EM Command Center / Pediatrics & Obstetrics • 3 min read • 3 sections

Precipitous Delivery & Neonatal Resuscitation

Critical emergency protocol for out-of-hospital or ED precipitous delivery, obstetric delivery crises, and immediate neonatal resuscitation. Features step-by-step management of vertex delivery, shoulder dystocia maneuvering (McRoberts and suprapubic pressure), cord prolapse reduction, and the Neonatal Resuscitation Program (NRP) algorithms.

Resuscitation Quick Ribbon (First 2 Minutes)

High-Acuity

Normal Vertex Delivery:Control crowning, gently support perineum, check for nuchal cord (slip over head or clamp and cut), guide head downward to deliver anterior shoulder, then upward for posterior shoulder.

Shoulder Dystocia:Call for immediate help; call NICU and OB; execute HELPERR protocol: McRoberts maneuver + Suprapubic pressure.

Umbilical Cord Prolapse:Elevate presenting fetal head off the cord with a sterile gloved hand in the vagina; maintain elevation continuously while rushing directly to OR for emergency Cesarean section.

Neonatal Resuscitation (NRP Step 1):Warm, dry, stimulate, clear airway if obstructed (first 30 seconds).

NRP Step 2 (HR < 100 or apnea):Start Positive Pressure Ventilation (PPV) immediately at 40-60 breaths/min on room air (21% O2); apply pulse oximeter on RIGHT hand/wrist (pre-ductal).

NRP Step 3 (HR < 60 despite 30 sec effective PPV):Increase FiO2 to 100%, initiate 3:1 chest compressions (90 compressions + 30 breaths/min), insert emergency UVC/IO, and administer IV Epinephrine 0.02 mg/kg (0.2 mL/kg of 1:10,000).

Bottom-Line Clinical Pearl

In shoulder dystocia, NEVER apply fundal pressure, which impacts the shoulder further behind the symphysis pubis and causes uterine rupture. Immediately hyperflex maternal hips onto the abdomen (McRoberts maneuver) and apply firm downward SUPRAPUBIC pressure.

1. Shoulder Dystocia Emergency Protocol: The HELPERR Framework

Shoulder dystocia occurs when the anterior fetal shoulder becomes impacted behind the maternal symphysis pubis. Hallmark sign: The 'Turtle Sign' (fetal head retracts tightly against the perineum immediately after delivery):

Mnemonic Letter	HELPERR Maneuver	Technique & Anatomic Mechanism
H - Help	Call for Immediate Multidisciplinary Help	Mobilize Obstetrics, Pediatrics/NICU, Anesthesia, and nursing personnel to the resuscitation room.
E - Evaluate	Evaluate for Episiotomy	Episiotomy does not relieve bony obstruction but facilitates internal manual maneuvers.
L - Legs (McRoberts)	McRoberts Maneuver (Hyperflexion)	Sharply hyperflex and abduct maternal hips against maternal abdomen. Flattens lumbar spine and rotates symphysis pubis superiorly. Solves > 40-50% of dystocias.
P - Pressure	Suprapubic Pressure (NOT Fundal)	Assistant places heel of hand over maternal suprapubic region, pushing downward and laterally against anterior shoulder to dislodge and rotate it.
E - Enter	Internal Rotational Maneuvers	Rubin II (push posterior aspect of anterior shoulder toward fetal chest) or Woods Screw (push anterior aspect of posterior shoulder in 180-degree rotation).
R - Remove	Remove the Posterior Arm	Reach along posterior humerus, flex elbow, sweep forearm across fetal chest, and grasp hand to deliver posterior arm, reducing shoulder diameter by 2-3 cm.
R - Roll	Roll to Hands and Knees (Gaskin)	Turn mother onto all fours (hands and knees). Increases pelvic diameters and facilitates gravity-assisted traction.

2. Neonatal Resuscitation Program (NRP) 2025/2026 Algorithm

Neonatal resuscitation is focused on rapid lung aeration and ventilation. Hypoxia, not primary cardiac arrest, is the etiology of neonatal bradycardia:

Timeline	Heart Rate & Clinical Assessment	Mandatory Action / Intervention
0 - 30 Seconds	Term? Tone? Breathing/crying?	Warm (radiant warmer), dry, stimulate, position airway (sniffing position). Clear airway only if obstructed by secretions/meconium.
30 - 60 Seconds	Apnea, gasping, or HR < 100 bpm	INITIATE PPV (Positive Pressure Ventilation) at 40-60 breaths/min using room air (21% O2 for >= 35 weeks; 21-30% if < 35 weeks). Attach pulse oximeter to right wrist (pre-ductal).
At 60 Seconds	HR remains < 100 bpm despite PPV	Execute MR. SOPA ventilation corrective steps: Mask adjustment, Reposition airway, Suction mouth/nose, Open mouth, Pressure increase (up to 30 cmH2O), Alternative airway (LMA or ETT).
> 60 Seconds	HR < 60 bpm despite 30 sec of effective chest-rise PPV	Increase FiO2 to 100%. INITIATE CHEST COMPRESSIONS: 3:1 ratio (3 compressions to 1 breath = 90 compressions + 30 breaths = 120 events/min). Use two-thumb encircling technique over lower third of sternum.
Refractory Bradycardia	HR remains < 60 bpm after compressions	Emergency vascular access (Umbilical Venous Catheter UVC or intraosseous IO). Administer Epinephrine 0.02 mg/kg IV/IO (0.2 mL/kg of 1:10,000) every 3-5 min. Fluid bolus 10 mL/kg normal saline if hypovolemic/bleeding.

3. Umbilical Vein Catheterization (UVC) Steps

Cut the Cord: Slice the umbilical cord horizontally with a scalpel 1-2 cm above the abdominal wall skin margin.
Identify Vessels: Locate the TWO small, thick-walled, muscular umbilical arteries (at 4 and 8 o'clock) and the ONE large, thin-walled, open umbilical vein (at 12 o'clock).
Insert Catheter: Insert a 3.5F or 5.0F catheter into the vein only 2-4 cm until free return of blood is aspirated (low-lying emergency position, below the liver).
Secure & Flush: Secure with umbilical tape/purse-string; flush with normal saline. Catheter is now ready for emergency epinephrine and volume expansion.

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