10.3 Emergency Transport Delivery, Umbilical Cord Prolapse & Fetal Monitoring

10.3 Emergency Transport Delivery, Umbilical Cord Prolapse & Fetal Monitoring

Emergency Delivery Protocol in Critical Care Transport

En route emergency delivery occurs when labor progresses rapidly (precipitous labor). Recognizing imminent delivery and executing structured protocols ensures maternal and neonatal safety.

Assessment of Imminent Delivery

• Contractions occurring less than 2 minutes apart, lasting 60–90 seconds.
• Maternal urge to push or feeling of an involuntary bowel movement.
• Crowning: Visualization of the fetal scalp at the vaginal introitus during a contraction.

Transport Delivery Protocol

1. Vehicle Management: Pull the transport vehicle over to a safe location, stop motion, and set the climate control high ($75–80^\circ\text{F} / 24–27^\circ\text{C}$) to prevent neonatal hypothermia.
2. Perineal Protection: Apply gentle downward pressure to the emerging fetal head with a sterile gloved hand to prevent rapid expulsion and perineal laceration. Routine episiotomy is not recommended.
3. Nuchal Cord Assessment: Once the head delivers, slip a finger along the fetal neck to check for a wrapped umbilical cord.
   • If loose: Gently slip the cord over the infant's head or shoulders.
   • If tight/wrapped multiple times: Double-clamp the cord $2 \text{ cm}$ apart, carefully cut between the clamps with sterile scissors, and deliver the shoulders immediately.
4. Delivery of Shoulders: Guide the fetal head gently downward to allow the anterior shoulder to deliver beneath the pubic symphysis. Then, guide the head upward to deliver the posterior shoulder. Support the infant's body as it emerges.
5. Neonatal Care & APGAR: Place the infant directly on the mother's abdomen (skin-to-skin). Dry thoroughly with warm towels, discard wet linen, and stimulate. Perform APGAR scoring at 1 minute and 5 minutes. Clamp the cord $2–3 \text{ inches}$ from the umbilicus after 60 seconds (delayed cord clamping) and cut between clamps.

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Shoulder Dystocia Emergency Management

Shoulder dystocia occurs when the anterior fetal shoulder becomes impacted behind the maternal pubic symphysis after head delivery. It is a critical, time-sensitive obstetric emergency with a risk of fetal brachial plexus injury (Erb's palsy), severe hypoxia, and asphyxia.

                         [ SHOULDER DYSTOCIA ("Turtle Sign") ]
                                           │
          ┌────────────────────────────────┴────────────────────────────────┐
          ▼                                                                 ▼
[ ABSOLUTE CONTRAINDICATION ]                                    [ IMMEDIATE ACTIONS ]
- NEVER Apply Fundal Pressure!                                   - Stop Maternal Pushing!
  (Impulses shoulder further                                     - Note Delivery Time
   & tears uterus / brachial plexus)                             - Call for Assistance
                                                                            │
                                                                            ▼
                                                                [ McROBERTS MANEUVER ]
                                                                (Hyperflex & Abduct Legs
                                                                 Flat to Abdomen)
                                                                            │
                                                                            ▼
                                                                [ SUPRAPUBIC PRESSURE ]
                                                                (Downward & Lateral Pressure
                                                                 Above Pubic Bone)
                                                                            │
                                                                            ▼
                                                                [ INTERNAL ROTATIONAL MANEUVERS ]
                                                                (Rubin II / Woods Screw /
                                                                 Posterior Arm Delivery)

Management Algorithm (ALARM / HELPERR Protocol)

1. Stop Maternal Pushing Immediately! Pushing worsens shoulder impaction against the pubic bone.
2. ABSOLUTE CONTRAINDICATION: NEVER apply fundal pressure! Fundal pressure forces the anterior shoulder tighter against the pubic symphysis, risking uterine rupture and severe brachial plexus avulsion.
3. McRoberts Maneuver: Hyperflex the mother's legs tightly against her abdomen (knee-to-chest) while abducting the hips. This flattens the sacral promontory and rotates the pubic symphysis anteriorly, freeing the shoulder in up to 50% of cases.
4. Suprapubic Pressure: An assistant applies firm downward and lateral pressure directly above the pubic bone over the posterior aspect of the anterior shoulder to adduct the shoulder and dislodge it.
5. Internal Maneuvers: If McRoberts and suprapubic pressure fail, perform internal entry maneuvers (Rubin II, Woods Screw maneuver, or delivery of the posterior arm).

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Umbilical Cord Prolapse

Umbilical cord prolapse occurs when the umbilical cord slips past the presenting fetal part through the cervix into the vagina. Compression of the cord between the fetal body and maternal pelvis cuts off blood flow, causing sudden severe fetal hypoxia and profound fetal bradycardia.

                      [ UMBILICAL CORD PROLAPSE IDENTIFIED ]
                                         │
                                         ▼
                 [ 1. IMMEDIATE MANUAL ELEVATION OF PRESENTING PART ]
                 (Insert gloved hand; push fetal head UP off the cord.
                  HOLD POSITION CONTINUOUSLY until surgical delivery!)
                                         │
                                         ▼
                 [ 2. MATERNAL POSITIONING ]
                 (Knee-Chest, Steep Trendelenburg, or Left Lateral with Hips Elevated)
                                         │
                                         ▼
                 [ 3. CORD CARE & RESUSCITATION ]
                 - Wrap visible cord loosely in warm, saline-soaked sterile gauze
                 - DO NOT attempt to push cord back into uterus!
                 - Administer 100% FiO2 NRB, IV Fluid Bolus, Stop Oxytocin
                 - Consider Terbutaline 0.25 mg SC to stop contractions
                                         │
                                         ▼
                 [ 4. EXPEDITED SURGICAL TRANSPORT ]

Immediate Critical Interventions

1. Manual Elevation of Presenting Part: Insert a sterile gloved hand into the vagina and push the presenting fetal head or breech UPWARD and off the umbilical cord. Maintain this hand position continuously throughout transport until the surgeon delivers the fetus via emergency C-section!
2. Maternal Positioning: Place the patient in an exaggerated Knee-Chest position, steep Trendelenburg position, or left lateral position with pillows elevating the hips to let gravity pull the fetus off the cord.
3. Warm Saline Cord Wrapping: If a loop of cord protrudes from the vagina, wrap it loosely in sterile gauze saturated with warm normal saline.
   • CRITICAL WARNING: Do NOT attempt to push the cord back inside the vagina or cervix! Manual manipulation of the cord causes severe vasospasm, vessel thrombosis, and complete cessation of fetal perfusion.
4. Tocolysis & Transport: Administer $100% \text{ FiO}_2$, IV fluid bolus, discontinue oxytocin, and administer Terbutaline $0.25 \text{ mg}$ SC to suppress uterine contractions. Execute immediate expedited transport to a surgical C-section facility.

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Fetal Heart Rate (FHR) Monitoring & Interpretation

Continuous or intermittent FHR monitoring provides crucial insight into fetal oxygenation and autonomic nervous system integrity during transport.

Baseline Parameters & Variability

• Normal Baseline FHR: $110–160 \text{ bpm}$.
• Fetal Tachycardia: Baseline $> 160 \text{ bpm}$ for $> 10 \text{ minutes}$. Causes: maternal fever, chorioamnionitis, fetal hypoxia, maternal hyperthyroidism, sympathomimetic drugs (Terbutaline).
• Fetal Bradycardia: Baseline $< 110 \text{ bpm}$ for $> 10 \text{ minutes}$. Causes: severe fetal hypoxia, umbilical cord compression, maternal hypotension, local anesthetic toxicity.
• FHR Variability: Fluctuations in baseline FHR assessed in 10-minute windows:
  • Absent ($0 \text{ bpm}$ amplitude) or Minimal ($1–5 \text{ bpm}$): Reassuring if transient (fetal sleep state), but ominous if persistent (fetal acidemia, CNS depression).
  • Moderate ($6–25 \text{ bpm}$): Reassuring indicator of normal fetal cardiac innervation and adequate brainstem oxygenation.
  • Marked ($> 25 \text{ bpm}$): Acute fetal hypoxia or cord compression.

Deceleration Patterns & Pathophysiology

LION Intrauterine Resuscitation Protocol for Late Decelerations

• L — Left Lateral Positioning: Turn patient onto left lateral side (relieves IVC compression).
• I — IV Fluid Bolus: Administer a $500–1000 \text{ mL}$ bolus of Lactated Ringer's (corrects maternal hypotension and increases placental perfusion).
• O — Oxygen Administration: Administer $100% \text{ FiO}_2$ via non-rebreather mask at $10–15 \text{ L/min}$ (maximizes maternal-fetal oxygen pressure gradient).
• N — Notify & Stop Oxytocin (No Pitocin): Immediately stop oxytocin infusion to eliminate uterine tachysystole. Notify receiving facility for emergency C-section.

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Additional High-Yield Maternal/Fetal Blueprint Topics

The April 2026 Maternal/Fetal domain also tests preterm labor and PROM, multiple-birth delivery, and advanced obstetric procedures such as McRoberts maneuver and emergent (including perimortem) hysterotomy.

Preterm Labor and PROM

• PROM / PPROM: Premature rupture of membranes before labor onset increases infection risk and may precipitate preterm delivery. Transport priorities include sterile pad monitoring of fluid color/odor, maternal temperature surveillance, left-lateral positioning, and readiness for precipitous delivery.
• Preterm labor: Tocolysis (when ordered), antenatal corticosteroid timing awareness, magnesium for neuroprotection in eligible early preterm gestations (per sending-physician orders), and continuous fetal monitoring when available.

Multiple-Birth Transport

Twin or higher-order gestations raise risks of malpresentation, cord prolapse after delivery of the first neonate, postpartum hemorrhage, and need for two neonatal resuscitation setups. Prepare duplicate airway, warmth, and vascular-access equipment, and plan crew roles before departure.

Emergent / Resuscitative Hysterotomy

Perimortem (resuscitative) cesarean / hysterotomy is considered in maternal cardiac arrest with a fundal height suggesting viable gestation (classically ≥20–24 weeks) when ROSC is not immediate. Transport clinicians must know:

1. Start high-quality maternal ACLS immediately (manual left uterine displacement).
2. Definitive hysterotomy is a physician procedure aimed at improving maternal resuscitation physiology and, secondarily, neonatal survival.
3. Exam items often test prioritization of maternal chest compressions, airway, and rapid transport/notification rather than delaying ACLS for fetal assessment alone.