a.Initial management plan includes turning the patient to left lateral position,starting her on bolus dose of IV fluids and giving her facial oxygen. Check maternal pulse to avoid error in the diagnosis of bradycardia.If bradycardia settles after 3 minutes,expectant management can be allowed with continuous fetal monitoring by CTG. Realise that she is now a high risk woman in labour. FBS after 15-20 minutes should be done and plan of action should be based on the results.A quick history should be taken to detect the causes for brady cardia such as opiate administartion prior to the event,epidural top ups if any ,vomiting ,change of maternal position,any vaginal bleeding.Abdominal examination to look for fetal size to rule out fetal macrosomia,fetal presentation and engaegement to rule out fetal malpresentation,uterine tenderness.Vaginal examination to check cervical effacement,dilatation,application,position,station,caput,moulding and colour of liquor.If fetal bradycardia doesn't settle by 3 minutes and vaginal operative delivery is not possible,call for Grade 1 emergency Caesarean section under GA and inform Consultant Obstetrician ,Anaesthetist ,Neonatologist ,Senior midwife and theatre staff.If vaginal instrumental delivery can be done as per examination findings,obtain verbal consent by explaining the procedure.Type of instrument,need for adequate pain relief ,emptying of bladder,need for episiotomy and risks of perineal laceratins should be discussed in detail.
B.Maternal risk of Caesarean section include bleeding,pain,infection ,visceral injury,hysterectomy and VTE.
Fetal risks include hypoxia,asphyxia,trauma and death.Verbal consent should be obtained discussing the risks.Obtain IV access and blood should be crossmatched.Prophylactic antibiotics prior to skin incision,high entry of peritoneum to avoid bladder injury should be done.Higher incision on the lower uterine segment to avoid broad ligament injury and cervical trauma.Attention to hemostasis and senior assistance if blleding not under control/visceral injury.Postpartum analgesics and VTE prophylaxis .Debrief and document.Fill incident form and arrange followup.
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