LRH · EMERGENCY DEPARTMENT
OB & Neonatal Emergencies
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LRH · EMERGENCY DEPARTMENT

OB & Neonatal 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.

— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.

02 NOTIFY OB + NURSERY · WARM THE INFANT

Imminent normal delivery

CART6 · VAGINAL DELIVERY1 · AIRWAY / BREATHING
TIME OF BIRTH — STAMP IT AS THE BABY DELIVERS
kg or g
Set the time — the 1 and 5 minute marks appear here.
NOTHING LOGGED YET
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
ASK THE MOTHER — QUICK
Gestation + weeks + days — weeks drive equipment sizes
Number of babies
Prenatal care
Complications (tap all that apply)
Membranes / fluid (note time ruptured)
Opioids in labor
DRAWER 6STERILE OB KIT · WARMING PAD · BLANKETS
STEP 2 · DELIVERSLOW AND CONTROLLED
  • CHECK PRESENTATION FIRST
  • SHOULDER DYSTOCIA →Head delivers then retracts (turtle sign)
  • Wrong time? Fix it in the TIME OF BIRTH banner above.
NUCHAL CORD — WHAT TO DO1 IN 3 BIRTHS
⚠ NEVER CUT A LOOSE NUCHAL CORD
Common and usually harmless. Cutting it early costs the baby its circulation — make that the last resort.
  • → STEP 3 · THE 4-YES CHECK
STEP 3 · THE 4-YES CHECKAT BIRTH
THE 4-YES CHECK — ASK ALL FOUR OUT LOUD
GA weeks
ALL 4 YES
Skin-to-skin, dry hard, remove wet towels, hat.
ANY ONE NO ›
Clamp and cut now → warmer → start NRP.
Say the answers aloud so the recorder hears them. Tap ANY ONE NO to go to neonatal resuscitation; the fourth YES moves to delayed cord clamping below.
ALL FOUR YES · DELAYED CORD CLAMPINGAT LEAST 60 S
DELAYED CORD CLAMPING
Baby skin-to-skin, dry, hat. Wait for the cord — at least 60 s, or until it stops pulsating.
0:00
KEEP WAITING · AT LEAST 60 S
FIG 1 · CORD — TWO CLAMPS, CUT BETWEEN
BABY CUT CLAMPS 2–3 in / 5–8 cm
Delay at least 60 s if vigorous. Two clamps 2–3 in from the abdomen, cut between them. No cord traction on the placenta.
Two clamps 2–3 in from the abdomen, cut between. Then let the placenta deliver with gentle pushing — no cord traction. Watch maternal bleeding → card 06 if >500 mL or shock.
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
04 5 Fr ≥1.5 KG · 3.5 Fr <1.5 KG · CIRCULATION DRAWER

Umbilical vein catheterization

CART2 · CIRCULATION3 · LABS / MISC.
WEIGHT kg or g
OR WKS GESTATION +
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
FIG 1 · 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.
FIG 2 · 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.
FIG 3 · 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

CART5 · C-SECTION4 · POSTPARTUM HEMORRHAGE
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
FIG 1 · ROLES — WHERE EVERYONE STANDS
SLIDING DOOR HEAD OF BED FOOT OF BED PATIENT'S RIGHT PATIENT'S LEFT 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
Head of the bed on the patient's right — suction, tube, bag, meds.
OB
Patient's left side — operates.
OB RN
Patient's right, across from the OB — catches the baby, runs neonatal resuscitation.
ED RN
Beside the OB on the patient's left — opens the C-section kit, drops knife and gauze onto the bedside table; IV access and meds.
MOD
At the sliding door by the foot — organizes, clears the room, tracks the clock.
TELE NICU
Screen at the foot on the patient's right — documentation and resuscitation support.
1 · PRE-OXYGENATE & INDUCE
SURGICAL TIME OUT — TAP TO WALK ITREAD ALOUD
Hands off. Everyone stops and faces the bed. One person reads; each owner answers out loud.
2 · INTUBATE
3 · POST-INTUBATION & HANDOFF
↑ INDEX
08 ACTIVATE OB · PREP THE WARMER

Breech delivery

← DELIVERY (02)→ NRP ENGINE
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
THE BABY IS OUTNEXT
Hand the baby off and go straight to the birth sequence — stamp the time of birth, then ask the four questions out loud.
BABY IS OUT — STAMP TIME → NEONATAL RESUS → 02 · TIME OF BIRTH + THE 4-YES CHECK
All four yes: skin-to-skin and delayed clamping. Any one no: clamp now, warmer, neonatal resuscitation (card 03).
FIG 1 · 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.
FIG 2 · 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.
FIG 3 · 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.
↑ INDEX
09 CALL STAT · DELIVERY IS BY C-SECTION

Umbilical cord prolapse

← DELIVERY (02)→ NRP ENGINE
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 · CALL OUT & RELIEVE PRESSURE
2 · POSITION & BUY TIME
3 · CORD CARE
DELIVERY IS BY CESAREANNEXT
Nothing here delivers this baby. Everything you are doing is a bridge to the operating field — keep the presenting part elevated the whole way.
→ 05 · ED C-SECTION
At delivery the baby goes to the 4-yes check — or straight to neonatal resuscitation (card 03).
FIG 1 · 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.
FIG 2 · 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.
FIG 3 · 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.
↑ 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.
TIME SINCE MATERNAL ARREST
0:00
TAP START AT ARREST RECOGNITION — CALL THE TIME EVERY MINUTE
EQUIPMENT — GATHER / CHECKSCALPEL IS THE ONLY ESSENTIAL
1 · IMMEDIATE (WITH CPR)
2 · THE INCISION
3 · DELIVERY & MATERNAL CARE
DELIVERY
not yet delivered
FIG 1 · GESTATION CHECK — FUNDAL HEIGHT
36–40 32 20 = UMBILICUS FUNDUS ≥ UMBILICUS → PROCEED
Gestation >20 weeks = fundus at or above the umbilicus (each week ≈ 1 cm above it). If in doubt during arrest, the fundus-at-umbilicus rule decides — don't wait for ultrasound. Adapted from The Procedures Course — Resuscitative Hysterotomy Reference, Alfred STAR Program (Alfred Health).
FIG 2 · 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.
FIG 3 · 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 color 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
  • JADA System (vacuum-induced uterine tamponade)
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
11 MAGNESIUM FIRST · DELIVERY IS THE CURE

Eclampsia / severe preeclampsia

CLINICALLY REVIEWED 2026-08-17 — Lon Setnik. Approved, with the refractory-seizure step and head imaging added per #180. Written from the ACOG guidance cited below; confirm doses against local protocol and pharmacy.
1 · SEIZING + PREGNANT (OR ≤ 6 WK POSTPARTUM) = ECLAMPSIA
2 · MAGNESIUM MAINTENANCE & TOXICITY WATCH
3 · SEVERE-RANGE BLOOD PRESSURE
4 · DISPOSITION — DELIVERY IS THE DEFINITIVE TREATMENT
Sources: ACOG Practice Bulletin 222, Gestational hypertension and preeclampsia (Obstet Gynecol 2020;135:e237); ACOG Committee Opinion 767, emergent therapy for acute-onset severe hypertension (2019).
— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.