This section of our NREMT study guide provides a direct and comprehensive overview of obstetric and gynecologic emergencies, covering pregnancy, labor and delivery, delivery complications, and care of the newborn.
Pregnancy Fundamentals
Maternal Physiological Changes
- Blood Volume: Increases by up to 50%, which means a pregnant patient can lose a significant amount of blood before showing signs of shock.
- Heart Rate: Increases by 10 20 beats per minute.
- Respiratory System: Respiratory rate increases and tidal volume decreases, making them more susceptible to hypoxia.
- Blood Clotting: Blood clots more easily, increasing the risk of pulmonary embolism.
Supine Hypotensive Syndrome
In a patient in her second or third trimester, the weight of the uterus can compress the inferior vena cava when she lies supine. This reduces blood return to the heart, causing a drop in blood pressure. To prevent this, all late term pregnant patients should be transported tilted or lying on their left side.
Antepartum Emergencies (Complications Before Delivery)
Vaginal Bleeding
- Ectopic Pregnancy: A fertilized egg implants outside the uterus, usually in a fallopian tube. Presents with sudden, severe, unilateral lower abdominal pain and may have vaginal bleeding. This is a life threatening cause of internal hemorrhage.
- Spontaneous Abortion (Miscarriage): Loss of a pregnancy before 20 weeks.
- Abruptio Placentae: The premature separation of the placenta from the uterine wall. This is a life threatening condition that causes severe, constant abdominal pain and dark red vaginal bleeding.
- Placenta Previa: The placenta implants low in the uterus and partially or fully covers the cervical opening. The hallmark sign is painless, bright red vaginal bleeding.
Hypertensive Disorders
- Preeclampsia: A condition developing after 20 weeks of gestation characterized by hypertension, headaches, visual disturbances (seeing spots), and edema (swelling).
- Eclampsia: The onset of seizures in a patient with preeclampsia. This is a true life threatening emergency requiring immediate management of the airway and transport.
Gestational Diabetes
High blood sugar that develops during pregnancy, typically around the 24th week. Symptoms include increased thirst, frequent urination, and fatigue.
Labor and Delivery
Stages of Labor
- First Stage (Dilation): Begins with the onset of regular contractions and ends when the cervix is fully dilated (10 cm). This is the longest stage. The amniotic sac may rupture (“water breaks”) during this stage.
- Second Stage (Expulsion): Begins when the cervix is fully dilated and ends with the delivery of the baby. The mother will feel an intense urge to push or have a bowel movement. Crowning occurs when the baby’s head is visible at the vaginal opening.
- Third Stage (Placental): Begins after the baby is delivered and ends with the delivery of the placenta, which typically occurs within 30 minutes.
Assisting with a Normal Delivery
Delivery on scene is necessary if birth is imminent (crowning is visible).
- As the head emerges, apply gentle pressure to prevent an explosive delivery and support the perineum.
- Once the head is delivered, check for a nuchal cord.
- Suction the baby’s mouth and then the nose.
- Guide the head downward to deliver the anterior (upper) shoulder.
- Guide the head upward to deliver the posterior (lower) shoulder.
- Be prepared for the rest of the body to deliver quickly. Support the baby.
- Once the baby is delivered, clamp the umbilical cord 6 8 inches from the baby, place a second clamp 2 3 inches further away, and cut between the clamps.
- After the placenta delivers, you can perform a uterine massage to help control bleeding.
Delivery Complications
- Nuchal Cord: If the cord is wrapped around the baby’s neck, attempt to slip it gently over the baby’s head. If too tight, you must clamp the cord in two places and cut it immediately.
- Prolapsed Cord: The umbilical cord presents before the baby. This is an extreme emergency.
- Intervention: Place the mother in a knee chest position or supine with hips elevated. Insert a sterile, gloved hand into the vagina and physically lift the baby’s presenting part off of the cord. Maintain this position and transport immediately.
- Abnormal Presentations:
- Breech Presentation: The buttocks or feet present first. Support the baby’s body as it delivers, but if the head does not deliver within 3 minutes, you may need to form a “V” with your fingers inside the vagina to create space for the baby to breathe.
- Limb Presentation: A single arm or leg presents first. This cannot be delivered in the field. Place the mother in a head down, pelvis elevated position and transport immediately.
- Meconium Staining: The presence of fetal stool (a greenish or brownish yellow fluid) in the amniotic fluid, indicating fetal distress. If meconium is present, you must aggressively suction the baby’s mouth and nose as soon as the head is delivered and before the baby takes its first breath.
Postpartum and Newborn Care
Immediate Newborn Care
- Drying and Warming: Immediately dry the infant thoroughly with towels and wrap them in a warm, dry blanket. This is the most important step to prevent heat loss and stimulate breathing.
- Positioning and Suctioning: Position the infant on their back with the head slightly lower than the body. Suction the mouth and then the nose with a bulb syringe.
- Stimulation: If the baby is not breathing or crying, stimulate them by rubbing their back or flicking the soles of their feet.
APGAR Score
The APGAR score is assessed at 1 minute and 5 minutes after birth.
- Appearance: 2=Pink, 1=Body pink, extremities blue, 0=Blue/pale
- Pulse: 2=>100, 1=<100, 0=Absent
- Grimace: 2=Cries/pulls away, 1=Grimaces, 0=No response
- Activity: 2=Active movement, 1=Some flexion, 0=Limp
- Respiration: 2=Strong cry, 1=Slow/irregular, 0=Absent
At Risk Neonates and SIDS
- Neonates weighing less than 5.5 lbs or born before 36 weeks are considered premature and are at high risk for complications.
- SIDS (Sudden Infant Death Syndrome) risk factors include maternal smoking, maternal age less than 20, and low birth weight.
OB/GYN Knowledge Check
Test your understanding of the key obstetrics and gynecology concepts from this section.
1. A patient in her third trimester of pregnancy presents with painless, bright red vaginal bleeding. Which of the following conditions should you suspect?
2. You are assisting with a delivery and observe the umbilical cord presenting before the baby’s head. What is the most appropriate and critical immediate intervention for a prolapsed cord?
3. Immediately following the delivery of a newborn, what is the most important initial step to prevent heat loss and stimulate breathing?
4. To prevent Supine Hypotensive Syndrome, a late-term pregnant patient should be transported in which position?
5. While assessing the APGAR score of a newborn, you note a heart rate of 90 beats per minute. How many points should be awarded for the “Pulse” component?