name of policy child birth & maternal care in the

Name of Policy: Child Birth & Maternal Care in the Emergency Department

Policy Number: 3364-117-60

Approving Officer: AVP Patient Care Services/CNO and Medical Director

Responsible Agent: Nursing Director

Scope: All University of Toledo Campuses

Effective Date: August 1, 2020

Original Effective Date: August 1, 2020

X New policy proposal Minor/technical revision of existing policy Major revision of existing policy Reaffirmation of existing policy

(A) Policy statement

Patients presenting to the Emergency Department at the University of Toledo MedicalCenter who are pregnant where delivery is imminent will be cared for by qualified staff.After delivery in the Emergency Department and stabilization of mother and infant(s),mother and infant(s) will be transported to another institution for admission andcontinuing care. Transport for mother and infant(s) will be by the Mercy Health or thePromedica Toledo Hospital Neonatal Transport Unit.

(B) Purpose of policy

To provide guidelines to the Emergency Department staff on the care and management ofobstetrical patients in whom delivery is imminent, while in the Emergency Department.

(C) Procedure

(1) Pregnancy in Labor

(a) Initial examination will be conducted immediately by the ED attendingphysician

(b) The Obstetrician on call at Mercy Health or the Toledo PromedicaHospital will be notified immediately of the patient and the delivery status, presence of obstetric hemorrhage risk factors and/or maternal severe hypertension/preeclampsia.

(c) If the patient has an established OB physician, that physician will benotified

(d) After examination (“medical screening examination” per EMTALA) andconsultation with the OB attending /patient’s private physician, the patient may be transferred to another facility which provides OB services upon determination that the

3364-117-60 Child Birth in the Emergency Department

2

patient is at a level at which a safe transfer may be effectuated. The medical record should reflect that the examination included ongoing evaluation of maternal blood pressure and vital signs, fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation and status of the membranes.

(i) The transfer policy will be followed and consent to transfer completed.

(ii) Discretion will be used in transferring the patient by ambulance, critical care transport unit, or private car.

(ii) If Life Flight is used to transfer the patient, the Life Flight/Mobile Life Certification of Transport form must be completed by the transferring registered nurse and physician.

(e) If delivery is imminent, delivery will occur in the Emergency Department (ED), unless a cesarean section is necessary, in which case the patient will be taken to surgery

(2) Pregnant and Post-Partum patients with severe hypertension/preeclampsia (a) Acute onset of severe systolic hypertension, severe diastolic hypertension or both can occur during prenatal, intrapartum or post-partum periods. This requires urgent antihypertensive therapy. Treatment of evidence-based first-line agents should occur within 30-60 minutes of confirmation of severe hypertension in order to reduce the risk of maternal stroke. [ref evid-based practice- [1] at end of policy] (i) Maternal blood pressure and vital signs will be monitored on admission and minimally every 15 minutes until delivery or transfer. Vital signs are monitored using the correct cuff size as stipulated in UTMC general guidelines. The ED attending physician will be notified immediately if systolic BP is greater than 159mm Hg or if diastolic BP is greater than 109mm Hg. (ii) Seizure precautions will be immediately initiated (b) The ED Attending Physician will be in consultation with the identified Obstetrical Physician and OB Team as noted in part C. 1. d. of this policy. (c) Evidence-based medications used to treat severe hypertension/preeclampsia are readily available in the AcuDose including hydralazine, labetalol, and nifedipine. Magnesium sulfate is available for seizure prophylaxis. (3) Obstetrical Hemorrhage Risk Assessment and Checklist [see attached] Maternal hemorrhage, defined as a cumulative blood loss of > 1000 ml or blood loss accompanied by signs or symptoms of hypovolemia, remains the leading cause of maternal mortality world-wide. [2nd reference- as listed below]


3

(a) An evidence-based checklist identifying risk factors for obstetrical hemorrhage will beused on admission of an obstetric patient to the ED. The ED attending Physician will discuss the presenting exam with the OB attending physician accepting the patient for transfer.

(b) Uterotonic agents identified as first line treatment of uterine atony will be maintained in theED AcuDose identified as “OB Kit”. The OB Kit contains oxytocin injection 10 units/ml 1mlvial x1, misoprostol 100 mcg tablets x 10, and lidocaine 1% injection 5 ml x 1

Drug Dose Route Contraindications

Oxytocin

10 units

30 units in 500ml (Max 40 unit in 500ml IV)

IM or directly into myometrium

IV rate at 333ml- 500ml/hour Titrate per uterine tone

• Allergy to oxytocin

Carboprost (Hemabate)

250 mcg every 15-90 minutes as needed (max of eight doses or 2 mg)

IM or injected into myometrium; rotate sites if multiple injections required

• Asthma- absolutecontraindication

• Coronary artery disease• Cerebral artery disease• Raynaud’s Syndrome• Hypertension- relative

contraindication• Preeclampia- relative

contraindication

Methylergonovine 0.2 mg May repeat every 2-4 hours as needed after delivery of placenta

IM or injected into myometrium

• Vascular disease• Hypertension• Hepatic disease• Cardiac disease• Raynaud’s disease• Cerebral artery disease

Contraindicated in patients taking: • Protease inhibitors (amprenavir,

atazanavir, boceprevir,cobicistat,, darunavir,delavirdine, fosamprenavir,indinavir, letermovir, lopinavir,nelfinavir, ritonavir, saquinavir,simeprevir, telaprevir,tipranavir)

• CYP3A4 inhibitors(almotriptine, azithromycin,clarithromycin, dinoprostone,eletriptan, erythromycin,fluconazole, fluvoxamine,frovatriptan, itraconazole,ketoconazole, naratriptan,nefazodone, posaconazole,propatylnitrate, sumatriptan,telithromycin, voriconazole, ,zolmitriptan

Misoprostol 600mcg-1000mcg Rectal only • Allergy to prostaglandinsepoprostenol, enprostil,


4

fenprostalene, fluprostenol, gemeprost, iloprost, latanoprostene, latanoprost, limaprost, luprostiol, misoprostol, prostalene, sulprostone, (alprostadil, beraprost, bimatoprost, carboprost, cloprostenol, dinoprost, dinoprostone, tafluprost, travoprost, treprostinil, unoprostone)

*Tranexamic Acid-

(Pharmacy order-consider if initial medical

therapy fails within 3 hours of birth)

1 gram in 100ml (total volume 110ml)

1 gram over 10 min; may repeat in 30 minutes if bleeding continues

• Known thrombolic event during pregnancy

• History coagulopathy • Active intravascular clotting • Allergy to Tranexamic Acid

(c)In case of obstetrical hemorrhage, the Obstetrical Hemorrhage Checklist will be followed. The Team Leader at UTMC is the ED Attending. Scribes will be Recorders and the ED Primary Nurse will be the Primary Nurse.

(d) In case of obstetrical hemorrhage, The Mass Transfusion Protocol, Urgent Request for Uncrossmatched Blood and Rh(D) Immune Globulin policies will be initiated as per the Obstetrical Hemorrhage Checklist direction. (4) Delivery

(a) The patient will be placed in an ED treatment area with a door

(b) Vital signs and fetal heart tones will be taken and documented (c) Two IV lines will be started and oxygen will be readily available

(d) Explain all that will be taking place to the patient, prior to treatments, procedures, etc.

(e) Place the patient in stirrups

(f) Cleanse the perineum with an iodine-based or chlorhexidine-based

solution and rinse with normal saline

(g) Prep as directed by the physician, as time permits (h) Open OB pack

(i) Obtain infant warmer


5

(j) Note time of delivery, presentation of fetus (LOA, LOP, etc.)

(k) Perform and document APGAR score at time of delivery and 5 minutespost delivery

(l) Obtain and record baby’s length and weight

(m) Document delivery of placenta

(n) Document any medications given to either mother or neonate(s)

(o) Send placenta, properly labeled and in an appropriate container toPathology

(5) Disposition of Mother and neonate(s)

(a) If mother and neonate(s) are transferred to another institution whichprovides obstetrical services, they will be transported (ground or air) byMercy Health or by the Promedica Toledo Hospital Neonatal TransportUnit

(b) The neonate(s) will be registered using the time of delivery as the timeadmitted to the Emergency Department

(c) An Emergency Department medical record will then be completed on eachneonate

(6) Birth Certificate

(a) Obtain a hospital worksheet #1 and #2 from the Admitting Department

(b) These papers must be completed prior to transfer to another institution

(c) The birth certificate will be completed and signed by the EmergencyDepartment attending or the physician who actually delivers theneonate(s) and then sent to the Lucas County Bureau of Vital Statistics

(7) Emergency Department Medical Record – Mother

(a) An Emergency Department medical record will be generated for themother upon her arrival to the Emergency Department

(b) All records, laboratory reports, initial radiological interpretations, and anyother information obtained in the ED will be sent with the patient to thehospital she is being transferred to

(8) Identification


6

(a) Mother and neonate(s) identification bands will be made using the armbands currently used in the Emergency Department

(b) Bands containing the mother’s name, medical record number, date andtime of delivery, and sex of neonate will be made.

(c) Bands will be attached to each neonate’s ankle and the mother’s wrist

References: 1. The American College of Obstetricians and Gynecologists; “Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period; Committee OpinionNumber 767, Vol133, NO.2 February 2019https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co767.pdf

2. The American College of Obstetricians and Gynecologists; “Practice Bulletin No 183Postpartum Hemorrhage; Committee Opinion Number 183, Vol 130, NO.4. October 2017https://insights.ovid.com/crossref?an=00006250-201710000-00051

Approved by:

/s/ William Saunders III, MD. Date Medical Director

/s/ Monecca Smith, MSN, RN Date AVP Patient Care Services/CNO

Review/Revision Completed by: Nursing Director, Emergency Services 8/20

Review/Revision Date:

Next review date: 8/1/23 Policies Superseded by This Policy: •MS-034 Child Birth in the Emergency Department3364-87-34 Child Birth and Maternal Care in the EmergencyDepartment

https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co767.pdf

https://insights.ovid.com/crossref?an=00006250-201710000-00051

Rate of Oxytocin Administration After Delivery (30 units oxytocin/500 mL) for Prophylaxis and Treatment of Postpartum Hemorrhage

Time after delivery Vaginal Delivery Cesarean Delivery without Labor Cesarean Delivery with Labor

First hour (prophylaxis)

300 mL/hour 300 mL/hour 600 mL/hour until fascia closed, then 300 mL/hour

Second hour (prophylaxis) 150 mL/hour 150 mL/hour 150 mL/hour

If no IV (prophylaxis) 10 units oxytocin IM

If uterine atony (treatment) Increase rate to 600 mL/hour for 1 hour, followed by 150 mL/hour for 1 hour

Increase rate to 600 mL/hour for 1 hour, followed by 150 mL/hour for 1 hour

Increase rate to 600 mL/hour for 1 hour, followed by 150 mL/hour for 1 hour

150 mL/hr = 9 units, 300 mL/hr = 18 units, 600 mL/hr = 36 units

Treatment of Postpartum Hemorrhage

Order of Use if not contraindicated

Drug Dose, frequency Contraindications Side Effects

Prophylactic doses for all patients; 1st line for treatment

oxytocin (Pitocin) See chart above Hypersensitivity. Hypotension and tachycardia with high doses especially IV push, hyponatremia with prolonged infusion

2nd

line for treatment methylergonovine (Methergine)

0.2 mg IM every 2 to 4 hours Hypersensitivity. Hypertension, preeclampsia, or heart disease. Multiple doses of ephedrine given. Use of protease inhibitors.

Nausea, vomiting, hypertension, coronary artery spasm

3rd

line for treatment carboprost (Hemabate) 250 mcg IM or intra-myometrial every 15 to 90 minutes; maximum of 2 mg

Hypersensitivity. Active pulmonary disease (e.g. asthma), cardiac disease, renal disease, or hepatic disease.

Nausea, vomiting, diarrhea, fever, hypertension, headache, bronchospasm

4th

line for treatment misoprostol (Cytotec) 400 mcg sublingual or 1000 mcg rectal

Hypersensitivity. Nausea, vomiting, diarrhea, fever, headache

UIHC Post-Partum Hemorrhage Management Plan

(modified directly from CMQCC version 2.0)

Primary Nurse Second Nurse OB LIP Anesthesia LIP Labs &

Blood Bank

Stage 0 Every patient admitted to Labor & Delivery Pre-delivery risk assessment

Active management of 3rd

stage

Assess every patient for PPHrisk level on admission

Ask if patient will acceptblood products

QBL at every delivery

Assess every patient for PPHrisk level on admission

Active management of 3rd stage:1. Oxytocin per protocol 2. Gentle cord traction3. 15 second fundal massage

Be aware of PPH risk for all admitted patients

All patients: T&S

High Risk: Crossmatch 2u1. Abnormal placentation

(>2u per MFM/Gyn-Onc) 2. Antibody present (use

“Pretransfusion Special Testing” orderset, patient to have T&S drawn up to 72h prior to procedure)

Stage 1 Blood loss >500ml (vaginal) or >1000ml (Cesarean) “Rub + Drug” Call for help (charge RN, OB

chief, OB staff, anesthesia)

Confirm IV access (18G minimum)

Insert Foley catheter

Bring PPH cart to bedside

Place orders for “OB PPHStage 1”

Calculate QBL every 5-15 minutes

Repeat fundal massage

Assess for bleeding source

2nd uterotonic medication(Methergine preferred unless contraindicated)

Present to patient’s bedside,assist as needed

Crossmatch 2u (if not done on admission)

Stage 2 Continued bleeding with total blood loss under 1500ml Sequential progression

through medications &procedures

Keep ahead with blood products & volume

Check VS every 5 minutes

2nd IV (16G)

Draw labs

1L fluid bolus



Ask LIPs if IR consult needed

3rd uterotonic medication

Additional procedures asindicated (D&C, Bakri, B-Lynch)

Move to OR for further evaluation/exposure

Accompany patient to the OR

Assist in establishing IV access

Transfuse per clinical signs

Hemorrhage labs (CBC, DICpanel, electrolytes, Ca)

2u PRBCs to bedside

Consider FFP and/or other products

Stage 3 Total blood loss > 1500ml or > 2u PRBCs given or VS unstable or suspected DIC Massive Transfusion Protocol

Invasive surgical approaches to control of hemorrhage

Assist in preparing patient for surgery

Announce “Bleed Time-Out” every 1L of QBL (current QBL, transfusions, meds given,consults called, most recent labs)



Ask LIPs if GYN-ONC consult needed

Request scrub team fromMOR

Request Perfusion team forcell salvage system

Continue with procedures as indicated

Consider laparotomy (if not open)

Prepare for possible hysterectomy

Draw labs

Transfuse per Massive Transfusion Protocol

Consider central line and invasive monitoring

Consider cell salvage system

Consider Tranexamic Acid

Consider rFactor VIIa if DIC

Transfuse 2u PRBCs at minimum

Massive Transfusion Protocol

Repeat hemorrhage labs (CBC,DIC panel, electrolytes, Ca) every 1L of QBL

Main OR Charge Nurse: 36400 OB Emergency pager group 6777 (OB Chief, OB Staff, Anesthesia Resident, Anesthesia Staff): indicate “PPH, NICU not needed”

Cell Salvage: pager group “Perfusion” Blood bank: 62561

IR for uterine artery embolization: pager 5390

Gyn-Oncology: per hospital operator

Post-Partum Maternal Hemorrhage Order set

Establish IV access X2 (18 gauge minimum if able)

Begin 0.9% Sodium Chloride solution @ 100ml/hour

Oxygen at 2-4 liters per nasal cannula to maintain pulse ox of 95%

Type and screen

Vital signs every 15 minutes

For Vaginal Delivery

1. Oxytocin 30 units in 500 ml Normal Saline• Start at 300 ml/hour for the first hour after delivery• Decrease to 150 ml/hour for the second hour after delivery• For uterine atony increase the rate to 600 ml/hour for one hour followed by 150 ml/hour for

one hour2. Oxytocin 10 units IM if no IV access

For Postpartum Hemorrhage First Line for treatment

1. Oxytocin 30 units in 500 ml Normal Saline• Start at 300 ml/hour for the first hour after delivery• Decrease to 150 ml/hour for the second hour after delivery• For uterine atony increase the rate to 600 ml/hour for one hour followed by 150 ml/hour for

one hour2. Oxytocin 10 units IM if no IV access

For Postpartum Hemorrhage Second Line for treatment

1. Methylergonovine 0.2mg IM every 2 to 4 hours

For Postpartum Hemorrhage Third Line for treatment

1. Carboprost (Hemabate) 250 mcg IM every 15-90 minutes; maximum of 2 mg

For Postpartum Hemorrhage Fourth Line for treatment

1. Misoprostol (Cytotec) 400 mcg sublingual2. If unable to administer sublingual give Misoprostol (Cytotec) 1000 mcg rectal

name of policy child birth & maternal care in the

Documents