Welcome to Obstetrics for Emergency Nurses. This module is specifically about obstetrics for emergency nurses. The obstetric patient who comes to our emergency department can come for pregnancy-related concerns or non-pregnancy-related concerns. But because we do not get a lot of education about the recognition and care of obstetric patients in the emergency department, this module was created to help you to understand the physiologic processes of pregnancy, be able to identify high-risk situations, especially at triage, and assign appropriate acuity scores. We want to help you identify initial interventions and identify appropriate consulting specialties. Maternal mortality in the United States is a huge problem. We have in the United States one of the highest rates of maternal death in the world. This happens not just during pregnancy, but also within 42 days after pregnancy per 100,000 births. We have 17.4 maternal deaths per 100,000 births, and that is a 2018 statistic. If you look at other countries, you see that we are abysmal in comparison to Poland, Denmark, and Spain, and a little better than Romania or Costa Rica. What we find when we look at this carefully is that about 1 in 3 deaths among women during or within a year of their pregnancy are pregnancy-related. Women die of pregnancy, and for us in the emergency department, pregnancy is a high-risk condition for the patient presenting to the emergency department. As noted, these pregnancy-related deaths occur during pregnancy and delivery and up to an entire year postpartum. We want to be highly alert to patients' pregnancy history because 2 out of 3 deaths have been determined to be preventable. In other words, had we picked them up, we would have been able to intervene successfully. Another reason that this is a huge problem is that a lot of hospitals and systems are shutting down their OB facilities, and what this does is create what is called an obstetric desert, which means that those who are pregnant have to travel long distances to deliver. So, given that distance issue and the unpredictability of the birthing process, there is a shift to emergency departments for unplanned obstetric care, which lands us squarely in the middle of this problem. The emergency department is the place where people will come, especially as OB departments close. This map shows hospital closures of OB services over a 10-year period from 2004 to 2014. You can see that there are significant areas where there are no OB services. That's really concerning for us because those patients will end up in the ED for any unplanned care. When a patient presents to you with multiple fetuses, where the patient is carrying twins or triplets, those babies are going to be small. They are going to have poor heat regulation. They may have an immature respiratory system. One or more may be breech. You have got to keep them all warm and watch for respiratory stress. That becomes a bigger problem for you. The importance of triage decision-making is that we are setting the trajectory of care for the patient. But because most triage systems, particularly the Emergency Severity Index, or ESI, do not specifically address pregnancy or obstetric patients, we need a triage system that does. The model we can look to for guidance here is the Canadian Triage Acuity Scale, or CTAS. It includes a list of specific obstetric complaints that automatically generate an acuity score of 2. But even the CTAS does not include the postpartum patient. The place where we are going with this is that any woman with postpartum hypertension or pregnancy-related hypertension should be considered at high risk for morbidity and mortality. We see eclampsia throughout the second trimester and third trimester and fourth trimester, and women die from this, through all of those trimesters. We want to be very alert to postpartum or pregnancy-related hypertension. The critical piece in your triage decision is to establish pregnancy status. In our research, we found that in about 86% of cases, the status was not documented anywhere. We had no idea what the patient's pregnancy status was. It becomes an independent risk factor. It is almost a modifier of your triage score. The first thing you want to know about someone who is pregnancy-capable is, are you pregnant? Have you been recently pregnant within the last six weeks? Are you not pregnant, or do you not know? When you assess the patient who is pregnancy-capable and discloses a pregnancy status, you want to focus in on the maternal physical assessment and, if appropriate, fetal status, labor status, psychosocial needs, and the patient interview. You want to also identify not just physical instability potential, but also the potential for psychological instability. You have people who may be coming in with postpartum depression, and if you are not aware that they are in a postpartum state, you do not pick that up and plug them into the appropriate care. Another thing to do, especially if you do not have obstetric services at your hospital, is make early contact with an obstetric service. This is very important if you have a patient who comes in who is pregnant or postpartum and presents as if they are high-risk. You want to get on the horn to your OB friends as quickly as you can, whether they are in your hospital or in your system. The potential for transfer to a higher level of care may be necessary. When you look at maternal status, you want to first look at chief complaint or concern and the description of symptoms. You want to get a sense of gravita and para. How many times has the person been pregnant? How many deliveries? What were the outcomes of those pregnancies? Vital signs are critical, critical, critical, as is determining estimated date of confinement or gestational age, especially for the person who is unsure of the gestational age. A specific set of blood pressure readings may be very significant if it is past the 20-week period. If the patient does not know how far along they are, you have an obligation to figure that out because it is a risk factor. If your hospital has no OB services, you need to have somebody in your department who can establish gestational age by ultrasound or exam. Let's look at presenting complaints. Is there vaginal bleeding present? This is a really common presentation. You want to ask some very specific questions. How long has it been going on? How much? What is the color? Is it bright red? Is it dark? Any associated events? What happened immediately prior to that? Does the patient complain or express concern that something is not right? Does the patient have a pregnancy risk factor? You should be looking at what medications people are using, any drugs that they are using, allergies, and their medical and gynecological history, including prenatal care. And what we find is that about 15% of pregnant people receive inadequate prenatal care. Depending on where you are, that may be more or less, but it is an important consideration. If appropriate, you want to look at fetal status. What is the gestational age? Is there fetal movement or lack thereof? Was there movement and now there is not? You want to obtain fetal heart tones as appropriate. Somebody needs to be trained to do this. You want to ask about labor status. If that becomes appropriate, then you want to assess for contractions and their frequency, strength, and onset. Is the abdomen rigid? That is a red flag. Did their water break? We really struggle in the emergency department because we have a high tolerance for abnormal vital signs before we start to worry. What happens throughout pregnancy is that tidal volume increases, mean arterial pressure increases, and heart rate increases. You see very different vital signs throughout a pregnancy. But what is really critical to understand is that there is no reason for a pregnant person to be hypertensive. From a physiologic standpoint, that is not normal. You should take notes of changes in vital signs. Relating or mapping these to the patient's pregnancy status is going to be critical to assigning an acuity. This is a maternal early warning score. It is used in maternity units. It is not used in the emergency department, but I think it gives us some very valuable information about vital signs that you might encounter at triage. Pay attention to the vital signs that fall into the yellow and red boxes here, because it is significant. A systolic blood pressure of 140 puts the patient in a yellow alert status. There is something going on there. The same thing is true with respiratory rate, and to really pick up on that very early is critical. This is the case even if the patient is in there for something else. The pickup on these other potential problems is very, very important. This slide shows the Maternal Fetal Triage Index, or the MFTI. It was developed by the Association of Women's Health, Obstetric and Neonatal Nurses. This is the triage that they use for their population, but their population is generally in a childbirth center or in an obstetric setting, and it is for people who are known to be pregnant. But it gives us really good information about what is normal and what is not, vital signs, and other considerations. We in the ED can use this to get a sense of what is urgent and what is not. It is important to know that cardiovascular and hematologic considerations are one of the main causes of maternal death. These include hypertension, gestational hypertension, eclampsia, and pre-eclampsia. Understanding appropriate vital signs is critically, critically important. Another main cause of maternal death is postpartum hemorrhage. When a patient comes in complaining of vaginal bleeding, it is important to establish pregnancy and postpartum status. Pregnant people are in a hypercoagulable state, which puts them at high risk for DVTs and DPEs. Cardiomyopathy is also a complication of pregnancy and a main cause of maternal death. Let us talk a little bit about hypertensive disorders of pregnancy. Pre-eclampsia is always an ESI-2. It is a multi-system disorder. It results in vascular endothelial damage. Some of the first signs that we see are blood pressure of 140 over 90 mmHg or more than 30 mm systolic or 15 diastolic over their baseline. Now they may or may not know what their baseline is. Anything over 140 is something that you're going to put up a red flag about. If the patient shows up with that blood pressure and also facial, hand, and sacral edema, if they are complaining of rapid weight gain, any visual changes, headache, epigastric pain, in combination with that blood pressure, that is a 2 straight across the board. Eclampsia is all of the same symptoms of pre-eclampsia, plus the bonus of seizures, and can also produce a decelerating fetal heart rate, especially when the seizures are happening. Any pregnancy-capable patient who presents to your ED with a seizure should be suspected to be eclamptic. You have to establish pregnancy status in pregnancy-capable people who are seizing. Homolysis, elevated liver enzymes, low platelet count, and severe pre-eclampsia constitute what is called HELP syndrome. If you have a patient who is presenting with the signs of pre-eclampsia that have just been discussed, plus epigastric pain, they may or may not be normotensive. They may actually have an okay blood pressure, but they will present with some epigastric pain, and so again, the pregnancy-capable patient who presents with abdominal pain really needs to be screened closely and pregnancy status established. If you anticipate any of these hypertensive emergencies, you want to call your OB service. You want to give first-line treatment as ordered by your provider. There are a couple of different possibilities for that using antihypertensive medication. Cardiovascular emergencies that are directly related to pregnancy are cardiomyopathy, deep vein thrombosis, a pulmonary embolism problem, or hemorrhage. As pregnancy continues, the blood volume increases, and by the time a person is in their third trimester of pregnancy, uterine blood flow is up to almost three-quarters of a liter per minute. If that patient is hemorrhaging, you do not have a lot of time. This is an emergency you need to recognize. In cardiomyopathy, the patient can present with weakness or dizziness. They can be short of breath. They may have some chest pain. This can present a lot like congestive heart failure, but in a younger person. You want to assess their lung sounds, heart sounds, and vital signs. What we know is that in pregnancy, the workload of the heart increases, and this is why pregnancy-capable people or pregnant people develop cardiomyopathy. Because the workload of the heart is so much higher, cardiac output increases by up to 50%. The heart rate goes up 5 to 15%, and stroke volume increases. The heart is working harder. In susceptible people, this can cause cardiomyopathy. The increase in circulating volume in the pregnant patient has implications for cardiovascular strain. The blood volume can be up 50%, potentially straining the heart. In terms of assessing for hypotension, the nurse needs to be aware that hypotension is a very late and very ominous sign of decompensation. Pregnancy is a hypercoagulable state, meaning that people who are pregnant have changes in their clotting capacity and platelet aggregation, increasing the likelihood of a clot or a deep vein thrombosis that can then migrate to the lungs. This is not an uncommon presentation in a pregnant person, and you need to think about that. Part of the reason for the concern here is the Virchow's triad, which can cause thrombosis. You have got venous stasis, an alteration in the venous wall, and a hypercoagulable state. Pregnancy is a situation where this is a definite risk. The patients who present with shortness of breath and chest pain, and are pregnant, tend to be younger than most of the people that we worry about presenting with shortness of breath and chest pain. If you've got a 25-year-old presenting with shortness of breath and chest pain, you may not be as concerned unless that person is pregnant or has some other risk factors for pulmonary embolism, but pregnancy is a high-risk condition. The combination of pregnancy and shortness of breath and chest pain immediately kind of leads down the road of pulmonary embolism. This patient must be triaged as a two. Postpartum hemorrhage is a secondary hemorrhage. There is the risk of hemorrhaging immediately after delivery. What we see in the emergency department is this secondary presentation. The patient presents sometime after day three, after they have been discharged from the hospital. They come with bright red bleeding. They come with large clots. They come with bleeding that soaks through more than a pad an hour. These are the questions you have to ask your patient who complains of bleeding. Have you been pregnant recently or are you pregnant now? When did you deliver or when did your pregnancy end? What color is the bleeding? How heavy is it? How many pads are you soaking through in an hour? Are you passing clots? In combination with that, look at the patient. Are they tachycardic? Do they look clammy? Do they look like they are hypovolemic, weak, nauseated? Hypotension is always a late finding. Look for the tachycardia, the weakness, and the nausea. If they present you with a pad or a chuck or anything that has the bleeding in it, please consider weighing that to determine an objective blood loss determination. A lot of the time, what we find is when you eyeball it, you underestimate. Weighing pads, weighing chucks gives you a much better idea of how much blood is actually lost and can prompt you to action a little bit faster. Postpartum hemorrhage is a very important thing to consider. It can happen up to 12 weeks after delivery. Establishing delivery dates or pregnancy end date is absolutely critical in order for us as emergency nurses to determine risk. Normal bleeding after you have had a baby increases with movement after standing up and can include some clots, but it should decrease after about 10 days postpartum. It can continue in smaller amounts for 6 to 7 weeks after delivery, but it should never get heavier. It should never return back to bright red. The clots should not get bigger. A patient who is describing that pattern is going to be somebody that you want to flag. We have discussed uterine blood flow and hemorrhage as a significant cause of maternal death. What does this mean in terms of assessment of the pregnant patient? First of all, at no point in a pregnancy is it normal to be tachycardic or hypertensive. That is never, never normal, and a patient who presents to you who is pregnant or postpartum who has vital signs of tachycardia or hypotension needs to be flagged immediately. When we think about vaginal bleeding and how you are going to evaluate that, you want to ask about the onset and the amount of bleeding. Is it more or less than a menstrual period? What is the pad count? Have there been any previous episodes? What is the color of the bleeding and any precipitating events? Vaginal bleeding in the patient who is less than 20 weeks is a very common presentation. These patients can be assigned an ESI-3 if they are hemodynamically stable. You want to keep in mind that as the pregnancy progresses, more and more blood is flowing through the uterus and hemorrhage is a concern. Because the pregnant patient has increased blood volume, the pressure is going to be maintained longer. By the time that patient starts showing signs of hypotension, you are in big trouble. So assign ESI-3 if the patient is hemodynamically stable. What are some possible causes? In patients who are less than 20 weeks of gestational age, we worry about ectopic pregnancy or miscarriage. Those are two things that we are going to worry about. Vaginal bleeding of less than 20 weeks can also be due to implantation bleeding. The patient who is very early in their pregnancy who has some bleeding or spotting may just be implanting. It can be coming from the GI or GU system as well as from trauma. There can be coexisting cervical cancer, or a type of cancer called a molar pregnancy or hidatidiform mole pregnancy, or some other reason for the bleeding. Here is a little visual tool, a little decision algorithm. You have a patient who is complaining of some vaginal bleeding and they are less than 20 weeks, or they do not know if they are pregnant. You want to rule out an ectopic pregnancy, you want to evaluate for a spontaneous abortion or miscarriage, and then you want to look at their RH status or any other type of diagnosis. So that is sort of your decision tree or your evaluation of concern. An ectopic pregnancy is when an embryo implants outside the uterus. It usually happens in the fallopian tubes in 98% of ectopic pregnancies. It is a life-threatening emergency and it makes up about 2% of all pregnancies. This is not uncommon. For a patient who presents with abdominal pain and or vaginal bleeding and is pregnant, the incidence of ectopic pregnancy was actually found to be significantly higher. Once you establish pregnancy status in the patient who presents with abdominal pain, if there is also vaginal bleeding, you've got a pretty significant chance that this is an ectopic pregnancy and you need to treat it as such. This is another decision tree here. For a premenopausal woman with amenorrhea, abdominal pain, or vaginal bleeding, you do a pregnancy test. If it is positive, now you are going to go down the assessment. You are going to get an ultrasound. You are going to do an exam. You are going to get blood work. If they are not pregnant, they do not have ectopic pregnancy. So that initial ultrasound cardiography for the patient who has abdominal pain is really important because it rules out a whole bunch of bad things. It leaves a bunch, but rules out that particular bad thing which is a life-threatening emergency. What do you want to do with a patient with an ectopic pregnancy? Usually it is just medical management. You can administer methotrexate or do surgical management if necessary. A really important thing to keep in mind, because this was floating around for a while, is that you cannot remove an ectopic pregnancy from a fallopian tube and re-implant it in the uterus. And this is important to tell your patients. This is a non-viable pregnancy. It will not survive and it cannot be re-implanted. That idea is floating around somewhere and it is not the case. With vaginal bleeding over 20 weeks, it is important to establish gestational age in most hospitals. This is our decision tree, our decision point in the emergency department. Are you more than 20 weeks or less than 20 weeks? If you are more than 20 weeks, you go away. You go to the OB unit. But a lot of places, as mentioned, have closed down their OB services. We in the emergency department need to consider a number of emergent situations. We need to think about placenta previa or abruption and all kinds of issues. For bleeding in the second half of pregnancy, you need to consider if this is a viable fetus. If not, you have to manage the maternal condition exclusively. If the fetus is viable, you consider fetal well-being in your care. You want to get history, your initial orders, and a physical exam, which a provider will do. But that is something that you want to get as soon as possible. We worry about a couple of different complications. One of them is placental abruption. This is the separation of the placenta from the uterine wall before the third stage of labor. In other words, before it naturally separates. It can be partial or complete. It can be obvious or occult. It could be hidden. The patient presents with signs and symptoms of blood loss and shock. They have a painful abdomen and a firm uterus with no uterine relaxation. Often the patient can present with a backache. A pregnant person presenting with some back pain and dark and clotted vaginal bleeding is potentially experiencing placental abruption. Here is the important thing. The history of the patient can involve a really minor motor vehicle collision. The patient comes in after a fender bender. I got t-boned as I was driving to work today. This can cause placental abruption. These patients should never go to urgent care or fast track or wherever you would send your minor motor vehicle collisions. The pregnant patient with that history needs to be examined immediately. The same is true with a fall or the patient who presents as a result of intimate partner violence and who experienced any blows to the abdomen. It is extremely important to rule this out immediately. This is a very high risk patient, even if the mechanism of injury seemed very minor. You also want to ask about cocaine use, which can cause placental abruption, and you want to anticipate putting them in the left lateral recumbent position, giving them oxygen and getting them to obstetric care as soon as possible. Placenta previa is an implantation of the placenta at or near the cervical os. It can be low lying. It can be complete. The patient can present as really very anxious with painless bright red vaginal bleeding. They may or may not be in shock. You want to do oxygen, but you do not want to examine this patient because you do not want to go through the placenta, which is down by the cervical os, if placenta previa is what you suspect. You want to make it really clear to the provider that the bleed is painless so that they do not do a vaginal exam. And again, you want to get them to OB as quickly as you can. Risk factors for placenta previa are a previous cesarean section, a history of previa, a lot of multiple gestations, closely spaced pregnancies, and increased maternal age. Other things that you want to do for hemorrhage is be prepared to administer medications, administer blood products, get the patient to either interventional radiology or the operating room, or address tamponade using a BACRI balloon. It really is dependent on the patient situation and their pregnancy or postpartum status. Consider the patient who presents with shortness of breath. Again, you are concerned about pulmonary embolism, cardiomyopathy with fluid overload, or severe anemia. How are you going to do some risk stratification? If they are very high risk, you can go straight to the ultrasound. The bilateral leg ultrasound for pulmonary embolism. If you think they are kind of low risk, you can draw a D-dimer. Usually you would take care of them the same way that you would take care of any patient that you suspected of a pulmonary embolism. You just want to recognize that because pregnancy is such a hypercoagulable state, the risk is particularly high. Screening for PE is a critical assessment in the pregnant or recently pregnant patient. It is the number one cause of obstetric mortality. Here are some ways you can look at this problem. Using the PERC tool, obtaining a D-dimer, or getting a CT angiogram. This is a critically important rule-out process. What we see here with pulmonary changes is that tidal volume is increased and reserve volume and residual volume are decreased. That is due to the enlarging uterus. These changes in pulmonary function, specifically in decreased total lung capacity, mean that it's normal for a visibly pregnant person to feel a little short of breath, especially with exertion. However, the patient who presents to the ED with a specific complaint of shortness of breath requires a considered assessment, including respiratory rate, O2 sat, lung sounds, and screening for a pulmonary embolus. When you draw arterial blood gases, you are going to see a slightly increased pH. You are going to see a decreased PCO2, and you are going to see a decreased bicarbonate level. The normal state of pregnancy is some partially compensated respiratory alkalosis. What this means for assessment is that there is normal shortness of breath, partly caused by progesterone, which increases the respiratory rate. The uterus gets bigger and it pushes up on the diaphragm, leaving the patient feeling short of breath because they cannot fully drop their diaphragm and expand their lungs. However, the red flag is that the shortness of breath is accompanied by some chest pain, tachycardia, tachypnea, and a cough. The patient feels a little out of breath. That is not uncommon in pregnancy. But the shortness of breath accompanied by these other symptoms is a red flag, and that patient needs to be assigned a triage level of 2. Let us discuss gastrointestinal and genitourinary presentations. To the pregnant patient who comes in with nausea and vomiting, as nurses we say, well, you're pregnant, of course. But you want to be really careful, first of all, in establishing pregnancy status. Then you want to really drill down to the specific symptoms. You want to assess for dehydration because dehydrated people tend to go into labor early. You don't want that to happen. You want to look for other signs of infection and the patient who has a systolic blood pressure over 150 millimeters of mercury and nausea and vomiting. You want to have a high index of suspicion for preeclampsia. Understanding where the patient is in the pregnancy trajectory is going to be important to your assessment of risk. Urinary tract infections are a leading cause of sepsis in this patient group. There are a number of physical changes that make that more probable. You want to be highly alert to that because it is a major source of sepsis. For the patient who presents with UTI symptoms or pyelonephritis symptoms and is also pregnant, you want to screen for sepsis sooner rather than later. Let us look at some immediate labor and delivery complications. We have all had that patient who comes in about to deliver. Sometimes you are ready and sometimes you are not. You have a precipitous delivery and labor is progressing more quickly than anticipated. The patient comes in with bloody discharge, frequent contractions, a desire to push, and bulging membranes. You want to check for crowning before you move them anywhere. In an imminent delivery, we want to know a very functional history. How many fetuses is this person carrying? How far along are they? Is there any drug use in the last four hours? Has their water broken? Those are the four things that you need to know. Anything else is really nice. For the patient who is about to deliver in your ED, that is what you need to know. You may be in the triage area. You may be in the waiting room. Get some help, but stay with the patient. Do not try to impede the delivery. As the head appears, you check for the cord around the neck, wipe the mouth and nose, and deliver the baby. As long as it is breathing, put the baby on mom's belly or chest, dry it off there, and cover it up with a blanket. By this point, you should have some friends coming to visit. Just keep the baby warm and dry. That is the idea until the rest of the crew comes. The APGAR score is not something that you are going to be responsible for, but it is useful to know something about it. Just to understand what we are expecting, a healthy, strong baby should have a heart rate over 100 beats per minute, a good cry, and maybe it will sneeze. The baby is moving, pink, and this usually happens at the second score. You do two scores five minutes apart. For the baby that has zeros, is flaccid, has no response or is not breathing, then you are going to have to do some stimulation. You may have to do CPR. A lot of babies come out a little wifty. They are a little stunned, but they recover well, so this is something to which you want to pay attention. After delivery, you want to keep the baby warm and keep the baby with mom. Do not forget about mom. Take vital signs on mom. The placenta should deliver in 5 to 30 minutes. Save the placenta. If it was delivered in the ED, send it with the patient to OB. Do some fundal massage to help the uterus contract to stop any bleeding and get that patient to OB. The patient who presents with a prolapsed cord is scary for everybody involved. This is the protrusion of the umbilical cord before the presenting part of the baby. What that means is that it gets compressed between the head and the lower pelvic ring, and because the umbilical cord carries all the circulation, every time the patient has a contraction, the baby is not getting blood or oxygen. The patient can be highly anxious about this idea that something is hanging out of me. You want to immediately get the pregnant person on the stretcher in a knee-chest position with their butt up in the air. Get some high-flow oxygen, put on a sterile glove, elevate the head off the cord, and do not move. Get comfortable because you are going to be there until that patient gets to OB. You don't want to handle the cord, and you get that patient out of there because they need an emergent C-section to make sure that there is a good outcome. For the patient who presents with meconium-stained amniotic fluid, you will see green or yellow dark-colored fluid. You want to think that the baby might need their airway cleared of meconium. You want to have the bulb syringe and have equipment ready for suctioning if the patient presents with that as a sort of pre-existing event. You also want to consider the patient who presents with a breech presentation. In other words, the head is not coming out first. Feet are coming out first, or the butt is coming out first. You want to support that presenting part, and you want to keep it warm, and you want to get that patient out of your ED to OB or the OR as quickly as possible for a C-section. When a patient presents to you with multiple fetuses, where the patient is carrying twins or triplets, those babies are going to be small. They are going to have poor heat regulation. They may have an immature respiratory system. One or more may be breech. You have got to keep them all warm and watch for respiratory stress. That becomes a bigger problem for you. The takeaway from this presentation for you is that to identify patients at risk for any of these obstetric complications, you have to ask if they are pregnant. You have to ask, even if they are there for a sprained ankle, a cold, or anything you think is irrelevant. It is always relevant. You want to ask them in a place that they can answer you. That means not in the middle of the waiting room. You have to ask them if they are pregnant. If so, you have to establish gestational age because it will guide your assessment of risk. If they were recently pregnant, ask how recently. If they have been pregnant in the last 7 weeks, you are worried about preeclampsia and eclampsia. If they were pregnant in the last 12 weeks, that possibility of hemorrhage is always there. Vital sign red flags are a systolic blood pressure of over 140 mmHg or less than 90, or a heart rate over 100 beats per minute. These patients must be triaged as 2s, even if they are nervous, even if they say that is normal for them. You have to flag this, especially if the patient has those vital signs with a headache or with heavy bleeding, or with abdominal pain, chest pain, or shortness of breath. These patients have to be triaged as 2s and immediately assessed. The patient with minor trauma, the minor motor vehicle collision that may be coming to your fast track area, the patient who presents after an episode of intimate partner violence or a minor fall, if they are more than 20 weeks pregnant, these types of mechanisms can all cause an abruption. They have to have a quick assessment and evaluation, even if they appear stable at the time of presentation. For the patient with vaginal bleeding, you want to establish pregnancy status, determine the amount and the nature of the bleeding, and vital signs. Normal vital signs should be heart rate under 100 beats per minute, or a systolic blood pressure over 90 mmHg and less than 140. They can be assigned an ESI level of 3 if the vital signs are normal. We hope you have found this educational module on obstetrics for emergency nurses to be informative and useful to your practice. Questions and comments can be sent via email to enr at ena dot org.

obstetric emergencies

emergency department

high-risk situations

acuity scores

maternal mortality rates

triage decision-making

pregnancy-related complications

collaborate with obstetric services

obstetric care

emergency nurses

maternal mortality rate

triaging obstetric patients

delivery complications

improving outcomes