Emergency Delivery and Peripartum Emergencies

122
Emergency Delivery and

Peripartum Emergencies
Jeremy B. Branzetti
PRESENTING SIGNS AND SYMPTOMS

KEY POINTS
Labor is classically heralded by shedding of the mucous plug
• If shoulder dystocia is encountered, attempt the that was occluding the cervix (the “bloody show”), passage of
McRoberts maneuver with suprapubic pressure while clear fluid from the vagina from ruptured membranes (the
simultaneously calling for obstetric assistance. “water breaking”), and contractions. True contractions are
• Practitioners underestimate blood loss in postpartum organized and detectable by tocometry; tend to increase in
hemorrhage by as much as 50%. pain, frequency, and strength with time; and have associated
• Uterine inversion is relatively uncommon but is cervical changes. Braxton-Hicks contractions, commonly
associated with significant morbidity if not recognized called false labor, are characterized by unorganized myometrial
and treated promptly. activity without cervical changes. Other common symptoms at
• Up to 87% of patients with uterine rupture have no labor onset include abdominal pain and back pain.
pain, and up to 89% have no vaginal bleeding. In the emergency department (ED), the majority of patients
• Perimortem cesarean delivery is indicated in gravid seen in labor are in the latter part of stage I or stage II.1 Pre-
patients if more than 24 weeks pregnant and if arrest cipitous delivery is a common occurrence because most
continues after 4 to 5 minutes of cardiopulmonary patients whose labor progresses more slowly will have time
resuscitation. to get to their designated obstetric facility.
• The clinical examination of a term pregnant patient is
notoriously unreliable.
• Treatment of anaphylactoid syndrome of pregnancy is DIFFERENTIAL DIAGNOSIS AND
similar to that for sepsis and disseminated intravascular MEDICAL DECISION MAKING
coagulation and should begin immediately; the
diagnosis is one of exclusion, and patients must be For any woman encountered after 20 weeks of pregnancy,
treated promptly to survive. labor must be in the differential diagnosis. Although the ulti-
mate differentiation of false labor, or Braxton-Hicks contrac-
tions, is made by continuous tocometry, a good history can
often make the diagnosis.
For patients with a chief complaint of vaginal bleeding,
EMERGENCY DELIVERY placental abruption and placenta previa should be considered.
When the only complaint is passage of clear fluid from the
vagina, premature rupture of membranes (PROM) and preterm
PATHOPHYSIOLOGY premature rupture of membranes (PPROM) should be assumed
until proved otherwise.
For an uncomplicated delivery, no diagnostic testing is
During labor the fetus follows a series of stereotypic move- needed. In those without any prenatal care, a complete blood
ments known as the cardinal movements of labor. Although count and Rh status should be obtained.
the specifics have little bearing on the emergency physician’s For patients complaining of vaginal bleeding, placenta
approach to labor, the final movement typically leaves the previa or abruption should be assumed. Ultrasound is required
baby with the occiput anterior (relative to the maternal pelvis) to evaluate for previa. It is essential that placenta previa
and the head sharply flexed. This position offers the smallest be diagnosed early because vaginal delivery is absolutely con-
fetal head diameter and is therefore optimal for passage traindicated with this condition. Ultrasound is not useful in
through the pelvis. Any deviation from this position is by ruling out the diagnosis of placental abruption because toco-
definition a malpresentation, and these different presentations cardiographic monitoring in an obstetric suite is required.
are all associated with increasing morbidity and mortality. The
overwhelming majority of births, however, will require little
physician intervention beyond timely encouragement and TREATMENT
vigilance for complications.
The major point of triage is during stage I of labor. If care is
available in-house, transfer can be accomplished at any point
For a description of potential malpresentation, before crowning. If care requires out-of-hospital transfer, it is
along with management recommendations, see imperative to establish early and reliable contact with the
www.expertconsult.com
treating obstetrician to facilitate a safe plan of care.
1051
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SECTION XII WOMEN’S HEALTH AND GYNECOLOGIC DISEASES
Even though multiple physical interventions may be neces- shoulder. Once clear, the posterior shoulder is typically deliv-
sary with an abnormal delivery, an uncomplicated one typi- ered spontaneously or with upward traction in a similar
cally only requires measures that support smooth fetal passage. manner as just described. At this point the largest fetal diam-
Resuscitation equipment should be available immediately. eter has passed, and labor is generally smooth. The cord may
Episiotomies are no longer recommended during routine be clamped once it is accessible after passage of the fetus. If
pregnancies. They should be used sparingly and typically only the cord is tightly wound around the fetus, knotted, or abnor-
with complicated deliveries. If shoulder dystocia is encoun- mal in any way, it is clamped (typically at 7 and 10 cm) and
tered, hyperflexion of the maternal hips and knees (McRoberts cut once accessible. When free, the neonate is dried and
maneuver) and suprapubic pressure are first-line interven- warmed and its resuscitation needs evaluated. If available, a
tions that resolve most instances of dystocia. neonatologist should be present at any ED delivery.
Three classic signs indicate delivery of the placenta: sudden
lengthening of the cord, a gush of blood, and a change in the
shape of the uterine fundus. Once the fetus is clear, gentle
For more information on the management of diffi-
cult labor, see www.expertconsult.com traction on the cord should continue until these signs are seen.
After the placenta is delivered, typically within 20 minutes, it
is inspected for irregularities that may suggest retained tissue.
Manual abdominal massage of the uterine fundus will often
After determination of hemodynamic stability, the next pri- assist in uterine contraction. An infusion of oxytocin, typically
orities are to determine whether true labor is occurring and 20 units in a 1000-mL bag of normal saline infused at about
the appropriate disposition to achieve optimal medical care. 200 mL/hr, can be administered to hasten separation and
For any patient with a complaint of passage of clear fluid from assist in contraction of the uterus back into the pelvis.
the vagina without other signs and symptoms of labor (bloody
show and regular, progressing, often painful contractions), a
sterile speculum examination should be performed before a FOLLOW-UP, NEXT STEPS IN CARE,
gloved digital examination to evaluate for PROM. AND PATIENT EDUCATION
Once labor is confirmed, the goal is to evaluate the position-
ing (orientation in space relative to the maternal pelvis) and After the placenta is delivered and the neonate is stabilized,
presentation (body part palpable at the cervix) of the fetus, the mother should be evaluated for bleeding—the causes and
along with the degree of change in the uterine cervix. This treatment of which are covered next. If hemodynamically
includes assessment of station (level of decent into the pelvis stable after the first postpartum hour, the mother may be
relative to the maternal ischial spines), effacement (degree of transferred to the postpartum floor.
cervical thinning), and dilation of the cervical aperture. For
the emergency physician, determination of dilation and efface-
ment is the most important part of the examination—a fetus POSTPARTUM HEMORRHAGE
that is still contained within a closed and minimally effaced
cervix will probably be transferred to obstetrics whether or
not it is vertex (fetal head as the presenting part). EPIDEMIOLOGY
If delivery is imminent, the patient will have to remain in the
ED. A gynecologic bed with lithotomy position capability is Hemorrhage is a significant cause of maternal morbidity and
ideal, and a resuscitation bay with greater accessibility and is the second most common cause of peripartum deaths (fol-
equipment is recommended. A radiant warmer and appropriate lowing amniotic fluid embolism). Hemorrhage was a direct
airway equipment should be available. Positioning of the cause of more than 18% of 3201 pregnancy-related maternal
mother may require an approximate 10-degree tilt to the left to deaths in the United States from 1991 to 1997.3 Worldwide,
prevent uterine pressure on the inferior vena cava and associ- hemorrhage has been identified as the single most important
ated hypotension. When crowning occurs, the mother should cause of maternal death and is responsible for almost half of
be instructed to push along with the contractions, with the all postpartum deaths in developing countries.4
physician positioned in front of the introitus ready to accept Postpartum hemorrhage is the term used to describe exces-
the fetus. As soon as the head is accessible, continuous gentle sive blood loss after delivery. Classically, it is defined as more
countertraction should be administered to maintain it in a than 500 mL of blood loss in a vaginal delivery or more than
flexed position. This technique provides control of an explosive 1000 mL of blood loss in a cesarean delivery; however, careful
delivery, as well as avoidance of the high morbidity associated quantitative measures reveal that blood loss in the range of
with fetal neck hyperextension. Though once recommended, 500 to 1000 mL is actually average for both types of delivery.
the modified Ritgen maneuver has recently been shown to be Of note, practitioners often underestimate blood loss by as
associated with an increased rate of third-degree lacerations much as 50%.5 For the ED physician, the most important
and episiotomy in comparison with a “hands-off ” approach.2 causes of hemorrhage in the postpartum period are birth
Similar rates of perineal tears were found for each modality. trauma, uterine atony, uterine rupture, and uterine inversion.
When the head is clear, the fetus rotates 90 degrees. Suction
of the fetal mouth and nose should be performed as soon as
possible in the setting of meconium staining. Typically, the PATHOPHYSIOLOGY
shoulders will then be delivered, anterior first, without assis-
tance. Mild downward traction on the torso (not lateral flexion Separation and delivery of the placenta constitute the third
of the neck) may be required to assist passage of the anterior stage of labor. With separation of the placenta, there is also
1052
CHAPTER 122 Emergency Delivery and Peripartum Emergencies
severance of the numerous uterine arteries and veins that carry intravaginal, intraperitoneal, and retroperitoneal accumulation
600 mL/min of blood through the intervillous space. The most of blood can be overlooked.
important factor for hemostasis is contraction and retraction In a reported case series on uterine inversion, the most
of the myometrium to compress and obliterate the open common signs were shock and hemorrhage.6 With a complete
lumens of the vessels. inversion, the prolapsed uterus may be visible as a large, dark
Uterine atony, the most common cause of postpartum hem- red polypoid mass within the vagina or protruding through the
orrhage, is the result of a hypotonic uterus after delivery. introitus. If the fundus remains within the vagina, the diagno-
Factors that lead to uterine overdistention or that interfere with sis may be suspected because of dimpling, indentation, or
uterine contractility can cause uterine atony and are associated absence of the uterine fundus on abdominal examination or
with postpartum hemorrhage. Although it is important to keep because a mass is palpated in the cervix on bimanual exami-
these associations in mind, most cases of postpartum hemor- nation. Establishing the diagnosis of incomplete inversion can
rhage occur without any known predisposing factors. be quite difficult; severe hypotension, postpartum hemor-
Trauma to the genital tract during labor and delivery (lac- rhage, and subtle abnormalities on abdominal examination
erations of the perineum, vagina, vulva, or cervix) is the may be the only clues.
second most common cause of postpartum hemorrhage. Uterine rupture is also a difficult clinical diagnosis and
Abnormal placentation (placenta accreta, increta, or percreta) should be considered in any patient with unexplained peripar-
can contribute to postpartum hemorrhage in different ways: tum hemorrhage or hypotension. The classic findings of
(1) an adherent placenta or large blood clots prevent effective uterine rupture are “ripping” or “tearing,” suprapubic pain and
contraction of the myometrium, thereby impairing hemostasis tenderness, absence of fetal heart sounds, recession of the
at the implantation site, and (2) significant bleeding from the presenting parts, and vaginal hemorrhage. Signs and symp-
implantation site is more likely with placental separation of toms of hypovolemic shock and hemoperitoneum may follow.
abnormally adherent tissue. This classic manifestation is actually rare; 87% of patients
Uterine inversion is prolapse of the uterine corpus to or with uterine rupture have no pain and 89% have no vaginal
through the cervix. Uterine inversion may be incomplete bleeding. Pain is also an unreliable finding because of the
(inverted but does not go through the cervix) or complete (the altered response to noxious intraperitoneal stimuli by a
fundus protrudes through the cervix). In the more extreme stretched abdominal wall. Fetal distress is the most consistent
cases, the entire uterus may prolapse out of the vagina. Most finding (80% to 100%), with fetal bradycardia being the most
cases are acute and occur immediately after delivery and common sign.7 Most reports of uterine rupture describe
before the cervical ring constricts. If inversion occurs (or is patients with normal blood pressure or even elevated blood
noted) after cervical contraction, the inversion is termed sub- pressure without tachycardia. Abnormal maternal vital signs
acute. Chronic inversion takes place weeks after delivery. The are late indicators of severe hemorrhage. The most important
majority of cases of uterine inversion occur as a result of trac- risk factor for uterine rupture is a previous uterine scar; other
tion on the umbilical cord during removal of the placenta. factors are listed in Box 122.1.
Acute, significant hypotension is common.
Uterine rupture is classified by the degree (complete or
incomplete) and cause (spontaneous or traumatic) of the BOX 122.1 Risks for Uterine Rupture
defect. A complete uterine rupture is defined as a full-thickness
tear of the uterine wall and overlying serosa; it is associated Surgery or Procedure
with life-threatening maternal and fetal compromise. After Previous cesarean delivery (most common by far—1 in 125
complete rupture, the uterine contents may escape or partially subsequent pregnancies)
extrude from the uterus and into the peritoneal cavity. An Previous uterine rupture
incomplete uterine rupture is defined as uterine muscle sepa- Previous myomectomy incision (1 in 40 subsequent
ration with an intact visceral peritoneum (often from uterine pregnancies)
scar dehiscence). In an incomplete rupture, hemorrhage fre- External or internal version
quently extends into the broad ligament, which has a tam- Breach extraction
ponading effect. Forceful uterine pressure during delivery
Trauma or Environmental
Trauma
PRESENTING SIGNS AND SYMPTOMS
Cocaine use
Peripartum patients may lose a substantial amount of blood Structural Anomaly
before becoming hypotensive or feeling symptomatic. Imme- Congenital fetal or uterine anomaly
diate postpartum hemorrhage should be recognized as a Previous invasive molar pregnancy
potential complication of a precipitous delivery. The classic Uteroplacental abnormalities: adenomyosis or placenta
clinical manifestation is a woman with sudden massive vaginal increta or percreta
bleeding who is tachycardic, pale, and possibly diaphoretic or Pregnancy Related
hypotensive. However, three factors make this classic mani- Silent rupture in a previous pregnancy
festation flawed. First, an elevated pulse and decreased blood Persistent, intense contractions (spontaneous or iatrogenic)
pressure are insensitive indicators until large amounts of High parity (1 in 100 subsequent pregnancies); grand multi-
blood have been lost. Second, many patients will have steady parity (>7) increases the risk for rupture 20-fold8
bleeding that, although moderate in appearance, may escape In vitro fertilization
notice until serious hypovolemia develops. Third, intrauterine,
1053
massage and IV oxytocin should be initiated (Fig. 122.1 and

