Emergency Obstetric First-Response for the Midwife - Cheat Sheet
Your 30-minute exam-ready reference for recognizing and managing the five obstetric emergencies a midwife must master: PPH, shoulder dystocia, cord prolapse, eclampsia, and newborn resuscitation. Every fact here could be tested. Know the sequences, drugs, doses, and WHEN TO REFER.
Postpartum Hemorrhage (PPH)
Formulas
PPH defined: ≥500 mL blood loss (vaginal delivery) OR ≥1000 mL (cesarean) OR any blood loss making mother symptomatic
Meaning
Symptomatic = dizzy, pale, rising pulse, falling BP. The DEFINITION depends on volume OR clinical signs, whichever comes first.
Watch out
Students confuse PPH threshold — remember: 500 mL vaginal, 1000 mL cesarean, OR symptomatic (lower threshold = more important clinically).
When to use
Assess every patient in first 2 hours postpartum. Document estimated blood loss (EBL) carefully.
Common values
Value
≥500 mL
Symbol
500 mL
Quantity
PPH threshold (vaginal delivery)
Value
≥1000 mL
Symbol
1000 mL
Quantity
PPH threshold (cesarean delivery)
Value
10 IU IM
Symbol
10 IU
Quantity
Oxytocin first-line dose
Value
0.2 mg IM
Symbol
0.2 mg
Quantity
Methylergometrine dose
Value
800 mcg SL (or 600–800 mcg rectal)
Symbol
800 mcg
Quantity
Misoprostol dose
Value
1 g IV
Symbol
1 g
Quantity
Tranexamic acid dose
Value
~70%
Symbol
70%
Quantity
Percentage of PPH caused by atony
Important facts
- PPH is the LEADING CAUSE of maternal death globally.
- First action: FUNDAL MASSAGE (firm, continuous) until firm — atony resolves with massage alone in many cases.
- Oxytocin 10 IU IM is FIRST-LINE uterotonic; can also give 20 IU in 1 L IV fluid running fast.
- Empty the bladder (catheterize) — a full bladder prevents uterine contraction.
- IV fluids (normal saline or Ringer's lactate) run FAST; large-bore IV line is essential.
- Methylergometrine 0.2 mg IM is CONTRAINDICATED in hypertension or pre-eclampsia (risk of stroke).
- Second-line uterotonics: Methylergometrine 0.2 mg IM, Misoprostol 800 mcg SL (or 600–800 mcg rectal), Tranexamic acid 1 g IV.
- Bimanual uterine compression: one fist in anterior vaginal fornix (pushing UP), other hand on abdomen behind fundus (pushing DOWN) — compresses uterus between hands.
- Aortic compression (pressing fist into abdomen below umbilicus, against aorta) is a temporizing measure only — hold maximum 5 minutes.
- Check placenta: is it complete? Retained tissue = tissue hemorrhage = manual removal at hospital.
Key definitions
Uterine Atony
Example
Fundus feels doughy, not firm; bleeding continues with a soft uterus = atony = massage immediately.
Failure of the uterus to contract after delivery; soft, boggy fundus; the cause of ~70% of PPH.
The 4 T's of PPH
Example
Firm uterus + heavy bleeding = suspect Trauma; soft uterus + bleeding = suspect Tone.
Tone (atony, 70%), Trauma (lacerations, hematoma, inversion, rupture), Tissue (retained placenta/fragments), Thrombin (coagulation failure).
Uterotonic
Example
Oxytocin 10 IU IM is given immediately after delivery or at signs of PPH.
Drug that causes the uterus to contract; first-line is oxytocin; second-line are methylergometrine and misoprostol.
Diagrams to know
- The 4 T's — causes of PPH (Tone, Trauma, Tissue, Thrombin)
- Fundal massage technique (firm, circular, through the abdomen)
- Bimanual uterine compression (position of both hands)
Shoulder Dystocia
Important facts
- Shoulder dystocia is UNPREDICTABLE — can occur in any delivery, not just high-risk.
- Key first action: call for help and note the time.
- DO NOT apply strong traction on the head — this WORSENS dystocia and injures the baby.
- DO NOT apply fundal pressure — this pushes the baby further into dystocia.
- HELPERR sequence: Help (call), E (McRoberts), P (suprapubic pressure), E (enter/episiotomy), R (roll onto all fours/Gaskin), R (refer if unresolved).
- McRoberts maneuver (hyperflex thighs) resolves ~50–60% of cases — do this FIRST.
- Suprapubic pressure: assistant applies downward and LATERAL pressure above symphysis pubis to dislodge the anterior shoulder.
- Internal maneuvers (Rubin/Woods screw) and delivery of the posterior arm are advanced — refer if not successful with simple maneuvers.
- Episiotomy may be needed to make room for internal maneuvers.
- Gaskin maneuver: roll mother onto all fours (hands and knees) — gravity assists, posterior shoulder delivers first.
Key definitions
Shoulder Dystocia
Example
Baby's head delivers but then retracts back tightly; body does not follow = turtle sign.
After the head delivers, the anterior shoulder impacts behind the symphysis pubis and the body will not deliver with normal traction — a true emergency.
Turtle Sign
Example
Recognize this immediately — do NOT pull harder on the head.
The head delivers but retracts back against the perineum; restitution does not occur; classic sign of shoulder dystocia.
McRoberts Maneuver
Example
Mother supine, legs fully flexed — this single maneuver frees the shoulder in many cases.
Sharply hyperflex the mother's thighs onto her abdomen (knees to chest); rotates symphysis pubis and flattens sacrum; FIRST-LINE and resolves most cases.
Diagrams to know
- McRoberts maneuver (maternal position — thighs maximally flexed)
- Suprapubic pressure technique (direction and hand placement)
- Gaskin maneuver (all-fours position)
Umbilical Cord Prolapse
Important facts
- Cord prolapse is a TRUE OBSTETRIC EMERGENCY — baby will die without immediate relief of cord compression.
- First action: call for help IMMEDIATELY and arrange emergency cesarean transport.
- While preparing transport: keep the presenting part ELEVATED and OFF the cord by pushing it UP with a gloved hand.
- Position the mother to reduce compression: KNEE-CHEST or exaggerated Sims/left lateral with hips elevated (Trendelenburg).
- DO NOT try to push the cord back inside the vagina — this is futile and wastes time.
- DO NOT handle the cord excessively — handling causes vasospasm and reduces placental blood flow.
- If cord is outside the vagina: keep it WARM and MOIST with a warm, saline-soaked pad.
- STOP any oxytocin (inhibits contractions that might compress the cord further).
- Give oxygen to the mother (increases oxygen in fetal blood even with cord compression).
- Monitor fetal heart rate, but transfer is the ONLY definitive treatment — cesarean is required.
- Maintain elevation of the presenting part throughout transport to the operating room.
Key definitions
Cord Prolapse
Example
Membranes rupture, cord visible at introitus or in vagina, baby's heart rate drops = cord prolapse = emergency cesarean.
Umbilical cord slips below the presenting part (into or out of the vagina) after membranes rupture; presents part compresses the cord, cutting off baby's oxygen.
Knee-Chest Position
Example
Immediately position mother this way while keeping presenting part elevated off the cord.
Mother on knees with chest to the floor, head down, hips elevated; relieves pressure on the cord by changing the angle of descent.
Diagrams to know
- Knee-chest position (body posture)
- Hand placement for relieving cord compression (gloved hand in vagina, pushing presenting part UP)
- Trendelenburg position (elevated hips, mother on left side)
Eclampsia & Severe Pre-eclampsia
Formulas
Pre-eclampsia: New hypertension (BP ≥140/90 mmHg) + proteinuria after 20 weeks
Meaning
Both elevated BP AND proteinuria must be present; new onset after 20 weeks.
Watch out
Students forget BOTH criteria are needed — hypertension alone is NOT pre-eclampsia without proteinuria (unless severe features present).
When to use
Screen all pregnant women at each antenatal visit; assess at labor admission.
Severe pre-eclampsia: BP ≥160/110 mmHg OR BP ≥140/90 WITH severe features
Meaning
Either very high BP (≥160/110) alone, OR lower BP (≥140/90) but WITH symptoms: severe headache, visual disturbances, epigastric/RUQ pain, hyperreflexia.
Watch out
Severe features can occur at lower BP readings — the SYMPTOM CLUSTER is as important as the numbers.
When to use
Determine need for emergency treatment and urgent referral.
Eclampsia: Pre-eclampsia or severe pre-eclampsia + SEIZURES (convulsions)
Meaning
The addition of convulsions defines eclampsia as the most severe and immediately life-threatening form.
