OB Emergencies


  • Identify abnormal presentations present during childbirth
  • Discuss the management of a patient with an abnormal presentation during delivery
  • Describe a nuchal cord presentation
  • Discuss the procedures to take when a nuchal cord is present during delivery
  • Recognize the need for neonatal resuscitation during delivery
  • Discuss the management principles of neonatal resuscitation
  • Describe the routine care of a newborn not requiring resuscitation


  1. Assessment and History Taking of a Pregnant Patient
  2. Stages of Childbirth
    1. Dilation
    2. Expulsion
    3. Placental
  3. Abnormal Presentations In Childbirth
    1. Breech
      1. Buttocks or both feet present first
      2. Management
        1. Prompt transport (field delivery is not ideal)
        2. When delivery is unavoidable:
          1. Support buttock and legs
          2. Do not pull
          3. If head does not deliver within 3 minutes
            1. Arrange for immediate transport
            2. Insert gloved hand into the vagina and use your fingers to form a “V” on either side of the infants nose
            3. Push the vaginal wall away from the infant’s face
    2. Limb presentation
      1. One leg or arm protruding from vagina
      2. Management
        1. Do not touch the limb
        2. Do not attempt field delivery
        3. Provide supportive care and transport in the knee-chest position
    3. Multiple Births
      1. More than 1 fetus
      2. Management
        1. Manage as normal delivery, recognizing the need for additional equipment and personnel
    4. Prolapsed Cord
      1. Umbilical cord presents from the vagina prior to fetus
      2. Management
        1. Immediate transport in Trendelenburg or knee-chest position
        2. Insert two fingers of a gloved hand into the vagina to remove pressure off the cord
        3. Keep the cord moist with sterile dressing
        4. Do not attempt to pull the cord or push the cord back into the vagina
    5. Shoulder dystocia
      1. Shoulders unable to pass beyond pubic symphysis
      2. “Turtle sign”- head delivers but retracts back into the perineum because the shoulders are trapped.
      3. Management
        1. McRoberts maneuver- (buttocks off the end of the bed with thighs flexed upward) and apply firm pressure with your hand above the pubic symphysis
  4. Transport immediately (even if delivery attempt is unsuccessful)
  5. Nuchal cord
    1. Cephalic presentation but the umbilical cord is around the neck
    2. Common finding during delivery and rarely associated with adverse outcomes
  6. Management
    1. Attempt to slip the cord over the infant’s head.
    2. If unable to slip the cord up and over the head, clamp and carefully cut the cord
  7. Neonatal Resuscitation
    1. Assessment
      1. If “yes” is answered to these three questions, the infant stays with the mother and standard care continues, including maintaining the newborn’s temperature
        1. Full term gestation?
        2. Good muscle tone?
        3. Breathing or crying adequately?
      2. If “no” is answered to ANY of the above assessment questions, resuscitation efforts should be attempted in this sequence:
        1. First 30 seconds postpartum
          1. Dry the infant, then, warm and maintain normal temperature
          2. Position airway
          3. Clear secretions
          4. Stimulate
        2. 30-60 seconds postpartum
          1. Heart rate below 100/min or gasping/apnea
            1. Initiate positive pressure ventilation and monitor SpO2
          2. Labored breathing or persistent cyanosis
            1. Position and clear the airway, monitor SpO2, supplementary O2 as needed
        3. After one (1) minute postpartum
          1. Heart rate >100/min
            1. Provide post resuscitation care
          2. Heart rate <100/min
            1. Check chest movement
            2. Correct ventilations as needed
              1. ETT or appropriate supraglottic airway
          3. Heart rate >60/min
            1. Begin chest compressions coordinated with PPV and 100% O2
            2. Place on ECG monitor
            3. Considerations
              1. Advanced airway
  1. 2015 AHA/ECC Guidelines for Neonatal Resuscitation when meconium is present:
    1. a. Suctioning in the presence of meconium staining
    2. Vigorous neonates with good respiratory effort and muscle tone born through meconium stained amniotic fluid
      1. Do not benefit from suctioning
      2. Should stay with the mother to receive the initial steps of newborn care
  1. Gentle clearing of meconium from the mouth and nose with a bulb syringe may be done if necessary
  2. Presence of fetal distress, poor muscle tone, respiratory compromise when born through meconium-stained amniotic fluid
    1. Immediately initiate resuscitation efforts
    2. Initiate PPV if heart rate less than 100/min

IV.      Umbilical Cord Management

  1. Delayed cord clamping
    1. Reference: American Heart Association-Part 13-Neonatal Resuscitation
    2. Wait 30 seconds after delivery to clamp the cord
      1. Reduces intraventricular hemorrhage
      2. Reduces high blood pressure/blood volume
      3. Reduces need for transfusion after birth
      4. Reduces necrotizing enterocolitis
    3. Adverse findings
      1. Increased level of bilirubin

Content Creator: Carli Wymore
CAPCE Course Number: 22-EMTP-F3-5101
NJ Course Number: 141142
Total CE Hours: 1
Level: Basic
EMT-CE uses the NEMSES guidelines as the foundation for every course outline.