Pregnancy
2-7-a. Active Labor: Not Imminent
1) IV saline lock
2) Position patient in the left lateral recumbent position.
2-7-b. Active Labor: Impending Newborn Delivery
1) Administer O2 10 - 15 liters per minute via mask.
2) Start IV saline lock and prepare for delivery of newborn.
3) Check the perineum for crowning of the head, or prolapsed cord.
If prolapse is present, do the following:
a) Instruct patient not to push.
b) Position patient in knee-chest position (facing down).
c) Use gloved fingers to lift presenting part, and relieve compression of the cord.
4) For any OB complications (such as prolapsed cord, breech, shoulder, dystocia, etc.), COMMUNICATE with base station physician and stress the presence of the complicating factor.
5) If labor progresses to delivery:
a) Control the baby’s head to assist the mother: place one hand over the fetal head and apply minimal stabilizing pressure to prevent explosive birth and to carefully catch the baby.
b) Feel for cord wrapped around neck and, if present, lift it gently over the head.
If cord is too tight to lift over the head, double clamp the cord, then cut it between the clamps.
After delivery continue care as follows -
Baby:
1) Just after delivery, place baby on mother’s abdomen.
2) Suction baby’s mouth and nose with bulb syringe as needed to clear baby’s airway.
3) Clamp cord approximately 10 inches from the baby and second clamp 2 inches further towards mother. Cut the cord between the clamps.
4) Keep the newborn warm, dry, wrapped.
5) Do APGAR evaluations at 1 minute and 5 minutes.
6) Follow Neonatal / Newborn Resuscitation Pediatric SO or current NRP / NALS / PALS guidelines.
After delivery - Mother:
1) After “routine” healthy delivery of the baby and also the placenta, then apply firm rubbing pressure to the uterus through the lower abdominal wall.
2) If post-partum vaginal bleeding is severe: Add Oxytocin 20 units to 1 liter NS and run wide open until bleeding is controlled, or until 1 liter is infused.
3) If excessive hemorrhage or shock, [see 1-7. Shock/Hypovolemia].
2-7-c. Eclampsia
Pregnancy-related hypertension and hyper-reflexia, possibly progressing to seizures
1) Check glucose and treat if hypoglycemia [see 2-6-a. Hypoglycemia/Insulin Reaction].
2) Cardiac monitor
3) Minimize lights, noise, other stressors
4) Position left lateral recumbent.
5) Magnesium Sulfate 4 gm IV (in 100 ml NS) drip given slowly, over 20 minutes
6) If seizures continuing 5 min after beginning IV Magnesium Sulfate, administer Midazolam 2 mg IV/IN/IO/IM.
7) Continuous assessment of patient’s airway, VS, and mental status.
Magnesium Sulfate may cause hypotension and decreased respiratory drive, so monitor closely.
2-7-d. Vaginal Bleeding in Pregnancy Possible placenta previa or placental abruption:
1) Start 2 large bore IV lines
2) If necessary, treat for hypovolemic shock [see 1-7. Shock/Hypovolemia].
3) If > 20 weeks, position patient in left lateral recumbent.