Version May 2024
INTRODUCTION — Each year, hundreds of deliveries in the United States occur precipitously in emergency departments as well as outside of the hospital setting. In most of these cases, labor and delivery results in good outcomes in the absence of physician/midwife intervention or a traditional delivery site [1].
This topic is intended for health care providers (eg, emergency department, medical or surgical hospital unit) who do not perform obstetric deliveries as part of their usual practice. It will review the key points for assisting hospitalized patients in the process of imminently giving birth at a location other than the labor and delivery unit. One emergency department identified the following three issues as their main problematic areas related to these births: availability of accessible appropriate equipment; appropriate training for the clinical care of these patients before, during, and after a vaginal birth; and knowledge of the specialized documentation of the labor and delivery process, including disposition documentation [2].
Related topics on labor and delivery are presented in detail elsewhere.
●(See "Labor and delivery: Management of the normal first stage".)
●(See "Labor and delivery: Management of the normal second stage".)
●(See "Labor and delivery: Management of the normal third stage after vaginal birth".)
●(See "Inter-facility maternal transport".)
●(See "Overview of the routine management of the healthy newborn infant".)
In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.
DEFINITION AND ETIOLOGY — 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 [3]. Precipitous delivery is generally thought to result from abnormally low resistance of the birth canal, abnormally strong uterine contractions, lack of awareness of painful contractions, or some combination of these [4].
RISK FACTORS — The major risk factors for precipitous birth appear to be placental abruption, multiparity, and very small infant size, but data are inconsistent [5-7].
ASSESSMENT AND PREPARATION
●Call for help – There are two patients in an obstetric delivery. Ideally, an obstetric provider (eg, obstetrician, midwife, family practitioner) should be available for the mother, and a pediatric provider (eg, pediatrician, pediatric nurse practitioner, family practitioner) should be available for the infant.
●Rapid obstetric assessment – Quickly assess the woman's delivery history, medical history, and gestational age.
•Gravidity and parity – Gravidity refers to the number of prior pregnancies regardless of outcome, while parity refers to the number of births (preterm and term live births and stillbirths) but not miscarriages, pregnancy terminations, or ectopic pregnancies.
Women who have had a prior vaginal birth or have had a prior precipitous birth tend to have more rapid labors than women who have not had a prior vaginal birth.
•Gestational age – Most women, and their partners, will know their estimated due date (EDD) and the current gestational age of the pregnancy. If only the EDD is known, the current gestational age can be calculated (calculator 1). If only the date of the last menstrual cycle is available, the EDD and current gestational age can be calculated (calculator 2).
For those who do not know the EDD or are unable to communicate (eg, intoxicated), palpate the top of the uterine fundus. After 20 weeks of gestation, measuring the distance from the symphysis pubis to the top of the uterus (fundus) in centimeters crudely corresponds with the week of gestation (figure 1). Leiomyoma, twins, or higher-order multiple gestations; other factors affecting uterine size (eg, abnormal amniotic fluid volume); and obesity can reduce the diagnostic performance of physical examination-based gestational age assessment. (See "Prenatal assessment of gestational age, date of delivery, and fetal weight".)
Gestational age impacts the type of pediatric care that may be required. A birth before 37 weeks of gestation is considered preterm; these newborns are at increased risk of morbidity, particularly respiratory problems and difficulty maintaining their temperature. Most preterm infants born ≥26 and <37 weeks have a high likelihood of survival, while virtually no infant born <22 weeks will survive. From 22 to 25 weeks of gestation, chances of survival rapidly increase, and morbidity decreases with each additional week of gestation, as long as appropriate neonatal care is available. (See "Overview of short-term complications in preterm infants" and "Periviable birth (limit of viability)".)
•Obstetric and medical problems – Ask about obstetric issues, such as twin gestation, previous cesarean birth, fetal anomalies, maternal bleeding diathesis, or other medical conditions that may complicate delivery, the immediate maternal postpartum course, or immediate newborn care. For example, women with a previous cesarean birth are at risk for uterine rupture during labor, and women with a bleeding diathesis are at risk for postpartum hemorrhage, both of which can be life-threatening complications.
•Preeclampsia – Women with preeclampsia with severe features (table 1B) are at risk for developing seizures (eclampsia), which should be prevented by administration of magnesium sulfate intravenously or intramuscularly.
The most common magnesium sulfate regimen in patients with normal kidney function is:
-Intravenous – Loading dose 4 to 6 g of a 10% solution intravenously over 15 to 20 minutes followed by 1 to 2 g/hour as a continuous infusion
-Intramuscular – If intravenous access is not available, an alternative regimen is 5 g of a 50% solution intramuscularly into each buttock (total of 10 g) followed by 5 g intramuscularly every four hours (may be mixed with 1 mL of xylocaine 2% solution to reduce pain). Intramuscular administration results in more fluctuation in magnesium levels and is associated with more side effects, particularly pain at the injection site. (See "Preeclampsia: Intrapartum and postpartum management and long-term prognosis", section on 'Seizure prophylaxis'.)
•Status of fetal membranes – Determine if and when the fetal membranes ("bag of waters") ruptured (see "Preterm prelabor rupture of membranes: Clinical manifestations and diagnosis", section on 'Diagnostic evaluation and diagnosis').
While this information may not change the immediate care at the time of a precipitous birth, it will be important for the clinicians who assume care of the mother and baby. For example, rupture of membranes for ≥18 hours before delivery is a risk factor for early onset Group B Streptococcus infection in the newborn. (See "Group B streptococcal infection in neonates and young infants".)
●Physical examination – A pelvic examination is performed to determine the presenting fetal part and whether birth is imminent.
•Is the woman voluntarily pushing with her contractions? If so, she is more likely to be in the second stage of labor (cervix fully dilated) and about to give birth. (See "Labor: Overview of normal and abnormal progression", section on 'Definitions for the stages and phases of labor'.)
•Is the fetus visible and beginning to emerge from the vagina (ie, crowning) (picture 1A)? If so, birth is imminent, particularly if the fetus is visible when the woman is not pushing.
If the fetus is not visible, imminent birth is still likely if she wants to bear down/push or states she "can feel the baby coming" and the perineum distends with contractions.
The median second stage of labor (time from full cervical dilation to birth) is approximately 30 minutes in nulliparous women (no previous birth) and 12 minutes in multiparous women (one or more previous births). If contractions are more than two minutes apart, there may be time to transport the mother to Labor and Delivery for delivery under more controlled conditions.
•What is the presenting part? On transvaginal examination at full dilation, the hard rounded skull of a cephalic presentation can be distinguished from the soft irregular buttocks (and sometimes feet) of the breech presentation. The anal orifice is often also palpable with breech presentation. If ultrasound is available, presentation can be confirmed by imaging, if uncertain.
If a fluid-filled amniotic sac is visible, leave it alone until it ruptures naturally. If a foot is visible, do not pull on it. Vaginal breech delivery is presented in detail separately, but a critical point is to allow the baby in breech presentation to delivery naturally, without traction by the provider. (See "Delivery of the singleton fetus in breech presentation".)
●Prepare the woman and immediate area for delivery – Ideally, clean absorbent materials are placed under the mother to collect blood and body fluids eliminated during the birth process. Providers should wear personal protective equipment if available.
●Utilize available equipment – If there is time and the equipment is available, maternal temperature and blood pressure should be checked. Fever suggests chorioamnionitis. Hypertension (defined as systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg) is the key finding for preeclampsia. Preeclampsia can progress to eclampsia (ie, seizures) and can be associated with life-threatening complications (eg, hepatic rupture, pulmonary edema, stroke, kidney failure) (table 1A-B).
•(See "Intrapartum fever".)
•(See "Clinical chorioamnionitis".)
•(See "Preeclampsia: Clinical features and diagnosis".)
•(See "Preeclampsia: Antepartum management and timing of delivery".)
•(See "Eclampsia".)
The fetal heart rate can be checked with a Doppler device, by auscultation with a stethoscope, or with use of a portable ultrasound unit, if available. A normal fetal heart rate is between 110 and 160 beats per minute. (See "Intrapartum fetal heart rate monitoring: Overview" and "Intrapartum category I, II, and III fetal heart rate tracings: Management".)
●Position the mother for giving birth – Position the mother in a semi-sitting position, with hips flexed and abducted, and knees flexed (lithotomy position) (figure 2). In the absence of a birthing bed or table with stirrups, it is easier to assist birth of the baby if pillows, a stack of towels, or an upside-down bedpan is placed under the mother's hips and back to raise the perineum above the surface of the bed/stretcher. This provides additional room to maneuver when guiding the infant posteriorly to ease his/her shoulder under the symphysis pubis. Alternatively, the mother may lie on her side with her leg held up by a support person (figure 3).
EQUIPMENT AND SUPPLIES — For offsite deliveries, readily available materials can be used to aid a delivery.
If available, the following supplies make up a standard delivery kit:
●Antibacterial cleansers to wash your hands and the mother's perineum
●Gauze sponges
●Sterile gloves and gowns
●Clean cloth or gauze sponges to wipe infant's nose and mouth
●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 placental 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
●A diaper
In addition, appropriate equipment for neonatal resuscitation (eg, suction device, newborn-sized endotracheal tubes, and intubation blades) is desirable.
PROCEDURE — The key points for performing an emergency birth are presented in the table (table 2) and discussed in the following sections.
Images — The birth process (called the cardinal movements of labor) is illustrated in the diagrams (figure 4 and figure 5) and photographs (picture 1A-F).
Several videos that show how to deliver a baby are available online at no cost.
Intravenous access — If available, insert a large bore intravenous catheter (14 or 16 gauge) into an arm vein and draw a blood sample to have a clot for blood type and antibody screen if the patient hemorrhages and needs a transfusion. This line can be used to administer oxytocin to enhance uterine contraction after delivery of the placenta and for volume replacement in case of hemorrhage.
Instructions to the mother — Before the fetus is visible at the introitus, the mother will want to bear down and push according to her own reflex needs 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 fetal head is crowning, birth is imminent (picture 1A and picture 1B). The goal is to control, not restrain, fetal expulsion. Ask her to pant or make only modest expulsive efforts in an attempt to achieve a controlled birth (ie, gradual expulsion of the fetus), which is less likely to cause maternal or fetal trauma than an uncontrolled birth. (See 'Controlling and guiding the delivery' below.)
Controlling and guiding the delivery — The goal is to prevent the fetal head from descending rapidly and tearing through the introitus and perineum. The movement of the fetus through and out of the vagina are presented in the image (figure 4).
Episiotomy is not performed routinely. It is performed in approximately 10 percent of deliveries in the US [8,9], when the clinician believes enlarging the birth outlet to facilitate delivery of the fetus will benefit the mother or baby and warrants maternal exposure to the potential adverse outcomes associated with the procedure. (See "Approach to episiotomy".)
●Delivery of the head – One option is to place one hand on the crowning portion of the fetal head and apply light pressure to maintain the head in a flexed position (ie, hands-on approach). Use the other hand to ease the perineum over the fetal face (the most common fetal position at expulsion is facing the mother's back) (picture 1B and picture 1C). Do not pull on the head; let the mother gradually push it into your hands. Her strong urge to bear down will abate somewhat when the head is out. If the membranes still cover the baby's head, use a clamp, fingers, or forceps to rupture them.
An alternative approach is to avoid touching the perineum or fetus until the head is born (ie, hands-off approach). Neither approach has been proven to be superior [10].
●Restitution of the head – After the infant's head has delivered, it will usually rotate to the side (picture 1D). Feel for a loop of umbilical cord around the baby's neck. If present, gently slip it over the head. If it resists, it may be possible to slip it caudally over the shoulders and deliver the body through the loop. If these maneuvers are unsuccessful and leaving the cord alone is not feasible, doubly clamp and cut the cord. It is important not to rupture or avulse the cord because serious fetal/neonatal bleeding can occur. (See "Nuchal cord", section on 'Delivery'.)
●Delivery of the shoulders – With the next push, guide the head slightly downward so that the anterior shoulder slips under the symphysis pubis and delivers, then guide the head slightly upward to deliver the posterior shoulder over, rather than through, the perineum (picture 1E).
If the shoulders do not deliver easily, have your assistant or the mother sharply flex her thighs back against her abdomen (figure 6); this opens the pelvis to its maximum dimension. Ask her to push again. Do not pull on the head in an attempt to extract the baby if it does not slide out of the vagina easily. Advanced maneuvers for management of shoulder dystocia (eg, suprapubic [not fundal] pressure to disimpact the anterior shoulder, delivery of the posterior arm, rotational maneuvers) are described in detail separately. (See "Shoulder dystocia: Intrapartum diagnosis, management, and outcome".)
●Delivery of the body – Once both shoulders have delivered, the rest of the baby usually immediately follows (picture 1F). Document the time of expulsion. Use your hands to hold onto the back of the head and buttocks of the baby securely as it delivers. The baby can then be cradled against your body, with the back of its head in your cupped hand and its body supported by your forearm.
As soon as possible, place the baby on the mother's chest or upper abdomen (skin to skin) where she can cradle it and keep it warm. The infant can be wiped down while being held by the mother. In the absence of uterotonic agents, rapidly initiating breastfeeding helps to contract the uterus and decrease bleeding. The cord is not clamped/cut yet. (See 'Clamping and cutting the umbilical cord' below.)
Newborn care and assessment
●Protect the airway – The newborn's neck is held in a neutral to slightly extended position to open the airway. The nose and mouth are wiped of blood and mucus with a clean cloth. There is no strong evidence that routinely suctioning with a bulb or catheter is beneficial. However, if the infant appears to have an airway obstruction, use a bulb to gently suction the mouth first (avoid the posterior pharynx) and then the nose; newborns are obligate nose breathers [11]. The mouth is cleared first, so its contents are not aspirated if the newborn gasps when the nose is suctioned. (See "Labor and delivery: Management of the normal second stage", section on 'Spontaneous birth'.)
●Dry and keep warm – Drying the newborn promptly is important, as it significantly reduces heat loss. Maintaining body heat is an important initial step in caring for the newborn because hypothermia in the immediate newborn period increases oxygen consumption and metabolic demands and is independently associated with increased mortality. Low birth weight and preterm infants are particularly prone to rapid loss of body heat because of their large body surface area relative to their mass, thin skin, and decreased subcutaneous fat. (See "Overview of the routine management of the healthy newborn infant", section on 'Initial management'.)
If skin-to skin contact with the mother is not possible, additional ways to keep the infant warm after drying include swaddling in warm towels/blankets, performing skin-to-skin contact with a support person, placing it in a warm (36.5ºC) isolette, raising the environmental (room) temperature, and providing clothing. While the baby is being dried, cord clamping is delayed, as discussed below. (See 'Clamping and cutting the umbilical cord' below.)
●Stimulate – Drying the infant generally provides adequate stimulation. If the baby is limp and not breathing, tactile stimulation should be initiated promptly. Appropriate ways of providing this additional stimulation include rubbing the infant's back or chest or flicking the soles of the feet with your fingers. More vigorous stimulation is not helpful and may cause injury.
●Assess Apgar score – If possible, Apgar scores are recorded at one and five minutes after birth. The Apgar score assesses neonatal heart rate, respiratory effort, muscle tone, reflex irritability, and color. Up to two points are assigned for each variable (calculator 3). Approximately 90 percent of neonates have Apgar scores of 7 to 10, and generally require no special intervention. (See "Overview of the routine management of the healthy newborn infant".)
If the infant is not breathing or crying and/or has poor muscle tone, the initial steps in resuscitation include warming the infant, clearing the airway, and drying and stimulating the infant, as described above. The next steps depend on the respiratory and cardiac responses to these measures and are summarized in the algorithm (algorithm 1) and described in detail separately. (See "Neonatal resuscitation in the delivery room".)
Clamping and cutting the umbilical cord — The umbilical cord should not be clamped until at least 30 to 60 seconds have elapsed since fetal expulsion to facilitate the fetal to neonatal transition and increase infant iron stores. For preterm infants, delayed clamping results in reduced hospital mortality. (See "Labor and delivery: Management of the normal third stage after vaginal birth", section on 'Early versus delayed cord clamping'.)
If sterile instruments are available, doubly clamp the cord approximately four inches from the baby and cut the cord between the clamps with scissors or a knife. There are no nerve endings in the umbilical cord; cutting it is painless. If sterile instruments or tape for clamping/tying and cutting the cord are not available, the cord can be left connecting the baby to the placenta. A cool room temperature (compared with body temperature) causes the Wharton's jelly to swell and blood vessels in the cord to collapse and constrict, creating a natural clamp.
Once the cord is clamped, collect one red-top tube of blood from the placental end of the cord; this blood is used for determining the newborn's blood type and RhD status.
Delivery of the placenta — Do not pull excessively on the cord to deliver the placenta, which may still be attached to the uterus. The three classic signs indicating placental separation from the uterine wall are (1) lengthening of the umbilical cord out of the vagina, (2) a gush of blood from the vagina, signifying separation of the placenta from the uterine wall, and (3) change in the shape of the uterine fundus from discoid to globular with elevation of the fundal height.
Placental separation occurs naturally, usually within five minutes of expulsion of the infant; there is no maternal benefit in trying to hasten this process. Waiting 30 to 60 minutes after delivery, or even longer, is reasonable if bleeding is not profuse.
Contractions typically diminish after the baby is born, and then resume upon separation of the placenta. If the placenta is not expelled within approximately five minutes of seeing signs of placental separation, ask the mother to bear down and gently tug on the umbilical cord to deliver it while simultaneously applying counterpressure on her uterus [12]. Firm pressure should be placed on the mother's abdomen, just above her pubic symphysis, to secure the uterine fundus and prevent uterine inversion (uterus turns inside out). When the placenta protrudes from the introitus, grasp and gently rotate it to extract the placenta with the attached membranes. (See "Puerperal uterine inversion".)
After placental expulsion, a uterotonic drug is administered to stimulate the uterus to contract and remain contracted, which will reduce maternal blood loss. Oxytocin is infused into a maternal vein. A typical infusion is 30 units in 500 mL crystalloid infused at 334 mL/hour to provide 10 units over the first 30 minutes, followed by a maintenance rate of 125 mL/hour to provide 7.5 units over the next 60 minutes. Bolus intravenous injection is less safe, even at low doses. If there is no venous access, intramuscular injection (usually 10 units) is effective. (See "Management of the third stage of labor: Prophylactic pharmacotherapy to minimize hemorrhage".)
If oxytocin is not available, vigorously massage the uterine fundus (which will be at the level of the maternal umbilicus) to help it contract into a firm (like a contracted biceps) globular mass. A flabby fundus suggests atony, which is the most common cause of postpartum hemorrhage. Also attempt to initiate breastfeeding to stimulate uterine contractions.
Place the placenta in a bag or suitable receptacle for later examination. (See "Gross examination of the placenta".)
LACERATIONS — Inspect the perineum for lacerations. Superficial lacerations generally do not require any treatment. Deeper lacerations should be evaluated and treated by an obstetrician. Until the appropriate care providers and setting are available to repair lacerations, we advise the clinician to apply pressure to lacerations that are bleeding briskly until these lacerations can be repaired. Alternately, the laceration site can be firmly packed if sterile dressing material is available. (See "Repair of perineal lacerations associated with childbirth".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Labor".)
SUMMARY AND RECOMMENDATIONS
●Visual aids – To aid nonobstetric clinicians who must perform a delivery, the birth process is illustrated in diagrams (figure 4 and figure 5), photographs (picture 1A-F), and in online videos. (See 'Images' above.)
●Initial assessment and preparation – Call for help, take a brief obstetric/medical history, and determine the presenting part and likelihood of imminent birth. (See 'Assessment and preparation' above.)
●Equipment – For offsite deliveries that do not have access to a delivery cart, readily available materials can be used to aid a delivery. Clean clothing or linens that can be used to dry the baby are important to prevent hypothermia. (See 'Equipment and supplies' above.)
●Birthing procedure
•The key steps in attending a precipitous delivery outside of a labor and delivery unit are listed in the table (table 2). (See 'Procedure' above.)
•Providers who may attend a precipitous delivery outside of a labor and delivery unit should be aware of maneuvers for checking/reducing a nuchal cord, relieving shoulder dystocia, and massaging the uterine fundus to help it contract and reduce postpartum bleeding related to atony. (See 'Delivery of the placenta' above.)
•The umbilical cord should not be clamped until at least 30 to 60 seconds have elapsed since fetal expulsion. (See 'Clamping and cutting the umbilical cord' above.)
•Placental separation occurs naturally, usually within 30 to 60 minutes of expulsion of the infant; there is no maternal benefit to trying to hasten this process if bleeding is not profuse. (See 'Delivery of the placenta' above.)
•For women who sustain vaginal lacerations, apply pressure to briskly bleeding lacerations until repair is possible. (See 'Lacerations' above.)
●Newborn care – The key components of newborn care include clearing the airway, drying and stimulating the infant, keeping the infant warm, and assigning Apgar scores (calculator 3), if feasible. (See 'Newborn care and assessment' above.)
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