Emergency Management Stations

ABCDE Approach

Always begin with structured assessment:

• A — Airway: patent? obstruction? jaw thrust, suction, adjuncts
• B — Breathing: rate, SpO2, chest expansion, auscultation; high-flow O2
• C — Circulation: pulse, BP, CRT, urine output; two large-bore IV cannulae (14G), fluids, bloods (FBC, coag, crossmatch, lactate)
• D — Disability: AVPU or GCS, pupils, blood glucose
• E — Exposure: temperature, full examination, obstetric assessment (fetal heart, uterine tone, vaginal examination)

PPH Management Algorithm

1. Call for help (obstetric emergency team)
2. ABC — IV access, fluid resuscitation, bloods including crossmatch
3. Rub up the fundus (bimanual compression)
4. Identify cause (4 T's: Tone, Trauma, Tissue, Thrombin)
5. Uterotonics: oxytocin 5IU IV → ergometrine 500mcg IM → carboprost 250mcg IM → misoprostol 800mcg SL/PR → TXA 1g IV
6. Examination under anaesthesia if needed
7. Balloon tamponade (Bakri balloon)
8. Surgical: B-Lynch suture → uterine artery ligation → internal iliac artery ligation → hysterectomy
9. Activate massive transfusion protocol if needed (1:1 RBC:FFP)
10. Cell salvage if available

Eclampsia Management

1. Call for help — anaesthetist, senior obstetrician
2. Protect airway — left lateral position, do NOT restrain
3. Magnesium sulphate: 4g IV over 5-15 minutes (loading dose)
4. Maintenance: 1g/hr infusion for 24 hours
5. If further seizure: additional 2g bolus
6. Control hypertension: IV labetalol or oral nifedipine
7. Monitor: reflexes hourly, respiratory rate, urine output
8. Toxicity signs: loss of reflexes → respiratory depression → cardiac arrest
9. Antidote: 10ml 10% calcium gluconate IV
10. Plan delivery once stabilised

Shoulder Dystocia (HELPERR)

1. H — Help: call obstetric emergency team, note the time
2. E — Evaluate for episiotomy
3. L — Legs: McRoberts position (thighs hyperflexed onto abdomen)
4. P — Pressure: suprapubic (NOT fundal) — directed posteriorly and laterally
5. E — Enter: internal manoeuvres
   • Rubin II: fingers behind anterior shoulder, push towards fetal chest
   • Wood's screw: pressure on anterior aspect of posterior shoulder to rotate 180 degrees
6. R — Remove posterior arm: flex elbow, sweep forearm across chest
7. R — Roll to all-fours (Gaskin manoeuvre)

• NEVER apply fundal pressure — worsens impaction, risks uterine rupture
• Last resort: Zavanelli manoeuvre (cephalic replacement + emergency CS)

Cord Prolapse

1. Call for help — category 1 caesarean section
2. Immediately fill the bladder (500ml saline via catheter) to elevate presenting part
3. Position: knee-chest or Trendelenburg (head down)
4. Handle the cord as little as possible (vasospasm) — keep warm and moist
5. If cord is outside the vulva, gently replace into vagina
6. Manually elevate the presenting part to relieve cord compression
7. Tocolysis (terbutaline 250mcg SC) if uterine contractions
8. Continuous CTG monitoring
9. Emergency caesarean section (if cervix not fully dilated); assisted vaginal delivery if fully dilated and conditions met

Communication in Emergencies: SBAR

• S — Situation: "I'm calling about Mrs X who is having a massive PPH on delivery suite"
• B — Background: "She is a para 2 who had an SVD 30 minutes ago. She has had an estimated blood loss of 1500ml"
• A — Assessment: "She is tachycardic at 120bpm, BP 90/50, the uterus is atonic"
• R — Recommendation: "I need senior obstetric review immediately and would like to activate the massive transfusion protocol"

Team Briefing

• Clearly assign roles (airway/anaesthetics, resuscitation, procedure, documentation, communication)
• Use closed-loop communication (confirm instructions back)
• Call team members by name
• Debrief after the event (hot debrief + formal debrief later)

Key Points Examiners Mark

• Structured ABCDE approach (demonstrates systematic thinking)
• Calls for appropriate help early (does not try to manage alone)
• Clear communication (SBAR) with team
• Prioritises correctly (life-threatening issues first)
• Knows emergency algorithms (PPH, eclampsia, shoulder dystocia)
• Delegates effectively and assigns roles
• Remains calm and professional under pressure
• Documents events and debriefs the team/patient afterwards

Common Pitfalls

• Starting treatment before assessment (not following ABCDE)
• Failing to call for help early enough
• Applying fundal pressure in shoulder dystocia
• Forgetting tranexamic acid in PPH management
• Not monitoring magnesium sulphate toxicity (reflexes, respiratory rate)
• Poor team communication — not using names or closed-loop
• Forgetting to debrief the patient and family after the emergency

Clinically reviewed by NHS obstetricians and gynaecologists

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