Obstetric Emergencies for Paramedics: UK Guide

Obstetric Emergencies for Paramedics

Obstetric emergencies are among the most high-stakes calls a paramedic will attend. Whether you are a student paramedic on placement or preparing for your final assessments, understanding the pre-hospital management of obstetric emergencies is essential. These situations demand rapid assessment, calm clinical decision-making, and a solid grasp of both maternal and neonatal physiology. This guide covers the key conditions you are most likely to encounter, aligned with JRCALC guidelines and NHS practice in the UK.

Understanding Normal Labour

Before managing complications, you need a firm understanding of normal labour. Labour is divided into three stages:

1. First stage: Onset of regular contractions to full cervical dilation (10 cm). This can last many hours, particularly in primigravid women.
2. Second stage: Full dilation to delivery of the baby. Crowning occurs as the presenting part becomes visible at the perineum.
3. Third stage: Delivery of the placenta, typically within 30 minutes of birth.

In the pre-hospital environment, your role is to assess the stage of labour, determine whether delivery is imminent, and decide whether to remain on scene or transport. If the head is crowning, delivery on scene is almost always the safer option.

Pre-Hospital Delivery

If delivery is imminent, prepare your environment as best you can. Use your maternity pack and follow a calm, structured approach:

• Encourage the mother to adopt a comfortable position — semi-recumbent or on her side.
• Support the baby's head as it emerges; do not pull.
• Check for the cord around the neck (nuchal cord) — if present, attempt to loop it over the head gently.
• Deliver the anterior shoulder followed by the posterior shoulder with gentle guidance.
• Keep the baby warm immediately — dry thoroughly, cover the head, and use a plastic bag for neonates under 32 weeks to prevent heat loss.
• Clamp and cut the cord after one to three minutes (delayed cord clamping) unless resuscitation is required.
• Assign an APGAR score at one and five minutes.

Document the time of delivery accurately and ensure a pre-alert is sent to the receiving unit with gestational age, delivery details, and neonatal condition.

Neonatal Resuscitation

Approximately 10% of newborns require some resuscitation at birth. Follow the Newborn Life Support (NLS) algorithm:

• Dry and stimulate the baby; assess tone, breathing, and heart rate.
• If not breathing or heart rate is below 100 bpm, open the airway and give five inflation breaths using a neonatal bag-valve-mask.
• If heart rate remains below 60 bpm after ventilation, commence chest compressions at a 3:1 ratio with ventilations.
• Reassess every 30 seconds and pre-alert the receiving hospital immediately.

Pre-Eclampsia and Eclampsia

Pre-eclampsia is characterised by hypertension (BP ≥140/90 mmHg) and proteinuria after 20 weeks of gestation. It can rapidly progress to eclampsia, which involves generalised tonic-clonic seizures and represents a life-threatening emergency for both mother and baby.

Recognition

Key features to identify in your assessment include:

• Severe headache unresponsive to analgesia
• Visual disturbances (flashing lights, blurred vision)
• Epigastric or right upper quadrant pain
• Sudden oedema of the face, hands, or feet
• BP ≥160/110 mmHg in severe cases

Pre-Hospital Management

If eclamptic seizures occur, your immediate priorities are:

• Position the patient in the left lateral position to relieve aortocaval compression.
• Protect the airway and administer high-flow oxygen.
• Gain IV access and administer magnesium sulphate 4g IV over 5–10 minutes as per JRCALC guidelines — this is the drug of choice for eclampsia in the UK.
• Monitor BP continuously and pre-alert the maternity unit urgently.

Antepartum Haemorrhage

Antepartum haemorrhage (APH) is defined as bleeding from the genital tract after 24 weeks of gestation. The two major causes are placenta praevia and placental abruption.

• Placenta praevia presents with painless, bright red bleeding. The placenta lies over the cervical os, making vaginal delivery dangerous.
• Placental abruption presents with painful, dark bleeding and a rigid, tender uterus. It can be concealed, meaning external blood loss may not reflect internal haemorrhage.

Management focuses on IV access, fluid resuscitation if shocked, oxygen therapy, left lateral positioning, and rapid transport with a pre-alert. Do not perform a vaginal examination in the pre-hospital setting.

Postpartum Haemorrhage

Postpartum haemorrhage (PPH) is defined as blood loss exceeding 500 ml within 24 hours of delivery (major PPH is over 1000 ml). It is a leading cause of maternal mortality in the UK. Causes are remembered using the four Ts: Tone (uterine atony — most common), Trauma, Tissue (retained placenta), and Thrombin (coagulopathy).

Pre-hospital management includes uterine massage, fundal palpation, IV access with wide-bore cannulae, fluid resuscitation, and rapid transport. Oxytocin (Syntometrine) may be carried by paramedics working with enhanced drug lists — follow your local trust protocols.

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 an unpredictable emergency requiring immediate action.

Apply the HELPERR mnemonic:

• H — Call for Help
• E — Evaluate for Episiotomy
• L — Legs (McRoberts manoeuvre: hyperflexion of hips)
• P — Suprapubic Pressure (not fundal)
• E — Enter (internal rotational manoeuvres)
• R — Remove the posterior arm
• R — Roll the patient (all-fours position)

Document all manoeuvres attempted and the time from head delivery — this is critical for the receiving team.

Cord Prolapse

Cord prolapse is a time-critical emergency in which the umbilical cord descends below the presenting part, risking cord compression and fetal hypoxia. If you feel or see the cord at the perineum:

• Do not handle the cord excessively or allow it to dry out — cover with a warm, moist dressing.
• Position the mother in the knee-chest position or left lateral with hips elevated.
• Consider manually elevating the presenting part if trained to do so.
• Pre-alert the obstetric unit immediately — this is a surgical emergency requiring caesarean section.

Key Takeaways for Student Paramedics

Obstetric emergencies are rare but rapidly life-threatening. Success in managing them depends on preparation, rehearsed protocols, and clear communication with the receiving team. Know your JRCALC guidelines, understand when to transport rapidly versus manage on scene, and always treat both the mother and the baby as your patients.