Obstetric emergencies

Definition
Emergency is a serious situation or occurrence
that happens unexpectedly and demands
immediate action
Obstetric emergencies occur frequently and can
have catastrophic consequences for the
mother,baby and their family
Although it is unforeseen, preparation and
prevention should always be used to reduce the
risks of emergencies occurring eg. Eclamptic fit
can be prevented by giving mothers with severe
pre-eclampsia magnesium sulphate

Classification
A. Maternal (antenatal and postnatal)
1.Haemorrhage

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  APH
 PPH
2. Hypertensive disorders
 Pre-eclampsia
 Eclampsia
3. Uterine causes
 Inversion
 Rupture
4. Sudden maternal collapse
 Amniotic fluid embolism
 Pulmonary embolism
 Shock: sepsis, haemorrhage, anaphylaxis
 Cardiac causes: MI
 Intracranial events: bleeds, thrombosis
 Biochemical causes: hypoglycaemia

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B.FETAL
 Placenta praevia
 Abruption
 Atony
 Retained placenta
 Cord prolapsed
 Should dystocia
 Vasa previa

The structured approach to obstetric

emergencies
Developing a structured approach to
emergencies that can be practiced repetitively
provides staff with ordered sequence ofactions
that can help in a stressful and sometimes
chaotic situations
 Prepare and prevent
 Call for help
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  Talk to the patient
 Turn into the left lateral tilt
 Assess the airway: administer high flow
oxygen if airway is open and breathing
 Assess breathing and circulation
 Immediately commence CPR 100/ minute
Approach
1. Call for help
 Find out whether they are able to respond
 If the patient can responds appropriately,
then they must have open airway and be able
to move sufficient air to speak
 It also gives useful information about
neurological status
 If the patient is unable to respond, it should
trigger call for help, tilt to the left lateral
position and assessment of ABCDE
2. Assessing the airway (A)

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  Open the airway using the head tilt and chin
lift or a jaw thrust
 Check in the mouth for any obstructing
material like blood or vomit and remove it
with a suction
3. Assessing breathing and circulation
 Assess the breathing by looking for chest
movement and listening and feeling for
signs of air movement for 10 seconds
 If airway is open and patient is breathing,
high flow oxygen should be administered by
a mask
 Assess for circulation by feeling the carotid
pulse
 If no circulation or there is uncertainty,
commence CPR immediately
 Begin with 30 chest compression and 2
ventilation breaths

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  Compression should be done with both
hands placed on top another with straight
arms in the middle of the lower half of the
sternum in the midline
 The sternum should be depressed by 4-5cm
at a rate of 100 per minute
 If circulation is present but no breathing
( respiratory arrest), then ventilation breaths
with high flow oxygen should be given at a
rate of 10 breaths per minute withregular
check on the circulation
 Insert 2large bore cannulae at the antecubital
fossae (16 or 14 gauge)
Note
 Remember that there often two lives at
stake, and in most emergencies minutes or
event seconds counts
 Remember too, however, that panicking is
never helpful
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  Remember also that the fetus rarely needs to
be resuscitated directly, resuscitate the
mother and you will resuscitate the fetus
 Remember that obstetric emergencies can
cause profound lifelong psychological
problems for both the mother and her
partner

OBSTETRIC HAEMORRHAGES
Is the leading cause of maternal mortality world
wide
Is responsible for up to 50% of maternal deaths
in some countries
Antepartum haemorhage (APH)
Definition
Is any bleeding in pregnancy from viability but
prior to delivery

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Incidence
Affects 2-5% of pregnancies
Aetiology
The causes are classified into placental, fetal
and maternal
A. Placental causes
 Placental abruption
 Placental praevia
B. Fetal cause
 Vasa praevia
C. Maternal causes
 Cervical polyps
 Carcinoma of the cervix
 Varicose vein
 Local trauma
 Cervical ectropion
 Vagina infection and cervicitis
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  Idiopathic
Placental causes are the most worrying as the
mother’s and /or fetus’s life is in danger
The bleeding here may be more severe than with
other causes
However, any APH must always be taken
seriously, and any woman presenting a history
of fresh vaginal bleeding must be investigated
promptly and properly
The key question is whether the bleeding is
placental and is compromising the mother
and/or the fetus, or it has a less significant cause
History
How much bleeding?
Triggering factors (post-coital bleeds)
Associated with pain or contractions?
Is the baby moving?

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 Last cervical smear (
date/normal/abnormal)?
Examination
Vitals (PR, BP)
Is the uterus soft, firm or tender
FHR/CTG
Speculum examination, with particular
importance placed on visualizing the cervix
(having established that the placenta is not a
praevia, preferably using a portable
ultrasound machine)
Investigations
Depending on the degree of bleeding
Full blood count
Blood grouping
Cross match 6 units of blood if
praevia/abruption suspected

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 Ultrasound (fetal size, presentation, amniotic
fluid, placental position and morphology)
Abruptio placenta
Definition
Is the premature separation of the normally
situated placenta from the uterine wall
The bleeding is maternal and/or fetal
Is acutely dangerous for both the mother and the
fetus

Types
 Revealed abruption placentae
 Concealed abruptio placentae
 Mixed

Epidemiology

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Accounts for a third of allAPH
Incidence is 1 in 200pregnancies
0.4-2% of pregnancies

Risk factors
 Hypertension including pre-eclampsia
 Smoking
 Trauma to maternal abdomen
 Polyhydramnios
 Multiple pregnancy
 FGR
 Uterine factors like septated uterus
 Multiparity
 Advancing maternal age

Clinical manifestations
 Vaginalbleeding
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  Abdominal pain
 Maternal shock or collapse
 Tense tender uterus on palpation often
describe as woody hard
 Difficulty in palpating the fetus

Diagnosis
1. Clinical
 Shock out of proportion of external bleeding
 Unexplained extreme pallor
 Tense, tender and woody hard uterus
 Absent fetal heart sound
 Diminished urinary output
 Presence of coagulation disorders
2. Ultrasound
Not great value in the diagnosis
can show retroplacental clots
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Treatment
 Follow the structured protocol for managing
emergencies
 Blood for:
 Hb
 Haematocrit
 Coagulation profile
 Grouping and cross matching
 Urine for protein

Immediate delivery either by induction or

caesarean section
 Manage the complications

Complications

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  Shock
 DIC
 Renal failure
 Fetomaternalhaemorrhage
 Perinatal mortality
 Fetal growth restriction (FGR)

Differential diagnosis
 Placenta praevia
 Ruptured uterus
 Volvulus
 Twisted ovarian tumour
 Appendicular / intestinal perforation

Prevention
 Avoidance of precipitating factors such as
control of BP, smoking…

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  Educating the public on the risk factors and
emphasizing the importance of ANC

Placenta praevia

Definition
Is the implantation of the placenta in the lower
uterine segment
Lower uterine segment is that segment that lies
within 5cm from the internal OS
The bleeding is from the maternal not fetal
circulation and is more likely to compromise the
mother than the fetus

Classification
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A. Minor
 Grade I: encroaches on the lower uterine
segment
 Grade II: reaches internal OS (marginal)
B. Major
 Grade III: covers part of the OS (partial)
 Grade IV: completely covers the OS
(complete)
Epidemiology
 Accounts for 1/3 of APH
 Incidence ranges from 0.5-1%
Risk factors
 Multiparity
 Advancing maternal age
 Previous caesarean section
 Smoking
 Prior curettage
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Clinical features
 Vaginal bleeding which is:
 Of sudden onset
 Painless
 Causeless
 Recurrent
 The uterus is soft and non tender on
palpation
 The presenting part will be free

NB: VE is contraindicated

Diagnosis
1. Clinical
2. Ultrasound

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Complications
 Hypovolemic shock
 Malpresentation
 Prematurelabour
 Cord prolapse
 Intrapartumhaemorrhage
 PPH
 Low birth weight
 FGR

Treatment
 Resuscitation using the structured approach
of ABCDEF
 Deliver the baby by C/S

Vasa praevia

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Is when the placenta is attached to the
margin(battle dore) or into the membrane
(villamentous)
The insertion may be closed to the internal OS
or fetal vessels may run across the internal OS
in villamentous insertion leading to vasa praevia

Postpartum haemorrhage
Definition
Delivery associated with loss of blood of
≥500ml for vaginal and ≥1000ml for Caesarean
section

Classification
A. Primary PPH

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  Loss of ≥500ml from the genital tract within
24 hours after delivery
B. Secondary PPH
 Loss of ≥500ml from the genital tract
between 24 hours and 6 weeks after delivery
C. Minor PPH
 If blood loss is between 500-1000ml
D. Major PPH
 If blood loss is ≥1000ml

Risk factors
A.Maternal
1. Pre-existing
 Raised maternal age
 Primiparity
 Grand multiparity
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  Uterine fibroids
 Previous cs
 Bleeding disorder
 Obesity
 APH
 Previous PPH
2. Intrapartum
 Prolong labour
 Caesarean section
 Instrumental delivery
 Pyrexia in labour
 Episiotomy
B. Fetal
 Large baby
 Multiple pregnancy
 P]olyhydramnios
 Shoulder dystocia

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Aetiology
Can be remembered by the 4 Ts
1. Tone
 Uterine atony
 Common cause of PPH
2. Tissue
 Retained placenta or membrane
3. Trauma
 Injury to the birth canal
4. Thrombin
 Clotting disorders

Signs and symptoms

 Nausea and vomiting feeling of fainting
 Pallor
 Tachycardia
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  Low blood pressure
 Slow capillary refill > 2seconds

Diagnosis
Clinical: history and examinations
 Early recognition of blood loss
 Appreciation of risk factors
 Maternal signs of cardiovascular
compromise like tachycardia, low blood
pressure and cold peripheries

Management
Diagnosis and treatment occurs simultaneously
The above structured ABC approach should be
instituted
For severe PPH;
 Summon for help
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 Oxygen by mask initially
 2x 14-G cannulae
 FBC and clotting studies
 Cross match atleast 6 units of blood
 RFT and LFT
 IV fluid resuscitation preferably ringer’s
lactate
 Notify blood bank and haematologist
 Transfuse blood as soon as possible
 Massage the uterus to encourage
contractions
 Insert urinary catheter to empty the bladder
 Assess for genital tract injuries and repair
where possible
 Do vaginal examination to expel clots which
will prevent contraction of the uterus
 Continuous bleeding requires theatre
measures like

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  Uterine tamponade using uterine
balloon
 Radiological occlusion of the uterine
vessels
 Laparatomy for bilateral iliac artery
ligation
 Hysterectomy as a last resort

Prevention
 All mothers should attend ANC
 Train the people attending ANC
 Active management of third stage of labour

Secondary PPH

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Bleeding from the genital tract from 24 hours to
6 weeks after delivery
Aetiology
 Retained placental tissue
 Endometritis
 Hormonal contraception
 Bleeding disorder
 Choriocarcinoma

Uterine rupture
Definition
Tear or rupture in the uterus
Incidence
0.03-0.3%
Majority of cases occur during labour: i.e.
during late first stage or the active second stage
Risk factors
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  Previous c/s
 Previous uterine surgery or surgical
evacuation
 Induction of labour
 Augmentation of labour
 High parity
 Macrosomic fetus
 Placenta percreta
 Fetal version eg breech presentation
 Congenital uterine anomaly egunicornuate
uterus

Clinical features
 Abdominal pain (scar tenderness often not
relieved by epidural analgesia)
 Haematuria
 Vaginal bleeding
 Decelerations on CTG

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  Stoppage of contractions
 Signs of circulatory collapse

Management
 Immediate resuscitation using the ABC
protocol
 Immediate laparatomy to deliver the baby
and repair the uterus
 Hysterectomy as last resort

Umbilical cord accidents (cord prolapse)

Definitions
Cord presentation: presence of umbilical cord
below the fetal presenting part when the
membranes are intact

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Cord prolapse: presence of the cord below the
presenting part when the membranes are
ruptured

Incidence
1:500 deliveries

Pathophysiology
Occurs when the fetal presenting part does not
fit well into the maternal pelvis giving space for
the cord to prolapse when the membranes
ruptures

Risk factors
A. Maternal
 Pelvic tumours eg. Fibroids in the lower
segment
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  Narrow pelvis
B. Fetal causes
 Malpresentation eg. Breech
 Prematurity
 Multiple pregnancy
 Polyhydramnios
 Placenta praevia
 Large baby
 Malposition
 ARM
 FGR
 Being a second twin

Diagnosis
1. Clinical
Seeing the cord at the introitus
Feeling it during vaginal examination
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2. CTG: abnormal FHR

Management
 The immediate management is aimed at
minimizing the pressure of the fetal
presenting part on the cord while plans are
made to deliver the baby
 Move the woman 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 saline
 There should be minimal handling of the
cord
 Emergency caesarean section or forceps or
ventouse if cervix is fully dilated

Shoulder dystocia
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Definition
Need for additional obstetric manoevres to
release the shoulders after gentle downward
traction has failed

Incidence
o.6%

Risk factors
A. Maternal
 Diabetes mellitus
 Short stature
 Previous shoulder dystocia
 Obesity
B. Fetal
 Macrosomia
 Postmaturity
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C. Intrapartum
 Long first stage of labour
 Long second stage of labour
 Instrumental delivery
 Induction of labour

Diagnosis
Clinical
 When shoulders fail to deliver during the
next contraction after delivery of the head
 Sometimes is preceded by turtle sign: The
head appearing to be pulled back on to the
perineum at delivery

Management
 Call for help
 Ensure personnel are available
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 Drop the level of the delivery bed as low as
it will go and flatten the back of the bed so
that the woman is completely flat
 Remove the foot of the bed to allow access
 Assess for and perform episiotomy if needed
 Using one assistant on each of the mother’s
legs, flex and abduct the legs at the hip
(thighs to abdomen,known as MacRoberts
manoeuvre)
 This flattens the lumbosacral spine and will
facilitate delivery in around 90% of cases
 If this fails suprapubic pressure should be
applied by another assistant

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