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Precipitous birth not occurring on a labor and delivery

unit
Author: Vanessa A Barss, MD, FACOG
Section Editors: Vincenzo Berghella, MD, Allan B Wolfson, MD
Deputy Editor: Kristen Eckler, MD, FACOG

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Apr 2022. | This topic last updated: Mar 10, 2022.

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.

This topic will review the key points for assisting women during an imminent delivery of a
fetus in cephalic presentation. It is intended for health care providers who do not perform
obstetric deliveries as part of their usual practice (eg, emergency department, medical, or
surgical hospital unit). Related topics on labor and delivery are presented in detail elsewhere.

● (See "Labor and delivery: Management of the normal first stage".)

● (See "Labor: Overview of normal and abnormal progression".)
● (See "Inter-facility maternal transport".)

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. However, we encourage the reader to consider the
specific counseling and treatment needs of transgender and gender diverse 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 [1]. Precipitous delivery is
generally thought to result from abnormally low resistance of the birth canal, abnormally

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strong uterine contractions, lack of awareness of painful contractions, or some combination

of these [2].

RISK FACTORS

The major risk factors for precipitous birth appear to be placental abruption, multiparity, and
very small infant size, but data are inconsistent [3-5].

IMAGES

The birth process (called the cardinal movements of labor) is illustrated in the diagrams (
figure 1 and figure 2) and photographs ( picture 1A-F). In addition, the key points for
a precipitous delivery are presented in the table ( table 1).

Several videos that show how to deliver a baby are available online at no cost. One example
is available at Operational Medicine. Of note, this video includes use of episiotomy, which is
no longer routinely performed.

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 delivery or have had a prior precipitous
delivery tend to have more rapid labors than women who have not had a prior
vaginal delivery.

• 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

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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),
the top of the uterine fundus is palpated. 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 3).
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 delivery
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 "Short-term complications of the preterm infant" and
"Periviable birth (limit of viability)".)

• Obstetric or medical problems – Ask about obstetric issues, such as twin

gestation, previous cesarean delivery, 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 delivery 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.

Women with signs/symptoms of preeclampsia ( table 2A) are at risk of eclampsia

(seizure), which should be prevented by administration of magnesium sulfate
intravenously or intramuscularly, especially in women with severe hypertension or
symptoms ( table 2B). If magnesium sulfate is not available, phenytoin 1000 mg
loading dose infused intravenously over one hour is an alternative but is less
effective [6]. (See "Preeclampsia: Management and prognosis", section on 'Seizure
prophylaxis'.)

• Rupture of membranes – Determine if and when her "bag of waters" or amniotic

membranes ruptured (see "Preterm prelabor rupture of membranes: Clinical
manifestations and diagnosis", section on 'Diagnostic evaluation and diagnosis').
Increasing length of rupture of membranes increases the risk of intrauterine
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infection. While this information may not change the immediate care at the time of
a precipitous delivery, the information 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 part and whether delivery 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 deliver. (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, delivery is imminent, particularly if the fetus is visible when the
woman is not pushing.

If the fetus is not visible, imminent delivery 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 delivery) 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
or to the nearest emergency department 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".)

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● 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 intra-amniotic
infection. Maternal 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, renal failure) (
table 2A-B).

• (See "Preeclampsia: Clinical features and diagnosis".)

• (See "Preeclampsia: Management and prognosis".)
• (See "Eclampsia".)
• (See "Intrapartum fever".)

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".)

● Position the mother for delivery – Position the mother in a semi-sitting position, with
hips flexed and abducted, and knees flexed (lithotomy position) ( figure 4). In the
absence of a birthing bed or table with stirrups, it is easier to deliver a 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 5).

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
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● 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 1).

Intravenous access — If available, we insert a large bore intravenous catheter (14 or 16

gauge) into an arm vein and draw a blood sample for blood type and antibody screen. 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. We 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, delivery is imminent ( picture 1A and picture 1B). The goal
is to control, not restrain, fetal expulsion. We ask her to pant or make only modest expulsive
efforts in an attempt to achieve a controlled delivery (ie, gradual expulsion of the fetus),
which is less likely to cause maternal or fetal trauma than an uncontrolled delivery. (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 maternal introitus and perineum. The
movement of the fetus through and out of the vagina are presented in the image (
figure 1).

Episiotomy is not performed routinely. It is performed in approximately 10 percent of

deliveries in the US [7,8], 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".)

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● 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 [9].

● 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

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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 routine 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 [10]. 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 – Drying the newborn promptly is crucial, 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.

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 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".)

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If the infant is not breathing or crying and/or has poor muscle tone, the initial steps in
resuscitation are to dry, provide warmth, clear the airway, and stimulate, as described
above. The next steps involve ventilation (bag masking with positive pressure) and
supplemental oxygen (oxygen concentration 21 to 30 percent initially [100 percent
oxygen is not used initially]). If the infant's heart rate remains <60 bpm despite
adequate ventilation for 30 seconds, chest compressions and other advanced neonatal
resuscitation maneuvers are initiated when possible ( algorithm 1). (See "Neonatal
resuscitation in the delivery room".)

Clamping and cutting the umbilical cord — There is no urgency to clamping the umbilical
cord and it should not be clamped for a minimum of 30 to 60 seconds after birth to facilitate
the fetal to neonatal transition and increase infant iron stores. For preterm infants, delayed
clamping results in reduced hospital mortality [11].

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. (See "Labor and delivery: Management of the normal third stage after vaginal
birth", section on 'Early versus delayed cord clamping'.)

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 delivery of the baby, 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

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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
(eg, 20 units in 500 mL crystalloid over one hour) into a maternal vein. Bolus intravenous
injection is less safe, even at low doses. If there is no venous access, intramuscular injection
(usually 10 units) is effective. 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. (See "Management of the third stage of labor: Prophylactic
drug therapy to minimize hemorrhage".)

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 and other 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

● To aid nonobstetric clinicians who must perform a delivery, the birth process is
illustrated in diagrams ( figure 1 and figure 2), photographs ( picture 1A-F), and
in online videos. (See 'Images' above.)

● The initial assessment and preparation include calling for help, taking a brief medical
history, and determining both the presenting part and likelihood of imminent delivery.
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(See 'Assessment and preparation' above.)

● 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 after delivery. (See 'Equipment and
supplies' above.)

● The key steps in attending a precipitous delivery outside of a labor and delivery unit are
listed in the table ( table 1). (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 key components of newborn care include clearing the airway, drying and
stimulating the infant, keeping the infant warm, and performing Apgar scores, if
feasible. (See 'Newborn care and assessment' above.)

● There is no urgency to clamping the umbilical cord. (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, we advise the clinician to apply pressure to
briskly bleeding lacerations until repair is possible. (See 'Lacerations' above.)

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REFERENCES

1. Hughes EC. Obstetric-Gynecologic Terminology, Davis, Philadelphia 1972. p.390.

2. Abnormal labor. In: Williams Obstetrics, 24th ed, Cunningham FG, Leveno KJ, Bloom SL,
et al (Eds), McGraw-Hill Educations, 2014. p.462-463.

3. Sheiner E, Levy A, Mazor M. Precipitate labor: higher rates of maternal complications.

Eur J Obstet Gynecol Reprod Biol 2004; 116:43.
4. Mahon TR, Chazotte C, Cohen WR. Short labor: characteristics and outcome. Obstet
Gynecol 1994; 84:47.

5. Suzuki S. Clinical significance of precipitous labor. J Clin Med Res 2015; 7:150.

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13.05.22, 11:20 Precipitous birth not occurring on a labor and delivery unit - UpToDate

6. Duley L, Henderson-Smart D. Magnesium sulphate versus phenytoin for eclampsia.

Cochrane Database Syst Rev 2003; :CD000128.
7. Kozhimannil KB, Karaca-Mandic P, Blauer-Peterson CJ, et al. Uptake and Utilization of
Practice Guidelines in Hospitals in the United States: the Case of Routine Episiotomy. Jt
Comm J Qual Patient Saf 2017; 43:41.
8. Friedman AM, Ananth CV, Prendergast E, et al. Variation in and factors associated with
use of episiotomy. JAMA 2015; 313:197.

9. Aasheim V, Nilsen ABV, Reinar LM, Lukasse M. Perineal techniques during the second
stage of labour for reducing perineal trauma. Cochrane Database Syst Rev 2017;
6:CD006672.

10. Care of the newborn. In: Guidelines for Perinatal Care, 8th ed, Kilpatrick SJ, Papile L (Ed
s), American Academy of Pediatrics, American College of Obstetricians and Gynecologist
s, 2017. p.353.
11. Fogarty M, Osborn DA, Askie L, et al. Delayed vs early umbilical cord clamping for
preterm infants: a systematic review and meta-analysis. Am J Obstet Gynecol 2018;
218:1.
12. Hofmeyr GJ, Mshweshwe NT, Gülmezoglu AM. Controlled cord traction for the third
stage of labour. Cochrane Database Syst Rev 2015; 1:CD008020.
Topic 4449 Version 26.0

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GRAPHICS

Cardinal movements of birth process

The cardinal movements (or mechanisms) of delivery.

Reproduced with permission from: Wolters Kluwer. Copyright © 2009.

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Normal vaginal delivery

Five-step procedure for delivering an infant.

Reproduced with permission from: LifeART image. Copyright © 2009 Lippincott Williams & Wilkins.
All rights reserved.

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Delivery sequence from crowning through birth of

the newborn

Early crowning of the fetal head. Notice the bulging of the

perineum.

Reproduced with permission from: Wolters Kluwer. Copyright ©2009.

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Delivery sequence from crowning through birth of

the newborn

Late crowning. Notice that the fetal head is appearing face down.
This is the normal OA position.

OA: occiput anterior.

Reproduced with permission from: Wolters Kluwer. Copyright ©2009.

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Delivery sequence from crowning through birth of

the newborn

The clinician feels for a nuchal cord (ie, cord around the neck) and
prepares to guide the anterior shoulder under the symphysis pubis.

Reproduced with permission from: Wolters Kluwer. Copyright ©2009.

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Delivery sequence from crowning through birth of

the newborn

Beginning restitution (external rotation).

Reproduced with permission from: Wolters Kluwer. Copyright ©2009.

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Delivery sequence from crowning through birth of

the newborn

Both shoulders have delivered and the head has turned to line up
with the shoulders.

Reproduced with permission from: Wolters Kluwer. Copyright ©2009.

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Delivery sequence from crowning through birth of

the newborn

The body easily follows the shoulders.

Reproduced with permission from: Wolters Kluwer. Copyright ©2009.

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Key points in emergency delivery

1. Call for help. The mother and the baby should each have at least one clinician caring for them.

2. Briefly assess the mother to determine if delivery is imminent (baby's head is visible or
distending the perineum). Ask her if there are obstetrical or medical problems of which you
should be aware, such as twin gestation, preterm fetus, congenital anomalies, or maternal
bleeding diathesis.

3. Position the mother on pillows or towels so her hips are raised, flexed, and abducted.

4. Use an antibacterial cleanser to clean your hands and the perineum. Put on gloves.

5. Ask the mother to pant or make only modest expulsive efforts in an attempt to achieve a
controlled delivery.

6. Place one hand on the baby's head and apply gentle downward pressure to maintain it in a
flexed position and keep it from popping out of the vagina, and use the other hand to ease the
perineum over the baby's face. Don't pull on the head, let the mother gradually push it into your
hands.

7. Feel for a loop of umbilical cord around the baby's neck. If present, gently slip it over the head.
If it resists, either doubly clamp and cut it or leave it alone.

8. 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. Once both shoulders have delivered, the rest of
the baby immediately follows.

9. The mouth and nose should be wiped out with a clean cloth. There is no strong evidence that
routine 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. The mouth is cleared first so its contents are not aspirated if the newborn gasps
when the nose is suctioned. Do not raise the baby higher than the mother's abdomen to avoid
backflow of blood into the placenta.

10. Doubly clamp the umbilical cord and cut between the clamps.

11. Dry the baby to reduce heat loss. Keep the baby warm by swaddling in warm towels/blankets,
providing "skin to skin" contact with the mother, and keeping the room temperature warm.

12. The three classic signs of placental separation are (1) lengthening of the umbilical cord, (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 5 minutes of delivery, although
intervals of 30 to 60 minutes are reasonable if bleeding is not profuse. Controlled cord traction
can be helpful, with counter traction applied over the woman's pubic symphysis.

If the placenta is not expelled naturally, ask the mother to bear down and gently tug on the
umbilical cord to deliver it. Place a hand on the abdomen to secure the uterine fundus to prevent
uterine inversion. The postpartum fundus is palpable as a soft or firm mass at about the level of
the umbilicus.

13. After placental expulsion, massage the uterine fundus to help it contract into a firm globular
mass. A flabby fundus suggests atony, which is the most common cause of postpartum
hemorrhage.
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14. Administer oxytocin (20 units in 500 mL saline over one hour or 10 units intramuscularly).

15. Inspect the perineum for lacerations. Deep lacerations should be evaluated and treated by an
obstetrician. Apply pressure to lacerations that are bleeding briskly until these lacerations can be
repaired.

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Estimation of gestational age by fundal height

The solid lines indicate the height of the fundus by weeks of

gestation in a normally grown singleton gestation.

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Criteria for the diagnosis of preeclampsia

Systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg on at least 2
occasions at least 4 hours apart after 20 weeks of gestation in a previously normotensive
patient AND the new onset of 1 or more of the following*:

Proteinuria ≥0.3 g in a 24-hour urine specimen or protein/creatinine ratio ≥0.3 (mg/mg) (30
mg/mmol) in a random urine specimen or dipstick ≥2+ if a quantitative measurement is
unavailable

Platelet count <100,000/microL

Serum creatinine >1.1 mg/dL (97.2 micromol/L) or doubling of the creatinine concentration
in the absence of other renal disease

Liver transaminases at least twice the upper limit of the normal concentrations for the local
laboratory

Pulmonary edema

New-onset and persistent headache not accounted for by alternative diagnoses and not
responding to usual doses of analgesics¶

Visual symptoms (eg, blurred vision, flashing lights or sparks, scotomata)

Preeclampsia is considered superimposed when it occurs in a woman with chronic hypertension.

It is characterized by worsening or resistant hypertension (especially acutely), the new onset of
proteinuria or a sudden increase in proteinuria, and/or significant new end-organ dysfunction
after 20 weeks of gestation in a woman with chronic hypertension.

* If systolic blood pressure is ≥160 mmHg or diastolic blood pressure is ≥110 mmHg,
confirmation within minutes is sufficient.

¶ Response to analgesia does not exclude the possibility of preeclampsia.

Adapted from: American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin No. 222: Gestational
Hypertension and Preeclampsia. Obstet Gynecol 2020; 135:e237.

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In a patient with preeclampsia, the presence of one or more of the

following indicates a diagnosis of "preeclampsia with severe features"

Severe blood pressure elevation:

Systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg on 2 occasions at
least 4 hours apart while the patient is on bedrest; however, antihypertensive therapy generally
should be initiated upon confirmation of severe hypertension, in which case criteria for severe
blood pressure elevation can be satisfied without waiting until 4 hours have elapsed.

Symptoms of central nervous system dysfunction:

New-onset cerebral or visual disturbance, such as:

Photopsia, scotomata, cortical blindness, retinal vasospasm
Severe headache (ie, incapacitating, "the worst headache I've ever had") or headache
that persists and progresses despite analgesic therapy and not accounted for by
alternative diagnoses

Hepatic abnormality:
Impaired liver function not accounted for by another diagnosis and characterized by serum
transaminase concentration >2 times the upper limit of the normal range or severe persistent
right upper quadrant or epigastric pain unresponsive to medication and not accounted for by
an alternative diagnosis

Thrombocytopenia:

<100,000 platelets/microL

Renal abnormality:
Renal insufficiency (serum creatinine >1.1 mg/dL [97.2 micromol/L] or a doubling of the serum
creatinine concentration in the absence of other renal disease)

Pulmonary edema

Reference:

1. American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin No. 222: Gestational Hypertension
and Preeclampsia. Obstet Gynecol 2020; 135:e237.

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Lithotomy position for vaginal birth

If the woman cannot be placed in lithotomy position because a

suitable bed with stirrups is not available, 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.

Reproduced with permission from: Wolters Kluwer. Copyright ©2009.

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Mother on her side

Comparison of positions for pushing and delivery.

Reproduced with permission from: Wolters Kluwer. Copyright ©2009.

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McRoberts maneuver and suprapubic pressure

An assistant applies pressure suprapubically with the palm or fist, directing the
pressure on the anterior shoulder both downward (to below the pubic bone) and
laterally (toward the baby's face or sternum), and in conjunction with the
McRoberts maneuver. Suprapubic pressure is supposed to adduct the shoulders
or bring them into an oblique plane since the oblique diameter is the widest
diameter of the maternal pelvis. It is most useful in mild cases and those caused
by an impacted anterior shoulder.

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Neonatal resuscitation algorithm

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HR: heart rate; SpO2: oxygen saturation measured by pulse oximetry; ECG:
electrocardiogram; CPAP: continuous positive airway pressure; min: minute; ETT:
endotracheal tube; PPV: positive pressure ventilation; UVC: umbilical vein catheter; IV:
intravenous.

Reprinted with permission. Circulation 2020; 142:S524-S550. Copyright © 2020 American Heart Association, Inc.

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Contributor Disclosures
Vanessa A Barss, MD, FACOG No relevant financial relationship(s) with ineligible companies to
disclose. Vincenzo Berghella, MD Consultant/Advisory Boards: ProtocolNow [Clinical guidelines]. All of
the relevant financial relationships listed have been mitigated. Allan B Wolfson, MD No relevant
financial relationship(s) with ineligible companies to disclose. Kristen Eckler, MD, FACOG No relevant
financial relationship(s) with ineligible companies to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for
references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.

Conflict of interest policy

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