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Overview
This study guide covers obstetrics and pediatric emergencies for the EMT-Basic NREMT exam. Topics include the stages of normal labor and delivery, obstetric complications, newborn resuscitation, and pediatric assessment and emergencies. Mastery of these concepts is critical, as OB and pediatric calls require rapid recognition and precise, protocol-driven interventions.
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Normal Childbirth
The Three Stages of Labor
• Stage 1: Onset of contractions → full cervical dilation
• Stage 2: Full dilation → delivery of the baby (the "pushing" stage)
• Stage 3: Delivery of the placenta
> Key Point: The placenta should deliver within 30 minutes after the baby is born. Retention beyond this point may indicate a complication.
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Delivery Sequence and EMT Actions
| Step | Action |
|---|---|
| Crowning observed | Prepare for immediate field delivery |
| Head delivers | Check for nuchal cord first; slip over head if present |
| Baby delivered | Warm, dry, stimulate; assess breathing, HR, color |
| Baby breathing/crying | Clamp and cut the cord |
| After delivery | Manage mother; await placenta; monitor for hemorrhage |
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Umbilical Cord Clamping
• First clamp: ~10 cm from the baby
• Second clamp: ~5 cm farther from the first
• Cut: Between the two clamps
• Timing: Only after the baby is breathing and crying
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APGAR Score
| Letter | Component | 0 | 1 | 2 |
|---|---|---|---|---|
| A | Appearance (color) | Blue/pale all over | Blue extremities, pink body | Pink all over |
| P | Pulse | Absent | <100 bpm | ≥100 bpm |
| G | Grimace (reflex) | No response | Grimace | Cry/cough/sneeze |
| A | Activity (muscle tone) | Limp | Some flexion | Active motion |
| R | Respirations | Absent | Weak/irregular | Strong cry |
• Assessed at: 1 minute and 5 minutes after birth
• Score interpretation: 7–10 = normal; 4–6 = moderate concern; 0–3 = immediate resuscitation needed
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Key Terms – Normal Childbirth
• Crowning – Appearance of the baby's head at the vaginal opening; delivery is imminent
• Nuchal cord – Umbilical cord wrapped around the baby's neck
• APGAR – Standardized newborn assessment tool scored 0–10
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⚠️ Watch Out For
• Do not clamp the cord before the baby is breathing and crying — premature clamping can deprive the newborn of oxygenated blood.
• Crowning = prepare now. There is no time for transport; field delivery is imminent.
• The APGAR score is an assessment tool, not an indication to delay resuscitation — if the baby needs help, start immediately.
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Obstetric Complications
Bleeding Complications
| Condition | Bleeding Type | Pain? | Key Feature |
|---|---|---|---|
| Placenta Previa | Bright red, painless | ❌ No | Placenta covers cervical opening |
| Abruptio Placentae | Dark, heavy | ✅ Yes | Premature placental separation |
> Memory Trick: Previa = Painless. Abruption = Agony.
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Prolapsed Umbilical Cord
• Definition: Cord precedes the baby through the birth canal → cord compressed → fetal hypoxia
• EMT Interventions (priority order):
1. Place a gloved hand in the vagina to manually relieve pressure on the cord
2. Position mother in knee-chest position
3. Administer high-flow oxygen
4. Transport immediately — do not remove hand from vagina
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Breech Presentation
• Definition: Buttocks or feet deliver first instead of the head
• Risk: The head (largest part) delivers last, increasing risk of cord compression and airway obstruction
• EMT Action: Transport immediately; if body delivers but head is trapped, provide an airway by forming a "V" with your fingers to create a space for the baby to breathe
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Hypertensive Disorders of Pregnancy
| Condition | Definition | Key Signs |
|---|---|---|
| Pre-eclampsia | Hypertension + edema + proteinuria after 20 weeks | Facial/hand swelling, elevated BP, headache, visual changes |
| Eclampsia | Pre-eclampsia with seizures | Active seizures, life-threatening emergency |
> Critical: Eclampsia is pre-eclampsia that has crossed into seizure activity. Treat as a load-and-go emergency.
