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Группа авторов. Managing Medical and Obstetric Emergencies and Trauma
Table of Contents
List of Tables
List of Illustrations
Guide
Pages
Managing Medical and Obstetric Emergencies and Trauma. A Practical Approach
Dedication
Working group for fourth edition
Contributors to fourth edition
Working group for third edition
Contributors to previous editions. Contributors to third edition
Additional contributors to second edition
Additional contributors to first edition
Foreword to fourth edition
Preface to fourth edition
Acknowledgements
Contact details and further information
Updates
References
On‐line feedback
How to use your textbook. The anytime, anywhere textbook. Wiley E‐Text
To access your Wiley E‐Text:
Abbreviations
CHAPTER 1 Introduction
Box 1.1 Content of the mMOET online learning package
CHAPTER 2 Saving mothers’ lives: lessons from the Confidential Enquiries. 2.1 Introduction
2.2 How the enquiries work
Reporting
Expert assessment
Reports
2.3 Lessons from the past. Effective intervention
Obstetric injury
2.4 Recent lessons. Obstetric injury today
Who is at risk?
Age
Obesity
Socioeconomic classification
Ethnicity
2.5 Direct deaths. Hypertensive disease
Haemorrhage
Thromboembolism
Ectopic pregnancy
Abortion
Amniotic fluid embolism
Sepsis
Anaesthesia
2.6 Indirect deaths
Cardiac disease
Mental health conditions
Other indirect deaths
2.7 Coincidental deaths
2.8 Quality of care
2.9 The international dimension
2.10 Summary
2.11 Further reading
CHAPTER 3 Structured approach to emergencies in the obstetric patient
Learning outcomes
3.1 Introduction
Primary survey
Airway
Breathing
Circulation
Disability
Exposure
3.2 Resuscitation
Secondary survey
Assessment of the collapsed patient using the ABC approach
Management of the apparently lifeless (unresponsive) patient
Management of the seriously injured pregnant patient
Monitoring (applied during primary survey)
Adjuncts to assessment
Assess fetal well‐being and viability
3.3 Definitive care
3.4 Summary
CHAPTER 4 Human factors. Learning outcomes
4.1 Introduction
4.2 Extent of healthcare error
4.3 Causes of healthcare error
4.4 Human error
4.5 Learning from error
Improving team and individual performance
4.6 Communication
Effective communication with a feedback loop
4.7 Team working, leadership and followership
The leader
Who is the leader?
Physical position of the leader
Clear roles
Followership
Hierarchy
4.8 Situation (or situational) awareness
Level 1 – the basic level (What is going on? Collecting information)
Distraction
Level 2 (So what? Interpreting the information)
Level 3 (Now what? Anticipating the future state)
Team situation awareness
4.9 Improving team and individual performance
Awareness of situations when errors are more likely
Awareness of error traps
Cognitive aids: checklists, guidelines and protocols
Calling for help early
Using all available resources
Debriefing
4.10 Summary
4.11 Further reading
CHAPTER 5 Recognising the seriously sick patient
Learning outcomes
5.1 Introduction
5.2 Modified early‐warning systems
Box 5.1 SBAR
Breathlessness
Headache
Abdominal pain and diarrhoea
5.3 Summary
5.4 Further reading
Appendix 5.1 Blood gas interpretation. Lactate
ABG interpretation
Appendix 5.2 Radiology in the pregnant woman
CHAPTER 6 Shock
Learning outcomes
6.1 Introduction
6.2 Aortocaval compression and supine hypotension syndrome
6.3 Types of shock
Hypovolaemic shock: insufficient preload
Absolute hypovolaemia – blood loss, fluid loss
Important implications of pregnancy physiology in haemorrhage
Relative hypovolaemia – vasodilatation due to regional blockade
Cardiogenic shock – reduced cardiac contractility
Distributive shock – abnormal vascular resistance and fluid distribution
