Chapter 6 Admission emergencies
MANAGEMENT OF IMMINENT DELIVERY WITH OR WITHOUT FETAL COMPROMISE
The following procedures should be adopted if delivery is imminent.
• Reassurance. These women are often agitated and distressed on admission to hospital. Reassurance and supportive care are necessary. Discourage pushing until vaginal examination is performed.
• Transfer the woman to the delivery room if vaginal delivery is safe. If fetal distress is present, expedite delivery and anticipate the need for neonatal resuscitation.
• If there is indication for or need for recurrent caesarean section proceed to immediate delivery by caesarean section. For uncomplicated cephalic presentation when the fetal head is on the perineum a short period of close observation is acceptable, but anticipate assisted delivery if there is delay or onset of compromise.
SPECIFIC PROBLEMS
Cord presentation or prolapse
Always confirm gestational age before planning any further management.
Cord presentation
This occurs when the cord is in front of the presenting part of the fetus behind intact membranes. When the membranes are not ruptured, palpate through them with the tip of the fingers to exclude the presence of pulsation due to cord presentation or vasa praevia (Figure 6.1a). The diagnosis can also be made using ultrasound and colour flow Doppler, and is useful in circumstances such as an unstable breech presentation. Variable fetal heart rate decelerations may be evident.
Cord prolapse
Following membrane rupture the cord may prolapse through the cervix, may remain in the vagina or be expelled through the introitus (Figure 6.1b).
Cord prolapse occurs in approximately 0.2% of all births.
Points to remember in management
Figure 6.2 presents an algorithm for management of cord prolapse.
• If fetal demise is suspected confirm by scan and manage as for stillbirth. It has been reported that fetal activity could be visualised in cases of inaudible fetal heart tones and absent cord pulsation.
• Check the presence of pulsation, replace the cord in the warmth of the vagina and determine dilatation of the cervix.
• Deliver by forceps or ventouse if cervix is fully dilated and vaginal delivery is considered to be safe.
• If the cervix is not fully dilated, displace the presenting part of the fetus away from the cervix with examining digits to prevent cord compression (most effective). This manoeuvre is made easier if the mother is placed in Trendelenburg’s or knee-chest position. Some authors advocate a temporary measure by inserting a number 16 Foley catheter to fill the bladder with 500 ml of saline using a standard infusion set. Bladder filling raises the presenting part of the fetus away from the cord. (Digital elevation of presenting part is more effective.)
Major obstetric haemorrhage
• Haemorrhage remains one of the leading causes of maternal mortality in the world. It is the leading cause of maternal mortality in developing countries.
• Accurate measurement of blood loss is difficult hence a definition based on volume alone has shortcomings. Tachycardia (>120 beats per minute), hypotension (systolic below 100 mmHg), peripheral vasoconstriction and decreased urine output are important signs.
• Underestimation of blood loss may delay steps to prepare for or prevent further bleeding. Check haemoglobin and haematocrit levels as objective guides to blood loss.
Management
• Clear guidelines must be available for haemorrhage. These will include details for contact of senior obstetric staff, anaesthetists and haematologist.
• Basic resuscitation includes:
• Assess Airway and Breathing effort. Intubation may be indicated if the mother has depressed conscious level due to hypotension (near arrest scenario).
• Establish two 14 G intravenous lines and take 20 ml of blood for diagnostic test (full blood count, urea and electrolytes, coagulation screen and cross matching).
• Monitor pulse, blood pressure (direct or indirect), respiratory rate, oxygen saturation, urine output and fluid balance.
• Central venous pressure monitoring is recommended. Use antecubital fossa and long line, as safer when coagulopathy threatens. Fluid warmers and high pressure infusers are helpful in these situations. If CVP is more than 5 mmHg maintenance fluid volume is sufficient.
• A well-drilled multidisciplinary team of anaesthetists, haematologists, and maternity staff will achieve best results. Observe in high-dependency unit after resuscitation.
Box 6.1 gives details of blood component therapy.
Box 6.1 Blood component therapy
• O negative blood should be available on the delivery suite. This carries a small risk of sensitisation to ‘c’ antigen.
• After 48 hours storage, platelet numbers and function of important clotting factors (V and VIII) are reduced.
• Fresh frozen plasma (FFP) is separated from whole blood within 6 hours of donation and stored for up to 1 year at −20 °C to −30 °C. FFP provides all necessary clotting factors. Give 1 unit after 8 units of rapidly transfused blood. Use coagulation screen as guide.
• Cryoprecipitate contains more fibrinogen than FFP but lacks antithrombin III (coagulation inhibitor), which is depleted in obstetric related coagulopathies. Cryoprecipitate is useful for hypofibrinogenaemia.
• Platelet packs have a limited shelf life of 5 days and should be given through a platelet filter. Rarely indicated above a platelet count of 50 × 109/l.
• In the presence of maternal antibodies, blood should be cross-matched before onset of labour or caesarean section.
Antepartum haemorrhage
• Bleeding is due to:
• placental abruption or separation of the placenta, which is normally situated in the upper uterine segment
• placental praevia or separation of the abnormally situated placenta which lies in or encroaches onto the lower uterine segment
• vasa praevia. Bleeding is associated with rupture of blood vessels in the fetal membranes. Fetal blood is lost. Abnormal cord insertion or succenturiate placenta is commonly found. The Apt test can be used if bleeding of fetal origin is suspected. The basis of this test is that fetal haemoglobin is alkaline stable, whereas adult haemoglobin is not.
Important points to remember about vaginal bleeding in pregnancy
• A show is diagnosed only when blood-stained mucus is noted, usually in association with contractions. Presence of pure blood is not a show.
• A high presenting part or malpresentation on abdominal examination may be due to placenta praevia (irrespective of an early pregnancy ultrasound scan).
