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

Oxford Handbook of Midwifery (93 page)

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Call for the obstetric and anaesthetic team.
The best opportunity for replacing the uterus is as soon as the inversion occurs. This is especially important in the community situation. This will avoid blood loss and shock.
The woman should be laid flat. The foot of the bed should be raised.
The woman should be given an explanation to gain her consent and cooperation and have adequate analgesia.
Johnson’s manoeuvre
It may be possible to speedily reduce an inversion if the midwife recognizes the condition immediately and applies gentle pressure to the uterus starting at the point nearest to the cervix and working
towards the fundus. Thus the inverted uterus is pushed back, following the angle of the vagina, through the cervix then directing the push upwards towards the umbilicus to restore the normal position.
If the placenta is not delivered, and not bleeding it should be left
in situ
to avoid haemorrhage. The inverted uterus cannot contract.
If the woman’s condition is stable, there is some bleeding because of apparent separation and she has adequate analgesia the placenta can be removed if this facilitates repositioning.
IV ergometrine 0.25mg or 5 units of oxytocin slowly administered will secure a good contraction once the uterus is established in place.
Shock
If there is severe bleeding and hypotension the woman must be treated immediately and urgently for shock.
Two IV infusions are sited using a large bore cannula, and IV fluid commenced to help fast replacement of fluid and allow administration of drugs.
Respirations, pulse and blood pressure, and oxygen saturation are monitored.
Bloods are obtained for FBC and platelets, G&S and cross-match, coagulation.
Analgesia should be given urgently.
Catheterize the bladder and monitor output.
Transfer to theatre at the earliest opportunity.
Other methods to help replacement
Manual replacement of the uterus may be complicated by the development of a retraction ring between upper and lower segments or a tight cervix. The anaesthetist may give IV drugs to relax the uterus such as terbutaline 0.25mg or ritodrine 6mg before the obstetrician attempts replacement. However, this relaxation of the uterus may also be achieved by giving the woman a general anaesthetic.
Under general anaesthetic hydrostatic repositioning may be effective. The obstetrician replaces the inverted uterus in the vagina and ‘seals off’ the external labia with one hand. Several litres of warm saline are infused into the posterior vaginal fornix via an IV giving set. The fluid exerts pressure evenly over the uterus and pushes it back into position. The manual and hydrostatic methods may be used together.
CHAPTER 19
Emergencies
414
- Operative procedures are successful as a last resort. Laparotomy may be necessary under general anaesthetic. Forceps are placed on the round ligaments. The obstetrician pulls gently on the ligaments while a second operator pushes the uterus upwards from the vagina.
- The hand is kept inside the uterus until oxytocin (for example: Syntocinon
  ^®5U IV) has produced a firm effective contraction.
- Oxytocin (e.g. IV Syntocinon
  ^®20U in 500mL normal saline via a pump over 4h), should then be administered to keep the uterus contracted and to prevent recurrence.
  0 IV oxytocin should be used with caution in hypovolaemia.
  Post partum
- The woman should be observed in a high dependency area until stable.
- Broad-spectrum antibiotics should be given for 5 days minimum.
  1
  Arulkumaran S, Symonds IM, Fowlie A (2004).
  Oxford Handbook of Obstetrics and Gynaecology.
  Oxford: Oxford University Press.
  This page intentionally left blank
  CHAPTER 19
  Emergencies
  416‌‌
  Shock
  Collapse, due to failure of the woman’s circulatory system; the body is unable to receive oxygen and nutrition and to excrete waste. Acute shock must be reversed quickly to avoid chronic conditions and death.
  Causes specific to childbearing
- PPH
- Uterine rupture or inversion
- Undiagnosed intra-abdominal or genital tract haematoma
- Amniotic fluid embolism
- Eclampsia.
  Causes that may complicate childbearing
- Thromboembolism
- Pulmonary embolism, pulmonary oedema, Mendelson’s syndrome
- Sepsis (endotoxic/bacteraemic shock)
- Allergy (anaphylactic shock)
- Metabolic or endocrine (e.g. diabetic collapse)
- Haemorrhage from organ rupture or aneurysm
- Epilepsy, cerebrovascular accident, subarachnoid haemorrhage
- Heart failure, arrhythmias, myocardial infarction (b see also Cardiac conditions, p. 182)
- Substance misuse or overdose.
  Signs and symptoms
- Pale, cold, clammy, fingernails blue grey
- Dry mouth, thirsty
- Initially blood pressure is maintained then it falls
- Increasing pulse rate: thready and weak
- Increased respiratory rate: fast and shallow
- Oliguria, anuria if low blood pressure (systolic <80mmHg) continues
- Dizzy, restless, lethargic, sometimes in acute pain
- Mood change, altering consciousness.
  Management
  The first priority is resuscitation, but, at the same time, it is necessary to think about cause, so that treatment can be given.
- Call for emergency equipment and help from the obstetric and anaesthetic team.
- Explain briefly to the woman’s partner, and acknowledge anxiety. Give information as available.
- Position the woman flat or in recovery position if semi-conscious.
- Assess breathing and give oxygen via face mask.
- Assess vital signs, blood pressure, pulse, oxygen saturation.
- Site, or help site, large-bore (14 gauge) IV cannulae, enough to replace fluids.
- Take blood as indicated and requested by the obstetrician for FBC, G&S or cross-match, U/E, LFTs, coagulation screen, blood cultures, or blood glucose.
  SHOCK
  417
Support the anaesthetist to take and dispatch any arterial bloods for blood gases, to site a CVP line, and monitor readings.
Catheterize the woman and measure urine output hourly. Anuria, oliguria, and blood staining of the urine indicate low renal blood flow.
Help the team to facilitate speedy delivery of the baby if necessary.
Assist the obstetrician to perform a full clinical, including neurological, examination.
Addressing the cause of shock
Be ready with the following information at the onset of collapse, to help with diagnosis of the cause:
Has the woman:
Delivered baby and placenta?
Had excessive blood loss?
Been in pain, if so what area of the body?
Had a fit?
Any medical history of, for example, PIH, diabetes, epilepsy, heart condition?
Been given any medication?
Had pyrexia?
Haemorrhage
Diagnosis of haemorrhage (b see p. 392).
Septic shock
Diagnosis of septic shock during labour may depend on careful observa- tion and documentation of signs by the midwife. Document and report any persistent temperature >38°C. Such pyrexia is associated with cer- ebral palsy in the infant.
It usually begins with pyrexia, a restless mental state with warm, flushed complexion. Then hypotension, tachycardia, cold extremities, cyanosis, tachypnoea, jaundice, and coma may occur as late signs.
Predisposing factors include prolonged rupture of membranes, operative delivery, manual removal of placenta, and pyelonephritis.
Organisms associated with septic shock include:
- Escherichia coli
- Klebsiella
  sp
  .
- Proteus mirabilis
- Pseudomonas aeruginosa
- Staphylococcus aureus
- Bacteroides
  sp
  .
- Streptococcus
- Group A B-haemolytic streptococcus.
When sepsis is a possible cause of shock in labour, obtain MSU, high vaginal swab, and introital and rectal swabs and send for urgent culture.