Babies on a Plane: Air Travel, Pregnancy, and In-Flight Emergencies

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Depending on your perspective, the idea of delivering a baby on a plane might be exciting… or your worst nightmare! Today we’ll talk about what to think about in this scenario, and familiarize you with what you have available for this in-flight emergency.

First of all… what recommendations are there for air travel (i.e., can we prevent this??)

  • There is an ACOG Committee Opinion on Air Travel During Pregnancy (reaffirmed 2019)

  • Highlights:

    • Air travel is safe for pregnant folks, and there’s no increased risk of adverse events following occasional air travel.

    • Most airlines will allow for air travel up until 36 weeks.

      • The Points Guy blog had a recent post comparing airline policies, if you’re interested! 

      • If travel is necessary after 36 weeks, most airlines will require a doctor’s note clearing the patient to fly.

    • Remind patients traveling to reduce VTE risk with compression stockings, frequent movement/ambulation (at least 1x/hr), and adequate hydration.

    • Risk of radiation for occasional air travelers is fairly minimal.

How common is the scenario of a birth on a plane?

  • It’s not very common – but also hard to find estimates.

So if I’m on a 1 in 26 million flight… 

  • First – we’ll plug a paid app called AirRx that’s written for physicians to know about what in-flight emergencies are common, and what you can expect to have access to in a flight.

    • Information is destination/origin specific, so also useful for international air travel.

    • We’ll focus on US-origin (mostly domestic) flights.

  • Every flight has first aid kits:

    • If under 50 passenger seats, minimum 1 kit.

    • If 51-150, minimum 2.

    • If 151-250, minimum 3 - this is a Boeing 737 size.

    • If 251+, minimum 4. 

      • First aid kits on planes have some basic equipment, including antiseptic swabs, bandages, adhesive tape, and bandage scissors.  

  • Separately, all commercial aircraft in the USA are required to carry a separate “emergency medical kit” that contains more advanced equipment:

    • Stethoscope and BP cuff

    • Airway supplies

    • PPE for you (gloves, gown, etc).

    • IV tubing set with at least 500cc bag of NS 

    • Tylenol, benadryl, aspirin

    • Epinephrine, nitroglycerin, and atropine

    • Automatic external defibrillator

    • And some basic instructions for use of drugs in the kit.

  • You will also have access to oxygen and masks.

Who can help?

  • It’s good to keep in mind you have a team, and you’re never alone if you’re helping the crew respond to an in-flight emergency.

    • Always share with flight crew yourself, your level of training, and show a medical ID if you have it.

    • If someone has already volunteered, don’t be shy about volunteering, too – you never know who might have good skills to assist (especially if you’re an OB on a plane where a baby might be coming!).

    • Also if you’re the only one who has responded – feel free to ask the crew to keep asking for additional assists if you need more folks to help.

  • On board, you’ll have a flight crew:

    • Ask them to bring the emergency medical kit and first aid kit.

    • Ask one flight attendant to be an assist throughout the event (usually one will be assigned).

    • The crew will notify a ground medical support team, who is well-trained in a wide variety of scenarios as well as specific physiology of flight.

  • Talking to your ground medical crew:

    • Be explicit about your impression of what’s going on.

    • Keep what you say simple.

    • Keep talking and keep everyone informed – your pilot and crew are often trying to help with weighing a decision about whether emergency landing is warranted.

      • This is more than the medical decision – part of this is airport choice, whether the plane is safe to land (i.e., is the extra fuel of landing early making the plane too heavy for a safe landing), and whether resources are available to assist the patient where landing is considered.

      • Especially if there is concern for communicable disease, flight crew needs to be aware for themselves and to alert ground medical crew for transport considerations.

    • Be professional – all conversations with medical ground crew are recorded!

Starting your assessment

  • Get basic vitals - vital signs are vital!

  • Get your history.

  • Do what you do best as an OB – assess labor or not in labor!

    • You are limited in the air - you have your physical exam, and that’s about it.

    • Your goal is to promote safety of the patient and passengers with your professional assessment. 

    • You’ll have assistance from ground medical staff on what to do in specific scenarios regarding flight diversion.

  • Pregnant folks also have a lot of other things that can be occurring – keep your differential diagnosis broad and reassure folks if labor is not occurring. You may be the best person to limit panic in assessing a pregnant person on board a plane, regardless of the complaint.

  • If delivery is occurring, get help!

    • You know you need assistants, even if not trained.

    • Be prescriptive and talk out loud – think about how you simulate a shoulder dystocia. Now imagine that on a plane with no nurses, no backup, no anesthesia – you have to be directive in making sure you get what you need to succeed.

What about weird / crazy / undesirable scenarios in the air?

  • Preterm labor:

    • Remember these babies need breathing and warmth primarily!

      • In your emergency medical kit, you have equipment for PPV and oxygen that can be administered to babies.

      • Skin-to-skin, layers, and blankets are readily available on planes for warmth.

      • For super premature kids, we often will put them in plastic bags to help with heat retention… and on planes, there’s often several of those! Ask for a gallon Ziploc bag from volunteering passengers.

  • Malpresentation (i.e., breech or cord prolapse).

    • Don’t encourage pushing in these scenarios! Be clear with ground crew an emergent cesarean is needed and landing the plane needs to be a top consideration. 

    • Get patient into all fours for a cord prolapse, with chest down and butt up – this will help presenting parts stay off the cord.

    • If the baby is coming – go through our breech delivery episode and simulate breech deliveries while you can in training! 

  • Postpartum hemorrhage

    • You’re limited in what you can do here – bimanual massage, examination, pressure, and bandages. 

    • You have a limited amount of IV crystalloid on a plane you can give. 

    • Remember that nipple stimulation can help with oxytocin production – starting breastfeeding or doing nipple stim can get the uterus contracting.

    • Consider delaying placental delivery until the plane is landed – remember you have 30 minutes in an active management scenario. If there’s no active bleeding and baby is delivered, without oxytocin, it may be prudent to wait to not provoke bleeding.

What about medicolegal implications?

  • There is no relevant international law for assisting in-flight medical emergencies.

  • In the US, the Aviational Medical Assistance Act (aka, “Good Samaritan Act”) of 1998 states:

    • An individual shall not be held liable for damages in any action brought in a Federal or State court arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency, unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct.

      • The standard for malpractice here is significantly higher than it is in usual malpractice cases.

      • There is no example of a medical professional anywhere in the world who has been sued successfully for assisting an ill traveler

        • Actually - successful lawsuits have only occurred against airlines; and airlines will normally accept liability associated with requests for in-flight assistance. 

  • There likewise is no standard protocol for documentation of in-flight events and assistance; but individual airlines may have forms or policies.

    • It is advisable for you to create a secure document of your exam, assessment, and plan, or get a photo of a completed airline documentation form, for your own records in case you are asked to comment on the case later for any reason.

What about compensation?

  • The Good Samaritan law only applies to true “good samaritan” actions, so where no compensation is provided. Because of this, it’s not advisable to take any monetary compensation for assisting in an in-flight emergency.

    • These laws do not address non-monetary compensation (i.e., frequent flyer miles, seat upgrade, bottle of wine, etc.). 

      • However, just because they are not addressed doesn’t mean they may not be targeted, so most folks advise not accepting these gifts.

    • Lawsuits have been brought against assisting physicians; just none of them have succeeded in US courts to date.

Final Fun Facts

  • If a baby is born in flight, most of the time the child is given citizenship status of the parents.

    • If in US airspace, the child can also be given US birthright citizenship.

    • Sometimes, citizenship is awarded based on the country of registration of the plane.

  • The most recent baby we could find born on a plane occurred in Oct. 2022: