Pre delivery considerations

The role of the ED practitioner in a labouring patient is to determine:

  1. Is there any immediate threat to maternal life?

If so:

  • ABCDE approach – Remember, maternal physiology >20 weeks gestation is abnormal and requires specialist interventions for the management of ABC.(1,4) 
  • Manage in the left lateral position (to reduce aortovenous compression)(4)
  • Early involvement of ITU and Obstetric teams (physiology in the final trimester is abnormal and therefore all aspects of ABC will be difficult – get help early).

*The Resus Council UK have produced an excellent single page summary for the management of obstetric cardiac arrest

  1. If the mother is stable, is the delivery imminent (i.e. active second stage)?

This will determine whether the patient can be transferred to an on-site or off-site maternity unit (or if it’s not possible to avoid delivery in the ED).

Signs of imminent delivery include1:

  • Crowning (presenting part visible below the labia) – This baby will likely be delivered in the ED!
  • Complete cervical dilatation and/or effacement
  • Mother feels delivery is imminent (particularly if multiparous)
  • Spontaneous pushing
  • Bloody Show (Bright red blood mixed with mucous plug)
  • Perineal bulge
  • Labial separation
  • Anal relaxation and/or bulging or sensation of impending defecation
  1. If delivery is not deemed to be imminent, will the patient require transfer to an obstetric-led unit or a midwife-led unit?

NICE guidance3 suggests that the following factors indicate delivery in an obstetric-led unit:

Maternal factors Foetal factors
  • Pulse >120 bpm on 2 occasions 30 minutes apart
  • A single reading of raised diastolic BP (>120mmHg) or raised systolic BP (>160mmHg)
  • Raised diastolic BP or >90mmHg or systolic BP of >140mmHg on 2 consecutive readings taken 30 minutes apart
  • A reading of 2+ of protein on urinalysis and a single reading of either raised diastolic (>90mmHg) or systolic BP (>140mmHg).
  • Temperature of >38 degrees Celsius on a single reading (or >37.5 degrees Celsius on 2 consecutive readings 1 hour apart)
  • Any vaginal blood loss other than a “show”
  • Rupture of membranes more than 24 hours before the onset of established labour
  • The presence of significant meconium
  • Pain reported by the woman that differs from the pain normally associated with contractions
  • Any risk factors recorded in the woman’s notes that indicate the need for obstetric-led care


  • Abnormal presentation (including cord presentation)
  • Transverse or oblique lie
  • High (>4/5 palpable) or free-floating head in nulliparous women
  • Suspected foetal growth restriction or macrosomia
  • Suspected anyhydramnios or polyhydramonios
  • Abnormal heart rate
  • A deceleration in heart rate on intermittent auscultation
  • Reduced foetal movements in the last 24 hours reported by the mother




If the patient has not previously accessed maternity services it may be safer to transfer directly to an obstetric-led unit.

Patient transfer

A number of factors will need to be considered when forming strategies for patient transfer. These include the general condition of the mother, availability of local maternity services, local ambulance services and patient preference (all should be communicated with the mother at the earliest possible phase3. Early discussion with a local midwifery/obstetrics team will help to guide the decision-making process.

If inter-hospital transfer is required, clearly explain this to the mother and/or birthing partner(s) to include them in the decision-making process. During transfer, the mother may need to adopt multiple non-supine positions to maintain comfort (Ambulance services may have protocols in place for safe patient positioning, so early discussion is useful to ensure appropriate preparations are in place)1,3. If possible, transfer with an attending midwife or nurse, and consider any birthing partners that the patient may wish to be present.

Learning bites

  • Prompt assessment of maternal stability is required and any resuscitation attempts should follow the guidance put in place by the resuscitation council UK4.
  • Signs of imminent delivery include; Crowning, full cervical dilatation and effacement, active maternal effort, perineal bulging/labial separation, and maternal feeling of imminent delivery.