CHAPTER 12

MANAGEMENT OF DELIVERY AND NEWBORN

Objectives
 Outline the physiologic process of labor in the pregnant patient.
 Prepare to manage labor and delivery in the critically ill pregnant patient.
 Outline principles of evaluation and resuscitation of the neonate.

Case Study
You are called to attend a vaginal delivery of a 37-week fetus. Following delivery, the neonate
is apnoea and limp. The umbilical cord is clamped and cut. After performing the initial steps
at the radiant warmer, the neonate remains apnoea.
 Should you start resuscitation?
 If so, which action is the most appropriate to perform at this moment?

I. INTRODUCTION

The critical care specialist is not likely to be responsible for independently managing a
delivery or resuscitating a newborn in the ICU. It is recommended that pregnant women who
require intensive care services be hospitalized in an institution that has established maternal
and neonatal services, preferably including a neonatal ICU (NICU). Luckily, childbirth
requires little assistance or intervention. Understanding the physiology of labor, being properly
prepared, and observing signs of labor will greatly enhance optimally timed care for a laboring
mother and her neonate.

IV MANAGEMENT OF LABOR
Labor is categorized into 3 distinct stages.

A. First Stage of Labor

The initial stage of labor begins with regular uterine contractions that create cervical
change. The early phase of this stage may last hours or days and results in minimal cervical
change despite regular uterine contractions. The active phase of labor occurs when the cervix
dilates at a rate of approximately 1 cm each hour. The patient who is awake, conscious, and
capable ofcommunicating will typically report rhythmic abdominal or back pain, usually
occurring every 3 to 5 minutes. Vaginal discharge, fluid leaking from the vagina, or vaginal
bleeding is possible. An appropriately trained provider (ie, obstetrician, midwife, or other
experienced clinician) should evaluate the patient by assessing the fetal position and cervical
dilation, determining whether the amniotic membranes have ruptured, and noting indications
or contraindications to the mode of delivery (ceasarean versus vaginal). Continuous external
fetal monitoring will aid in this evaluation. The frequency of uterine contractions is detected
by a tocometer. The fetal status is assessed by continuous cardiographic monitoring (Figure
12-1). Rarely, internal monitors are placed to detect the fetal heart rate (fetal scalp electrode)
and to measure the pressure of uterine contractions (intrauterine pressure catheter).

Figure 12-1. Contractions (arrows) are shown occurring about every 2 minutes. The fetal
heart rate tracingis shown in the top panel.

Courtesy of Sharon Fullerton, RN.

 Flexion
 Internal rotation
 Extension
 Restitution
 External rotation
 Expulsion

This stage of labor is characterized by an overwhelming sense of constant pelvic pressure

and maternal pushing to deliver the fetus. The patient is typically placed in the dorsal lithotomy
position and prepared for delivery. Figure 12-2 provides an example delivery table setup.
Practitioners trained in delivery should be called for attendance. Delivery should be carried out
in clean conditions, although a sterile field is not required. The attendant should don personal
protective equipment (ie, gown, gloves, face mask). Clean absorbent pads should be placed
under the buttocks. Any fecal material should be wiped away. Because some manipulation of
the fetal shoulders will be needed,room for downward traction on the perineum should be
arranged; this can be achieved by elevating the mother's hips on a stack of clean towels or
moving her into a lateral decubitus position.
Management of second stage of labor is supportive as the patient pushes with a Valsalva
maneuver to allow the fetus to descend through the vaginal canal. The fetus can usually
negotiate the pelvis without assistance. In the normal vaginal delivery, gentle downward
counter-pressure is applied to the fetal head as it traverses slowly through the vulva, to limit
the degree of perineal laceration. The fetal head exits the pelvis by extension, so the forehead,
eyes, nose, mouth, and chin appear in sequence.

Figure 12-2. Example of equipment table setup fora vaginal delivery.

Courtesy of Nikki Kumura, MD and Scott A Harvey, MD.

C. Third Stage of Labor

The third stage of labor begins at the delivery of the newborn and lasts until the placenta
is delivered. Active management of this stage both shortens the process and decreases the risk
of post- partum hemorrhage. Oxytocin should be given (10 IU or 1 ampule intramuscularly; or
20 IU in 1 L normal saline or Ringer lactate solution, 500 mL/h for the first 30 minutes). One
hand should apply gentle downward traction on the umbilical cord, with the other hand pressing
above the symphysis pubis to apply upward pressure on the uterine fundus in a cephalad
direction. Too- vigorous cord traction can evert the entire uterus and result in a hemorrhage or
avulse the cord. Signs of placental separation are a sudden rush of blood, lengthening of the
cord outside the vagina, the uterus rising higher into the abdomen, and an increase in uterine
firmness on abdominal palpation. Oxytocin is continued at a rate of 125 mL/h for about 5 or 6
hours after the delivery of the placenta.
Following placental delivery, the uterine fundus should be firm at the level of the
umbilicus. Normal postpartum blood loss is up to 500 mL in an uncomplicated vaginal
delivery. Obstetric lacerations should be evaluated but need not be repaired immediately if they
are not bleeding heavily. The placenta should be inspected to ascertain whether it is intact;
retention of portions of membranes or the placenta causes uterine atony and hemorrhage.
 It is beyond the scope of this chapter to fully explain the mechanics of and procedures
in a complicated vaginal or cesarean delivery. The basic mechanics of delivery are described
in Appendix 2. A basic knowledge of appropriate abdominopelvic anatomy and physiology of
parturition is paramount to treating a gravid patient.
Sign of placental separation:
- Gush of blood
- Lengthening of the cord outside of the vagina
- Uterine rebound (Moving cephalad) in the maternal abdomen
- Placental delivery

Several conditions may inhibit an attempt at vaginal delivery. If the presenting part of
the fetus is too large to be accommodated by the maternal pelvis, the fetus may be prevented
from fully maneuvering through the birth canal. On occasion, the fetus may not tolerate the
labor process. These situations require repositioning the mother, operative vaginal delivery, or
performance of a cesarean delivery, depending on a multitude factors and the patient's stage of
labor. Addition- ally, cesarean delivery should be performed in the presence of the following
conditions: placenta previa, vasa previa, >2 prior cesarean deliveries, prior "classical" type
(vertical hysterotomy, not "low transverse") cesarean deliveries, active vulvovaginal herpes
simplex outbreak, umbilical cord prolapse, and macrosomia.

D. Term and Preterm Labor

In most cases, labor occurring at >34 weeks' gestation is rarely stopped, and expectant
management is common for this population. The results of laboratory assessment of Rh status
and vagino-rectal group B streptococcus (GBS) cultures are commonly known. If the GBS
results are unknown (prior to 37 weeks) or were positive (at any gestational age), prophylaxis
with penicillin is provided

2.Does the newborn have good muscle tone? Are the extremities flexed, and is the baby active?
3.Is the newborn breathing or crying?

If the answer to all 3 questions is yes, the neonate can stay with the mother, placed skin-
to-skin on her chest or abdomen. If any is answered no, the newborn should be brought to the
warmer and care continued there.
The neonate should be gently dried and kept warm. Secretions in the upper airway can
be wiped out gently with a cloth. Bulb suc- tion is reserved for those exposed to meconium-
stained fluid or if secretions are obstructing breathing.
Is this a term neonate that has adequate breathing, crying, and muscle tone? If answering
”yes” to this statement, the neonate can stay with the mother and likely does not require
resuctitation.

Any newborn who is preterm or is not vigorous should be placed in the warmer,
positioned on the back, with the head and neck neutral or slightly extended, to open the airway.
The mouth should be suctioned before the nose. The neonate should be dried unless gestation
was <32 weeks, in which case he/she is covered with a polypropylene sheet immediately to
reduce heat loss. The neonate's temperature should be monitored closely. The combination of
positioning, suctioning, and drying is often enough to stimulate breathing. If respiratory effort
is still inadequate, gently rub the back, trunk, or limbs. If this does not stimulate breathing, the
next step is positive pressure ventilation (PPV).

A. Neonatal Resuscitation
If the newborn is not breathing spontaneously, is only gasping, or the heart rate is <100
beats/min, PPV is indicated, using a bag-valve-mask apparatus. The bag can be self-inflating
or flow inflat- ing, but it should be sized for a newborn (<500 mL) rather than adult. For preterm
newborns, the device should deliver positive end-expiratory pressure (PEEP). The algorithm
for neonatal resusci- tation is given in Figure 12-4. Neonates seldom require resuscitation
because of a cardiac cause; it is usually a matter of respiratory failure, stemming from pdor
placental function before delivery or poor respiratory efforts after delivery. The transition from
fetal to neonatal respiration and circula- tion requires the following:
1. Fluid in the alveoli is absorbed.
2. Air replaces fluid in the alveoli, as the newborn takes a breath or cries.
3. Pulmonary vessels dilate.
4. As pulmonary blood flow increases, the ductus arteriosus constricts, and the antenatal
right-to- left shunt resolves.

8. Resuscitation with PPV Using Bag and Mask

If PPV is needed, select the correct mask size (ie, covers nose and mouth, no pressure
on chin or eyes). Resuscitation with 21% oxygen is as effective as with higher concentrations
and is associated with less risk. (If the neonate is <35 weeks' gestation, the oxygen
concentration can be 21% to 30%.) The flow meter should be set to 10 L/min. The pulse
oximeter is applied to the right hand, where blood supply is preductal and therefore not lowered
by venous admixture. Oxygen saturation normally rises in the first few minutes after birth as
transition to air breathing occurs;provides target oxygen saturation levels on pulse oximetry.
Peak inspiratory pressure should be started at 20 to 25 cm H20 . If the newborn has not yet
taken a breath, fluid remains in the alveoli, so compliance will be low. Full-term neonates may
require an initial peak inspiratory pressure as high as 30 to 40 cm H20 . After the first few
breaths, this can be lowered. The volume administered should generate only a gentle rise of the
chest; it will be much lower than the total volume of the bag. PPVis given at a rate of 40 to 60
breaths/min.
The heart rate is checked after 15 seconds of PPV; if ventilation was started because
of bradycardia, a response should be evident within 15 seconds. If no response is detected,
reevaluate the ventilation technique and correct as needed.

1. Adjust mask.
2. Reposition airway: ensure head is neutral or slightly extended.
3. Try PPV again, reassess. If not improved, proceed with suctioning of mouth and nose
(bulb syringe or suction catheter); open the mouth and lift the jaw forward.
4. Try PPV again, reassess. If not improved, increase inspiratory pressure by 5 to 10 cm
 H20 , up to a maximum of 40 cm H20 .
5. Try PPV again, reassess. If still not improved, place an endotracheal tube or laryngeal
mask airway. See Appendix 4 for recommendations on endotracheal tube selection.

The heart rate should be rechecked after 30 seconds of effective ventilation. The normal
rate is >100 beats/min. If the rate is <100 but >60 beats/min, call for help, reassess ventilatory
adequacy, listen for bilateral breath sounds, increase oxygen concentration to meet target
oxygen saturation levels on pulse oximetry, and reconsider whether an alternative airway is
needed.
If the heart rate is <60 beats/ min despite 30 seconds of effective ventilation (preferably
through an alternative airway), begin chest compressions. This will rarely be needed. Chest
compressions are performed by encircling the chest with the hands. Place the thumbs on the
sternum, just below an imaginary line connecting the neonate's nipples; the thumbs may be
side by side or one atop the other. Depth of compression is one-third the anteroposterior
diameter of the chest, and the rate is 90 compressions/min. In each 2-second cycle, 3
compressions and 1 ventilation are administered. After 60 seconds of chest compressions with
ventilations, check the heart rate. Stop compressions when the rate is 60 beats/min. If chest
compressions are still needed, increase the oxygen concentration to 100%, and consider
intubation. (The endotracheal tube insertion depth should be equal to the distance between the
tragus and nares length plus 1 cm.)

VI. POSTPARTUM MATERNAL CARE

Following delivery, the mother needs ongoing evaluation and care. Once the placenta
has been delivered, the uterus should contract, shrinking almost immediately to the level of the
umbilicus. The tone of the uterus constricts the spiral arteries and prevents hemorrhage.
Oxytocin should be continued for 5 to 6 hours if the bleeding has improved. Lacerations of the
perineum or vagina are identified and repaired. Over the next days to weeks, the uterus
involutes and remodels, returning to its pre-pregnancy size by 4 weeks. During this time,
heterogeneous material is normally visible within the uterus on ultrasound examination. The
decidua begins to separate by postpartum day 2, visibly manifested by a bloody vaginal
discharge (lochia), which becomes progressively lighter over time and dissipates by week 6.
Many women report continued discomfort, similar to labor contractions, for a few days
after delivery. These are usually managed with nonsteroidal anti-inflammatory agents, but may
require a mild opioid. Breast engorgement is common as early as postpartum day3 to 5 and can
be relieved by emptying the breasts (via nursing or pumping). If breastfeeding is not
undertaken, milk production will cease and the breasts involute in 7 to 14 days. Fever is
sometimes associated with breast engorgement, although the differential for fever is already
extensive in the ICU. Breastfeeding and pumping are typically encouraged, even in ICU
patients, for the neonatal benefits. A risk-to-benefit assessment should be performed, in
addition to careful evaluation of medications the woman is receiving.
Pregnancy associated hypervolemia corrects itself postpartum. Spontaneous diuresis
begins within the first postpartum day and may last a week. Perineal edema, lacerations, or
pain can be relieved by a cool pack applied to the perineum in the first 24hours. Other measures
include a spray bottle for perineal hygiene or a local anesthetic spray. Sitz baths may relieve
discomfort and promote healing.

CASE PRESENTATION : RESUSCITATION WITH PPV USING BAG AND MASK

You are called to attend a vaginal delivery of a 37-week fetus. Following delivery, the
neonate is apneic and limp. The umbilical cord is clamped and cut. After you perform the initial
steps at the radiant warmer, the newborn remains apneic.
You immediately ask for help and start PPV with 21% oxygen using a self-inflating
bag with a term mask at a pressure of 20 cm H20. Your assistant determines the heart rate is 70
beats/min and not increasing, and the chest is not moving with the ventilation. A pulse oximeter
is attached to the neonate's right hand.
You take corrective steps with the ventilation, adjusting the mask and repositioning the
head and neck. After you resume, your assistant reports no chest movement, so you suction the
mouth and nose, open the mouth, lift the jaw, and continue ventilating. Your assistant finds
that there is still no chest movement. After you increase the inflating pressure gradually from
20 to 25 cm H20, your assistant detects a "good chest rise." You continue ventilation for 30
seconds, monitoring
 APPENDIX 1
EQUIPMENT FOR NEONATAL RESUSCITATION

Data from American Heart Association/American Academy of Pediatrics. Textbook of

Neonatal Resuscitation.7th ed. Elk Grove Village, IL:American Academy of Pediatrics; 2016.

To warm:
 Preheated radiant warmer
 Warm towels or blankets
 Temperature sensor with cover
 Hat
 Plastic bag or plastic wrap (if <32 wee.ks' gestation)
 Thermal mattress (if <32 weeks' gestation)

To clear airway:
 Bulb syringe
 l0F or 12F suction catheter, attached to wall suction; wall suction at 80 to 100mm Hg

To ventilate:
 Stethoscope
 Flowmeter, set at 10 Lim.in
 Oxygen blender, set to21% (21%to 30% if <35 weeks' gestation)
 Positive pressure ventilation device (bag), auto-inflate or flow-dependent; T-piece
device recommended for preterm neonates
 8Ffeeding tube, large syringe
 Bladder retractor
 Two (2) skin/soft tissue retractors
 Suction tubing and Yankauer suction
 Two (2) scissors (curved or straight)
 Tissue forceps
 Fascia forceps
 Laparotomy sponges
 Obstetric forceps or vacuum
 Personal protective equipment
 Appropriate drapes (abdominal, under-buttocks)
Figure A2-l. Biparietal diameter of fetal head.

Courtesy of Lauren Plante, MD, and Aislinn Plante.

Figure A2-2 Fetal head in neutral or "military" position; the occipitofrontal diameter,
measuring approximately 11 cm, is presenting.

Courtesy of Lauren Plante, MD, and Aislinn Plante.

Figure A.2-3. When the fetal head is flexed on the neck, a smaller diameter is presented to the
pelvis than with the occipitofrontal diameter; the suboccipitobregmatic diameter is about 9.5
cm.
Courtesy of Lauren Plante, MD, and Aisllnn Plante.

FigureA2-4.Bony pelvis.

Courtesy of Lauren Plante, MD, and Aislinn Plante.

 APPENDIX 4
ENDOTRACHEAL TUBE SIZE

Tubes are selected according to the newborns weight and gestational age. If the
newborn weighs<1000 g and is <28 weeks gestational age, select a tube size of 2.5-mm internal
diameter and a catheter size of 5F or 6E If the newborn weighs between 1000 and 2000 g and
is 28 to 34 weeks gestational age, select a tube size of 3-mrn internal diameter and a catheter
size of 6F or 8F. If the newborn weighs >2000 g and is >34 weeks gestational age, select a tube
size of 3.5-mm internal diameter and a catheter size of 8F.