Obstetric Emergencies for Paramedics: UK Guide

Obstetric Emergencies for Paramedics: A Pre-Hospital Guide

Obstetric emergencies are among the most high-stakes situations a paramedic will encounter. While out-of-hospital births are relatively uncommon, when complications arise they can deteriorate rapidly — and the paramedic's role in recognition, stabilisation, and timely intervention can be life-saving for both mother and baby. This guide covers the key obstetric emergencies you need to understand for UK paramedic practice, aligned with JRCALC clinical guidelines.

Normal Labour: Knowing Your Baseline

Before recognising what's abnormal, you must understand normal labour. Labour is divided into three stages:

1. First stage: Onset of regular contractions to full cervical dilation (10 cm). Divided into latent and active phases.
2. Second stage: Full dilation to delivery of the baby.
3. Third stage: Delivery of the placenta, typically within 30 minutes of birth.

As a paramedic, you may arrive at any point in this process. A rapid but structured assessment — including gravidity, parity, gestational age, contraction frequency, and whether the membranes have ruptured — will guide your decision to transport or prepare for imminent delivery.

Imminent Delivery

Signs of imminent delivery include contractions lasting more than 60 seconds occurring every 2–3 minutes, the urge to push or bear down, crowning, or visible presenting part. In these cases, do not attempt to delay delivery or transport mid-delivery. Prepare your obstetric pack, maintain patient dignity, and support a controlled delivery.

After birth, dry and stimulate the neonate, clamp and cut the cord per your protocol, assess APGAR scores at 1 and 5 minutes, and initiate neonatal resuscitation if required. Active management of the third stage with oxytocin (if within your scope and formulary) can reduce the risk of postpartum haemorrhage.

Pre-eclampsia and Eclampsia

Pre-eclampsia is a multisystem disorder characterised by hypertension (≥140/90 mmHg) and proteinuria after 20 weeks of gestation. Eclampsia is the onset of seizures in a woman with pre-eclampsia and represents a true emergency.

Recognition

• Severe headache, often frontal
• Visual disturbances (flashing lights, blurred vision)
• Epigastric or right upper quadrant pain
• Facial or peripheral oedema
• Hypertension — BP ≥160/110 mmHg in severe cases
• Tonic-clonic seizures in eclampsia

Pre-hospital Management

Your priority is airway management, preventing injury during seizures, and rapid transport to an obstetric unit. Magnesium sulphate is the drug of choice for eclamptic seizures and is increasingly within paramedic formulary under JRCALC guidance — follow your trust's specific protocol. Avoid diazepam as a first-line agent in pregnancy where magnesium is available. Position the patient in the left lateral position to relieve aortocaval compression, establish IV access, and provide high-flow oxygen if SpO2 is below 95%.

Postpartum Haemorrhage (PPH)

Postpartum haemorrhage is defined as blood loss of more than 500 ml following a vaginal delivery, or more than 1000 ml following caesarean section. It is a leading cause of maternal mortality and must be recognised and managed promptly.

Causes — The Four T's

• Tone: Uterine atony (most common cause, ~80% of PPH)
• Tissue: Retained placenta or products of conception
• Trauma: Lacerations to the birth canal or uterine rupture
• Thrombin: Coagulopathy

Pre-hospital Management

Establish large-bore IV access (two lines if possible), begin fluid resuscitation, and apply uterine fundal massage if atony is suspected. Oxytocin, where within scope, can promote uterine contraction. Keep the patient warm to prevent coagulopathy from hypothermia. Pre-alert the receiving hospital with an obstetric emergency call. Do not delay transport — these patients can decompensate rapidly, and definitive management requires surgical and haematological support.

Placenta Praevia and Placental Abruption

These two conditions both present with antepartum haemorrhage but have distinct features:

• Placenta praevia: Painless, bright red vaginal bleeding. The placenta covers the cervical os. Avoid vaginal examination — this can provoke catastrophic haemorrhage.
• Placental abruption: Painful, often concealed bleeding. The placenta separates prematurely from the uterine wall. The uterus may feel hard and tender. Fetal distress is common.

Both require high-flow oxygen, IV access, fluid resuscitation as needed, left lateral positioning, and urgent transport with obstetric pre-alert.

Shoulder Dystocia

Shoulder dystocia occurs when the baby's anterior shoulder becomes impacted behind the maternal pubic symphysis after delivery of the head. It is unpredictable and requires immediate action to prevent hypoxic injury to the neonate.

HELPERR Mnemonic

• H — Call for Help
• E — Evaluate for Episiotomy (does not resolve bony obstruction but aids manoeuvres)
• L — Legs (McRoberts manoeuvre — hyperflex the maternal thighs onto the abdomen)
• P — Suprapubic Pressure (apply firm downward pressure above the pubic symphysis)
• E — Enter (internal rotational manoeuvres — Rubin II, Woods screw)
• R — Remove the posterior arm
• R — Roll the patient (all-fours position)

McRoberts manoeuvre combined with suprapubic pressure resolves the majority of cases. Avoid fundal pressure — this worsens impaction.

Cord Prolapse

Cord prolapse — where the umbilical cord descends past the presenting part — is an obstetric emergency carrying significant risk of cord compression and fetal hypoxia. On examination, the cord may be visible at the introitus or palpable on vaginal exam.

Pre-hospital management focuses on reducing pressure on the cord. Position the patient in the knee-chest position or left lateral with the hips elevated. If trained and within scope, digital elevation of the presenting part off the cord may be performed. Wrap any visible cord in a warm, moist dressing to prevent vasospasm. Urgent transport is essential — this is a time-critical emergency requiring immediate obstetric and theatre teams.

Key Principles for All Obstetric Emergencies

• Always consider two patients — maternal and fetal wellbeing
• Left lateral or left-tilt positioning to relieve aortocaval compression
• Early pre-alert to the appropriate obstetric unit
• Accurate documentation of timing, interventions, and fetal presentation
• Calm, clear communication with the patient and any birth partner present