17 Emergencies and procedures
Obstetric emergencies and procedures
Antepartum haemorrhage
Severe antepartum haemorrhage
The main causes of severe APH are placenta praevia (Fig. 17.1) and placental abruption. If the patient is collapsed and shocked, then a careful and efficient management protocol must be followed:
• Alert senior medical and midwifery staff.
• Estimate vaginal blood loss from history of pad usage, pooling and other subjective information; assess for signs of hypovolaemic shock, i.e. blood pressure, pulse, respiration rate, temperature.
• Auscultate fetal heart and commence continuous monitoring if fetal heart is present.
• Observe for signs of labour.
• Administer oxygen by facial mask.
• Insert intravenous (IV) line using large-bore cannula (may need two lines of access) and commence infusion of colloid (e.g. Gelofusine) ± crystalloid (e.g. Hartmann’s).
• Take blood samples for urgent full blood count, clotting screen, and crossmatch for 6 units of blood.
• Insert indwelling catheter for urinary output measurement.
• Alert anaesthetic registrar, theatre staff and paediatric registrar, and special care baby unit if the fetal heart is present.
Labour ward emergencies and procedures
Unconscious patient
Management
• Basic first aid: left lateral position, maintain airway, oxygen administration via bag and mask if not breathing.
• Assessment of situation and patient, including pulse, respiratory rate, blood pressure and fetal heart rate.
• Commence cardiopulmonary resuscitation if there is no cardiac output.
• Establish IV access, obtain blood for full blood count, renal function and electrolytes, serum glucose, liver function, coagulation screen and blood group (crossmatch if suspect haemorrhage).
• Monitor mother and fetus: electrocardiograph and vital signs, cardiotocograph to assess fetal well-being.
• Establish and treat cause of collapse.
• If there is no cardiac output within 10 minutes, consider an immediate caesarean section.
Management
• If oxytocin infusion is in progress, discontinue immediately
• If suspected, alert senior medical staff and arrange immediate delivery by caesarean section
• Postpartum haemorrhage (PPH) in a patient with a previous uterine scar could be due to uterine rupture. The patient should be managed according to the major obstetric haemorrhage guidelines and may require an exploration of the uterine cavity in theatre, with preparation for a laparotomy and caesarean hysterectomy if necessary.
Uterine inversion
This is inversion of the uterine fundus through the vagina.
Management
• Take blood (including crossmatch for 4 units) and establish IV access
• If the placenta is adherent, do not attempt to separate, but manually replace within the vagina
• Tocolytic therapy (salbutamol 500 μg in 10 ml normal saline IV) may be required
• Hydrostatic method to reduce the inversion (O’Sullivan method) – at least 4 l of warm sterile water connected by IV lines and tubing into the vagina as a douche
• Once uterus is reduced and placenta separated, give ergometrine 500 μg intramuscularly (IM) and then a 40 unit oxytocin infusion
Shoulder dystocia
Management
Alert senior medical and midwifery staff when delivery is imminent. If shoulder dystocia occurs:
• Do not pull hard on the fetal head as this may increase the amount of impaction within the pelvis.
• Position mother in McRoberts position (knee–chest or thighs abducted and hyperflexed on the abdomen supported by an assistant on each side) or on all fours.
• Perform an episiotomy to aid access to fetal shoulders/posterior arm.
• Clear baby’s nose and mouth of mucus.
• Apply firm suprapubic pressure and attempt basic method of delivery of the shoulders.
If this fails, attempt delivery of anterior shoulder using the Rubin manoeuvre (Fig. 17.2A):
• Place hand deeply in vagina behind anterior shoulder.
• With next contraction rotate the axis of the shoulders into the more favourable oblique diameter of the pelvis.
• Firm traction is made on the head, deflecting it towards the floor.
• Suprapubic pressure is exerted; this usually succeeds in bringing the anterior shoulder into and through the pelvis.
Extraction of posterior shoulder and arm
If this fails, attempt extraction of posterior shoulder and arm (Fig. 17.2B):
• Place hand deeply into vagina along the curvature of the sacrum and behind the baby’s posterior shoulder.
• Identify posterior arm, follow to elbow. Pass finger into the antecubital fossa to encourage flexion of the elbow joint. Grasp forearm and hand and sweep anteriorly across the baby’s abdomen and chest to deliver the posterior arm.
• Usually, normal head traction will now deliver the anterior shoulder. If not, rotate the baby 180° so that the anterior shoulder is now in the posterior position. It can then be extracted using the same manoeuvres.
