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

PREVENTABLE https://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 Communication Lack Of Recognizing Signs & Symptoms Misdiagnosis & Ineffective Treatment Failure In Care Systems & Processes

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

Sources: questions pertaining to Neo/HROB. 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 2018 3. Near Miss Mothers. NPR. https://www.youtube.com/watch?v=I5Dsn4obCa4&feature=youtu.be. Accessed May 2018 US Maternal Morbidity & Mortality Leading Causes & Regions

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

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§ionid=41304210 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, 2015 Pregnancy Vital Signs & Labs

Normal Pregnant VS Normal Labs • HR: 85 • Hct 34 • SBP: 114 • Platelets > 150 • DBP: 70 • AST & ALT ~ 35 • MAP > 70 • Creatinine < 1.0 • Goal: vital organ perfusion • WBC < 16 • Ensure adequate preload before initiating vasoactive drugs

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§ionid=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 2017 3. 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 & Transport ABCs 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 Risk Risk 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 2017 2. High Risk & Critical Care Obstetrics. N. Troiano, C. Harvey, B. Flood Chez. AWHONN 2013, 3rd Edition. Intrauterine Resuscitation Measures Lateral 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 136 http://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 & NRP

Source: 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, 2015 3. 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 2017 2. 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 2017 2. 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 seizures Source: 1. California Maternal Quality Care Collaborative: CMQCC. https://www.cmqcc.org/. Accessed August 2017 2. 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 Access Continuous Fundal Massage Uterotonics: Pitocin-dose & rate Consider TXA: Consult Rapid Transport: Surgical Center D&C -- Removal of Placental Parts OR --- Looking For Bleeders Activate Massive Hemorrhage Protocol

Image Source: dailymom.com

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 Thank You & Questions Neonatal Resuscitation & Pre-Transport Stabilization

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 weeks Rapid Assessment: Apnea, Dusky, HR palpable ~ 80bpm What Are Your Clinical Priorities? Tiny Ones: Preterm Delivery

• 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

Source 1. AAP. Neonatal Resuscitation Program. 7th Edition 2. The S.T.A.B.L.E. Program. 6th Edition Neonatal Vascular Access Emergent UVC: o18-20 gauge IV catheter: Prep—Tie—Cut--Cannulate o 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

Source 1. AAP. Neonatal Resuscitation Program. 7th Edition 2. 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 Admit 37.5 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 responsivness https://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 Chorioamnionitis Maternal fever/ infection Fetal tachycardia Foul 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

Source 1. AAP. Neonatal Resuscitation Program. 7th Edition 2. 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