Flight attendants team with medical advisers to aid passengers during in-flight labor and childbirth.
By Wayne Rosenkrans
AeroSafety World, May 2009
(Expanded version of article)
Airline crew responses to rare pre-term labor and childbirth during flight have been difficult for the industry to assess quantitatively compared with much more frequent types of in-flight medical events (IFMEs).1,2 Either situation may occur because a pregnant passenger fails to comply with an airline’s policy for travel or, more likely, because an unknown health factor or natural process disrupts her careful plans for the ideal full-term childbirth. In an aircraft cabin, both are serious, exposing the baby to high risk of injury, death or possibly health problems later in life even with timely emergency medical transport after landing to a neonatal intensive care unit.
Medical and cabin safety specialists — relatively comfortable with airline guidelines and readiness to deal with leading IFMEs such as heart attacks — today have sketchier information when it comes to pre-term labor and childbirth aboard a large commercial jet. As a result, researchers in several countries have called on governments and the airline industry to collect better data about these events to help them pursue more robust, evidence-based recommendations.3
For flight attendants, the practical effect is that what they study in first aid or medical training materials reflects the professional judgments of specialists based on a fairly limited number of events. Accounts of how aircraft crews have responded successfully to a pregnant patient’s crisis without compromising overall cabin safety or flight safety therefore have taken on added importance. Potentially valuable insights or lessons for understanding unexpected operational risk factors also can be found in brief narratives that flight attendants and pilots have submitted to publicly available confidential reporting systems.
MedAire’s MedLink Global Response Center, located within the emergency department at Banner Good Samaritan Hospital in Phoenix, had a total of 27 cases of in-flight labor in calendar years 2006, 2007 and 2008. Two cases involved in-flight births — one to a 20-year-old airline passenger and one to a 25-year-old airline passenger — and the circumstances of the 20-year-old passenger’s labor led to a medical diversion. The age of passengers in labor ranged from 16 to 43, and the average was 27, MedAire said. One baby was stillborn during pre-term labor that had begun during flight and continued at a hospital after landing; no other maternal or infant deaths occurred. These cases were among approximately 55,000 IFMEs in which MedLink provided ground-based medical advice.
The 20-year-old passenger was eight months pregnant, and she unexpectedly went into labor five hours into a 10-hour flight. “Two doctors and two nurses traveling aboard the flight voluntarily stepped forward to assist, with surprisingly little time to spare before delivery,” MedAire said. “A healthy baby girl made her entrance into the world at Flight Level 330 (approximately 33,000 ft) over Kazakhstan.”
Immediately after this delivery, a crewmember contacted the response center, and an emergency medicine physician — following MedLink protocols — collaborated with the medical volunteers, cabin crew and flight crew and provided them detailed guidance on post-delivery care; monitoring of the mother’s and baby’s medical conditions; and guidance on use of appropriate medications from the enhanced emergency medical kit. Other specialists concurrently suggested suitable medical diversion airports along the route, consulting their database and making arrangements for emergency medical transport upon landing at the airport selected by the captain. The data also showed that licensed medical professionals — such as physicians, nurses, midwives and emergency medical technicians — aboard these 27 flights had volunteered to assist in 18 cases (67 percent); the captain diverted the flight in eight cases (30 percent); and average time into the flight varied by flight length, with 37 percent of planned flight time elapsed when the short-haul aircraft crews learned of the labor, 59 percent elapsed on long-haul flights and 62 percent elapsed on medium-haul flights.
“None of our 27 total cases could be said to be a full-term labor,” said Paulo Alves, M.D., vice president, aviation and maritime health. “The numbers may be low, but the potential for complications is really high. No passenger with a full-term pregnancy had been allowed on board. We don’t have precise information about the gestational maturity aspect to make any further inference, but the fact that no babies had major initial complications suggests a good level of average maturity.”
Occasionally, in-flight labor escapes notice by the pregnant passenger and the cabin crew by masquerading as a cramp or back pain, or because the passenger is unaware of the pregnancy or psychologically is in denial. Other times the situation is complicated because the pregnant woman has not declared her late stage of pregnancy to the airline, and her health condition has not been discovered by airline ground personnel during passenger screening at the ticket counter or boarding gate.
“In some of our scenarios, it’s possible that the mom was intending to travel without revealing her condition; otherwise, she would not have been traveling,” Alves said. “She may intend to deliver somewhere closer to family, for example. To travel at the last minute, she could try to disguise the condition, but then when she asks the cabin crew for help after the beginning of the labor, often her labor already is advanced.”
Not Like TV
Numbers alone can’t capture what the flight attendants, medical volunteers, pregnant passengers and newborn babies experienced in these cases, said Heidi Giles MacFarlane, vice president of strategic development at MedAire. “We think of childbirth in an aircraft today as a low-resource situation involving health risks comparable to the increased mortality that a mother and child may experience in the underdeveloped world,” she said. “The issues also have much to do with passenger responsibility — the woman taking all necessary precautions, everything possible, to ensure that she is not going to deliver her baby on that airplane.”
About the only time that visibly pregnant women induce a little anxiety in a cabin crew during boarding, however, is on an ultra-long-range flight of more than 16 hours, Giles MacFarlane said. The cabin crew realizes that unless the aircraft is just leaving or arriving, an in-flight birth almost always would result in a medical diversion because the cabin crew and medical volunteers cannot be sure of the health status of the newborn, Alves added.
Ideally, establishing a positive relationship early in the flight will encourage each pregnant passenger to reach out immediately for help from a flight attendant at any sign of labor. “When boarding someone who is visibly expecting a baby, a flight attendant often can have a quick conversation, saying ‘Congratulations, when are you due? How exciting!’ The mother typically will reply, ‘I am due on such and such date.’ The flight attendant then can add, ‘If there is anything that I can do for you, please don’t hesitate to let me know.’ After building simple rapport, if that person gets into a critical situation, she likely will speak up.”
After departure, flight attendants periodically should check on the well-being of these passengers as time permits. Things get interesting quickly in pre-term labor scenarios, requiring cabin crews to recall what they know from training and to disregard what they know from popular culture. “In that situation, initial expectations are largely based on what flight attendants have seen on television shows,” Giles MacFarlane said. “Very often they have seen extreme, dramatic cases … lots of complications and problems. As soon as a passenger says ‘I think I’m in labor,’ they may think the passenger will have the baby in five minutes. In reality, the key to the whole response is to focus on a proper overall assessment of what is actually happening.”
More realistically, after labor begins, medical volunteers or flight attendants attending the mother generally will have at least 30 minutes to prepare before the birth. “Especially for a first-time birth, it will require some time from the initial contractions,” Alves said. “The time is not counted in seconds, it is in minutes and sometimes even in hours.”
This allows time to notify the flight crew, initiate a call to ground-based medical advisers and make a public address announcement for medical volunteers. In most cases, managing the pre-term labor scenario concludes with landing before delivery and handing off the passenger to emergency medical responders. “As a flight attendant, once the flight diverts, and the passenger in labor has been taken off the airplane, it’s not my problem any longer,” Giles MacFarlane said. “That’s normally a pretty short scenario, but I still would prepare for the situation where the diversion was expected but turned out not to be immediately possible.” Even if diversion is warranted from the standpoint of health risk, the captain may decide that, in the big picture, this action would not be safe for the flight.
If medical volunteers, a remote adviser or the pregnant passenger say in-flight childbirth is imminent, customary cabin crew teamwork in marshalling resources and dividing tasks has proven to be a key factor in successful outcomes whether a medical volunteer or flight attendant attends the delivery. “When they agree immediately on who is going to do what — similar to the model used to train for in-flight fire fighting — coordination can happen in seconds,” she said.
One of the first cabin safety issues then enters the picture: Where a passenger in labor can be accommodated best in the cabin. Flight attendants may have to weigh the safety risks of temporarily foregoing the maximum protection of passenger seats and a seat belt to position the woman on the floor of a galley, an action best avoided if another solution is workable.
