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Ob/Gyn Emergencies OB/GYN EMERGENCIES I. Obstetrics (OB). A. Childbirth – Woman in Labor. 1. Follow General Principles/Routine Care guidelines, assessing vaginal area for crowning and signs of meconium. 2. Initiate IV with NS/LR for possible fluid replacement. 3. If not crowning, transport the mother on her left side to the most appropriate facility based on her history and gestational development of the fetus. (See Transport Policy, Section II tables). B. Childbirth – Imminent Delivery. 1. If crowning is present at time of examination, prepare for immediate delivery and assess for possible meconium. 2. While coaching the mother, perform delivery making sure to prevent explosive delivery. 3. Check for cord wrapped around the baby’s neck. If present, unwrap or clamp and cut the cord before proceeding with the delivery. 4. Dry the baby and stimulate to a cry. C. Childbirth – Breech Delivery. 1. All efforts should be made to rapidly transport the mother to the closest, most appropriate facility. Place the mother in a gravity dependent, knee chest position and coach her not to push. 2. If delivery cannot be delayed, assess for type of breech delivery: Frank (bottom first) or Footling (feet first). a. If Frank: perform delivery, coaching the mother to prevent an explosive delivery. Dry the baby and stimulate to a cry. b. If Footling: place a gloved hand into the vagina along the newborn baby’s chest and face, keeping the cervix open while maintaining an air passage through the birth canal. Deliver the baby if possible, dry the baby and stimulate to a cry. D. Childbirth – Prolapsed cord. 1. Place mother on back and elevate the hips, or consider knee-chest position. 2. Place sterile gloved index and middle fingers into the vagina, pushing the infant up to relieve pressure on the cord. 3. Check cord for pulse and assure pulse is maintained. 4. Transport immediately. E. Childbirth – Meconium Present. 1. Assess the mother’s garments and the surrounding area while getting a good history of when her membrane ruptured and assess for the presence of meconium. Continue to deliver as above. 2. Once delivered, assess the baby for vigorous activity. a. For the vigorous baby, continue the care per Section F.2. below. 51 b. For the non-vigorous baby: i. Once delivered and prior to drying and stimulation, use a bulb syringe to suction the baby’s mouth and nose, clearing as much meconium from the oral and posterior pharynx as possible. ii. Continuously monitor the baby’s heart rate. iii. If the baby does not become vigorous or if the heart rate is < 100 place an ETT into the trachea and secure it for continued ventilation assistance and transport. iv. Provide resuscitative efforts following the guidelines listed below. F. Neonatal Resuscitation. 1. HR < 100, apneic, or weak respiratory effort (non-vigorous). a. Ventilate with 100% oxygen using a BVM at a rate of 40-60 breaths per minute. Hold the pop-off valve closed for the first 2 or 3 ventilations, assuring good expansion of the alveoli. Release the pop-off valve and continue ventilation as needed. b. Clamp and cut umbilical cord approximately 6-8” from baby. c. Dry and stimulate. d. If HR remains < 60 perform CPR at the rate of 120 per minute at a ratio of 3 compressions to 1 ventilation. e. Initiate IV/IO access. f. Check blood glucose levels and if < 60, give D10 5 mL/kg, or D25 at 2 mL/kg IV/IO push. Maximum concentration for newborn: 12.5% (0.125 gm/mL), therefore D25 must be prepared by mixing 25% dextrose 1:1 with NS. g. Administer epinephrine 1:10,000 0.01 mg/kg IV/IO push or 0.1 mg/kg 1:1000 ETT. h. Transport the newborn and the mother to the closest, most appropriate facility. 2. HR > 100, (vigorous). a. After one minute, clamp and cut umbilical cord approximately 6-8” from baby. b. Wrap the baby in a dry, warm blanket and place a hat on the head if available. c. Assess APGAR at 1 and 5 minutes (Appendix I). G. Post-Delivery Care. 1. Encourage the mother to nurse the newborn baby. 2. Allow the placenta to deliver naturally. Do not pull on the umbilical cord. Transport all passed tissue to the hospital for further evaluation. 3. Massage the fundus (uterus) to help control any postpartum bleeding. 4. For postpartum hemorrhage: a. Transport immediately. b. Place a sanitary napkin or trauma dressing over the vaginal opening. Do not pack anything into the vagina. c. Initiate IV NS/LR, titrate to BP > 90/S. 52 d. Re-assess the mother for signs of shock and hypoglycemia. Treat according to protocol. e. Transport the mother and the baby to the closest, most appropriate facility. H. Pre-Eclampsia/Eclampsia/Seizures/Hypertension. 1. Follow General Principles/Routine Care guidelines. 2. Initiate IV with NS. 3. Check blood glucose level and treat as needed. 4. Place the mother on her left side and transport to the closest most appropriate facility. Transport should be as smooth and quiet as possible to prevent/reduce seizure activity. 5. If the mother is seizing, follow the seizure protocol listed in Medical Emergencies. 6. In addition to above, give the mother magnesium sulfate 4 gm slow IV push over 5 minutes. I. Gestational Diabetic Problems. 1. Hypoglycemia: Follow General Principles/Routine Care guidelines and the Altered level of consciousness/unconsciousness protocol listed in Medical Emergencies. 2. Hyperglycemia: Follow General Principles/Routine Care guidelines and transport to the closest, most appropriate facility. J. Vaginal Bleeding (unrelated to post-delivery). 1. Assess perineum and vaginal area for signs of trauma or other problems. 2. Estimate amount of blood loss. Follow General Principles/Routine Care guidelines. 3. Place a sanitary napkin or trauma dressing over the vaginal opening. Do not pack anything into the vagina. 4. Initiate IV with NS/LR for possible fluid replacement. 5. Treat for hemorrhagic shock and keep patient warm. II. Gynecological Emergencies. Vaginal bleeding. 1. Follow General Principles/Routine Care guidelines, assessing perineum and vaginal area for signs of trauma or other problems. Estimate amount of blood loss. 2. Place a sanitary napkin or trauma dressing over the vaginal opening. Do not pack anything into the vagina. 3. Initiate IV with NS/LR for possible fluid replacement. 4. Treat for hemorrhagic shock and keep patient warm. 5. Inquire as to the possibility of pregnancy. 53 .
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