Delivery in the ER Preparedness for Antepartum, Intrapartum, and Postpartum Complications Joel Henry, M.D. Associate Professor, Ob/Gyn

I have no financial disclosures

Antepartum Complications Direct Pregnancy Related Other Systemic Complaints related to pregnancy

Pregnancy Related Bleeding Preterm Labor (<37 completed weeks from last menstrual period) Premature Rupture of Membranes

Third Trimester Bleeding Placenta Previa Placental Abruption Uterine Scar Disruption Vasa Previa Friable cervix

Third Trimester Bleeding Gentle Speculum exam is OK, but avoid a digital cervical exam unless an ultrasound reveals no Placenta Previa

Important Systemic Complaints Headache Hypertension (>140/90) Shortness of Breath (P.E, A.F.E., Cardiomyopathy) Leg Pain/Swelling

Hypertension Chronic Hypertension Gestational Hypertension Pre-eclampsia Chronic Hypertension with Superimposed Pre-eclampsia

Pre-eclampsia Severe Hypertension >160/105 IV Labetalol or Hydralazine Lower BP to reduce risk of CVA Prevent seizures with Magnesium Sulfate Expedite delivery

Intrapartum Assessment Presentation / Malpresentation Ultrasound for position Cervical Dilation Fetal Heart Rate (110-160 BPM)

Delivery Gentle back pressure on fetal head to control the delivery and reduce perineal trauma

Shoulder Dystocia Avoid Excessive Downward Traction !!! Flex maternal legs way back Rotate fetal body to oblique position Try to deliver posterior arm

Breech Avoid temptation to pull Allow maternal pushing to deliver to the level of the scapulae, with fetus facing downwards. Gently sweep arms out Keep fetal chin flexed, to deliver the head

Postpartum Care Active Management of the Third Stage 10 Units of Pitocin IM Fundal massage to firm up the uterine muscle Gentle traction on the umbilical cord to tell when the placenta has separated

Inspect cervix, vagina, and perineum for lacerations Postpartum Care Inspect cervix, vagina, and perineum for lacerations

Postpartum Complications Hemorrhage ( >500 ml blood loss) DIC Seizures

Perimortem Cesarean Immediate surgical delivery of a viable fetus if no maternal heart rate for 4 minutes