Obstetrics & Sexual Health
Sexual and reproductive health, pregnancy and its complications, birth and what can go wrong with it, the postpartum period and the newborn — what to look for, what it means, and what changes management.
Reproductive System Overview
Female Reproductive System
- Ovaries — produce oocytes, progesterone, oestrogen, inhibin & relaxin
- Uterine tubes — transport oocyte; normal site of fertilisation
- Uterus — site of implantation, foetal development & labour
- Vagina — receives penis during intercourse; birth canal
- Mammary glands — synthesise, secrete & eject milk
Male Reproductive System
- Testes — produce sperm & testosterone
- Ducts — transport, store & assist maturation of sperm
- Accessory sex glands — secrete liquid portion of semen
- Penis — contains urethra; passageway for ejaculation & urine
Sexual & Reproductive Health
WHO Definition
Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality — not merely the absence of disease. It requires a positive and respectful approach to sexuality and the possibility of safe, pleasurable experiences free of coercion, discrimination and violence.
Reproductive Health Includes
- Safe and satisfying sex life
- Freedom to choose if, when & how often to have a child
- Access to family planning & contraception
- Healthy pregnancy, safe delivery & healthy baby
- Protection from & treatment of STIs
- Support for FDV & sexual violence
Barriers to Sexual Health Access
- Cultural/religious taboos
- Language & health literacy
- Stigma & negative healthcare experiences
- Financial barriers
- Geographic access (remote areas)
- Gender norms & identity marginalisation
Cultural Competency
Trans and gender diverse people experience significantly higher vulnerability to HIV and STIs due to marginalisation, poor healthcare experiences, and barriers to gender affirmation services. A trauma-informed, culturally safe approach is essential for all patients.
Sexual Health Assessment Framework
Key principles when conducting a sexual health assessment in the prehospital setting:
1
Privacy & Safety — Ensure the patient is in a private, safe environment before beginning any assessment. Be mindful of other people present and ask permission before disclosing personal information.
2
Consent & Explanation — Explain why your assessment is necessary. Give the patient opportunity to ask questions and document consent obtained.
3
Chaperone — Offer another person to be present during examination. Always document whether a chaperone was offered and accepted or declined.
4
Relevant Communication — Ensure discussion and comments remain clinically relevant. Avoid personal information. Use non-judgemental, open language.
5
Findings & Documentation — Explain your findings, allow time for questions, and ensure thorough documentation including consent, chaperone, and clinical findings.
Implicit Bias
Implicit bias is a negative attitude of which one is not consciously aware. It is shaped by experience and learned associations. When present in patient care, it has the potential to negatively impact outcomes. Self-reflection and a trauma-informed approach are essential.
The Menstrual Cycle — 4 Phases
Menstruation
Follicular
Ovulation
Luteal
Menstruation (Days 1–7)
The uterine lining (endometrium) breaks down and leaves the body as a period. Lasts 3–7 days. Triggered by falling progesterone levels as the corpus luteum degrades.
Follicular Phase (Overlaps with Menstruation)
FSH stimulates growth of follicles in the ovaries. One dominant follicle produces oestrogen, which thickens the uterine lining in preparation for potential pregnancy.
Ovulation (~Day 14)
An egg leaves the ovary and travels down the fallopian tube towards the uterus. This is the period most likely for pregnancy. Triggered by an LH surge.
Luteal Phase (Days 15–28)
The ruptured follicle transforms into the corpus luteum, which produces progesterone and oestrogen in preparation for pregnancy. If pregnancy does not occur, the corpus luteum degrades, hormone levels drop, and the cycle restarts.
Dysmenorrhoea & Menorrhagia
Dysmenorrhoea Painful periods
- Pain begins before or soon after period; lasts 8–72 hours
- Cramping/lower abdominal pain, nausea, fatigue, diarrhoea
- Classically in young women who recently started regular periods
- Refer/transport when bleeding is heavy, unexplained, or pain is unusual
- Associated with pelvic pathology (e.g. endometriosis, fibroids)
- Usually occurs in later life
- Requires investigation for underlying cause
Menorrhagia Heavy periods
- Coagulopathy, iatrogenic anticoagulation, or endometrial changes
- Assess patient symptoms, age, and menstrual history
- Older post-menopausal patients suggest likelihood of pathological cause (e.g. cancer)
- Heavy bleeding associated with a pathological cause
- Intracavity — within uterine cavity
- Intramural — within the uterine muscle layer
- Extramural — outside the muscle
Endometriosis
Definition
A chronic condition where tissue similar to the uterine lining is found outside the uterus (e.g. bowel, bladder, ovaries). Endometrial tissue builds up due to excess progesterone; as levels recede, leftover tissue triggers recurrent inflammatory responses causing damage, pain, and neural sensitisation.
Key Features
- Highly variable but often intense pain
- Pelvic muscle spasm — difficulties with sex, tampons, exams
- Neural sensitisation → headaches, fatigue, lower back pain
- Often high co-morbid conditions
Hormonal Management
- Aim for as few periods as possible
- Progesterone thins endometrium → lighter, less painful periods
- Oestrogen thickens endometrium → heavier, more painful periods
- Managed by variety of contraceptive pills
Prehospital Management
- Stop aggravating activity
- Keep moving (normally) — pelvic stretches
- Exercise & regular sleep for nerve pathway management
- Avoid regular opioids (narcotics)
Contraception Overview
Prevention of unintended pregnancies reduces maternal ill-health, pregnancy-related deaths, and HIV transmission from mothers to newborns. Click each method to expand details.
Hormonal IUD
Releases low levels of progestogen. Can become dislodged — consider if patient presents with pelvic pain.
Implant (The Bar)
Subdermal rod releasing progestogen. Lasts up to 3 years.
Injection (Depo-Provera)
Contains progesterone. Given every 3 months.
Combined Pill
Contains oestrogen and progestogen. Taken daily.
Progestogen-Only Pill
Contains only progestogen. Often called the mini-pill.
Emergency Pill (Plan B)
Contains progestogen or ulipristal acetate. Up to 72–120hrs post-intercourse.
- Copper IUD — Makes uterine lining unsuitable for pregnancy; stops sperm reaching egg
- Diaphragm — Soft silicone dome preventing sperm reaching the egg
- Withdrawal — Stops sperm entering vagina (not highly reliable)
- Tubal ligation — Surgical procedure stopping sperm reaching the egg (permanent)
- Vasectomy — Surgical procedure stopping sperm leaving the penis (permanent)
Termination of Pregnancy (TOP)
Medical Abortion (Most Common — 1st Trimester)
- Mifepristone — Blocks progesterone; detaches placenta; softens/opens cervix
- Misoprostol — Causes uterine contractions; expels foetus & tissue
Side Effects
- Heavy bleeding, pain & cramping
- Nausea, dizziness, headache
Surgical Abortion
Vacuum curettage or instrumental curettage where uterine contents are removed via the cervix.
Potential Complications
- Very heavy bleeding / infection
- Retained products / ectopic pregnancy
- Continued pregnancy / failed abortion
Legal Framework
The legality of termination of pregnancy — including gestational limits and any approval requirements — varies significantly by jurisdiction. Be aware of the legal framework that applies where you practise.
Cervical Shock (Vasovagal Syncope)
Triggers
- Pain or emotional stress
- Cervical dilation
- IUD insertion, TOP, miscarriage
Signs & Symptoms
- Fatigue, dizziness, bradycardia, hypotension
- Pallor, sweating, nausea/vomiting
- Loss of muscle tone, ALOC
Management
1
ABCDE — Primary survey; rule out other causes
2
Stop manipulation — Cease further cervical dilation/manipulation immediately
3
Positioning — Head down, legs elevated (Trendelenburg)
4
VSS, AED readiness — Monitor vital signs; consider IV access (NaCl); transport
Ovarian Hyperstimulation Syndrome (OHSS)
A life-threatening complication of IVF hormone stimulation. Enlarged ovaries and increased vascular permeability result in fluid accumulation in the abdomen.
Mild OHSS
- Abdominal distension/discomfort
- Mild nausea/vomiting & diarrhoea
- Enlarged ovaries
Moderate OHSS
- All mild features
- Ascites confirmed on ultrasound
- Elevated HCT & WBC
Severe OHSS
- All mild/moderate features
- Severe abdominal pain & rapid weight gain
- Pleural effusion, oliguria/anuria, syncope
- Hyperkalaemia
Management
- Reassurance & respiratory management
- Assess dehydration, signs of DVT
- Antiemetic & analgesia
- Consider ovarian torsion as differential
Critical OHSS
- Acute renal failure
- Arrhythmia / pericardial effusion
- Thromboembolism / arterial thrombosis
- Sepsis
Time Critical
Critical OHSS requires urgent transport. Treat as per local clinical guidelines and escalate to critical care.
Testicular & Ovarian Torsion
Testicular Torsion · Surgical Emergency
- Spontaneous twisting of spermatic cord → compromised blood flow
- Acute, sudden onset unilateral scrotal pain with nausea/vomiting
- Can occur during sleep or after trauma
- High suspicion in pubertal boys
- Management: Analgesia, antiemetics, urgent transport
- Differentials: Epididymitis, infection, trauma, tumour
Ovarian Torsion · Surgical Emergency
- Twisting of ovary/fallopian tube around supporting structure
- Right ovary at higher risk (due to length)
- Unilateral pelvic pain → increasing frequency → N&V → pyrexia, tachycardia, hypotension
- Risk factors: mass, prior torsion, pregnancy, assisted conception, pelvic surgery
- Management: Symptomatic treatment, urgent transport
- Differentials: Appendicitis, ectopic pregnancy, endometriosis, ovarian cyst
Key Physiological Changes
Click each change to expand its clinical implications.
Volume increases up to 50%. CO increases; renin & erythropoietin produced. Side effects: pre-eclampsia (↓ O₂ to placenta), proteinuria. Significant haemorrhage can occur before shock signs appear.
Airway resistance declines; ribs expand due to diaphragm pressure. Side effects: dyspnoea, nasal congestion & nosebleeds. Hyperventilation is often normal in pregnancy.
Uterus pushes into abdominal cavity up to the xiphoid. Causes: oedema of lower limbs (IVC compression), heartburn, urinary frequency/stress incontinence, constipation, lordosis & back pain.
Normal weight gain due to foetus, amniotic fluid & placenta. Excess weight causes shift in centre of gravity → lordosis of spine. Foods rich in iron, calcium & protein are essential.
hCG, progesterone, oestrogen, relaxin, human placental lactogen & CRH all produced. hCG fluctuation causes morning sickness. Relaxin promotes pelvic flexibility for birth. CRH relates to timing of parturition.
Weight gain, soft tissue oedema & enlarged breasts may impede laryngoscopy. Increased risk of aspiration due to hormonal relaxation of gastro-oesophageal sphincter & delayed gastric emptying.
Fundal Height Assessment
Measured from symphysis pubis to fundus (top of uterus). Provides gestational age estimate.
| Weeks | Fundal Height |
|---|---|
| 12 weeks | Pubic symphysis |
| 20 weeks | Level of umbilicus |
| 36 weeks | Near xiphoid process |
Gravida & Parity
Gravida — number of times a woman has been pregnant, regardless of outcome.
Parity — number of births at >24 weeks gestation, alive or stillborn.
Miscarriage
Important
Never diagnose early miscarriage in the prehospital environment. Bleeding in pregnancy, while not normal, is not uncommon and often continues to a healthy full-term pregnancy. Explain that the exact outcome cannot be known without a full assessment.
Complete Miscarriage
All pregnancy tissue has passed and bleeding has stopped.
Incomplete Miscarriage
Some pregnancy tissue remains in the uterus. Risk of continued bleeding and infection.
Missed Miscarriage
The baby has died but remains in the uterus. May have no symptoms initially.
Clinical Presentation
- Lower abdominal pain & vaginal bleeding
- Hypotension, tachycardia, postural symptoms
- Complications: haemorrhagic shock, uterine sepsis (fever, rigidity, guarding, purulent discharge)
Management
- Symptomatic treatment with analgesia PO/IV
- Antiemetics as required
- IV fluids if hypotensive/bleeding
- Comfort, emotional support & transport
Bleeding Volume Guide
Any bleeding in pregnancy is abnormal and should be investigated. Use this guide to estimate blood loss and urgency:
Liner
~20 mL
Requires Review
Regular Pad
~100 mL
Urgent Review
Maternity Pad
~200 mL
Urgent Hospital
Soaked Maternity Pad
~400 mL
Urgent Transport
Bluey Pad
~500 mL
Time-Critical — Immediate
Ectopic Pregnancy
Surgical Emergency
Ectopic pregnancy occurs when the embryo implants outside the uterus (most commonly the fallopian tube). Occurs in approximately 11 in 1000 pregnancies. Suspected ruptured ectopic is a surgical emergency requiring rapid transport.
Signs & Symptoms
- Abdominal/pelvic pain & amenorrhoea
- Vaginal bleeding, pallor, dizziness/syncope
- Urinary symptoms, GI symptoms
- Shock/collapse (ruptured)
Management
- Assess for & treat hypovolaemic shock
- Appropriate analgesia & antiemetics
- IV fluids if indicated
- Rapid transport — surgical facility
Hyperemesis Gravidarum (HG)
Not Morning Sickness
HG is a potentially life-threatening pregnancy condition causing severe nausea/vomiting, weight loss, malnutrition, dehydration, and long-term health issues for both mother and baby.
Risk Factors
- Younger age / first pregnancy
- Extreme high/low body weight
- Migraines & allergies
Transport Red Flags
- Intake <1 meal per day
- Inadequate urine output
- Weight loss >500g/week
- Inability to tolerate antiemetics
Compassionate Care
- Warm blankets, quiet environment
- Warm IV fluids
- Avoid IM injections (pain sensitisation)
- Take complaints seriously
Pre-Eclampsia & Eclampsia
Pre-Eclampsia BP ≥ 140/90
- High blood pressure + proteinuria
- Swelling hands/feet (non-dependent oedema)
- Headaches, vision changes, abdominal pain, N&V
- Can persist after birth; affects multiple systems
Management
- Supportive care; conservative fluid (risk of pulmonary oedema)
- Determine evidence/risk of seizure
- Transport and pre-alert as appropriate
Eclampsia Seizure Activity
Eclampsia refers to seizure activity occurring when pre-eclampsia is not treated.
Management
- Assess need for resuscitation
- Prevent further seizures — Magnesium sulphate, Midazolam
- Control hypertension
- Decision regarding delivery; rapid transport
Gestational Diabetes (GDM)
Pathophysiology
- Placental hormones → insulin resistance (2–3× higher insulin need)
- Usually resolves post-pregnancy but ↑ risk of Type 2 Diabetes later
- Managed with diet, exercise; some need metformin/insulin
Foetal Complications
- Macrosomia (large baby) → shoulder dystocia risk
- Neonatal hypoglycaemia & RDS
- Premature birth
- ↑ Risk childhood obesity & Type 2 Diabetes
VTE in Pregnancy
Highest Risk of Maternal Death
VTE is the most common cause of maternal death. Pregnancy increases VTE risk 4–5 times, with the greatest risk during the postpartum period.
Pregnancy represents all three components of Virchow's Triad:
Venous Stasis
Hormonally-mediated decrease in venous tone; gravid uterus compresses pelvic veins.
