Obstetric & Gynecological Emergencies

While most pregnancies result in normal deliveries, EMTs must be prepared for both routine and complicated deliveries in the field. Understanding normal labor and delivery, recognizing complications, and knowing how to care for both mother and newborn are critical EMT skills.

Stages of Labor

Signs of Imminent Delivery (Prepare for Field Delivery)

• Crowning visible (baby's head visible at vaginal opening)
• Strong, uncontrollable urge to push or bear down
• Contractions less than 2 minutes apart lasting 60-90 seconds
• Sensation of needing to have a bowel movement
• Rupture of membranes (water breaking)

Decision: Transport or Deliver?

• If crowning is present or delivery appears imminent, prepare for field delivery
• If no crowning and contractions are >5 minutes apart, transport
• When in doubt with a first pregnancy, there is usually time to transport

Normal Delivery Procedure (EMT Level)

1. Prepare the environment -- OB kit, clean towels, bulb syringe, clamps, warm blankets
2. Position mother on her back with knees drawn up and apart (or position of comfort)
3. As head delivers, check for nuchal cord (umbilical cord around neck) -- if present, attempt to slip it over the head; if too tight, clamp and cut
4. Support the head as it delivers -- do NOT pull
5. Suction the mouth first, then the nose (only if copious secretions or meconium)
6. Guide the shoulders -- gentle downward pressure for anterior shoulder, then upward for posterior
7. Note the time of birth
8. Dry, warm, and stimulate the newborn
9. Clamp the cord in two places (approximately 6 inches from baby) and cut between clamps
10. Deliver the placenta -- save it for hospital inspection
11. Assess for postpartum hemorrhage

APGAR Scoring

The APGAR score is assessed at 1 minute and 5 minutes after birth. Each component is scored 0-2.

Interpretation:

• 7-10: Normal -- routine care
• 4-6: Moderately depressed -- stimulation and possible assisted ventilation
• 0-3: Severely depressed -- aggressive resuscitation needed

Newborn Resuscitation

Initial Steps (First 30 Seconds)

1. Dry the baby thoroughly with warm towels (prevents heat loss)
2. Warm -- remove wet towels, wrap in dry blankets, keep covered
3. Stimulate -- flick the soles of the feet or rub the back
4. Suction only if the airway is obstructed by secretions
5. Assess breathing and heart rate

If the Newborn Needs Help

• Apneic or gasping after stimulation: Begin positive pressure ventilation (PPV) with BVM at 40-60 breaths/min
• Heart rate <100 bpm: Provide PPV with supplemental oxygen
• Heart rate <60 bpm after 30 seconds of PPV: Begin chest compressions (2-thumb encircling technique, lower third of sternum)
• Compression-to-ventilation ratio for newborns: 3:1 (90 compressions + 30 ventilations per minute)

Obstetric Complications

Breech Presentation

• Buttocks or feet present first instead of head
• Do NOT attempt to pull the baby out
• Support the baby's body as it delivers
• If the head does not deliver within 3 minutes, create an airway by placing a gloved hand in a V-shape around the baby's mouth and nose
• Rapid transport

Prolapsed Umbilical Cord

• Cord presents before the baby (visible or palpable in the vagina)
• Do NOT push the cord back in
• Insert a gloved hand and gently push the presenting part off the cord
• Position mother in knee-chest position or Trendelenburg
• Keep the cord moist with sterile saline
• Rapid transport -- this is a life-threatening emergency

Postpartum Hemorrhage

• Defined as blood loss >500 mL after delivery
• Most common cause: uterine atony (uterus fails to contract)
• Treatment: Uterine massage (firmly massage the uterus through the abdomen), have baby nurse (stimulates oxytocin), keep mother warm, IV fluids (ALS), rapid transport

Eclampsia

• Seizures occurring in a pregnant or recently postpartum woman with preeclampsia
• Preeclampsia signs: hypertension, edema, headache, visual disturbances
• Eclampsia is a life-threatening emergency -- manage seizure, protect airway, position on LEFT side, rapid transport

Ectopic Pregnancy

• Fertilized egg implants outside the uterus (usually in fallopian tube)
• Signs: lower abdominal pain (often unilateral), vaginal bleeding, signs of shock
• If ruptured: severe internal bleeding, peritoneal signs, hemodynamic instability
• Treatment: high-flow O2, treat for shock, rapid transport

Placenta Previa vs. Abruptio Placentae

Supine Hypotensive Syndrome

• In late pregnancy, the enlarged uterus can compress the inferior vena cava when the mother lies supine
• This reduces venous return to the heart, causing decreased cardiac output and hypotension
• Symptoms: dizziness, nausea, pallor, diaphoresis when supine
• Treatment: Position the mother on her LEFT side (left lateral recumbent)
• If spinal immobilization is needed, tilt the backboard 15-30 degrees to the left or manually displace the uterus to the left