SOP Guideline Obstetric Emergencies by dkw12103

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									                                          Feidhmeannacht na Seirbhise Siainte



                                               HSE Mid-West Ambulance Service
    Feidhmeannacht na Seirbhise Slrunte
        Health Service Executive


  Title: SOP/Guideline Obstetric Emergencies

Reference No.               SOP/GL No 002       Drafted by:       Mr. John Burton, Training
                                                                  Officer

Revision No.                1                   Approved by:



                                                                  Mr. Pat baii,Chief
                                                                  Ambulance Officer



                                                                  Dr. Anton Dempse
                                                                  Clinical Director



                                                                  Dr. Cathal O'Donnell,
                                                                  Consultant i
                                                                  Medicine
Approval Date:              March 2009          Responsible for   Chief Am Ian e Office,
                                                1m plementation   Training &Development
                                                                  Officer
Revision date:               March 2011         Responsible for   Chief Ambulance Office;
                                                Evaluation:       Training &Development
                                                                  Officer
Number of Pages:             14 pages           Responsible for   Chief Ambulance Office;
                                                Revision:         Training &Development
                                                                  Officer; Ambulance
                                                                  Service Medical Advisor


  Title: SOP/Guideline Obstetric Emergencies



   Document Reference Number: SOP/GL No 002
   Revision Number: 1
   Approval Date: March 2009
Table of Contents


1.0   Policy Statement            ....................................... 3

2.0   Purpose       .....................................................3

3.0   Scope ............................................................3

4.0   Definitions and Abbreviations ......................... 3

5.0   Responsibility ................................................4

6.0   Procedure ................................................ 4-11

7.0   Implementation Plan ................................. 11

8.0   Evaluation and Audit ..................................... 11

9.0   Frequency of Review .................................... 11

10 .0 Method used to review operation of the policy .12

11.0 References .................................................. 12

12 .0 Appendices ................................................. 12

13.0 Signature Sheet ............................................ 13




Title: SOP/Guideline Obstetric Emergencies



Document Reference Number: SOP/GL No 002
Revision Number: 1
Approval Date: March 2009




                                                                              2
1.0   Policy Statement:

      The Ambulance Service HSE Mid-Western Area is committed to providing a
      safe, effective and high quality service to patients, health care professionals
      and health care facilities. This policy outlines how the service will manage
      obstetric emergencies



2.0   Purpose
      2.1    To ensure that all staff are aware of the local SOP in place when
             dealing with obstetric emergencies (maternity calls) as referred to in
             PHECC Clinical Practice Guidelines.
      2.2    Mid-Western Regional Hospital Ennis, Mid-Western Regional Hospital
             Nenagh, and St Johns Hospital Limerick do not have onsite Obstetric
             Services. Obstetric emergencies are not to be transported to these
             hospitals.



3.0   Scope

      This SOP applies to all staff in the National Ambulance Service (Mid-
      West Region).



4.0   Definitions and Abbreviations
      4.1    BBA - Born Before Arrival
      4.2    CPG - Clinical Practice Guideline
      4.3    Responding Practitioner - PHECC Registered Paramedic/Advanced
              Paramedic
      4.4    SOP-Standard Operating Procedure
      4.5    CAG-Clinical Advisory Group: Chief Ambulance Officer, Training &
             Development Officer, Ambulance Service Medical Advisor (Consultant
             in Emergency Medicine)
      4.6    ALS-Advanced Life Support




Title: SOP/Guideline Obstetric Emergencies



Document Reference Number: SOP/GL No 002
Revision Number: 1
Approval Date: March 2009




                                                                                        3
5.0   Responsibility
      5.1    It is the responsibility of each staff member to adhere to this SOP.

      5.2    It is the responsibility of the Training and Development Department
             audit compliance with the SOP.

      5.3    It is the responsibility of the Chief Ambulance Officer to ensure
             compliance is monitored and any remediation required is undertaken.


6.0   Procedure
      Paramedics and Advanced Paramedics are able to contact the Labour ward in
      the Regional Maternity Hospital for advice when necessary. The contact
      number is- -

      6.1    Emergency Childbirth (reference C.P.G. 9a)

      6.1.1 For all maternity calls, the responding practitioner(s) shall respond
            without requesting the services of a midwife to travel.

      6.1.2 On arrival, the responding practitioner(s) should carry out a normal
            assessment; this includes details of frequency and severity of
            contractions, whether "the show" has been seen and whether the
            membranes have ruptured. The patient should also be asked if
            she is aware of any other considerations about the birth that will assist
            the responding practitioner(s) with the assessment.

      6.1.3 Any escorts (i.e. partner/parent) should be reminded about
            arrangements for their return.

      6.2    Born before Arrival- BBA (reference C.P.G. 9a, 1d)

      6.2.1 Relates to all cases where the baby is born before the pregnant mother
            arrives at the place where the baby's delivery was planned.




Title: SOP/Guideline Obstetric Emergencies



Document Reference Number: SOP/GL No 002
Revision Number: 1
Approval Date: March 2009




                                                                                        4
      6.2.2 At Home On arrival at the patient's address, the responding
            practitioner(s) determine(s) that, because of prevailing
            circumstances, advancement of labour, patient's history, distance to
            hospital, traffic and road conditions, etc. that the baby is likely to be
            born before the journey can be completed. In these cases it is far
            better to remain at the patient's home and conduct the delivery there
            than to transport the patient. With premature babies (in whom neonatal
            resuscitation may be required), practitioners should initiate transport as
            soon as possible.


      6.2.3 At another location-in these cases, the National Ambulance Service
            responds to a 999 call from a member of the public. A patient goes
            into labour unexpectedly, away from her own home. Again,
            because of prevailing circumstances the responding practitioner(s)
            determine(s) that arrival at hospital before birth is unlikely. Provide for
            the patient's modesty and privacy.

      6.2.4 Unexpected Birth in the Ambulance In these circumstances, the
            ambulance should be brought to a stop and parked up safely. Inform
            Ambulance Control of the circumstances.

      6.2.5 In each of the above, inform the expectant mother of your assessment.
            Explain what you propose to do. Don't forget the role of the partner; if
            he is present he should be involved as much as possible.


6.3   Emergency Child Birth Scenarios

      6.3.1 Normal Delivery (reference C.P.G. 9a)

             A.     Babies are capable of delivery by themselves.
             B.     Position mother and prepare equipment for birth
             C.     Consider Entonox for pain relief
             D.     Monitor vital signs
             E.     Note any events of potential relevance (such as the appearance
                    of the top of the baby's head at the vulva (crowning), a show,
                    bleeding) - note the time of an event using the 24 hour clock
             F.     Receive the baby as it delivers - any handling should be
                    minimal, and designed to protect the baby



Title: SOP/Guideline Obstetric Emergencies



Document Reference Number: SOP/GL No 002
Revision Number: 1
Approval Date: March 2009



                                                                                          5
             G.      If amniotic sac is intact, rupture it and remove from baby's face
             H.      Suction mouth then nose, if required
             I.      Never advance the catheter further than the uvula
             J.      Allow shoulders to deliver

             K.      Allow rest of body to deliver; baby can be slippery, support well
             L.      Once cord has stopped pulsating, clamp cord at 4",6" and 8"
                     from baby's abdomen. Cut between 6" and 8". If ends of cord
                     are seeping blood, clamp them again.
             M.      Dry baby thoroughly; wrap baby in warmed blankets
             N.      Be aware of dangers of using silver swaddle on a cold baby.
             O.      Assessment - stable baby - give to mother
             P.      When placenta delivers, place in placenta bag and bring to
                     hospital
             Q.      Keep a careful note of all dressings used, and account for them
                     afterwards - blood soaked dressings or towels should be
                     retained and given to nursing/midwifery staff at Maternity Unit.


      6.3.2 Care in the Third Stage and After Delivery

             A.      If the mother has suffered a tear, protect using a sterile dressing
             B.      If she is bleeding from the external part of the tear, firm pressure
                     may be needed to reduce haemorrhage.

      6.3.3 Breech Presentation (reference C.P.G. gc)

             A.      Ideally, a breech birth should not be delivered pre-hospital. If
                     delivery has to take place pre-hospital prior to arrival of expert
                     help:

             •    Request ALS
             •    Contact Ambulance Control and seek assistance of a GP if ALS not
                  available.

      Management

             A.      Position mother in the lithotomy position (in which the patient is
                     on their back with the hips and knees flexed and the thighs
                     apart. The position is often used for vaginal examinations and
                     childbirth)
             B.      Consider Entonox



Title: SOP/Guideline Obstetric Emergencies
Document Reference Number: SOP/GL No 002
Revision Number: 1
Approval Date: March 2009


                                                                                          6
             C.       Support the baby as it emerges. Avoid manipulation of the
                      baby's body (stimulation may provoke baby to breath prior to
                      delivery).
             D.       Once the nape of the neck is visible at the vulva, place one
                      hand, palm up onto baby's face.
             E.       Grasp both baby's ankles in other hand
             F.       Do not pull on baby
             G.       Rotate baby' legs in an ark in an upward direction as
                      contractions occur
             H.       If the baby has not been successfully delivered after five
                      Contractions/2-3 minutes, the delivery has become obstructed.
                      Contact Ambulance Control to pre-alert the nearest Maternity
                      Unit of an obstructed breech delivery and your estimate time of
                      arrival.
             I.       Avoid manipulation of the baby's body. Provide gentle support
                      during transportation.
             J.       Encourage mother to adopt knees to chest (McRobert's) position
             K.       Give high % oxygen to mother at earliest opportunity.
             L.       Monitor mother closely.

6.3.4 Prolapsed Cord (reference C.P.G. 9b)

             A.       After the waters break, the umbilical cord descends through the
                      cervix ahead of the presenting part. It may protrude from the
                      vagina. The baby is then in acute danger.
                  •   Request ALS
                  •   Contact Ambulance Control and seek assistance of a GP if ALS
                      not available



      Management

             A.       Try not to handle the cord. This can provoke spasm and foetal
                      hypoxia.
             B.       Do not allow the cord to become dry or cold
             C.       Wrap cord in warm wet pack (normal saline)
             D.       Initiate transport to hospital without delay.
             E.       Consider elevating foot end of stretcher during transport and/or
                      Simm's position
             F.       If partial delivery occurs on route and delivery of the head is
                      delayed, seek advice



Title: SOP/Guideline Obstetric Emergencies

Document Reference Number: SOP/GL No 002
Revision Number: 1
Approval Date: March 2009



                                                                                         7
6.3.5 Cord tightly around Baby's Neck (reference C.P.G. 9b)

      6.3.5.1        Request ALS
      6.3.5.2        Contact Ambulance Control and seek assistance of a GP if ALS
                     not available

      Management

                A.    Act immediately to release the cord
                B.    Try to slip cord gently around baby's neck or shoulder
                C.    Do NOT pull on cord
                D.    If cord cannot be slipped off, clamp cord in two places and cut
                      between clamps and then ease cord form around neck
                E.    Manage the delivery as per CPG 9a

6.3.6 Short Cord « 40 cm) (reference C.P.G. 9b)

      Management

      Deliver in normal way taking extra care not to apply traction to cord

6.3.7 Cord Rupture (CPG 9b)

                A.    Apply additional clamps to cord
                B.    Apply direct pressure with sterile dressing
                C.    Manage the delivery as per CPG 9a as necessary

6.3.8 Antepartum Haemorrhage

                A.    Haemorrhage from the genital tract after 24 completed weeks of
                      pregnancy and before labour
            B         Request ALS
            C         Contact Ambulance Control and seek assistance of a GP if ALS
                      not available


      Management

                A.    Airway, Breathing and Circulation
                B.    Provide high-concentration 02 via a non-rebreathing mask
                C.    Assess and document respiratory rate, pulse rate and quality,
                      capillary refill time, blood pressure and obstetric history.


Title: SOP/Guideline Obstetric Emergencies

Document Reference Number: SOP/GL No 002
Revision Number: 1
Approval Date: March 2009



                                                                                        8
             D.    If patient is haemodynamically unstable seek ALS if not already
                   done
             E.    Position mother in left lateral tilt
             F.    Do not examine abdomen or vagina
             G.    Initiate transport to hospital without delay
             H.    Contact Ambulance Control to pre-alert the receiving Maternity
                   Unit of the situation and your impending arrival

6.3.9 Postpartum Haemorrhage

            A.     Haemorrhage of 500ml or more within 24 hours of delivery, but
                   usually with or immediately after delivery of the placenta.
            B.     Request ALS
            C      Contact Ambulance Control and seek assistance of a GP if ALS
                   not available


      Signs/Symptoms

             A.    Often a history of prolonged labour, large baby or several
                   previous labours
             B.    Placenta is out but uterus feels soft and relaxed
             C.    Brisk fresh blood loss
             D.    Expelled placenta incomplete


      Management

             E.    Airway, Breathing and Circulation
             F.    Provide high-concentration 02 via a non-rebreathing mask
             G.    Assess and document respiratory rate, pulse rate and quality,
                   capillary refill time, blood pressure and obstetric history.
             H.    If patient is haemodynamically unstable seek ALS if not already
                   done
             I.    Initiate transport to hospital without delay
             J.    Perform external massage of the uterus
             K.    Contact Ambulance Control to pre-alert the receiving Maternity
                   Unit of the situation and your impending arrival


6.3.10 Pre-Eclampsia

      Pregnancy-induced hypertension with significant proteinuria. A dangerous
      condition which tends to worsen


Title: SOP/Guideline Obstetric Emergencies

Document Reference Number: SOP/GL No 002
Revision Number: 1
Approval Date: March 2009



                                                                                     9
      Signs/Symptoms

             A.    Raised BP
             B.    Proteinuria
             C.    May be symptom-free
             D.    Headache
             E.    Photophobia
             F.    Blurred vision or "flashing lights"
             G.    Upper abdominal pain
             H.    Vomiting
             I.    Disorientation and dizziness
             J.    Increased reflexes
             K.    Jaundiced

      Management

             A.    Care for the patient calmly
             B.    Limit interventions only to procedures required to treat the
                   patient
             C.    Keep noise to a minimum
             D.    If the patient has photophobia, avoid direct light sources.
                   Reduced ambient light can hinder adequate observation.
             E.    Do not leave patient unattended and be alert for changes in their
                   condition


6.3.11 Eclampsia

      The end-point of pre-eclampsia in susceptible women. Characterized by
      generalised convulsions identical to those in grand mal epilepsy

      Signs/Symptoms

             A.    In an eclamptic fit twitching occurs, then unconsciousness and
                   convulsions, with tonic (rigid) and clonic (violent twitching)
                   phases. Typically, the tonic and clonic phases together take 1-2
                   minutes. Varying degree and duration of coma follows, with a
                   risk of further fitting. As in epilepsy, tongue-biting, vomiting
                   and urinary incontinence are common.




Title: SOP/Guideline Obstetric Emergencies

Document Reference Number: SOP/GL No 002
Revision Number: 1
Approval Date: March 2009




                                                                                  10
      Essential information for Maternity Unit

             A.     Nature and number of fits
             B.     Level of consciousness
             C.     Blood pressure
             D.     Approximate stage of pregnancy


      Management

             A.     Airway, Breathing and Circulation
             B.     Provide high-concentration 02 via a non-rebreathing mask
             C.     Request ALS if not already done
             D.     Assess and document respiratory rate, pulse rate and quality,
                    capillary refill time, blood pressure and obstetric history.
             E.     Initiate transport to hospital without delay. Arrange for ALS
                    intercept if possible
             F.     Inform the Maternity Unit of the situation and your impending
                    arrival


7.0   Implementation Plan
      This protocol will be agreed with all stakeholders for implementation by April
      6 th 2009



8.0   Evaluation and Audit
      All obstetric emergencies cared for by the Ambulance Service be evaluated
      by the Training and Development officer in conjunction with the Ambulance
      Service Medical Advisor.



9.0   Frequency of Review

      This SOP will be reviewed by the Clinical Advisory Group whenever
      circumstances, a relevant event or changes to Clinical Practice Guidelines
      dictate.




Title: SOP/Guideline Obstetric Emergencies

Document Reference Number: SOP/GL No 002
Revision Number: 1
Approval Date: March 2009




                                                                                       II
10.0 Method used to review operation of Standard Operating
     Procedure

10.1   The Training and Development Department will monitor compliance
       with this SOP on a regular basis through evaluation of Patient Care
       Records and any deviation will be investigated to identify any
       remedial action or training required.
10.2   Incident/Near Miss Reports will also be the subject of a review,
       either formal or informal as circumstances dictate.



11.0 References
       Neonatal Resuscitation Program

       Clinical Practice Guideline - CPG 1d

       Clinical Practice Guideline - CPG 9a

       Clinical Practice Guideline - CPG 9b

       Clinical Practice Guideline - CPG 9c



12.0 Appendices

Appendix A - SOP Acknowledgement form




Title: SOP/Guideline Obstetric Emergencies

Document Reference Number: SOP/GL No 002
Revision Number: 1
Approval Date: March 2009




                                                                             12
Signature Sheet

I have read, understand and agree to adhere to the attached guideline:

Print Name           Signature             Area of Work         Date




Title: SOP/Guideline Obstetric Emergencies

Document Reference Number: SOP/GL No 002
Revision Number: 1
Approval Date: March 2009



                                                                         13
APPENDIX 1




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