Emergency Medicine

CONDITIONS IN L ATE PREGNANC Y

386 Obstetric and Gynaecological Emergencies

(i) Aim for a diastolic blood pressure of 90–100 mmHg to reduce the

risk of cerebrovascular accident and further seizures.

10 The only definitive treatment of eclampsia is delivery, once seizures are

controlled, hypoxia is corrected and treatment of the severe hypertension is

under way.

Emergency delivery

MANAGEMENT

1 Call the obstetric team and paediatric or neonatal team immediately.

2 Allow the mother to lie or sit semi-upright, and give her 50% nitrous oxide

with oxygen (Entonox™) during the first half of the contractions.

3 A mediolateral episiotomy may be needed in primiparous women.

4 Ask the mother to pant and thus to stop pushing as the head crowns, usually

with the occiput upwards/face down, which is followed by rotation (restitu-

tion) of the head laterally.

5 Clamp and cut the cord immediately if it is wound tightly around the baby’s

neck.

(i) Otherwise the cord can be clamped off or tied with two 2/0 silk

ties at leisure at least 1 min after delivery, and divided.

6 The next contraction delivers the anterior shoulder by gentle downward

traction on the head, which is followed by the posterior shoulder and

trunk.

7 Then deliver the baby by lifting the head and trunk up and over the sym-

physis pubis, to lie on t he mot her’s abdomen.

8 Aspirate mucus from the baby’s nose and mouth, and keep the baby warm by

wrapping it in a blanket. Be prepared to intubate if t here is apnoea.

9 Avoid the temptation to pull on the cord in the routine management of the

third stage of labour, for fear of causing uterine inversion.

(i) Palpate the abdomen to exclude the possibility of a second fetus,

and gently massage the uterus to stimulate uterine contraction.

(ii) Give oxytocin 10 units i.m. This helps prevent post-partum

haemorrhage and aids delivery of the placenta.

(iii) An alternative is oxytocin 5 units with ergometrine

(Syntometrine™) 500 g (1 mL) i.m., but this is associated with

nausea, vomiting and hypertension, and has little advantage over

oxytocin alone.

10 Encourage the mother to commence suckling her baby immediately, as this

will naturally stimulate uterine contraction, help to expel the placenta and

reduce the risk of haemorrhage.