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Supine Hypotensive Syndrome
• Cause: The gravid (pregnant) uterus compresses the inferior vena cava when the mother lies flat, reducing venous return and cardiac output
• Prevention/Treatment: Transport in the left lateral recumbent position (left side down)
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Key Terms – Obstetric Complications
• Prolapsed cord – Cord presents before the baby in the birth canal
• Breech presentation – Baby positioned buttocks/feet first
• Placenta previa – Placenta implanted over the cervical os; painless bright red bleeding
• Abruptio placentae – Premature placental separation; painful dark bleeding
• Pre-eclampsia – Hypertension + edema + proteinuria (>20 weeks)
• Eclampsia – Pre-eclampsia + seizures
• Supine hypotensive syndrome – IVC compression by gravid uterus in supine position
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⚠️ Watch Out For
• Never remove your hand from the vagina in a prolapsed cord — your hand is the only thing keeping the baby alive during transport.
• Placenta previa is painless — abruptio is painful. Know the difference.
• Eclampsia is NOT just bad pre-eclampsia — the addition of seizures makes it a separate, more critical emergency.
• Always transport pregnant patients on their left side, even if they resist — explain why.
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Newborn Resuscitation
Initial Steps (Birth to 30 Seconds)
1. Warm the infant (dry thoroughly, remove wet linens)
2. Position the airway (slight sniffing position, not hyperextended)
3. Clear the airway if needed (suction mouth then nose)
4. Stimulate by rubbing the back or flicking the soles of the feet
5. Assess breathing, heart rate, and color
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Resuscitation Decision Tree
```
Born → Warm, Dry, Stimulate, Assess
↓
Breathing? HR > 100? Pink?
↓ NO
Begin PPV (40–60 bpm)
↓
After 30 seconds of PPV — HR still < 60?
↓ YES
Begin Chest Compressions
```
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Newborn Resuscitation Thresholds
| Finding | Action |
|---|---|
| HR < 100 bpm OR apneic/gasping | Begin PPV at 40–60 breaths/min |
| HR < 60 bpm after 30 sec of PPV | Begin chest compressions |
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Key Terms – Newborn Resuscitation
• PPV (Positive Pressure Ventilation) – Assisted ventilation delivered via BVM
• Apneic – Not breathing
• APGAR – Assessment tool used at 1 and 5 minutes post-birth
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⚠️ Watch Out For
• The heart rate threshold for PPV is 100 bpm — many students confuse this with the adult threshold.
• The heart rate threshold for compressions is 60 bpm — only after 30 seconds of effective PPV.
• PPV rate for newborns is 40–60 bpm — much faster than the adult rate of 10–12 bpm.
• Stimulate before moving to PPV — some newborns will respond to drying and stimulation alone.
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Pediatric Assessment
Pediatric Assessment Triangle (PAT)
The PAT is a hands-off, visual tool used within the first 30–60 seconds to form a general impression.
| Component | What to Assess |
|---|---|
| Appearance | Muscle tone, interactiveness, consolability, gaze, cry/speech |
| Work of Breathing | Respiratory effort, accessory muscle use, abnormal sounds, positioning |
| Circulation to Skin | Skin color (pallor, mottling, cyanosis) |
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Normal Pediatric Vital Sign Ranges
| Age Group | Respiratory Rate | Heart Rate |
|---|---|---|
| Newborn (0–1 mo) | 30–60 bpm | 120–160 bpm |
| Infant (1–12 mo) | 25–50 bpm | 100–160 bpm |
| Toddler (1–3 yr) | 24–40 bpm | 90–150 bpm |
| Preschool (3–5 yr) | 22–34 bpm | 80–140 bpm |
| School age (6–12 yr) | 18–30 bpm | 70–120 bpm |
> Exam Focus: Toddler respiratory rate of 24–40 bpm is frequently tested.
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Infant Airway Considerations
• Infants are obligate nose breathers — their tongues are proportionally large, blocking oral breathing
• Clinical implication: Nasal secretions can cause significant respiratory distress in infants — suction promptly
• The infant airway is also: smaller, softer, more anterior, and more easily obstructed than an adult airway
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Key Terms – Pediatric Assessment
• PAT (Pediatric Assessment Triangle) – Rapid visual assessment tool: Appearance, Work of Breathing, Circulation to Skin
• Obligate nose breather – Infant who cannot effectively breathe through the mouth
• Mottling – Irregular, blotchy skin discoloration indicating poor perfusion
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⚠️ Watch Out For
• The PAT is a visual assessment — you should be able to complete it without touching the child.
• Higher respiratory rates are normal in younger children — don't mistake a normal infant rate for tachypnea.
• Pediatric patients can compensate well and then deteriorate rapidly — frequent reassessment is essential.
