LRH · EMERGENCY DEPARTMENT
OB Emergencies
BETA
Not yet ready for clinical use. Shared for feedback and practice only — do not use it to direct the care of a patient.
Content is unverified and unapproved. Every situation requires nuance; use your professional judgment and your department's policies.
LRH · EMERGENCY DEPARTMENT

OB Emergencies

Name the situation · claim leadership · aim the team. Tap a card.
A reference to assist professional decision-making — not a policy or protocol. Every situation requires nuance; use your professional judgment to vary from this source.
EQUIPMENT
OB / neonatal cart — what is in each drawer
DELIVERY
02Imminent normal delivery 07Shoulder dystocia 08Breech delivery 09Umbilical cord prolapse
NEWBORN
03Neonatal resuscitation 04Umbilical vein catheterization
MATERNAL EMERGENCY
05ED C-Section 06Postpartum hemorrhage 10Resuscitative hysterotomy
02 NOTIFY OB + NURSERY · WARM THE INFANT

Imminent normal delivery

CART6 · VAGINAL DELIVERY1 · AIRWAY / BREATHING
NAME
“Imminent birth in the Emergency Department.” Crowning or precipitous progression.
CLAIM
ED physician delivers · RN warms and preps the kit · name a recorder.
AIM
Deliver, run the 4-yes check, keep the baby warm and with the mother.
STEP 1 · PREPAREDRAWER 6 · VAGINAL DELIVERY
DRAWER 6STERILE OB KIT · WARMING PAD · BLANKETS
STEP 1B · DELIVER THE BABYSLOW AND CONTROLLED
  • IF IT IS NOT A NORMAL DELIVERY
NUCHAL CORD — WHAT TO DO1 IN 3 BIRTHS
Common and usually harmless. Cutting it early costs the baby its circulation — make that the last resort.
  • → STEP 2 · THE 4-YES CHECK
STEP 2 · DELIVER, THEN THE 4-YES CHECKAT BIRTH
TIME OF BIRTH — STAMP IT AS THE BABY DELIVERS
Set the time — the 1 and 5 minute marks appear here.
THE 4-YES CHECK — ASK ALL FOUR OUT LOUD
TERM?
GOOD TONE?
BREATHING
OR CRYING?
MOTHER
STABLE?
ALL 4 YES
Skin-to-skin, dry hard, remove wet towels, hat.
ANY ONE NO
Clamp and cut now → warmer → start NRP (card 03).
One “no” sends the baby to the warmer. Say the answers aloud so the recorder hears them.
STEP 3 · IF ANY NO — CLAMP NOWFIRST 30 S
  • FIRST 30 SECONDS — FROM CARD 03
  • GO TO 03 · NEONATAL RESUSCITATION →
STEP 3 · IF ALL FOUR YES — CORD & PLACENTA30–60 S
CORD — TWO CLAMPS, CUT BETWEEN
BABY CUT CLAMPS 2–3 in / 5–8 cm
Delay 30–60 s if vigorous. Two clamps 2–3 in from the abdomen, cut between them. No cord traction on the placenta.
STEP 4 · APGARTHE RECORDER OWNS THIS
BORN AT — : —
APPEARANCE · COLOR
PULSE · HEART RATE
GRIMACE · REFLEX
ACTIVITY · TONE
RESPIRATION
–/10
Apgar at 1 minute. Score it, do not act on it — resuscitation is driven by heart rate and breathing.
↑ INDEX
03 LMA BY WEIGHT · CALL THE CLOCK EVERY 30 S

Neonatal resuscitation

CART1 · AIRWAY / BREATHING2 · CIRCULATION
NAME
“Newborn is not vigorous — starting resuscitation.”
CLAIM
Airway lead · compressions · meds · recorder — by name.
AIM
Chest rise, HR >100, SpO₂ on target. Reassess every 30 s.
PACER — TIMER & RHYTHMSOUND ON
0:00
REASSESS
EVERY 30 S
Low click = compression. Long tone = squeeze the bag. Double chime marks every 30 s — call the heart rate out loud.
On iPhone the silent switch mutes web audio — flip it off before you start.
1 · INITIAL STEPSFIRST 30 S
2 · HEART RATE CHECKNEXT 30 S
  • ≥100Breathing well: routine care, skin-to-skin, keep monitoring.
  • <100Start PPV, 40–60 breaths per minute — room air at term, 21–30% if preterm. Confirm chest rise.
  • NO CHEST RISE — MR SOPA
    Mask adjust · Reposition head · Suction mouth and nose · Open the mouth · Pressure up · Airway alternative (LMA or ETT)
  • Reassess heart rate after 30 s of chest-rising PPV.
3 · HR STILL <601-MINUTE CYCLES
  • Secure the airway (LMA or ETT), 100% O₂, then run 60-second cycles:
  • 3:190 compressions + 30 breaths per minute. Count “one-and-two-and-three-and-breathe.”
  • EPI0.02 mg/kg IV = 0.2 mL/kg of 0.1 mg/mL, via UVC (page 04). Repeat every 3–5 min.
  • Blood loss or poor perfusion: NS 10 mL/kg over 5–10 min.
  • At the end of every cycle: state the heart rate, SpO₂, and elapsed time aloud.
WHICH LMA FITS?SIZE BY WEIGHT
DRAWER 1AIRWAY / BREATHING — TOP DRAWER
LMA 0 under 2 kg LMA 0.5 2 kg and over
  • LMA 0Under 2 kgETT 2.5–3.0 · blade 00–0 · depth = weight in kg + 6 cm
  • LMA 0.52 kg and overETT 3.0–3.5 · blade 0–1 · depth = weight in kg + 6 cm
  • Seat the cuff, confirm chest rise and ETCO₂. An LMA beats a failed intubation — reach for it early.
HEART RATE DECIDES THE NEXT MOVE
≥100
Breathing well — routine care, skin-to-skin, keep monitoring.
60–99
PPV 40–60 / min. No chest rise → MR SOPA. Reassess in 30 s.
<60
Secure airway, 100% O₂, compressions 3:1. Epi 0.02 mg/kg via UVC.
Recheck every 30 s and call the number out loud. Chest rise is the test that PPV is working.
TARGET PREDUCTAL SpO₂ — PROBE ON THE RIGHT HAND
1 MIN
60–65%
2 MIN
65–70%
3 MIN
70–75%
4 MIN
75–80%
5 MIN
80–85%
10 MIN
85–95%
50%75%100%
A blue baby at 3 minutes with SpO₂ 72% is on target. Do not chase 100%.
COMPRESSIONS — 3 : 1, NOT ADULT CPR
B
B
190 compressions + 30 breaths every minute — 15 events every 3 seconds.
2Count aloud: “one-and-two-and-three-and-breathe.”
3Thumbs encircling, lower third of sternum, depth ⅓ of the chest.
Two rescuers: one holds the airway and gives the breath, one compresses. Reassess HR after 60 s.
↑ INDEX
04 5 Fr ≥1.5 KG · 3.5 Fr <1.5 KG · CIRCULATION DRAWER

Umbilical vein catheterization

CART2 · CIRCULATION3 · LABS / MISC.
NAME
“No IV access — placing an umbilical vein catheter.”
CLAIM
Proceduralist and assistant · someone keeps resuscitation running.
AIM
Free blood return at 2–4 cm, line secured, meds going in.
VESSELS — ONE VEIN, TWO ARTERIES
  • Vein: thin wall, wide lumen, usually 11–12 o’clock. Cannulate this one.
  • Arteries: thick wall, pinpoint lumen, constrict shut.
1 · PREPARE
2 · CUT & IDENTIFY
3 · INSERT TO 2–4 CM
CORD CROSS-SECTION — CANNULATE THE VEIN
11–12 O’CLOCK ✓ VEIN ✕ ✕
✓One vein — thin wall, wide gaping lumen, usually at 11–12 o’clock. This one.
✕Two arteries — thick wall, pinpoint lumen, constricted shut.
INSERT — INTO THE VEIN, THEN SECURE
CATHETER INTO THE VEIN INSIDE THE STUMP VEIN ✕ ARTERY PURSE-STRING ON THE STUMP ABDOMEN
The catheter enters the vein at the top of the stump; the dotted run is the part you cannot see. Purse-string goes around the stump — then tape-bridge the catheter.
DEPTH — STOP AT FREE BLOOD RETURN
02 cm4 cm TIP ZONE 2–4 cm ABDOMEN MEASURED FROM THE CUT SURFACE
Zero is the cut surface. Advance 2–4 cm — term ≈ 4, preterm ≈ 2 — until blood draws back freely. Never force, never deeper for “more line.”
↑ INDEX
05 2 ATTEMPTS MAX · iGEL EARLY

ED C-Section

CART1 · AIRWAY / BREATHING5 · C-SECTION
NAME
“Crash cesarean in the ED — safely get access and secure the airway.”
CLAIM
Intubator · airway assistant · meds · OB lead · MOD — assign aloud.
AIM
First-pass tube, then “OB, you may start.”
ROLES — WHERE EVERYONE STANDSASSIGN BY NAME
DOOR HEAD OF BED FOOT OF BED ED MDintubator RT / RNairway assist OBoperates OB RNcatches the baby ED RNopens the kit MODorganizer TABLE kit · knife · gauze TELE NICU
ED MD
Head of the bed — airway and intubation.
RT / RN
At the MD's right — suction, tube, bag, meds to the head.
OB
Left side of the bed — operates.
OB RN
Right side, across from the OB — catches the baby, runs neonatal resuscitation.
ED RN
Left of the OB — opens the C-section kit, drops knife and gauze onto the bedside table; IV access and meds.
MOD
At the door by the foot — organizes, clears the room, tracks the clock.
TELE NICU
Screen at the foot, far corner — documentation and resuscitation support.
1 · PRE-OXYGENATE & INDUCE
2 · INTUBATE
3 · POST-INTUBATION & HANDOFF
SURGICAL TIME OUT — TAP TO WALK IT60 S · READ ALOUD
Hands off. Everyone stops and faces the bed. One person reads; each owner answers out loud.
↑ INDEX
06 CALL OB STAT · RECORD THE TIME

Postpartum hemorrhage

CART4 · POSTPARTUM HEMORRHAGE2 · CIRCULATION3 · LABS / MISC.
NAME
“Postpartum hemorrhage in the ED.” >500 mL or signs of shock.
CLAIM
One provider on massage · RN on access · recorder on the clock.
AIM
Uterus firm, bleeding stopped, OB at the bedside.
STEP 1 · RECORD TIME0 MIN
STEP 2 · ACCESS & MEDS0–5 MIN
STEP 3 · IF STILL BLEEDING5–15 MIN
STEP 4 · IF IT PERSISTS>15 MIN
PPH CLOCK — THE RECORDER CALLS EVERY 5 MIN
0 MIN
Note the time · call OB STAT · fundal massage · Foley.
0–5 MIN
Two large-bore IVs · type & cross · oxytocin 10 u IM + 10 u/L wide open · TXA 1 g.
5–15 MIN
Misoprostol 1000 mcg PR · massage continues · reassess tone and volume aloud.
>15 MIN
2 units O-negative · pack the vault with Kerlix · OB at the bedside.
Start the clock at recognition, not at arrival. Every dose and every EBL number goes to the recorder.
ESTIMATING BLOOD LOSS — SOAKED, NOT SPOTTED
4×4 gauze
10 mL
Lap sponge
100 mL
Peri pad
100 mL
Underpad
250 mL
Floor spill
50 cm
500 mL
≥500 mL VAGINAL · ≥1000 mL CESAREAN = PPH
Visual estimates run 30–50% low. Weigh what you can: 1 gram = 1 mL.
↑ INDEX
07 ANNOUNCE IT · TIMEKEEPER EVERY 60 S

Shoulder dystocia

CART6 · VAGINAL DELIVERY
NAME
“Shoulder dystocia.” Say the word out loud.
CLAIM
Physician at the perineum · 2 assistants on legs · 1 suprapubic · timekeeper.
AIM
Deliver the shoulder in maneuver order. No fundal pressure.
STEP 1 · ANNOUNCE
STEP 2 · FIRST-LINE MANEUVERS
STEP 3 · IF McROBERTS FAILS
HELPERR — THE ORDER
  • Still stuck: Zavanelli, symphysiotomy, cleidotomy.
PRESSURE GOES SUPRAPUBIC — NEVER FUNDAL
✓ SUPRAPUBIC FUNDUS PUBIC BONE ✕ NEVER FUNDAL PUBIC BONE
Heel of the hand just above the pubic bone, pushing down and toward the baby’s face. Fundal pressure impacts the shoulder further and ruptures uteri.
HELPERR — 30 SECONDS EACH, THEN THE NEXT ONE
H
Call for help — start the clock, name a timekeeper.
E
Evaluate for episiotomy — makes room for hands, not for the shoulder.
L
Legs — McRoberts: knees to chest, flattens the sacrum.
P
Suprapubic pressure — steady, then rocking.
E
Enter — Rubin II, Woods screw, reverse Woods.
R
Remove the posterior arm — sweep across the chest.
R
Roll to all fours — Gaskin.
McRoberts plus suprapubic pressure resolves most of them. Announce each maneuver so the recorder can log the time.
→ BACK TO 02 · THE 4-YES CHECK
↑ INDEX
08 ACTIVATE OB · PREP THE WARMER

Breech delivery

CART6 · VAGINAL DELIVERY1 · AIRWAY / BREATHING
NAME
“Breech delivery in progress — hands off.”
CLAIM
Proceduralist hands off · RN on the warmer · OB activated.
AIM
To the umbilicus, then the scapula, then flex the head.
1 · HANDS OFF
2 · ARMSTO THE SCAPULA
3 · THE HEAD
HANDS ON THE BONY PELVIS — NOTHING ELSE
STILL INSIDE HEAD PERINEUM ✓
✓Thumbs on the sacrum, fingers on the iliac crests — bone only.
✕Never grip the abdomen or soft tissue: liver and kidney injury.
·Hands off completely until the scapulae are visible. Let her push it out.
Hands off until the scapulae show, then thumbs on the sacrum and fingers on the iliac crests. Traction anywhere else injures the liver or kidneys.
LØVSET — ROTATE TO REACH THE STUCK ARM
BEFORE BACK UP ARM BEHIND — OUT OF REACH 180° BACK STAYS UP AFTER BACK UP NOW IN FRONT — SWEEP IT OUT
Hold the bony pelvis and rotate the trunk half a turn, keeping the back upward. The trapped posterior arm comes forward under the symphysis where you can sweep it across the chest. Rotate back the other way for the second arm.
MAURICEAU–SMELLIE–VEIT — FLEX THE HEAD
YOUR FOREARM — BODY STRADDLES IT TWO FINGERS ON THE CHEEKBONES CHIN TO CHEST OTHER HAND SHOULDERS ASSISTANT SUPRAPUBIC
The body rests on your forearm. Two fingers on the cheekbones flex the chin onto the chest; the other hand rides the shoulders. An assistant presses suprapubically to keep the head flexed. Never pull on the jaw.
→ BACK TO 02 · THE 4-YES CHECK
↑ INDEX
09 CALL STAT · DELIVERY IS BY C-SECTION

Umbilical cord prolapse

CART6 · VAGINAL DELIVERY
NAME
“We have a cord prolapse.” Cord ahead of the baby, often bradycardia.
CLAIM
Examiner keeps the hand in · RN moves the bed · OB, anesthesia, OR.
AIM
Pressure off the cord until delivery in the OR.
1 · RELIEVE PRESSURE
2 · CALL & POSITION
3 · CORD CARE
LIFT THE PRESENTING PART OFF THE CORD
UTERUS CANAL HEAD CORD TWO FINGERS PUSH UP
Two fingers in the vagina hold the presenting part off the cord — continuously, into the OR and onto the table. Do not let go to reposition.
POSITION — TAKE WEIGHT OFF THE CORD
TRENDELENBURG HEAD LOW HIPS HIGH KNEE–CHEST HIPS HIGH CHEST DOWN
Steep Trendelenburg on the stretcher, or knee–chest if she can hold it. Fill the bladder with 500 mL if transfer will be long.
EXPOSED CORD — WARM, MOIST, UNTOUCHED
WARM SALINE GAUZE CORD
✕ DO NOT PUSH THE CORD BACK IN
Handling causes vasospasm. Cover it, keep it warm, and move to cesarean delivery.
→ BACK TO 02 · THE 4-YES CHECK
↑ INDEX
10 CPR NEVER STOPS · EQUIPMENT IN THE NEO CART

Resuscitative hysterotomy

CART5 · C-SECTION6 · VAGINAL DELIVERY1 · AIRWAY / BREATHING
NAME
“Maternal arrest — resuscitative hysterotomy now.” Fundus at or above the umbilicus, not reversible.
CLAIM
Team lead decides · proceduralist cuts · LUD continues · recorder on times.
AIM
CPR never stops. Deliver to save both.
1 · IMMEDIATE (WITH CPR)
2 · THE INCISION
3 · DELIVERY & MATERNAL CARE
INCISION — VERTICAL MIDLINE, UMBILICUS TO SYMPHYSIS
UMBILICUS SYMPHYSIS 10 BLADE
Skin, fat, fascia in one stroke; fingers split the rectus. Vertical uterine incision, extended with fingers or bandage scissors.
THREE CLAMPS — KEEP THE GAS SEGMENT
BABY PLACENTA CUT CORD GAS SEGMENT DRAW WITHIN 60 MIN
Two clamps on the baby side, cut between them; a third toward the placenta traps a doubly-clamped segment for the cord gas.
↑ INDEX
CART 6 DRAWERS · TOP TO BOTTOM

OB / neonatal cart

Every drawer has a colour and a shape. The same badge marks each card that needs something from it — tap a badge to jump here, tap a drawer to see what is inside.
123456 SHAPE = DRAWER, EVEN IN GREYSCALE OR LOW LIGHT
DRAWER 1Airway / Breathing OPEN +CLOSE −
  • Infant LMA 0 and 0.5
  • ETT 2.5–3.5 · blades 00–1
  • Neonatal BVM + PEEP valve, masks
  • Bulb syringe, suction catheters, meconium aspirator
  • Pulse oximeter + monitor leads
  • Adult: ETT 6.0/6.5/7.0, bougie, iGel
DRAWER 2Circulation OPEN +CLOSE −
  • UVC 5 Fr and 3.5 Fr, umbilical tape
  • Stopcocks, flushes, three-way
  • Large-bore IV 14/16 G · IO
  • NS / LR, pressure bag
  • Blood pressure cuffs
DRAWER 3Labs / Misc. OPEN +CLOSE −
  • Type & cross, CBC, CMP, coags
  • Cord gas syringes, ABG kit
  • Feeding tubes
  • Foley bag, urine container
  • Labels, specimen bags
DRAWER 4Postpartum Hemorrhage OPEN +CLOSE −
  • Oxytocin 10 units
  • TXA 1 g
  • Misoprostol 1000 mcg
  • Sterile Kerlix for packing
  • Foley catheter kit
  • Graduated drape, sterile gloves
DRAWER 5C-section OPEN +CLOSE −
  • Sterile C-section kit
  • 10 blade, bandage scissors, forceps
  • 0 chromic suture, skin stapler
  • Chlorhexidine / betadine splash prep
  • Sterile drapes, gowns
DRAWER 6Vaginal Delivery OPEN +CLOSE −
  • Sterile OB kit — cord clamps, scissors, bulb
  • Chemical warming pad
  • Receiving blankets, towels, hat
  • Saline gauze
  • Umbilical tape
↑ INDEX