Case Details
OBGYN Case: Difficult Delivery
A 23 year old woman calls 911 for abdominal pain. She is pregnant and her due date is tomorrow. This is her fourth pregnancy and she has had three prior vaginal deliveries. This pregnancy has been uncomplicated. She has not had any vaginal bleeding or leakage of fluid and she can feel fetal movement. She began having contractions 1 hour ago, but things became “intense” about 30 minutes ago, so she called 911.
She has no chronic medical problems.
On examination, she is breathing heavily and having contractions every 2 minutes. Her vital signs are HR 90, BP 112/77, RR 18, O2 saturation 100% on RA
What are the next steps in the management of this patient?
This patient is a multiparous patient in active labor. She should be assessed to see if the fetus is crowning. She is not yet crowning, so transportation to the nearest birthing center should be initiated immediately.
Santa Clara: Gynecological and Obstetrical Emergencies 700-A18
For BLS, routine medical care should be initiated (700-S04) including oxygen titration as appropriate. Her vital signs should be monitored frequently (700-A10).
For ALS transport, vascular access should be obtained.
San Mateo: Adult Medical Treatment Protocols, Pregnancy Complications
Routine medical care should be initiated including oxygen titration as appropriate. She should be placed in left lateral recumbent position. Her vital signs should be monitored frequently and she should be placed on a cardiac monitor. Oxygen should be given. Two large bore IVs should be placed and her blood glucose should be assessed. The receiving facility should be notified. Approved birthing centers include Kaiser Redwood City, Peninsula Medical Center, Sequoia Hospital, Stanford Hospital, and UCSF Benioff Mission Bay. Document all times (delivery, contraction frequency and length, time cord was cut, etc.).
Case Update
Paramedics begin patient transport and obtain vascular access on the way to the nearest birthing center. Repeat vital signs are HR 85, BP 121/75, RR 18, O2 saturation 99% on RA. She has sudden leakage of clear fluid. On examination, the fetal head is not crowning, but the umbilical cord is visible coming out of her vagina.
What are the next steps in the management of this patient?
This patient has a prolapsed umbilical cord.
Santa Clara: Gynecological and Obstetrical Emergencies 700-A18, Prolapsed Cord
Consider placing second IV. Place mother in the supine position with her head lower than her hips. Insert a gloved hand into the vagina and gently push the presenting part of the fetus off of the umbilical cord. Do not tug on the umbilical cord. If you can feel the baby’s nose and mouth, split fingers into a “V” to create an opening. Do not attempt to reposition the cord. Do not remove your hand. Cover the exposed umbilical cord with a saline soaked gauze.
San Mateo: Pregnancy Complication
A second IV should be placed. Wrap the prolapsed cord in saline soaked gauze. Contact base hospital for medical direction.
Learning Points
Umbilical cord prolapse occurs when the umbilical cord passes beyond the presenting fetal part and falls into the cervix or vagina. Cord prolapse is an obstetrical emergency because if the umbilical cord is compressed, the fetus will receive less oxygen and may not survive. Patients with cord prolapse require urgent delivery by cesarean section. Elevating the presenting fetal part off of the umbilical cord by placing a gloved hand within the vagina can improve blood flow through the cord until delivery. Similarly, placing a patient in a supine position with her head below her hips can help decrease pressure on the prolapsed cord and may improve the oxygen supply to the fetus.
Case Conclusion
The paramedics provided initial resuscitation for this patient’s umbilical cord prolapse. The patient was taken immediately to the operating room for an emergency cesarean section. The baby required some initial resuscitation by the neonatal pediatrics team and was admitted to the neonatal intensive care unit for one day. The patient and her baby were discharged home from the hospital after four days.