Oxford Handbook of Midwifery (91 page)

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Authors: Janet Medforth,Sue Battersby,Maggie Evans,Beverley Marsh,Angela Walker

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If oxytocin is used to induce or augment labour the midwife should be vigilant that contractions occur no more than four in 10min and last approximately 60s. The amount of oxytocin given should be carefully monitored in multiparous women.
The midwife should consider disproportion or abnormal presentation when labour is delayed.
Signs and symptoms
Silent rupture
Associated with previous caesarean section and partial scar separation: perhaps some blood loss PV but no haemorrhage at site of scar dehiscence.
Mildly raised maternal pulse (>100bpm), pale.
Some abdominal pain, scar tenderness. Epidural may sometimes mask the pain.
Contractions may continue but no progress in labour.
Irregularities of fetal heart, but, if diagnosed, fetus born alive.
Typical signs
Develops over an hour or two
Low abdominal pain, unlike contraction pain, continuous
Tenderness on abdominal palpation
Vomiting
Faintness, pale
Blood loss PV, variable amount
Rising pulse
Signs of fetal compromise, variable decelerations, bradycardia.
If undiagnosed—hypotension and shock, absent FHR.
Violent rupture
Strong uterine contraction. The woman reports ‘something giving way’ and sharp pain in lower abdomen.
Contractions cease and the abdominal pain is continuous.
The woman has a sense of foreboding that something serious has happened. She becomes anxious.
Blood loss PV/haematuria.
On abdominal palpation the fetus is felt close to the fingers and the presenting part can be moved easily and may not be in the pelvis.
Maternal tachycardia, shock, and collapse soon occur.
The FHR is profoundly bradycardic or absent.
Management
Briefly explain to the woman and partner.
Alert senior obstetric and anaesthetic team.
The consultant should be called.
Ensure IV access with large bore (16 gauge) cannula and commence IV infusion; infuse quickly.
Give the woman oxygen via a face mask.
Alert theatre staff to prepare urgently for laparotomy.
CHAPTER 19
Emergencies
400
- Follow protocol for major obstetric haemorrhage. Cross-match six units (b see Major obstetric haemorrhage, p. 392).
- Transfer the woman to theatre immediately in the hope of delivering a live baby if the FHR is still recordable.
- b See Emergency LSCS, p. 379.
  Postnatally
- Admit the woman to HDU.
- Close monitoring of maternal condition especially fluid balance and oxygen saturation.
- Prescribe broad spectrum antibiotics for 5 days.
  1
  The Practice Development Team (2009).
  Jessop Wing, Labour Ward Guidelines 2009–2010.
  Sheffield: Sheffield Teaching Hospitals NHS Trust.
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  CHAPTER 19
  Emergencies
  402‌‌
  Eclampsia
- Eclampsia is rare: <1% of pre-eclamptic women have fits.
- Eclampsia can occur at any time in the second half of pregnancy. It may occur in labour or post partum.
- Cerebral oedema and spasm, clots, or haemorrhages in small arteries may be causative.
- Most women make a good recovery. However, some die or are left with permanent disability. The fetus is at risk of acute asphyxia and may die. Repeated or continuous fits carry high morbidity/mortality for mother and fetus, therefore prompt treatment and control is vital.
  Signs and symptoms
- Headache and blurred vision, epigastric pain, nausea, and vomiting, drowsiness, or confusion may precede the onset of a fit. However, sometimes these types of symptoms occur after the fit, with no forewarning.
- Eclamptic convulsions appear similar to epileptic fits: repetitive, jerky, violent muscle spasms. Loss of consciousness occurs, the woman may hold her breath, bite her tongue, or be incontinent of urine.
- Convulsions last about a minute. If the fit continues status eclampticus ensues.
  The midwife’s response
- Call for senior obstetrician, anaesthetist, midwifery, and support staff.
- Ask for emergency eclampsia drugs and resuscitation equipment. You should know the location of these in your unit.
- Note the time of onset.
- Try to maintain a private, safe physical environment.
- Turn the woman to her left side and ensure a clear airway.
- Give oxygen at 4L/min via face mask.
- When possible, observe respiration, oxygen saturation, pulse and blood pressure and level of consciousness (see also Table 19.2).
- Talk to the woman, reassuring her of the presence of help and support.
  Immediate management by the obstetric team
  If a fit occurs, the mother must be stabilized before urgent delivery of the baby.
- Site an IV large-bore cannula and take blood for FBC, clotting, G&S, U/E and urates, LFTs.
- Seizures are controlled with a loading dose of magnesium sulphate 4 gm IV over 20min. Women treated with magnesium sulphate have fewer recurrent seizures than those treated with diazepam or
  phenytoin. However the latter may be used if the former is unavailable. The obstetrician may give 5–10 mg IV Diazemuls
  ^®over 2–5min.
- After the initial episode, transfer the woman, accompanied by the emergency team, to the HDU, to stabilize her condition further.
- The fetal heart should be monitored continuously—eclampsia and antihypertensive agents may cause abnormal fetal heart patterns.
  ECLAMPSIA
  403
Give IV magnesium sulphate slowly to prevent further fitting:
- After the initial loading dose of 4g IV; e.g. a bag of 50mL IV 5% glucose is used and 8mL of IV 50% magnesium sulphate added. It is infused over 20min.
- Follow with a continuous IV regimen: magnesium sulphate 1g/h for 24h (e.g. use 150mL of 5% glucose and add 48mL of 50% magnesium sulphate; infuse at 8.3mL/h via an Alaris
  ^®pump).
Monitor the woman for signs of toxicity:
- Warm/flushing, slurring of speech, visual disturbance, nausea
- Weakness, drowsiness, hypotension
- Loss of deep tendon reflexes
- Respiratory depression (14–16 respirations per min is minimum)
- O
  ₂saturation reducing below 95%
- If Diazemuls
  ^®and magnesium sulphate are administered in succession there is a risk of maternal respiratory depression.
Refer side-effects to the consultant, discontinue infusion, and give oxygen, The obstetrician may wish to monitor MgSO
₄blood levels: therapeutic range is 1.5–2.5mmol/L.
If the woman’s diastolic blood pressure is >100mmHg, labetalol 20mg may be given by slow IV injection. Then maintenance therapy may be given:
- The maternal diastolic blood pressure should be maintained at 95–105mmHg.
- If the woman is asthmatic hydralazine may be used (b see Maternal monitoring, management, and treatment, p. 336). Follow local protocols.
  Occurrence of an eclamptic fit is the end-stage of the condition and the risks to the woman and fetus are too great to justify prolonging pregnancy.
Urgent delivery, usually by caesarean section, will be arranged by the consultant obstetrician as soon as the woman’s condition allows. However, induction may be attempted if the woman’s condition remains stable with no further fits, the cervix is favourable for
induction (Bishop score >6, b see Bishop score, p. 365), and delivery is likely to occur quickly—the presentation is cephalic and the CTG is reassuring.
Make every effort to support the obstetric team in keeping the woman and family informed about care decisions.
If the woman’s condition deteriorates and fitting recurs or continues, the anaesthetist may sedate and ventilate the patient.
CHAPTER 19
Emergencies
404
Eclamptic seizure: example of chart for emergency recordings
Table 19.2
Eclampsia recordings
Action or treatment Time and recording
Time of seizure Time help called Time help arrived
Airway-left lateral, O
₂Breathing
Circulation—blood pressure, pulse, large bore IV infusion
FBC, Clotting, G&S, U&E, LFTs Eclampsia tray
Drugs (state)
Blood pressure and pulse:1 2
3
Time of transfer to HDU Monitoring fetal heart
Source: The Practice Development Midwives (2009). Sheffield Teaching Hospitals NHS Trust.
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CHAPTER 19
Emergencies
406‌‌
Amniotic fluid embolism
- This is a rare condition affecting pregnant women, typically occurring during labour but can occur antenatally and up to 48h post partum. It may happen at amniocentesis, termination of pregnancy, or caesarean section.
  ¹It carries a high maternal mortality rate.
- Amniotic fluid enters the maternal circulation. Fetal skin cells or meconium in the amniotic fluid cause platelet thrombi to form blocking the pulmonary vessels. Pulmonary hypertension ensues ultimately leading to right-sided heart failure. Amniotic fluid may also cause DIC.
  Possible predisposing factors or cause
- It cannot be predicted or prevented.
- There are similarities in blood pattern and clinical findings in anaphylactic and septic shock and amniotic fluid embolism.
- Intrapartum placental abruption.
  Signs and symptoms
- A sudden change in the woman’s behaviour or mood may be an early feature of the onset of hypoxia
- Maternal anxiety and feelings of doom
- Dyspnoea, tachypnoea, cyanosis
- Pink frothy sputum
- Hypotension
- Convulsions may occur (can precede respiratory symptoms)
- Bleeding PV/haemorrhage
- Shock/collapse.
  Subsequent picture and complications
- Hypoxia may cause permanent neurological damage.
- Massive haemorrhage may occur as a result of DIC
  (b see Disseminated intravascular coagulation, p. 410).
- Acute renal failure as a result of hypotension.
- Anoxia and neurological damage to fetus.
- Death of both mother and fetus.
  Management
  ²
- The woman’s life may depend on early detection and immediate action by the midwife.
- Call for emergency resuscitation team including obstetrician, anaesthetist. Inform haematologist and chest physician on call.
- Assess airway and breathing: give 100% oxygen via face mask initially. Use pulse oximeter.
- Assess blood pressure and pulse. For the maintenance of circulation and to combat hypotension site/help site an IV infusion. Diuretics and drugs which support the cardiac muscles to contract effectively (dopamine and digoxin) may be given to the woman.
- Take bloods and dispatch for FBC, cross-match 4 units, coagulation screen, U/E, blood glucose, blood culture, blood gases.
- Organize electrocardiogram (ECG) and portable chest X-ray.
  AMNIOTIC FLUID EMBOLISM
  407