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Obstetric
Complications
Christopher Ebright, BEd, NREMT-P
EMS Education Coordinator
Acadian Companies
National EMS Academy
Lafayette, Louisiana
EMS/Nursing l 80113/30513
Objectives
1. Identify pre-delivery
complications.
2. Identify procedures for
handling abnormal
deliveries.
3. Recognize common
post-delivery complications.

EMS/Nursing l 80113/30513
 Pre-delivery
Complications
Trauma
Trauma in Pregnancy
Causes of maternal
injury in decreasing
order of frequency:
vehicular crashes
falls
penetrating objects
Trauma in Pregnancy
The greatest risk of fetal
death is from maternal
distress
 Supine
Hypotensive
Syndrome
Supine Hypotensive
Syndrome
Usually seen3 rd

trimester
Problem coincides with
supine positioning
Supine Hypotensive
Syndrome
Fetal/uterineweight
compresses the inferior
vena cava (IVC),
reducing preload and
cardiac output
Supine Hypotensive
Syndrome
Manage with left lateral
recumbent (LLR)
positioning and fluids
Supine Hypotensive
Syndrome
Continue evaluating
patient
internal bleeding
dehydration
Supine Hypotensive
Syndrome
issues regulating blood
vessels and NOT
regulating pressure
appropriately
Supine Hypotensive
Syndrome
Check to see if volume
depletion is an issue
Ectopic
Ectopic Pregnancy
Very common and often
missed
Chief complaint -
abdominal pain
Ectopic Pregnancy
A fertilized ovum
implants and develops
outside the normal
uterine cavity
Ectopic Pregnancy
Sites
fallopian tubes (95%)
abdominal cavity
ovaries
Ectopic Pregnancy
Why?
Infections
pelvic inflammatory
disease (PID)
intrauterine device (IUD)
previous abortions
Ectopic Pregnancy
Why?
Pelvic/ovarian tumors
Tubal surgery
Anatomical defect (rare)
All women of childbearing
age who present with acute
onset of abdominal pain and
signs or symptoms of shock
should be considered to
have an ectopic pregnancy
until proven otherwise!
Ectopic Pregnancy

What are you going to see?

Depends on how intact the

fallopian tubes are
Ectopic Pregnancy
Before rupture
ask when last menstrual
period (LMP) was
usually <6 weeks (no
more than 8 weeks)
Ectopic Pregnancy
mild vaginal bleeding or
brown-stained discharge
mild spasmodic
cramping/acute stabbing
pain
Ectopic Pregnancy
After rupture
severe bleeding into the
abdomen
vaginal bleeding minimal
compensated/
decompensated shock
Ectopic Pregnancy
Options?
Rapid airway, breathing,
and circulation (ABC)
assessment/recognition
Priority transport
Shock management
 Do NOT
overload with fluids

Maintain profusion!
Placenta
Previa
 Placenta Previa
Placenta implants
partially or completely
in the lower part of the
uterus
 Placenta Previa
Happens in 1 in every
200 pregnancies
 Placenta Previa
Four types
low lying
marginal
partial
complete
 Low Lying
Lower third of the
uterus
Vaginal delivery
possible, but not likely
 Marginal
Covers a margin of the
cervix
Has to be a caesarean
section
 Partial
Covers even more of
the cervix
 Complete
Covers entire opening
 Placenta Previa
Risk factors
age
multiparity
previous caesarian
section
Placenta Previa
dilation and
curettage (D&C)
smoking
 Placenta Previa
Signs and symptoms
bleeding
bright red
painless
Placenta Previa
spontaneous
nontender abdomen
no change in fundal
height
no stress on baby
 Placenta Previa
Treatments
ABC support
intravenous (IV) fluid
support (maintain
profusion)
Placenta Previa
transport for definitive
treatment caesarean
section (c-section)
 Abruptio
Placentae
Abruptio Placentae
Premature separation of
a normally situated
placenta in the upper
part of the uterus
Abruptio Placentae
Typically a trimester
3 rd

complication
Partial or complete
separation; hemorrhage
is concealed
 Partial separation Complete separation Partial separation
(concealed hemorrhage) (concealed hemorrhage) (apparent hemorrhage)
Abruptio Placentae
What caused it?
Preeclampsia
Chronic hypertension
Trauma
Dont know
Abruptio Placentae
Findings
scant outward dark red
blood flow WITH pain
acute onset
Abruptio Placentae
uterus becomes tender
and rigid if hemorrhage
is retained
signs and symptoms of
shock inconsistent with
amount of visible
bleeding
Abruptio Placentae
Fluid resuscitation as
needed (PRN)
Transport in LLR
position
Definitive caesarean
section
General Assessment
Normal Delivery
Normal Delivery
Normal Delivery
Normal Delivery
Normal Delivery
Normal Delivery
Normal Delivery
Abnormal
Deliveries
 Umbilical Cord
Presentation
If the umbilical cord
presents before the fetal
head, check cord for
pulse
 Umbilical Cord
Presentation
Cord becomes
compressed between
fetus and pelvis
 Umbilical Cord
Presentation
Associated with breech
presentation,
multigravidity, large
fetus
 Umbilical Cord
Presentation
Position the mother in a
knee-chest position
 Umbilical Cord
Presentation
Insert a sterile, gloved
hand into the birth canal
and push the presenting
part of the fetus off the
cord
 Umbilical Cord
Presentation
Check cord for
pulsations and cover
cord with sterile towel
moistened with saline
 Umbilical Cord
Presentation
Have mother pant with
contractions to avoid
bearing down
High-flow oxygen
Breech Presentation
Increased
risk of
prolapsed cord, cord
compression
Breech Presentation
Occurswhen the fetus
buttocks or lower
extremities are the
presenting part
Breech Presentation
Associated with
preterm birth, placenta
previa, multigravidity
Breech Presentation
Breech delivery
deliver the buttocks, then
deliver to the umbilicus
extract a 4 - 6 inch loop
of the cord
Breech Presentation
rotate newborn for
anterior/posterior
shoulder positioning
apply gentle traction until
axilla appear
Breech Presentation
Ifthe head will not
deliver, then form a V
with fingers and press
the vagina away from the
newborns nose
Breech Presentation
Temporary airway is
established
Transport with moms
hips elevated
Limb Presentation
Occurs when an
extremity is the
presenting part
Caesarean section
is mode of delivery
Limb Presentation
Transport in knee-chest
position
Caesarean section is
mode of delivery
 Cephalopelvic
Disproportion
Size of the fetus head
vs. moms pelvis
One of the most
common causes of
difficult labor
 Cephalopelvic
Disproportion
Themother is often
primigravida and
experiencing strong,
frequent contractions for
a prolonged period
Cephalopelvic Disproportion

Causes
Increased fetal weight
>10 lbs. (chin, forehead
stuck in pelvis?)
diabetic mother
multigravida mother
Cephalopelvic Disproportion

Causes
Cervical rigidity
Remedy
basic standard of care
3 Ds
Cephalopelvic Disproportion

Causes
3 Ds
discovery
delivery to ambulance

diesel (drive like crazy)

Shoulder Dystocia
Fetal shoulder becomes
lodged against the
mothers pubic bone
Cannot be detected until
after the head delivers
Shoulder Dystocia
Oncedetected, begin
monitoring time closely
Haveanother EMT
support the head and
maintain the airway
Shoulder Dystocia
McRobertsposition
opens up pelvis to create
more room
Shoulder Dystocia
McRoberts position
supine position
head up
pull knees up onto chest
and have her push
Shoulder Dystocia
Maternal
postpartum bleed
perineal tear
uterine rupture
fracture of symphysis pubis
vaginal lacerations
Shoulder Dystocia
Fetal
clavicle fracture
humerus fracture
fetal hypoxia
brachial plexus injury
fetal death
Shoulder Dystocia
Be prepared to transport
immediately in case
delivery is not possible
Also be prepared to
resuscitate the newborn
Meconium Staining
Meconium Staining
Lightgreen to darker
green; thick
Intubation/suction will be
necessary to clear the
airway
Suctioning Meconium
Suctioning Meconium
Suction out orally by:
manual suction
bulb syringe
Do NOT suction nose
Suctioning Meconium
Intubate baby
(tube becomes suction
catheter)
Suctioning Meconium
 Postpartum
Complications
 Postpartum
Bleeding
Loss of more than
liter of blood
immediately following
delivery
 Postpartum
Bleeding
Why?
vaginal/cervical tears
multiple births
large newborn

lack of uterine tone

 Postpartum
Bleeding
Options?
Uterine massage
Consider oxytocin
Placental pieces
 Postpartum
Bleeding
Options?
Shock management
Breastfeed baby
Fluid replacement
 Uterine Rupture
Spontaneous or
traumatic rupture of the
uterine wall
blunt
penetrating
normal birth process
Uterine Rupture
history of:
caesarean sections
uterine dysfunction

anatomical defect
Uterine Rupture
bleeding caused by
rupture (internal)
shock
weird presentations
abdominal pain
 Uterine Rupture
Characterized by
sudden abdominal
pain, steady tearing
sensation, active labor
 Uterine Rupture
Sudden cessation of
labor and/or fetal heart
tones
Uterine Inversion
Uterusgets turned
inside-out after delivery
umbilical cord traction
fundal implantation of
placenta
Uterine Inversion
Signs and symptoms
profuse vaginal bleeding
vasovagal effects - vitals
are disproportionate to
blood loss
Obstetric Complications
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EMS/Nursing l 80113/30513
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Conflicts of Interest:
Christopher Ebright, BEd, NREMT-P has disclosed that no financial
interests, arrangements or affiliations with organization/s that could
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Off-label Use:
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with off-label or unapproved uses are discussed within this activity.

Nursing l 30513
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