EMS

Lights, Sirens, Complicated Delivery: Ohio CORES Series

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Are you prepared for an OB emergency? In this special six-part podcast series, the Ohio CORES team at The Ohio State University explores the management of pregnant and postpartum women in emergency situations. Each episode focuses on a high-stakes obstetrics scenarios, including: 1) maternal morbidity and mortality, 2) postpartum hemorrhage, 3) hypertensive emergencies, 4) cardiac arrest in pregnant patients, 5) peripartum cardiomyopathy, and 6) complicated vaginal deliveries. Whether you’re in the field, ED, ICU, or on L&D, this series equips you with the knowledge to respond when seconds count.

Ohio CORES (Collaborative Obstetric Resuscitation Education and Simulation) is an interdisciplinary team of educators from The Ohio State University dedicated to improving care for pregnant and postpartum women in critical condition  through high-impact education and simulation training. Supported by funding from the Ohio Department of Children and Youth, Ohio CORES delivers obstetric emergency education to healthcare providers across the state.

In this EMS-focused Crash Cart EM episode, we tackle three high-stakes delivery emergencies: prolapsed cord, breech delivery, and shoulder dystocia. Learn practical, field-ready tips for recognition, initial management, and when to transport—because what EMS does matters for both mom and baby.

Guests: Katie Connell, RN, BSN, C-EFM, CLC; Thomas Connell Firefighter/NREMT-P
Host: Kim Bambach, MD
Editors: Amy Helder; Katie Connell, RN, BSN, C-EFM, CLC; Nicole McGarity, MHI, BSN, RN, CEN; Anneliese Sinclair; Cynthia Shellhaas, MD, MPH; Kim Bambach, MD

1. Prolapsed Cord

  • Cord prolapse is when the umbilical cord exits the cervix before the fetus.
  • A visible cord is a true emergency due to risk of fetal hypoxia.
  • Insert a gloved hand into the vagina and elevate the presenting part off of the cord. Elevate the fetal head manually if this is the presenting part even if you are having trouble keeping the cord between your fingers. Avoid compressing the cord with your fingers.
  • Maintain your hand in place throughout transport until hospital handoff.
  • Position the patient knee-to-chest to reduce cord compression.
  • Clearly alert the receiving hospital that you are managing a prolapsed cord and en route so that they can prepare for emergency delivery/OR.

2. Breech Delivery

  • A delivery where the fetus presents with buttocks, feet, or other body parts instead of the head. Approximately 3% of all deliveries are breech.
  • Allow spontaneous delivery of the legs and trunk without pulling.
  • Support the baby’s body and head gently if delayed—never apply traction to the neck. A towel is around the infants torso to help lift and support.
  • If progress stalls or an arm presents first, transport rapidly for operative delivery.

3. Shoulder Dystocia

  • When one or both shoulders become stuck during vaginal delivery. Usually the anterior shoulder is trapped behind the pubic symphysis.
  • Complications include: fetal brachial plexus injury (due to overaggressive traction), clavicle fracture, fetal hypoxia (due to impaired respirations and/or compression of the umbilical cord), postpartum hemorrhage, and perineal lacerations.
  • Suspect shoulder dystocia if the head delivers and then retracts tightly (“turtle sign”).
  • Perform the McRoberts maneuver (knees to chest) and apply suprapubic pressure—not fundal pressure. This combination will resolve ~50% of obstructions.
  • If that fails, attempt the Gaskin maneuver (all fours) with gentle downward traction.
  • Additional maneuvers are possible, however this is very difficult in the prehospital setting so emphasis should be on rapid transport if these maneuvers are unsuccessful.

4. EMS Pearls

  • Always bring an OB kit, even for routine transports—you may need it.
  • Keep mom and baby together by transporting them to the same OB-capable facility.
  • Ask every reproductive-age patient if they are pregnant or recently postpartum.
  • Recognize complications early and transport rapidly when needed.
  • Place an IV in all pregnant patients—even for routine complaints—because they can decompensate quickly.

