presentation in child birth

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The way a baby is positioned in the uterus just before birth can have a big effect on labor and delivery. This positioning is called fetal presentation.

Babies twist, stretch and tumble quite a bit during pregnancy. Before labor starts, however, they usually come to rest in a way that allows them to be delivered through the birth canal headfirst. This position is called cephalic presentation. But there are other ways a baby may settle just before labor begins.

Following are some of the possible ways a baby may be positioned at the end of pregnancy.

Head down, face down

When a baby is head down, face down, the medical term for it is the cephalic occiput anterior position. This the most common position for a baby to be born in. With the face down and turned slightly to the side, the smallest part of the baby's head leads the way through the birth canal. It is the easiest way for a baby to be born.

Head down, face up

When a baby is head down, face up, the medical term for it is the cephalic occiput posterior position. In this position, it might be harder for a baby's head to go under the pubic bone during delivery. That can make labor take longer.

Most babies who begin labor in this position eventually turn to be face down. If that doesn't happen, and the second stage of labor is taking a long time, a member of the health care team may reach through the vagina to help the baby turn. This is called manual rotation.

In some cases, a baby can be born in the head-down, face-up position. Use of forceps or a vacuum device to help with delivery is more common when a baby is in this position than in the head-down, face-down position. In some cases, a C-section delivery may be needed.

Frank breech

When a baby's feet or buttocks are in place to come out first during birth, it's called a breech presentation. This happens in about 3% to 4% of babies close to the time of birth. The baby shown below is in a frank breech presentation. That's when the knees aren't bent, and the feet are close to the baby's head. This is the most common type of breech presentation.

If you are more than 36 weeks into your pregnancy and your baby is in a frank breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Most babies in a frank breech position are born by planned C-section.

Complete and incomplete breech

A complete breech presentation, as shown below, is when the baby has both knees bent and both legs pulled close to the body. In an incomplete breech, one or both of the legs are not pulled close to the body, and one or both of the feet or knees are below the baby's buttocks. If a baby is in either of these positions, you might feel kicking in the lower part of your belly.

If you are more than 36 weeks into your pregnancy and your baby is in a complete or incomplete breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Many babies in a complete or incomplete breech position are born by planned C-section.

When a baby is sideways — lying horizontal across the uterus, rather than vertical — it's called a transverse lie. In this position, the baby's back might be:

• Down, with the back facing the birth canal.
• Sideways, with one shoulder pointing toward the birth canal.
• Up, with the hands and feet facing the birth canal.

Although many babies are sideways early in pregnancy, few stay this way when labor begins.

If your baby is in a transverse lie during week 37 of your pregnancy, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of your health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a transverse lie, talk with a member of your health care team about the choices you have for delivery. Many babies who are in a transverse lie are born by C-section.

If you're pregnant with twins and only the twin that's lower in the uterus is head down, as shown below, your health care provider may first deliver that baby vaginally.

Then, in some cases, your health care team may suggest delivering the second twin in the breech position. Or they may try to move the second twin into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

Your health care team may suggest delivery by C-section for the second twin if:

• An attempt to deliver the baby in the breech position is not successful.
• You do not want to try to have the baby delivered vaginally in the breech position.
• An attempt to move the baby into a head-down position is not successful.
• You do not want to try to move the baby to a head-down position.

In some cases, your health care team may advise that you have both twins delivered by C-section. That might happen if the lower twin is not head down, the second twin has low or high birth weight as compared to the first twin, or if preterm labor starts.

• Landon MB, et al., eds. Normal labor and delivery. In: Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 19, 2023.
• Holcroft Argani C, et al. Occiput posterior position. https://www.updtodate.com/contents/search. Accessed May 19, 2023.
• Frequently asked questions: If your baby is breech. American College of Obstetricians and Gynecologists https://www.acog.org/womens-health/faqs/if-your-baby-is-breech. Accessed May 22, 2023.
• Hofmeyr GJ. Overview of breech presentation. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Strauss RA, et al. Transverse fetal lie. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Chasen ST, et al. Twin pregnancy: Labor and delivery. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Cohen R, et al. Is vaginal delivery of a breech second twin safe? A comparison between delivery of vertex and non-vertex second twins. The Journal of Maternal-Fetal & Neonatal Medicine. 2021; doi:10.1080/14767058.2021.2005569.
• Marnach ML (expert opinion). Mayo Clinic. May 31, 2023.

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Breech, posterior, transverse lie: What position is my baby in?

Fetal presentation, or how your baby is situated in your womb at birth, is determined by the body part that's positioned to come out first, and it can affect the way you deliver. At the time of delivery, 97 percent of babies are head-down (cephalic presentation). But there are several other possibilities, including feet or bottom first (breech) as well as sideways (transverse lie) and diagonal (oblique lie).

Fetal presentation and position

During the last trimester of your pregnancy, your provider will check your baby's presentation by feeling your belly to locate the head, bottom, and back. If it's unclear, your provider may do an ultrasound or an internal exam to feel what part of the baby is in your pelvis.

Fetal position refers to whether the baby is facing your spine (anterior position) or facing your belly (posterior position). Fetal position can change often: Your baby may be face up at the beginning of labor and face down at delivery.

Here are the many possibilities for fetal presentation and position in the womb.

Medical illustrations by Jonathan Dimes

Head down, facing down (anterior position)

A baby who is head down and facing your spine is in the anterior position. This is the most common fetal presentation and the easiest position for a vaginal delivery.

This position is also known as "occiput anterior" because the back of your baby's skull (occipital bone) is in the front (anterior) of your pelvis.

Head down, facing up (posterior position)

In the posterior position , your baby is head down and facing your belly. You may also hear it called "sunny-side up" because babies who stay in this position are born facing up. But many babies who are facing up during labor rotate to the easier face down (anterior) position before birth.

Posterior position is formally known as "occiput posterior" because the back of your baby's skull (occipital bone) is in the back (posterior) of your pelvis.

Frank breech

In the frank breech presentation, both the baby's legs are extended so that the feet are up near the face. This is the most common type of breech presentation. Breech babies are difficult to deliver vaginally, so most arrive by c-section .

Some providers will attempt to turn your baby manually to the head down position by applying pressure to your belly. This is called an external cephalic version , and it has a 58 percent success rate for turning breech babies. For more information, see our article on breech birth .

Complete breech

A complete breech is when your baby is bottom down with hips and knees bent in a tuck or cross-legged position. If your baby is in a complete breech, you may feel kicking in your lower abdomen.

Incomplete breech

In an incomplete breech, one of the baby's knees is bent so that the foot is tucked next to the bottom with the other leg extended, positioning that foot closer to the face.

Single footling breech

In the single footling breech presentation, one of the baby's feet is pointed toward your cervix.

Double footling breech

In the double footling breech presentation, both of the baby's feet are pointed toward your cervix.

Transverse lie

In a transverse lie, the baby is lying horizontally in your uterus and may be facing up toward your head or down toward your feet. Babies settle this way less than 1 percent of the time, but it happens more commonly if you're carrying multiples or deliver before your due date.

If your baby stays in a transverse lie until the end of your pregnancy, it can be dangerous for delivery. Your provider will likely schedule a c-section or attempt an external cephalic version , which is highly successful for turning babies in this position.

Oblique lie

In rare cases, your baby may lie diagonally in your uterus, with his rump facing the side of your body at an angle.

Like the transverse lie, this position is more common earlier in pregnancy, and it's likely your provider will intervene if your baby is still in the oblique lie at the end of your third trimester.

Was this article helpful?

What to know if your baby is breech

What's a sunny-side up baby?

What happens to your baby right after birth

How your twins’ fetal positions affect labor and delivery

BabyCenter's editorial team is committed to providing the most helpful and trustworthy pregnancy and parenting information in the world. When creating and updating content, we rely on credible sources: respected health organizations, professional groups of doctors and other experts, and published studies in peer-reviewed journals. We believe you should always know the source of the information you're seeing. Learn more about our editorial and medical review policies .

Ahmad A et al. 2014. Association of fetal position at onset of labor and mode of delivery: A prospective cohort study. Ultrasound in obstetrics & gynecology 43(2):176-182. https://www.ncbi.nlm.nih.gov/pubmed/23929533 Opens a new window [Accessed September 2021]

Gray CJ and Shanahan MM. 2019. Breech presentation. StatPearls.  https://www.ncbi.nlm.nih.gov/books/NBK448063/ Opens a new window [Accessed September 2021]

Hankins GD. 1990. Transverse lie. American Journal of Perinatology 7(1):66-70.  https://www.ncbi.nlm.nih.gov/pubmed/2131781 Opens a new window [Accessed September 2021]

Medline Plus. 2020. Your baby in the birth canal. U.S. National Library of Medicine. https://medlineplus.gov/ency/article/002060.htm Opens a new window [Accessed September 2021]

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Fetal Presentation, Position, and Lie (Including Breech Presentation)

• Key Points |

Abnormal fetal lie or presentation may occur due to fetal size, fetal anomalies, uterine structural abnormalities, multiple gestation, or other factors. Diagnosis is by examination or ultrasonography. Management is with physical maneuvers to reposition the fetus, operative vaginal delivery , or cesarean delivery .

Terms that describe the fetus in relation to the uterus, cervix, and maternal pelvis are

Fetal presentation: Fetal part that overlies the maternal pelvic inlet; vertex (cephalic), face, brow, breech, shoulder, funic (umbilical cord), or compound (more than one part, eg, shoulder and hand)

Fetal position: Relation of the presenting part to an anatomic axis; for transverse presentation, occiput anterior, occiput posterior, occiput transverse

Fetal lie: Relation of the fetus to the long axis of the uterus; longitudinal, oblique, or transverse

Normal fetal lie is longitudinal, normal presentation is vertex, and occiput anterior is the most common position.

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

Several common types of abnormal lie or presentation are discussed here.

Transverse lie

Fetal position is transverse, with the fetal long axis oblique or perpendicular rather than parallel to the maternal long axis. Transverse lie is often accompanied by shoulder presentation, which requires cesarean delivery.

Breech presentation

There are several types of breech presentation.

Frank breech: The fetal hips are flexed, and the knees extended (pike position).

Complete breech: The fetus seems to be sitting with hips and knees flexed.

Single or double footling presentation: One or both legs are completely extended and present before the buttocks.

Types of breech presentations

Breech presentation makes delivery difficult ,primarily because the presenting part is a poor dilating wedge. Having a poor dilating wedge can lead to incomplete cervical dilation, because the presenting part is narrower than the head that follows. The head, which is the part with the largest diameter, can then be trapped during delivery.

Additionally, the trapped fetal head can compress the umbilical cord if the fetal umbilicus is visible at the introitus, particularly in primiparas whose pelvic tissues have not been dilated by previous deliveries. Umbilical cord compression may cause fetal hypoxemia.

