5.3 Obstetrics & Gynecology
Key Takeaways
- Pregnancy is divided into three trimesters; key prehospital terms include gravidity (number of pregnancies), parity (number of deliveries), and crowning (the fetal head visible at the vaginal opening), which signals imminent delivery.
- A prolapsed umbilical cord is a true emergency: relieve cord pressure by elevating the presenting part, position the mother knees-to-chest or in Trendelenburg, keep the cord moist, and transport immediately.
- Postpartum hemorrhage is the leading delivery complication; manage with uterine fundal massage, encourage the newborn to breastfeed, treat for shock, and provide rapid transport.
- Newborn care follows the inverted-pyramid sequence of warming, drying, positioning, suctioning if needed, and stimulation; the APGAR score is assessed at 1 and 5 minutes.
- Most newborns needing help respond to warming, drying, stimulation, and effective ventilation; chest compressions are started only if the heart rate stays below 60 beats per minute despite adequate ventilation.
Why This Section Matters
Obstetrics and gynecology fall inside the large Medical/Obstetrics/Gynecology domain. Childbirth is one of the few field events where the AEMT may manage two patients at once — mother and newborn — and where time-critical recognition (prolapsed cord, breech, hemorrhage) directly affects survival.
Obstetric Terminology and Normal Delivery
Pregnancy lasts about 40 weeks, divided into three trimesters. Useful field terms:
| Term | Meaning |
|---|---|
| Gravidity | Total number of pregnancies |
| Parity | Number of deliveries carried to viability |
| Crowning | Fetal head visible at the vaginal opening |
| Bloody show | Mucus plug discharge, often before labor |
| Amniotic sac | Fluid-filled membrane around the fetus |
Labor has three stages: (1) onset of contractions to full cervical dilation, (2) full dilation to delivery of the baby, and (3) delivery of the placenta. Crowning signals that delivery is imminent and the AEMT should prepare to deliver on scene rather than transport.
Steps of a Normal Delivery
- Support the head as it delivers; do not pull.
- If the umbilical cord is around the neck (nuchal cord), gently slip it over the head.
- Suction the mouth then the nose only if the airway is obstructed by secretions.
- Support the body as the shoulders and trunk deliver; the newborn is slippery.
- Keep the newborn at the level of the vaginal opening, dry and warm it, and assess breathing.
- Clamp and cut the cord per protocol after pulsations stop or as directed.
- Deliver the placenta; do not pull on the cord. Save the placenta for the hospital.
Delivery Complications
Prolapsed umbilical cord — the cord presents before the baby and is compressed, cutting off fetal oxygen. This is a true emergency: position the mother in knees-to-chest or Trendelenburg, use a gloved hand to gently push the presenting part off the cord, keep the exposed cord moist and warm, give the mother oxygen, and transport immediately.
Breech presentation — buttocks or feet present first. Allow the body to deliver spontaneously and support it. If the head does not deliver within a few minutes and the airway is trapped, form a "V" with two gloved fingers to create an airway around the infant's nose and mouth while transporting rapidly.
Postpartum hemorrhage — excessive bleeding after delivery, the leading delivery complication. Perform uterine fundal massage (firm circular massage of the firm grapefruit-sized uterus above the pubic bone), encourage the newborn to breastfeed (releases natural oxytocin), treat for shock, and transport rapidly. Do not pack the vagina.
Other emergencies to recognize: pre-eclampsia/eclampsia (hypertension, edema, headache, visual changes; seizures define eclampsia), placenta previa (painless bright-red bleeding), and abruptio placentae (painful bleeding with a rigid uterus).
Newborn Care and APGAR
Most newborns need only to be warmed, dried, positioned, and stimulated. Follow the inverted pyramid: warm and dry, position the airway, suction only if needed, and provide tactile stimulation by rubbing the back or flicking the soles.
The APGAR score is assessed at 1 minute and 5 minutes, scoring 0-2 in each of five categories for a maximum of 10:
| Sign | 0 | 1 | 2 |
|---|---|---|---|
| Appearance (color) | Blue/pale | Body pink, extremities blue | Fully pink |
| Pulse | Absent | Below 100 | Above 100 |
| Grimace (irritability) | None | Grimace | Cry, cough |
| Activity (tone) | Limp | Some flexion | Active motion |
| Respiration | Absent | Slow, irregular | Strong cry |
Neonatal resuscitation is driven by heart rate, not the APGAR number. If the heart rate is below 100 with poor breathing, begin positive-pressure ventilation. If the heart rate stays below 60 despite 30 seconds of effective ventilation, begin chest compressions at a 3:1 compression-to-ventilation ratio. Keep the newborn warm at all times; hypothermia worsens every other problem.
Gynecologic Emergencies
Non-pregnancy gynecologic complaints include vaginal bleeding, ectopic pregnancy (a fertilized egg implanted outside the uterus — suspect it in any woman of childbearing age with abdominal pain, with or without bleeding, because rupture causes life-threatening internal hemorrhage), pelvic inflammatory disease, and sexual assault. AEMT care: treat hypoperfusion, give oxygen as indicated and IV fluids per protocol, maintain privacy and dignity, do not examine the vagina internally, preserve evidence in assault cases, and transport.
Pediatric Overview
Children are not small adults. Use the Pediatric Assessment Triangle (PAT) for a rapid "from the doorway" impression: Appearance (tone, interactivity, consolability), Work of Breathing (retractions, nasal flaring, abnormal sounds), and Circulation to Skin (pallor, mottling, cyanosis). Children compensate well and then crash suddenly, so respiratory distress is the most common pathway to pediatric arrest — manage the airway aggressively. Use length-based weight estimation tools for equipment and any AEMT-scope dosing, and keep caregivers involved to reduce distress.
During delivery the AEMT sees a loop of umbilical cord protruding from the vagina before the baby. The most appropriate immediate action is:
Two minutes after delivery, a newborn has a heart rate of 50 despite 30 seconds of effective bag-valve-mask ventilation. The next step is to:
A woman of childbearing age has severe lower-abdominal pain and light-headedness. Her last menstrual period was about seven weeks ago. The AEMT should be most concerned about: