Obstetric Emergencies and Complicated Deliveries - NREMT Paramedic Level

1. Identify the defining feature of placenta previa that guides field management decisions.

   Painless third-trimester vaginal bleeding. Painless bleeding suggests low-lying placenta covering the cervix, prompting avoidance of vaginal exams to prevent massive hemorrhage.

2. What is the most important immediate action when shoulder dystocia is recognized after head delivery?

   Initiate McRoberts maneuver with suprapubic pressure. This maneuver rotates the pubic symphysis cephalad to widen the pelvic outlet and facilitate delivery of the impacted shoulder.

3. What is the recommended position for a patient with suspected prolapsed umbilical cord during transport?

   Knee-chest or Trendelenburg to reduce cord compression. These positions use gravity to displace the fetal head from the pelvis, alleviating pressure on the prolapsed cord and improving fetal oxygenation.

4. What is the antidote for magnesium sulfate toxicity in an obstetric patient?

   Calcium gluconate. Calcium gluconate antagonizes magnesium's effects on neuromuscular transmission, reversing respiratory depression or cardiac toxicity.

5. Which delivery finding is an indication for immediate neonatal resuscitation readiness due to aspiration risk?

   Meconium-stained amniotic fluid. Meconium indicates fetal distress and potential aspiration, necessitating preparedness for airway suctioning and ventilation in the newborn.

6. What is the first-line prehospital care for significant third-trimester vaginal bleeding?

   High-flow oxygen, treat shock, left lateral position, rapid transport. These measures support maternal oxygenation, stabilize hemodynamics, reduce vena cava compression, and ensure prompt definitive care like cesarean section.

7. Which obstetric bleeding condition is more likely to present with concealed hemorrhage and shock?

   Abruptio placentae. Abruption often involves retroplacental bleeding that remains hidden, leading to hypovolemia and maternal-fetal compromise more rapidly than previa.

8. Which medication is commonly used for postpartum hemorrhage from uterine atony when allowed by protocol?

   Oxytocin. Oxytocin induces myometrial contractions to compress spiral arteries and reduce hemorrhage from inadequate uterine tone post-delivery.

9. What is the correct direction of suprapubic pressure for shoulder dystocia (fundal vs suprapubic)?

   Suprapubic pressure only; never apply fundal pressure. Suprapubic pressure pushes the fetal shoulder downward and inward to reduce dystocia, while fundal pressure can worsen impaction or cause injury.

10. What is the primary medication used to prevent recurrent seizures in eclampsia?

    Magnesium sulfate. Magnesium acts as a central nervous system depressant to stabilize neuronal membranes and prevent eclamptic convulsions.

11. What is the recommended management for a limb presentation (single arm/leg) in labor?

    Do not attempt delivery; cover with sterile dressing; rapid transport. Limb presentation indicates transverse lie or footling breech, which cannot be safely delivered prehospitally and requires cesarean section.

12. What is the classic triad of preeclampsia used for recognition in the prehospital setting?

    Hypertension, proteinuria, edema. This triad indicates endothelial dysfunction in pregnancy, signaling risk for progression to eclampsia and need for blood pressure management.

13. What is the key management for uterine inversion recognized after delivery with severe hemorrhage?

    Treat shock, cover exposed uterus with moist sterile dressing, rapid transport. Shock treatment stabilizes the patient, moist coverage prevents infection and drying, and transport allows surgical correction.

14. Which immediate action is indicated for a gravid patient with a seizure (suspected eclampsia)?

    Protect airway, left lateral position, administer magnesium per protocol. Airway protection prevents aspiration, left lateral reduces aortocaval compression, and magnesium controls seizures in suspected eclampsia.

15. What is the most likely cause of postpartum hemorrhage when the uterus feels boggy and enlarged?

    Uterine atony. A boggy uterus fails to contract effectively after delivery, leading to persistent bleeding from open placental site vessels.

16. What is the correct prehospital management for breech delivery when the body delivers but the head is trapped?

    Create airway with gloved fingers; rapid transport; do not pull. Gloved fingers maintain an airway for the fetus, while avoiding traction prevents cervical spine injury, prioritizing rapid hospital intervention.

17. What is the defining feature of abruptio placentae (placental abruption) in the field?

    Painful bleeding with uterine tenderness/rigidity. Pain and tenderness indicate placental separation, guiding assessment for shock due to potential concealed bleeding.

18. What is the standard field management for a frank breech presentation before delivery progresses?

    Rapid transport; do not attempt field delivery unless imminent. Frank breech increases risks like cord prolapse, necessitating obstetric expertise for safe delivery unless birth is unavoidable.

19. Which maternal position is used in the McRoberts maneuver to relieve shoulder dystocia?

    Hyperflex maternal hips: knees to chest. Hyperflexion flattens the lumbosacral angle, increasing pelvic diameter to dislodge the anterior shoulder from the pubic symphysis.

20. What is the immediate management for postpartum hemorrhage due to uterine atony in the field?

    Fundal massage and encourage breastfeeding if appropriate. Massage stimulates uterine contraction, and breastfeeding releases oxytocin, both promoting involution to control bleeding from poor tone.

21. What is the key prehospital management for a prolapsed umbilical cord with a palpable cord?

    Elevate presenting part; knee-chest; keep cord moist; rapid transport. Elevating the presenting part relieves cord compression, knee-chest positioning uses gravity, and moisture prevents drying, all while expediting hospital delivery.

22. What is the correct management for a retained placenta with ongoing postpartum bleeding in the field?

    Do not pull on cord; treat shock; uterine massage; rapid transport. Pulling risks further hemorrhage or inversion, so supportive care and massage control bleeding until hospital removal.

23. What is the correct management when a nuchal cord is found around the newborn neck after head delivery?

    Slip over head if loose; clamp and cut if tight. A loose cord can be gently maneuvered without harm, but a tight one requires division to prevent strangulation and allow delivery progression.

24. What finding defines eclampsia rather than preeclampsia?

    Seizure activity in a patient with preeclampsia. Seizures result from cerebral vasospasm and edema in preeclampsia, distinguishing it as a medical emergency requiring anticonvulsant therapy.

25. Which intervention should you avoid in a prolapsed umbilical cord when the cord is outside the vagina?

    Do not attempt to push the cord back into the vagina. Pushing the cord back risks infection, vasospasm, or further prolapse, potentially worsening fetal hypoxia.

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