March 31, 2025

For this week's Monday Morning Message, we discuss umbilical cord prolapse, which is when the umbilical cord comes out of the cervical opening before the baby. Please see below for more information and how to save the baby, as umbilical cord prolapse could block oxygen and blood flow to the baby. 

You are called to the residence of a 24-year-old female who is 34 weeks pregnant and experiencing labor pain. She feels like she has to push; you examine the vaginal area and she shows the following:  

You immediately recognize a prolapsed cord and remember that the basics can help save this child. You ask the patient to take the following position. This will take the baby off the cord. Here, you feel for a pulse on the cord. It is hard to feel, so you place a sterile gloved hand against the hardened area of the skull and apply gentle pressure until you feel a pulse on the cord. You place gentle saline-soaked gauze around the cord and transfer to an OB center for emergent C-section.  

This patient has a risk of premature birth as the major cause of her prolapsed cord. Other dangers of prolapsed cord include multiparity, low birth weight, prematurity, breech, polyhydramnios, placenta abnormalities, and obstetrical procedures.

Risk Factors

The take-home message is to provide perfusion to the baby through maneuvers or positioning until surgical intervention can be accomplished. As always, taking the patient to the right place for the right care is critical. Thanks for all that you do and please stay safe out there. 

Sincerely,

Don Spaner, MD

March 24, 2025

911 is called for a 34-year-old, third-trimester patient at her OB’s office. She has a B/P of 230/140, P= 80, and a headache with lower extremity edema and brisk lower extremity reflexes (DTR). The OB physician wants her transferred to UH CMC main campus labor and delivery and asks the crew, “Do you have labetalol and magnesium?” Her office does not have these available and is happy to hear you are carrying both. Following protocol, you advise starting with 10 mg of labetalol over 2 minutes IV and 6 grams of magnesium over 1 hour. You advise her that you will monitor pressure, and check reflexes every hour during your care. After 15 minutes, her B/P is 180/100, so you call medical control while going to CMC. They order 20 mg IV and in 15 minutes, the repeat pressure is 140/90, pulse is 60 and DTR is ¼ bilateral lower extremities. The rest of the transfer goes uneventful, and you have prevented preeclampsia from becoming eclampsia and ensured a safe delivery for mother and baby. Well done. 

As you complete the transfer, you and your partner discuss the causes and risks of preeclampsia and eclampsia. You remember that leaking calcium channels puts these patients at significant risk of muscular irritability and peripheral originated seizures that move centrally, which makes these different than epileptic seizures. In addition, you remember that benzodiazepines should be avoided as much as possible, as they freely cross the placenta and can be harmful to the baby. Since magnesium is Mg++ and calcium is Ca++, magnesium antagonizes calcium effects and prevents ongoing calcium-leaking seizure activity, stopping the seizure at its source. Blood pressure control is just as important as antagonizing calcium effects. If there is no bradycardia, labetalol is safe and frequently used in our preeclamptic patients. It is both an alpha blocker and a beta blocker, so a smooth, safe reduction in hypertensive emergencies is usually experienced. The key is that this drug is dose-dependent; if 10 mg of labetalol doesn’t meet your specific protocol requirements of a systolic less than 140 and diastolic less than 90 for your preeclamptic patients, just adding 10 mg will not get you there. The usual method is to double your dose to get the desired effect. This is where medical control can certainly assist. The following reminds us who is at risk for preeclampsia:

Please remember to include medical control early and monitor the patient closely. If we overdo magnesium, it may cause the diaphragm to lose function. This is easily prevented by repeating the DTRs regularly and when you don’t get a reflex, simply turn off the magnesium until the reflexes return. This can feel stressful for the provider, but this is a very common complication in pregnancy, and all that is required is close and careful monitoring of these patients. Delivery is considered curative, but the actual risk of preeclampsia can occur up to six weeks after delivery. This is important for any postpartum patient who is hypertensive, and the same care should be provided. 

Thanks for all you do and stay safe out there. 

Sincerely,

Don Spaner, MD

March 17, 2025

What’s normal in pregnancy? This is one of those very interesting questions. I enjoy telling a wonderful anecdote, about presenting my OB patient to the obstetrician. I tell students that no matter what I say, the response from the obstetrician is, “That’s normal in pregnancy.” 

I let them know the pulse in this third-trimester patient is 110 BPM. “That’s normal”.  

The BP is 90/50. “That’s normal.” 

The respirations are 22 RPM. “That’s normal.” 

The pulse ox is 94%. “That’s normal.” 

Her leg fell off. “That’s norm... what?” Gotcha, that is not an over exaggeration. So, when do we know when a vital sign, labs, elevated WBC is normal? Below is a table with normal vitals, depending on the gestational age.

So the question is truly, when is abnormal, really abnormal? This is not always an easy answer, but the answer usually depends on the clinical picture. Are there signs of shock if the blood pressure is lower and the heart rate is high? The clinical picture of poor organ perfusion is critical. The most sensitive, energy-requiring organ is the brain. Hypotension and tachycardia would be very abnormal in the setting of altered mentation. Orthostatic worsening and near syncopal events with standing may also indicate CNS compromise. Decreased urine output, might indicate renal poor perfusion. In addition, simply ask yourself, “How does the patient look?” The other issue is that the pregnant patient carries more than 25% more volume of intravascular blood, as she has to perfuse the baby and the placenta. The critical point here is that it may take a higher volume loss to clinically discover shock. Just as important and critical is how a mom looks, which could mean that the baby is in more distress. That being said, mom comes first. If we can’t keep mom healthy, the baby will suffer.  

Realizing what is normal versus what is not can certainly be challenging in pregnancy. Remember to use your clinical skills and make the proper decisions accordingly.

As always, your team of medical directors is always available for input and support. Thank you for all that every one of you do. Stay safe out there. 

Sincerely,

Don Spaner, MD

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