1. Delivering a baby

2. Delivery in ED Not common in the emergency department with obstetric services in hospital May happen in carpark/ambulance bay Certainly may happen at Maryborough

3. Diagnosis Check EDD – concern if <36weeks Prenatal care G/P Bloody show Rupture of membranes Contractions – length/frequency Urge to push

4. Preparation Call O&G, paeds Determine if patient able to go to delivery ward Ask nurse in charge if there is a midwife on shift Assess cervix, feel presenting part Equipment – –Resuscitaire, –Neopuff, –ETT/suction, –Drapes, towels –Cord clamps and scissors

5. Delivery Patient in lithotomy position Prep and drape the area Look for head. Once nose is visible suction airway and check for cord around neck –Remove cord if present. –If you can’t then clamp and cut the cord then get the baby out

6. Delivery Deliver the anterior shoulder –Gentle traction downwards –Push over mother’s bladder if needed Once the shoulders are out the rest of the baby will follow Wait 30 seconds then clamp and cut the cord

7. Third stage Go slow Allow the cord to lengthen Gentle traction once placenta comes free Inspect the placenta to make sure it is intact

9. PPH Normal delivery – about 500mL blood loss Four Ts: Tissue, tone, trauma, thrombin Start with 2 large IVCs, send FBC, Group and hold, xmatch, coags, UEC No more than 2-3 litres of crystalloid before blood

10. Tissue Can you get the placenta out? – continuous cord traction Examine the placenta – is it intact? If not then speculum exam If no placenta in vaginal vault the start fundal massage

11. Tone Feel the uterus – is it firm? If not then oxytocin 5 units and massage –May repeat dose once Ergometrine – 250mcg –May repeat once after 15 minutes Misoprostal – 800-1000mg

12. Trauma Speculum exam –Bleeding from vaginal vault – suture or pack –Bleeding from Os – Apply pressure, give drugs, wait for O&G

13. Thrombin Check coags, fbc, crossmtach Activate MTP if any abnormality so that clotting factors are given If bleeding persists transfer to OT Consider tranexamic acid