Obstetric Emergencies: Preeclampsia Symptoms, Eclampsia, Shoulder Dystocia and Breech Delivery

Most births EMS attends are normal, and most of the work is supporting the mother and keeping the baby warm. A few obstetric emergencies are different: they are uncommon, they are time-critical, and the first person to recognize them is often a field provider. This guide covers the hypertensive disorders of pregnancy (preeclampsia, eclampsia and HELLP syndrome), supine hypotension, shoulder dystocia, breech delivery, a prolapsed cord and postpartum hemorrhage, as principles.

Hypertensive disorders of pregnancy

High blood pressure in pregnancy ranges from a mild problem to a life-threatening one. ACOG, the US professional body for obstetrics, defines high blood pressure in pregnancy as a systolic of 140 or more or a diastolic of 90 or more, and a systolic of 160 or more or a diastolic of 110 or more as the severe range.

Preeclampsia symptoms and warning signs

• A severe headache that does not go away.
• Visual changes: blurring, spots, flashing lights or loss of vision.
• Pain in the upper right abdomen or under the breastbone, which can be mistaken for heartburn.
• Nausea or vomiting in the second half of pregnancy.
• Shortness of breath, which can mean fluid on the lungs.
• Sudden swelling of the face or hands. Swelling of the feet and ankles alone is common in normal pregnancy and is not a reliable sign.
• Confusion, agitation or a change in behavior.
• A blood pressure in the severe range.

Eclampsia

A seizure in a patient past about 20 weeks of pregnancy, or in the weeks after delivery, is eclampsia until proven otherwise, even if no high blood pressure was ever recorded. Check a blood glucose to rule out hypoglycemia, protect the patient from injury and put nothing in the mouth. Magnesium sulfate, given per protocol, is the first-line anticonvulsant for eclampsia because it addresses the cause of an eclamptic seizure rather than only stopping it, and is better at preventing the next one; a benzodiazepine is commonly the protocol's backup. Every dose and route is your protocol's.

• Position the patient on her left side, which protects the airway after a seizure and takes the uterus off the great vessels.
• Suction, oxygen and assisted ventilation as needed, and watch the breathing closely after the seizure.
• Keep stimulation low: dim lights, a quiet environment and a smooth transport. Bright light, noise and repeated painful procedures can provoke another seizure.
• Notify the receiving facility early. The definitive treatment of preeclampsia and eclampsia is delivery, and your protocol decides where she goes.

Supine hypotension

From about 20 weeks, when the top of the uterus reaches roughly the level of the navel, a pregnant patient lying flat on her back can have the weight of the uterus press on the inferior vena cava. Less blood returns to the heart, the cardiac output falls, and she may become dizzy, pale and hypotensive, with less blood reaching the fetus.

• Transport a patient in later pregnancy on her left side, or tilted to the left, unless something prevents it.
• If she must stay supine, for example on a backboard or during CPR, manually displace the uterus to the left: push or pull it up and to her left by hand.
• During CPR on a patient with a uterus at or above the navel, the AHA recommends continuous manual left uterine displacement while compressions continue.

Shoulder dystocia

Shoulder dystocia is a delivery in which the head is born but the shoulders do not follow, because the front shoulder is caught behind the mother's pubic bone. The classic sign is the turtle sign: the head delivers and then pulls back tight against the perineum. It is a true emergency, because the baby cannot breathe effectively while the chest is trapped in the birth canal.

1. Recognize it and say it out loud, call for help, and note the time the head delivered.
2. Do not pull hard on the baby's head. Traction on the head can injure the nerves of the neck and arm.
3. McRoberts maneuver: with the mother on her back, flex her thighs sharply back toward her abdomen, one helper on each leg. This flattens the pelvis and often frees the shoulder.
4. Suprapubic pressure: a helper presses firmly just above the pubic bone, on the side of the baby's back, to push the front shoulder down and under the bone. This is suprapubic pressure, not pressure on the top of the uterus. Pressing on the fundus can make the impaction worse.
5. If the shoulders still do not deliver, follow your protocol. Some protocols teach further steps such as moving the mother onto her hands and knees. Transport while continuing, and notify the receiving facility.
6. Expect the newborn to need resuscitation, and have the equipment ready.

Breech delivery

In a breech presentation the buttocks or feet come first instead of the head. Many breech babies are born without trouble, but the head, the largest part, comes last and can become trapped. The principle commonly taught is hands off: let the mother's contractions deliver the baby.

1. Keep your hands off until the body has delivered to about the shoulder blades. Pulling on the baby, the legs or the cord is how a breech delivery becomes an injury. Never pull.
2. Once the body is out, support it from underneath. Keep the baby warm, because cold air can make the baby gasp while the head is still inside.
3. Let the arms deliver on their own. If they do not, any maneuver to free them is your protocol's and your training's; do not pull. Then let the head deliver with the next contraction.
4. If the head does not deliver promptly, make an airway: with a gloved hand, place two fingers in a V on either side of the baby's nose and push the vaginal wall away from the face, and keep them there.
5. Transport rapidly with early notification, whether or not the delivery finishes on scene, and expect the newborn to need help breathing.

A single arm or leg presenting on its own (a limb presentation) is not a delivery that can be completed in the field. Do not pull on it. Position the mother as your protocol directs and transport.

Prolapsed cord

A prolapsed cord is the umbilical cord coming out ahead of the baby. Each contraction squeezes it between the baby and the pelvis and cuts off the baby's blood supply. It is one of the most time-critical emergencies in the field.

• With a gloved hand, push the presenting part of the baby up and off the cord, and keep it there. Do not let go until a receiving team takes over.
• Position the mother knee-chest, or on her back with her hips raised well above her head, so gravity helps keep the baby off the cord. This is a cord-specific position, not a shock treatment.
• Do not try to push the cord back in. Keep it warm and moist, and handle it as little as possible.
• Transport immediately and notify the receiving facility.

Postpartum hemorrhage

Postpartum hemorrhage is heavy bleeding after birth and a leading cause of maternal death worldwide. ACOG currently defines it as a cumulative blood loss of 1,000 mL or more, or blood loss with signs or symptoms of hypovolemia, within 24 hours of birth; older teaching used 500 mL after a vaginal birth. Field estimates of blood loss usually underestimate it, so watch the patient as well as the blood.

The causes are usually taught as the four Ts: tone (a uterus that does not contract, by far the commonest), trauma (tears and lacerations), tissue (placenta left behind) and thrombin (a clotting problem). Because pregnancy increases the circulating volume, a mother can lose a large amount of blood before her vital signs change, and a falling blood pressure is a late sign.

• Fundal massage, once the placenta has delivered, or as your protocol directs if it has not: with one hand cupped just above the pubic bone to support the lower uterus, massage the top of the uterus (the fundus) firmly with the other until it becomes firm. Reassess often, because it can soften again.
• Putting the baby to the breast, or nipple stimulation, causes the body to release its own oxytocin and helps the uterus contract.
• Look for and apply direct pressure to bleeding from a visible tear.
• Do not pull on the cord to deliver the placenta. If the placenta delivers, bring it with you.
• Treat for shock as your protocol directs, including any uterotonic medication your service carries, given per protocol.
• Transport without delay and notify the receiving facility.

Calculate the shock index, remembering that the adult range does not apply in pregnancy

The newborn

Every one of these emergencies can deliver a newborn who needs help. At birth, ask whether the baby is term, has good tone, and is breathing or crying. Keep every newborn warm and dry, and if any answer is no, follow the NRP algorithm, which has its own reference guide in this library. Almost every newborn who needs help needs help breathing.

Score an Apgar at 1 and 5 minutes, a record of transition rather than a guide to resuscitation

The short version

• Preeclampsia is new high blood pressure after 20 weeks with protein in the urine or signs of organ involvement. Headache, visual changes and upper abdominal pain are the warning signs.
• Eclampsia is a seizure on top of preeclampsia, and it can happen up to weeks after delivery. Check the glucose, protect the airway, keep stimulation low, and treat per protocol.
• Later in pregnancy, keep the patient on her left side or displace the uterus to the left.
• Shoulder dystocia: the turtle sign. Call for help, do not pull, and use McRoberts and suprapubic pressure as your protocol allows.
• Breech: hands off until the shoulder blades show, support the body, never pull, and make an airway if the head is stuck.
• Prolapsed cord: lift the baby off the cord and keep your hand there, knee-chest or hips up, and go.
• Postpartum hemorrhage: fundal massage, the baby to the breast, treat for shock and transport.