A fracture is a complete or partial break in the continuity of a bone. When the force applied to a bone exceeds its structural strength, the bone tissue yields, resulting in a break. In emergency midwifery and obstetric care, fractures typically occur due to road traffic accidents, falls during pregnancy, or severe physical trauma.
Bones can break from direct impact, where the fracture happens right at the spot where the force hits, or indirect impact, where the force travels along the bone and causes a break at a distant point. Understanding how the injury happened gives midwives vital clues about the severity of the damage and potential hidden injuries.
When assessing a pregnant woman or any emergency patient with a suspected bone injury, midwives look for specific clinical indicators. Recognizing these signs quickly ensures prompt and appropriate first aid.
Fractures are broadly categorized based on how the bone breaks and whether the skin remains intact.
Before providing any emergency care for a fracture, the midwife or first responder must evaluate the environment to ensure it is safe. Rushing into a hazardous scene—such as a busy roadway or a structurally unstable building—puts both the provider and the patient at risk.
Once the scene is safe, perform a primary survey using the ABCDE approach:
Immobilization means keeping a broken bone and its surrounding joints from moving. Proper immobilization reduces pain, prevents sharp bone ends from tearing nearby blood vessels and nerves, and limits further soft tissue damage.
When applying a splint, always immobilize the joint above and the joint below the fracture site. For example, if a patient has a fracture in the lower leg (tibia), you must secure both the ankle and the knee joints. Never try to push a protruding bone back into the skin; doing so introduces bacteria deep into the tissue. Instead, cover the wound gently with a clean dressing and immobilize the limb as it lies.
In resource-constrained or pre-hospital settings, midwives may need to improvise splints using available materials such as wooden boards, rolled newspapers, cardboard, or even tying an injured leg to the uninjured leg.
Rigid splints provide firm support if they are well-padded with cloth or cotton to prevent pressure sores. Soft splints, like folded blankets or pillows, work well for ankle or lower leg injuries when tied securely with bandages. Always check that ties are snug enough to hold the splint in place but loose enough not to cut off blood flow.
Applying a splint or bandage is not the end of care; continuous observation is vital. A tight bandage can act like a tourniquet, cutting off blood supply to the limb and causing permanent tissue damage or gangrene.
Check the neurovascular status of the injured limb every fifteen minutes. Assess the pulse below the fracture site, check the skin color to ensure it is not pale or blue, feel the skin temperature to ensure it is warm, and test capillary refill by pressing a fingernail and watching how fast the pink color returns. If circulation is compromised, loosen the splint immediately.
While initial first aid stabilizes the patient, many fractures require specialized orthopedic care that cannot be provided in a primary health clinic or remote maternity center. Midwives must recognize when a patient needs urgent referral.
Situations requiring immediate hospital transfer include: