Preterm and term vaginal bleeding evaluation Assess amount of hemorrhage by “pad” count and POC Hgb and transport commercial to Bethel OB Triage (if EGA > 20 weeks, otherwise to the ER) if vital signs stable and hemorrhaging allows. Consider IV fluids as needed.
Labor in the Village
- Chief complaint: Contractions, vaginal bleeding or other suggestive of labor
- Ascertain gestational age, parity and Be-in-Bethel (BIB) date (should be documented on Problem List).
- Get clear history of contractions—duration, frequency, strength.
- Get history of complications—review OB chart to review placental location, prenatal course.
- Find out when last had sex or pelvic exam.
- Make sure health aides dip a urine, get blood pressure and continue to accurately record contractions. Have them assign someone to palpate uterus.
- There is no availability of continuous monitoring—just a Doppler and manual palpation.
- If the CHA has not sent you an RMT in RAVEN, start a RAVEN alert note or a word document that you can copy and paste into a RAVEN alert note. Use this to document the frequent call backs.
- If the CHA has sent you a RAVEN RMT be sure to document your advice and call back information.
- If seems like preterm labor is a possible diagnosis—
- Start IV fluid, give Motrin 800 mg if not allergic, give terbutaline, give dexamethasone.
- Repeat terbutaline q 30 min for up to 3 additional doses if contractions continue and patient tolerates. .
- Can repeat IVF if seems dehydrated.
- If contractions do not stop and it is before the BIB, activate a medevac.
- If it is after the BIB and there is a compelling reason such as possible breech or transverse presentation or hypertension, consult HROB and consider a medevac.
- If contractions stop, can monitor in village until they can come in commercial.
- Do not fly someone commercial who could deliver en route regardless of gestational age.
- You really cannot tell who is or is not in labor over the phone— do not hesitate to consult HROB for these patients.
If a POC HGB and vital signs are stable this patient may go to the ER in Bethel on the next available flight. She should be warned that she may in be in Bethel for at least 2-3 days as part of the evaluation. There is also a risk she may bleed to death if she remains in the village.
[Link to OB-Newborn/OB Special Circumstances/Labor in the Village]] If a (non-preterm) delivery is imminent in the village, encouraging the CHA to marshal resources in the clinic area for delivery is important including finding the most experienced (even former) CHA or traditional mid-wife. If the term laboring mother is unstable (or didn’t sign a BIB agreement) then activating a medevac to bring the patient to Bethel OB Triage is appropriate.