General Approach to All Patients

Obstetric & Gynecological Emergencies

General Considerations for Pregnant Patients

  • Determine the date of the last menstral period (LMP) and approximate weeks gestation
  • Patients in the late 2nd or 3rd trimester (≥28 weeks) should be transported in a left lateral recumbent position (including those immobilized on a back board) to avoid compression of the inferior vena cava by the gravid uterus

Childbirth

Basic Life Support

  • Supplemental oxygen
  • Do not place fingers or hand inside birth canal for assessment
  • If presenting part is not the head (i.e. foot, arm, or buttock first) immediately begin transport to the nearest OB receiving facility; continue supportive care en route
  • Delivery:
    • Slow, controlled delivery of head; apply gentle perineal pressure
      • If the umbilical cord is wrapped around the child's neck, gently unwrap prior to completion of delivery
    • Observe for meconium staining
      • If present, suction oral pharynx and nose as soon as head is delivered
    • Following delivery, follow newborn resuscitation protocol
    • Double clamp cord 10-12 inches from abdomen
    • Cut cord between clamps
    • Maintain body temperature
    • Allow spontaneous delivery of placenta; do not apply traction to umbilical cord for placental delivery
    • If placental delivery occurs, package in biohazardous waste bag and hand over to hospital staff upon arrival
  • Postpartum:
    • For newborn, see newborn resuscitation protocol
    • Assess for postpartum hemorrhage
    • Gently massage abdominal wall overlying the uterine fundus until firm

Advanced Life Support

  • Transport to nearest OB receiving facility
  • See newborn resuscitation protocol

Pre-eclampsia & Eclampsia

Pregnancy induced hypertension, pre-eclampsia and eclampsia are conditions typically encountered in late 2nd or 3rd trimester pregnancy, and less commonly in the postpartum period. Clinical manifestations may include elevated blood pressure (SBP >160 mmHg or DBP > 120 mmHg), headache, confusion, agitation or seizures.

Advanced Life Support

  • Full ALS Assessment and Treatment
  • If the patient is ≥ 20 weeks pregnant, administer Magnesium Sulfate 4 grams IV over 10 minutes for either of the following:
    • Active seizures
    • Systolic BP > 160 mmHg or Diastolic BP > 120 mmHg on two readings
  • If the patient is < 20 weeks pregnant or post-partum, and Magnesium is being considered, contact Medical Control for orders
  • For active seizures administer Midazolam (Versed) 5 mg IM or intranasal via MAD OR 2.5 mg IV
    • If seizures continue or re-occur repeat Midazolam (Versed) 5 mg IM or intranasal via MAD OR 2.5 mg IV; wait at least 5 minutes from initial dose
    • Do NOT delay treatment to obtain intravenous access, begin with IM dose unless IV is already established
  • Blood glucose measurement
    • If < 70 mg/dL administer Dextrose 50% 25 gm Slow IV
    • See General Illness protocol for additional detail

Vaginal Bleeding

  • A visual inspection of the vaginal area to look for crowning or presenting parts is appropriate, but do not place fingers or hand inside birth canal during assessment
  • 1st or 2nd Trimester or unknown pregnancy status
    • Position of comfort
  • 3rd Trimester Bleeding (≥28 weeks)
    • Lateral recumbent position

Advanced Life Support

  • If bleeding moderate or heavy perform Full ALS Assessment and Treatment
  • If gestational age known to be < 20 weeks transport to closest hospital
  • If gestational age known or possibly > 20 weeks transport to closest OB receiving facility
  • Transport any products of conception or fetal material present at the scene to the receiving facility

Obstetrical Transport Destination

If delivery is not imminent, transport to patient’s requested obstetric (OB) receiving facility.

Patient known to be < 20 weeks gestation:

  • 1st day of last menstrual period < 20 weeks ago
  • Available information verifying gestational age < 20 weeks (e.g. known due date)
  • Transport to closest emergency department

Patient known or possibly ≥ 20 weeks gestation:

  • Imminent delivery or medically unstable mother
    • Transport to nearest ED
  • Non-traumatic abdominal, pelvic or back complaints, vaginal bleeding/spotting or any vaginal fluid leak or discharge
    • Transport to closest OB receiving facility
      • Patient's preference should be considered if condition allows
      • Includes minor trauma patients

Pregnancy & Trauma:

  • Transport all pregnant patients meeting Trauma Alert criteria or Trauma RED to Orlando Regional Medical Center (or other State Approved Trauma Center)
  • Trauma Yellow or Green can be transported to ED of closest OB receiving facility
  • If < 20 weeks gestational age, minor trauma patients can be transported to nearest ED

Central Florida OB Receiving Facilities as of 08/01/2013

  • Health Central
  • Florida Hospital Altamonte (Seminole County)
  • Florida Hospital Celebration (Osceola County)
  • Florida Hospital Orlando
  • Florida Hospital Waterman (Lake County)
  • Florida Hospital Winter Park
  • Osceola Regional (Osceola County)
  • Winnie Palmer Hospital