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L28 Obstetric emergencies
This document summarizes several obstetric emergencies including maternal collapse, sepsis, hemorrhage, eclampsia, amniotic fluid embolism, umbilical cord prolapse, shoulder dystocia, uterine inversion, uterine rupture, and head impaction during cesarean section. For each emergency, it outlines risk factors, warning signs, management principles, and prevention strategies. The document provides concise yet comprehensive guidance on recognizing and responding to critical situations that can arise during pregnancy and childbirth.
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L28 Obstetric emergencies
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- 3. • ABCDE resuscitation+ IV access + diagnosis of the cause and treat it • For these reasons it is considered appropriate to empty the uterus to aid maternal survival by performing a peri -mortem Caesarean section if CPR performed with lateral tilt is ineffective after 5 min after 20 weeks GA
- 4. ABCDE A: Airway –with cervical spine control B: Breathing: If breathing is present, give high-flow oxygen. If breathing is absent, start ventilation C: Circulation – with haemorrhage control Left tilt , CPR if circulation is absent 30 : 2 compression : ventilation D: Disability – neurological status : Glasgow coma scale of 8 or less indicates intubation E: Exposure • Assess fetal wellbeing and viability: deal with threat to life of fetus. • Assess fetal wellbeing using cardiotocography (CTG).
- 6. FURTHER READING • Forfurther reading see MRCOG guideline for maternal collapse
- 7. SEPSIS • Most commoncause is Group A streptococci • Risk factors: ruptured membranes immunocompromised patients Immunosuppressants obesity diabetes minority ethnic group origin, anaemia urinary tract infections vaginal discharge, previous pelvic infection group B streptococcal infection amniocentesis Cervical cerclage group A streptococcal infection in close contacts
- 8. WARNING SYMPTOMS &SIGNS Pyrexia Hypothermia Tachycardia increased respiratory rate hypotension Oligouria reduced levels of consciousness
- 9. SEPSIS 6 Administer broad-spectrumantibiotic within 1 hour of recognition of severe sepsis In the event of hypotension and/or a serum lactate ≥4 mmol/l, deliver an initial minimum 20 ml/kg of crystalloid or an equivalent. If there is no response, administer vasopressors for hypotension that is not responding to initial fluid resuscitation to maintain mean arterial pressure (MAP)
- 10. In the eventof persistent hypotension despite fluid resuscitation and/or lactate ≥4 mmol/l, aim to achieve : central venous pressure (CVP) of ≥8 mmHg Central venous oxygen saturation ≥70% mixed venous oxygen saturation ≥65% Severe sepsis may be defined as: Temperature >38ºC or <36ºC. Heart rate >100 beats per minute. Respiratory rate >20 respirations per minute. White cell count >17 × 109/l or <4 × 109/l with >10% immature band forms Antibiotic for sever sepsis combination of either piperacillin/tazobactam or a carbapenem plus clindamycin
- 11. HEMORRHAGE • Antepartum andpostpartum hemorrhage • Please read previous lectures • Some algorithms for management next
- 15. ECLAMPSIA • Cerebral hemorrhageis the most common cause of death in patients with eclampsia • Prevention: magnesium sulphate in women with sever preeclampsia • Risk factors: uncontrolled hypertension, primigravidity, obesity, black ethnicity, diabetes and age <20 years. • Warning signs: epigastric pain and right upper quadrant tenderness, headache, uncontrolled hypertension, agitation, hyper-reflexia and clonus, facial (especially periorbital) oedema, poor urine output, papilloedema.
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- 17. AMNIOTIC FLUID EMBOLISM •amniotic fluid entering the maternal circulation lead to cardiorespiratory compromise and severe disseminated intravascular coagulation and collapse • Diagnosed at postmortem, with the presence of fetal cells (squames or hair) in the maternal pulmonary capillaries • Risk factors: induction of labour, women 35 years or older and multiple pregnancy. • Warning signs: maternal collapse, shortness of breath, chest pain, feeling cold, light- headedness, restlessness, distress and panic, pins and needles in the fingers, nausea and vomiting.
- 18. MANAGEMENT • 30% ofpatients dying in the first hour and only 10% surviving overall • Manage as any collapse with ABC • Treat DIC • Perimortem caesarean section should be carried out within 5 minutes or as soon as possible after cardiac arrest
- 19. UMBILICAL CORD PROLAPSE •the descent of the umbilical cord through the cervix alongside or past the presenting part in the presence of ruptured membranes • occur in 0.1–0.6% of pregnancies • perinatal mortality rate 91 per 1,000 • Warning signs: signs of fetal distress on CTG following artificial or spontaneous rupture of membranes.
- 20. PREVENTION OF CORDPROLAPSE • with transverse, oblique or unstable lie, elective admission to hospital after 37+0 weeks’ gestation allows for quick delivery should membranes rupture • Women with non-cephalic prelabour preterm rupture of membranes should be managed as inpatients • Avoid artificial induction of labour when the presenting part is non-stable and/or mobile • When performing vaginal examination avoid upward pressure on the presenting part
- 21. RISK FACTORS FORCORD PROLAPSE Polyhydramnios multiparity multiple pregnancy/second twin unstable, transverse and oblique lie fetal congenital abnormalities low birthweight (<2.5 kg) internal podalic version large balloon catheter induction of labour
- 25. SHOULDER DYSTOCIA a vaginalcephalic delivery that requires additional obstetric manoeuvres to deliver the fetus after the head has delivered and gentle traction has been unsuccessful in delivering the shoulders
- 26. COMPLICATIONS Maternal complications perineal trauma(third- and fourthdegree tear) postpartum haemorrhage psychological trauma Recurrence (10-15 %) Fetal complications brachial plexus injury (2–7% at birth reducing to 1–3% at 12 months of age) fractured clavicle or humerus (1–2%) hypoxic brain injury Mortality
- 27. PREVENTION OF SHOULDERDYSTOCIA • Early recognition of the possibility of shoulder dystocia • Control of diabetes and gestational diabetes and plan appropriate mode of delivery (cs if more than 4 kgs) • Plan delivery for fetal macrosomia (cs if more than 4.5 kgs ) • Control maternal diabetes • Careful planning of delivery in previous shoulder dystocia
- 28. RISK FACTOR Macrosomia poorly controlledgestational and insulin-dependent diabetes maternal obesity Fetal macrosomia previous shoulder dystocia Instrumental delivery Warning sign : turtle sign
- 31. UTERINE INVERSION • Theuterus turned in out • Four degrees : • first degree when the 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 • total inversion occurs when the vagina and uterus are inverted.
- 32. RISK FACTORS Inappropriate Placentaldelivery with lax uterus and fundal placenta full dilatation cesarean sections Malpresentations prolonged second stage unsuccessful instrumental delivery in prolonged second stage, hyperstimulated uterus Abnormally adherent placenta
- 35. UTERINE RUPTURE • Disruptionof all layers of the uterus • Disruption up to the serosa called dehiscence • Most commonly in patients with previous cs scar • Overall incidence 2:10.000 • Incidence in TOLAC-VBAC 21:10.000 (trial of labor after cesarean) (vaginal delivery after cesarean)
- 36. RISK FACTORS • Previousuterine scar ( CS , myomectomy …….) • Multiparity • Advanced maternal age • Forceps delivery with cervical trauma • Uterine anomalies • Fetal malpresentation (obstructed labor ) • Trauma • Use of oxytocin and prostaglandin • Overdistended uterus
- 37. WARNING SYMPTOMS • Firstcommon sign is abnormal fetal heart trace • maternal shock • unable to auscultate fetal heart • unable to palpate any presenting part on vaginal examination • severe sudden abdominal pain • Vaginal bleeding
- 38. MANAGEMENT • Deliver thefetus urgently • Resuscitate the mother • urgent laparotomy is then required to examine and repair the uterine rupture if possible • Hysterectomy in un-repairable rupture
- 40. HEAD IMPACTION INCS • Might occur in cs done after failed vaginal delivery as in failed instrumental delivery , macrosomia or failure to descent in the second stage of labor • Stop oxytocin and give uterine relaxant • De-engagement of the head can be done from the cs scar by converting it to transverse position and pulling it up gently , or by dislodgment and elevation of the head by an assistant vaginally by hand or vaccum very gently • Delivery of the baby by breech delivery might be used but need extension of the uterine scar , sometime J or inverted T scar is needed .