Managing Menacing Maternal Mishaps
By Mitchell Byrd, MD; Benjamin W. Weston, MD, MPH; Paul E. Pepe, MD, MPH; David Miramontes, MD;
Thomas W. Engel II, MD, MPH
Funding shortfalls, loss of appropriate staffing and lower birth rates have all contributed to nationwide closures of obstetrical healthcare facilities, particularly those in nonurban locations.1 Rural areas have faced the worst challenges.1 A 2022 U.S. Government Accountability Office (GAO) report found that, nationwide, more than half of rural counties did not have proper obstetrical services.1 A follow-up report by the March of Dimes Foundation calculated that this problem had impacted as many as 150,000 births during 2022 and that subsequently, from 2022-24, an additional 4% of those obstetrical care centers closed, leaving 35% of all U.S. counties without adequate obstetrical services.2 Even in urban areas, the number of hospitals without proper obstetrical capabilities continued to increase, from 31% a decade ago, to 36% by 2022.3
While access has become progressively challenging, rates of maternal mortality have also been on the rise. The maternal mortality ratio, the number of pregnancy-associated deaths per 100,000 live births, steadily increased in the U.S. over previous decades, from 7.2 in 1987 to a peak of 33.2 in 2021. While declining somewhat since 2021, they still continued to be relatively high (18.4%) in 2024.4 The reported leading associated causes of these deaths were hemorrhage (14.1%), infections (14.4%), blood clots (10.7%) and hypertensive disorders of pregnancy (7.7%), among others.4 Moreover, taken altogether, cardiovascular conditions (cardiomyopathy, hypertension, heart failure, etc.) can account for the largest proportion of U.S. maternal deaths and, according to recent analyses, most were preventable deaths.5 Delays in care, both prehospital and at appropriate receiving facilities, are key factors contributing to this morbidity and mortality.
The decreasing access to appropriate-level care (let alone high-quality obstetrical services) is a growing concern for prehospital clinicians, especially those serving less populated regions with a sparsity of ambulance availability. Among those concerns are the associated impacts on 9-1-1 resources when the closest appropriate receiving hospital for such patients is quite distant. In such regions, the combined distances traveled during the initial response to the patient and subsequent transport out of their local territories is further compounded by lengthy (nonemergent, posted-speed) return to that home jurisdiction. Accordingly, such circumstances can create absences of EMS resources for other time-critical emergencies, especially when that territory may just be served by only one or two ambulances and/or volunteer responders. In that respect, there are also the finite challenges of infrequent encounters and lack of familiarity with such cases among the individual responders. Therefore, all of these circumstances combined can understandably affect optimal decision-making regarding dispositions and even abilities to confidently manage these emotionally charged and often complex cases.
This growing national crisis for EMS, both urban/suburban and rural, has led to the evolution of comprehensive, evidence-based guidelines and the related need for better training. As a result, the National Association of EMS Physicians (NAEMSP) partnering with the American College of Obstetrics and Gynecologists (ACOG), jointly recently released three model guidelines designed to support the prehospital care of high-risk obstetrical emergencies, both prepartum and postpartum, across a spectrum of conditions.6 These latest guidelines not only expand on well-established prehospital interventions, but, in addition, they have now updated diagnostic considerations and therapies using both evidence-based data and multi-disciplinary consensus. In the end, these guidelines advocate for widespread access to certain therapies as well as more aggressive EMS management. This focus is particularly applicable to the realms of preeclampsia/eclampsia and hemorrhage interventions. In turn, these recommendations may significantly affect EMS protocols and training.
Of note, the layout of the guidelines is somewhat unique. They first present general information that can be applicable to any EMS clinician, whether basic or advanced level, followed by more detailed guidance tailored to each practitioner’s scope of practice standards. Ultimately, however, proper implementation of the recommendations provided within these guidelines will also be dependent on local medical director oversight and protocol mechanisms (e.g., delegated practice versus committees), the training level of responding EMS clinicians, distances from capable facilities, and a given state’s regulations regarding EMS scope of practice and designated transport destinations. Nonetheless, for our purposes here, the authors have abstracted and summarized the three pivotal guideline updates derived from these consensus recommendations.
Postpartum Hemorrhage
Postpartum hemorrhage remains one of the leading causes of maternal death, both worldwide and in the United States.7 While severe postpartum bleeding (>1000mL) usually presents within the first 24 hours after delivery, the guideline places emphasis on unanticipated bleeding that can occur up to a month (or even 12 weeks) post partum.7 Regardless of timing, the initial management is the same. First, attempt to increase uterine tone through delivery of the placenta (if still present), fundal massage, and use of intravenous (IV) or intramuscular (IM) oxytocin. Of course, any externally visible lacerations should be sought and have direct pressure applied. Parenteral misoprostol, another therapeutic option, is recommended if long transport times are expected. Today, resuscitation with blood products, including low-titer O+ blood, red cells and/or plasma is becoming increasingly available among many EMS agencies. Such transfusions should be considered to both replace blood losses as well to help improve vascular homeostasis. Evolving practices regarding management of uncontrollable hemorrhage emphasize the earliest administration of IV tranexamic acid (TXA) within the first three hours of birth.8 In this case, the published guidelines under discussion recommend that TXA be given as an initial 1-gram dose followed by another 1-gram dose 30 minutes later if bleeding continues, a recommendation largely based on the ground-breaking 2017 WOMAN trial.9 However, to maintain standardization with current protocols now used for other hemorrhagic conditions, some prehospital systems manage postpartum hemorrhage patients with an immediate 2-gram dose of TXA.
Elevated Blood Pressure
Early detection of pregnancy-associated hypertension is critical to prevent premature deliveries and the risk of “small for gestational age” infants as well as to mitigate the potential for eclamptic seizures, both before and after birth.10 Early detection and rapid treatment of severe maternal hypertension, both pre and postpartum, is associated with an overall mortality benefit.11
While recognizing that accurate assessment of associated hypertensive disorders of pregnancy (and preeclampsia in particular) can be complex, these guidelines provide concise and more simplified rules for EMS clinicians. These concerning conditions generally arise after 20 weeks of gestation, but also can occur up to six weeks postpartum, and occasionally even later.12,13
The guidelines call for treatment within 30-60 minutes including more advanced level EMS intercept if treatment is not immediately available through the initial responding EMS crews. Specifically, severe maternal hypertension indicative of preeclampsia “with severe features” should be identified rapidly using a blood pressure (BP) limit of systolic BP ≥ 160 mmHg or diastolic BP ≥ 110 mmHg. If these findings are confirmed with repeat measurements persisting over 15 minutes, therapeutic interventions should be administered immediately.
The most recommended treatment is IV labetalol as the first choice or hydralazine as a good alternative. Another choice can be oral nifedipine if the other therapies are not available to the responding crews. Nitroglycerine was not recommended. Fourth, the diagnosis of preeclampsia was simplified to include patient-reported/caretaker findings in addition to blood pressure thresholds of systolic BP 140-159 mmHg or diastolic BP 90-109 mmHg. Importantly, a preeclampsia presentation with severe features should prompt immediate administration of magnesium sulfate, both in a loading dose (starting with a 4-gram dose upfront) and an ensuing infusion as available.
Eclampsia
Eclampsia occurs most commonly in the first 48 hours post-delivery, but the risk continues for six weeks postpartum and sometimes longer.14 Depending on numerous factors, maternal mortality has ranged from 5% to 20%.15 While the latest guidelines emphasize that any seizure during pregnancy could potentially be eclamptic in nature, it further states that other seizure causes such as alcohol withdrawal, infection, or hypoglycemia should be assessed before eclampsia is identified definitively. Nonetheless, the first line treatment for eclamptic seizures remains an infusion of IV magnesium (or IM if there is limited intravascular access), a relatively benign intervention. Fortunately, most eclamptic seizures are relatively short-lived and do not progress to status epilepticus.12 If the seizure becomes protracted or does not respond to magnesium, EMS clinicians should always consider those other causes of seizures and their respective treatments. In this case, benzodiazepines such as midazolam are usually the prehospital treatment of choice for seizures and they can also be used as second line therapy in eclampsia, pre and postpartum. Though not mentioned in these guidelines, ketamine is increasingly being recognized as an effective intervention for terminating benzodiazepine-resistant status epilepticus.16 The risk/benefit ratio of ketamine in pregnant patients is an area worthy of discussion as research and guidelines continue to develop. Once seizure activity stops, whether with magnesium or the second-line drugs, continued monitoring for severe ranges of hypertension should still occur.17 One should still maintain a high level of suspicion for eclampsia in patients with unknown pregnancy status, as well as the consideration for noneclamptic seizures in pregnant patients.
While EMS interventions are not a substitute for access to high-quality obstetrical care facilities, the ability to recognize and immediately treat certain life-threatening perinatal complications is a critical task for those earliest responders. Agency medical directors, training staff, and chief officers should review these recommendations in detail, coordinate preemptively with the appropriate receiving facilities and their responsible obstetrical clinicians, provide the appropriate protocols and training, and learn from each case in follow-up. Although centers providing quality obstetrical care are contracting nationwide, these guidelines may help to mitigate the attendant risks for the patients we serve.18
References
1. Maternal Health: Availability of hospital based obstetric care in rural areas accessible version. Government Accountability Office. (10/2022). GAO-23-105515. Washington, D.C. https://www.gao.gov/assets/730/723431.pdf
2. Nowhere to Go: Maternity Care Deserts Across the U.S. 2024 REPORT. March of Dimes (2024). https://www.marchofdimes.org/sites/default/files/2024-09/2024_MoD_MCD_Report.pdf
3. Kozhimannil KB, Interrante JD, Carroll C, et al. Obstetric care access at rural and urban hospitals in the United States. JAMA. 2025;333(2):166–169. doi:10.1001/jama.2024.23010. https://pubmed.ncbi.nlm.nih.gov/39630475/
4. Data from the pregnancy mortality surveillance system. CDC Public Health. (January 30, 2025). https://www.cdc.gov/maternal-mortality/php/pregnancy-mortality-surveillance-data/index.html?cove-tab=2
5. Briller J, Trost SL, Busacker, et al. Pregnancy-related mortality due to cardiovascular conditions. Maternal Mortality Review Committees in 32 U.S. States, 2017 to 2019. JACC Adv 2024 Nov 8;3(12):101382. doi: 10.1016/j.jacadv.2024.101382
6. New EMS Obstetric Emergency Guidelines. NAEMSP. (2025, April 16). https://naemsp.org/news/now-available-new-ems-obstetric-emergency-guidelines/
7. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstetrics & Gynecology 130(4):p e168-e186, October 2017. | DOI: 10.1097/AOG.0000000000002351
8. Postpartum Hemorrhage - Hemorrhage Model EMS Guidelines. NAEMSP (April 16, 2025). https://naemsp.org/wp-content/uploads/2025/04/Hemorrhage-Model-EMS-Guideline_with-logos_Secured-1.pdf
9. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105-2116. doi:10.1016/S0140-6736(17)30638-4 . https://pubmed.ncbi.nlm.nih.gov/28456509/
10. Buchbinder, A. Sibai, BM., Caritis, S. et. al. Adverse perinatal outcomes are significantly higher in severe gestational hypertension than in mild preeclampsia, American Journal of Obstetrics and Gynecology, Volume 186, Issue 1,2002, Pages 66-71,ISSN 0002-9378, https://doi.org/10.1067/mob.2002.120080. (https://www.sciencedirect.com/science/article/pii/S0002937802024882)
11. Gupta M, Greene N, Kilpatrick SJ. Timely treatment of severe maternal hypertension and reduction in severe maternal morbidity. Pregnancy Hypertens. 2018 Oct;14:55-58. doi: 10.1016/j.preghy.2018.07.010. Epub 2018 Jul 31. PMID: 30527119. https://pubmed.ncbi.nlm.nih.gov/30527119/
12. Braunthal S, Brateanu A. Hypertension in pregnancy: pathophysiology and treatment. SAGE Open Med. 2019 Apr 10;7:2050312119843700. doi: 10.1177/2050312119843700. PMID: 31007914; PMCID: PMC6458675. https://pubmed.ncbi.nlm.nih.gov/31007914/
13. Elevated BP EM Model Guidelines. NAEMSP (April 16, 2025). https://naemsp.org/wp-content/uploads/2025/04/Elevated-BP-Model-EMS-Guideline_with-logos_Secured-1.pdf
14. Magley M, Hinson MR. Eclampsia. [Updated 2024 Oct 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554392/
15. Laskowska M. Eclampsia: A critical pregnancy complication demanding enhanced maternal care: a review. Med Sci Monit. 2023 Jul 7;29:e939919. doi: 10.12659/MSM.939919. PMID: 37415326; PMCID: PMC10334845. https://pubmed.ncbi.nlm.nih.gov/37415326/
16. Scheppke KA, Pepe PE, Garay SA, et al. Effectiveness of Ketamine As a Rescue Drug for Patients Experiencing Benzodiazepine-Resistant Status Epilepticus in the Prehospital Setting. Crit Care Explor. 2024;6(12):e1186. doi:10.1097/CCE.0000000000001186, https://pubmed.ncbi.nlm.nih.gov/39642307/
17. Eclampsia Model EMS Guideline. NAEMSP (April 16, 2025). https://naemsp.org/wp-content/uploads/2025/04/Eclampsia-Model-EMS-Guideline_with-logos_Secured-1.pdf
18. Erekson E. Nuki G, Mick N, et al. Evaluation, stabilization, and transfer of pregnant and postpartum patients presenting to emergency departments without inpatient obstetric services. Ann Emerg Med 2026;87:365-373.
About the Authors
Mitchell Byrd, MD, is an emergency physician resident at the University of Wisconsin.
Benjamin W. Weston, MD, MPH, is Chief Medical Director for Milwaukee County EMS.
Paul E. Pepe MD, MPH, FAEMS, MCCM, is coordinator of the Metropolitan EMS Medical Directors (aka “Eagles”) Global Alliance, Dallas, Texas.
David Miramontes, MD, is Medical Director for the City of San Antonio Fire Department.
Thomas W. Engel II, MD, MPH, is Assistant Medical Director, Milwaukee County Office of Emergency Management
