Obstetric Emergencies, Stabilization & Transport Considerations

Yvette Gonzalez, MS, RN, C-NPT, C-EFM, RMH High Risk Obstetric & Neonatal Transport Clinical Manager

This outreach education presentation is intended as an overview of basic concepts surrounding assessment of the

pregnant patient, OB complications and stabilization priorities for maternal patients.

Follow designated county protocols, policies and guidelines for actual care of obstetric and newborn patients.

60% of Maternal Deaths

PREVENTABLEhttps://www.youtube.com/watch?v=I5Dsn4obCa4&feature=youtu.be

Source: Maternal Mortality Review. https://www.cdcfoundation.org/sites/default/files/files/ReportFromNineMMRCs.pdf. Accessed March 2018.

Causes Of PREVENTABLE Mortality & Severe Morbidity

Failed CommunicationLack Of Recognizing Signs & Symptoms

Misdiagnosis & Ineffective TreatmentFailure In Care Systems & Processes

https://www.youtube.com/watch?v=I5Dsn4obCa4&feature=youtu.be questions pertaining to Neo/HROB.

Sources:1. Maternal Mortality Review. https://www.cdcfoundation.org/sites/default/files/files/ReportFromNineMMRCs.pdf. Accessed March 2018.2. Preventing Maternal Death. TJC Sentinel Event Alert. Sentinel Events. https://www.jointcommission.org/assets/1/18/SEA_44.PDF. Accessed March 20183. Near Miss Mothers. NPR. https://www.youtube.com/watch?v=I5Dsn4obCa4&feature=youtu.be. Accessed May 2018

For every American woman who dies from childbirth, 70 nearly die

US Maternal Morbidity & MortalityLeading Causes & Regions

Source: 1. National Vital Statistics Maternal Morbidity. https://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_04.pdf. Accessed March 2018.2. Meeting the Challenges of Measuring and Preventing Maternal Mortality in the United States. https://www.cdc.gov/grand-rounds/pp/2017/20171114-maternal-mortality.html. Accessed April 2018. 3. Sentinel Event Alert: Preventing Maternal Death. TJC. https://www.jointcommission.org/assets/1/18/SEA_44.PDF. Accessed April 2018

Normal Physiologic Changes In Pregnancy

Cardiovascular • Influence of Hormones, Hemodynamics & Vital Signs

Hematologic • Increased Circulating Blood Volume & Coagulation

Respiratory• Compensated Respiratory Alkalosis: pH 7.4-7.45 & PaCO2 27-32

• O2 Consumption, MV, & Tv

• Delayed gastric emptying---risk for aspiration!

Sources:1. Hayes, Meghan; Larson, Lucia (2012). "Chapter 220. Overview of Physiologic Changes of Pregnancy". Principles and Practice of Hospital Medicine The McGraw-Hill Companies.

https://accessmedicine.mhmedical.com/content.aspx?bookid=496&sectionid=41304210 March 20182. Cardiac Arrest In Pregnancy. AHA Scientific Statement. https://doi.org/10.1161/CIR.0000000000000300 Circulation. 2015;CIR.0000000000000300. Accessed March 2018. Originally published October 6, 2015

Pregnancy Vital Signs & Labs

Normal Pregnant VS

• HR: 85

• SBP: 114

• DBP: 70

• MAP > 70

• Goal: vital organ perfusion

• Ensure adequate preload before initiating vasoactive drugs

Normal Labs

• Hct 34

• Platelets > 150

• AST & ALT ~ 35

• Creatinine < 1.0

• WBC < 16

Source: Hayes, Meghan; Larson, Lucia (2012). "Chapter 220. Overview of Physiologic Changes of Pregnancy". Principles and Practice of Hospital Medicine The McGraw-Hill Companies. https://accessmedicine.mhmedical.com/content.aspx?bookid=496&sectionid=41304210 Accessed March 2018

Causes of Arrest in OB Patients

B –E –A –U –C –H –O –P –S

Bleeding-DIC, Embolism, Anesthetic complications, Uterine atony, Cardiac

disease, Hypertensive disease, Other, Placental, Sepsis

Other Considerations : Peripartum Cardiomyopathy, & Vascular Dissections

Source:1. The American Heart Association 2010 Guidelines for the Management of Cardiac Arrest in Pregnancy: Consensus Recommendations on Implementation Strategies. http://www.jogc.com/article/S1701-2163(16)34991-X/pdf . 2. American Heart Association: AHA. Maternal Cardiac Arrest. http://circ.ahajournals.org/content/132/18/1747. Accessed March 20173. Direct Causes of Maternal Mortality. Dartmouth.edu. Countdown to 2015 Decade Report (2000-2010), World Health Organization (2010).