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

In face presentation, the head is hyperextended, and position is designated by the position of the chin (mentum). When the chin is posterior, the head is less likely to rotate and less likely to deliver vaginally, necessitating cesarean delivery.

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

The fetal neck is usually somewhat deflexed; thus, a larger diameter of the head must pass through the pelvis.

Progress may arrest in the second phase of labor. Operative vaginal delivery or cesarean delivery is often required.

Position and Presentation of the Fetus

If a fetus is in the occiput posterior position, operative vaginal delivery or cesarean delivery is often required.

In breech presentation, the presenting part is a poor dilating wedge, which can cause the head to be trapped during delivery, often compressing the umbilical cord.

For breech presentation, usually do cesarean delivery at 39 weeks or during labor, but external cephalic version is sometimes successful before labor, usually at 37 or 38 weeks.

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Fetal Positions for Labor and Birth

Knowing your baby's position can you help ease pain and speed up labor

In the last weeks of pregnancy , determining your baby's position can help you manage pain and discomfort. Knowing your baby's position during early labor can help you adjust your own position during labor and possibly even speed up the process.

Right or Left Occiput Anterior

Illustration by JR Bee, Verywell 

Looking at where the baby's head is in the birth canal helps determine the fetal position.The front of a baby's head is referred to as the anterior portion and the back is the posterior portion. There are two different positions called occiput anterior (OA) positions that may occur.

The left occiput anterior (LOA) position is the most common in labor. In this position, the baby's head is slightly off-center in the pelvis with the back of the head toward the mother's left thigh.

The right occiput anterior (ROA) presentation is also common in labor. In this position, the back of the baby is slightly off-center in the pelvis with the back of the head toward the mother's right thigh.

In general, OA positions do not lead to problems or additional pain during labor or birth.  

Right or Left Occiput Transverse

Illustration by JR Bee, Verywell  

When facing out toward the mother's right thigh, the baby is said to be left occiput transverse (LOT). This position is halfway between a posterior and anterior position. If the baby was previously in a posterior position (in either direction), the LOT position indicates positive movement toward an anterior position.

When the baby is facing outward toward the mother's left thigh, the baby is said to be right occiput transverse (ROT). Like the previous presentation, ROT is halfway between a posterior and anterior position. If the baby was previously in a posterior position, ROT is a sign the baby is making a positive move toward an anterior position.

When a baby is in the left occiput transverse position (LOT) or right occiput transverse (ROT) position during labor, it may lead to more pain and a slower progression.

Tips to Reduce Discomfort

There are several labor positions a mother can try to alleviate pain and encourage the baby to continue rotating toward an anterior position, including:

• Pelvic tilts
• Standing and swaying

A doula , labor nurse, midwife , or doctor may have other suggestions for positions.

Right or Left Occiput Posterior

When facing forward, the baby is in the occiput posterior position. If the baby is facing forward and slightly to the left (looking toward the mother's right thigh) it is in the left occiput posterior (LOP) position. This presentation can lead to more back pain (sometimes referred to as " back labor ") and slow progression of labor.

In the right occiput posterior position (ROP), the baby is facing forward and slightly to the right (looking toward the mother's left thigh). This presentation may slow labor and cause more pain.

To help prevent or decrease pain during labor and encourage the baby to move into a better position for delivery, mothers can try a variety of positions, including:

• Hands and knees
• Pelvic rocking

Mothers may try other comfort measures, including:

• Bathtub or shower (water)
• Counter pressure
• Movement (swaying, dancing, sitting on a birth ball )
• Rice socks (heat packs)

How a Doctor Determines Baby's Position

Leopold's maneuvers are a series of hands-on examinations your doctor or midwife will use to help determine your baby's position. During the third trimester , the assessment will be done at most of your prenatal visits.   Knowing the baby's position before labor begins can help you prepare for labor and delivery.

Once labor begins, a nurse, doctor, or midwife will be able to get a more accurate sense of your baby's position by performing a vaginal exam. When your cervix is dilated enough, the practitioner will insert their fingers into the vagina and feel for the suture lines of the baby's skull as it moves down in the birth canal.   It's important to ensure the baby is head down and moving in the right direction.

Labor and delivery may be more complicated if the baby is not in a head-down position, such as in the case of a breech presentation.

How You Can Determine Baby's Position

While exams by health practitioners are an important part of your care, from the prenatal period through labor and delivery, often the best person to assess a baby's position in the pelvis is you. Mothers should pay close attention to how the baby moves and where different movements are felt.

A technique called belly mapping can help mothers ask questions of themselves to assess their baby's movement and get a sense of the position they are in as labor approaches.

For example, the position of your baby's legs can be determined by asking questions about the location and strength of the kicking you feel. The spots where you feel the strongest kicks are most likely where your baby's feet are.

Other landmarks you can feel for include a large, flat plane, which is most likely your baby's back. Sometimes you can feel the baby arching his or her back.

At the top or bottom of the flat plane, you may feel either a hard, round shape (most likely your baby's head) or a soft curve (most likely to be your baby's bottom).

Guittier M, Othenin-Girard V, de Gasquet B, Irion O, Boulvain M. Maternal positioning to correct occiput posterior fetal position during the first stage of labour: a randomised controlled trial .  BJOG: An International Journal of Obstetrics & Gynaecology . 2016;123(13):2199-2207. doi:10.1111/1471-0528.13855

Gizzo S, Di Gangi S, Noventa M, Bacile V, Zambon A, Nardelli G. Women’s Choice of Positions during Labour: Return to the Past or a Modern Way to Give Birth? A Cohort Study in Italy .  Biomed Res Int . 2014;2014:1-7. doi:10.1155/2014/638093

Ahmad A, Webb S, Early B, Sitch A, Khan K, MacArthur C. Association between fetal position at onset of labor and mode of delivery: a prospective cohort study .  Ultrasound in Obstetrics & Gynecology . 2014;43(2):176-182. doi:10.1002/uog.13189

Nishikawa M, Sakakibara H. Effect of nursing intervention program using abdominal palpation of Leopold’s maneuvers on maternal-fetal attachment .  Reprod Health . 2013;10(1). doi:10.1186/1742-4755-10-12

Choi S, Park Y, Lee D, Ko H, Park I, Shin J. Sonographic assessment of fetal occiput position during labor for the prediction of labor dystocia and perinatal outcomes .  The Journal of Maternal-Fetal & Neonatal Medicine . 2016;29(24):3988-3992. doi:10.3109/14767058.2016.1152250

Bamberg C, Deprest J, Sindhwani N et al. Evaluating fetal head dimension changes during labor using open magnetic resonance imaging .  J Perinat Med . 2017;45(3). doi:10.1515/jpm-2016-0005

Gabbe S, Niebyl J, Simpson J et al.  Obstetrics . Philadelphia, Pa.: Elsevier; 2012.

By Robin Elise Weiss, PhD, MPH Robin Elise Weiss, PhD, MPH is a professor, author, childbirth and postpartum educator, certified doula, and lactation counselor.

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Presentation and position of baby through pregnancy and at birth

9-minute read

If you are concerned about your baby’s movements, contact your doctor or midwife for advice immediately.

• If you baby is in a breech presentation, your doctor may recommend trying a technique called an external cephalic version to try and move your baby while they are still in the uterus for an easier birth.

What does presentation and position mean?

Presentation refers to the part of your baby’s body that is facing downwards in the direction of the birth canal.

Position refers to where your baby’s occiput (the bottom part of the back of their head) is in relation to your body.

If your baby is in a breech presentation , then position refers to where your baby’s sacrum (lower back) is in relation to your body.

People — including medical professionals — sometimes use these terms incorrectly. Sometimes when speaking about babies in breech presentation, the word ‘position’ will be used to refer to their presentation. For example, you may read information or hear people say ‘breech position’ instead of ‘breech presentation’.

What are the different types of presentation my baby could be in during pregnancy and birth?

Most babies present headfirst, also known as cephalic presentation. Most babies that are headfirst will be vertex presentation. This means that the crown of their head sits at the opening of your birth canal.

In rare cases, your baby can be headfirst but in face or brow presentation, which may not be suitable for vaginal birth.

If your baby is in a breech presentation, their feet or bottom will be closest to your birth canal. The 3 most common types of breech presentation are:

• frank or extended breech — where your baby’s legs are straight up in front of their body, with their feet up near their face
• complete or flexed breech — where your baby is in a sitting position with their legs crossed in front of their body and their feet near their bottom
• footling breech — where one or both of your baby’s feet are hanging below their bottom, so the foot or feet are coming first

Read more on breech presentation .

What are the different positions my baby could be in during pregnancy and birth?

If your baby is headfirst, the 3 main types of presentation are:

• anterior – when the back of your baby’s head is at the front of your belly
• lateral – when the back of your baby’s head is facing your side
• posterior – when the back of your baby’s head is towards your back

How will I know what presentation and position my baby is in?

Your doctor or midwife can usually work out your baby’s presentation by feeling your abdomen. They may also double check it with a portable ultrasound. Your baby’s presentation is usually checked around 36 weeks .

Your doctor or midwife will also confirm your baby’s head position in labour by examining your belly and using an ultrasound , and they may also do a vaginal examination . During the vaginal examination they are feeling for certain ridges on your baby’s head called sutures and fontanelles that help them work out which way your baby is positioned.

What is the ideal presentation and position for baby to be in for a vaginal birth?

For a vaginal birth, your baby will ideally be headfirst with the back of their head at the front of your belly, also known as being in the anterior position. This position is best for labour and birth since it means that the smallest part of your baby’s head goes down the birth canal first.

When does a baby usually get in the ideal presentation and position for birth?

Your baby will usually be in a headfirst position by 37 weeks of pregnancy. Around 3 in every 100 babies will be in breech presentation after 37 weeks.

Your baby’s position can change with your contractions during labour as they move down the birth canal, so their exact position can change during labour.

What are my options if baby isn't in the ideal presentation or position for a vaginal birth?

If your baby is in a breech presentation, your doctor may recommend a technique called an external cephalic version (ECV) to try and move your baby while they are still in the uterus . An ECV involves your doctor using their hands to apply pressure on your belly and help turn your baby to a headfirst position. It has a 1 in 2 chance of success and is a safe option in most pregnancies.

There is no evidence to show that alternative therapies, such as exercises, acupuncture or chiropractic treatments, help your baby change from a breech presentation to headfirst.

If your baby remains breech, your doctor may discuss having a breech vaginal birth. Not all doctors and hospitals offer this option. They may also suggest you birth your baby with a planned caesarean section .

If your baby’s presentation is headfirst but the position of your baby’s head is not ideal for labour, it can lead to a longer labour, and potential complications . The position of your baby’s head will often change as your labour progresses. If it doesn’t, sometimes you can still give birth without assistance, or you may need your doctor to help turn your baby’s head or help your birth with a vacuum or forceps .