Sepsis
Anaphylaxis
Burns
Obstructive shock
6.4 Symptoms and signs of shock
Hypovolaemic shock
Increase in heart rate
Skin, capillary refill, mental state and urine output
Capillary refill time (CRT)
Mental state
Narrowed pulse pressure
Systolic hypotension
Recognition of hypovolaemia
Pitfalls in the recognition of shock in pregnancy
6.5 Principles of treatment. Hypovolaemic shock
C: Circulation
Septic shock
Cardiogenic shock
Anaphylactic shock
Box 6.1 Management of anaphylactic shock
6.6 Summary
6.7 Further reading
CHAPTER 7 Sepsis
Learning outcomes
7.1 Introduction and definition
7.2 Sepsis in pregnancy
Box 7.1 Classification of maternal infection aligned with the WHO classification of maternal death
7.3 Pathophysiology of sepsis
Clinical manifestations of haemodynamic alterations
7.4 Microbiology
7.5 Clinical issues and presentation
7.6 Monitoring, investigations and urgent treatment
Airway and breathing
Fluids
Vasopressors
Early source identification and control of infection
Influenza A/H1N1
Treatment
Recommendations
SARS‐CoV‐2
Treatment
7.7 Summary
7.8 Further reading
Appendix 7.1 Viral rash in pregnancy
CHAPTER 8 Intravenous access andfluid replacement. Learning outcomes
8.1 Intravenous access
8.2 Alternatives to peripheral venous access. Intraosseous access
Uses for IO cannulae
Contraindications to use of IO cannulae
Complications of insertion
CVP line access and monitoring
Practical tips for the use of CVP lines
Ultrasound‐guided access
8.3 Intravenous fluid administration. Circulatory volumes
Fluid warming and pressure devices
8.4 Types of intravenous fluid. Crystalloids
Balanced salt solutions
0.9% sodium chloride (‘normal’ saline)
Dextrose solutions
Synthetic colloids
Blood products
Crossmatching blood
Red cell concentrate
Citrate anticoagulation
Fresh frozen plasma
Cryoprecipitate
Platelets
Decision making to aid coagulation support in obstetric haemorrhage
Cell salvage
Cell salvage for Jehovah’s witnesses
8.5 Clinical signs guiding fluid replacement
Box 8.1 Response to resuscitation by intravenous fluids. Signs improve and remain improved
An initial but unsustained improvement in vital signs followed by regression to abnormal levels
Vital signs remain abnormal
No response
Use of acid–base status and lactate to guide resuscitation
8.6 Fluid administration in special circumstances
Pre‐eclampsia/eclampsia. Fluid management prior to delivery
Fluid management post delivery
Sepsis
Cardiac disease
8.7 Summary
8.8 Further reading
CHAPTER 9 Acute cardiac disease in pregnancy
Learning outcomes
9.1 Introduction
9.2 Cardiac disease
9.3 Chest pain
Box 9.1 Red flags in a pregnant patient presenting with chest pain
Myocardial infarction/acute coronary syndrome
Aortic dissection
Shortness of breath
Box 9.2 Red flags in a pregnant patient presenting with breathlessness
Pulmonary oedema
Palpitations
Box 9.3 Red flags in a pregnant patient presenting with palpitations
9.4 Summary
9.5 Further reading
CHAPTER 10 Airway management and ventilation. Learning outcomes
10.1 Introduction
10.2 Airway assessment. Importance of patency, maintenance and protection of the airway
Circumstances in which an airway problem is likely to occur
Assessment of the airway
Assessment of ventilation
10.3 Airway management
Suspected cervical spine injury
Clearing the obstructed airway
Head tilt/chin lift (no cervical spine injury suspected)
Jaw thrust
Suction
How to check if the airway is clear
Maintaining the airway
Oropharyngeal airway
Nasopharyngeal airway
10.4 Advanced airway techniques
Endotracheal intubation
Intermittent oxygenation during difficult intubation
Correct placement of the endotracheal tube
Failed intubation in the obstetric patient
