Emergent delivery


  • There are 4 million deliveries per year in the US with the highest pregnancy rates seen in 25-29 year old females[1]

Stages of Labor

  • 1st stage of labor - Passage of cervical mucus plug to full cervical dilation and effacement
    • ~8 hours in nulliparous and ~5 hours in multiparous
  • 2nd stage of labor - Full cervical dilation to delivery of infant
  • 3rd stage of labor - Placental delivery
  • 4th stage of labor - 1st hour after placental delivery

6 Cardinal Movements of Fetal Descent[2]

  1. Engagement
  2. Flexion
  3. Descent
  4. Internal rotation
  5. Extension
  6. External rotation

Clinical Features

Differential Diagnosis

Emergent delivery and related complications


Cervical Dilatation

  • 0 cm (closed/fingertip) to 10 cm (complete/fully dilated)


  • Assessment of the cervical length
  • Percentage of normal 3-4 cm long cervix
    • 4cm cervix = 0%
    • 0cm (thin) cervix = 100%

Station (-5 to +5)

Distance of the presenting body relative to the maternal ischial spines

  • -3 = beginning of second stage of labor
  • 0 = in line with the plane of the maternal ischial spines
  • +3 = impending delivery
  • +4 to +5 = crowning



  • Position patient in the dorsal lithotomy position[3]
  • Put on personal protective equipment
  • Prepare suction, airway equipment, and warmer for infant
  • Place OB and NICU consults

Emergent Delivery Instructions (2nd Stage)

Perineal inspection

  • Infants head bulges the perineum
  • Gentle digital stretching may prevent tears and lacerations
  • Support the perineum with a sterile towel and place the other hand over the occiput to promote fetal head extension

Slowly deliver the head

  • Check for nuchal cord, if present reduce the cord around neck or clamp and cut

Deliver anterior shoulder

  • Position hands on either side of the head and exert a gentle downward force[4]

Deliver posterior shoulder

  • Maintain position of hands and apply a small amount of upward traction

Delivery of the body

  • Controlled expulsion helps to prevent perineal lacerations

After delivery of infant

  • Hold the infant securely
  • Position in a manner that facilitates the flow of blood from the placenta to the infant
  • Stimulate and dry the infant
  • Clamp then cut the umbilical cord 6-8 cm distal to insertion at umbilicus with sterile scissors
  • Place infant in a warm incubator
  • Check APGAR scores at 1, 5, and 10 minutes after delivery
  • See newborn resuscitation for complications

Emergent Delivery Instructions (3nd Stage)

  • Placental delivery
  • Maintain suprapubic fundal pressure, provide gentle cord traction and allow spontaneous placental separation
  • Placenta usually delivers within 10-30 minutes
    • Avoid excessive cord traction to prevent uterine inversion
    • Signs of placental separation: cord lengthens, sudden gush of blood, and uterine fundus moves cephalad in abdomen
    • Inspect for missing placental segments
  • Start oxytocin 20U-40U in 1L NS at 200-500 mL/hr or give oxytocin 10U IM in a patient without IV access
    • Administering oxytocin prevents 40% of PPH

Emergent Delivery Instructions (4th Stage)

  • 1st hour after placental delivery
  • Palpate abdomen and check for the achievement of uterine firmness and contraction
  • Period of time with highest risk for postpartum hemorrhage (>500 mL blood)


  • Admit


Postpartum Emergencies

See Also


  1. Cunningham, F., Leveno, K., Bloom, S., Spong, C., Dashe, J. Williams Obstetrics, 24th Ed. McGraw-Hill Education, 2014. Chapter 47.
  2. Tintinalli, Judith E., J. Stephan Stapczynski, O. John Ma, David M. Cline, Rita K. Cydulka, Garth D. Meckler, The American College of Emergency Physicians. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7th Ed. The McGraw-Hill Companies, Inc. 2011. Chapters 103-105.
  3. Marx, John MD, Hockberger, R. MD, Walls, R. MD. Rosen’s Emergency Medicine-Concepts and Clinical Practice 8th Ed. Elsevier, 2013. Chapters 34, 37, 178, 179.
  4. Del Portal DA et al. Emergency department management of shoulder dystocia. J Emerg Med. 2014 Mar;46(3):378-82.