Approximately 15% of pregnant women develop complications that require special obstetric care, with up to 5% requiring surgery, including C-sections. Basic obstetric care includes the ability to assess the mother and fetus; do episiotomies; manage hemorrhage, infection, and eclampsia; deliver multiple births and breech presentations; use a vacuum extractor; and provide care for women after genital mutilation.10
An excellent online professional resource for routine and emergency obstetric care (with good illustrations) is WHO's book, Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors. Download it at www.who.int/reproductive-health/impac/.
Another excellent professional resource is the Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO) book, Emergency Obstetric Care:Quick Reference Guide for Frontline Providers, which is available to download from the USAID web site: http://dec.usaid.gov/index.cfm?p=search.getCitation&CFID=4497507&CFTOKEN=62906948&rec_no=127959.
Diagnosing pregnancy without a human chorionic gonadotropin (HCG) level relies on signs and symptoms, some of which can be quite nebulous. The only three physical findings of pregnancy that most clinicians can rely on are palpating the enlarged uterus, hearing the fetal heartbeat, and seeing the baby in the birth canal.
If you really must have lab test results to diagnose pregnancy in austere circumstances, use the frog test, which is much easier than the fabled rabbit test. Using a male frog (the common North American frog, Rana pipiens), the test is simple, rapid, and inexpensive. Inject 1 mL of the patient's early-morning, concentrated urine sample (or blood serum obtained at any time) into the frog's dorsal lymph sacs (back area behind the head). Blood serum is preferable, since it can be obtained any time and is less likely to cause toxic deaths in the frogs. Using a microscope, examine the frog's urine at 30-minute intervals for 3 hours. If the test is positive, the frog will have spermatozoa in its urine. During the summer, the accuracy of the test decreases, but this can be partially compensated for by refrigerating the frogs.11
Without ultrasound to date the pregnancy, the less-reliable method of counting from the patient's last menses must be used. One way to get the due date is to add 9 months and 7 days from the onset of the patient's last period. For those using lunar time for measurements rather than a calendar, assuming that the woman's cycles are "1 moon" (4 weeks) apart, the due date would be "10 moons" after the onset of the patient's last menses.
Once the fundus can be felt, the gestational age is closely related to the fundal height (Fig. 28-1).
Fundal height related to gestational age.
Any hollow tube made from wood, bamboo, plastic, clay, or metal can be used as a fetoscope. The optimal size is a piece about 15 cm long, with a hollow core 3 to 4 cm in diameter.12,13
Counting the fetal heart rate with a stethoscope or Doppler is accurate and has good inter-observer reliability.14 Skilled practitioners can often hear the baby's heartbeat by the seventh or eighth month just by putting their ear to the patient's belly in a quiet room. However, the heartbeat is easier to hear with a stethoscope or a fetoscope. (For improvised stethoscopes, see Chapter 5, Basic Equipment.)
If the baby's heartbeat is heard best below the umbilicus, the baby is probably in the head-down position. If it is heard best above the umbilicus, the baby is most likely head-up (breech).
Non-pharmacological treatment includes locally applied heat and cold. Heat can be applied as a hot water bottle, hot bath, or microwaved wheat pillow (see "Heating the Bed" in Chapter 5, Basic Equipment). Locally applied ice packs often work well for headaches. If non-pharmacological treatment is ineffective, consider using local anesthetic infiltration or regional anesthetic blocks, depending on the location of the pain. If those don't work or they are not applicable, use acetaminophen 1 g q6hr.15
If a woman passes tissue during her first trimester and the os has closed again, check her vital signs and, if normal, send her home. Tell her to return if there is increased bleeding or any sign of infection.
If she is spotting, reassure her that most pregnancies with only spotting go to term without difficulty. Check her vital signs; if normal, send her home.
If she has been bleeding and the os is open, she has an incomplete or inevitable miscarriage. She can wait for passage of more tissue and for the os to close. If the os remains open, she will need the products of conception removed.
If vaginal bleeding occurs after a miscarriage, delivery, or abortion, and a speculum or forceps is not available, use a sterile- or clean-gloved hand to feel the cervical os. Check for products of conception that are not permitting the os to contract. If necessary, use a non-gloved, but clean, hand. If material seems to be at the os, but it is too slippery to hold, use sterile gauze or a cloth boiled in water wrapped around your fingers to try to grasp and remove the tissue.
Simple tests can help to determine a pregnant woman's well-being.
Checking her weight may be the most difficult test to improvise without a scale. However, other observations, such as her overall body habitus (e.g., extremely thin or fat face), may help a little. You are trying to see that the woman is not too thin due to parasites, HIV, drug use, hyperemesis, or lack of food. She should gain at least 20 lb (9 kg) during the pregnancy. You also want to be sure that she has not gained more than 42 lb (19 kg) during the pregnancy, or more than 3 lb (1.5 kg) a week or 8 lb (3 kg) in a month, especially during the last 2 months of pregnancy. If she has gained too much weight, check her for diabetes, preeclampsia, or twins.
Check the mother's vital signs. (See Chapters 7, Vital Signs, Measurements, Triage, and 5, Basic Equipment, for ways to improvise these tests.) If her blood pressure (BP) is >140/90, beware of preeclampsia. Also check for peripheral edema, especially in the hands and face, and for very brisk reflexes (clonus).
Test her urine for protein. While the easiest method is a urine dipstick, you can also test for protein by heating the urine. (See "Protein" under "Urinalysis" in Chapter 19, Laboratory, for the method.)
If an ultrasound is available, what you can do with it depends on both the machine's and your own capabilities. Dating the pregnancy by measuring the fetus is relatively easy. Determining the sex and looking for fetal abnormalities or the placenta's position can all be done with relatively little training.
Without ultrasound, use external measurements to help determine the pregnancy's progress. The basic rule is that the fundal height increases by ~2 fingerbreadths each month. At 3 months, the fundus is just above the pubic symphysis. At 5 months, it is at the umbilicus, and at 8.5 to 9 months, it is almost up to the costal margin. One or two weeks before delivery, it drops a bit. Use a tape measure to check the fundal height and record it for each visit (see Fig. 28-1).
Most pregnant women, especially those in resource-poor situations, need to have supplemental iron. Mix ferrous salts in a palatable solvent (e.g., juice) to make an acceptable iron mixture.16
Ectopic pregnancies can be life threatening. Women presenting with abdominal pain, vaginal bleeding, or hypotension need to have this diagnosis excluded or treated. While ultrasound has virtually eliminated the use of diagnostic culdocentesis from the developed world, it still is valuable for diagnosing ectopic pregnancies and pelvic infections in austere circumstances.
The procedure is simple (for the clinician). Pick up the posterior cervix with a single-tooth tenaculum (Fig. 28-2). This is often when patients feel the most pain. Apply it very slowly, counting from "1" to "30" while the teeth are applied. Then infiltrate the posterior fornix with a local anesthetic. Insert a 16- or 18-gauge needle into the cul-de-sac. Aspirate. If blood returns, wait 6 minutes to see if it clots. If it does, it is most probably due to the needle entering a pelvic vein. If it doesn't clot, the blood is from a ruptured ectopic pregnancy or ovarian cyst. If pus returns, the patient has pelvic inflammatory disease. If a small amount of straw-colored fluid is withdrawn, that is physiologic. If no fluid is returned, the tap is non-diagnostic; repeat it.
Culdocentesis from the clinician's viewpoint.
Preeclampsia/Eclampsia Diagnosis and Treatment
Preeclampsia's hallmarks are hypertension and proteinuria after 20 weeks' gestation. Hypertension is a BP ≥140/90 in a woman who has not previously been hypertensive. (Improvised methods to take the BP are described in Chapter 7, Vital Signs, Measurements, and Triage. A qualitative urine protein test can be found in Chapter 19, Laboratory.) The women also frequently have sudden weight gain or the presence of swelling of the face and hands—especially upon awakening. Indicators of severe preeclampsia include the presence of severe headaches, hyperreflexia, blurred or double vision, upper abdominal pain, oliguria, and pulmonary edema. Depending on available resources, women with preeclampsia or severe preeclampsia should be treated.
The first drug to try (that may be available) to treat active seizures in eclampsia is diazepam 10 mg IV over 2 minutes. If necessary, the IV preparation can also be given rectally.17,18 Repeat this dose if another seizure occurs. If referral is delayed or if the woman is in late labor, start a maintenance drip of 40 mg diazepam in 500 mL normal (0.9%) saline (NS) or lactated Ringer's solution, run over 6 to 8 hours at a level to keep the patient sedated, but arousable. Limit the dose to 100 mg diazepam in 24 hours. Stop the drip if respirations slow to ≤16/min.19
Since diazepam has erratic absorption IM and, in some situations, it may not be possible to start an IV in edematous or seizing patients, the rectal route has been successfully used. Demonstrating its utility in remote areas, Dr. Povey wrote,
At Maputo Central Hospital [Mozambique] we have many times used it to control eclamptic convulsion, following which it is possible to access a vein and to continue management with magnesium sulphate . . We use 20 mg of the IV preparation of diazepam in a 10-mL syringe. The needle is removed, the barrel is lubricated, and the syringe is inserted into the rectum for half its length. The contents are discharged, the syringe is left in place, and the bullocks are held together for 10 min to prevent expulsion of the drug. If convulsion is not controlled within 10 min, an additional 10 mg is instilled. Alternatively, the drug can be injected into the rectum through a urinary catheter. In circumstances in which IV administration is impossible or dangerous, as in a primary care unit that lacks the appropriate equipment or skills, we advise the rectal loading dose described above followed by an hourly rectal dose of at least 10 mg, depending upon the size of the woman and her clinical response. This method is invaluable when a patient must be transported for a long distance by human carriers, animal cart or truck.18
Magnesium sulfate (MgSO4) is traditionally the first-line medication used for preeclampsia and eclampsia.20 However, it is not available in many of the world's hospitals and birthing centers.19 Magnesium sulfate treatment is expensive, not only because of the medication but also because of the need to hospitalize and monitor the patient. However, MgSO4 treatment for preeclampsia costs less and prevents more eclampsia in less-developed countries than in the developed countries.
To use it, administer a loading dose of 4 g MgSO4 IV over 5 minutes. (Warn the patient that she will feel warm when the drug is given.) Then, immediately give 5 g MgSO4 (50% concentration is best) mixed with 1 mL 2% lidocaine in each buttock as a deep IM injection. After 15 minutes, if seizure persists or recurs, give 2 g MgSO4 IV over 5 minutes. If referral is delayed or the woman is in late labor, repeat the IM injections in each buttock using half the dose of MgSO4 (i.e., 5 g total). Give it in alternate buttocks every 4 hours for 24 hours after delivery or the last seizure. Before every MgSO4 dose, be certain that the respiratory rate is ≥16/min, patellar reflexes are present, and urine output is ≥30 mL/hr. The antidote for respiratory depression is calcium gluconate 1 g (10 mL of 10% solution) IV administered over 10 minutes.19
The third drug to try, if available, is phenytoin (Dilantin). It is not as effective as MgSO4. Give 10 mg/kg IV at a rate of ≤25 mg/min. Two hours later, give 5 mg/kg IV. Begin a maintenance dose of 200 mg tid IV or po 12 hours later.17
Terminating the pregnancy is the definitive treatment for preeclampsia. In almost all cases, this means a term or near-term delivery.
If the woman's membranes have broken but labor has not started, labor sometimes can be inducted by administering an enema (carefully, so as not to infect the vaginal area) or by giving 60 mL castor oil in 240 mL fruit juice.21
Boulton described the method (not often used) of using local anesthesia for the perineum and vagina: "The technique of topical analgesia of the skin of the perineum and the mucous membrane of the introitus of the vagina for spontaneous delivery, suction extraction and suturing of perineal lacerations is simple and efficacious. Lidocaine gel 2% can be used for the purpose but the 10% aerosol is superior. The dose should not exceed 200 mg lidocaine to mucous membranes and 200 mg to the surrounding skin. [More than] 90% of patients receiving spraying alone report satisfactory relief of pain; blood lidocaine did not exceed 2.4 mcg/mL, which is well below the toxic level (10 mcg/mL)."22
Bilateral pudendal blocks provide excellent anesthesia over the perineum and lower third of the vagina. They reduce pain during vaginal delivery and minor gynecological procedures, provide some introital relaxation, and are adequate anesthesia for repairing lacerations or episiotomies. A pudendal block does not, however, provide adequate anesthesia when extensive obstetric manipulation is required.
This block requires a small-gauge (22-gauge) spinal needle, 10 mL 1% lidocaine for each side, and a needle guide (e.g., Iowa trumpet) that allows the needle to protrude only 1.5 cm out of the distal end. The needle guard can be improvised by cutting 1.5 cm off the needle's plastic sheath, as is done when making a needle guard to aspirate peritonsillar abscesses. This guide can also be used when doing a paracervical block.
Then palpate the ischial spine through the vagina. The spine can be felt as a distinct boney "bump" quite separate from the rest of the pelvic wall. Insert the needle guide along the palpating finger to a point on the sacrospinous ligament, about 1 cm from its insertion onto the ischial spine. Insert the needle through the guide and into the sacrospinous ligament. Aspirate and then slowly infiltrate 3 mL 1% lidocaine. Advance through the ligament and inject 3 mL more anesthetic as the plunger loses resistance. Then withdraw the needle into the guide, and move the guide just above the ischial spine; inject the rest of the anesthetic. Repeat the process on the other side. It takes 10 to 20 minutes for the block to take effect. If the block does not work on one side, administer another 5 mL of anesthetic on that side. When giving a pudendal block during labor, locally infiltrate the area for an episiotomy, in case that procedure needs to be done before the block takes effect.
Spinal anesthesia is discussed in Chapter 14, Anesthesia—Local and Regional. However, giving these blocks to pregnant patients involves some special considerations. First, these women should receive at least 1.5 L crystalloid before the lumbar puncture (LP). Be careful if the woman has a bleeding disorder, such as occurs in moderate to severe eclampsia. Also, in general, pregnant patients need less anesthetic medication to achieve the same level of anesthesia than women who are not pregnant. The general doses and techniques are given as follows.
For a C-section, the block should extend to T6, about the level of the sternum. Use one of the following typical doses to achieve that level23:
If the spinal is for a forceps delivery, 1 mL of a hyperbaric anesthetic, given with the mother in a sitting position, is usually adequate. When removing a retained placenta, inject 1.5 mL hyperbaric solution with the mother sitting up; then lay her down.
Anesthesia for C-Sections
The methods for using local and general anesthetics, including ketamine for C-sections, are discussed in Chapters 14, Anesthesia—Local and Regional, and 15, Sedation and General Anesthesia.
In certain cases of obstructed labor or when there is head dystocia (and a C-section is not possible and alternative maneuvers have not succeeded), two procedures might work: symphysiotomy and, if the fetus has died, fetal craniotomy.
Recommended by WHO to avoid maternal and fetal complications during difficult vaginal deliveries, symphysiotomy is surgically dividing the cartilage of the symphysis pubis, usually under local anesthesia.24 Performed in the second stage of labor, it temporarily enlarges the pelvic outlet from 1 to 3 cm, permitting a vaginal delivery. Contraindications include a dead fetus (see "Fetal Craniotomy" below), incomplete cervical dilatation, and a non-longitudinal lie.
The 2- to 3-minute procedure, generally done in the labor ward, was commonly performed throughout the 20th century. After inserting a catheter to drain the bladder, use local anesthesia to liberally anesthetize the area. Place a finger in the vagina behind the pubic symphysis and make a 1.5- to 3-cm skin incision. Then divide the cartilage at the pubic symphysis. Deliver the baby.
Although women often experience more and longer postoperative pain after this procedure than with a Cesarean section, most women can walk using a walker or chair within 2 to 4 days; 95% can be discharged from hospital within 2 weeks.
Scar tissue between the pubic bones permanently enlarges the pelvis. Post-symphysiotomy patients sometimes experience pain over the symphysis or in the sacroiliac joints or urinary incontinence—although less often than after normal vaginal deliveries. Rarely, problems with walking occur.25
If the fetus has died or the mother's life is at risk and the child cannot be delivered in any other way, reduce the fetal head size with a craniotomy. This makes a vaginal delivery possible. If a fetus has hydrocephalus, passing a needle into the head to drain the fluid can reduce the head size sufficiently for vaginal delivery.
Craniotomies were often performed before C-sections became common. In cases of fetal death and hydrocephalus, they are still frequently done in less-developed countries. Drs. Smith and Neill describe the craniotomy procedure (Fig. 28-3):
In some cases, where the sutures are very loose, the evacuation of the brain is often sufficient, as the bones of the cranium collapse so much by the pressure of the womb that the child may be expelled by the natural powers. Should this not be the case, the brain must be evacuated, and extracting force applied. The instruments required are of two kinds, the one to perforate the skull, and the other to extract.
It is not absolutely necessary . . that the os uteri should be entirely dilated, although the wider the orifice is, the less danger will there be of injuring that organ. The rectum and bladder having been previously emptied, the woman is to be placed in the [lithotomy] position. The perforator should then be carefully applied upon the groove between two fingers of the left hand, previously introduced, and placed upon the part of the head, which it is proposed to open. It must now be passed forwards with a semi-rotatory motion until it penetrates the bone; if the scissors are used [to perforate the skull, then separate] the handles as widely as possible. The cutting edges are then to be placed at right angles to the first incision, and again separated, so as to make an [x-shaped] opening. The instrument should now be passed into the skull, and the brain broken up, after which [the instrument] should be withdrawn. Then [use an instrument to grasp] the inside or outside of the head, and [extract the fetus], being very careful to guard the soft parts of the mother. If the head cannot be delivered in this manner, recourse must be had to the craniotomy forceps and the bones broken up and extracted in pieces.26
Craniotomy for head dystocia. (Reproduced from Smith and Neill.27)
Drs. Smith and Neill go on to note that the mother will need special care after this procedure.
About 4% of pregnant women experience significant antepartum hemorrhage from placenta previa, abruptio placenta, or uterine rupture.28
In cases of placenta previa when the mother is hemorrhaging during labor and when there is no other option (e.g., C-section), you may have to revert to the old methods to save the woman's and, possibly, the child's life. These include moving the baby (i.e., version) so the foot protrudes from the vagina for traction, using a towel clip or forceps to grab the baby's scalp (if it is a vertex presentation) to apply traction, or, in less-severe cases, rupturing the membranes.
Using forceps on the fetal skull to tamponade the bleeding is very effective. It can be done even when the os has dilated only enough to admit one finger at a time. Once the forceps are applied, mild traction (1 to 1.5 lb) abruptly stops the bleeding. This method saves nearly all the mothers' lives, although the neonatal mortality varies widely. Using traction, only 44% of the children survived. This, however, was better than the 7% survival using "version."29
Removing a dead fetus can prove difficult if it is in the breech position. One method of removal is to pass a large balloon (Foley) catheter into the fetus's rectum, inflate it with water, and pull on the catheter. According to Verkuyl, this makes extraction easy and avoids maternal complications.28
Emergency Childbirth Kit (~1.5 Lb)
This kit is designed to be carried in a 36- × 36-inch baby blanket. For births occurring outside the medical facility or in shelters or refugee camps, this portable kit may prove useful.
- One 36- × 36-inch "receiving" blanket
- Plastic to wrap around the kit
- One or two diapers
- Four sanitary napkins (wrapped)
- ID bands for mother and baby
- Short pencil
- Sterile package containing:
- Small pair of blunt-end scissors
- Four pieces of white cotton tape, 0.5 inches wide by 9 inches long
- Four cotton balls
- Roll of 3-inch-wide gauze
- Six 4-inch squares of gauze
- Two to six safety pins
Additional medical supplies that may prove useful for those who know how to use them are: a syringe with oxytocin; bulb syringe; intubation equipment; ketamine; IV needles, tubing, and normal (0.9%) saline (NS); surgical scrub; sterile gloves; and scalpel. These take a bit more room and double or triple the kit's weight. Most importantly, only those who have the knowledge required to use them correctly should use these items.
To prepare the kit, lay out the plastic sheet and open the blanket onto it. Put all the equipment in the center. (If additional medical supplies are included, the IV solutions and tubing may have to be carried separately.) Pull the two opposite corners of the blanket and plastic together and tie them. Do the same with the opposite corners, pulling them tight enough so that nothing will fall out. Add another knot so there is a loop to sling over the arm for carrying the kit.
Preparation for Childbirth
Have the mother lie on a clean surface. Waterproof the mattress with plastic sheeting or pads made from several thicknesses of paper covered with cloth. Over this, put a clean bed sheet. Place the mother on her left side for labor and gather available equipment for delivery and care of the neonate.
Prepare a bed for the baby which, when lined with a blanket, can be a clothes basket; a box; or a dresser drawer placed on a table, stable chairs, or the floor. If possible, warm the baby's blanket, shirt, and diapers with a hot water bottle, warm bricks, or a bag of salt that has been heated.
Examine the patient to determine how much the cervix has dilated. The woman should begin pushing when the cervix is completely dilated (10 cm) and no cervix can be felt on either side of the fetal head.
Check the fetal heart rate every 15 minutes prior to pushing and following each contraction. Normal fetal heart rate is 120 to 160 beats/min. While the heart rate often drops with the contractions, it should recover to normal prior to the next contraction.
An immediate C-section is indicated if any one of the following is present: (a) The fetal heart rate drops below 100 beats/min and stays low for more than 2 minutes. (b) The baby's head is not the presenting part. Use an ultrasound, if available. (c) Acute uterine hemorrhage persists for more than a few minutes (suggestive of placental abruption or previa).30
Place the patient on her back or tilted slightly to the left. When the patient begins pushing, flex her hips to optimally open the pelvis. Have assistants support her legs when she pushes and relax them between contractions.
