Pre-Hospital Obstetric Emergency Training

Transcription

1 Pre-Hospital Obstetric Emergency Training The Practical Approach Advanced Life Support Group EDITED BY Malcolm Woollard Kim Hinshaw Helen Simpson Sue Wieteska A John Wiley & Sons, Ltd., Publication

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3 Pre-Hospital Obstetric Emergency Training The Practical Approach

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5 Pre-Hospital Obstetric Emergency Training The Practical Approach Advanced Life Support Group EDITED BY Malcolm Woollard Kim Hinshaw Helen Simpson Sue Wieteska A John Wiley & Sons, Ltd., Publication

6 This edition first published 2010 c 2010 by Blackwell Publishing Ltd BMJ Books is an imprint of BMJ Publishing Group Limited, used under licence by Blackwell Publishing which was acquired by John Wiley & Sons in February Blackwell s publishing programme has been merged with Wiley s global Scientific, Technical and Medical business to form Wiley-Blackwell. Registered office: John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial offices: 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 111 River Street, Hoboken, NJ , USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at The right of the author to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patents Act All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or website may provide or recommendations it may make. Further, readers should be aware that Internet websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom. Library of Congress Cataloging-in-Publication Data Pre-hospital obstetric emergency training : the practical approach / Advanced Life Support Group ; edited by Malcolm Woollard... [et al.]. p. ; cm. Includes bibliographical references and index. ISBN (alk. paper) 1. Obstetrical emergencies. 2. Emergency medical technicians. I. Woollard, Malcolm. II. Advanced Life Support Group (Manchester, England) [DNLM: 1. Obstetric Labor Complications prevention & control. 2. Emergency Medical Services methods. 3. Emergency Treatment methods. 4. Health Personnel education. 5. Inservice Training methods. WQ 330 P ] RG571.P dc A catalogue record for this book is available from the British Library. Set in 9/11.5pt Meridien by Aptara R Inc., New Delhi, India Printed and bound in

7 Contents Working Group, vi Contributors, vii Foreword, viii Preface, ix Acknowledgements, xi Contact details and website information, xii Chapter 1 Obstetric services, 1 Chapter 2 Law, ethics and governance related to pregnancy, 7 Chapter 3 Anatomical and physiological changes in pregnancy, 18 Chapter 4 Normal delivery, 28 Chapter 5 Structured approach to the obstetric patient, 38 Chapter 6 Emergencies in early pregnancy and complications following gynaecological surgery, 53 Chapter 7 Emergencies in late pregnancy, 62 Chapter 8 Emergencies after delivery, 111 Chapter 9 Care of the baby at birth, 125 Chapter 10 Management of non-obstetric emergencies, 136 Chapter 11 Cardiac arrest and shock in pregnancy, 166 Abbreviations, 185 Glossary, 187 References, 192 Index, 195 v

8 Note to text: Drugs and their doses are mentioned in this text. Although every effort has been made to ensure accuracy, the writers, editors, publishers and printers cannot accept liability for errors or omissions. The final responsibility for delivery of the correct dose remains with the practitioner administering the drug. vi

9 Contributors Sally Evans Kim Hinshaw Helen Simpson Mark Woolcock Malcolm Woollard Jonathan Wyllie Midwifery, Middlesbrough Obstetrics and Gynaecology, Sunderland Obstetrics and Gynaecology, Middlesbrough Pre-Hospital Care, Truro Pre-Hospital Care, Coventry Neonatology, Middlesbrough Dedication With thanks to our families for their tolerance and support during the development of this manual and its associated course. vii

10 Foreword I was delighted and pleased to read POET which gives practical advice to a range of practitioners. Although it is intended for pre-hospital practitioners there is valuable information for nurses, midwives, general practitioners (GPs) and pre- and postregistration doctors. The chapters cover a wide variety of topics starting from the organisation of obstetric services to details of anatomy, physiology and normal delivery. Once this is covered, the chapters logically proceed to a general approach to the obstetric patient followed by management of emergencies in early and late pregnancy and during delivery. The illustrations and flow charts of care pathways make it simple to read and to keep in mind the logical steps to be taken to provide the best care. The chapter on Care of the baby at birth is a welcome chapter for such a book. The management of non-obstetric emergencies, cardiac arrest and shock in pregnancy has different management issues compared with a woman who is not pregnant. The knowledge needed for these is provided in a way that could be easily understood. This chapter will be useful for a different range of practitioners. POET is a comprehensive book that covers the knowledge needed for pre-hospital practitioners. But I would recommend this book for a wider audience of nurses, midwives, GPs and A&E doctors who may face the pregnant mother in an outside hospital setting or in a hospital with no maternity service provision. The authors deserve credit for simplifying a complex subject and for covering the knowledge needed on this topic for pre-hospital practitioners. S. Arulkumaran FRCOG, PhD Professor and Head of Obstetrics and Gynaecology St George s University of London November 2009 viii

11 Preface Pre-hospital obstetric incidents make up a significant proportion of the more costly litigation claims against UK ambulance services. These claims are based either on an alleged failure to identify and manage a problem or lack of appropriate equipment for the treatment of a preterm baby. For a number of years after the UK national paramedic curriculum was introduced in the UK, it included no specific training on the management of obstetric emergencies at an advanced life support level. Most staff received only a half-day of lectures during their initial ambulance technician training at the beginning of their career. Since 1999, advanced obstetrics and gynaecology became a mandatory part of the paramedic course for new entrants but with the expectation that existing paramedics would receive update training. Our experience has indicated, however, that paramedics in many parts of the UK have not had the opportunity to do so. A confidential enquiry into maternal and child health (CEMACH) report has indicated that many of the pregnant women dying had chaotic lifestyles and found it hard to engage with maternity services. The ambulance service may be the initial contact with the health service for these patients and their peers who become unwell but are fortunate enough to survive. The CEMACH report identifies the need for a widened awareness of the risk factors and early signs and symptoms of potentially serious problems in pregnancy, and makes a number of key recommendations that could be addressed in part by appropriately trained pre-hospital practitioners. For example, it states: All clinical staff must undertake regular, written, documented and audited training for: The identification, initial management and referral for serious medical and mental health conditions which, although unrelated to pregnancy, may affect pregnant women or recently delivered mothers The early recognition and management of severely ill pregnant women and impending maternal collapse ix

12 x PREFACE The improvement of basic, immediate and advanced life support skills. A number of courses provide additional training for staff caring for pregnant women and newborn babies. There is also a need for staff to recognise their limitations and to know when, how and whom to call for assistance. This manual and its associated Advanced Life Support Group training course (also called POET) hope to meet these educational needs for a range of pre-hospital practitioners. Both the text and the course have been developed by a multi-disciplinary team of senior paramedics, consultant obstetricians and midwives, all of whom are practicing clinicians and experienced educators. POET course teaching teams have a similar multi-professional membership with a shared philosophy of combining pre-hospital and obstetric expertise. Although we anticipate that paramedics and pre-hospital physicians will make up the bulk of our readership and course candidates, POET will also be of value to nurses working in walkin and unscheduled care centres and to midwives and to GPs particularly those working at a distance from further support. It is our sincere hope that POET will build the confidence and competence of pre-hospital practitioners and thus contribute to reducing the incidence of maternal and fetal mortality and morbidity. Malcolm Woollard, Helen Simpson, Kim Hinshaw and Sue Wieteska November 2009

13 Acknowledgements A great many people have worked hard to produce this book and the accompanying course. The editors thank all the contributors for their efforts and all POET providers and instructors who took the time to send their comments during the development of the text and the course, in particular Bernadette Norman who completed a full review of the text. We also acknowledge Rachel Adams at ALSG for her support. We are also greatly indebted to Kate Wieteska for producing the first draft of the line drawings that illustrate the text and thank the ALSG/CAI Emergency Maternal and Child Health (EMCH) programme and the ALSG Managing Obstetric Emergencies and Trauma (MOET) course for the shared use of some of their line drawings. Finally, we thank, in advance, those of you who will attend the POET course; no doubt, you will have much constructive critique to offer. xi

14 Contact details and website information ALSG: BestBETS: For details on ALSG courses visit the website or contact: Advanced Life Support Group ALSG Centre for Training and Development Ellesmere Street Swinton, Manchester M27 0LA Tel: +44 (0) Fax: +44 (0) Updates The material contained within this book is updated on approximately a four-yearly cycle. However, practise may change in the interim period. We will post any changes on the ALSG website, so we advise you to visit the website regularly to check for updates (url: updates are on the course pages). The website will provide you with a new page to download and replace the existing page in your book. References To access references visit the ALSG website references are on the course pages. On-line feedback It is important to ALSG that the contact with our providers continues after a course is completed. We now contact everyone 6 months after his or her course has taken place asking for on-line feedback on the course. This information is then used whenever the course is updated to ensure that the course provides optimum training to its participants. xii

15 CHAPTER 1 Obstetric services OBJECTIVES Having read this chapter, the practitioner should be able to: understand the relationship between the different professional groups involved in the management of the obstetric patient understand the function and importance of hand-held records and how to use them effectively ORGANISATION OF OBSTETRIC SERVICES, EPIDEMIOLOGY OF OBSTETRICS AND GYNAECOLOGICAL EMERGENCIES AND ROLE OF THE AMBULANCE SERVICE, GENERAL PRACTITIONER AND MIDWIFE The organisation Obstetrics is a multidisciplinary specialty in which midwifery and medical staff work together to provide optimal care. The majority of care is performed in the out-of-hospital setting and by community midwives. Inpatient antenatal care is now uncommon and not usually for long periods. Similarly, the postnatal length of stay for all women, even those with Caesarean section, has also been reduced, with the majority of care occurring in the community. General practitioners (GPs) have in recent years become less and less involved in all aspects of pregnancy care, although there are still a small number who are involved in care in labour. Place of delivery Women undergo a risk assessment prior to delivery to help them choose where to deliver. This assessment is undertaken by their Pre-Hospital Obstetric Emergency Training, 1st edition. By Malcolm Woollard, Kim Hinshaw, Helen Simpson and Sue Wieteska. Published 2010 by Blackwell Publishing, ISBN: