Obstetrical Emergencies

Obstetrical Emergencies

Recognition:
  • 3rd trimester bleeding: vaginal bleeding occurring ≥ 28 weeks of gestation.
  • Preterm labor: onset of labor/contractions prior to the 37th week of gestation
  • Malpresentation: presentation of the fetal buttocks or limbs.
  • Prolapsed umbilical cord: umbilical cord precedes the fetus.
  • Shoulder dystocia: failure of the fetal shoulder to deliver shortly after delivery of the head.
  • Postpartum hemorrhage: active bleeding after uterine massage and oxytocin administration.
  • Pre-eclampsia/Eclampsia: BP > 160/100, severe headache, visual disturbances, edema, RUQ pain, seizures
EMT STANDING ORDERS
  • Routine Patient Care
  • Do not delay transport for patients with obstetrical emergencies, provide early notification to the receiving facility.
  • If gestational age is known to be < 20 weeks, transport to closest hospital.
  • If gestational age is known to be > 20 weeks or fundus is palpable at or above the umbilicus, contact Medical Direction regarding destination determination.
  • Call for AEMT/Paramedic intercept & Assisst them in patient care.
For third trimester bleeding
  • Suspect placenta (placenta in lower uterine segment)
  • placental abruption (placenta separated from the wall delivery); because hemorrhage may into the cavity, shock can develop despite relatively little vaginal bleeding.
  • Do not perform digital examination
  • Place patient the left lateral position
  • Monitor hemodynamic stability (see Protocol – Adult (56 Medical))
For breech birth (Presentation of buttock):
  • not on newborn. and to proceed normally.
  • If the have delivered, gently elevate trunk legs to delivery of the head.
  • the head is delivered 30 seconds legs, place two fingers into to infant’s mouth. Press the vaginal wall away from infant’s mouth to the fetal airway.
For limb presentation:
  • Place mother in knee-chest or Trendelenberg position.
  • Do attempt delivery; transport emergently as surgery is likely. 
For prolapsed cord:
  • Discourage pushing the mother
  • mother in knee-chest or position.
  • Place a the mother’s vagina decompress the by elevating the presenting part off of the cord. 
  • warm, saline soaked dressing.
For shoulder dystocia:
  • Suspect newborn’s head normally and then retracts perineum are trapped. 
  • Discourage by the mother
  • Support baby’s head, not pull on it. 
  • nasopharyx and oropharynx, as needed
  • Position mother with buttocks end stretcher and thighs flexed (McRobert’s position).  Apply firm with an open hand immediately above pubic symphysis (McRobert’s maneuver).
  • If the above method is unsuccessful, consider rolling the the all-fours position.
postpartum hemorrhage:
  • massage fundus until uterus firm.
  • If possible, initiate breast feeding
For in (regardless etiology)
  • See Arrest Protocol – Adult (1 Cardiac)
  • For patient ≥ 20-gestation if fundus is palpable at above the level of the umbilicus, apply left (LUD) with the patient supine position to decrease compression.  should be maintained during CPR.  If ROSC is achieved, patient should be placed in the lateral position.
  • Transport nearest emergency department
AEMT/ PARAMEDIC STANDING ORDERS:
  • Establish IV access above the diaphragm.
  • For preterm labor:
    • 20 mL/kg 0.9% NaCl, may repeat once.
  • After delivery of placenta(s).
  • If postpartum hemorrhage is present
  • Control with direct pressure.
  • Perform uterine massage.
  • Encourage the mother to nurse the baby.
  • Continued hemorrhage after uterine massage and oxytocin administration, see Tranexamic Acid (TXA) Protocol – Adult (18 Trauma) and consider Tranexamic Acid (TXA):
    • Mix 1 gram of TXA in 100 ml of 0.9% NaCl or LR; infuse via wide open IV/IO bolus over approximately 10 minutes.
  • Notify receiving facility of TXA administration prior to arriving
  • Inform medical control prior to any attempt to assist in pre-hospital delivery.
PEARLS:

The amount of bleeding is difficult to estimate. Menstrual pad holds between 5 – 15 mL depending on type of pad. Maternity pad holds 100 mL when completely saturated. Chux pad holds 500 mL. Estimate the amount of bleeding by number of saturated pads in last 6 hours. Consider transporting the soiled linen to the hospital to help estimate blood loss.

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