NREMT Obstetrics & Gynecology Emergencies 3 — Questions and Answers

Question 1: A patient delivers a baby in the field. After 20 minutes, the placenta has not been delivered. The EMT should:

Pull on the umbilical cord to manually extract the placenta
Transport to the hospital; do not attempt to pull the placenta out (Correct answer)
Manually reach into the uterus to remove the placenta
Clamp the cord again and wait another 20 minutes

Correct answer: Transport to the hospital; do not attempt to pull the placenta out

Placenta delivery normally occurs within 30 minutes of delivery. Attempting to pull or manually remove the placenta in the field risks uterine inversion and hemorrhage. Transport without manipulation.

The third stage of labor — delivery of the placenta — normally occurs within 5 to 30 minutes after delivery of the baby. Signs of placental separation include a gush of blood, the cord lengthening at the vaginal opening, and the uterus becoming firm and globular. If these signs are present, the patient can be instructed to push to facilitate delivery of the placenta. However, the EMT should never pull on the umbilical cord to extract the placenta. This can cause uterine inversion (the uterus turns inside out through the cervix), which is itself a life-threatening emergency associated with massive hemorrhage, neurogenic shock from vagal stimulation, and uterine incarceration. Retained placenta (placenta not delivered within 30 minutes) also increases the risk of postpartum hemorrhage. If the placenta has not delivered within 30 minutes in the field, the EMT should transport the mother (and baby) to the hospital without attempting manual removal. Monitor for postpartum hemorrhage — massage the uterine fundus gently through the abdomen to promote uterine contraction and reduce bleeding. Document the time of delivery and the status of placental delivery in the PCR.

Question 2: Postpartum hemorrhage is defined as blood loss exceeding how much after vaginal delivery?

100 mL
250 mL
500 mL (Correct answer)
1000 mL

Correct answer: 500 mL

Postpartum hemorrhage (PPH) is defined as blood loss greater than 500 mL following vaginal delivery (or 1000 mL following cesarean section). It is a leading cause of maternal mortality worldwide.

Postpartum hemorrhage (PPH) is defined as blood loss exceeding 500 mL following vaginal delivery or 1000 mL following cesarean section. It is the leading cause of maternal mortality worldwide and a significant cause of severe maternal morbidity. PPH occurs in approximately 5% of all deliveries. The most common cause of PPH is uterine atony — the failure of the uterus to contract after delivery, which normally compresses the spiral arteries supplying the placental bed. Other causes include retained placental fragments, lacerations of the vagina or cervix, and coagulopathy. The '4 T's' mnemonic summarizes the causes: Tone (atony), Tissue (retained placenta), Trauma (lacerations), and Thrombin (coagulopathy). Prehospital management of PPH includes fundal massage (bimanual external massage of the uterine fundus to stimulate contraction), oxygen administration, IV fluid resuscitation if within scope, and rapid transport. The patient may be positioned supine or with legs elevated to maintain venous return. Treat for shock if signs are present (pallor, tachycardia, hypotension). Quantify blood loss as accurately as possible and document the clinical picture for the receiving team. Pre-notify the hospital of PPH so that obstetric and blood bank teams can prepare.

Question 3: A pregnant patient at 28 weeks gestation has been in a motor vehicle collision and appears hemodynamically stable. The EMT should:

Treat and release since vital signs are stable
Transport supine on a backboard if spinal injury is suspected, and monitor for delayed signs of placental abruption
Position in left lateral recumbent to prevent supine hypotension, and transport to a facility with obstetric capabilities (Correct answer)
Focus only on obvious injuries; the fetus is well protected by amniotic fluid

Correct answer: Position in left lateral recumbent to prevent supine hypotension, and transport to a facility with obstetric capabilities

Pregnant trauma patients should be positioned left lateral when possible to prevent aortocaval compression (supine hypotension). Obstetric capabilities at the receiving facility are important for fetal monitoring.

The anatomical and physiological changes of pregnancy significantly affect the assessment and management of trauma patients. After approximately 20 weeks of gestation, the gravid uterus can compress the inferior vena cava when the patient is supine, reducing venous return to the heart and causing supine hypotension syndrome. This can result in decreased cardiac output affecting both maternal and fetal perfusion. For this reason, pregnant trauma patients who are beyond 20 weeks should be transported in the left lateral decubitus position whenever possible, or the uterus should be manually displaced to the left if the patient must be maintained on a backboard (tilt the backboard 15-30 degrees with padding under the right hip). This displaces the uterus off the vena cava without compromising spinal immobilization. Placental abruption (premature separation of the placenta) is a common and potentially fatal complication of blunt abdominal trauma in pregnancy, even with relatively minor mechanisms. It may not be immediately apparent — abdominal tenderness, uterine rigidity, or vaginal bleeding may develop over time. For this reason, all pregnant trauma patients beyond 20 weeks should be transported to a facility capable of obstetric monitoring and evaluation, regardless of how stable they appear initially.

Question 4: What is the primary concern when a patient in the third trimester lies flat on her back during transport?

