C H I L D B I R T H / O B S T E T R I C A L E M E R G E N C I E S OBSTETRICAL EMERGENCIES Pre and Post‐Partum

UNIVERSAL PATIENT CARE PROTOCOL IV / IO PROCEDURE Capnography Procedure

Eclampsia Mild Pre‐ or Bleeding AFTER BIRTH Bleeding DURING st Patent Actively Seizing Post‐partum Post‐Partum Hemorrhage 1 Trimester – , hypertension < 6 weeks Ectopic Pregnancy 2nd & 3rd Trimester – SBP 140 and / or DBP 90 Previa / Abruptio Placenta with Edema, Headache, Visual Disturbances, or Epigastric Discomfort MAGNESIUM SULFATE NORMAL SALINE BOLUS Pad, do not pack bleeding, 4 – 6 grams To Maintain MAP > 65 save, and bring with patient IV / IO over 2 ‐ 4 minutes or SBP 90 / Radial Pulses MAGNESIUM SULFATE if NIBP Unavailable ONLY IF MAGNESIUM FAILS AND ALL IS USED 4 – 6 grams IV / IO over 20 ‐ 60 minutes NORMAL SALINE BOLUS MIDAZOLAM (VERSED) To Maintain MAP > 65 2.5 mg IV / IO or 5 mg IM / IN Reassess BP OXYTOCIN (PITOCIN) or SBP 90 / Radial Pulses if OR 10 Units IM OBSTETRICAL LORazepam (ATIVAN) For all deliveries regardless NIBP Unavailable 1 – 2 mg IV / IO / IM / IN off bleeeding

i If Midazolam (Versed) or If SBP is > 160 and / or LORazepam (Ativan) DBP 110 also give Unavailable, LABETALOL (TRANDATE) If evidence of current / See Medication Section 20 mg slow IV previous uncontrolled for diazePAM (Valium) If no improvement in 5 min hemorrhage, then HR > 120 and / or SBP < 90, 40 mg slow IV within 60 mins of injury Consider TRANEXAMIC ACID (TXA) 1 Gram mixed in 100 ml D5W over 10 mins If SBP is > 160 and / or DBP 110 also give LABETALOL (TRANDATE) 20 mg slow IV If no improvement in 5 min

then 40 mg slow IV

QUIET RAPID TRANSPORT to appropriate facility CONTACT receiving facility CONSULT Medical Direction where indicated APPROPRIATE transfer of care Transport to Hospital with OB CAPABILITIES

EMT Intervention AEMT Intervention PARAMEDIC Intervention Online Medical Control

Northeast Ohio Regional EMS Protocol 4 | 12 C H I L D B I R T H / O B S T E T R I C A L E M E R G E N C I E S OBSTETRICAL EMERGENCIES

HISTORY  Past medical history  Vaginal bleeding  Pre‐eclampsia / eclampsia  Hypertension meds  Abdominal pain  Placenta previa   Seizures  Placenta abruptio  Prior / births  Hypertension  Spontaneous abortion  Gravida (pregnancies) /  Severe headache para (live births)  Visual changes  Edema of hands and face

KEY POINTS  Exam: Mental Status, Abdomen, Heart, Lungs, Neuro General Information  Any woman of child bearing age with syncope should be considered an until proven otherwise.  May place patient in a left lateral position to minimize risk of supine hypotensive syndrome.  Ask patient to quantify bleeding ‐ number of pads used per hour.  Any pregnant patient involved in a MVC should be seen immediately by a physician for evaluation and fetal monitoring.  DO NOT apply packing into the .  Be alert for fluid overload when administering fluids.  Consider starting a second IV if the patient is experiencing excessive vaginal bleeding or maintain BP 90 systolic,  Transport to an appropriate OB facility if the patient is pregnant, Abortion / Miscarriage OBSTETRICAL  The patient may be complaining of cramping, nausea, and vomiting.  Be sure to gather any expelled tissue and transport it to the receiving facility.  Signs of infection may not be present if the abortion/miscarriage was recent.  An abortion is any pregnancy that fails to survive over 20 weeks. When it occurs naturally, it is commonly called a ”miscarriage”. Abruptio Placenta  Usually occurs after 20 weeks.

 Dark red vaginal bleeding.

 May only experience internal bleeding.  May complain of a “tearing” abdominal pain. Ectopic Pregnancy  The patient may have missed a menstrual period or had a positive pregnancy test.  Acute unilateral lower abdominal pain that may radiate to the shoulder.  Any female of childbearing age complaining of abdominal pain is considered to have an ectopic pregnancy until proven otherwise. Pelvic Inflammatory Disease  Be tactful when questioning the patient to prevent embarrassment.  Diffuse back pain.  Possibly lower abdominal pain.  Pain during intercourse.  Nausea, vomiting, or fever.  Vaginal discharge.  May walk with an altered gait do to abdominal pain. Placenta Previa  Usually occurs during the last trimester.  Painless.  Bright red vaginal bleeding. Post‐Partum Hemorrhage  Post‐partum blood loss greater than 300 ‐ 500 ml.  Bright red vaginal bleeding.  Be alert for shock and hypotension. Uterine Inversion  The uterine tissue presents from the vaginal canal. Cover with sterile saline dressing.  Be alert for vaginal bleeding and shock. Pre‐Eclampsia / Eclampsia  Severe headache, vision changes, or RUQ pain may indicate pre‐eclampsia.  In the setting of pregnancy, hypertension is defined as a BP greater than 140 systolic and greater than 90 diastolic, or a relative increase of 30 systolic and 20 diastolic from the patient's normal (pre‐pregnancy) blood pressure.  Often caused by prolonged, obstructed, or non‐progressive labor.  Severe abdominal pain. Vaginal Bleeding  If the patient is experiencing vaginal bleeding, DO NOT pack the vagina, pad on outside only.

Northeast Ohio Regional EMS Protocol 5 | 12