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CHAPTER 3 Structured approach to emergencies in the obstetric patient

Algorithm 3.1 Structured approach to emergencies in the obstetric patient

Learning outcomes

After reading this chapter, you will be able to:

 Identify the correct sequence to be followed in assessing and managing seriously ill or seriously injured patients

 Outline the concept of the primary and secondary surveys

3.1 Introduction

The structured approach refers to the ‘ABCDE’ approach to life saving. The aim of the structured approach is to provide a system of assessment and management that is effective, and simple to remember, in the heat of an emergency. It can be applied to any patient with a threat to life, be that from illness or injury. Assessment is divided into primary survey and secondary survey. The approach is the same for all: adults, children, the elderly and pregnant women.

Primary survey

The system follows a simple ABCDE approach, with resuscitation taking place as problems are identified, i.e. a process of simultaneous evaluation and resuscitation.

The primary survey uncovers immediately life‐threatening problems by priority, i.e. in the order in which they will most quickly kill. The medical sequence in the ABCDE approach is that an Airway problem will kill the patient more quickly than a Breathing problem, which in turn will kill a patient more quickly than a Circulation problem, which in turn will kill a patient more quickly than a Disability (neurological) problem.

Airway

Assess whether the airway is open by look, listen and feel. If not open, proceed to open the airway using simple manoeuvres, such as head tilt and chin lift, followed by more complex actions (as detailed in Chapter 10) where necessary. Manoeuvres to secure the patient’s airway should not cause harm, or further harm, to the cervical spine. Therefore, if an injury to the cervical spine is suspected the cervical spine must be immobilised during airway care.

Breathing

Look, listen and feel for respiration, using supplementary oxygen and ventilatory support as required.

Circulation

Assess the circulation by checking perfusion, heart rate and blood pressure. Volume replacement and haemorrhage control may be needed (see Chapters 6 and 8).

Disability

Assessment and support of the functioning of the neurological system including an assessment of conscious level (ACVPU), the pupils and a blood sugar.

Exposure

Adequately expose the patient to make a full assessment, taking care to avoid cooling and potential hypothermia by adjusting the environment.

3.2 Resuscitation

The resuscitation phase is carried out at the same time as the primary survey. Life‐threatening conditions are managed as they are identified. Do not move on to the next stage of the primary survey until a problem, once found, has been corrected. If the patient’s condition deteriorates, go back and reassess, starting again with ABCDE.

Secondary survey

The secondary survey is a comprehensive assessment, which takes place after life‐threatening problems have been found and treated (primary survey) and uncovers problems that are not immediately life threatening. Ensure a full history is taken using AMPLE as an aide memoire:

The secondary survey is performed once the patient is stable. The secondary survey might not take place until after surgery, if surgery has been necessary as part of the resuscitation phase. The secondary survey is a top‐to‐toe and back‐to‐front process, as follows:

 Scalp and vault of skull

 Face and base of skull

 Neck and cervical spine

 Chest

 Abdomen

 Pelvis

 Remainder of spine and limbs

 Neurological examination

 Rectal and vaginal examinations, if indicated

 Examination of wounds caused by injury. Note: do not remove foreign objects from penetrating wounds, they may be tamponading a bleeding vessel

If the Glasgow Coma Score has not been evaluated in the primary survey it should be performed during the secondary survey (see Chapter 19).

Assessment of the collapsed patient using the ABC approach

First, speak loudly to the patient. To prompt manual uterine displacement (MUD) early in the process of resuscitation, remember:

‘Hello, how are you Ms MUD?’

The response gives you several pieces of clinical information. To be able to respond verbally, the patient must have:

 Circulating oxygenated blood (i.e. has not had a cardiopulmonary arrest)

 A reasonably open airway

 A reasonable tidal volume to phonate

 Reasonable cerebral perfusion to comprehend and answer

If the patient does not respond then we cannot make the above assumptions.

Management of the apparently lifeless (unresponsive) patient

The approach to an apparently lifeless patient is the cardiopulmonary resuscitation (CPR) drill, which starts with opening the airway and assessing breathing, then proceeding to CPR as necessary (see Chapter 11 for details).

Management of the seriously injured pregnant patient

In the seriously injured patient who has signs of life, the following approach is taken.

If possible receive the ATMIST handover from the pre‐hospital team and ensure left lateral tilt is ongoing or manually displace the uterus.

1 Primary survey and resuscitation: identify life‐threatening problems and deal with these problems as they are identified. In a multiply injured patient <C> precedes ABCDE. <C> is control of Catastrophic haemorrhage such as applying a tourniquet and compression bandage to an amputated limb.

2 Assess fetal well‐being and viability: may require delivery.

3 Secondary survey: top‐to‐toe, back‐to‐front examination.

4 Definitive care: specific management.

Continuous re‐evaluation is very important to identify new life‐threatening problems as they arise.

Monitoring (applied during primary survey)

 Pulse oximetry

 Heart rate/electrocardiogram (ECG)

 Blood pressure

 Respiratory rate

 End‐tidal CO2 monitoring is appropriate in an intubated patient

 Urine output: as a measure of adequate perfusion and fluid resuscitation

 Fetal heart monitoring will reflect the haemodynamic status of the mother until a circulation problem is addressed as part of the primary survey and as such provides information on the adequacy of maternal resuscitation in the primary survey

The pulse oximeter limitations are that the patient must be well perfused to obtain a reading. Ambient light and dyes, such as nail polish or circulating methaemoglobin, can cause erroneous readings. A fall in oxygen saturation is a late sign of an airway, breathing or circulation problem.

Adjuncts to assessment

 Blood tests (full blood count, blood group and save, venous blood gas, urea and electrolytes, thromboelastography, Kleihauer)

 Essential radiographs during the primary survey and resuscitation are chest and pelvis

 FAST (focused assessment with sonography for trauma) scan

Assess fetal well‐being and viability

Use ultrasound to:

 Detect fetal heart and check rate

 Ascertain the number of fetuses and their positions

 Locate the position of the placenta and the amount of liquor

 Look for retroplacental bleeding and haematoma

 Detect an abnormal position of the fetus and free fluid in the abdominal cavity, suggesting rupture of the uterus

 Detect damage to other structures

 Check for free fluid and blood in the abdominal cavity

Adequately resuscitating the mother will improve the outcome for the fetus.

3.3 Definitive care

Definitive care takes place under the supervision of relevant specialists. It is of utmost importance to the patient’s continued quality of life.

3.4 Summary

A systematic approach of primary survey (simultaneous assessment and resuscitation), fetal assessment, secondary survey and definitive care enables the clinician to give the best patient care possible in complex situations.