Obstetric Emergencies / Childbirth¶
Category: Special Populations Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf; UCLA EMT Ultimate Study Guide (2026) Last updated: 2026-05-06
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¶
- Open OB kit; don sterile gloves; create sterile field
- Examine perineum: cord, crowning, presenting part, bleeding, amniotic fluid, meconium
- 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
- Do APGAR scoring at 1 and 5 minutes (see apgar-score for full scoring reference)
- Transport mother and baby; bring all blood-soaked pads and passed tissue
- 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
NREMT Differentiators¶
OB Emergencies Grid¶
| Condition | Key Feature | Bleeding | Presentation | Priority |
|---|---|---|---|---|
| Placenta Previa | Placenta covers cervical os | Painless bright red vaginal bleeding | Third trimester | High |
| Placental Abruption | Placenta separates from uterine wall | Painful, dark bleeding (may be concealed) | Third trimester; trauma or cocaine | High |
| Pre-eclampsia | HTN + proteinuria | No significant bleeding | BP >140/90, headache, visual changes, edema | High |
| Eclampsia | Pre-eclampsia + seizures | No significant bleeding | Seizing pregnant patient | Highest |
| Ectopic Pregnancy | Fertilized egg implants outside uterus | Internal bleeding → shock | <12 weeks, missed period, sharp unilateral pain | Highest |
| Miscarriage (Spontaneous Abortion) | Fetal loss <20 weeks | Variable, crampy | First/second trimester | Moderate–High |
KEY DIFFERENTIATOR — Previa vs. Abruption: Previa = painless bright red bleeding (placenta at the exit). Abruption = painful, dark, may have no visible bleeding (internal). Both are obstetric emergencies but abruption often involves trauma and is harder to recognize.
KEY DIFFERENTIATOR — Pre-eclampsia BP: In pregnancy, BP normally FALLS in the second trimester. Any BP >140/90 in a pregnant patient = pre-eclampsia until proven otherwise.
Delivery Complications Grid¶
| Complication | Key Finding | EMT-B Action |
|---|---|---|
| Nuchal cord | Cord around baby's neck | Gently slip over head; if can't → clamp and cut |
| Breech | Buttocks or feet first | Support but do NOT pull; ALS + rapid transport |
| Prolapsed cord | Cord before baby | Left lateral + Trendelenburg + gloved hand elevating presenting part |
| Limb presentation | Arm or leg visible | Do NOT deliver; rapid transport |
| Meconium | Green/brown fluid | Do NOT routinely suction; only if thick and neonate needs PPV |
| Post-delivery hemorrhage | Heavy bleeding after delivery | Fundal massage; transport immediately |
KEY DIFFERENTIATOR — Prolapsed Cord: Cord comes out before baby = obstetric emergency. The baby's head will compress the cord and cut off blood flow. Left lateral + steep Trendelenburg + your gloved hand pushing the presenting part off the cord until surgical delivery. Do NOT try to replace the cord.
Pregnancy Physiology Changes — NREMT High-Yield¶
| Parameter | Change in Pregnancy | Clinical Significance |
|---|---|---|
| Blood pressure | Decreases mid-pregnancy, rises to near-normal at term | "Normal" BP may actually be elevated for this patient |
| Heart rate | Increases ~10–20 bpm | Baseline tachycardia is normal |
| Blood volume | Increases 40–50% | More reserve before shock signs appear |
| Respiratory rate | Slight increase | Progesterone drives breathing |
| Supine hypotension | Aortocaval compression in supine position | Left lateral decubitus for all critically ill pregnant patients |
NREMT RULE — Left Lateral: All critically ill or injured pregnant patients (>20 weeks): left lateral decubitus or manual left uterine displacement. The gravid uterus compresses the inferior vena cava in supine position, reducing cardiac output by up to 30%.
Related¶
- apgar-score — full APGAR reference: component definitions, scoring table, timing, resuscitation context
- neonatal-resuscitation — resuscitation of the neonate who does not breathe
- primary-assessment — mother's airway, breathing, and circulation always first
- seizure — eclamptic seizure management
- bleeding-control-shock — hemorrhage and shock in obstetric bleeding
Sources¶
raw/protocols/nm-sop-guidelines-treatment-2022.pdf— Imminent Delivery (p. 18–19); Childbirth Complications (p. 20–22)