Postpartum Hemorrhage and NRP

This case is written by Dr. Donika Orlich. She is a PGY5 Emergency Medicine resident at McMaster University who also completed a fellowship in Simulation and Medical Education last year.

Why it Matters

Deliveries in the Emergency Department are, by definition, high risk deliveries. However, they are relatively rare. This case highlights some of the “worst case scenarios” that one may face after a delivery in the ED. In particular, it showcases:

  • The key first steps required for NRP in the 60 seconds after delivery
  • The later stages of NRP, including CPR and intubation
  • The approach to a patient with postpartum hemorrhage, including transfusion, fundal massage, administration of uterotonics, and a search for retained products

Clinical Vignette

EMS Patch: “We have a 26 year-old female who is 38 weeks pregnant and appears to be in active labor. She is complaining of severe abdominal pain and has had some vaginal bleeding. We don’t see any crowing yet, but the patient feels the baby’s head is about to come out. Patient’s Vitals as follows: HR 120, BP 140/85, RR 20, O2 100% on room air. ETA 2 minutes.”

Case Summary

The team receives advanced notification from EMS about a woman who is imminently delivering. Upon arrival, delivery will be uncomplicated, but the neonate will appear lifeless. Neonatal resuscitation should be initiated. Eight minutes into the neonatal resuscitation, the team leader will be notified that the mother continues to hemorrhage and is becoming hypotensive. They must begin concurrent workup and management of the mother while continuing to run the neonatal resuscitation. Second & third line medical therapies for uterine atony will be needed, and also manual uterine exploration and packing. Early consultation should be made to NICU, ICU, OB, and Interventional Radiology.

Download the case here: PPH and NRP Combined Case

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