NREMT Obstetrics & Gynecology Emergencies 2 — Questions and Answers

Question 1: A pregnant patient at 36 weeks gestation presents with painless vaginal bleeding. The EMT's priority should be:

Perform a vaginal examination to assess the source of bleeding
Transport rapidly, avoid vaginal examination, and monitor mother and fetus (Correct answer)
Apply direct pressure to the vagina to control bleeding
Reassure the patient that spotting is normal in late pregnancy

Correct answer: Transport rapidly, avoid vaginal examination, and monitor mother and fetus

Painless vaginal bleeding in late pregnancy is a sign of placenta previa (abnormally located placenta). Vaginal examination is contraindicated as it can cause catastrophic hemorrhage. Rapid transport is required.

Painless vaginal bleeding in the third trimester is a classic presentation of placenta previa, a condition where the placenta is abnormally positioned over or near the cervical os. When the cervix begins to dilate or is disturbed by examination, the placenta can separate from the uterine wall, causing massive hemorrhage that is immediately life-threatening to both mother and fetus. The cardinal rule for EMTs encountering painless third-trimester vaginal bleeding is: DO NOT perform a vaginal examination. Even a single finger inserted into the cervix can trigger catastrophic hemorrhage from placenta previa. The EMT should position the patient in the left lateral recumbent position (to relieve pressure on the inferior vena cava and improve maternal cardiac output), apply high-flow oxygen, establish IV access if within scope and time permits, and transport immediately to a facility capable of emergency obstetric care. It is important to distinguish placenta previa from placental abruption, which also presents in the third trimester but typically with painful vaginal bleeding and uterine rigidity. Both are emergencies requiring rapid transport, but the no-vaginal-exam rule is particularly important for placenta previa. Monitor maternal vital signs closely for signs of hemorrhagic shock.

Question 2: During delivery, the baby's head is crowning but after delivery of the head, the shoulders cannot be delivered. This is known as:

Cephalic presentation
Breech presentation
Shoulder dystocia (Correct answer)
Prolapsed cord

Correct answer: Shoulder dystocia

Shoulder dystocia occurs when the baby's anterior shoulder becomes impacted behind the maternal pubic symphysis after delivery of the head, preventing further delivery. It is an obstetric emergency.

Shoulder dystocia is a life-threatening obstetric emergency occurring when the baby's anterior shoulder becomes impacted behind the maternal pubic symphysis after the head has been delivered. This prevents further delivery and can cause umbilical cord compression, fetal hypoxia, and neurological injury within minutes. It occurs in approximately 0.5-2% of vaginal deliveries. Prehospital management of shoulder dystocia is challenging. The McRoberts maneuver is the first-line intervention: the mother's legs are hyperflexed onto her abdomen, which rotates the pubic symphysis superiorly and increases the functional diameter of the pelvis. Suprapubic pressure (not fundal pressure) can be applied simultaneously to dislodge the impacted shoulder. Fundal pressure must be avoided as it worsens the impaction. If these maneuvers fail, the EMT should prepare for transport while continuing maneuvers, pre-notify the receiving facility, and request ALS intercept if available. Do not apply traction to the baby's head, as this can cause brachial plexus injury (Erb's palsy). Time is critical — each minute of shoulder dystocia increases the risk of fetal acidosis and permanent neurological injury. Document the time the head was delivered and the interventions attempted.

Question 3: A pregnant patient at 32 weeks is experiencing seizures and has a blood pressure of 170/110 mmHg. She has no prior history of seizures. This presentation is most consistent with:

Gestational diabetes
Eclampsia (Correct answer)
Placental abruption
Hyperemesis gravidarum

Correct answer: Eclampsia

Eclampsia is defined as new-onset seizures in a woman with preeclampsia (hypertension and proteinuria in pregnancy). It is a life-threatening complication of pregnancy requiring immediate intervention.

Eclampsia is the occurrence of grand mal seizures in a woman with preeclampsia (defined as new-onset hypertension with proteinuria or end-organ dysfunction after 20 weeks of gestation). It represents severe end-organ dysfunction and is associated with significant maternal and fetal mortality and morbidity. Risk factors include nulliparity, multiple gestation, chronic hypertension, diabetes, and extremes of age. The prehospital management of eclampsia focuses on preventing injury during seizures, managing the airway, and providing emergent transport. The definitive treatment — delivery of the fetus and placenta — can only occur in the hospital setting. Magnesium sulfate is the drug of choice for treating eclamptic seizures and preventing recurrence, but administration typically requires ALS or hospital care. For EMTs, key interventions include: protecting the patient from injury, positioning left lateral recumbent, high-flow oxygen, IV access if within scope, dimming lights and reducing auditory stimulation (as sensory stimuli can trigger additional seizures), and immediate transport with pre-notification. Monitor fetal heart tones if equipment is available. Blood pressure should not be rapidly reduced in the field without medical direction guidance.

Question 4: Upon delivery, the umbilical cord is wrapped around the baby's neck (nuchal cord). The EMT should:

Immediately cut the cord before delivering the body
Attempt to loop the cord over the baby's head; if tight, clamp and cut before body delivery (Correct answer)
Pull the baby's body quickly to snap the cord free
Stop the delivery and transport immediately

Correct answer: Attempt to loop the cord over the baby's head; if tight, clamp and cut before body delivery

A nuchal cord should be looped over the baby's head if loose enough. If the cord is too tight to loop, it should be double-clamped and cut before delivering the body to prevent cord avulsion.

A nuchal cord — umbilical cord wrapped around the baby's neck — occurs in approximately 20-30% of deliveries. In most cases, a nuchal cord is loose enough to slip over the baby's head or body without interrupting the delivery. The EMT's first action upon delivering the head should be to check for a nuchal cord by running a finger around the back of the neck. If the cord is loose, it can be gently slipped over the baby's head or, if it is over the shoulder, the body can be delivered through the loop. If the cord is too tight to be looped over the head without significant tension, two clamps should be applied to the cord approximately 2 inches apart, and the cord should be cut between the clamps before delivering the body. This prevents the cord from being torn or avulsed as the body delivers, which could cause significant fetal hemorrhage. After delivery with cord cutting, proceed normally with body delivery and newborn assessment. Document that a nuchal cord was present and describe the management. If the baby shows signs of distress after delivery, prioritize airway, stimulation, and warmth before detailed assessment.

Question 5: Following a normal delivery, normal findings in a newborn at 1 minute include all of the following EXCEPT:

Heart rate of 120 beats per minute
Pink trunk with blue hands and feet (acrocyanosis)
Vigorous crying and active movement
Central cyanosis with no respiratory effort (Correct answer)

Correct answer: Central cyanosis with no respiratory effort

Central cyanosis (blueness of the trunk, lips, and face) with absent respiratory effort is abnormal in a newborn at 1 minute and requires immediate resuscitative intervention.

Newborn assessment in the first minute of life uses the APGAR score (Appearance, Pulse, Grimace, Activity, Respiration) evaluated at 1 and 5 minutes. Understanding what is normal versus abnormal in this brief window is critical for EMTs who may need to initiate newborn resuscitation. Normal findings at 1 minute include: heart rate greater than 100 beats per minute, good respiratory effort with crying, active muscle tone, response to stimulation, and pink coloration of the trunk (central color). Acrocyanosis — blueness of the hands, feet, and sometimes lips — is normal in the first minutes of life due to peripheral vasoconstriction and incomplete circulatory transition from fetal to neonatal physiology. Central cyanosis — blueness of the trunk, lips, and mucous membranes — is not normal and indicates significant hypoxemia requiring supplemental oxygen and potentially positive pressure ventilation. Absent respiratory effort at 1 minute is also abnormal and requires immediate intervention: stimulate (dry and rub the back), suction if needed, and if no improvement within 30 seconds, initiate bag-valve-mask ventilation at 40-60 breaths per minute. A heart rate below 100 bpm in a newborn with poor respiratory effort requires ventilation; below 60 bpm despite adequate ventilation requires chest compressions.

Question 6: A pregnant patient at 38 weeks calls EMS because she thinks she is in labor. On examination, the EMT observes the umbilical cord protruding from the vagina. The most important immediate intervention is:

Attempt to push the cord back into the vagina
Clamp and cut the cord immediately
Place the mother in a position to relieve pressure on the cord and transport emergently (Correct answer)
Deliver the baby as quickly as possible

Correct answer: Place the mother in a position to relieve pressure on the cord and transport emergently

Prolapsed cord is a life-threatening emergency. The priority is to relieve pressure on the cord (preventing fetal hypoxia) by positioning the mother (knee-chest or Trendelenburg) and transporting immediately. Never push the cord back or cut it.

Umbilical cord prolapse — where the umbilical cord descends through the cervix ahead of the presenting part of the fetus — is a true obstetric emergency with high fetal mortality if not managed immediately. When the fetal presenting part (usually the head) descends, it compresses the cord against the pelvis, interrupting fetal blood flow and oxygenation. Each minute of cord compression increases the risk of fetal hypoxia and neurological injury. The EMT's priorities are: (1) relieve pressure on the cord by positioning the mother in knee-chest position or Trendelenburg (head down, pelvis elevated) — this uses gravity to move the presenting part away from the cord; (2) if trained and directed by medical direction, a gloved hand may be gently inserted into the vagina to manually elevate the presenting part off the cord; (3) keep the cord moist and warm with a saline-dampened cloth if it is exposed; (4) DO NOT push the cord back into the vagina; (5) DO NOT clamp or cut the cord; (6) transport immediately with continuous fetal monitoring. Pre-notify the receiving hospital so that an emergency cesarean section team can be prepared. This is one of the few true prehospital obstetric emergencies where the primary intervention is positioning and rapid transport rather than field delivery.

NREMT Obstetrics & Gynecology Emergencies 2

A pregnant patient at 36 weeks gestation presents with painless vaginal bleeding.
The EMT's priority should be: