Author: Hannah Bell / Editor: Charlotte Davies / Reviewer: Mark Chester / Codes: ObP7, SLO1, SLO4, SLO6 / Published: 10/01/2018 / Reviewed: 09/09/2025
It started as a normal nightshift full of the usual head injuries, drink and drugs. I’d gone to through to the eye room to remove a piece of metal from a cornea, when I heard the tannoy…. ‘Dr Bell to Resus…..IMMEDIATELY’.
During those few seconds, thoughts ran through my head. I was one of two senior registrars on that night, as was usual for my busy department. he other registrar I was working with was excellent. Slightly less senior than me, but a good, solid, competent reg. If Frances was asking for me to go immediately, it must be something pretty bad. I went…. Immediately.
She had the ultrasound out. ‘I can’t really get a good picture Hannah, but I think she’s in labour.’
Those words sent dread and fear running through me. I like to think I’m pretty competent at most things, but delivering a baby was something I feared, like most other EM doctors. Maybe it’s the lack of exposure during medical school, as we fought to get into labour room with the long line of midwifery students. In fact, I had never delivered a baby- I’d watched at medical school from the back of the room, not entirely sure what was happening. Luckily I’d been on an Emergency Obstetric Course with Frances a month or so ago. So, we breathed, and I said, ‘We’ve got this’.
I’ll spare you the gory details, but everything went fine. Delivering that baby turned an awful nightshift into one of the best shifts of my career, and I don’t mind admitting, I shed a wee tear on the way home in the car.
So, if a concealed pregnancy in emergency labour comes into your ED, here’s what you need to do to deliver that baby like a pro…
Stay Calm
There’s no point in getting in a flap. If you’re calm but decisive, that will keep both the team and the patient calm. After all, these things usually just happen by themselves. More than likely you’ll not need to actually DO anything.
Check The Diagnosis
Make sure she’s actually pregnant and in labour. Often, the patient will give you no history of pregnancy, they might not even know! Obesity can obscure the ‘baby bump’, often an anterior placenta can mean that very little foetal movements are felt, and denial can surprise you, especially with mental health or in teenage patients. The ultrasound can give you an idea-but in this case the head was in the pelvis, so we didn’t see much. Can you see a head? A late sign, granted, but if you see a head, you know things are imminent.
Call The Midwife
Call a midwife, an obstetrician, and, if available, a neonatologist. In settings without on-site neonatal teams, initiate early referral to a tertiary neonatal unit and prepare for transfer if needed. The major concern in a concealed pregnancy is that you don’t know what gestation you are dealing with, or if the baby is breech for example. As I said, mostly labour happens the right way naturally, but you want someone experienced there as soon as possible.
Prepare
Split your team into 2. One team to deal with mum, and a second to deal with the baby. If this baby is preterm, you’re going to need that second team to know what they’re doing. Get out the Resuscitaire, turn on the heater, attach the oxygen and prepare equipment. For Mum, you really only need towels, and a cord clamp. A few incontinence pads under her bum not only helps to keep everything clean, but allows assessment of bleeding if there is any. You might need to gently clean the perineal area during labour, so a maternity pad or sanitary towel is good to have to hand.
Do Not attempt to move the mother to delivery suite if:
* Contractions are regular, last more than 30 seconds and are less than 2 minutes apart
* The baby’s head is crowning, or you can see any other part of the baby
* The mother’s perineum is bulging with each contraction
* The mother has previously delivered and thinks the baby will be born soon.
Reassure
Mum is likely to be petrified. She’s possibly got no idea what’s happening to her. She thought she had appendicitis and suddenly you’ve told her she’s having a baby. She’s probably lying on a resus trolley semi-naked. Not the dignified water birth she had imagined. Courses teach us to have our patients on a chair, a ball, on all fours- whatever the patient needs or wants. In reality, we don’t know if this baby is 24 or 42 weeks, and whether it’s upside down or back to front. So she’s on a resus trolley- where we feel like we have control of the situation, and I think that’s fine, but a bit of reassurance that everything is going well and she’s doing a good job goes a long way. Allocate a nurse to hold her hand, help her breathe, mop her brow, and explain what’s happening. There is no necessity to keep checking obs- doing so might make us feel better but it is not required, and only makes the patient uncomfortable. Similarly, putting in a cannula might make us feel in control as doctors, but it will probably not be required.
Give Her Some Analgesia
Labour is sore, I’ve done it myself, so I verify this! There is no harm in some Entonox, every ED has some. If she’s pushing, it’s best to take it away, as it’s difficult to push and suck Entonox at the same time. She can have it back in between contractions.
Wait…
Once you see the head, then it’s all go. Encourage panting — short, shallow breaths through an open mouth — to help the mother resist the urge to push. This helps control the speed of delivery and reduces the risk of perineal tearing. Then, when mum feels ready or has another contraction, encourage gentle pushing until the head is out. The head should restitute — that is, rotate about 90 degrees so the shoulders align with the widest part of the pelvis. This natural turning helps the shoulders pass through more easily, as they are oriented perpendicularly to the head. Support it, but don’t pull. On the next contraction, guide the head downwards to allow delivery of the anterior shoulder, and then upwards to allow delivery of the posterior shoulder. This should be very gentle, there is absolutely no ‘pulling’ required, you are really just taking the weight and supporting. Baby should deliver itself quickly after this.
Assess Baby
Usually all that is required is to catch the baby, gently clear the face, and wrap in a towel with a quick rub before transferring them — with cord attached — onto Mum’s abdomen and chest for skin-to-skin time. If they don’t pink up and cry immediately, continue stimulating with the towel, focusing on the back and limbs. If the baby remains blue, floppy and unresponsive, you need to clamp and cut the cord and take the baby to the Resuscitaire.
To clamp a cord – put 2 clamps in the middle of the cord and cut between them. This allows enough length for insertion of umbilical lines later if the Neonatology team require to do this. If the baby is well, there’s no rush to clamp the cord — wait at least a minute, or until the rest of the team arrives. However, if the baby remains blue, floppy and unresponsive despite stimulation, clamp and cut the cord promptly and transfer the baby to the Resuscitaire for neonatal life support.
Deliver The Placenta
If you have a labour ward on site, most Obstetric teams will be happy for you to leave the placenta in-situ for them to deliver later, either in the ED or after transfer to labour ward. If you’re not lucky enough to have Obstetrics on site, then you’ll need to deliver the placenta yourself. As soon as possible after delivery, administer 500 mcg/1 mL Syntometrine IM — unless contraindicated. In patients with hypertension or other risk factors, Oxytocin 10 IU IM is a suitable alternative and is the preferred first-line agent in many maternity settings.
During the first strong contraction, you may notice a small rush of blood and a lengthening of the cord as the placenta separates from the uterus. At this point, a little controlled traction on the cord, meaning gentle, steady pulling while supporting the uterus with your other hand, will usually deliver the placenta. Be very careful not to pull too hard, as this can cause uterine inversion.
Problems with Childbirth
Hopefully everything will go smoothly, and if it doesn’t, a midwife or the obstetric team will have arrived. If it’s really all going wrong, remember your ABCs. Here are a few specific problems to be aware of:
Shoulder Dystocia
This is when the shoulders are not delivered within five minutes of the head. This is an emergency and you must call for help immediately. The unborn baby is likely to be distressed and may require immediate resuscitation after delivery — so have the neonatal team and equipment ready. The McRoberts’ manoeuvre should be your first action. Ask two team members to flex the mother’s hips by drawing her knees tightly up towards her shoulders while she lies flat. This tilts the pelvis, straightens the sacrum, and often frees the impacted shoulder — it’s successful in around 40% of cases. At the same time, another team member can apply suprapubic pressure: a firm, downward pressure just above the pubic bone, angled slightly toward the baby’s back. This helps to rotate the anterior shoulder under the symphysis pubis. Do not apply traction to the baby’s head.
McRoberts manoeuvre – image via Wikimedia Commons
Cord Prolapse
When you look, the cord is seen at the vulva. This is an extreme emergency. The cord can become compressed by the baby – cutting off the baby’s oxygen supply. Do not touch the cord, or the baby. Put the mother on her knees, chest down and buttocks raised. Re-call for help – urgent c-section.
Breech Position
This is when the baby comes out bottom first rather than head first! It is another emergency because the baby is likely to get stuck. You need a midwife. Move the mother into a supported squatting or semi – recumbent position. Do NOT touch the baby until the baby is free of the birth canal. If you touch the baby, you will startle it, so it will do a star fish impression – will reflexively extend limbs, making delivery more difficult. Encourage her to breathe out in slow, gentle, sighing breaths, or in little puffs. If you can see the bottom and Mum gets the urge to push don’t discourage her. Support the mother’s legs and perineum. When the neck is free of the pubic arch, lift the baby by the feet.
Post-partum haemorrhage (PPH)
PPH is bleeding >500ml following birth. It can happen up to 28 days after delivery. Life threatening PPH occurs in 1 in a 1000 deliveries in the UK. Treatment: Consider obstetric major haemorrhage call. Treat for shock. Provide fundal massage. Empty the bladder (catheter).
Pat Your Team On The Back
You did a good job, and you’ll likely be a bit emotional, it is quite something!
Recommended Courses
- mMOET (Managing Medical Obstetric Emergencies and Trauma): ALSG Course Dates and Venues.
- PROMPT (Practical Obstetric Multi-Professional Training): promptmaternity.org
- If you are in Scotland – Scottish Core Obstetric Teaching and Training in Emergencies Course (SCOTTIE)
RCEMLearning Resources: