08 Special Populations
A practical EMT study guide to recognizing and managing obstetric, newborn, and pediatric emergencies through age-appropriate assessment, stabilization, and transport decisions.
Initial priorities in obstetric emergencies
Special-population care begins with the same priorities used for any emergency: scene safety, standard precautions, a general impression, level of consciousness, airway, breathing, and circulation. Identify immediate threats such as severe bleeding, shock, seizures, respiratory distress, or cardiac arrest before completing a focused history.
For a pregnant patient, ask about estimated gestational age, gravida and para, prenatal complications, contractions, rupture of membranes, vaginal bleeding, fetal movement, due date, medications, and the location of obstetric care. Pregnancy increases maternal blood volume, so serious hemorrhage may exist before blood pressure becomes abnormal. Do not use a normal blood pressure or a calm appearance to rule out shock.
Treat the pregnant patient and fetus as two patients, while prioritizing maternal airway, breathing, circulation, and hemorrhage control. Request additional resources early and transport to an appropriate facility when complications are suspected.
Takeaway: Early recognition, maternal stabilization, and timely transport are more important than completing a lengthy history before treating an immediate threat.
Time-critical pregnancy complications
Vaginal bleeding before delivery should be treated as potentially serious hemorrhage. Place pads externally to collect and estimate blood loss; do not insert anything into the vagina. Treat for shock and transport promptly.
Severe abdominal pain may indicate ectopic pregnancy, placental abruption, uterine rupture, or another time-critical condition. Ectopic pregnancy can include abdominal pain, vaginal bleeding, referred shoulder pain, weakness, or syncope.
A seizure during pregnancy or after delivery may indicate . Protect the patient from injury, maintain the airway, support oxygenation and ventilation as needed, check glucose, and transport rapidly. Follow local protocols for advanced treatment.
Late in pregnancy, supine hypotension can occur when the uterus compresses major blood vessels while the patient lies flat. When spinal injury is not suspected, place the patient in a left-lateral position or manually displace the uterus to the patient’s left while maintaining airway and spinal precautions as indicated.
Pregnancy is not a reason to withhold defibrillation during cardiac arrest. Begin high-quality CPR, use the AED as indicated, request advanced life support, and follow current cardiac-arrest-in-pregnancy protocols.
Takeaway: Bleeding, abdominal pain, seizure, positional hypotension, and cardiac arrest require rapid threat recognition rather than reassurance from initially normal vital signs.
Imminent delivery and childbirth complications
Prepare for delivery when the patient has a strong urge to push, contractions are close together, the perineum is bulging, or the fetal head is crowning. If delivery is not imminent and transport can be completed safely, transport to an appropriate obstetric facility. If delivery is imminent, deliver on scene rather than attempting high-risk transport.
For a normal vaginal delivery:
Use PPE and prepare a clean, warm area.
Support the fetal head as it emerges. Do not pull on the head or body.
Check for a nuchal cord. If it is loose, gently slip it over the head. If it is tight and cannot be reduced, follow local protocol for clamping and cutting.
Guide the head and shoulders only as they naturally rotate; do not apply traction.
After birth, dry and warm the newborn, note the time of birth, and assess breathing and heart rate.
If the newborn is vigorous and does not require resuscitation, provide skin-to-skin contact, cover both patients, and continue temperature monitoring when feasible.
Manage the umbilical cord only according to local protocol and training. Do not delay newborn ventilation for cord care.
Treat the placenta as a specimen if it delivers. Never pull on the cord or attempt to force placental delivery.
Complicated deliveries require additional caution. With a breech presentation, do not pull on the infant; support the body as it delivers, create an airway space if the head is delayed, request immediate advanced support, and transport rapidly. With shoulder dystocia, call for help, avoid traction and fundal pressure, and perform only maneuvers authorized by local protocol, commonly maternal hip flexion with suprapubic pressure. Prepare for neonatal resuscitation.
For meconium-stained fluid, do not routinely suction the mouth and nose solely because meconium is present. Assess breathing, tone, and heart rate, and provide ventilation when indicated.
Takeaway: Support rather than pull, avoid unnecessary vaginal examination and fundal pressure, and prioritize newborn ventilation when it is needed.
and shock
Heavy bleeding after delivery can rapidly cause shock. A soft or boggy uterus suggests uterine atony, but also consider genital-tract lacerations, retained placental tissue, uterine rupture, and clotting problems.
Management includes:
Estimate blood loss and reassess frequently.
Maintain warmth and provide oxygen or ventilatory support as indicated.
Request advanced life support and transport rapidly.
Massage the uterus through the abdomen if it is soft or boggy and local protocol permits.
Save and transport expelled tissue when appropriate.
Never pull on the umbilical cord.
Provide early hospital notification.
A patient who is pale, confused, or heavily bleeding should be treated for shock even if a single blood-pressure reading does not appear severely abnormal. Pregnancy-related blood-volume changes can mask early deterioration.
Takeaway: Control the immediate threat, support perfusion and ventilation, reassess continuously, and do not delay transport.
