Oxford Handbook of Midwifery (90 page)

Stabilization

CHAPTER 19
Emergencies

394

Major antepartum haemorrhage

• This is bleeding from the genital tract (after 20 weeks and before delivery) of greater than 500mL (or causing deterioration in the maternal or fetal condition).
  
• The haemorrhage is usually from the placenta. A placental abruption or bleeding placenta praevia is present. It may sometimes be concealed within the abdominal cavity.
  
• The aim is to resuscitate and stabilize the woman (as above), and assess fetal well-being as soon as possible.
  

  If, on examination of the abdomen, you find that:
  

• The uterus is woody hard
  
• The woman is in continuous pain/experiencing strong contractions
  
• The fetal heart is heard;
  

  the woman should be transferred immediately to theatre and the con- sultant obstetrician and team, anaesthetist, and paediatrician called.
  

• Prompt action is needed to save the fetus.
  
• Management depends on the maternal and fetal conditions and gestation.
  

  Major postpartum haemorrhage
  

• This is bleeding from the genital tract of more than 500mL (or bleeding causing maternal compromise).
  
• In cases where there is a loss of 1000mL, admission to HDU is indicated.
  
• The primary PPH occurs immediately following delivery. Uterine atony is the most common cause. The uterus is soft, the fundus difficult to palpate, or high and full of blood clots.
  

  Immediate care
  

• Call for help from the obstetric team.
  
• Explain briefly to woman and partner. Direct relatives to a suitable waiting point.
  
• Rub up a contraction:
  
  • Feel for the fundus of the uterus
    
  • If it is soft/relaxed, massage the fundus using a circular movement
    
  • A contraction should occur.
    
• Prepare for and start an IV infusion of normal saline 500mL with 40 units oxytocin at 125mL/h via a pump. The prescription may vary with local policy. FBC and cross-match 2–4 units blood urgently.
  
• Consider giving 250micrograms ergometrine IV.
  

  Avoid in hypertension, asthma, cardiac disease, impaired pulmonary, renal, or hepatic function.
  

• Or (in the above cases) use IV oxytocin 5 units slowly. IV oxytocin should be used with care when the woman is hypovolaemic. Given as a bolus it may cause dangerous profound hypotension.
  
• Catheterize the bladder and measure all fluid intake/output.
  

  Investigate cause
  

• Deliver the placenta and expel blood clots with gentle pressure at the fundus.
  
• Consider whether any retained products remain, causing uterine atony.
  

  

  MAJOR OBSTETRIC HAEMORRHAGE
  

  395
  

• With the fingers of the right hand bent over, they are inserted into the vagina and the hand is made into a fist at the anterior vaginal fornix
  
• The palm of the left hand is placed abdominally, using the tips of the fingers to lift the uterus slightly forward, to position the hand behind the uterus
  
• The uterus is compressed between the left and the right hands.
  

• Additional doses may be given up to a maximum of 2mg but always more than 15min apart.
  
• Intramyometrial Hemabate
  ^®
  is given via a spinal needle trans- vaginally or trans-abdominally.
  
• Side-effects include pyrexia, vomiting, hypertension.
  

  0 Caution in hypertension, asthma, cardiac disease, impaired pulmonary, renal, or hepatic function. Prostaglandins may be fatal if administered IV.
  

• The balloon is filled with warm saline
  
• This packs the cavity and may arrest bleeding, and is left in place for 24h
  
• Oxytocin 40 units in 1L of normal saline is given over 24h to maintain the uterine tone
  
• Antibiotic cover is indicated.
  

In the most severe cases of bleeding, when other surgical techniques have been unsuccessful
³
and the patient is severely shocked, hysterectomy may be the only option.

Further reading

Arulkumaran S, Symonds IM, Fowlie A (2004).
Oxford Handbook of Obstetrics and Gynaecology
. Oxford: Oxford University Press.

1. Confidential Enquiry into Maternal and Child Health (2007).
   Saving Mother’s Lives: 2003–2005. The Seventh Report of the Confidential Enquiry into Maternal Deaths in the UK
   . London: RCOG.
   
2. Confidential Enquiry into Maternal and Child Health (2004).
   Why Mother’s Die 2000–2002. The Sixth Report of the Confidential Enquiry into Maternal Deaths in the UK
   . London: RCOG.
   
3. The Practice Development Team (2009).
   Jessop Wing, Labour Ward Guidelines 2009–2010
   . Sheffield: Sheffield Teaching Hospitals NHS Trust.
   

   

   CHAPTER 19
   Emergencies
   

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   Table 19.1 Postpartum haemorrhage patient label

   Action or observation Time and recording

   Time of delivery

   Time of bleed

   Time help arrived

   Airway—give O 2

   Breathing

   Circulation—blood pressure and pulse

   Site 2 large bore IV infusions

   Gelaflex ®

   FBC, clotting, cross-match 2 units

   Check placenta is complete

   Bimanual compression

   Check for trauma

   Check clotting screen

   Preparation for theatre

   Transfer to theatre

   Blood pressure and pulse

   Blood pressure and pulse

   Blood pressure and pulse (5 min intervals)

   Source: The Practice Development Team (2005). Sheffield Teaching Hospitals NHS Trust.

   1. Rub up a contraction
      
   2. Catheterize bladder
      
   3. 20IU oxytocin in 500mL normal saline at 250mL/h
      
   4. IV ergometrine
      
   5. Hemabate
      ^®
      250micrograms intramuscularly (senior opinion)
      

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   CHAPTER 19
   Emergencies
   

   398‌‌
   

   Uterine rupture
   

   Definition
   

   This is a dangerous complication of pregnancy and labour when there is a laceration of the uterine wall. Tears may extend to uterine vessels and haemorrhage ensue. Uterine rupture is a cause of maternal and fetal death.
   

   Types
   

   Incomplete
   

   • The depth of the myometrium may be torn. The perimetrium remains intact.
     
   • The external myometrium may be torn but the laceration does not extend into the body of the uterus. This may lead to intraperitoneal haemorrhage.
     

     Complete
     

     All layers of the uterus involved. There is direct communication between the uterine and abdominal cavity and the fetus may be expelled from the uterus into the abdominal cavity.
     

     Factors associated with risk of rupture during labour
     

   • Scar rupture following caesarean section (both lower and upper segment incision), hysterotomy, myomectomy, previous rupture repair. Scar dehiscence is the most common cause of rupture.
     
   • Spontaneous rupture resulting from strong uterine contractions. It is sometimes associated with use of oxytocin, especially in multiparous women or with obstructed labour.
     
   • Traumatic rupture from instruments, e.g. a high rotational forceps delivery or from manipulation (e.g. internal podalic version and breech extraction of second twin) when there is previous scarring.
     
   • Trauma may occur as a result of accident.
     

     Prevention
     

     For women with a uterine scar
     

   • On admission to labour ward the midwife should ensure that a birth plan discussion is documented in the notes by a senior obstetrician and that the woman is satisfied with the plan.
     
   • If VBAC is anticipated good progress in labour should be observed and any fetal heart abnormalities reported to the obstetrician by the midwife.
     
   • If augmentation of labour is indicated IV oxytocin must be prescribed by the registrar and administered with care.
     
   • Induction should be overseen by a consultant obstetrician and proceedings documented carefully in the case notes. Amniotomy is the preferred method. However, one or two doses of dinoprostone gel 1mg PV (prostaglandin) may be given but repeat doses should preferably be avoided and further management discussed. Propess pessary may be used with caution—remove after 12h.
     ¹
     

UTERINE RUPTURE

399

Spontaneous rupture