Emergency Delivery

Recognition of imminent delivery

• Strong, frequent contractions, an urge to push, or the woman reporting "the baby is coming".
• Visible bulging perineum or crowning on inspection.
• If crowning is visible, there is usually no time to transfer to a delivery suite — prepare to deliver where the patient is.

Preparation

Normal delivery — step by step

1. Support, don't pull

   Encourage controlled breathing/pushing with contractions. Support the perineum; do not pull on the baby's head.

2. Support the head as it delivers

   Guide (do not pull) the head as it extends. Check for a nuchal cord once the head is delivered.

3. Check for cord around the neck

   If a loose nuchal cord is present, slip it over the head. If tight and cannot be reduced, practice is debated: clamp-and-cut between two clamps before the shoulders deliver is traditional, but cutting before delivery removes the fetal blood reservoir — some clinicians instead deliver the body through the loop with the cord intact (the "somersault" approach). If midwifery or obstetric help is present, be guided by them.

4. Deliver the anterior shoulder

   With the next contraction, guide the head gently downward to deliver the anterior shoulder under the pubic symphysis.

5. Deliver the posterior shoulder

   Then guide the head upward to deliver the posterior shoulder, followed by the rest of the body, which usually delivers quickly.

6. Dry and stimulate

   Dry the baby thoroughly with a warm towel (this is also the primary stimulation), note the time of birth, and assess tone, breathing and heart rate.

Cord clamping, skin-to-skin & APGAR

• Delayed cord clamping — where immediate resuscitation is not required, delay clamping for at least 60 seconds (RCUK NLS 2021); a longer delay may be beneficial if the clinical situation allows.
• Place the baby skin-to-skin with the mother if both are stable, keeping the baby warm and dry.
• Assign an APGAR score at 1 and 5 minutes (and further if resuscitation ongoing).

Active management of the third stage

• Oxytocin 10 IU by intramuscular injection, given with delivery of the anterior shoulder or immediately after the baby is born (per NICE intrapartum care guidance) — this reduces the risk of postpartum haemorrhage.
• Controlled cord traction to deliver the placenta once signs of separation are present (cord lengthening, small gush of blood, uterus rises and firms).
• Examine the placenta and membranes for completeness once delivered.

Postpartum haemorrhage — first response

• Uterine massage ("rubbing up" the fundus) to encourage contraction — the first and fastest intervention.
• Give a second uterotonic per local protocol/PPH bundle if bleeding continues.
• Tranexamic acid (TXA) as part of the PPH bundle.
• Escalate early — call for senior obstetric, anaesthetic and haematology support; activate the major haemorrhage protocol if bleeding is significant.
• Ensure the bladder is empty (a full bladder impairs uterine contraction).

Shoulder dystocia

Suspect shoulder dystocia when the head delivers but retracts against the perineum ("turtle-neck sign") and gentle downward traction fails to deliver the anterior shoulder. Call for help immediately and state clearly "this is shoulder dystocia".

• McRoberts' manoeuvre — lay the mother flat, remove pillows, and hyperflex her hips with legs pulled toward her abdomen. This alone resolves most cases (RCOG Green-top 42).
• Suprapubic pressure — applied behind the anterior shoulder to disimpact it from the symphysis, combined with McRoberts.
• Do not apply fundal pressure — it worsens impaction and risks uterine rupture.
• If these fail, further internal manoeuvres are an obstetric-led escalation (e.g. delivery of the posterior arm, internal rotation) — call obstetrics urgently if not already present.

First steps of newborn resuscitation (NLS 2021)

• Warm, dry and stimulate — most babies establish breathing with this alone.
• Assess tone, breathing and heart rate; if not breathing adequately, give 5 inflation breaths, checking for chest movement.
• If no chest movement, recheck head position, consider two-person airway support, and repeat inflation breaths before escalating to chest compressions per the NLS algorithm.
• Keep the baby warm throughout — hypothermia worsens outcomes.

References