Precipitous Delivery
Renae Buehner RNC, BSN
Labor and Delivery Unit Supervisor
Avera McKennan Hospital
Definition: Precipitous Delivery, aka
Precip
Occurs when cervical dilatation is faster than 5
cm per hour (or 1 cm every 12 minutes) in
nulliparas and 10cm per hour (1cm every 6
minutes) in multiparas. (Kennedy, Ruth, &
Martin, 2009)
The term precipitate or precipitous labor has
been defined as a labor that lasts no more than
three hours from onset of regular contractions
to delivery. (Barss, 2014)
Treatment
• The best action for precipitous labor is to
anticipate a rapid descent of the fetus and a
spontaneous delivery.
• Prepare for the potential of a stressed
newborn
What do you do first?
PANIC!!!
No really…
• Call for help. There are two patients in a delivery, the mother and
the infant; each should have at least one health care provider. An
obstetrician and pediatrician or family practitioners should be
summoned, if available.
• Ask the woman her gravidity and parity. Find out if she has any
obstetrical or medical problems, such as twin gestation, preterm
fetus, previous cesarean delivery, fetal anomalies, or other medical
conditions. Also ask if she has a headache, or epigastric pain, or
vision changes which are signs of preeclampsia.
• Perform a brief assessment: Is the fetus visible and beginning to
emerge from the vagina (ie, crowning)? Is the presenting part the
scalp, buttocks, or foot? In 95 percent of pregnancies, the
presenting part is the fetal head. Is the amniotic sac intact? If it is,
leave it alone until it ruptures naturally.
Assess the situation
•If there is time and equipment is available, check
the maternal temperature and blood pressure.
•Fever suggests chorioamnionitis.
•Maternal hypertension (systolic blood pressure
≥140 mmHg or diastolic blood pressure ≥90
mmHg).
•Preeclampsia can progress to eclampsia (seizures)
and can be associated with life-threatening
complications (hepatic rupture, pulmonary edema,
stroke, renal failure)
Patient Preparation
• Insert an IV, 16-20 gauge. This can be used for
oxytocin infusion after delivery and fluid
volume replacement.
• Collect blood tubes for CBC,T&S, and RPR
What to expect
• Shaking is normal. It is usually a sign of
transition. Comes from surge of hormones
including adrenaline.
• As the baby comes down the birth canal you
will see the perineum flatten, then bulge.
Often you will see rectal bulging.
• Cervical change usually brings bloody show.
• Often the patient will need guidance on how
to breathe and get control.
She’s Pushing!
What you need:
• Sterile gloves and gowns
• Bulb syringe to remove fluid and mucus from the infant's mouth
and nose
• Two sterile clamps to clamp the umbilical cord
• Sterile scissors or knife to cut the umbilical cord between the
clamps
• A red top tube to collect fetal blood from the end of the cut
umbilical cord
• Clean towels, sheets, and/or blankets to dry and swaddle the infant
• Blankets to keep the mother warm
• Suitable containers for the placenta and wet, bloody clothing and
sheets, etc.
• A diaper and infant hat
What to expect cont
• The uterus should relax between contractions.
• FHTs should be checked by a Doppler device,
by auscultation with stethoscope, or with use
of a portable ultrasound unit, if available.
• Normal FHR is 110-160 bpm
• FHR may decrease with the contraction. This is
a sign of head compression. When the
contraction is letting up the FHR should come
back up.
Cardinal Movements
• Cardinal Movements. This refers to the
movements made by the fetus during the first
and second stage of labor. As the force of the
uterine contractions stimulates effacement
and dilatation of the cervix, the fetus moves
toward the cervix. When the presenting part
reaches the pelvic bones, it must make
adjustments to pass through the pelvis and
down the birth canal
Delivery
• Before the fetus is visible, the mother will want to
bear down and push in response to the pain of
contractions and the pressure felt from descent of the
fetal head.
• Ask her to pant through the peak of her contractions
and try to rest and breathe normally between them.
This helps to keep her from bearing down and
delivering before additional help is available.
• If the head is crowning, ask her to pant or make only
small pushes in an attempt to achieve a controlled
delivery, which is less likely to cause maternal or fetal
trauma.
Large crown, note bulging of perineum
Delivery
• Place gentle pressure on the head as it
emerges. Don’t press hard against it, only
enough to allow controlled birth.
Gentle pressure on head and
perineum support
Delivery
• Once the head is delivered, allow the fetus to
restitute to a side.
• Feel for a cord loop around the fetal head. If
there is cord noted, reduce over head if loose. If
it resists, either doubly clamp and cut the cord or
leave it alone.
• Give gentle downward pressure for anterior
shoulder
• Gentle upward pressure for posterior shoulder.
Delivery
• If you have resistance with the shoulders or
see the “turtle sign” have an assistant flex the
patient’s thighs back. This should open the
pelvis to it’s maximum dimension.
• If resistance continues, have your assistant
apply suprapubic pressure.
McRoberts/Suprapubic Pressure
Delivery
• Once the shoulders deliver, the rest will slide
out.
• Double clamp the cord and cut the cord
between the clamps.
• Bring baby to mother’s chest and dry off the
baby in mother’s arms
Immediately After Delivery
• Start IV infusion of pitocin 30units in 500cc
normal saline at 250cc/hr. Allow to run for 2
hours or until empty. Increase the rate as
needed for boggy uterus or increased
bleeding.
• Precip deliveries are a higher risk for post
partum hemorrhage. Consider pitocin 10 units
IM in addition to the IV
Placenta Delivery
• Wait for it… The placenta can deliver immediately
after the baby or can take up to 30 minutes.
• Signs of placenta seperation: gush of blood,
lengthening of the cord, change in the shape of
the uterus.
• Control the delivery of the placenta by providing
gentle downward traction of the cord with one
hand and the other hand supports the fundus.
The mother can assist by gentle bearing down
with a contraction.
• Note if there is a 3 vessel cord.
Placenta retention
• If it has been 30 minutes and the placenta
shows no sign of delivering, consider manual
removal and/or possible d&c.
Post Partum Hemorrhage
• Cumulative blood loss of >=1000ml OR blood loss
accompanied by signs/symptoms of hypovolemia
within 24 hours following the birth process
(includes intrapartum loss).
• Signs/symptoms of hypovolemia may include
tachycardia, hypotension, tachypnea, oliguria,
pallor, dizziness, or altered mental status
• Cumulative blood loss of 500-999ml alone should
trigger increased supervision and potential
interventions as clinically indicated
Post Partum Hemorrhage
• Interventions:
1. Pitocin infusion
2. Methergine- use cautiously in patients with
hypertension
3. Hemabate-use cautiously in patients with asthma
4. Fundal massage
5. Manual evacuation of the uterus, bimanaul massage.
6. Last resort- apply aortic pressure until more help is
available.
Post Partum Hemorrhage
• Where is the bleeding coming from?
• Uterine atony? Cervical laceration? Labial
laceration.
• Inspect the vaginal walls, labia and cervix
Baby is delivered, what do we do with
it?
• If the baby is crying and moving, go straight to
mother’s chest. Direct skin to skin with mom
and baby improves outcomes including
breastfeeding, post partum depression, and
bonding (www.nbci.ca)
Apgar Scores
• If able, start the apgar timer at birth. It will
alarm at 1 minute, 5 minutes, and 10 minutes.
Sign
0
1
2
Heart Rate
not detectable
<100
>100
Respiratory Rate
absent
slow, irregular
good, crying
Muscle tone
flaccid
some extremity flexion
active motion
Reflex Irritability
no response
grimace
grimace, cough,
sneeze, gag
Color
blue, pale
body pink, extremities blue
completely pink
Apgar Score
• Useful for a quick evaluation of newborn. May
helpful in the initial evaluation for
resuscitation
• 7-10: doing well, no assistance is usually
needed
• 4-6: may need some resuscitation
• 0-3: resuscitation needed immediately
Apgar Scores
• Remember: the apgar score is a clinical
evaluation of the need for newborn
resuscitation. It does not determine newborn
hypoxia, acidosis, or neurologic impairment,
nor does it predict long-term outcomes.
(Kennedy, 2009)
Newborn Resuscitation
Newborn Assessment
• Initial assessment at birth includes:
Head- shape, bruising, fontanelles- soft, bulging,
sunken- sutures- overriding, seperated
Heart- rate, rhythm, murmur?
Lungs- rate, rhythm, clear or coarse- if coarse
encourage crying
Bowel sounds- present or absent
Skin- color, rash, petechia, birth marks, skin tags
Limbs- all 10 fingers and toes
Genitalia- normal, ambiguous
Newborn Assessment
• Along with initial assessment, obtain vital
signs.
• Recheck after 1 hour, 3 hours, 6 hours, and
PRN
• Normal heart rate 110-160
• Normal respirations 40-60
• Normal temp 97.6-99.5
Maternal Assessment
• Initial assessment includes:
Head to toe assessment, including high risk
assessment-ha, vision changes, reflexes, pain
Fundus- firm, boggy, firms with massage,
midline, deviated to right or left, height
Lochia- small to moderate, rubra, small clots
Abnormal lochia- no flow, constant moderate
trickle, clots plum size or bigger, foul odor
Maternal Assessment
• Breast/nipple assessment- nipples everted,
flat, inverted- breasts soft, filling, tender
• Assessment and vital signs of the mother
should be performed at least every 15
minutes x4, every 30 minutes x2, then BID and
PRN.
• Encourage breastfeeding if mother and baby
status allow. Note latch, swallow, and duration
Questions?
References
• Barss, V. (2014, Mar). Up to Date. Retrieved Apr
2014, from Up to Date, Inc: www.uptodate.com
• Kennedy, B., Ruth, D., & Martin, E. J. (2009).
Intrapartum Management Modules. Philadelphia:
Wolters Kluwer Lippincott Williams & Wilkins.
• http://www.nbci.ca/index.php?option=com_cont
ent&id=82:the-importance-of-skin-to-skincontact-&Itemid=17