A recent Confidential Enquiry into Maternal and Child Health report recommends all clinical staff caring for pregnant women undertake training in the early recognition and management of severely ill pregnant women.
The key skills are recognising a patient is seriously ill (not necessarily in reaching a definitive diagnosis), implementing generally applicable treatment strategies, and making a timely decision about when to move the patient to skilled obstetric care.
The aim is to recognise life-threatening problems to facilitate immediate management, and to quickly identify the need for rapid transportation.
1) Circulation/massive external haemorrhage
Is there a significant volume of blood visible without needing to disturb the patient's clothing?
- Able to talk = airway open.
- Gurgling = fluid in the airway requiring suction; snoring = tongue, swelling or possible foreign body obstruction
- If unresponsive, open the airway and look in. Use suction for fluids or manually remove solid obstructions.
- Respiratory rate and effort - are accessory muscles used?
- Oxygen saturations.
- Auscultate. Wheeze = bronchospasm; coarse sounds = pulmonary oedema.
- Give oxygen based on findings.
- Radial pulse rate / volume
- Skin colour / temperature. Pallor, cold, damp skin = shock.
- Bleeding - check underwear, pads, surface the patient is sitting on; examine introitus with consent. Ask about bleeding. How many pads used in what time?
Check for visible blood loss and feel under the patient.
1. Check introitus - soaked pads or underwear, wounds.
2. Check thoracic cavity for internal bleeding - trauma tenderness, wounds, crepitus, patterning from clothes and seat belts, discolouration.
3. Check abdominal cavity for internal bleeding - tenderness, guarding, firm woody uterus, wounds, patterning from clothes and seat belts, discolouration.
4. Check pelvis following high-speed impact with complaint of hip or low back pain; bruising. Do not compress or palpate the pelvis as this may dislodge clots.
5. Check the femurs for signs of fracture following trauma (tenderness, deformity, open fractures). This can be remembered as 'blood on the floor and five more'.
- Document BP - the systolic is most valuable if you suspect shock.
- AVPU assessment: alert, responding only to voice, responding only to pain, or unresponsive?
- Posture - normal, convulsing (focal / generalised), abnormal flexion, abnormal extension.
- Pupil size and reaction.
- Briefly examine introitus - bleeding? Presenting part? Prolapsed loop of cord? Waters broken? Does perineum bulge with contractions? Significant perineal tear post-delivery? Can you see part of uterus?
- Is the room warm? Is newborn at risk of hypothermia?
- Evaluate if the patient is time critical, decide the need for immediate transport to hospital or whether to treat at the scene. Call for paramedics and midwife.
7) Fundal height
- Below the umbilicus suggests a delivered fetus is unlikely to survive.
Get to the point quickly
Time-critical problems needing rapid management and transportation for definitive care in an obstetric facility include: significant blood loss at any stage of pregnancy or in the postpartum period; suspected abruption, placenta praevia, or uterine rupture; cervical shock; eclampsia or significant hypertension; shoulder dystocia; cord prolapse; suspected amniotic fluid embolus; retained placenta; uterine inversion; refractory maternal or neonatal cardiac arrest; and newborn with poor vital signs.
If transport to hospital is possible, the care provided on scene should be restricted to securing the patient's airway, ensuring adequate ventilation and to controlling significant haemorrhage. When time permits, obtain an obstetric history and refer to patient-held records.
Haemorrhage may be largely concealed and shock may therefore be out of all proportion to the revealed blood loss, so treat according to the BP.
Few compensatory mechanisms for shock are available in late pregnancy, and circulation to the uterus will be compromised at an early stage to protect the mother at the cost of the fetus. Consequently, earlier and more aggressive fluid replacement is required than is the current standard of care for haemorrhage in other patients.
Remember that a gravid uterus will compress the inferior vena cava in recumbent patients resulting in significant circulatory compromise.
Consequently pregnant patients must be moved into a 15 to 30 degree left lateral tilt as the first intervention.
The definitive treatment of cardiac arrest in pregnancy is caesarian section, and to maximise its efficacy this should be accomplished within five minutes.
Consequently on-scene treatment should be minimal and rapid transfer to hospital commenced without delay.
Again, immediately positioning the patient in a 15 to 30 degree left lateral tilt is essential or blood flow with chest compressions will be inadequate.
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Professor Woollard is director of pre-hospital, emergency and cardiovascular care applied research group at Coventry University
Lewis G (ed.) Saving Mothers' Lives - Reviewing maternal deaths to make motherhood safer 2003-2005. London: Confidential Enquiry into Maternal and Child Health, 2007.