Watch out
Do NOT confuse eclampsia with other causes of seizures — eclampsia is defined by the obstetric context (pregnancy/postpartum + hypertension + seizure).
When to use
A seizing pregnant or postpartum woman = eclampsia until proven otherwise.
Common values
Value
≥140/90 mmHg
Symbol
140/90
Quantity
Pre-eclampsia BP threshold
Value
≥160/110 mmHg
Symbol
160/110
Quantity
Severe pre-eclampsia BP threshold
Value
20% solution
Symbol
4 g
Quantity
MgSO4 IV loading dose concentration
Value
4 g over 5–20 minutes
Symbol
4 g
Quantity
MgSO4 IV loading dose volume
Value
50% solution
Symbol
10 g total
Quantity
MgSO4 IM loading dose concentration
Value
5 g each buttock
Symbol
5 g
Quantity
MgSO4 IM loading dose per buttock
Value
5 g IM every 4 hours
Symbol
5 g
Quantity
MgSO4 maintenance dose
Value
24 hours after last fit or delivery
Symbol
24 hours
Quantity
MgSO4 maintenance duration
Value
1 g IV (10 mL of 10% solution)
Symbol
1 g
Quantity
Calcium gluconate antidote
Value
16 breaths/minute
Symbol
16 bpm
Quantity
Minimum respiratory rate (toxicity threshold)
Value
30 mL/hour (100 mL per 4 hours)
Symbol
30 mL/hr
Quantity
Minimum urine output (toxicity threshold)
Important facts
- Magnesium sulfate (MgSO4) is the DRUG OF CHOICE for eclampsia — NOT diazepam (which is less effective and outdated).
- Pritchard loading dose: 4 g IV (20% solution) over 5–20 minutes PLUS 10 g IM (50% solution) — 5 g deep into each buttock with 1 mL of 2% lignocaine to reduce pain.
- Zuspan regimen (alternative): 4–6 g IV loading, then 1–2 g/hour by IV infusion.
- Midwife's role: give loading dose and arrange urgent referral — MAINTENANCE is continued at receiving facility or during accompanied transport.
- Maintenance dose: 5 g of 50% MgSO4 deep IM every 4 hours, alternating buttocks, for 24 hours after last fit or after delivery.
- MONITOR for toxicity BEFORE each maintenance dose: respiratory rate (RR) ≥16, patellar reflexes present, urine output ≥30 mL/hour.
- WITHHOLD MgSO4 if: RR < 16 breaths/min, patellar reflexes absent, or urine < 30 mL/hour (or < 100 mL in 4 hours).
- Antidote for MgSO4 toxicity: Calcium gluconate 1 g IV (10 mL of 10% solution) given slowly over ~3 minutes if respiratory depression occurs.
- First-response to eclamptic fit: turn mother onto LEFT SIDE, clear airway, give oxygen, do NOT restrain, do NOT force objects into mouth, stay with her.
- Severe hypertension control (if trained/ordered): aim to lower dangerous BP (not normalize it); agents include hydralazine, labetalol, nifedipine.
- Definitive treatment of eclampsia/pre-eclampsia is DELIVERY — refer urgently to CEmONC facility.
Key definitions
Magnesium Sulfate (MgSO4)
Example
Pritchard regimen: 4 g IV (20%) over 5–20 min PLUS 10 g IM (5 g each buttock, 50%) = loading dose.
The anticonvulsant of choice for prevention and treatment of eclamptic seizures; NOT diazepam (outdated in eclampsia).
Pritchard Regimen (MgSO4 loading)
Example
Given at first eclamptic fit or in severe pre-eclampsia with severe features; maintain therapy for 24 hours after last fit or after delivery.
Standard loading dose in Philippines/BEmONC: 4 g of 20% MgSO4 IV slowly + 10 g of 50% MgSO4 IM (5 g each buttock with lignocaine 2% 1 mL to reduce pain).
Magnesium Toxicity Signs
Example
Before each maintenance dose, check knee reflexes; if absent, do NOT give dose.
RR < 16 breaths/min, absent patellar (knee) reflexes, or urine output < 30 mL/hour (< 100 mL in 4 hours) — withhold next MgSO4 dose if any present.
Diagrams to know
- Pritchard MgSO4 loading regimen (IV + IM breakdown)
- Signs of magnesium toxicity (RR, reflexes, urine output)
- Position of mother during eclamptic fit (left side, airway clear)
Neonatal Resuscitation — Helping Babies Breathe (HBB)
Formulas
Golden Minute: Within 60 seconds of birth, a non-breathing baby should be BREATHING WELL or being VENTILATED with a bag and mask.
Meaning
The first 60 seconds are critical for preventing hypoxic brain injury; delayed resuscitation = increased risk of death or disability.
Watch out
Students delay — remember, 60 seconds is the limit; start bag-mask ventilation at the bedside, do NOT wait to transport.
When to use
Use this principle for every birth; start ventilation immediately if baby is not breathing after stimulation.
Common values
Value
60 seconds
Symbol
0–60 sec
Quantity
Golden Minute window
Value
~1 in 10
Symbol
10%
Quantity
Proportion of newborns needing help
Value
40–60 breaths per minute
Symbol
40–60 bpm
Quantity
Bag-and-mask ventilation rate
Value
21% oxygen
Symbol
21%
Quantity
Room air oxygen concentration
Value
< 60 beats per minute
Symbol
< 60 bpm
Quantity
Heart rate threshold (low)
Important facts
- About 1 in 10 newborns need help to start breathing.
- FIRST step: dry the baby thoroughly and provide warmth — drying itself is stimulation.
- Assess immediately: is the baby CRYING/BREATHING? A crying baby = no immediate resuscitation needed; provide routine EINC care (skin-to-skin, keep warm).
- If NOT breathing or gasping after drying/stimulation: clamp and cut cord, move to warm resuscitation surface.
- Position the head in NEUTRAL ('sniffing') position to open airway — not flexed, not extended.
- Clear the airway ONLY if secretions or meconium are OBSTRUCTING it — gentle suction mouth first, then nose.
- Start bag-mask ventilation immediately if no breathing — use self-inflating bag with correctly sized mask (covers nose and mouth, chin included, NOT eyes).
- Ventilation rate: 40–60 breaths per minute.
- Key sign of EFFECTIVE ventilation: RISING CHEST — this is how you know the bag-mask is working.
- If chest is NOT rising: reapply mask seal, reposition head, clear airway if needed, open mouth slightly, try again.
- Use ROOM AIR (21% oxygen) for term newborns initially — high oxygen is not given first-line.
- Reassess heart rate after effective ventilation: if heart rate remains low (< 60), continue ventilating.
- Heart rate < 60 despite good ventilation requires advanced help (chest compressions, medications) — refer urgently.
- Effective ventilation alone corrects the VAST MAJORITY of newborns — most do not need medications or compressions.
- Once baby breathes well: return to mother for SKIN-TO-SKIN and monitoring; refer any baby needing prolonged resuscitation or remaining unwell.
Key definitions
Bag-and-Mask Ventilation (BMV)
Example
Mask covers nose and mouth (chin included, eyes NOT); ventilate at 40–60 breaths/min; success = rising chest.
Manual ventilation of a non-breathing newborn using a self-inflating bag and correctly sized mask; the first-line resuscitation technique.
Golden Minute
Example
Baby born at 0:00; by 0:60, baby must be breathing or ventilated — this is the exam-critical principle.
The critical first 60 seconds after birth during which breathing should be established or ventilation begun; delay increases hypoxic damage risk.
Diagrams to know
- HBB decision tree (crying vs. non-breathing vs. gasping pathway)
- Bag-and-mask ventilation technique (hand position, mask placement, chest rise indicator)
- Neutral head position (sniffing position) — correct and incorrect
- Signs of effective ventilation (rising chest, color change)
Core Principles Across ALL Obstetric Emergencies
Important facts
- CALL FOR HELP is the FIRST action in EVERY emergency — do not manage alone.
- Start an IV line (large-bore) in EVERY emergency — it is the highway for fluids and drugs.
- STAY WITH THE WOMAN — do not leave her unattended in an emergency.
- BEGIN FIRST-LINE MANAGEMENT immediately — do not wait for transport to start life-saving interventions.
- PREPARE TO REFER — have transport arranged; keep management running during transfer.
- The midwife's role: recognize the emergency, perform first-line stabilization, and refer to CEmONC.
- Do NOT attempt definitive management (surgery, advanced medications) — that is not the midwife's scope in emergencies.
- Document everything: time of onset, interventions given, response, and time of referral.
- In remote/underserved areas: use phone/radio to consult with receiving facility about management during transport.
- Maintain clear communication with the patient and family about the emergency and the need for referral — informed consent/agreement is important even in emergencies.
Key definitions
Basic EmONC (BEmONC)
Example
At an RHU or BHS, a midwife does PPH first-response, eclampsia loading, and resuscitation — then refers to CEmONC.
Basic emergency obstetric and neonatal care — life-saving interventions a midwife must provide (e.g., IV fluids, uterotonic, magnesium sulfate, bag-mask ventilation); recognize complications and refer.
Comprehensive EmONC (CEmONC)
Example
Cord prolapse, failed shoulder dystocia, eclamptic coma = CEmONC referral.
Full surgical and specialist care — cesarean section, blood transfusion, laparotomy — available only at tertiary hospitals; the destination for referred emergencies.
Recognize and Refer
Example
See PPH → massage + oxytocin + IV → refer. See cord prolapse → keep presenting part UP → refer urgently for cesarean.
The midwife's core duty in emergencies: recognize the condition, start first-line management, and REFER without delay — NOT to attempt definitive management.
Diagrams to know
- Generic emergency response flow: Call → Assess → First-line manage → Refer → Transport
- IV fluid management in emergencies (large-bore line, run fast, monitor intake/output)
Must remember
- PPH ≥500 mL (vaginal) OR ≥1000 mL (cesarean) OR symptomatic (dizzy/pale/tachycardic); uterine ATONY (~70%) = soft uterus + massage FIRST.
- PPH management order: Fundal MASSAGE → Oxytocin 10 IU IM → Large-bore IV + fluids fast → Empty bladder → Bimanual compression if needed → Second-line drugs (methylergometrine, misoprostol, tranexamic acid) → REFER.
- Shoulder dystocia = turtle sign (head retracts after delivery); McRoberts maneuver (hyperflex thighs) FIRST, then suprapubic pressure; NEVER fundal pressure or strong head traction.
- Cord prolapse = cord below presenting part after membrane rupture; KNEE-CHEST or Trendelenburg position, push presenting part UP off cord with gloved hand, keep cord warm/moist, do NOT push cord back in, urgent cesarean referral.
- Eclampsia = pre-eclampsia + SEIZURES; Magnesium sulfate (NOT diazepam) = Pritchard loading: 4 g IV (20%) + 10 g IM (5 g each buttock, 50%) immediately; maintenance 5 g IM every 4 hours for 24 hours.
- MgSO4 toxicity signs = RR < 16, absent patellar reflex, urine < 30 mL/hour; WITHHOLD dose if any present; antidote = calcium gluconate 1 g IV (10 mL of 10%).
- Newborn resuscitation (HBB) = GOLDEN MINUTE (60 seconds to breathing or ventilation); dry/stimulate, assess cry, bag-mask ventilate at 40–60 bpm if not breathing, success = rising chest, use room air (21%).
- Across ALL obstetric emergencies: CALL FOR HELP → START IV LINE → STAY WITH WOMAN → FIRST-LINE MANAGE → REFER TO CEmONC WITHOUT DELAY.
- The midwife's scope in emergencies: RECOGNIZE the condition, STABILIZE with first-line BEmONC, and REFER for definitive care — NOT to attempt surgical or advanced specialist management.
- Pre-eclampsia = BP ≥140/90 + proteinuria (both required); severe = BP ≥160/110 or BP ≥140/90 WITH severe features (headache, visual disturbance, epigastric pain, hyperreflexia).
Last minute tips
- EXAM TIP: Any question about a seizing pregnant woman = answer is MAGNESIUM SULFATE LOADING (Pritchard: 4 g IV + 10 g IM), NOT diazepam. This is heavily tested and is the single most important drug in obstetric emergencies.
- EXAM TIP: Shoulder dystocia = the TURTLE SIGN is the giveaway. Students sometimes confuse it with arrest of descent; remember restitution fails and head retracts. The answer is always McRoberts FIRST (hyperflex thighs), NEVER fundal pressure.
- EXAM TIP: PPH causes (the 4 T's) — memorize the percentage: Tone ~70%, Trauma ~15%, Tissue ~10%, Thrombin ~5%. Know that atony is most common, so MASSAGE FIRST is always the first action. Methylergometrine is CONTRAINDICATED in hypertension/pre-eclampsia (high stroke risk).
- EXAM TIP: Cord prolapse scenarios will test your knowledge of knee-chest positioning and the principle of KEEPING PRESENTING PART ELEVATED OFF CORD — DO NOT push cord back in (this is a common wrong answer). Know that cesarean is the only definitive treatment.
- EXAM TIP: The 'Golden Minute' for newborn resuscitation (60 seconds to breathing/ventilation) is HEAVILY TESTED. Know the HBB sequence: dry/stimulate → assess → if not breathing → bag-mask at 40–60 bpm, room air, continue until chest rises or heart rate improves. Effective ventilation alone fixes most babies (no compression/meds needed).
Comparison tables
The 4 T's of PPH — Quick Identification
| Cause (The T) | Mechanism | Clinical Clue | First-Response Action | |
|---|---|---|---|---|
| TONE (Atony) — ~70% of cases | Uterus fails to contract after delivery | Soft, boggy, non-contracted uterus | Bleeding with SOFT fundus = MASSAGE IMMEDIATELY | Fundal massage, oxytocin 10 IU IM, empty bladder |
| TRAUMA — ~15% of cases | Lacerations, hematoma, inversion, rupture | Vaginal/perineal tears; hematoma swelling; inverted/ruptured uterus | Bleeding with FIRM uterus = look for injury | Inspect cervix/vagina, apply pressure, repair if trained, refer if severe |
| TISSUE — ~10% of cases | Retained placenta or placental fragments/membranes | Placenta/fragments left in uterus; bleeding continues | Incomplete placenta at delivery; heavy bleeding persists | Check placenta completeness, refer for manual removal if retained |
| THROMBIN — ~5% of cases | Coagulation disorder (clotting failure) | Blood does not clot; oozing from all sites | Bleeding that does NOT stop despite uterine contraction | IV fluids, tranexamic acid 1 g IV, refer urgently for transfusion |
Pre-eclampsia vs. Severe Pre-eclampsia vs. Eclampsia
| Condition | BP Threshold | Proteinuria Required? | Symptoms/Features | Management Priority |
|---|---|---|---|---|
| Pre-eclampsia (Mild) | BP ≥140/90 mmHg | YES (required) | Usually asymptomatic or mild headache | Monitor closely, antihypertensive if BP uncontrolled, plan delivery |
| Severe Pre-eclampsia | BP ≥160/110 mmHg OR BP ≥140/90 WITH severe features | YES (if BP ≥140/90); NO if BP ≥160/110 alone | Severe headache, visual disturbances, epigastric/RUQ pain, hyperreflexia, seizure risk | Give MgSO4 loading (Pritchard), control BP if trained, urgent delivery/referral |
| Eclampsia | Variable (usually elevated) | Often present (pre-eclampsia history) | SEIZURES (convulsions) — the defining feature | MgSO4 loading immediately, manage airway, urgent cesarean referral, consider ICU care |
Shoulder Dystocia — HELPERR Sequence at a Glance
| Step (HELPERR) | Action | Rationale | Success Rate / Notes |
|---|---|---|---|
| H — Help | Call for help (pediatrics, anesthesia), note time | Team-based approach; time documentation for cord damage risk | Essential — baby is at risk of asphyxia |
| E — McRoberts | Sharply hyperflex mother's thighs onto abdomen (knees to chest) | Rotates symphysis pubis, flattens sacrum, increases pelvic outlet diameter | Resolves ~50–60% of cases; do this FIRST |
| P — Suprapubic Pressure (Mazzanti) | Assistant applies downward and lateral pressure above symphysis pubis | Dislodges anterior shoulder from under pubic arch | Effective in ~20–30% additional cases |
| E — Episiotomy / Enter Maneuvers | Episiotomy to create room; Rubin/Woods screw maneuver (internal rotation); deliver posterior arm | Adds room for maneuvers; internal rotation frees stuck shoulder | Advanced technique — refer if not successful with simple maneuvers |
| R — Roll (Gaskin) / Refer | Roll mother onto all fours (hands and knees); or prepare for urgent referral if unresolved | Gravity-assisted delivery; posterior shoulder often delivers in this position | If still unresolved → urgent cesarean or advanced facility; baby's life at risk |
Magnesium Sulfate Loading Regimens — PH Context
| Regimen | IV Component | IM Component | Total Time | Notes |
|---|---|---|---|---|
| Pritchard (Standard in PH/BEmONC) | 4 g of 20% MgSO4 IV over 5–20 minutes | 10 g of 50% MgSO4 IM (5 g each buttock) with 1 mL 2% lignocaine | ~30–60 minutes total | Most commonly taught; easy to remember and deploy in RHU/BHS settings |
| Zuspan (Alternative) | 4–6 g IV bolus over 20–30 minutes, then 1–2 g/hour IV infusion | None (all IV) | Infusion continues until 24 hours post-delivery | Used where continuous IV infusion available; less IM injections |
When to WITHHOLD MgSO4 — Toxicity Signs Checklist
| Sign | Threshold / Finding | What It Means | Action |
|---|---|---|---|
| Respiratory Rate (RR) | RR < 16 breaths/minute | Respiratory depression from magnesium overdose | WITHHOLD dose; give oxygen; monitor closely; have calcium gluconate ready |
| Patellar Reflex | Absent (cannot elicit knee-jerk reflex) | Deep CNS magnesium toxicity | WITHHOLD dose immediately; high risk of respiratory failure next |
| Urine Output | < 30 mL/hour (or < 100 mL in 4 hours) | Kidney unable to clear magnesium; accumulating to toxic levels | WITHHOLD dose; catheterize if not already done; monitor I&O closely |
| Loss of Patellar Reflex + Respiratory Depression | Both signs present together | SEVERE magnesium toxicity; respiratory failure imminent | STOP all MgSO4; give oxygen; prepare to ventilate; give calcium gluconate 1 g IV immediately |
Newborn Resuscitation Decision Tree — HBB Pathway
| Baby's State at Birth | Is Baby Crying/Breathing Well? | Next Action | Outcome / Monitoring |
|---|---|---|---|
| Vigorous/Crying | YES — good cry, active movement | Routine EINC care: dry, skin-to-skin, keep warm, delayed cord clamping if stable | Return to mother; monitor breathing and color; no resuscitation needed |
| Non-breathing/Gasping | NO — gasping or silent | Dry thoroughly (stimulation), position head neutral, clear airway if obstructed | Reassess in 10 seconds: is baby now breathing? If YES → EINC care; if NO → START BAG-MASK VENTILATION IMMEDIATELY (Golden Minute) |
| During Bag-Mask Ventilation | Monitor for chest rise (sign of effective ventilation) | Ventilate at 40–60 breaths/min with room air (21%); reassess heart rate after 15–30 seconds | If heart rate rising and baby starts breathing → wean ventilation; return to mother. If HR < 60 and not rising → continue ventilation, consider advanced help (compressions, drugs) and REFER urgently |
Diagrams
PPH Recognition and First-Response Sequence
Step-by-step first-response management for PPH, showing decision points (soft vs. firm fundus), intervention sequence, and refer pathway. This is the most tested emergency sequence in PRC exams.
Shoulder Dystocia — HELPERR Maneuver Sequence
The complete HELPERR sequence showing decision points and success rates at each step. Emphasizes McRoberts as first-line (resolves ~60%) and avoidance of fundal pressure and forceful traction (both worsen dystocia).
The 4 T's of PPH — Cause, Clue, and Action
Mind map showing the four causes of PPH, their clinical clues, and immediate first-response actions. Tone (atony, 70%) is highlighted as the most common — massage is the first action.
Umbilical Cord Prolapse — Immediate First-Response
Immediate recognition and first-response actions for cord prolapse. Emphasizes the critical principle of elevating the presenting part off the cord and maintaining that elevation throughout transport (the lifesaving intervention).
Eclamptic Fit — Immediate First-Response & MgSO4 Loading
Immediate management of eclamptic seizure, including airway protection and the Pritchard MgSO4 loading protocol (4 g IV + 10 g IM). Shows toxicity checks and maintenance protocol. MgSO4 is the anticonvulsant of choice (NOT diazepam).
Newborn Resuscitation (HBB) — Golden Minute Decision Tree
Step-by-step HBB decision pathway showing the critical 'Golden Minute' principle (60 seconds to breathing or ventilation). Emphasizes assessment for crying baby (routine care) vs. non-breathing baby (immediate BMV). Success indicator is rising chest.
Distribution of PPH Causes (The 4 T's)
Visual breakdown of PPH causes by percentage. Uterine atony (Tone) accounts for ~70% of cases, emphasizing why fundal massage is the FIRST and most critical action.
Pre-eclampsia Progression States
State diagram showing the progression from normal pregnancy through pre-eclampsia, severe pre-eclampsia, to eclampsia. Illustrates the points at which MgSO4 loading is initiated and the pathway to urgent delivery/referral.