Rapid OB Assessment Primary Impression & Priorities?

Prenatal care, history & current condition?• GPTPAL?

• How many weeks is she?

• Complications with this pregnancy?

• Complications with past pregnancies?

• Medical History? Medications?

• Vaginal bleeding? Leaking fluid?

• Pain: location, continuous or rhythmic?

• Injured: MOI?

What about the fetus??• Does she feel fetal movement (typically present by 20 weeks)?

• Dopper FHR (normal 110-160)?

Source: ASTNA, Patient Transport: Principles & Practice. 4th Edition

How Many Weeks Pregnant Is She? Fundal Height Assessment?Viable Fetus (>23 weeks)?

Peri-Transport Optimal Maternal Positioning

Lateral Uterine Displacement Improves Maternal CO &

Fetal Perfusion!

Source: Aortocaval Compression Conundrum in Obstetrics. https://journals.lww.com/anesthesia-analgesia/Citation/2017/12000/The_Aortocaval_Compression_Conundrum.7.aspx. Accessed March 2018.

OB Care Priorities: Stabilization & TransportABCs

Lateral Positioning: ~ 15 degrees

Vascular Access & Fluid Bolus • If indicated: LR or NS

Treat Mom To Treat Fetus!!• Uteroplacental Unit-New “End-Organ”

During Transport: • Ensure stability of mother and fetus during transport• Obtain frequent maternal vital signs & fetal assessment

• Fetal movement? Doppler FHR? Vaginal bleeding present?

Source: Trauma in the Obstetric Patient. American College of Emergency Physicians. https://www.acep.org/Clinical---Practice-Management/Trauma-in-the-Obstetric-Patient--A-Bedside-Tool/. Accessed March 2018.

Uteroplacental Blood Flow & Bleeding During Pregnancy

Source: 1. ACOG. Bleeding During Pregnancy. https://www.acog.org/Patients/FAQs/Bleeding-During-Pregnancy. Accessed March 2017.2. https://www.acog.org/-/media/Districts/District-II/Public/SMI/v2/he-06b-AF-140516-HemChecklist-Binder.pdf?dmc=1&ts=20171212T2152159656. Accessed March 2017.

Placental Abruption: Bleeding RiskRisk Factors?

Placental Detachment• May present with dark red & painful bleeding, OR

• Bleeding may be occult, rigid abdomen with severe pain !!

Source: Bleeding During Pregnancy. ACOG. https://www.acog.org/Patients/FAQs/Bleeding-During-Pregnancy. Accessed March 2018

Abnormal Placental Implantation• Previa: Bright red, painless bleeding with or without UC’s

• Invasive Placental Implantation: C/S & Hemorrhage Risk

•Rapid transport to surgical & MTP capability center

Source: Placenta Previa-Obstetric Risk Factors & Pregnancy Outcome. https://www.ncbi.nlm.nih.gov/pubmed/11798453. Accessed March 2018

#1Cause of Maternal Death: OB Trauma

Primary Causes: MVA, Intimate Partner Violence Abuse, & Falls• Risk of abdominal trauma & hemorrhage

Physiologic Changes Can Mask Signs of Shock• Increased blood volume, cardiac output, mild tachycardia

Uteroplacental Unit: Risk for Maternal Fetal Hemorrhage & Fetal Compromise

Source: Trauma In The Obstetric Patient. American College of Emergency Physicians. https://www.acep.org/Clinical---Practice-Management/Trauma-in-the-Obstetric-Patient--A-Bedside-Tool/. Accessed March 2018

OB Trauma: Stabilization, Assessment & Transport

• Communication: Trauma Center, OB & Neonatal Teams: Prepare For 2+ Patients

• OB Assessment • Primary & Secondary Survey

• ABCDE

• MOI

• Fetal Assessment: FHR – FetalMovement?

• Bleeding?

• Rigid Abdomen?

• EDD? Viability?

• Labs & Diagnostics: • KB, Rh & FAST Scan-Ultrasound

1. ACOG. Bleeding During Pregnancy. https://www.acog.org/Patients/FAQs/Bleeding-During-Pregnancy. Accessed March 20172. High Risk & Critical Care Obstetrics. N. Troiano, C. Harvey, B. Flood Chez. AWHONN 2013, 3rd Edition.

Intrauterine Resuscitation MeasuresLateral Positioning

• Optimize perfusion to uteroplacental unit

IV Fluid Bolus: Based on clinical condition

• Correction of maternal hypotension is essential!!

Oxygen Supplementation :• May optimize maternal oxygenation status and fetal oxygen delivery.

Reduction of Uterine Activity: Tocolysis

Source: Maternal Oxygen Administration As An IntraUterine Resuscitation Measure During Labor. Simpson, Kathleen Rice. MCN: The American Journal of Maternal/Child Nursing: March/April 2015 - Volume 40 - Issue 2 - p 136http://www.sfnmjournal.com/article/S1744-165X(08)00061-9/abstract. Accessed March 2018.

OB Cardiac Arrest & Perimortum Cesarean Delivery

Recognition, CRM, & Teamwork

BLS, ACLS & ATLS

Positioning• Laterally to improve preload & CO

Primary Impression & Delivery• Every Minute Matters

• Rapid Assessment: Is Fetus Viable & Alive?

• Maternal Death Imminent?

• Prepare for Delivery & NRPSource: 1. Aortocaval Compression Conundrum in Obstetrics. https://journals.lww.com/anesthesia-analgesia/Citation/2017/12000/The_Aortocaval_Compression_Conundrum.7.aspx. Accessed March 2018.2. Cardiac Arrest In Pregnancy. AHA Scientific Statement. https://doi.org/10.1161/CIR.0000000000000300 Circulation. 2015;CIR.0000000000000300. Accessed March 2018. Originally published October 6, 20153. Preparing For Clinical Emergencies In Obstetrics. ACOG. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Patient-Safety-and-Quality-Improvement/co590.pdf?dmc=1&ts=20180426T2325399798. Accessed March 2018

Tick Tock...Every Minute Matters

Preterm Labor &

Preterm Premature Rupture of Membranes

• Primary Impression?, Consult, & Pre-transport Stabilization

• Optimize Tocolysis

• Fetal Protection: Magnesium Sulfate, Antenatal Steroids & Antibiotics

• Evaluate Progression Of Labor: Cervical Exam

• Transfer To Higher Level Of OB & Neonatal Care Source:1. Society For Maternal Fetal Medicine. Implementation of the Use of Antenatal Corticosteroids in the Late Preterm Birth Period in Women at Risk for Preterm Delivery. August 2016. Accessed March 2017. 2. ACOG. Management of Preterm Labor. https://www.acog.org/Womens-Health/Preterm-Premature-Labor-and-Birth. October 2016. Accessed March 2017 3. The American College of Obstetricians and Gynecologists Committee on Obstetric Practice Society for Maternal-Fetal Medicine. Magnesium Sulfate In Obstetrics. January 2016. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co652.pdf?dmc=1&ts=20171212T2253317113. Accessed August 2017.

The Pressure Is On…..OB Hypertensive Emergencies

Defined: SBP >160mmHg, or DBP > 100mmHg, acute-onset, & persistent (>15 min)

Severe systolic hypertension--most important predictor of cerebral hemorrhage in OB patients• Goal B/P: Range of 140-160/90-100 mmHg to preserve fetal perfusion!!• Severe hypertension can occur antepartum, intrapartum or post-partum (6 wks)

Stabilization Considerations: • Magnesium Sulfate, Antihypertensives, Anticonvulsants, Transport & Delivery

Source:1. California Maternal Quality Care Collaborative: CMQCC. https://www.cmqcc.org/. Accessed August 20172. ACOG. Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period. April 2017. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co692.pdf?dmc=1&ts=20171212T2343034025.

Accessed May 2017

Image Source: https://www.thirdstopontheright.com/may-is-preeclampsia-awareness-month-do-you-know-the-signs-and-symptoms/. Accessed April 2018

Preeclampsia, HELLP & Eclampsia

Cerebral Effects Cardiac/Vascular

Pulmonary Liver Renal Fetal

Labs: Obtain Hct, Platelets, LFT’s, Cr, Coags

Preeclampsia Assessment

Treatment-Stabilization: Magnesium Sulfate, Antihypertensives, Anticonvulsants, Delivery

Source: 1. California Maternal Quality Care Collaborative: CMQCC. https://www.cmqcc.org/. Accessed August 20172. https://www.propublica.org/article/die-in-childbirth-maternal-death-rate-health-care-system. Accessed December 2017

HELLP Syndrome: State of Coagulopathy Variant of severe preeclampsia

Presentation similar to pre-eclampsia with or without hypertension

Diagnosis determined by laboratory confirmation of: • Hemolysis• Elevated Liver Enzymes• Low Platelets

Treated similar to PEC with addition of blood products (as needed): • PRBC’s and Platelets• Antihypertensive Medications: Labetalol or Hydralazine (as needed)• Magnesium Sulfate infusion

Source: 1. California Maternal Quality Care Collaborative: CMQCC. https://www.cmqcc.org/. Accessed August 2017

Eclampsia: Onset of Seizures With PEC• Initiate Magnesium Sulfate: Bolus then continuous infusion

• Rebolus Magnesium if seizure continues

• Lorazepam or Versed

• Other options: Diazepam, Phenytoin, & Keppra

• Maintain ABC’s and protect patient

• Difficult to obtain EFM tracing during maternal seizuresSource: 1. California Maternal Quality Care Collaborative: CMQCC. https://www.cmqcc.org/. Accessed August 20172. https://www.propublica.org/article/die-in-childbirth-maternal-death-rate-health-care-system. Accessed December 2017

Delivery Outside Of OB Unit : Now What??• Supplies: OB Kit & Neo Ventilation Device

• Place infant on mothers abdomen after birth

• Clamp cord 8-10 inches from baby• Use 2 clamps several inches apart: cut between clamps

• Delayed Cord Clamping X 30-60 seconds IF VIGOROUS

• Immediate Cord Clamping IF NONVIGOROUS

• Provide basic newborn care• Clear Airway & Optimal Airway Positioning

• Dry Thoroughly & Provide Warmth

• Continuous assessment of ABC’s

• Thermoregulation & Blood Glucose

Source: Neonatal Resuscitation Program. AAP. 7th Edition

Tiny Ones: Preterm Delivery

Delayed Cord Clamping:

IF vigorous DCC reduction of IVH

IF NONVIGOROUS immediate umbilical cord clamping & NRP

Thermoregulation & Neuroprotection:

Warming mattress, isolation bag, hat, nesting, & head alignment with gentle handling

NRP Guidelines:

Sp02 & ECG, CPAP, PPV, airway & perfusion support, careful fluid administration, glycemic control, early activation of neonatal & transport teams!

Source:1. AAP. Neonatal Resuscitation Program. 7th Edition.

Delivery of Placenta: Now What?

Anticipate within 20 min after delivery• Do not pull on cord

Normal blood loss ~ 500ml

Provide vigorous fundal massage!!

• Support lower uterine segment

• Ensure uterus stays contracted-firm

• Uterotonics: as needed

Source: ACOG Guidelines For Management Of Hemorrage. https://www.aafp.org/afp/2007/0401/p1101.html. Accessed 3/2018.

Postpartum Hemorrhage • Provide Vigorous Continuous Fundal Massage• Leading cause: uterine atony after birth• Goal: uterus remains contracted & firm

Adequate Vascular AccessContinuous Fundal MassageUterotonics: Pitocin-dose & rateConsider TXA: Consult Rapid Transport: Surgical CenterD&C -- Removal of Placental PartsOR --- Looking For BleedersActivate Massive Hemorrhage Protocol

Source: OB Hemorrhage V2 Toolkithttps://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit. CMQCC. California Maternal Quality Care Collaborative. Accessed 3/20/2018

Image Source: dailymom.com

Thank You & Questions

Neonatal Resuscitation & Pre-Transport Stabilization

Yvette Gonzalez, MS, RN, C-NPT, C-EFM, RMH High Risk Obstetric & Neonatal Transport Clinical Manager

This outreach education presentation is intended as an overview of basic concepts surrounding assessment of the

pregnant patient, OB complications and stabilization priorities for maternal and newborn patients.

Follow your designated hospital and county protocols, policies and guidelines for actual care of obstetric and newborn patients.

Case Study: EMS Dispatch Female Abdominal Pain

On Scene: Unexpected Newborn Delivery ~ 26 weeksRapid Assessment: Apnea, Dusky, HR palpable ~ 80bpm

What Are Your Clinical Priorities?

Tiny Ones: Preterm Delivery

Delayed Cord Clamping:

IF vigorous DCC reduction of IVH

IF NONVIGOROUS immediate umbilical cord clamping & NRP

Thermoregulation & Neuroprotection:

Warming mattress, isolation bag, hat, nesting, & head alignment with gentle handling

NRP Guidelines:

Sp02 & ECG, CPAP, PPV, airway & perfusion support, careful fluid administration, glycemic control, early activation of neonatal & transport teams!

Source:1. AAP. Neonatal Resuscitation Program. 7th Edition.

Neonatal Resuscitation & Stabilization Priorities

•NRP: A, B, C versus PALS• Airway, Airway, Airway• Ventilation Rate Adequate? Do You Have Slight Chest Rise?

• Stabilization Measures: The S.T.A.B.L.E. Program

• Glycemic Control• Thermoregulation• Perfusion Support• Preparation For Transport • Transfer to higher level of care

Source: http://www.abclawcenters.com/wp-content/uploads/2014/11/original_resuscitation_with_bagging_and_chest_compressions.jpg. Accessed August 2017.

Neonatal Airway Management: Babies are different…..• Anatomical Challenges• Ventilation Device Options• Establishing Effective Ventilation

• Correct Rate: 40-60• Slight Chest Rise

• Oxygenation

• Ongoing Airway Support modalities• Alternative Airway Needed?• Vt?• Common ventilation support: BVM Rate & Pressures

Source1. AAP. Neonatal Resuscitation Program. 7th Edition2. The S.T.A.B.L.E. Program. 6th Edition

Neonatal Vascular AccessEmergent UVC:

o18-20 gauge IV catheter: Prep—Tie—Cut--Cannulateo Single lumen UVC catheter 3-5 cm, obtain blood return o <1500 Grams/30 weeks 3.5 F and >1500 Grams/30 weeks 5.0 F

PIV Placement

• 24g

IO Placement

• EZ IO >3kg

Fluid Resuscitation

• NRP versus PALS

Source1. AAP. Neonatal Resuscitation Program. 7th Edition2. The S.T.A.B.L.E. Program. 6th Edition

Neonatal Fluid Resuscitation

Indication?

• Not responding to resuscitation

• Appears in “shock” hypo-perfused

• History of blood loss

DOSE: 10 ml/kg

SOLUTION: Normal Saline or O Rh- negative PRBC’s (if indicated)

ROUTE: PIV, UVC or IO

RATE: Over 5-10 min. Preterm precautions

Total neonatal circulating blood volume:

• 80-90ml/kg

Source:1. AAP. Neonatal Resuscitation Program. 7th Edition.

Case Study: ED Admit37.5 weeks, 3do, 3.1kg difficulty breathing, hypothermia

Tachypnea: Respiratory Rate 70-80

Increased WOB Grunting Retractions: Moderate/Severe

Hypoxemia: sp02 low 90’s

Hypoglycemia: BG 41

Hypothermia: 35.9 C

Hypotonic: decreased responsivnesshttps://www.youtube.com/watch?v=NBA9iigiDgk

CXR Findings In The ED: Suspected Pneumonia

Birth History Risk Factors?Before & During Birth

Prolonged Rupture of Membranes> 18 hours

PPROM

Maternal ChorioamnionitisMaternal fever/ infectionFetal tachycardiaFoul smelling amniotic fluid

Meconium aspiration

Neonatal Sepsis Clinical Priorities

• Rapid Consult, Stabilization & Transport to Regional Center

• NRP then STABLE

• Airway Support: noninvasive and/or invasive

• Perfusion Support: • Volume resuscitation/bolus

• Pressor support (ensure adequate preload)

• Glycemic Control: Glucose bolus (as needed) + MIVF

• Thermoregulation: Goal temp 36.5C-37.5C

• Sepsis screen: CBC w/differential and Blood Cultures

• Early initiation of antibiotics: Ampicillin & Gentamycin • Consider/discuss antivirals if neuro assessment abnormal

Case Study:ED, born @ term, 3.9 kg, 22 d/o

• Tachycardic: HR 170’s

• Labored Breathing

• Compromised Perfusion

• Acidotic

• Tender, distended abdomen

• Bilious vomiting

• Bloody stools

• Stopped eating

• Fussy all day

Suspected Bowel Obstruction?Clinical Priorities

• Rapid Consult, Stabilization & Transport to Pediatric Surgical Center

• Airway Support

• Perfusion Support

• Gastric Decompression: Orogastric Tube 8F or 10F

• Glycemic Control: Glucose bolus (as needed) + MIVF

• Thermoregulation

• Rapid Transport---Time Sensitive

Source1. AAP. Neonatal Resuscitation Program. 7th Edition2. The S.T.A.B.L.E. Program. 6th Edition

3. Journal of Obstetric Gynecologic and Neonatal Nursing. JOGNN. Lockridge, Caldwell, Jason (2003). Neonatal Surgical Emergencies: Stabilization & Management. Volume 31, Number 3.

Free Air On Xray Is A Surgical Emergency

Considerations For Altered LOC• T= Trauma

• H= Heart disease or Hypovolemia

• E= Endocrine – Hypoglycemia

• M= Metabolic--Electrolytes

• I= IEM

• S= Sepsis

• F= Formula error

• I= Intestinal catastrophes

• T= Toxins/ Poisons

• S= Seizures

Thank You & Questions