25 August 2021_Maternity Quick Reference Guide_DRAFT_V.1.3

DRAFT

M-QRH

Maternity -
Quick Reference

Handbook.

Emergency Protocols

August 2021

The guidelines in this handbook are not intended to be standards of
medical care. The ultimate judgement with regard to a particular clinical
procedure or treatment plan must be made by the clinician in the light of

the clinical data presented and the diagnostic and treatment options
available.

For wider emergency protocols that are not
specific to maternity, please refer to the main QRH

Location of Key Emergency Drugs/Equipment

Maternity Quick Reference Handbook (MQRH)

Author: Dr Elena Lynes, consultant obstetric anaesthetist.
References:

• UHCW Obstetric Anaesthesia Handbook OAH14-2021.
• The Association of Anaesthetists of Great Britain & Ireland - Quick

Reference Handbook.
• Obstetric Anaesthetist’ Association and Difficult Airway Society - Obstetric

Airway Guidelines 2015.
• Resuscitation Council UK - Resuscitation guidelines 2021.
• Royal College of Obstetricians and Gynaecologists Guidelines.
• Practical Obstetric Multi-Professional Training (PROMPT) 2021 Resources.

Maternal Emergencies / Collapse A to E assessment and Maternal Collapse
Maternal cardiac arrest
Obstetric Emergencies Anaphylaxis
Amniotic fluid embolism
Anaesthetic Emergencies Maternal sepsis
Pre-eclampsia and Hypertension
Neonatal Emergencies Eclampsia
Magnesium toxicity
Massive obstetric haemorrhage
Postpartum haemorrhage
Antepartum haemorrhage
Acute uterine inversion
Total spinal
High spinal block
Local anaesthetic toxicity
Remifentanil PCA induced serious side effects
Failed intubation in obstetrics
Can’t intubate, can’t oxygenate (CICO)
Shoulder dystocia
Cord prolapse
Fetal bradicardia

Neonatal resuscitation

Adult in-hospital resuscitation

Maintain Collapsed/sick
personal patient

safety Shout for HELP
and assess patient

Signs of life?

• Check for consciousness and normal breathing
• Experienced ALS providers should simultaneously

check for carotid pulse

NO YES
(or any doubt)

CARDIAC ARREST MEDICAL EMERGENCY

Call and collect* Call and collect*

CALL resuscitation team CALL resuscitation / medical
COLLECT resuscitation equipment emergency team if needed
COLLECT resuscitation equipment
High-quality CPR*
Assess*
Give high-quality CPR with oxygen
and airway adjuncts* ABCDE assessment –
recognise and treat
Switch compressor at every Give high-flow oxygen
rhythm assessment (titrate to SpO2 when able)
Attach monitoring
Defibrillation*
Vascular access
Apply pads/turn on defibrillator/AED Consider call for resuscitation/
Attempt defibrillation if indicated**
medical emergency team
Advanced life support (if not already called)

When sufficient skilled personnel Handover
are present
Handover to resuscitation/
Handover medical emergency team

Handover to * Undertake actions concurrently
resuscitation team if sufficient staff available

** Use a manual defibrillator if trained
and device available

1

A to E assessment and Maternal collapse
Box A Observation that trigger an emergency response

❶ Immediate action: Airway • Obstructed or noisy airway
• Assess maternal responsiveness verbal or by gentle shaking if no response.
• CALL for help: pull emergency bell. Breathing • Respiratory rate < 5 or > 35 bpm
• Lay patient on her back and manually displace the uterus if pregnant.
• 2222 ‘Obstetric emergency’ (State location). Circulation • Pulse rate < 40 or > 140 bpm
• Attach monitoring (SpO2, BP, ECG). Disability • Systolic BP < 80 or > 180 mmHg
• IV access early, send blood: FBC, U&E, LFTs, G&S, ABG. • Sudden decrease in continue level
• Delegate scribe. • Unresponsive or responsive to pain only
• Seizures
❷ Airway:
• Open airway if obstructed (head tilt/chin lift or jaw thrust). Box B Consider causes of maternal collapse
• Give 100% oxygen 15L/min via non-rebreathe mask.
• Aim for SpO2 > 94%. Head • Eclampsia • Intracranial
• 2222 Anaesthetic emergency (State location) if airway problem and anaesthetist • Epilepsy haemorrhage
not present yet. • Cerebrovascular
• Vasovagal
❸ Breathing: event response
• Look, listen, feel for general signs of respiratory distress (sweating, central
cyanosis, use of accessary muscles). Heart • Myocardial • Congenital heart
• Count RR, assess depth, patten of respiration, listen to the chest — see box A. infarction disease
• If no respiratory effort commence life support → go to page 2.
• Arrhythmias • Dissection of
❹ Circulation: • Peripartum thoracic aorta
• Look at the skin colour, feel skin temperature.
• Measure capillary refill time for 5 sec. (normal < 2 sec). cardiomyopathy
• Check pulses (central and peripheral) — see Box A.
• Measure BP — see box A. Hypoxia • Asthma • Pulmonary
• If no signs of cardiac output commence CPR → go to page 2. • Pulmonary oedema
• Assess for bleeding.
• Give fluid bolus 500 ml Hartmann’s. embolism • Anaphylaxis
• Insert catheter measure urine output.
Haemorrhage • Abruption • Uterine rupture
❺ Disability: • Uterine atony • Uterine inversion
• Genital tract • Ruptured
• Review and treat hypoxia and hypotension.
trauma aneurysm
• Check patient’s drug chart for reversible causes of collapse.
wHole body • Hypoglycaemia • Trauma
• Assess AVPU scale. (Alert, responsive to Voice, responsive to Pain, and Hazards • Amniotic fluid • Complications of

Unresponsive) embolism anaesthesia
• Septicaemia • Anaphylaxis
• Assess pupils.

• Measure blood glucose to exclude hypoglycaemia.
❻ Exposure:

• Examine abdomen.

• Legs for DVTs.
❼ Review all history, medications, observation charts, lab results, investigations.

❽ Plan ongoing care in appropriate location.

Do not move to the next step until action to correct problem has been taken.

Regularly review response to treatment. See box B for potential causes.

❾ Complete DATIX and DEBRIEF.

Adult advanced life support

Maintain Unresponsive and
personal not breathing normally

safety CPR 30:2
Attach defibrillator/monitor
Call resuscitation
team/ambulance

Assess rhythm

SHOCKABLE NON-SHOCKABLE

(VF/Pulseless VT) (PEA/Asystole)

1 shock Return of spontaneous
circulation
(ROSC)

Immediately resume Immediately resume
CPR for 2 min CPR for 2 min

Give high-quality Identify and treat Consider After ROSC
chest compressions, reversible causes
and: • Coronary angiography/ • Use an ABCDE approach
• Hypoxia percutaneous coronary • Aim for SpO2 of 94–98% and
• Give oxygen • Hypovolaemia intervention
• Use waveform capnography • Hypo-/hyperkalaemia/ normal PaCO2
• Continuous compressions if • Mechanical chest
metabolic compressions to facilitate • 12-lead ECG
advanced airway • Hypo/hyperthermia transfer/treatment
• Minimise interruptions • Thrombosis – coronary or • Identify and treat cause
• Extracorporeal CPR
to compressions pulmonary • Targeted temperature
• Intravenous or intraosseous • Tension pneumothorax management
• Tamponade – cardiac
access • Toxins
• Give adrenaline every Consider ultrasound imaging
to identify reversible causes
3–5 min
• Give amiodarone after