DIFFERENTIAL DIAGNOSIS AND MEDICAL Table 122.1). A Foley catheter should be placed.
DECISION MAKING If the placenta has been delivered, manual uterine explora-
tion may reveal uterine rupture or retained products or clots
Postpartum hemorrhage is a sign, not a diagnosis; it is impor- (which should be removed manually to improve uterine con-
tant to consider the cause of the postpartum hemorrhage traction). If the placenta is still in place and bleeding is
because it will often direct the treatment. The key to identify- ongoing, the placenta should be removed if a distinct cleav-
ing the cause of postpartum hemorrhage is the physical exam- age plane is palpated on exploration. If an indistinct cleavage
ination. Because uterine atony is the most common cause of plane is revealed, the diagnosis of placenta accreta is likely.
postpartum hemorrhage, accurate assessment of uterine tone In this case the placenta should not be removed in the ED.
is essential. To assess uterine tone, a hand is placed on the Bimanual uterine compression should continue, with the
anterior wall of the uterus (over the fundus) to palpate it. If a goal being to stabilize patients until they can be taken to the
soft, boggy, or very large uterus is felt, the diagnosis of uterine operating room.
atony is established. At this point, management of uterine Trauma to the genital tract can be diagnosed by careful
atony should be a priority over inspection for secondary inspection of the labia, vagina, and cervix for laceration
causes of bleeding. If a firm, contracted uterus is felt, a search or hematoma. Noncomplex (first or second degree), easily
for other causes should be initiated promptly. accessible lacerations can be repaired with absorbable suture.
Without palpation or visualization of a frankly prolapsed Cervical lacerations and third- and fourth-degree lacerations
uterus, it may be difficult to differentiate uterine inversion should be repaired by an obstetrician. Temporary hemostasis
from severe atony. Heavy bleeding may make visualization of may be achieved by direct pressure or, in the case of cervical
the cervix impractical. In addition, accurate abdominal palpa- lacerations, by gentle application of ring forceps to the bleed-
tion for a uterine fundus may be impossible in an obese ing point.
patient. Depending on factors such as patient stability, Retroperitoneal hematoma is a potentially life-threatening
resources, and diagnostic uncertainty, ultrasonography or condition that may be manifested as hypotension, cardiovas-
laparotomy may be necessary. In stable patients in whom the cular shock, or flank pain. Once a diagnosis is made,
diagnosis is uncertain and resources are available, prompt treatment should be supportive until the obstetrician, inter-
ultrasound scanning may be helpful.9 Ultrasonography may be ventional radiology, or the operating room is available.
able to identify retained products or clot in the uterus, but First-line interventions for atony are part of the initial
manual exploration is still needed. Ultrasound can also help management of postpartum hemorrhage—namely, initiation
detect peritoneal free fluid suggestive of uterine rupture. In of bimanual uterine compression, IV oxytocin, and clearing
selected circumstances in stable patients, a computed tomog- of products of conception and clots from the uterus. If bleed-
raphy scan can be useful in making the diagnosis in those with ing persists after the initial interventions, additional utero-
postpartum hemorrhage (retroperitoneal hematoma). If the tonic medications should be given (see Table 122.1). The
accompanying hemorrhage or shock is sufficiently alarming choice of agent may be influenced by the side effect profile,
to require immediate exploration, the correct diagnosis may but the best drug is probably the agent that is the most
be established only at laparotomy. quickly available in the ED. Interventional radiology may be
Although congenital coagulation defects may be relatively beneficial because embolization may control the bleeding. In
rare, consumptive, dilutional, and disseminated intravascular any case, temporizing measures may be required until defini-
coagulopathies are important considerations. Depletion of tive intervention (Table 122.2).
platelets and soluble clotting factors after blood loss and Uterine tamponade with sterile gauze and balloon tamponade
subsequent crystalloid and packed red blood cell replacement are commonly used temporizing measures. Uterine balloon
is difficult to distinguish clinically from disseminated tamponade has been described with large Foley catheters,
intravascular coagulopathy. Placental abruption, amniotic Sengstaken-Blakemore tubes, condom catheters, sterile gloves,
fluid embolism, HELLP syndrome (hemolysis, elevated liver and Rusch urologic catheters, as well as with catheters specifi-
enzymes, and low platelet count), and intrauterine demise cally designed to be used for uterine tamponade in patients with
are pregnancy-related risk factors for disseminated intravas- postpartum hemorrhage (SOS Bakri tamponade balloon).10
cular coagulation. Initial laboratory studies include a com-
plete blood count, coagulation studies, disseminated UTERINE INVERSION
intravascular coagulation panel, liver function tests, and basic Management of uterine inversion has two important compo-
metabolic panel. nents: treatment of hemorrhagic shock and immediate repo-
sitioning of the uterus (Fig. 122.2). Resuscitation should be
initiated immediately and continued while attempts are made
TREATMENT to reposition the uterus manually. If oxytocin is being infused,
it should be stopped once uterine inversion is suspected.
The most important aspects of managing postpartum hemor- The success of nonsurgical replacement depends on com-
rhage are obtaining hemostasis and treating shock, including pletion before the myometrium regains its tone. The reported
supplemental oxygen, placement of two large-bore intra rate of successful immediate reduction is between 40% and
venous (IV) lines, hemodynamic monitoring, and volume 80%.11 If initial measures are delayed or fail to relieve the
replacement. In addition, blood should be typed and cross- condition, the inversion may progress to the point at which
matched and 4 to 6 units of packed red blood cells should be operative treatment or even hysterectomy is necessary.
available. Consultation with the obstetrics service should be The most common nonsurgical replacement method is a
arranged. Along with the initial resuscitation, bimanual variation of the Johnson maneuver.12 The prolapsed uterus is
1054
Known or Transfuse blood