“Cabin crews definitely have run into responding health care professionals who have zero experience in this childbirth situation,” Giles MacFarlane said. Even highly qualified medical volunteers such as obstetrician-gynecologists find themselves out of their professional element, she said, so they appreciate a communication link that allows the remote medical adviser on duty “to keep them focused and walk them through a process to help medically.” Problems that the cabin crew should avoid, however, include presuming that the medical volunteer will know how to attend a childbirth inside an aircraft using all the resources available, and relinquishing control of the situation to the volunteer.
“Sometimes medical volunteers did not make the best decisions just because they were not in their usual ‘perfect’ environment to make them — or they made decisions that they were not trained to make,” Alves said. “The best combination is the remote doctor working with someone who has hands and eyes directly on the pregnant passenger.”
Medical oxygen may be helpful to some passengers during pre-term labor but is not essential. “To my knowledge, there is no specific role for oxygen for the mother during labor unless she is in distress or exhausted,” Alves said. “Later on, for the baby, there’s no doubt oxygen could be required because then he or she will be needing some respiratory support.”
MedAire’s IFMEs and reports filed with the U.S. National Aeronautics and Space Administration Aviation Safety Reporting System also serve as a reminder that pre-term labor and childbirth aboard an aircraft generate an unexpectedly high level of distraction and emotional involvement for pilots and flight attendants. “All aircraft crewmembers are trained on how to deal with distraction, but even those who have been trained in the best manner don’t necessarily succeed at not becoming distracted — particularly when something as unusual as this occurs,” Giles MacFarlane said.
Another often-reported safety issue is flight deck door security protocols that eliminate face-to-face updates between pilots and flight attendants concerning a passenger in labor or a childbirth, and complete reliance on spoken interaction via interphone. In real situations, message relay via the flight crew also has been extremely cumbersome with the possibility of delaying, if not miscommunicating, critical information, she said.
Another problem has occurred after flight attendants agreed to cover for another crewmember’s safety duties but subsequent distractions caused them to omit critical safety duties for some phase of flight, Giles MacFarlane said. Preparing the cabin for landing involves a relatively high workload level, for example.
“If even one cabin crewmember has been dedicated to caring for a passenger in labor, all other crewmembers have to communicate to ensure that that person’s duties are covered,” she said. “It is then very possible that a duty could be overlooked. If a childbirth is occurring during the landing phase, sterile cockpit procedures [limiting flight deck–cabin communication to messages immediately critical to safety of flight] also will mean that the cabin crew will hesitate to communicate with the flight crew.”
A recurrent issue in MedAire’s cases has been agreeing to complete another person’s major duties but missing some key details. “It is easy to check the cabin to be sure that luggage is properly stowed and that every passenger is secured,” Giles MacFarlane said. “It’s the smaller things — for example, verifying in a particular section that all of the galley carts were secured or that all the bins were double-latched — that others might overlook because those simply were not part of their group of duties. On landing, a cart that has not been double-latched very easily could be set loose, a cart compartment could come open, and containers could come flying into the cabin.”
In 2006, the Australian Transport Safety Bureau (ATSB) published an analysis of 95 recorded IFMEs that had caused medical diversions among the country’s registered civil aircraft from January 1975 through March 2006. Among all the onboard medical conditions resulting in diversion, “there was only one obstetric emergency, in which a … passenger went into imminent labor onboard the flight seven hours from the destination,” the report said.4 This compared with 33 heart attacks, six cases of epileptic seizures, four cases of respiratory illness, three cases of food poisoning, two cases of loss of consciousness and two cases of stroke. The ATSB report’s literature review also cited a French study, which reviewed how medical assistance had been provided to airline flights during an 11-year period, reporting two in-flight births.5
Policies of airlines for the carriage of pregnant passengers often vary from IATA travel recommendations, but data have been too limited to offer clues as to why small numbers of these events slip through the industry’s preventive measures every year. The second edition of the IATA Medical Manual, effective in January 2009, recommends that a woman diagnosed with a single uncomplicated pregnancy should not be accepted to fly beyond the end of the 36th week. A woman diagnosed with a multiple uncomplicated pregnancy should not be accepted to fly beyond the end of the 32nd week. In both cases, IATA says that clearance by an airline’s passenger medical clearance unit should not be required to fly, but a physician certificate should be required from the passenger after 28 weeks of pregnancy.
In a complicated pregnancy — that is, involving factors such as threatened miscarriage,6 anemia or high blood pressure induced by the pregnancy — a physician or other medical practitioner should make a case-by-case determination of fitness to fly. IATA’s recommendations also say that women should not be accepted to fly if they have active bleeding related to a threatened or completed miscarriage, but that the airline’s passenger medical clearance unit should clear them for flight after being medically stable without any bleeding or pain for 24 hours.
Newborn babies normally should not be accepted for air travel if they are less than 48 hours old; “fit and healthy” babies can travel at 48 hours of age but preferably seven days should elapse, IATA said.
Medical Kit Training
Transport Canada’s guidance to air carriers offers one example of simplifying cabin crew training objectives as preparing for an emergency delivery, the emergency delivery process, miscarriage and first aid for miscarriage. Canadian flight attendants are asked to define the term labor in this context; list the signs that indicate the beginning of labor; state the signs of imminent delivery; list the materials that will assist a crewmember in an emergency delivery; tell how to prepare the expectant mother for an emergency delivery; describe the role of the crewmember in an emergency delivery, including normal delivery and delivery with complications involving the umbilical cord, placenta and hemorrhaging; tell how to care for the newborn baby; tell how to care for the placenta and the umbilical cord following delivery; and describe how to care for the mother following delivery until ground-based medical aid is obtained.7
Training also prepares them to define the term miscarriage, list the signs and symptoms of miscarriage, and tell how to provide first aid for a passenger who has had a miscarriage. A sample crew training syllabus in the IATA Medical Manual similarly advises that the cabin crew training syllabus should cover pregnancy and childbirth, normal delivery, care of the newborn and complications of childbirth.
At least one enhanced emergency medical kit specified in U.S. Federal Aviation Regulations has been required since April 2004 aboard passenger-carrying airplanes operated under Part 121, which governs air carriers and commercial operators, with at least one flight attendant. In 2007, an international committee of the Aerospace Medical Association (ASMA) recommended the enhancements include more resources for attending pre-term labor, delivery and care immediately after childbirth. If all the recommendations have been adopted voluntarily by an airline, examples of relevant contents may include medication for postpartum (after-birth) bleeding, such as oxytocin in injectable form; umbilical cord clamp; major oral and injectable pain relief drugs; gloves; stethoscope; blood pressure measurement device, preferably the electronic type; non-mercury thermometer; syringes; antiseptic wipes; flashlight and batteries; and basic and advanced life support cards.8 Depending on the airline, a small suction device for removing mucus from a newborn infant’s nose and mouth also may be carried.
The ASMA committee also international committee behind consensus recommendations recently reiterated its position that the kits should contain a medication for postpartum bleeding, saying, “Although oxytocin has continued to be used extremely infrequently, the committee decided to retain it [as of 2007] for the same reason as was stated in the 2002 recommendations; [that is,] a relatively simple treatment that will save a life in a specific situation that can be reasonably predicted — it is almost impossible to eliminate the possibility of an onboard delivery in spite of the best passenger-clearance efforts [by airline medical departments].” Similarly, major oral analgesics were added to injectable forms so that flight attendants can administer pain relief drugs if recommended by ground medical support.9
Crew Report Examples
The pregnant captain of a Boeing 737-500 flying from San Francisco to Seattle reported her personal experience with premature labor, care from three physician passengers who volunteered, and how the safety aspects of the flight were managed, including declaring a medical emergency to air traffic control (ATC), which gave the flight priority and a vector direct to the planned destination. The captain said that she had followed airline policy that prohibited a pregnant pilot from operating as a flight crewmember later than the end of the seventh month of pregnancy, and that she had no signs or warning of imminent labor.10
Before leaving her station, she briefed the first officer, advised ATC of the medical situation, arranged for a captain flying as a passenger to take command, and notified dispatch of the change of command. “We were at the top of descent when my water broke [that is, amniotic fluid was released], which can bring on the first stages of labor,” the captain said. “There was another qualified captain, employed by our airline, on board. The deadheading captain was still in uniform with her flight kit and still legal to fly the remaining portion of this flight. I asked her to take over the aircraft and then laid down in the aft galley per [advice to stop the loss of fluid from] the doctors on board.” The flight crew conducted an uneventful landing, and the captain and baby were reported healthy after the pre-term baby was born 10 days after this flight.
Several flight attendants jointly reported that a childbirth began on a 777 flight from Narita International Airport, Japan, to Dallas-Fort Worth International Airport and resulted in a medical diversion to Salt Lake City International Airport. “A young female passenger entered the coach galley,” one flight attendant said. “She spoke Japanese and Portuguese only. From her body language, I realized she had abdominal pains. … The passenger was five months pregnant and having contractions. We laid her across the last row of center seats. [She] was on oxygen from the time we laid her across the seats. … An emergency room nurse answered the page [and monitored the situation]. … The captain came to the main cabin to discuss the situation with the nurse. The passenger was bleeding, in severe pain. Her water had broken and the baby’s crown [top of head] was showing. It was determined that we should land as soon as possible. Approximately 20 minutes later, we landed at Salt Lake City. Oxygen was started by emergency medical technicians, who placed the passenger on their gurney.”11
A 747-400 flight crew operating over Canada en route to Chicago O’Hare International Airport failed to complete a standard operating procedure after being advised that a passenger was going into labor. “[While I was] on break, the [relief] first officer called me to say we had a [passenger] going into labor,” the captain recalled. “They had already called dispatch. The purser used the in-flight telephone to talk with [the airline medical department]. The doctor’s opinion was that [the passenger] still had six to eight hours [of labor remaining] before giving birth. I made a call to dispatch, and the decision was to continue to O’Hare with lifeguard designation [indicating to ATC that the urgent medical nature of the flight requires expeditious handling]. [I then took] time to review the master flight plan and didn’t see any re-dispatch information. The relief first officers confirmed that they hadn’t received it. … It appears that the first officers were involved with the medical incident for some time before calling me, and with dispatch working another emergency, the re-dispatch [information] got overlooked. Paramedics met the flight.”12
Another report on the same occurrence said that the purser had told the 747 flight crew during cruise that a passenger was in labor with contractions one to two minutes apart. A relief pilot later reported, “We gave dispatch a heads-up and woke the captain one hour early. The purser indicated it was serious, and no medical personnel were answering her public address announcement for assistance. As the captain was getting dressed, we told dispatch to have a doctor standing by and we would call [the doctor] back from an [in-flight telephone] near the woman in labor. … After determining from the doctor that we could probably continue to O’Hare, I went back to the cockpit to apprise the captain of the status of the situation. [The operating flight crew] told me they were unable to join the conference call, and that the dispatchers were dealing with another medical emergency. Both the dispatchers and we had become focused on determining whether to stop short of O’Hare for medical attention, and did not complete the re-dispatch until after we determined we were continuing to O’Hare slightly after the re-dispatch fix.”13
Another flight crew operating an unspecified aircraft type under Part 121 found communication more difficult than expected after a passenger went into labor during cruise. They declared an emergency and conducted a medical diversion to a closer airport after obtaining medical assistance from on-board and ground-based physicians, and receiving information from cabin crew that the passenger had progressed to late stages of labor.14
“While en route to [the planned destination], I was alerted by the A flight attendant to a possible medical emergency involving a passenger,” the captain recalled. “The passenger was apparently going into labor. Two physicians were on board, and they aided the flight attendants. Dispatch was contacted and a [communication] patch was made to the company medical [department]. After information was relayed to medical, we were advised to continue to [the planned destination]. Shortly after — in about 10 to 15 minutes — we received another call from the flight attendant stating that the passenger was going into full labor. The on-board doctors highly recommended an immediate diversion or the baby would be born prior to reaching the destination. Company medical was contacted a second time and advised of the situation [including] that we were diverting to [a closer airport]. They concurred. We declared a medical emergency to the ATC center and received a clearance to … the nearest airport with medical facilities. Medical personnel were standing by to meet the aircraft upon arrival. Upon parking at the gate at the diversion airport, the medical personnel boarded and removed the passenger, who was in the process of delivery.