Any procedure or decision for a type of birth will only go ahead with your consent . You will be able to discuss all the options with your doctor, and based on your preferences for yourself and your baby’s safety, make a decision together .

Resources and support

The Royal Australian and New Zealand College of Obstetrics and Gynaecology has a factsheet about the options available to you if your baby is in a breech presentation at the end of your pregnancy .

Mercy Perinatal has information on external cephalic version (ECV) safety and benefits if your baby is in a breech presentation at the end of your pregnancy.

The Women’s Hospital has information about the different presentations and positions your baby could be in, and how it can affect your birthing experience.

Speak to a maternal child health nurse

Call Pregnancy, Birth and Baby to speak to a maternal child health nurse on 1800 882 436 or video call . Available 7am to midnight (AET), 7 days a week.

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Last reviewed: October 2023

Related pages

External cephalic version (ecv), malpresentation, breech pregnancy, search our site for.

• Foetal Version
• Breech Presentation

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Top results

Breech presentation and turning the baby

In preparation for a safe birth, your health team will need to turn your baby if it is in a bottom first ‘breech’ position.

Read more on WA Health website

Breech Presentation at the End of your Pregnancy

Breech presentation occurs when your baby is lying bottom first or feet first in the uterus (womb) rather than the usual head first position. In early pregnancy, a breech position is very common.

Read more on RANZCOG - Royal Australian and New Zealand College of Obstetricians and Gynaecologists website

External Cephalic Version for Breech Presentation - Pregnancy and the first five years

This information brochure provides information about an External Cephalic Version (ECV) for breech presentation

Read more on NSW Health website

When a baby is positioned bottom-down late in pregnancy, this is called the breech position. Find out about 3 main types and safe birthing options.

Read more on Pregnancy, Birth & Baby website

Malpresentation is when your baby is in an unusual position as the birth approaches. Sometimes it’s possible to move the baby, but a caesarean maybe safer.

Labour complications

Even if you’re healthy and well prepared for childbirth, there’s always a chance of unexpected problems. Learn more about labour complications.

ECV is a procedure to try to move your baby from a breech position to a head-down position. This is performed by a trained doctor.

Having a baby

The articles in this section relate to having a baby – what to consider before becoming pregnant, pregnancy and birth, and after your baby is born.

Anatomy of pregnancy and birth - pelvis

Your pelvis helps to carry your growing baby and is tailored for vaginal births. Learn more about the structure and function of the female pelvis.

Planned or elective caesarean

There are important things to consider if you are having a planned or elective caesarean such as what happens during and after the procedure.

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INTRODUCTION

PATHOGENESIS AND RISK FACTORS

● The fetus does not fully occupy the pelvis, thus allowing a fetal extremity room to prolapse. Predisposing factors include early gestational age, multiple gestation, polyhydramnios, or a large maternal pelvis relative to fetal size [ 2,3 ].

● Membrane rupture occurs when the presenting part is still high, which allows flow of amniotic fluid to carry a fetal extremity, umbilical cord, or both toward the birth canal.

Why would posterior position matter in labor?  The head is angled so that it measures larger. The top of the head molds less than the crown.

Baby’s spine is extended, not curled, so the crown of the head is not leading the way. Baby can’t help as much during the birth process to the same degree as the curled up baby.

Some posteriors are easy, while others are long and painful, and there are several ways to tell how your labor will be beforehand. After this, you may want to visit What to do when….in Labor .

Belly Mapping ® Method tips:  The Right side of the abdomen is almost always firmer, but the direct OP baby may not favor one side or the other. Baby’s limbs are felt in front, on both sides of the center line. A knee may slide past under the navel. 

The OP position (occiput posterior fetal position) is when the back of the baby’s head is against the mother’s back. Here are drawings of an anterior and posterior presentation.

• When is Breech an Issue?
• Belly Mapping® Breech
• Flip a Breech
• When Baby Flips Head Down
• Breech & Bicornuate Uterus
• Breech for Providers
• What if My Breech Baby Doesn't Turn?
• Belly Mapping ®️ Method
• After Baby Turns
• Head Down is Not Enough
• Sideways/Transverse
• Asynclitism
• Oblique Lie
• Left Occiput Transverse
• Right Occiput Anterior
• Right Occiput Posterior
• Right Occiput Transverse
• Face Presentation
• Left Occiput Anterior
• OP Truths & Myths
• Anterior Placenta
• Body Balancing

Look at the above drawing. The posterior baby’s back is often extended straight or arched along the mother’s spine. Having the baby’s back extended often pushes the baby’s chin up.

Attention: Having the chin up is what makes the posterior baby’s head seem larger than the same baby when it’s in the anterior position.

Because the top of the head enters (or tries to enter) the pelvis first, baby seems much bigger by the mother’s measurements. A posterior head circumference measures larger than the anterior head circumference.

A large baby is not the same issue, however. The challenge with a posterior labor is that the top of the head, not the crown of the head leads the way.

A baby with their spine straight has less ability to wiggle and so the person giving birth has to do the work of two. This can be long and challenging or fast and furious. Also, there are a few posterior labors that are not perceived different than a labor with a baby curled on the left.

Why? Anatomy makes the difference. Learn to work with birth anatomy to reduce the challenge of posterior labor by preparing with our Three Balances SM and more.

What to do?

• Three Balances SM
• Dip the Hip
• Psoas Release
• Almost everything on this website except Breech Tilt

In Labor, do the above and add,

• Abdominal Lift and Tuck
• Other positions to Open the Brim
• Open the Outlet during pushing

There are four posterior positions

The direct OP is the classic posterior position with the baby facing straight forward.   Right Occiput Transverse   (ROT) is a common starting position in which the baby has a bit more likelihood of rotating to the posterior during labor than to the anterior.   Right Occiput Posterior   usually involves a straight back with a lifted chin (in the first-time mother). Left Occiput Posterior places the baby’s back opposite the maternal liver and may let the baby flex (curl) his or her back and therefore tuck the chin for a better birth. These are generalities, of course. See a bit more about posterior positions in   Belly Mapping ® on this website. Want to map your baby’s position? Learn how with the   Belly Mapping ® Workbook .

Pregnancy may or may not show symptoms.   Just because a woman’s back doesn’t hurt in pregnancy doesn’t mean the baby is not posterior. Just because a woman is quite comfortable in pregnancy doesn’t mean the baby is not posterior. A woman can’t always feel the baby’s limbs moving in front to tell if the baby is facing the front.

The four posterior fetal positions

Four starting positions often lead to (or remain as) direct   OP   in active labor.   Right Occiput Transverse   (ROT),   Right Occiput Posterior   (ROP), and Left Occiput Posterior (LOP) join direct OP in adding labor time. The LOP baby has less distance to travel to get into an LOT position.

As labor begins, the high-riding, unengaged Right Occiput Transverse baby slowly rotates to   ROA , working past the sacral promontory at the base of the spine before swinging around to LOT to engage in the pelvis. Most babies go on to OA at the pelvic floor or further down on the perineal floor.

If a baby engages as a ROT, they may go to OP or ROA by the time they descend to the midpelvis. The OP baby may stay OP. For some, once the head is lower than the bones and the head is visible at the perineum, the baby rotates and helpers may see the baby’s head turn then! These babies finish in the ROA or OA positions.

Feeling both hands in front, in two separate but low places on the abdomen, indicates a posterior fetal position. This baby is Left Occiput Posterior.

Studies estimate 15-30% of babies are OP in labor. Jean Sutton in   Optimal Fetal Positioning   states that 50% of babies trend toward posterior in early labor upon admission to the hospital. Strong latent labor swings about a third of these to LOT before dilation begins (in “pre-labor” or “false labor”).

Recent research shows about 50% of babies are in a posterior position when active labor begins, but of these, 3/4 of them rotate to anterior (or facing a hip in an occiput transverse, head down position.

Jean Sutton’s observations, reported in her 1996 book, indicates that some babies starting in a posterior position will rotate before arriving to the hospital. Ellice Lieberman observed most posteriors will rotate out of posterior into either anterior or to facing a hip throughout labor. Only 5-8% of all babies emerge directly OP (13% with an epidural in Lieberman’s study). At least 12% of all   cesareans   are for OP babies that are stuck due to the larger diameter of the OP head in comparison to the OA head. It’s more common for ROT, ROP, and OP babies to rotate during labor and to emerge facing back (OA). Some babies become stuck halfway through a long-arc rotation and some will need a cesarean anyway.

The three anterior starting positions for labor

Why not ROA? ROA babies may have their chins up and this deflexed position may lengthen the course of labor. Less than 4% of starting positions are ROA, according to a Birmingham study. This might not be ideal for first babies, but is not a posterior position either.  

The spectrum of ease across posterior labors

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Baby’s posterior position may matter in labor

With a posterior presentation, labor may or may not be significantly affected. There is a spectrum of possibilities with a posterior baby. Some women will not know they had a posterior baby because no one mentions it. Either the providers didn’t know, or didn’t notice. If labor moved along, they may not have looked at fetal position clues since there was no reason to figure out why labor wasn’t progressing. If a woman didn’t have back labor (more pain in her back than in her abdomen), the provider may not have been “clued into” baby’s position.

Some posterior babies are born in less than 8 hours and position did not slow down labor. Some posterior babies are born in less than 24 hours and position did not slow down labor enough to be out of the norm. Some posterior babies are born in less than 36-48 hours without the need for interventions.

Some posterior labors are manageable when women are mobile, supported, and eat and drink freely, as needed. Some posterior labor needs extra support that a well-trained and experienced doula may provide, but that typically a mate or loved one would not have the skills or stamina to keep up with. Some posterior labors progress only with the help of a highly-trained pregnancy bodyworker or deep spiritual, or otherwise a non-conventional model of care. Or, they seem only able to finish with medical intervention.

Some posterior labors are served by an epidural, meaning the pelvic floor relaxes enough for the baby to rotate and come out. Some epidurals, on the other hand, make it so that a woman can not finish the birth vaginally.

NOTE:   Parents should know — some birth researchers, like Pediatrician John Kennell, are seriously asking whether a mother’s epidural turns off her body’s release of pain-relieving hormones which a baby relies on during childbirth. Some babies can’t turn and can’t be born vaginally and must be born by   cesarean. This is a spectrum of possibilities. I’ve seen every one of the above possibilities several times and can add the wonderful experience of seeing a woman laughing pleasurably and squatting while her posterior baby slid out on to her bedroom floor.

Possible posterior effects, some women will have one or two and some will have many of these:

The forehead that overlaps the pubic bone after labor starts must turn and drop into the pelvis to allow the birth to happen naturally. A cesarean finish of the labor is possible. Look at Abdominal Lift and Tuck in Techniques to guide you to solutions for easier engagement and progress.

• Longer pregnancy (some research shows this and some doesn’t)
• The amniotic sac breaking (water breaks, membranes open, rupture of membranes) before labor (1 in 5 OP labors)
• Not starting in time before induction   is scheduled
• Labor is longer and stronger and less rhythmic than expected
• Start and stop   labor pattern
• The baby may not engage, even during the pushing stage
• Longer early labor
• Longer active labor
• Back labor (in some cases)
• Pitocin may be used when labor stalls (but a snoring good rest followed by oatmeal may restore a contraction pattern, too)
• Longer pushing stage
• Maybe a woman has all three phases of labor lengthened by the OP labor or one or two of the three phases listed
• Sometimes the baby’s head gets stuck turned halfway to anterior – in the transverse diameter. This may be called a transverse arrest (not a   transverse lie ).
• More likely to tear
• More likely to need a vacuum (ventouse) or forceps
• More likely to need a   cesarean

These effects are in comparison to a baby in the   left occiput anterior   or   left occiput transverse   fetal position at the start of labor.

Who might have a hard time with a posterior baby?

This family just had a fast posterior birth of their second child! Ease in labor includes other factors beyond baby position.

• A first-time mom
• A first-time mom whose   baby hasn’t dropped into the pelvis by 38 weeks gestation   (two weeks before the due date)
• A woman with an   android pelvis   (“runs like a boy,” often long and lanky, low pubis with narrow pubic arch and/or sitz bones close together, closer than or equal to the width of a fist)
• A woman whose baby, in the third trimester, doesn’t seem to change position at all, over the weeks. He or she kicks in the womb and stretches, but whose trunk is stationary for weeks. This mother’s broad ligament may be so tight that she may be uncomfortable when baby moves.
• A woman who has an epidural early in labor (data supports this), before the baby has a chance to rotate and come down.
• A woman who labors lying in bed
• Low-thyroid, low-energy woman who has gone overdue (this is my observation)
• A woman who lacks support by a calm and assured woman who is calming and reassuring to the birthing mother (a doula)
• A woman put on the clock
• A woman who refuses all help when the labor exceeds her ability to physically sustain her self (spilling ketones, dehydration, unable to eat or rest in a labor over X amount of hours which might be 24 for some or 48 for others)
• A woman whose birth team can’t match an appropriate technique to the needs of the baby for flexion, rotation, and/or descent from the level of the pelvis where the baby is currently at when stuck

Who is likely to have an easy time with a posterior baby?

• A second-time mom who’s given birth readily before (and pushing went well)
• A posterior baby with a tucked chin on his or her mama’s left side with   a round pelvic brim
• An average-sized or smaller baby
• Someone whose posterior baby changes from right to left after doing inversions and other   balancing work , though the baby is still posterior
• A woman with a baby in the Left Occiput Posterior, especially if the baby’s chin is tucked or flexed
• A woman who gets bodywork, myofascial release, etc.
• A woman whose posterior baby engages, and does not have an   android (triangular) pelvis or a small outlet
• And of all of these, what is necessary is a pelvis big enough to accommodate the baby’s extra head size
• A woman who uses active birthing techniques — vertical positions, moves spontaneously and instinctively or with specific techniques from Spinning Babies ® , and other good advice
• A woman in a balanced nervous state, not so alert and “pumped up,” on guard, etc.

Any woman may also have an easier time than public opinion might indicate, too, just because she isn’t on this list. Equally, just because she is on the “hard” list doesn’t mean she will have a hard time for sure. These are general observations. They are neither condemnations nor promises. Overall, some posterior babies will need help getting born, while some posterior babies are born easily (easy being a relative term).

Let’s not be ideological about posterior labors.

While most posterior babies do eventually rotate, that can still mean there is quite a long wait – and a lot of physical labor during that wait. Sometimes it means the doula, midwife, nurse, or doctor is asking the mother to do a variety of position changes, techniques, and even medical interventions to help finish the labor. Patience works for many, but for some a   cesarean   is really the only way to be born. Read   What To Do When…in Labor .

What causes a baby to be posterior?

There is a rising incidence of posterior babies at the time of birth. We know now that epidural anesthesia increases the rate of posterior position at the time of birth from about 4% (for women who don’t choose an epidural in a university birth setting) up to about 13% (Lieberman, 2005). Low thyroid function is associated with fetal malposition such as posterior or breech. (See   Research & References .)

Most babies who are posterior early in labor will rotate to anterior once labor gets going. Some babies rotate late in labor, even just before emerging. Studies such as Lieberman’s show that at any given phase of labor, another 20% of posterior babies will rotate so that only a small number are still posterior as the head emerges.

My observations are that the majority of babies are posterior before labor. The high numbers of posterior babies at the end of pregnancy and in the early phase of labor is a change from what was seen in studies over ten years old. Perhaps this is from our cultural habits of sitting at desks, sitting in bucket seats (cars), and leaning back on the couch (slouching). Soft tissues such as the psoas muscle pair or the broad ligament also seem to be tight more often from these postures, from athletics (quick stops, jolts, and falls), from accidents, and from emotional or sexual assault.

Being a nurse or bodyworker who turns to care for people in a bed or on a table will also twist the lower uterine segment (along with some of the previously mentioned causes). This makes the baby have to compensate in a womb that is no longer symmetrical. Less often, the growing baby settles face-forward over a smaller pelvis, or a triangular-shaped pelvis (android). At the end of pregnancy, the baby’s forehead has settled onto a narrower than usual pubic bone, and if tight round ligaments hold the forehead there, the baby may have a tough time rotating. These are the moms and babies that I’m most concerned with in my work at Spinning Babies®. A baby that was   breech   beyond week 30 – 34 of pregnancy will flip head down in the posterior position. A woman with a history of breech or posterior babies is more likely to have a breech or posterior baby in the next pregnancy. However, she may not have an as long labor.

The best way to tell if your baby is OP or not, usually, is if you feel little wiggles in the abdomen right above your pubic bone. These are the fingers. They’d feel like little fingers wiggling, not like a big thunk or grinding from the head, though you might feel that, too. The little fingers will be playing by the mouth. This is the easiest indication of OP. The wiggles will be centered in the middle of your lower abdomen, close to the pubic bone. If you feel wiggles far to the right, near your hip, and kicks above on the right, but not near the center and none on the left, then those signal an   OA   or   LOT   baby (who will rotate to the OA easily in an active birth). After this, you might go to   What to do when…in Labor.

Check out our current references in the   Research & References   section.

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Emergency Obstetrics and Pediatrics

2-19. limb presentation.

Transport the mother to the hospital immediately if an arm or leg is presented first. Keep the mother in the delivery position (follow local guidelines.) DO NOT attempt to deliver the baby.

CAUTION: DO NOT try to pull on the presenting limb.

DO NOT try to replace the limb into the vagina.

DO NOT place your hand into the vagina unless there is a prolapsed cord.

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Ems prehospital deliveries.

Dallas T. Beaird ; Megan Ladd ; Suzanne M. Jenkins ; Chadi I. Kahwaji .

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Last Update: October 26, 2023 .

• Continuing Education Activity

While most deliveries take place in hospitals, there are cases where emergency medical services (EMS) are called to help with out-of-hospital deliveries, whether they are unexpected or planned but facing complications. In such situations, the initial priority is to swiftly transport both the mother and the infant, if the baby has already been delivered, to a hospital where they can receive appropriate care. Healthcare practitioners involved in these situations should possess the skills to assess the gestational age quickly, recognize if delivery is imminent, and be prepared to address any sudden issues that may arise.

Prehospital delivery primarily involves ensuring a controlled and guided delivery of the infant, managing immediate postpartum maternal bleeding, and providing limited care for the newborn until the patient can be safely transferred to a hospital. It's important to note that studies have demonstrated a higher risk of perinatal mortality in deliveries occurring outside a hospital compared to those within a hospital setting. Consequently, healthcare practitioners must be well-informed about prehospital delivery procedures, immediate postpartum care for both the mother and newborn, resuscitation techniques, and the management of common delivery complications.

The purpose of this activity for healthcare professionals is to enhance their competence when dealing with prehospital deliveries. It equips them with updated knowledge, skills, and strategies for promptly identifying complications, implementing effective interventions, and improving care coordination. Ultimately, this improves patient outcomes and reduces maternal and fetal morbidity.

• Identify indications for prehospital deliveries and recognize when an imminent birth is occurring.
• Assess pregnant patients in the prehospital setting to determine the stage of labor and maternal and fetal well-being.
• Implement appropriate prehospital obstetric protocols for managing labor and delivery, including techniques for delivering a baby in emergent situations.
• Collaborate with other EMS personnel and healthcare providers to ensure seamless care for both mother and newborn.
• Introduction

Prehospital delivery, often termed an unplanned out-of-hospital birth or birth before arrival, occurs when an infant is unintentionally born outside a hospital setting. In contrast to planned home births, these situations involve no prior preparations or access to healthcare practitioners and equipment. Sometimes, EMS personnel are summoned to transport planned home birth patients facing complications. [1]  

When EMS is called to aid an actively laboring patient, the foremost objective should be expeditiously transporting the mother to a hospital with obstetric services, if feasible. These facilities have obstetrically trained clinicians and the resources to handle potential complications. The American Academy of Pediatrics (AAP) and the American College of Obstetrics and Gynecology (ACOG) concur that hospitals and accredited birth centers offer the safest birthing environments. [2] However, sometimes there's insufficient time for transport before delivery. EMS healthcare practitioners are often summoned when a precipitous delivery has occurred or is imminent or the patient delivers en route. [3]

Unplanned prehospital deliveries have been linked to elevated perinatal mortality and morbidity risks for both the neonate and the mother. [4] [5] [6] [1] This is largely attributed to inadequate EMS obstetrical training in managing emergent deliveries and intrapartum complications, along with a failure to provide recommended neonatal resuscitation. [3] [7] [3] Hence, EMS practitioners must be well-versed in appropriate delivery techniques and immediate postpartum assessment and management for both the mother and neonate.

• Anatomy and Physiology

Pelvic Girdle

The pelvis forms a bony ring, which the fetus must pass through during delivery. The size and shape of the maternal bony pelvis, in correlation with fetal size and position, significantly impact the ease of delivery. In up to 3% of deliveries, the anterior fetal shoulder unexpectedly gets stuck behind the maternal pubic bone during delivery, resulting in an obstetric emergency called shoulder dystocia. [8] [9]

The uterus is a hollow, pear-shaped muscle in a female's pelvis. It houses the fetus, placenta, and fluid-filled amniotic sac during pregnancy. During labor, the uterus generates powerful rhythmic muscular contractions, forcing the baby through the pelvis outlet and ultimately out of the vaginal opening. [9]

The cervix is a fibromuscular tubular structure that forms the opening of the uterus, leading into the vagina. During labor, uterine contractions push the fetal head against the cervix, helping it to dilate and thin out (ie, efface), which allows passage of the fetus out of the uterus and into the vagina. [9]

The cervix is assessed on a vaginal exam using a sterile technique to monitor labor progress during labor. Cervical dilation is measured in centimeters through digital examination with 2 fingers. Full dilation is typically defined as reaching a dilation of 10 centimeters. Effacement is measured as a percentage of thinning; a cervix that is 100% effaced refers to a cervix that has become paper-thin. [9]  In active labor, before full dilation and effacement, the cervix can be felt as a rim of tissue on top of the infant's presenting body part, usually the head. When the cervix is fully dilated and effaced, it falls behind the fetal presenting part and is no longer palpable. Delivery may be imminent if the cervix is no longer palpable and the fetal head can be seen at the vaginal introitus. [9]

Fundal Height

The fundus is the upper part of the uterus, easily felt during an abdominal examination as a firm, rounded dome. Fundal height is the distance, measured in centimeters, from the top of the fundus to the top of the pubic bone. It's a quick way to estimate gestational age during the later stages of pregnancy. When the fundal height aligns with the umbilicus, it suggests around 20 weeks of gestation. For each centimeter above the umbilicus, another week is added to estimate gestational age. This method helps calculate the approximate gestational age based on fundal height. [8] [10] [8]

After delivery of the infant, the uterus should contract down, beginning its return to a nonpregnant size. As the uterus contracts down, it clamps off small blood vessels in the uterine muscle and significantly slows postpartum bleeding. Massaging the fundus can help stimulate this contraction and is useful in managing postpartum bleeding and hemorrhage. [11]

Placenta and Umbilical Cord

The placenta is the vital organ that links the fetus to the mother, facilitating the exchange of nutrients and gases. One side of the placenta adheres to the uterine wall, while the other side faces the infant. Typically, the umbilical cord attaches to the center of the placenta. After the baby is born, the uterus continues to contract, aiding in the detachment and expulsion of the placenta. Placental delivery is recognized by a sudden flow of blood and the lengthening of the umbilical cord. However, if the placenta separates prematurely, it can lead to fetal and maternal hemorrhage, and if the umbilical cord gets torn, it can cause rapid blood loss in the baby. [11]  

Stages of Labor

There are 3 stages of labor. Delivery of the fetus occurs in the second stage of labor.

• Stage 1: Begins with the onset of regular uterine contractions and cervical change and concludes when the cervix is fully dilated (ie, 10 cm). Labor tends to progress more slowly for women during their first delivery and faster with each subsequent delivery, but there are wide variations in what is considered normal. Active labor typically refers to when a patient's cervix begins to dilate quickly over time, which may not occur until 6 cm. [12] [9]
• Stage 2: Begins when the cervix is fully dilated at 10 cm and concludes after delivery of the fetus. Once the cervix is fully dilated, the average time to delivery in a woman laboring for the first time without an epidural is 36 minutes. The median time decreases with each successive delivery, up until the third delivery, to an average of 12 minutes with the second delivery and 6 minutes for any delivery after that. [12]  
• Stage 3: Begins immediately after delivery of the infant and ends after delivery of the placenta. Placental delivery usually occurs within 9 minutes of infant delivery on average. A retained placenta is typically defined as one that has not been delivered after 30 minutes. [11]
• Indications

Indications that delivery is imminent include:

• A strong, reflexive maternal urge to push or defecate [13]
• Intense contractions at regular intervals, ≤2 minutes apart
• Bulging perineum
• Crowning of the fetal head (ie, the fetal head is visible at the vaginal opening) or spontaneous separation of the labia by the presenting fetal part [14] [15] [16]
• Contraindications

There are few contraindications to unplanned prehospital delivery. The EMS healthcare practitioner can do little to delay or prevent delivery during spontaneous labor. If the EMS practitioner is close to the hospital, discouraging the woman from pushing may delay the delivery for a short while, depending on her dilation and the number of previous deliveries. During a precipitous delivery, uterine contractions are involuntary and are often strong enough to deliver an infant without much additional maternal effort. A strong and reflexive urge to bear down that the patient may be unable to suppress is usually present. Therefore, delivery may occur regardless of the patient's intentions, so EMS healthcare professionals must be prepared to deliver the infant en route to the hospital.

Two relative contraindications to vaginal delivery that EMS clinicians should be aware of are umbilical cord prolapse and breech, especially footling breech presentations. Umbilical cord prolapse, in which the umbilical cord is the presenting part, results in compression of the umbilical cord, which can lead to complications such as hypoxic brain injury and cerebral palsy. An emergent cesarean delivery is typically preferred; therefore, decompression of the cord should be attempted consisting of manual elevation of the fetal presenting part using 2 fingers or the whole hand through the vagina and placing the patient in a steep Trendelenburg or knee-chest position until experienced clinicians can perform a cesarean delivery in a hospital setting. [17]

A frank breech (ie, when the infant's buttocks are the presenting part) or a footling breech (ie, when the infant's foot is the presenting part) presentation occurs more frequently in preterm pregnancies and has a higher risk of complications compared to infants with a cephalic presentation. These patients also often require a cesarean delivery. EMS personnel should not perform any traction, and patients should be instructed to pant during contractions until the hospital can be reached, as specialized expertise is essential for these types of deliveries. [18] [19]

For most uncomplicated deliveries, minimal equipment is necessary. Ideally, in the prehospital setting, emergency medical professionals should have something to clamp and cut the umbilical cord and a dry cloth to dry and stimulate the infant, such as a towel. In emergency settings, typical obstetric and gynecological equipment may not be available, but if possible, EMS personnel should have the following items ready:

• Personal protective equipment (eg, a mask with face shield, gown, booties, sterile gloves)
• Towels or clean, dry cloths
• Blankets and infant hat
• Two umbilical cord clamps or hemostats
• Medical scissors or scalpel to cut the cord
• Container for the placenta
• Bulb suction
• Supplemental oxygen
• IV access equipment and crystalloid fluid
• Infant ventilation bags or a manometer to monitor inflating pressures during ventilation [7]

Equipment should be quickly and easily accessible to EMS healthcare practitioners or their assistants. Often, these items can be stored in an ambulance as part of an emergency delivery kit. However, equipment storage capacity within an ambulance is often limited, and some equipment may not be considered cost-effective. Furthermore, stocking may vary among different EMS systems. [8] [7]  Clean clothing can dry, stimulate, and warm the infant if no medical equipment is available during delivery. [7]

In a prehospital delivery, the EMS practitioner must make do with the personnel available. Ideally, the emergency medical professional performing the delivery should have at least 1 assistant. Hospital clinicians (eg, emergency, neonatologist, and obstetric physicians and nurses) should be notified ahead of the patient's arrival so that they may prepare necessary equipment for treatment (eg, infant warmers). [8] [10]

• Preparation

History and Physical Examination

The initial evaluation of a laboring patient by EMS is primarily to determine whether the patient is stable for transport to a hospital; a patient who demonstrates clinical signs of imminent delivery is considered unstable, and EMS may decide to perform a field delivery before transporting the patient and neonate to the hospital. Upon arrival, EMS personnel should attempt to rapidly obtain a focused history and physically examine the laboring patient to make this determination. [20] [13] Important information to obtain from the history includes:

• The estimated due date and gestational age of the pregnancy, if known. The first day of the last menstrual period to calculate an estimated due date and gestational age may be used if the patient does not know an estimated due date. [8]
• Number of pregnancies and the number of prior vaginal and cesarean deliveries
• Any pregnancy complications in current or prior pregnancies
• The onset of the contractions and their frequency 
• Clear yellow: normal
• Bloody: may indicate placental abruption or placenta previa
• Green: consistent with meconium, which increases the neonatal risk for respiratory complications  [8]
• If and where the patient received prenatal care
• Number of fetuses (singleton or twins) and perceived fetal movement
• Any nonobstetric health problems, allergies, and medications
• If the position of the fetus is known from a recent assessment (eg, recent ultrasound)  [8]

Maternal vital signs should be obtained in patients not delivered when EMS arrives, and fetal heart tones should be auscultated if a fetal heart Doppler is available. [10]  In addition to a focused chest examination, a rapid fundal height assessment should be performed to estimate the gestational age of the pregnancy. The diagnosis of active labor is beyond the scope of practice for EMS clinicians. Laboring patients should be transported to facilities with obstetric capabilities unless delivery appears imminent. This should be evaluated through visual inspection of the perineum if the patient has symptoms of rectal pressure, an urge to push, or contractions less than 2 minutes apart. EMS clinicians noting signs of an imminent delivery, including distention of the perineum by the presenting fetal part or the emergence of the fetal head past the vaginal introitus with contractions, should be aware that these are indications of an impending delivery and that preparation for a field procedure is required. [13]  

Unless intervention is indicated due to a breech delivery or prolapsed umbilical cord, a sterile digital examination of the vagina is typically not needed until the patient can be triaged by hospital clinicians who will assess cervical dilation and effacement, identify the presenting fetal part, and gauge the descent (ie, station) of the fetus. [13] Especially when there's noticeable vaginal bleeding, it's important to refrain from performing a digital examination until placenta previa can be ruled out as a potential cause. [10]  Examination of the perineum is most accessible for the EMS practitioner to perform with the patient in the dorsal lithotomy position (ie, supine with flexed hips and knees). [21]

Patient Positioning

Common Western delivery positions include the left-tilted dorsal lithotomy or semi-Fowler positions. Nevertheless, safe delivery can occur in various positions, such as left lateral decubitus, kneeling, squatting, or on hands and knees. EMS personnel should prioritize the mother's comfort, ensure accessibility for healthcare practitioners, and establish a secure area for the baby to prevent birth-related neonatal falls, which have been documented as causing birth trauma. [22] [21]

However, pregnant patients should not lie flat on their backs because this can reduce uteroplacental blood flow and the fetus due to aortic compression. Therefore, if lying supine, they should always have a rolled-up towel tucked under the left hip to tilt the patient or have the patient in a semi-reclined posture, sitting up at a 45-degree angle. [21]

• Technique or Treatment

In general, the goals of the delivering clinician are to reduce the risk of pelvic floor trauma for the parturient, provide initial neonatal support and resuscitation, and manage maternal and neonatal complications to optimize outcomes. If only 1 trained EMS practitioner is available, assistance from the patient's family, friends, or another nonclinical person to assist with the birth and provide maternal support is an option. [15]  In preparation for delivery, available supplies or the emergency delivery kit should be readily accessible to the EMS clinician assisting. Women delivering in the semirecumbent or left-tilted dorsal lithotomy positions should flex their hips and legs to open up the pelvic inlet. [9] The perineum and area below the patient's buttocks should be draped with clean towels. If time allows, the perineum and vaginal area should be quickly swabbed with a povidone-iodine solution. [10]

Active Pushing

As the fetal head emerges from the vaginal introitus, laboring patients will feel the urge to push or bear down due to the increased rectal pressure from the fetal head as it descends. Parturients delivering outside of a hospital should be encouraged to push when they feel a contraction begin. This typically will occur reflexively. [15] Additionally, parturients should be encouraged to breathe in a natural way, which often includes pushing with an open glottis (eg, moaning or screaming while bearing down) instead of pushing with a closed glottis (eg, Valsalva pushing). Although a common technique has been to coach parturients to push for 3 sets of 10 seconds while holding a deep breath, there is no evidence to suggest this approach provides any clinical benefit over parturient-driven pushing. [23]  It is important to note that a mother's perception of her birth experience depends on their clinician's empathy and interpersonal skills as much as their clinical abilities. Patients should be offered verbal encouragement to help keep them calm and focused while pushing with their preferred method. [24] [25]  

Approach to Delivery 

The majority of EMS-assisted deliveries involve quick and straightforward vaginal births. In this scenario, the primary responsibility of the EMS clinician is to assist in safely guiding and managing the baby's delivery to prevent any harm to the mother or the newborn. [10] [9]  Traditionally, the delivering clinician places 1 hand on the fetal head as it emerges and provides very gentle counter pressure, preventing the rapid expulsion of the fetus, while the other gloved hand is at the perineum, applying moderate manual pressure to provide perineal support as the fetal head emerges. However, studies have not shown this method to be any more beneficial than allowing the fetal head to emerge on its own using a hands-off approach. [26] [10] [9]  Routine use of episiotomy is  not recommended and should not be performed. [27] [9]

Usually, the fetal head emerges either facing down towards the maternal rectum or, less commonly, facing up towards the maternal abdomen during delivery. As the fetal body moves through the pelvis, a natural process called restitution occurs, where the head automatically turns to face one of the maternal thighs. This rotation usually takes a few seconds.

Once the fetal head has fully emerged and this rotation occurs, the delivering clinician should sweep their fingers around the fetal neck and feel for a nuchal cord. A nuchal cord is an umbilical cord wrapped around the neonate's neck. A nuchal cord, if present, may be wrapped more than once, tightly or loosely. If the umbilical cord is felt wrapped around the neck, the EMS clinician should attempt to reduce it by gently pulling the cord over the infant's head, taking care not to lacerate or avulse the cord; this should be repeated until all loops have been removed. [10] [9]  If the nuchal cord is too tight to pull over the infant's head, it may be left in place if delivery of the rest of the neonate is not impeded and removed from the neck as soon as the neonate is delivered. If a tight nuchal cord prevents the delivery from proceeding, the cord can be doubly clamped and cut before the body delivers. This should be an option of last resort; delivery of the anterior shoulder should be attempted first before clamping and cutting a tight nuchal cord to avoid neonatal asphyxia in case shoulder dystocia is encountered. [28]

After delivery of the fetal head and restitution, the neonate's shoulders will be delivered. With the infant's head facing 1 of the maternal thighs, the EMS clinician should gently grasp both sides of the head with a hand on each side. The delivering clinician should then apply gentle posterior traction (ie, toward the maternal rectum) to help guide the infant's anterior shoulder underneath the pubic bone. Immediately following delivery of the anterior shoulder, the neonate should be guided upwards (ie, toward the maternal abdomen) to deliver the posterior shoulder. From there, the passage of the rest of the body should happen quickly; clinicians should hold tightly to the neonate's head and body as it delivers, placing it gently on the maternal abdomen. [10] [9]

Delayed Umbilical Cord Clamping

There is no rush for the prehospital clinician to clamp the umbilical cord. Evidence shows that except for infants requiring immediate cardiopulmonary resuscitation (CPR), the umbilical cord should not be clamped until it has stopped pulsating, approximately 30 to 60 seconds following delivery. Some professional organizations recommend waiting up to 3 minutes. [29] [30]  Delayed cord clamping allows for the autotransfusion of up to 100 mL of oxygenated blood within the first 3 minutes after birth and is especially beneficial for preterm infants. [29]  Therefore, in most cases, the initial care (eg, clearing the airway, drying, stimulating, and warming the infant) and assessment of the newborn (eg, respiratory effort, tone, and heart rate [HR]) may be performed  before clamping  the cord.

To safely cut the cord, 2 clamps are placed on the umbilical cord, and the cord is transected between the clamps. Generally, it is advised that the proximal umbilical clamp be placed approximately 10 centimeters from the umbilicus. If necessary, this provides an adequate cord distance to place an umbilical catheter once the neonate reaches the hospital if they require resuscitation. The second clamp should be placed approximately 5 cm beyond the first, allowing adequate space to safely cut the umbilical cord with a sharp, ideally sterile, pair of scissors or scalpel. [10] [9]  

The cord should be kept clean and dry. If a standard aseptic technique (eg, use of sterile gloves, clamps, and scissors) was used to cut the cord, keeping the remaining umbilical stump clean typically does not require antiseptics (eg, chlorhexidine or alcohol swabs). However, antiseptics may be reasonable to prevent infection, depending on the delivery environment, such as in settings where sterile equipment is unavailable or if the cord becomes contaminated (eg, falling in the dirt). [31]

Immediate Postpartum Neonatal Evaluation

The AAP, among other international societies, recommends newborn care immediately following birth, including drying and stimulating the neonate, clearing the airway of secretions, ensuring adequate respiratory effort, and keeping them warm. After the infant is delivered, the EMS clinician should gently wipe the infant's nose and mouth to clear the mucus as they are placed directly skin-to-skin on the mother's chest or abdomen; bulb suctioning may not routinely be needed. [32] [33] The infant should be dried and rubbed vigorously within the first 60 seconds of birth with a clean towel or cloth to help stimulate the infant to breathe and cry, allowing it to clear its lungs from any remaining amniotic fluid. Most infants will have a strong respiratory effort after this initial stimulation. After ensuring the baby is dry and has a robust respiratory drive, it's essential to wrap them in a warm, dry towel or cloth. If a cloth isn't available, having direct skin-to-skin contact fosters bonding and helps maintain the infant's warmth. [32]  A food- or medical-grade, heat-resistant plastic bag can be used if skin-to-skin contact can not be maintained. [32]

Immediately after this initial drying and stimulating, or if additional help is available, the infant should be assessed on the maternal abdomen within 30 to 60 seconds of birth to determine if the neonate requires further resuscitative efforts. Key factors to consider include:

• Heart rate: An average newborn HR should be ≥100 bpm; it can be assessed by auscultation or palpation at the base of the umbilical cord.
• Respiratory effort: Normal effort should appear as vigorous crying or nonlabored breathing without gasping or apnea. An average newborn respiratory rate is 40 to 60 breaths/min.
• Color: The newborn's skin should be assessed for cyanosis. Any cyanosis should be documented in the record and carefully monitored, as cyanosis of the trunk or lips may indicate cardiorespiratory abnormalities. Isolated cyanosis of the distal extremities (ie, blue hands or feet) is common in the first few minutes of life and typically resolves within a few minutes.
• Tone: Newborns should display active movement in all their limbs and have regular muscle tone, meaning they should not appear limp.
• Reflex irritability (grimace response): The infant should spontaneously grimace, cough, sneeze, or vigorously cry in response to stimulation. [34] [35]

Additional assessments of the HR, respiratory effort, color, tone, and reflex irritability, components of the APGAR score, should be performed at 5 and 10 minutes of life. Findings from these initial assessments   are essential for hospital clinicians and must be documented in the record. [34] [35]  Infants who can breathe without difficulty and have good muscle tone typically do not require any additional immediate intervention. About 10% of infants may require additional stimulation beyond routine drying, which can be accomplished by rubbing the newborn's trunk or back or gently slapping the soles of the feet. Infants with difficulty breathing or an HR less than 100 bpm require additional neonatal resuscitation maneuvers. [34] [35] See the Complications section below.

After the initial assessment is complete and the infant and mother are determined to be stable, breastfeeding can be encouraged, which will help the infant maintain its blood glucose levels. Infants at risk for hypoglycemia should have their blood sugar level checked within the first hour of life, and they need to be monitored closely for evidence of hypoglycemia for the first few days. Infants at high risk for hypoglycemia include those born to mothers with diabetes, gestational or pregestational, and large or small infants of gestational age. [34] [35]

The infant should be reassessed every 30 to 60 minutes during the first 4 to 8 hours after birth and have a full general assessment within the first 24 hours of life. Therefore, neonates should be transferred into the care of clinicians trained in newborn care after an unplanned prehospital delivery. [34] [35]  

  Delivering the Placenta

The placenta often will deliver after the neonate has been successfully delivered and initially assessed to be stable. This typically occurs between 5 and 15 minutes after delivery but may take up to 30 minutes. Therefore, the patient and newborn should be transported at this time if a field delivery has been performed; the placenta does not have to be delivered first. If the placenta has not been delivered within 30 minutes, the patient should be transferred to an obstetric clinician to assist with removing the placenta, which may have implanted abnormally. These patients are at high risk for bleeding. In most cases, the placenta can deliver spontaneously with maternal effort alone. [36]  

While gentle traction on the umbilical cord reduces the risk of some postpartum hemorrhages and, therefore, is typically used by trained birth attendants to help deliver the placenta, cord traction can also result in cord avulsion and uterine inversion, which, although rare, can lead to significant morbidity. [37] [38]  Due to these risks and the somewhat limited benefits, controlled cord traction for placental delivery typically is not needed during prehospital deliveries by nonobstetric clinicians who lack dedicated training in this particular skill.  [38]  EMS clinicians should never pull on the cord. The placenta should naturally detach from the uterine wall as the uterus contracts following delivery; it should not require external force to separate.

If the placenta shows signs of separation from the uterine wall, the patient may be asked to bear down to deliver the placenta. Signs of placental separation include:

• The uterus becomes firmer.
• A sudden gush of blood from the vagina is noted.
• The umbilical cord begins to lengthen. [37]  

When the placenta is visible at the vaginal opening, it may be grasped by the cord as the patient pushes and gently guided outward. Once the placenta has been delivered, it needs to be inspected for any missing pieces because if the placenta is not intact, the retained products must be removed to prevent bleeding or infection. [36]  Therefore, the placenta should be kept in a container that can be transferred to hospital staff for evaluation by trained obstetric clinicians upon arrival.

