Obstetric

Imminent delivery with cord prolapse and meconium-stained fluid

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Adult · 35yr · female

Patient Information

Dispatch	You are called to a patient (Sarah Nguyen, 35YO female) at the Fremantle Festival main stage area. Bystanders report she is in active labour and says the baby is coming now.
Patient	Sarah Nguyen — 35yr (65kg)
Incident History	Pt is 38 weeks gestation, G2P1, reporting contractions every 2 minutes. Membranes ruptured approximately 20 minutes ago — bystanders note the fluid on the ground appears greenish-brown. Pt is distressed and has a strong urge to push.
Emergency Contact	David Nguyen (Husband) — 0412 384 917

Initial Rapid Assessment

Response	Alert
Airway	Patent. Self-maintaining. Speaking in short sentences between contractions.
Breathing	Increased rate, effort increased with contractions. No stridor or wheeze. SpO2 97% on room air.
Circulation	Radial pulse rapid and strong. Skin pale and diaphoretic. No external catastrophic haemorrhage visible. Greenish-brown fluid pooled beneath patient.
Disability	GCS 15 (E4V5M6). Alert and orientated to time, place and person. Anxious and distressed.
Exposure	Gravid abdomen, active contractions. On visual perineal inspection: umbilical cord visible at vaginal opening — cord prolapse identified. Amniotic fluid is greenish-brown indicating meconium staining.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	97% (RA)	Mild	22	108	118/74	<2s	15	4 4 ++	36.9	–	8
10 mins	99% (O2 NRB 15L)	Mild	20	104	114/70	<2s	15	4 4 ++	36.9	–	8

History Taking

Treatment Response

Diagnosis

This patient is suffering from imminent pre-hospital delivery complicated by umbilical cord prolapse with meconium-stained amniotic fluid, placing the fetus at high risk of cord compression and birth asphyxia requiring urgent action and preparation for neonatal resuscitation.

Facilitator Triggers — if trainees miss a critical step

! (If trainees do not perform a perineal inspection or fail to identify the prolapsed cord within the first 2 minutes — the patient begins screaming that she can feel the baby coming and the cord becomes more visibly prominent at the introitus. Prompt: 'You can see something at the vaginal opening.')
! (If trainees attempt to push the cord back into the vagina or handle the cord — facilitator advises: 'Do not touch or attempt to reposition the cord. What position should the patient be in?')
! (If trainees do not immediately position the patient in the knee-to-chest position — the patient's urge to push intensifies. Facilitator: 'The patient says she can feel the baby coming now.')
! (If trainees do not call for CSP support within 3 minutes of identifying cord prolapse — facilitator states: 'Your partner asks: Should we be getting help? What do you want to do?')
! (If delivery occurs and the newborn is not breathing — facilitator states: 'The baby is out. It is not crying. What do you do?' Expected: dry and stimulate with a towel; if no spontaneous breathing, begin BVM ventilation with infant mask and call for additional support immediately.)

Treatment Objectives

1. Ensure scene safety and don appropriate PPE (gloves, eye protection, gown) given exposure to blood and body fluids.
2. Perform Primary Survey — confirm patent airway, assess breathing and circulation, establish GCS.
3. Perform perineal inspection — identify umbilical cord prolapse (cord visible at vaginal opening) and note colour of amniotic fluid.
4. DO NOT touch or push the cord back — advise patient not to push; do NOT attempt to reinsert cord.
5. Immediately position patient in knee-to-chest position to keep fetal presenting part off the cord.
6. Administer oxygen via non-rebreather mask at 10–15 L/min — titrate to SpO2 94–98%.
7. Call for CSP support immediately — cord prolapse is a time-critical emergency beyond EHS scope; maintain patient in knee-to-chest until CSP or ambulance crew arrives.
8. Contact CSPSOC for clinical advice — advise of cord prolapse, gestation, and patient condition.
9. Prepare for birth if delivery is inevitable before help arrives: infant BVM, suction, towels, space blanket for warmth.
10. If delivery occurs — note and record time of birth; dry and stimulate newborn by rubbing back with towel; assess for spontaneous breathing.
11. If newborn is not breathing — begin BVM ventilation using infant mask; call for additional CSP support immediately.
12. Monitor maternal vital signs every 5 minutes — observe for post-delivery haemorrhage.
13. Do not attempt delivery of the placenta; if it delivers spontaneously place in a bag and transport with patient.
14. Keep mother and newborn warm.
15. Scenario ends on arrival of ambulance and IMISTAMBO handover.
16. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Cord Prolapse · Management of Obstetric Emergencies · Bag Valve Mask Ventilation

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Signs/Symptoms	Active labour contractions every 2 minutes, strong urge to push, sensation of pressure. Membranes ruptured approx 20 minutes ago with greenish-brown fluid.
Allergies	Nil known.
Medications	Nil regular medications. Iron supplements in pregnancy.
Pertinent History	G2P1 — previous vaginal delivery 3 years ago, uncomplicated. No antenatal concerns this pregnancy. Booked at King Edward Memorial Hospital (KEMH). No known placenta praevia.
Last Oral Intake	Light meal approximately 3 hours ago.
Events Leading	Pt was attending the Fremantle Festival with husband. Husband has stepped away briefly. Contractions intensified rapidly. Membranes ruptured while standing near the main stage.
Treatment Prior	Nil. Bystander called 000 and kept patient still on the ground.

Onset	Contractions began approximately 4 hours ago, progressively intensifying. Membranes ruptured spontaneously 20 minutes ago at the festival.
Pain	Severe contraction pain, 8/10, cramping lower abdomen and back radiating around pelvis.
Quality	Cramping, pressure, wave-like with each contraction.
Radiates	Lower back and pelvis.
Severity	8/10