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The anxiety experienced by emergency physicians caring for a woman in active labor is not simply due to the lack of familiarity with normal deliveries but also is due to the awareness of the potential for serious and rarely fatal complications of labor. In addition, the initial management of obstetric emergencies such as preeclampsia, eclampsia, and hemorrhage has major consequences for maternal and infant survival. It is therefore essential that the emergency physician becomes familiar with the management of the laboring patient and prepared for the unlikely event of precipitous delivery in the ED.

Precipitous delivery in the ED setting is relatively uncommon. With advances in prenatal care and nearly universal availability of obstetric units in the U.S., the incidence of out-of-hospital delivery has fallen to <1% of deliveries.1 In 2004, of these out-of-hospital deliveries, 65% were in a residence and 27% were in a birthing center.1 The desire for planned home deliveries exists, and sometimes rapid transport to the hospital is needed for difficult deliveries.

The largest prospective study of home births in the U.S. and Canada found that of the 5400 women who planned a home delivery, 12% of patients were transferred to a hospital intrapartum or postpartum. The majority of intrapartum transfers were for failure to progress, need for pain relief, and exhaustion, whereas the postpartum transfers were for maternal hemorrhage, retained placenta, or respiratory problems in the newborn.2

Many women prefer a planned home birth to avoid medical intervention or for cultural or religious reasons. However, many out-of-hospital deliveries occur because of lack of prenatal care, inadequate preparations by family members, lack of transportation options, location in remote areas, and premature delivery. A known practice is intentional precipitous labor, in which a woman, desiring to avoid hospital charges or intervention, delays care until the final stages of labor. It is important for emergency medicine providers to recognize how personal judgments about out-of hospital deliveries can interfere with the quality and efficiency of care provided.

EMS personnel must be trained to recognize active labor and manage the precipitous delivery appropriately. Pregnancy-related complications that may occur in the prehospital setting include preeclampsia, eclampsia, maternal hemorrhage, and complications of labor such as cord prolapse, malpresentation, shoulder dystocia, and fetal distress. This requires an integrated approach to management of the patient in labor, including knowledge by prehospital personnel of available obstetric and neonatal units in the system’s catchment area for appropriate transport.

The need to recognize maternal and neonatal complications in the prehospital setting has become more important with the availability of systems for transporting high-risk obstetric patients to specialty centers. The development of specialty centers has led to a significant decline in neonatal mortality. Care units for patients at high risk have proliferated, and as a consequence, transport of pregnant patients for reasons of hemorrhage, eclampsia or preeclampsia, fetal distress, multiple gestation, fetal anomalies, and other maternal health problems, including traumatic ...

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