(a)
Preparations prior to arrival
I will ensure bed is ready in AED ,COMMUNICATE TO consultant Obstetrician, Anesthetist, blood bank for O Rh negative blood, senior midwife and ask for extra trained people in resiuscitation of pregnant women and timekeeper/scribe .Crash trolley should be ready with tray for perimortem Caesarian, oxytocics and interventional radiologist, sonologist for bedside Ultrasound informed.Operation theatre should be informed exploratory laparotomy may be required including caesarian hysterectomy.
(b)
Initial management
Asssessment of consciousness, vitals, and pain score made.
Scribe instructed to document treatments,consultant arrivals,drug dosages,blood vacs and interventions done.
Temperature, pulse, Blood pressure, Respiratory rate and GCS score charted on MEOWS CHART.
Verbal consent taken if conscious and reassured she and baby will be taken care of otherwise resuscitation started with ABC. Any religious beliefs contrary to resuscitation/ blood transfusion to her or fetus msut be documented and enquiry made if any DO N ot Resuscitate advance directive has been ever signed previously.
Airways patency ensured and spinal brace applied while shifting her from Ambulance to AED bed until spinal injury ruled out.If required, goodells airway or intubation done with Oxugen 10 l/ min on flow. Pneumothorax rule dout in absence of silent lung and crepitations otherwise releived by needle puncture in anterior axillary line 2 nd Intercostal space.Hemothorax ruled out or closed Romovac drain in 9th Intercostal space inserted posteriorly.Assessment made for ventilatory support and shifting to tertiary care center.
Bliateral iv line wide bore 18 gauge cannula and Bloods sent foor CBC, GROUP AND SAVE, Urea and elactrolytes and ABG sample taken for saturation. CVP line inserted for ensuring corrrect fluid pressures and bladder catgerised to moniter input output .This is important as patient is in advanced pregnancy and pulmonary edema by aggressive fluid replacement is to be avoided.Warmed 2 liter crystalloids Hartmans followed by 1- 1.5 l colloid of warmed blood without filter givenas per hematologist advice and fluid requirements given.
This patient has internal haemorrhage or is in neurological shock.Stabilization and looking for cause and site of bleed must be done simultaneously.I f patient collpses by time of arrival, CPR AND PERIMORTEM caesarian may be required .The Neonatologist team must be informed as in advanced pregnancy baby may be salvageable.The patient is priority and until birth fetus has no legal rights .Even if uterus is intact with no abruption ,to reduce cardiorespiratory embarrassment and facilitate resucitation of mother within 4th to 5 th minute, perimortem caesarian can save her life and prevent brain ischemia.Once she is resuscitated she may be shifted to OT for suturing.If conscious consent for hysterectomy for PPH/rupture uterus taken.
Communication with her relatives must be made repeatedly to inform what steps have been taken and patient progress to relieve their anxiety .Complete report documented and signed with designation as in case of adverse outcome/casuality it will be important medicolegal document .Incident reporting done.
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