1: Shoulder Dystocia Condition: Arrested delivery Objective: Deliver infant Perinatal Critical Event Guide  ALERT everyone in room of Shoulder Dystocia  Note time (Press Apgar timer, or Mark on strip)  CALL for help  Second provider  NICU team  More Nurses  Consider Anesthesia  Get stool for Suprapubic Pressure  After 2 minutes, call to open OR Maneuvers McRoberts: hyperflex thighs & abduct hips Suprapubic pressure: push shoulder in direction of face Woods Screw: pressure to posterior shoulder, rotate 180 o Delivery of posterior arm: Insert hand posteriorly & sweep arm across the chest and into vagina Gaskin: patient on all 4 hands and knees Zavanelli: manually flexing and replacing head into uterus 1 DRAFT – Nov 2012 SCAL Lurvey, Retta, Osborn, Fox Lee All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the material lies with the reader.

 ALERT everyone in room of Seizure  CALL for help  Second provider  Anesthesia  More Nurses  ASSIGN Recorder (Charge Nurse)  If postpartum, secure infant  VITAL SIGNS: BP, O2, Fetal Heart Rate  ABCs  Position airway to keep open, Place oxygen  Position patient on side to prevent aspiration  Monitor Fetal heart rate, Expect a deceleration  Magnesium, 4g loading dose  Antihypertensives  Labetalol 20mg, 40mg, 80mg every 10 minutes, Max 220mg  Hydralazine 5mg, 10mg every minutes Perinatal Critical Event Guide DRAFT – Nov 2012 SCAL Lurvey, Retta, Osborn, Fox Lee All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the material lies with the reader. 3. Eclamptic Seizure Condition: Eclamptic seizure Objective: Stablize mother, monitor fetal heart rate, treat the seizure 3 Don’t forget your ABCs Airway (assess and secure) Breathing (100% FiO 2 ) Circulation (adequate IV access) Fetal Heart Rate Expect a deceleration Stabilize mom first If bradycardia remains for 3-4 minutes after seizure resolves, consider C-section

Perinatal Critical Event Guide DRAFT – Nov 2012 SCAL Lurvey, Retta, Osborn, Fox Lee All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the material lies with the reader. 6: Neonatal Resuscitation Condition: Failed airway (2 unsuccessful attempts or oxygen saturation less than 85%). Objective: Establish adequate oxygenation/ventilation. 6  CALL Code PINK  Start Apgar Timer when baby out  ASSIGN Recorder (Charge Nurse)  Bring in NICU Rapid Response Cart (Green)  Stimulate, warm and dry infant for 30 sec  VITAL Signs: HR, O2  Not breathing/Grunting or HR <100  Start bagging baby (Positive Pressure Ventilation)  Make sure Bagging is effective  If not, DON’T MOVE ON. Troubleshoot equipment and seal on baby  Reasses HR and O2 every 30 seconds  If HR < 60, start Chest compressions and continue Bagging  If HR between 60 and 100, Continue Bagging baby  Continue Bagging or compressions until help arrives NRP HR <60 Chest compressions AND PPV HR PPV only SpO2 after birth 1 min60-65% 2 min65-70% 3 min70-75% 4 min75-80% 5 min80-85% 10 min85-95%

 ALERT everyone in room of Hemorrhage  CALL for help  Second provider  Anesthesia  More Nurses  ASSIGN Recorder (Charge Nurse)  Secure baby  VITALS – BP, HR, O2, QBL  Hemorrhage Kit/Cart and Bakri Balloon in Room  IV Second Line, Bolus 2 NS or LR (warm fluids or warm patient)  Give Hemostatic agents, only one of each  VITALS Q 5 MINUTES, Call Out and Record  QBL update if bleeding continues  Foley Cath (Record initial amount of urine)  Activate OB Hemorrhage protocol for Blood loss >1500ml or VS changes  After 4 units PRBCs, add 4 units FFP and 1 unit platelets  Bleeding continues: Insert Bakri Balloon  Bleeding continues: Move to OR for surgical intervention Perinatal Critical Event Guide DRAFT – Nov 2012 SCAL Lurvey, Retta, Osborn, Fox Lee All reasonable precautions have been taken to verify the information contained in this publication. The responsibility for the interpretation and use of the material lies with the reader. 8: Postpartum Hemorrhage Condition: Acute massive bleeding. Objective: Stop bleeding, maintain hemodynamic stability, avoid coagulopathy and hysterectomy. 8 Consider Causes of PPH TONE: Bakri Balloon or B-Lynch IF ATONY TISSUE: D&C IF Retained Products TRAUMA: Repair of Laceration IF Trauma THROMBIN: Massive Transfusion (recom factor VIIa) IF DIC TRANSFUSION BEGINS - RATIO 4 PRBCS: 4 FFP: 1 PLTS INTERVENTIONS BY PROVIDER Medications: Pit, Methergine, Misoprostol, Hemabate Exam, Remove clots Bakri Balloon D&C Consider Interventional Radiology OR Interventions (B-Lynch, O’Leary, Hysterectomy) If provider requests labs drawn: CBC, Lytes, INR/PTT, Fibrinogen, Lactate