The Complicated Delivery: What do you do?
- Sep 29th, 2016
- Jamie Linker
Authors: Jamie Linker, MD, MBE (Senior EM Resident Physician, University of Pennsylvania), Christopher Tems, MD (EM Attending Physician, TeamHealth Special Operations), and Kevin R. Scott, MD (@K_ScottMD, EM Attending Physician, University of Pennsylvania) // Edited by: Jamie Santistevan, MD (@Jamie_Rae_EMdoc, Admin and Quality Fellow at UW, Madison, WI) and Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW Medical Center / Parkland Memorial Hospital)
A 19 year-old female is wheeled into your emergency department screaming, “I’m having a baby!” and yelling out in pain. She reports this is her first pregnancy and she is having contractions about every 2 minutes. She has not had any prenatal care, and thinks her last period was about 9 months ago. She denies any medical problems or surgical history. She takes no medications and has no known allergies.
Vitals are obtained by the nurse while you are speaking to the patient: HR 124, BP 126/82, RR 26, spO2 100%, T 98.4.
The patient appears distressed and gravid but otherwise normal. You perform a rapid gynecologic exam to check her station and cervical dilation and find her to be crowning. You instruct your team members to place an IV, prepare for imminent delivery, prepare the infant warmer and equipment, and call obstetrics and neonatology for help.
Deliveries that occur in the emergency department are often higher risk than those that occur on the labor floor. The ED sees a higher proportion of women with precipitous deliveries, immigrants and other patients without access to care, and those who are unaware of or in denial of their pregnancies. In addition, the OB populations who encounter unexpected complications are more likely to present to the emergency department rather than an office or labor floor. ED OB patients often have little or no prenatal care, and ED births have a higher perinatal mortality . The emergency provider needs to expect the unexpected during a delivery, including precipitous delivery, shoulder dystocia, malpresentation, umbilical cord emergencies, hemorrhage, and multiple gestations.
Preparing for Delivery
Call for additional emergency department staff, along with appropriate external support including obstetrics and pediatrics. Remember that there will soon be two patients, and have the team prepare for neonatal care. This includes obtaining and turning on the infant warmer, opening supplies needed for delivery and neonatal care, and preparing resuscitation equipment including a device to provide positive pressure ventilation for the infant. Obtain IV access in the mother so that oxytocin, fluids, blood, and other medications may be administered as needed during the delivery. Remember to wear personal protective equipment, including a gown, mask, eye protection, shoe covers, and sterile gloves. Although difficult during precipitous deliveries in the ED, try to keep the patient and her family informed about what is happening and what to expect.
Case 1: Shoulder Dystocia
Returning to our case above, you deliver the fetal head and then notice the head retract slightly—the ominous “turtle sign”. With the next push you are unable to deliver the anterior shoulder using gentle, downward traction of the head. You recognize a shoulder dystocia and try to remember what to do next to aid the delivery.
Shoulder dystocia is a subjective clinical diagnosis when gentle traction is insufficient to deliver the fetal shoulders after delivery of the fetal head. It occurs in 0.2–3% percent of all births , but cannot usually be anticipated or prevented as most patients lack factors that would suggest increased risk . The fetal shoulders can become malpositioned, with the anterior shoulder impacted behind the symphysis pubis, or less commonly with the posterior shoulder obstructed by the sacral promontory. Complications to the fetus can include nerve injury, acidemia, asphyxia, and clavicular fractures. The mother can suffer postpartum hemorrhage and third and fourth degree perineal lacerations. Nerve injury results from stretching of the brachial plexus, either from uterine contractions against the impacted shoulder or from provider traction on the head. Acidemia and asphyxia are caused by compression of the umbilical cord or of the blood vessels in the neck by a tight nuchal cord. A previously well-oxygenated term infant needs to be delivered within five minutes to prevent asphyxia  and subsequent cortical injury; preterm or previously-insulted fetuses will have less time. Clavicular fracture may be caused by the provider to facilitate delivery, or by the forces of delivery itself. The goal of management is to prevent injury to the fetus or mother, although temporary injuries (e.g. clavicular fractures) are acceptable if necessary in order to prevent permanent injury or death of the child. Even if the emergency provider does everything right, there can still be significant morbidity.
General Management of Shoulder Dystocia
- Instruct the mother to stop pushing as soon as shoulder dystocia is recognized.
- Rapidly assign team members to the tasks below as you begin maneuvers to relieve the dystocia.
- Call for additional help, including nurses, OB, pediatrics, and anesthesia.
- Instruct someone to start a timer and call out 60-second intervals.
- Make sure the mother has IV access and monitoring, and apply oxygen to maximize oxygenation of the fetus.
- Position the mother with her buttocks flush with the edge of the bed to provide optimal access for executing maneuvers and providing posterior-directed leverage.
- Catheterize the bladder to decompress it and improve any anterior obstruction from distension.
- Ask for a stool for a team member to stand on for the application of suprapubic pressure.
- Assign team members to hold each of the mother’s legs for hyperflexion.
- Prepare for neonatal resuscitation—turn on the warmer, open supplies, and designate a team.
Maneuvers for Relieving Shoulder Dystocia
Management should start with simple, less invasive procedures and progress to more complex ones. There have been no randomized clinical trials demonstrating superiority of any particular maneuver used in the management of shoulder dystopias . Start with the McRoberts maneuver, in which the legs are flexed with the knees pulled up towards the mother’s chest, and assign a team member to apply suprapubic pressure. These maneuvers are less invasive than others and are often successful. If these maneuvers fail, the provider should next attempt the Gaskin all-fours maneuver (if the mother is mobile and does not have anesthesia), rotational maneuvers such as the Woods corkscrew or Rubin maneuvers, or delivery of the posterior arm (Barnum maneuver). Throughout all maneuvers, avoid excessive neck rotation, head and neck traction, and fundal pressure as these can stretch the brachial plexus, further impact the shoulders, or cause uterine rupture. After the infant is delivered, sending umbilical cord gases (both arterial and venous) can assist the pediatricians in further evaluation and management.
The HELPERR mnemonic  is used by some to assist in remembering the management steps:
- Help – Call OB, neonatology, anesthesia
- Empty bladder – Catheterize to increase AP diameter
- Legs flexed – McRoberts maneuver
- Pressure – Suprapubic to dislodge anterior shoulder
- Enter vagina – Rubin or Woods corkscrew maneuver
- Remove posterior arm – Barnum maneuver
- Roll – Gaskin maneuver
Classically, the “E” in HELPERR stood for episiotomy, though in current practice catheterizing and emptying the bladder is a more appropriate step. Episiotomy is no longer routinely recommended. While episiotomy does provide more room for manipulation of the posterior shoulder, it does not relieve the bony obstruction of the anterior shoulder or prevent brachial plexus injury [6,7].
McRoberts Maneuver 
- Lay the mother flat on her back, and flex both knees up against the lateral abdomen.
- This increases the AP diameter by rotating the symphysis pubis cephalad and flattening the sacrum .
- McRoberts should be the initial approach for releasing the impacted shoulder (with suprapubic pressure)—McRoberts position alone is successful up to 42% of the time and is less invasive than other maneuvers .
- Apply suprapubic (not fundal) pressure with a palm or fist.
- Direct the pressure on the anterior shoulder of the fetus, both downward (directed below the pubic bone) and anteromedially (toward the fetus’s face or sternum).
- Apply 30 seconds of continuous pressure or try rocking.
- Place assistant on a stool if needed for leverage.
- This pressure is less effective in obese patients, as external pressure is not as well translated to the fetus.
Image of McRoberts maneuver and suprapubic pressure 
Gaskin All-Fours Maneuver 
- The mother is placed on her hands and knees.
- The fetus may become dislodged during the position change itself.
- The fetus is delivered by gentle downward traction on the posterior shoulder (the shoulder against the maternal sacrum) or upward traction on the anterior shoulder (the shoulder against the maternal symphysis).
- This position increases pelvic diameters plus adds the assistance of gravity.
- Gaskin is a good choice if the patient cannot tolerate internal manipulation as described below.
The Rubin and Woods maneuvers, and especially the Barnum maneuver, generally require adequate anesthesia to tolerate the provider’s hand in the vagina, making their use more challenging in ED deliveries.
Rubin Maneuver 
- The provider’s fingers are placed on the dorsal surface of the posterior fetal shoulder and used to rotate the shoulder 30 degrees anteromedially towards the fetal face.
- If the anterior fetal shoulder is more accessible, it can be used instead, with the provider’s hand placed on the dorsal surface of the anterior fetal shoulder.
- The Rubin maneuver adducts the fetal shoulders, decreasing the shoulder axis diameter and displacing it from anteroposterior to the oblique diameter of the pelvis.
Image of Rubin maneuver 
Woods Corkscrew Maneuver 
- Pressure is applied to the posterior shoulder to rotate it posterolaterally (toward the spine) allowing the fetus to turn 180 degrees, being careful not to twist the fetal head and neck.
- The winding movement functions similar to a screw, advancing the descent.
The Woods and Rubin maneuvers can be combined to increase the rotational forces. One shoulder can be pushed from the fetus’s front while the other shoulder is pushed from the back in the same clockwise or counterclockwise direction. If one direction does not work, the other should be tried. Pushing the fetus up into the pelvis can help the manipulations. The pressure on the anterior shoulder can also be applied externally through the abdomen using suprapubic pressure. The Woods and Rubin maneuvers can also be combined with the McRoberts maneuver.
Barnum Maneuver (Delivery of the Posterior Arm) 
- The provider’s hand is inserted into the vagina with the palmar surface tracking along the fetal chest until the posterior forearm can be grasped and pulled out.
- If the arm is extended, pressure to the antecubital fossa flexes the elbow to bring the forearm into reach along the fetal chest (and may decrease the risk of humerus fracture).
- If the forearm cannot be reached, sliding fingers into the posterior axilla may allow the provider to pull the shoulder far enough down to reach the arm. If there is not enough room for the provider’s hand, a soft catheter can be slipped through the axilla to apply traction, but this carries a higher risk of Erb’s palsy or humerus fracture.
- Delivering the posterior shoulder reduces the shoulder diameter by 2–3 cm.
- If posterior arm delivery is insufficient for fetal delivery, the fetus can be rotated 180 degrees and the maneuver repeated for the other arm.
- If the posterior arm cannot be flexed and delivered, the provider’s hand is already in position to attempt the Woods maneuver instead.
- The Barnum maneuver may be more effective than rotational maneuvers , but may be even more difficult to tolerate without anesthesia.
Maneuvers of Last Resort
The above maneuvers achieve delivery nearly 100% of the time , but more invasive or extreme methods may be necessary to prevent mortality if they are unsuccessful.
Fracture of the Fetal Clavicle
- Direct finger pressure is applied rapidly at the midpoint of the clavicle, or the midpoint is pulled outward rapidly, to break the fetal clavicle.
- This shortens the biacromial diameter as the fracture fragments overlap.
- The fracture can injure underlying vascular and pulmonary structures, but the bone typically heals without deformity.
Zavanelli Maneuver 
- This requires immediate availability of a surgeon and anesthesiologist.
- The fetal head is pushed back up into the pelvis and then a cesarean delivery is performed.
- Flex the head and try to reverse the movement the fetus took on the way down.
- Consider administering a tocolytic like terbutaline (0.25 mg SC q20 min prn) or other uterine relaxant like nitroglycerin (50-200 mcg IV q2 min prn), which may or may not be helpful in facilitating the maneuver.
- If the Zavanelli maneuver is unsuccessful, the surgeon can consider “abdominal rescue” . A low transverse hysterotomy is performed and the anterior shoulder is rotated transabdominally through it to vaginally deliver the posterior shoulder followed by the fetus.
Case 2: Breech Presentation
An hour later another pregnant woman rolls in to the emergency department with an impending delivery. You prepare as above, and this time when you perform your gynecologic exam you note buttocks at the perineum instead of a cranium. You recognize that a breech delivery is imminent, and cannot believe you are about to perform another complicated delivery!
Breech presentation occurs in approximately 4% of live births . With a normal vertex presentation, the fetus’s large head dilates and occludes the cervical opening, clearing space for the body to follow and blocking the umbilical cord from prolapsing. Breech presentations, particularly incomplete breeches, are prone to problems with cervical dilation and umbilical cord prolapse as they lack a good dilating wedge. Asphyxia can result from head entrapment or from umbilical cord prolapse with subsequent compression. Improper attempts at delivery can also cause fetal head and neck trauma from traction, including brachial plexus injuries. Cesarean section is therefore the preferred method of delivery, but likely no longer an option once the delivery is imminent.
Types of Breech Presentations 
Frank Breech: Both hips are flexed with the knees extended and the feet near the head. This accounts for 60–65% of all breech presentations and has 0.5% incidence of cord prolapse.
Complete Breech: Both the hips and the knees are flexed, occurring in 5% of all breech presentations and has 5–6% incidence of cord prolapse.
Incomplete Breech: At least one hip is not completely flexed, which could result in a foot as the presenting part. This occurs in 25–35% of all breech presentations, with 15–18% incidence of cord prolapse. It occurs more commonly in premature births.
Image of breech presentations  A.) Frank breech presentation B.) Complete breech presentation C.)Incomplete breech presentation
Addressing Vaginal Breech Presentation
Prepare for delivery as above, including calling for help. An obstetrician and pediatric provider should be summoned immediately. If the fetus has not yet emerged from the vagina, the mother should be instructed not to push, attempting to delay the delivery until she can be transported to the labor floor or an obstetric expert can arrive in the emergency department. “Panting” by the mother and administration of a beta sympathomimetic drug (like terbutaline) may help limit the pushing and expulsive forces. If any part of the fetus has emerged from the vagina, delivery must proceed as below.
Vaginal Breech Delivery
- Place the mother in the dorsal lithotomy position.
- Evaluate for rupture of membranes and prolapsed cord. If the cord is presenting with the breech, pull out a 10–15 cm loop to provide room to work.
- Consider performing a mediolateral episiotomy to provide room for maneuvering, though there is wide practice variation and no data from randomized controlled trials to support this .
- Allow the delivery to happen spontaneously. Support the fetus’s body after the umbilicus appears but do not apply traction or squeeze the waist and abdominal organs.
- Wrapping a towel around the fetus provides for better traction after the legs deliver.
- Pull out the 10–15 cm loop of umbilical cord after the umbilicus delivers if not yet already done.
- Keep the fetal sacrum anterior with the fetal face and abdomen away from the symphysis.
- Encourage the mother to bear down strongly until the scapulae are visible.
- Sweep the flexed arms across the chest to deliver each. Rotate the body to deliver the arms, each from an anterior position.
- Perform the Mauriceau-Smellie-Veit maneuver to deliver the head once the fetal chin is at the pelvic inlet. The provider’s arm is placed under the fetus with the middle fingers on the fetal maxilla and the fetal legs straddling the forearm. The maxillary fingers plus occipital pressure with the other hand promote head flexion and descent as the body is slightly elevated .
- The fetus should be delivered well within 10 minutes, as the umbilical cord will be compressed during delivery causing acidosis.
Image of Mauriceau maneuver with Bracht maneuver (suprapubic pressure on occiput) 
Additional Vaginal Breech Delivery Maneuvers, if needed
- The mother can be repositioned in any way that feels most comfortable with the thighs flexed and apart, including crouching or kneeling.
- Use the Pinard maneuver to deliver the legs if they are extended in a frank breech. Apply pressure to the back of the knee and externally rotate the thigh while rotating the fetal pelvis in the opposite direction. This flexes the knee and delivers the foot and leg. Perform it in the opposite direction if needed to extract the other leg.
Image of Pinard maneuver 
- The arms usually deliver crossed in front of the chest. Traction can cause extension of the arms above the head and shoulder dystocia. Rotate the fetus through 180 degrees to deliver the first arm from the anterior side in a transverse orientation, then back the other way to deliver the other arm. If this is insufficient, the provider’s finger can be slid along the fetal scapula, over the shoulder, and into the antecubital fossa to sweep the fetal arm down across the chest to deliver it.
Image of Retained fetal arm delivery 
- If the hairline does not appear after the shoulders, avoid traction and deliver suprapubic pressure to flex the head (Bracht maneuver) . (See image above for Mauriceau maneuver, which includes the Bracht maneuver).
- The head can become entrapped in a partially dilated cervix. The skull also does not have as much time under pressure to mold as it would in a vertex delivery. Uterine relaxants can be administered to facilitate delivery of the head (terbutaline or nitroglycerin) .
- The Zavanelli maneuver (as above) can also be considered as a last resort for head entrapment, although it is not well described for use in breech deliveries .
Precautions During Breech Delivery and Actions to Avoid
- Do not rupture the membranes, as this can cause cord prolapse.
- Do not place traction on or overly squeeze the fetus during delivery, as this can cause injury. Traction causes head extension and squeezing can injure abdominal organs.
- Do not hyperextend the neck, which can cause spinal cord injury or dystocia.
- Do not attempt the Mauriceau maneuver too soon, as it can induce the Moro reflex .
- Do not apply traction to the jaw or mouth during the Mauriceau maneuver, as it can cause temporomandibular joint injury.
- Do not hold the fetal trunk more than 45 degrees above horizontal during delivery, which could apply damaging traction on the cervical spine.
- Compound presentations involve an extremity as the presenting part rather than the head or buttocks. Compound presentations have a 10–20% cord prolapse rate and thus are ideally managed with cesarean rather than vaginal delivery, though this may not be an option in the precipitous delivery. Once a fetal extremity has presented in the vagina, reduction of the presenting part should not be attempted as this increases the risk of cord prolapse.
Face and Brow Presentations
One in 550 live births are a face presentation, while 1 in 1400 have a brow presentation . Both have larger engaging diameters than vertex presentations. Mentum (chin) anterior presentations usually deliver vaginally. Mentum transverse and brow presentations usually correct and deliver spontaneously. However, persistent mentum posterior or brow presentations require delivery by c-section.
Case 3: Umbilical Cord Prolapse
You are exclaiming to your colleagues that you cannot believe you have already performed two complicated deliveries in a single shift when you receive notification that a third pregnant woman is arriving, and seems to be in active labor! You don sterile gloves to check her cervix, and are concerned when you see the umbilical cord at the introitus. You recognize a prolapsed cord and call for help.
50% of cord prolapses are associated with malpresentations. Cord prolapse occurs in 0.1–0.6% of all deliveries, and carries a perinatal mortality rate of just below 10% . OB should be called and the mother prepared for emergency cesarean section. However, if labor has progressed far enough that vaginal delivery is imminent, it should be performed as the most rapid method of delivery . If delivery is not imminent, as arrangements are being made for the OR, care should be focused on reducing pressure on the prolapsed cord. The cord should not be manipulated as this can induce vasospasm and subsequent fetal hypoxia .
Instruct the mother not to push. Position the mother prone in the knee-chest position with the bed in Trendelenburg to enlist the assistance of gravity. Any presenting fetal parts should be manually elevated with a provider’s hand to reduce pressure on the cord. The patient should be transported to the operating room and prepared for surgery with the provider’s hand still in the vagina. Instillation of 500–700 mL normal saline into the bladder via Foley catheter may also help lift any presenting fetal parts off the cord .
If cesarean delivery is not an option at her current location, the mother should be placed knee-chest in Trendelenburg and the bladder filled for transport. The cord should be kept warm and moist, so if it is outside the vagina it should be replaced and held in with moist sterile gauze. Initiate fetal heart monitoring, and administer a tocolytic if fetal bradycardia occurs and persists . If the bradycardia does not resolve with tocolytics, umbilical cord reduction may be the only option, although outcomes have historically been poor. The cord is gently pushed back up towards the uterus above the presenting part. If the head is the presenting part, the head is lifted and the cord is placed over the head into the nuchal area. An assistant providing gentle suprapubic pressure in the cephalad direction may help elevate the fetal head and prevent conversion to a malposition . Nuchal loops and body cords should be anticipated with delivery.
Prolapsed cord and knee-chest position 
As you high five your team members for successfully facilitating three complicated deliveries, you think about the key points to remember next time this occurs . . . if ever.
Take-Home Points for complicated Deliveries
- Complicated deliveries are infrequently performed, high-stress procedures. Call for OB and neonatology early, in addition to extra ED team members. Make sure someone prepares to care for the neonate.
- To relieve shoulder dystocia, avoid excess traction, hyper flex the mothers legs and apply suprapubic pressure, then progress to fetal maneuvering as needed.
- During breech delivery, allow the delivery to happen spontaneously without traction while supporting the fetal body, then prevent excess neck extension while delivering the head.
- If cord prolapse occurs, do not manipulate the cord. Minimize pressure on the cord with maternal knee-chest positioning and elevation of presenting parts while preparing for emergency cesarean section.
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