Pregnant patients with Severe Life threatening conditions e.g serious trauma, cardiac arrest, serious medical condition
- Manage as per ALS/ATLS/MOET guidance (Don’t forget uterine displacement manually).
- Complete triage of patient and assess fetal gestation and viability. This is not primarily to assess fetal well-being but to influence maternal management
- Obstetric/Gynae Registrar to be fast bleeped and to attend resus as soon as possible. If they are not contactable or unable to immediately attend, contact the on-call obstetric consultant.
- Phone the midwifery LDRP coordinator on Tel 01422 223524
- Senior midwife to accompany SpR.
- Prepare resus area for emergency caesarean section (equipment in ED).
- Call the obstetric consultant on call if not already done.
- Contact the neonatal unit if delivery is imminent. (But do not delay delivery awaiting neonatal team’s arrival)
Pregnant patients with a major medical illness potentially requiring admission, e.g. severe asthma/suspected PE
- Manage as per normal protocols for that condition.
- Obstetric/Midwifery input may be required, therefore contact the LDRP Coordinator telephone 01422 223524.
- Dependent on the clinical situation, appropriate specialty team to review and/or inform the consultant of admission.
- Daily review/status check of the patient in relevant clinical areas.
Minor injury or medical illness not necessarily requiring admission, e.g. minor fracture or mild asthma attack
- Manage as per normal protocols and treat as appropriate.
- If there are no fetal or obstetric concerns, discharge as appropriate.
- Pregnant women attending less than 16 weeks to be discussed with the Early Pregnancy Assessment Unit( EPAU)
- All pregnant women attending ED with reduced fetal movements should be referred to either the Maternity Assessment Centre (MAC) as soon as possible.
- If there is a history of reduced fetal movements, bleeding per vagina, headache, raised blood pressure or history of a knock to the abdomen or abdominal pain or concerns or anxiety; then an antenatal review would be indicated by an obstetric/gynae doctor or midwife.
- It may be appropriate for the women to be reviewed in ED or Maternity Assessment Centre (MAC) after discussion with a midwife, the obstetric registrar or SHO on call. If the woman is to be reviewed in MAC or other maternity areas she should be escorted to the area.
- NB: have a low threshold for suspected thromboembolic disease and possibly escalate
Stable women with an obstetric problem with no other issues, e.g. labour, PV bleeding, abdominal pain, reduced foetal movements, raised blood pressure, or headache
- All pregnant women attending with reduced ED with reduced fetal movements should be referred to either the Maternity Assessment Centre (MAC) or Antenatal Day Unit (ANDU) as soon as possible.
- Contact the maternity unit via the midwifery co-ordinator on LDRP Tel 01422 223524
- Transfer to ANDU/MAC/LDRP as advised by above.
- If the woman is to be reviewed in ANDU/ MAC/ LDRP she should be escorted to the area.
- Pregnant women attending less than 16 weeks to be discussed with the Early Pregnancy Assessment Unit (EPAU)
- Ensure the woman has booked for maternity care. If she has not booked for care she should be asked to arrange the booking appointment
If these women have presented during working hours the on call registrar (bleep 509) can assess if the patient can be managed in ANDU at HRI depending on gestation and severity of symptoms. Out of hours contact MAC or LDRP at CRH.
Pregnant patients who have attempted suicide or presented with a psychiatric problem
- Contact the mental health liaison team to come and review the patient
- Psychiatric services to be contacted following the Guideline for. The Care of Pregnant Women Suffering Maternal Mental Health Problems available on the Intranet.
- Associated injuries/illness to be treated appropriately as per previous categories.
- If there is a history of reduced fetal movements, bleeding per vagina, headache, raised blood pressure or history of abdominal trauma or abdominal pain, call the obstetric Registrar on call for advice and possible review.
- The on call team should inform the patient’s consultant or assign a consultant as per unit policy.
- Contact the LDRP co-ordinator Tel 01422 223524 to inform community midwifery team and Perinatal Mental Health Lead.
- Antenatal follow-up (with community midwife or consultant as appropriate) appointment to be arranged within 10 days of discharge from hospital or psychiatric care.
Pregnant patients who present as victims of domestic abuse (suspected or confirmed)
- Treat any injuries sustained as discussed depending on the category.
- If there are any obstetric concerns, a history of reduced fetal movements, bleeding per vagina, headache, raised blood pressure or history of a trauma to the abdomen or abdominal pain; or concerns raised by the woman then please contact the maternity unit via LDRP for advice and possible review.
- Safeguarding protocols should be enacted, even if this is her first pregnancy.
- Contact the LDRP co-ordinator Tel 01422 223524 to ensure community midwifery follow-up
- Provide support and information, explaining that violent assault by a partner represents a real potential threat to her life in the future, the willingness of police to protect her and the availability of domestic abuse support organisations
- Please refer to the Trust Midwifery Domestic Abuse Guideline available on the Intranet.
In the case of patient with Massive Haemorrhage weather that be from Trauma, Surgical, O&G, UGIB, you can activate the MTP
- Do the Basics – don’t forget ABCD
- Inform Transfusion and get someone to run a G&S sample down
- FFP can take up to 45min and platelets come from Leeds
- If you no longer need the MTP – inform transfusion and return products ASAP
Rhesus (Rh)-D negative women, pregnant with Rh-D positive foetus are at risk of developing antibodies against future pregnancies if/when they suffer a sensitising event. (Remember, this should be considered a standard treatment for all Rh-D negative women, as we are never certain of the fathers Rh-D status) Read more
Preform intimate examinations on Sexual assault/Rape patients
- Unless life-threatening injuries are suspected e.g Haemorrhage.
- As our examination will inevitably destroy evidence that may aid this patient’s case
- Consider contamination injury (HIV, HepB, HepC) – Guide
- Consider emergency contraception
- Children must have police referral for safeguarding
- Refer to The Sexual Assault Referral Centre, either via Police or Self referral
Bleeding in early pregnancy is a relatively common problem and in the many cases (esp. with spotting) the pregnancy remains viable. However, bleeding in early pregnancy should never be thought of as normal, and it is vital that we investigate this appropriately.
Communication is also vital at a very stressful time
- Who you are discussing this pregnancy in front of? – Does the patient want them to know
- Manage expectations – There is nothing we or mum can do to change the out come of the pregnancy apart from ensuring mum is well
- Ensure the patient has all the details they need – Return advice, clinic time, where to go, what is happening
- Be sensitive to the patients feelings – Patients respond very differently, be careful not to impose your emotions/assumptions on the situation
Anti-D immunoglobulin guide
Search: ectopic pregnancy, Ectopic Pregancy, pv bleed, MISCARRIAGE, vaginal bleed, EPAU
MHRA (Medicines & Healthcare products Regulatory Agency) has recently published a warning regarding the use of ondasetron in early pregnancy.leading to a small but significant risk of cleft lip. – LINK HERE
“Recent epidemiological studies report a small increased risk of orofacial malformations in babies born to women who used ondansetron in early pregnancy. Key evidence was an observational study of 1.8 million pregnancies in the USA of which 88,467 (4.9%) were exposed to oral ondansetron during the first trimester of pregnancy. The study reported that ondansetron use was associated with an additional 3 oral clefts per 10,000 births (14 cases per 10,000 births versus 11 cases per 10,000 births in the unexposed population). These data were recently reviewed within Europe and considered to be robust.”
Patients with vomiting in early pregnancy requiring antiemetics you can review the guidance on “Hyperemesis Gravidarum”
Radiology are now requesting blood pregnancy testing reproductive females from 10-35days from last period. But what is wrong with urine pregnancy testing?