Your first day as a doctor

Here's one for you (relatively short but based on real life).

You are in A&E at 3am (this stuff always happens at 3am). The "red phone" goes off - an ambulance is bringing a woman in labour to you. She is 33 weeks pregnant. They do not think they have time to get to the antenatal ward which is approx half a mile away at the other end of the hospital. Your reg is busy putting in a chest drain. You have one minute before she arrives. What do you do?

Right ok..

My first thought is half a mile in an ambulance is not a long time. Why is this so urgent? Presumably there's some information we're missing?
How long has she been in labour? What caused the premature labour?

First thoughts are to find out more info about the woman coming into A&E, then maybe alert antenatal anyway as they can come to you if the patient can't be moved?

They don't think they have time before she delivers. That is all you know.

Generally when an ambulance picks up a labouring woman they just go straight to labour ward, so this one has seriously spooked the crew.

Right ok.. well in that minute before she arrives I'd just try to assemble everyone I can. Lets get a delivery team down here and a trauma team as well.
Something must have happened so I'd rather be extra cautious and be red faced sending people away than be understaffed and struggle to keep the patients alive.

I'm not sure if a chest drain is urgent but if it can wait I would delay it at least the minute. If it is urgent and as an F1 I was competent I would ask to swap places with the consultant and deal with something I knew I could handle rather than something I was unsure about whether I could handle.. if that makes sense

Delivery team (by which I presume you mean obstetric emergency team) is good, put out a 2222 call for them - but they're at the other end of the hospital too, so won't be there by the time she arrives. What are the trauma team going to contribute? Who else might you want and what kit would you like?


This one is not life-threatening, but the reg is scrubbed and halfway through the procedure, so cannot abandon it.

And FWIW, as an F1 you will not be doing chest drains unsupervised. In this scenario you're an F2 (as I was) - I can do them but still not confident enough to go unsupervised, and I don't think I'm abnormal on that front.

Delivery team (by which I presume you mean obstetric emergency team) is good, put out a 2222 call for them - but they're at the other end of the hospital too, so won't be there by the time she arrives. What are the trauma team going to contribute? Who else might you want and what kit would you like?

I think for this scenario I'm going to have to use the "I haven't actually started medical school yet" excuse since I don't actually know what I need to do
I will be reading though to see what other people suggest and see what the correct course of action would be.

At my current state all I'm thinking is , this premature labour has probably come on quickly causing the rush, so I'm thinking something has gone wrong with the mother, whether it be trauma or otherwise. So I've got the obstetric emergency team on the way to help with possible delivery of the baby (actually probably probable delivery) and I'd want someone else there to help care for the mother.
But as for specific kits and people I honestly don't know so will have to reside to the back benches of this thread for now

At 33/40, I'd probably want at least a paediatrician, if not a neonatologist, to be called. Possibly pre-alert theatres if there's a possibility of an emergency C-Section (presuming this isn't something you can do in the resus dept of A&E ). As for kit, how much specialist obstetric gear do you keep in A&E? Forceps? Ventouse?

What do we know about the condition of the mother? Is she medically unwell? Anaesthetist on hand would be useful if critically unwell, and for pain relief in labour (tho if she's that close to delivering that she can't go another half mile, I suspect pain relief is probably too little too late).

Delivery team (by which I presume you mean obstetric emergency team) is good, put out a 2222 call for them - but they're at the other end of the hospital too, so won't be there by the time she arrives. What are the trauma team going to contribute? Who else might you want and what kit would you like?
.

Guess.

I guess they would have said if she was seizing, but still maybe a good idea to know where to find some anti-epileptics in case it's eclampsia?

It's 3am, it will take 20 mins for the A&E and paeds consultants to get here, but if you think it'll help give them a call (if you have time). You have already made an obstetric and (on Becca-Sarah's suggestion) neonatal crash call and fast bleeped the anaesthetist.

Why do you need theatres?

All the above ideas are good, though if it really is as imminent as the ambulance crew suggest, a HIV screen etc is not going to change anything. If it hasn't been established by the ambulance crew though, IV access and x-match is essential. No idea about salbutamol IV, but if she's in advanced second stage, I doubt it will work.


In the drugs cupboard in resus. Good thought.

So, your minute is up. Appropriate crash calls have gone out, you have a bay in resus ready with a delivery pack (this contains clamps, swabs, everything you need for a vaginal delivery), a cannula trolley, some IV fluids. You and the resus nurse are in aprons and gloves, and you've managed to rope in another SHO to help out.

You can hear the sirens coming up to the main entrance. Anything else you want?

Good point, you may as well do everything in A+E. If not involved already, get someone to hunt down the DMR.

Have just woken up - great case Helenia. Thank you for posting. Fascinating and unfamiliar territory for me and good to be on the receiving end!

We haven't considered airway, so I would add that to the preparations. Prepare a non-rebreather, bag-and-mask, and some emergency airways (Guedels, NPAs, LMAs), and, praying that we don't need it, an RSI set-up - laryngoscope, tested and with a variety of blades, and ETTs in a range of sizes, pre-lubed, plus a bougie and plenty of drugs.

Though it is resus, check the monitoring is working and ready to be applied straight away (BP cuff, sats monitor, capnograph, defib/cardiac monitor, 12-lead ECG) as well as ensuring other emergency kit is nearby (catheter trolley, chest drain kit, arterial line trolley). Maybe a portable USS if the department has one.

And get some fluids set up and ready to go! Crystalloid, colloid, and check we have O negative blood in just in case. I'd wait to see what state she is on arrival before necessarily summoning senior help besides a neonatologist and obstetrician, and just focus on ABCs.

There is one other (quite large) piece of kit that nobody's mentioned yet, but this may just be because people haven't done much obstetrics. Any final guesses before I give the game away on that?

You can see both vaginal and anal dilation, suggesting delivery really is imminent, but bulging out from the vagina is what looks like a shiny yellow balloon. What now?

Incubator?

Sounds like the amniotic sac to me! Rupture it!

Close - resuscitaire. For those who haven't done O&G yet, it looks something like this:

It's kind of an all-in-one resuscitation station for a baby. The overhead bit is a heater, as newborns are small, wet and very prone to hypothermia. All the dials on the back are for oxygen, suction etc and in the drawers underneath you have intubation kit (not that I have a clue how to use that), cannulas and stacks of towels, hats etc.

So, you send the other SHO to turn on the resuscitaire - it is in the paeds resus bay at the other end of your resus room.



Yup, although babies can be delivered completely in their amniotic sac (indeed this used to be considered good luck and that they might have special powers), you can't see what the hell is going on and wouldn't know what to do if this did happen. So you put on some goggles and gingerly take a little pinch with some forceps - membranes suddenly give way and you narrowly avoid an amniotic fluid shower.

While you summoned up the courage to do this, the ambulance crew have been giving you a bit of history - this is the lady's first pregnancy, she's otherwise fit and well and has had normal antenatal care so far and everything has been fine (so will have had screening for infectious diseases and so on). She is Rh +ve. She started having contractions a few hours ago but firstly didn't believe she could be in labour, and then wanted to wait for her boyfriend to get home before calling the ambulance.

So, membranes gone, but still no sign of any of your specialist teams. What now? (apart perhaps from a change of underwear?!)

Assess labour - presentation, station, etc. Get CTG monitoring on? What did the amniotic fluid look like - meconium?

We don't have a CTG in A&E. The fluid was a little mec stained but mostly clear. You can see the head and it's descending as she pushes. Quite rapidly.