Clean her perineum with sterile antiseptic solution or soap and water. If this is the patient's first delivery, anesthetize the perineum in case an episiotomy is needed.
The fetal head delivers by extension. Push upward on the fetal chin through the perineum to assist this process. Control the rate of the head's delivery with the opposite hand.
If an episiotomy is needed, cut the posterior midline from the vaginal opening approximately half the length of the perineum, and extend about 2 to 3 cm into the vagina.
After delivering the head, suction the baby's mouth and nose, and then palpate the neck for a nuchal cord. If a nuchal cord is present, loop it over the child's head or clamp it twice and cut it.
Put your hands along the side of the child's head and have the mother push again to deliver the anterior shoulder. Apply gentle downward traction to get the shoulder to clear the pubis. Direct the fetus anteriorly to allow delivery of the posterior shoulder. The remainder of the body rapidly follows. Wrap the infant in dry towels.
Once the neonate is delivered, double-clamp or double-tie the cord and cut it between the ties. Sterilized shoestrings or strips of a sheet folded into narrow bands 1 inch wide and 9 inches long can be used to tie the umbilical cord. Boil them for about 20 minutes or immerse them in 70% isopropyl alcohol for at least 20 minutes before use. Have four ready to use, just in case any are dropped.
To cut the umbilical cord, use a sterilized knife, pair of scissors, or razor blade. Either boil these utensils (preferred) or immerse them in 70% isopropyl alcohol for no less than 20 minutes and, preferably, for 3 hours.
The placenta usually delivers within 15 minutes of delivery, but may take up to 60 minutes. Delivery of the placenta is heralded by uterine fundal elevation, lengthening of the cord, and a gush of blood. While waiting, place gentle pressure on the cord, but avoid vigorous uterine massage and excessive cord traction.
Immediately put an ID anklet or bracelet on the child. This is especially important if the child is born in a large group shelter or refugee camp.
Inspect the placenta for evidence of fragmentation that can indicate retained products of conception. Following placental delivery, administer oxytocin 20 units by drip or IM, methylergonovine maleate 0.2 mg IM, or have the patient breastfeed (although breastfeeding is not that effective in helping the uterus to contract).30
Following delivery of the placenta, inspect the vagina (especially the posterior fornix), cervix, perineum, and periurethral areas for lacerations.
Repair vaginal and cervical lacerations with 3-0 absorbable suture, if available.
If the anal sphincter is lacerated, repair it with 2-0 absorbable suture using interrupted or figure-eight stitches.
If the patient's rectum has torn, carefully repair the rectal-vaginal septum with interrupted 3-0 absorbable sutures. A second layer of sutures overlapping the tissue layers decreases the risk of breakdown.
Patients with a periurethral tear may require urethral catheterization. In addition to lacerations, hematomas in the vulva, vagina, or retroperitoneum may occur.30
Even in the United States under routine conditions, home deliveries had a high rate of neonatal complications: nuchal cord (12% of the time), cyanosis (9%), apnea/pulseless (6%), apnea only (4%), feet-first breech (3%), toilet bowel retrievals (3%), amniotic sac intact (1%), and twins (1%). Maternal complications were minimal.31
A system for keeping newborns warm and for improving survival has been termed the "warm chain" or "Kangaroo care." It is described in Chapter 34, Pediatrics and Neonatal.
Squatting Chair for Delivery
Fashion a squatting chair for vaginal deliveries by firmly attaching strong, outward-facing legs (for stability) to the underside of a toilet seat. Figure 5-9 shows the seat being used as a bucket toilet. Generally these seats are made of wood, so they need to be sanded and covered with several coats of polyurethane or similar varnish.32
Unusual Obstetric Presentations
Entire books have been written on how to manage unusual presentations. Rather than using improvised equipment, managing them takes extensive knowledge and experience. Prepare in advance: read the books, get help, or do a C-section. (Think of a C-section as the cricothyrotomy of pregnancy. When nothing else works, that gets the patient out of trouble.)
C-sections in a dead or dying mother have little chance of success. Since fetal distress precedes maternal hemodynamic instability, fetal survival is unlikely in hypovolemic cardiac arrests. In non-hypovolemic cardiac arrests (or in severe shock, where taking the baby may be the only way to save the mother), a C-section must be done within 4 to 5 minutes if the baby is to survive.33 Generally, emergency C-sections are done because of problems with the pregnancy or the delivery.
Local Anesthesia for C-Section
In case you have to do a C-section without spinal or general anesthesia, you can administer local anesthesia with good effect. Make a wheal of local anesthetic 3 to 4 cm on either side of the midline, from the symphysis pubis to 5 cm above the umbilicus. Inject the anesthetic through all layers of the abdominal wall with a long needle. Keep the needle almost parallel to the skin, being careful not to pierce the peritoneum or insert the needle into the uterus, which is easy to do since the abdominal wall is very thin at term. Use up to 100 mL of 0.5% lidocaine with epinephrine 5 mcg/mL (1:200,000). Although infiltrating the abdomen may be uncomfortable for the mother, don't administer IV analgesics or sedatives; they adversely affect the baby. If necessary, you can safely give up to 0.5 mL/kg IV ketamine for analgesia. Once the baby is delivered, give the mother IV opiates, if needed.34
Place the patient with her left side up, using an IV bag or towel to displace the uterus to the left. Quickly prep her from just below the breasts to mid-thigh. See Fig. 28-4.
Enter the abdomen through a lower-midline incision.
Identify and incise the peritoneal reflection of the bladder transversely, and create a bladder flap to retract the bladder out of the field.
Carefully incise the uterus transversely across the lower uterine segment (where the uterine wall thins).
Once the amniotic membranes are visible or opened, extend the incision laterally, either bluntly or by carefully using bandage scissors. Avoid the uterine vessels laterally. If necessary, extend the incision at one or both of its lateral margins in a J-fashion with a vertical incision.
Elevate the presenting fetal part into the incision, with an assistant providing fundal pressure.
Deliver the fetus, suction the nose and mouth, and clamp and cut the cord. Hand the infant off for care.
Apply gentle traction on the cord to deliver the placenta; massage the uterus.
Begin oxytocin (or an alternative), if available.
Using a gauze sponge, clean the inside of the uterus, and vigorously massage the fundus to help the uterus contract.
Quickly close the incision with large (size 0) absorbable sutures. A single layer (running, locking to provide hemostasis) is adequate for transverse incisions. Avoid the lateral vessels. If the incision has a vertical extension, close it in 2 or 3 layers.
Once hemostasis is assured, close the fascia and abdomen.
Emergency C-section. (Source: US Army.36)
Hemorrhage is the underlying cause of >25% of maternal deaths in the developing world. Blood loss occurs rapidly, since the gravid uterine blood flow is 600 to 900 mL/min at term. With uterine atony, the woman loses blood at the rate of >500 mL/min. Early postpartum hemorrhage is seen in 10% of women due to uterine atony (1:20 incidence), genital lacerations, retained placenta, and uterine inversions (1:6400 incidence).37
Most postpartum hemorrhage stems from uterine atony (failure of uterine contracture). This bleeding may be torrential and fatal.
Initial management includes manual uterine exploration for retained placenta. Without anesthesia or with only a pudendal block, this procedure is painful. Place an open sponge (gauze) around the fingers of your dominant hand and place the opposite hand on the patient's uterine fundus. Apply downward pressure. Gently guide your fingers through the open cervix and palpate for retained placenta. The inside of the uterus should feel smooth, and retained placenta will feel like a soft mass of tissue. Remove this tissue manually or with a large curette, if available.38
If no tissue is encountered, use both hands to apply vigorous uterine massage to improve uterine tone. Give medications, if available. Usually, that will be oxytocin: 40 international units (IU) in 1000 cc IV or up to 10 IU given IM. Never give it IV push. If no medication is available and the bleeding is not heavy, encourage the patient to breastfeed or do nipple stimulation to increase endogenous oxytocin release.
If these measures do not stop the bleeding quickly, begin the measures described below.
Postpartum Hemorrhage Control
Significant postpartum hemorrhage (>500 mL within 24 hours after delivery or enough to affect physiological functions) is not uncommon, occurring in about 3% of women in many populations. This results in ~150,000 annual deaths. Up to 90% of women with significant postpartum hemorrhage have no identifiable risk factors. So, in a delivery, one should always assume that it might occur.
The problem with treating postpartum hemorrhages effectively is that clinicians often do "too little, too late." They delay in transfusing blood, transfuse too little, and delay initiating surgical treatment. Often, the delays are due to trying different oxytocics and massaging the uterus in the hope that this would stop the hemorrhage.39 There is also a reluctance to perform unnecessary and difficult surgery.40
If available, oxytocin, ergotamine, and 800 mcg of misoprostol can often successfully stop hemorrhage. Oxytocin normally works within 3 minutes. If the problem is a retained placenta, injecting 20 to 30 IU oxytocin mixed with an equal amount of NS into the umbilical vein may allow the placenta's removal without resorting to anesthesia.41
The key element to managing these patients is to immediately prepare for, and then quickly go on to, the next step if the method being used does not immediately show results. If the patient is already in shock, use the next step—tamponading the uterus and giving blood and blood products—while giving oxytocics. If the bleeding does not stop, prepare for surgery.
If the bleeding occurs while the abdomen is open for a C-section, infuse oxytocics while compressing the uterus with two longitudinal sutures along its long axis to prevent it from relaxing and filling with blood.42 If that is not effective, use a balloon device and prepare to do a hysterectomy if that does not immediately stop the bleeding.
Visual estimation is an inaccurate method to determine how much blood a woman is losing intra- and postpartum. To measure the amount of blood loss, employ the same method as in cholera; that is, while the woman is in the birthing position, use a plastic sheet to funnel blood into a bucket. After about 2 hours, move her to a cholera bed (with the same bucket) so that any blood lost continues to flow into the bucket.43 Mark several buckets in advance, inside and outside, at 500-mL increments.
Do not use uterine packing to control postpartum hemorrhage unless no other options are available.44 Problems with using packing to control postpartum hemorrhage include the trauma inflicted by blindly placing gauze packs, the time it takes to insert them, and the need to pack them tightly enough to control the hemorrhage. Most importantly, you cannot tell whether the procedure is successful until after the blood soaks through the gauze—demonstrating that it has failed.40
Condom and Foley Catheters
Condom catheters can be successfully used to tamponade massive postpartum hemorrhage. Use a heavy suture to tightly tie a large condom to the end of a urethral balloon (Foley) catheter. Insert it through the open os until the condom is completely within the uterus and inflate it through the main catheter lumen with 250 to 500 mL NS, or until the bleeding completely stops. Clamp the catheter. If it doesn't stop immediately, the bleeding usually stops within 15 minutes. Most clinicians pack the vagina around the catheter (Fig. 28-5).
Inflated condom-urethral balloon catheter.
Some clinicians have kept the balloon in place for 24 to 48 hours, depending on the initial intensity of blood loss. However, it probably needs be in place for 12 hours. If bleeding recurs, it can quickly be replaced. Even with longer placements, however, no intrauterine infections usually occur.45
A temporizing measure, while waiting to transfer the patient for surgery or transfusion, is to place a pneumatic anti-shock garment (e.g., military anti-shock trousers [MAST] or a similar device). While a similar non-inflating device has been successfully tested for postpartum hemorrhages, even though they are relatively inexpensive (<$200 US), they are not likely to be available.46 MAST or an improvisation to apply pressure to the pelvis and legs is worth trying, since it may help the resuscitation process.47 Be careful not to overinflate the trousers, and don't apply too much external pressure.
Uterine inversion is a rare cause of major postpartum hemorrhage and shock, often presenting with abdominal pain and an impalpable or vaginally appearing uterus (procidentia). It most often occurs with fundal implantation of the placenta and inappropriate traction on the umbilical cord in the presence of an atonic uterus.
Pharmacologic relaxation may be needed to reinsert the uterus. One readily available option is to use sublingual nitroglycerine (NTG), which causes rapid uterine relaxation. Its onset is 30 to 45 seconds, with peak action at 90 to 120 seconds. It lasts up to 5 minutes. Intravenous NTG can also be used, but is less readily available. Sublingual NTG 800 mcg should completely relax a partially inverted uterus within 30 seconds, so that it can be reduced.37
Gentian violet (1% solution in water) is an excellent improvised treatment for Candida albicans nipple infections. About 10 mL is sufficient for an entire treatment. Nursing mothers with a yeast infection of the nipple may experience severe nipple pain, as well as deep breast pain. The pain is often burning, lasts throughout the feeding, and may radiate into the mother's armpit or into her back. Gentian violet nearly always brings rapid relief.
Have the patient dip a cotton-tipped applicator into the gentian violet and put it in the baby's mouth to suck on for a few seconds. If the entire mouth isn't colored with the dye, have her spread the dye over the tongue and buccal mucosa. Then have the baby breastfeed. If both nipples are not purple at the end of feeding, paint the nipples with gentian violet. Repeat this treatment once a day for 3 to 4 days. If the patient is not better by the third day, consider other diagnoses.
Advise the patient that the gentian violet stains clothing, but not skin. Any skin discoloration disappears in a few days. While using this treatment, boil or stop using any artificial nipples.48