In this session you will learn about two very important techniques for emergency care of the pregnant woman who is either:
This study session is preparation for the practical skills training in both these techniques, which you will receive during an attachment in a health centre or hospital. Here we introduce you to the equipment you will need, and describe how to start and maintain IV fluid therapy and how to catheterise the bladder of the pregnant woman. You will also learn to follow infection control procedures while performing these techniques.
Before you begin either of these techniques, explain to the woman in local language what you are going to do and why she needs this procedure. Tell her that as soon as you have finished doing it, she must go to the higher health facility for further treatment.
Make sure that transportation is being arranged while you are setting up the IV fluid therapy or bladder catheterisation.
22.1 Define and use correctly all of the key words printed in bold. (SAQs 22.1, 22.2 and 22.3)
22.2 Explain the reasons for giving IV fluid therapy or catheterising the bladder of a pregnant woman. (SAQ 22.1 and 22.3)
22.3 Describe the equipment, the preparation and the procedure for starting intravenous (IV) fluid therapy, including selecting a suitable venipuncture site, and inserting and removing a cannula from a vein. (SAQs 22.1 and 22.2)
22.4 Describe how you would monitor IV fluid therapy. (SAQ 22.1)
22.5 Describe the equipment, the preparation and the technique of how to insert and remove a urinary catheter. (SAQs 22.1 and 22.3)
22.6 Describe the infection control procedures required to reduce the risk of infection resulting from IV fluid therapy or catheterising the bladder. (SAQ 22.1 and 22.2)
A pregnant woman who is haemorrhaging will rapidly develop a state of shock; unless you take action quickly she will soon become unconscious and die.
What are the signs of shock? (You learned this in Study Session 20.)
The woman will look pale, especially inside her lower eyelids and the palms of her hands; her diastolic blood pressure (the bottom number) is below 60mmHg – sometimes much lower; and her pulse is high, often more than 100 beats per minute.
In order to save her life, you need to know how to start intravenous (IV) fluid therapy (also known as IV fluid resuscitation or IV infusion). This means getting special fluids into her blood circulation through a hollow needle called a cannula inserted into a vein, to replace the fluid part of the blood she is losing. You should do this before you urgently refer her to a hospital or health centre, where they will give her a blood transfusion. Women in labour, or soon after delivery of the baby, may also haemorrhage (as you will learn in the Labour and Delivery Care Module). You should start IV therapy quickly whenever you detect that a woman is haemorrhaging.
The first step in the process of initiating IV fluid therapy is to assemble and check the equipment you need (see Figure 22.1). You can place everything on a very clean large dish or locally available tray. We will describe the equipment in detail after you have looked at Figure 22.1.
When you prepare to give a person IV fluid therapy you have to keep everything clean and use sterile techniques (free from germ contamination) as much as possible. This may be difficult in a rural home, but you can reduce the risk of infection if you follow the instructions in Box 22.1.
Gauge is pronounced ‘gage’. The largest commonly available cannula is gauge 18 or 20.
You must choose a cannula with the appropriate size of needle for the required purpose. The size is referred to as the gauge of the cannula, and each size is given a number – the larger the number, the bigger the cannula.
Why do you think you should choose a large gauge cannula if you are giving IV fluid therapy to a pregnant woman who is haemorrhaging?
The woman has lost a significant amount of blood. Therefore, you need to get replacement fluids into her blood system as quickly as possible. You need a large gauge cannula so you can infuse a large amount of fluid into her vein in a short time.
The next step is identifying a good venipuncture site, that is the site where you will ‘puncture a vein’ by inserting the IV cannula. Figure 22.2 shows some commonly used sites in the hand and forearm.
In selecting the site for venipuncture:
The visibility of the veins can be improved by encouraging the woman to close her hand into a fist and then open it again several times, lowering the arm and stroking the chosen venipuncture site. As you become more experienced, you will find it easier to choose a suitable vein which is easily visible, not twisted, where you think you can enter your cannula easily.
Once you decide where to insert your IV cannula, apply a tourniquet about three finger-widths above the chosen venipuncture site (Figure 22.3a). Then feel for the vein with your gloved finger (Figure 22.3b). Clean the site with alcohol (Figure 22.3c) or soap and water.
Then stretch the skin taut and stabilise the vein with your non-dominant hand — meaning keeping it stretched so that it does not move easily and you miss your target with the needle. Pierce the skin with the IV cannula over vein at a 45 degree angle; first you push the needle into the skin and then aim at the vein (Figure 22.4). As you approach the vein, lower the angle to about 10 degrees and insert the cannula into the vein.
Look for blood ‘flash back’ (blood shooting back along the barrel of the cannula), which tells you that the needle is in the vein. Release the tourniquet at this point, then push the cannula further into the vein until you are well into the vein.
The cannula is a metal needle with plastic over it, and it is the plastic part that remains in the vein. Gently remove the metal needle part of the cannula, leaving the plastic part in the vein.
You then stabilise the plastic part of the cannula with a plaster, or clean rope or cloth wrapped around the venipuncture site (Figure 22.5).
Connect the IV tubing to the IV fluid bag and open the roller clamp to let fluid flow down the tube. Do this before connecting the other end of the tubing to the cannula. Flushing with fluid ensures there are no air bubbles in the tube before you begin infusing fluid into the patient.
Once the IV tubing has been connected to the cannula, push the roller to the top of the clamp (see Figure 22.6). This allows the fluid to run down the tube and into the woman’s vein as quickly as possible. The flow rate should be as fast as you can run it because the woman is losing a lot of blood. Maintain this high flow rate at all times, including during transportation to the health facility. Make sure the IV fluid bag is kept higher than the woman’s arm, or the flow rate will slow down even if the roller clamp is fully ‘open’.
A routine has to be established for monitoring the progress of IV fluid therapy, beginning at the bag of fluid and ending at the venipuncture site. The flow rate should be checked every 15 minutes for as long as the woman is with you. If the flow has slowed down, check if the IV tubing has twisted, or if the position of the woman’s hand or arm has twisted to obstruct the flow, and straighten them out. The flow rate in emergency fluid replacement should run as fast as possible.
Make sure you monitor the woman’s pulse and blood pressure every 15 minutes.
If you are giving IV fluid therapy to treat shock due to blood loss, what would you expect to happen to the pulse rate and blood pressure as the IV fluids are infused?
With adequate infusion the pulse rate will decrease and blood pressure will increase. (After infusing two to three bags of IV fluid, the expectation is for the pulse to slow down and the blood pressure to start rising towards normal.)
As soon as you have completed the IV fluid therapy set up, refer the woman to a higher health facility as quickly as possible. Go with her if you can.
Look for any swelling around the venipuncture site compared with the other hand (or arm), as this may signal that the cannula has moved and the fluid is running into the soft tissue instead of into the vein. If you see swelling, loosen the plaster and remove the IV cannula. Choose a new venipuncture site and use a new sterile IV cannula to enter a new vein and reconnect the IV fluid bag.
IV fluid therapy is stopped when the woman does not need additional fluid any more, or when the venipuncture site has developed an infection (the skin around the site will be red and will feel painful to the patient if you touch it). Sometimes patients may be given too much IV fluid in a short time and this may put stress on the heart because the blood volume has become too large. Fluid can also get into the lungs and in such cases the patient will have difficulty breathing, cough and sometimes become confused. This is not likely to happen while the patient is with you because you will refer her immediately after you started the IV infusion. But in case you encounter this situation, stop the infusion and refer the woman to the next higher facility immediately for further treatment.
You can stop the infusion by closing the roller clamp so no more fluid runs down the tube. Leave the cannula in place for someone at the health facility to remove under sterile conditions.
Explain what you will be doing to the patient, put on your gloves and turn the roller clamp to the ‘off’ position. Check that the flow of fluid along the tube has stopped. Remove the plaster or other stabilising material over the cannula while holding the cannula in place with your other gloved hand. With a clean dry swab held over the venipuncture site, withdraw the cannula and apply pressure with your fingers to the site for a minute or two. Then swab the site with antiseptic or alcohol to remove any germs that may be near the puncture hole. When the skin is dry, cover the site with a plaster if you have one.
Always make sure the cannula is intact and dispose of it safely in a puncture-proof container.
A pregnant woman in labour who cannot urinate as a result of compression on the outflow tube (urethra) from the bladder, will have great discomfort. At the same time, the full bladder will further obstruct the passage of the unborn baby by occupying space in the pelvis. She needs to have a catheter (sterile rubber or plastic tube) inserted into her bladder to let the urine out before you refer her to a higher health facility. The technique is called catheterisation. This procedure may even allow the birth of the baby to progress. Without it, if labour begins, she may be unable to give birth normally. Women who are a long time in labour may also need catheterisation if their bladder becomes obstructed. If the woman’s bladder is distended it will feel like a soft bag of water lying above her pubic bone. When she is lying flat on her back, you may see the full bladder as a rounded mass.
Tell her what you are going to do and why she needs the procedure. Then ask her to lie on her back with her head lifted and her legs flexed, with feet wide apart. Cover her lower body except the genital area with a clean cloth to reduce embarrassment for her if other people are present.
Assemble the necessary equipment for the procedure and lay them on a very clean dish or tray (see Figure 22.7). We will describe the equipment in detail after you have looked at Figure 22.7.
What is the first thing you should do before you open any of the sterile equipment packages?
Wash your hands thoroughly with soap and water for at least 15 seconds.
Once your patient is prepared and informed and your equipment is ready, put on the sterile or very clean gloves and clean around the woman’s vulva and perineal area with antiseptic solution or alcohol, starting from the urethral opening and swabbing outwards (Figure 22.8a). If you don’t have antiseptic solution, clean the area thoroughly with soap and water.
Why do you think it is important to clean the area starting with the urethral opening and swabbing outwards?
