Patient in Labour

Context

Although the exact numbers are unknown, labour and birth in the ED is understood to be a rare occurrence thanks to the ready access of UK maternity services¹. There are however, reasons why patients in labour may present to the ED instead of maternity services. These include; concealed pregnancy, maternal denial of pregnancy, lack of knowledge about maternity services, preterm rupture of membranes (PROM), chorioamnionitis, pre-eclampsia/Eclampsia, illicit drug use, maternal trauma, and maternal cardiac arrest^1,2.

While the majority of spontaneous births (approximately 90%) require practically no medical intervention²,  it is essential that ED practitioners are prepared to manage both normal and abnormal presentations of labour; including delivery and peripartum complications, and to appropriately stratify for transfer to obstetric services.

Definition and Pathophysiology

A detailed summary of the anatomy and physiology of labour can be found by going here.

For the purposes of this article, we will divide the mechanism of labour into 3 stages as outlined by NICE³:

Learning bites

• Labour can be divided into 3 main stages based on cervical changes and contractions.
• Delivery of the baby will occur during the active second stage of labour
• Preparations for patient transfer/delivery should take this into consideration depending on the stage of labour.

History

When managing women in labour, NICE guidance³ suggests:

“Treat all women in labour with respect. Ensure that the woman is in control of and involved in what is happening to her and recognise that the way in which care is given is key to this. To facilitate this, establish a rapport with the woman, ask her about her wants and expectations for labour, and be aware of the importance of tone and demeanour and of the actual words used³.”

Sources for the history can include the mother, birth partner or attending persons, antenatal screening notes, and the assigned midwife/maternal services.

Key components in the history:

• Gravidity/Gravida (Total number of pregnancies, regardless of outcome)
• Parity/Para (Number of pregnancies carried over 24 weeks)
• Past medical and surgical history

Current pregnancy

• Gestational age/due date? (If unknown, can be calculated using first day of last menstrual period, subtract 3 months and add 1 week)
• Number of babies expected to be delivered.
• Any complications during pregnancy? (E.g., hypertension, diabetes)
• Any known congenital abnormalities?
• Any maternal infections? Any fevers?

Previous pregnancies

• Any complications with previous pregnancies/births?

Since start of “labour” symptoms

• Are there contractions? When did contractions start? What length? What strength? How frequent?
• Any leaking of fluid or bleeding PV? (Timings essential – consider normal show vs heavy bleeding e.g. Placenta praevia)
• Have the membranes ruptured? When in relation to start of contractions? (If PROM >24 hours before onset of contractions there is increased risk of neonatal sepsis)
• What is the colour of the amniotic fluid? (Dark green/brown staining may suggest excess meconium)
• When was the last time the patient felt the baby move? How have movements been in the last 24 hours?
• Any alcohol or illicit drug use?

Examination

Initial examination should follow an ABCDE approach.

Examination of the pregnant abdomen should include:

• Fundal height (Measure from pubic symphysis to the fundus)
• Foetal lie (Longitudinal/Transverse/Oblique)
• Foetal position
• Presentation (Breech vs cephalic)
• Engagement (measured as fingers palpable per abdomen 5/5 – 0/5)

PV examination

For a labouring mother, PV examination can be a distressing experience (particularly in an unknown, often crowded environment in ED. For this reason PV examination in the ED should ONLY be performed if it will actively change the management plan for the patient (in other words, if we are unsure about the diagnosis OR if delivery is suspected to be imminent).^(1-3) DO NOT perform an examination is there is excessive PV bleeding (Placenta Praevia) or suspicion of PROM as this may worsen bleeding or introduce infection¹.

• When performing PV examination explain clearly to the mother why it is indicated and provide adequate analgesia (e.g. Entonox 50:50)³
• Palpate the cervix to assess effacement (0-100%) and dilatation (0-10cm)
• Determine foetal station (position of presenting part in relation to the ischial spines)

Foetal assessment

Compared to a labour unit, the ED has limited equipment available to perform this accurately (e.g. Cardiotocography, CTG). However, it is possible to perform some basic assessments by: Auscultating the foetal heart (using a handheld Doppler or Pinnard stethoscope) for a minimum of 1 minute immediately after a contraction³. Palpate the mother’s pulse at the same time to differentiate the two heartbeats. Record any accelerations or decelerations heard (Normal variability 5-25bpm over 25 minutes).

Foetal heart rate	Category
110-160bpm	Reassuring
100-109bpm Or 161-180 bpm	Non-reassuring
<100bpm or >180bpm	Abnormal

Parameters for Foetal Heart Rate: Adapted from NICE guidance³.

• POCUS: In the hands of an experienced practitioner, POCUS may be beneficial in assessing foetal heartbeat, position, presentation, and, in the case of mothers with limited antenatal history will help identify the number of foetuses present¹.

Learning bites

• It is helpful to take a focussed clinical history combined with any antenatal screening notes +/- collateral history
• Priority for assessment is ABCDE, followed by examination of the pregnant abdomen and foetus
• PV examination should ONLY be performed if it will change the management plan (i.e. unclear labour or potential imminent labour)
• Normal Foetal HR ranges from 110-160bpm (5-25bpm variability is normal).

• Urinalysis (assess for protein +/- HCG if unsure about pregnancy)
• Blood tests (obtain simultaneous IV access)
• Full blood count
• Renal function
• Liver function tests
• Coagulation screen
• Crossmatch samples (Early discussion with your local transfusion service is advisable if the patient has attended antenatal screening or if urgent blood transfusion will be required)⁹.
• Blood cultures (if suspecting maternal sepsis)

Learning bite

• Arrange urinalysis, blood tests and crossmatch screening for all patients presenting in suspected labour.

Pre delivery

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* 

2. 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

3. 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.

Delivery in the ED

The majority of spontaneous vaginal deliveries require minimal medical intervention and a supportive approach is all that will be required^1,2. However, as ED deliveries are an infrequent occurrence it is worthwhile preparing for the worst.

Location

• “Resus” (Ensure 2 spaces available: for mother and baby)

Equipment

• Towels + Gauze
• Sterile gloves
• Umbilical cord clamps (or surgical clamps) x 2
• Surgical scissors
• Entonox (50:50)
• Large plastic/metal bowl (for placenta)
• Female urinary catheter 
• Birthing partner (if possible) 
• Resuscitaire/Neonatal resuscitation equipment

Personnel

• Maternal team: Comprising ED +/- midwives +/- obstetrics
• Neonatal team: Comprising ED +/- Paediatrics 
• ITU/anaesthetics

Management of the active second stage of labour 

For the purpose of this section, we will cover some specific advice for managing delivery in the ED. If you would like to watch a simulation of a normal vaginal delivery, please follow this link. 

• Position: Support the mother however possible, and allow her to adopt whatever position is comfortable without adding distress.
• Analgesia with Entonox (50:50) is recommended by NICE and is readily available in an ED setting³. Other analgesic methods (including opioids) are unlikely to be suitable in the ED and may cause harm to mother or baby³.
• “Guard the perineum!” Precipitous deliveries are associated with a higher degree of perineal trauma than non-precipitous due to higher velocity of delivery¹. Once the baby is crowning, place a gloved hand at the perineum and gently squeeze the two sides together to provide support and reduce the chance of perineal tearing^1,3. Routine episiotomy is not indicated, but may be indicated in some circumstances (See “complications” below).
• Suctioning of the foetal oropharynx is not recommended routinely³.
• Fundal pressure may be provided once the anterior shoulder has been delivered, however it is best avoided prior to this due to risk of shoulder dystocia⁵.
• Avoid brachial plexus injury by applying gentle axial traction when pulling the baby’s head and neck (Depending on the mother’s position this may be more difficult)¹.
• Uterotonic agents should ideally be administered after delivery of the anterior shoulder, and before clamping of the cord, to reduce the risk of Postpartum Haemorrhage (PPH)^3,8. NICE and RCOG guidelines recommend the use of Oxytocin 10 units (iU) via intramuscular injection^3,8.While other agents are available (Ergometrine, Syntometrine) there is limited evidence of superior efficacy compared to Oxytocin and they can be associated with higher rates of nausea and hypertension³.

Once the baby is delivered, immediately dry them with towels to stimulate them to breathe. If there is respiratory effort (crying) and minimal concern, then the baby can be placed on the mother’s chest to provide skin-to-skin contact¹. Any concern about the baby should be managed with the allocated Neonatal Resuscitation team to facilitate rapid assessment and management following established neonatal resuscitation guidelines. 

