⚡ TIME-CRITICAL — PREPARE FOR IMMEDIATE TRANSFER + PRE-ALERT
Labour &
Imminent Birth
JRCALC Apr 2026 · Cephalic presentations only · v1.0
⚠️ For BREECH (buttocks/foot presenting) — refer to Breech Birth guideline. Do NOT use this tool.
This tool is for cephalic presentations (head presenting first).
Patient History
Obtain with interpreter if required. These answers determine the risk pathway.
Gestation & Pregnancy
Weeks gestation
Under 37 weeks (Preterm)
37–41 weeks (Term)
42+ weeks (Post-dates)
Unknown
Number of babies
Single
Twins
Triplets+
Gravida / Parity
1st pregnancy
Previous birth(s)
Previous caesarean section
Previous severe perineal tear (3rd/4th degree)
Waters / Membranes
Waters intact
Waters broken
Clear liquor
Meconium stained
Blood stained
Offensive smelling
⚠️ Waters broken more than 18 hours in a term pregnancy = HIGH RISK
High Risk Factors — Tap All That Apply
Any positive = time-critical conveyance to obstetric unit required (unless birth imminent)
Maternal
Consultant-led care
Diabetes (any)
Hypertension / pre-eclampsia
Bleeding in pregnancy >20wks
Previous caesarean
Limited antenatal care
Concealed pregnancy
Drug / alcohol misuse
Age ≥40 years
BMI ≥30
Cardiac condition
Clotting disorder
Previous obstetric emergency
Mental health conditions
Sickle cell disease
Beta-blockers in use
Current infection
Placenta praevia / accreta
Fetal
Shoulder dystocia (history)
Cord prolapse (history)
Twins / triplets
Congenital abnormalities
Small for gestational age
Safeguarding concerns
🚨 HIGH RISK PREGNANCY — Time-critical conveyance to nearest obstetric unit required. If birth imminent, manage on scene then convey immediately after with pre-alert.
Special Circumstances
Planned homebirth
Waterbirth planned / in progress
Freebirth
🏠 Planned homebirth — contact maternity services to attend per local guidelines. Stay on scene until midwife arrives. If patient/baby abnormal obs or red flags — convey immediately, do not wait for midwife.
🛁 Waterbirth — outside scope of ambulance clinicians. Ask patient to leave water. If they decline, follow special waterbirth protocol (Section 12.1 JRCALC). Request midwife. Document all discussions.
Freebirth — legal in UK. Request maternity services regardless of previous refusals. Provide care per JRCALC. Escalate to senior clinician. If baby born — care in best interests of child. Do not leave scene without midwife handover.
Contraction Assessment
Contraction Pattern
Time from end of one contraction to start of next. Ask patient to raise hand if verbal communication difficult.
Frequency
Irregular
Every 5 min
Every 3 min
Every 1–2 min ⚡
⚡ Contractions every 1–2 minutes — assess for imminent birth signs NOW
Abnormal Contractions — Time-Critical
🚨 Abnormal contractions — time-critical conveyance to nearest obstetric unit with pre-alert. NB If birth is imminent, it takes priority — manage birth then convey immediately.
Normal Contractions
After 36+6 weeks gestation
Pain comes and goes
Abdomen is soft between contractions
All patients in labour require fetal monitoring — recommend conveyance to hospital. If homebirth planned, request midwife per local guidelines.
Signs of Imminent Birth
Gain consent to observe external vaginal area during a contraction. Internal examination is NOT within scope of ambulance clinicians.
Stay and Prepare to Facilitate Birth if ALL Present
AND either of:
Continuous Dynamic Assessment — 10 Minute Rule
If staying on scene but no progress after 10 minutes (same presenting part visible) — prepare to extricate. Time-critical transfer to nearest obstetric unit with pre-alert.
⏱️ 10 minutes elapsed — no progress = prepare to extricate and transfer time-critically
Preparing for Birth
Immediate Actions
Environment & Equipment
Supporting Birth of the Baby
Hands poised once head visible. Do NOT pull on the baby at any point.
1
Head visible — hands poised
One clinician must have hands poised in preparation for birth as soon as head is visible.
2
Crowning — encourage panting
At crowning (head remains visible and doesn't slip back between contractions) — encourage patient to pant. This slows the birth of the final part of the head and reduces risk of perineal trauma.
3
Head born — await restitution
After the head is born, the baby's head should turn to the side between or during the next contraction. This is called restitution and is normal.
4
Body born during next contraction
The remainder of the baby should be born during the next contraction. Allow patient to push guided by their body. If body NOT born during next contraction after head = SHOULDER DYSTOCIA — refer to Shoulder Dystocia guideline immediately.
5
Support and lift to abdomen
Support the baby as the shoulders and body are born. Lift the baby towards the patient's abdomen. Do NOT pull.
6
Check cord around neck
The cord may be around the baby's neck — this does NOT require removal during delivery. Baby can be born with cord in place. If cord remains around neck or body following birth, unloop it.
🚨 SHOULDER DYSTOCIA — if body not born after head during next contraction, refer to Shoulder Dystocia guideline immediately.
Special Birth Situations
En caul (membranes intact)
Amniotic membranes presenting
Twin birth
En Caul: Pull some membranes away using index finger and thumb. Tear with fingers. If too tough — use scissors tip to make small incision close to pinched fingers. Peel membranes from mouth and nose. Remove membranes, clamp and cut cord, undertake newborn assessment and thermoregulation.
Amniotic membranes presenting: Do NOT burst membranes. If presenting part not visible behind sac — time-critical transfer. If sac bursts — observe for presenting part. Foot/feet/hands/cord = time-critical Breech Birth protocol. Head presenting and progressing — stay and facilitate birth.
Twin birth: Request 2nd and 3rd resource + advanced care team. Birth Twin 1 per normal protocol then clamp and cut cord immediately. Assess and thermoregulate Twin 1. Contractions may decrease — attempt to extricate for Twin 2 unless imminent. Twin 2 at higher risk of hypoxia. Apply birth time labels to each twin. Monitor for PPH — higher risk after twin birth. Do NOT give uterotonics with 2nd fetus in situ.
Initial Newborn Assessment
Place baby directly on patient's abdomen. Dry and stimulate with dry towel. Assess with cord intact over first 60 seconds.
60-Second Cord Timer
Cord should remain intact for at least 60 seconds while assessing and performing thermoregulation.
Thermoregulation — Immediate
Target temp: 36.5–37.5°C
Newborn Assessment — Tap Normal or Abnormal for each
If ANY parameter is ABNORMAL — clamp and cut cord immediately and START NEWBORN LIFE SUPPORT
Do NOT use a defibrillator at any point for monitoring or NLS
Colour
Check centrally — mucous membranes (gums)
✓ Centrally perfused (pink gums)
✗ Centrally cyanosed >1 min
Not yet assessed
Tone
✓ Flexed / Good tone
✗ Floppy
Not yet assessed
Breathing Rate
Normal: 40–60 per minute
✓ 40–60/min
✗ Below 40/min
Not yet assessed
Heart Rate (Stethoscope)
Normal: 100–160 per minute
✓ 100–160/min
✗ Below 100/min
Not yet assessed
🚨 ABNORMAL FINDING — Clamp and cut cord immediately. START NEWBORN LIFE SUPPORT. Refer to NLS guideline.
✓ All parameters within normal range. Continue thermoregulation and monitoring.
Optimal Cord Management
At birth, 1/3 of baby's blood volume is in the placenta. Cord intact for ≥60 seconds reduces morbidity and mortality.
Clamp Immediately If
Cord is snapped (if at baby's abdomen — apply pressure, time-critical conveyance with pre-alert)
Cord prevents effective newborn life support
Further babies to be born (twins)
Optimal Cord Clamping
⚠️ Ensure newborn's fingers and genitals are clear of scissors. Be aware of blood spurting from cord — bodily fluid risk.
Third Stage of Labour — Placenta
Controlled cord traction and prophylactic uterotonics are NOT within scope of ambulance clinicians — midwives only.
20-Minute Placenta Timer
If placenta still in situ 20 minutes after birth — time-critical conveyance to obstetric unit with pre-alert.
Actions to Promote Placenta Delivery
🩸 Excessive bleeding ≥500ml or haemodynamic compromise → refer to PPH guideline
Placenta Transport
Examining placenta and membranes for completeness is NOT within scope of ambulance clinicians.
Transport
Transport Checklist
If separate ambulances — ensure maternity staff aware of location of both mother/birthing person and baby so they can reunite as soon as appropriate.
Preterm Specific
Transfer to Hospital
🚨 Time-critical conveyance to nearest obstetric unit with pre-alert.
Pre-Alert Must Include
⚠️ Be ready for situation to change en-route. If birth becomes imminent — pull over, stop and manage birth before continuing.
Obstetric Complications & Emergencies
Tap any complication for management guidance. These are reference points — follow individual JRCALC guidelines where specified.
💔 Maternal Cardiac Arrest
🩸 PPH
⚠️ Pre-eclampsia / Eclampsia
👶 Shoulder Dystocia
🔴 Cord Prolapse
🔄 Breech Presentation
⚕️ FGM
❓ Concealed Pregnancy
🏥 Destination Decision
📞 SBAR Handover
🌍 Ethnic Minority Risk
📋 Physiology of Pregnancy
💔 Maternal Cardiac Arrest
🚨 Resuscitation of the MOTHER is always the priority. Effective maternal resuscitation = effective fetal resuscitation.
Pre-alert nearest ED with obstetric unit — prepare for emergency perimortem caesarean section (resuscitative hysterotomy)
Key Modifications to Standard ALS
📞 Pre-alert must state: gestational age, maternal arrest, request for theatre readiness for perimortem caesarean / resuscitative hysterotomy
Refer to Maternal Resuscitation JRCALC guideline and Cardiac Arrest During Pregnancy guideline
🩸 Postpartum Haemorrhage (PPH)
PPH = blood loss ≥500ml OR any blood loss causing signs of hypovolaemic shock
Pregnant women compensate better due to increased blood volume (45%). Hypovolaemia is a LATE sign — hypotension indicates significant loss already occurred.
Blood Loss Estimation
Volume
Appearance
~50ml
Small puddle / soaked pad
~200ml
Large soaked pad, small pool
~500ml
Pool approximately 30cm diameter
≥500ml
⚡ PPH THRESHOLD
Management
Uterotonics (e.g. Syntometrine) — midwives only. NOT within scope of ambulance clinicians unless locally approved.
Refer to PPH JRCALC guideline
⚠️ Pre-eclampsia & Eclampsia
Pre-eclampsia: hypertension + proteinuria after 20 weeks. Eclampsia: seizures in pre-eclampsia patient.
Features of Pre-eclampsia
BP ≥140/90
Severe headache
Visual disturbances
Epigastric pain
Facial / hand oedema
Vomiting
Eclampsia Management
Ongoing eclamptic convulsions = nearest ED (not just obstetric unit)
Refer to Pre-eclampsia and Eclampsia JRCALC guideline
👶 Shoulder Dystocia
🚨 OBSTETRIC EMERGENCY — Body not born during next contraction after head.
Do NOT pull on the baby's head. Do NOT apply fundal pressure.
HELPERR Mnemonic
If in waterbirth — ask patient to promptly stand up and exit pool. Standing may release the baby — hands poised at all times.
Refer to Shoulder Dystocia JRCALC guideline
🔴 Cord Prolapse
🚨 TIME-CRITICAL EMERGENCY — Cord presenting before or alongside presenting part. Risk of fetal hypoxia from cord compression.
Management
Refer to Cord Prolapse JRCALC guideline
🔄 Breech Birth
🚨 Breech birth carries significant risk of fetal hypoxia. Baby will likely require NLS. Prepare NLS area immediately.
⚠️ Meconium is more common in breech — document and hand over but does not change management.
⚠️ Cord prolapse more common with breech — refer to Cord Prolapse guidance if cord visible.
Step 1 — Is Birth Imminent?
LEAVE IMMEDIATELY — Do Not Deliver on Scene
Time-critical transfer to nearest obstetric unit with pre-alert if ANY of these:
Do NOT attempt vaginal delivery on scene in these circumstances.
STAY — Birth Imminent
Stay and prepare to facilitate birth on scene ONLY if:
Buttocks ARE visible AND advancing through the vaginal entrance (introitus)
Step 2 — Maternal Position
Position to Aid Gravity
Encourage upright position — gravity assists descent. Ensure bottom is OFF the floor to allow baby to hang down.
SEMI-RECUMBENT
Keep buttocks AT THE EDGE of bed/surface. Baby's back must face TOWARDS you. Baby hangs down under own weight.
ALL-FOURS
Baby's abdomen must face TOWARDS you. Baby can be delivered onto bed/floor — ensure safe landing area.
Step 3 — Start 5-Minute Timer When Buttocks Born
⏱️ 5-Minute Rule
When BOTH buttocks are born — start timer. Baby MUST be fully born within 5 minutes.
Delay beyond 5 minutes is associated with poor outcomes. If manoeuvres are not working within this time — rapid transport to hospital.
5:00
Time remaining — baby must be born
Encourage CONTINUOUS pushing from this point — do not wait for contractions. Allocate a team member to watch the timer only.
Step 4 — Hands Poised Approach
Observe — Hands Poised
Many breech births occur spontaneously without intervention. Do not handle the baby unless necessary.
Signs of fetal hypoxia — intervene immediately if ANY present:
Do NOT touch the umbilical cord — causes vasospasm and interrupts oxygen to baby.
Ensure baby's back faces mother's abdomen at all times — 'tum to bum'. If rotation needed, hold over BONY PELVIS only — never soft tissue of abdomen.
Step 5 — Manoeuvres if Delay
Legs Delayed
If legs do not deliver spontaneously:
Arms Delayed
When scapula (shoulder blade) is seen, elbows/arms should be visible:
⚠️ Gain consent before any internal manoeuvre. Do NOT pull on baby. Do NOT apply pressure to soft abdominal tissue.
Head Delayed
🚨 Head delay is the most dangerous complication — act immediately.
Semi-recumbent position
All-fours position
⚠️ Gain consent before any internal manoeuvre.
Transport — Partially Delivered Baby
If Moving with Breech in Progress
Document all timings and any manoeuvres performed — essential for handover.
⚕️ Female Genital Mutilation (FGM)
Women may not know FGM has taken place — clear communication and history-taking essential.
Types
Type 1 — Partial/total removal of clitoris
Type 2 — Clitoris + labia minora removal
Type 3 (Infibulation) — Narrowed vaginal opening — CANNOT give birth unassisted. Scar tissue prevents passage of baby without de-fibulation.
Type 4 — Other harmful procedures
Obstetric Risks
Prolonged and obstructed labour
Increased episiotomies and perineal tears
Increased PPH risk
Increased caesarean section rate
Increased neonatal hypoxia and brain damage risk
Maternal death from obstructed labour
Pre-hospital Management
FGM is a human rights violation and form of child abuse. Mandatory reporting under Female Genital Mutilation Act 2003.
❓ Concealed / Unknown Pregnancy
Any woman of childbearing age MAY be pregnant. High index of suspicion for abdominal pain or PV bleeding.
Consequences of concealment can be fatal for both mother and baby.
🏥 Destination Decision
Nearest Emergency Department with Obstetric Unit: • Cardiac arrest • Major airway problems • Ongoing eclamptic convulsions • Severe uncontrollable bleeding
Nearest Full Obstetric Unit (NOT a birthing centre): • Shoulder dystocia • Mild to moderate bleeding • Other obstetric emergencies • High risk pregnancy in labour
Birthing Centre / Standalone Midwifery Unit — NOT appropriate for emergencies: • No resident obstetrician, anaesthetist or neonatologist • No specialist neonatal facilities • Cannot perform advanced obstetric or neonatal interventions
Mother's preferred unit may be overridden in emergency — nearest appropriate centre takes priority
Consider accessibility — out-of-hours, locked doors, corridors and lifts. Pre-alert arrangements and telephone numbers should be readily available per local procedures.
📞 SBAR Communication Tool
SBAR promotes accurate and unambiguous handover of clinically relevant information between healthcare professionals.
S — SITUATION
Who are you? Who are you calling about? What is the immediate problem? "I'm calling about [patient], she is [X] weeks pregnant and has [presenting problem]"
B — BACKGROUND
Relevant history — gravida/parity, gestation, antenatal care, high risk factors, current medications, allergies, liquor status, contraction pattern