This book is intended to inform and educate practitioners about the management of emergencies and the many associated skills. These emergencies may happen in a range of settings from fully equipped and staffed obstetric units to the stand-alone unit or homebirth. The practitioner has a professional responsibility to meet the standards necessary and to become so familiar with these skills that they can adapt them to any setting. They must be able to team work effectively and appropriately manage all the help available. In an ideal situation, the emergency will be supported by a full obstetric, paediatric, anaesthetic and operative team as required, with additional support from haematology, pathology, microbiology, blood bank, pharmacy and porters. When the practitioner is alone they must simultaneously initiate emergency management and call for assistance.

This chapter cannot cover all professional responsibilities associated with emergency management. It will concentrate on the need to achieve and maintain professional standards, continue professional development, maintain a high standard of record keeping, and show awareness of accountability.

Achievement and maintenance of professional standards

The standards of clinical expertise achieved by midwives are controlled by a number of training and monitoring processes. This begins at the interview and admission stage to midwifery training. The profession is looking not only for those academically able, but also for those whose personalities and ethical stance will enhance the profession and improve standards of care. Service users, clinicians, and midwifery tutors jointly decide on the selection approach to be used and which candidates have met these exacting standards. All training programmes align with 
stringent Nursing and Midwifery Council (NMC, 2009) guidelines and are variously quality monitored throughout (see Figure 1.1). The aim is to achieve clinical competency at the point of qualifying (alongside the skills of life-long learning).

With employment there comes a period of preceptorship (support, monitoring, and development). This is followed by regular employer and professional body review with standards monitored against local policies, as well as professional standards such as: The Code (NMC, 2015) (see Figure 1.2); Standards to support learning and assessment in practice (NMC, 2008) (see Figure 1.3); Standards of medicine management (NMC, 2007) (see Figure 1.4); Standards for competence for registered midwives (NMC, 2011) (see Figure 1.5); and, in addition, a great number of local hospital protocols. Periodic Revalidation (NMC, 2017) is required and this can only be met through a combination of clinical experience and continuing professional development (CPD) (see Figure 1.6).

Continuing professional development

In order to perform within expected standards of care, the professional has a duty to maintain skill competencies and knowledge levels. The process of Revalidation ensures that midwives engage in CPD, but most midwives will surpass any minimum levels set.

Midwives should maintain critical awareness of:

• Current research.
• Topical literature.
• Local and national statistics, case conferences, audits.
• E-learning material.
• Conference material.
• Local and national guidelines, for example NICE.
• New medications for use in obstetrics.
• Risk management reports.
• Evidence from the numerous reports produced by Mothers and Babies: Reducing Risk through Audits and Confidential Enquires across the UK (MBRRACE-UK).

They must attend clinical skills updates including:

• Interprofessional/multidisciplinary skills sessions in house.
• Local skills and drills requirements such as fire safety awareness, manual handling, blood products, documentation, etc.
• National/international skill courses, for example Advanced Life Support in Obstetrics (ALSO), Newborn Life Support (NLS), Practical Obstetric Multi-Professional Training (PROMPT).
• Limitations and capabilities including communication and referral.

Record keeping

A high standard of contemporaneous record keeping has long been understood to be an essential component of good practice. The NMC (2015) provides midwives with guidance on the principles of good record keeping. Yet, it can remain an issue during complaints investigations and is often included as a development requirement during supervised practice. During an emergency, record keeping becomes both a greater challenge and a greater necessity. Best practice would allocate the role of scribe to an individual best suited to the role – someone sufficiently experienced to know the important elements to include. Alongside this it requires:

• Clear, concise, accurate, factual, legible, and contemporaneous statements without abbreviations (unless explained).
• Records to follow local guidelines such that everyone knows where things are recorded.
• Observations of maternal, fetal, or neonatal health recorded.
• Date and time.
• Signatures and printed name.
• Medications recorded including dosage, time of administration, and any reactions.
• All actions taken are noted (including by whom) – whether successful or unsuccessful.
• Reference to any referrals made – the time and to whom, as well as the reason for the referral.

Accountability

Accountability is the taking of responsibility for ones own actions and ability to defend decision making. The professional may be questioned at any time (often years after an event) by a client, employer, professional regulatory body, or through a legal challenge. The professional is judged on whether they performed to the expected standard of care. This is based on the normal standards of professional practice typical at the time of the event. Expectations are also individualised to the circumstances of the incident and are expected to encompass:

• Identification of potential risk.
• Taking preventative measures.
• Competent practice.
• Support of the woman’s informed choices.

Communication is considered to be a two-way interaction in which information is both given and received. This interaction is not only about the content of the communication but also about the process itself and the context in which it is being delivered (see Boxes 2.1 and 2.2). Communication is made up of verbal and non-verbal cues and is not a simple message exchange. It includes not only what is said but also how it is said (intonation), alongside the body language that accompanies it. Then, interpretation of the message by the recipient is influenced by numerous factors including: their own life-experience; knowledge level; socio-cultural issues; health and emotional state; disability; and the environment in which it is received. At the time of an emergency, there also may be anxiety, pain, shock, and fear to interfere with effective listening. Numerous heightened emotions will impact on both sides of the communication.

Informed consent

Informed consent may be gained verbally, in writing, and through the actions of the individual conveying consent. In some emergency situations, aspects of consent may have been gained even before the emergency occurred, for example gaining permission to use an oxytocic drug should a woman begin to haemorrhage. However, in most situations the emergency is unpredictable, unexpected, and the pace of change makes informed consent a challenge.

Achieving a holistic approach to communications between the professionals and the women they care for throughout an emergency is challenging. Whilst keeping the woman informed and gaining consent remain a priority, there are now multiple professionals involved (see Box 2.3) and time is limited. The priority for care becomes the management of the immediate emergency and associated pathophysiology. The concentration will be on emergency practical skills and interprofessional communications to achieve optimal outcomes (see Boxes 2.4 and 2.5). Additionally, the woman may be tired, medicated, frightened, and in pain, which affects her capacity to understand, retain information, appreciate the implications, and communicate her opinions (as expected by the Mental Capacity Act, 2005). All aspects of the management must be directed in the best interests of the woman.

This is not about underestimating the role of communication in general and informed consent in particular. It is about how much more challenging communications become in situations of uncertain outcomes, time limits, and rapidly changing management. It becomes essential that a member of the team takes the role of staying at the head of the bed, with the woman. They should explain and interpret events at an appropriate level. The speed at which the emergency management progresses may not always allow detailed explanations of evidence, discussions, and time for questions, but the essentials must still be applied, and the views of the woman passed back to the team. Communications should include full awareness of body language, good listening skills, and the ability to balance appropriately the information shared in the time available.

Clarification and ongoing communications

It is important that there is a full appreciation of how information is shared. Beware of using unfamiliar words without explaining their meaning, and appreciate that it is not only ‘what is said’ that portrays a message. Even the most skilful professional can unintentionally communicate through negative intonation or body language.

Be prepared for questions and anxiety. A balance is required between appropriate levels of honesty and realistic reassurances, without making guarantees that may not be achievable. Whilst some information needs to be shared immediately, the full extent of the problem in an emergency can only be determined retrospectively. Therefore, in most cases it is advisable to keep ongoing explanations simple, gaining permission to concentrate on the management of the emergency as the priority, but also giving reassurances that a full explanation of events will follow. This enables a full understanding of the concern to be known, and prevents the early sharing of misleading information (when the emergency may still change, reduce, or escalate). It also allows the woman time to digest the problem and begin to recover from the physical management and emotional shock associated with it.

Communications following the emergency

Following a traumatic episode such as an obstetric or neonatal emergency, adrenaline levels are raised and the woman may be in a state of further anxiety and stress. These are normal responses which will resolve naturally for the majority of women. It is important to appreciate that involvement in an emergency does not typically lead to a lasting stress disorder. Communications following the emergency are not intended as a debriefing exercise, particularly as evidence suggests a single-session may do more harm than good (Bastos et al., 2015). Communications after an emergency are an opportunity to discuss the event in more detail, allow questions, then clarify any misunderstandings following a basic explanation of the emergency and its management. The woman must feel comfortable and be able to discuss aspects openly. Rather than a one-sided commentary by the professional, there should be a two-way conversation that fulfils the needs of the woman.

It is important to appreciate personal limitations and to not cross professional boundaries. Be honest about the limits of your expertise and involve the specialist or more senior practitioners in explanations of their role, as required. This is particularly relevant when breaking bad news – you may need to arrange for a more experienced, senior or specialist colleague to join you during the information sharing.

Every woman will have a different reaction to an emergency; there may be any number of aspects affecting her ability to assimilate information. Emotions can be affected by, for example, being in a postoperative state, in pain, sleep deprived, or hormonal. Cultural, ethnic, and social issues may also affect responses. It is important that any reactions to communications from you are received non-judgementally. It may be appropriate for you to offer to invite the husband/partner to attend and be available to answer any further questions once they have arrived.

At the end of the discussion, you should explain the care pathway and ongoing management that, with her consent, will follow the emergency. This should include specific information on:

• Any referral you will make for follow-up care (to whom, why, when, and how).
• Further screening or diagnostic investigations you will request (by whom, when, and what this will entail).
• Daily management (by whom, when, and what this will entail).
• Expected progress, side effects, and potential problems that may occur.
• How to make contact if she has any further questions.
• Alternative information sources available.

A maternal death is defined by the World Health Organization (WHO), as the death of a woman during pregnancy or up to 6 weeks postpartum as a result of conditions associated with, or made worse by, pregnancy (WHO, 2010). In the UK between 2011 and 2013, there were 214 maternal deaths, of which 69 were attributed to ‘direct’ causes such as amniotic fluid embolism, haemorrhage, sepsis, and thromboembolic disorders (Knight et al., 2015). The remaining 145 women died as a result of indirect causes. While the need to resuscitate a young, fit, healthy woman is an increasingly rare occurrence, maternal collapse can and does happen and the outcome is dependent on effective and prompt action by those caring for her. Approximately 50% of maternal deaths are due to preventable and, therefore, treatable causes; the fact that the need to resuscitate a pregnant or recently delivered woman is a rarity suggests that regular drills for midwives and obstetricians should be undertaken if an individual’s skills are to be maintained at a high standard.

Thus, the definition of maternal resuscitation is the support of a woman’s life in the event of sudden collapse accompanied by apnoea and/or cardiac arrest.

Physiology

The systems of the woman’s body adapt during pregnancy and therefore it is essential that these are understood so that effective resuscitation can take place (see Table 3.1).

Predisposing factors

• Thromboembolic disorders.
• Haemorrhage.
• Amniotic fluid embolism.
• Seizure – eclamptic and epileptic.
• Sepsis.
• Anaphylaxis.
• Accident.
• Pre-existing medical conditions.
• Psychiatric conditions.

Management (see Figure 3.2)

This is an emergency. It is essential to note that a woman who is not responding and whose breathing is abnormal is experiencing a cardiac arrest requiring early intervention and resuscitation. The sequence of interventions is as follows (Resuscitation Council (UK) 2015):

• Before approaching the woman make sure that it is safe for you to do so.
• Try to elicit a response from the woman by speaking to her in both ears. If she responds, try to find out what has happened.
• Airway – put a hand on the forehead of the woman and with two fingers under the point of her chin, tilt her head by lifting the chin to open the airway.
• Breathing – bend down close to the woman’s face, turn to look towards the woman’s feet and for no more than 10 seconds:
  • Look for chest rise – this may be shallow or absent.
  • Listen for the sound of breathing.
  • Feel for exhaled breath on your cheek.