Midwifery Emergencies at a Glance E-Book

Denise Campbell

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Wiley Series on Cognitive Dynamic Systems
• Sprache: Englisch

Seitenzahl: 312

Veröffentlichungsjahr: 2018

Beschreibung

Midwifery Emergencies at a Glance is a succinct, illustrated guide covering the practical skills needed to manage obstetric and midwifery emergencies, as well as high-risk midwifery care. It provides clear guidance on the factors which predispose to complications so that preventative management can be employed whenever possible.  Broad-ranging yet easy-to-read, Midwifery Emergencies at a Glance details the underlying physiology and pathophysiology related to the emergency and explores both the physical and psychological care of the woman, partner and newborn during and following the emergency. 

Key features:

• Evidence-based, with guidance from the NMC, RCOG, NICE, and The Resuscitation Council
• Presented in an innovative, visual style that makes the key concepts easy to understand
• Provides helpful websites that expand on various topics as well as providing information on support groups for the woman and her family

Midwifery Emergencies at a Glance is an ideal guide for practising midwives, pre‐registration student midwives, general practitioners and junior doctors to support both revision and clinical practice. 

Leseprobe

Midwifery Emergencies

at a Glance

Denise (Dee) Campbell

MA, PgDip, BSc, RM, RN, FHEA

Principal Lecturer and Programme Tutor in

Midwifery (retired)

University of Hertfordshire

Hatfield, UK

Susan M. Carr

MA, PgCert, BSc, RM, RN, FHEA

Principal Lecturer and Programme Leader in Midwifery

University of Hertfordshire

Hatfield, UK

Series editor:

Ian Peate OBE, FRCN

This edition first published 2018 © 2018 John Wiley & Sons, Ltd.

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The right of Denise (Dee) Campbell and Susan M Carr to be identified as the authors of this work has been asserted in accordance with law.

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Limit of Liability/Disclaimer of WarrantyThe contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organisation, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organisation, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. ­Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.

Library of Congress Cataloging-in-Publication DataNames: Campbell, Denise, 1961– author. | Carr, Susan M. (Susan Mary), 1954– author. Title: Midwifery emergencies at a glance / by Denise (Dee) Campbell, Susan M. Carr. Description: Hoboken, NJ : John Wiley & Sons, Inc., 2018. | Series: At a glance series |  Includes bibliographical references and index. | Identifiers: LCCN 2018015376 (print) | LCCN 2018015920 (ebook) | ISBN  9781119138020 (pdf) | ISBN 9781119138044 (epub) | ISBN 9781119138013 (pbk.) Subjects: | MESH: Obstetric Labor Complications | Midwifery | Emergency  Treatment—methods | Handbooks Classification: LCC RG571 (ebook) | LCC RG571 (print) | NLM WQ 165 | DDC  618.2/025—dc23 LC record available at https://lccn.loc.gov/2018015376

Cover image: © Natalia Deriabina/Getty Images Cover design by Wiley

CONTENTS

Cover

Title page

Copyright page

Preface

Abbreviations

About the companion website

Part 1: Professional issues

1: Professional standards

Achievement and maintenance of professional standards

Continuing professional development

Record keeping

Accountability

2: Communications during an emergency

Informed consent

Clarification and ongoing communications

Communications following the emergency

Part 2: Emergency skills

3: Maternal resuscitation

Physiology

Predisposing factors

Management (see Figure 3.2)

4: Neonatal resuscitation

Physiology

Predisposing factors

Management (Wyllie et al., 2015) (see Figure 4.1)

5: Antepartum haemorrhage

Can antepartum haemorrhage be predicted?

Causes/predisposing factors

Management

6: Primary postpartum haemorrhage

Risk factors

Causes

Management: a holistic approach

7: Secondary postpartum haemorrhage

Risk factors

Causes

Presentation

Investigations

Management (Frank et al., 2017; Mavrides et al., 2016)

8: Occipito posterior positions

Definition and incidence

Predisposing factors

Possible complications

Possible outcomes of labour

Delivery of the persistent OP fetus

9: Face and brow presentations

Incidence

Predisposing factors

Complications – face presentation

Complications – brow presentation

Delivery of a face presentation

10: Breech presentations

Definition

Predisposing factors

Delivery of extended arms (Løvset manoeuvre)

Head delivery (modified Mauriceau–Smellie–Veit manoeuvre) (see Figure10.5)

11: Cord presentation and prolapse

Definitions

Predisposing factors

Recognition

Management

Vasa praevia

12: Twins

Incidence and complications

Predisposing factors

Zygosity and chorionicity

Twin delivery

Management of the third stage

13: Shoulder dystocia

Risk factors

Maternal and fetal complications

Management – a systematic approach

HELPERR (see Figure 13.2)

14: Uterine dystocia – failure to progress

Power

Passenger

Passage

Patterns of poor progress

Identifying failure to progress

Complications

Management considerations

15: Manual removal of the placenta

Incidence

Causes

Predisposing factors (Urner et al., 2014; John et al., 2015; Shinar et al., 2016)

Management (Chongsomchai et al., 2014; Duffy et al., 2015; Cummings et al., 2016; Maher et al., 2016; NICE, 2017a)

Possible complications

16: Adhered or partially adhered placenta

Definition

Incidence

Predisposing factors (Fitzpatrick et al., 2012b)

Diagnosis

Management (Johnston & Paterson-Brown, 2011; Walker et al., 2013; Cunningham et al., 2014; Fitzpatrick et al., 2014)

17: Uterine inversion

Risk factors and causes

Classification (see Figure 17.1)

Signs and symptoms

Management

18: Uterine rupture and scar dehiscence

Definition

Incidence

Recognition

Management (Cunningham et al., 2014)

Outcomes and complications

Part 3: Medical and psychological emergencies

19: Post-traumatic stress disorder

Predisposing factors (Lev-Wiesel, et al., 2009; Andersen et al., 2012; Grekin and O’Hara, 2014; Ayers et al., 2016)

Diagnosis

Resultant risks to mother and newborn

Preventative management of known risk

Acute management in an emergency

20: Postnatal depression (mood disorder)

Predisposing factors (Haskett, 2010; Cunningham et al., 2014)

Signs and symptoms

Risks to mother and newborn

Preventative management

Acute management in an emergency

21: Puerperal (postpartum) psychosis

Aetiology

Predisposing factors (Essali et al., 2013; 
Lewis et al., 2016)

Signs and symptoms (see Box 21.1) (Haskett, 2010; Bergink et al., 2015; Lewis et al., 2016)

Risks to mother and newborn (Gutteridge and Lazarus, 2008)

Preventative management of known risk

Acute management in emergency 
(Haskett, 2010; Cantwell et al., 2015)

22: Pre-eclampsia

Hypertensive disorders of pregnancy

Definitions

Pre-eclampsia

Complications

23: Eclampsia

Definition

Incidence

Early warning signs

Convulsion progress

Management

Complications (Permezel, 2015b)

24: Venous thromboembolism

Risk factors

Signs and symptoms of acute VTE

Diagnosis and management (Thomson & Greer, 2015; NICE, 2016a)

25: Amniotic fluid embolism

Background

Incidence

Predisposing factors

Pathophysiology (see Figure 25.1)

Signs and symptoms

Management

26: Disseminated intravascular coagulation

Aetiology

Causes

Pathophysiology (see Figure 26.1) (Erez et al., 2015)

Signs and symptoms of DIC

Clinical diagnosis (Erez et al., 2015)

Clinical care

Ongoing management

27: Prelabour rupture of membranes

Physiology

Prelabour rupture of membranes (PROM)

Preterm PROM

28: Preterm labour and delivery

Incidence

Predisposing factors

Prediction and diagnosis

Prevention

Management (RCOG, 2011; NICE, 2015b; NICE, 2016c)

Possible outcomes and complications

Part 4: Associated skills

29: Instrumental vaginal delivery

Incidence

Indications (Bahl et al., 2011; Nikpoor and Bain, 2013; Permezel and Paulsen, 2015; NICE, 2016d)

Contraindications

Choice of instrument

Management (Bahl et al., 2011; Suwannachat et al., 2012; Permezel and Paulsen, 2015; NICE, 2016d)

30: Preparation and transfer to the operating theatre

Antepartum preparations (see Figure 30.1)

Consent

Preparation for theatre

31: Role of the scrub midwife or nurse

Preoperative preparations

Intrapartum responsibilities

Postoperative responsibilities

32: Receiving the baby in the operating theatre

Antepartum preparations

Intrapartum responsibilities

Postpartum responsibilities (Macdonald & Johnson, 2017)

33: Immediate care following surgery

Postoperative care

34: Electronic fetal monitoring – actions following a suspicious or pathological trace

Reasons for continuous CTG monitoring

Risks impacting CTG monitoring

Definition of a suspicious or pathological CTG trace (NICE, 2017b)

Management

35: Fetal scalp electrode

Predisposing factors

Indications

Contraindications

Management

Removal

Possible outcomes and complications

36: Fetal blood sampling

Indications

Contraindications

Choosing which test to use

Management

Possible outcomes and complications

37: Recognising the deteriorating woman

Track and trigger

Monitoring

Escalation

Teamwork and communication

38: Examination per vaginam

Indications for performing a VE (Harris, 2011)

Contraindications

Risk factors

Procedure (Johnson & Taylor, 2016)

Findings (see Figure 38.2)

39: Speculum examination

Indications for use

Contraindications for use

Preparation for a speculum examination

Performing a speculum examination (Johnson & Taylor, 2016)

Completing the speculum examination

40: Urinary catheterisation

Definition

Possible indications

Catheterisation during emergency care

Risks associated with catheterisation

Risk reduction

Method of catheterisation

41: Venepuncture

Purpose of venepuncture (Harris, 2008)

Anatomy of the vein

Issues associated with venepuncture

Preparation

Procedure

42: Intravenous cannulation

Contraindications

Structure of the vein (Martini et al., 2014)

Preparation

Procedure (Harty, 2017)

43: Blood transfusion therapy

Reasons for blood administration

Risk factors (NHLBI, 2012)

Management of a blood transfusion

44: Artificial rupture of membranes

Indications

Contraindications

Possible benefits

Potential risks and possible complications

Management of ARM

45: Oxytocic augmentation

Physiology

Causes of delay

Issues to take into consideration

Contraindications

Management

46: Third- and fourth-degree tears

Classifications

Incidence

Predisposing factors (Melamed et al., 2012; Gurol-Urganci et al., 2013; Fernando et al., 2015)

Prevention (Fernando et al., 2015) (see also Box 46.1)

Management (Fernando et al., 2013; Fernando et al., 2015)

47: Perineal suturing

Evidence gap

Predisposing factors to perineal trauma (Pergialiotis et al., 2014)

Management of suturing (RCM, 2012; NICE, 2014)

Possible complications

48: Maternal sepsis

Risk factors

Diagnosis

Immediate management – prompt and rapid

49: Source isolation nursing

Sources of infection and routes of transmission

General principles (Dougherty et al., 2015)

Precautions – a systematic approach

50: Group B streptococcus

Risk factors (NICE, 2016e)

Maternal and fetal complications

Diagnosis – neonatal (Group B Strep Support, 2016) (see Figure 50.1)

Management of maternal GBS infection

51: Infection control

Infection risks

Infection prevention

Signs of infection

Part 5: Self-assessment

Multiple choice questions

Multiple choice answers

References

Index

Notes

Wiley end User License Agreement

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Preface

Statement 15 of The Code (Nursing and Midwifery Council, 2015) reminds us that a midwife ‘must always offer help if an emergency arises in the practice setting or anywhere else' – the expectation is one of competent assessment and prompt actions in response to an obstetric or neonatal emergency. The intention of this book is to provide clear guidance on the factors which predispose to complications, so that preventative management can be employed whenever possible. Moreover, it should provide a concise, ordered overview which clearly directs the midwife through the management of an emergency in the specific order that the skills will be required. This is a resource that is intended to help guide the development of essential skills, but also to support the revision and maintenance of the skills during continuing professional development. In addition, many emergency situations may require additional, associated skills and so many of these are also included in this book. These may be useful in assisting in the progress of emergency management or to provide further review, screening or diagnostics.

The need to comply with the ‘At A Glance' style, with chapters typically reduced to a double page, has presented its challenges. As midwifery lecturers, we have struggled to omit aspects that have previously been fundamental to our teaching sessions, such as the physiology behind the emergency and the evidence behind a particular management approach. We have had to reduce the detail to essentials only and become as succinct as was necessary. The result is a very pleasing, simple and clearly written guide, which gets straight to the heart of the skill, just as these books are intended to do. In addition, a page of varied figures provides additional information and/or improved clarity in a visual form. Its simplicity makes it a very useful tool – progressing directly to the specific management of the emergency.

For those with questioning minds who wish to increase their background knowledge, we have included, for your own analysis, many of the references that guide the management. Plus, the website contains the fully expanded answers to the multiple choice questions as not all the answers are to be found within the text – we hope this will encourage further reading.

This book is written predominantly with the midwife in mind –both for the student and for those already qualified. However, it would also support the education and continuing development of medical students, junior doctors, general practitioners and paramedics – any of whom may find themselves initiating emergency midwifery, obstetric or neonatal care.

Abbreviations

ACOG

American College of Obstetricians and Gynecologists

AED

Automated external defibrillator

AF

All fours

AFE

Amniotic fluid embolism

AP

Antero posterior

APA

American Psychiatric Association

APH

Antepartum haemorrhage

APTT

Activated partial thromboplastin time

ARM

Artificial rupture of membranes

BMI

Body mass index

BP

Blood pressure

bpm

Beats per minute

BVM

Bag, valve and mask

CODP

College of Operating Department Professionals

CPD

Cephalo-pelvic disproportion

CPD

Continuing Professional Development

CPR

Cardio-pulmonary resuscitation

CRP

C-reactive protein

CS

Caesarean section

CTG

Cardiotocography

CTPA

Computerised tomography pulmonary angiogram

DBP

Diastolic blood pressure

DIC

Disseminated intravascular coagulation

DTA

Deep transverse arrest

DVT

Deep vein thrombosis

ECG

Electrocardiography

ECT

Electroconvulsive therapy

ECTG

Electrocardiotocography

EPDS

Edinburgh Postnatal Depression Scale

FBC

Full blood count

FBS

Fetal blood sampling

FDP

Fibrinogen degradation products

fFN

Fetal fibronectin

FSE

Fetal scalp electrode

GAS

Group A streptococcus

GBS

Group B streptococcus

GMC

General Medical Council

HDU

High dependency unit

HELLP

Haemolysis, elevated liver enzymes, low platelet count (syndrome)

HVS

High vaginal swab

ICU

Intensive Care Unit

IM

Intramuscular

ISBT

International Society of Blood Transfusion

IV

Intravenous

IVF

In vitro

fertilisation

JPAC

Joint United Kingdom Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee

LFT

Liver function tests

LMWT

Low molecular weight heparin therapy

LSCS

Lower segment Caesarean section

LVS

Low vaginal swab

MDT

Multidisciplinary team

MEOWS

Modified Early Obstetric Warning System

MROP

Manual removal of the placenta

NEWS

National Early Warning System

NHLBI

National Heart, Lung and Blood Institute

NICE

National Institute for Health and Care Excellence

NICU

Neonatal intensive care unit

NMC

Nursing and Midwifery Council

NPSA

National Patient Safety Agency

OA

Occipito anterior

OASI

Obstetric anal sphincter injuries

OOB

Obstetric Observation Bay

OP

Occipito posterior

PE

Pulmonary embolism

PEEP

Positive end expiratory pressure

PET

Pre-eclamptic toxaemia

PP

Placenta praevia

PP

Presenting part

PPH

Postpartum haemorrhage

PPROM

Preterm premature rupture of membranes

PROM

Premature rupture of membranes

PTSD

Post-traumatic stress disorder

RCM

Royal College of Midwives

RCOG

Royal College of Obstetricians and Gynaecologists

REM

Rapid eye movement

SATS

Oxygen saturation

SBAR

Situation, Background, Assessment, Recommendation

SBP

Systolic blood pressure

SCBU

Special care baby unit

SHOT

Serious hazards of transfusion

SIRS

Systemic inflammatory response

SR

Semirecumbent

UKTIS

United Kingdom Teratology Information Service

VTE

Venous thromboembolism

WHO

World Health Organization

About the companion website

Part 1Professional issues

Chapters

Section 1 Professionalism

1

Professional standards

2

Communications during an emergency

1Professional standards

This book is intended to inform and educate practitioners about the management of emergencies and the many associated skills. These emergencies may happen in a range of settings from fully equipped and staffed obstetric units to the stand-alone unit or homebirth. The practitioner has a professional responsibility to meet the standards necessary and to become so familiar with these skills that they can adapt them to any setting. They must be able to team work effectively and appropriately manage all the help available. In an ideal situation, the emergency will be supported by a full obstetric, paediatric, anaesthetic and operative team as required, with additional support from haematology, pathology, microbiology, blood bank, pharmacy and porters. When the practitioner is alone they must simultaneously initiate emergency management and call for assistance.

This chapter cannot cover all professional responsibilities associated with emergency management. It will concentrate on the need to achieve and maintain professional standards, continue professional development, maintain a high standard of record keeping, and show awareness of accountability.

Achievement and maintenance of professional standards

The standards of clinical expertise achieved by midwives are controlled by a number of training and monitoring processes. This begins at the interview and admission stage to midwifery training. The profession is looking not only for those academically able, but also for those whose personalities and ethical stance will enhance the profession and improve standards of care. Service users, clinicians, and midwifery tutors jointly decide on the selection approach to be used and which candidates have met these exacting standards. All training programmes align with 
stringent Nursing and Midwifery Council (NMC, 2009) guidelines and are variously quality monitored throughout (see Figure 1.1). The aim is to achieve clinical competency at the point of qualifying (alongside the skills of life-long learning).

With employment there comes a period of preceptorship (support, monitoring, and development). This is followed by regular employer and professional body review with standards monitored against local policies, as well as professional standards such as: The Code (NMC, 2015) (see Figure 1.2); Standards to support learning and assessment in practice (NMC, 2008) (see Figure 1.3); Standards of medicine management (NMC, 2007) (see Figure 1.4); Standards for competence for registered midwives (NMC, 2011) (see Figure 1.5); and, in addition, a great number of local hospital protocols. Periodic Revalidation (NMC, 2017) is required and this can only be met through a combination of clinical experience and continuing professional development (CPD) (see Figure 1.6).

Continuing professional development

In order to perform within expected standards of care, the professional has a duty to maintain skill competencies and knowledge levels. The process of Revalidation ensures that midwives engage in CPD, but most midwives will surpass any minimum levels set.

Midwives should maintain critical awareness of:

Current research.

Topical literature.

Local and national statistics, case conferences, audits.

E-learning material.

Conference material.

Local and national guidelines, for example NICE.

New medications for use in obstetrics.

Risk management reports.

Evidence from the numerous reports produced by Mothers and Babies: Reducing Risk through Audits and Confidential Enquires across the UK (MBRRACE-UK).

They must attend clinical skills updates including:

Interprofessional/multidisciplinary skills sessions in house.

Local skills and drills requirements such as fire safety awareness, manual handling, blood products, documentation, etc.

National/international skill courses, for example Advanced Life Support in Obstetrics (ALSO), Newborn Life Support (NLS), Practical Obstetric Multi-Professional Training (PROMPT).

Limitations and capabilities including communication and referral.

Record keeping

A high standard of contemporaneous record keeping has long been understood to be an essential component of good practice. The NMC (2015) provides midwives with guidance on the principles of good record keeping. Yet, it can remain an issue during complaints investigations and is often included as a development requirement during supervised practice. During an emergency, record keeping becomes both a greater challenge and a greater necessity. Best practice would allocate the role of scribe to an individual best suited to the role – someone sufficiently experienced to know the important elements to include. Alongside this it requires:

Clear, concise, accurate, factual, legible, and contemporaneous statements without abbreviations (unless explained).

Records to follow local guidelines such that everyone knows where things are recorded.

Observations of maternal, fetal, or neonatal health recorded.

Date and time.

Signatures and printed name.

Medications recorded including dosage, time of administration, and any reactions.

All actions taken are noted (including by whom) – whether successful or unsuccessful.

Reference to any referrals made – the time and to whom, as well as the reason for the referral.

Accountability

Accountability is the taking of responsibility for ones own actions and ability to defend decision making. The professional may be questioned at any time (often years after an event) by a client, employer, professional regulatory body, or through a legal challenge. The professional is judged on whether they performed to the expected standard of care. This is based on the normal standards of professional practice typical at the time of the event. Expectations are also individualised to the circumstances of the incident and are expected to encompass:

Identification of potential risk.

Taking preventative measures.

Competent practice.

Support of the woman’s informed choices.

2Communications during an emergency

Communication is considered to be a two-way interaction in which information is both given and received. This interaction is not only about the content of the communication but also about the process itself and the context in which it is being delivered (see Boxes 2.1 and 2.2). Communication is made up of verbal and non-verbal cues and is not a simple message exchange. It includes not only what is said but also how it is said (intonation), alongside the body language that accompanies it. Then, interpretation of the message by the recipient is influenced by numerous factors including: their own life-experience; knowledge level; socio-cultural issues; health and emotional state; disability; and the environment in which it is received. At the time of an emergency, there also may be anxiety, pain, shock, and fear to interfere with effective listening. Numerous heightened emotions will impact on both sides of the communication.

Informed consent

Informed consent may be gained verbally, in writing, and through the actions of the individual conveying consent. In some emergency situations, aspects of consent may have been gained even before the emergency occurred, for example gaining permission to use an oxytocic drug should a woman begin to haemorrhage. However, in most situations the emergency is unpredictable, unexpected, and the pace of change makes informed consent a challenge.

Achieving a holistic approach to communications between the professionals and the women they care for throughout an emergency is challenging. Whilst keeping the woman informed and gaining consent remain a priority, there are now multiple professionals involved (see Box 2.3) and time is limited. The priority for care becomes the management of the immediate emergency and associated pathophysiology. The concentration will be on emergency practical skills and interprofessional communications to achieve optimal outcomes (see Boxes 2.4 and 2.5). Additionally, the woman may be tired, medicated, frightened, and in pain, which affects her capacity to understand, retain information, appreciate the implications, and communicate her opinions (as expected by the Mental Capacity Act, 2005). All aspects of the management must be directed in the best interests of the woman.

This is not about underestimating the role of communication in general and informed consent in particular. It is about how much more challenging communications become in situations of uncertain outcomes, time limits, and rapidly changing management. It becomes essential that a member of the team takes the role of staying at the head of the bed, with the woman. They should explain and interpret events at an appropriate level. The speed at which the emergency management progresses may not always allow detailed explanations of evidence, discussions, and time for questions, but the essentials must still be applied, and the views of the woman passed back to the team. Communications should include full awareness of body language, good listening skills, and the ability to balance appropriately the information shared in the time available.

Clarification and ongoing communications

It is important that there is a full appreciation of how information is shared. Beware of using unfamiliar words without explaining their meaning, and appreciate that it is not only ‘what is said’ that portrays a message. Even the most skilful professional can unintentionally communicate through negative intonation or body language.

Be prepared for questions and anxiety. A balance is required between appropriate levels of honesty and realistic reassurances, without making guarantees that may not be achievable. Whilst some information needs to be shared immediately, the full extent of the problem in an emergency can only be determined retrospectively. Therefore, in most cases it is advisable to keep ongoing explanations simple, gaining permission to concentrate on the management of the emergency as the priority, but also giving reassurances that a full explanation of events will follow. This enables a full understanding of the concern to be known, and prevents the early sharing of misleading information (when the emergency may still change, reduce, or escalate). It also allows the woman time to digest the problem and begin to recover from the physical management and emotional shock associated with it.

Communications following the emergency

Following a traumatic episode such as an obstetric or neonatal emergency, adrenaline levels are raised and the woman may be in a state of further anxiety and stress. These are normal responses which will resolve naturally for the majority of women. It is important to appreciate that involvement in an emergency does not typically lead to a lasting stress disorder. Communications following the emergency are not intended as a debriefing exercise, particularly as evidence suggests a single-session may do more harm than good (Bastos et al., 2015). Communications after an emergency are an opportunity to discuss the event in more detail, allow questions, then clarify any misunderstandings following a basic explanation of the emergency and its management. The woman must feel comfortable and be able to discuss aspects openly. Rather than a one-sided commentary by the professional, there should be a two-way conversation that fulfils the needs of the woman.

It is important to appreciate personal limitations and to not cross professional boundaries. Be honest about the limits of your expertise and involve the specialist or more senior practitioners in explanations of their role, as required. This is particularly relevant when breaking bad news – you may need to arrange for a more experienced, senior or specialist colleague to join you during the information sharing.

Every woman will have a different reaction to an emergency; there may be any number of aspects affecting her ability to assimilate information. Emotions can be affected by, for example, being in a postoperative state, in pain, sleep deprived, or hormonal. Cultural, ethnic, and social issues may also affect responses. It is important that any reactions to communications from you are received non-judgementally. It may be appropriate for you to offer to invite the husband/partner to attend and be available to answer any further questions once they have arrived.

At the end of the discussion, you should explain the care pathway and ongoing management that, with her consent, will follow the emergency. This should include specific information on:

Any referral you will make for follow-up care (to whom, why, when, and how).

Further screening or diagnostic investigations you will request (by whom, when, and what this will entail).

Daily management (by whom, when, and what this will entail).

Expected progress, side effects, and potential problems that may occur.

How to make contact if she has any further questions.

Alternative information sources available.

Part 2Emergency skills

Chapters

Section 2 Resuscitation

3

Maternal resuscitation

4

Neonatal resuscitation

Section 3 Haemorrhage

5

Antepartum haemorrhage

6

Primary postpartum haemorrhage

7

Secondary postpartum haemorrhage

Section 4 Malpresentations and multiple pregnancy

8

Occipito posterior positions

9

Face and brow presentations

10

Breech presentations

11

Cord presentation and prolapse

12

Twins

Section 5 Dystocia

13

Shoulder dystocia

14

Uterine dystocia – failure to progress

Section 6 Placental separation problems

15

Manual removal of the placenta

16

Adhered or partially adhered placenta

Section 7 Uterine emergencies

17

Uterine inversion

18

Uterine rupture and scar dehiscence

3Maternal resuscitation

A maternal death is defined by the World Health Organization (WHO), as the death of a woman during pregnancy or up to 6 weeks postpartum as a result of conditions associated with, or made worse by, pregnancy (WHO, 2010). In the UK between 2011 and 2013, there were 214 maternal deaths, of which 69 were attributed to ‘direct’ causes such as amniotic fluid embolism, haemorrhage, sepsis, and thromboembolic disorders (Knight et al., 2015). The remaining 145 women died as a result of indirect causes. While the need to resuscitate a young, fit, healthy woman is an increasingly rare occurrence, maternal collapse can and does happen and the outcome is dependent on effective and prompt action by those caring for her. Approximately 50% of maternal deaths are due to preventable and, therefore, treatable causes; the fact that the need to resuscitate a pregnant or recently delivered woman is a rarity suggests that regular drills for midwives and obstetricians should be undertaken if an individual’s skills are to be maintained at a high standard.

Thus, the definition of maternal resuscitation is the support of a woman’s life in the event of sudden collapse accompanied by apnoea and/or cardiac arrest.

Physiology

The systems of the woman’s body adapt during pregnancy and therefore it is essential that these are understood so that effective resuscitation can take place (see Table 3.1).

Predisposing factors

Thromboembolic disorders.

Haemorrhage.

Amniotic fluid embolism.

Seizure – eclamptic and epileptic.

Sepsis.

Anaphylaxis.

Accident.

Pre-existing medical conditions.

Psychiatric conditions.

Management (see Figure 3.2)

This is an emergency. It is essential to note that a woman who is not responding and whose breathing is abnormal is experiencing a cardiac arrest requiring early intervention and resuscitation. The sequence of interventions is as follows (Resuscitation Council (UK) 2015):

Before approaching the woman make sure that it is safe for you to do so.

Try to elicit a response from the woman by speaking to her in both ears. If she responds, try to find out what has happened.

Airway

– put a hand on the forehead of the woman and with two fingers under the point of her chin, tilt her head by lifting the chin to open the airway.

Breathing

–

bend down close to the woman’s face, turn to look towards the woman’s feet and for

no more than 10 seconds:

Look

for chest rise – this may be shallow or absent.

Listen

for the sound of breathing.

Feel

for exhaled breath on your cheek.

If the woman is breathing, place her in the recovery position and call for help. Do not leave her and reassess the situation regularly.

If she is not breathing:

Call for help

– either call 999 if out of hospital and request a paramedic ambulance, or if in a clinical setting, pull/push the emergency buzzer and ask the person who responds to initiate a cardiac arrest alert and then return to help you with a pocket face mask or bag-valve–mask system if available) and an automated external defibrillator (AED). It has been shown that early use of an AED, within 3–5 minutes of collapse, may increase the victim’s chances of survival by as much as 50–70%

Circulation

If the woman is obviously pregnant, reduce aortocaval compression by manually displacing the uterus to the woman’s left by either using two hands to pull the uterus towards you or one hand to push it away from you (Murphy & Cullinan, 2017). If this is not possible, or you are on your own, then tilt the woman onto her left side by placing whatever is at your disposal beneath her right side – ideally from her shoulder to her knee.

Commence chest compressions at a rate of 100–120 per minute, depressing the chest by 5–6 cm and allowing it to recoil between compressions without removing your hands, to encourage the refilling of the heart. Kneel beside the woman and place the heel of one hand in the centre of her chest with the heel of the second hand on top of the first. Interlace the fingers, lifting those of the lower hand off the woman’s chest to avoid damage to the ribs. With your arms and back straight and your shoulders directly above your hands (perpendicular to her chest), deliver the compressions.

When assistance returns continue chest compressions but add two inflation breaths each lasting 1 second at a ratio of two breaths to 30 chest compressions, maintaining a head tilt and chin lift throughout.

As soon as the AED arrives, switch on the machine, attach the pads to the woman’s chest, and follow the spoken instructions. If a shock is required, ensure all personnel stand away and oxygen is removed from the woman, then deliver the shock as instructed (Perkins

et al

., 2015).

Immediately resume cardiopulmonary resuscitation.

In the event of a pregnant woman requiring resuscitation, a perimortem Caesarean section must be performed by a trained medical practitioner within 5 minutes of the decision to resuscitate, or if the mother fails to respond with a return of spontaneous circulation within 4 minutes of commencing effective resuscitative measures.

When to stop:

Qualified help arrives to take over.

The woman shows signs of spontaneous breathing.

You become exhausted.

Note: If more than one rescuer is present, alternate roles every 2 minutes to prevent fatigue, ensuring minimum delay during changeovers.

Following completion of the resuscitation, contemporaneous notes of the event must be completed, as well as an incident report form as per NHS Trust protocol. All present, including the parents, may require time to be debriefed.

4Neonatal resuscitation

Neonatal resuscitation is a systematic approach to supporting the neonate in the transition from placental to pulmonary respiration (see Figure 4.1