Supine Position for women in labor with ROM (rupture of membrane)

[MJG]

Hey folks,

a quick question (to everyone from everywhere):
What procedure do your protocols suggest for women in labor with ROM (rupture of membrane)?
How do you transport women who call you for rom (with foetus head engaged or not)?

Why am I asking? I'm a german paramedic currently looking into that topic. In Germany we get these kind of calls quite often and doctors and midwifes quite often tell pregnant women to call the emergency services if they experience rom. Some only advise them to do so if they have special conditions (eg. polihydramnios, infections, multiparas) or if the foetus head wasn't engaged at the last pregnancy screening with their gynaecologist.
Point is: We transport them in a strictly supine position. So we even carry them down the stairs and so on.

I found out, that this recommendation seems only to be given in a very limited amount of countries, so I'm wondering how you do it in the US and elsewhere.
Personally, I think from an evidence based approach, that this practice is too much of a good thing and probably outdated as most high risk pregnancies with the risk of an umbilical cord prolapse get a primary c-section anyway.

Alright - Thanks for your replies in advance and sorry for my crappy english. If you are interested in literature about that topic, just write me a text.

Stay safe everyone!

 

[MJG]

EDIT: Supine may be the wrong word. It's mostly recommended to keep them lying down, turned on the left side. I think you get the idea.

 

[PrincessAnika]

here we call that left lateral recumbent
I just went and reread the specific protocol, and it doesn't say anything about transport, only about delivery - and doesn't specify position except in hypotension, which is specified as LLR. All the pts I've taken in labor have been transported position of comfort - for some that is on the stretcher, for others its sitting up on the bench seat.

speaking as a mother, once I hit active labor the LAST thing I wanted to do was lay down.

I believe standard of care for prolapse is elbows and knees, but don't remember being taught much else specific.....

 

[Mariemt]

Left side is best if mother isn't arguing with you! I would allow position of comfort.

As for prolapse. Hips up on pillows! Use hand and fingers to lift head off cord.

 

[PrincessAnika]

sorry, should have clarified: much else specific related to pt position during transport for general maternity/labor. absolutely minimize pressure on the cord in prolapse. ty!

 

[Aprz]

It doesn't really matter which side you put them on, but you want to put them on their side to take the fetus weight off of the mother's aorta and inferior vena cava (prevent supine hypotensive syndrome). Usually left lateral recumbent because it's awkward for the patient to face the ambulance wall and it gives me a better visualization of the patient (watch their face for grimacing, quick access to their mouth for airway management, able to watch their mouth, neck, chest, and abdomen to monitor respirations). I don't do this for any specific OB/GYN emergency, I do it for pregnant women usually around >20 weeks when their baby bump is noticeable.

 

[JPINFV]

Left lateral recumbent is what is taught, but unless the mother is hypotensive, it's not needed. Women in delivery in L&D are, for the most part, on their backs, not their sides.

 

[Mariemt]

Left lateral recumbent is what is taught, but unless the mother is hypotensive, it's not needed. Women in delivery in L&D are, for the most part, on their backs, not their sides.

Oh heavens, no way will you strap a woman down on her back in active labor, and no longer is it the norm to be on their backs. Usually it is more upright, squatting.
As a woman who has delivered 3 children, you would have much better luck transferring me sitting straight up, on my side fetal position, or even in captains chair during hard labor. Let's remember she will be belted down, not free to move around. Being on her back is not going to be the most comfortable.

 

[JPINFV]

Oh heavens, no way will you strap a woman down on her back in active labor, and no longer is it the norm to be on their backs. Usually it is more upright, squatting.
As a woman who has delivered 3 children, you would have much better luck transferring me sitting straight up, on my side fetal position, or even in captains chair during hard labor. Let's remember she will be belted down, not free to move around. Being on her back is not going to be the most comfortable.

Last I checked, the back of the gurney does move to a sitting position. Not every patient in the ambulance is on a backboard.

 

[abckidsmom]

As much as the ideal position for a woman in labor is to be upright, it's simply not possible in an ambulance. Seatbelts, and all 5 of them, are needed for the transport. Most of the time women have spent so much time lying on their left sides and drinking a glass of water as directed by the American Obstetric Conglomeration that they are comfortable that way.

I usually transport women in active labor seated on the cot with their feet down on the floor, straddling the cot, or in left lateral recumbent, or in the extreme emergency, the knee-chest position.

 

[Household6]

Speaking as a patient, I'd rather be transported on the jump seat if I was in active labor. Labor is rarely the huge emergency that many EMS *coughMENcough* think it is.

Membrane rupture does put the pt at slight risk for a prolapsed cord if the baby's head hasn't properly dropped to station. That's probably the only situation where I'd deviate from our seatbelt protocols-- Put mom's tushie on the head of the Stryker, then get familiar with my gloved hand..

The way we were taught in Doula school (don't laugh, it was awesome, everyone should do it) was to insert a "V" with our forefinger and middle finger, and cradle the prolapse in our palm. That takes the pressure off, and also helps to keep the cord warm.

Use a ABD to absorb the amniotic fluid, save it for the OB dept to examine for any discoloration.

To the OP, I think your English is great. It's got to be one tough language to learn.

 

[Carlos Danger]

Left lateral recumbent is what is taught, but unless the mother is hypotensive, it's not needed. Women in delivery in L&D are, for the most part, on their backs, not their sides.

What about fetal perfusion? Isn't it possible to have a decrease in uteroplacental blood flow due to compression of the lower aorta, which won't necessarily be reflected in a BP taken in the upper extremity?

 

[Mariemt]

Last I checked, the back of the gurney does move to a sitting position. Not every patient in the ambulance is on a backboard.

No, I would have been able to handle my legs straight out, or even with the knees slightly bent. No way. And what did a back board have to do with it? Unless mom fell off a cliff to rupture her membranes, she's not getting one..

 

[ZombieEMT]

From my experience, I have always (which is not frequent) transported a patient in active labor with the strether in fowlers and position of comfort, which usually is knees up. I try my best to secured as many restraints as I can, but I am not going to delay the transport to secured the foot strap. Also, if ever I felt the baby was going to be coming immediately, the ambulance would be pulled over for delivery or remain on scene if known prior to transport.

 

[Handsome Robb]

We tried to ride elbows and knees on the gurney one day in the box going code.

I'll never subject anyone to that. You go on the cot backwards and ill elevated your legs and pelvis.

 

[unleashedfury]

Lateral Recumbent position is taught to us for hypotensive patients to alleviate pressure on the vena cava and the aorta.

As far as a patient who may be in active labor, its going to be a matter of what is comfortable for them at the moment if they are stable. I also call in to the hospital and request direct access to the maternity ward to alleviate the issues of parking her in the ED to go upstairs to get prepared and so on. after watching my two kids being born the last thing I want to do is aggravate a mother in labor. That could be punishable by death :unsure:

For the most part the patient who may be initiating labor, needs a comfortable ride, If she is ready to go and cannot wait to hit the hospital we are instructed to deliver on scene and move with mother and child to the hospital.

 

[Handsome Robb]

Lateral Recumbent position is taught to us for hypotensive patients to alleviate pressure on the vena cava and the aorta.



As far as a patient who may be in active labor, its going to be a matter of what is comfortable for them at the moment if they are stable. I also call in to the hospital and request direct access to the maternity ward to alleviate the issues of parking her in the ED to go upstairs to get prepared and so on. after watching my two kids being born the last thing I want to do is aggravate a mother in labor. That could be punishable by death :unsure:



For the most part the patient who may be initiating labor, needs a comfortable ride, If she is ready to go and cannot wait to hit the hospital we are instructed to deliver on scene and move with mother and child to the hospital.

Your EDs don't bypass pregnant patients?

Anything over 20 weeks up here that's related to the pregnancy goes past the ER to L&D unless there's something that needs to be addressed first (traumatic injury, airway problem) something like that.

Can actually be like pulling teeth to stay in the ER with a pregnant patient.

 

[unleashedfury]

Your EDs don't bypass pregnant patients?

Anything over 20 weeks up here that's related to the pregnancy goes past the ER to L&D unless there's something that needs to be addressed first (traumatic injury, airway problem) something like that.

Can actually be like pulling teeth to stay in the ER with a pregnant patient.

The local hospital does not have a maternity ward closest for me is about 20 miles away. it works different during the day where you can bypass I have to call in at night as the whole crew is on call, give them enough time to get there with the catchers mitt.

 

[Handsome Robb]

The local hospital does not have a maternity ward closest for me is about 20 miles away. it works different during the day where you can bypass I have to call in at night as the whole crew is on call, give them enough time to get there with the catchers mitt.

I'm too used to being able to pick from 4 hospitals plus the VA.

 

[unleashedfury]

I'm too used to being able to pick from 4 hospitals plus the VA.

My options

Local Hospital about 8 minutes transport time. Generalized care, no maternity, cardiac, Neuro, or trauma team. They have a part time ortho team that has banker hours, and on call shifts.

3 other hospitals within 30 minutes - 2 offer maternity, ortho, and mental health services.

Level 1 trauma center about 30 to 40 minutes ground and its a one stop shop. you need it they got it.