General Management of Shock in a Patient with Vulval Haematoma (BP 85/50 mmHg)

1. Airway

• Ensure a patent airway - this is always the first priority
• If GCS ≤8 or airway is compromised, perform rapid sequence intubation

2. Breathing / Oxygenation

• Administer high-flow supplemental oxygen (100% O₂ via non-rebreather mask)
• Aim for SpO₂ >95%
• Consider intubation and mechanical ventilation if breathing is inadequate or work of breathing is excessive
• Attach continuous pulse oximetry

3. Circulation (IV Access and Fluid Resuscitation)

• Establish two large-bore IV cannulae (14-16G) - insert above and below the diaphragm if indicated
• If peripheral venous access is difficult, use intraosseous access
• Administer a fluid bolus: 20 mL/kg warm isotonic crystalloid (normal saline or Hartmann's/Ringer's lactate) rapidly; repeat if no improvement
• If no response to 2 crystalloid boluses, initiate blood transfusion: packed red blood cells (pRBCs) at 10 mL/kg
• Give warmed fluids to prevent hypothermia
• Aim for damage control resuscitation while the patient is still bleeding - avoid excessive crystalloid (causes dilutional coagulopathy); give equal volumes of pRBCs and fresh frozen plasma

4. Haemorrhage Control (Cause-Specific but Concurrent)

• The primary treatment of haemorrhagic shock is arresting the haemorrhage - fluid resuscitation is only supportive to maintain cardiac perfusion
• Apply local compression/pressure packing over the haematoma if bleeding is ongoing
• Definitive surgical control to be arranged urgently

5. Positioning

• Place the patient in the supine position with legs elevated (Trendelenburg / modified shock position) to augment venous return - unless contraindicated (e.g. head injury, respiratory distress)

6. Monitoring (Minimum)

• ECG - continuous cardiac monitoring
• Pulse oximetry - continuous
• Blood pressure - non-invasive every 5 minutes; consider arterial line if not rapidly correcting
• Urine output - insert urinary catheter; target ≥0.5 mL/kg/hr in adults (a reliable indicator of renal perfusion)
• Temperature - prevent/treat hypothermia
• Additional: CVP line, serum lactate, base deficit for ongoing assessment

7. Investigations (Send simultaneously)

• Full blood count, coagulation profile (PT, APTT, fibrinogen), blood group and cross-match
• Arterial blood gas (lactate, base excess)
• Serum urea, electrolytes, creatinine
• Serum glucose

8. Coagulopathy Management

• Give tranexamic acid as early as possible to reduce hyperfibrinolysis (especially within 3 hours of haemorrhage onset)
• Correct existing coagulopathy with blood products: cryoprecipitate for low fibrinogen, platelets for thrombocytopenia/dysfunction
• Avoid excessive crystalloids which cause dilutional coagulopathy

9. Warmth

• Keep the patient warm; use warm IV fluids and warm blankets
• Hypothermia worsens coagulopathy and acidosis (the "lethal triad" = hypothermia + coagulopathy + acidosis)

10. Prevent Further Injury / Analgesic Cover

• Manage pain judiciously (excessive opioids can worsen hypotension)
• Reassess frequently using the ABCDE approach

Key Principle (Bailey & Love's Surgery, p. 36)

"Haemorrhage is treated by arresting the bleeding - not by fluid resuscitation or blood transfusion. Although necessary as supportive measures to maintain organ perfusion, repeated volume replacement without arresting haemorrhage simply results in continued bleeding, dilutional coagulopathy, hypothermia and worsening haemodynamic instability."

Precautions During Birth of a Preterm Baby at 34 Weeks Gestation (Late Preterm)

A. ANTEPARTUM PRECAUTIONS (Before the Birth)

1. Antenatal Corticosteroids (ACS)

• Give betamethasone 12 mg IM x2 doses, 24 hours apart (or dexamethasone 6 mg IM x4 doses, 12 hours apart)
• Most effective if given before 34 weeks; at exactly 34 weeks their benefit is marginal but still considered
• Purpose: accelerate fetal lung maturity, reduce risk of respiratory distress syndrome (RDS), intraventricular haemorrhage (IVH), and necrotising enterocolitis (NEC)

2. Magnesium Sulphate for Neuroprotection

• Administer if delivery is anticipated before 34 weeks - magnesium sulphate reduces the risk of cerebral palsy
• At 34 weeks it may still be considered based on local protocol

3. Tocolysis (if appropriate)

• Tocolytics (calcium channel blockers, prostaglandin inhibitors, beta-adrenergic agonists) may be used to delay delivery long enough for corticosteroids to take effect
• Contraindicated if: uterine infection (chorioamnionitis), severe haemorrhage, non-reassuring fetal status, fetal death or lethal anomaly
• Magnesium sulphate alone is NOT recommended purely as a tocolytic

4. Delivery Setting

• Arrange delivery at a tertiary care / level III NICU facility
• NICU team should be notified and present at delivery
• Paediatrician / neonatologist must be present at birth

5. Ultrasound Assessment

• Confirm fetal presentation (breech is more common in preterm - warrants caesarean consideration)
• Assess estimated fetal weight, amniotic fluid index, biophysical profile
• Very low birth weight infants (<1500g) with breech - caesarean preferred to prevent head entrapment

B. INTRAPARTUM PRECAUTIONS (During Labour and Delivery)

1. Mode of Delivery

• Vaginal delivery is generally acceptable at 34 weeks if vertex presentation
• Caesarean section is preferred for: breech/transverse lie, fetal distress, placenta praevia, or if vaginal delivery poses risk of trauma to the fragile preterm skull
• Avoid prolonged labour

2. Fetal Monitoring

• Continuous electronic fetal monitoring (cardiotocography/CTG) throughout labour
• Preterm fetuses are more susceptible to intrapartum asphyxia
• Watch for non-reassuring fetal heart rate patterns - prompt intervention required

3. Analgesia/Anaesthesia Precautions

• The preterm infant is more sensitive to drugs used in obstetric analgesia due to:
  • Less plasma protein available for drug binding
  • Higher bilirubin levels (compete for protein binding)
  • Poorly developed blood-brain barrier
  • Decreased drug metabolism and excretion
• Minimize opioid use; prefer regional anaesthesia (epidural/spinal)
• If general anaesthesia needed (emergency CS): use standard rapid sequence induction
• Tocolytic drug interactions to be aware of:
  • Calcium channel blockers - can cause hypotension and cardiac conduction defects
  • Beta-agonists - cause maternal tachycardia, risk of pulmonary oedema
  • Magnesium sulphate - potentiates neuromuscular blocking agents

4. Episiotomy

• A liberal/routine episiotomy was traditionally performed for preterm delivery to protect the fragile preterm head from pressure during crowning
• Current practice: selective episiotomy if needed

5. Avoid Traumatic Delivery

• Avoid difficult operative vaginal delivery (high forceps) for a preterm infant
• Gentle outlet forceps may be used to protect the preterm head, but with caution

C. IMMEDIATE POSTNATAL PRECAUTIONS (At Birth - For the Baby)

1. Warmth (Thermoregulation) - PRIORITY

• Warm the delivery room to 25-26°C
• Dry and wrap the baby immediately after delivery
• Use warm blankets, radiant warmer, or polyethylene plastic wrap (occlusive wrap without drying) for very preterm infants
• Preterm neonates lose heat rapidly due to large surface area, thin skin, and poor subcutaneous fat

2. Skilled Neonatal Resuscitation Team at Delivery

• Neonatologist/paediatrician must be present before delivery
• Resuscitation equipment must be ready:
  • Radiant warmer on
  • Suction ready
  • Bag-mask ventilation (appropriately sized - size 0 or 00 mask)
  • Intubation equipment (ETT sizes 2.5-3.0)
  • Surfactant ready if needed

3. Cord Clamping

• Delayed cord clamping (DCC) for 30-60 seconds is recommended for preterm infants (unless resuscitation is immediately needed)
• DCC improves blood volume, reduces risk of IVH, reduces need for blood transfusion, and lowers risk of necrotising enterocolitis

4. Airway and Breathing

• Assess and stimulate - dry and stimulate to breathe
• If no spontaneous breathing: begin positive pressure ventilation (PPV) with a T-piece resuscitator or bag-mask
• Target SpO₂ with a saturation probe on the right hand (pre-ductal)
• Avoid hyperoxia - start resuscitation with 21-30% oxygen (NOT 100%) in preterm infants; titrate to target saturations
• If persistent respiratory distress: consider early CPAP or intubation + surfactant administration

5. Apgar Scoring

• Record Apgar score at 1 and 5 minutes; continue at 10 minutes if low

6. Prevention of Complications

7. NICU Admission

• All babies born at 34 weeks should be admitted to the neonatal unit/NICU for monitoring, respiratory support, feeding assistance, and warmth

Key Principle

"In selection of anesthetic drugs and techniques for delivery of a preterm infant, concerns regarding drug effects on the newborn are far less important than prevention of asphyxia and trauma to the fetus." - Barash's Clinical Anesthesia, 9E

"Preterm delivery accounts for up to 35% of neonatal deaths. Severe problems that may develop include respiratory distress syndrome, intracranial haemorrhage, hypoglycaemia, hypocalcaemia, and hyperbilirubinaemia." - Barash's Clinical Anesthesia, 9E