I was literally yanked out of a patient’s room last month by the neck of my scrubs. Our amazing ED charge nurse kept it brief, “Bobby, somebody’s crowning”. The infant was blue at first, but pinked up quickly with a little stimulation, suction and a warm blanket. I didn’t get fooled by the 1-minute O2 sat of 70%. We were at 95% by minute 8 of life.
So far things were looking good. Looking over at mom from the neonatal warmer, my optimism waned. Her placental delivery was a bit too brisk and it was followed by a large rush of blood. She looked pale and her pressures were soft. Our OB attending hadn’t yet arrived and she was hemorrhaging. Uterine massage, pitocin IM plus infusion, mass transfusion protocol…the day was saved and both mother and baby are thriving. Still, I realized a refresher was in order. I went home that night and read up on precipitous delivery in the ED. Here’s what I learned.
Prehospital and ED delivery are frequently associated with a poor prenatal care and thus a high rate of maternal and infant complications. Brunette et al found a 25% rate of neonates requiring resuscitation and an 8.7% rate of perinatal deaths with infants delivered in the ED. One patient quickly becomes two and both patients have just experienced a significant event (giving birth / being born) that can be associated with life threatening complications.
Bobby Redwood, MD, MPH, FACEP
Complications during delivery in the Brunette review were numerous and included nuchal cord, breech presentation, shoulder dystocia, postpartum hemorrhage, pre-eclampsia, prolapsed cord, and meconium staining. While things MAY go smoothly for both mother and baby, failure to activate OB, peds, blood bank and NICU teams (if available) can lead to the overwhelming of ED resources and poor patient outcomes.
If you have a heads up from EMS, here are some key pre-arrival interventions that may just save a life:
(1) Page a CODE ED DELIVERY or—if that does not exist—alert the OB, NICU, and pediatrics teams that they are needed in the ED emergently. If you’re in a rural shop, call a CODE BLUE and wave off the help if you end up not needing it.
(2) Clear two resuscitation bays and assign a dedicated ED RN and ED tech to each room
(3) Locate and pull out the neonatal crash cart and precipitous delivery cart
(4) Alert pharmacy of the need for specialty medications (i.e. pitocin)
(5) Alert blood bank of a potential mass transfusion situation
(6) Assign team roles early, just in case neonatal or maternal resuscitation are required
When caring for the mother and delivering the infant, here are some common complications and interventions:
(1) Nuchal cord. Bring the cord over the infant’s head or deliver head and then cut the cord to facilitate delivery.
(2) Breech presentation. Lovset maneuver and episiotomy if needed. Alert OR for possible C-section.
(3) Shoulder dystocia. McRobert’s maneuver, suprapubic pressure, posterior arm or shoulder delivery, and internal rotational maneuvers
(4) Prolapsed cord. Elevate presenting part.
(5) Meconium staining. High level of suspicion for aspiration or fetal distress.
(6) Postpartum hemorrhage. Uterine massage, pitocin infusion, and mass transfusion protocol.
(7) Pre-eclampsia. IV magnesium and IV antihypertensives for very high BPs.
You just caught a baby! Here’s a summary of basic delivery aftercare:
(1) Position the infant in a manner that facilitates the flow of blood from the placenta to the infant
(2) Stimulate and dry the infant
(3) Clamp then cut the umbilical cord 3cm distal to insertion at umbilicus with sterile scissors (wait 30-60 seconds after delivery to do this)
(4) If uncomplicated delivery with clear airway and good respiratory support, mother may hold child immediately (skin to skin)
(5) If mother or infant is unstable, pass infant to receiving team
(6) Place infant in a warm incubator
(7) Check APGAR scores at 1, 5, and 10 minutes after delivery
It all sounds very simple, until it’s happening on your watch. I hope this brief review helped you dust off the cobwebs on an uncommon, but core EM topic. Wishing you all a lack of precipitous deliveries as you wrap up 2025!