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Pediatric Emergencies
Respiratory Emergencies Comparison
| Condition | Age Group | Key Signs | Critical Action |
|---|---|---|---|
| Croup | 6 months – 3 years | Barking/seal-like cough, stridor, hoarseness; worse at night | Keep calm, humidified O₂, transport |
| Epiglottitis | Any (classically 2–7 yr) | High fever, drooling, muffled voice, tripod/sniffing position | Do NOT examine throat; keep calm, O₂, rapid transport |
> Memory Trick: Croup = Cough (barking). Epiglottitis = Emergency (don't examine).
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Epiglottitis — Critical Danger Signs
• High fever
• Drooling (cannot swallow due to swelling)
• Muffled/"hot potato" voice
• Preference for tripod or sniffing position
> ⚠️ NEVER examine the throat of a suspected epiglottitis patient. Stimulating the airway can cause complete obstruction and death.
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Febrile Seizures
• Definition: Seizure triggered by a rapid rise in body temperature (not the temperature itself)
• Age group: 6 months to 5 years
• Key facts:
- Usually self-limiting
- Most are benign, but cannot assume this in the field
- Treat as any other seizure: protect airway, position, O₂, transport
- Do NOT attempt to lower fever as primary treatment in the field
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Pediatric Cardiac Arrest
• Most common cause: Respiratory failure/arrest (hypoxic event)
- This differs from adults, where primary cardiac events (VF/VT) are more common
• Implication: In pediatric arrest, early, effective airway management and ventilation are paramount
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Pediatric CPR Ratios
| Rescuers | Compression:Ventilation Ratio |
|---|---|
| Single rescuer (adult or child) | 30:2 |
| Two rescuers (pediatric only) | 15:2 |
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Key Terms – Pediatric Emergencies
• Febrile seizure – Seizure caused by rapid temperature rise; ages 6 months–5 years
• Croup – Viral upper airway infection; barking cough, stridor; ages 6 months–3 years
• Epiglottitis – Bacterial epiglottic swelling; drooling, fever, muffled voice; life-threatening
• Tripod position – Child leans forward on hands to open airway; sign of severe respiratory distress
• Stridor – High-pitched inspiratory sound indicating upper airway obstruction
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⚠️ Watch Out For
• Croup vs. Epiglottitis: Both cause stridor, but epiglottitis patients drool and appear toxic (very ill). Never examine the throat.
• Single-rescuer pediatric CPR is 30:2 — same as adults. The ratio only changes to 15:2 with two rescuers.
• Pediatric cardiac arrest is about airway first — think respiratory cause before cardiac cause.
• A child who is sitting still, quiet, and refusing to move may be sicker than they appear — altered mental status in a child is always concerning.
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Quick Review Checklist
Use this list to confirm your mastery before exam day:
Normal Childbirth
• [ ] Recall the three stages of labor in order
• [ ] Define crowning and explain its significance
• [ ] Describe the first action after the baby's head delivers (check for nuchal cord)
• [ ] State correct cord clamping distances (10 cm, then 5 cm farther) and timing
• [ ] Recall that placenta delivers within 30 minutes
• [ ] Name all five APGAR components and assessment intervals (1 min and 5 min)
Obstetric Complications
• [ ] Differentiate placenta previa (painless, bright red) from abruptio placentae (painful, dark)
• [ ] Describe full intervention sequence for prolapsed cord (hand in vagina → knee-chest → O₂ → transport)
• [ ] Explain breech presentation and associated risks
• [ ] Distinguish pre-eclampsia from eclampsia (seizures = eclampsia)
• [ ] State correct transport position for pregnant patients (left lateral recumbent) and why
Newborn Resuscitation
• [ ] List the initial resuscitation steps in order (warm, position, clear, stimulate, assess)
• [ ] State HR threshold for PPV (< 100 bpm or apneic)
• [ ] State HR threshold for compressions (< 60 bpm after 30 sec of PPV)
• [ ] Recall newborn PPV rate (40–60 bpm)
Pediatric Assessment
• [ ] Name the three components of the PAT (Appearance, Work of Breathing, Circulation to Skin)
• [ ] State normal toddler respiratory rate (24–40 bpm)
• [ ] Explain why infants are obligate nose breathers and the clinical implication
Pediatric Emergencies
• [ ] Compare croup and epiglottitis (signs, age, critical actions)
• [ ] State why you never examine the throat in suspected epiglottitis
• [ ] Identify febrile seizure age range (6 months