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Obstetric Emergencies / Childbirth

Category: Special Populations Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf Last updated: 2026-04-03

Overview

Obstetric emergencies and prehospital delivery are relatively uncommon but high-acuity events. The EMT-B must be prepared to manage normal delivery, recognize obstetric complications requiring immediate intervention or ALS intercept, and resuscitate a neonate if needed. The guiding principle: "Treat the child by treating the mother" — maternal oxygenation and perfusion directly determine fetal wellbeing.

Key Points

Signs of imminent delivery: - Regular contractions lasting 45–60 seconds at 1–2 minute intervals - Crowning (presenting part visible at vaginal opening) - Patient feels urge to bear down or feels need to have a bowel movement

Critical complications requiring physician/ALS: - Multiple births - Excessive bleeding - Breech presentation - Meconium (greenish or brownish amniotic fluid) - Limb presentations - Transverse presentation - Prolapsed umbilical cord

Do NOT routinely suction the infant's airway — suctioning is now reserved for obvious airway obstruction or when PPV is required. When suctioning is needed: mouth first, then nose.

Cord clamping: Clamp cord 6–10 inches from baby, two clamps 2–3 inches apart, then cut between clamps.

Obstetric History

Key elements to obtain (history-taking): - EDC (estimated date of confinement) / due date - Length of pregnancy (gestational age) - Number of pregnancies and live births (gravida, para, abortions) - Last menstrual period (LMP) - Prenatal care summary - Number of expected babies (multiples?) - When contractions started, frequency, any bleeding, need to push - Previous/current illness: cardiac, diabetes - Prior pregnancies complications, prior C-section - Drug use

Normal Delivery Procedure

  1. Open OB kit; don sterile gloves; create sterile field
  2. Examine perineum: cord, crowning, presenting part, bleeding, amniotic fluid, meconium
  3. If birth is imminent and normal vertex presentation: a. Reassure mother; encourage panting between contractions (not pushing) b. Slight pressure on head to allow slow controlled delivery — do NOT delay; do NOT pull c. Once head delivers: instruct to stop pushing d. Do NOT routinely suction — suction only for obvious obstruction or if PPV needed e. Support body as delivery proceeds — baby will be extremely slippery; do NOT pull f. Dry and wrap in blanket; cover head; stimulate baby (flick feet, rub back) to breathe/cry g. If baby does not breathe spontaneously → Neonatal Resuscitation h. Clamp cord 6–10 inches from baby; 2–3 inch gap between clamps; cut between clamps i. If post-delivery bleeding: massage mother's abdomen/uterus (fundal massage) j. Do NOT pull on umbilical cord — bring birth products to ED k. Place sterile pad over vaginal opening; cover mother l. Record time of birth
  4. Do APGAR scoring at 1 and 5 minutes (see apgar-score for full scoring reference)
  5. Transport mother and baby; bring all blood-soaked pads and passed tissue
  6. Monitor neonate vital signs and APGAR every 5 minutes

APGAR Score — see apgar-score for full component definitions and resuscitation thresholds:

Sign 0 1 2
Skin Color (Appearance) Blue, Pale Body pink, extremities blue Completely pink
Heart Rate (Pulse) Absent <100 >100
Irritability (Grimace) No response Grimaces Cries
Muscle Tone (Activity) Limp Some flexion Active motion
Respiratory Effort Absent Slow, irregular Strong cry

Score 7–10 = normal; 4–6 = moderate depression; 0–3 = severe depression

Newborn normal vital signs: - Respirations: 30–60/min - Pulse: 100–160 bpm - BP (systolic): 50–70 mmHg

Obstetric Complications

Nuchal cord (cord around neck): - Gently pull/slip over head or shoulders - If will not slip over either: clamp twice, cut between clamps, proceed with delivery

Breech delivery: - Contact physician (OB) for instructions; initiate immediate transport to OB-capable hospital - Allow spontaneous delivery to level of umbilicus — support body; do NOT pull - Apply suprapubic pressure to promote head descent - Rotate infant to anterior-posterior shoulder position - Extract 4–6 inch loop of cord to prevent traction - If head does not deliver: position infant face-down; mother's legs toward shoulders; suprapubic pressure; gloved hand in vagina with V formation on maxilla — rapid transport

Prolapsed umbilical cord: - IMMEDIATE transport to OB-capable hospital — emergency C-section is definitive management - Left lateral decubitus + extreme Trendelenburg position - High-flow oxygen to mother - Insert gloved hand into vagina and gently push presenting part away from cord until cord pulsates - Do NOT attempt to replace cord into uterus - Moist sterile dressing over cord if able

Pre-eclampsia / Eclampsia: - Pre-eclampsia: pregnancy >20 weeks, BP >140/90, headaches, visual disturbances, RUQ pain, lower extremity edema - Eclampsia: pre-eclampsia + seizures = life-threatening - Keep in left lateral recumbent position; away from stimuli (bright lights, loud noise) - Secure airway; administer oxygen titrated to condition - Monitor for seizures; if seizing, follow Seizure Guideline - ALS: Magnesium sulfate 4g slow IV/IO; if unsuccessful → midazolam or diazepam - If severe pre-eclampsia (SBP >170 OR SBP >150 + DBP >100 + 2 of: severe HA, blurry vision, abdominal pain): contact MCEP for possible magnesium 2g IV/IO

Shoulder dystocia: - Infant shoulders impact symphysis pubis - Hyperflex mother's hips to knee-chest position - Apply firm suprapubic (not fundal) pressure to dislodge shoulder

Vaginal bleeding: - Pre-delivery: consider placental abruption (especially with trauma or cocaine use) - Post-delivery: most likely uterine atony (failure to contract) — massage fundus vigorously - ALS: IV isotonic fluid to maintain vital signs; Oxytocin (paramedic only)

Maternal cardiac arrest: - Apply manual left uterine displacement (displace uterus from right to left to reduce aortocaval compression) - Follow cardiac arrest guidelines (same medications and doses as non-pregnant patient) - Transport immediately if infant estimated >24 weeks gestation — C-section at hospital within 4–5 minutes of arrest - Contact Medical Control and receiving facility to prepare team

NM Protocol Notes

From NM EMS Treatment Guidelines (2022):

EMT-B scope for normal delivery: All steps above apply; key NM specifics: - If birth imminent with complications (multiple, breech, meconium, excessive bleeding): contact physician and consider rapid transport + ALS intercept - Limb/transverse presentation: immediate transport; ALS intercept; not likely to deliver vaginally

Post-delivery hemorrhage: - Massage fundus (suprapubic) - If placenta delivered and heavy bleeding continues (ALS/EMT-I scope): OXYTOCIN 10–20 USP units in 500 mL isotonic at 10–15 gtts/min - IV/IO isotonic at flow rate to maintain adequate vital signs (EMT-I/P scope)

NREMT Relevance

High-frequency exam topic: - Signs of imminent delivery: urge to push, contractions <2 min, crowning - Do NOT routinely suction; suction mouth before nose only when needed - Do NOT pull on the baby during delivery - Do NOT pull on umbilical cord after delivery - APGAR scoring: know all 5 components and scoring - Normal newborn HR: 100–160; RR: 30–60 - Fundal massage for post-partum hemorrhage - Prolapsed cord: left lateral + Trendelenburg + gloved hand elevating presenting part - Breech: support body; do NOT pull on infant

Sources

  • raw/protocols/nm-sop-guidelines-treatment-2022.pdf — Imminent Delivery (p. 18–19); Childbirth Complications (p. 20–22)