Obstetrical emergencies &

its management
 INTRODUCTION

• Pregnancy is a journey in every women’s life expecting a fruitful outcome.

• An emergency is defined as a serious situation or occurrence that happens

unexpectedly and demands immediate action.

• Obstetric emergencies are health problems that are life-threatening for

pregnant women and their babies.

• An obstetric emergency may arise at any time during pregnancy, labour and
postpartum.
 Obstetrical emergencies during pregnancy

Abortion

Ectopic pregnancy

Placenta previa

Placental abruption

Preeclampsia & Eclampsia

Abortion
Rupture of fallopian
tube

Hemorrhage

Hypovolemic
shock

Death
Antepartum hemorrhage
 Obstetrical emergencies during labour

Cord prolapse

Vasa previa

Shoulder dystocia

Placenta accreta

Rupture of uterus

Inversion of uterus

Amniotic fluid embolism

1.Umbilical cord prolapse
 Cord prolapse……….contd
Causes
• Malpresentation: Breech/shoulder
• CPD
• Polyhydramnios
• Multiple pregnancy
• PROM
• Placenta previa
• Pelvic tumours
• Prematurity
Cord prolapse….contd
Diagnosis
• Cord pulsations felt in P/V
• CTG shows variable decelerations
• Cord lying outside vulva
• USG – cord loops
• Fundal pressure causes bradycardia
• Meconium stained liquor
Management of cord prolapse

1. Discontinue the vaginal examination to reduce the risk of rupturing the

membranes.

2. Call for help and inform obstetrician immediately

3. Monitor continuously the FHR and fetal well- being

4. Instruct not to push

5.Lift presenting part off the cord
a) Keep the gloved hand inside the vagina
b) Position the mother - Knee chest/Exaggerated Sim’s - To minimise
the cord compression.
c) Bladder filling
 Management of cord prolapse…..CONTD

6.Administration of oxygen(4 – 6 litres) by face mask.

7.Obstetrical management :

If cord pulsation is felt – based on cervical dilation – assisted vaginal

delivery/ Emergency CS(within 15 minutes).

If no cord pulsation allow the labour to progress normally.

2.Vasa previa
• Unprotected fetal vessels traverse the fetal membranes
over the internal cervical os.

• These vessels may be from either a velamentous

insertion of the umbilical cord or may be joining an
accessory (succenturiate) placental lobe to the main disk
of the placenta.

• If these fetal vessels rupture the bleeding is from the

fetoplacental circulation, and
fetal exsanguination will rapidly occur, leading to fetal
death
 Vasa previa…..continued
Diagnosis
• The classic triad of the vasa praevia is: membrane rupture, painless vaginal
bleeding and fetal bradycardia or fetal death.

• Alkali denaturation test detects the presence of fetal hemoglobin in vaginal

bleeding.

Management

• Elective caesarean section

• Steriod for lung maturity in case of preterm labour.

Risk factors

• Maternal obesity

• Fetal macrosomia

• Previous shoulder dystocia

• Postterm delivery
 Wood’s
maneuver
 Placenta accreta
• Placenta accreta is a serious
pregnancy condition that occurs when
the placenta grows too deeply into the
uterine wall.

• It's also possible for the placenta to

invade the muscles of the uterus
(placenta increta) or grow through the
uterine wall (placenta percreta).
Inversion of uterus
Johnson’s
maneuver
 Rupture of uterus
Def : Dissolution in the continuity of uterine wall anytime beyond 28 weeks of
pregnancy

Etiology
1.Scar rupture – LSCS, Previous operation

2.Iatrogenic rupture – injudicious use of oxytocics, internal podalic version, difficult

forceps delivery, manual removal of placenta and destructive operation.

3.Spontaneous – obstructed labour, uterine malformation

4.Traumatic rupture
 Rupture of uterus

Types:
Types
a. Complete : when uterine cavity
communicates directly to peritoneal
cavity

b. Incomplete : Uterine cavity is

separated by visceral peritoneum of
uterus or broad ligament

c. Scar dehiscence: when there is

separation part of previous uterine scar
with intact peritoneal coat.
Clinical features
• Previous scar- dull aching pain in suprapubic region initially followed by scar
tenderness & tachycardia.

• Obstructed labour – vigorous uterine contraction followed by sudden and severe

bursting abdominal pain, cessation of progress of labour, fetus can be felt abdominally,
fetal death & all signs of internal hemorrhage present.
Management
• Emergency laparotomy with blood transfusion

• Subtotal/Total hysterectomy

• Repair of rupture with low parity

 Amniotic fluid embolism
• Amniotic fluid embolism is a rare cause of maternal collapse specific to pregnancy,
believed to be caused by amniotic fluid entering the maternal circulation.

• This causes acute cardiorespiratory compromise and severe disseminated

intravascular coagulation.

• In some cases, there may be an abnormal maternal reaction to amniotic fluid as the
primary event.

• It is difficult to diagnose in life, and is typically diagnosed at postmortem, with the

presence of fetal cells (squames or hair) in the maternal pulmonary capillaries.
Obstetrical emergencies during postpartum
 Postpartum hemorrhage
• Postpartum haemorrhage (PPH) is probably one of the most common obstetric
emergencies. It is a leading cause of death(37%) in India.

• It is defined as:

• Primary PPH. Loss of 500 mL blood from the genital tract within 24 hours of delivery.

• Secondary PPH. Loss of 500 mL blood from the genital tract between 24 hours and

6 weeks post delivery.

Etiology of primary PPH
 a)Tone - Uterine atony
• Uterine atony, is a serious condition that can occur after childbirth. It occurs when the
uterus fails to contract after the delivery of the baby,

• Predisposing factors:
• Over distension of uterus(multiple • Anemia
pregnancy, Macrosomia • Uterine fibroids
&polyhydramnios) • General anasthatic drugs(Halothane)
• Retained products of conception • Precipitate labour
• Prolonged labour • Chorioamnionitis
• Oxytocin augmentation • Magnesium sulphate treatment of PIH
• Grand multiparity
• APH
b)Tissue – Retained placenta

• Retained placenta – Succenturiate, Membranes, cotyeledons

• Placenta accreta – Placenta previa, adherence of placenta over

previous C.Section scar, repeated uterine curettages and
myomectomies.
 c) Genital tract trauma

• Perineal tear, episiotomies, ruptured

vulval varicosities, Precipitate labor,
macrosomic babies and instrumental
deliveries can cause cervical, vaginal and
vulval lacerations.

• Uterine rupture(Prostaglandins,
oxytocics, obstructed labor and previous
scar)
 d) Clotting - Coagulopathy

• Amniotic fluid embolism

• Abruptio placenta
• Sepsis
• Severe pre-eclampsia
• Chorioamnionitis
• Idiopathic thrombocytopenia
Causes of secondary PPH

• Retained products of conception – cause of delayed PPH in half of the

cases.

• Infection

• Breakdown of uterine wound

• Chronic subinvolution of uterus

• Trophoblastic diseases and endometrial cancer(rare)

 1.Prophylactic management
Aim:
 prevention of atonic PPH
 Identification of high-and low risk patients
High risk Low risk
• Correct anaemia in antenatal period • Active management in the 3rd stage of labor
• Hospital delivery by experienced obstetric - Early clamping of umbilical cord
team. - Administration of prophylactic oxytocics at the
• Establish intravenous line with a wide bore delivery of anterior shoulder
cannula before 2nd stage - Brandt –Andrews technique to deliver the
• Active management of 3RD stage placenta.
• Cross match/blood transfusion
• Prophylatic IV oxytocin drip 40IU for duration
of 6 hours after delivery.
 2.General management

• Call for assistance from multidisciplinary team(Anesthatist,Consultant obstetrician,

hematologist, theater staff and nursing staff).

• Rapid assessment of patient’s general condition – establish the cause of PPH, amount of
blood loss and degree of hypovolemia).

• Resuscitate the mother(minimum 2 IV cannula size – 14-16G, crystalloids or colloids

infusion or plasma or blood transfusion depending on the blood loss).

