• Give drugs as appropriate:
– Syntocinon 10 units by slow IV injection or IM if not already given by this route
– Ergometrine 0.5 mg by slow IV injection
– Syntocinon infusion at 10 iu per hour (e.g. 40 units in 500 ml Hartmann’s at 125 ml/h)
– Carboprost (Haemabate) 0.25 mg IM (repeated at intervals of not less than 15 minutes to a maximum of eight doses)
• If bleeding persists, transfer to operating theatre and consider the other Ts.
Trauma
If bleeding continues, consider the possibility of lacerations, a rup- tured or inverted uterus. Continue bimanual compression until appropriate help is available.
Tissue
• If the placenta is delivered, ensure it is complete
• If the placenta is not delivered, a manual removal of placenta or manual examination of the uterus may be indicated as described previously
Thrombin
Coagulation disorders are very rare and are usually identifi ed in the antenatal period. However, a large blood loss from one of the above causes may lead to the blood clotting mechanisms to become deranged. This is identifi ed through blood clotting studies.
As with any event, documentation is vital, particularly fl uid input and output, drugs given, who was present and what was done in what order, with timings. A scribe has a very important role in emergency scenarios and enables accurate, contemporaneous record keeping.
Following the event, it is helpful to use the documentation to debrief the woman and her family, as well as the staff.
Incidence: Severe pre-eclampsia/eclampsia is a major factor in maternal and fetal mortality and morbidity, and if not detected and monitored at the earliest opportunity can sometimes prog- ress to eclampsia extremely rapidly.
• Five in 1000 women in the UK will suffer severe pre-eclampsia in pregnancy and for fi ve in 10,000 women this will lead to eclampsia
• The mortality rate from severe pre-eclampsia/eclampsia is 1.8 per cent whilst those who will suffer from major complications the rate is 35 per cent (RCOG 2006)
• Eclampsia remains the second leading cause of maternal deaths in the UK and substandard care is constantly stated as being a major factor in a number of deaths (CEMACH 2004)
• In 2000–2002, CEMACH (2004) reported 14 maternal deaths due to pre-eclampsia or eclampsia
• Pre-eclampsia/eclampsia is the single leading identifi able risk factor in pregnancy associated with stillbirth. Twenty per cent of stillbirths are due to this cause in otherwise viable babies (Con- fi dential Enquiry into Stillbirths and Deaths in Infancy 1997)
• Serious morbidity associated with pre-eclampsia/eclampsia can occur from 20 weeks’ gestation to after delivery. It should be noted that the earlier pre-eclampsia presents, the more serious it can be. Onset prior to 32 weeks’ gestation has the most serious outcome, with many women needing delivery within 72 hours (Sibai et al. 1994)
The midwife is usually the fi rst professional in a position to detect pre-eclampsia and it is vital that she involves the obstetricians imme- diately so a management plan can be put in place and attempt to prevent progression to eclampsia.
Risk factors:
• First pregnancy
• Age 40 years or above
• History of pre-eclampsia in a mother or sister
• History of previous pre-eclampsia/eclampsia
• Body mass index >35 at booking
• Multiple pregnancies
• Pre-existing vascular disease, for example diabetes, hyperten- sion or renal disease (PRECOG 2004)
Signs and symptoms
It is important to note that some women who present with eclamp- sia will have no pre-existing signs or symptoms. Therefore, the
midwife must be aware of the risk factors of developing pre-eclamp- sia at booking and refer and monitor closely throughout the preg- nancy. Women also need to be informed of symptoms of worsening disease so they are able to alert the midwife if they have any concerns.
Hypertension
Hypertension is said to occur when the diastolic blood pressure (BP) is 90 mm/HG or more on two occasions and the systolic BP is above 140 mm/Hg or above. The CEMACH Report (2004) has highlighted that whilst diastolic BP is one of the important indices of the severity of pre-eclampsia it is thought that it is the systolic BP which causes intracerebral haemorrhage. It therefore recommended that antihypertensive treatment should be considered for a systolic BP of 160 mmHG or above. However, if signs of severe disease are present, medication should be commenced at lower levels (RCOG 2006).
It should also be noted that eclampsia is not always preceded by severe hypertension, with 34 per cent of eclamptic women having a maximum diastolic BP of 100 mm/Hg or below (PRECOG 2004).
Automatic BP devices will measure BP lower than a conventional sphygmomanometer (CEMD 2002). Therefore, a baseline reading with an automatic device should be compared with a conventional device so accurate comparisons can be made. The mercury sphyg- momanometer remains the gold standard against which new BP monitor accuracy is judged (MHRA, 2005).
Proteinuria
A dipstick analysis of urine that reveals a 2+ of proteinuria or more should be confi rmed by a 24-hour urine collection. A urine protein excretion of 300 mg or more over 24 hours is signifi cant (PRECOG 2004).
NB Whenever BP is measured in pregnancy a urine sample should be tested for proteinuria at the same time. The CEMD Report (2002) highlighted that midwives had failed to test for proteinuria in women who went on to develop severe pre-eclampsia.
Severe headaches
These could be a sign of cerebral involvement.
Visual disturbances
Due to papilloedema, this is a swelling of the optic nerve and a sign of increased intracranial pressure.
Vomiting
One of the signs of increased intracranial pressure is vomiting.
Epigastric Pain
This is of particular concern if severe and may be associated with vomiting. It will be described by the woman as severe and there will be tenderness on palpation (PRECOG 2004).
Signs of clonus
Clonus is rapid rhythmic movements and is described as alternate muscle relaxation and contraction resulting in brisk refl exes.
Small for gestational age fetus
This could be one of the fi rst signs of pre-eclampsia and occurs in 30 per cent of pre-eclamptic pregnancies (RCOG 2006). It is impor- tant that fundal height is measured, any abnormalities reported and a growth scan arranged if indicated.
Reduced fetal movements
This may indicate fetal compromise due to placental insuffi ciency.
Analysis of blood
Blood tests can provide important information about the severity of the disease and to what extent the maternal system has been affected.
It is recommended that these are repeated daily when the results are normal, but more frequently if the clinical condition changes (RCOG 2006). Full blood counts, urea and electrolytes and liver function tests should be obtained to detect worsening disease, possible renal failure and HELLP (haemolysis, elevated liver enzymes, low plate- lets) syndrome.
Platelets
A falling platelet count is associated with worsening disease. Below 100 may mean there is an associated coagulation abnormality and clotting studies are indicated (RCOG 2006).
Alanine Aminotransferase (ALT) / Aspartate Aminotransferase (AST)
Above 75 iu/l is signifi cant and above 150 iu/l is associated with increased morbidity to the mother (RCOG 2006).
Urates
Rising urate rates can indicate worsening disease. Normal rates are between 0.149 and 0.369 mmol/l.
Creatinine
Rising level can indicate renal involvement with risk of renal failure.
Normal rates are between 62 and 106 umol/l.
Management of an eclamptic seizure
It should be noted that 44 per cent of women will have their fi rst fi t within 48 hours following delivery, 38 per cent in the antenatal period and 18 per cent during labour (APEC 2005). Almost 2 per cent of women suffering eclamptic seizures will die, 23 per cent will require ventilation and 35 per cent will have at least one major complication, including pulmonary oedema, renal failure, dissemi- nated intravascular coagulation, HELLP syndrome, acute res piratory distress syndrome, stroke or cardiac arrest. Stillbirth or neonatal death occurs in approximately 1 in 14 cases of eclampsia (Munro 2000).
Help from a senior obstetrician and anaesthetist should be sum- moned. If in the community an emergency ambulance manned by paramedics must always be summoned and the woman should be protected from injury during the convulsion. Following convulsion the woman should be placed in a left lateral position and given oxygen. Assessment of the airway, breathing and circulation is required as well as measurement of blood pressure, pulse, tempera- ture and oxygen saturation.
If not already instigated, intravenous access is required. In the treatment of eclampsia and pre-eclampsia magnesium sulphate is the anticonvulsant of choice (CEMACH 2004). A loading dose of magnesium sulphate 4 g should be given by infusion pump over 5–10 minutes, followed by a maintainence dose of 1 g/hr for 24 hours after the last seizure. (RCOG 2006).
Antihypertensive therapy is required to reduce the BP and this is provided according to local protocol. Blood is taken from the woman and is sent for grouping and saved. A full blood count, analysis of urea and electrolytes along with tests for liver function and clotting are also required.
If the woman is suffering breathing problems as a result of laryn- geal oedema or if she is presenting with status eclampticus (con- tinuous convulsions) she will require intubation and ventilation (Arulkumaran et al. 1997).
Fetal monitoring is required to assess fetal wellbeing if the baby is not already delivered. Delivery should be undertaken as soon as
the maternal condition is stable as this is the only defi nite way to resolve the crisis (Arulkumaran et al. 1997).
An accurate fl uid balance must be maintained. This is important as another cause of maternal death from pre-eclampsia/eclampsia is pulmonary oedema which can be attributed to fl uid overload.
Strict and vigilant fl uid balance is essential. Fluids should be restricted to 85 ml/hr and hourly urine output measured using an indwelling urinary catheter (CEMD 2002). Urinary output
of <30 ml/h is signifi cant and must always be reported to an
obstetrician/anaesthetist.
Pre-eclampsia/eclampsia remains one of the leading causes of maternal deaths in the UK. Therefore, the midwife needs to be aware of the risk factors and signs of the disease and ensure that women are screened regularly throughout pregnancy. Women who are high risk must be referred early for specialist care. If pre-eclampsia is detected, prompt referral must be made so the woman can be assessed and monitored appropriately. This will ensure that she receives optimum care and in some cases progression to eclampsia may be prevented.
Conclusion
Emergency scenarios occur both in and out of hospital. Fortunately, they are relatively uncommon in the community setting where mid- wives are more likely to be working without close access to obstetric support. However, it is midwives in these settings who will have to be prepared to carry out these procedures should the need arise.
When faced with an emergency situation, the key points are to:
• Call for appropriate help – paramedic assistance out of the hos- pital setting
• Deal with the emergency
• Work effectively as a team – good communication required
• Document the events and action taken clearly – this is a profes- sional requirement (NMC 2004) and helpful for analysis of the event. Remember that if it’s not written it didn’t happen!
• Report the incident through the incident reporting system
• Debrief after the event with colleagues and a Supervisor of Midwives
• Refl ect on the event
If possible, a member of the team should be allocated to remain with the woman and her partner to ensure communication and offer support throughout the emergency situation (NICE 2006).
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