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HLT-LPN37-04 · Lesson 6 · 14 clock hours · practice

Obstetric Emergencies: Recognition and Priority Action

Objective. Students correctly identify clinical signs of obstetric emergencies—including umbilical cord prolapse, shoulder dystocia (nurse support role), amniotic fluid embolism, and postpartum hemorrhage—and execute priority LPN actions including positioning, escalation, and hemorrhage assessment.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.

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Obstetric Emergencies: Recognition and Priority Action

Obstetric emergencies develop rapidly and can be fatal for the mother, the fetus, or both. As an LPN, your role is to recognize warning signs early, take immediate supportive actions within your scope, and escalate without delay to the RN or provider. Speed and correct priority sequencing save lives.

Umbilical Cord Prolapse

Cord prolapse occurs when the umbilical cord slips through the cervix ahead of or alongside the presenting part, compressing the cord and cutting off fetal blood flow. It is most common when membranes rupture and the presenting part is not well applied to the cervix—for example, with a breech presentation or a very small fetus.

Signs: Sudden, severe variable decelerations on the fetal monitor; cord visible at the vaginal opening or palpable on vaginal exam (performed by RN or provider, not the LPN independently).

Priority LPN actions:

1. Call for help immediately—this is an obstetric emergency requiring a provider now.

2. Position the patient to relieve cord compression: place her in the knee-chest position or Trendelenburg (head down, hips elevated) as directed by the RN or protocol.

3. If the cord is visible and outside the vagina, cover it with a sterile moist saline gauze to prevent drying and vasospasm—do NOT push the cord back in.

4. Administer supplemental oxygen by face mask per order.

5. Prepare for emergency cesarean delivery.

Do NOT attempt to push the cord back into the uterus or perform a vaginal exam to assess dilation independently.

Shoulder Dystocia

Shoulder dystocia occurs when the fetal head delivers but the anterior shoulder becomes stuck behind the mother's pubic symphysis. This is a delivery emergency managed by the provider and RN. The LPN's role is supportive.

Signs: The fetal head delivers and then retracts against the perineum ("turtle sign"); delivery does not progress.

Priority LPN actions (support role):

1. Call for help and activate the emergency response per facility protocol.

2. Assist with positioning—the McRoberts maneuver requires the patient's legs to be hyperflexed against her abdomen; assist the patient and hold the leg as directed.

3. Apply suprapubic pressure (not fundal pressure) when instructed by the provider—suprapubic pressure dislodges the shoulder, while fundal pressure worsens impaction.

4. Document time of head delivery and actions taken.

Do NOT apply fundal pressure—this drives the shoulder deeper and can cause fetal injury or death.

Amniotic Fluid Embolism (AFE)

AFE occurs when amniotic fluid enters the maternal circulation, triggering a sudden cardiovascular and respiratory collapse along with coagulopathy (disseminated intravascular coagulation, DIC). It is rare but carries a very high mortality rate.

Signs: Sudden onset of severe dyspnea, hypoxia, hypotension, and altered mental status during labor or immediately postpartum; cardiac arrest may follow; excessive, uncontrolled bleeding due to DIC.

Priority LPN actions:

1. Activate the emergency response system (code) immediately.

2. Stay with the patient and maintain airway; position her on her left side if pregnant to relieve aortocaval compression.

3. Apply high-flow oxygen.

4. Establish or maintain IV access and prepare for rapid fluid administration and blood product administration per orders.

5. Assist the RN and provider with resuscitation; document all interventions and times.

Do NOT leave the patient alone or delay calling the code while waiting to see if symptoms improve.

Postpartum Hemorrhage (PPH)

PPH is defined as blood loss that threatens the patient's hemodynamic stability after delivery—generally considered significant when blood loss exceeds approximately 500 mL after vaginal birth or 1,000 mL after cesarean. The most common cause is uterine atony (a boggy, soft, non-contracted uterus).

Signs: Heavy vaginal bleeding, clots, uterus that feels soft and poorly contracted (boggy) on palpation, rising pad count, tachycardia, hypotension, pallor, diaphoresis.

Fundal Assessment and Massage:

Palpate the fundus by placing one hand just above the symphysis pubis to stabilize the lower uterine segment and the other hand cupped at the fundus. The fundus should be firm, midline, and at approximately the umbilicus in the early postpartum period. A boggy fundus requires massage.

