Emergency Obstetric First-Response for the Midwife - Concept Map
Emergency Obstetric First-Response
Related concepts
Postpartum Hemorrhage (PPH)
Sub concepts
- The 4 T's framework (Tone, Trauma, Tissue, Thrombin)
- Uterine atony as primary cause (~70%)
- First-response sequence: massage → oxytocin → IV fluids → catheter → trauma check
- Second-line uterotonics and advanced management
- Signs of shock and fluid resuscitation
- Bimanual compression and aortic compression
Relationship to central
Leading cause of maternal death; midwife's primary emergency management skill
Shoulder Dystocia
Sub concepts
- Turtle sign as key recognition feature
- HELPERR sequence (Help, McRoberts, suprapubic pressure, internal maneuvers, episiotomy, roll)
- McRoberts maneuver as first-line intervention
- Prevention of fundal pressure and forceful traction
- Suprapubic (Mazzanti) pressure technique
- Gaskin maneuver and positional management
Relationship to central
Unpredictable obstetric emergency requiring immediate recognition and specific maneuvers
Umbilical Cord Prolapse
Sub concepts
- Recognition: cord below presenting part after membrane rupture
- Pathophysiology of cord compression and fetal hypoxia
- Knee-chest and Trendelenburg positioning
- Manual elevation of presenting part
- Care of prolapsed cord outside vagina
- Urgent cesarean referral protocol
- Maintenance of cord compression relief during transport
Relationship to central
True obstetric emergency requiring immediate pressure relief and urgent referral for cesarean
Eclampsia and Severe Pre-eclampsia
Sub concepts
- Definitions: hypertension criteria (BP ≥140/90), proteinuria, severe features
- Magnesium sulfate (MgSO4) as anticonvulsant of choice
- Pritchard regimen loading dose (4 g IV + 10 g IM)
- Maintenance dosing and timing (every 4 hours for 24 hours post-fit/delivery)
- Magnesium toxicity signs and monitoring parameters
- Calcium gluconate as antidote
- Airway protection during seizure management
- Severe hypertension control principles
Relationship to central
Hypertensive emergency in pregnancy requiring magnesium sulfate first-line management
Neonatal Resuscitation (Helping Babies Breathe - HBB)
Sub concepts
- The Golden Minute principle (60-second window)
- Drying, warming, and stimulation
- Assessment of breathing and crying
- Airway positioning and clearance
- Bag-and-mask ventilation technique
- Ventilation rate (40-60 breaths/min) and room air use
- Rising chest as success indicator
- Heart rate assessment and ongoing evaluation
- EINC and Unang Yakap post-resuscitation care
Relationship to central
Core midwifery skill for newborns requiring first-response breathing support
Universal First-Response Principles
Sub concepts
- Call for help immediately
- Stay with the woman/baby
- Start large-bore IV line
- Begin first-line interventions
- Monitor vital signs and response
- Prepare for urgent referral to CEmONC facility
- Maintain continuity of care during transport
- Document and communicate findings
Relationship to central
Common emergency management framework across all obstetric emergencies
BEmONC and CEmONC Competencies
Sub concepts
- BEmONC: Basic Emergency Obstetric and Neonatal Care at RHU/lying-in level
- CEmONC: Comprehensive Emergency Obstetric and Neonatal Care at hospital level
- Midwife's role: detect, initiate first-line care, and refer
- Appropriate referral timing and protocols
- Communication with receiving facility
Relationship to central
Organizational framework for midwife emergency responsibilities
Shock Management and Fluid Resuscitation
Sub concepts
- Recognition of shock signs: tachycardia, hypotension, pallor, weak pulse
- Large-bore IV access (18-20G needle)
- Rapid IV fluid infusion (normal saline or Ringer's lactate)
- Positioning: keep warm, elevate legs
- Oxygen therapy when available
- Continuous vital sign monitoring
- Target BP and perfusion restoration
Relationship to central
Critical support measure across hemorrhagic and hypertensive emergencies
Concept connections
- Postpartum HemorrhageUniversal First-Response PrinciplesPPH follows the same call-help, IV-line, and referral framework as all obstetric emergencies
- Postpartum HemorrhageShock Management and Fluid ResuscitationBlood loss leads to shock; IV fluids and positioning are critical support measures in PPH
- The 4 T's FrameworkFirst-Response SequenceThe 4 T's guide which action to prioritize: massage for atony first, then check for trauma/tissue/clotting
- Shoulder DystociaHELPERR SequenceHELPERR is the mnemonic that organizes the exact steps a midwife performs in shoulder dystocia
- McRoberts ManeuverSuprapubic PressureBoth are first-line positional and mechanical approaches; McRoberts is tried first, suprapubic is concurrent if needed
- Umbilical Cord ProlapseUrgent Cesarean ReferralCord prolapse cannot be managed vaginally; immediate cesarean delivery is the only definitive solution
- Knee-Chest and Trendelenburg PositioningUmbilical Cord ProlapseThese positions relieve pressure on the prolapsed cord while awaiting transport and cesarean delivery
- EclampsiaMagnesium Sulfate ManagementMagnesium sulfate is the only first-line drug for eclamptic seizures; no alternative drug is as effective
- Pritchard Loading DoseMaintenance DosingLoading dose (4g IV + 10g IM) is followed immediately by maintenance (5g IM every 4 hours for 24 hours)
- Magnesium Toxicity MonitoringCalcium Gluconate AntidoteRespiratory depression, absent reflexes, or low urine output indicate toxicity; calcium gluconate reverses it
- Neonatal ResuscitationGolden Minute PrincipleThe 60-second window from birth is critical; effective ventilation must begin within this window
- Bag-Mask VentilationRising Chest SignRising chest indicates effective ventilation; absence of chest rise means technique needs correction
- Neonatal ResuscitationEINC and Unang YakapAfter successful resuscitation, care transitions to skin-to-skin contact and routine essential newborn care
- Call for HelpAll Five EmergenciesThe first action in every obstetric emergency is calling for help; delays cost lives
- Large-Bore IV LineIV Fluid ResuscitationLarge-bore access (18-20G) enables rapid fluid administration to prevent/treat shock
- Urgent Referral to CEmONCAll Five EmergenciesEvery obstetric emergency requires timely referral to a facility with advanced capability
- BEmONC CompetenciesMidwife Role: Detect and ReferBEmONC defines what midwives can manage (first-line care); CEmONC defines what requires referral
- Severe Pre-eclampsiaEclampsiaSevere pre-eclampsia with seizures becomes eclampsia; magnesium sulfate prevents progression
- Vital Sign MonitoringShock ManagementRising pulse, falling BP, and pale/cold skin indicate shock progression; guide fluid infusion rate
- Maintain Care During TransportContinuity of TreatmentFirst-line maneuvers and medications must be continued without interruption during referral transport
- Oxytocin 10 IU IMMethylergometrine 0.2 mg IMOxytocin is first-line uterotonic; ergometrine is second-line if oxytocin fails; never use ergometrine in hypertension
- Airway ProtectionEclamptic Seizure ManagementTurning onto left side and clearing mouth are first protective actions before magnesium administration
- Drying and StimulationNeonatal Breathing AssessmentDrying is stimulation; if baby does not cry/breathe after drying, resuscitation begins immediately
- Heart Rate AssessmentContinued Ventilation DecisionIf heart rate remains below 100 after effective ventilation, continue bag-mask; below 60 requires advanced help
- Placenta InspectionTissue Cause of PPHIncomplete or retained placenta is the 'tissue' cause of PPH; must be recognized and referred for removal
- Episiotomy in Shoulder DystociaHELPERR SequenceEpisiotomy is the fifth step in HELPERR, performed to create room for internal maneuvers if positional maneuvers fail
- Document and ReportSafe HandoverComplete documentation of emergency recognition, actions taken, and maternal/neonatal response ensures continuity of care at receiving facility
Diagrams
Emergency Obstetric First-Response: Comprehensive Concept Map
Comprehensive mind map showing all five major obstetric emergencies managed by midwives, their recognition features, first-response sequences, and universal principles. Central concept branches into specific emergencies, each with recognition, management, and referral pathways.
Postpartum Hemorrhage First-Response Algorithm
Step-by-step decision tree for managing postpartum hemorrhage at a RHU or lying-in clinic. Shows the sequence from recognition through initial management to referral preparation, emphasizing the critical decision points and actions.
Shoulder Dystocia: HELPERR Sequence in Action
HELPERR mnemonic sequence for shoulder dystocia management. Shows each step (Help, McRoberts, Suprapubic pressure, Enter maneuvers, Episiotomy, Roll) with decision points, emphasizing that McRoberts and suprapubic pressure are first-line before more invasive maneuvers.
Eclamptic Seizure: Magnesium Sulfate First-Response
First-response management of eclamptic seizure using the Pritchard regimen. Shows immediate protective actions, loading dose administration, maintenance dosing protocol, toxicity monitoring, and referral pathway with emphasis on magnesium sulfate as the drug of choice.
Umbilical Cord Prolapse: Emergency Relief and Referral
Management pathway for umbilical cord prolapse emphasizing immediate cord compression relief through positioning and manual elevation, cord protection if external, and urgent cesarean referral with maintenance of compression relief during transport.
Neonatal Resuscitation: Golden Minute Algorithm (HBB)
Golden Minute algorithm for neonatal resuscitation emphasizing drying and stimulation, positioning, airway assessment, and immediate bag-mask ventilation with monitoring of chest rise as success indicator and heart rate for ongoing management decisions.
Universal Emergency First-Response Framework
Universal seven-step framework applicable across all obstetric emergencies: call for help, stay with patient, establish IV access, start emergency-specific first-line care, monitor continuously, prepare referral, and maintain care during transport. Shows how all specific emergencies feed into this common protocol.
Magnesium Sulfate Toxicity Monitoring State Diagram
State transitions during magnesium sulfate administration showing the monitoring checkpoint before each maintenance dose, safety criteria, hold conditions, toxicity assessment, antidote administration, and total duration of treatment.
Causes of Postpartum Hemorrhage (The 4 T's Distribution)
Pie chart showing the relative frequency of the four main causes of postpartum hemorrhage. Uterine atony (Tone) accounts for approximately 70% of cases, making fundal massage the most critical first action a midwife should take.