Asynchrony EM: The Difficult Delivery

New to Asynchrony EM? It's an asynchronous learning course in its third year at Brown EM. Digital resources and #FOAMed are curated and packaged by topic, following Brown EM's curricular calendar. In the spirit of #FOAMed, we've started putting it out there for the EM community at large. Check out the theme song, the 'extras', and the discussion questions -- and leave us your thoughts in the comments section.

Note: Brown EM residents must complete the modules (including discussion/quiz) in Canvas to obtain credit hours.



Here in Asynchrony EM --being asynchronous and all -- we're a little late for Halloween. So we're serving up the scariest stuff we can think of now, as we enter our new curricular block (OB/Gyn.)


Happy Ending! But how do we get here?

Happy Ending! But how do we get here?

It's all terrifying. Even more so if you wind up working somewhere where OB isn't in house 24/7. And the delivery doesn't even need to be 'difficult' per se -- any unexpected delivery in the ED is a pulse-quickening event (and we'll discuss normal deliveries, too.)

But before we start, as always: this week's theme song! Here's Motown queen Diana Ross and -- "I'm Coming Out."  

(You got other theme song ideas? Tweet me at @GitaPensaMD.)


OK, no more pun and games -- back to the scary stuff at hand. 

1) Let's start with the mother of all procedures (fine, one more pun) -- the peri-mortem C-section -- also now known as resucitative hysterotomy. (Disclosure: I have never done one. Never even seen one. In fact, just thinking about it makes me twitch, especially working community single-doc-coverage nights with no in-house OB or peds. Murphy's law dictates that if it's gonna happen, it's gonna happen when you have the fewest hands available to help.)

Peri-Mortem C-Section: from EM:Crit. The actual videocast (at the very bottom, the "Wee") is 10 minutes. Watch it. The St Emelyn's link is no longer working, but do click through and read Dr. Press's posts on his personal experiences doing PMCS. (You'll see he doesn't set much store by the numbers 24 or 4.) The more times you read about it, think about it, envision it, list the steps out loud, do it in SIM--the more ready you will be. (Me too.)  Also, WATCH the 3-minute life-identical simulation video, because it's AWESOME--just remember they do not demonstrate the mother being bounced around with CPR while they spend forever closing the uterus, which is why Dr. Press, in his post, suggests just packing it all with towels and moving on. 

Now one more: From Mayo Clic EM, A New Mindset: From Peri-mortem C-Section to Resuscitative Hysterotomy (August 2015). The proposed algorithm (published in Am J Obstet Gynecol, July 2015) is both reasonable and helpful. 


2a) Now that I've got your attention with a rare and horrible event, let's do a review of what will undoubtedly happen to you at some point in your career, if it hasn't happened yet: the precipitous delivery in the ED (or in the parking lot, a car backseat, or -- I swear, it really did happen, and it was quite problematic--a revolving door.)  Unlike the peri-mortem C-Section, this usually ends with a good outcome and a nice story to tell over a beer. Usually... (Cue scary soundtrack....)

- First an overview: First 10 EM: Precipitous Delivery in the ED

- Now, as much detail as you want -- peruse this Medscape article to fill in your gaps, but what I really want you to do is click on "Multimedia Library" at the bottom of the left-hand menu, and then go through the slide show. Watch the video at Image 6. Take note that once the shoulder is coming, you better be ready to catch! If you're lucky, it happens fast.

Medscape: Normal Delivery of the Infant

b) And what if it doesn't happen fast? What if the shoulder is stuck?

-First 10 EM: Shoulder Dystocia 

-That's the overview. Now read this for more detail: CoreEM: Shoulder Dystocia

c) And what if the presenting part is....a butt?!

If you see the butt coming out first...butt out. Meaning: be as hands-off as you can (see below).

-Start with this video. You can skip the end bit with the forceps, as you will not be using them (unless you have had significant training.)

Vaginal Breech Birth


-Then read some more detail here: Jacobi EM: Breech Delivery

-Then back to First 10 EM for the step by step. (He does a nice, concise job with these. Save them in your phone somewhere...)  First 10 EM: Breech Presentation

(Aside: Not covering footling/incomplete breech presentations today. Those are even scarier!)


3) A five minute review video of postpartum hemorrhage from EM in 5 Because sometimes it happens.


4) Lastly: important, but somewhat fuzzy stuff. How do we best train for these situations? What the heck is 'metacompetence'? Read a Resus M.E. post about it. Then let's talk about it (hit the comment section below.)


5) The OPTIONAL (slightly tangential) EXTRAS:

a) Because you also have to worry about the baby...In October 2015, the AHA updated their Neonatal Resuscitation guidelines. The Full Text of this update is available here: Neonatal Resusciation  

b) Aspiration of Neonatal Pneumothorax -- In case you didn't know it was a thing.

c) I've had to play clean-up crew in the ED after a nasty home birth gone wrong, and would never have considered trying to give birth at home myself-- but home births are apparently en vogue again. Here's a well known OB blogger's take on it:

2015: This year in homebirth deaths and disasters from The Skeptical OB

d) Did you know there's a whole TV series called "I Didn't Know I Was Pregnant?" (O.M.G.)


That's it for this week! Keep tuned for our next module in OB/Gyn.

**Brown EM Residents, remember you have to complete your modules in Canvas (hit the discussion board, and pass the quiz) to claim credit.**

Other EM Readers, let us know in the comment section:

  • Are there other #FOAMed resources about these topics that you would recommend?
  • Have you performed a resucitative hysterotomy? Tell us about it, and give us some pointers.
  • Done a breech delivery in triage? Brag about it here--and leave us some teaching points.
  • Discussion regarding the concept of metacompetence: how do you summon the courage to do what needs to be done when a rare procedure (cricothyrotomy, resuscitative hysterotomy, burr hole, etc.) is needed? What advice do you have for residents?