• Complications

Obstetric Lacerations

Lacerations are common after vaginal deliveries, especially with the first delivery. Lacerations may involve the perineum, vagina, vulva, periclitoral, or periurethral tissue. Perineal tears are the most common and are classified by degrees of severity as follows:

• First degree: laceration of the perineal skin only
• Second degree: extension of a laceration from the perineal skin to the perineal muscles 
• Third degree: laceration involving the anal sphincter
• Fourth degree: laceration extending from the perineal skin through to the anal sphincter complex and anal epithelium  [39]

Nonperineal lacerations are often superficial and do not need to be repaired unless actively bleeding; however, if performed, repair of lacerations requires appropriate training, lighting, visualization, and pain control. ACOG recommends that the judgment of an obstetrically trained clinician be used to determine whether or not a first or second-degree laceration should be repaired. [39]  Most second-degree lacerations are repaired, but no evidence supports surgical repair over expectant management. However, a trained obstetric clinician should surgically repair third- and fourth-degree lacerations. If significant bleeding from a laceration is identified, it typically can be conservatively managed by applying pressure until an appropriately trained clinician can evaluate and provide treatment as indicated. [39]  

Breech Delivery

Breech presentations are the most common type of malposition encountered. Breech vaginal deliveries are associated with higher levels of neonatal morbidity and mortality. [40] This is because the fetal head, the largest and hardest fetal body part to move through the maternal pelvis, can become entrapped within the pelvis after the body delivers. During this time, the umbilical cord can become compressed as it runs alongside the fetal head, and the fetus is deprived of oxygen until the head is delivered. Whenever feasible, these patients should be taken to the hospital for delivery. Even if a fetal foot or buttock is visible at the vaginal opening, reaching a hospital facility for a safer delivery may still be possible. However, once the fetus has been delivered to the level of the neonatal umbilicus, a breech delivery is imminent, and the EMS clinician should be prepared for on-scene delivery. [10]

For the delivering clinician to perform the maneuvers of a breech delivery, the mother should be placed in the semi-recumbent position. The infant should be allowed to deliver spontaneously, without any assistance from the EMS clinician, to the level of the neonatal umbilicus. The EMS clinician can then hook their fingers around the infant's hips and apply downward traction; additionally, if not already facing down, the infant should be rotated so that its spine is facing up. As the fetal body continues to deliver, the delivering clinician may support the fetal body on their forearm and deliver the legs, 1 at a time, by grasping the thigh and sweeping the leg up and out while flexing the knee. [10]  When the scapulas are visible, the neonate should be rotated 90 degrees to face 1 of the maternal thighs. The EMS clinician should then sweep their fingers over the anterior arm, bending at the elbow and moving it down and across the infant's chest until the arm is out of the vagina. The infant should then be rotated 180 degrees to the other side, and the process should be repeated to deliver the second arm. [10]

To deliver the head, the infant should be placed so that it is lying on the forearm of the delivering clinician with the fetal legs straddling the forearm. The clinician should use the other hand to grasp the shoulders and apply downward traction until the back of the head is visible. At this point, the index and middle fingers of the bottom hand should be placed on the infant's face to apply downward pressure to the infant's maxilla while an assistant applies firm maternal suprapubic pressure. These maneuvers should allow the fetal head to flex and move under the pubic bone. Keeping downward pressure on the face and suprapubic pressure on the maternal abdomen, the delivering clinician elevates the infant's body straight up into the air toward the maternal abdomen, with the infant held between the clinician's 2 forearms, allowing the face and the entire head to deliver. [10]

Shoulder Dystocia

Shoulder dystocia occurs when the infant's shoulder becomes impacted behind the maternal pubic bone, causing the infant's body to get stuck in the birth canal. This complication is difficult to anticipate, but risk factors include macrosomia, maternal diabetes, maternal obesity, and fetal postdates. Recognizing and managing this complication quickly is crucial because prolonged dystocia can result in severe fetal morbidity (eg, asphyxiation, clavicle fracture, and brachial plexus injury). [41]

Shoulder dystocia can be expected when, following the delivery of the fetal head, it either firmly retracts against the perineum or starts moving back into the vagina during the intervals between contractions. This is known as the turtle sign because it can appear like a turtle pulling its head back into its shell. This occurs because the fetal head is expelled as the mother pushes, but because the fetal shoulder is stuck behind the pelvic brim when the mother stops pushing, the head gets pulled back into the vaginal canal. The delivering clinician should call for additional help when this sign is observed. [42]

Several maneuvers can be used to resolve the dystocia. Before attempting maneuvers, the delivering clinician should check for a nuchal cord and remove it if possible. If a tight nuchal cord is noted, the cord can be doubly clamped and cut before the body delivers. This should be an option of last resort; the anterior shoulder should be delivered before clamping and cutting a tight nuchal cord to avoid neonatal asphyxia due to shoulder dystocia. [28]

The first maneuver to attempt should be the McRoberts maneuver. [43] To perform this maneuver, assistants should sharply flex the parturient's thighs up onto her abdomen/chest (resulting in hyperflexion at the hips). If no one is available to help, the mother can be instructed to "pull your knees up to your armpits" or "pull your thighs onto your chest." This position alters the angles within the pelvis, allowing more room for the shoulders to move through the pelvis. [44]  Simultaneously with or immediately after a short trial in the McRoberts position, the assistant should be asked to apply pressure above the maternal pubic bone to help manually dislodge the impacted shoulder. [45]  If both of these maneuvers are unsuccessful, the delivering clinician can reach their hand into the posterior vagina and attempt to grasp the posterior forearm of the fetus, flexing it at the elbow. Then, the clinician can sweep the arm up and across the fetal chest, delivering the posterior arm. This alters the angle of the shoulder girdle and is often enough to relieve the dystocia. [28] [43]  They can also attempt to rotate the fetus in the birth canal by pushing on the back side of the anterior fetal shoulder and rotating 30 degrees toward the fetal face. [28] [43]  If the infant still has not been delivered, the mother can be flipped onto her hands and knees, and these maneuvers can be repeated in the new position.

Umbilical Cord Prolapse

Umbilical cord prolapse is when a loop of the umbilical cord gets stuck below the head of the fetus. This is concerning because the fetal head can compress the cord as the delivery progresses, preventing oxygenated blood from getting to the baby. These patients should be taken to a facility capable of performing a cesarean delivery. If the EMS clinician feels a pulsating cord of tissue consistent with a prolapsed umbilical cord on the vaginal exam, the mother should be instructed to stop pushing and be placed in the Trendelenburg position. The delivering clinician should attempt to decompress the cord by placing their hand into the vagina and pushing the fetal presenting part, typically the head, back up into the vagina and holding it there until instructed to remove their hand by the delivering surgeon at the hospital. [18]  The clinician elevating the head should be prepared to maintain that position with the patient in the operating room. [28]

Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is when the mother loses more than 500 mL of blood after a vaginal delivery. [46]  It is one of the leading causes of pregnancy-related maternal death worldwide. [47]  Much of the treatment involves getting the patient to a hospital that provides obstetric care. Still, there are several things the prehospital delivering clinician can do to assist in this situation.

EMS personnel should take the patient's vitals, establish IV access, and administer fluids similar to any traumatic hemorrhage. EMS clinicians should communicate to the receiving hospital that postpartum hemorrhage is suspected so that preparations for management can be made (eg, massive transfusion protocol). [11] They should also attempt to identify the cause of the hemorrhage so they can attempt to stop the bleeding. The most common cause of PPH is uterine atony, which causes 70% to 80% of cases. [48] Usually, the uterus begins to contract spontaneously after the baby has been successfully delivered. Thus, the myometrium effectively clamps down on the hemorrhaging spiral arteries, preventing further blood loss. Vigorous massage of the uterine fundus can stimulate this uterine contraction. If this is insufficient, bimanual uterine massage can be done by placing 1 hand within the vagina and the other on the maternal abdomen over the uterine fundus and compressing the uterus between their hands, similar to putting pressure on a wound. [49]

In a hospital setting, administering oxytocin immediately following the delivery of the infant is the most critical intervention for reducing the risk of PPH. For this reason, ACOG, the World Health Organization, and the American Academy of Family Physicians all recommend the universal administration of a uterotonic agent, usually oxytocin, following all births by obstetric clinicians. [48]  

Estimation of maternal blood loss (EBL) should be recorded. Typical vaginal deliveries have an EBL of less than 500 mL, and blood loss may be significantly less. (One standard soda can is approximately 300 mL.) Estimating blood loss can be difficult, as up to several hundred milliliters of amniotic fluid may be mixed with the blood. In general, bleeding should slow significantly within the first few minutes after delivery, especially after delivery of the placenta. If bleeding persists at a significant rate or if large blood clots, such as those the size of an apple, are observed, clinicians should be concerned about the possibility of a postpartum hemorrhage. Uterine massage should be continued until bleeding improves, or hospital clinicians can administer oxytocin. It can be administered intramuscularly (IM) or by slow IV infusion. IV bolus has been associated with cardiovascular collapse. A standard dosage is either 10 units administered IM or 5 to 10 units given as an IV bolus. It can be given at any time after the delivery of the infant's anterior shoulder, as there is no clearly defined optimal timing for its administration. [48] [11]  If the patient has IV access, up to 30 units can be added to 500 to 1000 mL of fluid and given as a continuous infusion. [48]

In addition to uterine atony, other less common causes of PPH include heavy bleeding from lacerations, retained placental fragments or membranes, or an acute coagulopathy (eg, disseminated intravascular coagulation). Therefore, a careful pelvic exam and rapid transfer to a hospital with obstetric clinicians are also appropriate. [11]

Neonatal Resuscitation

About 1% of infants struggle with the transition to extrauterine life and require some level of CPR beyond standard warming, drying, and stimulation (eg, rubbing the trunk). [50] Neonatal resuscitation is similar to standard CPR for a young infant. It may include positive pressure ventilation (PPV), endotracheal intubation and airway suctioning, chest compressions, and other interventions. Neonates should be assessed to determine if they require further resuscitative interventions  within the first 60 seconds after birth. The following are indications that further resuscitation is required: a preterm neonate, absence of vigorous crying or effective breathing, and poor muscle tone. The following resuscitation protocol is recommended by the AAP, ACOG, the American Heart Association (AHA), and a 2022 international consensus for neonates demonstrating difficulty with birth transition. [50] [32]

• Bulb suction the mouth first, then the nose, to prevent aspiration if the neonate gasps during nasal suctioning. 
• Avoid vigorous suctioning of the posterior pharynx. This may cause reflex bradycardia and damage the mucosa, which can interfere with feeding.
• Warm, dry, and stimulate the neonate by replacing wet towels or cloths and rubbing with a dry towel.
• Monitor blood oxygen saturation (SPO 2 ). The target SPO 2  increases with increasing minutes since birth. The target SPO 2  at 1 minute of life is only 60% to 65%; this target increases by 5% every minute for up to 5 minutes. At that point, the SPO 2  target is 80% to 85%; at 10 minutes of life, it is 85% to 95%.
• Consider continuous positive airway pressure. [32] [50]
• Most term babies do not require supplemental oxygen with PPV.
• Supplemental oxygen should be used judiciously and guided by pulse oximetry readings and target SPO 2  levels. Adequate ventilation alone is usually enough to restore HR in newborn infants.
• Monitor SPO 2  with pulse oximetry.
• Consider electrocardiography (ECG) monitoring.
• If the HR stays <100 bpm despite PPV, check ventilation and consider intubation. [32] [50]
• Start chest compressions, coordinated with PPV.
• Perform neonatal intubation if not done already.
• Give 100% oxygen.
• Perform ECG monitoring.
• If there is no response after 45 to 60 seconds of effective compressions, give epinephrine 0.1 to 0.3 mL/kg of 1:10,000 solution IV, equaling 0.01 to 0.03 mg/kg. [32] [50]

Neonatal Hypothermia

Neonatal hypothermia is associated with increased mortality, and this risk increases as the neonate's temperature drops further from 97.7 °F (36.5 °C). [51]  This risk is even more pronounced in premature infants. Hypothermia may also be associated with intraventricular hemorrhage and neonatal respiratory issues. Additionally, the temperature of infants (without asphyxiation) on admission strongly predicts morbidity and mortality.