Newborn assessment and resuscitation
At birth, determine whether the newborn is term, has good muscle tone, and is breathing or crying. If all three findings are present, provide routine care: maintain warmth, dry the newborn, support skin-to-skin contact, and continue evaluation.
If any initial finding is unfavorable, warm and dry the newborn, position the airway, stimulate, and clear the airway only if needed. The key reassessment variables are breathing and heart rate.
Apnea, gasping, or a heart rate below : begin , attach pulse oximetry, and consider cardiac monitoring.
Heart rate remaining below : perform ventilation corrective steps and consider an advanced airway according to provider level and protocol.
Heart rate below despite effective ventilation: begin coordinated chest compressions and ventilation, request advanced support, and follow neonatal resuscitation protocols.
Persistent cyanosis or labored breathing with a heart rate of at least : apply pulse oximetry, provide oxygen as indicated, and consider CPAP if available within the system.
Target preductal oxygen saturation rises gradually after birth. The 2025 neonatal algorithm lists approximately at 2 minutes, at 3 minutes, at 4 minutes, at 5 minutes, and at 10 minutes.
Continue monitoring respiratory effort, heart rate, color, oxygen saturation when available, muscle tone, activity, temperature, and blood glucose when indicated. Apgar scores at 1 and 5 minutes can communicate condition, but scoring must not delay ventilation or other resuscitative care.
Takeaway: Warmth and effective ventilation come first; use heart rate to decide when to escalate care.
Pediatric assessment and recognition of deterioration
Children may compensate for illness or injury until they deteriorate abruptly. A normal blood pressure does not rule out shock. Evaluate trends, work of breathing, mental status, skin signs, interaction with the caregiver, and the child’s overall appearance.
The provides a rapid first impression before touching the child:
Appearance: tone, interactiveness, consolability, look or gaze, and speech or cry.
Work of breathing: abnormal sounds, retractions, nasal flaring, body positioning, and respiratory effort.
Circulation to the skin: pallor, mottling, cyanosis, and abnormal skin color.
Follow the triangle with a hands-on primary assessment. Keep the child with the caregiver when safe, observe before touching, use a calm voice and simple explanations, assess airway and breathing, measure oxygen saturation and pulse when available, evaluate skin signs and mental status, and obtain blood pressure when indicated. Obtain an accurate weight in kilograms when possible because medication and fluid doses are weight-based. Reassess frequently.
Respiratory distress may include increased work of breathing, retractions, nasal flaring, tachypnea, abnormal breath sounds, and anxiety. is suggested by altered mental status, exhaustion, poor respiratory effort, bradycardia, cyanosis, or decreasing responsiveness. Treat as an immediate threat requiring airway and ventilatory support.
Takeaway: In pediatrics, appearance, breathing effort, and skin circulation often reveal deterioration before hypotension occurs.
Pediatric airway, resuscitation, and safety
Children have smaller airways and can deteriorate quickly from edema, secretions, or fatigue. Use appropriately sized equipment and avoid excessive head extension. Maintain a neutral or slight sniffing position for an infant and a neutral position appropriate to body size for a child. Suction only when secretions obstruct the airway.
For a child with a pulse but inadequate breathing, provide ventilations according to current BLS guidance: approximately 20–30 breaths per minute, or one breath every seconds, followed by reassessment.
If a child is unresponsive, is not breathing normally, and has no definite pulse within 10 seconds, begin CPR. Also begin CPR when the heart rate is below with signs of poor perfusion despite effective oxygenation and ventilation. Use an AED as soon as available and use a pediatric attenuator when available and appropriate. For two healthcare rescuers, use cycles of 15 compressions and 2 breaths; for a lone rescuer, use 30 compressions and 2 breaths until another rescuer arrives unless local protocol specifies otherwise.
For foreign-body airway obstruction:
Mild obstruction: encourage coughing and observe closely.
Severe obstruction in an infant: alternate 5 back blows with 5 chest thrusts.
Severe obstruction in a child: alternate 5 back blows with 5 abdominal thrusts.
Unresponsive patient: begin CPR and remove an object only if it is visible. Never perform a blind finger sweep.
Early pediatric shock indicators include tachycardia, delayed capillary refill, cool or mottled skin, weak peripheral pulses, anxiety, and decreased urine output reported by the caregiver. Late indicators include hypotension, bradycardia, altered mental status, and weak or absent central pulses. Treat the immediate life threat, prevent heat loss, use age- and size-appropriate equipment, and transport seriously ill or injured children to a facility capable of pediatric care.
For trauma and safeguarding concerns, use spinal motion restriction and trauma assessment when indicated. Compare the mechanism with the history and physical findings. Unexplained injuries, injuries in different stages of healing, patterned bruising, delayed care, or an inconsistent history may indicate abuse or neglect. Ensure safety, document objective findings, follow mandatory-reporting laws and agency procedures, and do not accuse caregivers at the scene.
Takeaway: Pediatric care depends on early ventilation and oxygenation, correctly sized equipment, frequent reassessment, and calm involvement of the caregiver when safe.