Everything here is a hospital problem, and the value of a page like this is entirely in the minutes before the ambulance arrives — where positioning, one instruction not to push, and knowing what not to do change outcomes more than almost anywhere else in first aid.
1. Bleeding
| When | What to do |
|---|---|
| Any bleeding in pregnancy | Assessment, always — there is no volume small enough to ignore. Heavy bleeding, or bleeding with constant severe abdominal pain and a hard tender abdomen, suggests placental abruption: 999, lie on the left side, keep warm, nothing by mouth. Note that abruption can bleed largely internally, so what you can see may be a fraction of what has been lost |
| After delivery — postpartum haemorrhage | 999. Rub up a contraction: firm circular massage of the top of the uterus through the abdomen until it hardens under your hand. Empty the bladder if possible, since a full one prevents the uterus contracting. Put the baby skin to skin and let them feed — the oxytocin released does the same job as the drug. Keep her flat, legs raised, warm |
Blood loss after birth is routinely underestimated, and a young fit woman compensates until she does not — see the bleeding chapter on why blood pressure falls last. Soaking a pad in under an hour, or any faintness, is an emergency regardless of what the number says.
2. Pre-eclampsia and eclampsia
The reason blood pressure is measured at every antenatal appointment, and the symptoms that matter are ones people attribute to being pregnant.
- Severe headache that does not settle, visual disturbance — flashing, blurring, spots — pain below the ribs, particularly on the right, vomiting, sudden swelling of the face, hands or feet, or feeling generally dreadful. Any of these after 20 weeks is a same-day call, and epigastric pain in particular is repeatedly dismissed as indigestion.
- Eclampsia is a seizure on that background. Manage the seizure as in the collapse chapter — protect the head, time it, nothing in the mouth — then left lateral position and 999. Say the word "eclampsia": magnesium sulfate is the treatment and it changes the response.
- It can present up to six weeks after delivery, which is when it is missed, because everyone has stopped looking.
3. Cord prolapse — rare, and the one where position is the treatment
A loop of cord visible or felt at the vulva after the waters break
- 999 immediately, and say "cord prolapse". This is one of the few genuinely minutes-matter obstetric emergencies, because the cord is being compressed and the baby's oxygen supply with it.
- Do not push the cord back in and handle it as little as possible — handling causes the vessels to spasm, which is the harm you are trying to prevent.
- Change her position to take the weight off it: knees to chest on all fours with the head down, or lying on the left side with hips raised on cushions. Either works; the aim is to move the baby off the cord using gravity.
- Tell her not to push, even if she has the urge.
- Keep any exposed cord warm and moist with a warm wet cloth, and keep her warm.
4. Birth before arrival
Most rapid deliveries proceed without help. The job is to catch, keep warm, and not intervene.
999, and get her comfortable
Any position she wants. Gloves if there are any. Towels, and the room as warm as you can make it — newborns lose heat extraordinarily fast and hypothermia is the commonest avoidable harm here.
Support, do not pull
Let the head deliver in its own time and support it. Never pull on the head, the shoulders or the cord. If the cord is around the neck, gently loop it over the head or let the baby deliver through it.
Keep the baby warm — and it is done differently at term and preterm
At or near term: dry vigorously with a towel — the drying is also the stimulation — then discard the wet towel, put the baby skin to skin on her chest, and cover both, including a hat. A vigorous crying baby needs nothing else.
Preterm, and roughly under 32 weeks, the advice inverts: dry the head only, put a hat on, and put the body into a clear polyethylene bag or wrap without drying it, head out. This is standard resuscitation practice, not improvisation — a very preterm baby loses heat through evaporation faster than a towel can keep up with, and drying wastes the warmth you are trying to hold. A clean food-grade bag is the usual item; a clear freezer or oven bag will do. Head out, face uncovered, and nothing over the mouth or nose. If no bag can be found quickly, dry very gently and wrap in a warm towel rather than delaying — and if the baby has already been dried, a bag is still worth using.
Either way, skin to skin with the mother is the best heat source available and should be the default wherever the baby does not need active resuscitation.
Leave the cord alone
Do not cut it and do not tie it. There is no hurry, delayed clamping is beneficial, and a cord cut with anything to hand is an infection and bleeding risk for no gain.
Let the placenta come on its own, and keep it
Do not pull the cord to hasten it. Put it in a bag or bowl for the midwife — it needs checking for completeness. Then watch for bleeding, and rub up a contraction if it starts.
