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.

(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

(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

(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 with the patient to the hospital she is being transferred to

(8) Identification

5 3364-117-60 Child Birth in the Emergency Department

(a) Mother and neonate(s) identification bands will be made using the arm bands currently used in the Emergency Department

(b) Bands containing the mother’s name, medical record number, date and time of delivery, and sex of neonate will be made.

References: 1. The American College of Obstetricians and Gynecologists; “Emergent Therapy for Acute- Onset, Severe Hypertension During Pregnancy and the Postpartum Period; Committee Opinion Number 767, Vol133, NO.2 February 2019 https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co767.pdf

2. The American College of Obstetricians and Gynecologists; “Practice Bulletin No 183 Postpartum Hemorrhage; Committee Opinion Number 183, Vol 130, NO.4. October 2017 https://insights.ovid.com/crossref?an=00006250-201710000-00051

Approved by: Review/Revision Date:

/s/ William Saunders III, MD. Date Medical Director

/s/ Monecca Smith, MSN, RN Date AV P P atient Care Services/CNO

Review/Revision Completed by: Nursing Director, Emergency Services 8/20

Next review date: 8/1/23 Policies Superseded by This Policy: • MS-034 Child Birth in the Emergency Department 3364-87-34 Child Birth and Maternal Care in the Emergency Department

6 Rate of Oxytocin Administration After Delivery (30 units oxytocin/500 mL) for Prophylaxis and Treatment of Postpartum Hemorrhage

Time after delivery Vaginal Delivery Cesarean Delivery without Labor Cesarean Delivery with Labor

First hour 300 mL/hour 300 mL/hour 600 mL/hour until fascia closed, (prophylaxis) then 300 mL/hour

Second hour (prophylaxis) 150 mL/hour 150 mL/hour 150 mL/hour

If no IV (prophylaxis) 10 units oxytocin IM If uterine atony (treatment) Increase rate to 600 mL/hour for 1 Increase rate to 600 mL/hour for 1 Increase rate to 600 mL/hour for 1 hour, followed by 150 mL/hour for hour, followed by 150 mL/hour for hour, followed by 150 mL/hour for 1 hour 1 hour 1 hour

150 mL/hr = 9 units, 300 mL/hr = 18 units, 600 mL/hr = 36 units

Treatment of Postpartum Hemorrhage

Order of Use if not Drug Dose, frequency Contraindications Side Effects contraindicated Prophylactic doses for all oxytocin (Pitocin) See chart above Hypersensitivity. Hypotension and tachycardia patients; with high doses especially IV 1st line for treatment push, hyponatremia with prolonged infusion 2nd line for treatment methylergonovine 0.2 mg IM every 2 to 4 hours Hypersensitivity. Nausea, vomiting, (Methergine) Hypertension, preeclampsia, hypertension, coronary artery or heart disease. spasm Multiple doses of ephedrine given. Use of protease inhibitors. 3rd line for treatment carboprost (Hemabate) 250 mcg IM or intra- Hypersensitivity. Nausea, vomiting, diarrhea, myometrial every 15 to 90 Active pulmonary disease fever, hypertension, minutes; maximum of 2 mg (e.g. asthma), cardiac disease, headache, renal disease, or hepatic bronchospasm disease. 4th line for treatment misoprostol (Cytotec) 400 mcg sublingual or 1000 Hypersensitivity. Nausea, vomiting, diarrhea, mcg rectal fever, headache UIHC Post-Partum Hemorrhage Management Plan

(modified directly from CMQCC version 2.0)

Labs & Primary Nurse Second Nurse OB LIP Anesthesia LIP Blood Bank Stage 0 Every patient admitted to Labor & Delivery  Pre-delivery risk assessment  Assess every patient for PPH  Assess every patient for PPH  Be aware of PPH risk for all  All patients: T&S  Active management of 3rd risk level on admission risk level on admission admitted patients  High Risk: Crossmatch 2u stage  Ask if patient will accept  Active management of 3rd 1. Abnormal placentation blood products stage: (>2u per MFM/Gyn-Onc)  QBL at every delivery 1. Oxytocin per protocol 2. Antibody present (use 2. Gentle cord traction “Pretransfusion Special 3. 15 second fundal massage Testing” orderset, patient to have T&S drawn up to 72h prior to procedure) Stage 1 Blood loss >500ml (vaginal) or >1000ml (Cesarean)  “Rub + Drug”  Call for help (charge RN, OB  Bring PPH cart to bedside  Repeat fundal massage  Present to patient’s bedside,  Crossmatch 2u (if not done on chief, OB staff, anesthesia)  Place orders for “OB PPH  Assess for bleeding source assist as needed admission)  Confirm IV access (18G Stage 1”  2nd uterotonic medication minimum)  Calculate QBL every 5-15 (Methergine preferred unless  Insert Foley catheter minutes contraindicated) Stage 2 Continued bleeding with total blood loss under 1500ml  Sequential progression  Check VS every 5 minutes  Place orders for “OB PPH  3rd uterotonic medication  Accompany patient to the OR  Hemorrhage labs (CBC, DIC through medications &  2nd IV (16G) Stage 2”  Additional procedures as  Assist in establishing IV access panel, electrolytes, Ca) procedures  Draw labs  Calculate QBL every 5-15 indicated (D&C, Bakri, B-  Transfuse per clinical signs  2u PRBCs to bedside  Keep ahead with blood  1L fluid bolus minutes Lynch)  Consider FFP and/or other products & volume  Ask LIPs if IR consult needed  Move to OR for further products evaluation/exposure Stage 3 Total blood loss > 1500ml or > 2u PRBCs given or VS unstable or suspected DIC  Massive Transfusion Protocol  Assist in preparing patient for  Place orders for “OB PPH  Continue with procedures as  Draw labs  Transfuse 2u PRBCs at  Invasive surgical approaches surgery Stage 3” indicated  Transfuse per Massive minimum to control of hemorrhage  Announce “Bleed Time-Out”  Calculate QBL every 5-15  Consider laparotomy (if not Transfusion Protocol  Massive Transfusion Protocol every 1L of QBL (current QBL, minutes open)  Consider central line and  Repeat hemorrhage labs (CBC, transfusions, meds given,  Ask LIPs if GYN-ONC consult  Prepare for possible invasive monitoring DIC panel, electrolytes, Ca) consults called, most recent needed hysterectomy  Consider cell salvage system every 1L of QBL labs)  Request scrub team from  Consider Tranexamic Acid MOR  Consider rFactor VIIa if DIC  Request Perfusion team for cell salvage system Main OR Charge Nurse: 36400 OB Emergency pager group 6777 (OB Chief, OB Staff, Anesthesia Resident, Anesthesia Staff): indicate “PPH, NICU not needed” Cell Salvage: pager group “Perfusion” Blood bank: 62561 IR for uterine artery embolization: pager 5390 Gyn-Oncology: per hospital operator Post-Partum Maternal Hemorrhage Order set

Establish IV access X2 (18 gauge minimum if able)

Begin 0.9% Sodium Chloride solution @ 100ml/hour

Oxygen at 2-4 liters per nasal cannula to maintain pulse ox of 95%

Type and screen

Vital signs every 15 minutes

For Vaginal Delivery

1. Oxytocin 30 units in 500 ml Normal Saline • Start at 300 ml/hour for the first hour after delivery • Decrease to 150 ml/hour for the second hour after delivery • For uterine atony increase the rate to 600 ml/hour for one hour followed by 150 ml/hour for one hour 2. Oxytocin 10 units IM if no IV access

For Postpartum Hemorrhage First Line for treatment

For Postpartum Hemorrhage Second Line for treatment

1. Methylergonovine 0.2mg IM every 2 to 4 hours

For Postpartum Hemorrhage Third Line for treatment

1. Carboprost (Hemabate) 250 mcg IM every 15-90 minutes; maximum of 2 mg

For Postpartum Hemorrhage Fourth Line for treatment

1. Misoprostol (Cytotec) 400 mcg sublingual 2. If unable to administer sublingual give Misoprostol (Cytotec) 1000 mcg rectal