3 shocks
• Identify and treat reversible

causes

2 Box A Specific problems:
4 H’s, 4 T’s:
Maternal cardiac arrest
• Hypoxia • Vagal tone
❶ Immediate action: • Hypovolaemia • Drug error
• CALL for help: pull emergency bell. Note time. • Hypo/hyperkalaemia • Local anaesthetic toxicity
• Lay the bed flat, start chest compressions. • Hypothermia • Eclampsia
• COLLECT cardiac arrest trolley. • Acidosis
• 2222 ‘Maternal cardiac arrest’ (State location). • Tamponade • Anaphylaxis
Senior help (Anaesthetic and Obstetric). • Thrombosis • Embolism, air/amniotic
Neonatal team. • Toxins
• Delegate one person to chest compressions 100 min-1 (30:2). • Tension pneumothorax fluid
• Manual left uterine displacement if pregnant. • Massive blood loss
• Delegate task of evaluating potential causes — see Box A.
• Delegate scribe. Box B Drugs

❷ Airway: • Fluid bolus 500 ml.
• Open airway (head tilt/chin lift or jaw thrust). • Adrenaline 1000 µg — may be given in increments.
• Look, listen, feel for signs of life for 10 seconds. • Atropine 0.5-1 mg if vagal tone likely cause.
• Give 100% oxygen via bag-mask, ventilate if not breathing. • Amiodarone 300 mg after 3rd shock.
• Magnesium 2 g for polymorphic VT/hypomagnesaemia.
❸ Breathing: • Calcium chloride 10% 10 ml for magnesium overdose,
• Check chest symmetry, rate, breath sounds, SpO2, ETCO2.
• Definitive airway when anaesthetist arrives. hypocalcaemia or hyperkalaemia.
• Thrombolysis for suspected massive pulmonary
❹ Circulation:
• Attach defibrillator pads with minimal interruption of chest embolus.
compressions.
• Check rate and adequacy of chest compressions (visual and ETCO2). Box C Defibrillation
• Encourage rotation of personnel performing compressions.
• IV access, send blood: FBC, U&E, LFTs, G&S, ABG. Continue compressions while charging: 150-200 J.

• If IV access fails or impossible use intraosseous (IO) route. DO NOT check pulse after defibrillation.
• Check ECG rhythm for no more than 5 seconds.
• Give fluid bolus 500 ml Hartmann’s.
• Follow Resuscitation Council (UK) and ERC Guidelines.
• See Boxes B and C for reminders about drugs and defibrillation.

❺ Perimortem caesarean section within 5 minutes after collapse if
resuscitation not successful.

❻ Consider extracorporeal CPR (ECPR) as a rescue therapy if ALS
measures are failing.

❼ Systematically evaluate potential underlying problems and act

accordingly — see Box A.

❽ If there is return of spontaneous circulation, consider establishing

anaesthesia.

❾ Complete DATIX and DEBRIEF.

Refractory anaphylaxis A = Airway

No improvement in respiratory or cardiovascular symptoms Partial upper airway obstruction/stridor:
despite 2 appropriate doses of intramuscular adrenaline Nebulised adrenaline (5mL of 1mg/mL)
Total upper airway obstruction:
Establish dedicated Seek expert1 help early Expert help needed, follow difficult airway algorithm
peripheral IV or IO access
Critical care support is essential B = Breathing

Give rapid IV fluid bolus & Start adrenaline infusion Oxygenation is more important than intubation
If apnoeic:
e.g. 0.9% sodium chloride Adrenaline is essential for treating • Bag mask ventilation
all aspects of anaphylaxis • Consider tracheal intubation
Severe/persistent bronchospasm:
Give IM* adrenaline Follow local protocol • Nebulised salbutamol and ipratropium with oxygen
every 5 minutes until adrenaline OR • Consider IV bolus and/or infusion of salbutamol or

infusion has been started Peripheral low-dose IV adrenaline infusion: aminophylline
*IV boluses of adrenaline are • Inhalational anaesthesia
not recommended, but may be • 1 mg (1 mL of 1 mg/mL [1:1000]) adrenaline in
appropriate in some specialist 100 mL of 0.9% sodium chloride C = Circulation
settings (e.g. peri-operative) while
• Prime and connect with an infusion pump via a Give further fluid boluses and titrate to response:
an infusion is set up dedicated line Child 10 mL/kg per bolus
Adult 500–1000 mL per bolus
Give high flow oxygen DO NOT ‘piggy back’ on to another infusion line • Use glucose-free crystalloid
Titrate to SpO2 94–98% DO NOT infuse on the same side as a BP cuff as this will
interfere with the infusion and risk extravasation (e.g. Hartmann’s Solution, Plasma-Lyte®)
Monitor HR, BP, pulse oximetry • In both adults and children, start at 0.5–1.0 mL/kg/hour, Large volumes may be required (e.g. 3–5 L in adults)
and ECG for cardiac arrhythmia Place arterial cannula for continuous BP monitoring
and titrate according to clinical response Establish central venous access
Take blood sample • Continuous monitoring and observation is mandatory
for mast cell tryptase • ↑↑ BP is likely to indicate adrenaline overdose IF REFRACTORY TO ADRENALINE INFUSION
Consider adding a second vasopressor in addition
Continue adrenaline infusion to adrenaline infusion:
and treat ABC symptoms • Noradrenaline, vasopressin or metaraminol
• In patients on beta-blockers, consider glucagon
Titrate according to clinical response Consider extracorporeal life support

1Intravenous adrenaline for anaphylaxis to be given only by experienced specialists in an appropriate setting. Cardiac arrest – follow ALS ALGORITHM

• Start chest compressions early
• Use IV or IO adrenaline bolus (cardiac arrest protocol)
• Aggressive fluid resuscitation
• Consider prolonged resuscitation/extracorporeal CPR

3 Signs and symptoms

Anaphylaxis • Unexplained hypotension
• Unexplained bronchospasm (wheeze may be absent if
❶ Immediate actions:
CALL for help: severe)
Pull emergency bell. • Unexplained tachycardia or bradycardia
2222 ‘Obstetric emergency’ (State location). • Angioedema (often absent in severe cases)
Note the time. Allocate scribe. • Unexpected cardiac arrest where other causes are

❷ COLLECT cardiac arrest trolley, ANAPHYLAXIS BOX. excluded
❸ Remove all potential causative agents — see Box A. • Cutaneous flushing in association with one of more of
❹ GIVE IM Adrenaline — see Box B.
❺ Airway and Breathing: the signs above (often absent in severe cases)

• GIVE 100% oxygen via non-rebreathe mask and ensure adequate Box A Potential causative agents
ventilation:
• Important culprits: antibiotics, IV iron.
• Maintain the airway and, if necessary, secure it with tracheal
tube. • Consider chlorhexidine as cause (impregnated
catheters, lubricants, cleansing agents)
❻ Circulation:
• Left lateral if still pregnant. Box B Drugs to treat hypotension
• Elevate patient’s legs if there is hypotension.
• If systolic blood pressure < 50 mmHg or cardiac arrest, start • Adrenaline: IM 0.5 mg (= 0.5 ml of 1:1000)
CPR immediately. • IV 50 µg (= 0.5 ml of 1:10 000) Trained doctors only
• Give rapid IV crystalloid: 20 ml.kg-1 initial bolus, repeated until • If no IV access, intraosseous adrenaline dose same as IV
hypotension resolved (Large volumes may be required). • Adrenaline infusion regimes:

❼ Give drugs to treat hypotension — see Box A: - 5 mg in 500 mL dextrose = 1:100 000, titrate to
• Hypotension may be resistant and may require prolonged effect
treatment.
• GIVE second adrenaline bolus 5 min after the first dose. - 3 mg in 50 mL saline. Start at 3 ml.h-1 (= 3 µg.min-1),
• START an adrenaline infusion after two boluses if refractory titrate to effect maximum 40 ml.h-1 (= 40 µg.min-1)
anaphylaxis.
• If hypotension resistant, give alternate vasopressor (e.g. • Glucagon: 1 mg, repeat as necessary
metaraminol, noradrenaline infusion +/-vasopressin) • Vasopressin: 2 units, repeat necessary (consider
• Give glucagon in ß-blocked patient unresponsive to adrenaline.
infusion)
❽ Take 5-10 ml blood sample for serum tryptase as soon as patient
is stable (yellow bottle).
• Plan for repeat sample at 1-2 hours and >24 hours.