Other methods for maintaining the airway
Supraglottic airway devices
Surgical airway
10.5 Management of ventilation
Extubation
10.6 Summary
10.7 Further reading
Appendix 10.1 Practical procedures. Oropharyngeal airway insertion. Equipment
Procedure
Pocket mask use. Equipment
Procedure
Laryngeal mask insertion. Equipment
Procedure
Complications
Surgical airway
Box 10A.1 Scalpel cricothyroidotomy
Complications
CHAPTER 11 Cardiopulmonary resuscitation in the pregnant patient
Learning outcomes
11.1 Introduction
Basic life support
Advanced life support
11.2 Management of CPR
Perform manual uterine displacement
Open the airway
Assess breathing (and signs of life: circulation)
Start CPR
Automated external defibrillation
Attaching AED pads (or position gel pads for manual defibrillator)
11.3 Follow the advanced life support algorithm
Shockable rhythms
Non‐shockable rhythms
Reversible causes of cardiac arrest
Doubt about the rhythm
Other drugs
11.4 Physiological changes in pregnancy affecting resuscitation
Vena caval occlusion
Changes in lung function
Efficacy of ventilation
11.5 Perimortem caesarean section
When to do it
Where to do it
How to do it
Fetal outcome
Decision to abandon CPR if unsuccessful
11.6 Communication, teamwork and human factors
Logistics
11.7 Summary
11.8 Further reading
CHAPTER 12 Amniotic fluid embolism
Learning outcomes
12.1 Introduction
12.2 Incidence of AFE
12.3 Clinical manifestations
Other clinical manifestations
AFE: definition 1
AFE: definition 2
12.4 Symptoms and signs
Suspecting an AFE
12.5 Diagnosis of AFE
12.6 Management of AFE
Airway/breathing
Circulation
Risk of recurrence
Neonatal outcome
12.7 Summary
12.8 Further reading
CHAPTER 13 Venous thromboembolism
Learning outcomes
13.1 Introduction
13.2 Pathophysiology of thromboembolism
13.3 Clinical presentation of pulmonary embolism
13.4 Management of thromboembolism
13.5 Investigations for patients with a possible pulmonary embolism. Chest radiograph
Doppler ultrasound
Other investigations
Further imaging
D‐dimer testing
13.6 Treatment of thromboembolism
Maintenance treatment
Anticoagulant therapy during labour
Anticoagulant therapy in the immediate postpartum period
13.7 Summary
13.8 Further reading
CHAPTER 14 Resuscitation of the neonate at birth
Learning outcomes
14.1 Introduction
14.2 Normal physiology
14.3 Pathophysiology
14.4 Equipment for newborn resuscitation
Box 14.1 Equipment for newborn resuscitation
14.5 Strategy for assessing and resuscitating a neonate at birth
Call for help
Start the clock
At birth
Keep the neonate warm
Assessment of the newborn neonate
Breathing
Heart rate
Outcome of the initial assessment
Resuscitation of the newborn. Airway
Meconium aspiration
Breathing (inflation breaths and ventilation)
Circulation
Drugs
Adrenaline
Glucose
Bicarbonate
Fluids
Naloxone
Response to resuscitation
Discontinuation of resuscitation
14.6 Laryngeal masks
14.7 Tracheal intubation
14.8 Preterm neonates
Box 14.2 Guidelines for the use of plastic bags for preterm neonates (<32 weeks’ gestation) at birth
CPAP via mask versus intubation
14.9 Actions in the event of poor initial response to resuscitation
14.10 Birth outside the delivery room
14.11 Communication with the parents
14.12 Summary
CHAPTER 15 Introduction to trauma
Learning outcomes
15.1 Introduction
15.2 Aetiology and epidemiology
15.3 Obstetric complications of trauma
15.4 Organisation of trauma care
15.5 Trauma call timeline for a pregnant trauma patient
Streamlined assessment
15.6 Damage control resusucitation
’Turning off the tap’ at C
15.7 Interventional radiology
15.8 Summary
15.9 Further reading
CHAPTER 16 Domestic abuse. Learning outcomes
16.1 Introduction
Scale of the problem
What keeps women in abusive relationships?
16.2 Domestic abuse and pregnancy
Recognising domestic violence in pregnancy
Diagnosing domestic abuse
Referral for help
Medicolegal aspects
Safeguarding of children
Communication and teamwork
Audit standard
16.3 Summary
16.4 Useful contacts
16.5 Further reading
CHAPTER 17 Thoracic emergencies. Learning outcomes
17.1 Introduction
Types of injury to the chest
17.2 Initial assessment and management of thoracic emergencies
Primary survey and resuscitation
Assessment of fetal well‐being and viability
Secondary survey
17.3 Life‐threatening chest injuries
Airway obstruction
Tension pneumothorax
Open pneumothorax (sucking chest wound)
Massive haemothorax
Tracheobronchial injury
Cardiac tamponade
Radiological investigations in chest trauma
17.4 Potentially life‐threatening chest injuries
Pulmonary contusion
Myocardial contusion
Diaphragmatic disruption
Oesophageal disruption
Traumatic aortic disruption
Chest wall disruption (flail chest)
17.5 Summary
17.6 Further reading
Appendix 17.1 Practical procedures. Needle decompression. Equipment
Procedure (modified from the principles of ATLS)
Complications
Finger and tube thoracostomy (chest drain insertion) Equipment (Figure 17A.1)
Procedure (modified from the principles of ATLS)
Complications
CHAPTER 18 Abdominal trauma in pregnancy. Learning outcomes
18.1 Introduction
18.2 Trauma to the uterus
Abruption
Uterine rupture
Penetrating injury
Amniotic fluid embolus
Trauma‐related haemorrhage
18.3 Primary survey and resuscitation
Airway with cervical spine control
Breathing, manual uterine displacement
Circulation
Diagnosis. FAST scans
Computed tomography
Indications for caesarean section in multiple trauma
Solid and hollow visceral injury
18.4 Secondary survey
Pelvic trauma
18.5 Summary
18.6 Further reading
CHAPTER 19 The unconscious patient. Learning outcomes
19.1 Introduction
Box 19.1 Causes of a decreased level of consciousness in the pregnant patient
19.2 Principles of treatment of the unconscious patient
Primary and secondary brain injury
Cerebral perfusion
19.3 Primary survey and resuscitation. Airway
Breathing
Circulation
Disability
19.4 Assessment of fetal well‐being and viability
19.5 Secondary survey
Pupillary function
Lateralising signs, such as limb weakness
Level of consciousness
Eye opening (E)
Verbal response (V)
Motor response (M)
Reassessment
Changes in vital signs
19.6 Types of head injury
Diffuse primary brain injury
Focal primary brain injury
Intracranial and extracerebral bleeding. Extradural haemorrhage
Subdural haemorrhage
Subarachnoid haemorrhage
Intracerebral penetration
Other injuries. Scalp wounds
Skull fractures
Linear skull fractures
Depressed skull fractures
Open skull fractures
Basal skull fractures
19.7 Summary
19.8 Further reading
CHAPTER 20 Spine and spinal cord injuries. Learning outcomes
20.1 Introduction
20.2 Immobilisation and motion restriction techniques
Cervical spine
Thoracic and lumbar spine
20.3 Evaluation of a patient with a suspected spinal injury
Spinal assessment
Neurological assessment
20.4 Principles of treatment in spinal injuries
Primary survey. Airway
Breathing
Circulation
Abdominal injuries
Locomotor injuries
Skin
Secondary survey
Bladder
20.5 Summary
20.6 Further reading
CHAPTER 21 Musculoskeletal trauma. Learning outcomes
21.1 Introduction
21.2 Primary survey
Major pelvic disruption with haemorrhage
Major arterial haemorrhage
Long‐bone fractures
Crush injuries
21.3 Secondary survey
Types of limb‐threatening injuries
Open fractures and joint injuries
Vascular injuries and traumatic amputations
Compartment syndrome
Nerve injuries secondary to fracture dislocation
21.4 Summary
21.5 Further reading
CHAPTER 22 Burns
Learning outcomes
22.1 Introduction
Severity of the burn
Assessment of burn depth
22.2 Pathophysiology of burns. Airway and respiratory effects
