia is not maternal pulse!
  • fetal hypoxia, cong. heart block (esp. in women with SLE), structural heart defects
  • maternal hypothermia, prolonged hypoglycaemia, beta blockers
• early decelerations:
  • inversely mirror strength of contraction
  • not of consequence but if nadir is < 100bpm, check for cord prolapse
• variable decelerations:
  • abrupt onset & return to baseline heart rate
  • at any stage of contraction, or even between contractions
  • warrant Rx if:
    • severe (FHR falls 60bpm from baseline or nadir < 90bpm)
    • persistent
  • Mx:
    • speculum to exclude cord prolapse
    • correct maternal hypotension if present
    • oxygen 10L/min
    • change to lateral decubitus position
    • ? amnioinfusion if delivery not imminent
    • ? tocolysis if obstetric help not available & no PV bleeding
    • IV fluids
• late decelerations:
  • FHR falls at peak of uterine contraction & returns to baseline after contraction completed
  • if repetitive, usually indicate placental insufficiency & require prompt Rx:
    • as for variable decelerations & urgent delivery
• prolonged sudden deceleration to nadir < 80bpm:
  • may be due to uterine hyperactivity
  • Mx as for variable deceleration, but if vaginal delivery not imminent & persistent FHR in range 60-80bpm for > 5min & fetus > 25-26wks then immediate C.S.

• bloods for FBE, U&E, glucose, blood group & Abs, rubella, Hep B/C, HIV, syphilis
• vaginal swab for GpBStrept.
• ? cervical swab for chlamydia if not bleeding & membranes not ruptured
• estimate gestational age:
  • LMP
  • fundal height (tape measure from pubic symphysis in cm = wks)
  • US
• routine vital signs & FHR