Download EMERGENCY DELIVERY

Emergency Delivery
Pre-eclampsia / eclampsia
EMERGENCY DELIVERY
On rare occasions, women in labour may present to the Emergency Department. There are three main
groups:
1.
Women who have had antenatal care but are from out of town and unaware that there are no
obstetric services here.
2.
Concealed / denied pregnancy – with no antenatal care
3.
In labour with complications e.g. trauma, haemorrhage or eclampsia.
The later 2 cases are high risk of themselves and the first is of increased risk
because of lack of expertise here. It is desirable to triage the patient to the
resuscitation room.
ASSESSMENT
History
 LNMP
 Gestation
 Antenatal history and carer
 Previous pregnancies and complications
 Medial history
 Medications
 Allergies
 Contractions / blood loss / rupture of membranes
 ? Multiple babies
Examination
 General examination
 Abdominal examination
- Presenting part
- Foetal HR (normal 120 – 160)
- Lie
- Position
- Station
- Contractions
 Vaginal examination
- Cervical dilation
- Effacement
- Softening
- Position
- Station
- Presentation attitude
- Descent
Do not do a PV if any bleeding. Assess via sterile speculum examination.
Once assessment is complete, discuss with the obstetrician on call at NWH
as the options are:



Delivery in ED + obstetric assistance. If cervical dilation is >6cm,
position occiput anterior and contractions are regular, delivery is
imminent and the patient should not be transferred.
Caesarean at Auckland
Transfer to NWH
If delivery is imminent, paediatric backup can be obtained by paging 777 for a
paediatric emergency to resus. If more time is available, liaise with the
paediatric medical registrar or consultant.
MANAGEMENT OF LABOUR
Necessary equipment is in the “baby box” in the resus store room.
1st Stage (Rhythmic contractions  10cm dilated)
Observation
 Maternal vital signs
 PV loss
 Contractions
 Foetal heart rate (120 – 160)
 CTG if available (not currently)
Analgesia
 Opiates – IV boluses
 Entonox
 Reassurance
Hydration
 IV fluids – take blood for FBC, groups and hold
 Nil orally
2nd Stage (Full cervical dilation to delivery)

Continue as above

Lithotomy position is easiest for the inexperienced attendant.

Control the head, which will rotate as it is delivered.

Consider episiotomy:
- if going to tear
- 10ml 1% lignocaine
- right lateral

Check for cord when head delivered and remove it from the head. If very
tight clamp with 2 cord clamps and cut between.

Wipe the face and suction nose and mouth.

Deliver shoulders – anterior then posterior by gentle down ward traction.

Clamp the cord at 30 seconds. Cut with sterile scissors.

Dry the baby and keep warm. See “Neonatal Resuscitation”.

Palpate for a second baby.
3rd Stage (Delivery of the Placenta)

Give oxytocin
- oxytocin 5 units or 5 units IV or
- ergometrine 0.25mg IM or
- syntometrine (5 units oxytocin + 0.5mg ergometrine) IV

Controlled cord traction – 1 hand on uterus other steady pressure on
placenta / cord.

Rub up the fundus

Check the placenta for:
- size (15 – 20cm)
- thickness (2 – 2.5cm)
- weight 500g
- calcification
- completeness
If the placenta has not been delivered in 30 minutes, or there is excessive
blood loss (600ml = PPH). manual evacuation in theatre is required.
4th Stage (1st hour)

Continue monitoring

Clean up the patient, repair any episiotomy or tear if confident, if not place
a pack and refer to obstetric registrar.

Give fluid

Transfer the mother and baby to National Women’s

Baby check should be done by paediatric registrar
PRE-ECLAMPSIA / ECLAMPSIA
DEFINITIONS
1.
PRE-ECLAMPSIA
Syndrome occurring after 20 weeks of pregnancy with some or all of:

Hypertension:
> 90mmHg diastolic
> 140mmHg systolic
> 25mmHg rise

Renal impairment
- Proteinuria > +1 on dipstick
- Generalised oedema
Severe pre-eclampsia is defined as the addition of one of the following:

Hypertension:

Proteinuria: > +3 on dipstick
> 5g / 24 hours

Olguria:

Creatinine: > 0.09mmol/L

Neurological symptoms:

Pulmonary oedema

Liver dysfunction:

Haematological dysfunction: - Thrombocytopaenia
- DIC
- Haemolysis
> 110 diastolic
> 160 systolic
<500mls / 24 hours
<30mls / hr
- Persistent headache
- Visual disturbance
- Hyper-reflexia with clonus
- Agitation / confusion
- Right UQ pain
- Elevated bilirubin
- Elevated transaminases
2.
HELLP SYNDROME
Syndrome of haemolysis. Elevated liver enzymes and low platelets.
40% develop DIC. Other complications include intrahepatic
haemorrhage, subcapsular haematoma formation and liver rupture.
1/3 if cases are diagnosed post-partum.
3.
ECLAMPSIA
Seizures occurring after 20 weeks of pregnancy. They may occur postpartum.
MANAGEMENT
Following standard emergency resuscitation, specific management aims to
control hypertension and seizures.
General Management
 Left lateral decubitus position or supine with wedge
 ABC’s
 Monitor - Maternal BP, ECG, Sa02, pulse, urine output. Consider
arterial
line and CVP
- Foetal HR
Discuss with the NWH obstetric physician on call as soon as
practical.
SPECIFIC MANAGEMENT
1.
2.
Seizures (eclampsia) / severe pre-eclampsia
 The anti-convulsant of choice is magnesium sulphate – see
“Magnesium Sulphate Infusion”.

Uncontrolled seizures require standard seizure management, which
may include phenytoin or intubation and barbiturate infusion.

Delivery is indicated once the patient is stable. Usually the patient can
be stabilised for transport to National Women’s.
Hypertension
 Treatment aims to maintain placental blood flow whilst preventing
maternal complications:
Treat:
Systolic >160mmHg
Diastolic >110mmHg
Reduce to 130 – 130mmHg
Reduce to 95 – 100mmHg
The agent of choice is:

Hydralazine
- Direct arteriolar vasodilator. Improves placental flow.
- 5mg IV bolus then infuse at 2 – 20mg/hour
There is no evidence that one other anti-hypertensive is better than
another however a B-blocker may be needed to control the
tachycardia induced by hydralazine or if hydralazine is inadequate in
controlling the BP.
 Labetolol
Non selective beta-blocker. Does not decrease placental flow.
- 10mg IV bolus then infuse at 1 – 2mg/min
NB:
Magnesium sulphate is also an anti-hypertensive agent and may be
adequate on its own
 Coagulopathy
Standard management i.e. Vitamin K; FFP
REFERENCES:
1. Duley L; Gulmezaglu A.M; Henderson-Smart D.J. Anticonvulsants for
women with pre-eclampsia. (Cochrane Review) In : The Cochrane Library
Issue 3, 2000. Oxford : Update Software.
2. Duley L; Henderson-Smart D.J. Drugs for rapid treatment of very high
blood pressure during pregnancy. (Cochrane Review) In : The Cochrane
Library Issue 3, 2000. Oxford : Update Software.
3. Duley L; Henderson-Smart D.J. Magnesium sulphate versus diazepam for
eclampsia. (Cochrane Review) In : The Cochrane Library Issue 3, 2000.
Oxford : Update Software.
4. Duley L; Henderson-Smart D.J. Magnesium sulphate versus phenytoin for
eclampsia. (Cochrane Review) In : The Cochrane Library Issue 3, 2000.
Oxford : Update Software.
MAGNESIUM SULPHATE INFUSION
Indications:
The indications for use of magnesium sulphate infusions are:
Eclamptic seizure
Or
Pre-eclampsia with:

Persistent severe headache, or

Repeated visual disturbance, or

Hyper-reflexia with more than 2 beats of clonus, or

Agitation or confusion
Special Precautions:
Special precautions need to be taken with the following conditions:




Myasthenia Gravis or other neuromuscular disorder
Cardiac disease
- arrhythmia or cardiomyopathy
Current drug therapy - lithium
- aminoglycoside (gentamicin)
- paralysing anaesthetic agents
Renal impairment  urine output <30ml/Hr
 creatinine >0.08
In these patients, toxicity is a major risk and the Obstetric Physician should be consulted
before magnesium sulphate is used. An alternative anticonvulsant (e.g. phenytoin) may be
more appropriate.
DOSAGE AND THERAPEUTIC GOAL
Therapeutic Goal:
1. To eliminate clonus
2. Therapeutic range = 2.5 – 3.5 mmol/L
Dosage:
MgSO4 comes in 5ml ampoules containing 10mmol = 2.54g
Step
1
Action
Loading
5g (20mmol) intravenously over 20 minutes
(2x5ml amps) in 100ml of 0.9% normal saline by infusion pump
over 20 minutes. Mix well.

2
Maintenance
Follow immediately by a maintenance infusion of 1.5g (6mmol)/hr i.e. 10g
(40mmol) (4x5ml amps) into 80ml of 0.9% normal saline making a total
volume of 100ml / (withdraw 20ml from 100ml bag of base fluid first). Mix
well.
Concentration = 0.1g (0.4mmol)/per ml.
1.5g (6mmol)/hr = 15ml/hr

3
The loading dose may be accompanied by flushing, nausea and vomiting.
 Give Maxolon 10mg IV as a slow bolus if required.

4
5

After one hour of infusion check the serum magnesium level.
If serum magnesium level is sub therapeutic give a further loading dose
by infusion pump over 20 minutes.
Serum Magnesium
Dose over 20 minutes
<1.8
2.5g (10mmol) over 20 minutes
1.8 – 2.2
1.25g (5mmol) over 20 minutes
>2.2
nil
 Then continue maintenance infusion
6

Repeat serum assay 2 hourly until a stable therapeutic level is reached
i.e. constant serum level over 2 assays 2 hours apart on the same
infusion rate.
If the therapeutic goal is not achieved with this regimen seek the advice of the
Obstetric Physician


7
8

Measure the serum creatinine at the same time as each magnesium
level.
Magnesium sulphate infusion is continued for a minimum of 24 hours
post delivery.
MONITORING OF MAGNESIUM SULPHATE INFUSION
Goal
The goal of clinical monitoring is to avoid magnesium toxicity.
Maternal
The following table describes maternal monitoring of magnesium sulphate
infusion.
Step
Recordings
½ hourly
Laboratory
Tests
Monitor
 Tendon reflexes
 BP
 Oxygen saturation
 Urine Output
 Serum magnesium
Finding
Absent or reduced
<110/70
<95%
<30ml/hr x 2
<2.1
>3.5
Action
Stop infusion.
Consult Obstetric
Physician immediately
Continue as per protocol
Stop infusion.
Consult Obstetric
Physician immediately
Continue as per protocol

Serum Creatinine
<0.08
>0.08
Stop infusion.
Consult Obstetric
Physician immediately
Once a stable therapeutic level is reached without evidence of toxicity, monitoring may be relaxed to 2
hourly.
Foetal Recordings
Step
Foetal monitoring
should be performed
per obstetric
instructions




Magnesium Sulphate Effects
Magnesium sulphate may reduce variability and increase length
and frequency of non-reactive cycles.
Magnesium sulphate will not alter baseline rate nor produce
decelerations.
Any such changes are suggestive of hypoxia and should be
managed according to usual obstetric criteria.
A 60 minute baseline CTG prior to magnesium sulphate loading
is useful but should not delay appropriate magnesium loading.
TOXICITY AND ANTIDOTE
Toxicity

Toxicity is usually seen in the context of renal impairment.

Magnesium causes an osmotic diuresis; therefore an “adequate” urine output alone is not
indicative of adequate renal function.

It is essential to measure the serum creatinine at regular intervals i.e. with each serum
magnesium level.
Symptoms of Toxicity

The following symptoms may indicate toxicity:
-
Absent reflexes
Hypotension, vomiting, flushing, drowsiness, slurred speech
Respiratory depression / arrest
Cardiac arrhythmia / arrest
Note: Toxicity is a clinical diagnosis. Serum magnesium levels associated with toxicity are variable
but always >4mmol/L. Minor toxic symptoms may be seen at lower levels.
Management of Toxicity

ABC’s

Calcium gluconate 1g (1 x 10ml amp) in 100ml 0.9% normal saline over 20 minutes

The antidote reverses the anticonvulsant effect and therefore seizures may be precipitated.
Alternative anticonvulsants should be considered during reversal.
REFERENCE
Magnesium Sulphate Infusion. Clinical Procedures Manual. NWH April 1998.