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Child Birth & Maternal Care in The Name of Policy: Child Birth & Maternal Care in the Emergency Department Policy Number: 3364-117-60 Approving Officer: AVP Patient Care Services/CNO and Medical Director Effective Date: August 1, 2020 Responsible Agent: Nursing Director Original Effective Date: August 1, 2020 Scope: All University of Toledo Campuses X New policy proposal Minor/technical revision of existing policy Major revision of existing policy Reaffirmation of existing policy (A) Policy statement Patients presenting to the Emergency Department at the University of Toledo Medical Center who are pregnant where delivery is imminent will be cared for by qualified staff. After delivery in the Emergency Department and stabilization of mother and infant(s), mother and infant(s) will be transported to another institution for admission and continuing care. Transport for mother and infant(s) will be by the Mercy Health or the Promedica Toledo Hospital Neonatal Transport Unit. (B) Purpose of policy To provide guidelines to the Emergency Department staff on the care and management of obstetrical patients in whom delivery is imminent, while in the Emergency Department. (C) Procedure (1) Pregnancy in Labor (a) Initial examination will be conducted immediately by the ED attending physician (b) The Obstetrician on call at Mercy Health or the Toledo Promedica Hospital will be notified immediately of the patient and the delivery status, presence of obstetric hemorrhage risk factors and/or maternal severe hypertension/preeclampsia. (c) If the patient has an established OB physician, that physician will be notified (d) After examination (“medical screening examination” per EMTALA) and consultation with the OB attending /patient’s private physician, the patient may be transferred to another facility which provides OB services upon determination that the 3364-117-60 Child Birth in the Emergency Department patient is at a level at which a safe transfer may be effectuated. The medical record should reflect that the examination included ongoing evaluation of maternal blood pressure and vital signs, fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation and status of the membranes. (i) The transfer policy will be followed and consent to transfer completed. (ii) Discretion will be used in transferring the patient by ambulance, critical care transport unit, or private car. (ii) If Life Flight is used to transfer the patient, the Life Flight/Mobile Life Certification of Transport form must be completed by the transferring registered nurse and physician. (e) If delivery is imminent, delivery will occur in the Emergency Department (ED), unless a cesarean section is necessary, in which case the patient will be taken to surgery (2) Pregnant and Post-Partum patients with severe hypertension/preeclampsia (a) Acute onset of severe systolic hypertension, severe diastolic hypertension or both can occur during prenatal, intrapartum or post-partum periods. This requires urgent antihypertensive therapy. Treatment of evidence-based first-line agents should occur within 30-60 minutes of confirmation of severe hypertension in order to reduce the risk of maternal stroke. [ref evid- based practice- [1] at end of policy] (i) Maternal blood pressure and vital signs will be monitored on admission and minimally every 15 minutes until delivery or transfer. Vital signs are monitored using the correct cuff size as stipulated in UTMC general guidelines. The ED attending physician will be notified immediately if systolic BP is greater than 159mm Hg or if diastolic BP is greater than 109mm Hg. (ii) Seizure precautions will be immediately initiated (b) The ED Attending Physician will be in consultation with the identified Obstetrical Physician and OB Team as noted in part C. 1. d. of this policy. (c) Evidence-based medications used to treat severe hypertension/preeclampsia are readily available in the AcuDose including hydralazine, labetalol, and nifedipine. Magnesium sulfate is available for seizure prophylaxis. (3) Obstetrical Hemorrhage Risk Assessment and Checklist [see attached] Maternal hemorrhage, defined as a cumulative blood loss of > 1000 ml or blood loss accompanied by signs or symptoms of hypovolemia, remains the leading cause of maternal mortality world-wide. [2nd reference- as listed below] 2 3364-117-60 Child Birth in the Emergency Department (a) An evidence-based checklist identifying risk factors for obstetrical hemorrhage will be used on admission of an obstetric patient to the ED. The ED attending Physician will discuss the presenting exam with the OB attending physician accepting the patient for transfer. (b) Uterotonic agents identified as first line treatment of uterine atony will be maintained in the ED AcuDose identified as “OB Kit”. The OB Kit contains oxytocin injection 10 units/ml 1ml vial x1, misoprostol 100 mcg tablets x 10, and lidocaine 1% injection 5 ml x 1 Drug Dose Route Contraindications 10 units IM or directly into myometrium Oxytocin • Allergy to oxytocin 30 units in 500ml IV rate at 333ml- (Max 40 unit in 500ml IV) 500ml/hour Titrate per uterine tone • Asthma- absolute contraindication Carboprost 250 mcg every 15-90 minutes IM or injected into • Coronary artery disease (Hemabate) as needed (max of eight doses myometrium; rotate • Cerebral artery disease or 2 mg) sites if multiple • Raynaud’s Syndrome injections required • Hypertension- relative contraindication • Preeclampia- relative contraindication • Vascular disease 0.2 mg IM or injected into • Hypertension Methylergonovine May repeat every 2-4 hours as myometrium • Hepatic disease • Cardiac disease needed after delivery of • Raynaud’s disease placenta • Cerebral artery disease Contraindicated in patients taking: • Protease inhibitors (amprenavir, atazanavir, boceprevir, cobicistat,, darunavir, delavirdine, fosamprenavir, indinavir, letermovir, lopinavir, nelfinavir, ritonavir, saquinavir, simeprevir, telaprevir, tipranavir) • CYP3A4 inhibitors (almotriptine, azithromycin, clarithromycin, dinoprostone, eletriptan, erythromycin, fluconazole, fluvoxamine, frovatriptan, itraconazole, ketoconazole, naratriptan, nefazodone, posaconazole, propatylnitrate, sumatriptan, telithromycin, voriconazole, , zolmitriptan Misoprostol 600mcg-1000mcg Rectal only • Allergy to prostaglandins epoprostenol, enprostil, 3 3364-117-60 Child Birth in the Emergency Department fenprostalene, fluprostenol, gemeprost, iloprost, latanoprostene, latanoprost, limaprost, luprostiol, misoprostol, prostalene, sulprostone, (alprostadil, beraprost, bimatoprost, carboprost, cloprostenol, dinoprost, dinoprostone, tafluprost, travoprost, treprostinil, unoprostone) • Known thrombolic event *Tranexamic Acid- 1 gram in 100ml (total volume 1 gram over 10 min; during pregnancy (Pharmacy order- 110ml) may repeat in 30 • History coagulopathy consider if initial medical minutes if bleeding therapy fails within 3 • Active intravascular clotting hours of birth) continues • Allergy to Tranexamic Acid (c)In case of obstetrical hemorrhage, the Obstetrical Hemorrhage Checklist will be followed. The Team Leader at UTMC is the ED Attending. Scribes will be Recorders and the ED Primary Nurse will be the Primary Nurse. (d) In case of obstetrical hemorrhage, The Mass Transfusion Protocol, Urgent Request for Uncrossmatched Blood and Rh(D) Immune Globulin policies will be initiated as per the Obstetrical Hemorrhage Checklist direction. (4) Delivery (a) The patient will be placed in an ED treatment area with a door (b) Vital signs and fetal heart tones will be taken and documented (c) Two IV lines will be started and oxygen will be readily available (d) Explain all that will be taking place to the patient, prior to treatments, procedures, etc. (e) Place the patient in stirrups (f) Cleanse the perineum with an iodine-based or chlorhexidine-based solution and rinse with normal saline (g) Prep as directed by the physician, as time permits (h) Open OB pack (i) Obtain infant warmer 4 3364-117-60 Child Birth in the Emergency Department (j) Note time of delivery, presentation of fetus (LOA, LOP, etc.) (k) Perform and document APGAR score at time of delivery and 5 minutes post delivery (l) Obtain and record baby’s length and weight (m) Document delivery of placenta (n) Document any medications given to either mother or neonate(s) (o) Send placenta, properly labeled and in an appropriate container to Pathology (5) Disposition of Mother and neonate(s) (a) If mother and neonate(s) are transferred to another institution which provides obstetrical services, they will be transported (ground or air) by Mercy Health or by the Promedica Toledo Hospital Neonatal Transport Unit (b) The neonate(s) will be registered using the time of delivery as the time admitted to the Emergency Department (c) An Emergency Department medical record will then be completed on each neonate (6) Birth Certificate (a) Obtain a hospital worksheet #1 and #2 from the Admitting Department (b) These papers must be completed prior to transfer to another institution (c) The birth certificate will be completed and signed by the Emergency Department attending or the physician who actually delivers the neonate(s) and then sent to the Lucas County Bureau of Vital Statistics (7) Emergency Department Medical Record – Mother (a) An Emergency Department medical record will be generated for the mother upon her arrival to the Emergency Department (b) All records, laboratory reports, initial radiological interpretations, and any other information obtained in the ED will be sent
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