March 10, 2025

You are called emergently for a motor vehicle accident at a local market in which a nearly full-term pregnant patient was struck from behind. She was wearing her seat belt across her abdomen and is currently complaining of significant lower abdominal pain. She has no other complaints and has the following vital signs: B/P= 86/70, heart rate is 130 BPM, breathing 24 RPM, sats are 98% and capnography is 24. Palpation of the abdomen is firm and very tender.

You are very concerned with placenta abruption and decide to go to a trauma center that also provides OB care, as going to a trauma center without OB capability could be a multi-life-threatening mistake. In addition, you are considering tranexamic acid (TXA) for obvious signs of hemorrhagic shock. You remember that although the typical healthy pregnant third-trimester patient has low normal blood pressure and mild tachycardia, signs of hemorrhagic shock may be overlooked or later obvious findings. Here, we have a narrow pulse pressure, low capnography and significant tachycardia, so we assume this is significant (more than 30%) blood loss. Generally, we avoid TXA antepartum because it freely crosses the placenta, but with hemorrhagic shock, expect and order for pre-hospital TXA. Tertiary trauma centers will provide blood products according to fibrinogen, platelet and hemoglobin levels, but even with hemorrhagic shock pregnant patients, massive transfusion will not be withheld. IV large bore, monitoring, oxygen, and left lateral positioning are all important in this critical patient’s pre-hospital care. With close monitoring and transport decision-making, rapid surgical care can be incredibly lifesaving.

There are many risk factors to consider with placenta abruption. Here, the cause of seatbelt trauma is significant and obvious with such severe pain and signs of shock. However, many other events increase the risk of placenta abruption. Smoking, which vasoconstricts placenta vessels and cocaine abuse, also a vasoconstrictor, both contribute to the risk of placenta abruption. There is also a genetic link, so if a patient’s sister had an abruption, her risk is also increased. Any trauma increases placental abruption risk, but so does hypertension and increased maternal age.

The bottom line is that your skills and decision-making in these critical third-trimester bleeding events can make a real difference. Don’t forget the basics:

• Never do a vaginal exam during third-trimester bleeding.

• Position the patient on their left lateral side.

• Provide appropriate fluid resuscitation, keeping in mind that appropriate blood products and immediate surgery will be required. 

• Large bore IVs are very appropriate if time permits.

• Reassurance and compassion will go a long way in your patient care.

We will always be available for medical direction, and together we will make the best decisions for this patient.

Sincerely,

Don Spaner, MD

March 3, 2025

Nothing is more exciting than an emergency provider’s involvement with a newborn. However, because it is low frequency and a high-risk event, it can be very stressful for many EMS emergency providers. According to the U.S. Census Bureau, only 8% of births have various complications, meaning 92% occur without any complications. As an emergency physician, I always prepare for the worst and hope for the best, but these recent statistics help me keep things in perspective. It is also uncommon for an emergency physician to deliver babies in the emergency department. We are all prepared for the worst and know that 92% of the time, it will be a very enjoyable experience. 

To prepare for delivery I remember the basics:

• Help mom through the transition. She is doing all the work, so we must be there, with the family and support her.

• Listen to her, coach her with breathing techniques, and encourage her when it is time to push.

• As crowning occurs, remember to feel around the neck for a cord. This may be the best time to gently assist the cord off the neck.

• As the head presents, bulb suction the nose and mouth. The rest occurs with your support. Now the anterior shoulder presents and then the posterior shoulder delivers.

• As this new bundle of joy delivers, we dry and place the baby on mom’s chest. This skin-to-skin moment is a critical part of bonding, encourages breastfeeding and mitigates hypothermia.

• Keeping the 30-60 second rule on normal delivery, it is time to clamp and cut the cord.

• As the placenta prepares to deliver, I prepare 10 units of oxytocin and inject this IM as per the pre-hospital protocol.

• Again, it is time to go back to the basics to mitigate post-partum hemorrhage. Fundal massage will help to firm the uterus and reduce post-partum bleeding. Allowing the baby to suckle will also help release more oxytocin.  

In the later weeks of this OB lecture month, we will discuss the complications of pregnancy regarding the third trimester. For today, let’s enjoy the miracle of life and enjoy the part you get to play in this amazing event. As a prior paramedic some 40+ years ago, I specifically remember delivering my first baby on the corner of East 55th and Euclid, with my partner, Sharon. Trust me, “you will never forget the babies you deliver in the field.” We deal with so much tragedy in emergency medicine, this is one of those extremely powerful and positive moments you will treasure forever. 

Sincerely,

Don Spaner, MD