Three Days After Delivering Her Baby a 30 Year Old Woman Complains of a Sudden

• abdominal pain
• labour
• pregnancy

Large numbers of patients with intestinal hurting present to their general practitioners and emergency departments every year. Most require no specific medical intervention but some volition require urgent infirmary admission. The elderly and paediatric patient present particular challenges. The very young ofttimes give a poor history or can very chop-chop deteriorate. The elderly may have a very complicated medical history and misleading signs. A longitudinal study found that 50% of elderly patients (65 or over) with abdominal pain required access.¹ Because of the difficulty of assessment in these groups of patients you should have a lower threshold for referral.

Abdominal pain has numerous causes but information technology is not necessary to reach a specific diagnosis. The aim is to determine on a management plan, to know when to monitor a patient at abode, and to rule out the more than serious pathology. Almost patients can exist adequately assessed by the simple techniques described and an accurate programme formed for the patients farther management.

This article volition focus on initial assessment and management and not on specific weather condition. There are numerous texts that will give the basic outline of symptoms for dissimilar pathologies.^{2, 3} More than 30 women die each yr in the UK as a direct consequence of pregnancy. The Confidential Enquiry into Maternal Deaths 1997–99^iv stated that "Women are yet dying of potentially treatable conditions where the utilise of uncomplicated diagnostic guidelines may assistance to identify conditions such equally ectopic pregnancy, sepsis and pulmonary embolism".

Key points

• Abdominal hurting is very common

• The very young and very former tin can present a specific challenge

• It is oft unnecessary to brand a diagnosis to plan your management

• In women of childbearing age e'er consider the possibility of pregnancy

OBJECTIVES

• Recognise the severely ill patient and manage appropriately

• Evaluate and manage stable patients

• Management of intestinal pain in women

• Management of pregnancy and its complications

THE Main SURVEY

All patients should be assessed using the ABCD approach. Abdominal pain can be immediately life threatening (primary survey positive). Such cases demand to be identified early so that appropriate intendance tin start immediately (box 1).

Box 1 Life threatening causes of abdominal pain

• Generalised peritonitis with shock

• Acute bowel obstruction

• Ruptured intestinal aortic aneurysm

• Acute mesenteric infarction

• Ruptured ectopic pregnancy

• Placental abruption and other complications of pregnancy

• Toxic shock syndrome

I unusual cause of shock-like syndrome in pregnancy is supine hypotension. If a meaning woman is laid on her back for a prolonged period the uterus obstructs the inferior vena cava resulting in a decrease in venous return, cardiac output, and hypotension. If the uterus is palpable above the navel, lie the patient in the left lateral position.

Central signal

• Do non lie a heavily pregnant adult female on her back

Main survey positive

These patients nowadays in a variety of ways but airway and animate assessment requires the same approach as in whatever other life threatening situation. Shock is the main immediately life threatening problem in patients with abdominal pain (box ii).

Box 2 Common presentations of "principal survey positive" patients

• Collapse

• Shock

• Rigid belly

• Heavy vaginal bleeding

• Complications of labour

Shock can exist owing to either hypovolaemia or sepsis. En road to hospital obtain intravenous access and draw blood for cross matching. Retrieve to complete the patient details on the claret specimen tube. No intervention should filibuster transfer to definitive medical care. Intravenous fluid resuscitation in abdominal haemorrhage should be based on the principle of hypotensive resuscitation, aiming to give enough fluid to maintain a radial pulse.⁵

Key point

• If the radial pulse is palpable, the claret pressure tin can be causeless to be adequate. If absent, aim to give fluid until radial pulse is palpable again.

These patients are likely to be in pain. Intravenous opioid analgesia may be given en road but monitor the blood pressure closely and titrate small doses in unstable patients. Show shows that hurting relief does not affect subsequent clinical assessment and that it removes dissentious physiological stresses and improves accuracy of examination.⁵

Key points

• Some causes of abdominal pain are immediately life threatening

• Treat as able but do non filibuster definitive transfer

• Fluids should be given based upon the principle of hypotensive resuscitation

• Intravenous opioid analgesia tin can be given to salvage pain

Box 1 summarises the most common life threatening problems. However, many common abdominal problems such as astute appendicitis can be life threatening if not promptly diagnosed and treated. This emphasises the importance of reassessment of patients with continuing or worsening symptoms.

Consider potentially serious medical conditions not direct related to the alimentary canal that tin likewise present as intestinal pain (box iii). A focused history and examination will help in identifying such cases (run into below).

Box three Medical conditions presenting with abdominal hurting

• Inferior myocardial infarction

• Pneumonia

• Pulmonary infarction

• Diabetic ketoacidosis

• Inflammatory bowel disease

• Pyelonephritis

Specific potential threats to life in women (meet box iv)

Ectopic pregnancy classically presents with vaginal bleeding and abdominal hurting, but there may also exist associated internal haemorrhage that may give ascension to shoulder tip pain. The degree of daze may exist disproportional to the observed claret loss. The woman may be unaware of pregnancy and may not give a history of a missed period. These patients need fast transport to an advisable unit. Obtain venous admission en route if possible. Give enough fluids to maintain the radial pulse and high flow oxygen. Warning the receiving unit and ensure the gynaecologist is aware.

Box four Potential treats to life in women

• Ectopic pregnancy

• Incomplete miscarriage

• Genital tract trauma

• Pulmonary embolism

• Toxic shock syndrome

An incomplete miscarriage may result in products of conception caught in the cervix that leads to profound vagal stimulation with bradycardia and shock. These patients need urgent infirmary admission because removal of these products will lead to a rapid clinical comeback and reduction in bleeding. Any tissue passed should accompany the woman to hospital.

Pulmonary embolism is still responsible for a number of maternal deaths. Have a low index of suspicion and refer pregnant women with shortness of breath or pleuritic chest pain.

Toxic stupor syndrome is caused by invasive staphyloccal or streptococcal infections and is usually associated with tampon use. The picture is ane of septicaemic shock. Manage by fast transport, intravenous access en road, and oxygen.

Issues in afterwards pregnancy

A number of complications of pregnancy pose potential threats to life, not only for the mother only likewise to the fetus (box five). This is a very high run a risk expanse of practice where the inexperienced practitioner must inquire for the patient to be reviewed by the obstetric squad.

Box 5 Potential threats to life in tardily pregnancy

• Placental abruption

• Placenta praevia

• Pregnancy induced hypertension (pre-eclampsia and eclampsia)

• Pulmonary embolism

Placental abruption

This occurs when the placenta separates from the uterus before nascence. There is abiding severe pain, and the uterus unremarkably volition be rigid and with a sustained contraction. There may be vaginal bleeding but much of the blood is retained within the uterus so the degree of daze volition ordinarily be out of proportion to the amount of revealed bleeding. Rapid transfer to hospital is essential—with intravenous access and high menstruum oxygen. The receiving unit of measurement should be alerted every bit emergency caesarean section will probably exist required.

Placenta praevia

This oftentimes presents with painless vaginal bleeding unless the patient is in labour. It is due to the placenta covering the internal part of the cervix. This tin lead to catastrophic vaginal bleeding every bit the neck dilates at the commencement of labour.

Pregnancy induced hypertension—pre-eclampsia and eclampsia

In early pregnancy the blood pressure level is usually lower than normal. A claret force per unit area of 140/xc mm Hg might seem fairly normal but in a meaning woman implies pregnancy induced hypertension until proved otherwise (see box half dozen).

Box vi Symptoms and signs of severe pre-eclampsia

• Headache

• Visual disturbance

• Upper abdominal pain

• Generalised oedema

• Brisk reflexes

• Reduced urine output

• Blood force per unit area >140/xc or rising in diastolic from previous readings

• Ankle swelling

• Proteinuria

Pre-eclampsia is a condition specifically associated with pregnancy, usually just not always occurring in the late stages of pregnancy. Classically it presents with hypertension, proteinuria, and oedema. When the status worsens the adult female may complain of upper right sided or epigastric abdominal pain, headache, nausea and vomiting. She may become confused and have very brisk reflexes. Plumbing fixtures can then follow. Unless the woman is a known epileptic, any fit in pregnancy is managed every bit a probable eclamptic fit. Fits attributable to eclampsia may pose significant airway bug. Manage these as in any other fit by simple airway manoeuvres. If the fit is not self limiting intravenous diazemuls should be given supplemented by magnesium sulphate once the patient arrives in hospital. Information technology is likewise essential to control the blood pressure every bit shortly as possible. Urgent transfer to an obstetric unit of measurement is required.

EVALUATION OF THE STABLE PATIENT

If the primary survey shows no requirement for resuscitation so a secondary survey can be undertaken using the SOAPC organization. History and examination has been shown to be very effective in distinguishing organic and not-organic causes of pain.⁷

Subjective information

The history is the virtually important assistance in reaching a diagnosis. The correct questions can very chop-chop allow the assessor to gauge the severity of the problem too rule out the serious causes of abdominal pain.

The main questions are related to the hurting (box 7), other symptoms, previous handling, or medical contacts in this episode, as well every bit the standard by medical, drug, allergy, and social history.

Box 7 The questions that should be asked about the pain. "PQRST"

Pain related questions

• Provoking or palliative factors

• Quality—constant/colicky

• Radiation and site of hurting, for instance, shoulder tip

• Southeverity and systemic symptoms

• Timing—was onset sudden or insidious, did information technology alter over time?

Pain—precipitating and palliative factors, quality, timing, and radiations

Precipitating and palliative factors may requite important clues. The patient with peritonitis will ordinarily prevarication nonetheless with move or coughing worsening the pain. In contrast the patient with colic will often be restless, trying to find a comfy position.

Quality—intestinal pain is commonly described every bit "peritoneal" or "colicky". If the parietal peritoneum is aggravated and so the pain will be well localised to the expanse of the pathology. In contrast, visceral pain tends to be poorly localised. Pain arising from foregut structures (mouth to the proximal one-half of the duodenum) is felt in the upper belly, pain from mid-gut structures (distal one-half of the duodenum to middle of the transverse colon) is felt around the umbiliacus, and the hind gut (rest of colon to rectum) is felt in the lower abdomen.

Colicky pain is unremarkably attributable to spasm of a tubular structure, oft around a blockage. Colicky hurting is therefore more commonly biliary, intestinal, or ureteric in origin.

Radiation of the pain may aid in diagnosis. Renal pain tends to radiate "loin to groin". Diaphragmatic irritation, for case, ruptured ectopic, may radiate to the shoulder tip considering of their mutual innervation (C3,four,5).

Systemic symptoms—(nausea/vomiting/urinary/gynaecological) symptoms may exist helpful in diagnosis but can also be misleading. For case, constipation is associated with obstruction but is non always present. It is important to found the patient's normal bowel habit.

Diarrhoea is normal in gastroenteritis simply may besides be attributable to overflow related to chronic constipation, irritation of the pelvic peritoneum (for example, pelvic appendicitis) or partial obstacle. Faecal blood may point inflammatory bowel disease, cancer, or parasitic infection.

Urinary symptoms may suggest urinary tract infection (UTI) just non all UTIs cause abdominal pain.

In the female person patient a menstrual history should be taken. Gynaecological causes should be considered. All women of child bearing historic period with abdominal pain who accept missed menstruation must take ectopic pregnancy excluded.

Timing—Pain with a sudden onset is probably an acute severe outcome, for example, ruptured aneurysm or perforated viscus. In contrast a gradual onset suggests an inflammatory or infective cause.

Hurting may alter over time, for example, appendicitis starts with a colicky periumbilical pain due to obstruction. This and so leads to infection and a localised inflammation of the parietal peritoneum.

Medical history

If the patient has previously presented with the aforementioned trouble it is important to keep an open up mind. Diseases tin progress, complications may arise, and the patient'due south status change.

Medical history can reveal other abdominal bug or chronic illnesses (for instance, angina) that may indicate y'all towards a diagnosis.

Certain drugs are associated with gastrointestinal side effects. Non-steroidal anti-inflammatory agents increment risk of peptic ulceration and bleeding. Many antibiotics crusade diarrhoea and some can crusade life threatening issues such as pseudomembranous colitis.

Key points

• A good history is your about important diagnostic tool

• Always repeat a full history even if the patient has been seen previously

• Do not forget gynaecological problems in the female person patient

OBJECTIVE INFORMATION

This consists of exam and investigations on scene (if available or relevant) and is summarised in box 8.

Box viii Summary of examination of patient with abdominal hurting

Scheme for examination

General

• Posture—curled upward/agitated (colic); flat/bent knees (peritonism)

• Colour—pale; jaundice

• Vital signs

• Oral cavity (foetor), tongue, peel turgor for hydration

• Lymph nodes

Abdomen

• Look—amplification, move, flanks bruising

• Feel—bear witness of peritonitis, pulses, hernial orifices

• Listen—bowel sounds

• Testicles

• PR/PV if appropriate (be cautious if no chaperone)

Other

• Respiratory system

• Cardiovascular system

Patient preparation

In an ideal setting, test of the abdomen would entail ensuring that the patient is exposed from "nipple to articulatio genus", and PR or PV examinations performed. However, it is very likely that these will be hard and often impossible in the community setting. If carrying out a PR/PV exam, explain all stages to the patient and accept a chaperone present at all times. Exceptions to this rule would be where the patient is very unwell and there is an obvious clinical demand, for example heavy PV bleeding or imminent childbirth.

Vital signs

Vital signs accept been discussed in primary survey and are oft the about sensitive indicators of a serious problem. It is unlikely that the normotensive, apyrexial patient with a pulse rate of eighty has an immediately life threatening abdominal problem at the time of exam, just is no guarantee that such a condition may not develop.

Other full general signs such equally assessment of hydration and smelling the breath for foetor (sweet scent indicating ketosis) may help assess the general land of health.

The abdomen

The patient should be fully exposed within the boundaries of decency and conscientious inspection carried out.

Look especially for obvious distension, swellings, hernias, or other masses or scars of previous operations. The patient should be examined with the arms by the side and so as to decrease abdominal wall muscle tension.

Ask the patient to take a deep breath and then to cough while observing the patient's reaction and intestinal movement. The patient with peritoneal irritation will avoid movement or the pain will be increased.

Experience—before palpating the abdomen enquire the patient to point to the site of greatest hurting and then start examination as far away from this point as possible. Initially use gentle, shallow palpation earlier palpating more securely. In an area of specific tenderness due to peritoneal irritation there will ordinarily be guarding—a spasm of the overlying abdominal muscles.

Percussion over the area of tenderness giving pain suggests peritoneal irritation. Testing for rebound tenderness is no longer considered appropriate.

Assess for organomegaly of the liver and spleen by always starting in the correct lower quadrant and moving toward the hypochondia to avoid missing a grossly enlarged organ.

Murphy's sign is elicited by pressing the fingertips up towards the right costal margin and asking the patient to exhale deeply. If the gall bladder is inflamed, the patient will experience hurting when breathing in equally the gall bladder descends and comes into contact with the palpating hand.

E'er assess the inguinal and femoral hernia orifices. Obstacle secondary to a strangulated or incarcerated hernia is a diagnosis often missed by inexperienced clinicians. It is usually appropriate at this point to assess the scrotum in the male person.

Heed—auscultate for at least ane minute in a single location. Absenteeism of bowel sounds suggests pregnant pathology while high pitched tinkling sounds may also propose obstruction.

Rectal and vaginal examination—in the community setting these examinations may be difficult. Unless they are likely to add useful diagnostic information that might forestall hospital referral, they should be omitted.

Intestinal exam is difficult in overweight, elderly, and paediatric patients, and those with a reduced conscious level. You lot need to take into account the less than ideal nature of your examination in the assay of the trouble.

Investigations

Investigations that may be of use in the community are urine dipstick testing for urinary tract infection or haematuria, claret glucose testing in possible diabetic keto-acidosis, and a pregnancy exam in whatsoever adult female of childbearing age. This should be performed with patient consent. In singular epigastric pain an ECG may exist indicated.

Cardinal points

• Exam helps to refine your history diagnosis

• A structured exam volition assistance avoid missing of import data

• Exercise not forget the hernial orifices

• PR and PV should only be done if calculation useful clinical data that may preclude hospital referral

• Consider near patient testing in selected cases

ANALYSIS

Sure symptoms are absolute indications for admission while others are more relative and rely on assessment and the degree of certainty about the diagnosis (see table 1).

View this table:

• View inline

Table ane

 Absolute and relative indications for referral to hospital

In the adult female of childbearing age, always consider the possibility of ectopic pregnancy. If at that place is whatever doubt discussion with the gynaecology team is mandatory.

Table 2 lists the common diagnoses in patients with acute abdominal pain and the "classic" signs and symptoms. However, many intestinal conditions tin can present in an singular fashion as well signs and symptoms may change. Thus, the need for a loftier index of suspicion.

View this table:

• View inline

Table 2

 Common diagnoses and their common presentation

Intestinal pain in women

The assessment principles are described to a higher place. The menstrual history must be taken and pregnancy or its complications always suspected (box 9).

Box 9 Of import causes of abdominal pain in women

Mutual

• Urinary tract infection.

• Pelvic inflammatory disease.

• Dysmenorrhoea

• Labour

Uncommon

• Ectopic pregnancy

• Appendicitis

• Biliary colic

• Ovarian syndromes

• Miscarriage

Rare

• Ovarian hyperstimulation syndrome

• Curtis Fitzhugh syndrome

• Toxic shock syndrome

Ectopic pregancy

This is a diagnosis that should be considered in all women of reproductive age. Classically the patient will accept lower abdominal pain, a history of a late or missed period, and signs of peritoneal irritation. Unfortunately the symptoms and signs may be misleading. You lot should have a high index of suspicion if the woman has a history of infertility, has missed a menses while using an intrauterine contraceptive device, or has been sterilised. The management has been outlined in the section on main survey.

Key points

Always consider the possibility of ectopic pregnancy in women with abdominal pain.

• If no history of missed menses bank check if terminal period was normal (in time, elapsing and blood loss)

• Ask about contraception

Common issues

Cystitis is very common with classic symptoms of frequency and dysuria. Systemic symptoms such every bit nausea, vomiting, and fever are non usual in simple cystis. The abdominal pain is less of a feature than the urinary symptoms and the abdomen is rarely tender. Urine analysis gives a typical picture with protein and white cells and often some blood. Ane important pitfall is that other causes of pelvic inflammation tin can also cause frequency and dysuria. For instance, a pelvic appendicitis will cause abdominal pain, dysuria, frequency and even poly peptide, blood and white cells on urine analysis.

Pitfall

Whatsoever cause of pelvic inflammation may crusade dysuria and frequency

Virtually women with cystitis volition exist systemically well and will have no major abdominal signs. Cystitis is diagnosed past sending a midstream specimen of urine for civilization and sensitivity and is treated with oral fluids and antibiotics. Alkylating agents may give symptomatic relief.

Pyelonephritis is associated with urinary symptoms but the patient is unwell, has loin pain, is pyrexial, and ofttimes has nausea or vomiting. If the systemic symptoms are balmy and so outpatient treatment is possible. If the patient cannot tolerate oral antibiotics nor has pregnant systemic symptoms and signs, then they volition need referral to hospital.

Dysmenorrhoea

Pain at the fourth dimension of the menses is an extremely common symptom. If the flow is late or the amount of bleeding is abnormal then ectopic pregnancy or miscarriage should be considered. There are no major abdominal signs. A pregnancy test should be done. A non-steroidal anti inflammatory such equally mefenamic acid is the all-time symptomatic treatment for this trouble.

Early on pregnancy vaginal bleeding/miscarriage

A miscarriage is the loss of a pregnancy before xx weeks gestation. The usual symptom is vaginal bleeding. At that place is ofttimes some abdominal pain but this is not usually astringent. If the bleeding is not severe (for instance, less than in normal period), the pregnancy is less than 12 weeks and the patient is well and stable contact the gynaecology unit of measurement to adjust review at an early pregnancy assessment unit of measurement. If the bleeding is heavy, at that place is tachycardia or bradycardia and hypotension, products of conception take been passed, or if the abdominal pain is severe, refer for immediate gynaecological assessment.

Pelvic inflammatory illness

Infections of the fallopian tubes and surrounding tissues are common in sexually active women. Typically in that location may be a history of vaginal discharge and lower intestinal hurting. The differential diagnosis includes urinary tract infection, appendicitis, and ectopic pregnancy. Patients with mild symptoms should be advised to consult their primary care dr. or get to a genitourinary medicine clinic as shortly as possible. Patients who accept missed a period, have a positive pregnancy test, or have significant systemic upset should exist referred to infirmary for further investigations.

Ovarian cysts, mid-cycle ovulation hurting

Ovarian cysts may rupture or undergo torsion. The cyst may non exist large enough to feel abdominally but there volition be rebound tenderness and signs of peritonism. At that place may be a mild fever. If the right ovary is involved the presentation is similar to appendicitis. Refer to the gynaecology team.

Mid-bicycle ovulation pain occurs at ovulation. As the follicle ruptures there may be balmy irritation of the peritoneum. The patient is well, she is at the midpoint of a normal menstrual cycle, the symptoms are short lived, vital signs are normal, there are no systemic symptoms. Check a pregnancy examination. Propose simple analgesia merely emphasise the need to seek farther advice if the pain does not settle, gets worse, or other symptoms develop.

Ovarian hyperstimulation syndrome—this is a gynaecological emergency, which may be life threatening. It generally occurs in women who are having ovulation induced under the intendance of an assisted conception unit of measurement. Large cysts appear in the ovaries and fluid shifts from the circulation to produce ascites and a shock-like clinical syndrome. These patients will take abdominal pain and significant systemic upset. If a women undergoing IVF or other methods of assisted conception develops abdominal pain, refer urgently to the appropriate gynaecological team.

Programme FOR PATIENTS WITH Abdominal Pain

A risk stratification arroyo will give a good guide as to the advisable direction plan. This involves using your analysis to put patients in one of five groups.

Group 1—features suggesting hospital referral

At that place are very clear signs of definite surgical pathology with a big number of typical features of illness, for example classic appendicitis. In these patients the management program is straightforward and picayune further investigation is needed in the emergency department. These patients should, therefore, be referred to the appropriate inpatient team (for example, surgical admissions unit).

Group 2—patients who need a illness "rule out"

There are borderline cases with some features of a diagnosis but the clinical motion-picture show is non sufficiently articulate to make a definite determination on management. They need further investigation and possibly further observation. This group will include the very immature, the older patient, and cases where in that location are communication difficulties. These may need to be referred to A&E or to the appropriate inpatient team.

Group 3—common features permitting diagnosis of a problem that may exist treated at home

For instance the young adult female with definite signs of urinary tract infection and no signs of other pathology, or a articulate history of a likely self limiting gastroenteritis in an otherwise fit and healthy person.

Group iv—type of patient who may be treated by a expect and see approach

This grouping has no specific symptoms or signs that indicate serious pathology at the time of assessment. Do non give a "diagnosis" such equally "constipation" or "UTI" when at that place are no specific symptoms or signs or confirmatory test results.

These patients may be managed at habitation with advice that the diagnosis is not articulate merely at present there are no signs of serious pathology. The patient should exist advised to seek farther communication if symptoms fail to settle or go worse.

Grouping 5—social implications

Some patients may demand referral, such as the very elderly or very young, because of difficulty coping at home equally well every bit the trend for more rapid deterioration in condition.

Fundamental point

• As a full general principle, if a patient consults for a third fourth dimension in a few days with the same problem then they should be referred for a specialist stance

Advice

Advice in abdominal pain is both with the patient and with other agencies.

The patient

If they are to be managed at home then they should have a full caption of your findings and, if possible, probable diagnosis and its usual progression/resolution. If the diagnosis remains unclear reassure the patient that there are no signs of serious disease that crave admission at present merely they should seek further consultation if things worsen.

If they crave admission explicate why equally clearly and concisely every bit possible in straightforward linguistic communication.

Other agencies

If the patient requires admission and then a articulate, curtailed, and legible letter to the admitting team is appropriate in all but the imminently life threatening instance (for case, AAA). This should include the important details from the history and examination every bit well every bit details of whatsoever previous consultations if known.

If the patient is managed at habitation ensure details are entered in the GP notes or details sent to the patients GP equally advisable.

Normal labour

If delivery is not imminent transfer to labour ward or contact community midwife. However, the emergency practitioner may be faced with a woman in preterm labour, or with a concealed or unsuspected pregnancy who is nearly to deliver. The local obstetric unit should be contacted to asking an on call community midwife to ask them to attend. A detailed clarification is found in many texts (JRCALC, Ambulance service manual, WHO spider web site.^{8, nine} Box 10 summarises management).

The central activeness is to provide gentle support.

Box 10 Summary of the management of normal labour

• If the membranes take broken harbinger coloured fluid will exist seen, if the fluid is green this may be indicative of fetal compromise, although a minor number of green streaks is mutual

• Every bit the head is delivering ask the woman to pant and merely give minor pushes

• Put the fingers of ane hand against the head to go on it flexed. Support the perineum with the other paw

• The head will usually deliver with face looking downwardly towards the mothers buttocks

• Once the head is delivered ask the woman not to push

• Allow the head to turn spontaneously

• Place the easily on either side of the caput

• At the next contraction ask the adult female to button

• Gently movement the head posteriorly to evangelize the anterior shoulder

• Once the anterior shoulder is delivered, lift the caput anteriorly to evangelize the posterior shoulder

• Support the body as information technology is delivered

• Place the baby on the mother's abdomen

• Dry the baby, discard wet towels, and cover with dry towel

• Appraise animate and heart rate, near babies will weep or breath inside xxx seconds and have a rate over 100

• There is no rush to cut the umbilical cord, if all is well then place the cord clamps and cut the cord after it has stopped pulsating

• Palpate the abdomen to ensure that there is but 1 baby

Syntometrine should be given presently after commitment if information technology is available as it reduces bleeding and aids separation of the placenta. This should only be given when it is quite certain that this is non a multiple pregnancy.

Pitfall

Syntometrine or ergometrine will exacerbate hypertension—use syntocinon instead. None of these drugs should be given if there is a possibility of multiple pregnancy until all babies are delivered

Multiple births

In that location is usually a reasonable time delay between commitment of the showtime babe and the 2d. The placenta should be left in situ and arrangements made to transfer the mother into an obstetric unit. If the urge to push occurs again delivery should be equally detailed elsewhere.

Breech

This is when the feet or lesser are delivered start. You should avoid handling the baby. If necessary any force per unit area should be placed around the infant'south pelvic girdle to ensure that the babe remains with its back uppermost. Ideally the mother should give birth at the border of the bed so the baby can hang freely to allow gravity to aid delivery. Once the nape of the cervix is visible hold the baby's feet and gently sweep them in upwards arc to a vertical position to aid delivery of the caput.

Direction of issues

Cord prolapse

If the string (a rope like construction) is seen protruding through the vagina the woman should be transported urgently to infirmary. If possible she should exist placed in an all fours position with the caput downward and buttocks up in the air to reduce pressure on the cord and allow oxygen to attain the baby. Put warm saline swabs on the cord (if readily bachelor, practise not filibuster transport). Warn the receiving unit of measurement to prepare for emergency caesarean section.

Shoulder dystocia

Subsequently the head delivers the shoulders should follow inside the adjacent 2 contractions. If they do not deliver do Not pull on the baby's head, simply encourage the female parent to push button with her hips and knees sharply flexed upward towards her shoulders, or alternatively encourage her to turn onto all fours on her easily and knees. Pressure can exist put on the inductive shoulder to promote adduction of the shoulders. Stand backside the baby's back and press obliquely downwardly above the symphysis pubis.

Postpartum haemorrhage

If heavy haemorrhage occurs intramuscular syntometrine should be given, intravenous access obtained. If the placenta has delivered the uterus may be aided in its contraction by rubbing the lower abdomen. Make urgent arrangements to transfer into hospital.

SUMMARY

Abdominal pain is a common presentation to the community practitioner. Well-nigh presentations can be managed at dwelling house with simple advice and support, however some require admission for further assessment.

A structured approach to direction will avert missing the serious signs and symptoms of potentially life threatening illness. Detail care is required in the very elderly or very young because history taking and examination can be difficult.

Acknowledgments

Nosotros would similar to thank Peter Driscoll and Malcolm Woollard for their detailed comments and critiques of drafts of this paper.

REFERENCES

1. ↵

   Dang C, Aguilera P, Dang A, et al. Acute intestinal hurting: four classifications can guide assessment and management. Elderliness 2002;57:30–ii.

2. ↵

   Simon S, Everitt H, Birtwhistle J, et al. Oxford handbook of full general do. Oxford: Oxford University Press, 2002.

3. ↵

   Greaves I, Dyer P, Porter One thousand. Handbook of firsthand intendance. London: WB Saunders, 1995.

4. ↵

   Department of Health. Why mothers die 1997–1999. The fifth study of the U.k. confidential enquiries into maternal deaths. London: HMSO, 2001; (http://www.cemach.org.uk).

5. ↵

   Smail Due north, Wang P, Cioffi WG, et al. Resuscitation after uncontrolled venous hemorrhage: Does increased resuscitation volume amend regional perfusion? J Trauma 1998;44:701–eight.

6. American College of Emergency Physicians. Clinical policy: disquisitional issues for the initial evaluation and direction of patients presenting with a primary complaint of nontraumatic acute abdominal pain. Ann Emerg Med 2000;36:406–xv.

7. ↵

   Martina B, Bucheli B, Stolz M, et al. Offset clinical judgement by principal care physicians distinguishes well between nonorganic and organic causes of abdominal or breast hurting. J Gen Intern Med 1997;12:459–65.

8. ↵
9. ↵

kromesumforger.blogspot.com

Source: https://emj.bmj.com/content/21/5/606

Share :