This section of our NREMT Study Guide will help you prepare for the obstetrics & gynecology portion of the EMT exam. This study guide covers the different stages of pregnancy, complications of pregnancy, patient assessment of a pregnant patient, delivery of a newborn, post-delivery care, and delivery and post-delivery complications.
After reviewing this Obstetrics & Gynecology study guide, you will find five practice questions to test your comprehension of the material.
Stages of Pregnancy
The uterus is a muscular organ that protects and encapsulates the developing fetus. During labor, the uterus produces powerful contractions that help push the fetus through the birth canal, which comprises the vagina and the lower third (neck) of the uterus, known as the cervix. During pregnancy, the cervix develops a mucous plug that seals the opening to the uterus, preventing outside contamination.
When the cervix begins to dilate in preparation for delivery, the mucous plug falls into the vagina as pink-tinged mucus called “bloody show.” When a patient says she “lost her plug” or has “bloody show,” it typically represents the beginning of labor.
As the fetus grows, it requires a continuous supply of support and nutrients. The placenta is a disc-shaped structure that is attached to the wall of the uterus. The placenta supplies the fetus with nourishment and is connected to the fetus by the umbilical cord (often simply called “the cord”). The cord is the fetus’s lifeline, connecting the mother to the fetus through the placenta. Once the fetus is delivered, the placenta is delivered after separating itself from the uterus.
The “bag of waters” is also known as the amniotic sac. This bag-like membrane is filled with fluid where the fetus develops. The sac contains 500 to 1,000 mL of amniotic fluid that protects and insulates the fetus during pregnancy. Generally, the sac will rupture at the onset of labor, and the fluid will be released in a gush or trickle down the patient’s leg. This release of fluid helps lubricate the birth canal and remove any bacteria that could be passed to the fetus during delivery.
Complications of Pregnancy
Complications can occur during pregnancy even in previously healthy patients with no prior medical history. The following are the most common complications seen in pregnancy:
- Hypertensive disorders: Hypertensive disorders typically occur in patients who are pregnant for the first time. One disorder is called pre-eclampsia, or pregnancy-induced hypertension. This condition develops after the 20th week of gestation. A related condition called eclampsia is characterized by seizures due to hypertension. If a pregnant patient is having a seizure, lay her on her left side to prevent compression of the inferior vena cava by the pregnant uterus, maintain her airway, and administer oxygen.
- Bleeding: If a patient has an ectopic pregnancy, where the embryo develops outside the uterus (most often in a fallopian tube), internal bleeding may occur if the fallopian tube ruptures. Pregnant patients can also hemorrhage from the vagina before the onset of labor, indicating a spontaneous abortion (miscarriage), usually in the earlier stages of pregnancy. In later stages, bleeding can indicate abruptio placenta, where the placenta separates from the wall of the uterus. Another condition is placenta previa, where the placenta develops over and covers the cervix. Any hemorrhaging from the vagina is a life-threatening condition in a pregnant patient, and immediate, rapid transport is required. If ALS is available to respond, consider calling them for advanced medical treatment.
- Gestational diabetes: This type of diabetes can occur in patients during the second half of their pregnancy who have no prior history of diabetes and is typically resolved once the fetus is delivered.
Patient Assessment During Pregnancy
You may be called for a pregnant patient complaining of contractions. Sometimes, there will be time to transport the patient to the hospital (typically when it is the patient’s first child). Other times, delivery will be imminent, and the newborn must be delivered before reaching the hospital. As with any call, you will first perform a scene size-up to determine if the scene is safe to enter. Take standard precautions, wearing gloves and a gown and using eye and face protection if delivery has already started or if it is near. Consider calling for advanced life support (ALS) if it is reported that the patient is pregnant with more than one fetus or if the patient is in a high-risk pregnancy.
Determine the nature of illness (NOI) or mechanism of injury (MOI). Not all calls for a pregnant patient will be to assist with the delivery. You may have been called for a traumatic event or medical emergency. Remember to stay focused and not develop tunnel vision when you hear the patient is pregnant.
During your primary assessment, form a general impression, assessing for life threats or if delivery is imminent. After addressing and treating any life-threatening conditions, prepare to deliver on the scene if it is imminent. If delivery is not imminent, transport the patient and perform your secondary assessment, history taking, and reassessment en route to the hospital. Pregnant patients in their second and third trimesters of pregnancy should be transported on their left side when possible.
Be sure to alert the receiving hospital as soon as possible that you are transporting a pregnant patient. They will advise you if you should go to the emergency department or labor and delivery (L&D) based on your report.
Delivery of a Newborn
In the event you need to assist with the delivery of a newborn in the field, it is important to know the three stages of a normal delivery without complications:
- Dilation of the cervix
- Delivery of the fetus
- Delivery of the placenta
The first stage begins when the patient starts having contractions and ends when the cervix is fully dilated. The first stage is usually the longest, with an average of 16 hours for a patient’s first delivery. Besides contractions, other signs of the onset of labor are bloody show and the patient’s water breaking. In true labor, the contractions will become more intense, closer together, and last 30 to 60 seconds each.
The second stage of labor begins when the fetus enters the birth canal and ends when the newborn has been delivered. Patients in this stage of labor will generally have an urge to “push” or feel like they need to have a bowel movement. As an EMT, you must not allow pregnant patients who have the urge to push to go to the bathroom, as they may deliver the newborn in the toilet.
Some patients will also tell you they have the urge to push and say, “The baby is coming.” When that happens, you must look at the vagina and see if the baby’s head appears at the opening. If so, the baby is “crowning,” and you must be prepared to assist with the delivery.
If the patient is not already lying on a flat, hard surface, have her do so. Have the patient remove her undergarments and clothing or push them up to her waist. Try to preserve the patient’s privacy and modesty as much as possible, covering her lower body with a sheet if possible.
With the patient on her back, have her keep her legs and knees flexed, with her feet flat on the floor and her knees spread apart. Place towels, pillows, or blankets under her hips for comfort. If the patient prefers another position, that is fine as long as you can still assist with the delivery.
To prepare for delivery, don personal protective equipment (PPE) if you have not already done so, place towels or sheets on the floor around the delivery area, and carefully open your obstetrics (OB) kit so the contents remain sterile. Have your partner at the patient’s head to comfort and soothe her and provide supplemental oxygen if the patient will allow it.
While at the vaginal opening, you will monitor for crowning and be prepared to assist with the delivery of the newborn. Once the newborn’s head appears, use your hands to support the head as it emerges. The newborn’s body will naturally turn to the right or left, so allow the head to move in the same direction. Feel the infant’s neck to see if the umbilical cord is wrapped around it. If so, gently lift the cord over the head without pulling on the cord. Continue supporting the head and body until the newborn is completely delivered. Newborns are very slippery, so hold them firmly but gently.
Post-Delivery Care
As soon as the newborn is delivered, hand the baby to the mother if she will allow it. If not, place the infant on the mother’s abdomen so skin-to-skin contact can begin. Dry the newborn and wrap them in a clean blanket or towel to provide warmth, keeping their head covered and their face exposed. Keep their neck in a neutral positionto maintain an open airway, with their head slightly lower than the rest of their body to prevent aspiration. Use a sterile gauze pad to wipe the newborn’s nose and mouth if needed.
Once the umbilical cord has stopped pulsating, use two clamps from the OB kit, placing one clamp 6 inches from the newborn’s body and the other clamp 2 to 4 inches apart. With the clamps firmly in place, cut the cord between the two clamps with a sterile scalpel or scissors.
The newborn should be pink and breathing on their own. Have your partner evaluate the newborn, obtain the 1-minute and 5-minute Apgar scores, and complete the initial care while you return your attention to the mother and the delivery of the placenta, which is the third and final stage of delivery.
The placenta is attached to the end of the umbilical cord coming out of the mother and will usually deliver itself within a few minutes after birth, but it can be as long as 30 minutes afterwards. Do not pull on the cord to speed up the delivery of the placenta; it will deliver on its own. Once delivered, place the cord and placenta in a plastic bag and transport it with the mother and child. Hospital staff will inspect the placenta to ensure the entire placenta was delivered and parts do not remain inside the mother.
Delivery and Post-Delivery Complications
At times, deliveries will not be normal. Some complications while assisting in delivering a newborn include the following:
- Breech delivery: The infant’s buttocks are present instead of the head, called a breech presentation.
- Prolapsed cord: The umbilical cord comes out of the vagina before the fetus.
- Limb presentation: An arm or leg presents from the vagina instead of the head.
Generally, in a breech presentation, there is time to transport the patient to the hospital, and delivery will not be performed in the field. In the cases of a prolapsed cord and limb presentation, delivery must be surgically performed in a hospital. The patient needs to be rapidly transported to the hospital.
Some post-delivery complications include the placenta not delivering after 30 minutes, excessive bleeding before the placenta delivers, or hemorrhaging after the placenta delivers. If the placenta has not been delivered within 30 minutes or if there is excessive bleeding before or after the delivery of the placenta, these are considered serious emergencies. The patient and newborn need to be promptly transported to the hospital.
Place sterile pads over the patient’s vagina, administer supplemental oxygen, and monitor her vital signs closely. Do not pack sterile pads directly into the vagina, and do not discard bloody pads, as the hospital staff will try to determine the amount of blood loss. While you are attending to the patient, do not forget to monitor the newborn (your second patient) while keeping them warm to prevent heat loss.