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Obstetric Emergencies, Stabilization & Transport Considerations 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&sectionid=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&sectionid=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
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