What is the approach to managing precipitous labour in a low-risk multiparous woman with no significant medical history in the Emergency Department (ED)?

Management of Precipitous Labour in the Emergency Department

For a low-risk multiparous woman presenting with precipitous labour in the ED, prepare for immediate delivery on-site rather than attempting transfer, focus on controlled delivery technique to minimize maternal trauma, administer oxytocin 5-10 IU IM/slow IV immediately after delivery, and actively manage the third stage with uterotonics while avoiding manual placental removal unless severe hemorrhage occurs. 1, 2

Initial Assessment and Decision-Making

Risk Stratification for Imminent Delivery

• Assess for signs of imminent delivery before considering any transfer: multiparous status, rapid cervical change, uncontrollable urge to push, visible presenting part, and short interval between contractions 1, 3
• Risk of delivery during transport is 0-2% for threatened preterm labour but substantially higher in active precipitous labour, making imminent delivery a contraindication to transfer 1
• Multiparous women progress more rapidly through labour stages and require heightened vigilance for precipitous delivery 4, 5

Preparation and Team Activation

• Activate obstetric consultation immediately while preparing for ED delivery, as most precipitous deliveries result in good outcomes but require readiness for complications 4, 5
• Assemble equipment: sterile delivery kit, bulb suction, cord clamps, warm blankets for neonate, oxytocin, and emergency airway equipment 6, 4
• Alert neonatal team or arrange for neonatal backup, particularly if preterm delivery is anticipated 1

Delivery Management

Controlled Delivery Technique

• Minimize maternal trauma through controlled delivery: support the perineum, control head delivery to prevent precipitous expulsion, check for nuchal cord after head delivery 6, 4, 5
• Position the mother in left lateral or semi-recumbent position based on maternal preference and clinical circumstances 7
• Be prepared for complications including tight nuchal cord (reduce if loose, clamp and cut if tight), shoulder dystocia (McRoberts maneuver, suprapubic pressure), and breech presentation 4, 5

Immediate Post-Delivery Actions

• Dry and stimulate the neonate immediately, assess for spontaneous respirations, and provide warmth 6, 4
• Delay cord clamping for 1-3 minutes after birth unless neonatal resuscitation is required, as this benefits neonatal outcomes without increasing maternal blood loss 2
• Suction mouth and nose only if secretions are obstructing breathing; routine aggressive suctioning is not indicated 6

Third Stage Management

Active Management Protocol

• Administer oxytocin 5-10 IU via slow IV or IM injection immediately after delivery of the infant (at shoulder release or immediately postpartum) 2, 8
• Do NOT perform manual removal of the placenta routinely; await spontaneous placental separation which typically occurs within 30 minutes 1, 2
• Gentle controlled cord traction may be applied after signs of placental separation (cord lengthening, gush of blood, uterine fundus rises and becomes firm) 2

Uterotonic Administration Details

• Oxytocin is the first-line uterotonic agent for all women, including those with respiratory conditions 2, 8
• Avoid ergometrine in women with hypertension or respiratory disease due to risk of bronchospasm and hypertensive crisis 2
• For postpartum hemorrhage control, oxytocin 10-40 units may be added to 1000 mL non-hydrating diluent and infused at rate necessary to control uterine atony 8

Complication Management

Postpartum Hemorrhage

• Manual removal of placenta should NOT be performed outside specialized structures except in severe uncontrolled hemorrhage, given technical difficulties and inability to ensure adequate analgesia and aseptic conditions 1, 2
• If severe PPH occurs (>1000 mL blood loss), administer tranexamic acid 1g IV slowly within 1-3 hours of bleeding onset 1, 2
• Initiate bimanual uterine compression, ensure bladder is empty, and massage uterine fundus to promote contraction 1
• Prepare for urgent transfer to obstetric facility with multidisciplinary capabilities if hemorrhage is not controlled 1

Retained Placenta

• In the ED setting, if placenta is not delivered within 30-60 minutes and there is no severe hemorrhage, transfer to obstetric facility rather than attempting manual removal 1
• Continue oxytocin infusion during transfer to maintain uterine tone 8

Post-Delivery Stabilization and Transfer

Maternal Assessment

• Monitor vital signs every 15 minutes for first hour: blood pressure, pulse, temperature, respiratory rate 6
• Assess uterine tone by palpating fundus; it should be firm at or below umbilicus 6, 4
• Inspect perineum for lacerations requiring repair; minor lacerations may be managed in ED, but extensive tears require obstetric consultation 6, 5
• Estimate blood loss and monitor for signs of ongoing hemorrhage 1

Neonatal Assessment

• Perform Apgar scoring at 1 and 5 minutes 6, 4
• Maintain neonatal temperature (skin-to-skin contact with mother or radiant warmer) 6
• Monitor for respiratory distress, particularly in precipitous deliveries where lung fluid clearance may be suboptimal 4

Transfer Coordination

• Non-medicalized transfer is appropriate for stable mother-infant dyads without complications 1
• Medicalized transfer should be considered on case-by-case basis for complications such as uncontrolled hemorrhage, maternal instability, or neonatal distress 1, 3
• Direct communication between ED physician and receiving obstetric team is essential to coordinate care and document clinical course 3

Critical Pitfalls to Avoid

• Never attempt transfer once delivery is imminent; delivery during transport carries significant risks 1
• Avoid routine manual placental removal in the ED setting; this increases infection and hemorrhage risk without adequate analgesia or sterile conditions 1, 2
• Do not delay oxytocin administration after delivery; immediate administration is critical for preventing PPH 2, 8
• Do not use ergometrine as first-line uterotonic; oxytocin is safer and equally effective 2
• Avoid aggressive traction on umbilical cord before placental separation, as this may cause uterine inversion or cord avulsion 2
• Do not routinely suction vigorous neonates; this may cause bradycardia and laryngospasm 6