suspected components
coagulopathy (cryoprecipitate)
Abdominal pain
Consider uterine
and/or shock
rupture CT if stable (see
ABCs, w/out
Suspected retroperitoneal UR section)
notify OB, significant
postpartum hematoma
bloodbank, vaginal bleed
hemorrhage
IR
Mass protruding Replace uterus
Uterine inversion
from or in vagina (see UI section)
Associated sudden
Consider AFE See AFE section
CV collapse?
No Placenta
Explore
uterus delivered?
Yes
Indistinct Distinct Uterine

cleavage cleavage massage
plane? plane? and oxytocin
Consider Extract
placenta placenta Fundus Fundus
accreta firm? soft?
Try other
oxytocics:
Bimanual Methergine, OB available
Presumed
compression, Hemabate, to go to
uterine atony
stabilize for OR Prostin E2, or OR/IR?
and probable misoprostol
hysterectomy No
Consider atony
treatment Consider
and rule out temporizing
other causes measures:
balloon,
Inspect for uterine pack,
cervical, factor VII,
vaginal, aortic compression
or vulvar
lesions
Uterine rupture
See UR
suspected or
Vaginal vulvar Laceration No lesions section
confirmed
hematoma found
Retained
≤4 cm and ≥4 cm and Repair if Explore Remove
placenta
stable growing possible uterus
or clot
Consider
coagulopathy,
Ice and Drain, No DIC (bedside
pack, and Still
recheck abnormalities test or empiric
recheck bleeding
found treatment)
Fig. 122.1 Algorithm for postpartum hemorrhage management strategies. ABCs, Airway, breathing, and circulation; AFE, amniotic
fluid embolism; CT, computed tomography; CV, cardiovascular; DIC, disseminated intravascular coagulation; IR, interventional radiology;
OB, obstetrics; OR, operating room; UI, uterine inversion; UR, uterine rupture.
1055
Table 122.1 Medications
DRUG DOSAGE CLASS COMMENTS
Uterotonic
Oxytocin (Pitocin) 20-40 U/L by wide-open IV Do not give an IV push; IV infusion

infusion at 10 mL/min or first-line choice, IM second choice
10-20 units IM
Methylergonovine 0.2 mg IM, may repeat q2h (max Ergot Contraindicated in those with
(Methergine, 5 doses) preeclampsia or hypertension
Ergonovine)
Carboprost 0.25 mg (250 mcg) IM, may Prostaglandin (15-methyl May cause transient O2 desaturation;
tromethamine repeat q15-90min (max 8 prostaglandin F2α analogue) contraindicated in those with active
(Hemabate) doses) cardiac, renal, pulmonary, or hepatic
disease
Misoprostol (Cytotec) 600-1000 mcg SL or PR; single Prostaglandin (prostaglandin E1 May cause bronchospasm
dose analogue)
Prostaglandin E2 20-mg uterine suppository, may Prostaglandin May transiently decrease blood
(Dinoprostone or repeat q2h pressure
Prostin E2)
Factor VIIa 35-200 mcg/kg, may repeat q2h Human recombinant factor VIIa
(NovoSeven) until hemostasis achieved
Tocolytic
Magnesium sulfate 4 g IV over 20-min period, then Magnesium enzymes Monitor for side effects; has prolonged
2- to 3-g/hr infusion cofactor effects; calcium gluconate may be
needed to reverse tocolysis when
the uterus in place
Terbutaline 0.25 mg SC, may repeat q20min Terbutaline beta-agonist May cause hypotension; tachycardia
common; hold if heart rate >120
beats/min
Nitroglycerin 50 to 100 mcg IV, may repeat as Nitroglycerin nitrate Rapid onset and half-life; transient
needed hypotension; have ephedrine (10 mg
IV) available as remedy
IM, Intramuscular/intramuscularly; IV, intravenous/intravenously; PR, per rectum; SL, sublingually.
cupped in the operator’s palm, and firm upward pressure is bleeding has stopped. Antibiotics should be started as
applied to move the uterus up through the cervix along the soon as practical. Uterotonics are continued for at least 24
natural curve of the pelvis toward the umbilicus until it is in hours.
place. Usually when the inverted mass is pushed upward, the If all other efforts have failed to reposition the inverted
uterus automatically reverts, with the fundus returning to its uterus, operative intervention is required. If the uterus was
anatomic position. If the placenta has not separated, it should repositioned with the placenta attached, manual removal can
not be removed. be attempted once the use of relaxants is stopped. Uterotonics
If initial repositioning is unsuccessful, myometrial relax- should be initiated, and if the placenta cannot be removed
ation with pharmacologic agents should be attempted. Mag- easily, it should be left in place.
nesium sulfate, terbutaline, and nitroglycerin (attractive
because of its easy availability and short half-life) are the UTERINE RUPTURE
agents most commonly used (see Table 122.1).13 Attempts at Initial management of uterine rupture differs and is based on
manual repositioning of the uterus should continue. the stability of the patient and fetus. Because the results of
After successful reduction, the uterus should be supported examination are normal in most patients with uterine rupture
for several minutes to allow the ligaments to return to and because fetal distress is the most common finding, initial
their original state while uterotonics are administered. If management will probably be the same as that for other causes
magnesium sulfate was administered as a tocolytic, calcium of acute fetal distress—urgent delivery.
gluconate can be given to reverse the tocolytic effect. Fluid The physician should consult obstetrics on an emergency
and blood replacement and manual uterine massage should basis, ensure adequate IV access, notify the blood bank, and
be maintained until the uterus is well contracted and the alert the neonatal team to be ready for intensive care newborn
1056
Table 122.2 Temporizing Measures for Hemostasis of Postpartum Hemorrhage
METHOD PROCEDURE COMMENTS
Uterine packing Layer sterile gauze within the uterus, with the distal May adhere to the uterine wall and removal required;
end going out through the os does not allow monitoring of ongoing bleeding;
start prophylactic antibiotics
Balloon tamponade If available and time allows, use bedside

ultrasonography to confirm that the balloon is
beyond the internal os before inflation to avoid
damage to the cervical canal; give prophylactic
antibiotics and continue oxytocin infusion
Foley catheter Insert a large bulb catheter (24 French) into the uterus Multiple catheters may be needed (in a sterile
Instill with 80-100 mL of saline overbag), which makes the inner lumen difficult to
Pack the vagina to avoid expulsion of the catheter monitor
SOS Bakri balloon Insert into the uterus Best option if available; allows direct measurement
Instill 300-500 mL of saline through the stopcock of ongoing bleeding via the open inner lumen;
Pack the vagina developed for postpartum hemorrhage; balloon
conforms to the shape of the uterine cavity
Sengstaken-Blakemore Cut off the distal (“stomach”) end of the tube Does not conform to the shape of the uterine cavity;
tube Insert inside the uterine cavity with the end cut off, proximal bleeding can be
Infuse 75-300 mL of saline monitored through the lumen; may be available
Pack the vagina to avoid expulsion of the tube from the gastrointestinal department laboratory if
not available in the emergency department
Rusch catheter Using a 60-mL bladder syringe, inflate the balloon via Urologic catheter used for bladder stretching; may
the drainage port with 150-500 mL of saline be available in the urology department
Pack the vagina to avoid expulsion of the tube
Condom catheter Slide the condom over the end of the Foley catheter A sterile rubber catheter is fitted with a condom
and tie it off with string to close the end
Inflate with 250-500 mL of saline and clamp the end
Pack the vagina to avoid expulsion of the tube
Vaginal packing Pack the vagina with a blood pressure cuff placed Various techniques have been described; concern
inside a sterile glove for bleeding proximal to the vaginal pack
Increase pressure to 10 mm Hg above systolic blood
pressure
Noninflatable antishock Begin application at the ankles and progress Adjust the panels if any discomfort or dyspnea;
garment sequentially up to the abdomen contraindicated in women with heart failure or
mitral stenosis
resuscitation. If these resources are not available in the hos- mother, as well as pediatric or neonatal services for the
pital, arrangements should be made for immediate transfer. newborn. All patients who deliver in the ED should be admit-
For unstable patients, prompt, aggressive resuscitation is an ted to an obstetric floor after delivery or stabilization of the
important temporizing measure until definitive surgical repair acute complication.
is performed. Fetal morbidity almost invariably occurs because
of catastrophic hemorrhage, fetal anoxia, or both. In a study
of 99 cases of uterine rupture, the best fetal outcomes were PERIMORTEM CESAREAN DELIVERY
noted when surgical delivery was accomplished within 17
minutes from the onset of fetal distress.7
If the patient is stable, no signs of fetal distress are present, or EPIDEMIOLOGY
the diagnosis is unclear, ultrasonography can be useful. Ultra-
sound findings include lack of normal orientation, uncertain pla- Maternal arrest is estimated to occur in 1 in 4000 to 6500
cental location, fetal demise, and absence of amniotic fluid. pregnancies in the United States.14-16 In any maternal arrest
that occurs beyond 24 weeks’ gestation, perimortem cesarean
delivery should be considered as a potentially lifesaving inter-
FOLLOW-UP, NEXT STEPS IN CARE, vention for both the mother and the fetus.17
AND PATIENT EDUCATION When comparing causes of death in the cohort of women
undergoing perimortem cesarean delivery with all maternal
Obstetric consultation should be obtained on an emergency deaths, trauma accounts for a larger proportion in the former
basis to assist in the delivery and postpartum care of the group.18 Perimortem cesarean delivery is one of the oldest
1057
• ABCs
Is UI acute?
Uterine • 2 large-bore IV lines
(before cervical
inversion • STOP any oxytocin
ring contracts)
• Notify OB
Yes
• Manually support uterus
for several minutes Uterus Immediate attempt No
• Discontinue tocolytics in place to reduce uterus
• Start uterotonic meds
(see Table 122.1) Failed
attempt
Initiate tocolytic therapy:

Initiate bimanual magnesium sulfate,
uterine compression terbutaline, or nitroglycerin
(see Table 122.1)
Remove placenta if
necessary (if not Reattempt to
abnormally adherent) reduce uterus when
once uterus contracts patient is stable
and bleeding is controlled
Failed
attempt
• Continue uterotonic Consider general

meds for 24 hours anesthesia with
• Start IV antibiotics halogenated agent
Failed
attempt
Surgical
repositioning
of uterus
Fig. 122.2 Algorithm for uterine inversion management strategies. ABCs, Airway, breathing, and circulation; IV, intravenous; OB,
obstetrics; UI, uterine inversion.
caesare”—consequently the name cesarean operation. The

TIPS AND TRICKS first documented maternal survival after cesarean delivery
was a Swiss woman sectioned by her husband in 1500.
Peripartum Hemorrhage
Use an endotracheal tube 0.5 to 1 mm smaller than you
would normally use because the airway may be narrowed PATHOPHYSIOLOGY
from edema.
Even under ideal conditions, cardiac output from chest com-
Compensate for reduced ventilation volumes (because of an
pressions in a gravid patient is about 10% of normal. Cardiac
elevated diaphragm) with a higher respiratory rate.
output can be improved by displacing the uterus or tilting the
The left lateral position, manual uterine displacement, and
patient (left lateral decubitus position); however, a decrease
perimortem cesarean delivery may improve the maternal
in effective chest compressions occurs with an increase in the
circulation.
patient’s body tilt.20
Do not use a femoral vein for a central line.
Fetal outcomes are most directly related to the time from
Follow the standard advanced cardiac life support guide
maternal arrest to delivery. Other important variables are the
lines for resuscitation, medications, and defibrillation
maturity of the fetus, the performance and effectiveness of
doses (remove any fetal or uterine monitors before
maternal cardiopulmonary resuscitation, the cause of the
defibrillation).
maternal arrest, and the availability of a neonatal intensive
Administer calcium gluconate (1 ampule or 1 g) for arrest
care unit (NICU).
from suspected magnesium toxicity.
surgical procedures in history, with the first reference to a DIFFERENTIAL DIAGNOSIS AND MEDICAL
successful postmortem cesarean section recorded in 237 DECISION MAKING
bce.19 Under the emperors of Rome, the Caesars, a law
decreeing that a child be excised from the womb of any Perimortem cesarean delivery is indicated for gravid patients
woman who died late in pregnancy became known as the “lex more than 24 weeks pregnant (or the uterine fundus is four
1058
BOX 122.2 Procedure for Perimortem

Cesarean Delivery
AMNIOTIC FLUID EMBOLISM
Using a No. 10 blade, make a midline vertical incision that

EPIDEMIOLOGY
goes through all abdominal layers to the peritoneal cavity,
which extends from the umbilicus to the pubic Amniotic fluid embolism and the resulting anaphylactoid syn-
symphysis. drome of pregnancy occur in late pregnancy or immediately
Separate the rectus muscles in the midline and enter the postpartum. Though rare (roughly 1 in 8000 to 80,000 preg-
peritoneum. If available, retractors can be used to expose nancies), it is responsible for about 10% of all maternal deaths
the anterior surface of the uterus. If the bladder is full, in the United States and is the most common cause of peri-
it may be seen inferior to the uterus. A Foley catheter partum death.22
is optimal, but under pressing conditions the bladder can
be drained with a small scalpel incision and applied
pressure.
PATHOPHYSIOLOGY
To enter the uterus, start with a vertical incision through the
lower uterine segment until amniotic fluid is obtained or Despite knowledge of this deadly syndrome for more than 80
the uterine cavity is clearly entered. Next, lift the uterine years, its cause and pathophysiology are not fully understood.
wall away from the fetus with two fingers and use blunt The criteria to make the diagnosis are still controversial, and
scissors to extend the incision vertically to the fundus; no management interventions have been proved to improve
allow generous exposure. The membranes should be rup- outcomes or prevent the syndrome.23 The term anaphylactoid
tured and the baby delivered. syndrome of pregnancy is considered more appropriate than
Suction the infant’s mouth and nose, and clamp and cut the the term amniotic fluid embolism because of lack of evidence
cord. If the mother regains stable vital signs, remove the supporting a causative embolic event.24
placenta and repair the uterus, abdomen, and bladder. Anaphylactoid syndrome of pregnancy, from a clinical,
hemodynamic, and hematologic standpoint, is similar to ana-
phylaxis and septic shock and suggests the possibility of a
shared pathophysiologic mechanism.25 The syndrome appears
80 100 to be initiated after maternal intravascular exposure to fetal
% Infants
60
40 50
tissue. Fetal-maternal tissue transfer is common and probably
20 normal. It is proposed that when fetal antigens breach a mater-
0 0 nal immunologic barrier in some women, release of endoge-
0-5 6-10 11-15 16-25 nous mediators is triggered, and an anaphylactoid syndrome
can occur.24
Time interval (minutes)
Neurologic damage is seen in as many as 85% of survivors
% Survival of anaphylactoid syndrome.25 The mechanism of neurologic
% Neuro intact injury is thought to be severe hypoxia leading to encephalopa-
thy and seizures. The increased metabolic demand concurrent
Fig. 122.3 Perimortem cesarean delivery: fetal outcomes in with seizures (seen in 50%) may worsen the brain injury,
relation to time interval from maternal arrest to delivery. especially in the setting of hypoxia.3 Disseminated intravas-
cular coagulation developed within 4 hours of initial evalua-
tion in more than 80% of patients.25 If diffuse bleeding occurs,
fingerwidths above the umbilicus if the gestational age is hemorrhagic shock can contribute to the hypotension.
unknown) if arrest continues after 4 to 5 minutes of cardio-
pulmonary resuscitation. In a study by Katz et al.,17 among
the cases with available data on maternal hemodynamics PRESENTING SIGNS AND SYMPTOMS
during resuscitation, more than half the women had a “sudden
and often profound improvement, including return of pulse The classic manifestation of anaphylactoid syndrome of preg-
and blood pressure at the time the uterus was emptied.” The nancy is acute hypoxia or respiratory arrest with associated
study concluded that perimortem delivery should be per- cardiovascular failure, altered mental status, seizures, and
formed within 4 minutes of maternal arrest if resuscitation coagulopathy in the immediate peripartum period. It typically
was ineffective. An update published in 2005 strongly sup- occurs abruptly and with catastrophic outcomes, but less
ported this conclusion,17 and the 2010 American Heart Asso- severe forms of this syndrome have been described. In about
ciation guidelines for cardiac arrest associated with pregnancy 10% of patients the diagnosis is made postpartum, and it has
agree with this window (even sooner if it is clear that the been diagnosed as late as 48 hours postpartum.
mother has a grave or nonsurvivable injury).21
DIFFERENTIAL DIAGNOSIS AND MEDICAL

TREATMENT DECISION MAKING
See Box 122.2, “Procedure for Perimortem Cesarean Deliv- The National Registry’s criteria for the diagnosis of amniotic
ery,” and Fig. 122.3. fluid embolism are included in Box 122.3. The diagnosis of
1059
vasopressors, and inotropes as needed. The blood bank should

BOX 122.3 National Registry Criteria for be notified and packed red blood cells, platelets, fresh frozen
the Diagnosis of Amniotic Fluid Embolism plasma, cryoprecipitate, and factor replacement should all be
used as needed to treat disseminated intravascular coagula-
Acute hypotension or cardiac arrest tion. If the fetus is still not delivered at the time of arrest,
Acute hypoxia (defined as dyspnea, cyanosis, or respiratory perimortem cesarean delivery should be initiated within 4 to
arrest) 5 minutes of resuscitation.
Coagulopathy (defined as laboratory evidence of intravascu-
lar consumption or fibrinolysis or severe clinical hemor-
rhage in the absence of other explanations)
Onset during dilation and evacuation, labor, cesarean deliv-
RED FLAGS
ery, or within 30 minutes postpartum
Absence of other significant, confounding conditions or
explanation of the symptoms and signs listed here Underestimating the degree of blood loss in patients with
peripartum hemorrhage or not appreciating moderate-
appearing bleeding
Modified from Clark SL, Hankins GD, Dudley DA, et al. Amniotic fluid
Delaying uterine inversion replacement, which increases
embolism: analysis of the national registry. Am J Obstet Gyrecol
1995;172:1158-69. mortality (increases the risk and degree of hemorrhage
and shock) and decreases the likelihood of success
ful nonsurgical repositioning because of cervical
constriction
BOX 122.4 Differential Diagnosis Not performing emergency cesarean delivery in maternal
of Anaphylactoid Syndrome (>24 weeks of gestation) cardiac arrest not immediately
of Pregnancy (Amniotic Fluid Embolism) reversed by cardiopulmonary resuscitation
Overlooking intrauterine, intravaginal, intraperitoneal, or ret-
Cardiovascular Collapse, Hypotension roperitoneal accumulation of blood in a hemodynamically
Acute coronary syndromes, myocardial infarction unstable peripartum patient
Cardiomyopathy Presuming that patients with active bleeding are stable
Pulmonary embolism because they have normal vital signs
Anesthesia complications, transfusion reaction
Sepsis, systemic inflammatory response syndrome
Respiratory Arrest
Pulmonary embolism, air embolism
Anesthesia complications, transfusion reaction
FOLLOW-UP, NEXT STEPS IN CARE,
Aspiration AND PATIENT EDUCATION
Altered Mental Status, Seizure Patients who survive long enough to be transferred to the
Eclampsia intensive care unit have a better prognosis, but the overall
Cerebrovascular accident mortality is reported to be 60%.25 In one study, only 8% of
Hypoglycemia patients who had cardiac arrest as part of the initial findings
Coagulopathy survived neurologically intact. The infant survival rate was
Disseminated intravascular coagulation reported to be 70%, but almost half of the survivors had neu-
Consumptive coagulopathy from hemorrhage rologic damage. If arrest occurs, a short arrest-to-delivery
interval is associated with improved neonatal outcomes.25
anaphylactoid syndrome of pregnancy is one of exclusion. Its

dramatic and rapid onset should prompt immediate action;
death has been reported in 30 minutes to 7 hours after onset, For expanded content on nonvertex
with most deaths occurring within the first 2 hours. The initial presentation in delivery, cord-related
signs and symptoms can be difficult to differentiate from complications, shoulder dystocia, premature
rupture of membranes and preterm premature
those seen with other serious causes, but management,
rupture of membranes, and multiple gestations,
with a focus on cardiopulmonary stabilization, is similar see www.expertconsult.com.
(Box 122.4).
TREATMENT
REFERENCES
No studies have shown that targeted intervention improves
maternal prognosis. Management includes early definitive References can be found on Expert Consult @
airway control with endotracheal intubation, IV fluids, www.expertconsult.com.
1060
physicians lack practical experience in identifying fetal

NONVERTEX PRESENTATION IN presentation.
DELIVERY Ultrasound is extremely helpful in confirming fetal lie if it
is available on an emergency basis. To date, no studies have
evaluated the diagnostic ability of bedside ultrasound per-
EPIDEMIOLOGY formed by emergency medical physicians in the setting of
emergency delivery. Although information obtained from this
Excluding nuchal cord, breech presentation is the most modality is helpful, it does not directly alter the basic manage-
common malpresentation of the fetus. It complicates 4% of ment principles of emergency delivery of a breech fetus;
all births with a bias toward premature, low-birth-weight instead, it clues the physician to a potentially difficult delivery
infants. Frank breech is the most common, followed by foot and underscores the need for urgent obstetric assistance.
ling and complete. Prolapsed umbilical cord is a dreaded
complication of breech presentation and was demonstrated to
be a negligible risk with frank breeches, occurred about 5% TREATMENT
to 6% of the time with complete breeches, and had an alarm-
ing incidence of 15% to 20% with footling breeches.26 After assessment of the ABCs (airway, breathing, and circula-
tion) of the mother, evaluation of fetal heart tones (FHTs),
and a brief focused history, the physician should arrange for
PATHOPHYSIOLOGY immediate obstetric/gynecologic and NICU assistance. Even
though many breech presentations will be delivered with
Breech presentation is typically divided into complete (hips minimal complications, a significant proportion will not.
and knees flexed), frank (hips flexed, knees extended), and Therefore, if at all possible, transfer to a facility with in-house
incomplete (one or both hips extended, termed footling). Pre- obstetrics is indicated. If delivery is unavoidable, adequate
maturity and congenital defects are the primary risk factors nursing assistance will be needed. Frequent serial FHT mea-
associated with breech presentations. Because of the abnor- surements can be used to document fetal health, but ED
mal presenting body part, the cervical aperture may not be management in the absence of obstetric/gynecologic assis-
fully occluded, which can allow the cord to potentially pro- tance will not change based on these heart rates.
lapse and entangle with the fetus at any point after membrane Although a few ancillary maneuvers may be called for
rupture. Alternatively, a nuchal arm may occur in which the during a breech delivery, the most important one is patience.
fetal arm is entrapped posterior to the neck. This complication It is generally agreed that the physician need only provide
may result in fracture of the clavicle or humerus, brachial support to the mother until the umbilicus is at the introitus for
plexus injury, or hypoxic insult from entrapment of the two reasons. First, the cervix needs to have sufficient time to
fetal head. dilate to prevent entrapment of the aftercoming head. Second,
The other nonvertex presentations include face, brow, and traction on the fetal body will cause it to descend in the pelvis
transverse lie. In a face presentation the fetal head is in full and remove the potential stabilizing effect of the contracted
extension. A brow presentation is midway between this and uterus on the fetal head. Without this effect, the head is likely
vertex. A transverse lie is an instance in which the fetal pole to move from normal, stable flexion to extension. Hyperexten-
is transverse relative to the maternal pelvis, a situation likely sion of the neck during passage can cause catastrophic cervi-
to never be seen by an ED physician given the impossibility cal spine injury.
of delivering a fetus in this position. Maternal expulsive efforts are the primary force required
to deliver the fetus. If it becomes clinically necessary, an
episiotomy may be performed to provide additional working
DIFFERENTIAL DIAGNOSIS AND MEDICAL room and easier passage of the fetus. In addition, throughout
DECISION MAKING any of the following maneuvers, gentle downward traction
should be applied. Once accessible, the bony pelvis should be
The differential diagnosis for fetal malpresentation includes the landmark used to successfully grip and manipulate the
breech (as well as determination of the subtype of breech), fetus. A warm, wet towel over the fetus can help prevent slip-
other nonvertex presentations, prolapsed umbilical cord, and page associated with vernix.
multigestation delivery. Shoulder dystocia, though certainly Although they often pass spontaneously, the legs may need
an abnormal presentation, is easily differentiated by its occur- assistance to be freed in a frank breech presentation. Once the
rence after the delivery of a vertex head. One must also buttocks have passed through the introitus, the provider frees
be vigilant for the potential aforementioned complications a given leg by placing two fingers on medial aspect of the
associated with breech delivery—a nuchal arm (fetal thigh and pushes laterally while holding the fetal body stable.
arm entrapped posterior to the neck) and a prolapsed, entra This external rotation brings the knee through the introitus
pped cord. and frees the leg. This maneuver is then repeated on the other
When the sterile glove examination is performed, the physi- leg (Fig. 122.4).
cian may feel either the buttocks (including the sacral bone, No more than gentle downward traction should be applied
ischial tuberosities, and anus—the latter two occurring in a until the fetal scapulae are visible. At this point, rotation of
horizontal line with respect to each other) or one of the the fetal torso 90 degrees in one direction should elicit deliv-
extended fetal legs. Insertion of a finger into the fetal anus ery of a shoulder, followed by 180-degree rotation in the other
should reveal the reflexive sphincter tone. There may also direction for the remaining shoulder (clockwise for the left
be meconium on withdrawal of the finger. Still, most ED and counterclockwise for the right) (Fig. 122.5). The goal is
1060.e1
head in flexion during its removal. The physician should kneel

on one knee while performing this maneuver to be at the level
of the maternal pelvis and prevent the tendency to lift the fetus
(and extend the neck) while extracting. Ancillary staff may
provide suprapubic pressure to assist in this maneuver, which
should be performed in tandem with maternal expulsive
efforts.
Once delivered, the neonate should be assessed and resus-
citated in the usual fashion. Treatment of the mother should
continue as usual until passage of the placenta and assessment
for hemorrhage or other postpartum complications.
If at any point an entangled umbilical cord should become
apparent, manual decompression should be performed. If it
cannot be manually reduced immediately, all maternal efforts
to push should be stopped, and emergency cesarean section is
required. Other temporizing measures include placing the
A mother in the knee-chest position, filling the bladder with
saline, or tocolysis—ideally these measures should be decided
with obstetric consultation.
Face, brow, and transverse presentations are simple to
manage from an emergency medicine perspective. Face and
brow presentations may spontaneously evolve to a favorable
situation, thereby giving rise to the obstetric adage “if a face
is progressing, leave it alone.” Any facial or brow presentation
that does not progress and every transverse lie require surgical
intervention. There are no additional ED maneuvers for these
presentations, only for their potential complications such as
prolapsed cord or hemorrhage.

AND PATIENT EDUCATION
Obstetric consultation should be obtained on an emergency
basis to assist in the delivery and postpartum care of the
B mother, as well as pediatric or neonatal services for the
newborn. All patients who deliver in the ED should be admit-
ted to an obstetric floor after delivery or stabilization of the
Fig. 122.4 After spontaneous expulsion of the umbilicus, acute complication.
external rotation of each thigh (A) combined with opposite rotation
of the fetal pelvis results in flexion of the knee and delivery of each
leg (B). (From Gabbe SG, Niebyl JR, Simpson JL, et al. CORD-RELATED COMPLICATIONS
Obstetrics—normal and problem pregnancies. 5th ed. Philadelphia:
Churchill Livingstone; 2007.)
EPIDEMIOLOGY
Higher rates of prolapse and entanglement are associated with
to turn the fetus “into” the shoulder that is attempting to be abnormalities in fetal presentation, such as abnormal lie,
freed. If this maneuver does not free the shoulder, a nuchal breech orientation, and compound presentation, with prema-
arm should be suspected. The physician should attempt to turity, and with multiple gestations. A nuchal cord is extremely
manually splint and sweep the flexed arm over the thorax (in common, with at least one loop appearing in upward of 30%
a manner similar to posterior shoulder delivery for shoulder of pregnancies. This finding alone rarely results in fetal mor-
dystocia) to enable its passage. Upper extremity and clavicle bidity27 and should perhaps be considered a normal variant.
fractures are a common complication.
The Mauriceau maneuver (Fig. 122.6) is used if the fetal
head fails to pass easily. The physician slips the index and PATHOPHYSIOLOGY
middle fingers under the anterior surface of the fetus and
places them against the fetal maxilla. The fetal torso therefore Umbilical cord complications can occur in any delivery.
rests on the physician’s forearm with the legs straddling down. Because of the compact environment, the fetal limbs are
The other hand is then inserted over the fetal back to grasp closely approximated to the body and are rarely the site of
the shoulders and provide downward traction in concert with entanglement. Instead, loops of cord are more commonly
traction on the maxilla, not the mandible, to keep the fetal found around the neck or fetal torso. Compression most often
1060.e2
A B
Fig. 122.5 When the scapulae appear under the symphysis, the
operator reaches over the left shoulder, sweeps the arm across the
chest (A), and delivers the arm (B). Gentle rotation of the shoulder
girdle facilitates delivery of the right arm (C). (From Gabbe SG,
Niebyl JR, Simpson JL, et al. Obstetrics—normal and problem
pregnancies. 5th ed. Philadelphia: Churchill Livingstone; 2007.)
C
occurs as the cord passes through the cervix or, rarely, from
tension applied around an entangled fetal part. The most
important factor in these situations is patency of the umbilical
vessels with sufficient blood flow. If a cord is tightly entrapped
or impacted on a structure, blood flow will be inadequate and
fetal hypoxia will result. Functionally, the only way to pre
vent fetal hypoxia in this situation is to restore umbilical
blood flow either by manually decompressing the cord or by
completing delivery so that the fetus is capable of oxygenating
independently.

DECISION MAKING
Umbilical cord prolapse is a fairly straightforward diagnosis
Fig. 122.6 Cephalic flexion is maintained by pressure (heavy
arrow) on the fetal maxilla (not the mandible!). Frequently, delivery
that is made by identifying the cord on passage through the
of the head is easily accomplished with continued expulsive force introitus or by palpation during vaginal examination. Given
from above and gentle downward traction. (From Gabbe SG, Niebyl the unreliable presence of continuous tococardiographic mon-
JR, Simpson JL, et al. Obstetrics—normal and problem itoring in the ED, monitoring of the fetal heart rate cannot be
pregnancies. 5th ed. Philadelphia: Churchill Livingstone; 2007.) the main modality used to help diagnose occult cord compres-
sion. Nuchal or torso loops are common, and several loops
may be identified. Rarely, knots, kinks, or torsion of the cord
1060.e3
may occur. Diagnosis of a fetus with abnormal presentation

raises the likelihood of a cord emergency. No ancillary radio- SHOULDER DYSTOCIA
graphic or laboratory tests can be used to diagnose a prolapsed
or entrapped cord.
EPIDEMIOLOGY
TREATMENT Shoulder dystocia is recorded to occur in anywhere from 0.2%

to 3% of all births—the variance being caused by discordant
As with any patient in labor, the ABCs, FHTs, and a brief definitions of this condition. Spong et al. proposed criteria
focused history are the first priority. Early obstetric and neo- that include greater than a 60-second delay between delivery
natal help should be called once either emergency delivery or of the fetal head and delivery of the body or the use of ancil-
a cord-related complication is recognized. Sufficient ancillary lary delivery maneuvers,30 but this was found to prospectively
staff to resuscitate two patients should be available, and a type identify only 72% of cases of shoulder dystocia.31
and crossmatch should be ordered for both potential hemor- Many risks for shoulder dystocia have been proposed,
rhage and Rh antigen determination. including (but not limited to) fetal macrosomia, maternal dia-
As soon as cord prolapse is recognized, the treatment of betes, maternal obesity, and previous history of dystocia.
choice is emergency cesarean section. Manual decompression However, most studies that have posited these risk factors for
of the umbilical cord from the fetal presenting part must be dystocia are retrospective and are not borne out prospectively.
maintained until cesarean section is performed. If accom- The most consistent risk factor is fetal macrosomia—based
plished in less than 10 minutes, infant mortality from prolapse on actual, not estimated weight. Still, even for neonates
drops significantly. Compression usually occurs at the level of weighing more than 4000 g at delivery, shoulder dystocia will
the cervix because this is the point of smallest diameter in the complicate only 3.3% of deliveries.32
birth canal (especially when the presentation is nonvertex). Although its occurrence can be terrifying, death from dys-
When prolapse is recognized, all maternal pushing should tocia is relatively rare. One study showed the approximate
cease. The clinician must provide continuous manual separa- incidence of fatal shoulder dystocia to be 0.025 per 1000
tion of the presenting part from the cord to maintain patent flow deliveries.33 The most common injury associated with shoul-
until an emergency cesarean section is performed. Other tech- der dystocia is brachial plexus palsy, which has been reported
niques to assist in removing some pressure from the cord are in up to 20% of deliveries involving shoulder dystocia. Thank-
to place the mother in either the Trendelenburg or knee-chest fully, the large majority of these palsies are transient.
position while continuing to hold manual decompression.
In the rare instance in which obstetric surgical assistance is
not going to be available on a timely basis, the provider may PATHOPHYSIOLOGY
need to manually reduce the cord into the uterus and rapidly
deliver the fetus vaginally. Reduction of the cord into the In shoulder dystocia, the fetal shoulders fail to clear the pelvis
uterus, called funic reduction, should be done only when properly. The fetus assumes a position that places the shoul-
consultation with an obstetrician reveals that no other viable ders in an anteroposterior plane between the pubis and sacrum,
option is available to quickly treat the prolapse. whereas in a normal delivery they are slightly oblique from
In the case of nuchal or body loops, it should be remem- this orientation (Fig. 122.7). This abnormal position forces the
bered that a loose loop of cord will probably still have good fetus to pass through a narrower pelvic diameter, which results
perfusion. It has been repeatedly demonstrated that a nuchal
cord alone does not have a significant impact on fetal
outomes.28,29 Therefore, in the absence of arrest of labor or
identifiable cord entrapment, the cord should simply be
reduced from the fetal neck and labor allowed to proceed as
usual. However, excessive manipulation of the cord should be
avoided to prevent vasospasm. Once the fetal mouth and nares Natural axis of shoulders
are suctioned and spontaneous respirations are initiated, the
cord may be clamped and separated from the neonate in the
usual fashion.

AND PATIENT EDUCATION Axis of head

mother, as well as pediatric or neonatal services for the
newborn. All patients who deliver in the ED should be admit- Fig. 122.7 After delivery of the head, “restitution” results in the
ted to an obstetric floor after delivery or stabilization of the long axis of the head reassuming its normal orientation to the
acute complication. Actively prolapsed cords need to be man- shoulders as seen here. (From Gabbe SG, Niebyl JR, Simpson JL,
ually decompressed and the mother taken to the operating et al. Obstetrics—normal and problem pregnancies. 5th ed.
room for delivery by cesarean section on an emergency basis. Philadelphia: Churchill Livingstone; 2007.)
1060.e4
in shoulder impaction. Most of the time the impaction occurs

when the anterior shoulder fails to clear the pubis. Maneuvers
that augment these impactions are the basis of treatment.

