Emergency Childbirth and Newborn Handoff

Time-critical once the head is visible or the mother has an urge to push: deliver safely, control bleeding, and start newborn care at once.

Some births cannot wait for the hospital. Emergency childbirth is delivery in the field, in the ED or in transport. You have three jobs. Deliver the baby safely. Control the bleeding after birth. Start newborn care at once if the baby needs it.

How It Works

• Delivery: Support the head and perineum, check for a nuchal cord, and deliver the shoulders without pulling on the baby.
• Placenta: Let the placenta deliver. Do not pull on the cord unless a trained attendant is performing controlled cord traction.
• Bleeding: A firm uterus is what stops it. Oxytocin and fundal massage come first. Tranexamic acid follows, within 3 hours of birth.
• Newborn: Dry, warm and stimulate the baby. Breathing and heart rate decide the next step. A baby who needs no resuscitation gets at least 60 seconds of deferred clamping. A baby who does still gets the initial steps during deferred clamping, but needs ventilation within 60 seconds of birth if apneic, gasping or below 100/min despite those steps.

Where It Fits

Bleeding after birth follows the FIGO postpartum hemorrhage sequence: uterotonic, uterine massage, tranexamic acid, then transport. Newborn care follows the 2025 AHA/AAP neonatal algorithm (2025 AHA Guidelines for CPR and ECC, Part 5). Maternal cardiac arrest is a different problem. With fundal height at or above the umbilicus (roughly 20 weeks or more), it needs manual left uterine displacement, and resuscitative delivery follows if circulation does not return (2025 AHA Guidelines for CPR and ECC, Part 10). That pathway is separate. See Special Populations.

Indications

• Delivery imminent: head visible at the vulva or an uncontrollable urge to push, with no time to reach a hospital
• Baby born before arrival: drying, warming, assessment and resuscitation if needed
• Bleeding after birth (postpartum hemorrhage): uterotonic, fundal massage and tranexamic acid per protocol
• Seizure in pregnancy or the postpartum period with severe-range blood pressure: magnesium per protocol

Absolute Contraindications

When the birth is imminent, there are none. A head that is already visible is not a reason to wait for transport.

Relative Contraindications & Cautions

• Delivery not yet imminent: transport the mother to an obstetric unit when local protocol allows
• Hypertension, toxemia, preeclampsia or eclampsia: ergometrine (methylergometrine) is contraindicated, so exclude them before use
• Cardiovascular or peripheral vascular disease, sepsis, or strong or moderate CYP3A4 inhibitors (for example, protease inhibitors, macrolides, azole antifungals): ergometrine is avoided or used with caution, per the label precautions
• Oxytocin: hypersensitivity to the drug (label)
• Expected multiple birth: call early for additional ALS or obstetric support
• Known thromboembolic event: avoid tranexamic acid unless medical direction decides otherwise (see the tranexamic acid page)

Consider an Alternative

• Stabilize and transport when the head is not visible and the mother is not in the second stage, per local protocol
• Seizure with severe-range blood pressure: magnesium sulfate per protocol, then transport to an obstetric unit

Team Roles During the Procedure

• Operator: Delivers the baby and manages the perineum and the shoulders.
• Newborn lead: Dries, warms, clears the airway if needed, and runs the breathing and heart-rate checks.
• Maternal monitor: Checks the fundus, blood loss, pulse and blood pressure, and gives uterotonics per protocol.
• Recorder: Times the birth, cord clamping, placenta, drug doses and any change in the baby.

Imminent Delivery Signs

• Head at the vulva: The baby may come with the next contraction or two.
• Urge to bear down: The pushing is involuntary, and the perineum bulges.
• Rapid progress: Contractions are close together. The mother cannot wait for transport.
• History: Gestational age, prenatal care, number of babies expected, bleeding, seizures and recent blood pressure.

Physiologic Risk

• Severe-range blood pressure: SBP ≥160 mmHg or DBP ≥110 mmHg, persistent for at least 15 min; with headache, visual change or seizure, treat as preeclampsia with severe features per protocol.
• Hemorrhage risk: Shock index above 0.9 (heart rate divided by systolic pressure), or heavy bleeding before the placenta has delivered.
• Fundal height at or above the umbilicus (roughly 20 weeks or more): A pregnant patient in arrest needs manual left uterine displacement with compressions from the start (2025 AHA Guidelines for CPR and ECC, Part 10, COR 1).

Equipment

Sizing

No time to weigh? Use the protocol's estimate. If there is time, weigh the baby. Every epinephrine volume and weight-based calculation hangs on that number. The math is on weight-based dosing and equipment sizing.

Patient Positioning & Preparation

Knees bent, mother comfortable. Have the stretcher ready to move. A second person on scene before the birth helps, if you can get one.

These are typical adult and newborn doses, for reference. Check them against local protocol and the current drug label.

Doses vary by protocol; follow local protocols and medical direction.

Phase 1: Prepare

1. Call for help early: Request ALS and obstetric support, and a second provider. If transport is still possible, tell the receiving facility the delivery is under way.
2. Set up the delivery: Open the clean kit, warm the newborn towels, and confirm the cord clamps or ties and suction are at hand.
3. Take the history: Gestational age, number of babies, bleeding, seizures and blood pressure, then record the time.

Phase 2: Perform

4. Support the head and perineum: Use a gloved hand to control the head as it delivers. Do not push on the head or pull on the baby.
5. Check for a nuchal cord: If the cord is around the neck, try to slip it over the head first. A tight cord that cannot be disengaged is clamped and cut before the rest of the delivery, per local protocol. See Figure 1.
6. Deliver the shoulders: Use gentle downward traction, then gentle upward traction, to deliver the shoulders. If the shoulders do not follow, call for help and act at once: hyperflex the mother's thighs onto her abdomen (McRoberts), apply firm suprapubic pressure (not fundal pressure), and do not pull on the head. Follow local protocol and medical direction.
7. Dry and warm the baby: Dry the baby, remove wet towels, and cover the head. Start the breathing and heart-rate assessment.

Phase 3: Confirm & Secure

8. Time the cord clamp: If the baby is breathing and does not need resuscitation, delay clamping the cord for at least 60 seconds. Do not milk the cord in a preterm baby under 28 weeks.
9. Let the placenta deliver: Do not pull on the cord. Use controlled cord traction only if a trained attendant is performing it, as FIGO advises.

10. Give oxytocin: Before giving it, palpate the abdomen to confirm no second baby. Give 10 units IM after the placenta delivers, or IV only as a diluted infusion per protocol or medical direction. Never an undiluted rapid IV push. Record the time.
11. Massage the uterus until firm: Use both hands on the fundus until the uterus is firm and the bleeding slows. If massage alone does not firm the uterus, use bimanual compression per protocol. See Figures 2 and 3.
12. Give tranexamic acid if bleeding continues: 1 g IV over 10 minutes within 3 hours of birth, with a second 1 g dose if bleeding continues at 30 minutes, per protocol.
13. Transport with the bleeding plan running: Keep the fundus under review, keep the newborn warm, and notify the receiving team of the birth.

Primary Confirmation

Confirmation means the baby is breathing or crying, with good tone and a heart rate of at least 100/min. The mother's uterus is firm and the bleeding is slowing. A heart rate of 60 to 99/min confirms nothing. It means the baby still needs ventilation.

Secondary Confirmation

• Placenta delivered and checked for completeness
• Blood loss estimated and the pad count recorded at each check
• Perineum checked for lacerations and bleeding
• Maternal pulse and blood pressure stable or improving
• Newborn temperature in the 36.5–37.5 °C (97.7–99.5 °F) range

Ongoing Monitoring

• Mother: Fundus, bleeding, pulse, blood pressure and mental status, repeated per protocol
• Newborn: Breathing, heart rate, colour, tone and temperature
• After magnesium: Reflexes and respirations before each dose and during infusion

Pediatrics

• Newborn ventilation: Ventilate within 60 seconds of birth if the baby is gasping or apneic, or the heart rate is below 100/min despite the initial steps (2025 AHA Guidelines for CPR and ECC, Part 5, COR 1).
• Compressions: If heart rate stays below 60/min after 30 seconds of effective ventilation, add chest compressions (COR 1), coordinated 3:1 with ventilation (COR 2b) (2025 AHA Guidelines for CPR and ECC, Part 5).
• Epinephrine: 0.01–0.03 mg/kg IV/IO (0.1–0.3 mL/kg of 1:10,000), repeated every 3–5 minutes, if heart rate stays below 60/min after 60 seconds of chest compressions with adequate ventilation (2025 AHA Guidelines for CPR and ECC, Part 5: intravascular epinephrine COR 1; repeat doses COR 2b).
• Cord and temperature: Delay cord clamping at least 60 seconds for a baby who does not need resuscitation (preterm COR 1; term COR 2a, 2025 AHA Guidelines for CPR and ECC, Part 5). Keep the temperature at 36.5–37.5 °C (COR 1).
• Preterm: Do not perform intact cord milking before 28+0 weeks (COR 3: Harm). From 28+0 to 36+6 weeks it may be reasonable (COR 2b) only when deferred clamping cannot be done (2025 AHA Guidelines for CPR and ECC, Part 5).
• Oxygen: At 35 weeks or more, it may be reasonable to start on room air (21%). At 32 to 34+6 weeks, start at 21 to 30%. Under 32 weeks, start at 30 to 100% and titrate to pulse oximetry targets (2025 AHA Guidelines for CPR and ECC, Part 5, COR 2b for each range).
• Warmth in preterm babies: Use a plastic bag or wrap, alone or with a radiant warmer, to prevent hypothermia (2025 AHA Guidelines for CPR and ECC, Part 5, COR 2a, LOE B-R).
• Dosing: Use weight-based dosing and pediatric vital sign ranges; see also equipment sizing.

Multiple Births

• After the first birth, check the abdomen for a second baby. Expect the second birth to need the same steps.
• Expect two cords, two newborns and possibly two placentas. Call for more help early.
• Obstetric care for a multifetal pregnancy is a transport decision. Follow local protocol.

Abnormal Presentation

• Prolapsed cord: Keep the presenting part off the cord, have the mother in knee-chest or hands-knees position, and transport immediately. Do not push the cord back in unless local protocol says so.
• Breech or other malpresentation: Do not pull on the baby. Support the body, let it deliver with gravity, and call for help. Follow local protocol and see the complicated delivery page.

Preeclampsia & Eclampsia

• Severe-range blood pressure with seizure: Treat the seizure and give magnesium sulfate per protocol: 4 g IV loading dose (rate no faster than 150 mg/min per the label, except in severe eclampsia with seizures), then 1–2 g/hr.
• Severe-range blood pressure: Magnesium prevents seizures but does not lower blood pressure. Treat with antihypertensives per protocol (see labetalol or hydralazine).
• Magnesium toxicity: Watch respirations and reflexes; stop the infusion for loss of reflexes or slow or shallow breathing. Give IV calcium per the label (10 to 20 mL of a 5% calcium solution, diluted if desirable) or per protocol. Name the salt and check the vial strength before giving: calcium gluconate is stocked as 1,000 mg per 10 mL (10%); see the magnesium sulfate page. Magnesium is not for patients with heart block or myocardial damage without medical direction.
• Ergometrine: Do not give with hypertension, preeclampsia or eclampsia (label contraindications).

Maternal Cardiac Arrest

• Manual left uterine displacement with compressions when fundal height is at or above the umbilicus (COR 1, 2025 AHA Guidelines for CPR and ECC, Part 10), started with CPR (see the emergency box in Complications).
• Standard compression hand position; airway management is prioritized (COR 1, 2025 AHA Guidelines for CPR and ECC, Part 10).
• Resuscitative delivery (perimortem cesarean) is indicated if circulation does not return with standard resuscitation (COR 1, 2025 AHA Guidelines for CPR and ECC, Part 10); an obstetric or surgical team performs it, as in the emergency box above.
• After magnesium, consider magnesium toxicity in the differential; calcium is reasonable in this setting (COR 2a, 2025 AHA Guidelines for CPR and ECC, Part 10), given per protocol.

Immediate Aftercare

• Keep massaging the uterus until it is firm, and check bleeding and vital signs at each stage.
• Dry and warm the newborn; keep the baby with the mother for warmth if the protocol allows.
• Check that the placenta is complete before transport.

Ongoing Maintenance

• Mother: Keep IV or IO access and the uterotonic plan running; reassess after each move.
• Newborn: Keep the temperature at 36.5–37.5 °C and watch breathing and heart rate.

Transport Considerations

• Transport to an obstetric-capable facility when local protocol allows; notify the receiving team early.
• Reassess the fundus and bleeding after each move, because bleeding can restart in transit.
• Keep the newborn warm and monitored in a moving vehicle; reassess breathing after each change.

Pearls

• Support the head: Control the head with a gloved hand and do not push on it.
• Check the cord before the shoulders: A loose nuchal cord slides right over the head.
• Delay the clamp: A baby who needs no resuscitation gets at least 60 seconds with the cord intact.
• Massage is treatment: FIGO recommends uterine massage to treat postpartum hemorrhage.
• Count the time: Tranexamic acid is given within 3 hours of birth. Write down the birth time.

Common Pitfalls

• Pulling the cord → Let the placenta deliver unless a trained attendant is performing controlled cord traction.
• Waiting for transport while the head is out → Deliver the baby where the mother is and transport after.
• One check of the uterus → Recheck repeatedly until the handoff.
• Pink baby assumed to be fine → Check breathing and heart rate at every stage.

Skill Maintenance

• Run regular simulated deliveries with a newborn manikin, including cord clamping timing and the nuchal cord check.
• Practice the uterine massage and bimanual technique on a birthing simulator.
• Rehearse the newborn ventilation and compressions sequence with the timing of the 30-second and 60-second checkpoints.
• Use a written checklist and assign roles before each drill, then debrief the time of each event.