• Catheterize the bladder.

• Regular monitoring of the patient’s blood pressure, pulse rate, LOC, pad chart,
intake/output chart and uterine fundal height.
 3.Specific management
a) ATONIC PPH(80%)
1.To encourage uterine contraction, fundal message needs to be performed first.
 Management of Atonic PPH……CONTD
2.Re-examine the placenta and membrane for completeness and presence of succenturate lobe.

3.IM syntometrine 1ml or IV ergometrine 0.25mg may be administered. It has combined rapidly
acting effect of oxytocin(within 45 second) and sustained action ergometrine(around 3 hours).

4.If the above measures fail, IV infusion of oxytocin(40 – 100IU) in 500ml of normal saline is
administered.

5.If the uterus remains atonic, IM carboprost/Hemabate(15 methyl-PG F2 α) 250µ gm can be

administered. This can be repeated after 15 minutes for a maximum of 3 doses. Misoprostol 800µ
gm given rectally as an alternative.
 Management of Atonic PPH……CONTD
6. If the bleeding still persists, bimanual compression of the uterus or aortic
compression is performed until the patient could be transported to OR for appropriate

surgical management.
- Examination under anesthesia
- Temponade test
Surgical management – atonic PPH

- Uterine compression suture

• B-Lynch suture
• Hemostatic suturing(Multiple square)

- Devascularization procedure
• Bilateral uterine artery ligation
• Bilateral internal iliac artery ligation
• Arterial embolization

• Hysterectomy
 Role of Nurse in handling obstetrical emergencies
• Risk assessment when admitting mother in labour room

• Efficient Vaginal examination and notification of findings(MSAF, cord pulsation)

• Plotting of partograph and early reporting of abnormality

• CTG monitoring and its interpretation

Role of Nurse in handling obstetrical emergencies

• Knowledge about Oxytocics in labour

• Keen observation skills

Drug IV IM
OXYTOCIN IMMEDIATE 3-5 MINUTES
Duration : 20 minutes Duration : 30-60 minutes
after stopping IV
Methergine Immediate 2-5 minutes
Role of Nurse in handling obstetrical emergencies
• Prompt identification & reporting

• Familiarization on protocols followed in labour room

• Prompt documentation

• Emergency communication codes(blue)

• Team collaboration

• Participation in simulation emergency drills

 Conclusion
Knowledge and proactive skills will help the midwife to identify and manage the
obstetrical emergencies in a efficient way.

• Act Promptly

• Be alert to identify the onset and Be familiar with recent evidence based, technical
skills

• Care with concern

• Document accurately

• Execute emergency measures with competence

 Reference
1. Shirish Shelth(2011). Essentials of Obstetrics. 2nd edition. Jaypee company.P.489-494.

2. Shurish Daftary, Sudip Chakravarti(2014). Manual of obstetrics.2nd edition. Elsevier.

3. Dutta, D. C. (2008). Text book of Gynecology.(6th ed.). London: New central book agency

4. Dacey, Wilcox (2011). Preparing for clinicalEmergencies in Obstetrics ansGynecology, Journal of Perinatalcare 35: 2076-82 Retrived from
http://www.pnjournals.com/clinicalemergencies/obs ans Gyne/2076-82.

5. Gosman, Nelson (2010). Establish a rapid response team required from http://www.ihi.org/criticalcar/establish rapidresponseteam.htm.

6. Pilliteri, A. (2006).Manual and child Health Nursing – care of child bearing and child rearing family. (5th Ed.). Philadelphia: Lippincott Company

7. Lowdermilk, and Perry. (2008). Maternity and Women’s Health care.(8th ed.). New York : Mosby company

8. Bennet and Brown. (2008). Myles text book of Midwives. (15th edition).Philadelphia: Churchil Livingston.

Net Reference:

• http://calsprogram.org/manual/volume3/Section22/OB15-ThirdStagePostpartum.html

• http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Sep5(3)/Pages/85.aspx

• http://www.alsg.org/uk/MOET

• http://en.wikipedia.org/wiki/Obstetrics