7 Things EMS Needs to Know About High-Risk OB Emergencies (Part 2)

Pregnant and postpartum patients can deteriorate in ways that are easy to underestimate. High-risk OB emergencies require more than knowing how to deliver a baby. EMS clinicians need to recognize red flags, ask questions, and prepare early.

In part 2 of the 7 Things EMS podcast on OB emergencies (see part 1), Dan Limmer and expert Rachel Tank discuss seven topics that can change an EMS call quickly:

1. Pregnancy physiology changes everything - especially shock

2. Maternal sepsis

3. Placenta previa vs. placental abruption

4. Shoulder dystocia

5. Breech birth

6. Premature delivery

7. Cardiac arrest in pregnancy

Pregnancy physiology changes everything

Pregnancy can make a very sick patient look stable, at least at first. Blood volume increases during pregnancy, and a patient may lose a significant amount of blood before their blood pressure drops or they develop the classic signs of shock.

A slightly faster heart rate, softer blood pressure, increased respiratory effort, and a lower CO₂ can all occur during pregnancy. But those same findings can also be early clues that something is wrong.

The key is not to write off abnormal vitals as “just pregnancy.” Use your patient assessment skills: What happened? How does the patient look? Is the pulse pressure narrow?

Maternal sepsis

This sepsis type does not always announce itself with a high fever and an obvious source of infection. Sometimes the patient simply says, “I don’t feel right.”

Hearing these words matters.

Pay attention to unusual fatigue, weakness, confusion, or a noticeable decline in what the patient can do. Ask the patient to tell you more. Then look for possible infection sources, including urinary symptoms, respiratory illness, uterine infection, or wound complications.

Important: Pregnancy can blur the usual signs of infection and shock. Vague symptoms deserve a close look.

Placenta previa vs. placental abruption

Vaginal bleeding during pregnancy should get attention.

With placenta previa, the classic presentation is painless, bright-red bleeding. A placental abruption happens when the placenta separates from the uterine wall too early. These patients may have abdominal pain, tenderness, a rigid or hard abdomen, trauma, and vaginal bleeding. Ask about even “minor” trauma, including falls, low-speed crashes, or bumping the abdomen. Also ask about risk factors such as hypertension, smoking, alcohol, stimulant use, and diabetes.

Shoulder dystocia

Shoulder dystocia happens when the baby’s head delivers but the shoulders get stuck. It is not common.

Important: It helps to practice shoulder dystocia before the real call.

Use McRoberts positioning by bringing the patient’s legs tightly toward the chest. Add suprapubic pressure (pressure just above the pubic bone), not pressure on the top of the uterus.

Do not pull on the baby’s head or neck. Call for help early and notify the receiving hospital.

Breech birth

A breech presentation means the baby is not coming head-first. The buttocks or both feet may present first. If delivery is already happening, a buttocks-first or both-feet-first birth may be deliverable in the field.

A single hand or foot, though, is a major warning sign. That presentation needs urgent transport whenever possible.

If a breech delivery cannot be avoided, stay calm and do not pull. Let the delivery progress slowly, provide gentle assistance only when needed, and prepare for the possibility of a prolapsed cord or difficulty delivering the head. Mom delivers the baby; EMS helps.

Premature delivery

Premature babies can have trouble breathing and staying warm. They are at higher risk for hypoxia and bradycardia. Be ready to warm, dry, stimulate, position the airway, and provide ventilation.

Prepare early if a premature delivery is possible. Warm the ambulance, have towels and newborn equipment ready, and reduce heat loss with warm blankets and a hat. Depending on local protocol, clear plastic wrapping or a plastic bag up to the neck can also help preserve body heat.

Remember: Once the baby is born, you have two patients. One of you should focus on the newborn and the others care for the mother.

Cardiac arrest in pregnancy

For cardiac arrest in pregnancy, use standard ACLS. Medications, doses, defibrillation settings, and chest-compression location do not change.

At 20 weeks or greater, move the uterus from right to left to reduce pressure and improve blood return to the heart. Give that job to one specific team member.

Prioritize airway management early.

Takeaway

High-risk OB calls can be subtle right up until they are not. Pregnancy may hide shock, infection, bleeding, and respiratory decline. Trust your assessment and pay attention when the story, vital signs, or patient appearance do not quite fit.

This article is based on the two-part "OB Emergencies" episodes of the 7 Things EMS podcast by Limmer Education, hosted by Dan Limmer with guest Rachel Tank of the National Medical Education and Training Center (NMETC). EMS professionals can earn continuing education credit for these episodes at LC-ready.com.