I was attending my routine antenatal clinic at St Mary Community Centre. The clinic had been fully booked and I was already running behind schedule. As I went out to get the next woman on the appointment list, a young woman came up to me and stated, in short sentences, that she did not have an appointment on that day but was feeling really sick and was finding it hard to breathe. I quickly took her inside the clinic room to conduct a further assessment. The midwife I was working with started by telling the woman that we had no time to examine walk-ins that week and she would have to make an appointment for the next week. I interrupted the midwife and politely said, “I really think we should just do a quick examination on her.” The midwife took a quick glance at the woman and clued into the severity of this woman's condition. The woman was a G1p0 in her early twenties; she was 37 or 40 weeks into gestation.
- Airway, patient talking in short sentences.
- Breathing, respiration rate 31, unable to obtain a spot as we did not have the required equipment in the clinic.
- Circulation, woman was warm and well perfused, Heart Rate 110 beats per minute, Blood Pressure 136/87, cap refill less than two seconds.
- Glasgow Comma Scale15. Woman stated she had been finding it hard to breathe over the last week and it was increasingly getting worse, she had been afebrile, she also said she had 9/10 central chest pain that was not radiating anywhere.
She had no medical history of asthma, deep vein thrombosis, no recent chest infections
The woman stated she had good foetal movement and on auscultation with a Doppler the foetal heart rate was 140-150 beats per minute with good accelareation.
I explained to the woman that she would need to go to the hospital for further medical examination like for X-ray, Electro Cardiogram, CTG and blood. The woman stated she had no way of getting to the hospital so I informed her that I would call for an ambulance. I also called the hospital and notified them that I would be sending her for a residual volume examination.
My suspicion of the severity of her condition was confirmed with a diagnosis of a pre eclampsia later that day. The woman commenced on Cleaxane 80 mg blood pressure and spent the rest of her pregnancy in hospital where she went on to have a C-section.
Detection of Labour/Birth in Obstetric Medical Emergency
The obstetric emergency was an emergency C-section for foetal distress. The woman was G3P2 and presented a 40+1 weeks gestation with a history of Spontaneous Rupture of Membrane (clear liquor) and contraction 4 in 10, moderate in tone. On admission I found a full set of observations including abdominal palpation and a CTG trace. The rationale behind this was to assess the maternal and fetal well-being.
The woman's observations were all within normal limits but the trace was suspicious with an incresed fetal baseline of 160 and reduced variability. The obstetrics and gynaecology doctor was asked to review the trace and they ordered intravenous fluids in the hope to improve the variability of the trace by increasing the circulation volume of mother and baby. The woman was also moved into a different position such as the right and left lateral recumbent position. Even with these interventions the trace did not improve as it continued to have a high baseline and started showing shallow decelerations. A vaginal examination was attempted with consent that showed the woman to be 4 cm dilated, at two stations. Another review by the obstetrics and gynaecology team was requested and a decision to operate for an emergency C-section was made. An consent was obtained for the operation and reassurance was given to the woman. The baby was born with Apgars of 7 at 1 minute and 9 at the 5 minutes. Initial resuscitation of babies with the neopuff was given with tactile stimulation. The neonatologist was present at the birth as it was an emergency C-section with a non reasuring trace. The overall outcome of this emergency was postive as mother and baby were both well postnataly.
Detection of Postnatal Emergency
The obstetric emergency in this case was a Post Partum Haemorrhage. The woman was G8P6 38+3/40 had a normal vaginal delivery with no complications. Active management of the third stage of labour was used as intramuscular administration of 10 international units of oxytocin with Controlled Cord Traction (CCT). On examination of the placenta the membranes were intact and the placenta was complete with central insertion of the cord. Following the birth of the placenta, her observations were all within normal limits, the fundus was firm and central just below the umbilical and at this point the estimated blood loss was 200 ml. I left the room for approximately five minutes so I could attend to the cord blood gases. On arrival back to the room the woman complained of a gush of blood, I immediately took note of the blood loss and estimated it to be around 400 ml, still trickling .I felt her fundus which had become boggy, I immediately gave her fundus a massage and buzzed for the other midwife to come give me a hand.
I inserted an 18 G intravenous cholangriogram; we then gave the woman 30 units of Oxytocin in 1000 ml n/s running at 250 ml s/heart rate. At this point the fundus was firm and all obersevation remained stable. An Indwelling Cathereter (IDC) was placed to empty the bladder and help the uterus contract. While inserting the IDC, the midwife I was working on examining the vulva, vagina, perineum, and anus to identify any genital lacerations. It was noted there was a second vaginal tear. The obstetrics and gynaecology doctor was called in to repair the injury. Once the wound was repaired the bleeding stopped. I contained to do 15 minutes fundal check on the woman over the next heart rate and routine observations. A full blood count was obtained which showed the woman’s haemoglobin 89 the estimated blood loss was 1100 ml per second. The woman didn't require a blood transfusion but was placed on iron tablets.
Detection of a Neonatal Emergency
I was working in a very busy postnatal ward when suddenly when a mother came screaming up the corridor, saying that her baby is not breathing. After a quick examination of the baby it was noted that the baby was cyanosed around the lips and non-responsive. I quickly pressed the emergency buzzer and whisked the baby into the resuscitation room.
I started by trying to stimulate the baby by rubbing my hands across the baby at this point another nurse joined me. She started to tap out the heart rate and noted it was around about 80. Baby still remained unresponsive so I initiated giving the baby oxygen via the neopuff and at this point the baby started to cry and colour started to return to the baby. Not long afterwards the emergency team arrived and took over the resuscitation. The baby was taken down to the Neonatal Intensive Care Unit where he continued to have similar episodes and was later diagnosed with a serve case of Gastro-Esophageal reflux.