Rosen & Barkin's 5-Minute Emergency Medicine Consult (195 page)

• When cause is unclear, admit.
  
• If delirium has not resolved, admit.
  

Patient could be discharged if:

• Treatable cause is found and treated
  
• Mental status clears while in the ED
  
• Reliable caregivers are available
  
• Follow-up is ensured
  

• Follow-up depends on underlying condition.
  
• When delirium has resolved within ED stay, close follow-up with primary care provider, preferably in <2 days.
  
• Patients and caregivers should be counseled carefully regarding return precautions:
  
  • Any recurrence of delirium should prompt a return to the ED.
    
  • Delirium can be a life-threatening condition.
    

• Identify underlying cause
  
• Delirium is often missed by emergency physicians and maintaining an awareness of delirium as a syndrome is critical.
  

• Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency department patients: Recognition, risk factors, and psychomotor subtypes.
  Acad Emerg Med
  . 2009;16:193–200.
  
• Inouye SK. Delirium in older persons.
  N Engl J Med
  . 2006;354:1157–1165.
  
• Lonergan E, Luxenberg J, Areosa Sastre A. Benzodiazepines for delirium.
  Cochrane Database Syst Rev
  . 2009;(4):CD006379.
  

CODES

• 291.0 Alcohol withdrawal delirium
  
• 293.0 Delirium due to conditions classified elsewhere
  
• 780.09 Other alteration of consciousness
  

BASICS

• Delivery in ED is rare:
  
  • Incidence of ED deliveries in US is not known.
    
  • Health care systems in which patients have little prenatal care tend to have greater incidence of ED deliveries.
    
• ED deliveries usually occur in 1 of the following 3 scenarios:
  
  • Multiparous patient with history of prior rapid labor
    
  • Nulliparous patient who does not recognize symptoms of labor
    
  • Patients with lack of prenatal care, lack of transportation, or premature labor
    

DIAGNOSIS

• True labor presents as uterine contractions occurring at least every 5 min and lasting 30–60 sec.
  
• Significant vaginal bleeding with labor demands immediate assessment for placenta previa or abruption.
  

• Last menstrual period and estimated gestational age (EGA)
  
• Recent infections
  
• Pregnancy history, complications
  
• Prior C-section
  
• Prenatal care
  
• Abdominal/pelvic cramping
  
• Ruptured membranes (amniotic sac)
  
• May report incontinence
  
• Urge to push or have a bowel movement
  
• Bloody show—loss of mucous plug
  

• Signs of imminent delivery:
  
  • Fully effaced and dilated cervix (∼10 cm in term infant)
    
  • Palpable fetal parts
    
  • Bulging of perineum
    
  • Widening of vulvovaginal area
    
• Try to determine fetal position and presenting part by palpation of the uterus
  

• Sterile
  bimanual pelvic exam is the most useful tool to assess presence of labor and possibility of imminent delivery:
  
  • Assess dilation, station, and effacement
    
  • No pushing until full dilation
    
  • Bimanual exam should
    not
    be done with vaginal bleeding until ultrasound (US) can rule out placenta previa.
    
• Fetal heart tones (FHTs) should be obtained by Doppler
  

• If patient is in active labor, CBC, blood typing, and Rh screen should be sent:
  
  • Kleihauer-Betke testing should be ordered after delivery if Rh-negative mother gives birth to Rh-positive child
    
  • Rh immunoglobulin can be administered to mother within 72 hr of delivery
    
• Urinalysis if there is concern about urinary tract infection or preeclampsia
  

• Imaging studies are not needed for uncomplicated vaginal deliveries
  
• 3rd-trimester vaginal bleeding should have emergent US to evaluate for placental abruption or placenta previa
  
• If time permits, US can help locate the position and anatomy of the placenta
  

• Braxton Hicks contractions:
  
  • Irregular uterine contractions that do not result in cervical dilation or effacement
    
