Approach to Precipitous Delivery in the Emergency Department: Best Practices for Managing Emergent Vaginal Deliveries and Associated Complications

Abstract

Precipitous deliveries in the emergency department are one of the highest-acuity events that emergency providers manage. These deliveries can range from uncomplicated to wrought with difficulty. They require emergency care providers to manage intrapartum complications, such as nuchal cords, shoulder dystocia, and breech presentation, and maternal complications such as uterine atony, birth canal trauma, and postpartum hemorrhage. Delivery may additionally necessitate resuscitative hysterotomy or neonatal resuscitation. Our narrative review discusses preparatory practices, normal labor and delivery progression, and brief guidelines for managing complications of precipitous deliveries for emergency medicine providers.

1. Introduction

A precipitous delivery is labor and delivery that progresses rapidly, often cited as labor and delivery that is completed within 3 h of the onset of regular contractions [1]. Approximately 3% of deliveries in the United States are precipitous, though globally, this figure can be far higher, with some sources referencing an incidence up to 14% [1,2]. While many precipitous deliveries result in positive outcomes, they are associated with both maternal and neonatal complications, including nuchal cords, shoulder dystocia, breech presentations, and postpartum hemorrhage [2]. Many factors predispose patients to precipitous delivery, including low birth canal resistance, as seen in cases of multiparity, and increased uterine contraction strength [3]. All deliveries presenting to the emergency department (ED) should be considered precipitous, though some may further be classified as imminent deliveries when the patient presents further progression in labor with complete cervical dilation and effacement. While some precipitous deliveries are not imminent and the patients may be transported to obstetric units, ED providers may find themselves as the primary physicians managing an imminent delivery. Providers must appropriately activate resources and equip themselves to best care for a precipitous delivery and its associated complications. In this narrative review, we summarize the literature published within the last five years available on PubMed with a focus on precipitous delivery and its complications. Ultimately, we use these articles to review best practices for the management of emergent vaginal deliveries and related complications.

2. Management of Precipitous Delivery

2.1. Preparation

Preparation for a precipitous delivery should begin far in advance with the familiarization of obstetric services and protocols available to an emergency medicine (EM) provider. For many providers, this will include the early activation of obstetric and possibly anesthesia teams upon the arrival of a delivering patient to the ED. Early activation of these resources is crucial to better patient care and the timeliness of evaluations by all necessary specialties. In centers without consistent or immediate obstetric provider access, some EDs may utilize general surgery services for precipitous deliveries that necessitate operative management or consult outside hospitals with these obstetric providers for transfer if clinically feasible. Furthermore, EM providers must remember that precipitous deliveries include two patients, and pediatric or neonatal services, if available, should be consulted for patients presenting with precipitous deliveries.

After familiarization with the human resources available, EM providers should familiarize themselves with available equipment to conduct a precipitous delivery. It may benefit providers to assemble delivery kits to be utilized, both for maternal and fetal management. We suggest a minimum supply kit of sterile personal protective equipment (gloves, gown, mask, and eye protection), two sterile clamps or hemostats, surgical scissors, towels, a scalpel, suture material, and materials for fetal resuscitation such as a suction bulb and wall, neonatal-sized endotracheal tubes, intubation blades, BVM, and a fetal warmer [4]. With the familiarization and preemptive gathering of these materials, EM providers can focus on patient care immediately on presentation. A reference sheet of suggested materials and a checklist can be found below (Figure 1 and Figure 2), in addition to a quick reference sheet for the management of common complications, which are discussed later.

Precipitous deliveries are highly stressful and emotional deliveries due to the inherent nature of the event as well as the maternal and neonatal risk; preparation and education are highly impactful in the execution of these deliveries. Providers may benefit from simulating these events with their consultants to best prepare the team for calm, cohesive resuscitations and deliveries when they arise. Simulations of precipitous deliveries would be most beneficial if individualized to the resources available at respective facilities, and they also should include simulations of some of the associated complications of precipitous deliveries, as noted below.

2.2. Initial Evaluation in the Emergency Department

The initial evaluation in the emergency department should focus on the imminence of delivery and stability of the mother and fetus, as well as the activation and obtainment of resources as noted above. Providers should prioritize maternal vitals, ensuring that intravascular (IV) access is obtained, as well as perform a brief examination of the mother and an evaluation of fetal heart tones. Key to this step is the activation of human resources as noted above, which may include obstetric, anesthesia, pediatric teams, or even general surgery teams, depending on resource availability. The roles of different teams and providers should be assigned for effective leadership and management of the delivery.

Next, providers should continue with a vaginal examination. First, conduct a visual inspection for vaginal bleeding or crowning. Profuse vaginal bleeding without crowning may be indicative of placenta or vasa previa, and further physical manipulation should be deferred to avoid hemorrhage risk [2]. A subsequent evaluation should be conducted through a sterile vaginal assessment to assess cervical dilation, effacement, fetal station, and presenting fetal part [4]. Supplemental examination with a sterile speculum exam can be conducted if fetal station and cervical dilation or effacement are unable to be assessed via a digital examination, and ultrasound can prove a useful tool if the presenting part is unable to be determined through a physical exam. A total of 95% of deliveries past 36 weeks will be cephalic in presentation [4]. Physical examination will also aid in determination if the rupture of membranes has occurred. If the delivery is imminent, the patient should not be transported or transferred, and the delivery should occur in the ED. Other patients who are not fully effaced, dilated, or otherwise not clinically imminent when they present may merit transport to labor and delivery units dependent on the risks, benefits, and facility policies [4].

If time allows, providers should elicit further history from the patient. Key historical items to review include gravidity, parity, pregnancy dating, number of babies, complications of pregnancy, and the medical history of the mother [2]. In addition, the history of current presentation and labor symptoms can assist in the determination of imminence of delivery, for example, contraction onset, frequency, and rupture of membranes. Furthermore, the patient may be able to provide their blood type, though a type and screen should be sent to verify this.

2.3. Precipitous Delivery Analgesia

If the patient desires, ED providers should administer analgesia during labor. Anesthesia providers may assist if available, though ED providers are capable of providing and administering key analgesic options in labor.

A frequent medication in the ED, acetaminophen, may provide relief for mild to moderate pain in labor. Intravenous acetaminophen is a safe option with a low side effect profile for intrapartum analgesia. A dose of 1000 mg IV acetaminophen is recommended over nonsteroidal anti-inflammatory drugs (NSAIDs), which risk premature closure of the ductus arteriosus [5].

Commonly used in labor and delivery, nitrous oxide (N₂O) provides rapid onset analgesia in 30 to 60 s through an inhaled combination of 50% N₂O and 50% oxygen for self-administered analgesia via face mask. The medication clears rapidly from the blood and therefore does not significantly impact labor progression or neonatal outcome. It has few side effects, though it may cause nausea, drowsiness, and dizziness [5].

Opiates may additionally be used for analgesia for precipitous deliveries. Fentanyl is a synthetic opiate with a short duration of action that can be provided intravenously or intranasally for pain control. Fentanyl does not cross the placenta in significant amounts and carries low risk of negative maternal or fetal outcomes. It may cause side effects of nausea, vomiting, and sedation. The suggested dosing is 50–100 mcg IV hourly for pain [5].

3. Normal Labor and Postpartum

3.1. Stages of Labor

After the initial evaluation, precipitous deliveries remaining in the emergency department should be assisted through any remaining stages of labor. Throughout the stages of labor, the fetus will progress through seven cardinal movements on its descent: engagement, flexion, descent, internal rotation, extension, external rotation, and expulsion. First, the fetal head engages with the pelvis, causing it to flex and allowing further descent caudally. During descent, the fetal head transitions laterally, either anterior or posterior facing with internal rotation. As the fetal head passes underneath the pubis, the head extends until delivery, where it will externally rotate for the neonate’s face to rotate laterally for external rotation. Ultimately, the infant is completely expelled or delivered [4,6].

The first stage of labor is signaled with the onset of regular contractions with cervical change. It is commonly subdivided into the latent and active phase, which are from 0 to 6 cm for the latent phase and 6–10 cm for the active phase. Typically, the active phase will progress more rapidly than the latent phase. The second stage of labor begins after cervical dilation to 10 cm and ends with the delivery of the newborn. The third stage of labor follows neonatal delivery and culminates in the delivery of the placenta. Placental separation characteristically occurs within 5 to 30 min after the second stage of labor is complete and is preceded by a gush of blood and umbilical cord lengthening. Should the third stage last longer than 30 min, the patient may need manual placenta removal as a longer duration increases the risk of postpartum hemorrhage [6]. Precipitous deliveries in the ED are likely to present in the active stage of labor or the second stage; they present infrequently in the third stage if the delivery precedes the arrival. These stages are critical for EM providers to be prepared to manage.

In the second stage of labor, the patient should be encouraged to push for three 10 s intervals during each contraction. The provider can place warm compresses to the perineum to decrease perineal trauma. At the 5+ station, or crowning, stabilizing pressure can be placed on the perineum with a sterile towel with another hand holding the fetal head. The patient should cease pushing, while contractions prompt the remainder of the delivery. At the delivery of the head, the neck is inspected for the presence of a nuchal cord, which is reduced if possible. Next, the anterior shoulder is delivered. The provider places their hands along the sides of the neonate’s head, with their fingers pointed toward the face, applying gentle downward traction. Hand placement is maintained and followed with the application of gentle upward traction to deliver the posterior shoulder. Once the posterior shoulder is delivered, the remainder of the neonate’s body will follow, and the rate of passage should be controlled by the delivering provider. Once the neonate is fully delivered, it can be placed for skin-to-skin contact on the mother’s chest for the evaluation of Apgar scoring and delayed cord clamping, as detailed below. Current research continues to show the benefit of delayed cord clamping greater than 30–60 s following delivery to reduce infant anemia, improve neonatal iron stores, and improve neurodevelopmental outcomes [7].

Finally, the third stage of labor progresses with placental delivery. Gentle traction can be placed on the cord using a single sterile clamp after the cord is clamped and cut. While providing traction, pressure is placed on the fundus to stabilize it within the abdomen to facilitate uterine contraction and reduce the risk of uterine inversion or retained placenta. After delivery, the placenta should be inspected visually to ensure it is intact and not missing membranes or lobes [8]. Thus, the third stage of delivery is completed and postpartum management as well as neonatal assessment should ensue.

3.2. Normal Postpartum Management

Postpartum management begins following the completion of the third stage of labor. Postpartum management includes the reassessment of maternal stability, active management of postpartum bleeding, and neonatal assessment. Separate teams, if available, should aid the ED provider in managing both patients, with one team for maternal management and an additional team for neonatal assessment.

After the placenta is delivered, postpartum bleeding and uterine tone should be actively managed with the administration of 10 IU IM of oxytocin. Active management of postpartum bleeding reduces the risk of postpartum hemorrhage at the time of birth [9]. The vagina and cervix are examined for lacerations or abrasions, and lacerations that are greater than second degree, or first- and second-degree lacerations that are not hemostatic, should be repaired [10].

As noted previously, skin-to-skin contact between the mother and infant should be performed as an evidence-based practice to augment bonding and breastfeeding, as well as decrease the duration of the third stage of labor [11]. Thus, evaluation of the newborn should be initiated during skin-to-skin contact. This can best be performed by a dedicated pediatric or neonatology team if available, or a separate team of providers than those who are assessing the mother. Grossly, if the infant is near term or full term, has appropriate tone, audible crying, and appropriate respirations, the infant can be dried and remain with the mother for warming with blankets and body heat [12]. Infants that are not vigorous should be transferred to the warmer for resuscitation. Hypothermia increases the oxygen consumption of the infant and correlates with mortality regardless of gestational age [13]. If, after these steps, the infant’s respirations do not improve, clear the airway through positioning and the removal of secretions with a bulb syringe or suction. If respirations are still inadequate or the infant has a heart rate less than 100 bpm after suction, reassessment, and repositioning, begin positive pressure ventilation with a bag valve mask to a target respiratory rate of 40 to 60 breaths per minute.

Following this initial minute period, providers calculate an Apgar score, based on appearance, pulse, grimace, activity, and respiration, each scored from 0 to 2. Providers will repeat a score every five minutes to achieve a score of seven or completion in a 20 min time period [12]. Apgar scores will be a key data point in the handoff to pediatric and neonatal providers upon the transition of care.

4. Complications of Precipitous Delivery

Precipitous delivery may present with intrapartum complications, both maternal and fetal, such as nuchal cords, shoulder dystocia, and breech delivery, as well as postpartum complications, such as postpartum hemorrhage, birth canal trauma, retained placental tissue, and more [14].

4.1. Nuchal Cord

A nuchal cord is a complication present in approximately 24% of deliveries [15]. It is defined as at least one full wrapping of the umbilical cord around the fetal neck. The nuchal cord should be assessed and addressed as the head delivers. The delivering provider should palpate and visualize the fetal neck to assess for a nuchal cord. While having a high incidence, often nuchal cords are easily reducible in 98% of cases, with few requiring neonates to have advance resuscitation or ICU stays [15]. For loose cords that are easily reduced, this can be performed prior to delivery. On tight nuchal cords that are irreducible, a somersault maneuver may be attempted rather than clamping and cutting the cord. A somersault delivery is performed through the nuchal cord while maintaining the fetal head in close proximity to the mother’s thigh rather than directly expelled toward the provider to reduce traction on the cord. Once the infant’s body has been delivered, the nuchal cord is reduced [16]. Should a reduction or somersault not be feasible, the cord may be clamped and cut as a last resort, though taking note of potential complications for anemia, shock, and cerebral palsy [4].

4.2. Shoulder Dystocia

Shoulder dystocia (SD) is another complication of precipitous delivery that EM providers may encounter. SD is the failure of the fetal anterior shoulder to deliver following delivery and the downward traction of the head. The reported incidence of SD varies, though it can occur in 0.3% to 7% of cephalic vaginal deliveries [17]. SD requires rapid recognition and management as its delay may ultimately result in fetal disability or death from injury and delivery arrest as well as maternal morbidity. Fetal macrosomia and maternal diabetes increase the risk of SD, though not all cases have attributable risk factors [4]. Several maneuvers can assist in remedying SD, though no single sequence of maneuvers has been shown to be the most effective. These maneuvers include the McRoberts maneuver, internal rotational maneuvers, delivery of the posterior arm, and Gaskin maneuver. As a last resort, an episiotomy should be considered.

First, begin with the McRoberts maneuver as it is noninvasive and simple to perform [18]. The McRoberts maneuver is performed with the hyperflexion of the mother’s thighs towards her abdomen, with one provider flexing each leg. Concurrently, an additional provider places the heel of their hand or a fist over the suprapubic region, which is overlying the fetus’s anterior shoulder [19]. This suprapubic pressure displaces the fetus’s anterior shoulder below the mother’s pubic symphysis to assist in the reduction in dystocia. The McRoberts maneuver with suprapubic pressure is found to resolve at least 25% of dystocias and greater than 94% of dystocias when combined with additional maneuvers [20].

Next, the provider may attempt internal rotational maneuvers: the Rubin II and Woods corkscrew maneuvers. To perform the Rubin II maneuver, the provider places their fingers on the posterior aspect of the fetus’s anterior shoulder, pushing the fetus’s shoulder anteriorly towards the fetal chest to dislodge the anterior shoulder. Similarly, the Woods corkscrew maneuver is performed with the provider placing their fingers on the anterior aspect of the fetus’s posterior shoulder to push posteriorly. These maneuvers can be performed in isolation or concurrently. If unsuccessful, the reverse Woods corkscrew maneuver can be attempted by simply changing their finger location to the posterior aspect of the fetus’s posterior shoulder rather than the anterior aspect of the posterior shoulder [21].

If these maneuvers are ineffective at reducing the anterior shoulder, the provider should attempt the delivery of the fetus’s posterior arm. By placing one hand behind the fetus’s posterior shoulder onto the fetal elbow, the provider can grasp the fetal forearm. In a sweeping motion, the fetal forearm is moved across the fetal chest to deliver the hand of the posterior forearm, thereby reducing the fetus’s shoulder diameter and releasing the anterior shoulder [21].

Lastly, the delivery by the mother on all fours, or the Gaskin maneuver, can be attempted. This positioning can increase the mother’s pelvic outlet diameter to assist in shoulder delivery. It also allows for second attempts of internal rotational maneuvers in this new position with a greater pelvic outlet diameter, increasing the odds of success [21].

Should all above methods fail to relieve the dystocia, a cesarean section is the next avenue of care if obstetric providers are immediately available to assist. Without obstetric assistance, the ED provider may be left to the last resort of an episiotomy, of which the utility is primarily to assist in performing secondary maneuvers. An episiotomy alone will not likely relieve the dystocia, as the dystocia is secondary to bony obstruction rather than soft tissue [21]. A summary of the maneuvers that should be attempted can be found below (

Table 1. An outline of maneuvers to relieve shoulder dystocia.

Maneuver	Description
McRoberts and suprapubic pressure	Two providers assist with hyperflexion of the mother’s hips and knees; an additional provider places suprapubic pressure on the mother
Rubin II	Place 2–3 fingers on the posterior aspect of the fetus’s anterior shoulder; push the shoulder anteriorly towards the fetal chest
Woods corkscrew	Place 2–3 fingers on the anterior aspect of the fetus’s posterior shoulder; push the shoulder posteriorly towards the fetal back
Reverse Woods corkscrew	Place 2–3 fingers on the posterior aspect of the fetus’s posterior shoulder; push the shoulder anteriorly towards fetal chest
Posterior arm	Place one hand on the elbow and forearm of the fetus’s posterior shoulder, flex the fetus’s elbow to sweep the forearm across the chest, and deliver the posterior shoulder
Gaskin maneuver	Mother is positioned on hands and knees; attempt rotational maneuvers of the fetus in this position if needed

).

4.3. Breech Presentation

Delivery may also be complicated by breech presentation. Breech presentation occurs in 4% of term pregnancies and is associated with greater morbidity than cephalic presentations, often due to head entrapment resulting in asphyxiation or umbilical cord prolapse [19]. Even with a successful delivery, breech presentation carries the risk of brachial plexus injury and trauma to the birth canal. There are three types of breech presentation: Frank breech (most common), complete breech, and incomplete breech. A Frank breech bodes most favorably for delivery, where the fetal hips are flexed and knees extended to position the fetus within the pelvic outlet. In a complete breech, the fetal knees and hips are both flexed completely. Last, an incomplete breech position, also termed footling breech, presents with the knees flexed and the feet beneath the buttocks as the first presenting part. This position has a high risk of head entrapment.

For the ED provider, breech presentations should be managed in the operating room with an obstetrician if one is available, or the patient should be transferred to a facility with the capability to perform a cesarean if feasible for early labor as planned. Vaginal breech deliveries had double the risk of perinatal mortality than breech cesarean deliveries [22]. In the absence of obstetric assistance or transfer ability, pediatric and anesthesia teams should be consulted for assistance. If these obstetric assistance or transfers are unavailable, the ED provider should prepare for a breech delivery [4].

Management of a breech delivery, after the initial call for assistance, is focused on the non-manipulative progression of labor. Allow the delivery to occur at a natural pace without traction on the fetal body, as an increased delivery pace and forced evacuation increase the risk of fetal entrapment at the pelvic inlet. The provider can support the fetal body during delivery to avoid traction if needed. When the delivery has progressed to being able to visualize the fetal feet, legs, and trunk to the level of the umbilicus, the provider should gasp the fetal pelvis with a sterile towel and maintain the back of the fetus in an anterior position to assist with head delivery. The delivery of the arms may necessitate intervention if not spontaneously delivered with maternal effort. Rotating the fetus 90 degrees to one direction with a finger sweep over the anterior shoulder to sweep the arm across the chest can help move the fetal arm to a deliverable position. This is repeated on the second side following a 180-degree rotation of the fetus. Lastly, the head can be delivered once the nape of the infant’s neck is visible; the provider’s forearm is placed under the infant’s body with legs on either side. The provider places two fingers on their first hand under the fetal maxilla, while their second hand is placed on the fetal back with one finger flexing the head downwards. Once in this position, the provider places downward traction on the shoulders, simultaneously lifting the fetus upward and outward [4].

4.4. Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is a recognized complication of precipitous delivery and the leading overall cause of morbidity and mortality in deliveries in the United States. PPH was mostly recently defined by The American College of Obstetricians and Gynecologists in 2017 as cumulative blood loss of greater than 1000 mL and associated signs and symptoms of hypovolemia within 24 h following the birth process [23]. Early detection and intervention in PPH reduce morbidity and mortality from PPH [24]. However, notably, estimated blood loss in a precipitous delivery is difficult to evaluate and can often be underestimated due to the speed of delivery and time at presentation, and significant bleeding with symptoms or hemodynamic instability merits consideration of PPH. The etiology of PPH is often divided into four categories, deemed the four “Ts”: tone, trauma, tissue, and thrombin. Treatments of PPH focus on the underlying etiology. If not already placed, two large bore IVs should be obtained with the maternal type and screen sent with the intent to administer blood products [25]. Massive transfusion should be activated per facility protocols, with blood product administration recommended at 1500 mL of blood loss or noted hemodynamic changes [26]. These steps should be completed while investigating for the primary etiology of postpartum hemorrhage.

4.5. Tone

Tone, or uterine atony, is estimated to be the etiology of PPH in 80% of cases and should serve as the first avenue of intervention for ED providers [23]. Uterine atony can be identified by the palpation of a soft, relaxed uterus postpartum. Atony is initially treated with bimanual massage, bladder decompression via foley catheter, and, ultimately, uterotonic medications [18]. Recommended agents are oxytocin, methylergonovine, carboprost, and misoprostol (

Table 2. Summary of medications utilized to treat postpartum hemorrhage.

Medication	Dosage	Contraindications	Side Effects
Oxytocin (Pitocin)	20 IU in 500 mL NS given over 10 min; 10 IU IM	Caution for overuse	Rare, though can cause hypotension
Carboprost (Hemabate)	250 mcg into myometrium q15–90 min, max 2 mg	Patients with asthma, hepatic, renal, or cardiac disease	Nausea, vomiting, diarrhea
Methylergonovine (Methergine)	0.2 mg IM or IV q2–4 h	Hypertension	Nausea, vomiting, diarrhea, hypertension
Misoprostol (Cytotec)	800–1000 mcg rectally, or 600–800 mcg sublingually	Cardiovascular disease, anticoagulation	Nausea, vomiting, diarrhea, pyrexia
Tranexamic acid	1 g IV over 10 min within 3 h of delivery; 1 g repeat dose if bleeding continues	Hypersensitivity	Headache, abdominal pain, hypotension

).

Oxytocin is recommended prophylactically following delivery, with the administration of 10 IU IM or 20 IU in 500 mL of normal saline given over 10 min. Oxytocin has fewer side effects or associated adverse events than other uterotonic agents, and the main contraindication to postpartum administration is known hypersensitivity to the medication [27]. Oxytocin is often readily available in facilities with obstetric capacity as it is a common medication for labor augmentation [25].

Next, providers may consider misoprostol. Misoprostol functions as a prostaglandin E1 analog. It has a relatively delayed onset of action, with its onset typically at 30 min depending on the route of administration. It can be administered orally, sublingually, or rectally for treatment of postpartum hemorrhage, though is contraindicated in patients with histories of cardiovascular disease or taking anticoagulation [25].

Methylergonovine is another alternative uterotonic. It functions as a serotonergic agonist and adrenergic agonist to stimulate uterine contraction with an onset of 1 to 3 min. The recommended dosage is 200 mcg IM or IV, and it is contraindicated in patients with hypertension [25].

Carboprost is another alternative to assist in the treatment of PPH. Carboprost acts as a prostaglandin analog to stimulate uterine contraction. The recommended dose is 250 mcg IM, which can be given every 15–90 min for a maximum of 2 mg, or a total of eight doses. Its onset is rapid, though the concentration peaks at 15 min. It should not be given to patients with asthma to avoid bronchospasm and is contraindicated in patients with identified hepatic, renal, and cardiovascular disease [25].

Last, tranexamic acid (TXA) may be utilized in the treatment of postpartum hemorrhage. This medication works to inhibit fibrinolysis, stabilize clot formation, and support hemostasis. It has been found to reduce postpartum blood loss in both vaginal and cesarean deliveries and is recommended at the time of PPH identification if within 3 h of delivery. The suggested dose for treatment of postpartum hemorrhage is 1 g IV infused over 10 min, with a second dose of 1 g if bleeding continues after 30 min or begins again within 24 h of the first dose. The main contraindication is hypersensitivity to the medication. As a notable side effect, if infused too rapidly, TXA may cause hypotension [28].

If the preceding management is ineffective, ED providers should consider an intrauterine balloon tamponade. This method may be more effective specifically in lower uterine atony, as uterotonics have a delayed onset in the lower uterine segment. If no such device is available, the uterus should be packed with gauze. Uterine compression sutures in a B-lynch formation may also be utilized, though this may have repercussions for future pregnancies [25].

4.6. Trauma

Trauma refers to physical trauma to the birth canal, including lacerations and abrasions [25]. Lacerations are classified by the degree of penetrated tissue, with first-degree lacerations affecting solely the skin or epithelium, second-degree lacerations affecting the perineal muscles, third-degree lacerations affecting the anal sphincter complex, and fourth-degree lacerations affecting the anorectal mucosa [10]. Perineal lacerations and abrasions occur in up to 90% of nulliparous and up to 70% of multiparous women; many of these injuries are first- or second-degree lacerations [10]. The birth canal should be examined for traumatic injury following the third stage of labor. Local anesthesia can be utilized to treat pain prior to repair. Hemostatic first- and second-degree lacerations may not require a repair if they approximate well anatomically or may be repaired with skin adhesive. Deeper lacerations and lacerations causing significant bleeding should be repaired using a 2-0 or 3-0 polyglactin suture for first- and second-degree lacerations, while 4-0 polyglactin may be needed for fourth-degree lacerations. Providers should use running stitches and close individual layers to allow for full tissue healing [10].

4.7. Tissue

Tissue commonly refers to retained products of conception, such as placental tissue, or large clots within the uterus. ED providers should be prepared to perform a manual intrauterine exploration to evaluate for retained products [25]. Providers should begin with sufficient analgesia prior to the manual exploration. A banjo curette, or manual removal with gauze, may be utilized to remove retained products from the uterus. Ultrasound may be a useful adjunct in identifying retained products as mixed echogenic structures within the uterus, though protocols for such identification are still developing [26,29].

4.8. Thrombin

Lastly, thrombin refers to coagulopathy in the postpartum period. ED providers should consider this in patients with severe preeclampsia, HELLP syndrome, placental abruption, amniotic fluid embolism, or known inherited coagulopathies as these pathologies may cause consumptive coagulopathies [25].

4.9. Blood Products in PPH

Patients with PPH may require a transfusion; some studies estimate every 1 in 79 deliveries requires a transfusion [30]. No strict criteria exist for initiating transfusion in PPH, though transfusion is often initiated if blood loss exceeds 1.5 L or if the patient has blood loss in conjunction with hemodynamic changes. Infusion ratios are derived primarily from the trauma literature, as the obstetric literature has not released transfusion recommendations. Balanced transfusion is recommended with a ratio of 1 pRBC:1 FFP:1 platelets. In the development of disseminated intravascular coagulation, physicians must also consider cryoprecipitate in addition to balanced transfusion. The aim of transfusion treatment is hemoglobin levels greater than 8 g/dL, fibrinogen levels greater than 2 g/L, platelets greater than 50,000/microliter, and aPTT and PT less than 1.5 times the normal value [26].

5. Resuscitative Hysterotomy

Resuscitative hysterotomy, formerly referred to as perimortem cesarean delivery, is a rare though high-acuity procedure performed when a pregnant patient at greater than 20 weeks gestation experiences cardiac arrest. The procedure augments maternal venous return through the relief of maternal aortocaval compression as well as facilitates fetal survival. It is conducted in conjunction with cardiopulmonary resuscitation (CPR) and left uterine displacement intending to complete the hysterotomy after four minutes of CPR and within 5 min of arrest. While the five-minute timeframe is the goal to promote fetal neurologic outcomes and survival rates, fetal survival and maternal benefit have been shown in up to 15 min, or less frequently, in up to 30 min following arrest. Maternal survival from hysterotomy has been reported broadly to be from 17 to 72%, with fetal survival ranging from 11 to 80%. The procedure has few contraindications, including achieving return of spontaneous circulation (ROSC) prior to initiation, a gestational age less than 20 weeks, or having no trained physician available to complete the procedure [31].

To perform a resuscitative hysterotomy, begin with cleansing the abdomen with sterile cleansing fluid, such as iodine, if possible. Then, a trained provider makes a midline, vertical incision on the maternal abdomen from approximately 4 cm inferior to the xiphoid process to the pubis through the abdominal wall. A small vertical incision is made on the uterus until the return of amniotic fluid or the visualization of entry into the uterine cavity, after which the provider lifts the uterine wall away from the fetus. Using scissors, the provider extends the incision vertically to deliver the infant [12].

Following fetal delivery, the placenta is removed from the uterus. At this point, the uterus can be closed with absorbable sutures [31]. Uterine closure may also be delayed until ROSC is achieved or surgical assistance is available, during which time the abdomen should be packed with sterile gauze or pads and held with manual pressure [12]. Providers should consider broad-spectrum antibiotics and uterotonic medications following resuscitative hysterotomy, though with caution when administering oxytocin due to associated hypotension [12,31].

One major controversy pertains to the timing of resuscitative hysterotomy. While current guidelines recommend its initiation within five minutes of maternal arrest to optimize outcomes, emerging data suggests fetal survival is possible beyond this window, up to 15 or even 30 min post-arrest in select scenarios. Maternal condition may impact the decision to delay resuscitative hysterotomy, such as reversible causes of cardiac arrest that may otherwise be remedied, such as electrolyte abnormalities, hypothermia, traumatic injuries, or others that may be bridged with uterine displacement to augment venous return rather than immediate hysterotomy. Providers must use their clinical decision making to decide the timing for a resuscitative hysterotomy, which may include factors such as fetal gestational age, the circumstances of the mother’s cardiac arrest, and the facility’s capabilities to provide definitive management for the mother and neonate.

6. Neonatal Resuscitation

Following delivery, the emergency provider must prepare for neonatal assessment and, if necessary, neonatal resuscitation. The Neonatal Resuscitation Program offers frequently updated guidelines to aid providers in neonatal care; here, we offer a summary of suggested measures for providers.

After initial drying and stimulation, resuscitation should be initiated for any newborn that persistently has poor tone, respirations, or decreased heart rate. First, the neonate should be placed on a fetal warmer during resuscitation to avoid hypothermia. Then, fetal heart rate should be assessed as one of the first signs of neonatal distress; if less than 100, positive pressure ventilation (PPV) should be attempted. Heart rate may be assessed via pulse oximetry or electrocardiogram (ECG), though ECG is notably more accurate. If the neonate is apneic or gasping, positive pressure ventilation is similarly indicated [2,32].

Once it is determined that the neonate requires ventilation support, PPV should begin with an initial positive inspiratory pressure of 20–25 cm H₂O with an initial positive end-expiratory pressure (PEEP) of 5 cm H₂O. Perform PPV for 30 s and assess the neonate for an improved heart rate. If the heart rate does not improve to greater than 100, the provider can adjust the mask, head position, jaw position, and or suction the airway to improve efficacy. If these measures similarly are unsuccessful, further management would include either laryngeal mask airway (LMA) or endotracheal (ET) intubation [32]. With endotracheal intubation, the current recommendation is for uncuffed tubes by weight, with infants greater than 3000 g with a 3.5 mm ET tube, a 3.0 mm ET tube for infants between 1250 and 3000 g, and a 2.5 mm ET tube for infants less than 1250 g [12].

If the heart rate remains less than 60 beats per minute after 30 s of PPV, the provider must begin chest compressions. At this point, intravenous access should be obtained if not already obtained; peripheral access may be difficult, and the resuscitation team may need to access the umbilical vein instead. If chest compressions are initiated, it is also recommended to utilize an endotracheal intubation or LMA for PPV. The air in the room may be initially utilized during resuscitation, but supplemental oxygen at 100% may be required if chest compressions are initiated to achieve target oxygen saturations of greater than 95% or until the heart rate recovers. During this time, the provider should also prepare epinephrine. Epinephrine should be administered if the heart rate remains less than 60 beats per minute after 60 s of chest compressions with PPV at 100% oxygen. The medication can be administered intravenously, intraosseously, or through the endotracheal tube. The recommended intravenous dosing is 0.01–0.03 mg/kg while the endotracheal dose is 0.05–0.1 mg/kg of 1:10,000 epinephrine [32].

If the clinical scenario is suspicious regarding possible blood loss, the provider may consider fluid bolus of 10 mL/kg of crystalloid fluid or blood if available. Should all the above measures prove unsuccessful with an undetectable heart rate after 10 min, or the infant has a persistent APGAR of 0 at 10 min, the provider should consider the discontinuation of resuscitative efforts [12].

When conducting neonatal resuscitation, providers must also consider resuscitative efforts within an ethical scope, in cases such as extreme prematurity, prolonged anoxia, or congenital anomalies. While aggressive interventions may seem reflexively appropriate in high-stakes ED scenarios, such decisions may lead to prolonged suffering or nonviable outcomes. Decisions to terminate resuscitative efforts may best be made by incorporating shared decision making with the family and neonatology teams when feasible.

7. Discussion

Research investigating the emergency management of precipitous deliveries specifically in the ED is limited, and recommendations for practice are often based on recommendations for obstetric providers that are adjusted to suit the comparatively limited resources of the ED.

Notably, though the research conducted for delivering providers is strong and well established, organizations such as ACOG, The Neonatal Resuscitation Program, and more provide evidence-based practices for delivering providers to utilize in managing precipitous deliveries. As providers who do not frequently manage deliveries, we maintain that preparation is a key component to patient care in an ED precipitous delivery. Emergency providers who proactively train and simulate obstetric emergencies are better equipped to manage the dual patient scenario of mother and neonate. The utilization of prepared delivery kits and rapid team mobilization reflects a systems-based approach that enhances patient outcomes. Ultimately, this sentiment is well-backed by education research, in which simulations and obstetric curriculums enhance emergency practitioners’ comfort, knowledge, and ultimately management of obstetric emergencies [33,34].

However, preparation cannot mitigate all challenges; for example, emergency departments frequently lack consistent access to obstetric specialists, creating variability in care. Many complications and procedures associated with precipitous delivery are foreign to emergency providers or infrequently trained and ultimately are best managed by dedicated obstetric providers when feasible. For example, breech presentations and shoulder dystocia demand nuanced, high-risk interventions that may exceed the procedural comfort of many emergency providers. Likewise, underdiagnosis or delayed recognition of postpartum hemorrhage due to estimation errors in blood loss can lead to missed early interventions. Ultimately, while these procedures and practices must be trained by emergency providers to the best of their ability, it would be naïve to suggest that obstetric management of these complications is not superior and should be utilized whenever able. This can understandably present a challenge and high variance in patient care with limited obstetric availability and access in resource-limited settings, a challenging gap which emergency providers may be utilized to fill. It is important to recognize the potential for these new disparities to impact efforts regarding maternal morbidity and mortality, whose rates were previously notably disparate across socioeconomic and racial boundaries across international health systems [35].

Furthermore, many of the scenarios and complications encountered while caring for precipitous deliveries are highly stressful events with serious ethical and medicolegal implications. For example, dilemmas include performing a resuscitative hysterotomy in facilities without direct access to obstetric or even general surgery care, or prolonged resuscitative efforts in severely preterm neonates or with significant congenital abnormalities. No standards exist to guide emergency physicians in their management of these challenging scenarios, and often choices are left to clinical judgment and institutional policy. Given these limitations, we suggest that research be focused on the effects of precipitous delivery management on maternal and neonatal outcomes specifically in the emergency department. Emergency providers would benefit from research on the incidence of precipitous delivery in the emergency department and maternal and fetal outcomes, fetal outcomes of shoulder dystocia management in the ED, in recognizing postpartum hemorrhage in the emergency department and the impact of this on maternal outcomes, and more, though with the recognition that these events may be difficult to evaluate due to their limited frequency.

In conclusion, ongoing education and evidence-based studies on the outcomes of these deliveries are vital to optimizing future outcomes for both mothers and neonates in this high-acuity scenario.

8. Summary

The evaluation and management of precipitous delivery in the emergency department are high-acuity events. The keys to managing precipitous deliveries include the preparation of resources prior to patient presentation and provider education. Possessing knowledge of a normal labor and delivery allows providers to identify abnormal progression and intervene. ED providers must have the education and training to manage precipitous delivery complications. Nuchal cords are often reducible, though, in the worst cases, may require early clamping and cutting. The McRoberts maneuver with suprapubic pressure can relieve shoulder dystocia in many cases or be supplemented with additional maneuvers to achieve delivery. Breech presentations are a feared complication and require hands-off management to achieve the best outcomes. Precipitous deliveries can be complicated by PPH; while most PPH is attributed to uterine atony and can be aided with uterotonics, ED providers should investigate for obstetric trauma, retained tissue, and coagulopathies to provide treatment. Emergency providers must also possess updated knowledge and skills in neonatal resuscitation to care for infants born in precipitous deliveries. Lastly, emergency providers must familiarize themselves with the resuscitative hysterotomy should pregnant patients experience cardiac arrest in their care. Overall, our review serves as an overarching approach to precipitous deliveries for emergency providers.