OBSTETRICS EMERGENCIES

BY: FARAH
MASHITAH
HAFIZ
ADEEB
 OBSTETRICS EMERGENCIES

A group of serious conditions, situations

DEFINITION or disorders that happen unexpectedly during

pregnancy, labor or after delivery that
demands immediate management and
interventions.
In any emergency situation, the first action should be to call for help. After this, a
systematic evaluation and resuscitation should be conducted in the following
order:

1. (A) Airway

5. (E) Environment & 2. (B) Breathing &

exposure. ventilation

3. (C) Circulation with

volume replacement and
4. (D) Disability control of bleeding.
A: Assessing the airway
1. Check in the
mouth for any
obstructing material.

2. Remove using
suction.

3. Open airway by
head tilt and chin
lift or jaw thrust.
B: Breathing and C: Circulation
1. Assess breathing for 10 2. If the airway is open and 3. Check for carotid pulse.
seconds by looking at chest the patient is breathing, If there is no circulation,
movement & listening or high flow oxygen should be commences
feeling for signs of air administered via a face cardiopulmonary
movement. mask. resuscitation (CPR) .

5. If the patient begins to 4. This can be continued

6. Two large bore cannula
(16- or 14-gauge) should
be inserted
into both cubital fossa.
breath spontaneously, until the
place them in recovery arrival of skilled help
position & closely where intubation can be
monitored. performed.

7. Defibrillator pads 8. Treat accordingly &

should be applied to assess specific treatment
the cardiac rhythm. initiated.
 Difficulties in resuscitation due to pregnancy
• In pregnant patients (>20 weeks), enlarged uterus compresses the inferior vena cava.
• Thus, reduce the venous return to the heart when the patient is lying flat on their back.
• Thus, patient is put on left lateral tilt position.
1. Compression of the
large abdominal blood • This will lift the heavy uterus away from the abdominal vessels.
vessels.

• Reduce the lung functional residual capacity.

2. Pressure by the • Making the lungs more difficult to ventilate.
pregnant uterus on the
diaphragm.

• Increase the likelihood of aspiration of the stomach contents into the lungs.
3. Oesophageal
sphichter become more
relax.
 • Due to aortocaval compression,
obstruction to ventilation & increased
oxygen requirements.
• If resuscitation has not been successful
by 4 minutes, an immediate Caesarean
4. Presence of a section should be conducted, with the
fetus within the aim of having the baby delivered by 5
uterus minutes.
Fetal Emergency

1. Umbilical
cord accidents
(cord prolapse) 2. Shoulder
dystocia
FETAL DISTRESS &
ABNORMAL CTG
DEFINITION
• Fetal distress is defined as depletion of oxygen and accumulation of
carbon dioxide, leading to a state of “hypoxia and acidosis ” during
intra-uterine life that may result in permanent fetal brain damage or
death.
What can cause fetal distress?
A. Intrauterine fetal distress
• Maternal hypoxia (anaesthesia,heart failure, severe anaemia, during
eclamptic fits ,severe pulmonary disease)
• Placental
1. Placental compression-prolonged labour, tonically contracted uterus.
2. Placental separation
3. Uteroplacental insufficiency –Improper / inadequate trophoblastic
invasion and placentation in the first trimester.Lateral insertion of
placenta,Reduced maternal blood flow to the placental bed.
4. Foetoplacetal insufficiency--Vascular anomalies of placenta and cord,
Decreased placental functioning mass(.Small placenta, abruptio
placenta, placenta previa, post term pregnancy.)
• Obstetrics (true knot, tight coiling around fetal neck ,rupture of vasa
previa, hematoma of cord).
• Prolonged compression of head of fetus –compression of respiratory
center
B. Asphyxia neonatorum
• Persistance of intrauterine causes after birth –edema of brain due to
compression
• Obstruction of respiratory passages (mucus,amniotic fluid, blood)
• Paralysis of respiratory center due to cerebral haemorrhage
• Depression of respiratory center due to anaesthesia,drug like pethedine
• Congenital malformation like atelectasis
• prematurity
Effects of Fetal hypoxia
Fetal hypoxia is associated with severe complications in all systems.

