Labor and Delivery in the Emergency Department

Updated: Jun 07, 2022
  • Author: Thomas E Benzoni, DO, MT(ASCP); Chief Editor: Mark A Clark, MD  more...
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Practice Essentials

Few events cause more stress for the full time emergency physician than a pregnant woman at full term who is ready to deliver in the ED. This article discusses the delivery of a newborn in the ED; for a more general discussion of full-term obstetric delivery, see the Medscape article Normal Delivery of the Infant.


Signs of imminent delivery, as follows, should be noted:

  • Bloody show, the expulsion of the mucus plug from the cervix

  • Breakage of the amniotic sac (bag of waters). Determine the appearance of the fluid expelled. Clear fluid is normal, thin fluid is meconium (fetal intestinal contents consisting of the remains of swallowed amniotic fluid mostly composed of sloughed digested skin cells) stained, and thick pea-soup fluid is heavy meconium.

  • The sensation of impending defecation or an urge to push

Also see Presentation.


The infant death rate for 2019 was 558.3 per 100,000 live births. [1]  Approximately 700 women die each year in the United States as a result of pregnancy or delivery complications. [2]

Several items, including the umbilical cord and placenta previa, can be felt at initial vaginal examination. Note the following: 

  • Umbilical cord compression: Have medical personnel insert a sterile gloved hand into the vagina, into the cervix, and against the pelvic wall, while maintaining space between the index and middle fingers for the cord to pass uncompressed. This individual should accompany the patient and stay in this position until the operating surgeon or obstetrician directs otherwise.
  • Placenta previa: Copious vaginal bleeding usually heralds placenta previa. The mother may be aware of this condition prior to admittance to the ED. Do not perform a vaginal examination in a patient who is bleeding vaginally and in labor. Order an immediate ultrasonography, type and cross-match blood, and alert a surgeon and an obstetrician.

Stillbirth may occasionally occur; despite everyone's best efforts, a child may be born without signs of life. Psychological support for the parents is mandatory. Grieving occurs, with all of its potential for pathologic processes. If available, a clergyperson or counselor should visit the parents. Recommend a support group to the parents.


Few laboratory tests are useful. Initial determination of the patient's hemoglobin level and Rh blood group status is required. If the patient has received prenatal care, other laboratory tests have been performed.

Kleihauer-Betke testing can be ordered after delivery for Rh-negative mothers of Rh-positive infants. (One unit of Rh immunoglobulin per 15 mL fetal blood in the mother's circulation is administered intramuscularly within 72 h of delivery.)

Also see Imaging Studies.


Prehospital care

Provide oxygen.

Obtain intravenous access.

Generally, transport the patient in the left lateral recumbent position; use this position especially if the expectant mother's blood pressure decreases (because of pressure on the vena cava, which reduces return to the heart).

Prepare for field delivery, because little can be done to prevent the birth.

Emergency department care

See Emergency Department Care.

Also see Medication.

Coronavirus disease 2019 (COVID-19)

Patients with COVID-19 suffer maternal morbidities at a higher rate (up to 9%) than the general population. [3]  Additionally, emergency department personnel must be protected from COVID-19 transmission. While the American College of Obstetrics and Gynecology does not consider the second stage of labor to be an aerosol-generating activity, some authors recommend that personnel wear full personal protective equipment (PPE), including an N95 respirator in place of a standard facemask. [4]


Consult an obstetrician and/or a neonatologist as needed.



Pregnancy and delivery are natural processes that have been occurring for millennia. For millennia, delivery of the pregnant woman was the province of nonmedical (such as there was) personnel. As medical care progressed, nurses began the systematic medicalization of prenatal, delivery, and postnatal care (nurse-midwifery). This transition began in Europe, eventually crossing the Atlantic.

In the United States, physicians have become involved only in the relatively recent past. Therefore, attendance to the natural course is mandatory; interventions are indicated only in the event of deviations from the natural or expected course.




The precise incidence of US ED deliveries of pregnant full-term patients is unknown. In 2021, 3,659,289 births were registered in the United States. The fertility rate (births per 1000 women aged 15-44 y) was 56.6 births per 1000 women. Additionally, 10.48% of US births were preterm. The cesarean delivery rate rose in 2021, to 32.1% of all US births. [5]  The low birthweight (< 2,500 g) rate in the fourth quarter of 2021 was 8.51%. [6]


Fertility rate statistics have 15 years as the lower cutoff point. However, laboratory testing should be performed to rule out pregnancy when any female capable of reproduction (potentially as young as 9 y) presents with abdominal complaints and when pregnancy cannot be ruled out at physical examination.