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CINDY MITCHELL, RN, BSN, MSHL
ADMINISTRATOR – SOUTH CENTRAL ILLINOIS PERINATAL CENTER
HSHS ST. JOHN’S HOSPITAL
Preparing for OB Patients in the Emergency Department
DISCLOSURES
I have nothing to disclose
OBJECTIVES
Understand Illinois Perinatal Healthcare Code (640)
Understand how Emergency Departments fit into 640
Understand what resources are available to Emergency Departments
Understand current projects in Illinois related to perinatal patients
Understand available education
ILLINOIS REGIONALIZED PERINATAL HEALTHCARE CODE 640
Illinois has a regionalized perinatal system – broken down into 10 regions
Also referred to as Administrative Code or 640
Each hospital with a functional emergency department is assigned to an administrative perinatal
center (APC)
http://ilga.gov/commission/jcar/admincode/077/07700640sections.html
10 Regions/APC’s
6 Chicagoland Area
1 Rockford
1 Peoria
1 Springfield
1 Southern Illinois (St. Louis)
Each APC has an Administrator and an Educator(s)
HOSPITALS WITHOUT OBSTETRIC SERVICES
Considered Level 0
Have a functioning emergency department
Must maintain a Letter of Agreement (LOA) with Administrative Perinatal Center (APC)
Understand guidelines for transfer or transport of perinatal patients
Utilize telephone numbers for consult and/or transfer to a perinatal center
Educational needs assessment for ED staff and provision of education programs to maintain
perinatal skills
HOSPITALS WITHOUT OBSTETRIC SERVICES
“Non-Birthing Center hospitals do not provide perinatal services, but have a
functioning emergency department. All licensed general hospitals that operate an
emergency department shall have a letter of agreement with an APC for referral of
perinatal patients, regardless of whether the hospital provides maternity or newborn
services…”
http://ilga.gov/commission/jcar/admincode/077/077006400000400R.html
LETTER OF AGREEMENT (LOA)
All hospitals must have one
Different depending on level of care
If you don’t provide OB services the LOA and contact will be via the Emergency Department
If your hospital provides OB services the LOA and contact will typically be through the OB
nursing care manager/director
Beneficial to obtain a copy for your review
LETTER OF AGREEMENT
Hospitals without delivery services
Pregnant women presenting to Hospital will have evaluation of fetus prior to discharge in consultation
with Maternal-Fetal Medicine physician at Administrative Perinatal Center or Level III Center. All maternal
and neonatal transports out of the institution will be done after consulting with the respective specialist
(Maternal – Fetal Medicine or Neonatologist) at the Level III Center. The Hospital will consult and/or
transfer to Level III Center any high-risk maternal-fetal and neonatal patients who require the services of a
Level III Center. Low risk maternal-fetal and neonatal patients may be transported to the nearest facility
providing maternity services.
WHAT TO DO WHEN A PREGNANT OR POSTPARTUM PATIENT PRESENTS TO THE ED
… evaluation of fetus prior to discharge in consultation with Maternal-Fetal Medicine physician at Administrative
Perinatal Center or Level III Center...
If you are a hospital without OB services you need to contact the APC or Level III hospital
APC and Level III’s required to have transport services
There is a dedicated number you need to call
Suggest posting that in the ED so it is easy to find
HOSPITALS WITH OB SERVICES
Recommend a policy outlining what gestational age women are sent to the OB floor vs.
remaining in the ED (the cut off is typically 20 weeks)
Recommend the policy includes postpartum patients (up to 6 weeks) presenting to the ED
Recommend the policy specifies conditions for when women stay in the ED and the OB staff
come to the ED to assess the fetus
There must be a documented fetal evaluation done prior to the woman being discharged home
LEVELS OF CARE- STANDARDS
Know what level of care your
facility is designated to provide
PREPARING FOR OB PATIENT (INCLUDE POSTPARTUM)
What you need to know:
Is your patient of child bearing age (12 yrs – 51 yrs)
Is your patient pregnant?
Has your patient had a baby within the last 6 weeks?
Has your patient had a baby within the last year?
Indicator: Patients of childbearing age are routinely queried as to whether
they are pregnant, or have delivered in the last 12 months.
CASE STUDY
24 yo Female saw PCP 3 times over the last 3 weeks with c/o increased headaches and congestion. HA became more severe; she
developed N/V; had slightly elevated BP, blurred vision and facial swelling in the office. PCP started her on Lasix and metoprolol.
Patient denies pregnancy.
She presents to the ED for unrelieved HA:
Throbbing HA
Pain 5/10
Onset: 10 hrs ago
Constant
Elevated BP (200/100)
Nausea
Blurred Vision
LMP 7 months ago (known to be irregular)
CASE STUDY
Presents at 2303
Labs 2334
Assisted to BR – cannot see when asked how long urine has looked like that – “coke colored”
To radiology for CT scan 2337
0004 pt had grand mal seizure tx with Ativan
Called for transport to hospital with ICU
Urine pregnancy test done after seizure and POSITIVE
CASE EXAMPLE
To ICU at another hospital, pregnancy test results not communicated
Had more seizures in ICU lasting > 2 min – Intubated for airway protection
PLT 31K
In renal failure
Elevated liver enzymes
Serum pregnancy test done – hcg 13K
MFM notified of pregnant pt with seizures in ICU
4 gm Magnesium Sulfate initiated
CASE STUDY
Pt taken to the OR
Required multiple doses of labetalol, hydralazine, and esmolol drip
Delivered 31 wk gestation male infant
APGARS 0/6/7 requiring resuscitation with chest compressions and intubation
Baby taken to the NICU for further management
Baby ultimately did well and went home at about 4 weeks of age
Mom spent ~ 2 weeks in the hospital
Discharged home on bp meds and lovenox
Follow up with General surgery for her laparoscopic cholecystectomy; ophthalmology for blurred/dim vision
IMPORTANCE OF KNOWING PREGNANCY STATUS
Women sometimes don’t know or won’t admit – recommend including in policy women of child
bearing age have pregnancy test
Decisions for management will depend on results
If a woman presents to your ED and has delivered within the last 6 weeks she needs to be sent
to the front of the line and triaged first – the example in Case 1 – can also happen postpartum
If a woman that has delivered within the last year would present to your ED and not survive
Illinois collects that info and this patient would be captured as a maternal death
POSTPARTUM CASE STUDY
Importance of understanding PP women and their need to be cared for at a facility that is designated to
manage that condition during pregnancy.
Woman delivers at hospital A and is discharged home without complications
7 days later she presents via EMS to an ED at Hospital B (Hospital B has no OB services)
On presentation Pt is described as seizing and foaming at the mouth. Pt was intubated and sent to
Hospital C with the dx of PP eclampsia
Hospital C is designated Level II
POSTPARTUM CASE STUDY
Pt transported without involvement of Maternal – Fetal Medicine specialist
Remained at a hospital in ICU that is not designated in Illinois to manage that condition
OB providers not involved in the moving of this patient from Hospital B – Hospital C
Mom did recover and was able to be discharged home – so a good outcome.
BUT… Sometimes that isn’t the case
RESOURCES AVAILABLE TO ED’S
24/7 Consultation Services
24/7 Transport Services for maternal and neonatal patients
Educational offerings (Hemorrhage, HTN, OB emergencies, stabilization of the newborn, etc)
Administrative (changing LOA’s, questions/concerns with moving patients, necessary education)
APC’s are required to help
OUTREACH EDUCATION
OBSTETRIC Trauma in the OB patient
BLS skills for the pregnant patient
Pre-hospital management of the laboring patient
Risk assessment
Didactic presentation with skills practice
Delivery of newborn/Delivery of placenta
Standards of care/equipment
Skills practice
Review of equipment, resources, and roles of EMS providers
NEONATAL
Neonatal resuscitation
Risk assessment
Situational awareness
Didactic presentation with skills practice
Airway management
Skills practice
Thermoregulation
Standards of care/equipment
Skills practice
Review of equipment, resources, and roles of EMS providers
RECOMMENDED SUPPLIES
OBSTETRIC SUPPLIES
Speculums
Doppler
Limited bedside US (if available)
Warm blankets
Cord clamps/kochers/bandage scissors
Oxytocin
IV supplies
NEONATAL SUPPLIES
Cord clamps
Blankets, Hat, Chemical mattress, plastic wrap
Bulb suction
Self-inflating neonatal ambu-bag with various
sized masks
Neonatal oxygen masks- various sizes
EXPECTATIONS FROM THE PERINATAL PROGRAM
Hospitals WITHOUT OB services – have the APC transport line number posted
Hospitals WITH OB services – interdepartmental policy and communication ASAP with the OB
department – will the patient receive care in the ED or be cared for on the OB floor.
Policies should include pregnant patients and patients up to 6 weeks postpartum
Ongoing Education: Each APC has educator(s) that are a resource and the expectation would be
for each emergency department to demonstrate what education has been done relating to the
perinatal population
RECOMMENDATIONS FROM IDPH
Continuing Education for staff and providers
Understand that BP elevation in pregnant and postpartum patients is considered an emergency when systolic is >
160 and/or diastolic > 110
OB Hemorrhage Education Program
Work closely with APC’s so that women deliver at the right level of care
Participation from Emergency Department in IDPH committees
IDPH INITIATIVES AND HOW ED’S FIT IN
Maternal Morbidity and Mortality Report
Obstetric Hemorrhage Project
Hypertension Initiative
Maternal and Neonates affected by Opiates
RESOURCES
Illinois Regionalized perinatal healthcare code 640
http://ilga.gov/commission/jcar/admincode/077/07700640sections.html
Guidelines for Perinatal Care 7th edition (2017); American Academy of Pediatrics and
the American College of Obstetricians and Gynecologists
http://dph.illinois.gov/sites/default/files/publications/publicationsowhmaternalmorbiditymo
rtalityreport112018.pdf