DECISION MAKING
Shoulder dystocia is caused by arrest of labor after passage
of the fetal head. It classically results in the “turtle sign,” in
which the fetal head retracts against the perineum after it is
delivered because of shoulder impaction on the pelvis.
Because most causes of arrest of labor occur before passage
of the head, the only other significant clinical entity to con-
sider is uterine rupture. In this instance, failure of uterine
integrity leads to compromised fetal expulsive force and
similar retraction of the fetal head. This complication is dis- Fig. 122.8 Gentle, symmetric pressure on the head will move the
cussed in the earlier section of this chapter on causes of posterior shoulder into the hollow of the sacrum and encourage
postpartum hemorrhage. delivery of the anterior shoulder. Care should be taken to not “pry”
The diagnosis of dystocia is typically confirmed when the anterior shoulder out asymmetrically because of the potential for
application of gentle downward traction does not lead to pro- trauma to the anterior brachial plexus. (From Gabbe SG, Niebyl JR,
gression of labor. The head is typically facing 3 or 9 o’clock Simpson JL, et al. Obstetrics—normal and problem pregnancies. 5th
ed. Philadelphia: Churchill Livingstone; 2007.)
with respect to the mother. The majority of cases of dystocia
are described as being related to anterior shoulder impaction.
Posterior or bilateral shoulder dystocia can also occur and neck and brachial plexus. If this does not result in fetal pro-
should be suspected if the initial maneuvers aimed at clearing gression, the McRoberts maneuver should be performed next.
the anterior shoulder fail to produce fetal passage. This degree Ancillary staff should provide suprapubic pressure concur-
of impaction is quite complicated and will probably require rently. The McRoberts maneuver (Fig. 122.9) is performed by
obstetric expertise to alleviate. tightly flexing the maternal hips or knees to “pull” the pubis
Shoulder dystocia is a purely clinical diagnosis. No labo back over the anterior fetal shoulder, ideally inducing its
ratory or radiologic testing is needed or helpful in its passage. This maneuver is favored first by most clinicians
diagnosis. because of its simplicity and effectiveness—retrospective
studies, however, indicate it works approximately 40% of the
time.34 These studies have shown that if this maneuver is
TREATMENT combined with suprapubic pressure, the success rate climbs
to between 54% and 59%.35 Suprapubic pressure ( Fig. 122.10)
The most important issue in treating shoulder dystocia is to is intended to aim a force directly over the site of the impacted
be prepared; providers must quickly recognize its clinical anterior shoulder and assist it in sliding beneath the pubis.
features and be knowledgeable about treatment techniques. Fundal pressure has not been shown to be effective in dis-
Panicked forceful traction on the fetal head and neck will not impacting a shoulder and should not be used. If the mother is
disimpact a dystocia and may lead to fetal injury, which may clinically stable and there is a stable surface on which to
include fetal clavicular or humeral fracture, brachial plexus perform it, the “all-fours” or “Gaskin” position may be
injury, or worst of all, fetal hypoxia with brain damage attempted. The reversal of gravitational force combined with
or death. altered pelvic dimensions may result in disimpaction—50%
Shoulder dystocia must be suspected if passage of the fetal of cases in one series were managed by this technique alone.36
body is delayed after delivery of the head. If it has not already The aforementioned maneuvers may be repeated in this
been done, an obstetrician and NICU or pediatrician staff position.
member should be called for assistance immediately. The If these techniques are not successful, the physician should
mother should be monitored appropriately, and if available, a attempt a Woods screw or Rubin maneuver. In the Woods
FHT monitor should be applied. If the latter is not possible, screw maneuver the physician palpates the posterior shoulder
tococardiographic measurements should be obtained and and exerts a force on its anterior side to effect a rotation. This
trended. brings the posterior shoulder around to the anterior side,
If the anterior shoulder does not deliver spontaneously, the which both frees the anterior shoulder and aligns both shoul-
provider may grasp both fetal parietal eminences and provide ders in the ideal oblique pelvic plane. The Rubin maneuver
downward shifting motion traction to “slip” the shoulder (Fig. 122.11) is another rotational technique that is the reverse
under the pubis. A rotary, fulcrum, or bending motion that of the Woods screw maneuver: pressure is applied from the
brings one fetal ear closer to the ipsilateral shoulder should posterior side of whichever shoulder is reachable until fetal
be avoided to prevent brachial plexus injury (Fig. 122.8). axial rotation occurs. Some inward pressure on the fetal head
The delivering physician should exert mild downward trac- (into the vagina) may be required to disimpact a wedged
tion on the fetal head while keeping the cervical spine in line. shoulder before these techniques are used. The decision to
This maneuver prevents use of the head as a fulcrum to “pry” perform either maneuver should be based on accessibility of
the shoulder free, which could lead to stretching of the fetal the fetus and clinical response to their implementation.
1060.e5
Fig. 122.9 The least invasive maneuver to disimpact the shoulders is the McRoberts maneuver. Sharp ventral flexion of the maternal hips
results in ventral rotation of the maternal pelvis and an increase in the useful size of the outlet. (From Gabbe SG, Niebyl JR, Simpson JL,
et al. Obstetrics—normal and problem pregnancies. 5th ed. Philadelphia: Churchill Livingstone; 2007.)
to a dimension that can pass through the pelvis. This maneu-

ver is technically difficult, and clavicular and humeral frac-
tures with associated nerve damage may occur. The physician
locates the posterior arm and first flexes the forearm with
pressure applied into the acromioclavicular fossa. The flexed
arm is then adducted over the chest of the fetus and out of the
maternal pelvis (Fig. 122.12). If labor does not proceed with
this maneuver alone, it may be combined with one of the
aforementioned rotary techniques.
If access to the intrapelvic fetal body is suboptimal, an
episiotomy is indicated. However, it is important to note that
episiotomy is no longer routinely recommended during deliv-
ery. Management by episiotomy or proctoepisiotomy has been
associated with a nearly sevenfold increase in the rate of
severe perineal trauma without the benefit of reducing the
occurrence of neonatal depression or brachial plexus palsy.37
Because of these findings, episiotomy is now recommended
Fig. 122.10 Moderate suprapubic pressure will often disimpact only on a clinical as-needed basis to perform maneuvers
the anterior shoulder. (From Gabbe SG, Niebyl JR, Simpson JL, required to disimpact the fetal shoulders. Episiotomy alone
et al. Obstetrics—normal and problem pregnancies. 5th ed. will not alleviate the dystocia because it does nothing to
Philadelphia: Churchill Livingstone; 2007.) correct the underlying impaction of the shoulder on the
pelvis—it merely provides improved access to the fetal body
If these maneuvers fail, delivery of the posterior arm should to perform manipulations required to complete delivery. To
be attempted. This should be the last intrapelvic maneuver perform an episiotomy, the vaginal fourchette and perineum
attempted given its high association with fetal injury. Delivery are first anesthetized with 1% to 2% lidocaine. The physician’s
of the posterior shoulder aims to reduce the bisacromial diam- fingers are used to both expose the area to be incised and
eter (shoulder width) of the fetus, thereby returning the fetus provide a physical block between the scissors and the
1060.e6
A B
Fig. 122.11 Rubin or reverse Wood screw maneuver for shoulder dystocia. A, Rotate the posterior shoulder. B, Deliver the rotated
shoulder. (From Roberts JR, Hedges JR. Clinical procedures in emergency medicine. 5th ed. Philadelphia: Saunders; 2009.)

AND PATIENT EDUCATION
newborn. If evidence of fetal distress develops or if routine
maneuvers fail to lead to progression of labor, emergency
delivery by cesarean section may be necessary.
PREMATURE RUPTURE OF
MEMBRANES AND PRETERM
A
PREMATURE RUPTURE
OF MEMBRANES
EPIDEMIOLOGY
Rupture of fetal membranes occurring without evidence of
labor is called PROM. It occurs infrequently—less than 5%
of pregnancies are affected. If this event takes place before 37
weeks’ gestation, it is called PPROM. Factors that have been
associated with PROM include infections, maternal smoking,
placentation abnormalities such as abruption or previa, mal-
nutrition, and connective tissue disorders.
B PATHOPHYSIOLOGY
Fig. 122.12 The operator inserts a hand and sweeps the

The chorion and amnion make up the commonly labeled
posterior arm across the chest and over the perineum. Care should “membranes” that surround the growing fetus, with the
be taken to distribute the pressure evenly across the humerus to tougher and thicker chorion surrounding the thinner and more
avoid unnecessary fracture. (From Gabbe SG, Niebyl JR, Simpson elastic amnion. As pregnancy progresses, the structural integ-
JL, et al. Obstetrics—normal and problem pregnancies. 5th ed. rity of these membranes degrades. This breakdown, combined
Philadelphia: Churchill Livingstone; 2007.) with a dilating cervix to act as a focal stress point, is thought
to allow timely, spontaneous rupture in a normal delivery.
Amniotic fluid contents have certain biochemical differ-
delivering fetus. The scissors are then used to incise through ences from vaginal fluid, and these differences are the basis
about one half of the perineum. Care must be taken to try to of some common tests that allow accurate diagnosis of PROM:
avoid extending into the anal sphincter or, worse yet, into the a higher pH (higher in amniotic than in vaginal fluid) and the
anal mucosa and cause third- or fourth-degree lacerations, tendency of amniotic fluid to microscopically crystallize or
respectively. “fern” when allowed to air-dry on a glass slide.
1060.e7
vagina.41 Many EDs do not have a microscope easily available,

