EMS:
Obstetric Emergencies
Not Deliveries
Dan O’Donnell
Departments of Emergency Medicine
IU School of Medicine
Importance
• You will see these patients daily on runs
• Stressful situations
• Treating two patients
Case #1
• 23 y/o pregnant white female with vaginal
bleeding x 4 hours.
Case 1
• Time and Severity
-- Onset and # pads/ hour
• Assess length of pregnancy
-- LNMP, fundal height, Ob hx
• Contributing factors
-- Trauma, Abuse, Pain, Clots, Ob complications,
Contractions, substance abuse
Case 1
• VS: RR 20/ HR 120 / BP 90/50 afebrile
• Cool, Clammy and diaphoretic
• Prolonged cap refill
• Pt reports painless vaginal bleeding approx 10
pads/hour. No cramping or Contractions
• Unsure of dates: LNMP 5 months ago. Fundal
height at umbilicus.
Treatment
• High Flow Oxygen
• Two Large bore IV’s with NS wide open
• Left Lateral Recumbent Position
– if Gestational Age > 20 weeks.
• Transport Emergently
– > 20 weeks gestational age or unstable pt.
Why Give Oxygen???
• Anemia of Pregnancy
– Physiologic
• Greater increase in plasma volume compared to red cell mass
– Fe Deficiency Anemia
• Subjective Dyspnea
– Elevation in Diaphragm
• Ascends approx. 4 cm
– Progesterone-induced hyperventilation
• Breathing for two
Treatment
• High Flow Oxygen
• Two Large bore IV’s with NS wide open
• Left Lateral Recumbent Position
– if Gestational Age > 20 weeks.
• Transport Emergently
– > 20 weeks gestational age or unstable
Venous Access/Fluid Resuscitation
• Hard to Quantify Blood Loss
• Anemia of Pregnancy
• Hypotension in Mom = Massive
Hypotension in Fetus
– compensatory mechanisms: vasoconstriction,
tachycardia to save mom.
Treatment
• High Flow Oxygen
• Two Large bore IV’s with NS wide open
• Left Lateral Recumbent Position
– if Gestational Age > 20 weeks.
• Transport Emergently
– > 20 weeks gestational age or unstable
Inferior
Vena Cava
Aorta
Left Lateral Recumbent Position
• Supine Hypotension Syndrome
–
–
–
–
Gravid Uterus Compressing IVC
Decreased Blood return to heart
Hypotension
More Common once GA > 20 weeks
• All vitals should be obtained in this position
if possible
– Trauma pt: Place wedge under right side of
board.
Estimation of Gestational Age
• Fundal Height Estimation
– 12 weeks: top of fundus at symphysis pubis
– 20 weeks at umbilicus
– add 1 week per cm above that.
• Fetus Viability at 23 weeks
Vaginal Bleeding in the Pregnant
Patient
• 1st half of pregnancy
-- Abortion (Most Common), Ectopic Pregnancy, GTD
• 2nd half of pregnancy
-- Placenta Previa, Abruptio Placenta , Preterm Labor, Bloody
show
• Postpartum hemorrhage
-- Uterine Atony, Uterine Rupture, Retained Placenta
Products, Uterine Inversion, Coagulopathy
Ectopic
• Fetus implanted somewhere other than uterus
• Risk Factors
- IUD, PID, previous ectopic, race, infertility tx,
smoking, tubal ligation
• Clinical features
-Abdominal Pain, vaginal bleeding, syncope,
hypotension
• Deadly
Placenta Previa
• Painless Bright Red Blood Per Vagina
• Placenta implantation over cervical os
– as cervix shortens, placental vessels tear
– Avoid digital or speculum exam
• Hx may be obtained from patient-increased risk
with multiparity and prior c-section
Abruptio Placenta
• Painful, Dark Vaginal Bleeding
• Premature Separation of Placenta from
Uterus
• Uterine tenderness/contractility
Abruptio Placenta
• Risk Factors
– Trauma and hypertension are greatest risks, also
increased maternal age, cocaine, smoking, prior history
• Must also be considered in patients with
abdominal pain but no vaginal bleeding
• High risk to fetus if sufficient compromise
to placental blood and oxygen flow
Postpartum Hemorrhage
• Uterine Atony most common cause
– lacerations, rupture, retained placenta products
• Massage the uterus until firm
– Check fundus every 5 minutes for firmness and repeat
massage as necessary
• Ask about delivery of Placenta
– bring placenta if present
Case 2
• 25 y/o BF in active Labor.
Case 2
•
•
•
•
Due Date
Frequency of Contractions
Hx of Pregnancies: Preterm or Postterm
Sensation of the need to move bowels
– delivery imminent
• Presence of crowning
– delivery imminent
• Rupture of Membranes
– Gush of fluid
Case 2
• VS: RR 20 / HR 110/ BP 110/70
• “water has broke but I think I’m way early”
• Contractions every 5 minutes: painful
• Fundal Height: few(4-5) cm above
umbilicus
• I feel something coming out………...
Prolapsed Umbilical Cord
• Prematurity and Breech are greatest risk
factors
• Umbilical Cord presents before fetus
– compression of cord and fetal distress
• Oxygen and IV
Prolapsed Umbilical Cord
• Place mother in Trendelenburg position
• Knee to Chest
• Elevate presenting part off of umbilical cord
– Keep elevated until relieved by doctor
– never try to replace cord
Case 4
• Called for a woman who has just given birth
• Delivery performed by new midwife
• Upon Arrival patient is pail and the bed is
soaked in blood
Case 4 Continued
• P 165, BP 80/p, R 32, SaO 98% on NRB
• Severe lower abdominal pain and cramping
• Continuous hemorrhage noted as you move
her to the bed
Postpartum Hemorrhage
• Caused by atony of the uterus after
placental delivery
• Can be caused by retained placenta
• High flow 02
• Massage the fundus of the placenta until
firm
• 2 large bore IVs
Case 4
• 21 y/o pregnant BF with complaint of
abdominal pain and malaise
Case 4
• Generalized abdominal pain and blurry
vision over the last couple of days
• No prenatal Care
• First pregnancy
Case 4
• VS: RR 20/ BP 160/90 / HR 100
• Edema to hands and face
• Fundal Height above the umbilicus
• Pt looks very “jittery”
Preeclampsia
• Pregnancy induced hypertension, proteinuria, and
pathologic edema (hands and face, persisting throughout the
day)
• Occurs 20 weeks GA to 2-4 weeks postpartum
• Risk Factors
– Females less than 20, primigravidas, high cholesterol, cigarette
smoking, family history, twin or molar pregnancies
• Only real treatment is delivery
Preeclampsia
• O2 and IV
• Left lateral recumbent position
• No lights or sirens, darkened ambulance
En Route patient begins to have generalized
tonic clonic seizure………….
Eclampsia
• Preeclampsia with seizure
• Warning signs—headache, nausea and vomiting, visual
disturbances, MAP > 161, hyperreflexic
• Routine seizure protocols should be followed
– diazepam(Valium) is safe in pregnant pts.
– Check blood sugar
• First line Treatment is Magnesium Sulfate 4-6
grams IV/ 15 minutes.
Case 5
• 26 y/o pregnant female involved in low
speed MVA where she was rear-ended
• Did have mild abdominal pain but now
resolved
• Refusing transport
• Should we encourage her to seek medical
care?
Minor Trauma in Pregnancy
• Even Minor trauma can cause major
complications
Minor Trauma in Pregnancy
• Less than 20 weeks
– Can do TVUS to test for viability
– If there is injury there is little that can be done
• Greater than 20 weeks
– Will admit for 4 hour tocofetal monitoring
• Rec transport of all pregnant women even with
minor trauma
– At least OB F/U
Take Home Points
• Left Lateral Recumbent Position
• Estimate Gestational Age by using Fundal
Height
• Oxygen and Fluids in pregnant patient
• Recommend transport of all pregnant
trauma patients