• Muscular low back pain
  
• Round uterine ligament pain
  
• Other causes of abdominal pain, such as torsion of the ovary, appendicitis, nephrolithiasis
  

TREATMENT

• Place patients in left lateral recumbent position
  
• Emergency medical services (EMS) personnel should be adequately trained and have proper equipment available for delivery
  
• EMS transportation of high-risk obstetric patients
  before
  delivery:
  
  • Lower neonatal morbidity and mortality
    
  • Faster and less expensive when compared with transportation of neonate
    after
    delivery
    
• Use of air transport for obstetric patients has been shown to be safe and effective:
  
  • Altitude during flight can result in hypoxia for fetus; pregnant patients should be placed on supplemental oxygen
    

• Immediate sterile pelvic exam to assess for cervical dilation, effacement, station, or presenting parts (if no vaginal bleeding)
  
• Patients in active labor should be transferred to labor and delivery immediately unless delivery is imminent
  
• If patient is completely dilated and fetal parts are on perineal verge, prepare for ED delivery
  

• Obstetrician should be notified that delivery will be occurring in ED
  
• Pediatrician or neonatologist and NICU should be notified
  
• Prepare for neonatal resuscitation
  
• Place patient in supine position or Sims position
  
• Begin IV saline or D5NS and supplemental oxygen, and place patient in lithotomy position
  
• Assemble obstetric (OB) pack:
  
  • Bulb syringe
    
  • 2 sterile Kelly clamps
    
  • Sterile Mayo scissors
    
  • Umbilical clamp
    
• Neonatal resuscitative equipment should also be available
  
• If time permits, sterilize vaginal area with povidone-iodine (Betadine)
  
• Uncomplicated vaginal delivery should occur as follows:
  
  • As crowning occurs, deliver head in controlled fashion, guiding it through introitus with each contraction.
    
  • Routine episiotomy is not necessary; however, if perineum is tearing, perform midline episiotomy by placing 2 fingers behind perineum and make straight incision toward (but not including) rectum with sterile Mayo scissors.
    
  • After fetal head is delivered, quickly suction nasopharynx, then feel around neck for nuchal cord:
    
    • If present, manually reduce over head
      
    • If nuchal cord is too tight, double clamp, cut cord, and deliver infant immediately
      
  • Apply gentle downward pressure on fetal head with uterine contractions:
    
    • Deliver anterior shoulder
      
    • Posterior shoulder and remainder of infant will rapidly deliver
      
  • After delivery, infant should be held at level of uterus and oropharynx suctioned again
    
  • Double clamp cord with sterile Kelly clamps and cut between them
    
  • Infant should be stimulated, warmed, and dried:
    
    • If cyanosis is present, infant should be given oxygen and resuscitated
      
    • Follow neonatal resuscitation protocols if necessary
      
  • Place umbilical clamp
    
  • Placenta will spontaneously deliver in 20–30 min:
    
    • Observe mother closely for postpartum hemorrhage
      
  • Uterine massage can aid in separation of placenta from uterus and limit uterine atony:
    
    • Avoid placing traction on umbilical cord because this can lead to inversion of uterus or rupture cord
      
  • If patient has severe bleeding and placenta is not passing spontaneously, patient should be taken immediately to operating room
    
  • After delivery of placenta, it should be examined for any irregular or torn areas suggestive of retained placental products
    
• In uncomplicated delivery, use of drugs is not necessary:
  
  • Massage of uterus is all that is needed to facilitate cessation of bleeding after placenta has been delivered
    
• Postpartum uterine bleeding is common:
  
  • Uterus, vagina, and perineum should be inspected for laceration
    
  • If no laceration is found, assume uterine atony
    
  • If uterus does not contract in response to uterine massage, administer oxytocin IV
    
  • Continued massage of uterus may be helpful if bleeding still persists; then give methylergonovine maleate (Methergine) IM
    
  • If bleeding is not responding to these measures, then carboprost tromethamine (Hemabate) can be administered IM