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Chapter 16‌
Emergencies in midwiferyLiz Smith
University of Hull, Hull, UK
Brenda Waite
Diana Princess of Wales Hospital, Grimsby, UK
Learning outcomesOn completion the reader will be able to:

describe the management of shock and the process of maternal resuscitation

explain the predisposing factors, signs and symptoms of key obstetric emergencies

discuss the role of the midwife in the management of key obstetric emergencies

recognise the psychosocial care needs of the woman and family during and following emergency

situations.

Although pregnancy and childbirth are usually normal physiological events, complications and

emergencies can arise. The role of the midwife in recognising and providing immediate care for obstetric emergencies is central to improving outcomes for women and their babies. This chapter aims to provide an outline of key obstetric emergencies in pregnancy and childbirth with an emphasis on the immediate care the midwife should provide to support the woman physiologically and psychologically until the interprofessional team can initiate medical and/or surgical interventions. The chapter is not intended as a definitive guide to all obstetric emergen- cies and will provide an overview only of those covered. Guidance for further reading and a ‘finding out more’ section can be found at the end of the chapter.

The chapter begins with assessment, shock and maternal resuscitation to provide an under- standing of general approaches to immediate care in emergencies and then addresses the specifics of some key complications.

, First Edition. Edited by Louise Lewis.

© 2015 John Wiley & Sons, Ltd. Published 2015 by John Wiley & Sons, Ltd. Companion website: www.wileyfundamentalseries.com/midwifery

The effective assessment of women is essential to the detection of deviations from the normal

and in particular in determining those conditions likely to cause significant deterioration in maternal and/or fetal wellbeing. To be effective, however, assessment needs to be holistic and individualised; results of observations, screening tests and examinations need to be considered in context with baseline norms for that woman and the overall trends they demonstrate. It is vital that as much information as possible is gathered within assessment whether that is part of an antenatal examination, intrapartum observations or a postnatal examination. It is there- fore important not just to focus on the physical results, but to communicate effectively with the woman to find out about how she feels and any symptoms she may be experiencing. It is also essential to use observational skills; it is sometimes easy to get carried away with checking pulse and blood pressure and not notice the fact that the woman has become pale and clammy for instance. Record keeping is also a key element of noticing trends – blood pressure may still be within normal limits but is demonstrating an overall upward trend. This is why assessment tools such as the partogram are useful in monitoring progress in labour and Modified Early Obstetric Warning Scoring Systems (MEOWS) are recommended for use in obstetrics as well as intensive and high dependency units (see Figure 16.1). It is not sufficient to record findings from assess- ments; midwives need to think about what the data indicates in terms of well-being and health in order that any deterioration is picked up quickly as early recognition of abnormalities and complications such as those discussed in this chapter can improve outcomes for mother and baby. Box 16.1 outlines some key indicators of effective assessment.

Shock is defined as a syndrome of impaired tissue oxygenation and perfusion due to a variety

of causes (Worthley 2000). In essence this means that the cardiovascular system fails to deliver enough oxygen and nutrients to the tissues to meet metabolic needs. The effect of shock and the associated lack of oxygen will lead to metabolic acidosis, cell swelling, necrosis, organ failure and death unless both the symptoms and cause are treated.

Shock is classified into four types:

Hypovolaemic –
this can be haemorrhagic as in ante or postpartum haemorrhage or due to severe dehydration which can occur in association with hyperemesis or severe gastroenteritis.

Cardiogenic –
this can be due to ischaemia, infarction, myopathy or arrhythmias.

Distributive –
this includes septic, neurogenic and anaphylactic shock.

Obstructive –
includes shock due to pulmonary or amniotic fluid embolism.Shock can also be divided into phases which describe its progression:

Stage One:
Compensated shock where the body activates mechanisms to compensate for the effects of shock and the patient demonstrates subtle signs and symptoms.

Stage Two:
Uncompensated shock where signs and symptoms become obvious and thepatient may demonstrate reduced neurological function, oedema and respiratory distress. Medical management is essential to prevent deterioration to Stage Three.

Stage Three:
Irreversible shock where the patient deteriorates rapidly as damaged cells start

to die.

Signs and symptoms of shock are outlined in Table 16.1.