Cases

Chapter 16 Emergencies in midwifery

Case 1: Post-partum haemorrhage (PPH)

Gemma is a 19-year-old primigravida, who was admitted in active labour at 39 weeks after an uncomplicated pregnancy. As part of the antenatal assessment a vaginal examination was performed and her cervix was found to be fully effaced and 4 cm dilated. She progressed normally to full cervical dilatation, but had a prolonged second stage requiring syntocinon infusion for augmentation and instrumental delivery of a baby weighing 4600 g. Syntometrine 1 mL was given intramuscularly with the anterior shoulder and the placenta and membranes were delivered within 5 minutes. Gemma then passes two large blood clots vaginally and has a steady trickle of blood loss for the ensuing 2 minutes. Her BP is 95/55 and she says she is feeling faint.

Questions

• a) What factors exist in this case that predispose Gemma to have a PPH?

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  Correct answer:

  • Baby weighing over 4.5 kg.
  • Protracted second stage of labour.
  • Instrumental delivery.
  • Syntocinon infusion.

• b) What immediate treatment should Gemma be given?

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  Correct answer:

  • Call for help (emergency buzzer).
  • The woman needs to be in a semi-recumbent position preferably on a bed.
  • Ascertain the cause of bleeding.
  • Ensure the uterus is well contracted - rub up a contraction.
  • Catheterise the bladder.
  • Consider further dose of oxytocin (syntocinon infusion).
  • Measure and record vital signs.
  • If the woman is able, put the baby to the breast to stimulate oxytocin release.
  • Depending on severity of the vaginal blood loss, insert two wide bore IV cannulas, take venous bloods samples, and administer IV fluid as prescribed.
  • Bi-manual compression of the uterus may need to be employed where bleeding persists.
  • Transfer to theatre.
  • Follow Basic Life Support interventions if required.

• c) What may be the cause of Gemma's bleeding?

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  Correct answer:

  • Tone - atonic uterus.
  • Trauma - perineal, vaginal wall or cervical lacerations.
  • Tissue - retained placenta and or membranes.
  • Thrombin - clotting abnormalities.

Case 2: Shoulder dystocia

Lisa is a Gravid 2 Para 1 with a three-year-old son who was born by normal vaginal birth at term weighing 3.2 kg. She opted for a home birth and is now in the second stage of labour. The head delivers, but the shoulders fail to respond to gentle traction. The signs of shoulder dystocia such as turtle necking are present.

Questions

• a) List the actions that should be taken by the two midwives present.

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  Correct answer:
  Explain to patient and partner.
  Encourage woman to lay flat and come to end of bed.

  • H - HELP Call the ambulance urgently and inform the maternity hospital.
  • E - Evaluate for episiotomy if it will make internal manoeuvers easier.
  • L - Legs McRoberts manoeuvre (30-60 seconds).
  • P - Suprapubic external pressure (30-60 seconds).
  • E - Enter the vagina (Rubin II manœuvre, Woodscrew manœuvre, reverse woodscrew manœuvre 30-60 seconds).
  • R - Remove the posterior arm.
  • R - Roll over onto all fours.

  Squire, C. (2011) Shoulder dystocia. In: Boyle, M. (ed.) (2011) Emergencies Around Childbirth, 2nd edn. London: Radcliffe Publishing.
  The order of these manoeuvers may be different - it is up to the clinician at the time to decide which the best actions are and in which order. Ensuring all manoeuvers are documented, the time spent on each manoeuvre and whether each manoeuvre was successful. It is also important to document which shoulder was impacted.

• b) Which of the possible manoeuvres for shoulder dystocia would you use first in this situation?

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  Correct answer:
  Roll over onto all fours position.

Case 3: Umbilical cord prolapse

The community midwife is called to attend a woman at her home who is Gravid 5 Para 4 and 37 weeks pregnant. The woman is concerned she can feel 'something bulging at the opening of the vagina'. The woman is not contracting; the membranes have spontaneously ruptured and it is clear liquor. The paramedic crew have been called by the hospital to also attend urgently.

Questions

• a) What are the risk factors for umbilical cord prolapse?

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  Correct answer:

  • Multiparty
  • Low birth weight
  • Prematurity
  • Fetal congenital anomalies
  • High presenting part - unengaged
  • Polyhydramnios
  • Malpresentation, e.g. breech, shoulder
  • Unstable lie of the fetus
  • Low birth weight
  • Multiple pregnancy

• b) What would the midwife's priorities and actions be?

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  Correct answer:
  The priority is to prevent the presenting part from compressing the cord and obstructing blood flow and oxygenation to the fetus.
  Vaginal examination to alleviate pressure on the cord; this can be achieved by inserting two fingers into the vagina onto the presenting part and applying pressure to elevate the presenting part above the pelvic inlet (Squire 2011).
  Encourage mother to get into the ambulance quickly and adopt the exaggerated Sims position (left lateral position with head tilted down and elevating the woman's buttocks) relieving pressure on the umbilical cord. This is the safest position for transfer in an ambulance to the hospital.
  Auscultate the fetus as appropriate.
  Communicate with the labour ward ensuring help is available as soon as you arrive.
  Maintain accurate record keeping and explain actions to woman and partner.