Prehospital Obstetric Emergencies
Obstetric calls are among the most anxiety-provoking for EMS providers. The NREMT tests your ability to manage normal deliveries, recognize complications, and provide neonatal resuscitation. Understanding the physiology and systematic approach to these calls builds confidence and competence.
Assessing the Pregnant Patient
Key assessment questions for a patient in labor:
- What is your due date? (Gestational age determines viability and potential complications)
- Is this your first pregnancy? (Multiparous patients typically deliver faster)
- How far apart are contractions? (Less than 2 minutes apart suggests imminent delivery)
- Do you feel the urge to push? (Indicates the baby is in the birth canal)
- Has your water broken? Note the color of the fluid (clear is normal, green/brown suggests meconium)
- Any complications with this or previous pregnancies?
Normal Field Delivery
If delivery is imminent (crowning, strong urge to push, contractions less than 2 minutes apart):
- Position the mother on her back with knees drawn up, or on her left side
- Apply gentle pressure to the baby's head as it delivers to prevent explosive delivery
- Check for the umbilical cord around the neck. If present, attempt to slip it over the head. If too tight, clamp in two places and cut between clamps
- Support the head as it rotates. The shoulders will deliver with the next contraction
- Support the body. The baby will be slippery
- Dry and stimulate the newborn immediately. Dry vigorously with a towel and suction the mouth then nose
- Clamp the cord in two places (about 6 inches from the baby) and cut between clamps
- Keep the baby warm and continue assessment
Complications
Breech Presentation
The buttocks or feet deliver first. Support the body as it delivers but do NOT pull. If the head does not deliver within 30 seconds of the body, create an airway by placing your gloved fingers alongside the baby's nose and mouth to push the vaginal wall away. Transport immediately.
Prolapsed Umbilical Cord
The cord delivers before the baby, getting compressed between the baby and the birth canal. This is a life-threatening emergency. Position the mother in knee-chest position. Insert a gloved hand into the vagina and push the presenting part off the cord. Do NOT attempt to push the cord back in. Keep the cord moist and warm. Rapid transport for emergency cesarean section.
Postpartum Hemorrhage
Bleeding more than 500 mL after delivery. Causes include uterine atony (most common), retained placenta, and lacerations. Massage the uterine fundus firmly through the abdomen to stimulate contraction. Encourage breastfeeding if possible (stimulates oxytocin release). Apply direct pressure to perineal lacerations. Treat for shock and transport rapidly.
Neonatal Resuscitation
Most newborns require only drying, warming, and stimulation. If the baby is not breathing or is gasping after 30 seconds of stimulation:
- Begin positive pressure ventilation with a BVM at 40-60 breaths per minute
- If heart rate remains below 60 after 30 seconds of effective ventilation, begin chest compressions: 3 compressions to 1 ventilation ratio, compressing one-third the depth of the chest
- Compress using the two-thumb encircling technique (preferred) or two-finger technique