OBSTETRIC EMERGENCIES

Prof. Dr. Iram Chaudhry

FCPS (OBS&GYNAE), MHPE.
Bahawalpur.
INTRODUCTION
An emergency is defined as a serious situation or occurrence that
happens unexpectedly and demands immediate action.
In obstetrics, emergencies can be classified as:
maternal (occurring antenatally and postnatally) and fetal.
• Obstetric emergencies are common and often result in significant
maternal and fetal morbidity and mortality.
• It is essential these are managed in a methodological stepwise
manner to limit morbidity and mortality.
OBSTETRIC EMERGENCIES
The collapsed/unresponsive patient
Sepsis
Obstetric haemorrhage
Eclampsia
Amniotic fluid embolism
Umbilical cord prolapse
Shoulder dystocia
Thrombosis and thromboembolism
Uterine inversion
Uterine rupture
Impacted head at caesarean section
THE COLLAPSED PATIENT
Structured approach to manage obstetric emergencies.
The pregnant woman is tilted to the left to move the pregnant
uterus off the abdominal vessels, thus improving cardiac
output.
INITIAL MANAGEMENT
• A,B,C measures
• D: Disability – neurological status using the AVPU score (Alert, responds to Voice,
responds to Pain, Unresponsive).
Following initial resuscitation perform a Glasgow coma score (GCS).
GCS ≤8 indicates a compromised airway and will require intubation.

• E, exposure, examination and monitoring: Vitals, ECG,IOP, Catheterization and NG tube.

• Resuscitation
• Fetal wellbeing: CTG
• Notes Review
• Definitive treatment: investigations and plan treatment: depending on underlying cause
DIFFERENTIAL DIAGNOSIS
Pulmonary embolism
• Thrombosis is consistently the most common cause of maternal
death.
• PE is more common in the puerperium, can occur at any time in
the antenatal and post-natal period.

Amniotic fluid embolism

• A rare cause of maternal collapse.
• Amniotic fluid entering the maternal circulation leading to acute
cardiorespiratory compromise and severe disseminated
intravascular coagulation.
 Amniotic fluid embolism
Diagnosis:
Typically diagnosed at postmortem (presence of fetal cells in the maternal
pulmonary capillaries)
Symptoms:
breathlessness – chest pain – feeling cold – lightheadedness –
restlessness, distress and panic – pins and needles in the fingers – nausea
and vomiting.
Management:
Structured ABC approach
Perimortem caesarean section within 5 minutes or as soon as possible
after cardiac arrest.
 Umbilical cord accidents (cord prolapse)
• Fetal emergencies The fetus may be severely affected by any of the
preceding maternal emergencies that occur before delivery.
• Some emergencies directly affect the fetus without major immediate
physical compromise of the mother.
• Major abnormalities of the fetal heart rate, esp. prolonged fetal
bradycardia, call for immediate delivery.
• A cord presentation is the presence of umbilical cord below the fetal
presenting part when the membranes are intact.
• Cord prolapse is the presence of the cord below the presenting part
when the membranes are ruptured.
 Diagnosis
• Most commonly, it is diagnosed by seeing the cord at the introitus, or
feeling during a vaginal examination.

• Abnormal fetal heart rate pattern as compression of the umbilical vein

causing deep variable decelerations, then bradycardia.
CORD PROLAPSE & CORD PRESENTATION
Management
Immediate management:
minimize the pressure on the cord, while planning to deliver the baby.

This is achieved by moving the woman on to all fours with the head
down, applying pressure vaginally to push the presenting part out of
the pelvis, or by filling the bladder with 500 mL of saline.

• Total cord compression for longer than 10 minutes will cause cerebral
damage and, if continued for around 20 minutes, death.
Shoulder dystocia
It is defined as a vaginal cephalic delivery that requires additional
obstetric manoeuvers to deliver the fetus after the head has delivered
and gentle downward traction has failed to deliver the shoulders’.
Identification of the Risk factors and Prevention:
• Diagnosis and optimal control of gestational and insulin-dependent
diabetics
• Instrumental vaginal delivery
• Maternal obesity
• Short stature and pelvic anatomy.
• Women with previous shoulder dystocia delivery ( 10–15%)
• Fetal macrosomia
Shoulder dystocia
Warning signs:
• Failure of restitution of head following delivery of the head
• Turtle sign: retraction of the fetal head against the perineum
Maternal complications:
• Increased perineal trauma
• Postpartum haemorrhage
• Psychological trauma.
Fetal complications:
• Brachial plexus injury (2–7% at birth reducing to 1–3% at 12 months)
• Fractured clavicle or humerus (1–2%)
• Hypoxic brain injury.
• Fetal death
SHOULDER DYSTOCIA
Clinical Management
Step One: Recognize the problem
“Prolonged head-to-body expulsion time” Objectively defined as 60
seconds.

Perform HELPERR pneumonic

• H – Help – Call for additional assistance
• E – Evaluate for episotomy
• L – Legs (McRobert’s Maneuver)
• P – Pressure (suprapubic)
• E – Enter the vagina
• R – Remove the posterior arm
• R – Roll the patient – To hands and knees
Uterine inversion
• A rare complication usually occurring during the third stage of labour.
Incidence between 1:2000 and 1:6000.
• Occurs when the uterus is partially or wholly inverted
The uterine fundus descends either in the uterine cavity, through the
cervix or beyond the introitus.
Four degrees of inversion:
1st inverted fundus extends to but not through the cervix;
second degree when the inverted fundus extends through cervix but
remains within the vagina;
third degree when the inverted fundus extends outside the vagina;
finally, total inversion occurs when the vagina and uterus are inverted.
Risk factors:

Full dilatation sections,

Malpresentations,
Prolonged second stage,,
Unsuccessful instrumental delivery,
Hyperstimulated uterus.
Intravenous Syntocinon™ prior to a decision to Deliver by
caesarean section
MANAGEMENT:

• Attempt manual replacement as soon as the diagnosed.

• Replacement of the uterus under anaesthetic.
• Hydrostatic replacement by running 2–3 litres of warm saline
via tubing into the vagina using your hands to create a seal
round the vulva. Start oxytocin infusion.
• If this is unsuccessful, surgical procedures including
hysterectomy.
Manual Replacement of Inverted Uterus
Uterine rupture

• is a catastrophic event with significant associated maternal

and fetal morbidity and mortality.
• Mostly occurs during third stage of labour.
• Common with previous delivery by caesarean section.
• In the UK, the estimated incidence of uterine rupture was 2
per 10,000 pregnancies overall.
• These rates increased to 21 per 10,000 pregnancies in women
with a previous caesarean delivery planning vaginal delivery.
THANK YOU

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