CCT: OB VAGINAL &

PURPOSE: A. To provide consistent, optimal care during transport for the obstetrical patient experiencing vaginal or postpartum bleeding.

SCOPE: A. All current Lifeline employees. DEFINITIONS A. None GUIDELINES A. Initiate the Standard of Care Obstetric Patient Maternal Vaginal Bleeding during A. Request sending provider to perform sterile speculum exam for cervical evaluation in the presence of vaginal bleeding in previa diagnosis or unknown placental location. DO NOT perform digital sterile vaginal exam. B. Assess maternal vitals, fetal status, and contraction pattern per the Obstetric Care – General Care on Transport Protocol. C. Assess for abdominal tenderness and rigidity. Notify HROB Medical Control if present. D. Initiate 2nd large bore IV site. If needed for maternal VS or intrauterine resuscitation, administer NS (0.9%NaCl) wide open and titrate to maintain a SBP of greater or equal to than 90mmHg. Prepare to treat for . Refer to LifeLine Fluid Management and Component Therapy protocol for shock treatment and contact HROB Medical Control immediately. E. Administer O2 10 liters/min per non-rebreather mask as needed for maternal VS or intrauterine resuscitation. F. Consider the use of blood products if available after 2 liters of normal saline has infused. Consult CCT team and update HROB Medical Control. G. Transport in left lateral recumbent position if greater than 20 weeks gestation and/or uncontrollable bleeding present. Based on assessment of maternal and fetal stability, refer to Obstetric Patient – Emergencies requiring diversion to closest facility protocol. H. Assess and document volume of bleeding by # pads soaked per hour. Replace soaked sanitary pads as needed. Do not insert into . Save soaked pads in plastic biohazard bag and transport with mother to receiving facility to facilitate accurate QBL.

TOP Postpartum Hemorrhage A. : Massage the fundus of the after delivery of placenta continuously until firm. If unable to locate fundus due to maternal body habitus, perform bimanual massage of the uterus using sterile technique until fundus is firm. Evacuate clots as necessary. Fundal massage should be continued while other steps are initiated. If bleeding continues in the presence of a firm fundus, consider the cause is NOT , consult Obstetric Patient – Emergencies requiring diversion to closest facility protocol, and contact HROB Medical Control immediately. • Once fundus becomes firm, discontinue continuous fundal massage and assess fundus q 5 minutes for firmness. Repeat massage as necessary to maintain firmness.

• In the presence of Bakri or other uterine tamponade device, DO NOT massage the uterus. Determine fundal height by palpating top of uterus and document as number of finger widths above/below umbilicus. Compare to fundal height measurement performed at sending facility. If this measurement has increased, assume blood is collecting behind the tamponade device and contact HROB Medical control for update. o Before leaving sending facility with Bakri/tamponade device in place, document fundal height, date/time of device placement, volume of device fill, and presence/absence of vaginal packing. B. Administer O2 10L/min per non-rebreather mask. C. Initiate 2nd large bore IV site and administer NS (0.9% NaCl) wide open to maintain a SBP of greater than or equal to 90 mmHg. Prepare to treat for shock. Refer to LifeLine Fluid Management and Blood Component Therapy protocol for shock treatment and contact HROB Medical Control immediately. D. Consider placement of Foley catheter. E. Replace soaked sanitary pads as needed. Do not insert into vagina. Save soaked pads in plastic biohazard bag and transport with mother to receiving facility to facilitate accurate QBL. F. Medical Management a. FIRST: Administer Pitocin then contact HROB Medical Control before adding a second agent • Pitocin () 30 units in 500ml NS IV at 36 units/hr (note units, not mU) • If no IV access or if premixed oxytocin unavailable, give 10 units oxytocin IM x1 b. SECONDARY AGENTS: • Cytotec () 800 mcg per rectum Cautious use: maternal cardiac disease • Methergine (methylergonovine) 0.2mg IM X1 Cautious use: current hypertension

TOP • Hemabate ( tromethamine) 0.25mg IM X1 Cautious use: asthma G. In the event that there is ongoing severe life-threatening postpartum hemorrhage despite manual uterine massage, maximal therapy with oxytocin, and 15 minutes after first dose of Hemabate and/or methergine, contact HROB Medical Control. H. In the event of , wrap inverted uterus in moistened sterile towels and contact HROB Medical Control.

Required Documentation: Document any communication with HROB Medical Control in the transport record.

Citations/References: Belfort, M. (2020, 15 May). Postpartum hemorrhage: Medical and minimally invasive management. Retrieved August 21, 2020, from https://www.uptodate.com/home Norwitz, E.R. and Park, J.S. (2019, May 31). Overview of the etiology and evaluation of vaginal bleeding in pregnant women. (V.A. Barss and C.J. Lockwood, Eds.) Wolters Kluwer. Retrieved June 1, 2019.

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