If the baby does not breathe
Dry, stimulate, and if there is still no breathing after that, five inflation breaths then newborn resuscitation — see the resuscitation chapter. Keep 999 on the line; they will talk you through it.
Two things not to attempt. If the buttocks or a foot present first, or if the head delivers and the shoulders do not, those are manoeuvres for trained hands — stay on the line and follow the call handler. And do not put her flat on her back for a prolonged period at any point in late pregnancy: the uterus compresses the great vessels and drops her blood pressure. Left side, or propped.
5. Maternal collapse and CPR in pregnancy
- Standard CPR, with one modification: from around 20 weeks, have someone displace the uterus manually to the woman's left — two hands from her right side, pushing the bump up and across — which is preferred to tilting the whole body, because a tilted chest makes effective compressions much harder. The aim is to take the weight off the great vessels so compressions can actually move blood.
- Hand position slightly higher on the sternum than usual, because the diaphragm is pushed up.
- Say she is pregnant and how many weeks. It changes the destination and the team, and beyond a certain gestation it changes what is done on arrival.
- Otherwise 30:2, an AED as normal — defibrillation is safe in pregnancy.
6. Preterm labour, and buying time
Regular painful tightenings, a low backache that comes and goes in a pattern, ruptured membranes or bleeding before 37 weeks. It is a 999 or maternity-unit call, immediately, and the reason urgency matters is not usually that the baby is about to arrive — it is that a delay of even 24 to 48 hours changes the outcome substantially, because it buys time for antenatal corticosteroids to mature the baby's lungs, for magnesium sulfate where indicated, and for transfer to a unit with a neonatal intensive care cot.
That is what tocolysis is for. It does not treat the cause and it does not prevent preterm birth. It buys hours, and those hours are used for something specific.
What the UK gives
NICE recommends nifedipine as first-line tocolysis, with atosiban where nifedipine is contraindicated. Both are hospital decisions and both require the woman to be somewhere she can be monitored.
Transdermal glyceryl trinitrate
A nitric oxide donor, applied as a skin patch, which relaxes uterine smooth muscle. It has a thirty-year evidence base and it is not UK guideline therapy, which are both true and are usually reported as though only one of them were.
| What the evidence shows |
|---|
| Lees and colleagues reported in the Lancet in 1994 that patches arrested preterm labour in a small consecutive series, and in 1999 that GTN and ritodrine achieved similar acute tocolysis, with a lower overall preterm delivery rate and fewer side effects on GTN. |
| A Canadian randomised double-blind placebo-controlled trial followed in 2007, and a systematic review and meta-analysis of transdermal nitroglycerin for preterm labour in 2013. The Cochrane review of nitric oxide donors covers the class. |
| The counterweight, stated because it exists: more recent comparisons have found oral nifedipine superior to GTN patches on both efficacy and side-effect profile. The evidence is not one-directional and the trials are small. |
Contested — a real effect on uterine contractility that is not in dispute, attached to clinical trial evidence that is limited, mixed, and has not persuaded UK guideline committees.
Why it is nonetheless interesting in an emergency, pre-arranged
- It is a patch. No cannula, no swallowing, no pump, and it works through skin — which matters when someone is contracting, vomiting, or two hours from a unit.
- It is stable at room temperature, cheap, and small. It can sit in a bag for weeks. That is what makes a pre-arranged plan possible at all.
- It acts within about an hour, and transdermal delivery avoids the first-pass metabolism that makes oral nitrates useless for this.
- The bar it has to clear is low. The goal is not to stop labour but to buy the hours in which steroids work and a transfer happens. Judged against that, an imperfect tocolytic that can be applied at home by someone who already has it is a different proposition from one that requires admission first.
Contraindications and cautions matter here and are the reason it is a prescribing decision. Bleeding first: antepartum haemorrhage or placenta praevia rules it out, as does ruptured membranes and any suspicion of chorioamnionitis. Then hypotension or circulatory compromise, nitrate sensitivity, concurrent phosphodiesterase-5 inhibitors, glaucoma, raised intracranial pressure, obstructive hypertrophic cardiomyopathy. Caution in advanced labour, maternal cardiac disease, hypertensive disorders of pregnancy, antepartum haemorrhage, growth restriction, or any concern about fetal wellbeing. Headache is very common, often severe, and hypotension and transient tachycardia occur — which is also why a plan has to include what to do when those happen.