“Communication was difficult, delayed and usually required relaying information through numerous people — flight attendant to pilot to medical [department] — because of very poor communication quality,” the report said. “Numerous frequency changes occurred and re-establishment of communication is delayed and difficult, resulting in delayed time to make decisions. It also requires at least one pilot to divert all his attention to establishing and maintaining these communication lines open, leaving the other pilot to fly, navigate, coordinate with the controlling agency — a one-man cockpit. Satellite telephones would solve this problem.”
A 757 flight crew declared a medical emergency to ATC for priority while on an oceanic route because a pregnant passenger appeared to be experiencing a miscarriage in the cabin. Direct routing was coordinated from Havana and Miami air route traffic control centers. The long-haul flight crew’s third pilot, who had been on a rest break in the cabin, later said, “We had an emergency medical technician on board who advised us [that the woman] was OK to go to Miami International Airport as the other options were Kingston, Jamaica, or Havana. She was laying across the three seats with minimal bleeding. The passenger was 10 weeks pregnant and 44 years old. … We advised dispatch and had the physician on call available if matters changed. The paramedics met the flight and took the passenger to the hospital.”15
- Estimated date of delivery (EDD) is calculated from the current date, first day of the last menstrual period, ultrasound date and gestational age by ultrasound. Pre-term refers to delivery before completion of 37 weeks of gestation.
- If a passenger has complied with airline rules derived from IATA recommendations for travel while pregnant, her in-flight labor by definition will be pre-term — that is, at least four weeks before the EDD for a single uncomplicated pregnancy and eight weeks before the EDD for an uncomplicated multiple pregnancy. Delivery at term means during a normal range of 37 to 42 complete weeks.
- Sand, Michael; Bechara, Falk-Georges; Sand, Daniel; Mann, Benno. “Surgical and Medical Emergencies On Board European Aircraft: A Retrospective Study of 10,189 Cases.” Critical Care Volume 13 (2009), 13.
- Newman, David G. “An Analysis of In-flight Passenger Injuries and Medical Conditions, 1 January 1975 to 31 March 2006.” Australian Transport Safety Bureau Air Transport Safety Report. Aviation Research and Analysis Report no. B2006/0171. October 2006.
- The ATSB report cited Szmajer, M.; Rodriguez, P.; Sauval; Charetteur, M.P.; Derossi, A.; Carli, P. “Medical Assistance During Commercial Airline Flights: Analysis of 11 Years Experience of the Paris Emergency Medical Service (SAMU) Between 1989 and 1999.” Resuscitation, Volume 50, 2001, 147.
- Miscarriage means the natural death of an embryo or fetus up to 22 weeks of gestation, and the highest risk for this occurs during the first three months of pregnancy. Stillbirth refers to natural death of a fetus between 22 weeks and full-term pregnancy.
- Transport Canada. “8.15, Childbirth and Miscarriage.” Flight Attendant Training Standard. Sept. 8, 2008.
- Thibeault, Claude; Evans, Anthony; Air Transport Medicine Committee, Aerospace Medical Association. “Emergency Medical Kit for Commercial Airlines: An Update.” Aviation, Space, and Environmental Medicine. Volume 78, December 2007. The article presents the committee’s currently recommended contents, and some items relevant to in-flight labor and childbirth are among those that exceed requirements of national aviation regulations.
- U.S. National Aeronautics and Space Administration. Aviation Safety Reporting System (ASRS) report no. 469022, March 2000.
- ASRS report no. 476876, June 2000.
- ASRS report no. 521120, August 2001.
- ASRS report no. 520984, August 2001.
- ASRS report no. 778430, March 2008.
- ASRS report no. 593689, September 2003.