Back pain from uterine weight
Aspiration risk from gastroesophageal reflux
Supine hypotension syndrome from aortocaval compression (Correct answer)
Increased respiratory effort from diaphragm elevation

Correct answer: Supine hypotension syndrome from aortocaval compression

The enlarged uterus in the third trimester can compress the aorta and inferior vena cava when supine, reducing cardiac output and causing maternal hypotension (supine hypotension syndrome).

Supine hypotension syndrome, also called aortocaval compression syndrome, is caused by the weight of the gravid uterus compressing both the inferior vena cava (reducing venous return to the heart) and the abdominal aorta (increasing downstream vascular resistance) when the pregnant patient lies flat on her back. This can reduce cardiac output by up to 30% in the third trimester, causing maternal hypotension, dizziness, nausea, and fetal hypoperfusion. The simple solution is left lateral tilt: positioning the patient on her left side or tilting her 15-30 degrees to the left displaces the uterus away from the great vessels, restoring venous return and improving cardiac output. During transport, this can be accomplished by placing padding or a wedge under the patient's right hip. EMTs should be alert for signs of supine hypotension in pregnant patients transported flat: tachycardia, pallor, dizziness, and dropping blood pressure that improves when positioned to the left. This is particularly important during resuscitation of pregnant cardiac arrest patients — left lateral displacement must be maintained while performing CPR, typically accomplished by manually displacing the uterus to the left while the patient remains on her back for compressions.

Question 5: An EMT arrives to find a woman who has just delivered in the back of a car. The baby is not crying, is limp, and has a heart rate of 70 bpm. The first intervention should be:

Begin chest compressions immediately
Dry and stimulate the baby while opening the airway (Correct answer)
Place the baby in a warm blanket and transport rapidly
Administer blow-by oxygen at 6 L/min

Correct answer: Dry and stimulate the baby while opening the airway

The initial steps for a newly born infant in distress are: dry, warm, stimulate, and open the airway. Stimulation alone may be sufficient to initiate spontaneous respirations. A heart rate of 70 is low but not below the threshold for immediate compressions.

Neonatal resuscitation follows a structured algorithm beginning with the initial assessment and basic stabilization steps. For every newly born infant, the EMT should: (1) warm — place under radiant heat or dry thoroughly to prevent hypothermia; (2) dry — vigorously dry the infant with a towel, which also provides tactile stimulation; (3) stimulate — rub the back and flick the soles of the feet; (4) position — place in the 'sniffing' position to open the airway (slight neck extension). These initial steps take approximately 30 seconds and should be performed simultaneously. After stimulation, reassess: heart rate, respiratory effort, and color. If the heart rate remains below 100 bpm but above 60 bpm and the baby is not breathing adequately despite stimulation, the next step is positive pressure ventilation (PPV) with bag-valve-mask at 40-60 breaths per minute using 21% oxygen (room air) initially. Chest compressions are indicated when the heart rate falls below 60 bpm despite 30 seconds of adequate positive pressure ventilation. With a heart rate of 70 bpm, compressions are not yet indicated — stimulation and PPV take priority. Throughout resuscitation, maintaining warmth is critical as hypothermia in newborns dramatically worsens outcomes.

Question 6: A patient in active labor reports feeling a strong urge to push and says the baby is coming. The EMT sees crowning. The proper technique for controlling the head delivery is:

Tell the patient to push as hard as possible to speed delivery
Apply gentle counterpressure to the baby's head to guide a slow, controlled delivery (Correct answer)
Pull down on the baby's head to assist delivery
Cover the vaginal opening with a sterile drape and transport immediately

Correct answer: Apply gentle counterpressure to the baby's head to guide a slow, controlled delivery

Gentle counterpressure to the crowning head guides a slow, controlled delivery, reducing the risk of rapid expulsion that can cause maternal lacerations and neonatal injury.

When crowning is observed, delivery is imminent and the EMT should prepare for controlled delivery. Applying gentle counterpressure to the crowning head — not pulling, but rather providing resistance to slow the rate of advancement — helps achieve a controlled, gradual delivery of the head. This reduces the force of expulsion and decreases the risk of perineal lacerations in the mother and traumatic injury to the neonate. As the head delivers, the EMT should support it with one hand and guide it gently downward to allow the anterior shoulder to pass under the pubic symphysis. The head should not be pulled or rotated — gentle support and gravity are sufficient. After the head is delivered, check for a nuchal cord. Have the mother stop pushing momentarily by breathing through contractions, which gives time to assess the cord. After shoulder delivery, the rest of the body delivers rapidly — support the baby with both hands, as a wet newborn is extremely slippery. Note the delivery time, assess the baby immediately, and begin the initial steps of neonatal assessment and care. Encourage the mother throughout the process and keep her informed of progress. Designate team roles if a partner is present: one EMT manages delivery and newborn, the other monitors the mother.

NREMT Obstetrics & Gynecology Emergencies 3

A patient delivers a baby in the field.
After 20 minutes, the placenta has not been delivered.
The EMT should: