A Rare Package Delivery - The Emergency Medical Minute

A Rare Package Delivery

Chief Complaint:

Can we get a doctor?


37-year-old female presents to the ED. Triage nurse announces on the overhead paging system for a doctor to an acute room. In the background, a woman screaming is heard. Due to the acuity of the clinical picture, no further history is obtained.

Pertinent Exam Findings:

General Appearance: Upon arrival to the room, the patient is waddling into the room, and screaming in pain
Respiratory: Tachypnic, speaks full sentences
Cardiovascular: Tachycardic and regular
Gastrointestinal: Gravid, contractions noted
Genitourinary: Crowning of head, baby appears blue, amniotic sac is intact

ED Course:

2018: Patient brought into room from triage

2019: Labor and delivery paged

2021: Baby Delivered, amniotic sac ruptured by ED physician with blunt hemostat, umbilical cord cut

2022: L&D nurses at bedside. Apgar score of 8

2023: OB at the bedside. Patient is G2,P1, 40 weeks, getting prenatal care

2026: Patient transported upstairs to L&D with OB for placental delivery

Image is not the actual patient, but a stock photo from Jana Brasil, professional birth photographer. Image from Instagram/janabrasilfotografia

Diagnostic Studies:




En caul births are defined as a fetus that is delivered completely contained within the amniotic sac and they are rare, very rare. En caul births occur about 1 in 80,000 births. For some perspective, in the U.S. there are approximately 4 million births per year and thus the ratio would equate to 50 en caul births in the U.S. per year. En caul most commonly occurs during c-section, making this case even more unique. Most en caul births are actually associated with prematurity and low gravida as well.

Lastly, in 2015, the Centers for Disease Control and Prevention reported that approximately 3% of deliveries in the United States were precipitous in nature. By definition, births in the ED are precipitous. Again, using about 4 million births per year that would mean there are about 120,000 U.S. births that are precipitous. Even fewer than this occur in the ED, as not all precipitous births occur in the ED. Precipitous delivery is defined as rapid labor lasting less than three hours. Thus, 1/120,000 x 1/80,000 is 1 in 10 billion, which is the most conservative odds of an emergency physician seeing this.


Clinical Appearance

Management in ED:

Caul itself is generally harmless and easily removed. It should be noted that using scissors, scalpels or other sharp objects pose an unnecessary risk to the neonate.


Interestingly, some literature describes this as being protective. However, the benefits are primarily described in preterm births. Compared with premature vaginal non-en caul deliveries intact amniotic membranes provide a protective buffer from mechanical forces. Other benefits include the opportunity to complete a course of steroids, high cord pH, higher 5-minute Apgar scores for extremely preterm infants, protection from cord prolapse, and decreased risk of entrapment of the head in the setting of an insufficiently dilated cervix.

Lastly, a case report from 1975 describes en caul birth at 34 weeks, living in the caul for 25 minutes on its way to the hospital and then undergoing immediate resuscitation. Follow up three years later had documentation of no complications.

Main Points:

    • En caul births in general are rare, in the ED it is even more rare, term vaginal en caul births are the most rare, and switching into a shift that this occurs during is the rarest delivery, maybe ever in the history of deliveries.
    • En caul births may be protective.
    • Don’t use sharp instruments to break the amniotic sac.


  1. Abouzeid H, Thornton JG. Pre-term delivery by caesarean section ‘en caul’: a case series. Eur J Obstet Gynecol Reprod Biol 1999;84:51-3.
  2. Prabakar C, Nimaroff ML. Perfectly packaged: upon delivery,the infant was still enclosed in the amniotic sac. Am J Obstet Gynecol 2012; 207:80.e1.
  3. Rohail Malik et al, Extremely Preterm (23 Weeks) Vaginal Cephalic Delivery En Caul and Subsequent Postpartum Intraventricular Hemorrhage and Respiratory Distress: A Teaching Case. Case Reports in Obstetrics and Gynecology. 2018.


Aaron Wolfe, DO, FACEP


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