3.9 OBSTETRICAL EMERGENCIES
There are a significant number of problems that may be classified as Obstetrical Emergencies. These emergencies include, but are not limited to the following: abortion, (spontaneous, threatened, inevitable, incomplete, criminal, therapeutic and elective), trauma, ectopic pregnancy, pre-eclampsia, eclampsia, abnormal deliveries (breech, prolapsed cord, limb presentation, and multiple births), bleeding during any trimester, complications of labor and delivery (antepartum hemorrhage, abruptio placenta, placenta previa, uterine rupture, uterine inversion, toxemia of pregnancy, pulmonary embolism and post-partum hemorrhage).
Pre-existing medical conditions can lead to obstetrical complications. The primary concerns are diabetes, hypertension, heart disease and substance abuse. All of these conditions may adversely affect the developing fetus and therefore, may complicate the delivery of the fetus and compromise the health of the mother and child.
All obstetrical emergencies resulting in bleeding disorders should be managed as though the patient is at risk for hypovolemic shock and should be considered an acute emergency requiring efficient management and transport per the Shock Protocol (excluding PASG/MAST therapy). The Obstetrical Emergencies protocol relates to complications of birth and their pre-hospital management.
ASSESSMENT / TREATMENT PRIORITIES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated.
3. Administer high concentration oxygen by non-rebreather mask as determined by patient's condition.
4. Determine patient's hemodynamic stability and symptoms. Continually assess Level of Consciousness, ABCs and Vital Signs. Treat all life threatening conditions as they become identified.
5. Obtain appropriate history related to event, (gravidity, parity, length of gestation, estimated date of delivery, prior C-sections, prior obstetrical or gynecological complications, bleeding, pain, vaginal discharge, LMP), Past Medical History, Medications, Drug Allergies, and Substance abuse.
6. Management of unscheduled field delivery with or without obstetrical complications as they are identified: (see appropriate procedures in this protocol)
- Vaginal Bleeding
- Supine-Hypotensive Syndrome
- Abruptio Placenta
- Pre-eclampsia and Eclampsia
- Placenta Previa
- Uterine Inversion
- Postpartum Hemorrhage
7. Obstetrical emergencies that result in shock should be managed according to the Shock Protocol, excluding the utilization of PASG/MAST.
8. Obstetrical emergencies due to trauma should be managed according to the Abdominal Trauma Protocol: Special Considerations.
9. Transport patient to the nearest appropriate facility as defined by regional point-of-entry protocols.
TREATMENT
BASIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated.
3. Administer high concentration oxygen by non-rebreather mask as determined by patient's condition.
4. Determine patient's hemodynamic stability and symptoms. Continually assess Level of Consciousness, ABCs and Vital Signs. Treat all life threatening conditions as they become identified.
5. See specific management protocols below and follow appropriate treatment procedures.
6. Activate ALS intercept, if deemed necessary and if available
7. Contact MEDICAL CONTROL. Medical Control may order:
a. Utilization of PASG/MAST (leg compartments ONLY)
8. Initiate transport as soon as possible with or without ALS
9. Notify receiving hospital
INTERMEDIATE PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated.
3. Administer high concentration oxygen by non-rebreather mask as determined by patient's condition.
4. Determine patient's hemodynamic stability and symptoms. Continually assess Level of Consciousness, ABCs and Vital Signs. Treat all life threatening conditions as they become identified.
5. See specific management protocols below and follow appropriate treatment procedures
6. ALS STANDING ORDERS
a. Provide advanced airway management (if indicated).
b. Initiate IV Normal Saline while in transport. If suspect hypovolemic etiology, patient is in shock or exhibits signs and symptoms of shock: administer a 250 cc-500 cc bolus and titrate IV to patients hemodynamic status.
7. Contact MEDICAL CONTROL. Medical Control may order:
a. administration of additional IV Normal Saline
b. Utilization of PASG/MAST (leg compartments ONLY)
8. Activate Paramedic intercept, if deemed necessary and if available
9. Initiate transport as soon as possible with or without Paramedics.
10. Notify receiving hospital.
PARAMEDIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated.
3. Administer high concentration oxygen by non-rebreather mask as determined by patient's condition.
4. Determine patient's hemodynamic stability and symptoms. Continually assess Level of Consciousness, ABCs and Vital Signs. Treat all life threatening conditions as they become identified.
5. See specific management protocols below and follow appropriate treatment procedures.
6. ALS STANDING ORDERS
a. Provide advanced airway management (if indicated).
b. Initiate IV Normal Saline while in transport. If patient is in shock or exhibits signs and symptoms of shock: administer a 250 cc to 500 cc fluid bolus and titrate to patient's hemodynamic status.
c. Cardiac monitor/dysrhythmia recognition.
7. Contact MEDICAL CONTROL. Medical Control may order:
a. Administration of additional IV Normal Saline.
b. Utilization of PASG/MAST (leg compartments ONLY)
c. Depending upon patient's condition, further treatment modalities may be required as listed below.
- Magnesium Sulfate 10% 1- 4 gm IV over three (3) minutes (i.e., for eclampsia).
- Ativan (Lorazepam) 2mg-4mg slow IV push or Intramuscularly (IM) (i.e., for eclamptic seizures)
- Valium (Diazepam) 2-4 mg slow IV push or Intramuscularly (IM) (i.e. for eclamptic seizures)
- Calcium Chloride 10% 2 mg-4 mg/kg slow IV push over 5 minutes. (Antidote for Magnesium Sulfate)
- Pitocin (Oxytocin) 10 units IM after delivery of placenta. (management of postpartum hemorrhage) NOTE: Consider possibility of multiple fetuses prior to administration of Pitocin.
8. Initiate transport as soon as possible.
9. Notify receiving hospital.
SPECIAL CONSIDERATIONS FOR OBSTETRICAL EMERGENCIES
When administering emergency care for any of the following conditions, remember that you are treating a primary patient who may be embarrassed, apprehensive and frightened for herself and her unborn child. Therefore, it is important for you to treat her with respect and kindness and to provide her with emotional support. However, in actuality, you are treating two (2) patients.
VAGINAL BLEEDING:
Vaginal bleeding during any given time during pregnancy is not normal and is always of concern. Though the exact etiology of the bleeding cannot be determined in the pre-hospital setting, the onset of bleeding may provide clues to indicate the etiology. For example, bleeding early in the pregnancy may suggest an ectopic pregnancy or spontaneous abortion. Third-trimester bleeding is often the result of an abruptio placentae or placenta previa but, it also may be the result of trauma. Due to the variable mechanisms for bleeding, the amount of blood loss will vary anywhere from spotting to extensive hemorrhage that will require aggressive resuscitation measures.
NOTE: The amount of visualized vaginal blood loss is NOT a reliable indicator as to the actual amount of blood loss occurring. Visualized blood loss will most likely be out of proportion to the degree of shock, inasmuch as several of the bleeding etiologies may conceal the actual blood loss.
Treatment: Follow general treatment guidelines as indicated in protocols. Treat for shock; administer high concentration of oxygen, keep patient warm and place patient in a left lateral recumbent position. Advanced procedures should include 1-2 IVs of Normal Saline (recommended during transport) followed by a 250 cc - 500 cc fluid bolus of Normal Saline. Titrate IV flow rate to patient's hemodynamic status.
This presentation is usually during the third trimester or after twenty (20) weeks of gestation and is a partial or complete separation of the placenta from the wall of the uterus. This condition may present with blood loss ranging from none at all to severe. The patient will most likely complain of severe pain characterized as a severe "tearing" sensation. The more extensive the abruption (tear), the more likely there will be a greater severity of pain and blood loss.
NOTE: Vaginal examinations should never be performed since it may cause a rupture in the placenta resulting in severe life threatening hemorrhage and may precipitate labor.
Treatment: Follow general treatment guidelines as indicated in Obstetrical protocol. Treat for shock; administer high concentration of oxygen, keep patient warm and place patient in a left lateral recumbent position. Advanced procedures should include 1-2 IVs of Normal Saline followed with a 250 cc - 500 cc bolus of Normal Saline. Titrate IV flow rate to patient's hemodynamic status.
Condition when the placenta attaches to the lower portion of the uterus such that it partially or completely covers the cervical opening. The implantation of the placenta occurs early in the pregnancy. However, it is usually not discovered or manifest complications until the third trimester. Common signs and symptoms include: "painless" bright red vaginal bleeding. As a general rule, all incidents of painless vaginal bleeding during pregnancy are considered to be placenta previa until proven otherwise. Another complication of a placenta previa is that the placenta may be the presenting part during delivery, thus will require an emergency cesarean delivery in hospital. NOTE: Vaginal examinations should never be performed since it may cause a rupture in the placenta resulting in severe life threatening hemorrhage and may precipitate labor.
Treatment: Follow general treatment guidelines as indicated in the Obstetrical Emergencies protocol. Treat for shock; administer high concentration of oxygen, keep patient warm and place patient in a left lateral recumbent position. Advanced procedures should include 1-2 IVs of Normal Saline followed with a 250 cc - 500 cc bolus of Normal Saline. Titrated IV flow rate to patient's hemodynamic status.
SUPINE-HYPOTENSION SYNDROME:
This condition usually occurs during the third trimester of pregnancy and while the pregnant patient is in a supine position. The increased mass and weight of the fetus and the uterus compress the inferior vena cava resulting in a marked decrease in blood return to the heart reducing cardiac output which results in a drop in BLOOD PRESSURE: hypotension. Precipitating factors to this syndrome may be the result of dehydration or a reduced circulating blood volume. Therefore, an attempt should be made to determine whether or not there is any evidence of dehydration and/or blood loss.
Treatment: Follow general treatment guidelines as indicated in the Obstetrical Emergencies protocol. If it appears to only be Supine-Hypotension Syndrome, reposition the patient to a left lateral recumbent position. If there is evidence of dehydration and/or blood loss, you should also treat for shock; administer high concentration of oxygen, keep patient warm. Advanced procedures should include 1-2 IVs of Normal Saline followed with a 250 cc - 500 cc bolus of Normal Saline. Titrated IV flow rate to patient's condition.
HYPERTENSIVE DISORDERS OF PREGNANCY: PRE-ECLAMPSIA and ECLAMPSIA
These disorders occur in approximately 3%-5% of pregnancies. Formerly known as "toxemia of pregnancy," these disorders are characterized by hypertension, weight gain, edema, protein in urine, and in late stages, seizures. Pre-eclampsia, in addition to the signs and symptoms just noted, is characterized by headaches and visual disturbances. Eclampsia is further complicated by seizure disorders with resultant high morbidity/mortality for both mother and child.
Treatment: Follow general treatment guidelines as indicated in Obstetrical protocol. Administer high concentration of oxygen and place patient in a left lateral recumbent position. Advanced procedures should include EKG/cardiac monitoring, IV of Normal Saline (KVO). Medical Control may order: Magnesium Sulfate 10% 1 gm to 4 gm IV over three (3) minutes. Ativan (Lorazepam) 2mg-4mg slow IV push or I ntramuscularly (IM). Antidote for Magnesium Sulfate is Calcium Chloride 10% 2 mg-4 mg/kg slow IV push over 5 minutes.
NORMAL DELIVERY / COMPLICATIONS OF LABOR:
Labor is divided into three (3) stages: The first stage begins with the onset of uterine contractions and ends with complete dilation of the cervix. The second stage begins with the complete dilation of the cervix and ends with delivery of the fetus. The third stage begins with the delivery of the fetus and ends with delivery of the placenta.
In general, the most important decision to be made with a patient in labor is whether to attempt delivery of the infant at the scene or transport the patient to the hospital. Factors that effect this decision include: frequency of contractions, prior vaginal deliveries, maternal urge to push, and the presence of crowning. The maternal urge to push and/or the presence of crowning indicate that delivery is imminent. In such cases, the infant should be delivered at the scene or in the ambulance.
Those conditions that prompt immediate transport, despite the threat of delivery, include: prolonged membrane rupture, breech presentation, cord presentation, extremity presentation, evidence of meconium staining, and nuchal cord (cord around infants neck).