For fundal massage: use a firm, circular motion at the fundus while keeping the lower hand stabilizing below. Massage until the uterus firms. Express clots by applying gentle downward pressure once the uterus is firm. Do NOT forcefully push downward on a boggy uterus without stabilizing the lower segment—this can cause uterine inversion.

Measuring Blood Loss: Use calibrated perineal pads; weigh pads if a scale is available (1 gram = approximately 1 mL blood loss). Count pads and note saturation time.

Priority LPN actions:

1. Perform fundal massage; notify the RN immediately.

2. Apply a clean, quantified perineal pad and begin counting blood loss.

3. Assist the patient to urinate or prepare for catheterization (a full bladder displaces the uterus and prevents contraction).

4. Report using SBAR; stay with the patient.

5. Administer uterotonic medications (e.g., oxytocin) only per specific order and within facility LPN medication administration scope.

Escalation and SBAR

Every obstetric emergency requires immediate escalation. Use SBAR: Situation (what is happening now), Background (relevant history), Assessment (what you think is occurring), Recommendation (what you are asking for). Clear, direct communication prevents delay.

Safety Reminders

Key terms10

Cord prolapseEmergency in which the umbilical cord descends through the cervix ahead of or beside the presenting part, compressing the cord and threatening fetal oxygenation.
Turtle signRetraction of the fetal head against the maternal perineum immediately after delivery, indicating the anterior shoulder is impacted behind the pubic symphysis (shoulder dystocia).
Shoulder dystociaObstetric emergency in which the fetal anterior shoulder becomes impacted behind the maternal pubic symphysis after delivery of the head, preventing further progress.
McRoberts maneuverRepositioning technique for shoulder dystocia in which the patient's thighs are sharply flexed against her abdomen to flatten the lumbar lordosis and rotate the pubic symphysis upward, freeing the impacted shoulder.
Amniotic fluid embolism (AFE)Rare, life-threatening emergency in which amniotic fluid enters the maternal circulation, causing sudden cardiovascular collapse, severe hypoxia, and coagulopathy.
Uterine atonyFailure of the uterus to contract adequately after delivery; the most common cause of postpartum hemorrhage, resulting in a soft, boggy uterus on palpation.
Postpartum hemorrhage (PPH)Excessive blood loss after childbirth that threatens maternal hemodynamic stability; classically defined by volume thresholds or any blood loss causing signs of hemodynamic compromise.
Fundal massageTechnique in which the nurse applies firm circular pressure to the uterine fundus (with the lower hand stabilizing the uterus above the symphysis) to stimulate uterine contraction and control postpartum bleeding.
SBARStructured communication tool: Situation, Background, Assessment, Recommendation; used to deliver concise, organized clinical reports during escalation to the RN or provider.
Suprapubic pressureDownward and lateral pressure applied just above the pubic symphysis by an assistant during shoulder dystocia management to dislodge the impacted anterior shoulder; distinct from—and used instead of—fundal pressure.

Worked examples3

1. A postpartum patient soaked one perineal pad completely in 15 minutes. The pad is a standard calibrated pad rated at 500 mL when fully saturated. How much estimated blood loss (EBL) does this represent, and how would you document the finding?
  1. Step 1: Identify the pad's calibrated capacity. The calibrated pad holds 500 mL when fully saturated.
  2. Step 2: The pad was described as completely (fully) saturated in 15 minutes, so the estimated blood loss from this pad = 500 mL.
  3. Step 3: Rate of loss = 500 mL ÷ 15 minutes ≈ 33 mL per minute, which is rapid and clinically significant.
  4. Step 4: Document: 'One perineal pad fully saturated in 15 minutes; estimated blood loss 500 mL. Fundus assessed as boggy, midline, at the umbilicus. RN notified via SBAR at [time].'
Answer: Estimated blood loss from this pad is 500 mL in 15 minutes. This rate of bleeding is an emergency finding; notify the RN immediately using SBAR and perform fundal assessment.
2. During fundal assessment, you palpate the fundus 2 fingerbreadths above the umbilicus and it feels soft. The patient delivered 1 hour ago. What is your interpretation and what two immediate actions do you take first?
  1. Step 1: Interpret the finding. At 1 hour postpartum the fundus should be firm and at approximately the level of the umbilicus (±1 fingerbreadth). A fundus that is soft (boggy) indicates uterine atony.
  2. Step 2: A fundus 2 fingerbreadths above the umbilicus may indicate a full bladder displacing the uterus upward; assess bladder distension.
  3. Step 3: Immediate action 1—Perform fundal massage: place one hand above the symphysis pubis to anchor the lower uterine segment, cup the other hand at the fundus, and apply firm circular massage until the uterus firms.
  4. Step 4: Immediate action 2—Notify the RN immediately with SBAR report; do not leave the patient.
Answer: The findings suggest uterine atony (possibly worsened by a full bladder). Perform fundal massage immediately and notify the RN via SBAR. Also assess for bladder distension, as a full bladder prevents uterine contraction.
3. You are weighing a used perineal pad to quantify blood loss. The dry pad weighs 25 grams. After use, the pad weighs 175 grams. Using the standard conversion of 1 gram = 1 mL of blood, what is the estimated blood loss from this pad?
  1. Step 1: Identify the weight of the blood-soaked pad: 175 grams.
  2. Step 2: Subtract the dry pad weight: 175 g − 25 g = 150 g.
  3. Step 3: Apply the conversion: 150 g × 1 mL/g = 150 mL.
  4. Step 4: Document: 'Perineal pad weighed; estimated blood loss 150 mL from this pad.'
Answer: Estimated blood loss from this pad is 150 mL. Document the finding, add it to cumulative blood loss totals, and report to the RN.
In class: Scenario carousel: four stations, each presenting an obstetric emergency scenario card; students read findings, write the emergency identified, list two immediate LPN actions, and state one thing they must NOT do independently outside LPN scope—rotate every 8 minutes. · Simulation: postpartum patient with excessive vaginal bleeding; students perform uterine fundal assessment, identify boggy uterus, perform fundal massage on simulator, measure simulated blood loss on calibrated pad, and report via SBAR to RN. · Group debrief using a structured format: identify what was recognized correctly, what action came first and why, what was escalated and to whom, and what documentation is required—instructor facilitates and corrects priority sequencing.
Materials: Birthing/postpartum simulator, calibrated perineal pads (simulated blood loss), SBAR cards, scenario station cards, personal protective equipment (gloves, gown), maternal-newborn textbook, NCLEX-PN test plan (Physiological Adaptation; Safety and Infection Control)
Check: Correct emergency identification at ≥ 3 of 4 carousel stations; fundal massage performed correctly per skills checklist (pass = correct hand placement, direction, and documentation of findings); SBAR includes all elements.

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.

Physiological Adaptation
1. A patient at 38 weeks gestation has a sudden rupture of membranes and the nurse notes the umbilical cord protruding from the vaginal opening. Which action has the highest priority?
Physiological Adaptation
2. The nurse is assisting during a vaginal delivery when the provider announces shoulder dystocia. The RN instructs the nurse to help with McRoberts positioning. Which action reflects correct implementation?
Safety and Infection Control
3. During active labor, a patient suddenly develops severe shortness of breath, drops in blood pressure, and loses consciousness. The nurse suspects amniotic fluid embolism. What is the first action?
Physiological Adaptation
4. A nurse palpates a postpartum patient's fundus and finds it boggy and deviated to the right of midline. What is the most likely cause of the deviation?
Physiological Adaptation
5. When performing postpartum fundal massage, why does the nurse place one hand just above the symphysis pubis before massaging the fundus?
Safety and Infection Control
6. An LPN is reporting a postpartum patient's condition to the RN using SBAR. The nurse states: 'This is the patient in room 4 who delivered 2 hours ago. She is now soaking a pad every 10 minutes. Her fundus is boggy and at the umbilicus. I believe she is experiencing postpartum hemorrhage. I need you to come assess her immediately.' Which element of SBAR is represented by the statement 'I believe she is experiencing postpartum hemorrhage'?
Safety and Infection Control
7. During a shoulder dystocia emergency, which action by the nurse is contraindicated because it worsens fetal impaction?
Physiological Adaptation
8. A postpartum patient who delivered vaginally 30 minutes ago has a blood pressure of 88/52 mm Hg, heart rate of 122 beats per minute, and is pale and diaphoretic. The perineal pad is heavily saturated. Which interpretation of these findings is correct?
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