❾ Consider Cetirizine10-20 mg if skin symptoms persist.
❿ Plan ongoing care in suitable location.

Contact critical care team Bleep 2909.
⓫ Complete DATIX and DEBRIEF.



4 Classic triad 2. Hypoxia 3. Coagulopathy
1. Hypotension
Amniotic fluid embolism
Diagnostic criteria
❶ Immediate actions:
CALL for help. Acute maternal collapse with one or more features below:
Pull emergency bell. Note the time.
2222 ‘Obstetric Anaesthetic Emergency’ (State location). • Acute fetal compromise • Hypotension
• Cardiac arrest • Maternal haemorrhage
❷ COLLECT cardiac arrest trolley. • Cardiac rhythm problems • Seizure
• Coagulopathy • Shortness of breath
❸ Airway and breathing: • Premonitory symptoms
• Give 100% oxygen via non-rebreathe mask. excluding where
• Maintain the airway, anaesthetist to intubate if required. (agitation, numbness, haemorrhage is first
• Ensure adequate ventilation. restlessness) presenting feature

❹ Circulation: Box A Intralipid
• Manual left uterine displacement if still pregnant.
• IV access X 2, Take bloods: FBC, U&E, Clotting, G&S, Cross match 4 USE 20% Intralipid®
units. Consider ECG, ECHO, Chest Xray, TEG.
• If cardiac arrest → go to Page 2. Immediately

❺ Treat haemostatic failure — cryoprecipitate, platelets. • Give initial IV bolus of lipid emulsion 1.5 ml.kg–1 over 1 min
(~100 ml for a 70 kg adult)
2222 ‘Massive Obstetric Haemorrhage’ (State location).
• Start IV infusion of lipid emulsion at 15 ml.kg–1.h–1
Irrespective of amount of blood loss!
(17.5 ml.min-1 for a 70 kg adult)
• Give Tranexamic Acid 1 g over 10 min as anti-fibrinolytic.
• Maintain normothermia. At 5 and 10 minutes:
❻ Contact haematology/blood bank (25398) for advice. • Give a repeat bolus (same dose) if:

Will require larger volumes of cryoprecipitate or fibrinogen o cardiovascular stability has not been restored or
concentrate. o an adequate circulation deteriorates
❼ Supportive treatment. At any time after 5 minutes:
❽ Consider other causes: • Double the rate to 30 ml.kg–1.h–1 if:
• Pulmonary embolism.
• Acute left ventricular failure. o cardiovascular stability has not been restored or
• Acid aspiration syndrome.
• Eclampsia. o an adequate circulation deteriorates
• Local anaesthetic toxicity.
Do not exceed maximum dose 12 ml.kg–1 (70 kg: 840 ml)
❾ Consider lipid rescue if other measures fail — see Box A.
❿ Plan ongoing care in suitable location.

Contact Critical care team Bleep 2909.
⓫ Complete DATIX and DEBRIEF.



5 Box A Signs of sepsis

Maternal Sepsis • Raised respiratory rate • Requires O₂ to maintain
(RR > 25) sats >92%
❶ Immediate actions:
Recognise signs of sepsis — see Box A. • Tachycardia • Poor peripheral perfusion
CALL for help. (HR > 100 bpm) (cap refill > 2 seconds)
Inform obstetric and anaesthetic team.
Consider causes of sepsis — see Box B. • High or low temp
• Skin clamminess
Attach monitoring: BP, SpO2, HR. (> 38oC or < 36oC) • Confusion/agitation
• Rash or mottled skin
❷ Follow Sepsis Six pathway below. • Hypotension
❸ Airway/Breathing: (systolic BP < 90 mmHg)

• Give oxygen, aim for SpO2 >94%. Box B Causes / Risk factors for sepsis
• Monitor respiratory rate.
• Perform chest examination. • Retained products of • Obesity
• Consider CXR if respiratory is a likely cause. conception • Following an invasive
❹ Circulation:
• Insert IV cannula and take bloods: blood gas, • Manual removal intrauterine procedure
• Prolonged ruptured (e.g. amnio, CVS)
lactate, FBC, U&Es, coagulation and cultures. • Cervical suture
• Obtain urine sample for urinalysis. membranes • Impaired immunity
• Record hourly urine output, consider urinary catheter. • Prolonged labour • Diabetes mellitus
• Administer IV fluids if resuscitation required. • Caesarean section • Respiratory infection
• Continuous fetal monitoring if still pregnant. • Premature labour • Wound infection
❺ Give intravenous antibiotic within 1 h (seek microbiology
advice if required).
❻ Disability:
• Access AVPU.
• Glucose.
❼ Complete the examination.
• Look for likely cause of sepsis.
❽ Repeat observations every 30 minutes or continuous if
indicated.
❾ Plan ongoing care in a suitable location.

❿ If patient is not improving contact critical care outreach team
(Bleep 2909).

Do not forget the baby! Does it need IV antibiotics?



6

Severe Pre-eclampsia and Hypertension

❶ Immediate actions: • Severe hypertension — systolic blood pressure =>160 mmHg +
• Alert anaesthetists, obstetricians, midwife in charge. Diastolic pressure =>110 mmHg
• Apply monitoring — blood pressure, heart rate, oxygen
saturations, CTG. • Severe pre-eclampsia — pre-eclampsia that does not respond
to treatment or associated with headache, visual
❷ Airway and breathing: disturbance, nausea and vomiting, epigastric pain, oliguria,
• Give supplemental oxygen via nasal cannula if SpO2 as well as progressive deterioration in laboratory tests
<94%. ( ↑creatinine, ↑LFTs, ↓ Platelets), or fetal growth failure.
• Auscultate chest, look for signs of pulmonary oedema.
Box A Treatment of severe hypertension
❸ Circulation:
• IV access, take bloods: FBC, U&E, Clotting, LFTs, G&S. Labetalol 200 mg orally repeat dose after 30 min
• Consider arterial line, especially if requires IV - if good response maintain 200 mg TDS or
antihypertensives.
• Monitor fluid balance, restrict fluids 1ml/kg/hr. Nifedipine 10 mg orally repeat after 30 min
• Consider catheter, monitor proteinuria. - if good response maintain 10 mg QDS or

❹ Treat hypertension — see Box A. IV Labetalol (5mg/ml)
• loading dose - 10 ml (50 mg) over 2 min repeat every 5
❺ Neurological assessment min (max 4 doses) until BP controlled
• AVPU score. • Maintenance - start infusion at 4ml/hr, double infusion
• Reflexes. every 30 min until BP controlled (max rate 32ml/hr)
• Clonus.
IV Hydralazine (1mg/ml)
❻ Prevent seizures with magnesium sulfate — see Box B • loading dose - 5 ml (5 mg) over 15 min repeat after 20 min
If eclamptic fit → page 7. • Maintenance - start infusion at 5ml/hr titrate to response
(max rate 18ml/hr)
❼ Plan for birth:
• First stage — consider epidural, continuous CTG. Box B Magnesium sulfate emergency regime
• Second stage — shorten if symptomatic. Loading dose:
• Third stage — give oxytocin NOT ergometrine. • 4 g Magnesium sulfate over 5-10 minutes

❽ Plan ongoing care in a suitable location. Draw up 8 ml of 50% MgSO4 (4 g) followed by 12 ml of

0.9% normal saline into 20 ml syringe.

Stabilise maternal condition prior to delivery.
Maintenance dose:
• 1g/hour Magnesium sulfate

Draw up 20 ml of 50% MgSO4 (10 g) followed by 30 ml of

0.9% normal saline into 50 ml syringe.



7 Box A Magnesium sulfate emergency regime

Eclampsia Loading dose:
• 4 g Magnesium sulfate over 5-10 minutes
❶ Immediate actions:
• CALL for help: Pull emergency bell. Draw up 8 ml of 50% MgSO4 (4 g) followed by 12 ml of
• 2222 ‘Obstetric Emergency’ (State location). 0.9% normal saline into 20 ml syringe.
• Note time, allocate scribe.
• COLLECT Eclampsia Box from the resuscitation trolley. Maintenance dose:
• 1g/hour Magnesium sulfate
❷ Airway and breathing:
• Left lateral (Recovery) position. Draw up 20 ml of 50% MgSO4 (10 g) followed by 30 ml
• Give 100% Oxygen via non-rebreathe mask. of 0.9% normal saline into 50 ml syringe.
• Chin lift / jaw thrust.
Recurrent seizures:
❸ Circulation: • 2 g Magnesium sulfate over 5-10 minutes
• IV access as soon as able, take bloods: FBC, U&E,
Clotting, LFTs, blood gas, Glucose. Draw up 4 ml of 50% MgSO4 (2 g) followed by 6 ml of
• Stop IV fluids if running. 0.9% normal saline into 10 ml syringe.
• Consider arterial line.
Box B Treatment of severe hypertension
❹ Control seizures:
• Give Magnesium bolus and Infusion — see Box A. Labetalol 200 mg orally repeat dose after 30 min
• Protect patient from trauma. - if good response maintain 200 mg TDS
• Consider benzodiazepines in ongoing seizures.
or
❺ Treat hypertension — see Box B. IV Labetalol (5mg/ml)
• loading dose - 10 ml (50 mg) over 2 min repeat
❻ Stabilise maternal condition prior to delivery. every 5 min (max 4 doses) until BP controlled
• Maintenance - start infusion at 4ml/hr, double
❼ Plan for birth. infusion every 30 min until BP controlled (max
❽ Consider other causes if recurrent, prolonged seizures: rate 32ml/hr)
Nifedipine 10 mg orally repeat after 30 min
• Hypoglycaemia - if good response maintain 10 mg QDS or
• Hyponatraemia IV Hydralazine (1mg/ml)
• Intracranial haemorrhage • loading dose - 5 ml (5 mg) over 15 min repeat
• Epilepsy after 20 min
• Space-occupying lesion • Maintenance - start infusion at 5ml/hr titrate to
• Cerebral vein thrombosis response (max rate 18ml/hr)
Organise urgent investigations and imaging (CT, MRI)

❾ Monitor for Magnesium toxicity → go to Page 8.
❿ Plan ongoing care in a suitable location.



8 Box A Signs of magnesium toxicity

Magnesium Toxicity • Loss of deep tendon reflexes
• Respiratory depression
Recognise magnesium toxicity signs — see box A • Respiratory arrest
• Cardiac arrest
❶ Immediate management:
CALL for help: Box B Serum magnesium levels

• Inform anaesthetic and obstetric teams. > 5.0 mmol/L
• Stop magnesium infusion. • Stop infusion
• Ask for senior help
❷ Airway and Breathing: • Give calcium
• Give oxygen to keep SpO2 >94%.
• Monitor respiratory rate. 3.5-5.0
• Ensure adequate lung ventilation. • Stop infusion for 15 min
• Intubate if required. • Restart at half previous rate if urine output
>20 ml/hr
❸ Circulation: • Consultant advice if urine output <20 ml/hr
• Monitor blood pressure and HR.
• Take bloods: magnesium levels — see Box B, 2-3.5
FBC, U&E, Clotting, LFTs, Blood gas. • Therapeutic range

❹ Disability: Box C Sedation score (AVPU)
• Assess AVPU score — see Box C.
• Check blood glucose. A - alert
V - responds to verbal command
❺ Give Calcium gluconate 10 ml 10% if no P - responds to pain only
clinical improvement. U - unresponsive

❻ Plan ongoing care in suitable location.



9 Transfusion goals for damage control resuscitation

Massive Obstetric Haemorrhage (MOH) • Maintain platelet count > 50 x109 l-1
• Maintain PT and APTT <1.5 x mean control (FFP)
Blood loss in excess of 1500 ml or continuous loss of 150ml/min • Maintain fibrinogen >2.0 g.l-1 (cryoprecipitate)
• Avoid DIC (maintain blood pressure, treat/prevent
❶ Immediate actions:
• CALL for help: Pull emergency bell. acidosis, avoid hypothermia, treat hypocalcaemia and
• 2222 ‘Massive Obstetric Haemorrhage’ (State location). hyperkalaemia)
• Senior staff to attend (obstetric and anaesthetic).
• One midwife to scribe — use MOH-CPR form. Box A Uterotonics

❷ Airway / Breathing: Syntometrine (oxytocin 5 IU and ergometrine 500 mcg)
• 100% Oxygen via non-rebreathe mask. • IM dose 1 ampoule
• Reduce Isoflurane to 0.8% end-tidal if under GA. Oxytocin (Syntocinon)
• IM dose 10 IU
❸ Circulation: • IV bolus 5 IU slowly, repeat if required
• Large-bore cannulas x 2. • Caution, if unstable omit bolus use infusion at 25 ml/hr
• Prevent aorto-caval compression if still pregnant.
• Consider arms out, A-Line, ABGs every 30 min. Infusion (20 IU in 50 ml) at 20ml/hr reduce by 5 ml/hr
every 30 min as able
❹ Control any obvious bleeding: Ergometrine
• Inflate internal iliac balloons if in place. • IM dose 500 mcg
• Uterine massage, pressure, pack. • IV dose 50-100 mcg repeated as necessary
• Uterotonics — see Box A. Carboprost (Hemabate)
• Surgical haemostasis (iliac artery ligation, hysterectomy). • IM 250 mcg every 15 min repeated up to 8 doses
Misoprostol
❺ Give tranexamic acid and replace calcium — see Box B. • 1000 mcg rectally

❻ Call blood bank 25398 (⌗ 2169) — give details, make Box B Other drugs
requests.
• Communicate which products required. Calcium:
• Communicate how quickly they required. • 10 ml of 10% calcium chloride IV.

❼ Use Belmont rapid infuser and fluid warming equipment. Tranexamic acid:
❽ Active patient warming (monitor temperature). • 1 g IV bolus.
❾ Discuss management plan between obstetric, anaesthetic • Then: 30 mins later 1 g over 1 hour.

and nursing/midwifery teams:
• Consider interventional radiology.
• Consider other surgical help.
❿ Monitor progress:
• Use point of care testing: Hb, lactate, coagulation (use TEG).
• Use lab testing: FBC, U&E, coagulation and fibrinogen.

⓫ Plan ongoing care in an appropriate clinical area.

⓬ Complete DATIX and DEBRIEF.



10 Box A Tranexamoc acid

Postpartum haemorrhage (PPH) TRANEXAMIC ACID:
• 1 g IV bolus, then:
❶ Immediate actions:
• CALL for help: Pull emergency bell. repeat dose 30 mins later - 1 g over 1 hour.
• 2222 ‘Obstetric Emergency’ (State location).
• Lie patient flat. Box A Uterotonics
• Allocate scribe.
• COLLECT PPH Box. Syntometrine (oxytocin 5 IU and ergometrine 500mcg)
• Attach monitoring early: BP, SpO2, HR. Monitor every 5 • IM dose 1 ampoule
min during resuscitation. Oxytocin (Syntocinon)
• IM dose 10 IU
❷ Airway / Breathing: • IV bolus 5 IU slowly, repeat if required
• 100% Oxygen via non-rebreathe mask. • Caution, if unstable omit bolus use infusion at 25 mls/hr

❸ Circulation: Infusion (20 IU in 50 ml) at 20ml/hr reduce by 5ml/hr
• Massage uterus to expel clots, Bimanual compression. every 30 min as able
• Large-bore cannula x 2. Ergometrine
• Take blood samples: FBC, Clotting, Fibrinogen, G&S, • IM dose 500 mcg
Cross-match. • IV dose 50-100 mcg repeated as necessary
• Give fluid bolus - Hartmann’s 500 ml. Carboprost (Hemabate)
• Give Tranexamic acid — see Box A. • IM 250 mcg every 15 min repeated up to 8 doses
• Uterotonics — see Box B. Misoprostol
• Place urinary catheter. • 1000 mcg rectally

❹ Assess cause: Tone, Trauma, Tissue, Thrombin.
❺ Massage uterus / Bimanual compression / Examine for

tissue damage / Repair tears.
❻ Weigh all swabs, drapes, bedding for accurate blood loss

estimation.
❼ Plan ongoing care in an appropriate clinical area and

inform relevant teams.

IF blood loss in excess of 1500 ml or continuous loss

of 150 ml/min activate MOH protocol → go to page 9.



11 Box A Potential Cause of Bleeding

Antepartum haemorrhage (APH) • Placenta praevia.

❶ Immediate actions: • Abruption.
• CALL for help: Pull emergency bell. • Uterine rapture.
• 2222 ‘Obstetric Emergency’ (State location).
• Left lateral position • Vasa praevia.

❷ Airway / Breathing: Box B Tranexamic acid
• Give 100% Oxygen.
Tranexamic acid:
❸ Circulation: • 1 g IV bolus over 10 min,
• Large-bore cannula x 2. • Repeat dose 30 mins later 1 g over 1hour
• Take blood samples: FBC,U&E, LFTs, Clotting, Fibrinogen, G&S,
Cross-match 4 units. After birth
• Observations: RR, pulse, BP, O2 saturations — use MOEWS
chart. • Be aware of significant PPH - see page 10.
• Give fluid bolus - Hartmann’s 500 ml. • Active management of third stage.
• Commence Oxytocin infusion at 20ml/hr
❹ Clinical history / Cause of bleeding — see Box A.
Oxytocin 20IU in 48ml of 0.9% Saline
❺ Auscultate fetal heart( FH), continuous CTG, USS for placental
site.

❻ Examination:
• Abdominal (tone, tenderness)
• Vaginal (blood loss, stage of labour).

DO NOT perform VE until placenta praevia excluded!

❼ Give Tranexamic acid — see Box B.
❽ Monitor blood loss — accurate fluid balance.
❾ Should the birth be expedited? (maternal or fetal compromise)

• Mode of birth.
❿ Plan ongoing care in appropriate clinical area and inform

relevant teams.
IF blood loss in excess of 1500 ml or continuous loss of

150ml/min activate MOH protocol → go to page 9



12

Acute uterine inversion Signs and symptoms

❶ Immediate action: • PPH (obvious or concealed).
• Cardiovascular shock (could be out of proportion to the
• CALL for help: Pull emergency bell.
2222 ‘Obstetric emergency’ (State location). blood loss).
• The sudden appearance of a large, dark red mass
• Lie patient flat
accompanying the placenta or a mass in the vagina.
• Inform women of need to reposition the uterine fundus. • Severe abdominal pain.
• Attach monitoring early: BP, SpO2, ECG leads. • Inability to feel the fundus abdominally.
• Neurogenic shock (due to vagal stimulation).
❷ Airway / Breathing:
Box A Uterine relaxants
Give 100% oxygen via non-rebreathe mask.
❸ Circulation: • Terbutaline - SC 250 mcg
• Glyceryl trinitrate - one metered dose sublingual
• IV access large bore x 2. • Salbutamol - Inhalation of metered dose.
• Send bloods: FBC, U&E, Clotting, cross match 4 units. • General anaesthesia if multiple attempts

• Commence IV fluids.

• Insert catheter.
❹ Attempt immediate manual replacement.

• Consider uterine relaxants — see Box A.

• Successful - DO NOT REMOVE PLACENTA. Box B Hydrostatic method

• Transfer to theatre. • Silastic vacuum cap placed in vagina to occlude the
2222 Category one theatre case (State location). vaginal opening.

• Prepare to prevent and treat PPH. • Wide bore IV giving set to be attached to silastic cap.
• 2 L warmed Normal saline rapidly infused through the
Atonic uterus in 90% cases of uterine inversion.
IV giving set. Fluid should be placed 100-150 cm above
❺ If replacement unsuccessful: the level of vagina.
• Consider uterine relaxants — see Box A.
• Attempt manual or hydrostatic replacement — see box B. Box C Uterotonics
• Prepare for laparotomy.
Oxytocin (Syntocinon)
❻ After uterus replaced keep it in place manually for few • IV bolus 5 IU slowly, repeat if required
minutes to prevent re-inversion. • Infusion (20 IU in 50 ml) at 20 ml/hr
Ergometrine
❼ Administer uterotonics — see Box C. • IV dose 50-100 mcg repeated as necessary.
❽ Deliver placenta. Carboprost (Hemabate)
❾ In case of PPH → go to page 10. • IM 250 mcg every 15 min repeated up to 8 doses.
Misoprostol
❿ Plan ongoing care in suitable location. • 1000 mcg rectally.



13

Total spinal Box A Induction of anaesthesia

❶ Immediate actions: • Consider reduced dose of hypnotic drug to avoid
• CALL for help: Pull emergency bell. further hypotension. A full induction dose will not be
• 2222 ‘Obstetric anaesthetic emergency’ (State location). necessary if the patient’s consciousness is already
• Attach monitoring early: BP, SpO2, HR. impaired.

❷ Reassure patient, they may be fully aware. • Consider midazolam.
• Plan RSI as soon as possible — see Box A. • Neuromuscular blockade may not be necessary for

❸ Airway and Breathing: tracheal intubation if the patient is unconscious,
• Give 100% Oxygen. paralysed and apnoeic.
• Chin lift / jaw thrust.
• Bag / mask ventilate if no respiratory effort. Box B Drug doses
• Consider supraglottic airway or tracheal intubation.
Bradycardia:
❹ Circulation: • Atropine: 0.6-1.2 mg
• Give IV fluid by rapid infusion — see Box B. • Glycopyrrolate: 0.2-0.4 mg
• Elevate legs. Do not use head-down tilt.
• Relieve aorto-caval compression (Wedge). Hypotension:
• Bradycardia: give atropine or glycopyrrolate — see Box B. • Metaraminol: 1-2 mg boluses repeated or standard
• Hypotension: give metaraminol or ephedrine — see Box B.
• CPR may be necessary to circulate drugs. preparation (10 mg in 50 ml 0.9% Saline) at higher
rate.
❺ Consider expedited delivery of baby to manage: • Ephedrine: 6-12 mg boluses repeated up to max 30
• Risk to mother of unrelieved aorto-caval compression. mg (tachyphylaxis limits further usefulness).
• Risk to fetus of impaired feto-placental oxygen delivery.
Fluids:
❻ Consider other causes including: • Hartmann’s 500 ml bolus.
• Aorto-caval compression.
• Local anaesthetic toxicity.
• Embolism.
• Vasovagal event.
• Haemorrhage.

❼ Plan ongoing care in a suitable location.
❽ Complete DATIX and DEBRIEF.



14

High spinal block Risk factors for high regional block

❶ Immediate action: • Accidental dura puncture
• STOP Epidural infusion if epidural in situ. • Accidental subdural placement of epidural catheter
• Reassure the patient. • Large or rapid epidural top-up
• Sit patient upright in bed. • Spinal infection with epidural in place
• Connect monitoring: pulse oximeter, BP. • Epidural top-up after recent spinal injection

❷ CALL for help: Warning signs of rising block
• Bleep labour ward Anaesthetist #2178, or
• Consultant LW anaesthetist #5054 during the day, or • Nausea
• Duty anaesthetist #2813. • ‘Not feeling right’
• Breathlessness
❸ Airway and Breathing: • Tingling, numbness or weakness in the fingers or arms
• Give Oxygen if SpO2 <95%. • Difficulty speaking
• Assess breathing, rate and depth, SpO2. • Difficulty swallowing
• Sedation
❹ Circulation:
• Make sure IV cannula in place and patent. Box A Drug doses
• Give IV fluid bolus 500 ml Hartmann’s if blood pressure
low. Bradycardia:
• Elevate legs. Do not use head-down tilt.
• Relieve aorto-caval compression. (Wedge) • Atropine: 0.6 mg
• Bradycardia: give atropine or glycopyrrolate — see Box A. • Glycopyrrolate: 0.2-0.4 mg
• Hypotension: give metaraminol or ephedrine — see Box A.
Hypotension:
❺ Disability: • Metaraminol: 0.5-1mg boluses repeated or standard
• Assess AVPU.
• Assess block hight. preparation (10 mg in 50 ml 0.9% Saline) at higher rate.
• Ephedrine: 6-12 mg boluses repeated up to max 30 mg
❻ If block still rising → go to page 13.
(tachyphylaxis limits further usefulness).
❼ Plan ongoing care in a suitable location.



15

Local Anaesthetic Toxicity Signs of severe toxicity:

❶ Immediate actions: • Sudden alteration in mental status, severe agitation or loss
• CALL for help: Pull emergency bell. of consciousness, with or without tonic-clonic convulsions.
• 2222 ‘Obstetric Anaesthetic Emergency’(State location).
• Cardiovascular collapse: sinus bradycardia, conduction
❷ Stop Epidural pump. blocks, asystole and ventricular tachyarrhythmias may all
occur.
❸ COLLECT cardiac arrest trolley and LIPID RESCUE PACK.
• Local anaesthetic toxicity may occur some time after an
❹ Airway and Breathing: initial injection.
• Give 100% oxygen (Non-rebreathe mask)
• Maintain the airway and if necessary intubate. Box A INTRALIPID
• Ensure adequate lung ventilation.
• Hyperventilation may help reduce acidosis. USE 20% Intralipid®


❺ Circulation: Immediately
• Intravenous access. • Give initial IV bolus of lipid emulsion 1.5 ml.kg–1 over 1 min
• Treat hypotension, brady- and tachyarrhythmia.
• Consider intravenous lipid emulsion — see Box A. (~100 ml for a 70 kg adult)
• If cardiac arrest: • Start IV infusion of lipid emulsion at 15 ml.kg–1.h–1
− Start continuous CPR → go to page 2.
− GIVE intravenous lipid emulsion — see Box A. (17.5 ml.min-1 for a 70 kg adult)
− Recovery may take >1 hour.
− Call cardiologist. At 5 and 10 minutes:
− Consider cardiopulmonary bypass if available. • Give a repeat bolus (same dose) if:

❻ Control seizures with small incremental dose of o cardiovascular stability has not been restored or
benzodiazepine, thiopental or propofol. o an adequate circulation deteriorates

❼ Plan ongoing care in suitable location. At any time after 5 minutes:
• Double the rate to 30 ml.kg–1.h–1 if:

o cardiovascular stability has not been restored or

o an adequate circulation deteriorates

Do not exceed maximum dose 12 ml.kg–1 (70 kg: 840 ml)

Appendix A:

Troubleshooting & Management of Side Effects

of Remifentanil PCIA

Low Oxygen Saturations Respiratory Over Sedation Bradycardia/
Depression Sedation score + P or U Hypotension
only
Respiratory rate <8bpm P= Responds to pain only HR <50bpm and/or
Sp02 Less than 94% for
U= Unresponsive SBP <90mmHg
>15 secs
Respiratory rate >8bpm

Remove PCA handset Call for help
Remove PCA handset
Give Oxygen 2-4L/min via Wake the patient – shake and shout
nasal cannula Prop the patient up to a semi-upright position
Give 15L/min O2 via Non-rebreather facemask
Restart PCA if Sp02 Call the Anaesthetist but do NOT leave the patient unattended
recovers to ≥94% Pull the emergency alarm if Sp02 <90% or patient remains unresponsive
Do NOT restart PCA until after review by Anaesthetist
Call Anaesthetist: if Sp02
remains between 90-94% If RR remains <8 and/or Give 250 mL Hartmann’s
in spite of O2 Sedation score remains P or U If HR remains <50, give Atropine
Give Naloxone 200 micrograms IV 600 micrograms
Pull Emergency Alarm: if
Sp02 falls below 90% in
spite of Oxygen

Observations recorded: Every 15 mins for 1st hour and thereafter every 30mins

Remain with patient at all times

STOP PCA when vertex is visible or at least 10mins before cord clamping
TENS and Entonox may still be used

Anaesthetist Responsibilities: Pump Set Up:
Take 20 mL from 250 mL bag of 0.9% Sodium Chloride
Verbally consent patient and give Information and reconstitute 5mg Remifentanil and put back into
leaflet the bag and mix thoroughly (20 mcg/ml)

Record baseline observations on chart/K2 ≥ 50kg = 1.5mls = 30mcg bolus
Set up pump <50kg = 1ml = 20mcg bolus

Explain to patient how to use PCA Adjust dose depending on response
- Increase to 40 mcg if analgesia inadequate
- Anticipation: press at first sign of - Reduce dose if significant side effects occur
contraction
Use dedicated 20/22-gauge cannula
- Only patient may press PCA - No bionector
Remain with patient for first 5 boluses - Opposite arm to NIBP
- Avoid using back of hand (if possible)
Prescribe Naloxone (IV), Ranitidine (PO) and
Prochlorperazine (buccal)

Review regularly & support Midwifery team

16

Remifentanil PCA induced serious side effects

❶ Immediate actions: Serious side effects of remifentanil PCA
CALL for help / Pull emergency bell.
Remove PCA handset. Respiratory depression:
• Respiratory rate < 8 bpm.
Do not leave patient!
Over sedation:
❷ Airway and breathing: • Sedation score P or U
• Try to wake patient up — shake and shout.
• Left lateral (Recovery) position or semi-upright. Bradycardia/Hypotension:
• Give 100% Oxygen via non-rebreathe mask. • Heart rate < 50 bpm
• Chin lift / jaw thrust. • Systolic blood pressure < 90 mmHg

❸ If SpO2 < 90% or patient remains unresponsive despite
oxygen supplementation:
• 2222 ‘Anaesthetic emergency’ (State location).

❹ If respiratory rate < 8 or sedation score P/U — see Box A: Box A Sedation score (AVPU)
• Give naloxone — see Box B.
• If no respiratory effort → ventilate using bag-mask. A - alert
V - responds to verbal command
❺ Circulation: P - responds to pain only
Monitor heart rate — if < 50 bpm: U - unresponsive
• Give atropine — see Box B.
• Give Hartmann’s 250 ml. Box B Drugs

❻ Do not restart PCA until review by anaesthetist. Naloxone - 200-400 mcg IV repeat as required
Atropine - 600mcg IV
❽ If PCA restarted — continue observations every 15 min for
the first hour and 30 min thereafter.

Remain with patient at all times!



Failed obstetric intubation 17

❶ Immediate actions: Wake
• Declare failed intubation. • Maintain oxygenation.

• CALL for help: Pull emergency bell. • Maintain cricoid pressure if not impeding ventilation .

• 2222 ‘Anaesthetic emergency’ (State location). • Either maintain head-up position or turn left lateral recumbent .

• If rocuronium used, reverse with sugammadex.

❷ Maintain oxygenation. • Assess neuromuscular blockade and manage awareness if
• Supraglottic airway device (maximum 2 attempts)
Remove cricoid pressure during insertion. paralysis is prolonged.

• Anticipate laryngospasm / can’t intubate, can’t oxygenate.
• Face mask +/- oropharyngeal airway (consider 2 person
technique). Proceed with surgery
Reduce/remove cricoid pressure. • Maintain anaesthesia.
• Maintain ventilation.
❸ Able to maintain adequate oxygenation: • Anticipate laryngospasm /can’t intubate, can’t oxygenate.
• If essential / safe → proceed with surgery. • Minimise aspiration risk:
• If not → wake patient up.
- maintain cricoid pressure until delivery (if not impeding
❹ Not able to oxygenate → Can’t intubate, can’t ventilation).
oxygenate (CICO)
Declare CICO, give 100% oxygen. - reapply cricoid pressure if signs of regurgitation.
Call additional surgical airway help (ENT, ITU). - empty stomach with gastric drain tube.
- minimise fundal pressure.
❺ Exclude laryngospasm — ensure neuromuscular blockade. - administer H2 receptor blocker i.v. if not already given.
• Senior obstetrician to operate.
❻ Proceed to Front-of-neck access. • Inform neonatal team about failed intubation.
• Consider total intravenous anaesthesia.
❼ Able to maintain adequate oxygenation:
• If essential / safe → proceed with surgery. After waking
• If not → wake patient up. • Review urgency of surgery with obstetric team.
• Intrauterine fetal resuscitation as appropriate.
❽ Plan extubation and ongoing care. • For repeat anaesthesia, manage with two anaesthetists.
❾ Complete DATIX and DEBRIEF. • Anaesthetic options:

- Regional anaesthesia preferably inserted in lateral position.
- Secure airway awake before repeat general anaesthesia.

Algorithm 3 – can’t intubate, can’t oxygenate

Declare emergency to theatre team
Call additional specialist help (ENT surgeon, intensivist)

Give 100% oxygen
Exclude laryngospasm – ensure neuromuscular blockade

Perform front-of-neck procedure

Is oxygenation
restored?

No Yes

Maternal advanced life support Is it
Perimortem caesarean section essential / safe
to proceed with surgery
immediately?*

No Yes

Wake§ Proceed with surgery§

*See Table 1, §See Table 2
© Obstetric Anaesthetists’ Association / Difficult Airway Society (2015)

18

Can’t intubate, can’t oxygenate (CICO) Box A Equipment instructions

❶ Immediate actions: Airway rescue trolley, FoNA drawer:
• Check optimal airway management is in place. • Scalpel with number 10 blade
• Maintain anaesthesia. • Bougie with coudé (angled) tip
• Supply 100% oxygen either by tightly fitting facemask, • Tracheal tube, cuffed, 6 mm
supraglottic airway device or nasal high flow.
Box B Stab, Twist, Bougie, Tube technique
❷ Consider ONE final attempt at rescue oxygenation via • Identify the cricothyroid membrane (If unable, go to
upper airway if not already done. • Single transverse incision through skin and membrane
• Rotate scalpel 900 with sharp edge facing caudally
❸ Declare CICO. • Slide angled tip of bougie past the scalpel into the
• CALL for help (additional staff and surgical airway
expertise e.g. ENT, ICU). trachea
• 2222 ‘Anaesthetic emergency’ (State location) • Railroad tube over bougie
• COLLECT airway rescue trolley
• COLLECT cardiac arrest trolley. Box C If Box B fails - Scalpel, Finger, Bougie technique
• Make an 8-10 cm vertical incision head to toe
❹ Give neuromuscular blocking drug now.

❺ Prepare for Front of Neck Access – FoNA - see Box A. orientation
• Use blunt dissection to retract tissue to identify
• Position patient - full neck extension.
• If cardiac arrest → go to page 2. trachea
❻ Operator position: • Stabilise the trachea and proceed as in Box C through
• Right-handed operator stands on patient’s left hand
the

side. cricothyroid membrane
• Left-handed operator stands on patient’s right hand

side.
❼ Perform a ‘laryngeal handshake’ to identify the

laryngeal anatomy.

❽ Perform FoNA to intubate trachea via cricothyroid

membrane using technique in Box B.
• If cricothyroid membrane cannot be identified, use

technique in Box D.
❾ Secure tube, continue to oxygenate patient and ensure

adequate depth of anaesthesia.
❿ Plan ongoing care, complete DATIX and DEBRIEF.



19

Shoulder dystocia Risk factors for shoulder dystocia

Diagnose shoulder dystocia — see Box A Pre-labour Intrapartum
❶ Immediate actions: • Previous shoulder dystocia • Prolonged first stage of
• Macrosomia >4.5 kg
CALL for help: Pull emergency bell. • Diabetes mellitus labour
• Maternal BMI > 30 kg/m2 • Secondary arrest
2222 ‘Obstetric emergency’ (State location). • Induction of labour • Prolonged second stage
CALL Neonatal team. • Oxytocin augmentation
• Assisted vaginal delivery
Allocate scribe.
❷ Discourage pushing, lie flat, buttocks to edge of bed Box A Diagnosing shoulder dystocia

remove pillows. Look for signs of shoulder dystocia:
❸ McRoberts’ manoeuvre (thighs to abdomen).
❹ Suprapubic pressure and routine axial traction. • Difficulty with delivering face and chin.
❺ Consider episiotomy if it makes internal manoeuvres • Head remains tightly applied to the vulva or retracting.
• Failure of restitution of the fetal head.
easier. • Failure of shoulders to descend.
❻ Deliver posterior arm or
❼ Internal rotational manoeuvres. Routine traction in axial direction can be used to diagnose.
❽ Call consultant obstetrician and anaesthetist if not

present.
❾ Consider all four position if appropriate or
❿ Repeat steps 3 to 9.
⓫ Consider cleidotomy, Zavanelli manoeuvre or

Symphysiotomy.
⓬ Baby to be reviewed by neonatal team.

Attempt each manoeuvre for up to 30 seconds

before moving to the next.



20

Cord prolapse Recognising prolapse

❶ Immediate actions: • Umbilical cord visible/protruding from vagina
• CALL for help: Pull emergency bell. • Cord palpable on vaginal examination
• Abnormal fetal heart on auscultation/CTG
• 2222 ‘Obstetric emergency’ (State location).
Box A Methods to relieve pressure on the cord
• Vaginal examination:
If fully and delivery imminent → Deliver the baby. • Manually elevate presenting part
• Position woman:
❷ Relieve pressure on the cord — see Box A.
• Manually elevate presenting part. - Exaggerated Sims position - move woman into left
• Position woman. lateral position with head down and pillow under left
• Consider bladder filling. hip
• Consider tocolysis — see Box B.
- Knee-chest position
❸ IV access, take bloods FBC, U&E, G&S. • Consider bladder filling and apply dry pad to try keep

❹ Continuous monitoring of fetal heart. cord inside vagina
- Insert caterer and fill bladder with 500 ml 0.9% Saline
❺ Prepare for immediate birth. • Consider tocolysis
- Terbutaline 0.25 mg subcutaneously
2222 ‘Category one theatre case
Neonatal team to attend’. Box B Tocolitic drugs

❻ Consent for caesarean section, anaesthesia. • Terbutaline SC 250 mcg

❼ Regional anaesthesia advised if no fetal heart
compromise.

❽ Umbilical cord gases post delivery.



21

Fetal bradycardia Box A ‘Rule of three’ for fetal bradycardia

❶ Immediate action: • 3 min - call for help
• Lay women on her left side. • 6 min - move to theatre
• Note time — see Box A. • 9 min - prepare for operational delivery
• Stop oxytocin if running. • 12 min - aim to deliver the baby
• CALL for help: Pull emergency bell.
• Consider causes of bradycardia — see Box B. Box B Causes of bradycardia
• Start intrauterine resuscitation — see Box C.
Reversible Irreversible
❷ Airway / Breathing: • Position of the mother • Scar rupture
Consider oxygen. • Epidural placement, • Cord prolapse
• Massive abruption
❸ Circulation: recent bolus • Prolonged ongoing
• IV access. • Medications (oxytocin,
• Give fluids Hartmann’s 500 ml. hypoxia
• Check BP, to rule out hypotension. local anaesthetics) • Terminal bradycardia
• Interventions (ARM)
❹ Examination: • SROM before death
• Vaginal examination to establish labour progress, • Rapid fetal decent
exclude cord prolapse and plan for delivery. • Hyper stimulation
• Consider terbutaline if hyper stimulated.
Box C Intrauterine resuscitation
❺ If fetal heart rate not recovered:
• 2222 ‘Category one Caesarean section’ (State • Left lateral position.
location). • Stop oxytocin infusion if running.
• Give IV fluids.
❻ Reassess the heart rate in theatre to plan for • Terbutaline 250 mcg SC if hyper stimulation.
anaesthesia. • Give oxygen via face mask.

❼ Call neonatal team.

Preterm AT ALL TIMES ASK “IS HELP NEEDED”NNeewwbboorrnnlliiffeessuuppppoorrtt
< 32 weeks MAINTAIN TEMPERATURE
APPROX 60 SECONDS (Antenatal counselling)
Place undried in Team briefing and equipment check
plastic wrap + TITRATE OXYGEN TO ACHIEVE TARGET SATURATIONS
radiant heat Birth

Inspired oxygen Delay cord clamping if possible
28–31 weeks 21–30%
Start clock / note time
< 28 weeks 30% Dry / wrap, stimulate, keep warm

If giving inflations, Assess
start with 25 cm H2O Colour, tone, breathing, heart rate

Acceptable Ensure an open airway
pre-ductal SpO2 Preterm: consider CPAP

2 min 60% If gasping / not breathing
• Give 5 inflations (30 cm H2O) – start in air
5 min 85% • Apply PEEP 5–6 cm H20, if possible
• Apply SpO2 +/- ECG
10 min 90%
Reassess
If no increase in heart rate, look for chest movement

If the chest is not moving
• Check mask, head and jaw position
• 2 person support
• Consider suction, laryngeal mask/tracheal tube
• Repeat inflation breaths
• Consider increasing the inflation pressure

Reassess
If no increase in heart rate, look for chest movement

Once chest is moving continue ventilation breaths

If heart rate is not detectable or < 60 min-1
after 30 seconds of ventilation

• Synchronise 3 chest compressions to 1 ventilation
• Increase oxygen to 100%
• Consider intubation if not already done or laryngeal

mask if not possible

Reassess heart rate and chest movement
every 30 seconds

If the heart rate remains not detectable or < 60 min-1
• Vascular access and drugs
• Consider other factors e.g. pneumothorax,

hypovolaemia, congenital abormality

Update parents and debrief team
Complete records

22

Neonatal resuscitation Acceptable pre-ductal SpO2

❶ Immediate actions: • 2 min 60%
CALL for help: Pull emergency bell. • 3 min 70%
2222 ‘Neonatal emergency’ (State location). • 4 min 80%
Note time. • 5 min 85%
• 10 min 90%
❷ Dry the baby, wrap, stimulate.
Maintain normal temperature. Box A Drugs

❸ Assess colour, tone, breathing, heart rate. • Drugs are needed rarely and only if there is no significant
Monitor SpO2 + ECG. cardiac output despite effective lung inflation and chest
compression.
❹ Airway and breathing:
If gasping or not breathing: • Adrenaline 10micrograms/kg(0.1mL/kg of 1:10,000
•Open the airway. solution). If this is not effective, a dose of up to 30
•Give 5 inflation breaths (30 cm H2O term babies, 25 cm micrograms/kg (0.3 mL/kg of 1:10,000 solution) may be
H2O for pre-term) start in air. tried.
•Apply PEEP 5-6 cm H2O, if possible.
• Sodium bicarbonate 1 - 2 mmol/kg of bicarbonate (2 to 4
❺ Reassess: mL/kg of 4.2% bicarbonate solution).
If no increase in heart rate look for chest movement
during inflation. • Glucose recommended is 250mg/kg (2.5mL/kg of
10%glucose).
❻ If chest not moving:
•Recheck head and jaw position. Box B Other potential causes for collapse
•Consider 2-person airway control.
•Consider suction, laryngeal mask, tracheal tube. • Pneumothorax.
•Repeat inflation breaths. • Hypovolaemia.
•Look for response. • Congenital abnormalities.

❼ When chest moving:
•If heart rate not detectible or < 60 bpm - ventilate for 30
sec increase O2 guided by oximetry.
•Reassess heart rate.
•If still <60bpm - start chest compressions (ratio 3:1).
•Increase oxygen to 100%.
•Reassess heart rate every 30 seconds.
•If still not detectible or <60bpm - consider venous access
and drugs — see Box A.

•Consider other factors — see Box B.
❽ Update parents.
❾ Plan ongoing care in appropriate location.
❿ Complete DATIX and DEBRIEF.