UNSCHEDULED NORMAL FIELD DELIVERY
1. Maintain universal blood and body fluid precautions.
2. Follow general treatment guidelines as indicated in Obstetrical Emergencies protocol.
3. Document pertinent gestational/labor history:
- history of hypertension, diabetes, edema or other pertinent medical/surgical history
- history of previous obstetrical complications
- history of previous pregnancies/deliveries
- identify expected date of delivery
- identify possibility of multiple births
- identify length of time between contractions
- identify presence/absence of membrane rupture
- identify presence/absence of vaginal bleeding
4. Determine need for imminent delivery or need for immediate transport
5. Position mother for delivery.
6. Whenever possible, use sterile or aseptic technique
7. Coach mother to breathe deeply between contractions and to push with contractions.
8. As the head crowns control with gentle pressure and support the head during delivery and examine neck for the presence of a looped (nuchal) umbilical cord. If cord is looped around neck, gently slip it over the infant's head (If unable to do so, clamp cord in two places and cut between clamps to release the cord).
9. Suction mouth, then nose of the infant as soon as possible.
10. Support the infant's head as it rotates for shoulder presentation.
11. With gentle pressure, guide the infant's head downward to deliver the anterior shoulder and then upward to release the posterior shoulder. Complete the delivery of the infant.
12. Hold infant firmly with head dependent to facilitate drainage of secretions. Clear infant's airway of any secretions with sterile gauze and repeat suction of infant's mouth, then nose using bulb syringe.
13. Apply two clamps to umbilical cord (if not already done due to Nuchal cord): the first one is placed approximately ten (10) inches from the infant and the second is placed 2"-3" proximal to the first clamp (7"-8" from infant's abdomen). Cut cord between clamps and check for umbilical cord bleeding. If umbilical cord bleeding is evident apply additional clamp(s) as needed.
14. Dry infant and wrap in warm towels/blanket (cover infant's head).
15. Place infant on mother's abdomen for mother to hold and support.
16. Note and record infant's gender and time of birth.
17. If infant resuscitation is not necessary, record APGAR score at 1 minute and 5 minutes post-delivery.
18. If infant resuscitation is necessary, follow neonatal resuscitation protocol.
19. Delivery of the Placenta: (do not delay transport)
- As the placenta delivers, the mother should be encouraged to push with contractions.
- Hold placenta with both hands, place in plastic bag or other container and transport with mother to receiving hospital. NEVER "pull on" umbilical cord to assist placenta delivery.
- Evaluate perineum for tears. If present, apply sanitary napkins to the area while maintaining direct pressure.
20. Initiate transport as soon as possible.
21. Notify receiving hospital.
COMPLICATIONS OF LABOR
The largest part of the fetus (head) is delivered last. In general, breech presentations include buttocks presentation and/or extremity presentation. An infant in a breech presentation is best delivered in the hospital setting since an emergency cesarean section is often necessary. However, if it is necessary to perform a breech delivery in a pre-hospital setting, the following procedures should be performed:
1. Maintain universal blood and body fluid precautions.
2. Follow general treatment guidelines as indicated in Obstetrical Emergencies protocol.
3. Document pertinent gestational/labor history
- history of hypertension, diabetes, edema or other pertinent medical/surgical history
- history of previous obstetrical complications
- history of previous pregnancies/deliveries
- identify expected date of delivery
- identify possibility of multiple births
- identify length of time between contractions
- identify presence/absence of membrane rupture
- identify presence/absence of vaginal bleeding
4. Determine need for imminent delivery or need for immediate transport
5. Position mother for delivery.
6. Whenever possible, use sterile or aseptic technique
7. Allow the fetus to deliver spontaneously up to the level of the umbilicus. If the fetus is in a front presentation, gently, extract the legs downward after the buttocks are delivered.
8. After the infant's legs are clear, support the baby's body with the palm of the hand and the volar surface of the arm.
9. After the umbilicus is visualized, gently extract a 4"-6" loop of umbilical cord to allow for delivery without excessive traction on the cord. Gently rotate the fetus to align the shoulder in an anterior-posterior position. Continue with gentle traction until the axilla is visible.
10. Gently guide the infant upward to allow delivery of the posterior shoulder.
11. Gently guide the infant downward to deliver the anterior shoulder.
12. During a breech delivery, avoid having the fetal face or abdomen toward the maternal symphysis.
13. The head is often delivered without difficulty. However, be careful to avoid excessive head and spine manipulation or traction.
14. If the head does not deliver immediately, action must be taken to prevent suffocation of the infant.
- Place a gloved hand in the vagina with the palm toward the babies face.
- With the index and middle fingers, form a "V" on either side of the infant's nose.
- Gently push the vaginal wall away from the infant's face until the head is delivered.
- If unable to deliver infant's head within three (3) minutes, maintain the infant's airway with the "V" formation and rapidly transport to the hospital.
SHOULDER DYSTOCIA
This occurs when the fetal shoulders impact against the maternal symphysis, blocking shoulder delivery. Delivery entails dislodging one shoulder and rotating the fetal shoulder girdle into the wider oblique pelvic diameter. The anterior shoulder should be delivered immediately after the head:
1. Maintain universal blood and body fluid precautions.
2. Position mother on her left side in a dorsal-knee-chest position to increase the diameter of the pelvis.
3. Attempt to guide the infant's head downward to allow the anterior shoulder to slip under the symphysis pubis.
4. Gently rotate the fetal shoulder girdle into the wider oblique pelvic diameter. The posterior shoulder usually delivers without resistance.
5. Complete the delivery as above.
SUPINE HYPOTENSIVE SYNDROME
This condition manifests itself when a woman is in her third trimester of pregnancy in the supine position. The combined weight and mass of the fetus, uterus and the placenta compresses the inferior vena cava resulting in a reduced blood return to the heart which subsequently reduces cardiac output and therefore, will cause a drop in BLOOD PRESSURE. Unless there is another reason for hypotension (i.e., blood loss, or dehydration) this condition is self correcting if the patient is placed in a left lateral recumbent position. If severe hypotension is present: assume possibility of significant internal hemorrhage and treat patient per Shock Protocol.
PROLAPSED UMBILICAL CORD
This occurs when the cord slips down into the vagina or presents externally after the amniotic membranes have ruptured. Fetal asphyxia may rapidly ensue if circulation through the cord is not re-established and maintained until delivery. If umbilical cord is seen in the vagina, insert two fingers of a gloved hand to raise the presenting part of the fetus off of the cord.
1. Maintain universal blood and body fluid precautions.
2. Position the mother in Trendelenburg or knee-chest-position to relieve pressure on the cord.
3. Instruct the mother to "pant" with each contraction to prevent her from bearing down
4. Insert two gloved fingers into the vagina and gently elevate the presenting part to relieve pressure on the cord and restore umbilical pulse. DO NOT attempt to reposition or push the cord back into the uterus.
5. If assistance is available, apply moist sterile dressings to the exposed cord.
6. Maintain hand position during rapid transport to the receiving hospital. The definitive treatment is an emergency cesarean section.
UTERINE INVERSION
This is a turning "inside out" of the uterus. Signs and symptoms include postpartum hemorrhage with sudden and severe abdominal pain. Hypovolemic shock may develop rapidly.
1. Maintain universal blood and body fluid precautions.
2. Follow standard hemorrhagic shock protocol.
3. Do not attempt to detach the placenta or pull on the cord.
4. Make one (1) attempt to reposition the uterus:
- Apply pressure with the fingertips and palm of a gloved hand and push the uterine fundus upward and through the vaginal canal.
- If procedure is ineffective, cover all protruding tissues with moist sterile dressings and rapidly transport to hospital.
POSTPARTUM HEMORRHAGE
This is defined as the loss of 500 ml or more of blood in the first twenty-four (24) hours following delivery. The most common cause is the lack of uterine muscle tone and is most frequently seen in the multigravida and/or multiple birth mother. However, any other obstetrical malady may cause hemorrhage.
Follow general treatment guidelines as indicated in protocols. Treat for shock; administer high concentration of oxygen. Advanced procedures should include 1-2 IVs of Normal Saline (recommended during transport) followed by a 250 cc - 500 cc fluid bolus of Normal Saline. Titrate IV flow rate to patient's hemodynamic status. Medical control may order: Pitocin (Oxytocin) 10 units IM after placenta delivers or mix 10-40 units in 1,000 ml of Normal Saline (check administration dosage). CAUTION: Consider possibility of multiple fetuses before administration of Pitocin.
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HELPFUL PRODUCTS & FURTHER EDUCATION
-- by Phyllis A. Balch, James F. Balch - 2nd Edition
-- by Phyllis A. Balch, James F. Balch - 4th Edition
-- by Phyllis A. Balch
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