This avoids wiping germs from the perineal area towards the urethral opening; they could be carried inside when the catheter is inserted.
Use your non-dominant hand to carefully pull back the labia majora to fully expose the urethral opening. (You may wish to look back at the detailed drawing of the female external genitalia in Figure 3.2 in Study Session 3.) Lubricate the 16FC catheter if you have proper lubricant (don’t use anything else) and slowly insert the catheter into the urethral opening (Figure 22.8b).
Once well into the bladder, you will see urine flowing out through the end of the catheter. Use the syringe to inject 5 ml of sterile water into the tube leading to the catheter balloon; this makes the balloon swell up and anchors the catheter in the bladder so it won’t pull out when the patient moves (see Figure 22.9). Pull on the catheter very gently to feel the resistance.
Then connect the catheter to the sterile drainage tubing so the urine flows into the collecting bag. Make sure the collecting bag is placed below the level of the bladder, or the urine will not flow into it. If you do not have a sterile collecting bag, then let the urine drain into a very clean container. This is called an ‘open’ system and it carries a bigger risk of infection passing up the drainage tube and into the bladder. Ideally, the drainage should be a ‘closed’ system with the urine draining into a sterile bag.
As soon as you have completed the procedure, refer the woman to a higher health facility as quickly as possible. Go with her if you can.
When you are providing care to the woman who is catheterised, understand that she may feel some discomfort in her bladder area. Reassure her to reduce anxiety by explaining why you want to keep the catheter in place.
You should also keep her clean by wiping away any urine that might have leaked from the catheter; this may make her wet and embarrass her, or irritate her skin and also increase her anxiety.
When it is time to remove the catheter, prepare the necessary items on a very clean tray or dish.
Explain to the woman that she may feel some soreness or slight burning pain when she urinates normally for the first few times, but her bladder will soon be functioning normally.
This concludes the Antenatal Care Module. You have learned many things in the 22 study sessions about looking after the pregnant woman who is healthy and whose pregnancy is progressing normally, and also about the interventions you should make if you detect danger signs and symptoms. Your knowledge and skill can prevent many complications and save the lives of women and their unborn babies who get into difficulties. In the next Module, you will learn about Labour and Delivery Care.
In Study Session 22 you have learned that:
Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the questions that follow below. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.
Which of the following statements is false? In each case, explain what is incorrect.
A A woman who is in shock due to loss of blood should be referred immediately without beginning IV fluid therapy.
B Remove and reposition the IV cannula if the venipuncture site swells and is painful.
C If you don’t have a plaster to put over the venipuncture site there is no need to stabilise the IV cannula in the vein.
D You can stop giving IV fluid if the woman’s blood pressure and pulse return to normal and she is no longer bleeding.
E The syringe is for injecting sterile water into the bag collecting urine from the drainage tube in the bladder.
F Wash your hands thoroughly with soap and water before you touch the patient or the equipment.
G The flow rate should be as fast as possible when you start IV fluid therapy for a woman who is in shock.
A is false. A woman who is in shock (low blood pressure and rapid pulse) due to blood loss needs IV fluid therapy to be started before referral.
B is true. You should remove and reposition the IV cannula if the venipuncture site swells and is painful. This indicates that the fluid is going into the tissues instead of into the vein.
C is false. If you don’t have a plaster to put over the venipuncture site, you should stabilise the IV cannula by tying very clean cloth around it. If the cannula is not stabilised it can pull out of the vein.
D is true. You can stop giving IV fluid if the woman’s blood pressure and pulse return to normal and she is no longer bleeding.
E is false. The syringe is for injecting sterile water into the catheter balloon (not the collecting bag) to inflate the balloon so it anchors the catheter in the bladder.
F is true. You should wash your hands thoroughly with soap and water before you touch the patient or the equipment.
G is true. The flow rate should be as fast as possible when you start IV fluid therapy for a woman who is in shock.
Rearrange the following list into the correct sequence of actions when you start IV fluid therapy.
Using the following two lists, match each numbered item with the correct letter.
Wash your hands.
Put the patient in the lying down position.
Put on sterile or very clean gloves.
Identify the possible site for the IV cannula insertion.
Tie a tourniquet about three finger-widths above the venipuncture site.
Clean the venipuncture site with antiseptics, alcohol or soap and water.
Take the cannula from the sterile package and insert it at the venipuncture site; then withdraw the needle, leaving the plastic cannula in the vein.
Open the sterile IV tubing and connect the tubing to the bag of IV fluid and hang it higher than the patient or ask someone to hold it up for you.
Connect the cannula to the bag of IV fluid and open the roller clamp.
Define what catheterisation means and why it may be necessary in the pregnant woman in labour. List at least five items of equipment you need to conduct this procedure.
Catheterisation of the bladder means introducing a sterile rubber or plastic tube into the urethra and then into the bladder to drain urine when the bladder is obstructed. Bladder obstruction can happen in a long or obstructed labour when the baby presses down on the urethra and blocks the normal flow of urine. The items of equipment you need are: