Oxford Handbook of Midwifery (89 page)

the breech is recommended unless there is a complication.

• Gentle support might be given to the baby allowing the buttocks to rest on the midwife’s cupped hands. This may slow the birth of the head a little and prevent sudden decompression.
  
• The midwife should be familiar with the above manoeuvres.
  
• A breech baby may be slower to breathe at delivery and resuscitation equipment should be ready.
  
• Conduct third stage according to maternal preference.
  

  Complications of breech delivery
  

1
Hannah ME, Hannah WJ, Hewson SA,
et al
. (2000). Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial.
Lancet
356
, 1375–83.

CHAPTER 18
High-risk labour

388‌‌

Retained placenta

The third stage is concluded when the placenta is delivered complete. If bleeding is not excessive, it is reasonable to wait for delivery of the pla- centa. If the placenta is undelivered after 30min (active management) or 1h (physiological) a diagnosis of retained placenta is made.

Causes

• The physiological third stage may be longer.
  
• During the active third stage, unless the placenta is delivered quickly by controlled cord traction, Syntometrine
  ^®
  /ergometrine may cause a constriction of the muscles of the lower segment and os, which prevents delivery until the action has worn off.
  
• The placenta may still be partially attached.
  
• Placenta accreta is when the placenta is morbidly adherent to the uterine wall.
  

  Immediate management
  

• Inform the obstetrician if there is heavy blood loss. A partially adherent placenta where there is bleeding is an obstetric emergency.
  
• Assess by abdominal palpation whether the uterus feels contracted. If it feels ‘boggy’, lacking tone on palpation, and a contraction is not easily stimulated and intramuscular Syntometrine
  ^®
  has been given, inform the obstetrician. Otherwise:
  
  • Take any cord bloods required
    
  • Explain the problem to the mother. She may be pleased to breast feed the baby, which will encourage oxytocin release and stimulate uterine contractions. This may expel the placenta naturally
    
  • Ask the woman, if she is able, to sit upright on a bed pan and blow sharply into her fist (causing sudden downward movement of the diaphragm) or encourage maternal effort
    
  • Obtain permission from the woman to ensure an empty bladder by passing a urinary catheter.
    
  • If Syntometrine
    ^®
    has been used for active third stage, wait 30min and attempt controlled cord traction again.
    
  • If this fails or the cord snaps, manual removal in theatre is usually indicated.
    

    Manual removal of the placenta
    

• Contact the registrar, theatre, and anaesthetist.
  
• Good analgesia is required. This means topping up an existing epidural, siting a spinal anaesthetic, or possibly a general anaesthetic.
  
• The procedure is explained to the woman and consent obtained.
  
• Accompany the woman during transfer to theatre.
  
• An IV infusion is sited using a large cannula and bloods taken for FBC and to cross-match two units of blood.
  
• The woman is placed in lithotomy position, aseptic precautions taken, and the bladder is catheterized. The obstetrician controls the fundus with the left palm on the abdomen and the right hand is passed into the uterus. The placenta is sheared off the uterine wall and removed on the palm of the hand.
  

RETAINED PLACENTA

389

fit for transfer to the postnatal ward.

Placenta accreta

Very rarely, if the placenta cannot be separated, it may be morbidly adherent.

in situ
to absorb during the postnatal period.

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Emergencies during pregnancy, labour, and postnatally
‌

Chapter 19

391

Maternal

Major obstetric haemorrhage
392

Uterine rupture
398

Eclampsia
402

Amniotic fluid embolism
406

HELLP syndrome
408

Disseminated intravascular coagulation
410

Acute uterine inversion
412

Shock
416

Maternal resuscitation
420

Guidelines for admission to HDU
424

Maternal mortality
425

Blood tests results during pregnancy, detecting deviations from the norm
426

Fetal

In utero
transfer
432

Hypoxia and asphyxia
434

Cord presentation and cord prolapse
440

Vasa praevia
444

Shoulder dystocia
446

Guidelines for admission to neonatal ICU
450
Guidelines for admission to transitional care
452
Neonatal resuscitation
454

Perinatal mortality
459

Intrauterine death and stillbirth
460

CHAPTER 19
Emergencies

392‌‌‌

Major obstetric haemorrhage

The definition of a major haemorrhage is an estimated blood loss of

>1000mL or a blood loss which causes clinical shock in the woman.

Conditions that increase the risk of haemorrhage

• Placenta praevia
  
• Placental abruption
  
• Large or multiple uterine fibroids
  
• Previous PPH with complications
  
• Grand multiparity
  
• Multiple pregnancy
  
• Prolonged labour
  
• Polyhydramnios
  
• Precipitate labour.
  

  Causes
  

• Uterine atony
  
• Trauma—lacerations and uterine rupture
  
• Retained placenta/morbidly adherent placenta
  ¹
  
• Rarely:
  
  • Uterine inversion
    
  • Coagulation problem.
    

    Prevention and preparation
    

• Haemorrhage is a major cause of maternal morbidity and mortality in the UK and is increasing.
  ²
  
• Women known to be at high risk should attend antenatal clinic to discuss prevention.
  
• Antenatal anaemia should be treated.
  
• Prepare a major haemorrhage pack and a well-rehearsed haemorrhage drill should be in place on the labour ward.
  
• Under certain circumstances (e.g. severe placenta praevia) cross-match several units of blood and have them immediately available before the woman’s estimated delivery date (EDD).
  
• Ensure that blood is available when the woman at high risk of bleeding has been admitted to labour ward.
  
• Inform the obstetric and anaesthetic team and haematologist immediately on the arrival or delivery of a patient known to be at high risk.
  

  Signs and symptoms
  

• Signs may be obvious:
  
  • Deterioration in the woman’s condition
    
  • Visible copious bleeding vaginally
    
  • Bulky or soft, uncontracted uterus (postpartum).
    
• Sometimes signs are less apparent:
  
  • The woman looks pale
    
  • She feels cold and clammy
    
  • Her pulse is rising
    
  • Her blood pressure is falling.
    

    

    MAJOR OBSTETRIC HAEMORRHAGE
    

    393
    

    • She may have nausea/fainting and be restless/drowsy
      
    • Blood loss vaginally could be concealed.
      

    Immediate care