The AHA 2022 CPR guidelines recommend maintaining infant temperatures between 97.7 °F (36.5 °C) and 99.5 °F (37.5 °C) for optimal outcomes. [50]  The best options for maintaining normal temperatures include the following:

• Skin-to-skin contact, covered by a blanket with healthy neonates.
• Use of a radiant warmer, if available.
• Placing the infant in a clean, food-grade plastic bag up to the neck level, swaddling them, and holding them against the warm bodies of appropriate adults (eg, parent, EMS personnel) may be beneficial in highly low-birth-weight infants.
• Getting the baby into a warm, temperature-controlled room or increasing the temperature in the room to ≥78.8 °F (23 °C). [50]  
• Clinical Significance

While prehospital deliveries are rare for EMS practitioners, the practitioners must have a solid understanding of proper delivery techniques and how to manage common emergency complications. Ideally, laboring patients should be transported to a medical facility equipped for obstetric and neonatal care before delivery takes place. However, there are situations where there isn't enough time for transportation, and the delivery occurs either upon EMS arrival or during transport. [3]

Unplanned prehospital deliveries have been linked to increased perinatal mortality and morbidity for both the newborn and the mother. [4] [5] [6] [1] This is often due to insufficient training among EMS personnel in managing emergent deliveries, handling common intrapartum complications, and providing basic recommended neonatal resuscitation. [3] [7] Therefore, healthcare practitioners should continually update their knowledge, skills, and strategies for promptly identifying complications, performing effective interventions, and coordinating care. This ensures that EMS clinicians remain composed during prehospital deliveries and strive for the best possible outcomes for the mother and the newborn.

Typically, uncomplicated deliveries require minimal intervention from EMS personnel, mainly providing support and conducting basic assessments. Critical aspects of the delivery process include assisting with expulsing the fetal head and anterior shoulder and performing the initial steps of neonatal resuscitation. EMS clinicians should also be able to address common complications that may arise during childbirth, such as shoulder dystocia, umbilical cord prolapse, postpartum hemorrhage, and neonatal respiratory distress, until the patient can be safely transported to a hospital.

• Enhancing Healthcare Team Outcomes

When responding to a call for assistance during labor, the initial priority should be to swiftly transport the mother to a hospital equipped with obstetric care. It's essential to notify hospital clinicians, including emergency, neonatologists, obstetric physicians, and nurses, before the patient's arrival so they can prepare the necessary equipment, such as infant warmers, and be ready for treatment if required. In a hospital setting, trained obstetric professionals can conduct the delivery in a controlled environment, equipped to handle any potential complications. [8] [10]

However, circumstances may not always allow sufficient time to transport the mother to the appropriate facility. In such cases, EMS practitioners must be well-versed in the proper delivery techniques. [22] [52] To optimize patient outcomes, it is essential to maintain detailed documentation of the EMS team's interventions and ensure sound clinical care to facilitate effective communication between healthcare professionals. This is crucial because the delivery circumstances and the newborn's initial condition can influence how physicians or other advanced practitioners manage these patients upon their transfer to the hospital. Additionally, EMS clinicians should be capable of providing a verbal report when transferring patients to hospital-based clinicians.

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Disclosure: Dallas Beaird declares no relevant financial relationships with ineligible companies.

Disclosure: Megan Ladd declares no relevant financial relationships with ineligible companies.

Disclosure: Suzanne Jenkins declares no relevant financial relationships with ineligible companies.

Disclosure: Chadi Kahwaji declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Beaird DT, Ladd M, Jenkins SM, et al. EMS Prehospital Deliveries. [Updated 2023 Oct 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• Vaginal delivery of breech presentation. [J Obstet Gynaecol Can. 2009] Vaginal delivery of breech presentation. Kotaska A, Menticoglou S, Gagnon R, MATERNAL FETAL MEDICINE COMMITTEE. J Obstet Gynaecol Can. 2009 Jun; 31(6):557-566.
• Describing Prehospital Deliveries in the State of Michigan. [Cureus. 2022] Describing Prehospital Deliveries in the State of Michigan. Eisenbrey D, Dunne RB, Fales W, Torossian K, Swor R. Cureus. 2022 Jul; 14(7):e26723. Epub 2022 Jul 10.
• Perinatal risks of planned home births in the United States. [Am J Obstet Gynecol. 2015] Perinatal risks of planned home births in the United States. Grünebaum A, McCullough LB, Brent RL, Arabin B, Levene MI, Chervenak FA. Am J Obstet Gynecol. 2015 Mar; 212(3):350.e1-6. Epub 2014 Oct 15.
• Review Prehospital Management of Peripartum Neonatal Complications by Helicopter Emergency Medical Service in the South West of the Netherlands: An Observational Study. [Air Med J. 2020] Review Prehospital Management of Peripartum Neonatal Complications by Helicopter Emergency Medical Service in the South West of the Netherlands: An Observational Study. Oude Alink MB, Moors XRJ, de Jonge RCJ, Hartog DD, Houmes RJ, Stolker RJ. Air Med J. 2020 Nov-Dec; 39(6):489-493. Epub 2020 Aug 20.
• Review Providing Care for Infants Born at Home. [Pediatrics. 2020] Review Providing Care for Infants Born at Home. Watterberg K, COMMITTEE ON FETUS AND NEWBORN. Pediatrics. 2020 May; 145(5). Epub 2020 Apr 20.

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Rory McIlroy receives Wells Fargo trophy via helicopter in ceremony to honor fallen area police officers

CHARLOTTE, NORTH CAROLINA - MAY 12: Rory McIlroy of Northern Ireland poses with the trophy after the final round of Wells Fargo Championship at Quail Hollow Club on May 12, 2024 in Charlotte, North Carolina. (Photo by Ben Jared/PGA TOUR via Getty Images)

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Rory McIlroy received the Wells Fargo Championship trophy via helicopter, as part of a ceremony to honor fallen police officers from a local shooting earlier this month. The special moment neatly complemented McIlroy’s special performance, with the tournament also announcing a $125,000 donation to the Charlotte-Mecklenburg Police Foundation in memory of the fallen officers.

McIlroy finished 17 under at Quail Hollow Club for a five-stroke victory over Xander Schauffele, his fourth victory at the Charlotte, North Carolina venue. As he partook in the winner’s festivities of which he has become accustomed (this marked McIlroy’s 26th TOUR title), a helicopter descended and landed on Quail Hollow’s 18th fairway, with Lee Greenwood’s anthemic “God Bless the USA” playing through the speakers. Charlotte-Mecklenburg Chief of Police Johnny Jennings exited the helicopter with the trophy, flanked by the Honor Guard up the fairway and onto the green, and placed the trophy in the center of a wreath featuring yellow and red roses.

The presentation also included a moment of silence in memory of the officers who were shot. Four area officers – Sam Poloche, Joshua Eyer, William “Alden” Elliot and Thomas M. Weeks, Jr. – were shot and killed April 29 while attempting to serve a warrant at a Charlotte-area home. Four additional officers were also shot in the incident.

Weeks had served as a tournament volunteer at the Wells Fargo Championship, as well.

“Because of the incredible commitment that the Charlotte-Mecklenburg Police Department has done with the Wells Fargo Championship, and in support of the families of the fallen officers and the remainder of those officers that stand behind the badge, we’re announcing a gift today of $125,000 to the Charlotte-Mecklenburg Police Foundation in support of your officers,” said Kendall Alley, General Chair, Champions for Education.

“Their legacy will forever inspire us to strive for a better tomorrow,” said Quail Hollow Club President Johnny Harris. “Let us carry their memory in our hearts and continue to honor their sacrifice through our actions and deeds.”

Rutgers University doctoral student gives birth on same day she defends dissertation

NEW BRUNSWICK, New Jersey -- This Mother's Day will be especially poignant for a New Jersey woman who will not only celebrate being a mom, but also becoming a doctor.

Tamiah Brevard-Rodriguez was working on her doctoral dissertation presentation from Rutgers University when she went into labor on March 25.

She was only eight months pregnant and was scheduled to deliver her dissertation defense that day.

"I was physically prepared for a pregnancy, mentally my brain was not on a baby," she said. "So I was having a very emotional response to knowing I was in labor, knowing I had this defense. I was literally shaking."

She had everything planned out with staff and faculty at Rutgers to examine standards Black women face on historically white college campuses.

But things went off schedule when her water broke. Brevard-Rodriguez's wife rushed to their car after their doula told them to get moving as contractions increased.

The drive to the hospital was a race against time.

"The doula is trying to tell me don't grunt him out, just breathe and I'm like 'this baby is coming,'" Brevard-Rodriguez said.

At that point, her wife, Alyza Brevard-Rodriguez, said she was probably driving 120 mph on the highway.

"I had three pushes, so the first one was baby's head was crowning, second push he was out, third one we were just there," Brevard-Rodriguez said.

Once at the hospital, baby Enzo was checked out and all was well.

But since Tamiah was well-rehearsed for the dissertation, she delivered her defense about seven hours after Enzo came into the world.

"I was like, I think I could do it. I was prepared for it, what did I do, some final touches on it and I did the study," she said.

She said all she needed was a nap, a shower and to regroup.

No one knew about the delivery until after the successful defense was complete.

Brevard-Rodriguez will graduate on Sunday, which is also Mother's Day.

Related Topics

• FAMILY & PARENTING
• BABY DELIVERY
• RUTGERS UNIVERSITY

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