Hypercoagulability
Altered coagulation factors responsible for haemostasis during pregnancy.
Endothelial Damage
Pelvic vein endothelial damage at birth or from venous hypertension.
Prehospital Considerations
Maintain high suspicion in pregnant and postpartum patients. Avoid supine positioning. DVT often proximal and left-sided. Transport to maternity facility if possible. Manage as per local clinical guidelines for DVT/PE.
Trauma in Pregnancy
- Weight gain, soft tissue oedema & enlarged breasts may impede laryngoscopy
- Landmarks for surgical airway more difficult to identify
- ↑ Risk of regurgitation/aspiration — hormonal relaxation of gastro-oesophageal sphincter, delayed gastric emptying
- ↑ Oxygen consumption and reduced functional residual capacity
- Give oxygen to ALL pregnant patients regardless of SpO₂
- Hyperventilation often normal
- Thoracostomy/chest drain must be placed higher due to diaphragm elevation
- IVC compression in supine position → avoid supine positioning
- Increased HR is normal — do not rely on HR alone
- Significant haemorrhage can occur BEFORE signs of shock appear
- Foetus can be in shock even if mother is not
- ↑ Vascularity of pelvic area → life-threatening haemorrhage in pelvic fractures
Key Trauma Injuries Specific to Pregnancy
Premature labour — trauma → prostaglandin release → contractions. Placental abruption — may occur after minor trauma; can present 3–4 days post-incident. Uterine rupture — tear in uterine wall; life-threatening. Foetal-maternal haemorrhage — Rhesus sensitisation risk.
Resuscitation of the Pregnant Patient
1
Best hope for foetal survival is maternal survival — All basic/advanced life support principles apply: early CPR, early defibrillation, prompt airway management.
2
Hand position — Higher chest compressions may be required due to elevation of diaphragm from gravid uterus.
3
Uterine displacement (≥20 weeks) — Manual left lateral displacement to reduce aortocaval compression. If not possible, tilt 15–30° left with support padding.
4
Intubation ASAP — Overcome difficult airway changes from physiological alterations of pregnancy.
5
Rapid transport — Consider resuscitative hysterotomy (perimortem caesarean) at hospital to increase probability of ROSC.
Common Causes of Cardiac Arrest in Pregnancy
Anaesthetic cause, hypovolaemia, amniotic fluid embolism, VTE, and cardiac cause. All are potentially reversible — aggressive resuscitation is warranted.
Stages of Labour
1st Stage
2nd Stage
3rd Stage
First Stage — Cervical Dilation
- Uterus begins to contract
- Cervix is dilating (0 → 10cm)
- Baby is moving down
- Ends when cervix is fully dilated (10cm)
Second Stage — Birth of Baby
- Signs of imminent birth: pressure to push, very close/strong contractions
- Contraction every 1–2 minutes
- Baby is born
- Assess for nuchal cord after birth of head
Third Stage — Delivery of Placenta
- Birth of the placenta (do not pull on cord)
- Administer IM oxytocin into the thigh within 1 minute of birth
- Clamp cord when limp; cut between clamps
- Skin-to-skin contact; encourage breastfeeding
- Assess blood loss — normal <500mL
Prehospital Birth Procedure
1
Primary survey & determine strength of contractions
2
Visual inspection — Can you see the baby's head? Prepare birth area & support woman in comfortable position
3
Panting — Advise mother to pant to slow the baby's release; support head and body as it is released
4
Newborn assessment — Place baby on mum's abdomen; quickly dry with warm towel; note colour, tone & crying
5
Cord clamping — Apply 3 cord clamps at 10, 15 & 20cm; cut between 2nd and 3rd clamps; delayed clamping preferred (wait for limp cord)
6
Oxytocin (IM) — Administer within 1 minute of birth into the thigh muscle to reduce bleeding
7
Deliver placenta — Expect delivery; do not pull on cord; assess level of blood loss; transport
APGAR Score
APGAR is a score commonly used to summarise newborn condition at 1 minute and 5 minutes after birth. It guides assessment of resuscitation response — it is not used to determine whether resuscitation is necessary.
| Sign | Score 0 | Score 1 | Score 2 |
|---|---|---|---|
| Appearance (Colour) | Blue/pale all over | Blue extremities, pink body | Completely pink |
| Pulse (Heart Rate) | Absent | <100 bpm | ≥100 bpm |
| Grimace (Reflex) | No response | Grimace | Cry, cough, sneeze |
| Activity (Tone) | Limp | Some flexion | Active motion |
| Respiration | Absent | Weak/irregular | Strong cry |
Score 7–10
Normal
Routine newborn care
Score 4–6
Moderate
Stimulation & O₂ support; reassess
Score 0–3
Critically Low
Immediate resuscitation required
Postpartum Haemorrhage (PPH)
Classification
- Moderate PPH — ≥500 mL in first 24 hours
- Severe PPH — ≥1000 mL blood loss
- Major haemorrhage — ≥2500 mL blood loss
The 4 T's — Causes of PPH
- Tone — Poor uterine tone (most common)
- Tissue — Retained placenta preventing contraction
- Trauma — Lacerations of birth canal/perineum
- Thrombin — Coagulopathy/clotting factor consumption
Management
Massage uterus to expel clots and harden. Administer uterotonics (oxytocin). For severe haemorrhage: external aortic compression or bimanual compression. Transport urgently. Haemodynamic compromise may be the first sign as blood loss estimation can be inaccurate.
Drug Safety Categories in Pregnancy
Pregnancy drug-safety categorisation is one framework for weighing medication risk in pregnancy, here using categories A–X. Category systems and individual drug classifications vary by jurisdiction — always confirm against your local resource. Select each category to view definition and examples:
Category A — Safe
Taken by a large number of pregnant women without any proven increase in malformations or harmful effects to the foetus.
ParacetamolFolic acidIron supplements
Category B — Limited Data (No evidence of harm)
Taken by limited numbers of pregnant women; no increase in malformations observed. Animal studies show no evidence of increased foetal damage. Subcategories B1, B2, B3 reflect extent of animal data available.
Metformin (B3)Some antihistamines (B1)
Category C — Pharmacological Effects May Cause Harm
Pharmacological effects have caused or may cause harmful effects on the foetus or neonate without causing malformations. Effects may be reversible.
Ibuprofen (3rd trimester)CodeineSome antidepressants
Category D — Evidence of Foetal Risk
Drugs that have caused, are suspected of causing, or may cause increased incidence of foetal malformations or irreversible damage.
ValproatePhenytoinThalidomide
Category X — Contraindicated
Such a high risk of permanent damage that they should not be used in pregnancy or when there is a possibility of pregnancy.
Isotretinoin (Roaccutane)ThalidomideMisoprostol (for non-obstetric use)
Shoulder Dystocia
Time Critical
Anterior foetal shoulder impacted against the symphysis pubis after birth of head. Diagnosis: contraction + maternal effort + good traction >60 seconds without delivery = shoulder dystocia. Anticipate neonatal resuscitation and PPH post-dystocia.
Click each manoeuvre to view technique detail:
McRobert's Position
External — 1st line
Suprapubic Pressure
External — Combined with McRobert's
All Fours Position
External — Maternal repositioning
Wood Screw Manoeuvre
Internal — Rotate shoulders
Posterior Arm
Internal — Upright positioning
Cord Clamp & Cut
Last resort — Nuchal cord only
McRobert's Position
Hyperflex the mother's thighs against her abdomen by positioning helpers on each side. This flattens the lumbar lordosis and rotates the symphysis pubis superiorly, increasing the functional diameter of the pelvis. Most effective when combined with suprapubic pressure.
Hyperflex the mother's thighs against her abdomen by positioning helpers on each side. This flattens the lumbar lordosis and rotates the symphysis pubis superiorly, increasing the functional diameter of the pelvis. Most effective when combined with suprapubic pressure.
Suprapubic Pressure
An assistant applies firm downward and lateral pressure just above the pubic symphysis (on the foetal back side) while the birth attendant applies traction. This dislodges the anterior shoulder from behind the symphysis. Do not apply fundal pressure.
An assistant applies firm downward and lateral pressure just above the pubic symphysis (on the foetal back side) while the birth attendant applies traction. This dislodges the anterior shoulder from behind the symphysis. Do not apply fundal pressure.
All Fours (Gaskin Position)
Ask the mother to get on all fours. This repositions the foetal shoulders relative to the pelvis and uses gravity to assist disimpaction. Simple and effective — particularly useful in prehospital settings where space is limited.
Ask the mother to get on all fours. This repositions the foetal shoulders relative to the pelvis and uses gravity to assist disimpaction. Simple and effective — particularly useful in prehospital settings where space is limited.
Wood Screw Manoeuvre
Insert fingers vaginally and apply pressure to the front of the posterior shoulder to rotate the baby. Combined with reverse Wood Screw (Rubin II), this rotates the shoulders into the wider oblique diameter of the pelvis.
Insert fingers vaginally and apply pressure to the front of the posterior shoulder to rotate the baby. Combined with reverse Wood Screw (Rubin II), this rotates the shoulders into the wider oblique diameter of the pelvis.
Posterior Arm Delivery
Insert hand posteriorly, identify the foetal forearm/elbow, flex and sweep it across the chest and deliver it. Reduces bisacromial (shoulder-to-shoulder) diameter, allowing delivery. Appropriate for upright positioning.
Insert hand posteriorly, identify the foetal forearm/elbow, flex and sweep it across the chest and deliver it. Reduces bisacromial (shoulder-to-shoulder) diameter, allowing delivery. Appropriate for upright positioning.
Cord Clamp & Cut — Last Resort
Only for a tight nuchal cord that cannot be managed by the somersault technique. Clamp in two places and cut between clamps to allow birth. This is a last-resort intervention.
Only for a tight nuchal cord that cannot be managed by the somersault technique. Clamp in two places and cut between clamps to allow birth. This is a last-resort intervention.
Cord Prolapse
3–5 Minutes from Cord Compression to Brain Damage
Cord prolapse occurs when the umbilical cord presents before the foetal presenting part after membranes rupture. This is a true obstetric emergency.
Types
- Cord presentation — Membranes intact; cord below presenting part. Do NOT rupture membranes.
- Cord prolapse — Ruptured membranes; cord lies below presenting part
- Occult prolapse — Cord alongside (not in front of) presenting part
Management
- Position patient in chest down, knees up position immediately
- Elevate presenting part to relieve cord compression
- Time-critical transport — do not delay
- Maintain position throughout transport
Breech Presentation
Frank Breech (Most Common)
Legs extended at knees, thighs flexed against abdomen. Bottom presents first.
Complete Breech
Both legs flexed at hips and knees. Buttocks and feet present together.
Incomplete/Footling Breech
One or both feet tucked under buttocks; foot presents first.
Important Principles
Breech presentation has ↑ risk of requiring resuscitative measures. Paramedics are never required to perform vaginal examination. Lovset's Manoeuvre — downward traction + rotation to release arms. Mauriceau-Smellie-Viet — delivery of aftercoming head with gentle pressure on cheekbones and shoulders.
Placental Abruption & Placenta Praevia
Placental Abruption
- Premature detachment of placenta from uterine wall
- Can be concealed (no external blood) or revealed (visible bleeding)
- Risk factors: previous abruption, blunt trauma, cocaine/meth use, multiple pregnancies
- Foetal: intrauterine hypoxia, premature birth
- Maternal: hypovolaemic shock, renal failure
- May occur after minor trauma; can present 3–4 days post-incident
Placenta Praevia
- Placenta partially or completely covers the cervical os
- Embryo embeds in bottom of uterus → placenta develops inferiorly
- Often self-resolving as uterus grows; if not, thinning of placenta causes rupture
- Key indicator: Painless vaginal bleeding
- Differentiated from abruption by absence of pain
- Manage per local clinical guidelines — urgent transport
Mastitis & Postpartum Infections
Mastitis
Inflammation of breast tissue. Breast engorgement & nipple damage can lead to mastitis. If untreated → breast abscess.
Signs & Symptoms
- Flu-like symptoms: fever, chills
- Red, swollen, hot, painful area of breast
Management
- Continue feeding/expressing; gentle massage
- Ice packs; analgesia; anti-inflammatories; antibiotics
- Hospital if IV antibiotics or surgical drainage required
Puerperal (Postpartum) Infection
Infection of genitourinary tract, surgical wound, or breasts occurring up to 42 days postpartum. Group A Streptococcus is the leading cause of severe maternal sepsis.
Diagnosis (2+ of following)
- Pelvic pain & fever
- Abnormal/foul-smelling vaginal discharge
- Delay in uterine involution
Management
Treat per sepsis principles and your local sepsis guidelines. Transport to an appropriate maternity facility (ideally where the woman gave birth) if possible. Pre-alert.
P-SCAD (Pregnancy-Related Spontaneous Coronary Artery Dissection)
Rare but Potentially Lethal
P-SCAD is a separation within the arterial wall by intramural haematoma. Mean presenting age 33 years; typically occurring around 23–24 days postpartum or 32 weeks gestation. Vast majority (>85%) are multiparous.
Contributing Factors
- Hormonal changes causing structural changes to tunica media
- Connective tissue disorders
- >50% increase in cardiac output during pregnancy
- Haemodynamic effects of labour & breastfeeding hormonal changes
Clinical Presentation — Treat as ACS
- Chest pain, dyspnoea, diaphoresis, nausea, dizziness
- ST elevation on ECG
- Ventricular arrhythmias & cardiogenic shock
Perinatal Mental Health
Prevalence
1 in 5 women experience a perinatal mental health problem during pregnancy or in the first year after birth. Mental health conditions in the perinatal period often go undetected and untreated.
Postpartum Psychosis
- Medical emergency — requires urgent assessment
- Rapid, spectacular onset — often within hours of delivery, up to first few weeks
- Loss of reality, hallucinations, delusions, disorganised behaviour
- Causes: Genetics/bipolar history, severe sleep deprivation, rapid hormonal changes, physical stress of birth
Postnatal Depression
- Mood: sadness, hopelessness, difficulty concentrating, thoughts of death/suicide
- Behaviour: fatigue, appetite changes, new risk-taking, urges to self-harm
- Relationships: withdrawal from friends/family, less interest in joyful activities
- Refer to GP, mental health services, PANDA helpline: 1300 726 306
Newborn Transition — Foetal to Extrauterine Life
Major circulatory changes occur at birth when the placenta is removed. Understanding these helps recognise when things go wrong:
Minutes after birth
- Foramen ovale closes (L atrial pressure > R)
- Lungs inflate; fluid replaced by air
Hours after birth
- Ductus arteriosus constricts (high O₂ + ↓ prostaglandins)
- Umbilical arteries constrict
Days after birth
- Ductus venosus & umbilical vein close
- Transition from parallel to series circulation complete
Normal Neonatal Values
| Parameter | Normal Range |
|---|---|
| Heart Rate | 100–160 bpm |
| Respiratory Rate | 40–60 breaths/min |
| Temperature | 36.5°C – 37.5°C |
| SpO₂ (at 10 min) | >95% |
Initial Newborn Assessment
- Response to stimulation — drying with towel, environment change
- Breathing — regular respirations → regular heartbeat
- Muscle tone — flexed & active vs floppy & minimal movement
- Skin colour — often not totally pink in first minutes; assess breathing & tone
Neonatal Resuscitation — The Golden Minute
Aim: Baby breathing well within 1 minute of birth
Normal newborns should have a HR >100 bpm by 2 minutes after birth. APGAR at 1 min and 5 min. Always seek senior clinical guidance and follow local guidelines prior to ceasing resuscitation on a newborn.
1
Preparation — Warm environment; newborn bag & masks, suction device, towel, stethoscope; check equipment
2
At birth — Place on mother's abdomen; note time of birth; dry thoroughly (head, body, back, limbs) to stimulate breathing
3
Assess breathing — Raise jaw, check for secretions; rub back to stimulate. If not breathing → cut cord and move to firm surface
4
Ventilation — Position head; mask over nose & mouth (tight seal); squeeze bag smoothly; observe chest rise; ventilate for 1 minute (breathe 2-3 rhythm)
5
If no chest rise — Reposition head → check & clear secretions → larger breaths → consider BVM adjustment
6
Post-resuscitation — Skin-to-skin; warm blankets; monitor every 15 min (HR, breathing, temp, colour); encourage breastfeeding
Ceasing Resuscitation
Appropriate to consider stopping if heart rate is undetectable and remains so for 10 minutes. However, resuscitation is generally not recommended under 23 weeks gestation. Clinicians are strongly advised to seek senior clinical guidance before ceasing efforts.
Thermoregulation & Hypothermia Prevention
Why Newborns Lose Heat Easily
- Thin skin, less subcutaneous fat → blood vessels close to surface
- High surface area-to-body mass ratio
- Cannot shiver
- Rely on brown adipose tissue (BAT) — limited supply, not renewed
4 Modes of Heat Loss
- Radiation — to nearby cool objects without contact
- Conduction — via direct contact with cold surfaces
- Evaporation — from wet skin (major source at birth)
- Convection — to cool air or drafts
Management by Gestation
- Dry immediately; skin-to-skin with mother
- Warm blanket over both; beanie & booties
- Encourage breastfeeding within first hour
- Dry the baby; skin-to-skin and cover both
- Woolly hat; monitor temperature
- Early advanced/critical care attendance; transport to a neonatal unit (NICU/SCN)
- If born wet & warm: place IMMEDIATELY into polyethylene bag (maternity kit) whilst still wet
- Entire body in bag; zip-lock; head outside the bag
- Dry head well; place woollen hat
- If arrived post-birth (cold): dry first
- PEEP recommended; transport to NICU
Neonatal Jaundice
Overview
Occurs in ~60% of full-term and ~80% of preterm babies in the first week. Hyperbilirubinaemia = imbalance between bilirubin production, conjugation & elimination.
Warning: Kernicterus
Rare but serious complication — chronic neurological sequelae including cerebral palsy, hearing loss, gaze problems & enamel defects from unconjugated hyperbilirubinaemia.
Signs & Symptoms (Severity Scale)
- Yellowing of whites of eyes
- Yellowing face → arms → torso → legs (intensity ↑ with bilirubin levels)
- Lethargy, difficulty waking, high-pitched crying, poor feeding
- Seizures (severe)
Hospital Management
- Phototherapy (blue light converts bilirubin to water-soluble form)
- IV immunoglobulin & blood transfusion if severe
Neonatal Infection
Any Fever (>38°C) in a Neonate Warrants Transport
Neonatal infections are one of the leading causes of neonatal deaths. Unwell neonates often present with non-specific findings. Note: fever is not always present — hypothermia (<36.5°C) can also indicate infection.
Signs & Symptoms to Assess
- Bulging/sunken fontanelle; neck stiffness; altered tone
- Pallor, cyanosis, jaundice
- Lethargy, poor feeding, decreased activity
- Weak peripheral pulses; tachycardia; reduced urine output
- Grunting, tachypnoea, increased WOB
- Rash, fever, joint swelling
High-Risk Groups
- Premature & low birth weight babies
- Known medical condition / congenital anomaly
- Group B streptococcal mother
- Prolonged membrane rupture prior to birth
- Required resuscitation at birth
- Socially disadvantaged families
Common STIs — Quick Reference
Bacterial
Causative
Chlamydia trachomatis
Symptoms
Often asymptomatic; genital discharge & pain, painful urination, testicular pain
Complications
PID, infertility, ectopic pregnancy, preterm birth
Treatment
Doxycycline or Azithromycin
At Risk
Young sexually active people; mother-to-newborn transmission possible
Causative
Neisseria gonorrhoeae
Symptoms
Mostly asymptomatic; penile discharge, dysuria if urethral infection
Complications
PID, infertility; severe neonatal eye infections via mother-to-newborn
Treatment
Antibiotics (ceftriaxone preferred)
At Risk
MSM, young sexually active, Aboriginal & Torres Strait Islander in remote areas
Stages
Primary → Secondary → Latent → Tertiary
Symptoms
Sores initially; if untreated → systemic illness (rash, organ damage)
Complications
Vertical transmission → low birth weight, prematurity, stillbirth
Treatment
Penicillin-based antibiotics
At Risk
High prevalence in MSM and remote Aboriginal & Torres Strait Islander communities
Viral
Transmission
Contact with bodily fluids from person with detectable viral load; vertical (mother-to-child) & breastfeeding
Symptoms
Fever, rash, myalgia, diarrhoea (acute); can be asymptomatic for years
Complications
Opportunistic infections (AIDS), cardiovascular disease, kidney disease
Treatment
Antiretroviral therapy (ART) — not curative but suppresses viral load
Onset
Symptoms 1–4 months after exposure; resolve after 1–3 months (acute)
Symptoms
Anorexia, nausea, jaundice, right upper quadrant pain
Risk Factors
Ethnic background, family history of chronic hepatitis/hepatocellular carcinoma
Complications
Cirrhosis (↑ risk: age, alcohol, smoking, co-infection); extra-hepatic manifestations
Symptoms
Anogenital ulceration, erythema, itching/tingling; urethritis; rarely CNS involvement
Neonatal Risk
Neonatal HSV infection possible — serious complication
Treatment
Valaciclovir, Aciclovir, Famciclovir (antivirals); regular analgesia; catheterisation may be needed
Parasitic
Transmission
Spreads through genital touching or sexual intercourse
Symptoms
Vaginal discharge or penile urethritis; can be long-standing if untreated
Note
Uncommon in urban settings; infection clears quicker in penis than vagina
The LIVES Approach — Sexual Assault Response
Click each letter to explore the principle in detail:
L
Listen
I
Inquire
V
Validate
E
Enhance Safety
S
Support
Listen carefully — Approach the patient with empathy and kindness. Give them your full attention. Allow the person to speak in their own words at their own pace without interruption or judgment.
Inquire about needs and concerns — Ask what they need right now. Assess for injuries requiring immediate treatment. Determine whether they feel safe. Ask about police referral and hospital treatment preferences.
Validate their feelings — Make the patient feel heard and believed. Use a validation statement: "What happened to you is not your fault." Normalise their emotional response. Avoid questioning the patient's account.
Enhance safety — Discuss the plan to protect them from further harm. Quickly assess for any serious injuries. Ensure the immediate environment is safe. Provide police referral if appropriate.
Support — Help connect the patient to information, services, and support. Get to know support services in your area. Refer to a local sexual assault & family-violence support service — these are typically free, confidential and available 24/7.
Forensic Considerations
Minimising Evidence Contamination
- Ensure patient is on a clean stretcher
- Limit people touching the patient — double glove
- Advise against washing/showering — affects evidence collection
- Encourage patient to collect/keep affected clothing
- Clear and concise documentation is critical
Possible Injuries to Assess
- Strangulation — significant ↑ risk of future fatality
- Head injury
- Penetration with an object
- Bodily injuries (bruises, cuts, abrasions)
- Genital injuries
Strangulation — Common Mechanisms of Injury
Venous compression (stagnant hypoxia), arterial compression (ALOC from ↓ O₂), airway compression, skin/soft tissue trauma, blood vessel damage (thrombus/dissection), vital structure damage (muscle, cartilage, nerve, spinal column), and cardiac dysrhythmia from carotid node pressure.
Mandatory Reporting
In many jurisdictions, paramedics have legal obligations to report suspected abuse — particularly of children and vulnerable people. Reporting duties, who is a mandated reporter, and the relevant age thresholds vary by location — know and follow your local mandatory-reporting laws. Many services do not have a specific sexual assault guideline but do have a suspected abuse pathway. Document all findings clearly and objectively.
Intimate Partner Violence (IPV)
Paramedic's Unique Role
Paramedics frequently encounter IPV and have a unique perspective — they are able to observe patients and signs of IPV inside their home environment. A person's immediate safety is always the priority.
Use the Recognise → Respond → Refer → Record framework:
Recognise
Respond
Refer
Record
Recognise Indicators of IPV
- Associated mental health disorders & suicidal ideation
- Medical signs including pregnancy-related complications
- Trauma including signs of assault & violence
- Signs of control (e.g. partner won't allow patient to be alone)
Respond Appropriately
- Ensure patient is alert and in a safe, private environment
- Use indirect, non-judgemental, open questions
- Focus conversation around fear and safety
- Allow patient to use their own words
- Use a validation statement so the patient knows they are heard
Provide Referral Options
- Referral agencies should be specific to the area and situation
- Consult a wide range of agencies for encompassing options
- Specialist support services — direct the patient to a local sexual assault & family-violence service offering 24/7 free, confidential phone/online counselling
Record & Document
- Proper record of injuries can help corroborate a story and identify perpetrators
- Document objectively and accurately
- Confidentiality is still key — follow legal requirements
Domestic Violence in Pregnancy
Key Considerations
- If DV already exists, it is likely to increase in severity during pregnancy
- Young women (18–24) are most at risk
- Pregnancy triggers perpetrator jealousy — signifies autonomous control
- There are now 2 people at risk — mother and unborn child
Poor Birth Outcomes
- Low birth weight & prematurity
- Post-natal depression
- Unintended pregnancies more common in abusive relationships
Specialist Support Services
National and local sexual assault & family-violence counselling services — typically free and confidential. Direct the patient to the service relevant to your location.
Keep going
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