Abstract
An increasing number of parents are choosing to give birth in midwife-led settings such as alongside midwifery units and freestanding midwifery units [1]. These are midwife-led facilities which may be on the same premises as an obstetric unit (alongside [AMU]) or away from an obstetric unit on its own premises (freestanding [FMU]). The National Institute for Health and Care Excellence (NICE) [2] published guidance for healthcare professionals and parents on the safety of birthing in these units. Evidence has found that it is safer for primiparous women to give birth in either an AMU or an FMU and for multiparous women to give birth at home [3, 4]. This is because women are less likely to need intervention such as the use of forceps or epidural for analgesia than if they give birth in obstetric-led facilities. With the introduction of a government-supported paper, ‘Better Births’ [5], more emphasis is being put on information and education for parents on birthing in community-based settings to increase home birth rates and the care given in the community (Figure 17.1).
Introduction
An increasing number of parents are choosing to give birth in midwife-led settings such as alongside midwifery units and freestanding midwifery units [1]. These are midwife-led facilities which may be on the same premises as an obstetric unit (alongside [AMU]) or away from an obstetric unit on its own premises (freestanding [FMU]). The National Institute for Health and Care Excellence (NICE) [2] published guidance for healthcare professionals and parents on the safety of birthing in these units. Evidence has found that it is safer for primiparous women to give birth in either an AMU or an FMU and for multiparous women to give birth at home [3, 4]. This is because women are less likely to need intervention such as the use of forceps or epidural for analgesia than if they give birth in obstetric-led facilities. With the introduction of a government-supported paper, ‘Better Births’ [5], more emphasis is being put on information and education for parents on birthing in community-based settings to increase home birth rates and the care given in the community (Figure 17.1).
Figure 17.1 Trends in home births in the United Kingdom.
The aim of this chapter is to aid the prompt recognition of obstetric emergencies in midwifery-led settings. It will also describe the immediate management of these emergencies with the limited equipment available in low-risk settings. The obstetric emergencies covered will be postpartum haemorrhage, shoulder dystocia, undiagnosed breech presentation, cord prolapse, preeclampsia and eclamptic fit.
Postpartum Haemorrhage
Key Facts
Postpartum haemorrhage (PPH) remains one of the leading causes of maternal death in both developed and underdeveloped countries [6]. Prompt recognition and effective management of PPH is vital for improved outcomes for mothers experiencing an obstetric haemorrhage. In midwife-led settings, particularly at home or in a freestanding midwifery unit (FMU), it is essential for midwives to be up-to-date with their clinical skills in identifying and managing PPH with limited resources.
Definition Blood loss from the birth canal following the birth of the baby of 500 mL or more [7]. However, any amount of blood loss which causes the mother to be symptomatic should be treated as an obstetric haemorrhage. There are two types of PPH, a primary PPH whereby the excessive blood loss occurs within the 24-hour period following the birth of the baby. A secondary PPH whereby excessive blood loss occurs after 24 hours postpartum and any time up to 12 weeks postnatally. Obstetric haemorrhage can be defined as minor, a loss of 500 mL to 1000 mL or major, greater than 1000 mL, which can cause hemodynamic instability known as disseminated intravascular coagulation [DIC] [7].
There are four main causes of PPH (4T’s):
Tone (uterine atony)
Trauma (to the genital tract during childbirth)
Tissue (retained products such as the placenta)
Thrombin (clotting disorder of the mother)
Although the majority of PPHs occur with no known risk factors, research has found there to be some identifiable risk factors associated with PPH both antenatally and during labour [7]. As this chapter discusses management in midwife-led settings, women with known antenatal risk factors for PPH should be recommended to labour and birth in an obstetric-led facility. However, if risk factors are not identified until in labour it is important midwives familiarise themselves with these, so they are able to identify a possible need for transfer to an obstetric-led facility early and prior to the birth of the neonate. The possible risk factors are [7, 8]:
Quick labour
Prolonged labour
Bladder distention
Elevated blood pressure
Retained placenta or placental tissue
Retained blood clots
Healthcare professionals attending births in low-risk settings should always be prepared to deal with emergencies such as a postpartum haemorrhage. This includes ensuring having the appropriate basic equipment (Figure 17.2) available to them which can be used in these settings, including
Figure 17.2 Emergency kit in the MW setting.
Key Management
Management of a postpartum haemorrhage requires early identification of the cause of the haemorrhage. This can be quickly assessed as soon as a PPH has been identified. Delivery of the placenta at this stage is imperative for identification of the cause and for sufficient contraction of the uterus. An oxytocic drug should be used and given intramuscularly; the choice of drug is dependent on other factors such as the mother’s blood pressure. If the blood pressure is not known or there have been any high readings, then oxytocin 10 IU should be given intramuscularly. If the mother’s blood pressure has remained stable throughout labour then Syntometrine can be used as an alternative; this contains ergometrine and oxytocin and is associated with more effective contraction of the uterus for management of the third stage of labour [9].
In most midwife-led settings including at home births a second birth attendant is called to be present for the birth, if this is the case, the placenta should be delivered and then checked by the second attendant to ensure it is complete and to rule out one of the four T’s, Tissue – retained birth products. At the same time the birth attendant is able to assess if the blood is clotting to rule out another of the four T’s, Thrombin – a coagulation disorder.
Key Actions to Improve Outcomes
In midwife-led settings it will take longer for help to arrive, in an AMU this will be less than in an FMU or home birth, but management should be the same. In an FMU or homebirth an ambulance will need to be called. This should be done immediately after a PPH is diagnosed and can be done by the birth partner or a birth attendant. An ambulance should be called using 999 or 911, state who you are, the address where assistance is needed and why you are calling. The receiving hospital should also be contacted to make them aware the woman is being transferred and may need to go to theatre.
A second oxytocic drug should be given, especially in the case of uterine atony, and the uterus should be massaged to ‘rub-up’ a contraction, thus assessing for ‘Tone’; this will help to contract the uterus and minimise bleeding. If the uterus feels ‘boggy’ (not well contracted) a catheter should be inserted to keep the bladder empty and bimanual compression (Figure 17.3) should be performed to minimise blood loss while waiting for the ambulance to arrive. If there is another midwife in attendance, they should start intravenous oxytocin, 40 IU in 500 mL of sodium chloride and should be run at a rate of 10 IU per hour. Oxygen should also be started via a face mask and observations recorded regularly to monitor the woman.
Figure 17.3 Bimanual uterine compression.
Shoulder Dystocia
Key Facts
A shoulder dystocia is an acute obstetric emergency which, like many emergencies, is time critical. It is defined as a vaginal birth of a cephalic infant which requires manoeuvres after the head has been born to further assist the birth [10]. It is one of the most feared obstetric emergencies among midwives, particularly those working in community settings. Managing this scenario in an obstetric-led unit gives some comfort to the attending midwives knowing there is senior obstetric help available in a matter of seconds. However, those working in midwifery-led settings and home births may very well find themselves managing this complication on their own without the availability of obstetric help. Shoulder dystocia is possibly the most unpredictable of all obstetric emergencies in terms of most shoulder dystocias occurring in mothers with no known risk factors, making preparing for its occurrence very difficult [11]. Therefore, all healthcare practitioners providing intrapartum care in midwife-led settings should approach birth with an awareness that a shoulder dystocia may occur with any mother and thus be prepared to manage such an incident at all times.
The better prepared one is for such an emergency and the more the physiology and mechanics of a shoulder dystocia are understood the better able the practitioner is to resolve the complication quickly and efficiently. Research has shown that a reduction in the head-to-body birth interval (<5 minutes) is vital to reduce the risk of fetal acidosis and hypoxic ischaemic encephalopathy (HIE) [12]. In community settings where there is no obstetric input it is vital that midwives are competent in resolving such complications as a shoulder dystocia and therefore need to be knowledgeable in the manoeuvres used to resolve the complication. If practitioners are not confident or competent in the management of a shoulder dystocia brachial plexus injury can occur with incorrect management which can have long-standing complications for the baby [13]. The NHS Litigation Authority (NHSLA) reports on adverse outcomes associated with patients making claims against the Trust involved. The NHSLA’s latest report found that 46% of the injuries caused from a shoulder dystocia were associated with mismanagement of the resolution of the complication. They also reported that not all of the injuries were from excessive axial traction, but excessive maternal propulsive force may also have contributed to some of these injuries [14].
Risk factors which midwives working in community-based settings should be more aware of are
Fetus feels large for dates on palpation
Body mass index (BMI) >30
Prolonged first stage of labour
Prolonged second stage of labour
Key Management
Management of a shoulder dystocia can be described using a pneumonic HELPERRS, however, it must be noted that the manoeuvres used do not have to follow the order of the pneumonic and can be conducted in any order.
H – call for help
E – evaluate for an episiotomy
L – legs into McRoberts position
P – suprapubic pressure (30 seconds consistent followed by 30 seconds intermittent)
E – enter the vagina to perform internal manoeuvres
R – remove the posterior arm of the fetus
R – roll the mother onto all fours
S – start again
Calling for help in community-based settings depends on where the birth is taking place. In an AMU an emergency bell should be activated to summons the help from other midwives, one of the attending midwives should put out an emergency ‘obstetric emergency’ call for obstetric assistance. In an FMU an emergency bell should still be activated; however, there will be no obstetric assistance. A second midwife and possibly a healthcare assistance or maternity support worker should arrive to assist with the birth. This may also include calling for an ambulance for transfer into an obstetric unit if the complication cannot be resolved, a further emergency follows such as a postpartum haemorrhage or if neonatal resuscitation is required. During a home birth the midwife must ensure they have the means to call for an ambulance in case of an emergency; there will be no obstetric backup in this instance [15].
Evaluating for an episiotomy should be done promptly and performed if it will enable better access to perform internal rotational manoeuvres. An episiotomy itself will not resolve the complication, which is supported by a recent systematic review which found no evidence to support the use of an episiotomy for the management of a shoulder dystocia [16].
The McRoberts manoeuvre (Figure 17.4) is an extremely effective technique for resolving shoulder dystocia, reportedly in up to 90% of cases. The McRoberts manoeuvre uses maternal positioning of hyperflexion and abduction of the mother’s legs to flatten the sacrum and increase space in all diameters of the pelvis. Evidence has shown that this manoeuvre should be the first used once a shoulder dystocia has been diagnosed. It causes the least trauma to mother and baby, significantly reducing morbidity and because it is so highly effective reduces the need for use of rotational manoeuvres [10].
Figure 17.4 The McRoberts manoeuvre.
Suprapubic pressure is another manoeuvre which is commonly used and has shown to be effective for the resolution of a shoulder dystocia. Used in combination with the McRoberts manoeuvre, it has the most effectiveness. To perform the manoeuvre the practitioner places both hands together in the CPR position and uses the palm of the under hand to apply first constant pressure to the posterior aspect of the anterior fetal shoulder. The idea is to reduce the diameter of the fetal shoulders and push the shoulder underneath the mother’s pubic bone where it has been caught. If this is unsuccessful, after 30 seconds of constant pressure the practitioner can change to a rocking motion for a further 30 seconds.
The use of the McRoberts manoeuvre and suprapubic pressure in combination is shown to be effective and is associated with low rates of neonatal injury. Therefore, it can be seen these are suitable manoeuvres to initiate immediately for the resolution of shoulder dystocia prior to conducting more invasive manoeuvres which could potentially cause an increase in neonatal and maternal injury [13]. The use of this manoeuvre in a midwife-led setting is a very appropriate and effective method for resolving a shoulder dystocia without any medical assistance being available. Even with only one trained practitioner in attendance the use of support staff and birth attendants can be used to conduct the McRoberts manoeuvre while the trained practitioner is able to perform the suprapubic pressure.
If a shoulder dystocia is unresolved following the use of the McRoberts manoeuvre and suprapubic pressure, the practitioner now needs to consider entering the vagina to perform internal rotational manoeuvres to resolve the complication. There are four rotational manoeuvres which can be used:
1. Rubins II. The practitioner enters their fingers at the five or seven o’ clock position (depending on the side which the baby’s back is on) followed by running the fingers up the back of the baby until they are behind the posterior aspect of the anterior shoulder (Figure 17.5). One should then try to push the shoulder forward underneath the pubic bone. This can be done using constant pressure followed by a rocking motion as with suprapubic pressure. The woman should be encouraged to stop pushing during the manoeuvre, as this will only worsen the complication.
2. Woodscrew manoeuvre. This manoeuvre is so called because the clinician is trying to rotate the baby, like unscrewing a bottle, to change the position of the shoulders so the baby can be born underneath the maternal pubic bone (Figure 17.6). The practitioner’s fingers be placed on the posterior aspect of the anterior fetal shoulder and the anterior aspect of the posterior fetal shoulder, trying to rotate the baby using either a constant pressure or a rocking motion.
3. Reverse woodscrew. If the aforementioned manoeuvres are unsuccessful, the fetus may need to be rotated in the opposite rotation to change the position of the shoulders further. The practitioner should move the fingers to the opposite shoulders. One hand will move up from the posterior shoulder to the anterior aspect of the anterior shoulder and the other down from the anterior shoulder to the posterior aspect of the posterior shoulder. Again, either constant pressure or a rocking movement can be used trying to try and change the position of the shoulders, so the anterior shoulder can move further posteriorly and be born past the pubic bone.
4. Removal of the posterior arm. This is the final of the rotational manoeuvres and research has shown it to be the most effective [13]. The practitioner needs to enter the vagina the side on which the baby is facing and must run the fingers down the posterior arm to the antecubital fossa. Application of gentle pressure leads to the flexion of the posterior arm, which should be held and swept across the baby’s body and face, rotating the baby and releasing the anterior shoulder which has been caught on the maternal pubic bone.
