Obstetrical Emergencies Flashcards
Obstetrical Standing Orders
Assessment - Focused History
• Number of previous pregnancies (GRAVIDA)
• Number of previous viable births (PARA)
• Last Menstrual Cycle
• Show of blood: document time, amount, etc.
• Water broke: document time, color of water, etc.
• Documented multiple births
• Gestational Diabetes
• Narcotic use
• Due date
• Frequency and length of contractions
• Feeling of having to push or have a bowel movement
• If crowning, prepare for a field delivery, but do not delay transport to the closest
appropriate hospital.
• Transport patients in their third trimester not in active labor on their left side
Obstetrical Patients are defined as ____
Pregnancy 20 weeks or greater
Obstetrical Patients transport decisions
• Patients less than 20 weeks are GYN cases and can be transported to closest ED.
• Over 20 weeks with any abdominal/pelvic pain transport to the closest OB hospital.
• Over 20 weeks with a minor concern can go to the closest ED.
( IF PATIENT IS OVER 20 WEEKS WITH ANY CONSTITUTIONAL SYMPTOMS TRANSPORT TO OB HOSPITAL)
• Stable patients over 20 weeks may go to the OB hospital of their choice within 40 minutes.
• Over 20 week and in cardiac arrest transport to closest OB Hospital
• Over 20 weeks and trauma transport to Trauma/OB Hospital
Breech Birth
- Feet or Buttocks Presentation
• If the head does not deliver within 3 minutes of the body, elevate the mother’s hips
(knee to chest position) and insert a gloved hand into the vagina and push the vaginal
wall away from the baby’s nose and mouth.
• Expedite transport while maintaining the knee to chest position and the baby’s airway.
• Administer blow by oxygen to the newborn.
Ectopic Pregnancy
• Ectopic pregnancies usually occur in the first trimester and may present with sudden onset of severe lower abdominal pain and/or
vaginal bleeding.
• Patients with amenorrhea, vaginal bleeding and abdominal pain are highly suspicious for an ectopic pregnancy.
• Other signs & symptoms of an ectopic pregnancy include: referred pain to the left shoulder, Cullen’s Sign (periumbilical ecchymosis) or
Grey Turner’s sign (ecchymosis of the flanks), abdominal distention and tenderness.
Spontaneous Abortion
• Spontaneous abortions usually occur before 20 weeks of gestation.
Signs and symptoms include: abdominal cramping, vaginal bleeding and the passage of tissue or fetus.
Treatment for Complications of Early Pregnancy
- Assess and treat for shock.
* Rapid transport to any approved OB or GYN facility.
Placenta Abruptio
- Sudden onset of severe abdominal pain and tenderness
- Painful uterine contractions
- Vaginal bleeding with dark red blood
- Patient may present in shock
Placenta Previa
• Characterized by painless vaginal bleeding (bright red blood)
Uterine Rupture
• Sudden, intense abdominal pain and vaginal bleeding
Treatment for Third Trimester Complications
• Treatment for third trimester bleeding is aimed at the prevention or treatment of shock.
• Transport patients in their third trimester on left side by elevating the right side of their body 4-6 inches with towels or pillows or by manually displacing the uterus to the left.
• All patients with third trimester bleeding shall be transported to approved OB facility.
• If it is necessary to perform MICCR on a pregnant patient in their third trimester, manually displace the uterus to the left rather that tilting
the patient to the left.
Eclampsia - Information
Severe pre-eclampsia occurs and is characterized by HTN, AMS, visual disturbances, HA, and/or pulmonary edema. Eclampsia is characterized by any of the severe preeclampsia signs/symptoms associated with seizures or coma. Either condition can occur for up to 30 days postpartum.
Severe Pre-Eclampsia and Eclampsia (Gestational Age over 20 weeks) is defined as ___
a SBP greater than 160 mmHg OR a DBP of greater than 110 mmHg on two consecutive blood pressures, 5 minutes apart, with one of the following signs/symptoms: • AMS • Headache • Visual Disturbances • Pulmonary Edema
Pre-Eclampsia and Eclampsia
Treatment
- Check Blood Glucose
- Magnesium Sulfate: as per infusion Protocol
- And Magnesium Sulfate IM: 2GM/IM - 4ml (Lateral Thigh)
- Seizure: follow Seizure Protocol
Meconium Staining
• Meconium will appear as a yellow to dark green substance that may be
noted as a greenish tint to the amniotic fluid or a thick dark green substance coming from the vagina or covering the neonate’s head.
• If upon delivery of the head there is meconium staining present, use a bulb syringe to clear secretions from the mouth and then nose before delivery of the shoulders.
• Meconium aspirators are rarely needed, however consideration for
usage may be given in patients whose airway is obstructed by meconium that cannot be cleared by simpler methods.
Obstetrical Emergencies
Normal Delivery
- Position patient on her back with knees flexed and feet flat on the floor.
- Control delivery of the head, with gentle perineal pressure.
- Do not apply manual pressure to the uterine fundus prior to the birth of the child.
- Do not pull or push on the fetus.
- Do not allow sudden hyperextension of the newborn’shead.
- Once the head delivers, support the newborn’s head and suction the mouth and then the nose.
- Support the newborn’s head as it rotates to align with the shoulders, gently guide the newborn’s head downward to deliver the anterior shoulder.
- Once the anterior shoulder delivers, gently guide the newborn’s head upward to deliver the posterior shoulder and the rest of the body.
Obstetrical Emergencies
Upon Delivery of the Newborn.
• Dry, warm, and stimulate the newborn.
• Wait until the cord stops pulsating before clamping the cord (usually 3-5minutes).
• Clamp the umbilical cord in the following fashion:
• Place the first clamp 4” away from the newborn’s body.
• Milk the cord away from the newborn and towards the mother (this will minimize splatter).
• Place the second clamp 2” away from the first, towards the mother.
• Cut the cord between the two clamps.
• The newborn can be placed on the mother’s chest or abdomen. This will keep the newborn’s umbilical
cord at about the level of the placenta.
• Record an APGAR score at 1 and 5 minutes and document the delivery time.
• Apply firm continuous pressure, manually massaging the uterine fundus after the placenta delivers.
• Preserve the placenta in the bag provided with the OB Kit or a “Red Bio-Hazard bag” for inspection by the receiving hospital.
Neonatal Resuscitation
Following Birth
First 30 seconds
* Clear of Meconium
* Breathing or Crying
* Good muscle tone
* Color pink
* Term
YES = Routine Care
- Provide warmth
- Clear airway
- Dry
NO =
- Provide warmth
- Position: clear airway prn
- Dry, stimulate, reposition
- Oxygen prnNeonatal Resuscitation
Following the initial assessment in the first 30 seconds
- Evaluate respirations
- HR
- Color
Breathing & HR >100 & Pink - Supportive Care
Apnea or HR <100 - 30 seconds positive pressure ventilations
- Ventilating HR >100 & Pink
- Ongoing Care
- If HR remains <60 begin 30 seconds of positive pressure ventilation and chest compressions.
• Ventilations are performed at a rate of 40 BPM
• The compression to ventilation ratio is 3:1
• Check a BGL on all infants
requiring resuscitation - If Pt’s HR remains <60 Administer Epinephrine 0.01 mg/kg
Neonatal Resuscitation
Triangle
Dry, Suction, Tactile Stimulation, position \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Bag & Mask Ventilation \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Chest Compression \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Intubation \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Drugs
Nuchal Cord
• Check for the presence of a nuchal cord after delivery of the head.
• If the cord is around the neck, gently hook your finger under the loop and pull it over
the newborns head. You may have to repeat this if there is more than one loop present.
• If you are unable to free the cord, clamp the cord in two places and cut the cord
between the clamps.
Prolapsed Umbilical Cord
• Place mother in the knee to chest position and manually displace the uterus to the left.
• Insert a gloved hand into the vagina, pushing the newborn up and away from the umbilical cord regardless if there is a pulse present or not. Maintain this position during transport and frequently reassess the umbilical cord for the presence of a pulse, as
contractions are likely to compress the umbilical cord.
• Wrap the exposed cord in a moist sterile dressing and expedite transport to closest OB facility.
