6: Structured approach to the obstetric patient

CHAPTER 6
Structured approach to the obstetric patient


6.1 Structured approach


A practitioner’s approach to any clinical encounter should always be predictable and structured. This approach:



  • Enables early and continual identification of life‐threatening conditions
  • Assists in a systematic and thorough assessment of the patient
  • Minimises the possibility of missing signs, symptoms or conditions
  • Promotes a professional attitude
  • Protects against criticism or complaint

The structured approach to an obstetric patient augments the standard approach to increase awareness of the signs and symptoms likely to compromise the mother and/or the unborn baby. The responding practitioner carries out a quick scan of the scene and the patient as they approach.This is referred to as a ‘global overview’. The standard ABCDE approach is maintained and extended to ABCDEFG. The ‘F’ refers to the fundus and the ‘G’ encourages the practitioner to ‘get to the point quickly’ in order to facilitate transfer for appropriate care. The right level of definitive care for an obstetric patient includes a properly equipped obstetric department, operating theatre or emergency department.


6.2 Obstetric primary survey


Global overview


The obstetric primary survey consists of the first ‘hands‐on’ examination of the pregnant patient. In the pre‐hospital environment, the responding practitioner needs to make an assessment of the situation as they approach the patient, before starting the primary survey (Figure 6.1). This global overview is a ‘hands‐off’ process and starts to corral the practitioner’s thoughts on the seriousness of the situation. During the global overview, the following should be considered:



  • Circulation/massive external haemorrhage – this is defined as catastrophic haemorrhage that is readily visible without the need to disturb the patient’s clothing
  • Airway – is the patient talking, making snoring or gurgling sounds, or not making any sounds at all?
  • Breathing – is the patient speaking in whole sentences? Have they adopted a position that suggests respiratory compromise?
  • Circulation – is the patient pale or flushed, or a normal colour?
  • Disability – is the patient talking, moving or making sounds?
  • Environment – is there blood on the floor or clothing of the patient? Has the baby been born yet? What position is the patient in? Is the home clean? Is it warm? Are there other children present?
  • Fundus – does the patient look as if she is in the first, second or third trimester?
  • Get to the point quickly – start the primary survey!
Photo of a woman seated on the floor, leaning on a table with her left hand placed over her stomach and her right hand on the floor. In front of the woman is a man in squat position.

Figure 6.1 Obstetric primary survey – global overview


Primary survey


The obstetric primary survey consists of the first ‘hands‐on’ examination of the pregnant patient. The aim of the primary survey is to rapidly identify life‐threatening problems through a systematic and structured approach, and to manage each problem as it is encountered. It is important to reach an early determination of the priority for transportation. The primary survey should be modified in the presence of trauma – see Chapter 10 for details.


It is important to remember there are potentially two patients – neither the mother nor a newly born baby should be overlooked whilst assessing and caring for the other. Both may be at risk, or one may need more urgent attention than the other – it may not be possible to determine which until a primary survey has been completed on both patients. For the primary survey of newborn babies, see Chapter 14.


Circulation/massive external haemorrhage



  • Is there a significant volume of blood visible without the need to disturb the patient’s clothing?

    • On the floor?
    • Is the patient’s clothing soaked?
    • Are there a number of blood‐soaked pads?


Airway



  • Is the patient able to talk? (yes would indicate the airway is clear)
  • Is the patient making unusual sounds? (gurgling suggests fluid in the airway, snoring suggests tongue/swelling/foreign body obstruction)
  • Protect the cervical spine if significant injury is suspected
  • If the patient is unresponsive, open and inspect the airway and consider suction or removal of any obstruction


Breathing



  • Assess the presence, work and efficacy of breathing; acknowledge respiratory rate and effort
  • Assess for the presence of cyanosis, tracheal deviation or neck vein distension
  • If not breathing adequately, ventilate
  • In alert and responding patients, obtain an oxygen saturation level and administer oxygen based on clinical findings
  • Inspect and palpate for chest movement and symmetry
  • Percuss for resonance, and auscultate for added sounds


Circulation



  • In an unresponsive patient, assess for signs of circulation
  • In an alert and responding patient, assess the radial pulse rate and volume
  • Assess skin colour and temperature
  • Assess for bleeding – check underwear, pads, the surface the patient is sitting on, and briefly examine the introitus with the patient’s consent and considering their privacy. Ask the patient about bleeding – if they have discarded pads, how saturated were they? How many pads have they used in what time period?
  • Measure blood pressure
  • Think ‘BLOOD ON THE FLOOR AND FIVE MORE’ (Box 6.1)



Figure 6.2 indicates how difficult it can be to estimate blood loss when encountered on different materials and surfaces.

Photos of soiled sanitary towel, soaked sanitary towel, small soaked swab, incontinence pad, large soaked swab, 100 cm diameter floor spill, PPH on bed only, PPH spilling to floor, and full kidney dish.

Figure 6.2 Estimating obstetric blood loss. *Multidisciplinary observations of estimated blood loss revealed that scenarios (e–f) are grossly underestimated (>30%).


(Source: Bose P, Regan F, Paterson‐Brown S. Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions. BJOG, 18 July 2006. Reproduced with permission of John Wiley & Sons)



Disability



  • Perform an AVPU assessment of conscious level (is the patient alert, responding only to voice, responding only to pain, or unresponsive?)
  • Assess patient’s neurological status
  • Assess the patient’s position and note any abnormal posture (convulsing, abnormal flexion, abnormal extension)
  • Assess pupil size and reaction


Expose/environment/evaluate



  • If you have not already done so, briefly examine the introitus – is there any evidence of bleeding? Can you see a presenting part of the baby? Is there a prolapsed loop of cord? Have the waters broken? Does the perineum bulge with each contraction? If the baby has been delivered, is there a significant perineal tear? Can you see part of the uterus?
  • Is the environment warm and discrete? Are the surroundings as clean as you can make them if you are going to deliver on site?
  • Make an early evaluation about how time critical the patient’s problem is. If the patient’s status is time critical, decide immediately whether you need to transport the patient urgently to hospital, or whether it is more prudent to treat them at the scene – remember to call for skilled obstetric help if this is the case


Fundus



  • Make a quick assessment of fundal height (Figure 6.3): a fundus at the level of the umbilicus equates to a gestation of approximately 20 weeks. By definition, a fundal height below the umbilicus suggests that if the fetus is delivered it is unlikely to survive

A human abdomen with curved lines indicating fundal height estimation of 12, 14–16, 20, 24, 40, 32, 40, and 36–38.

Figure 6.3 Fundal height estimation


Get to the point quickly



  • Remember the aim is to identify time‐critical problems as quickly as possible, to allow for rapid management and, if appropriate, transfer to a suitable obstetric facility for definitive care. These problems include:

    • Significant blood loss at any stage of pregnancy or in the postpartum period
    • Suspected abruption, placenta praevia or uterine rupture
    • Eclampsia or significant hypertension
    • Shoulder dystocia
    • Cord prolapse
    • Suspected amniotic fluid embolus
    • Retained placenta
    • Uterine inversion
    • Cervical shock
    • Refractory maternal cardiac arrest
    • Refractory neonatal cardiac arrest
    • Newborn with poor vital signs


Patients who have one or more of these problems are unlikely to be comprehensively managed outside of an obstetric facility.


If transport to hospital is possible, the care provided on scene should be restricted to that necessary to secure the patient’s airway, ensure adequate ventilation and to control significant compressible haemorrhage.

Mar 9, 2019 | Posted by in EMERGENCY MEDICINE | Comments Off on 6: Structured approach to the obstetric patient
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