Obstetric emergencies for paramedics: imminent delivery, shoulder dystocia and postpartum bleeding

Every obstetric call has at least two patients, and only one of them can tell you how she feels. That one fact explains most of what makes these calls hard. For many crews, obstetric emergencies are among the least frequent calls a paramedic sees, so the skills sit unused for long stretches and then have to work perfectly on a kitchen floor or in a moving ambulance.

This case breakdown follows a single imaginary call through its decision points: whether to stay or go, a delivery that stalls at the shoulders, and bleeding that won't settle afterward. The clinical detail is deliberately general. Your service's medical directives and the provincial standards define what you can do and how.

#Obstetric emergencies: the paramedic's first decision

You arrive to a woman in her third trimester, contracting strongly, who says the baby is coming. The first question isn't clinical detail. It's timing: will the baby arrive before you reach a hospital that can manage the birth?

Signs that delivery is imminent include:

• A strong, uncontrollable urge to push or bear down
• Crowning, or a presenting part visible at the vaginal opening
• Contractions that are close together and intense, with the patient unable to talk through them
• A history of fast previous labours

If birth looks imminent, preparing to deliver on scene is often safer than delivering in a moving vehicle. If there is time, transport. Gather what you can quickly: gestation, number of babies expected, prenatal problems, previous caesarean section, whether the waters have broken and what colour the fluid was. Call for a second crew early. If a baby is born, you'll suddenly have two patients and only one set of hands each.

#Supporting a normal delivery

Most births proceed without intervention. Your job is to support, not to rush. In general terms:

• Position the mother comfortably, with room to deliver and a warm area ready for the baby
• Allow the head to deliver gradually, supporting it rather than pulling
• Check for a cord around the neck and manage it per your directives
• Let the body deliver with the next contraction
• Dry, warm and stimulate the newborn, and assess breathing and tone straight away

Keep the newborn warm. Heat loss is fast and is one of the most preventable problems in out-of-hospital births. Skin-to-skin contact with the mother helps both patients.

#When the shoulders don't follow: shoulder dystocia

In our call, the head delivers, then pulls back tightly against the perineum, sometimes described as the "turtle sign". The next contraction comes and the body doesn't follow. This is shoulder dystocia: the baby's shoulder is caught behind the mother's pubic bone.

It is uncommon and difficult to predict. The principles are consistent across most guidance:

1. Call for help and note the time. The time from head delivery to body delivery matters for the baby and for your handover.
2. Don't pull hard on the head, and don't push on the top of the uterus. Both can cause injury and make things worse.
3. Work through the manoeuvres your directives describe. These commonly start with repositioning the mother, flexing her thighs sharply toward her abdomen, combined with firm pressure just above the pubic bone to help free the shoulder.
4. Change position if the first steps fail. Some protocols include moving the mother onto her hands and knees.
5. Prepare for newborn resuscitation. A baby delivered after a shoulder dystocia may need help breathing.

Shoulder dystocia is the clearest example of why obstetric calls need rehearsal. The steps are simple to read and hard to recall in sequence when the clock is running.

#After the birth: postpartum haemorrhage

The baby is out and breathing. Ten minutes later, your partner points out that the pads under the mother are soaked and still filling. Postpartum haemorrhage is one of the leading causes of maternal death worldwide, according to the World Health Organization, and it can develop quickly.

Practical principles:

• Recognize it early. Estimating blood loss by eye is unreliable and often underestimates it. Watch the patient, not just the pads: rising heart rate, pallor, anxiety and falling blood pressure are late and serious signs.
• Massage the uterus. A soft, boggy uterus is the most common cause. Firm fundal massage helps it contract.
• Encourage breastfeeding or skin-to-skin contact if mother and baby are able, which can help the uterus contract.
• Give medications your directives allow. Some services carry uterotonic drugs or tranexamic acid for this situation. The indication, timing and dose are directive-specific.
• Treat shock and move. Establish access, keep the patient warm, transport promptly and notify the receiving hospital early.

Don't deliver the placenta by pulling on the cord. Let it come on its own, keep it, and bring it to hospital.

#Two patients at once

The defining challenge of obstetric emergencies is divided attention. A newborn who needs stimulation and a mother who is bleeding both need you in the same minute.

Things that help:

• Request a second unit early, ideally before the birth, not after
• Assign roles out loud: one paramedic for the mother, one for the baby
• Keep a simple timeline: time of birth, head-to-body interval, placenta delivery, medications
• Hand over both patients clearly, including the newborn's condition since birth

#For training leads

Low-frequency, high-stakes calls are where scenario practice earns its keep. Crews can't build reliable obstetric judgement from the occasional real call.

Training ideas:

• Run shoulder dystocia scenarios with a visible timer so learners feel the pressure of the interval
• Build cases where the haemorrhage begins after the team has relaxed and turned attention to the baby
• Use two-patient scenarios that force explicit role assignment and early resource requests
• Repeat at intervals, not just once during initial training, so the sequence stays fresh

Platforms like Imedica let learners walk through branching versions of these cases between hands-on sessions, so the decision sequence is familiar before they ever face it on a call.

#Takeaway

Obstetric emergencies are uncommon for most paramedics, which is exactly why they need deliberate practice. Recognize imminent delivery, support normal births without rushing, have a stepwise plan for shoulder dystocia, treat postpartum bleeding early and firmly, and plan from the start for two patients.

Drafted for Imedica Field Notes. Physician review of this article is pending.