scottish emergency maternity care course for the non

Scottish Emergency Maternity Care Course for the Non-Maternity Professional

Sustaining quality maternity care outside/out with the specialist maternity environment in

Scotland

Promoting multiprofessional education and development for maternity care in Scotland

Contents Acknowledgements 1 Aims and Outcomes of the Course 3 Glossary of Terms and Abbreviations 7 Chapter 1 Multiprofessional Team Approach 11 Chapter 2 About Pregnancy 23 Chapter 3 Risk Management And Risk

Assessment

43 Chapter 4 About Labour 55 Chapter 5 Emergency Normal Labour And

Delivery (No complications)

77 Chapter 6 Immediate Care Of The Newborn 97 Chapter 7 Dealing With An Emergency Situation 107 Chapter 8 Chapter 9

Resuscitation And Trauma Neonatal Resuscitation

129 134

Chapter 10 Referral And Transport 143 Chapter 11 Frequently Asked Questions 149 Recommended Reading 151 Websites 153 Appendix 1 155 Appendix 2 161

© Scottish Multiprofessional Maternity Development Programme 2013 1

Acknowledgements Acknowledgements are given to the original project team, under the auspices of the University of Paisley, who developed the project and published their evaluation report in 2006. Thanks are also due to the Scottish Multiprofessional Maternity Development Programme’s group workers who produced the original manual in 2013. Updated by Lucy Powls and Helene Marshall on behalf of SMMDP 2013 Finally, appreciation is given to Dr Brian Magowan – Consultant Obstetrician and Gynaecologist at the Borders General Hospital, Melrose – for the use of his materials and illustrations on normal birth in Chapter 5.

2 © Scottish Multiprofessional Maternity Development Programme 2013


AIMS AND OUTCOMES OF THE COURSE

Welcome to the Scottish Emergency Maternity Care Course.

Aim of the Course The purpose of this course is to support the wider multi-professional group of health care staff who may be involved in emergency maternity situations arising outside the maternity environment in Scotland. The overall aim is to provide these individuals with supplementary knowledge and skills necessary to help them deal appropriately with maternity care emergencies.

Learning Outcomes On completion of the course, the non-maternity healthcare professional in an emergency maternity care situation will be able to:

• Describe the roles, responsibilities and the scope of practice of each of the professional groups in the available team.

• Demonstrate an appropriate knowledge of related professional, legal and ethical issues.

• Demonstrate an appropriate knowledge of the normal development of pregnancy.

• Demonstrate an appropriate knowledge of the processes involved in labour and birth.

• Demonstrate an appropriate knowledge of risk management including risk assessment.

• Demonstrate an awareness of the commonest emergencies related to maternity care and the initial management possible in a non-maternity care setting.

• Communicate, refer and transfer appropriately.


Course Material This distance-learning pack will provide you with all the core learning resources you will require to complete this part of the course.

There are numerous activities and scenarios that you are expected to complete as you work through the pack. These are designed to encourage multi-professional working and sharing of knowledge in your local area.

Facilitated Workshop A workshop will be arranged once you have completed the pre-course reading, activities and submitted the quiz assessments. Trainers will be available to provide you with support to work through a range of scenarios and activities related to emergency maternity care situations. This will also provide an opportunity to clarify any issues.

Assessment of Knowledge and Skills Skills Inventory You will be asked to complete an initial skills inventory at the beginning of the course to identify areas you may need updating in skills and knowledge. You will be asked to repeat this skills inventory again on completion of the course. Formative assessment using several topic specific quizzes should be completed before attending the workshop.

NB: Text presented in shaded boxes is essential information


Quizzes There are four short quizzes you will be asked to complete as you work through the pack. This is to ensure you know the main points of the related content. The quizzes are related to the following topics:

• Multiprofessional team approach (page 19) • About pregnancy (page 36) • Labour and childbirth (page 68) • Immediate care of the newborn (page 96)

The questions in each quiz relate to the key points of the learning resources. The quizzes take the form of true/false questions or multiple choice-type responses. Once you have completed each quiz please send them to your local course coordinator who will lead the workshop later or the Scottish Multiprofessional Maternity Development Programme Office. (Local course coordinator’s name and contact details will be supplied with the course materials). Each test carries a value of 10 marks and the target mark is 80% as in each of the Scottish Multiprofessional Maternity Development Programme’s courses. If you do not achieve 80% you will have the opportunity to discuss any areas of concern with the local course coordinator. Scenario-based assessment This ‘hands on’ practical assessment is completed at the end of the facilitated workshop. For the assessment you will work through appropriate scenarios related to potential emergency maternity care situations arising in the absence of a midwife or medical assistance. You will get feedback on your performance. The main focus of the assessment is on the action taken in relation to your understanding of the action needed and whether it demonstrates safe practice. You will have an opportunity to practice these scenarios with other individuals on the course during the workshop. The trainer/assessor uses a detailed assessment checklist of expected responses and action points for the scenarios. You will get immediate feedback from the trainer and you will have the opportunity for further discussion. You will have an opportunity for a reassessment if necessary once any required remedial teaching


Regional local course facilitation will assist in the preparation of any additional course information relevant to your practice location. You are also expected to collect information, guidelines and protocols with reference to maternity emergencies for your local area. This pre-course information provides you with an overview of the main points to give you an insight to the course. Good luck.


GLOSSARY OF TERMS AND ABBREVIATIONS Amniotic fluid This is the fluid surrounding the baby. Amniotic sac This is the bag of membranes containing the baby Antenatal

Refers to the period before birth (natal refers to being born).

Antepartum Refers to the period before the act of giving birth. APH

Antepartum haemorrhage.

Breech Birth A baby who is born with the bottom coming first i.e. the bottom is in the lower part of the uterus.

Breech Presentation

Refers to a baby in utero who is lying with the bottom down in the lower part of the uterus.

Cephalic Presentation

Cephalic refers to the head. This term refers to a baby in utero lying with the head down in the lower part of the uterus (i.e. the normal way for babies to be born).

Cervix

This is the lower section of the uterus (neck of the womb).

CLU Consultant Led Unit. CMU Community Maternity Unit. Dorsal

Refers to the position adopted by the body when the woman is lying on her back.

EDD Estimated date of delivery. Engagement

This occurs when the largest diameters of the baby’s head have gone through the brim of the pelvis (and into the birth canal).

Fetus

The fetus refers to the baby in uterus from 10 weeks until birth. (For the purpose of this programme the fetus will be referred to as the baby).

First Trimester

Relates to early pregnancy (first third) usually until about 14 weeks.

Fundus Refers to the top section of the uterus. Gestation

Relates to the period of development from conception to birth which is normally about 40 weeks.


Intrapartum Refers to the period during labour and birth. Lie

Refers to the way the baby is lying in the uterus. In normal situations this is ‘longitudinal lie’ when the long axis of the baby is parallel to the long axis of the uterus, usually with the baby’s head being in the lower part of the uterus and the bottom in the top of the uterus.

Miscarriage

Refers to any pregnancy that has ended before 24 weeks gestation (age of viability).

Multiparous

Refers to a woman who has had two or more births (referred to as ‘Grand Multiparous’ if the woman has had four or more births). Multi – relates to many Parous - relates to ‘parturition’ (giving birth).

Natal Refers to the birth of the baby Normal Birth

Relates to a vaginal birth occurring spontaneously with the head being born first. This is also called a spontaneous vertex delivery (SVD).

Parity

Refers to the birth of the baby after the age of viability (this is 24 weeks by the law). Relates to the term ‘parturition’ (giving birth).

Partum

The process of giving birth. Relates to the term ‘parturition’ (giving birth).

Placenta

This organ is the baby’s life support system in utero. It provides the baby with oxygen and all necessary nutrients and the organ removes waste materials.

Postnatal

Refers to the period after the end of labour during which the attendance of a midwife upon a woman and baby is required, being not less than ten days and for such longer periods as the midwife considers necessary (NMC 2012).


Postpartum

Refers to the period of time after birth (usually six weeks). This relates to the period when the woman’s body returns to the pre-pregnant state.

PPH Postpartum haemorrhage. Presenting Part

Refers to the part of the baby presenting in the pelvis. This would normally be the head (cephalic presentation).

Preterm

Refers to labour and birth occurring before 36 completed weeks of pregnancy.

Primiparous

Refers to a woman giving birth for the first time. Primi – relates to first Parous - relates to ‘parturition’ (giving birth).

Quickening

This refers to first movement of the baby in utero felt by the woman.

Rupture of membranes

Refers to rupture of the bag of membranes surrounding the baby in utero.

Second Trimester

Relates to the middle third of pregnancy between 14 and 28 weeks.

SVD

Spontaneous vertex delivery (i.e. normal birth). This is the most common way babies are born.

Supine

Refers to the position adopted by the body when the woman is ‘facing upwards’.

Term

Relates to the due date of the baby. This is normally about 40 weeks.

Third Trimester

Relates to the phase final third of pregnancy from 28 weeks until birth.

Trimester

Pregnancy is divided into three time phases called trimesters: early or first trimester, mid or second trimester and late or third trimester of pregnancy.

Vertex This refers to the crown of the baby’s head. Viability

This refers to the baby who is capable of living and surviving. The law sets this age which is currently 24 weeks gestation.


Further Terms and Abbreviations You can record below any other relevant terms or abbreviations you may want to refer to as you work through the course.


CHAPTER 1 MULTI-PROFESSIONAL TEAM APPROACH

Introduction ‘Emergency’ means a sudden, unexpected, event relating to the health or condition of a woman or baby which requires immediate attention (NMC 2012). The NMC (2012) state that normal processes, such as spontaneous labour at term, would not usually be considered an emergency if care has been planned. Two types of emergency situations occur in maternity care. Immediate assistance will be required during these situations:

1. An emergency situation occurring involving a pregnant woman presenting in labour. There are no complications and birth is imminent.

2. An emergency situation occurring situation can also rapidly become an obstetric or medical emergency (Lui, 2007).

Midwives and medical practitioners are the appropriately qualified professionals to deal with emergency maternity care situations. However, if these professionals are not available in emergency situations then other professionals are required to deal with the emergency (NMC, 2012).


Legal Situation for Childbirth The law states that only a registered midwife or medical doctor may attend a woman in childbirth as set out in the Nursing and Midwifery Order 2001 (http://www.legislation.gov.uk/uksi/2002/253/part/IX/made). This law extends to include student midwives and medical students under supervision. Others attending a woman in childbirth may be prosecuted. This legal stance protects women in childbirth. It ensures that the most appropriately trained professional is in attendance during childbirth. This prevents employers and midwives from arranging substitutes to act for them in the capacity as midwife (NMC, 2012). NB: In emergency maternity situations then the midwife or GP should be contacted in the first instance. Other professionals should only deal with the situation until they arrive. This section provides information about the role and scope of practice of professionals within the team, what is expected of each professional at an emergency situation and the related professional, legal and ethical issues.

Learning Outcomes On completion of the course, the professional in an emergency maternity care situation will be able to:

• Describe the role and responsibilities of each of the professionals in the group.

• Describe what is expected of each of the team members in relation to their scope of practice.

The main professional, legal and ethical issues are integrated throughout this section.

http://www.legislation.gov.uk/uksi/2002/253/part/IX/made


Multi-Professional Team Approach All individuals working within the health profession have a duty to work in collaboration in the interest of patient or client care. To work in collaboration the individual members of the team need to know the skills and expertise of each member and the contribution of each member in various situations. Team members should have mutual respect for the role and contribution each member has to make within the team setting (The Code: Standards of conduct, performance and ethics for nurses and midwives [NMC 2008];

www.scottishambulance.com.

Multi-Professional Team Members The course is aimed at health professionals who may come into contact with childbearing women when there is no direct access to a maternity care professional. To recap, this includes:

• Scottish Ambulance Service personnel. It will take account of the training needs of ambulance technicians.

• First and Second Level Registered Nurses and Doctors working in Accident and Emergency Departments and Out of Hours services.

• District Nurses and Practice Nurses working in the community or medical centres/clinics.

• The Family Health Nurse.

http://www.scottishambulance.com/

http://www.nmc-uk.org/Documents/Standards/The-code-A4-20


Scope of Practice Practitioners should always work within the scope of practice defined by their relevant governing bodies. “You must be able to demonstrate that you have acted in someone’s best interests if you have provided care in an emergency” “You must make referral to another practitioner when it is in the best interests of someone in your care.” “As a professional, you are personally accountable for actions and omissions in your practice and must always be able to justify your decisions” (The Code: Standards of conduct, performance and ethics for Nurses and Midwives, NMC 2008) Individual practitioners within the multi-professional team should be responsible for informing the other members of any areas of practice they have expanded and what role, skills and duties this enables them to perform. By completing the following activity this will give you an opportunity to find out about the individuals in your local multi-professional team.

Scope of Practice of Team Members Your local area will have a multi-professional group of practitioners who could be involved in an emergency maternity care situation. Find out the following information about the individual group members. List the members, their contact details and a summary of their current scope of practice. You can then reproduce this information to use as a quick reference guide for your area.


Member and Contact Details Scope of Practice


Consent and Confidentiality Although this is an emergency situation, professionals involved still need to gain consent from women for any care or possible procedures she may need. Before the woman agrees she should be given an explanation of what is happening to her, what she can expect to happen, and the reason for any care or procedures she may require. Either you or another team member should give this explanation and gain consent from the woman. Consent may be given verbally as long as both the information given and consent is witnessed and documented. Team members should always keep information about individuals and situations confidential unless the information needs to be shared for professional reasons (NMC, 2008). This includes personal details, medical details, social and domestic circumstances. All information and records are maintained in accordance with the Data Protection Act 1998 (http://www.legislation.org.uk).

Privacy and Dignity During and following the emergency situation privacy and dignity of the woman should be preserved as much as possible. This should be straightforward to preserve in a hospital setting. However, you may need to improvise to maintain privacy and dignity if the emergency occurs in a public setting.

Record Keeping A record of all the important aspects of care during the emergency situation should be available. These should be recorded as soon as possible after the emergency situation. You will be expected to provide this record if you have been involved in the emergency situation.

The essential information required includes:

• Timing of events. • Action taken and response of woman and/or her baby. • The outcome to the situation. • Date, your name and signature.

NB: You are advised to have an assistant to note down important events such as time of birth.

http://www.legislation.org.uk/


It is important that the members of the multi-professional team decide on how to keep a record of emergency maternity care situations when these occur in their local area (see activity at the end of this section). Most women now carry hand-held notes and these may be used by all providing care to the pregnant woman.

Note taking in an Emergency Maternity Care Situation

• Take a look at the templates on the Healthcare Improvement

Scotland web site to familarise yourself with the layout:

Get together as a team and decide on the most efficient way of keeping a record of events during emergency maternity care situations occurring in a variety of settings.

http://www.healthcareimprovementscotland.org/our_work/reproductive,_maternal__child/woman_held_maternity_record/swhmr_maternity_r


Legal Issues Notification of Births There is a legal obligation to provide a record of any birth, which has taken place. The birth needs to be notified, by law, under the Registration of Birth, Deaths and Marriages (Scotland) Act 1965 amended by the Stillbirth Definition Act 1992. The law states that all births (born alive or stillborn) need to be notified to the medical officer within 36 hours. The duty rests with the father or anyone present at the birth or within 6 hours of the birth. Please note the midwife usually undertakes this duty.

Registration of Births The father or mother must give the Registrar, within 21 days in Scotland of the birth, information about the birth. If the father or mother cannot do this, it falls to any person present at the birth, including the midwife. Definitions for the purpose of registration of births and deaths:

• A baby born at any stage of pregnancy who breathes or shows other signs of life after complete expulsion from its mother is born alive; if such a baby dies after the birth this must be certified by a medical practitioner, the birth and death must both be registered.

• A baby who has issued from its mother after the 24th week of pregnancy and has not at any time after being completely expelled from its mother breathed or shown any sign of life is a stillborn baby. A stillbirth certificate can be issued by a midwife or medical practitioner.

The process can be confusing for those not familiar with form filling and paper work. The local health board area usually supplies the forms. It would be more convenient if local arrangements were in place to support other professionals in any situation when the midwife was not available Recommendation: Contact your local midwife to discuss how birth notification within an emergency maternity care situation may be dealt with by other team members in her absence


• The birth before 24th week of pregnancy of a baby who did not breathe or show signs of life after complete expulsion from its mother is neither a live nor a stillbirth and need not be registered. The parents, however, may want to have a funeral service and local arrangements are required between the Registrar and the funeral undertaker.

Visit: http://www.readysteadybaby.org.uk/first-days-together/first-days/registering-the-birth-of-your-baby.aspx http://www.gro-scotland.gov.uk/regscot/registering-a-birth.html

Statutory Records

• Ask the midwife in your team to discuss birth notification and other records.

• The team members should come to a local arrangement about how statutory records can be completed in emergency maternity care situations.

Duty of Care All professionals working within the healthcare system owe a duty of care to patients/clients because of their job, e.g.: “You must be able to demonstrate that you have acted in someone’s best interests if you have provided care in an emergency” “You must make referral to another practitioner when it is in the best interests of someone in your care.” “As a professional, you are personally accountable for actions and omissions in your practice and must always be able to justify your decisions” (The Code: Standards of conduct, performance and ethics for nurses and midwives, NMC 2008)

http://www.readysteadybaby.org.uk/first-days-together/first-days/registering-the-birth-of-your-baby.aspx

http://www.readysteadybaby.org.uk/first-days-together/first-days/registering-the-birth-of-your-baby.aspx

http://www.gro-scotland.gov.uk/regscot/registering-a-birth.html


Health professionals will feel they have an ethical duty of care to the unborn baby. This is not an issue when the welfare of the woman and baby are compatible. However, in rare cases it may become an ethical dilemma if there is a conflict between the needs of the baby before birth and the needs of the woman. Legally the duty of care is firstly to the woman.

Ethical and Cultural Issues Professionals assisting at emergency maternity care situations should be aware that women from a variety of cultural backgrounds could be involved. It is sufficient at present to highlight that all women should be given as much privacy as required and to take care not to expose the woman’s body unnecessarily. Specific cultural issues need to be addressed. Ethical issues can complicate emergency maternity care situations. At times these may cause dilemmas for some professionals attending the situation. The common situations are listed below:

• Labour and birth occurring around the age of viability i.e. 24 weeks gestation.

• The woman refusing transfer or treatment. • Issues surrounding resuscitation of the baby.


Once you have studied this section you can now complete the 1st quiz. The Quiz will take you about 10 minutes to complete and then send it to your local course coordinator. Good Luck! Quiz No. 1 - Multi-Professional Team Approach Candidate Name: Date: Instruction: Please answer all questions. Tick only 1 answer TRUE/FALSE True False Question 1 The term ‘emergency in maternity care’ means a sudden, unexpected event relating to the health or condition of a woman or baby, which requires immediate attention.

Question 2 The law states that only a registered midwife or medical doctor may attend a woman in childbirth.

Question 3 Other individuals attending a woman in childbirth may be prosecuted.

Question 4 Employers and midwives are breaking the law if they arrange for and substitute other individuals to act in the capacity as midwife.

Question 5 In the absence of the midwife and medical practitioner, other professionals are required to demonstrate that they have acted in the woman’s best interest.


True False Question 6 Women still need to consent for any care and procedures even in an emergency situation.

Question 7 The current age of viability of the fetus is 24 weeks gestation.

Question 8 Individuals are responsible for any acts and omissions in their practice and must be able to justify their actions.

Question 9 Practitioners should always work within the scope of practice defined by the relevant governing bodies.

Question 10 The law states that all births (born alive or stillborn) need to be notified to the medical officer within 36 hours.


CHAPTER 2 ABOUT PREGNANCY

Introduction Pregnancy and childbirth is a normally occurring event for women. The woman’s body needs to adapt to support normal growth and development. Some changes are obvious such as physical appearance in shape and size. However, other changes can alter the way the body normally works. The changes are often dramatic and normally occur early in pregnancy and last until the birth. The changes cause the body to perform differently from the non-pregnant state. Therefore, it is important that anyone dealing with pregnant women has basic knowledge of these changes and how they can affect the woman. The placenta is an organ specific to pregnancy. It produces hormones to maintain pregnancy and nourish and oxygenate the baby. It is not essential for you to know the names of the hormones. However, it is essential for you to know that if anything happens to the placenta then both pregnancy and the life of the baby are at risk. It is important to know about any specific changes, which affects the way the woman’s body may function differently in an emergency situation. Only the main changes are presented below:

1. Cardiovascular system – circulation of blood and function of the heart. 2. Musculo-skeletal – joints.


Learning Outcome This section provides basic information about the development and progress of pregnancy. The focus is on normal uncomplicated pregnancy through the stages in development until term. On completion of this section the professional will demonstrate an appropriate knowledge of the normal development of pregnancy. Information about the following related issues are covered to enable this outcome to be achieved:

• The maternal changes of pregnancy. • Normal development and progress of pregnancy.

The relevance of this information to you:

• It provides you with an explanation about the main changes, which make a pregnant woman function and perform differently from the non-pregnant woman.

• It also provides you with an overview of the developments expected at each stage of pregnancy.

At times, some points are supported with additional information of interest. This has been included to provide you with a fuller explanation. A summary of the key points relevant to you as an emergency professional will be provided at the end of the relevant section.


Cardiovascular System This system includes the blood, heart and circulation. Blood Volume Blood volume in the healthy non-pregnant woman is about 5 litres. This volume increases by approximately 40% during pregnancy. The majority of the increase goes to the uterus (of which 80% will go to the placenta). An important change to note is the increase in platelets and other factors involved in blood clotting. The change results in a reduction of 4 minutes in the clotting time of blood during pregnancy and childbirth. NB: This means that the blood of pregnant women clots significantly quicker than non-pregnant women. This change to clotting time can reduce blood loss in times of haemorrhage. However, it can result in women also being more prone to the formation of small blood clots (especially if they are immobile or remaining in the same position over a period of time). Heart Function (or Cardiac Function) Cardiac output increases by about 40%. There is a small increase in heart rate by about 10–15 beats per minute. Later in pregnancy the growing uterus may displace the heart upwards and to the left due to the enlarging uterus. Blood Pressure (BP) Overall BP stabilises as pregnancy progresses. Postural Hypotension Pregnant women are more susceptible to postural hypotension. This is a lowering of blood pressure owing to the position of the woman. On standing upright the blood pressure may drop suddenly and women may feel light-headed or actually faint. This is a common problem and prevention is the best cure.


What you can do to avoid this is presented below. Action necessary:

• You can advise women to make sure they always change their body position slowly.

• If women are in the lying position, you can advise them to gradually change position to the sitting position before standing up.

Supine Hypotension When women lie on their back (dorsal) and face upwards (supine), then this position results in a reduction in blood pressure (BP). The reduction in BP is due to the weight of the uterus and the baby pressing on the large blood vessels returning blood to (inferior vena cava) and from the heart (aorta). This results in a reduction in maternal blood flow which in turn reduces maternal BP. This also means a reduced blood supply to the placenta and to the baby.

ACTION YOU NEED TO TAKE: Always discourage women from lying in the supine position from mid pregnancy onwards You should always encourage the woman to adopt an alternative safe position Examples are shown below:

• Lateral (side lying). • Upright or semi-upright. • Learning forward positions (including the woman being on all

fours)


Musculo-Skeletal System Ligaments and connective tissue become more lax especially in late pregnancy. Joints are at risk from lax movement and dislocation. The joints more at risk include:

• Joints in the vertebral column. • Pelvic and hip joints including symphysis pubis.

You should always take care when moving and positioning the woman

Other Changes of Interest The respiratory system changes are mainly physical due to the increasing size of the uterus. The thoracic cavity changes shape, mainly splaying of the lower ribs and the diaphragm displaced by up to 4cm. This can result in a change in the woman’s breathing pattern.

Additional reading: MacDonald S Magill-Cuerden J (eds) (2011) Mayes’ Midwifery A textbook for Midwives, 14th Edition. Bailliere Tindall, Edinburgh


Summary of Key Points about the Changes of Pregnancy and Implications for the Emergency Professional Changes of Pregnancy Implications for the

Emergency Professional Blood Volume Increases by approx.

40%. (80% of the increase is to the placenta)

Increased heart rate (10 - 15 bpm) Increased cardiac output and venous return

Clotting Time Decreases i.e. the blood clots more quickly

Avoid immobility The woman is at risk from venous thrombosis

Hypotension Postural and supine Avoid maternal positions that lower blood pressure and reduce blood flow to the placenta

Placenta The main organ for keeping the baby alive in the uterus

Avoid maternal positions that may reduce blood flow to the placenta

Joints and connective tissue

Laxity of joints and softening of connective tissue

Take care when changing the woman’s position, moving and transfer

Pregnancy and Progress Emergency situations can occur during any stage of pregnancy. You require information about the stages in development to help you to accurately assess any emergency maternity care situation arising. Estimated date of delivery (EDD) is the date expected for the baby to be born. Women and family are usually well aware of this date and can often quote the number of days, weeks or months until the baby is due.


Essential Information You Should Know

• The length of pregnancy is about 40 weeks (and usually called ‘term’)

• Women are deemed to be at low risk if they come within the following criteria as stated in Keeping Childbirth Natural & Dynamic programme:

Healthy women Singleton pregnancy Cephalic presentation

(head coming first) Labour is spontaneous Labour occurs between 37

weeks and 40 weeks plus 10 days

Primigravidae or multigravidae (of less than 5 babies)

• Emergency situations occurring between 24 and 36 completed weeks would be premature or pre-term. These situations are not within normal range and medical assistance or transfer to a specialist unit would be required

• Emergency situations occurring before 24 weeks should be referred to a medical practitioner or transferred to a specialist unit. Week 24 is the age of viability (see below):

o The age of viability is determined by law and is currently 24 weeks gestation. This means that babies born at or after 24 weeks are expected to live and are capable of surviving. Before this viable age babies are not expected to be capable of life or surviving (although some babies may live). If pregnancy does not continue then this pregnancy loss is termed as a ‘miscarriage’.

http://www.healthcareimprovementscotland.org/our_work/reproductive,_maternal__child/programme_resources/keeping_childbirth_na


Classification of Pregnant Women The term ‘parity’ refers to the number of times a woman has given birth. Women are classified by parity during pregnancy. Parity includes the number of times the woman has given birth plus the number of times she has previously been pregnant (resulting in a miscarriage). Women are usually familiar with these terms and may refer to them when giving you information. This information may help you to make an overall assessment about labour and birth times. Women giving birth for the first time usually take longer to go through the stages of labour and childbirth compared with women having subsequent births.

Examples of Parity Para 1 + 0 – this refers to a woman who has had one previous birth and no other pregnancies. Para 2 + 1 – this refers to a woman who has had two births and one pregnancy ending in miscarriage before 24 weeks gestation.

Primiparous - refers to a woman giving birth for the first time Multiparous - refers to a woman giving birth to her second or subsequent birth Grand multiparous - refers to a woman who has given birth at least four times before


Development and Progress of Pregnancy Visit:

Pregnancy is divided into three trimesters (phases):

• First trimester or early pregnancy – conception until 14 weeks. • Second trimester or mid pregnancy – from 14 weeks until 28 weeks. • Third trimester or late pregnancy – from 28 weeks until term.

During pregnancy the uterus is expected to grow at a predicted rate. First Trimester (Early Pregnancy)

• Early pregnancy is mainly a developmental phase.

Any emergency occurring during the first trimester (early pregnancy) is regarded as being an obstetric or medical emergency Do not leave the woman and get someone to assist you You will be expected to summon medical assistance immediately and arrange transfer to a specialist unit

http://www.readysteadybaby.org.uk/timeline/


Second Trimester (Mid Pregnancy)

• The uterus is growing and appears as a small ‘bump’. • The woman can feel the first movements of the baby around 16-20 weeks

for a first baby and earlier for subsequent pregnancies. • Braxton Hicks (practice) contractions may be felt around 28 weeks.

Third Trimester (Late Pregnancy)

• The uterus is expanding – usually the woman is obviously pregnant.

In the last four weeks of pregnancy:

• The uterus is usually reaching to the woman’s breastbone. • Normally the baby should be lying with his head down in the lower end of

the uterus (towards the pelvis). All other ways for the baby to lie are abnormal i.e. breech (bottom first).

Any emergency occurring during the second trimester (mid pregnancy) is regarded as being an obstetric or medical emergency Do not leave the woman and get someone to assist you You will be expected to summon medical assistance immediately and arrange transfer to a specialist unit

An emergency occurring between 28 and 36 completed weeks is regarded as being an obstetric or medical emergency Do not leave the woman and get someone to assist you You will be expected to summon medical assistance immediately and arrange transfer to a specialist unit


The woman will experience:

• ‘Lightening’ when the baby’s head moves down into the pelvis. • Engagement of the head occurs. • Braxton Hicks contractions on a regular basis.

Labour occurring after 37 completed weeks gestation will normally be regarded as being within the normal range for labour and birth unless there is evidence to suggestion a complication Do not leave the woman and get someone to assist you If uncomplicated then in the first instance you will be expected to summon the midwife. In the event of the midwife not being available then you will be expected to summon medical/paramedic assistance Transfer arrangements will need to be considered If there are complications then summon medical assistance immediately and arrange transfer to a specialist unit


How Pregnancy May Affect Women Pregnancy can affect women in the following ways:

• Physical The changes in physical appearance are usually obvious and the other changes have been presented earlier in the section.

• Psychological Women and partners need to adjust to the changes in their roles and responsibilities because of the new baby. This can also increase their levels of anxiety.

An emergency situation can add to these factors especially if the woman: • Is in early or mid pregnancy and the baby is at risk. • Still has several weeks until her EDD. • Does not feel she is coping with the contractions or pain. • Feels unsupported during this time. • Or her partner feels that they are responsible for the emergency situation.

This can have an extended psychological impact even if the outcome is satisfactory.

You should be aware of how women and their partners are feeling and try to support and reassure them through the situation.


Summary of Key Points: Normal Development of Pregnancy Key Point Comment Implication for Emergency

Professional Term

About 40 weeks This is the normal gestation for pregnancy.

Women deemed to be ‘low risk’

Healthy. Singleton pregnancy. Cephalic presentation. Labour is spontaneous. Labour occurs between 37– 40 weeks + 10 days. Primigravidae or multigravidae (less than 5 babies).

Obtain this information from the woman or partner to help with risk assessment. If the woman meets the criteria then she will be regarded as being in the ‘low risk’ (Green maternity pathway) category. This means that there is a low risk for any complications arising.

Preterm

Before 36 completed weeks.

This is out with normal range. (Red maternity pathway) Risk factors are present for the baby.

Viability

24 weeks Pregnancy loss before this gestation is called a miscarriage.

Multiparous Describes a woman giving birth for a second or subsequent time.

Usually each stage of labour is quicker. There is usually time to transfer in early labour. There is less time to transfer if labour is progressing. Prepare for the birth.


Key Point Comment Implication for Emergency Professional

Grand multiparous

A woman who has given birth four or more times.

Usually each stage is a lot quicker. Be prepared for a quick labour and birth. There is usually no time to transfer. Get immediate assistance.

First trimester (early pregnancy until 14 weeks)

Early development. All maternal changes are present.

Risk factors are present. Do not leave the woman. Get assistance. Summon medical assistance and arrange transfer.

Second trimester (middle pregnancy until 28 weeks)

Movement is felt. Braxton Hicks contractions may be felt around 28 weeks.

Preterm labour and birth. Risk factors are present. Do not leave the woman. Get assistance. Summon medical assistance and arrange transfer.

Third trimester

Between 28 and 36 weeks Labour presents before 37 weeks – this is preterm and risk factors are present. Do not leave the woman. Get assistance. Summon medical assistance and arrange transfer.


Key Point Comment Implication for Emergency Professional

Third trimester or Term

Between 37 and 41+ weeks. Normal presentation (baby) is lying head down in the uterus

Engagement (head) occurs – lightening.

If complications are present.

If labour presents with no complications at this point then this is regarded as being within the normal range for labour and birth. This is ‘low risk’. (Green Pathway) Summon the midwife. Do not leave the woman. Get other assistance. Transfer may be considered. Then summon medical assistance and arrange transfer.


Once you have studied this section you can now complete the second quiz. The quiz will take you about 10 minutes to complete and then send it to your local course coordinator. Good Luck! Quiz NO. 2 – About Pregnancy Candidate Name: Date: Instruction: This quiz contains questions to help you assess your

awareness of some issues associated with pregnancy. MULTIPLE CHOICE Tick only 1 answer Question 1 Women placed in the supine position are prone to: An increase in blood pressure A decrease in blood pressure Question 2 During pregnancy the joints and connective tissue: Become more lax Remain unchanged Become stiff Question 3


During pregnancy the heart rate can: Increase between 10 and 15 bpm Decrease between 10 and 15 bpm Remain unchanged Question 4 During pregnancy, the volume of blood: Decreases by 10% Increases by about 40% Increases by 10% Decreases by 40% Question 5 Which one of the following maternal positions should be avoided during late pregnancy: Side lying Upright Supine On all fours Question 6 During pregnancy, blood will clot: Significantly quicker than non-pregnant women Significantly slower than non-pregnant women Remains unchanged Question 7


In an uncomplicated pregnancy the blood pressure is more likely to: Stabilise as pregnancy progresses Increase as pregnancy progresses Question 8 The current age of viability of the baby (fetus) is: 26 weeks gestation 24 weeks gestation 22 weeks gestation 25 weeks gestation Question 9 In an uncomplicated pregnancy, women are deemed to be at ‘low risk’ if labour occurs between: 33 and 35 weeks + 3 days 30 and 34 weeks + 3 day 32 and 36 weeks + 3 days 37 and 41 weeks + 3 days Question 10 A woman giving birth for the first time is described as being: Primiparous Multiparous Grand multiparous


CHAPTER 3 RISK MANAGEMENT AND RISK ASSESSMENT

Risk Management: Introduction Risk assessment is an integral part of all health care providers role and is encompassed within clinical governance. Within this course we are now looking at how to apply this knowledge to the obstetric emergency. The Expert Group on Maternity services report 2002 (http://www.sehd.scot.nhs.uk/publications/egas/egas-05.htm) recognised that practitioners in Scotland needed to have relevant knowledge and skills in risk management. The report states that services should ensure that practitioners in community maternity units (CMUs) and remote and rural locations gain access to training on skills related to risk assessment and management.

What is Risk Management? Risk management is a means of reducing the risks of adverse events occurring by systematic assessment and review of risk factors and to seek ways to prevent their occurrence. This takes place in the clinical setting taking account of both clinical and non-clinical factors. Individuals requiring care should be subject to as little risk as possible and appropriate action should be taken to ensure all risk is minimised.

http://www.sehd.scot.nhs.uk/publications/egas/egas-05.htm


How Does This Relate to Emergency Maternity Care? The Keeping Childbirth Natural and Dynamic (KCND) pathways for maternity care recognise that pregnancy and childbirth are normal physiological processes and most women have the ability to have a normal birth. The pathways also recognise that women require to have a continuous risk assessment throughout pregnancy, labour and the postnatal period as risk status is dynamic and may change over time.

Midwives in partnership with women carry out the process of risk assessment on a daily basis. Moreover the non-clinical issues involved in risk management in remote locations are acknowledged within the EGAMS report (SEHD 2002). This report highlights that risk assessments carried out in clinical areas have tended to concentrate on clinical issues such as general medical and surgical health and obstetric history. These are unquestionably important, but consideration must also be given to non-clinical factors, such as:

• Geography and predicted weather conditions. • Nature, condition and use of available emergency equipment. • Nature of emergency back up and support. • Transfer arrangements.

These issues and training schemes have already been addressed in many areas of the world where there are large remote and rural geographical areas such as Australia. While the guidelines may differ from those we may use they are interesting in the context of rural practice.



Learning Outcomes On completion of this section the non maternity healthcare professional will be able to:

• Demonstrate an appropriate knowledge of risk management in relation to emergency maternity care.

• Describe risk factors and demonstrate appropriate knowledge to carry out risk assessment.

• Distinguish between normal and emergency situations. (This outcome links closely to ‘Assessing the Emergency the Situation’ within Chapter 5 on ‘Emergency Labour and Birth [No Complications]’).

This section also links closely to the following two outcomes dealt with in the Chapter on ‘Referral and Transport’.

• Demonstrate appropriate knowledge to utilise care pathways for emergency situations.

• Refer and transfer appropriately.

Risk Factors There is no such thing as zero risk for women who are pregnant or giving birth – an element of risk applies to all pregnancies and childbirth (SEHD 2002) http://www.sehd.scot.nhs.uk/publications/egas/egas-05.htm Risk factors are identified from all the areas that the practitioner takes into account when making decisions about the appropriate management of care for the woman. These areas include obstetric, medical, social, environmental and geographical as well as the maternal perspective of the woman and family. Obstetric and medical risk factors:

• Gestation of pregnancy. • Multiple pregnancy. • Health in this pregnancy. • Maternal and fetal well being. • Previous existing medical conditions. • Previous or current obstetric complications.



There are only a few examples, this will be discussed in more detail under risk assessment and further examples can be seen by clicking on this link: http://www.sehd.scot.nhs.uk/publications/egas/egas-05.htm to that chapter in the EGAMS Report. Social and maternal risk factors:

• Lifestyle issues, i.e. smoking, alcohol, drug intake etc. • Domestic environment. • Age. • Weight. • Family issues. • Maternal choice.

Environmental and geographical:

• Distance from clinical setting. • Distance from referral centre. • Availability of mode of transfer, i.e. ambulance, air ambulance, ferry,

lifeboat. • Ease of access to the patient. • Weather conditions.

Additional Reading: Wilson J, Symon A (eds) (2002) Clinical Risk Management in Midwifery: The right to a perfect baby. Butterworth-Heinemann



The focus of this activity is the environmental and geographical issues pertinent to your own service locality. Consider your local area. What is the distance of your areas from the nearest clinical maternity setting? Nearest clinical maternity setting: _______________________________________________________________ Distance in miles:_________________________________________________ Describe the geographical terrain including any known geographical obstacles: _______________________________________________________________ _______________________________________________________________ Distance you are situated from the nearest referral centre (if different from the above): ______________________________________________________________ What modes of transfer are available in your area: ______________________________________________________________


How long would it take for the available modes of transport to be arranged: _____________________________________________________________ _____________________________________________________________ Identify any obstacles involved with the available mode of transport including ease of access: ______________________________________________________________ ______________________________________________________________ Describe the range of weather conditions in your area: ______________________________________________________________ ______________________________________________________________ Identify the way the range of weather conditions can affect the emergency situation: ______________________________________________________________ ______________________________________________________________ Try to identify other non-clinical risk factors for your area: ______________________________________________________________ ______________________________________________________________ Detail any other information you require about the risk factors in your locality: ______________________________________________________________ _______________________________________________________________


Risk Assessment Risk assessment is the process carried out by the professional who finds him or herself in a potential emergency care situation. This process is divided into three stages:

• The initial assessment. • The primary assessment. • The secondary assessment.

Initial Assessment The initial assessment is a key process that has to be done before you can decide how to manage the patient. Initial assessment is based on:

• The scene. • The history of the accident or illness. • The examination of the patient.

Primary Assessment If the woman has been subjected to a major force or appears seriously ill then a primary assessment will be carried out: remember domestic violence was reported in 14% of women who died in the most recent Confidential Enquiry Maternal and Children’s Health:

This assessment may make clear whether this is primarily an obstetric emergency or an emergency involving a woman who happens to be pregnant, this will be important in deciding on transfer and referral


Airway Breathing Circulation Disability (neurological

assessment) Exposure and environment Fundal height (below umbilicus

is unlikely to represent viability) NB: You need to get this point quickly!

What is the presenting problem? For example, bleeding, contractions, ruptured membranes, etc. When carrying out the primary assessment then remember to take into account the physiological changes in pregnancy (refer to ‘Maternal Changes’ in Chapter 2 ‘About Pregnancy’).

Secondary Assessment

• What is the presenting problem? • Emergency or potential emergency? • DO YOU NEED HELP STRAIGHT AWAY?

If the woman has been receiving care during this pregnancy, ask to see her ‘maternity hand-held records’ You will want to gain the following information about the woman from these records.

• Medical history – is there any significant medical history? • Obstetric history – e.g. is there a history of preterm birth, instrumental

delivery, caesarean section, bleeding in pregnancy or in the postnatal period.

• Information about next of kin and the social support available.

If the woman is mobile and responsive the primary assessment is achieved by talking to the woman and the secondary assessment can be commenced

http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2010.0


• Attendance for care during this pregnancy – has there been regular care, has there been any problems?

• Hospital admissions – if admitted, what was the problem? Did it resolve? • Maternity unit for referral – in an emergency will transfer to nearest

referral centre but this can be useful for additional information concerning the woman.

• Blood results taken during this pregnancy – are all results within normal range? Is the rhesus factor negative or positive?

• When the baby is due – is the baby of viable gestation, how many weeks pregnant is the woman?

If these notes are not available the important information you can gain from the woman or companions includes:

• Name. • Address. • Date of Birth/Age. • Lead professional this pregnancy/referral unit (see referral pathway). • When is the baby due? • Health during this pregnancy. • History of previous pregnancies and births (e.g. normal or caesarean,

were they early?). • Medical history. • Medications or drug intake/smoker? • Assessment of present state of health.

• Blood pressure use non-automated sphygmomanometer for initial reading

CMACE (2011). • Temperature. • Urinalysis – dysuria? Increased frequency? • Pulse. • Pain – where, intensity, constant, intermittent, onset? • Has the woman felt the baby move today? (Reduced or absent fetal

movements are significant). • Vaginal bleeding – quantity (relate to soaking of sanitary towel). • Vaginal discharge (different to normal during this pregnancy). • Nausea, vomiting. • Oedema.

Remember results within the normal range do not preclude problems due to physiological differences in pregnant women


Remember the woman and her partner may be very anxious and will require your support and ongoing explanations of the plan for her care. Document all findings, including:

• Times. • Referrals. • Discussions re: what care, with who and when.

Using the information above and the referral pathway, design a risk assessment and referral form that applies to your local area.

Sample Transfer Guidelines 1. Ensure referral pathway is completed.

2. Ensure that documentation is complete and is transferred with the woman.

3. If the woman is visibly pregnant (greater than 20 weeks) then place in left

side-lying position (lateral).

4. If the woman is in labour then take incubator/hot box – if none available then use hot packs and blankets.

5. Take neonatal resuscitation equipment.

6. Monitor the woman.

7. Cannulate, if appropriate, prior to transfer – use a minimum 14/16 gauge cannula.

8. Administer fluids as advised by consultant led unit (CLU).

9. Note the time of departure and inform the CLU when leaving.

If your findings indicate that this is a possible obstetric emergency then follow the referral guidelines for immediate advice re: care and preparation for transfer


Referral Pathway (Sample)

TIME 1. Identify risk – follow risk assessment

2. Call second professional (as per local agreement)

3. Ambulance referral Call:

4. Contact CLU (referral centre) Call:

5. Liaise with senior registrar or consultant Obstetrician (and or paediatrician as appropriate) Contact senior midwife at CLU labour ward Contact neonatal transfer service if required Call:

6. Prepare for transfer (see Guideline)

7. Give full explanation to mother/family

8. Document reason for transfer

9. Contact relatives

10. Appropriate professional to escort (monitor vital signs if practical)

11. Full case notes to accompany mother

12. Document time of departure

13. Document time of arrival at CLU

14. Complete critical incident form


CHAPTER 4 ABOUT LABOUR

The Process of Labour and Childbirth: Introduction Assisting a woman in the birth of her baby in an emergency situation is one of the opportunities to be involved in a happy event. ‘Mother Nature’ is normally kind and the event is usually uncomplicated resulting in a positive outcome. Women and their families often need reassurance and support at this time. This section will deal with the processes involved in uncomplicated labour and childbirth. It is essential to have knowledge of the sequence of events occurring and to assist appropriately in an emergency situation. In an emergency situation the following criteria together decide that women are ‘low risk’ (HIS 2009 ) Visit:

This means that the risk factors for the women who meet the criteria are deemed to be low for developing complications. Midwives will normally provide the care for these women during pregnancy and childbirth.

• The woman has remained healthy in all respects.



• The pregnancy has remained healthy in all respects. • Labour has started spontaneously. • Labour has commenced between 37 weeks and 40 weeks plus 10 days. • The baby is lying with the head down in the pelvis.

Labour is expected to progress to a normal birth with no complications for mother and baby. To be able to assess and deal with an emergency maternity situation you will need to obtain the following information about labour and childbirth:

• Knowledge of the sequence of events occurring. • Understanding of the related terminology. • The implications of the findings of the situation.

This section is about labour and childbirth issues occurring within emergency maternity care situation. The information provided will help you and other members of the multi-professional team to:

• Recognise if the woman is in the low-risk category (Green Pathway). • Recognise that labour is uncomplicated and normal. • Have a clearer understanding of what team members are expected to do

for the woman. • Have a clearer understanding of what team members are expected to do

for the baby at birth. Have a clearer understanding of what team members are not expected to do for the woman and baby.

Learning Outcome This section provides basic information about the processes involved in labour and childbirth. It is based on the sequence of events related to any straightforward uncomplicated labour and birth situation. On completion of this section the professional will demonstrate an appropriate knowledge of the processes involved in uncomplicated labour and birth. The following related issues are covered to enable the learning outcome to be achieved:

• Information about labour. • Signs of labour. • Stages of labour.


• Maternal positions for labour.

To some extent key issues are addressed. However, additional information is provided in other sections to give the participants a fuller understanding of the situation.

NB: The section does not include the practicalities of dealing with an emergency situation. This information will be dealt with separately in the section covering ‘emergency labour and birth’


About Labour Women and partners are usually familiar with terminology related to labour and birth. They may refer to this terminology when providing you with information about the pregnancy. Therefore, a fuller explanation of some of the main terminology related to labour and birth is provided in this section. Labour progresses through three well defined stages as described below. It is important that as an emergency carer you are aware of what is happening in each of these stages. This will help you make decisions about how to deal with the emergency situation.

• First stage of labour: This stage occurs from the onset of regular uterine contractions until the cervix (neck of the womb) is fully opened. It can last from as little as a few minutes to many hours. The length of the first stage varies considerably. In women having their first baby it can last between 8 and 12 hours. It can last up to 6–8 hours for women having subsequent babies (the length for women usually reduces with each subsequent baby). Very rarely a woman can have precipitate labour where contractions and birth occur within an hour.

• Second stage of labour: This stage lasts from when the cervix is fully opened until the baby is born. The length of first stage varies considerably. It can last between 1 and 2 hours for women having their first baby and up to 30 minutes for women having a subsequent baby.

• Third stage of labour: This stage lasts from birth of the baby until the

placenta and membranes are delivered and bleeding is controlled. Again the length of this stage varies. It can take between 5 and 60 minutes for women whether it is a first or subsequent birth.

The duration of labour depends in part whether the woman is going through her first or subsequent labour. The process of labour and birth usually takes longer for women having their first baby.

NB: This is important information to consider when you are deciding if there is time to transfer the woman before the birth


Uterine Contractions Uterine contractions will open the cervix (the neck of the womb) to allow the baby to enter and pass through the birth canal for the birth. A uterine contraction follows the following distinct pattern detail below:

• Initial build up of contraction. • The contraction reaches a peak. • The contraction eases off. • The uterus relaxes

The uterus must get a chance to relax between contractions. It is during this period that the baby gets oxygen and nourishment from the placenta. The woman can readily feel the contraction which has the following characteristics. Characteristics of Uterine Contractions

• Causes the uterus to become firm. • Starts in the fundus (top section of the uterus). • Spreads across and downwards to all parts of the uterus. • Lasts longest in the fundus where it is most intense. • Fades from all parts together. • Disappears and the uterus becomes soft.

You will be able to feel the contraction if you lightly place your hand on the woman’s abdomen (this can be felt through the woman’s clothes). Contractions are usually assessed over a ten-minute period and described in relation to:

• How often the contractions are occurring (frequency). • How long the contractions are lasting (length). • How strong the contractions feel (strength). • How consistent the contractions are (regularity). • How is the woman coping with the contractions over this period.


Braxton Hicks Contractions This type of contraction tends to be called a practice contraction. They do not indicate labour has started although these can easily be mistaken for labour. These contractions are:

• More noticeable in late pregnancy. • Tend to be painless (or with varying degrees of discomfort or pain). • Usually irregular and can last between a few seconds and about one

minute.


Signs of Labour The signs that labour has started can be obvious or can be difficult to assess. It is important to get as much information as possible from the woman or her partner to assess whether she is in labour or not. The woman and partner will probably be anxious so you should stay calm. Possible Signs of Labour There are common signs that the woman may report to you. The woman may report one or more of the signs:

• Show. • Membranes ruptured or ‘waters breaking’. • Abdominal cramps/backache. • Contractions.

Information you may obtain from the woman:

• The appearance of a mucousy vaginal discharge (show) found on one or more occasions. This may be pinkish, reddish brown in colour or heavily blood stained.

Implication:

• The appearance of show indicates that the cervix (neck of the womb) is stretching and opening. It does not indicate that labour has started especially if there are no other signs.

• If show is associated with abdominal cramps, backache or mild contractions then it usually indicates that labour is either in the early stages or will start in the near future. It s common to find show at some stage during the labour although it may not be visible until nearer the birth.

‘Waters Breaking’ or Rupture of Membranes: Information you may obtain from the woman:

• A sudden gush or trickle of fluid is reported, which the woman could not control. This is usually clear in colour. (If the fluid is green or brown this is likely to be meconium stained liquor. Further details and discussion about meconium can be found on page 137 of chapter 9) Implication:

• This usually indicates that the membranes have ruptured. Again, this does

not indicate that labour has started unless it is associated with other signs such as contractions.


• If the woman has been contracting then she may feel that the contractions have become stronger. Labour will normally progress to the birth.

Abdominal Cramps/ Backache: Information you may obtain from the woman:

• The woman may report regular or irregular episodes of lower abdominal cramps and/or low back pain.

Implication:

• This usually indicates that the cervix is stretching and the woman is in early labour.

• These episodes may progress to become regular and more painful or they may subside.

Contractions: Information obtained from the woman:

• Women or their partner usually provide a good description of contractions in relation to when they started and how painful they are. However, the carer should be able to assess if the labour is true or false.

NB: In the event of the woman not being in labour but with ruptured membranes then you will need to notify this to the midwife or medical staff Reason for this – intact membranes provide a barrier against infection. Once the membranes have ruptured then the baby and uterus are exposed to the risk of infection Labour will need to be induced by the obstetrician if the woman does not go into spontaneous labour within 24–36 hours (the timing depends on local obstetric protocols)


True or False Labour: False labour occurs in many women. The contractions may be painful and may even be regular for a time. The woman often feels she is in labour and calls for assistance. The contractions will ease off after a time and no progress will be made. Implication:

• It is only time that will confirm that the woman is not in labour. In situations like this then the woman and her family must be reassured and supported as if can often be distressing for women to be told that labour has not started.

• In true labour, contractions are effective and are opening the cervix (neck of the womb). This is assessed by a vaginal examination and the woman will normally progress to the birth.

Normal Progress in Labour and Birth About First Stage of Labour – Normal Progress Women usually complain of backache or low abdominal cramps. This pain is described as radiating into the small of the back and then over the uterus. These progress to contractions.

Midwives and medical practitioners are the only professionals eligible to undertake a vaginal assessment. NB: Other members of the multi-professional team are NOT expected to do this – it is not within their scope of practice


Contractions in Early Part of First Stage of Labour

• Usually occur every 15–20 minutes and may last for about 30 seconds. • Fairly weak and may even be undetected by the woman as being

contractions. • Usually occur with regularity. • Over time the interval between the contractions reduces and the length,

strength gradually increases. • Women usually are very uncomfortable during contractions • Cervix is opening (dilating) - *information only

• Show may be present. • Membranes may rupture spontaneously. • Back pain may also be experienced. • Reassurance and support is required.

Contractions in Later Part of First Stage of Labour

• The time interval between contractions gradually reduces while the length and strength gradually increases.

• Pain experienced by women is usually intensified as the contractions become stronger and longer.

• The woman is usually requiring pain relief – information only*.

*You will not be expected to make this vaginal assessment. Only midwives and medical practitioners can assess the woman in this respect

Normally there is time to transfer the woman to a specialist unit for the birth. Factors you need to consider when making the decision are:

• Whether it is the woman’s first or subsequent baby • Traveling time • Geography • Weather conditions. • Availability of transport


• Cervix is progressing to full dilatation*. • Show may be present. • Membranes may rupture spontaneously. • The woman needs a lot of reassurance and support to cope.

By the end of the first stage the contractions may be occurring every 2–3 minutes lasting for about one minute and are usually strong and feel powerful. Women usually become increasingly anxious and distressed as the first stage of labour progresses. Pain relieving methods, reassurance and support are normally required to help the woman to manage her pain.

*You will not be able to administer pain relief unless it is within your scope of practice. You will be expected to support the woman during this time – reassurance, massage her lower back, change her to a more comfortable position, etc

In the later part of the first stage the possibility of transferring the woman is considerably reduced Factors, which may make the transfer possible include:

• It is the woman’s first baby • Someone in the team can remain with the woman on transfer • Transfer and transport can be arranged immediately • Weather conditions are favourable • Short traveling distance (less than 30 minutes)

If in doubt – get assistance and prepare for the birth Transfer the woman and baby afterwards, if required


About Second Stage of Labour – Normal Progress The pain becomes more intense and more frequent. The woman’s demeanour changes, she becomes more agitated and sweat can appear on her face and her pulse rate may increase. Second Stage of Labour

• Contractions usually occur 2–3 minutes apart. • They are more expulsive in nature and feel powerful. • She has a strong urge to push. • The woman may want to move her bowels (this is caused by the baby’s

head pressing on her rectum). • The perineum is usually bulging as the head advances. • The anus is gaping with the pressure of the head. • The baby’s head may become partly or fully visible in the birth canal (see

Fig 1, page 70) • Often the head will recede when the contraction tapers away. • This will continue until the head no longer recedes but remains at the

vaginal opening. When this happens then crowning of the head has occurred.

• At this point, the birth is imminent and the woman may be agitated due to the sensation of the head sitting at the vulva.

• The head will be born and may sit here like this for one more contraction. • The body is usually born with one contraction.

It is difficult to put an actual time scale on this stage. It varies across women and may last from a few minutes to one-to-two hours.

• Women having their first baby usually take longer in this stage, possible one – two hours.

• Women having their second or subsequent baby can have this stage completed in a few minutes.


About Third Stage of Labour – Normal Progress The baby is born (time noted) but the uterus continues to contract and the placenta becomes detached from the uterine wall. The walls of the uterus clamp together to stop bleeding and seal the blood vessels left exposed by the separated placenta. This information is only provided to give the participant a fuller explanation of what is happening in the woman’s body at this time. Under normal circumstances bleeding is minimal at this time. Any persistent fresh trickle or brisk bleeding is not normal. This will be discussed in Chapter 7 ‘Dealing With an Emergency Situation’.

The placenta becomes separated from the uterine wall and moves into the birth canal. The woman can feel this or it can be seen at the vulva. Signs to indicate the placenta has separated are:

• The woman has the urge to push down. • The placenta can be seen sitting at the vulva.

Put the baby to the breast if the woman has a contraction she can be encouraged to push out the placenta herself. Reassure the woman and explain to her what is happening.

NB: Do not touch the woman’s abdomen especially the uterus before the placenta is expelled. This can interrupt the normal process and result in bleeding

You will not be expected to do anything other than support the woman and observe for any signs of bleeding


Length of Third Stage The placenta is normally expelled within about 30 minutes after the birth but it can be between 5 and 60 minutes. Once the placenta is delivered the fundus of the uterus feels firm like a ‘cricket ball’. This is a good indicator that the uterus is contracting to stop the bleeding. Close monitoring is necessary if the placenta has not been expelled after 30 minutes. Later than this the placenta may be retained. This is a potentially hazardous situation in relation to haemorrhage.

Summary of the Stages of Labour Stage of labour

Duration

Primiparous

Multiparous

First Stage Second Stage Third Stage

8–12 hours 1–2 hours 5–60 minutes

6–8 hours 30 minutes 5–60 minutes

If there is any bleeding:

• Stay with the woman • Get assistance immediately


Maternal Positions for Labour Usually women adopt a variety of positions in labour to ease any pain or discomfort. In fact, women should be encouraged to take up the position they find most comfortable. Whilst some maternal positions have advantages for labour and should be encouraged, other positions should be discouraged because of the disadvantages for pregnancy and labour. Positions usually fall into categories of being upright, semi-sitting, side-lying and dorsal (on the back). The key points associated with the positions are summarised below:

• Upright positions take advantage of gravity and improve contractions. • Semi-sitting and side lying positions are restful and conserve the woman’s

energy. These positions can often slow down the pace of labour. • Positions allowing the woman to lean forward can help to reduce back

pain. • Dorsal positions where the woman is lying on her back cause supine

hypotension and increase back pain and should be actively discouraged.

Favourable Positions You Should Encourage

• Supported standing. • Supported squatting. • Sitting astride a chair. • On all fours. • Lateral (side lying).

Other Positions

• Sitting up in bed. Positions You Should Prevent the Woman Adopting

• Lying flat on her back.


Favourable Positions Where possible, you should encourage the woman to adopt favourable positions. The partner or companion can often assist the woman with specific positions. Supported Standing: Women usually need some form of support to keep their balance when standing up in labour. The woman can often support her upper body by leaning against the wall, leaning on a chair or on a work surface. Women tend to find that leaning forward in labour can relieve back pain.

Fig. 1.1 Supported standing position.

Supported Squatting: If the woman is using this position then her knees must always be lower than the hips. The partner can provide the support from behind by holding the woman under the arms. This is a tiring position for partners to sustain for any length of time because they need to hold up all of the weight. You should advise them to change from this position after short periods. The woman can also use the bed, a chair or household surfaces to support the upper body when adopting a squatting position. These two positions are ideal to help open the pelvis wider and to use the force of gravity to help the baby descend through the birth canal.

NB: In the squatting position the knees must never be higher than the hips or the pelvis size is restricted and too much strain is put on the woman’s joints


Sitting astride a Chair: In this position the woman can sit astride a hard dining room-type chair facing the back. The woman can lean forward onto the back of the chair using pillows or cushions for support. This position can also increase the pelvis size and encourage descent of the baby through the birth canal. Women find that leaning forward in this position can relieve back pain. On All Fours: The woman can adopt a kneeling position with the upper body supported. The floor will need some padding to protect the woman’s knees. This position allows the woman a lot of freedom of movement, e.g. she can lean forward during contractions to relieve backache or sway from side to side, etc. The woman can also adopt a position on all fours with her arms supporting her upper body. In this position the knees and arms should be kept about hip width apart.

Fig. 1.2 On all fours position.

Fig. 1.3 Lateral (side lying) position.

Lateral (Side Lying): The woman can lie down on her side. This is a helpful position especially if the woman is tired. (This position can also slow down the pace of labour). NB: This is an important point if you are involved in an emergency with labour advancing quickly. In these circumstances you should encourage the woman to adopt this position to let you get organised. It will not prevent labour advancing but it will reduce it to a more manageable pace for a short time only. It may just give you enough time to get organised.


Other Positions Semi-Sitt ing: The woman can sit up on the floor with the partner supporting the woman’s shoulders and back from behind. The partner’s knees should be placed either side of the woman. This position can restrict movement for the woman during labour but is often a position adopted for the birth. Sitting up in bed is an alternative position to lying down but this can put pressure on the pelvis. Plenty of pillows will be needed to support the woman’s back and shoulders. The partner can also provide support by sitting next to the woman and supporting the shoulders from behind.

Fig. 1.4 Semi-sitting position.

Position to Avoid Dorsal Posit ions (Lying On Back): You should prevent the woman from lying on her back as this causes supine hypotension and should be avoided. The weight of the baby presses down on the blood vessels returning blood to the heart. The blood vessel gets occluded between the baby and the maternal spine. As a result there is a reduction in the blood flow:

• To the heart. • From the heart. • To the placenta and to the baby.

This can have an adverse effect for both the woman and her baby. If this occurs during an emergency situation then you need to prevent the baby pressing down on the blood vessels. You can do this quickly and easily by asking the woman to change her position onto (L) Lateral using a wedge or firm pillow or by tilting the pelvis slightly in situations where changing position is not possible.


Once you have studied this section you can now complete the third quiz. The quiz will take you about 10 minutes to complete and then send it to your local course coordinator. Good Luck! Quiz No. 3 – Labour and Birth Candidate Name: Date: Instruction: Please answer all the questions. MULTIPLE CHOICE Tick only 1 answer Question 1 From the list below, identify the normal range (in weeks and days) for labour and birth to occur. 37 weeks – 41 weeks + 3 days 32 weeks – 36 weeks + 2 days 30 weeks – 35 weeks + 3 days 34 weeks – 36 weeks + 1 day Question 2 Consider the following signs. Identify the most likely signs to indicate that labour has started. Braxton Hicks contractions and show Braxton Hicks contractions Show Uterine contractions and show


Question 3 Which of the following positions should be avoided during labour and birth? Side lying Lying on back (dorsal) Upright On all fours Question 4 What are the advantages of women being in one of the upright positions during labour? Can help to reduce back pain, take advantages of gravity and improves contractions

Can help to reduce back pain, improves contractions and slows down labour

Can be restful, conserves the woman’s energy and can often slow the labour down

Question 5 Women having their first baby usually take longer in the second stage of labour. True False Question 6 The second stage of labour can be completed in a few minutes for some women having their second or subsequent baby. True False


Question 7 Braxton Hicks contractions always indicate that labour has started. True False Question 8 The following list accurately summarises three of the main events occurring in the second stage of labour:

- The baby’s head may be visible. True False

- Contractions become expulsive. True False

- The woman tends to bear down. True False Question 9 There should be minimal bleeding only during the third stage. True False


Question 10 The timing of the third stage varies but you should expect it to be completed between 30 minutes and 60 minutes.

True False


CHAPTER 5 EMERGENCY NORMAL LABOUR AND BIRTH (NO COMPLICATIONS)

Introduction By the time you come to this section you have already completed the previous related Chapters and quizzes. This included:

• Multi-professional team approach. o Roles and responsibilities of professionals. o Professional, legal and ethical issues.

• Pregnancy.

o Maternal changes and progress in pregnancy.

• Labour and childbirth. o Signs of labour. o Events occurring in each stage. o Maternal positions.

This Chapter now details the practical steps involved in providing emergency care for women during emergency labour and birth.


Although the immediate care of the newborn is introduced briefly it will be provided in more detail in the next Chapter.

Learning Outcome On completion of this Chapter the non-maternity professional will be able to provide immediate care for women in labour and the birth or an emergency maternity care situation. The following related issues are covered to enable the learning outcome to be achieved: 1. Assessing the situation. 2. Equipment and resources. 3. Assistance in the first stage of labour. 4. Assistance in the second stage of labour. 5. Immediate care of the newborn (refer to next Chapter). 6. Assistance in the third stage of labour. The thought of being involved in an emergency labour and birth can be daunting for other professionals who are not regularly in contact with pregnant women. The reality is that you may be involved in helping at an emergency. It is important that you get a good understanding of the practical steps involved in assisting at an emergency labour and birth. Therefore, it is recommended that you complete the following activities within this Chapter. These activities give you an opportunity to work through your feelings about this involvement and to practise making an initial assessment about labour and birth.


If you have been involved in an emergency labour and birth before you may want to take a few minutes to reflect on the situation.

• Make a note how you felt about your involvement. • Identify any factors that you felt went well or not.

If you have not been involved in an emergency labour and birth you may want to take a few minutes to reflect on the possibility of being involved.

• Note how you felt about this involvement. • Identify any factors that you feel you would need to know to

provide safe care or any other factors you want to raise.

Assessing the Situation Refer back to the Chapters on ‘Labour and Childbirth’ and ‘Risk Assessment’. Assessing the situation can be challenging. It is often easy to make an assessment when the woman is clearly in advanced labour and the baby is about to be born. If the woman is in earlier labour then the biggest dilemma for professionals in the emergency is whether there is time to transfer. The first action you must take is to call for assistance from the midwife or GP and paramedics.


Suggested Questions You Need to Ask to Help You to Make an Assessment QUESTION/ANSWER

IMPLICATIONS OF FINDINGS

Once you have established the woman’s name, etc., ask: Is this your first baby? First baby Subsequent baby Grand multiparous (> 4 babies)

Usually you can expect the stages of labour to be longer. Usually you can expect the process of labour to be much quicker with each pregnancy. Usually you can expect the woman to have a very quick labour and birth.

Are you having one baby? Singleton pregnancy Multiple pregnancy

This is usually associated with low risk for complications. This is usually associated with higher risk for complications.

When is your baby due? If the woman presents: Between 37 – 41 + weeks Between 24 – 36 + weeks Prior to 24 weeks

Work out the gestation from the due date. This is the range you normally would expect women to go into labour. Complications: Premature labour occurring at this time would result in a preterm baby. An emergency at this time occurs before the age of viability.


QUESTION/ANSWER

IMPLICATIONS OF FINDINGSF FINDINGS

When you last saw your midwife or doctor – did they say the way the baby was lying? Head first Breech (bottom first) The baby lying across the way.

This is the way you would expect the baby to be lying. This is normal – a vaginal birth is possible. This is not the normal way for the baby to lie. Immediate transfer is required. However, in an emergency – a vaginal birth is possible. This is abnormal. A vaginal birth is NOT possible. NB: Immediate transfer is required.

Did your midwife say whether the Baby’s head was engaged?

This normally occurs in the last few weeks with a first baby. The head may engage during labour with subsequent pregnancies.

Ask if there is any discharge (Show) and its appearance? Normal appearance Abnormal

It can be clear, pinkish or bloody. Indicates the cervix is beginning to open. This sign on its own does not usually indicate labour. Greenish, foul smelling, copious and runny.


QUESTION/ANSWER ANSWER

IMPLICATIONS OF FINDINGSF IONS OF FINDINGS

Ask if the membranes have ruptured i.e. ‘waters have broken’? If yes – when? Normal appearance of fluid Abnormal appearance Normal ruptured memebranes Be cautious. Possible complication: Ruptured membranes for more than 12 hours.

Take a note of the time Clear fluid draining. Complication: discoloured fluid draining (greenish). this can indicate fetal distress. Within past 12 hours – if contracting then this may be normal. If not contracting – then summon midwife. If not contracting and no signs of labour – refer to obstetrician and arrange transfer.

When did your labour start? This will give you an indication of the length of time since the woman first thought she was in labour. Assess this information along with other factors


QUESTION/ANSWER N/ANSWER

IMPLICATIONS OF FINDINGSF IONS OF FINDINGS

Ask the woman to describe how labour started and how she is feeling now. Backache, abdominal cramps. Contractions – how often? How long is each contraction lasting and how bearable or painful?

Usually indicates early labour if these signs are regular over a period of time. If irregular, not lasting long and more uncomfortable than painful – then the woman is more likely to be in early stages or not in established labour. If cramps and backache have progressed to regular contractions then this usually indicates that labour has started.

How often are the contractions? Number and description in every ten minutes. Women and partners are usually good at timing contractions.

How long do they last? Fleeting contractions usually indicate early stages of labour. The longer and stronger the contraction then the woman is more likely to be in labour.

How strong do the contractions feel? Observe how the woman is coping with a contraction.

This information can give you an idea of the possible stage of labour. The more distressed the woman is may indicate that labour is established and progressing well.

Is there any urge to push? If yes then it is likely that labour is progressing in late first stage or has progressed to second stage and the birth may be imminent.


QUESTION/ANSWER N/ANSWEION/ANSWER

IIMPLICATIONS OF FINDINGSF ATIONS OF FINDINGS

Ask the woman if she knows her blood group?

Take a note for other professionals.

Normal Abnormal signs: Bleeding Pain level

Show – this tends to be jelly like although it can be bloody at times as labour advances Any persistent fresh bleeding especially when this is more evident with contractions. If the woman is in excessive pain which is persistent.

Abdomen No evidence of progress to the birth.

Persistently firm (hard) abdomen, which does not soften between contractions. There should always be a period at the end of a contraction when the uterus is relaxed. Woman in second stage – head visible. Pushing over a long period with no evidence of giving birth.

OBSERVEERVE

OBSERVEEBVE

How the woman is acting during a contraction: coping with pain becoming distressed

The woman’s position: Encourage woman if possible to

keep active. Assist the woman with a

favourable position for labour. Involve the partner to support

woman. Help the woman to manage her

pain. Sometimes women adopt their best position for the birth if they feel the baby coming.


Normal Labour The important thing about normal labour is that it is normal (see Scottish Normal Labour and Birth Course Manual). Nonetheless, it is worth summarising the key points for those with limited experience in supporting women to give birth. The mechanism of labour involves:

• effacement and then dilatation of the cervix to 10 cm, i.e. full dilatation (first stage of labour)

• from full dilatation to expulsion of the baby by uterine contractions and maternal effort (second stage)

• from birth to the delivery of the placenta (third stage). The position of the head is described according to the position of the occiput (or back of the baby’s head) in relation to the mother’s pelvis. The flexed head usually enters the inlet of the pelvis in either the right or the left occiputo-transverse (occiputo-lateral) position (Fig. 2.1).

1 2 3

Fig. 2.1, 2.2 and 2.3: Normal labour.

As the head descends it reaches the V-shaped pelvic floor at the level of the ischial spines (Fig. 2.2). The V-shaped pelvic floor (which runs antero-posteriorly) encourages the head to rotate, usually to the occiputo-anterior position (Fig. 2.3, 2.4). The head then descends beyond the ischial spines and extends, until the occiput escapes under the pubic arch. As the head descends further it distends the vulva until it is eventually born (Fig. 2.5, 2.6).


4

5

6

Fig. 2.4, 2.5 and 2.6: Normal labour.


Restitution: When the head is born it rights itself with the shoulders. During the movement of internal rotation the head is slightly twisted because the shoulders do not rotate at that time. The babies neck is untwisted by restitution, the shoulders undergo a similar rotation. The head being free moves at the same time, so internal rotation of the shoulders is accompanied by external rotation of the head. Rotation follows the direction of restitution. The anterior shoulder can then be delivered by downward traction of the head, so that the lateral downward traction on the fetal trunk allows the shoulder to be freed (Fig. 2.7). The posterior shoulder is delivered with upward lateral traction and the rest of the baby usually follows without difficulty (Fig. 2.8).

7

8

Fig. 2.7 and 2.8: Normal labour.


The third stage is from the birth of the baby until delivery of the placenta. The uterus contracts, shearing the placenta from the uterine wall, and this separation is often indicated by a small rush of dark blood and a ‘lengthening’ of cord. The placenta can then be delivered by gentle cord traction (Fig. 2.9) but caution is required to avoid uterine inversion or retained placenta. It is advised that non maternity professionals do not use this method but support maternal effort.

9

Fig. 2.9: Normal labour.

Summary of the mechanism of labour • Head at pelvic brim in left or right occiputo-transverse position • Head descends and engages with flexion. • Head reaches the pelvic floor and occiput rotates to occiputo-anterior, the

occiput escaping under the pubic symphysis. • Head is born by extension. • Descent continues and shoulders rotate into the antero-posterior diameter

of the pelvis; the head restitutes (comes into line with the shoulders) at the same time.

• Anterior shoulder delivered by lateral flexion from downward pressure on the baby’s head. The posterior shoulder descends below the sacral prominence, and is delivered by lateral flexion upwards


Scenario of a Woman in Labour The information in the following file deals with the situation where the birth is imminent and there is no time to transfer or wait until assistance arrives. The practical information detailed is based on the typical scenario. For your own interest then you are advised to read this scenario and then:

• Identify the cues. • Underline the points that indicate the labour is normal. • Make an overall assessment.

Scenario: Angela is a 25-year-old pregnant woman. She is a Para 1 and her first baby was a normal birth. Angela’s new baby is due tomorrow. She sends for assistance in the afternoon because she thinks she is in labour. You are the only professional available. She saw her midwife two days ago and was told that the baby was a good size and was in the correct position for a normal birth. Angela has had some show but does not think her membranes have ruptured. She had backache and abdominal cramps overnight but still managed to get some sleep. The backache became worse in the morning and she started to have mild contractions until lunchtime. Since then the contractions have become stronger and painful. In the last hour she has become distressed and she now feels pressure. Angela becomes very distressed and agitated during the contractions and feels the baby coming. The midwife and GP are not available and it will take at least one hour until they arrive. You need to deal with the situation, what would you do?


Summary of Assessment The place where the emergency labour and birth takes place determines to what extent the emergency professional has access to assistance and resources. In these situations emergency professional should improvise where appropriate.

Reassurance The woman is usually anxious and frightened by the emergency situation. As the emergency professional you will need to remain calm, reassuring and supportive during the emergency. This is an important part of dealing with an emergency and cannot be emphasised enough.

Practicalities in Dealing with the Emergency Labour and Birth 1. Equipment and Resources If you do not have the necessary equipment or resources then you can improvise:

• Environment – warm, draught free and as private as possible.

This will depend on where the emergency has occurred e.g. woman’s home, A & E, clinic, outside etc.

You are dealing with this as an emergency maternity care situation Please remember that you are not expected to be a midwife You are expected to be an emergency professional working within your own scope of practice


• Warm blankets, towels. • Incontinence pads if available or use clean towels. • Sanitary pads. • Adequate light source. • Use gloves at all times (follow cross infection guidelines). • Plastic apron if available. • Normal birth pack if available, or alternatively sterile scissors and artery

forceps x 2 and cord clamp or ligature.

2. Assistance in the First Stage of Labour

• Ensure the environment is safe for dealing with the situation, i.e. for carer and for the woman.

• Encourage the woman to adopt the most comfortable position o refer to section on ‘Maternal positions for Labour and Birth’.

• Ensure the woman is offered as much privacy as possible. o offer a cover for warmth and preserve modesty.

• Make sure that only the most relevant personnel are with the woman. • Reassure the woman and her companion. • Remain with the woman.

What Else You Can Do to Help the Woman to Cope: Support the woman to move about and adopt any position she finds comfortable. This is likely to change throughout labour. Refer to the section on ‘positions for labour and birth’. Advise on alternative positions – refer to favourable maternal positions for labour. Avoid positions that restrict the blood flow to the baby e.g. the woman lying on her back. If the woman complains of having backache with contractions – then with permission, either you or her companion could massage the woman’s lower back when the contractions occur. This can often help to ease the backache. 3. Assistance in the Second Stage Of Labour Remember that babies are very capable of being born themselves. You are there to support the woman using the skills you have within your scope of practice.

• Ensure the environment is safe. • Help the woman to find a comfortable position


• Suggest that the woman may be more comfortable on her side or all fours as these positions improve uterine blood flow.

• Keep in touch with midwife, GP or other maternity care professionals for advice until they arrive.

• Note any events occurring which may be relevant for progress such as: - Any show - Any bleeding - Any evidence of amniotic fluid - Any evidence of the baby’s head in the birth canal.

• Ensure the woman is offered as much privacy as possible: - Offer a blanket for warmth and preserve modesty.

• Make sure that only the most relevant individuals are present. • Reassure the woman and companion. • Try to get assistance from other professionals if available. • Have a towel or something to cover the baby once born. • Encourage the woman to do what her body tells her to do and to push

when she feels the urge. • Do not direct the woman as to when and how to push. Leave this to the

woman. It may take the woman up to an hour to actively push the baby out.

• Once the head is visible try to prevent the woman from pushing by encouraging her to breathe - in and out.

• Encourage the mother to pant or puff so that the head advances slowly. • Do not apply any pressure to the baby’s head just let the head advance of

its own accord. • Support the head only and allow the baby to be born on its own. As the

baby’s head is being born encourage the woman to breathe the baby out rather than pushing – this may prevent any tearing of the soft tissues.

• There is sometimes a delay between the head and body being born the head may sit at the vulva until the next contraction delivers the body. During this time the baby’s shoulders may move into a position to be born.

• Support the baby’s body as it is born and direct it onto the mother’s abdomen and keep warm.

• Minimal handling only – just enough to protect the baby. See next Chapter on ‘Immediate Care of the Newborn’.

NB: The woman should not lie flat on her back because of the risk of supine hypotension


What Else You Can Do If the Birth Is Imminent: Keep in touch with the midwife, GP or other maternity care professionals for advice until they arrive. If the birth is advancing quickly when you arrive then you can ask the woman to adopt a side-lying position (refer to ‘side-lying illustration’ in ‘Positions for Labour and Birth’). This position can often slow down labour just enough to let you get organised for the birth Keep calm. Reassure the woman and family. 4. Care of the Newborn at Birth

• Note the time the baby is born. • Make sure the baby’s mouth and nose are clear:

- only if necessary gently wipe away any mucous present. • Dry the baby, rewrap in dry blanket/towel and keep warm (remember to

cover the head). • If the baby appears healthy and in good condition then there is no need

to clamp and cut the cord (leave attached and do not do anything to it). • Place the baby on mother’s abdomen “skin-to-skin” and cover both baby

and mother to keep warm. • Keep the baby at the level of the mother’s abdomen if still attached to the

cord. • If the woman intends to breastfeed then the mother can put the baby to

the breast (this also aids separation and expulsion of the placenta).

5. Assistance in Third Stage

• There is no rush to cut the cord. • Keep the baby level with the mother. • There is no need to clamp and cut the cord until you have access to two

sterile forceps and scissors. • If the mother has suffered a tear, then cover the area with a sterile pad. • Use pressure if there is any bleeding from the tear. • Await delivery of the placenta.

o in normal situations this can take anything from a few minutes up to about 30 minutes (and within an hour).

• Wait for signs that the placenta has separated from the uterine wall. These include:

o You may just see the placenta appearing at the vulva. o The mother may have a contraction and the urge to push down.


• The placenta will normally be expelled when the mother bears down. • There is no need to touch the cord or placenta.

o Allow the mother to expel the placenta naturally. • Once the placenta is expelled note the time. • If forceps and scissors available, clamp the cord twice with forceps and

cut between the forceps. Keep the forceps in place until a cord clamp available.

• If no instruments available keep baby and placenta together. o (Separate with a towel or napkin to prevent heat loss).

• Make sure that the mother does not have any bleeding and make sure her uterus is firm. This can be done by gently placing the hand over the fundus of the uterus – you will be able to feel it very firm. If in doubt or you can feel the fundus soft then you can stimulate a contraction to firm up the uterus by massaging the fundus of the uterus with a circular motion. You can stop doing this once you feel the fundus becoming firm.

• Replace any wet pads. • Make the mother comfortable and leave her with the baby.

Cutting the cord in an emergency situation You may need to clamp and cut the cord if the baby requires to be separated for resuscitation:

• You need something to clamp the cord, e.g. two artery forceps, cord clamp or a sterile cotton ligature.

• Hold the cord at least three finger breadths from the baby and apply the artery forceps or clamp.

• Place another artery forceps or clamp further along the cord. • Make sure the forceps or clamps are secure. • Cut the cord between the two forceps or clamps. • Take care you do not clamp and cut the cord too near the baby’s

abdomen. • It will not do any harm to leave the cord long especially if you are

improvising. On arrival the midwife or paramedics can then apply another cord clamp.

• Leave the cord long if the baby is not in a good condition at birth. The umbilical vessels may be used as a route for intravenous therapy if required by paediatric staff.


What If I Need to Dispose of the Placenta? The placenta and membranes need to be examined by the midwife. So it is important that you keep these until the midwife (or GP) can make sure that the placenta and membranes are complete. The midwife (or GP) will arrange for disposal once they have been examined. Follow the local guidelines for disposal of body fluids. This is usually in double plastic bags or a specialized container if this is available. Remember to transfer the placenta and membranes with mother and baby if it has still to be examined.

What Happens if the Baby is Born with the Cord Around the Neck?

• In many cases the cord is loosely around the neck, the shoulder or the body of the baby.

• This does not require any action. The baby will just be born through the cord.

• If after the head is born the baby does not advance after a few pushes then it may be that the cord is preventing the baby from being born.

In this situation you will need to take the following action:

• Ask the woman not to push. • Gently insert your forefinger above the neck of the baby with the woman

in the semi-recumbent position. • If you feel the cord then try to gently ease it over the baby’s head. • In the majority of cases then, this allows the baby to be born.

IN RARE CIRCUMSTANCES ONLY If the cord is too tight to slip over the head then the cord will need to be clamped and cut to allow the baby to be born. This should only be attempted if the cord is too tight to be slipped over the head. This will be discussed more fully during the workshop. The baby is born with no problems but the cord is too short to let the mother hold the baby in her arms. Clamp and cut the cord to prevent any pressure on the cord and placenta.


CHAPTER 6 IMMEDIATE CARE OF THE NEWBORN

Introduction At the birth the baby is immediately faced with a number of challenges. He now needs to survive on his own. To some extent he will need some immediate assistance at birth to help him to do this. The information provided in this section is to identify what can be done for the newborn and explain why it may be necessary.

Learning Outcome On completion of this section the professional in an emergency maternity care situation will be able to provide immediate care for the newborn. The following related issues are covered to enable this outcome to be achieved:

1. The healthy newborn including temperature regulation. 2. Assessing the newborn. 3. Immediate care of the newborn.

Active Resuscitation of the newborn will be dealt with in a later chapter.

NB: You can prevent problems occurring for the baby if you take prompt action at the time of birth


1. The Healthy Newborn The length of a pregnancy is around 40 weeks gestation and this is regarded as being ‘at term’. However, babies are often born before or after 40 weeks and are still within the normal range of development. Therefore, babies born between 37–41+ weeks gestation are referred to as being ‘term babies’. If pregnancy, labour and birth have been uncomplicated then these babies are expected to be:

• Healthy. • Within the range of birth weight and size for term babies. • Breathing with good colour. • Active with good muscle tone and reflexes.

Assessing the newborn at birth is discussed later in this Chapter. Before birth: The baby has been in an environment which kept him alive and maintained his temperature. His lungs and circulatory system have not been fully functioning. At birth: At birth the newborn has to make major adjustments including the following:

• To breathe on his own. • To establish his own circulation. • To control his body temperature.

How well the newborn makes these initial adjustments are crucial to his subsequent well being. Respirations: Most babies establish regular respirations within 60-90 seconds of birth and often many babies take their first breath immediately at birth.


As a point of interest for you, the following factors usually stimulate the baby to take its first breath:

• The effect of cool air on the baby’s face. • The sudden release of the chest wall as the baby is born. • Other possible stimulations for the baby to breathe are handling the baby,

cold, gravity, noise or light.

Circulatory changes: At birth the circulatory system has to adapt to function like the adult circulation (this was previously done by the placenta) but this initial change takes a few minutes and if breathing baby should change colour from blue to pink. Temperature regulation: At birth the baby enters a cooler environment. The temperature in utero may be around 37.7°C and the optimum environment the baby is born into is usually around 21°C (reduction in temperature of over 16°C).

Reasons (point of interest only for you)

• The baby has a large surface area and body mass ratio – his head comprises about 25% of his size and will lose heat quickly if not covered.

• The baby’s subcutaneous layer of fat is thin and provides poor insulation. • The baby has an immature heat-regulating centre in the brain – he cannot

shiver to generate heat.

NB: It is vital for you to maintain the baby’s temperature at birth (normal range 36–37°C). Babies always need help, as even healthy term babies cannot regulate their own temperature. Once it is dry use a hat or blanket to cover baby’s head and keep it warm

NB: ESSENTIAL INFORMATION It is important that at the birth you know how to maintain the baby’s temperature and why appropriate action is taken. The baby will become cold (hypothermic) very quickly in a matter of minutes if you do not take immediate action to keep his temperature from falling below the normal range


Babies can lose heat in four main ways (see Figure 3.1 below).

Fig. 3.1 Four ways a baby can lose heat. Evaporation: Heat is lost when any fluid is evaporated from the skin.

• The baby is at risk from the skin being wet. What you can do in the emergency situation:

• The baby is born wet. • Prepare to dry the baby immediately at birth. • Rewrap in a dry towel or blanket • Remember to dry the baby’s head.


Conduction: Heat is lost from the skin to any cold surface.

• The baby is at risk – if he comes into direct contact with any cold surface. What you can do in the emergency situation:

• Be prepared to prevent the baby form coming into contact with cold surfaces.

• Heat towels, drapes or baby linen etc. • If available – use special insulator blanket (not silver foil) • The mother’s temperature is always higher than the baby’s so place

mother and baby together preferably skin-to-skin on mother’s abdomen if circumstances permit.

Radiation: Heat is lost by radiation of heat from the baby to cold objects in the environment e.g. room wall, ambulance wall.

• The baby is at risk – if he is born into a cold atmosphere. What you can do in the emergency situation:

• Be prepared to prevent the environment being colder than the baby. • Switch on a heater or radiator, if available. • Dry the baby immediately and place him with his mother.

Convection: Heat is lost by currents of cool air passing over the surface of the body.

• The baby is at risk from draughts. What you can do in the emergency situation:

• Be prepared to prevent drafts by closing doors, windows and switching off fans, communication window and roof vents in the ambulance. etc.


Summary of Action to Keep the Baby Warm

• Make sure the room is warm. • Close all windows, doors and switch off fans. • Preheat any blankets, towels etc. • Dry baby immediately at birth. • Rewrap baby in dry towel or blanket • Skin-to-skin contact with the mother. • Cover the baby including the head (no skin left uncovered). • Use special insulator blanket or Transwarmer, if available.

2. Assessment of the Baby at Birth It is important that the general well being of the newborn is assessed at birth. The baby needs a little time to get his breathing established. Therefore, the initial assessment of general well being is usually left until one minute after birth. Summary of Assessment of Well-Being of the Newborn Sign Good Condition Fair condition

(Baby will need some form of resuscitation)

Poor Condition (Baby will need immediate resuscitation)

Colour Pink Body pink, extremities blue

Blue or pale

Respiratory effort

Good or crying Slow, irregular Absent

Muscle tone Active Some flexion of limbs

Limp

Reflex response to stimulus

Sneeze or cough Minimal grimace None

Heart rate Fast (over 100bpm)

Slower (less than of 100 bpm)

Absent (or very slow)

The best parameters to asses in a baby are: Colour Tone Breathing Heart rate

These will inform what action is required.

See later section on Neonatal Resuscitation


Once you have studied this section you can now complete the fourth quiz. The quiz will take you about 10 minutes to complete and then send it to your local course coordinator. Good Luck! Quiz No. 4 - Immediate Care of the Newborn Candidate Name: Date: Instruction: Please answer as many questions as you can. MULTIPLE CHOICE Tick only 1 answer Question 1 If a baby is placed on a cold surface he will lose heat by: Convection Conduction Evaporation Radiation Question 2 If a baby is placed in a room with a cool draft free atmosphere he will lose heat by: Convection Conduction Evaporation Radiation Question 3


If a baby is wet he will lose heat by: Convection Conduction Evaporation Radiation Question 4 If a baby is placed near an open window he will lose heat by: Convection Conduction Evaporation Radiation Question 5 A baby with a good condition at birth would be described as having all of the following: Pink in colour, active, crying, good reflexes and has a fast heart beat. Body pink with blue extremities, breathing, some flexion in the limbs, grimace and has a fast heart beat.

Body pink with blue extremities, has a slow heart beat, some flexion in the limbs and attempts to breathe

Question 6 A baby with a poor condition at birth would be described as having all of the following: Blue or pale in colour, limp, very slow heartbeat, no reflexes and would not be breathing.

Blue in colour, some flexion in limbs, some respiratory effort, minimal grimace and has a slow heart beat.

Blue or pale in colour, attempts to breathe, grimace and has a slow heart beat.

Question 7


A baby who was in a fair condition at birth would be described as having the following: Body pink, active, some flexion in limbs, sneezing reflex present and a slow heart beat

Body pink with blue extremities, slow irregular respiratory effort, grimace, and slower heart beat of less than 100 bmp, with some flexion in the limbs.

Extremities blue, slow irregular breathing, minimal grimace, slow heart beat and no reflexes.

Question 8 At birth the newborn is expected to have established regular respirations within: 60 seconds 10 seconds 100 seconds Question 9 At birth there is a temperature difference for the newborn between the uterus and the temperature the baby is born into. The temperature difference for the baby would be in the region of: A reduction of 16°C A reduction of 5°C An increase of 5°C No difference in the temperature Question 10 If action is not taken immediately at birth to maintain the baby’s temperature then which of the following is likely to happen: It would take a few minutes for the baby to become hypothermic It would take 30 minutes for the baby to become hypothermic The baby would maintain his body temperature


CHAPTER 7 DEALING WITH AN EMERGENCY SITUATION

Obstetric and Other Emergency Situations: Introduction This section deals with those emergency situations where the life of the woman or the baby is at immediate risk. This type of emergency situation needs prompt action by the emergency professional. The professional should be alert to the possibility that the emergency may or may not be directly associated with pregnancy. Basic life support in a pregnant woman is dealt with in a later section.

Bleeding in Pregnancy Any bleeding at any time in pregnancy will be cause anxiety for the pregnant woman. It is important to be sensitive in your care of the woman and her partner, but also not to falsely re-assure them.

• Half of all pregnancies miscarry before 12 weeks, many before the pregnancy is confirmed.

• 15–20% of confirmed pregnancies miscarry; 80% in the first trimester http://www.nhs.uk/conditions/pregnancy-and-baby/pages/miscarriage.aspx

If the woman is pregnant and complains of vaginal bleeding then you must assume that the bleeding is related to the pregnancy until the medical practitioner confirms the diagnosis.

http://www.nhs.uk/conditions/pregnancy-and-baby/pages/miscarriage.aspx

http://www.nhs.uk/conditions/pregnancy-and-baby/pages/miscarriage.aspx


Learning Outcome The health professional will have knowledge of the causes and management of bleeding in pregnancy. The following issues will be covered to enable the learning outcome to be achieved:

• Related terminology. • Bleeding in early pregnancy; possible causes and management. • Bleeding in late pregnancy; possible causes and management.

Terminology for Information

• Miscarriage – pregnancy ending spontaneously before 24 weeks. This can be; threatened, inevitable, complete or incomplete.

• Ectopic pregnancy – pregnancy which occurs outside the uterus. The term abortion in relation to a spontaneous miscarriage is inappropriate. Bleeding in Early Pregnancy The aetiology of spontaneous miscarriage is rarely determined in clinical practice. At least half are due to major genetic anomalies. The incidence of spontaneous miscarriage increases with age. Differential Diagnosis

• Ectopic pregnancy. • Molar pregnancy. • Cervical problems.

Signs and Symptoms

• Vaginal bleeding. • Lower abdominal pain accompanied by back pain. • A decrease in pregnancy symptoms; nausea, breast tenderness. • In a complete miscarriage the signs and symptoms will resolve

spontaneously while in an incomplete miscarriage the signs and symptoms do not resolve.


Management Bleeding Not Excessive

• Arrange appointment at early pregnancy unit. • Fast the woman before transfer. • Inform midwife/ health visitor.

Bleeding Heavily

• Carry out risk assessment. • Liaise with nearest Consultant Maternity Unit. • Arrange transfer to nearest Consultant Maternity Unit. • Cannulate with large bore cannulae x 2. • Commence fluids as directed by maternity care specialists. • Obtain bloods for FBC, x-matching and coagulation and send these with

the woman. • Document. • Keep the woman nil by mouth during transfer. • Transfer the woman in the lateral horizontal position with her legs

elevated or head down.

All women who bleed in pregnancy must have bloods taken to ascertain if anti-D is required.

A 23-year-old women who had a positive pregnancy test 3 weeks ago phones to say that she has been having lower abdominal pain for the last 2 hours and on going to the toilet, passed a blood clot.

• What questions do you ask the woman? • Who would you liaise with in your own area? • How would you manage the situation?


Ectopic Pregnancy An ectopic pregnancy occurs when implantation of the embryo occurs outside the uterus. Signs and Symptoms

• Can be difficult to diagnose. • Positive pregnancy test. • Pain – lower abdominal and unilateral. • Vaginal bleeding. • May be signs of haemoperitoneum – shoulder tip pain, rebound

tenderness and shock. • Vomiting and diarrhoea.

Management

• Carry out risk assessment. • Contact nearest Consultant maternity unit. • Arrange transfer as directed. • Cannulate. • Obtain bloods for FBC, x-matching and coagulation and send these with

the woman. • Document. • Transfer.

See NHS Health Choices for further information: http://www.nhs.uk/conditions/pregnancy-and-baby/pages/ectopic-pregnancy.aspx

http://www.nhs.uk/conditions/pregnancy-and-baby/pages/ectopic-pregnancy.aspx

http://www.nhs.uk/conditions/pregnancy-and-baby/pages/ectopic-pregnancy.aspx


Bleeding in Late Pregnancy Vaginal bleeding in late pregnancy is always taken seriously. This situation will usually require hospitalisation to diagnose the cause, to minimise risk to the mother and baby and to allow intervention specific to the diagnosis. Major Causes

• Placenta praevia. • Placental abruption.

Minor Causes

• Bloody show. • Cervicitis. • Polyp.

Placenta Praevia Placenta praevia occurs when the placenta, instead of implanting towards the fundus (top) of the uterus, implants low in the uterus near to or partially/completely covering the cervical os. Risk Factors

• Previous caesarean section. • Multiple birth. • High parity. • Uterine surgery. • Advanced maternal age. • Smoking.

Signs and Symptoms

• Painless bleeding, usually occurring near the end of the second trimester or the beginning of the third, most commonly around 26–28 weeks with formation of the lower uterine segment.

• The bleeding often occurs following intercourse.


Management Diagnosis will only be confirmed by ultrasound scan.

• Liase with nearest Consultant maternity unit. • Carry out risk assessment. • Arrange emergency transfer as directed. • Cannulate with 2 wide bore (size 16 gauge) if the woman is bleeding

heavily. • Obtain bloods for FBC, x-matching and coagulation and send these with

the woman. • Administer IV fluids as directed by maternity care professionals. • Administer O2 if bleeding heavily. • Document. • Transfer the woman in the lateral horizontal position with her legs



Placental Abruption Placental abruption describes when the placenta prematurely separates from the wall of the uterus, either partially or completely. Signs and Symptoms

• Mild or severe pain which in a contracting woman will remain between contractions.

• Bleeding – bleeding may be absent in 20% of cases, if hidden behind placenta. Nor does the amount of bleeding accurately reflect the extent of the abruption.

Management

• Liaise with CLU. • Carry out risk assessment – remember signs and symptoms of shock only

occur with the loss of 30% of body fluid due to physiological changes of pregnancy.

• Arrange transfer. • Cannulate appropriate to signs and symptoms. • Commence IV fluids, e.g. Colliod and Ringer’s Lactate. • Obtain bloods for FBC, x-matching and coagulation and send these with

the woman. • O2 if bleeding is excessive. • Complete documentation. • Transfer the woman in the lateral horizontal position with her legs



Hypertension in Pregnancy Hypertensive disorders affect 6–8% of pregnancies. The cause may be pre-existing hypertension or it may be associated only with the pregnancy. These conditions may be serious and potentially life threatening if undetected and potentially life threatening if undetected or untreated. Pre-eclampsia and eclampsia are hypertensive disorders of pregnancy and they continue to be a leading cause of maternal mortality and morbidity. Pre-eclampsia Pre-eclampsia is a multi-organ disease often exhibiting the classic triad of:

• Hypertension – blood pressure higher than 150/90mmHg on two episodes 6 hours apart.

• Proteinuria. • Oedema – this is the least reliable indicator, as 1/3 of women with pre-

eclampsia do not exhibit this sign.

Severe pre-eclampsia shows all the above clinical signs, with the addition of: • Headache. • Visual disturbance. • Epigastric pain. • Hypertension may be severe with a blood pressure higher than

160/110mmHg.

Eclampsia Eclampsia is characterised by the appearance of seizures in the pregnant woman who is not epileptic. It is a rare condition, with an incidence of 4.9/10,000 cases. Forty-four per cent of seizures occur in the postnatal period. In maternity cases it is important that you recognise the potential seriousness of these conditions. If in doubt you should refer the woman to the midwife or GP. Key Recommendations

• Pregnant women with a headache of sufficient severity to seek advice or with new epigastric pain should be referred to the midwife/GP as a matter or urgency.

• Blood pressure should be recorded and reported to specialist staff. • Transfer to an obstetric unit may be required following stabilisation. • An ambulance should be called for the transfer. • The woman should not be left on her own.


• The left lateral (side lying) position should be adopted • Ensure adequate airway management if compromised and give high-flow

O2 (e.g.15litres/min via reservoir bag)

Ergometrine (including syntometrine) should not be used for the third stage (give Syntocinon 10U IM or IV stat. instead) Depending on sphere of practice consider magnesium sulphate therapy: There is now very good evidence supporting the use of anticonvulsants in established eclampsia: magnesium sulphate is known to be significantly more effective than phenytoin or diazepam in preventing further convulsions (Lancet 1995;345:1455). In those with severe pre-eclampsia, magnesium sulphate halves the risk of eclampsia in and probably reduces the risk of maternal death (Lancet 2002, 359, 1877).

Cord Prolapse This occurs when the membranes have ruptured and the umbilical cord lies in front of the baby’s head (or breech). You will only know this if you see a loop of cord at the vulva. This is an emergency situation because the cord vessels become compressed between the pelvis and the baby which cuts off or reduces the amount of blood supply and oxygen getting to the baby. The principle of the immediate action you need to take:

• This is an obstetric emergency. • Get assistance urgently. • Do not leave the woman. • Relieve the pressure on the cord by repositioning the woman to get her

pelvis and buttocks higher than the level of her head (and maintain the position).

• This can be done in several ways: o By tilting the trolley or bed with head down and feet up. o By putting the woman in an exaggerated knee chest position on

the floor (or bed) (see Fig 4.1 below)


Fig. 4.1 Exaggerated knee–chest position.

o By putting the woman on her left side and using a pillow to raise her hips (exaggerated Simm’s position) (see Fig 4.2).


Fig. 4.2 Exaggerated Simm’s position.

• Do not handle the cord (touching the cord can make the vessels go into spasm and this will make the situation worse).

• Get assistance to summon medical aid and arrange transfer immediately. • Reassure the woman throughout this obstetric emergency as it will be

frightening for the woman and partner.

If this occurs in the first stage of labour: You will need to transfer the woman in this position. An emergency caesarean section will be required to deliver the baby. The outcome will depend on the extent of the cord compression and subsequent reduction in oxygen to the baby. If this occurs in the second stage: You will need to transfer the woman in this position. The birth will possibly be by assisted vaginal birth and again the outcome will depend on the extent of the cord compression and subsequent reduction in oxygen to the baby.


Other Obstetric Emergencies This section provides an overview of other obstetric emergencies you may need to deal with or assist other members of the team. Remember you are not expected to be a midwife or a medical practitioner.

An overview of each emergency situation is provided and the action required is outlined. If you are interested, you can obtain further information in any of the midwifery or medical textbooks in the Reference list. Shoulder Dystocia This term related directly to the birth of the baby. The baby’s head is born but there is difficulty (dystocia) in delivering the baby’s shoulders. This is due to one of the baby’s shoulders being trapped under the pubic bones.

To the inexperienced birth attendant there are often no obvious signs to indicate that the baby may experience difficulty with delivery of the shoulders. The midwife at the birth can usually detect warning signs. These include the head advancing slowly and the chin being difficult to deliver. The head also wants to recede back into the vagina because of the restriction due to the trapped shoulder. (You will not be expected to recognise these signs). Immediate action you will be expected to do:

• Summon immediate help. • Summon midwifery and medical assistance. • Arrange transfer (for the baby). • Try to keep calm. • Change the woman’s position.

NB: In these situations you will only be expected to work within your current scope of practice

NB: It is not a common emergency


It is important that you change the woman’s position to try and dislodge the shoulder. If the baby still does not deliver then try another position. Repeat this process. Positions (Refer To Maternal Positions for Labour) If the woman is lying down then:

• Help the woman to lie flat and to bring her knees up to her chest as far as possible (called McRoberts manoeuvre). This is like a squatting position when lying on your back (see Fig. 4.3 below). With one professional to each leg, the mother's legs are flexed hard against her abdomen and at the same slightly abducted outwards. This straightens the sacrum relative to the lumbar vertebrae and rotates the symphysis towards the maternal head, allowing the baby's shoulder to pass under by continuous traction on its head. This manoeuvre may be successful in 40–60% of cases.

Fig. 4.3 McRobert’s manoeuvre

• Apply external suprapubic pressure. (Fig 4.4 below) With the legs in the McRoberts position, suprapubic pressure is applied to posterior aspect of the anterior fetal shoulder at an angle of 45 degrees towards the fetal chest in an attempt to rotate the shoulder into the oblique and also to reduce the bisacromial diameter. This is used in conjunction with continuing head traction. If constant pressure fails, a rocking movement may be tried.


Fig. 4.4 External Suprapubic pressure Outcome for the Baby The baby can experience varying degrees of hypoxia. Either you or an assistant be prepared to resuscitate the newborn baby. The baby may also experience nerve damage and fractures but these can be managed after the emergency is over.

You are advised to practise these positions yourself and then with another colleague. This will help you to become proficient in using them in any maternity care situation including an emergency.

Breech Birth Breech presentation describes a fetus presenting bottom first. The incidence is about 20% at 20 weeks, 25% at 32 weeks and only 3-4% at term. Women presenting in advanced labour with an engaged breech usually give birth without adverse consequences. At full dilatation, the mother can be encouraged to push: the temptation to pull must be resisted. Ideally the baby should be left alone to delivery itself (‘hands off’) taking care to ensure the back remains uppermost when advancing. (Fig 4.5)


One of the key risks of breech delivery is that pulling may lead the head to extend and therefore become stuck at the pelvic brim. The importance of maternal effort at this stage, rather than traction from below, cannot be over emphasised – it allows the head to flex and minimises the risk of it becoming stuck at the pelvic brim.


Fig. 4.5 Vaginal breech delivery


Postpartum Haemorrhage Introduction It is normal for women to lose some blood following the birth. The blood is usually lost through trickling or oozing from the genital tract for a short time before reducing. The woman is usually well and does not have any signs of shock. The amount of blood is difficult to estimate if you are unfamiliar with this situation. However, any amount of blood loss where the woman is showing symptoms of shock should be regarded as being a postpartum haemorrhage (PPH). This is one of the most alarming and serious obstetric emergencies. Prompt competent action by the carer is crucial in controlling the bleeding and reducing the risk of maternal morbidity and even death. PPH is defined as being excessive bleeding (of greater than 500 ml) from the genital tract at any time following the birth of the baby up to six weeks after birth. It is defined as being a major PPH when blood loss is estimated to be around 1000 - 1500 ml. There are two types of PPH depending on when they occur:

1. Primary PPH refers to bleeding within the first 24 hours after birth. a. At the birth

i. Occurs when the placenta has not been delivered. ii. Occurs after the placenta has been delivered

b. Anytime within 24 hours after the birth.

2. Secondary PPH refers to bleeding between 24 hours and six weeks following the birth. This is usually caused by a fragment of the placenta or membranes retained in the uterus or the presence of a large clot.

NB: You should initiate immediate action if the woman shows any signs of haemorrhage and shock irrespective of the amount of blood loss you can see


Learning Outcomes The health professional will have knowledge of the management and causes of postpartum haemorrhage. The following related issues will be covered to enable the learning outcome to be achieved:

• Risk factors for PPH. • Recognition of PPH. • Management of PPH. • Transfer and referral of patient. • Recommendation regarding the management of PPH.

What You Can Do in the Emergency Situation Risk factors are poor predictors. You must always be prepared for PPH at the birth. It is vital that PPH is recognised early to ensure action is taken immediately. This is helped if you:

• Are vigilant in assessing the nature of the blood loss, e.g. continuous trickle, spurting, persistent flow, brisk bleed, etc.

• Continue to observe the woman for other signs that she is bleeding, e.g. becoming pale, shocked and deterioration in vital signs.

Action You Need To Take In PPH

• Prompt recognition. • Call for HELP immediately: • Get all available assistance to:

o Assist you. o Call for medical assistance. o Call the specialist maternity unit. o Call ambulance for support and transfer.

• Stay with the woman. • Immediately try to locate where the bleeding is coming from and try to

stem the bleeding (If the placenta has not delivered – resuscitate, you will not be expected to do anything else in this situation except continue as below).


Causes (the 4 T’s) Tone of the Fundus (cause of 90% of PPHs) If the placenta has delivered then the first thing you must do is check to make sure the fundus of the uterus is firm. If the fundus feels firm then it is likely that the bleeding is coming from the cervix vaginal track and perineum. If the fundus feels soft and relaxed (atonic) then you can reverse this by ‘rubbing up a contraction’. You can ‘rub up a contraction’ promptly by locating the fundus and massaging the uterus firmly in a circular motion (no undue pressure should be used). This will stimulate the uterus to contract (you can feel this happening). This may stem the bleeding (re-check the fundus as it may quickly become atonic again). A demonstration of the technique for ‘rubbing up a contraction’ will be covered in the workshop. Tissue (common) There may be some placental tissue, membrane or blood clot still in the uterus. This can prevent the uterus from contracting to stop bleeding from the placental site. Massage the fundus to try to expel any tissue or clots left in the uterus. Genital Tract Trauma (sometimes) If the fundus is firm then bleeding may be coming from trauma caused by the birth such as tears in the genital tract and perineum. Try to locate the area where the bleeding is coming from and apply pressure to stem the bleeding. Thrombin (rare) Coagulation problems, particularly Disseminated Intravascular Coagulation (DIC), may be present from a number of different causes. Secondary PPH This type of emergency can occur within six weeks of the birth but usually around two weeks following the birth. The woman is usually at home with her baby when this occurs. Fragments of tissue remaining in the uterus, blood clot or infection usually cause this PPH. All the above action will be required. However, the fundus usually cannot be located at this time. The woman will be transferred to the specialist unit for evacuation of the uterus. The woman will be very anxious especially about the care of her baby if transfer is required


Maternal Resuscitation In addition to identifying and arresting the haemorrhage you may need to start resuscitation of the woman as she can become shocked very quickly. (Follow local resuscitation guidelines for the action taken and the resources used). Recap on the tasks you may be expected to help with during resuscitation of the woman (this will depend on your scope of practice):

• Lie the woman flat

• A – Airway

• B – Breathing

• C – Colour

• Administer high flow oxygen

• Cannulate using wide-bore venflons (normally 14 or 16 Gauge as per local guidelines), take bloods for x-matching, FBC, clotting factors

• Fluid replacement – colloid

• Catheterise – In-dwelling

• Drugs:

o Syntocinon 5 - 10 iu by slow IV bolus o Ergometrine 500µg IM o Carboprost (Hemabate) 250μg (=1ml=1 ampoule) IM (not IV) or

intramyometrial (not licensed) with further doses not less than15 minutes apart up to a max of 8 times. Hemabate is contraindicated with cardiac, pulmonary, renal or hepatic disease. Side-effects include GI upset, particularly diarrhoea, and pyrexia.

o Misoprostol 800µg PR

• Bimanual Compression. This is usually required if bleeding continues despite the previous action taken. This will be discussed in the workshops

• Review possible causes – Tone, Trauma, Tissue, and Thrombin

NB: The administration of the above drugs will depend on your sphere of practice


• Communicate with maternity care professionals

• Document

• Prepare for transfer

Recommendations for Practice The triennial report Confidential Enquiry into Maternal and Child Health –Saving Mothers lives (CMACE 2011) assesses the main causes and trends in maternal deaths and makes recommendations for improving practice and services. Recommendations in relation to obstetric haemorrhage included:

• The provision of emergency drills for all staff and an awareness of the speed with which life-threatening haemorrhage may develop

• Local protocol for the management of major PPH as identified in the Framework for the maternity services. (SEHD 2001) and the EGAMS reports (SEHD 2002)

www.scotland.gov.uk/Publications/2003/01/16021/15810

http://www.scotland.gov.uk/Publications/2003/01/16021/15810



You are called to an emergency maternity care situation in your practice area involving a 26-year-old woman having her first baby. She proceeds to deliver a baby weighting 4.2 kg, immediately following delivery of the placenta she starts to bleed heavily. Describe the steps you would take in your practice area to manage this emergency situation.

Emergency Drills Practice the management of the above scenario with all members of the multi-professional team. It is important that everyone is aware of what is expected of each team member in this situation in relation to their scope of practice and responsibility.


CHAPTER 8 RESUSCITATION AND TRAUMA

Maternal Resuscitation and Trauma Learning Outcome The health professional will have knowledge about the management of maternal resuscitation and trauma. Cardiac Arrest in Pregnancy This is very rare in pregnancy. Cardiac arrest occurs in 1/30,000 pregnancies. Additional Information The following web site gives information on the causes of maternal deaths



Differences in the Management of Resuscitation and Trauma Compared to the Non-Pregnant Woman There are differences in management which are more marked as the pregnancy advances but Basic Life Support with the woman in left lateral should be administered (see Basic Life Support algorithm – Fig. 5.1) Defibrillation No modification. See the Advanced Life Support algorithm – fig 5.2 and the following web site which offers further guidance – www.resus.org.uk

http://www.resus.org.uk/


Fig. 5.1 Basic life support algorithm


Fig. 5.2 Advanced life support algorithm


Trauma Causes Car accident: prevention – always advise women regarding the correct positioning of the seat belt: ‘All women should be advised to wear a three-point seat belt throughout pregnancy, with the lap strap placed as low as possible beneath the ‘bump’ lying across the thighs and the diagonal shoulder strap above the ‘bump’ lying between the breasts. The seat belt should be adjusted to fit as snugly and comfortably as possible, and if necessary the seat should be adjusted. CMACE REPORT 2011

• Domestic violence: 30% of domestic violence starts in pregnancy. • Pregnant women involved in severe motor accidents are more likely to

suffer from abruption (separation of placenta from uterine wall). • In the last CMACE report (2011) 67 maternal deaths were associated with

psychiatric causes, 29 of which committed suicide. Management

• Risk assessment. • Liaise with nearest Consultant maternity unit. • Stabilise as directed and arrange transfer. • Manage as for any trauma case but taking into account the pregnancy

specific physiological changes. • Document. • Remember, it is the woman you are treating, not the baby, as the baby’s

survival is wholly dependent on the mother. • Even if the woman appears well, all pregnant women involved in trauma

need their pregnancy monitored.

Scenario: There is a car accident near where you are working. The passenger is heavily pregnant and there are no obvious vital signs when you arrive at scene moments later.

• What thoughts are going through your head? • What action will you take? • Who will you contact?

Consider your answers to these questions and refer to the algorithms.


CHAPTER 9 NEONATAL RESUSCITATION

Normal physiology Occlusion of the cord in utero, or clamping of the cord after birth, leads to acute hypoxia. The latter is thought to be the major stimulant for a baby to start respiration. Physical stimuli such as cold air, rubbing, or physical discomfort may also provoke respiratory efforts. If the baby fails to start breathing, the baby’s oxygen concentration falls further, the baby loses consciousness and enters ‘primary apnoea.’ After 5 or 10 minutes of primary apnoea spinal centres, which are normally suppressed by higher centres, begin to cause shuddering of the baby’s body at a rate of approximately 12/ minute (agonal gasps). Once this gasping stops, the baby enters ‘secondary’ (or ‘terminal’) apnoea and without intervention the outcome is death. The only way to tell whether a non-breathing newborn infant is in primary or secondary apnoea is by assessment of its response to resuscitation. If in primary apnoea, nearly all will start breathing within a few breaths; if secondary, the baby will usually gasp for some time before starting regular respiration. In reality, however, both are initially managed clinically in the same way.

Practical aspects of neonatal resuscitation Most babies born in primary apnoea will resuscitate themselves within 60–90 seconds given a clear airway. The basic approach to all resuscitation is therefore airway, breathing and circulation but there are a number of additions which will be considered in more detail in the following paragraphs:


Get help. Start the clock. Dry, wrap and keep the baby warm Assess colour, tone, respirations and heart rate Commence resuscitation:

• Airway • Breathing (lung inflation and ventilation) • Circulation • Drugs

Dry, wrap and keep the baby warm Dry the baby off immediately and then wrap in a warm dry towel. A naked wet baby can still become hypothermic despite a warm room, especially if there is a draught. Cold babies have increased oxygen consumption and are more likely to become hypoglycaemic and acidotic. They also have an increased mortality. If this is not addressed at the beginning of resuscitation it is often forgotten. Most of the heat loss is by evaporation - hence the need to dry the baby and then to wrap the baby in a dry towel. (fig 6.1) Babies also have a large surface area-to-weight ratio: heat can be lost very quickly.

Fig. 6.1 Dry, wrap and keep warm


Assessment

The APGAR score was proposed as a tool for evaluating a baby's condition at birth. Although the score, calculated at one and five minutes, may be of some use retrospectively, it is almost always recorded subjectively and retrospectively; it is not usually therefore used to guide resuscitation. ASSESSMENT

0

1

2

Colour

White

Blue

Pink

Tone

None (unconscious)

Poor

Good

Heart Rate

<60 bpm

<100 bpm

>100 bpm

Respiration

None

Gasping

Good, crying

Response to simulation

None

Minimal

Vigorous

Acute assessment will categorise the baby into one of the three following colour groups: 1. Pink, regular respirations, heart rate fast (>100 bpm). These

are healthy babies and they should be kept warm and given to their mothers.

2. Blue, irregular or inadequate respirations, heart rate slow (<100 bpm). If gentle stimulation does not induce effective breathing, the airway should be opened. If the baby responds then no further resuscitation is needed. If not, progress to lung inflation.

3. Blue or white, apnoeic, heart rate slow (<60 bpm). Whether an apnoeic baby is in primary or secondary apnoea the initial management is the same: • Open the airway, and look to see whether the chest is rising or

falling. • A reassessment of any heart-rate response then directs further

resuscitation.


Reassess heart rate and respiration every 30 seconds. Depending upon the assessment, resuscitation follows: airway, breathing and circulation, with the use of drugs in a few severe cases.

Airway Position the baby with the head in the neutral position (i.e. the face is parallel to the ceiling). Overextension may collapse the newborn baby's pharyngeal airway just as will flexion. Beware the large, often moulded, occiput.

Too flexed Neutral (correct position) Too extended

Fig 6.2: Head position. A folded towel placed under the neck and shoulders may help to maintain the airway in a neutral position (Fig. 6.2) and a jaw thrust may be needed to bring the tongue forward and open the airway, especially if the baby is floppy. Suction of the airways with a soft catheter should only be carried out under direct vision of the cords. Meconium Meconium-stained liquor in various guises is relatively common. Fortunately, though, meconium aspiration is a rare event and often occurs in utero before the birth. If the baby is vigorous, no specific action (other than drying and wrapping the baby) is needed. If the baby is not vigorous, inspect the oropharynx with a laryngoscope and aspirate any particulate meconium seen using a wide bore catheter. If the baby is not breathing and you have the skill, intubate the baby with an endotracheal tube (ideally with a meconium aspirator attached) and use this to suck out the trachea. If you are unable to intubate, call for assistance from someone who has the skill. While waiting for them to arrive, suck out the oropharynx with a wide bore suction catheter, as above, and then provide intermittent positive pressure ventilation.


Breathing

The first five breaths should be inflation breaths. These should be two- to three-second sustained breaths using a continuous gas supply (air), a pressure-limiting device, and a mask. If no such system is available then a 500 ml self-inflating bag and a blow-off valve set at 30-40 cm H20 pressure can be used. Use a transparent, soft reformable mask big enough to cover the nose and mouth of the baby. The use of oxygen probably carries no benefit over air in term babies.

Mask too small Correct mask size Mask too large Fig 6.3: Mask size The chest may not move during the first one to three breaths as fluid is displaced. Once the chest is inflated reassess the heart rate. Assess air entry by chest movement not by auscultation. In fluid filled lungs, breath sounds may be heard without lung inflation. If the heart rate responds it is safe to assume that the chest has been inflated successfully.

A Guedel airway may be used to help maintain the airway. It should be inserted under direct vision with a laryngoscope as shown. The correct size of airway should reach from the middle of the chin to the angle of the jaw. The correct way to support the mask is also illustrated.

Correct size of Guedel airway

Insertion with a laryngoscope

Keeping a seal with the mask

Fig 6.4: Maintaining airway

Once the chest is inflated, ventilation is continued at a rate of 30-40 ventilations per minute. Continue to reassess that the airway is clear and that the chest is inflating.


Circulation

If the heart rate remains slow (less than 60 bpm) once the lungs are inflated, cardiac compressions must be started. The most efficient way of doing this in the neonate is to encircle the chest with both hands, so that the fingers lie behind the baby and the thumbs are apposed on the sternum just below the inter-nipple line (Fig. 6.5). Compress the chest briskly to one third of its diameter. Current advice is to perform three compressions for each inflation of the chest.

Fig 6.5: Two-hand technique for cardiac compressions.

The purpose of cardiac compression is to move a small amount of oxygenated blood or drugs to the coronary arteries in order to initiate cardiac recovery. There is therefore no point in cardiac compression before the lungs have been inflated. Similarly, compressions are ineffective unless interposed breaths are of good quality and inflate the chest. The emphasis must be upon good-quality breaths followed by effective compressions. Once the heart rate is above 60 bpm and rising, cardiac compression can be discontinued.

Response to resuscitation

Often, the first indication of success will be an increase in heart rate. Recovery of respiratory drive may be delayed. Babies in terminal apnoea will tend to gasp first as they recover before starting normal respirations. Those who were in primary apnoea are likely to start with irregular but more normal breaths, which may commence at any stage of resuscitation.


Preterm babies

The more preterm a baby is, the less likely it is to establish adequate respirations. Preterm babies (less than 32 weeks) are also likely to be deficient in surfactant. The effort required to breathe is greater and yet the muscles are less developed. One must anticipate that babies born before 32 weeks may need help to establish prompt aeration and ventilation.

Preterm babies are more likely to get cold (higher surface area to mass ratio) and more likely to be hypoglycaemic (fewer glycogen stores). The temperature of very preterm babies can be maintained if they immediately placed in a plastic bag (without drying) under a radiant heater on the resuscitaire, leaving the face exposed and covering the head with a hat.

Action in the event of poor initial response to resuscitation after five inflation breaths

• Is the baby in the neutral position? • Is there a good seal on the mask? • Do you need jaw thrust? • Check for airway obstruction? • Consider Guedel airway?

• Is mask ventilation effective? Observe the chest wall movement and

consider endotracheal intubation.

• Is the endotracheal tube in the trachea or right main bronchus? Auscultate both axillae and observe movement.

• Does the baby have a pneumothorax? This occurs spontaneously in up to 1% of newborns but those needing action in the delivery unit are exceptionally rare.

• Auscultate the chest for asymmetry of breath sounds. A cold light source can be used to transilluminate the chest – a pneumothorax may show as a hyperilluminating area.

• If a tension pneumothorax is thought to be present clinically, a 21-gauge butterfly needle should be inserted through the second intercostal space in the midclavicular line. Alternatively, a 22-gauge cannula connected to a


three-way tap may be used. Remember that you may well cause a pneumothorax during this procedure.

• Does the baby remain cyanosed despite breathing with a good heart rate? There may be a congenital heart malformation, which may be duct-dependent, or there may be persistent pulmonary hypertension of the newborn.

• Is there severe anaemia or hypovolaemia? In the face of large blood loss,

10ml/kg 0-negative blood or a volume expander should be given.

These skills will be covered and there will be an opportunity to practise them during the workshop.

Fig 6.6: Head position


Fig 6.7: Newborn Life Support


CHAPTER 10 REFERRAL AND TRANSPORT

Introduction This section deals with transport and transfer of women and/or baby to a specialised unit at some distance away in emergency maternity care situations.

Modes of Transport

• By ambulance. • By ferry. • By air ambulance (fixed-wing aircraft or helicopter).

This Scottish Ambulance Service will advise on what is possible and most suitable and be responsible for arranging and coordinating the transfer details. (http://www.scottishambulance.com/)



Transfer by Air Ambulance

The Scottish Ambulance Service runs an air ambulance deployed from a number of sites. This service provides cover for the whole of Scotland including the islands. http://www.scottishambulance.com/WhatWeDo/TheParent.aspx) It is important that you are aware of the following key points in the event that you may well be involved in transport by the air ambulance service.

• If an emergency transfer is requested then it can take upwards of two hours to reach you depending on your location and current weather conditions.

• This delay maybe even longer if the ambulance crew is providing an on-call service from home or the air ambulance is already out on a mission.

• The final transfer arrangements are always made by the pilot and air media.

Factors to be considered when making this decision are based on safety and medical/obstetric reasons and include:

• Altitude. • Turbulence. • Time en-route. • If the birth is ongoing or imminent then it may be necessary to stay on

the ground.

NB: You need to follow the instructions of the pilot and air media at all times

http://www.scottishambulance.com/WhatWeDo/TheParent.aspx


Appropriate Positions for Transfer Ensuring left lateral tilt during ambulance transfer for cord prolapse

Fig 7.1:

Fig 7.2:


Ensuring airway of baby whilst transferring via ambulance

Fig 7.3:


Seek out one of the paramedics and the air ambulance service in your area. Discuss the practical issues involved in the transfer. If possible, this activity should be completed as a group activity. Establish the local guidelines for ambulance transfer from your area and to the regional referral centres for maternity care.

Scenario: A local woman who is 35-weeks pregnant asks you for advice when you are visiting her elderly mother at home. She tells you that she has had severe headaches and her vision is disturbed.

• What is your Primary Assessment? • Will you refer the lady? • Who will you refer her to? • Is this urgent? • How will you contact them?

Once again, be aware of who the appropriate professional to contact is and how to contact them. The key principles of referral and transfer of any patient is:

• Communication • Stabilisation • Expedient transfer to the most appropriate centre • Communication again and Documentation.


CHAPTER 11 FREQUENTLY ASKED QUESTIONS

Introduction This section provides a collection of frequently asked questions and responses. Much of this information is in the public domain e.g.

Frequently Asked Questions Why does labour go quicker after the membranes have ruptured? The intact bag of waters in front of the baby’s head acts like a cushion separating the bony head of the baby and the cervix. Membranes rupture, the fluid leaks out and the head sits on the cervix. It is common for labour to progress quicker if the membranes have ruptured. It also tends to make contractions more painful. The firm bony structure of the head stimulates uterine contractions. This usually occurs more if the woman adopts an upright position. What are Braxton Hicks contractions? These are called practice contractions. They usually occur from 28 weeks of pregnancy and get more regular in the last few weeks of pregnancy. The abdomen becomes firm for about 30 seconds and then relaxes – this is usually painless but can cause some discomfort. Braxton Hicks contractions do not indicate that labour has started.

http://www.babycentre.co.uk/

http://www.readysteadybaby.org.uk/


What is the best position for the woman to give birth in? If possible she should remain as active as possible and adopt different positions to provide most comfort. See the section on ‘Positions for Labour and Birth. What happens if the woman tears when the baby is born? Tears may happen and, in this event, put a pad over the tear. Apply pressure if the tear is bleeding. There is no need to do anything else unless bleeding continues – continue to apply pressure. What will I do if the baby does not breathe at birth? The baby would normally be seen to breathe at birth. However, some babies can be shocked and it takes up to a minute for them to adapt to life outside the uterus. Gently wipe away any mucous from the nose and mouth with a tissue. Handling and drying with a towel can often stimulate the baby to breathe. If the baby is in a fair to poor condition at the birth then he will need active resuscitation to help him breathe. Clamp and cut the cord. Move the baby to an area where you have access to resuscitate. Keep the baby warm. Refer to the section on “Resuscitation of the Newborn”. Do women always get a gush of water when the membranes rupture? Women will usually feel a gush of water if there is an escape of the fluid lying in front of the baby’s head. Often the head is well down in the pelvis and the fluid is trapped behind the head and cannot gush out when the membranes rupture. Women often report a trickle of fluid that they cannot control – this often suggests the membranes have ruptured. In some cases women are not aware that the membranes have ruptured. What will I do if I do not have any equipment for the birth? Firstly you need a safe place for the birth. Then you should improvise for equipment. You will need:

• Some papers or pads for the birth. • Something to cover the woman to preserve her dignity. • Something to dry the baby and something to keep him warm. • Some dry pads.

https://dl-web.dropbox.com/if


RECOMMENDED READING Boud, D., Keogh, R., Walker, D. (1985) Reflection: turning experience into learning. Kogan Page, London Burnard, P. (1991) Coping with stress in the health professions: A practical guide. Chapman Hall, London Boyd M. (2004) Emergencies around childbirth: a handbook for midwives. Radcliffe Medical Press, Oxford Liu, D.T.Y. (2007) Labour Ward Manual, 4th revised edition. Churchill Livingstone, London MacDonald S, Magill-Cuerden J. (eds) (2011) Mayes’ Midwifery A textbook for Midwives, 14th Edition. Bailliere Tindall, Edinburgh Magowan B, Owen P, Drife J. (eds) (2009) Clinical Obstetrics and Gynaecology 2nd Revised edition. Saunders Elsevier, Edinburgh Fraser D, Cooper M. (eds) (2009) Myle's Textbook for Midwives: With Pageburst online access. 15th edition. Elsevier, Edinburgh Royal College of Midwives. (2000) Risk Management Strategies. A midwife’s perspective. London: RCM Walsh D. (2007) Evidence-based care for normal labour and birth: A guide for midwives. Routledge, Oxon

Wilson J, Symon A. (eds) (2002) Clinical Risk Management in Midwifery: The right to a perfect baby? Butterworth-Heinemann, Edinburgh Woodward V, Bates K, and Young N (2005) Managing Childbirth Emergencies in Community Settings. Basingstoke: Palgrave Macmillan


WEBSITES http://www.resus.org.uk Resuscitation Council (UK) This site provides education and reference material to healthcare professionals and the general public in the most effective methods of resuscitation. http://scottishmaternity.org/ Scottish Multiprofessional Maternity Development Programme This site provide is the keystone for the Scottish Multidisciplinary Maternity Development Programme and provides details of its suite of courses for all maternity care professionals. http://www.nmc-uk.org/ Nursing and Midwifery Council The Nursing and Midwifery Council is an organisation set up by Parliament to protect the public by ensuring that nurses, midwives and health visitors provide high standards of care to their patients and clients. http://www.scottishambulance.com/ Scottish Ambulance Service This is the website of the Scottish Ambulance Service with up-to-date news about current services and training. http://www.also.org.uk/ Advanced Life Support Training in Obstetrics for Healthcare Professionals provides training for maternity care professionals in obstetric emergencies. http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2010.02847.x/pdf Centre for Maternal and Child Enquires (CMACE). Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006-08. The Eighth Report on Confidential Enquires into Maternal Deaths in the United Kingdom. BJOG 2011;118 (suppl. 1): 1-203. http://www.readysteadybaby.org.uk Ready Steady Baby Online NHS guidance for pregnancy, labour and birth

http://www.resus.org.uk/

http://scottishmaternity.org/

http://www.nmc-uk.org/


http://www.also.org.uk/

http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2010.02847.x/pdf

http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2010.02847.x/pdf

http://www.readysteadybaby.org.uk/


http://www.nmc-uk.org/publications/Standards/The-code/Introduction The Code: Standards of conduct, performance and ethics for nurses and midwives http://www.nmc-uk.org/Documents/NMC-Publications/Midwives%20Rules%20and%20Standards%202012.pdf Midwives Rules and Standards 2012 http://www.healthcareimprovementscotland.org/our_work/reproductive,_maternal__child/programme_resources/keeping_childbirth_natural.aspx Pathways for normal maternity care http://www.healthcareimprovementscotland.org/our_work/reproductive,_maternal__child/woman_held_maternity_record.aspx Scottish Women Handheld Maternity Record http://www.scotland.gov.uk/Publications/2011/02/11122123/0 Refreshed Framework for Maternity Care in Scotland http://www.legislation.gov.uk/ukpga/1998/29/contents Data Protection Act 1998 http://www.legislation.gov.uk/uksi/2002/253/contents/made The Nursing and Midwifery Order http://www.scotland.gov.uk/Publications/2003/01/16018/15750 The Expert Group on Acute maternity Services (EGAMS) report 2002

http://www.nmc-uk.org/publications/Standards/The-code/Introduction

http://www.nmc-uk.org/publications/Standards/The-code/Introduction

http://www.nmc-uk.org/Documents/NMC-Publications/Midwives%20Rules%20and%20Standards%202012.pdf

http://www.nmc-uk.org/Documents/NMC-Publications/Midwives%20Rules%20and%20Standards%202012.pdf

http://www.healthcareimprovementscotland.org/our_work/reproductive,_maternal__child/programme_resources/keeping_childbirth_natural.aspx



http://www.healthcareimprovementscotland.org/our_work/reproductive,_maternal__child/woman_held_maternity_record.aspx

http://www.healthcareimprovementscotland.org/our_work/reproductive,_maternal__child/woman_held_maternity_record.aspx


http://www.legislation.gov.uk/ukpga/1998/29/contents

http://www.legislation.gov.uk/uksi/2002/253/contents/made



APPENDIX 1

Professionals who may be required to provide emergency maternity care and their role

Midwife The formal definition of a midwife as adopted by the International Confederation of Midwives Council meeting, 19th July, 2005: Extract : ‘The midw ife is recognised as a responsible and accountable professional who w orks in partnership w ith women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midw ife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.’

http://www.internationalmidwives.org/who-we-are/policy-and-practice/icm-international-definition-of-th


Responsibility and Sphere of Practice A practising midwife means a registered midwife who has given notice of her intention to practise in accordance with Rule 3;

o If a midwife intends either to be in attendance upon a woman or baby during childbirth or to hold a post for which a midwifery qualification is required she must give notice of that intention

(NMC 2012) Scope of Practice: Midwife In an emergency maternity care situation the practising midwife is able to:

• Deal with uncomplicated labour and birth. • Deal with obstetric and medical emergencies in the absence of a medical

practitioner. • Administer entonox. • Administer pain relief as per scope of practice. • Administer syntometrine. • Perform adult resuscitation. • Perform neonatal resuscitation. • Refer appropriately using local referral pathway. • Assist in transfer arrangements. • Assist in transport arrangements. • If scope of practice has been expanded – Intravenous therapy. • Other areas of expanded scope of practice as identified by individual

midwives.

Scope of Practice: General Practitioner The general practitioner is suitably qualified to deal with all emergency situations. In an emergency maternity care situation the general practitioner is able to:

• Deal with uncomplicated labour and birth in the absence of the midwife. • Deal with obstetric and medical emergencies. • Administer entonox. • Administer pain relief. • Administer syntometrine.


• Intravenous therapy. • Perform adult resuscitation. • Perform neonatal resuscitation. • Refer appropriately using local referral pathways. • Assist in transfer arrangements. • Assist in transport arrangements. • Other areas of expanded scope of practice as identified by individual

general practitioners.

Scope of Practice: Scottish Ambulance Services – Paramedics The Scottish Ambulance Service (SAS) serves all of Scotland. The paramedics are professionals specifically trained to provide immediate care in all types of emergency situation. The scope of practice is determined by the SAS and this can often be extended depending on the requirements of the service in specific areas. In an emergency maternity care situation the paramedic is able to:

• Deal with uncomplicated labour and birth in the absence of a midwife. • Deal with obstetric emergencies in the absence of a midwife or general

practitioner. • Deal with medical emergencies in the absence of a general practitioner. • Administer entonox. • Administer pain relief as per scope of practice. • Intravenous therapy. • Perform adult resuscitation. • Perform neonatal resuscitation. • Refer appropriately using local referral pathways. • Deal with transfer arrangements. • Deal with transport arrangements. • Other areas of expanded scope of practice as identified by individual

paramedics.


Scope of Practice: First and Second Level Registered Nurses This would include all those practitioners registered on the various parts of the NMC register. All practitioners registered with NMC would follow ‘The Code: Standards of conduct, performance and ethics for nurses and midwives’ NMC (2008) http://www.nmc-uk.org/Publications/Standards/The-code/Introduction/ In the absence of a midwife, GP and paramedic, these practitioners will be required to deal directly with those situations below marked with an asterix*. If another professional arrives who has the expertise to deal with the situation then the first level registered nurse would be expected to assist them appropriately with the situations marked with an asterix*. This practitioner is able to continue working with those situations within their current scope of practice. In an emergency maternity situation the first level registered nurse is able to:

• *Deal with uncomplicated labour and birth. • *Deal with obstetric emergencies. • *Deal with medical emergencies. • *Perform neonatal resuscitation. • *Perform adult resuscitation.

This practitioner would be able to deal with the other situation below:

• Administer pain relief as per scope of practice. • Refer appropriately using local referral pathways. • Assist in transfer arrangements. • Assist in transport arrangements. • If scope of practice has been expanded – intravenous therapy. • Other areas of expanded scope of practice as identified by individual first

level registered nurses. • Other areas of expanded scope of practice as identified by individual first

and second level registered nurses.

http://www.nmc-uk.org/Publications/Standards/The-code/Introduction/


Scope of Practice: Scottish Ambulance Service Technicians Within the Scottish Ambulance Service this group of professionals is trained to technician level and will demonstrate the skills and duties relevant to this level (www.scottishambulance.com). In the absence of a midwife, GP and paramedic or other professionals – these practitioners will be required to deal directly with those situations below marked with an asterix*. If another professional arrives who has the expertise to deal with the situation then the ambulance technician would be expected to assist them appropriately with the situations marked with an asterix*. This practitioner is able to continue working with those situations within their current scope of practice. In an emergency maternity care situation the Scottish Ambulance Service technician is able to:

• *Deal or assist with uncomplicated labour and birth. • *Deal or assist with obstetric and medical emergencies. • *Perform or assist with adult resuscitation. • *Perform or assist with neonatal resuscitation.

The technician would be able to deal with the other situations below:

• Refer appropriately using local referral pathways. • Assist or deal with transfer arrangements. • Assist or deal with transport arrangements. • Other skills or duties as identified by individual technicians.



Other Personnel Scottish Ambulance Paramedics undertake more advanced basic training and may have done additional specific training in Obstetric emergencies and will be able to undertake all the activities above and more consistent with their additional training. In certain rural and remote areas in Scotland other individuals may be involved in emergency maternity care situations. This may include:

• Trained community first responders. • Ambulance drivers. • Police and RNLI. • Nursing auxiliaries. • Others as identified by local areas.

The trained community first responder is a local volunteer who agrees to be able to provide life-saving treatment to those people who are critically injured or ill in the first few minutes of an emergency situation before the ambulance arrives (http://www.scottishambulance.com/WorkingForUs/communityresilience.aspx). Other individuals may need to undertake this course. In these circumstances those individuals will work within the terms agreed with their respective employing authorities.

http://www.scottishambulance.com/WorkingForUs/communityresilience.aspx


APPENDIX 2 Please add in your own local information from your activities e.g. local contact details, guidelines, protocols to support you in the event of a maternity emergency.