Midwifery and obstetric emergencies C H A P T E R 2 2 Midwifery and obstetric emergencies

Introduction Obstetrical emergencies is dependent on the prompt action of the midwife. The midwife should remain calm attempt to keep the woman and her partner fully informed to obtain her consent and cooperation for procedures that may be needed. -pregnancy and labor are normal physiological ,regular routine observations of vital signs must be an integral part of midwifery care.

All staff should be trained in basic life support Communication among members of the multiprofessional team is essential to ensure the optimum outcome for the childbearing woman who becomes unwell and her baby

Communication focus on how to improve verbal communication. Use of the SBAR tool The tool consists of standardized prompt questions about the condition of an individual in four stages: Situation Background Assessment Recommendation.

The SBAR tool can be used in all clinical conversations: face-to face, by telephone or through collaborative multi-professional team meetings. Should be used in midwifery and obstetric emergencies

Vasa praevia when a fetal blood vessel lies over the cervical os, in front of the presenting part. This occurs when fetal vessels from a velamentous insertion of the cord or to a succenturiate lobe cross the area of the internal os to the placenta. fetal life is at risk possibility of rupture of the vessels leading to exsanguination unless birth occurs within minutes. Good outcome depends on antenatal diagnosis and birth by caesarean section before the membranes rupture (

Diagnosis - antenatally using ultrasound scan. palpated on vaginal examination when the membranes are still intact. If it is suspected, a speculum examination should be made. Fresh vaginal bleeding, particularly if it commences at the same time as rupture of the membranes, may be due to ruptured vasa praevia. Fetal distress disproportionate to blood loss may be suggestive of vasa praevia.

Management call for urgent medical assistance. (CTG). in the first stage of labor and the fetus is still alive, an emergency caesarean section is carried out. in the second stage of labor, the baby may be born vaginally. Caesarean section may be carried out but the mode of birth will be dependent on parity and fetal condition.

high fetal mortality ,so a pediatrician should therefore be present for the birth. Resuscitation urgent hemoglobin estimation a blood transfusion with O-negative blood

Presentation and prolapse of the umbilical cord Predisposing factors any situation where the presenting part is neither well applied to the cervix nor well down in the pelvis may make it possible for a loop of cord to slip down in front of the presenting part. Such situations include: high or ill-fitting presenting part high parity prematurity malpresentation multiple pregnancy hydramnios

Dentitions Cord presentation the umbilical cord lies in front of the presenting part, with the fetal membranes still intact. Cord prolapse The cord lies in front of the presenting part and the fetal membranes are ruptured Occult cord prolapse This is said to occur when the cord lies alongside, but not in front of, the presenting part.

Predisposing factors : High head If the membranes rupture spontaneously when the fetal head is high, a loop of cord is able to pass between the uterine wall and the fetus resulting in its lying in front of the presenting part. As the presenting part descends, the cord becomes trapped and occluded. Multiparity The presenting part may not be engaged when the membranes rupture and malpresentation is more common.

Prematurity The smaller size of the fetus in relation to the pelvis and the uterus allows the cord to prolapse. Babies of very low birth weight (<1500 g) are particularly vulnerable

Malpresentation Cord prolapse is associated with breech presentation, especially complete or footling breech. This relates to the ill-fifing nature of the presenting parts and also the proximity of the umbilicus to the bufocks. In this situation, the degree of compression may be less than with a cephalic presentation, but there is still a danger of asphyxia. Shoulder and compound presentation and transverse lie carry a high risk of prolapse of the cord, occurring with spontaneous rupture of the membranes.

Multiple pregnancy Malpresentation, particularly of the second twin, is more common in multiple pregnancy with the consequences of possible cord prolapse. Hydramnios The cord is liable to be swept down in a gush of liquor if the membranes rupture spontaneously. Controlled release of liquor during artificial rupture of the membranes is sometimes performed to try to prevent this

Cord presentation DX: vaginal examination when the cord is felt behind intact membranes. fetal heart monitoring (decelerations,) which occur if the cord becomes compressed. Management Under no circumstances should the membranes be ruptured. discontinue the vaginal examination, in order to reduce the risk of rupturing the membranes.

Medical aid should be summoned. assess fetal wellbeing, continuous electronic fetal monitoring The woman should be assisted into a position that will reduce the likelihood of cord compression. caesarean section is the most likely outcome.

Thanks