who obstetric emergencies

Clinical Practice Guidelines – Obstetrics

Obstetrics• Breechdelivery

• Cordprolapse

• Ectopicpregnancy

• Miscarriage

• Normalcephalicdelivery

• Placentalabruption

• Placentapraevia

• Pre-eclampsia

• Primarypostpartumhaemorrhage

• Secondarypostpartumhaemorrhage

• Shoulderdystocia

• Uterineinversion

• Uterinerupture

Version 1.0 – September 2011

Clinical practice guidelines Breech delivery

Clinical features

Signs of imminent delivery• increasingfrequencyandseverityofcontractionswithanurgetopush

• bloodstainedshow–althoughtthismaynotbeanimminentsign

• membranerupture

• bulgingperineum

• appearanceofthepresentingpart

Abreechbirthoccurswhenthefetusentersthebirthcanalwiththebuttocksorfeetfirst,withcommonvariationsbeingcomplete,frank,footingandknee(seeBreechbirthCPP).[1]

Theincidenceofbreechpresentationisaround3–4%withthemajorriskfactorsbeingmultiplepregnancyandpretermlabour.[2]

Breechdeliveryhasanassociatedhighriskofmaternalandfetalmorbidityandmortality.

Theprimaryfocusofpre-hospitalmanagementisrapidrecognitionofabreechbirthandlimitingmanipulationofthebabyuntilrequired,beinggentlebuttimelywiththenecessarytechniques.[2]

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Complete breech

Footling breech Kneeling breech

Frank breech

cpm_reference_list.pdf#page=6



Risk assessment

• Complicationsofbreechdeliveryinclude:[3]

- fetalhypoxia

- prolapsedcord

- headentrapment

- meconiumaspiration

- postpartumhaemorrhage

- inversionoftheuterus.

• Incorrectmanoeuvresorroughhandlingcaninjuretheinfant:

- spleenorliverdamage

- spinaldamageorfractures

- fracturedbonesordislocations

- softtissueinjuries

- cerebralhaemorrhage,ifthedeliveryistoorapid.

Additional information

• Preparationforneonateresuscitationshouldbemadeattheearliestsignofbreechpresentation.[4]

• ConsiderationshouldbesoughttoearlyICPorobstetricretrievalteambackup.

• Ensureanaseptictechniquewithappropriateinfectioncontrolmeasurestobetakenatalltimes.

• BeforeperformingtheLovesetsmanoeuvre,ensurethatadrycloth/padiswrappedaroundthepelvisofthebaby.Thiswillpreventtheparamedic’shandsfromslippingduringtheprocedureandprovidesomeprotectionforthebaby.

Breechdelivery–Page2of4




Clinical practice guidelines Breech delivery

Standard Cares

Cordcompressedagainstpubicarch?

Gentlypulldownloopofcord.

Allowneonatetodescendfreely.

Gentlypullcordaroundtoperineum

Positionmothersoneonatecanhangfreely

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Armsextended?

Observedescentuntilocciputvisible

Mauriceau-Smellie-Viet(MSVmanoeuvre)

Lovesetsmanoeuvre

Meconium/amnioticfluidpresentinmouth?

ManageasperCPG:

• Resuscitation–newborn

Clearairway

Isneonatebreathingorcryingwith

goodmuscletone? • Drybaby• Maintainwarmth• Provideskintoskincontact• Clampandcutthecord• Apgarscoreat1&5min• Conductpostnatalcares

TransporttohospitalPre-notifyasappropriate

Breechdelivery–Page4of4


Clinical practice guidelines Cord prolapse

Clinical features

• Umbilicalcordvisibleat,orexternalto,thevaginalopening

• Evidenceofmembraneshavingruptured

• Anonreassuringfetalstatus:[4]

- changeinfetalmovementpattern

- meconiumintheamnioticfluid(vaginaldischargemaybestainedgreen)

- fetaltachycardia>160bpm- fetalbradycardia<110bpm(morecommon).

Risk assessment

• Cautionisrequiredifmanoeuvringtheumbilicalcordaspinchingwillcancausevasospasm.[5]

• Anon-labouringpatienthasadecreasedriskofcordprolapse,butanypresentationcancompressthecord.

Cordprolapseisarareobstetricemergencythatisassociatedwithahighperinatalmortalityrate.[1]Itoccursafterthemembraneshaveruptured,whentheumbilicalcordslipsdowninfrontofthepresentingpartofthefetusandprotrudesintothevagina.Diagnosisismadebyvisualisingthecordatthevaginalopening,whichwillappearasabluishwhite,shiny,pulsatingstructure.

Thisconditionbecomesanissueaslabourprogressesandthepresentingpartdescends,compressingthecordandcuttingoffthefetalbloodsupply,leadingtohypoxiaandeventualfetaldemise.[2]

Theprincipleofpre-hospitalmanagementistomonitorthecordforpulsationsandusematernalpositioningtopreventcompression.Ifthecordstopspulsating,thepressurefromthepresentingpartwillneedtobealleviated,eitherindirectlyusinggravity(maternalknee-chestposition)ordirectly,bygentlypushingthefetusoffthecord.[2]

Riskfactorsforcordprolapseinclude:[3]

• Abnormalfetalpresentation

• Multiparity

• Lowbirthweight

• Prematurity

• Polyhydramnios

• Spontaneousruptureofmembranes.

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Standard Cares

Pulsatilecordevident?

• AssistmotherintotheSimsposition

• Askmothertogentlypushthecordbackintovagina(thismustbedonecarefullytoavoidvasospasm)


• Assistmothertoassumetheknee-chestposition

• Carefullyattempttopushthepresentingpartoffthecord

• Useamoistdressingtomaintaincordtemperatureandavoiddrying

ModifiedSimsposition

Knee-chest position–Thepatientmustbeadequatelysupportedandrestrainedifthereisaneed

totransportinthisposition


• Aprolapsedumbilicalcordrequiresanimmediatedelivery,whichisusuallyachievedbyCaesareansection.[3]

Note:OfficersareonlytoperformproceduresforwhichtheyhavereceivedspecifictrainingandauthorisationbytheQAS.

Cordprolapse–Page2of2



Clinical practice guidelines Ectopic pregnancy

Clinical features

Unruptured ectopic pregnancy• Historyofamenorrhea(usuallyonlyonemissedperiod)

• Abnormalvaginalbleeding

• Pelvicand/orabdominalpain

• Nausea

• Presyncopalsymptoms

Ruptured ectopic pregnancy• Collapse

• Shock

• Acuteseverepelvicand/orabdominalpain

• Shouldertippain(Kehr’ssign),fromfreebloodirritatingthediaphragmwhensupine

• Abdominaldistention

• Reboundtenderness

Ectopicpregnanciesoccurwhenthedevelopingembryoimplantsoutsidetheuterinecavity,withover98%occurringintheFallopiantubes.[1]Althoughthisconditioncanbelife-threatening,inthelastdecadedeathsinAustraliahavebeenextremelyrare.[2]Thiscanbeattributedtoimprovedearlydiagnosisandtreatment,despiteaworldwideincreaseofcasesfrommoreprevalentriskfactors,[1][3]suchas:

• Invitrofertilizationandfertilitytreatments

• Sexuallytransmittedinfections(e.g.chlamydia)

• Useofintrauterinedevices

• Advancedmaternalage

• Smoking

• Previoushistoryofectopicpregnancy

• Tubaldamageasaresultofsurgery

Themostsignificantcomplicationofectopicpregnancyistubalrupture,whichusuallyoccursbetween6–10weeksofgestationandcanresultinsignificanthaemorrhageandshock.[4]

Risk assessment

Ahighindexofsuspicionforectopicpregnancyshouldbemaintainedwithanyfemalepatientofchild-bearingageexhibitinganyoftheassociatedclinicalfeatures.

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Standard Cares

Suspectedrupture? Patientshocked?

Consider:• Analgesia• Antiemetic• IVfluid

Transporttohospital

Pre-notifyasappropriate

ManageasperCPG:• Shock

Ectopicpregnancy–Page2of2


Clinical practice guidelines Miscarriage

Risk assessment

Pre-hospitaldiagnosisofmiscarriagecanbedifficulttodetermine,particularlywherethePOCarenotobvious.

DefinitivediagnosisofmiscarriageisbasedonconfirmedpassageofPOCorultrasoundfindingsconsistentwithASUMcriteriaformiscarriagediagnosisatthereceivingfacility.[5]

Thereforedifferentialdiagnosisofantepartum/PVhaemorrhagemustinclude:

• Normalearlypregnancybleeding.

• Ectopicpregnancy.

• Sexualassault/nonaccidental-injury.

Ifpossible,alltissueandlargeclotsshouldberetainedandtransportedtothereceivingfacility.Ifterminationoccursintothefirsttrimesterorlatergestation,afetusmaybepassedoutofthevagina.Oftentheplacentawillnotseparate.Ifthisoccurs:

• Cutandclampthecord

• Wrapthefetus(Themothermayormaynotwishtoholdthefetus.)

Somefetuses<20weekswillshowsignsoflife(movement/gasp).Ifthefoetusislessthan20weeks,thenresuscitationisfutile.[6]

Europeanresuscitationguidelinesstatethatitispossibletoidentifyconditionsassociatedwithhighmortalitywherewithholdingrescusitationmaybeconsideredreasonable.Theseincludegestationalage<23weeksand/orbirthweight<400g.[7]

Miscarriageisdefinedasthespontaneouslossofpregnancybefore24weeksofgestation,withtheaetiologyforthemajorityofcasesbeingunknown.[1]Thereareseveraldifferentcategoriesofmiscarriage,someofwhicharemoresusceptibletointrauterineinfectionduetoretainedproductsofconception(POC),whichmayleadtosepticshock.[2]

Althoughvaginalbleedingandabdominalpainarecharacteristicsofamiscarriage,about25%ofpregnanciesareassociatedwithbleedinginthefirst12weeks.[3]Withthisinmind,itisimportantnottomakecommentsthatcouldbeinterpretedasadiagnosis.

Miscarriagehasbeenassociatedwithsignificantpsychologicalconsequencesandpatientshavebeenshowntobenefitfromappropriatecounsellingandsupport,whichshouldbeinitiatedinthepre-hospitalsetting.[4]

Miscarriageistheleadingcauseofante-partumhaemorrhage.Themostsignificantcomplicationsinclude:

• Haemorrhagicshock

• Uterinesepsis.

Clinical features

Clinical presentation includes:• Generalisedweakness

• Lowerabdominaldiscomfort

• Vaginalbleeding

• Hypotension

• Tachycardia.

Signs suggestive of intrauterine infection include:• Severeuterinepain/rigidity/guarding

• Purulentdischarge

• Fever.

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Standard Cares

Consider:

• Analgesia

Evidenceoffetus?

Cutandclampcord

Wrapfetus

ManageasperCPG:


Suspectedsepsis?ManageasperCPG:

• Sepsis

Significanthaemorrhage?Consider:

• IVfluid• Blood

Transporttohospital


Miscarriage–Page2of2


Clinical practice guidelines Normal cephalic delivery

Risk assessment

Gainingadequateprenatalhistorymaypre-emptcomplicationsassociatedwithdeliveryandinclude:

• Mal-presentation

• Multiplepregnancy

• Pre-eclampsia

• Placentaprevia

• Substanceabusedisorders

• Historyofobstetricorgynaecologicaldisorderoremergency.

Ensureanaseptictechniqueandalwaysuseappropriateinfectioncontrolmeasures.

Definitive care

Note –RefertoCPPfornormalcephalicdeliveryprocedures.

Normalcephalicdeliveryisdefinedasthemeansbywhichthenewborn,placentaandmembranesaredeliveredviathebirthcanalinwhich:

• Asinglenewbornpresentsviathevertex

• Thenewbornisbornbyvaginaldeliveryattermbetween37–42weeksgestation

• Thebirthiscompletedspontaneouslywithin18hours

• Nocomplicationsoccur.

Clinical features

Signs of imminent delivery• Increasingfrequencyandseverityofcontractionswithanurgetopush

• Showofoperculumplug–Whenthecervixdilates,theoperculumplugdislodgesfromthecervicalcanal

• Membranerupture(Thismaynotoccurandactivemembranerupturewillberequirediftheheadhasbeendeliveredwithoutmembranerupture)

• Bulgingperineum

• Appearanceofthepresentingpartatthevulva

Note –IfimminentdeliveryisinitiatedduetotraumarefertoTraumainpregnancyCPG.

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Careofthenewborn

• Ensuretheairwayisclearofamnioticfluid/meconium.

• Ensureexcessivetractionisnotplacedonthecord.

• Initiatetactilestimulationanddryingofthenewborntoencouragebreathing.

• Assessbreathingorcrying,muscletone,heartrate–newbornresuscitationCPG.

• Clampandcutumbilicalcordasrequired.Reassesscordforbleeding.After15minutesreclampifrequired.

• AssessAPGARscoreat1and5minutes,thenassessmotherandnewborncontinuallyeveryfiveminutes.

• Maintainnormothermiaandwarmenvironment.

Special note–Newbornhypothermiacanoccurquicklyanddepressbreathing.Itisveryimportanttokeepthenewbornwarmandskintoskincontactwillgreatlyassistthermoregulation.Payparticularattentiontokeepingtheheadcoveredasheatlossfromthenewbornheadcanbesubstantial.[1]

Apgar Score

0 1 2

Colour Blue/pale Pinkwithblueextremities Allpink

Respirations Absent Slow,irregular Goodcry

Heart Rate Absent < 100 > 100

Muscle Tone Limp Someflexion/extension Activemotion

Reflex / irritability

Noresponse Grimace Vigorouscough,

cry,sneeze

Normalcephalicdelivery–Page2of4


Clinical practice guidelines Normal cephalic delivery

Standard Cares

Patientinlabour?

Signsofimminentdelivery?Reassessenroute

Positionmother

Prepareequipment

Consideranalgesia

Cordprolapsed?ManageasperCPG:• Cordprolapse

Breechpresentation?ManageasperCPG:• Breechdelivery

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Ensurecontrolleddeliveryofhead

Cordlooparoundneck?Unloopcordoverhead,oriftootightclampandcutcord

Shouldersobstructed?

Controlrateofdelivery

Isamnioticfluidclear?• Goodbreathing/crying• Goodmuscletone

ManageasperCPG:


Postdeliverycares

ManageasperCPP:

• Shoulderdystocia

Normalcephalicdelivery–Page4of4


Clinical practice guidelines Placental abruption

Clinical features [1]

• Vaginalbleedingmaybeprofuseandoccurastheuteruscontracts.

• Constantpainintheabdomino-pelvicregion

• Bleedingmayrangefromabsenttoprofuse,occurringinwavesastheuteruscontracts.

• Tetanicuterinecontractions

• Uterinehypertonicity–feelsrigidonpalpation

• Fundalheightmayincreaseduetoexpandingintrauterinehaemorrhage.

• Signsofmaternalshock

• Nonreassuringfetalheartratepatterns

Risk assessment

• Diagnosisofplacentalabruptionshouldbeconsideredinanypregnantwomanwithabdominalpain,evenwithoutevidenceofhaemorrhageduetothepossibilityofanoccultbleed.

• Mildcasesmaynotbeclinicallyobvious.

Placentalabruptionoccurswhenanormallysituatedplacentaseparateseitherpartiallyorcompletelyfromtheuterinewall,resultinginhaemorrhagepriortothedeliveryofthefetus.ItisanobstetricemergencythatisassociatedwithseriousmaternalcomplicationssuchasDIC,shock,uterinerupture,oracuterenalfailure,andalsocontributestohighratesoffetalperinatalmortality.[1]

Theincidenceofplacentalabruptionisapproximatelyonein100–200pregnancies;howeverthefrequencyisincreasing,possiblyduetoatrendtowardslatermotherhood,orahigherincidenceofCaesareansections.[1]

Althoughblunttraumacanbeafactor,themajorityofcasesareidiopathic,howevernumerousriskfactorshavebeenidentified,[2]suchas:

• Gestationalhypertensionandpre-eclampsia

• PrevioushistoryofabruptionorCaesareansection

• Multiparityandadvancedmaternalage

• Intrauterineinfection

• Rupturedmembranesinthepresenceofpolyhydramnios

• Tobaccoorcocaineuse.

Managementisbaseduponearlyrecognition,especiallyinoccultbleeds,andpreventingmaternalhypotensioninordertoavoidfetalhypoxia.

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Additional information Placentalabruptioncanbeclassifiedintothreecategories:[2]

• Marginal,whereanedgehasseparatedaway

• Central,wherethecentrehasdetached

• Complete,wherethewholeplacentahascomeawayfromtheuterinewall.

Ascanbeseenfromthediagrams,onlyamarginalabruptionislikelytoresultinavisiblePVhaemorrhage.

Standard Cares

Evidenceofshock?

Avoidaortocavalcompression


Consider:•IVaccess•IVfluid•Analgesia•Antiemetics

Transporttohospital


Note:Officersmustbepreparedforspontaneousdelivery

Blood

Complete abruption

Central abruptionMarginal abruption

Blood

Blood

Placentalabruption–Page2of2


Clinical practice guidelines Placenta praevia

Risk assessment

Note:Undernocircumstancesperformadigitalinternalexaminationorallowanythingtobeplacedintothevaginatocontrolbloodlossasthiscanresultincatastrophichaemorrhage.[5]

Placentapraeviaoccurswhentheplacentaissituatedeitherpartiallyorwhollyintheloweruterinesegment.Thisbecomesrelevantduringthethirdtrimester(28–40weeks)whenthedownwardandoutwardthrustofthedevelopingfetusisaccommodatedbythethinningandstretchingoftheloweruterinewall.Thisexpansioncausessomedegreeofplacentalseparationandsubsequentbleeding.Thiscanworsenduringeffacementofthecervix,iftheplacentaisnearoroverthecervicalos.[1]

Furthermore,thepositionoftheplacentamayphysicallypreventnormalvaginaldelivery(seeadditionalnotes)andtherefore,appropriatemanagementreliesuponsuitableantenatalassessmentsandmonitoring.[2]

Theconditionbecomesanobstetricemergencyinthepresenceofantepartumhaemorrhage,asinitialsmallbleedshavethepotentialtodevelopintoprofusebloodlossthatcanthreatenboththemotherandthefetus.[3]

Pre-hospitalmanagementisfocusedonpreventingmaternalhypotension,asthiswillresultinbloodbeingshuntedawayfromthefetustomaintainmaternalbloodpressure,whichcancausefetalhypoxia.[4]

Clinical features

Clinical presentation can include:

• Severalsmallwarningbleeds

• Brightredblood

• Nopain,otherthanthatassociatedwithcontractions

• Asoft,non-tenderuterus

• Significantbloodloss,whichmayleadtohypovolaemicshock.


Grade 1–Thereisonlyasmallamountofplacentaencroachingonthelowersegmentwhichisclearofthecervicalos.Vaginalbirthispossible.

Grade 2–Theplacentaextendstothemarginoftheosbutdoesnotcoverit.Vaginalbirthmaybepossible.

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Grade 3–Theplacentacompletelycoverstheinternalos,butisnotcentrallyoverit.Vaginalbirthisnotpossibleasthefetalpassagewillcausetheplacentatoseparateprematurely,causingcatastrophichaemorrhage.

Grade 4–Theplacentacompletelycoverstheinternalosandiscentrallyoverit.Vaginalbirthisnotpossiblebecausethefetalpassageisprevented.

Standard Cares

Signsofshock?



Consider:•IVaccess•IVfluid•Analgesia•Antiemetic

Transporttohospital


Note:Officersmustbepreparedforspontaneousdelivery

Placentapraevia–Page2of2


Clinical practice guidelines Pre-eclampsia

Theprinciplepre-hospitalmanagementofthisconditionissupportivecareandthepreventionofeclampsia,withthelatterdefinedastheoccurrenceofoneormoreseizuressuperimposedonahistoryofpre-eclampsia.[1]

Ifeclampsiadevelops,thefocusofmanagementistoterminateanyseizuresinordertopreventmaternalandanysubsequentfetalhypoxia.

Clinical features

Clinical features can include:

• Neurological

- headache

- visualdisturbance

- seizure

- hyperreflexia

- clonus

• Respiratory

- acutepulmonaryoedema

• Cardiovascular

- hypertension

- generalisedoedema

• Gastrointestinal

- epigastricpain

- nauseaandvomiting.

Pre-eclampsiaisdefined[1]asamultisystemdisorderthatonlyoccursduringpregnancyafter20weeksgestation,andisdiagnosedbyeithera:

• Systolicbloodpressure(SBP)≥140mmHgand/or• Diastolicbloodpressure(DBP)≥90mmHg

plusoneormoreof:

• Neurologicalproblems

• Proteinuria

• Renalinsufficiency

• Liverdisease

• Haematologicaldisturbances

• Fetalgrowthrestriction.

Eclampsiaandpre-eclampsiaareleadingcausesofperinatalandmaternalmorbidityandmortality.Theycanleadtoplacentalabruption,DIC,cerebralhaemorrhage,hepaticfailureandacuterenalfailure.[2]

Thepre-hospitalmanagementofeclampsiaandpre-eclampsiaissupportivecareandthepreventionofeclampsia.

HELELP syndromeisconsideredavariantofseverepre-eclampsia(H aemolysis,E levatedL iverE nzymesandL owP latlets)[2]

RiskFactorsforpre-eclampsia:

• Primagravida

• Historyofpre-eclampsia

• Extremesofmaternalage

• Renaldisease

• Diabetes

• Obesity

• Familyhistory

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Standard Cares

Evidenceofeclampsia?

Consider:• IVfluid• Magnesiumsulphate

Highriskofeclampsia?• CNSdysfunction• Severepre-eclampsia

Minimise risk of eclampsia:• Maintainquietenvironment• Minimisebodymotion• Attainpositionofcomfort

Eclampsia• 1stlineoftreatmentismagnesiumsulphate

• 2ndlineoftreatmentismidazolamifmagnesiumsulphateisunavailableorseizureprolonged

Transporttohospital


Risk assessment

• Fluidadministrationshouldbeconservative,duetothehighriskofpulmonaryoedema.

• Patientssuspectedordiagnosedwithseverepre-eclampsiaaredeemedhighriskofeclampsia.

Definitive care

Theonlycureforpre-eclampsiaisdeliveryoftheplacenta,thereforecontinuedgestationpost-diagnosisisbasedonabalancebetweenpotentialmaternalmorbidityandcontinuedfetaldevelopment,withbothpatientsrequiringclosesurveillance.Drugtherapyoftenincludesantihypertensivesforthemotherandantenatalcorticosteroidstoacceleratefetallungmaturation.[3]

Pre-eclampsia–Page2of2



Clinical practice guidelines Primary postpartum haemorrhage

Risk assessment

• Nil


Inthecaseoftorrentialoruncontrolledhaemorrhage,applyexternalaorticcompression.Bimanualcompressionmayneedtobeperformedasalastresortwhenallelsehasfailedtosavethemother’slife.Thisprocedureisdifficult,extremelypainfulandmustbeperformedundermedicalconsultation.

Primarypostpartumhaemorrhage(PPH)occurswithin24hoursofdeliveryandconstitutesbleedingfrom,orinto,thegenitaltractofgreaterthan500millilitres,orsufficienttocausedeteriorationofthemother’scondition.[1]

Common causes of PPH (4T ’s)• Thrombin–coagulopathydisorders

• Tone–uterinehypotonicity

• Tissue–retainedproducts

• Trauma–ruptureduterus,uterineinversion,tearsofupperorlowergenitaltract)

ClinicalstaffhavebeenshowntosignificantlyunderestimatePPHbloodlosswhenmakingvisualassessments,sometimesbymorethan50%.[2]

Thenormalsignsofhaemorrhagicshockareoftenmaskedbythephysiologicalchangesduringpregnancyandsotachycardiamaynotdevelopuntilbloodlossexceedsonelitre.[2]

Therefore,withanyPPHthereneedstobeahighdegreeofsuspicion,withclosemonitoringofthepatienttoensureearlyrecognitionofapoorperfusionstatus.TheprinciplemanagementofprimaryPPHistopromoteuterinecontractions,sothatthe‘livingligatures’cannaturallylimitbloodloss.[3]

ActivecontrolledmanagementofthethirdstageoflabourisaleadingfactorinreducingtheriskofPPH.[4]Thisincludes:

• Controlledrateofdelivery

• Controlledcordtraction

Clinical features

• PVbleedthatcanbetorrentialanduncontrolled• Signsofshock• Restlessness• Enlargedandsoftuterusonpalpation

Uterus is pressedbetween hands

Left hand placed on abdomen

Bladder empty

Right hand placed in vagina, or at vulva

Bimanualcompression

Page1of2






Standard Cares

Torrential/uncontrolledhaemorrhage?

Note: Considerearlybackupduetopotientialoftwocriticallyillpatients.

Obviousexternaltearing?Directpressuredressing

Massagefundus

Consider:• Externalaorticcompression• Bimanualcompression• IVfluid


Haemorrhagecontrolled?

Haemorrhagecontrolled?

Consider:• Suckling• Emptyingbladder• IVfluid

Note:OfficersareonlytoperformproceduresforwhichtheyhavereceivedspecifictrainingandauthorisationbytheQAS.

Primarypostpartunhaemorrhage–Page2of2


Clinical practice guidelines Secondary postpartum haemorrhage

Clinical features

• OngoingPVbleed

• Changeinlochia–regressiontobrightredincreasingamounts,thelochiamaybeoffensive

• Pain–usuallylowerabdominal/pelvic

• Anaemia

• Pyrexia

• Sepsis

Risk assessment

• Nil

Secondarypostpartumhaemorrhage(PPH)isdefinedasbleedingfrom,orinto,thegenitaltract>24hours,oruptosixweeksafterdelivery.[1]Furthermore,theamountofbloodshouldbe500millilitresormore,orsufficientlosstocauseadeteriorationinthepatient’scondition.SecondaryPPHcanbecausedby:

• Infection

• Retainedfragmentsoftheplacentaormembranes.

Thisresultsinafailureoftheuterustocontract(sub-involution)leadingtoSPPH.

Definitive Care

• Drugtherapy–antibiotic,oxytocics,hormonetherapy

• Surgicalmanagement.

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Standard Cares

Haemodynamicallyunstable?ManageasperCPG:• Sepsis

Transporttohospital


Consider:

• IVfluid• Analgesia

Seondarypostpartumhaemorrhage–Page2of2


Clinical practice guidelines Shoulder dystocia

Clinical features

Shoulderdystociausuallybecomesobviousafterthefetalheademergesandretractsupagainsttheperineum,failingtoundergoexternalrotation(turtlesign).[3]

Shoulderdystociaisconfirmedwhenthestandarddeliverymanoeuvres(downwardtraction)failtodeliverthefetusandtheheadtobodydeliveryintervalisprolonged≥60seconds.[4]

Risk assessment [5]

Anincreasedriskofshoulderdystociaisreportedinassociationwith:

• Prolongedsecondstageoflabour

• Assisteddelivery

• Maternaldiabeteswithorwithoutmacrosomia

• Previousshoulderdystocia

• Alargefetus>4.5kg(macrosomia)• Historyofalargefoetus

• Maternalobesity

• Multiparity.

Anycombinationoftheabovefactorsmaysignificantlyincreasetheriskofshoulderdystocia.

Inshoulderdystocia,disproportionoccursbetweenthebisacromialdiameterofthefetusandtheantero-posteriordiameterofthepelvicinlet,resultinginimpactionoftheanteriorshoulderofthefetusbehindthesymphysispubis.[1]

Difficultdeliveryensues,requiringtheuseofadditionalmanoeuvresbeyondthedownwardtractionofthefetalhead.

Shoulderdystocia–WoodsScrewManoeuvre

Shoulderdystociaisassociatedwithseriouscomplicationsforboththemotherandbaby.[1]Perinatalmorbidityincludesasphyxia,birthtraumasuchasbrachialplexusinjuryandfracturedclavicles,andpermanentneurologicaldamage.

Fetaldeathcanalsooccurifnotrecognisedimmediatelyandtreatedpromptly.[2]

Impacted anterior shoulder

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Externalmanoeuvresincludethefollowing:

• McRobertsManoeuvre

• RubinIManoeuvre(suprapubicpressure)

• Rotationontoallfours

Manipulationofthefetuswithinthebirthcanalinclude:

• RubinIIManoeuvre

• WoodsScrewManoeuvre

• ReverseWoodsScrewManoeuvre

• Deliveryoftheposteriorarm

Paramedicsmustexhaustallexternalmanoeuvresfirstbeforeundertakingthemanipulationofthefetuswithinthebirthcanal.AdescriptionofeachofthesetechniquesisgivenintheshoulderdystociaCPP.Alwaysconsiderappropriatepainreliefasrequired.

Rubin II

Woods Screw Manoeuvre Woods Reverse Screw Manoeuvre

Rotation to all fours

Delivery of posterior arm

Rubin IMcRoberts Manoeuvre

Shoulderdystocia–Page2of4


Clinical practice guidelines Shoulder dystocia

Standard Cares

Position• Drawmaternalbuttockstotheedgeofthebed(removeorlowerthebottomofthebed)

• Flattentopofbed(onepillowonly)–McRobertsmanoeuvre

Consider:•Needforbackup•Urgency-Starttimerwhenshoulderdystociaisrecognised-Aimtodeliverbabywithin4minutes

• ExternalmanoeuvresBEFOREattemptinginternalmanipulation

Successful?

External Manoeuvres• McRobertsmanoeuvre• Suprapubicpressure(RubinI)• Applymoderatedownwardtractiontofetalheadaimingtodelivertheanteriorshoulder

Transporttohospital


Avoid the 3 P’s• Pushing• Pulling• Pivoting

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Transporttohospital


Internal manoeuvres

Listedinorderofimplementation:•RubinII•Woodsscrew•ReverseWoodsscrew•Deliveryoftheposteriorarm

Consider:•Gainingconsent•Timing-Donotspendtoolongoneachmanoeuvre

Document of events:Definetheseverityoftheshoulderdystocia(relativetothemanoeuvresrequired).Documentevents,managementandtheirtiming.Be prepared for sequelae:Mother: Postpartumhaemorrhage Perinealtrauma PsychologicaltraumaBaby: Birthtrauma Hypoxia

Shoulderdystocia–Page4of4


Clinical practice guidelines Uterine inversion

Clinical features

• Themostcommonpresentationispostpartumhaemorrhage.[1]

• Visualexaminationmayrevealamassatthevulva,butthisisonlyinaprolapseduterineinversion.

• Evidenceofshockiscommon.

• Severeabdominal/pelvicpainoccursduetoexcessivetractiononthebroadligamentandovarianligaments.

Risk assessment

• Thesepatientsareathighriskforinfection.Therefore,useanaseptictechniqueandalwaystakeappropriateinfectioncontrolmeasures.

Uterineinversionisarare,butpotentiallylife-threatening,obstetricemergencywheretheuteruscollapsesinonitselftovaryingdegrees:[1]

• Incomplete–thefundusreachesthecervix.

• Complete –thefunduspassesthroughthecervix,butdoesnotreachthevaginalopening.

• Prolapsed–thefundusextendsthroughthevaginalopening.

Thereisafurtherdifferentiationbytiming:

• Acute–lessthan24hourspostdelivery.

• Subacute–from24hoursto4weeks.

• Chronic –beyond4weeks.

Althoughtherearenodefinitivecauses,acommonfactorisanover-aggressivemanagementofthethirdstageoflabour,whichincludesexcessivefundalmassageandcordtractionpriortoplacentalseparation.[1]

Theprinciplepre-hospitalmanagementisaimedatsupportivecare,treatmentforshockandrapidtransporttoanappropriatefacility.[2]

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Standard Cares

Istherepostpartumhaemorrhage?

Transporttohospital


Consider:• Analgesia• Assistpatienttoattainpositionofcomfort

• Protectanyexposeduteruswithmoiststeriledressings

Consider:• IVfluid• Analgesia

Uterineinversion–Page2of2


Clinical practice guidelines Uterine rupture

Clinical features

Clinicalpresentationcanvaryfromsubtletosevere:[1]

• Uterinetenderness

• Nonreassuringfetalheartpatterns

• Lossofintrauterinepressureorcessationofcontractions

• Abnormallabourorfailuretoprogress

• Severelocalisedabdominalpain

• Vaginalbleeding

• Maternalhypovolaemicshock.

Risk assessment

• Nil

Uterineruptureisdefinedasatearingoftheuterinewallduringpregnancyordelivery.Itisoneofthemostlife-threateningobstetricemergencieswithahighrateofbothfetalandmaternalmortality.[1]AlthoughthemajorityofcasesarecausedbyapreviousCaesareanscar,[2]spontaneousincidencesdooccurandshouldbesuspectedifthereis:

• Evidenceofmaternalshock

• Difficultydefiningtheuterusonpalpation

• Easilypalpablefetalparts.

OtherthanahistoryofCaesareansectionoruterinesurgery,riskfactorsinclude:[1]

• Trauma

• Uterineanomalies

• Dystocia

• Useofuterotonicdrugs(inducedlabour)[3]

• Abnormalplacentation

• Advancedmaternalage

• Highbirthweight.

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Standard Cares


Traumarelated?

Evidenceofshock?

Transporttohospital


Consider:• IVaccess• Analgesia• Assistpatienttoattainpositionofcomfort

ManageasperCPG:• Traumainpregnancy


Uterinerupture–Page2of2

who obstetric emergencies

Documents

fetalhypoxia prolapsedcord