DIFFERENTIAL DIAGNOSIS AND MEDICAL and thus testing for ferning of the suspect fluid may be
DECISION MAKING impractical.
Particular attention should be focused on evaluating for
The differential diagnosis for fluid leakage includes bleeding, chorioamnionitis. If maternal fever or unexplained tachycar-
infection, and urinary incontinence. A good history, combined dia is present, the clinical examination should focus on other
with sterile speculum examination possibly supplemented by signs or symptoms of chorioamnionitis. For fetuses younger
Nitrazine pH testing, will often differentiate these causes. than 34 weeks and potentially as late as 37 weeks, prophylac-
The most common complaint in patients with PROM and tic antibiotic administration for PPROM has significantly
PPROM is passage of fluid from the vagina. It may be very improved outcomes.42 For patients after 37 weeks, who by
small in quantity or comparable with the volume noted at the definition have PROM, the question of antibiotics is less clear.
onset of normal labor. There is often continuous seeping of Unless clear evidence of infection or sepsis is present, con-
fluid with visible pooling in the posterior vaginal vault, and sultation with the obstetrician before administering antibiotics
the physician may notice leakage of clear fluid from the still- is prudent.
closed cervix. This leakage may be exacerbated by fundal Tocolytics are often used to prevent progression of labor
pressure or coughing. along with coincident steroid administration to hasten fetal
The history will often reveal a lack of associated contrac- lung maturity in premature infants. However, unless the time
tions, although the presence of Braxton-Hicks contractions to transfer of care is anticipated to be long, these agents
may complicate the diagnosis; differentiation is best left to the should probably not be administered in the ED—and certainly
obstetrician with access to full maternal-fetal monitoring. not without obstetric consultation.
However, sterile speculum examination in the ED should
allow adequate visualization of the cervix to determine
whether it is dilated. FOLLOW-UP, NEXT STEPS IN CARE,
The most significant variant is premature rupture with cho- AND PATIENT EDUCATION
rioamnionitis. Symptoms that suggest this infection are fever,
uterine tenderness, maternal or fetal tachycardia, malodorous Obstetric consultation should be obtained on an emergency
vaginal discharge, or elevated maternal white blood cell count. basis to assist in the care of a patient with suspected rupture
However, none are sufficiently sensitive or specific alone. of membranes, and in general, all these patients should
be admitted or transferred to obstetric care for further
management.
MANAGEMENT AND DISPOSITION
As with every third trimester patient encounter, assessment
and stabilization of maternal ABCs and fetal FHTs are the MULTIPLE GESTATIONS
initial priorities. If the patient complains of passage of fluid,
sterile speculum examination is performed to determine
whether any cervical dilation has occurred. If active crowning EPIDEMIOLOGY
is observed, ED delivery should be anticipated. If signs of
active labor are present but no presenting part is visible, Since the advent of and mainstream access to in vitro fertiliza-
digital examination is indicated to further assess dilation, tion treatments, the incidence of multiple-gestation pregnan-
station, and effacement. If fluid is noted on examination cies has risen greatly. However, these same patients are less
without associated signs of labor, digital examination is con- likely to be in the pool of patients seen in labor in the ED
traindicated and a work-up for PROM or PPROM can begin. because of the intensive prenatal care associated with fertility
Beyond recognition of PROM and PPROM, the most treatments. Patients who have twin or greater gestation by
important intervention is to abstain from a digital vaginal spontaneous means are also very likely to know of their status
examination. The risk for chorioamnionitis after premature and have heightened prenatal care. Multigestation pregnan-
membrane rupture appears to be directly related to the number cies have an inherently higher risk profile that increases with
of examinations performed. Recent data suggest that there is the number of fetuses, with the main factor being the higher
no increase in infectious complications if the number of tendency toward lower birth weight.
examinations is less than two.38 Nevertheless, only a sterile
speculum examination should be performed in the ED.
Nitrazine testing of vaginal fluid may be performed because PATHOPHYSIOLOGY
of its speed and simplicity. This information may be helpful
for the consulting obstetrician but will probably not change During gestation the fetus is surrounded by two separate
management in the ED. Most EDs are equipped with Nitra- membranes—the outer chorion and the inner amnion. This
zine, typically for ophthalmologic evaluation, and perfor- anatomic arrangement can be altered in the case of multiple
mance and interpretation of this test can take place at the point gestations (twins, the most common multiple gestation, will
of care. The vagina is typically an acidic environment, so a serve as the reference point here) (Fig. 122.13).
pH higher than 6.5 is consistent with ruptured membranes. In dizygotic twins (DZ), two separate ova, introduced by
Published sensitivities for this test range from 77% to 92%,39,40 either multiple ovulation or in vitro fertilization, are subse-
with false results most commonly being caused by inadequate quently fertilized by two separate sperm. This results in twins
samples or the presence of blood or bacterial infection of the that are as genetically different as siblings born at separate
1060.e8
pregnancy in the ED should occur with patients who have not

had prenatal care, if a uterus feels larger than anticipated for
dates, or if contractions seem to continue after delivery of the
first fetus. The most clinically useful tool is bedside ultra-
sound, which should easily distinguish a multigestational
pregnancy.
Twin A will be in a vertex position about 80% of the time,
with twin B being in vertex only half as often.43 Therefore,
one must not only anticipate the high likelihood of prematu-
rity associated with multiple gestations but must also be pre-
pared for the potential for a nonvertex delivery for twin B.
Monochorionic Monochorionic
monoamniotic diamniotic
TREATMENT
As with every gravid patient, evaluation of the ABCs and
FHTs and a brief focused history are the first priorities.
Obstetric and NICU assistance should be requested immedi-
ately, particularly given the universally increased morbidity
and mortality associated with multiple gestations.
In the absence of complications, the delivery itself is
handled the same as a singleton delivery—just repeated per
each fetus. If a multigestation pregnancy is identified, arrange-
Dichorionic diamniotic Dichorionic diamniotic ments for enough resources to handle the mother and each of
(fused placentae) (separate placentae) the new patients need to be made early. After delivery of the
Fig. 122.13 Placentation in twin pregnancies. (From Gabbe first child, there is a variable period before active labor of the
SG, Niebyl JR, Simpson JL, et al. Obstetrics—normal and problem subsequent child. Maternal monitoring and frequent FHT
pregnancies. 5th ed. Philadelphia: Churchill Livingstone; 2007.) evaluation should be performed during this time.
If twin A is nonvertex, every effort should be made to delay
labor until a cesarean section can be performed. If twin A is
vertex and B is not, attempted vaginal delivery is recom-
mended if the estimated fetal birth weight (EFW) is greater
times. All these twins have a separate chorion and amnion in than 2000 g.44,45 However, EFW measurements are not rou-
utero, although their placentas may fuse into one if they tinely performed in the ED, nor are continuous monitoring
implant in close proximity. modalities or providers experienced in twin deliveries avail-
In the case of monozygotic twins (MZ), a single zygote able. Therefore, the clinical status of the second twin and the
splits shortly after fertilization. The timing of this split deter- availability of obstetric assistance should be used to decide
mines whether there will be two separate chorions and the best course of action for twin B. The delay between deliv-
amnions, a shared chorion with two distinct amnions, or a ery of twin A and twin B may be fortuitous and provide the
shared chorion and amnion. The risk associated with the preg- needed time for obstetric assistance to arrive and assume care.
nancy progressively increases through the aforementioned If no help is available and crowning is occurring, the nonver-
situations, with dichorionic, diamnionic MZ twins having tex twin B should be handled as any other nonvertex
the same risk profile as a DZ twin pregnancy. In addition delivery.
to the risks associated with any multigestation pregnancy,
monochorionic, monoamnionic twins are susceptible to other
unique complications stemming from their shared anatomy. FOLLOW-UP, NEXT STEPS IN CARE,
This can range from vascular anastomoses leading to twin- AND PATIENT EDUCATION
twin transfusion syndrome through the creation of conjoined,
or Siamese, twins. Obstetric consultation should be obtained on an emergency
DIFFERENTIAL DIAGNOSIS AND MEDICAL newborn or newborns. All patients who deliver in the ED
DECISION MAKING should be admitted to an obstetric floor after delivery or
stabilization of the acute complication. If twins are known
The vast majority of twin pregnancies are discovered during and twin A is nonvertex, delivery by cesarean section is
prenatal ultrasound. Higher suspicion for a multigestation indicated.
1060.e9
24. Azegami M, Mori N. Amniotic fluid embolism and leukotrienes. Am J Obstet

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122

Emergency Delivery and

PRESENTING SIGNS AND SYMPTOMS

massage and IV oxytocin should be initiated (Fig. 122.1 and

Known or Transfuse blood

Indistinct Distinct Uterine

Table 122.1 Medications

DRUG DOSAGE CLASS COMMENTS

Oxytocin (Pitocin) 20-40 U/L by wide-open IV Do not give an IV push; IV infusion

IM, Intramuscular/intramuscularly; IV, intravenous/intravenously; PR, per rectum; SL, sublingually.

Table 122.2 Temporizing Measures for Hemostasis of Postpartum Hemorrhage

METHOD PROCEDURE COMMENTS

Balloon tamponade If available and time allows, use bedside

Initiate tocolytic therapy:

• Continue uterotonic Consider general

caesare”—consequently the name cesarean operation. The

BOX 122.2 Procedure for Perimortem

Using a No. 10 blade, make a midline vertical incision that

DIFFERENTIAL DIAGNOSIS AND MEDICAL

vasopressors, and inotropes as needed. The blood bank should

anaphylactoid syndrome of pregnancy is one of exclusion. Its

physicians lack practical experience in identifying fetal

head in flexion during its removal. The physician should kneel

FOLLOW-UP, NEXT STEPS IN CARE,

DIFFERENTIAL DIAGNOSIS AND MEDICAL

may occur. Diagnosis of a fetus with abnormal presentation

TREATMENT Shoulder dystocia is recorded to occur in anywhere from 0.2%

FOLLOW-UP, NEXT STEPS IN CARE,

Obstetric consultation should be obtained on an emergency

in shoulder impaction. Most of the time the impaction occurs

DIFFERENTIAL DIAGNOSIS AND MEDICAL

to a dimension that can pass through the pelvis. This maneu-

FOLLOW-UP, NEXT STEPS IN CARE,

Fig. 122.12 The operator inserts a hand and sweeps the

vagina.41 Many EDs do not have a microscope easily available,

pregnancy in the ED should occur with patients who have not

24. Azegami M, Mori N. Amniotic fluid embolism and leukotrienes. Am J Obstet

You might also like

Oxytocin (Pitocin) 20-40 U/L by wide-open IV Do not give an IV push; IV infusion