Carbon monoxide inhalation
Circulatory effects
Immediate first aid
22.3 Primary survey and resuscitation
Airway and breathing
Management of suspected carbon monoxide inhalation
Circulation
Pain relief
22.4 Secondary survey
Assess fetus
Electrical burns
22.5 Definitive care
22.6 Summary
22.7 Further reading
CHAPTER 23 Abdominal emergencies
Learning outcomes
23.1 Introduction
23.2 Pathophysiology of abdominal pain in pregnancy
23.3 Clinical approach to diagnosis: history, examination and investigations. History
Pain onset: acute versus gradual
Other important characteristics
Location of the pain and its likely cause. Uterine pain: abruption, degeneration of fibroids, chorioamnionitis or uterine contractions
Intraperitoneal (abdominal) pain
Inflammation and swelling of an organ (liver)
Vascular accident
Retroperitoneal
Referred and neurological pain
Examination
Investigations. Cardiotocography
Blood tests
Ultrasound
Radiographs
CT and MRI
23.4 Clinical management of abdominal emergencies
Acute appendicitis
Acute cholecystitis
Acute pancreatitis
Colonic pseudo‐obstruction
Sigmoid volvulus
Intestinal obstruction
23.5 Summary
23.6 Further reading
CHAPTER 24 Diabetic emergencies. Learning outcomes
24.1 Introduction
Background to diabetic ketoacidosis (DKA)
24.2 Pathophysiology of DKA
24.3 Presentation of DKA
24.4 Treatment of DKA
Management of DKA
Investigations in DKA
24.5 Hypoglycaemia in pregnancy
Management of hypoglycaemia
24.6 Summary
24.7 Further reading
CHAPTER 25 Neurological emergencies
Learning outcomes
25.1 Introduction
25.2 Headache
Classification of headache
Clinical history
Examination
25.3 Primary headache. Migraine
25.4 Secondary headache. Pre‐eclampsia
Cerebral venous thrombosis
Subarachnoid haemorrhage
Stroke
Ischaemic stroke
Haemorrhagic stroke
Management
Reversible cerebral vasoconstriction syndrome
Idiopathic intracranial hypertension
Postdural puncture headache
Management
25.5 Differential diagnosis of seizures in pregnancy. Eclampsia
Epilepsy
Other causes of seizures
Intracranial
Cardiac (collapse with jerking movements which could be mistaken for seizure activity)
Metabolic
Neuropsychiatric
Other
25.6 Acute management of a seizure
25.7 Summary
25.8 Further reading
CHAPTER 26 Perinatal psychiatric illness. Learning outcomes
26.1 Introduction
26.2 Mental health problems in pregnancy
26.3 Mental health problems after delivery
26.4 Confidential Enquiries into Maternal Deaths (CEMD)
Implications for obstetric practice
26.5 Management of mental health problems. Management of well ‘at‐risk’ women
Management of women with chronic severe mental illness
26.6 Labour ward crises
26.7 Neonatal paediatricians
26.8 Summary
26.9 Further reading
CHAPTER 27 Pre‐eclampsia and eclampsia
Learning outcomes
27.1 Introduction. Definitions
Epidemiology
27.2 Pre‐eclampsia
Box 27.1 Maternal and fetal complications of pre‐eclampsia. Maternal complications
Fetal complication
Box 27.2 Predisposing risk factors for pre‐eclampsia
27.3 Management of severe pre‐eclampsia. Symptoms and signs
General principles of management
Stabilise. Control of hypertension
Choice of antihypertensive
Labetalol
Nifedipine
Hydralazine
Prevent seizures
Magnesium sulphate protocol
Dose of magnesium sulphate
Monitor
Assessment of the fetus
Fluid balance
Coagulopathy
Planning delivery
Antenatal steroids
Magnesium sulphate
First stage of labour
Second stage of labour
Third stage of labour
Organisation and transfer
Postnatal care
27.4 Management of eclampsia
Immediate resuscitation
Control of seizure
Management of recurrent seizures while on magnesium sulphate
Eclampsia box
27.5 HELLP syndrome
27.6 Summary
27.7 Further reading
CHAPTER 28 Major obstetric haemorrhage
Learning outcomes
28.1 Introduction
Maternal mortality and the incidence of major obstetric haemorrhage
Definition and epidemiology
Major causes of primary or secondary obstetric haemorrhage. Causes resulting initially in hypovolaemia
Causes associated with coagulation failure
28.2 Major obstetric haemorrhage (MOH)
Recognition of haemorrhage
Specific situations leading to obstetric haemorrhage
Placental abruption
28.3 Maternal signs of shock
28.4 Management of major obstetric haemorrhage
Communication (‘call for help’) and documentation
Resuscitation and fluid replacement
Diagnostic tests
Near patient testing of haemoglobin and coagulation
Monitoring – evaluation of response
Management of the haemorrhage
Tone
Mechanical measures
Pharmacological measures
Advanced techniques
Tissue and trauma
Anaesthetic management
Regional or general anaesthesia
Cell salvage
28.5 Patients declining blood and blood products. Establishing wishes
Obtaining consent
Plan antenatal and intrapartum care
28.6 Summary
28.7 Further reading
CHAPTER 29 Caesarean section. Learning outcomes
29.1 Introduction
Prerequisites for caesarean section
29.2 Surgical technique for caesarean section
Skin incision
Entry
Assess the lower uterine segment
Exposure
Uterine incision
Delivery
Placenta
Closure of the uterus
Haemostasis
Drains
Closure
Postoperative procedure
Supervision
29.3 Specific difficulties encountered at caesarean section. Difficulty delivering the head in advanced labour
Access to the uterine cavity
Access to the fetus
Placenta praevia
Anterior placenta
Breech delivery
Premature delivery
Shoulder presentation
Extreme prematurity
Uterine trauma
Thromboprophylaxis
29.4 Audit standards
29.5 Summary
29.6 Further reading
CHAPTER 30 Abnormally invasive placenta and retained placenta. Learning outcomes
30.1 Introduction
30.2 Abnormally invasive placenta. Definition and incidence
Diagnosis of abnormally invasive placenta
Management of abnormally invasive placenta
Surgical considerations
Anaesthetic considerations
30.3 Retained placenta
Management of retained placenta
Anaesthesia for manual removal of the placenta
Technique of manual removal
30.4 Summary
30.5 Further reading
CHAPTER 31 Uterine inversion. Learning outcomes
31.1 Introduction
31.2 Recognition of uterine inversion
Symptoms and signs
Prevention
31.3 Management of uterine inversion
Manual replacement
Hydrostatic repositioning (O’Sullivan’s technique)
Medical approach
Surgery
31.4 Summary
31.5 Further reading
CHAPTER 32 Ruptured uterus. Learning outcomes
32.1 Introduction
32.2 Incidence and predisposing factors
Previous caesarean section
Morbidity and mortality from uterine rupture
Practice and training issues
Findings at the time of laparotomy
32.3 Management of ruptured uterus
Simple repair
Subtotal hysterectomy
Total hysterectomy
32.4 Summary
32.5 Further reading
CHAPTER 33 Ventouse and forceps delivery. Learning outcomes
33.1 Introduction
33.2 Training and simulation in obstetrics
Importance of non‐technical skills in OVD
33.3 Indications for operative vaginal delivery
Prerequisites for OVD
Safety matters and choice of instrument
Conditions where ventouse should be preferred to forceps
Conditions where forceps should be preferred to ventouse
33.4 Ventouse/vacuum cup
Safe delivery with ventouse
Box 33.1 Basic rules for safe use of the ventouse
Method of delivery with ventouse
Silicone rubber cup
Anterior metal cup
Posterior metal cup
Avoiding failure with ventouse delivery
Special indications for ventouse delivery
33.5 Forceps
Safe delivery with forceps
Box 33.2 Basic rules for the safe use of forceps
Method of delivery with traction forceps
Special indications for forceps delivery. Rotation
Face presentation
Aftercoming head of a breech baby
Box 33.3 Safety points for forceps delivery of the aftercoming head of a breech
The place of trial‐of‐instrumental delivery
The place of forceps after failure to deliver with ventouse
33.6 Following on from any instrumental delivery
33.7 Supervising an instrumental delivery
33.8 Documentation and debriefing
33.9 Summary
33.10 Online resources
33.11 Further reading
CHAPTER 34 Shoulder dystocia. Learning outcomes
34.1 Introduction
Definition and incidence
34.2 Clinical risks and outcomes of shoulder dystocia. Fetal mortality and morbidity
Maternal morbidity
Antenatal risk factors
Intrapartum risk factors
Training and teaching
Prevention
Induction of labour for suspected macrosomia
Documentation
Early detection
34.3 Management of shoulder dystocia
Sequence of management
Call for help
Episiotomy
McRoberts’ manoeuvre (with or without moderate traction)
Suprapubic pressure (with moderate traction)
Deliver the posterior arm and shoulder
Internal rotatory manoeuvres
Rubin II
Wood’s screw
Reverse Wood’s screw
‘Sling’ or posterior axillary sling traction
‘All fours’ position (Gaskin’s manoeuvre)
Other measures. Zavanelli’s manoeuvre (cephalic replacement)
Symphysiotomy
Intentional fracture of the clavicle (cleidotomy)
Approaches advocated by other authors
34.4 Following delivery
34.5 Medicolegal aspects
34.6 Summary
34.7 Further reading
CHAPTER 35 Umbilical cord prolapse. Learning outcomes
35.1 Introduction
Significance
35.2 Clinical management of umbilical cord prolapse. Aetiology
Other risk factors
Diagnosis of umbilical cord prolapse. Clinical suspicion
Vaginal examination
Ultrasound
Obstetric management of umbilical cord prolapse
Measures to reduce cord compression and improve the fetal heart rate
35.3 Documentation
35.4 Summary
35.5 Further reading
CHAPTER 36 Face presentation. Learning outcomes
36.1 Introduction
Aetiology
36.2 Clinical approach to face presentation. Diagnosis
Abdominal examination
Vaginal examination
Management
Intrapartum considerations. Face presentation
Mentoanterior position
Mentoposterior position
Vaginal manipulation in face presentations
36.3 Summary
36.4 Further reading
CHAPTER 37 Breech delivery and external cephalic version. Learning outcomes
37.1 Introduction
37.2 External cephalic version
Efficacy
Factors affecting success
Techniques to improve success
Alternative methods of producing cephalic version
Complications
Technique of external cephalic version
Preparation
Procedure
Post‐procedure
37.3 Vaginal breech delivery. Term birth
Preterm birth
Conduct of labour
First stage management
Conduct of delivery
Second stage management – assisted breech delivery
Alternative delivery techniques. Bracht’s technique
‘All fours’ technique
37.4 Failure to deliver
Nuchal arms
Head entrapment
Fetal back anterior (cervix fully dilated)
Fetal back posterior (cervix fully dilated)
Final options
Failure of the head to descend (incompletely dilated cervix)
Breech extraction
37.5 Medicolegal matters
37.6 Summary
37.7 Further reading
CHAPTER 38 Twin pregnancy. Learning outcomes
38.1 Introduction
38.2 Clinical approach to a twin pregnancy. Twin 1 vertex
Twin 1 non‐vertex
Intertwin delivery interval
External cephalic version versus internal podalic version for transverse twin two
Higher multiples
Previous caesarean section
Preterm/very low birth weight twins
Indications for caesarean section in twin pregnancy
38.3 Intrapartum management of vaginal twin deliveries. Management of the first stage
Management of the second stage
Management of the third stage
Internal podalic version
Caesarean section for twin two
38.4 Communication and team working
38.5 Summary
38.6 Further reading
CHAPTER 39 Complex perineal and anal sphincter trauma. Learning outcomes
39.1 Introduction
Definition
Episiotomy
39.2 Assessment of perineal trauma
39.3 Repair of trauma
Repair of third and fourth degree tears
Step 1: suturing the anal epithelium
Box 39.1 Instruments and sutures used for the repair of anal sphincter trauma. Instruments
Sutures
Step 2: suturing the anal sphincter
Procedure
Postnatal care
39.4 Training
39.5 Summary
39.6 Further reading
CHAPTER 40 Symphysiotomy and destructive procedures. Learning outcomes
40.1 Introduction
40.2 Symphysiotomy. Indications
Technique
40.3 Destructive procedures
Background
Craniotomy. Indications
Technique
Perforation of the aftercoming head/drainage
Craniocentesis
Decapitation. Indications
Technique
40.4 Summary
40.5 Further reading
CHAPTER 41 Anaesthetic complications in obstetrics
Learning outcomes
41.1 Introduction
Box 41.1 Specific anaesthetic recommendations from Confidential Enquiry reports. Airway
Anaesthetic emergencies
Critical care/illness
Other
41.2 Difficult intubation
Preparation for general anaesthesia
Failed intubation
Other complications. Premature extubation
Awareness
41.3 Regional blocks (epidural and spinal anaesthesia and analgesia)
Characteristics of spinal and epidural anaesthetics
Typical doses
Spinal block
Epidural block
41.4 Complications of regional anaesthesia
41.5 Complications due to local anaesthetic drugs
Hypotension
Management of hypotension
Motor block
Urinary retention
41.6 Serious immediate complications of local anaesthetic drugs. Local anaesthetic systemic toxicity
CNS toxicity
Cardiovascular toxicity
Management
Immediate management
Treat peri‐arrest arrhythmias
Control seizures
High spinal block
Total spinal block
41.7 Complications of opioids
41.8 Complications of technique
Failure of block
Postdural puncture headache
Management
41.9 Neurological damage
Neuropraxia
Infection (epidural abscess, meningitis or discitis) and haematoma
41.10 Effects of complications on the fetus
41.11 Summary
41.12 Further reading
CHAPTER 42 Triage. Learning outcomes
42.1 Introduction
42.2 Assessment of the pregnant woman. Obstetric triage
Obstetric trauma triage
42.3 Scenarios. Scenario 1
Order of priority
Scenario 2
Order of priority
42.4 Summary
42.5 Further reading
CHAPTER 43 Transfer. Learning outcomes
43.1 Introduction
43.2 ACCEPT approach
Assessment
Control
Communication
Evaluation
Is transfer appropriate for this patient?
Clinical urgency?
Transfer categories
Preparation and packaging
Patient preparation
Airway
Breathing
Circulation
Disability
Exposure
Equipment preparation
Personnel preparation
Packaging
Transportation. Mode of transport
Care during transport
Handover
43.3 Common coordination problems. Problem 1
Solutions
Problem 2
Solutions
Problem 3
Solutions
Problem 4
Solutions
43.4 Summary
43.5 Further reading
CHAPTER 44 Consent matters. Learning outcomes
44.1 Introduction. When is consent required?
Why is consent required? The legal and ethical considerations
Principle of decision making and consent
What makes consent valid?
44.2 Sufficient information
44.3 Capacity
Lack of capacity for consent: incompetence
The Mental Capacity Act
Box 44.1 Two‐stage assessment. Stage one
Stage two
Status of the fetus
44.4 Voluntarily given consent
44.5 Who can obtain consent?
44.6 Summary
44.7 Further reading
References and further reading. CHAPTER 2
CHAPTER 4
CHAPTER 5
CHAPTER 6
CHAPTER 7
CHAPTER 8
CHAPTER 9
CHAPTER 10
CHAPTER 11
CHAPTER 12
CHAPTER 13
CHAPTER 14
CHAPTER 15
CHAPTER 16
CHAPTER 17
CHAPTER 18
CHAPTER 19
CHAPTER 20
CHAPTER 21
CHAPTER 22
CHAPTER 23
CHAPTER 24
CHAPTER 25
CHAPTER 26
CHAPTER 27
CHAPTER 28
CHAPTER 29
CHAPTER 30
CHAPTER 31
CHAPTER 32
CHAPTER 33
CHAPTER 34
CHAPTER 35
CHAPTER 36
CHAPTER 37. External cephalic version
Term breech delivery
Preterm breech delivery
Breech delivery technique
CHAPTER 38
CHAPTER 39
CHAPTER 40. Symphysiotomy
Destructive procedures
CHAPTER 41
CHAPTER 42
CHAPTER 43
CHAPTER 44
Rulings
Index
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