Emergency Maternity Care & Communication

Quick Reference Manual (2013)

C A T H E R I N E M . S A L A M , C N M , M SJ U L I A N A VA N O L P H E N F E H R , C N M , P H D ,

C H A P T E R 1

Rural Settings, Communications Strategies

For this session you will develop your own directory of services based in your com-munity assessment.

Please add other numbers at the bottom of the table that you will need to know or you can give to your patients as a resource.

Agency telephone # director/contact personHealth department

Hospital #1 ED

Hospital #2 ED

Mental health clinic

OB/gyn practices

OB/gyn practices

OB/gyn practices

nurse-midwife practices

nurse-midwife practices

substance abuse treatment

transportation assistance

WIC program

medical assistance program

La Leche League

Gas & Electric company

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C H A P T E R 2

Decide Model

D: Down. . . calm down. Sit down if you can. Never be above anyone.

¬ When you are calm, the woman will become calm also and will be more amenable to work with you.

E: Evaluate. (In collaboration with the woman)

¬ Do a focused health and physical assessments within your bounds. If you are not experienced, avoid vaginal exams. You can find out a lot from the mother’s behavior and from what she tells you.

C: Connect. Eye contact, smile, lower voices.

¬ Women work well with those who are providing care and appreciate assis-tance from any care giver even though she may not exhibit that appreciation. Maintaining eye contact shows you care and you are there to listen to her. This helps her trust you and focuses your heightened awareness. Establish and main-tain eye contact

I: Involve. Ask if she will help you help her.

¬ Repeat: Women tend to work well with those who they perceive are sup-porting them. If you involve her as your collaborator she will get a sense that “we are in this together.” She wants to help you help her.

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D: Demonstrate. What do you want her to do?

¬ Use low cost teaching aides to communicate a variety of thoughts you have about her labor/birth/postpartum/baby. For example, dolls to demonstrate birth, teach breathing and coping techniques, pushing techniques, and breastfeed-ing techniques.

E: Educate. How can you give her information in short, directed messages.

Teach warning signs, fetal movement counts, hydration, who to call to get help with transportation, how to get on WIC, etc, breastfeeding support. Use short messages to reinforce demonstrations.

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C H A P T E R 3

Emergency delivery, postpartum & neonatal care

Vital signs norms:

Adult female BP pulse respirations temperature

100 – 140/ 60-90 60 – 100 16 – 20 97.0 – 99.0 oral

fetal heart rate 110 – 160

neonatal 50 – 70 /25 – 45not routinely measured

110 – 160 30 – 60 97.7 – 99.5 Axillary

Neonatal glucose levels:

50 – 60 mg/100 ml

20 – 40 mg/100 ml – feed

< 20 mg/100 ml – medical attention

S/sx of hypoglycemia

Mild: Hypothermia; irregular respirations; poor feeding; lethargy; abnormal cry

Moderate: apnea, cyanosis; tremors; limpness; 3+ mild signs

Severe: convulsions; 3+ moderate signs

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Taking a history with OLDCART

approach possible questions onset When did symptoms (contractions) start? Become regular? How

close to due date?

location Where do you feel them most?

duration How long do they last? How often are they occurring?

characteristics On a scale of 0 – 10, how would you rate your pain?

associated symptoms Any bloody show? Has your water broken? Color of fluid? Fetal movement?

relieving/aggravating factors What helps? Walking? Back rubs? What makes it worse?

treatment Have you taken any pain medications?

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C H A P T E R 4

FACES Pain Scale & Communication

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Face Communication Style

calm, caring, conversational

calm, caring, conversational

Speaks in sentences, demonstrate breathing techniques. Facilitative style - be encouraging (“You

can do this! Take it one at a time!”)

Speak in sentences, demonstrate breathing techniques. Facilitative style – be encouraging

(“You can do this! Take it one at a time.”)

Speak in phrases, eye contact, breath with her. Directive style - (“Stay focused!

Look me in the eyes!”)

Speak in phrases, eye contact, breath with her. Directive style - (“Stay focuses!”) Have only one person give directions - you can be that person or

assign a partner or family member

C H A P T E R 5

Apgar Score: 1 and 5 minutes after birth

Sign   0 1 2

Heart  rate   Absent   <100   >100  

Respiratory  effort  

Absent   Slow—irregular   Good  crying

Muscle  tone   Flaccid   Some  flexion   Active  motion

Reflex  irritability   None   Grimace   Vigorous  cry  

Color   Pale/blue   Body  pink,  extremities  blue  

Completely  pink  

Stabilization of mother:

1. Fundus

a. Firm, easy to feel

b. About 2 finger breadths below umbilicus after delivery, about the size of a large grapefruit

c. Check every 15 minutes for the first hour

2. Lochia

a. Similar to a menstrual period

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b. May be small clots

c. Check at same time as fundus

3. Breast -- Infant latches on

4. Bonding -- Holds, touches, inspects, talks to newborn

5. Voiding -- Should empty bladder within the first hour after delivery. If trans-porting, have her void first

6. Nourishment -- Offer fluids & food

7. Comfort

a. Mom’s tend to shake after delivery (hormonal response)

b. Offer warm blanket

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C H A P T E R 6

Antepartal, Intrapartal, Postpartum and Neonatal

Complications and Emergencies

Antepartum:

1st/ early 2nd trimester bleeding

Warning Signs:

1. Miscarriage

◦ Vaginal bleeding (light or heavy)

◦ Cramps

2. Ectopic

◦ Vaginal bleeding (may be light or brownish)

◦ Unilateral pelvic pain

Assessment:

•Onset?

•Location?

•Duration?

•Characteristics?

•Associated sx?

•Relieving factors?

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•Treatment?

R/O: Miscarriage; Ectopic Pregnancy

If abdominal pain and s/sx of shock

•Transport immediately; trendelenburg

•O2; large bore IV with ringers lactate or normal

•Saline

Late 2nd/3rd trimester bleeding

Warning Signs:

1. Previa

◦ Vaginal bleeding (painless, bright red)

◦ + fetal movement

◦ Belly soft

2. Abruption

◦ Vaginal bleeding (dark red)

◦ Pain (may be constant)

◦ May be little or no fetal movement

◦ Belly feels hard

R/O Placenta Previa

•Painless vaginal bleeding

•Bright red

•Reassuring fetal heart tones

•PE: Assess bleeding; Defer vaginal exam; Monitor maternal VS, FHTs

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Management:

•Ultrasound for Dx

•If no labor, conservative management

•If labor, cesarean section to prevent hemorrhage, shock and death

DECIDE: Eye contact, focused listening, emotional support.

Placental Abruption

•May or may not present with vaginal bleeding

•Bleeding (if present) is dark red

•Board-like abdomen

•Abdominal pain

•If contractions, pain persists between

•Non-reassuring fetal heart tones

PE: Assess VS, Bleeding, Fetal Heart Tones

Management

•Start IV

•Start oxygen mask

•Initiate emergency transport

Pre-eclampsia or Elevated Blood Pressure

Warning signs:

1. Elevated BP: >140/90

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OLDCART: May report headache not relieved by rest, medication; swelling; epigastric pain; blurred vision or “spots before eyes”

PE: take vital signs, check for hyperactive reflexes

Management:

•focus on immediate concerns for safety,

•quiet environment,

•left side,

•BP,

•start IV,

• arrange for transport

DECIDE: eye contact, focused listening , clear instructions; emphasize gravity of the situation.

Preterm Labor:

OLDCART

Warning signs:

1. Cramps/contractions greater than 5 – 6 X per hour

2. Change in vaginal discharge (mucusy or bloody)

3. Low backache

4. Pelvic pressure

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PE: VS, palpate uterine contractions; assess for rupture of membranes (visual)

Management:

•Prepare for emergency transport

•PO or IV hydration; if regular, painful contractions

•Keep baby warm (skin to skin with blankets)

•ABCs of neonatal resuscitation

DECIDE: Eye contact, focused attention. Clear instructions; acknowledge pa-rental concerns.

Substance Abuse:

OLDCART

PE: behavioral clues (hyperactivity or nodding off; pinpoint pupils; odor of marijuana); environmental clues: empty containers; little or no food in house

Management:

•Address presenting problem

a. In the hospital

•Urine tox screen

•Umbilical cord analysis (if available)

b. Social work consult

•CPS

•Resources for treatment

•Counseling for depression

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DECIDE: Non-judgmental approach – include questions regarding use of to-bacco, alcohol, prescription and non-prescription drugs in history.

Intrapartum Complications and Emergencies:

1.Meconium-stained amniotic fluid: baby has passed stool into amniotic fluid

2.If woman reports that her water broke: fluid is yellow, green or brown

3.Assess color, amount, & odor of fluid

4.Transport

5.At birth:

a. Vigorous newborn: routine management

b. Depressed newborn: Neonatal resuscitation with O2

DECIDE: remain calm, reassure parents.

Umbilical Cord Prolapse:

Cord visible at mother’s introitus before birth

Warning Signs:

1. Woman may report

◦ sudden gush of fluid

◦ Feel something coming out of vagina

2. If able to listen to fetal heart tones

◦ Sudden and prolonged decrease in rate

◦ Normal is 120 – 160 bpm

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Management:

•Emergency transport

•Position mother to keep fetal presenting part from compressing cord

•Elevate fetal presenting part manually (hand in vagina)

DECIDE: clear instructions; firm tone; significant other to follow with own car.

Shoulder dystocia:

Baby’s head is delivered and shoulder is stuck behind symphysis pubis (SP)

Warning Signs:

1. “Turtle sign”: after delivery of the head, you do not see restitution, but the head seems to pull back into the perineum. It may seem like the color is turning dark purple.

Management:

•NO fundal pressure! With woman in McRoberts, ask assistant to give su-pra pubic pressure ( push down right above pubic bone) to move shoulder from behind SP

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McRoberts position:

All fours position:

DECIDE: stay calm, call for backup, clear directions to mother, assistant(s)

Vaginal Breech Delivery:

Warning Signs:

1. Where does mom feel fetal movement the strongest?

◦ If in lower abdomen, suspect breech

2. Is she more than 4 weeks away from due date?

3. Is she carrying twins?

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Transport!

If delivery is imminent—(mother feels urge to push or says baby is coming)

prepare for delivery

Call for backup, prepare birth kit, prepare for possible neonatal resuscitation

Assist mother to firm surface,

Observe perineum for bulging and appearance of fetal buttocks

Wait for delivery of the body until you see the cord. DON’T PULL!

Encourage the mother to continue pushing

Support the baby’s body using a sterile towel until you see his hairline. This tells you that the head is ready to be born.

Have assistant put pressure above the mother’s pubic bone and ask the mother to push out the head.

Assess baby’s breathing, heart rate and color. Keep warm.

Cord around the neck:

Check for cord around the neck after head is born

1. If present, gently pull over head or push back over shoulder

2. If you feel a lot of resistance, go to somersault maneuver

a. Keep baby’s head close to the mother’s body

b. Deliver baby’s body

c. Unwrap cord

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Postpartum emergencies:

Postpartum hemorrhage: >500 ml (about 2 cups) of blood loss after delivery;

a. Early: w/in 1st 24 hours

b. Late: after 1st 24 hours

Warning Signs:

1. Heavy vaginal bleeding

2. Difficult to feel uterus abdominally

3. Placenta appears incomplete

Management:

•Uterine massage until feels like a cantaloupe

•Empty bladder –help mother to urinate

•Infant to breast or nipple stimulation

•Keep checking uterus

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•Save placenta

Meds if available

•Pitocin 10 units IM or 20-40 units in a liter of RL

•Methergine .2 mg IM (if no hx HTN or PIH)

If uterus is firm consider other causes for bleeding

1. Lacerations of perineum, vagina, cervix

•Apply pressure

•Transport for repair

2. Alert for s/sx of shock

•Monitor VS

•Start IV

•Give O2

•Put mother in Trendelenberg

•Cover her with warm blankets

Uterine Massage

DECIDE: eye contact, focused listening, clear instructions

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Postpartum warning signs:

1. Temperature > 100.4 F

2. Soaking a pad in less than one hour

3. Pain with urination or

•Frequency

•Urgency

•Retention

4. Pain in calf

•Heat

•Red streak

5. Chest pain

6. Breast pain

7. Foul smelling lochia

8. Uterine tenderness

9. Sadness > 2 weeks

10.Inability to cope

11.Thoughts of harming self or baby

Neonatal resuscitation:

Refer to APA, AHA laminated card

Newborn warning signs:

1. Dehydration

•Depressed fontanel

•< than expected # wet diapers

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•Weight loss (per parents)

2. Physiologic Jaundice

•Days 3 - 6 or 7 of life

•Blanch skin over bony prominence to check color underneath

•Progresses head to chest to lower extremities

•If infant jaundiced head to toe – transport

3. Pathologic

•Within the first 24 hours of life (rH incompatibility) or

•Does not resolve within first week

•Poor feeding

•Lethargy

•High bilirubin level for day of life

• Possible drug exposure

•S/sx of withdrawal

a.Crying/agitation

b.Disturbed sleep

c.Hyperactive Moro reflex

d.Increased muscle tone

e.Tremors

f.Sweating

g.Yawning

h.Poor feeding

•Possible cardiac anomaly:

a.Poor feeding

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b. Pallor

c. Blue color to lips, tongue or nails

d. Tachypnea

e. Heart murmur on auscultation

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References

Resources:

West Virginia

http://quickfacts.census.gov/qfd/states/54000.html

http://www.wvperinatal.org/default.htm

Cultural awareness

http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2& lvlID=11

Emergency preparedness

http://publish.amchp.org/programsandtopics/emergency-preparedness/Documents/AMCHP-Preparedness-Report-Nov-2007.pdf

Women’s Health

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004481/

http://womenshealth.gov/mental-health/illnesses/postpartum-depression.cfm

http://www.glowm.com/

Newborn Assessment

http://newborns.stanford.edu/PhotoGallery/GalleryIndex.htm

http://www.aap.org

http://pediatrics.aappublications.org/content/126/5/e140 0.full

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Acknowledgements

This project is supported in part by funds from the Division of Nursing (DN), Bureau of Health Pro-fessions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under grant number DO9HP07967 and Title VIII for $256,482. The information or content and conclusions are those of the author and should not be construed as the offi-cial position or policy of, nor should any endorsements be inferred by the Division of Nursing, BHPr, DHHS or the U.S. Government.”

Acknowledgments

Thanks to the planning committee: Ann Dacey, Nancy Tolliver, Angie Nixon, Ruth Walsh, Jay Ripley, Denise Smith, Greg Burd, Stefan Maxwell, Luis Bracero, Alan Chamberlain

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