Resources:

  1. Virtual Obstetric Emergency Simulation Training at The Ohio State University

Podcast: Play in new window | Download

Hypertensive Disorders of Pregnancy: Ohio CORES Series

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Are you prepared for an OB emergency? In this special six-part podcast series, the Ohio CORES team at The Ohio State University explores the management of pregnant and postpartum women in emergency situations. Each episode focuses on a high-stakes obstetrics scenarios, including: 1) maternal morbidity and mortality, 2) postpartum hemorrhage, 3) hypertensive emergencies, 4) cardiac arrest in pregnant patients, 5) peripartum cardiomyopathy, and 6) complicated vaginal deliveries. Whether you’re in the field, ED, ICU, or on L&D, this series equips you with the knowledge to respond when seconds count.

Ohio CORES (Collaborative Obstetric Resuscitation Education and Simulation) is an interdisciplinary team of educators from The Ohio State University dedicated to improving care for pregnant and postpartum women in critical condition  through high-impact education and simulation training. Supported by funding from the Ohio Department of Children and Youth, Ohio CORES delivers obstetric emergency education to healthcare providers across the state.

In this episode of Crash Cart EM, we continue our podcast series dedicated to obstetric emergency care. This episode focuses on pre-eclampsia and hypertensive disorders of pregnancy, which are a leading cause of maternal morbidity and mortality.  We’ll discuss key definitions, trends, and critical management strategies including the importance of timely interventions like magnesium sulfate and antihypertensive therapies. This episode underscores the necessity of interdisciplinary collaboration and provides actionable insights for emergency and OB providers to address hypertensive emergencies effectively across care settings.

Guests: Cynthia Shellhaas, MD, MPH; Kimberly Bambach, MD
Host: Sheryl Pfeil, MD
Editors: Amy Helder; Katie Connell, RN, BSN, C-EFM, CLC Nicole McGarity, MHI, BSN, RN, CEN; Cynthia Shellhaas, MD, MPH; Kim Bambach, MD

1. Why It Matters

  • Hypertensive disorders are among the leading causes of pregnancy-related deaths
  • Hypertensive disorders increase risk to both mom (seizure, stroke, increased need for C section, etc.) and baby (growth restriction, preterm birth, stillbirth, respiratory distress, etc.)

2. Preeclampsia: The Basics

  • New-onset hypertension ≥140/90 after 20 weeks + proteinuria or other signs of end organ damage
  • Severe range: ≥160/110
  • Can occur up to 12 weeks postpartum, even in patients with a normal pregnancy
  • Postpartum preeclampsia is often overlooked

3. Recognition is Key

  • Ask every reproductive-aged woman: Are you pregnant or have you been in the past year?
  • Look for red flags: headache, RUQ pain, shortness of breath, edema, seizure (eclampsia)

4. Treatment Principles

  • Act fast—this is not benign chronic hypertension
  • Treat BP ≥160/110 promptly:
    • Labetalol IV or Nifedipine PO
  • If seizing, give magnesium sulfate (IM or IV)
  • Always assess for airway compromise and monitor closely

5. When to Transfer

  • Pregnant or postpartum patient with hypertensive emergency → transfer to OB-capable hospital
  • Use medical transport if unstable or severe-range BP
  • Don’t delay- delivery may be the only definitive treatment

6. EMS & Rural Settings

  • EMS plays a vital role in early recognition and communication
  • Frameworks such as SBAR (Situation, Background, Assessment, Recommendation) and MIST (Mechanism, Injuries, Signs, Treatments) can convey key hand-off information
  • Start IVs, gather collateral, and give strong handoffs
  • Ask about pregnancy even when not obvious
  • Rural teams may need to initiate treatment before long transfers

Resources:

  1. Virtual Obstetric Emergency Simulation Training at The Ohio State University

Podcast: Play in new window | Download

CPR in Pregnancy: Ohio CORES Series

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Are you prepared for an OB emergency? In this special six-part podcast series, the Ohio CORES team at The Ohio State University explores the management of pregnant and postpartum women in emergency situations. Each episode focuses on a high-stakes obstetrics scenarios, including: 1) maternal morbidity and mortality, 2) postpartum hemorrhage, 3) hypertensive emergencies, 4) cardiac arrest in pregnant patients, 5) peripartum cardiomyopathy, and 6) complicated vaginal deliveries. Whether you’re in the field, ED, ICU, or on L&D, this series equips you with the knowledge to respond when seconds count.

Ohio CORES (Collaborative Obstetric Resuscitation Education and Simulation) is an interdisciplinary team of educators from The Ohio State University dedicated to improving care for pregnant and postpartum women in critical condition  through high-impact education and simulation training. Supported by funding from the Ohio Department of Children and Youth, Ohio CORES delivers obstetric emergency education to healthcare providers across the state.

In this episode of Crash Cart EM, we cover high-quality CPR in pregnancy- a rare emergency with a 7% survival rate. Learn how to adapt your resuscitation approach, avoid common pitfalls, and perform a resuscitative hysterotomy.

Guests: Jennifer Mitzman, MD; Kimberly Bambach, MD
Host: Sheryl Pfeil, MD
Editors: Rashelle Ghanem; Nicole McGarity, MHI, BSN, RN, CEN; Cynthia Shellhaas, MD, MPH; Kim Bambach, MD

1. Common Causes of Maternal Cardiac Arrest

  • Most common: Pulmonary embolism, hemorrhage (including trauma), hypertensive emergencies, infections, peripartum cardiomyopathy, and rare causes like stroke
  • Often occurs during or immediately after delivery
  • Risk factors: Advanced maternal age, African American race, high parity, and lack of prenatal care

2. What Stays the Same in CPR

  • Same compression rate (100–120/min), hand positioning and depth, defibrillation pad placement and energy levels, medication dosing (e.g., 1 mg epinephrine)

3. Key Differences in Pregnant Patients

  • Manual Lateral Uterine Displacement:
    • Displace uterus to the left to relieve IVC compression
    • Must be done manually- lateral tilt is no longer recommended
  • No LUCAS Device: LUCAS device use is not recommended for use in pregnancy due to safety concerns

4. Procedure and Airway Considerations

  • Prefer humeral IO (above diaphragm) over tibial
  • Chest tubes: Place higher (3rd–4th ICS) due to elevated diaphragm
  • Aggressive oxygenation: Avoid borderline sats—aim for 97–99%
  • High aspiration risk: Have readily suction available (two are helpful)
  • Airway edema common: Downsize ETT

5. Resuscitative Hysterotomy

  • Timing: If no ROSC by 4 minutes and >24 weeks gestation (or fundus at umbilicus), proceed
  • Purpose: Increases maternal preload and decreases afterload- improving perfusion. This is a resuscitative procedure for the pregnant patient and will also maximize chances of survival for the fetus. The procedure is still indicated in the case of fetal demise.
  • Steps:
    • Vertical midline incision
    • Dissect to the peritoneal cavity
    • Incise uterus
    • Deliver fetus, clamp/cut cord
    • Deliver placenta, pack uterus
    • Continue high-quality CPR throughout

7. Team Preparation & Simulation

  • The mental barrier is real– similar to performing a cricothyroidotomy
  • Debrief early, assign roles, and have equipment ready
  • Practice with simulation to improve readiness

Resources:

  1. Virtual Obstetric Emergency Simulation Training at The Ohio State University

Podcast: Play in new window | Download

Peripartum Cardiomyopathy: Ohio CORES Series

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Are you prepared for an OB emergency? In this special six-part podcast series, the Ohio CORES team at The Ohio State University explores the management of pregnant and postpartum women in emergency situations. Each episode focuses on a high-stakes obstetrics scenarios, including: 1) maternal morbidity and mortality, 2) postpartum hemorrhage, 3) hypertensive emergencies, 4) cardiac arrest in pregnant patients, 5) peripartum cardiomyopathy, and 6) complicated vaginal deliveries. Whether you’re in the field, ED, ICU, or on L&D, this series equips you with the knowledge to respond when seconds count.

Ohio CORES (Collaborative Obstetric Resuscitation Education and Simulation) is an interdisciplinary team of educators from The Ohio State University dedicated to improving care for pregnant and postpartum women in critical condition  through high-impact education and simulation training. Supported by funding from the Ohio Department of Children and Youth, Ohio CORES delivers obstetric emergency education to healthcare providers across the state.

In this special episode of Crash Cart EM, we explore peripartum cardiomyopathy- a rare but serious cause of heart failure in late pregnancy and the postpartum period. We’ll review key risk factors, clinical features, and strategies for recognition and early management.

Guests: Jennifer Mitzman, MD; Kimberly Bambach, MD
Host: Sheryl Pfeil, MD
Editors: Katie Connell, RN, BSN, C-EFM, CLC; Pallavi Jonnalagadda, PhD; Jennifer Mitzman, MD; Cynthia Shellhaas, MD, MPH; Kim Bambach, MD

1. Definitions and Risk Factors

  • Peripartum cardiomyopathy is a form of dilated cardiomyopathy causing heart failure.
    It occurs in the last month of pregnancy or within five months postpartum.
  • Risk factors include:
    • Hypertensive disorders (e.g., preeclampsia)
    • Advanced maternal age
    • Obesity
    • Multiparity
    • Cardiomyopathy is 4x more likely in black women and black women are 2x more likely to have persistently impaired cardiac function

2. Recognition

  • Often presents as acute heart failure: dyspnea, orthopnea, peripheral edema, or chest pain.
  • Watch for signs of volume overload, pulmonary edema, JVD, new murmurs, and wheezing (which may mimic asthma). Wheezing may be due to cardiogenic pulmonary edema, not asthma. New adult-onset “asthma” should raise suspicion for cardiac etiology. This diagnosis is often missed due to overlapping symptoms with normal pregnancy changes or obesity bias.
  • Always ask about recent pregnancy– especially in the case of the young female patient with unexplained respiratory symptoms.

3. Initial Management

  • ABCs (Airway, Breathing, Circulation) come first.
  • Support breathing with oxygen or early BiPAP– this may avoid risky intubation.
  • Initial workup includes ordering an EKG, troponin, BNP, chest X-ray, echocardiogram (or performing POCUS).
  • Judicious use of diuretics and inotropes may be needed.
  • Consult Cardiology and Maternal FM when appropriate. Consider transport to advanced OB/cardiac centers for definitive care.

Resources:

  1. Virtual Obstetric Emergency Simulation Training at The Ohio State University

Podcast: Play in new window | Download

Postpartum Hemorrhage: Ohio CORES Series

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Are you prepared for an OB emergency? In this special six-part podcast series, the Ohio CORES team at The Ohio State University explores the management of pregnant and postpartum women in emergency situations. Each episode focuses on a high-stakes obstetrics scenarios, including: 1) maternal morbidity and mortality, 2) postpartum hemorrhage, 3) hypertensive emergencies, 4) cardiac arrest in pregnant patients, 5) peripartum cardiomyopathy, and 6) complicated vaginal deliveries. Whether you’re in the field, ED, ICU, or on L&D, this series equips you with the knowledge to respond when seconds count.

Ohio CORES (Collaborative Obstetric Resuscitation Education and Simulation) is an interdisciplinary team of educators from The Ohio State University dedicated to improving care for pregnant and postpartum women in critical condition  through high-impact education and simulation training. Supported by funding from the Ohio Department of Children and Youth, Ohio CORES delivers obstetric emergency education to healthcare providers across the state.

In this special episode of Crash Cart EM, we dive into postpartum hemorrhage, a leading cause of pregnancy-related deaths in Ohio and globally. We’ll discuss definitions, common causes, and clinical signs. You’ll also learn key management strategies, including assessing blood loss, fundal massage, medications, and advanced interventions like Bakri balloons and surgical options.

Guests: Katie Connell, RN, BSN, C-EFM, CLC; Nicole McGarity, MHI, BSN, RN, CEN
Host: Jennifer Mitzman, MD
Editors: Cynthia Shellhaas, MD, MPH; Kim Bambach, MD

1. Definition & Timing

  • PPH is defined as blood loss greater than 1000 mL after vaginal or cesarean delivery.
  • It can occur immediately or be delayed up to 12 weeks postpartum.

2. Causes: The 4 T’s

  • Tone (uterine atony, the most common cause)
  • Tissue (retained placenta or products of conception)
  • Trauma (lacerations)
  • Thrombin (coagulopathies)

3. Recognition

  • Look for signs of hypovolemia such as tachycardia, pallor, and restlessness.
  • Vital signs may remain normal until significant blood loss has already occured. Use additional tools for assessment.

4. Estimating Blood Loss

  • Visual estimation is unreliable. Use scales or graduated drapes.
  • One gram of soaked material equals one mL of blood.

5. Initial Management

  • Start with fundal massage, establish two large-bore IVs, and give uterotonics (Pitocin, Methylergonovine, Hemabate, Cytotec, TXA).
  • Know contraindications such as avoiding Methylergonovine in hypertension and Hemabate in asthma.

6. Escalation

  • Use uterine tamponade devices like the Bakri balloon or Jada device.
  • If not available, consider Foley catheters or gauze packing.
  • Prepare early for surgery or transfer if bleeding continues.

7. Special Considerations

  • Always ask about recent pregnancy or delivery in reproductive-age patients with unexplained bleeding.
  • Early recognition and prompt action are critical.

Resources:

  1. Virtual Obstetric Emergency Simulation Training at The Ohio State University

Podcast: Play in new window | Download

Maternal Morbidity and Mortality: Ohio CORES Series

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Are you prepared for an OB emergency? In this special six-part podcast series, the Ohio CORES team at The Ohio State University explores the management of pregnant and postpartum women in emergency situations. Each episode focuses on a high-stakes obstetrics scenarios, including: 1) maternal morbidity and mortality, 2) postpartum hemorrhage, 3) hypertensive emergencies, 4) cardiac arrest in pregnant patients, 5) peripartum cardiomyopathy, and 6) complicated vaginal deliveries. Whether you’re in the field, ED, ICU, or on L&D, this series equips you with the knowledge to respond when seconds count.

Ohio CORES (Collaborative Obstetric Resuscitation Education and Simulation) is an interdisciplinary team of educators from The Ohio State University dedicated to improving care for pregnant and postpartum women in critical condition  through high-impact education and simulation training. Supported by funding from the Ohio Department of Children and Youth, Ohio CORES delivers obstetric emergency education to healthcare providers across the state.

In this special edition of Crash Cart EM, Dr. Sheryl Pfeil is joined by Dr. Cynthia Shellhaas and Nicole McGarity, RN, to kick off our new podcast series on obstetric emergency care. This episode explores the landscape of maternal mortality in Ohio, unpacking key definitions, concerning trends, preventable causes, and persistent health disparities. The conversation underscores the urgency of this issue across all healthcare settings- from academic hospitals to rural EDs and prehospital care.
Tune in to learn how simulation-based training is helping providers build the skills needed to improve maternal outcomes.

Guests: Cynthia Shellhaas, MD, MPH; Nicole McGarity, MHI, BSN, RN, CEN
Host: Sheryl Pfeil, MD
Editors: Katie Connell, RN, BSN, C-EFM, CLC; Rashelle Ghanem; Anneleise Sinclair; Kim Bambach, MD

Key Learning Points

1. Definitions and Trends

  • Pregnancy-associated death = death during pregnancy or within a year postpartum, regardless of cause.
  • Pregnancy-related death = death caused or aggravated by the pregnancy or its management. 61% are preventable.
  • U.S. maternal mortality rates have risen over the past decades.
  • Most deaths occur in the postpartum period. 67% occur after delivery- often weeks to months later.
  • Black women have a 3–4× higher mortality risk.

2. Recognition

  • Recognition is key, as many deaths occur outside of labor & delivery: EMS cares for ~30% of patients with pregnancy-related deaths. This is a touch-point where we can potentially intervene and help. 
  • Always ask: “Have you been pregnant in the past year?”. This is especially important for postpartum patients, where signs may be subtle.

3. Key Causes and Contributing Factors

  • Causes in the immediate postpartum period: infection/sepsis and hypertension.
    • Hypertension in pregnancy/postpartum patients is a medical emergency if BP ≥160/110 for 15+ minutes.
    • Sepsis risks include endometritis, retained products after pregnancy loss, and even breast infections.
  • Causes in the late postpartum period: Hemorrhage, thromboembolism, cardiomyopathy.
  • Mental health conditions, substance use, and lack of care coordination are common contributors.

4. System-Level Interventions

  • Data awareness: Institutions should examine their own data to identify clinical outcome disparities.
  • Effective handoffs and continuity of care are essential- especially across EMS, ED, OB, and inpatient teams.
  • Simulation training offers a safe, impactful way to prepare for high-risk, low-frequency events like eclampsia.

Resources:

  1. Ohio Maternal Health Data and Reports
  2. Ohio Pregnancy-Associated Mortality Review
  3. Virtual Obstetric Emergency Simulation Training at The Ohio State University

Podcast: Play in new window | Download