Management in the third stage of labour

“Active management” of the third stage of labour is associated with a reduced rate of PPH compared to “physiological management” and may therefore be preferred in an ED delivery^3,6. Active management consists of:

• Cord clamping and dissection
• Uterotonic agents +/- uterine massage
• Umbilical cord traction to deliver the placenta

Cord clamping can, in most cases, be delayed for 1-2 minutes post-delivery (or until pulsation of the cord ceases) to allow delivery of oxygenated blood to the newborn from the placenta^3,6. If there is concern for the wellbeing of the newborn, the cord may be clamped and dissected to allow for transfer to a neonatal resuscitation space¹.

In order to dissect the cord, place 2 clamps approximately 7-10cm along the umbilical cord from the baby (spaced roughly 5cm apart) and use surgical scissors to cut the cord between the clamps¹.

To prepare for delivery of the placenta, wrap the placental portion of umbilical cord in gauze and prepare the vessel for the placenta and membranes (plastic/metal bowl). Placental delivery will usually occur 5-15 minutes after foetal delivery¹ (if >30 minutes despite active management this would be considered “delayed” ³ and will require urgent Obstetrics input). Await signs that the placenta has started to separate from the uterine wall. Using a gloved hand, apply gentle, intermittent traction to the gauze-wrapped portion of cord (avoid excessive, prolonged force as this may cause uterine inversion).

Monitor (and if possible, measure) vaginal blood loss to assist in the management of PPH.

Once the placenta and membranes have been delivered, carefully inspect to ensure they are complete and that no products of conception (POC) have been retained. Inspect the perineum/genitalia to assess for trauma which may require surgical intervention.

Complications

Retained POC

• Definition: Either delayed third stage (>30 mins) or signs of incomplete POC³
• Urgent input is required from an obstetrics team
• IV Uterotonic agents can be considered to deliver a placenta in the presence of life-threatening bleeding
• If uterine exploration (+/- manual removal of POC) is deemed necessary, transfer urgently to an obstetric unit.

Postpartum Haemorrhage

• Definition: Loss of >500mL of blood from the genital tract within 24 hours of birth^3,8
• Minor PPH = 500-1000mL / Major = >1000mL (Of which Moderate = 1000-2000mL and Severe = >2000mL)³
• Causes: Uterine atony (most common cause), retained POC, genital/perineal trauma and coagulopathy [Can be remembered as the “4 Ts” (Tone, Tissue, Trauma and Thrombin)]^1,3,8.

Management:

• Initial measure should include emptying the bladder and uterine massage
• In Major PPH consider boluses of uterotonic agents⁸:
  Oxytocin 10iU intravenous
  OR Ergometrine 0.5mg IM
  OR Syntometrine 5iU/0.5mg IM
  *Repeat boluses may be required is bleeding is not controlled*
• Manage as per local obstetric haemorrhage protocols (ABO-Negative, Rhesus-negative and K-Negative blood should be transfused, or in emergency can utilise O-Rhesus D negative red cells). Discuss with your local transfusion laboratory to minimise transfusion error and delay⁹.
• Platelet +/- FFP transfusions may be required and directed by full blood count results and coagulation screens⁹.
• Controlled cord traction if placenta has not yet been delivered
• Arrange emergency transfer to an obstetric-led unit
• If initial measures are not effective, may require additional bonuses of prostaglandin agents (Misoprostol/Carboprost) 
• Consultation with haematology re adjuvant clotting factor administration (fVIIa)
• Intrauterine tamponade (via Balloon tamponade) is recommended whilst awaiting surgical intervention. If tamponade devices are not available, pack the uterine cavity with gauze/haemostatic gauze⁸.
• Tranexamic acid is not a recommended intervention in PPH due to lack of evidence for its efficacy and the increased risk of thromboembolic disease⁸.  However in the case of life-threatening haemorrhage or Maternal Cardiac Arrest, Tranexamic acid is recommended by the Resuscitation council UK⁴.

Shoulder Dystocia

Definition: Impaction of the anterior foetal shoulder behind the Pubic symphysis (PS) or the posterior shoulder behind the sacral promontory⁵.

Occurs infrequently (0.56-0.70% of vaginal deliveries) but requires quick and definitive action as it is associated with a high degree of maternal and peri-natal mortality (haemorrhage, fourth degree perineal tears, uterine rupture, brachial plexus injury and hypoxia/death of the newborn)¹.

• During delivery, observe for:
  – Difficulty with delivery of the face and chin
  – Failure of anterior shoulder descent with assistance >60 seconds after delivery of the head
  – Retraction of the foetal head into the vulva/perineum (“Turtle sign”)

Once recognised, instruct the mother to stop pushing. There are a number of manoeuvres that can then be attempted:

1. McRobert’s manoeuvre:

• Lie the mother flat with no pillows under the back
• Place one assistant on either side of the mother and move both maternal hips into complete flexion and slight abduction (i.e. knees-chest)
• The assistants should then hold the knees in place against the chest
• McRobert’s is associated with a high degree of success when performed correctly (as high as 90%)
• If shoulder delivery is not improved, applying suprapubic pressure (see next point) can be useful in assisting delivery.

2. Mazzanti manoeuvre:

• Ask an assistant to apply rolling pressure to the suprapubic region (can use a similar hand position to that adopted during CPR) in a downward and lateral direction in an attempt to disengage the impacted shoulder under the PS (DO NOT apply fundal pressure here as this will worsen the dystocia).

3. Wood-screw/Reverse Wood-screw manoeuvre:

• In this manoeuvre we are attempting to rotate the foetus within the birth canal to an oblique position to assist delivery of the anterior shoulder
• Insert two gloved fingers into the vagina aiming for the posterior surface of the anterior shoulder
• Insert your other hand with two fingers placed on the anterior surface of the posterior shoulder
• Apply pressure to the posterior shoulder and attempt to rotate the foetus anti-clockwise within the birth canal
• REVERSE Wood-screw can be attempted by applying pressure to the posterior surface of the posterior shoulder to rotate the infant clockwise.

4. Delivery of the posterior arm:

• Pass one hand into the vagina along the posterior arm to the elbow
• Flex the arm until the forearm can be gripped and swept across the foetal chest to deliver the posterior arm and shoulder
• If this does not aid delivery, it may be necessary to rotate the trunk to bring the freed arm into the anterior position, however this carries a high risk of orthopaedic injuries (clavicular/numeral fractures).

5. The “All Fours”/Gaskin manoeuvre:

• Position mother on her hands and knees. Apply gentle downward traction in an axial manner to the baby’s head.

Episiotomy is not always necessary (as this will not relieve the bony obstruction), however may be required if more space is needed within the vagina to perform digital manoeuvres⁵.

If the above procedures fail then specialised obstetric techniques may be required such as the Zavanelli manoeuvre (Vaginal replacement of the head to allow for Caesarean section), Cleidotomy (Surgical division of the clavicle or bending with a finger) or Symphysiotomy (dividing the anterior fibres of the symphysial ligament)⁵.

Breech presentation

Occurs in 3-4% of pregnancies and is associate with a 3-4 times higher morbidity rate than cephalic presentation (due to foetal distress, cord prolapse and head entrapment)^1,7.

To view a simulation of Breech delivery, follow this link.

Management:^1,7

Minimise touching the foetus and provide support below the level of the perineum to allow spontaneous delivery. Providing immediate traction to the foetus may extend the foetal head and lead to entrapment which increases the risk of asphyxiation. Direct assistance is required only in the event of an incomplete breech delivery¹.

• Delivery of the legs: If the legs are flexed (i.e. in a pike position), place a hand behind the foetal thigh and press gently in a lateral direction to allow delivery of each leg in turn. Continue to support the foetal pelvis (a towel may be useful to avoid slippage). Place your fingers over the anterior superior iliac crest with thumbs resting over the sacrum (this will prevent injury to the foetal abdominal soft tissue).
• Delivery of the arms: Rotate the foetus 90 degrees in either direction to create an anterior shoulder. Spontaneous delivery of the arms and shoulders may occur or may require sweeping of the arm across the chest with your fingers to facilitate delivery.
• Then rotate the foetus 180 degrees in the other direction to deliver the second arm.
• Delivery of the head: Rotate the infant so the sacrum is anterior again. Ask an assistant to apply suprapubic pressure to flex the head (NOT fundal pressure as this will worsen head entrapment).
• If the head does not deliver spontaneously, place your arm under the foetus for support and reach into the birth canal. Apply pressure to the maxilla with your index finger and middle finger on either side of the nose. Keep the Foetal body parallel to the floor (as excessive angulation upwards will hyperextend the neck and cause spinal cord injury)
• Using your other hand, hook the index and middle finger on each side of the neck, applying gentle downward traction to the shoulders until the suboccipital region appears under the pubis symphysis
• Elevate the foetal body upward toward the mother’s abdomen to complete delivery of the head.

Umbilical Cord Prolapse

Definition: Descent of the umbilical cord through the cervix alongside or past the presenting part in the presence of ruptured membranes (i.e. the cord presents between the presenting part and the cervix)⁶.

Although infant mortality in cord prolapse is high, incidence is low (0.1-0.6%)¹, with risk factors including; breech presentation, multiparity, low birthweight, preterm rupture of membranes, polyhydramnios, and multiple procedure-related factors such as artificial rupture of membranes with a high presenting part¹.

Patients at risk of cord prolapse should have been identified during antenatal screening. A high degree of suspicion should be held if risk factors are present. 

Speculum examination should be performed in these cases to assess for prolapse. Digital examination may be beneficial but can provoke cord prolapse through vasospasm of the cord and therefore it is recommended that the cord is not “handled” in an attempt to reinsert above the presenting part into the uterus^1,6.

If cord prolapse is diagnosed before full dilatation (i.e. vaginal birth is not imminent) then immediate transfer to a consultant-led obstetric facility should be arranged as urgent operative delivery will be required:

• The mother should be placed in either the knee-chest face-down position or the exaggerated Sims position (Left lateral with pillow under hip)⁶.
• Elevation of the presenting part (to minimise cord compression) can be performed either manually using two gloved-fingers inserted into the vagina, or by filling the urinary bladder using a Foley catheter attached to a blood giving set (Once the bladder is filled to distension with approx. 500-750mL, the catheter should be clamped until just prior to delivery)^(1,6)
• Tocolysis (e.g. Terbutaline 0.25mg SC) can be used to reduce contractions and limit bradycardia⁶, however this should only be delivered in ED with assistance from a senior obstetrician. 

If delivery is imminent, birth can be attempted at full dilatation using standard techniques and taking care to avoid impingement of the cord when possible¹.

Uterine inversion

• High risk for inability to reduce uterus and significant haemorrhage (Prepare appropriately)¹.
• Do not attempt to remove the placenta
• Attempt manual reduction by placing a hand in the vagina and applying counter pressure to the fundus towards the umbilicus
• If not promptly reduced, the lower uterine segment and cervix can contract and make further attempts futile. Urgent obstetric advice and review will be required including potential for surgical correction¹.

Learning bites

• When preparing for imminent delivery in the ED, call for senior help and request immediate presence of obstetrics, midwifery, paediatric and intensive care/anaesthetics.
• Establish 2 Resus spaces and 2 teams (Maternal and neonatal)
• 90% of deliveries will require minimal medical intervention
• Once the anterior shoulder is delivered, administer 10 units of Oxytocin via intramuscular injection
• Frequently monitor and prepare for complications including cord prolapse, shoulder dystocia, PPH, breech presentation and uterine inversion.

1. Sharp B, Sharp K, Wei E. Precipitous labor and emergency department delivery. Emergency Department Management of Obstetric Complications. 15 May 2019;:75–89.
2. Gupta AG, Adler MD. Management of an unexpected delivery in the emergency department. Clinical Paediatric Emergency Medicine. 2016;17 (2):89-98.
3. National Institute for Clinical Excellence (NICE) guideline: Intrapartum care for healthy women and babies. 2014 (Updated 2017). [Accessed 21 Oct 2022].
4. Deakin CD, Davies R, Patterson T, Lyon R, et al. Special circumstances guidelines [Internet]. Resuscitation council UK. Resuscitation Council UK; 2021 [Accessed 21 Oct 2022].
5. Royal College of Obstetricians and Gynaecologists (RCOG) Green-top Guideline No.42. Shoulder dystocia. 2005 (Updated March 2012).
6. Royal College of Obstetricians and Gynaecologists (RCOG) Green-top Guideline No.50: Umbilical cord prolapse. Nov 2014.
7. Royal College of Obstetricians and Gynaecologists (RCOG) Green-top Guideline No.20b: Management of Breech Presentation. March 2017.
8. Royal College of Obstetricians and Gynaecologists (RCOG) Green-top guideline No.52: Postpartum Haemorrhage, Prevention and Management. Dec 2016.
9. Royal College of Obstetricians and Gynaecologists (RCOG) Green-top. Guideline No. 47: Blood transfusion in Obstetrics. May 2015.