The fetus may suffer:

1. IUGR
2. Fetal movement decrease
3. Oligohydramnios
4. Meconium stained amniotic fluid
5. IUFD
The infant may suffer:
1) Hypoxic ischemic encephalopathy
2) Meconium aspiration syndrome
3) Acidosis with decompensation
4) Cerebral palsy
5) Neonatal seizures
CTG suggestive fetal compromise
1.Fetal tachycardia >160 bpm
2.Loss of baseline variability
3.Recurrent late deceleration
4. Persistent variable deceleration
5.Fetal bradycardia <100bpm for 3 mins
Baseline FHR changes
The pattern between uterine contractions.
• i- Baseline tachycardia:
- Mild: 160-180 beats/min.
- Severe: > 180 beats / min.
• ii- Baseline bradycardia:
- Mild : 100-120 beats/min.
- Severe: <100 beats/ min.
• iii- Loss of beat - to - beat variation:
Normally there is a change of 5-10 beats/ minute
every minute in FHR. Absence of this beat -to - beat
variation indicates fetal compromise.
Periodic FHR changes
The pattern with uterine contractions.
• i- Early deceleration:
- Decrease in the FHR with the onset of the uterine contraction and return to the baseline
with the end of the contraction.
- This is usually due to compression of the fetal head with vagal stimulation.
• ii- Late deceleration:
- Decrease in the FHR starts after a lag time from the onset of contraction and ends after a
lag time from its end.
It denotes uteroplacental insufficiency --- hypoxemia leads to hypoxia and metabolic
acidosis the delayed return to baseline worsens due to myocardial depression
• iii- Variable deceleration:- of different intensity, pattern, time of onset and offset.
It usually denotes cord compression especially in the presence of oligohydramnios.
Early & Late deceleration
Variable deceleration
Fetal bradycardia
• Acute fetal distress
(1)FHR
• FHR>180 beats/min (tachycardia)
<100 beats/min (bradycardia)

• (LD) Repeated Late deceleration

Placenta dysfunction
• (VD) Variable deceleration
Umbilical factors
(2) Meconium staining of the amniotic fluid
-grade I ,II ,III
(3) Fetal movement
-Frequently→decrease and weaken
(4) Acidosis
-FBS (fetal blood sample)
• pH<7.20
-pO2<10mmHg (15~30mmHg)
-CO2>60mmHg (35~55mmHg)
MANAGEMENT
1. Remove the induced factors actively
2. Correct the acidosis: 5%NaHCO3 250ML
3. Terminate the pregnancy
FHR>160 or <120 bpm
meconium staining (II~III)
 Meconium staining grade III amniotic fluid volume<2cm
FHR<100 bpm continually
Repeated LD and severe VD
 Baseline variability disappear with LD
FBS pH<7.20
Method of delivery
• If fetal heart rate abnormalities persist or there are additional signs of
distress (thick meconiumstained fluid), plan delivery:
• - If the cervix is fully dilated and the fetal head is not more than 1/5
above the symphysis pubis or the leading bony edge of the head is at 0
station, deliver by vacuum extraction or forceps;
• - If the cervix is not fully dilated or the fetal head is more than 1/5
above the symphysis pubis or the leading bony edge of the head is
above 0 station, deliver by caesarean section.
 Newborn Resuscitation: A Simple,
Effective Approach
• A simple self-inflating bag and small mask
can be used to resuscitate most newborns
with asphyxia
• . In most cases, any skilled provider who is
trained in good resuscitation skills and
who continues to maintain those skills can
easily perform the procedure.
• More complex procedures, such as
intubation and the use of oxygen, are
needed only in about 10 percent of cases
of birth asphyxia, when the newborn's
prognosis is very poor.
ANTEPARTUM
HEMORRHAGE
(APH)

Mashitah binti Ismail

 Per vaginal bleeding during DEFINITION
pregnancy in between 24 weeks
of gestation until before delivery
Causes of APH (3%)

Placental Local
o Placenta previa (1%) o Cervicitis
o Placenta abruptio (1%) o Cervical carcinoma
o Vasa previa o Cervical polyp
o Cervical ectropion
o Vaginal trauma
o Vaginal infection
 Placenta previa classification
• Low-lying
Type I • Encroaches uterine lower segment but does not reach
internal os

Type II • Marginal - anterior or posterior

• Reaches internal os but does not cover it

Type III • Partial

• Incompletely covers internal os

Type IV • Total
• Completely covers internal os
PLACENTA PREVIA CLASSIFICATION
PLACENTA ABRUPTIO CLASSIFICATION

• Hemorrhage into decidua basalis

• Usually insinuates in between the membranes and escapes through the cervix
Revealed • Blood loss is proportionate to the bleeding
hemorrhage

• Blood does not escape externally but is retained in between the detached placenta
and the uterus
Concealed • Hemodynamic instability despite no visible blood loss
hemorrhage

• A combination of revealed and concealed hemorrhage

Mixed • Hemodynamic instability is disproportionate to the visible blood loss
hemorrhage
PLACENTA ABRUPTIO CLASSIFICATION
 PLACENTA PREVIA PLACENTA ABRUPTIO

PAIN Painless Painful

UTERUS Soft, non-tender Tense, tender, irritable, hard to

palpate fetal part

FETAL POSITION Head is not engaged Head maybe engaged

Malpresentation may occur Normal

FETAL HEART Normal Absent or abnormal

ASSOCIATION No Yes
WITH PRE-
ECLAMPSIA

HAEMODYNAMIC Proportional to blood loss Signs of hypovolemic shock

SIGNS even mild or no blood loss due
to concealed bleeding
 History

Bleeding Associated Other symptoms Fetal well-being

• Site symptoms • Constitutional • Fetal movement
• Onset • Abdominal pain symptoms
• Trigger factor / event • Contraction
• Frequency • Vaginal discharge
• Duration • Show
• Amount • Leaking
• Color • Pruritus
• Smell
Gynaecological Past Medical
• Last Pap Smear • Bleeding disorder

Past obstetrics Social

• Previous history of placenta • High risk behaviours
previa
• Previous history of PROM
• Other maternal conditions /
problems

Others
• Sexual history
 • Only done after EXCLUDING placenta previa

Physical examination
• Can be done in patient with placenta previa in double set up technique
VAGINAL & • Cervix visualisation to rule out local causes of APH

SPECULUM

• Pallor
• Temperature
• Respiratory rate
• Pulse rate
• Blood Pressure
GENERAL • Peripheries

• Soft / tender
• Firm
• Gestational age
• Presentation
• Contraction
ABDOMINAL • Fetal heart beat
 Investigation

– Urine – Blood – Imaging

• Proteinuria • Full blood • Biophysical

• Glycosuria count profile
• Group cross- • Ultrasound
match • CTG
• Coagulation
profile
Management
1. Admit patient
2. Assess severity of blood loss
3. Order and prepare for blood transfusion
4. Beware of signs of shock
5. Assess fetal condition
6. Identify the cause of APH
7. Rule out any risk factors that may compromise the mother and the
fetus
8. Treatment
a) General – focuses on control of bleeding
b) Specific – depends on the cause of APH
Treatment based on cause of APH
: placenta previa
Depends on:
1) Severity of bleeding
• Mild : Monitor mother and fetal condition
• Moderate : Beware of signs of shock and correct first if present, prepare for blood transfusion
and monitor mother and fetal condition
• Severe : Correct shock by stabilizing patient vital signs, prepare for blood transfusion and
monitor mother and fetal condition
2) Gestational age
• < 37 weeks : Expectant management
• > 37 weeks : Induction of labour
3) Types of placenta previa
• Type I, II anterior : Normal delivery may be expected
• Type II posterior, III, IV : Emergency Caesarean Section
 TREATMENT BASED ON CAUSE OF APH
SEVERITY PERIOD OF GESTATION
OF < 37 WEEKS ≥ 37 WEEKS
BLEEDING
Mild Expectant management Induction of labour
Moderate Expectant management  Maternal / Fetal Induction of labour  Bishop score
monitoring
- Cervix favorable  Artificial Rupture
- Fetal heart sound reduces or unstable maternal of Membrane + Oxytocin infusion
condition : Emergency Caesarean section
- Cervix unfavorable  Emergency
- Fetus and mother remain stable : Continue Caesarean section
expectant management
Severe Fetal and maternal assessment

- Alive fetus  Emergency Caesarean section

- Intrauterine death  Artificial Rupture of Membrane + Oxytocin infusion

- Fetal demise  Resuscitation of mother

TREATMENT BASED ON CAUSE OF APH

Cervical polyps Cervical tumor

– Removal via a daycare procedure or – Based on stage and duration of
in OT under general anaesthesia pregnancy
POST-PARTUM
HEMORRHAGE
(PPH)

Mashitah Binti Ismail

 • Blood loss ≥ 500 ml from genital tract after birth until 6
weeks post-partum OR
DEFINITION • Any amount of blood loss from genital tract that
deteriorates mother general condition

Normal amount • Vaginal delivery: < 500 ml

• Caesarean: < 1000 ml

of blood loss • C-hysterectomy: < 1500 ml

• 500 – 1000 ml

Minor blood loss • Well-tolerated

• > 1000 ml

Major blood loss • Emergency situation

TYPES OF PPH PRIMARY SECONDARY

TIMING OF PPH Occurs within 24 hours after delivery Occurs anytime from 24 hours after
delivery until 6 weeks post-partum

CAUSES OF PPH 4 T’s - Retained POC and / Placenta

- TONE : Uterine atony - Endometritis
- TISSUE : Retained POC or - Dead tissue shedding due to
placenta obstructed labour
- TRAUMA : Injury to genital tract - Wound breakdown of Caesarean
- THROMBIN : Coagulopathies section
Maternal risk factors 4t change to
Pre-existing condition Intra-partum condition
• Advanced maternal age • Prolonged labor
• Primiparity
• Caesarean delivery
• Grandmultiparity
• APH • Instrumental delivery
• Previous PPH • Pyrexia in labor
• Previous caesarean section • Episiotomy
• Uterine fibroid
• Bleeding disorders
• obesity
 No need Large baby

FETAL
Shoulder Multiple
dystocia
RISK
pregnancy
FACTORS

Polyhydramnios
 Clinical features
Hemodynamic
instability
• Signs of blood loss Multi-systemic
• Signs of shock

Cause-dependent
Investigation

- Full Blood Count

• Anemia severity
• Infection
• Platelet count
- Group Cross-Match
- Coagulation profile
• Bleeding disorders
- Ultrasound
• Retained POC / placenta
 Active
management
of 3rd stage of
labour
• Oxytocin administration with
or following delivery
• Early cord clamping
• Controlled cord traction
• Uterine massage after
delivery of placenta
 MANAGEMENT – MINOR (no need minor) BLOOD LOSS

TONE TRAUMA TISSUE THROMBIN

• Bimanual uterine • Explore lower • Inspect placenta

• Observe clotting
massage genital tract • Consider FBC, blood
• Oxytocin 20 IU/L of • Consider exploring type and group cross-
normal saline uterus match, coagulation
• Retained placenta
• Infuse up to 500 ml screening
over 10 minor
• Genital tract
tear • Manual
• Soft, boggy removal of
uterus • Uterine • Blood not clotting
inversion placenta
• Curettage
• Methotrexate
• IM Carboprost 0.25 mg • Suture lacerations • Replace factors
• Per rectal Misoprostol • Drain hematomas > 3 • Fresh frozen plasma
1000 mg cm • Recombinant factor
• IM Methylergonovine • Replaced inverted VIIa
0.2 mg uterus • Platelet transfusion
 Surgical
• Arterial ligation
• Uterine
compression suture
• Hysterectomy

Signs of shock Resuscitation

• Brisk bleeding • 2 large bore IV
• Falling BP needles
• Rising Pulse • Oxygen by mask
PPH - BLOOD • Monitor
LOSS • BP
Conservative
• PR
• Rusch balloon
• Urine output insertion
• Team approach • Uterine artery
embolization
Management of secondary post
partum hemorrhage
• Assess volume loss
• Uterine massage
• Antibiotics
• Evacuation of clots after 4 hours antibiotics administered
• IM / IV oxytoxic drugs
Sheehan syndrome
- Complication of PPH
- We manage pph to prevent sheehan syndrome
- A rare but serious condition
- Due to blood loss severe enough to cause decrease of oxygen supply to
brain, i.e. pituitary gland
- Pituitary necrosis occurs leading to hypopituitarism
- Characterized by signs of decreased hormones secretion by pituitary
gland
HAFIZUDDIN ZAHARI
 DEFINITION
Pre-eclampsia is a disease of pregnancy characterized by a blood
pressure at least 140/90 mmHg recorded on at least two separated
occasion with at least 4 hours apart.
With the presence of at least 300mg protein in 24hours collected
urine or at least 1g/L (‘2 +’) on dipstick testing.
Which start after 20 weeks of pregnancy and resolve after 6
weeks of delivery
 eclampsia is pre eclampsia that associated with convulsion
 RISK FACTOR OF PRE ECLAMPSIA
 Primigravida
 40 years or more
 Obesity
 Multiparous with :
 Pre eclampsia in previous pregnancy
 10years or more since last childbirth
 1st degree relatives diagnosed with pre eclampsia
 Multiple pregnancy
 Diastolic pressure during booking is more than 80mmHg or more
 Underlying medical condition like pre-existing hypertension, renal
disease, diabetes mellitus, antiphospholipid antibody
 CLINICAL PRESENTATION
Patients with preeclampsia with severe features display end-organ effects and
may complain of the following:
Symptoms
 Frontal headache
 Visual disturbances: (transient cortical blindness d/t cerebral edema)
 Epigastric pain
 Weakness or malaise: May be evidence of hemolytic anemia
Signs
 Agitation
 Hyper-reflexia and clonus
 Edema: Sudden increase in edema or facial or hands edema
 Poor urine output
 COMPLICATIONS
COMPLICATIONS
Cardiovascular system (Heart) Maternal : High output failure, Pul edema
Placenta abruptio: d/t necrosis of end spiral arteries

Renal system (Kidney) Renal failure, Nephrotic syndrome,

glomerulonephritis
Liver Subscapular hemorrhage, Infarction & rupture,
Congestion, HELLP syndrome
Lung Aspiration Pneumonia( during fit)
CNS Eclampsia, Cerebral hemorrhage, Retinal detachment

Fetal Oligohydromnios, IUGR,IUD

 HELLP syndrome
 Hemolysis (the destruction of red blood cells)
 Elevated liver enzymes (AST/ALT >70iu/L)
 Low platelet count (<100x10^6)
 Represents damage to several organ systems. Can be seen in 5-10 % of
severe pre-eclampsia case.
 It is more common in multiparous women
 It may assoiciated with DIC, placenta abruptio & fetal death
 INVESTIGATION
LAB INVESTIGATION FOR PRE-ECLAMPSIA
1. Full blood count : heamoglobin level, platelet count, haematocrit
value
2. Urinalysis :to look for the presence of protein
3. Quantitation of protein: 24 hr collection
4. Liver function test : to rule out any elevation of liver enzyme due
to HELLP syndrome
5. BUSE and creatinine clearance: increase in severe renal
impairment
 INVESTIGATION TO MONITOR FETAL COMPLICATIONS
1. Ultrasound assessment of
- biophysical profile –look for IUGR
-Viability-IUD
- amniotic fluid volume- a/w oligohydramnios
- maternal and fetal dopplers
2. Cardiotocography
- indication for fetal well being. A loss of baseline variability
or decelerations may indicate fetal hypoxia.
 MANAGEMENT
Objectives of management of PE are:-
 To stabilize the blood pressure. Aim the diastolic pressure less than
90mmHg
 To prevent eclampsia and cerebral vascular accident.
 Complete restoration of maternal health
 If preterm  try to keep until term if possible
 If term  to ensure a safe termination of pregnancy
Patient with pre eclampsia
 Admitted to ward for further monitoring of blood pressure every 4
hours and other monitoring.
 Have a bed rest
 Started with oral antihypertensive( if DBP > 100mmHg)
- 1st line : oral methyldopa
- 2nd line : oral labetolol
- 3rd line : oral nifedipine
 In severe case which blood pressure more than or equal to 160/110
mmHg :
- IV hydralazine
i. Rapid control bolus 5mg over 10-15 minutes and repeat every 20
minutes if DBP >90mmHg
ii. For infusion pump : dilute 50mg hydralazine in 500cc normal
saline
iii. Maintainance dose : 1-10mg/hr
iv. For IV drip : 25mg hydralazine + 500cc noemal saline at 5-10
drop/min
- IV labetolol
i. Rapid control bolus : 10mg over 5-10minutes (max dose 200mg)
ii. Maintainance : 20-150mg/hour undiluted
iii. For infusion pump : dilute 200mg labetolol in 500cc normal saline
 In preterm pregnancy, give dexamethasone lung maturity and keep
until term if maternal and fatel condition are stable
 Term pregnancy  terminate pregnancy
 Management for impending
eclampsia/eclampsia
 If impending eclampsia : give IV MgSO4 to prevent convulsion
 If eclampsia occur, we need to focus on 4 subsection of management which
are :
i. Resuscitation and general management
- Recovery position, large bore IV cannula
- Maintain airway,O2 mask
- Abort fit by- MgSO4 with loading dose 4g IV bolus over 10-15 min (dilute in
12ml Nacl), 5g IM each buttock(10g)
- Or Diazepam IV 10mg bolus (1-2min) -use if there are no preferred drugs
available (Mgso4)
- Assess level of consciousness & neurological status
- Closely monitor vital signs - BP,PR,SPO2,RR,
ii. Anticonvulsive therapy
- MgSO4 à Maintainance dose: IV infusion of 1g/hour
- IM 5mg MgSO4 injected every 4 hours
- continue for 24hours after last fit or after delivery
iii. Antihypertensive therapy
- initiatiate parenterally if BP> 160/110mmHg
- IV hydralazine or IV labetolol
iv. Delivery
- Definite treatment
- within 6hrs after mother is stabilised
- if cervix favourable,cephalic: SVD
- if cervix not favaurable: induced first then LSCS
- Pediatrician informed n present at delivery
 UTERINE CAUSES
ADEEB QAREEMY
UTERINE RUPTURE

 Previously uterine injury.

 Associated with Caesarean section

 Scar tissue not strong as myometrium.

 Scarring by procedure as evacuation of P.O.C

RISK FACTOR
 Previous C-section
 Previous uterine surgery
 Induction of labor
 High parity
 Macrosomic fetus
 Placenta percreta
 Breech extraction
 Uterine anomaly.
DIAGNOSIS

 Scar tenderness
 Abdominal pain

 Vaginal bleeding

 Hematuria

 Contraction stop and deceleration on CTG

MANAGEMENT

 Immediate resuscitation of ABC

 Immediate laparotomy to deliver baby if patient comes early, and
repair the uterine rupture
 If patient comes late, laparotomy to delivery the dead baby, and
hysterectomy if repair is not possible
UTERINE INVERSION

 Rare
 Cause: traction on umbilical cord before placenta separation

 Can occur after vaginal delivery or C- section.

 +fundal placenta + short cord +morbidly adherent placenta

DIAGNOSIS

 Prolapsed uterus stretching the cervix

 Cause vagal stimulation => sign of CVS collapsed and shock

 Hemorrhage present

 Lack of palpable uterus in abdomen

 Feeling of dimple in uterine fundus

MANAGEMENT

 Resuscitate patient ABC approach

 Do not remove placenta if still attach (cause bleed)

 Replace uterus by manual compression through cervix

 Pouring warm saline into vagina via silc cup ventouse + tocolytic
agent to relax cervical ring
 Surgery, reposition the uterus from above
SUDDEN MATERNAL COLLAPSE
(PULMONARY EMBOLISM)
 Diagnosis : Can be cause of sudden cardiorespiratory collapse.
 Common presentation:-

-mild breathlessness
-inspiratory chest pain
-slight tachycardic
-mild pyrexia
INVESTIGATION

 Intial ECG
 Chest X-ray

 Arterial blood gases

 Ultrasound lower limb for DVT

 Ventilation/ perfusion scan

 Pulmonary angiogram CT guided

MANAGEMENT

 Urgent resuscitation by structured ABC approach

 Anticoagulant should be instituted.

 Consult with radiologist department

 Thromboprophylaxis Low Molecular Weight Heparin in high risk

patient.
AMNIOTIC FLUID EMBOLISM

 Rare caused of maternal collapse specific to pregnancy

 Amniotic fluid entering maternal circulation

 Cause acute cardiorespiratory compromise and severe

disseminated intravascular coagulation.
DIAGNOSIS
 Diagnosis
-breathlessness
-chest pain
-feeling cold
-lightheaded
-restless,panic
-pins and needles sensation
-nausea and vomitting
MANAGEMENT

 Poor prognosis,
 Management is supportive and require intensive care

 No specific therapies available.