Oxford Handbook of Midwifery (94 page)

CHAPTER 19
Emergencies

418

• Severe septic shock may precipitate DIC (b see Disseminated intravascular coagulation, p. 410).
  
• Admit to high dependency area for observation and care by a midwife. Very rarely, you may see the following.
  

  Anaphylactic shock
  

• This occurs because the woman has been exposed to an antigen against which she has been previously sensitized. The body releases histamine when challenged with the antigen, which dilates arteries and makes capillaries more permeable.
  
• The blood pressure falls and signs of shock are present.
  
• Typically this may occur following the administration of medicines such as anaesthetic agents or antibiotics.
  
• Adrenaline or ephedrine may be given by the anaesthetist.
  

  Cardiorespiratory collapse
  

• A fall in cardiac output occurs as a result of heart failure. Venous return is reduced. The lungs become congested with blood.
  
• Arrange chest X-ray, arterial gases, ECG, FBC, U/E.
  

  Neurological conditions
  

• Indicated by an alteration in consciousness when cardiorespiratory signs are not present.
  
• A magnetic resonance imaging (MRI) scan of the brain may be needed.
  

  Diabetic collapse
  

• The woman will typically be an insulin-dependent diabetic.
  
• The woman may become uncooperative, distant, and confused.
  
• She will feel faint, sweating but clammy.
  
• Give a drink with sugar if possible—unconsciousness will not then occur. If it does, it is quickly reversed by a glucagon injection or IV glucose fluids.
  

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  Emergencies
  

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  Maternal resuscitation
  

  Cardiopulmonary arrest is estimated to occur once in every 30 000 late pregnancies;
  ¹
  the outcome can be poor for both mother and unborn child. Basic resuscitation skills are an essential requirement of all midwives, who should be familiar with resuscitation guidelines and the location and use of resuscitation equipment provided.
  

  Although the incidence of arrest is low, there are emergency situations that may result in cardiopulmonary arrest necessitating resuscitation:
  

• Anaphylaxis
  
• Amniotic fluid embolism
  
• Cerebral aneurysm
  
• Eclampsia
  
• Embolism
  
• Epilepsy
  
• Haemorrhage
  
• Cardiac disease
  
• Placental abruption
  
• Pulmonary embolism
  
• Ruptured liver/spleen
  
• Septic shock
  
• Thromboembolism
  
• Total spinal
  
• Uterine rupture
  
• Uterine inversion.
  

  Responsibility of the midwife
  

• Provide effective basic life support to ensure adequate circulation and perfusion of vital organs.
  
• Participate in, and often initiate, advanced life support.
  

  In pregnancy
  

• Oxygen consumption is increased, therefore oxygen supply to the brain will diminish more rapidly than in a non-pregnant person.
  
• To optimize fetal outcome, support should be given to the mother.
  
• Basic life support should be initiated immediately.
  

  Resuscitation in a hospital setting
  

  If a woman collapses or is found collapsed:
  

• Pull the emergency buzzer/shout for help.
  
• Assess responsiveness. Gently shake her shoulders and shout.
  
• If she responds:
  
  • Send for medical assistance
    
  • Position in left lateral
    
  • Maintain airway
    
  • Give oxygen
    
  • Monitor vital signs
    
  • Consider venous cannulation
    
  • Stay with her until medical review and investigations.
    

    

    MATERNAL RESUSCITATION
    

    421
    

Airway

With your hand on the woman’s forehead, gently tilt her head back, remove any visible obstruction from the mouth, place your fingertips on the point of her chin and lift the chin to open the airway. If trauma to the head or neck is suspected, avoid this head tilt manoeuvre. Instead jaw thrust should be performed.

Breathing

Circulation

To perform chest compressions
: place the heel of one hand over the lower half of the sternum, place the heel of the other hand on top of the first hand, and extend or interlock the fingers. Do not apply pressure over the ribs, upper abdomen, or tip of the sternum. From above the woman, with arms straight, press down to depress the sternum 4–5cm. Release the pressure and repeat at a rate of about 100/min. Take equal time with compression and release to allow the chest to recoil.

• Apply ECG monitor/defibrillator pads
  
• Monitor pulse oximetry
  
• Monitor blood pressure
  
• Cannulate using ×2 large bore Venflon
  ^®
  
• Obtain bloods for urgent cross-match, FBC, coagulation screen, U/E, blood glucose, LFTs, and arterial blood gas
  
• Make notes of times, actions, and any fluid/drug treatment.
  

  

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  Emergencies
  

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  Considerations in pregnancy
  

  Airway
  

  It may be difficult to maintain an airway, and intubation may be difficult due to:
  

  • Neck obesity
    
  • Enlarged breasts
    
  • Glottic oedema.
    

    A bag-valve-mask is preferred, with two staff working together; one holding the mask and maintaining the airway and the other giving inflation breaths and chest compressions. If a pocket mask is nearby, use this until more help and equipment arrives, connect to oxygen as soon as possible. If the woman is unconscious a Guedal airway can be used to help maintain the airway.
    

    Breathing
    

    Due to delayed gastric emptying, reduced tone of stomach muscle sphincter, and increased pressure on the stomach from gravid uterus, there is an increased risk of regurgitation and pulmonary aspiration. Early intubation using cricoid pressure is preferable.
    ²
    Until the airway is protected by the insertion of a cuffed tracheal tube, aspiration can occur. Give each ventilation slowly over 2s, with volumes just sufficient enough to produce a visible chest rise (400–600mL). Allow the chest to deflate following each breath.
    

    Circulation
    

    There is an increased circulatory demand in pregnancy.
    

  • Prevent aorto-caval compression: pressure on the major vessels should be relieved by left lateral displacement of the uterus. This will improve venous return and cardiac output. Placing a Cardiff wedge or pillow under the right side will achieve this by tilting the woman by approximately 30°. Alternatively, raising her right hip, or manual displacement of the uterus to the left and upwards, will suffice until suitable equipment arrives.
    
  • Chest compression may be more difficult in this position.
    

    Advanced life support
    

    Treat arrhythmias according to standard protocols.
    

  • Avoid lidocaine when epidural anaesthesia has been used, as high levels of local anaesthetic may be present in the blood. Amiodarone is an alternative antiarrhythmic drug.
    
  • If 5min of in-hospital resuscitation is unsuccessful, emergency caesarean section is indicated to save the fetus (in the third trimester) and improve the prognosis for the mother. Advanced life support should continue during and after the procedure.
    ²
    

    Resuscitation out of the hospital setting
    

    Follow basic life support guidelines, assess responsiveness and breathing. If no response and no breathing, send for medical assistance. An emergency ambulance should be sent for, clear instructions are important stating ‘I have an unconscious, pregnant woman who is not breathing, we are at [address]’, as this should influence the type of assistance that is sent.
    

    

    MATERNAL RESUSCITATION
    

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    In the home setting a partner, friend, or neighbour could be given clear instructions and asked to call an ambulance. If alone and without the use of a phone, you will have to decide whether to start resuscitation or go for help. This might be influenced by the condition/cause of collapse and available equipment; however, if there is no breathing and/or pulse it is advisable to call medical assistance before attempting resuscitation, to ensure that advanced life support and defibrillation are available as soon as possible. If the likely cause of unconsciousness is a breathing problem,
    

    i.e. drugs/alcohol, 1min of CPR should be performed before going for help. If you are alone, you may need to use your knee to tilt the woman onto her left side; a cushion or clothing might have to be used while you call for assistance. On arrival of the ambulance basic life support should continue. Advanced life support may be initiated, depending on the skills of the team that arrives, and the woman should be transferred to hospital as soon as possible. The hospital should be notified of her pending arrival so that preparations can be made.
    

    Cross-infection
    

    All community midwives should carry equipment that will protect them when performing basic life support. Key fobs are available containing a single-use mask which, when placed over the victims mouth to perform mouth-to-mouth resuscitation will give some protection against cross- infection. Pocket masks are also available with one-way valves, which will prevent transmission of bacteria. In the hospital the midwife should wait for equipment to arrive before attempting ventilations. Chest compres- sions can be performed while waiting. Gloves and eye protection must be worn, and considerable care taken with needles and sharp instruments.
    

    Jaw-thrust manoeuvre
    

    Used to open the upper airway with minimal movement of the cervical spine. Using both hands, place the forefingers behind the angle of the jaw. Keeping the head and neck still, push the jaw forward and upwards, this will push the tongue forwards and away from the pharynx.
    

    Further reading
    

    Resuscitation Council (UK). (2010).
    Resuscitation Guidelines 2010.
    Available at: M http://www.
    resus.org.uk/pages/guide.htm (accessed 28.2.11).
    

    1. Jevon P, Raby M (2001).
       Resuscitation in Pregnancy. A Practical Approach.
       Oxford: Reed Educational and Professional Publishing.
       
    2. The Practice Development Team (2010).
       Jessop Wing HDU Skills Development
       (2010). Sheffield: Sheffield Teaching Hospitals NHS Trust.
       

       

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       Emergencies
       

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       Guidelines for admission to HDU
       

       Policy for admission may vary between units depending on facilities and available personnel. Admission to the HDU should be considered in the following situations:
       

       • Ante- or postnatal hypertensive women whose condition is deteriorating. For example, when the blood pressure is difficult to control, LFTs are abnormal, and signs of fulminating pre-eclampsia or cerebral agitation are present
         
       • Women who experience major haemorrhage which is causing maternal compromise
         
       • Women who experience blood loss of 1000mL or more
         
       • Women suspected of having pulmonary embolism or having signs of respiratory distress, hypoxia, tachycardia
         
       • Following LSCS, when the woman has insulin-dependent diabetes mellitus and a sliding scale with insulin and glucose is in progress
         
       • Any woman having had general anaesthesia
         
       • Women who receive diamorphine via epidural catheter
         
       • Women showing signs of shock, septicaemia, anaphylaxis
         
       • Status epilepticus
         
       • Women diagnosed with pulmonary oedema or suspected amniotic fluid embolism
         
       • Any woman requiring continuous oxygen therapy
         
       • Women suffering from HELLP syndrome or DIC (b see Disseminated intravascular coagulation, p. 410)
         
       • Any woman with an underlying medical or surgical condition which is compromising maternal condition, e.g. known symptomatic heart condition
         
       • Cardiac arrhythmia requiring continuous ECG monitoring
         
       • Women requiring CVP or arterial line
         
       • Woman transferred back from a general ITU.
         

         Guidelines for transfer out of HDU to ITU
         

         The woman requiring intensive care is unstable and requires multiple organ monitoring/support. The level of dependency is an important factor in determining appropriateness of intensive care. A woman needs urgent attention in the following situations (if there is no improvement in 2h, seek consultant review for transfer to ITU):
         

       • Women with chronic impairment of one or more organ systems, sufficient to restrict daily activities, and who require support for an acute reversible failure of another organ system
         
       • A woman not responding to commands
         
       • The woman with deteriorating respiratory rate not responding to treatment:
         
         • Inability to maintain own airway
           
         • Requiring advanced respiratory support
           
         • Oxygen saturation of <90% despite 60% inspired oxygen.
           
       • Pulse of <40bpm or >130bpm
         
       • Oliguria: urine output of less than 30mL/h for 3 consecutive hours.
         

    

    MATERNAL MORTALITY
    

    425‌‌
    

    Maternal mortality
    

    The
    Confidential Enquiry Into Maternal and Child Health
    ¹
    (CEMACH) reported 391 maternal deaths between 2000 and 2002. The purpose of the enquiry is to assist in identifying factors that may be detrimental to maternal health and to assist in improving the care that mothers receive in pregnancy and when they are newly delivered. The most common cause of direct death was thromboembolism, with an increased rate as a result of haemorrhage and those associated with anaesthesia. The most common cause of indirect death, and the largest cause of maternal deaths overall, was psychiatric illness.
    

    The CEMACH report
    ¹
    aimed to evaluate all the factors playing a part in women’s deaths, and further analysis reinforces the need to ensure that maternity services are designed to meet the needs of all women and, in particular, those who are vulnerable or disadvantaged in any way. Risk factors for maternal deaths are identified as follows.