OBSTETRICAL

EMERGENCIES
 DEFINITION

• AN UNFORESEEN COMBINATION OF
CIRCUMSTANCES OR THE RESULTING
STATE THAT CALLS FOR IMMEDIATE
ACTION

• LIFE -OR -DEATH SITUATION

• INFREQUENT, UNANTICIPATED,
UNPREDICTABLE NIGHTMARE
 Patient -1
• A 38 weeks G4P3 lady presents with
ROM and contractions. She is quite
distressed and thinks the baby is coming
out. You perform a pelvic examination
and next to the head you feel a pulsatile
cord…
 Cord Prolapse
• Presentation: Cord in front of presenting part
before the rupture of membranes
• Prolapse: Cord in front of presenting part
after rupture of
membranes
Occult prolapse

Cord lying
alongside the
presenting part
 Incidence (Anita pal, Kushgla, Sood 2006)
• Primigravida 0.45%
• Multigravida 0.66% (Risk ratio 2:3)
• Cephalic 0.3%
• Frank breech 0.9%
• Complete breech 5%
• Footling 10%
• Shoulder 15%
• Contracted pelvis 4-6 times
 Causes
• Malpresentation - face, brow, breech and shoulder
• Prematurity
• Polyhydramnios
• Multiple pregnancy
• Long cord (90-100 cm)
• PROM
• CPD
• Obstetric interventions - Amniotomy, Intrauterine
pressure catheter, scalp electrode, external cephalic
version, PROM, expectant management in preterm
 Dangers
• Mortality rate as high as 50%
• Hypoxia
• Spasm of vessels
• Operative trauma to suboxygenated fetus
• More with vertex than breech
• Descent in front than behind
• More in primi than multi
 Diagnosis
• Cord pulsations
• CTG shows variable decelerations
• Cord lying outside vulva
• USG – cord loops
• Fundal pressure
causes bradycardia
• Violent activity of
baby
• Meconium stained
liquor
 Prevention
• Refer to level II care
• USG for malpresentation and cord
presentation
• Foetal mointoring
• Avoid ARM in an unengaged head
• PV exam after ROM
 Management
• Lift presenting part off the cord
• Instruct NOT to push
• Position patient
Knee chest
Trendelenburg
Exaggerated position
Knee chest position
Trendelenburg position
Exaggerated sim’s position
 Management (cont..)
• Full bladder (Vago 1970)
• Vulval pad
• Replacement of cord
• Tocolysis (ritodrine)
• Forceps (Cx fully dilated)
• internal podalic version and breech
extraction
• Stat C-section
• Occult: Aminoinfusion
 Management (cont…)
• Funic Reduction
– Manual replacement of cord into uterus
– Cord gently pushed above presenting part
while other cord decompression techniques
are applied
– Rapid vaginal delivery
 Fetal Mortality
• Overall - 50%
• 1st stage of labour - 70%
• 2nd stage of labour -30%
• Neonatal death - 4%
• Perinatal mortality- 20%

< 5 minutes, prognosis good, > 5 mins,

damage and death.
 VASA PRAEVIA
• Fetal blood vessel lies in front of presenting
part
 Cont.,.
• The term vasa praevia is used when a fetal
blood vessel lies over the os, in front of the
presenting part.
• - This occurs when fetal vessels from a
velamentous insertion of the cord or to a
succenturiate lobe cross the area of the
internal os to the placenta.
 Cont.,,.
• The fetus is in jeopardy, owing to the risk of
rupture of the vessels, which could lead to
exsanguination.
• - Good outcome depends on antenatal diagnosis
and delivery by caesarean section before the
membranes rupture
• -Vasa praevia may be diagnosed antenatally using
ultrasound. Sometimes, vasa praevia will be
palpated on vaginal examination when the
membranes are still intact.
 Cont.,,.
• - If it is suspected a speculum examination
should be made.
Ruptured vasa praevia:
• -When the membranes rupture in a case of
vasa praevia, a fetal vessel may also
rupture.
• - This leads to exsanguination of the fetus
unless birth occurs within minutes.
 Diagnosis
• Fresh vaginal bleeding, particularly if it
commences at the same time as rupture of
the membranes, may be due to ruptured
vasa praevia.
• -Fetal distress disproportionate to blood loss
may be suggestive of vasa praevia.
 • The midwife should call
for urgent medical
Management assistance.
• The fetal heart rate
should be monitored.
• If the mother is in the
first stage of labour and
the fetus is still alive, an
emergency caesarean
section is carried out.
• If in the second stage of
labour, delivery should
be expedited and a
vaginal birth may be
achieved.
 Cont.,.,
• - Caesarean section may be carried out but
mode of birth will be dependent on parity
and fetal condition.
• -There is a high fetal mortality associated
with this emergency and a paediatrician
should therefore be present for the birth.
• -If the baby is born alive, resuscitation,
hemoglobin estimation and a blood
transfusion will be necessary.
 PATIENT -2
Mother is pushing with each
contraction and the baby’s head starts
to come out. However, with each push,
the baby’s head comes out and then
retracts back in towards the
perineum. You quickly recognize this
as the “turtle sign”
 Obstructed labour
• No advancement of presenting part despite strong,
uterine contractions.
Causes:
• Cephalo-pelvic disproportion.
• Malpresentation - shoulder/brow/persistent
mento posterior
• Deep transverse arrest
• Pelvic mass
• Fetal abnormalities - Hydrocephalus,
conjoined twins.
 Causes
Malpresentation:
 Signs of obstructed labour
• Presenting part fails to advance
• Cervical dilatation slow
• Formation of retraction ring
• Early rupture of membranes
• Formation of elongated sac of forewaters
• If neglected, dehydration, ketosis
• Caput succedaneum and moulding
• urine output decreases
• fetal distress
 Management
• Careful assessment of progress of labour
• Correct hydration
• Internal version
• Forceps application
• Stat C.Section
 Shoulder Dystocia

• Incidence: 0.23% to
2.09%
• Impaction of fetal
shoulders in maternal
pelvis
• Head to body
delivery time > 60s
 Risk factors
• Maternal Diabetes Mellitus
• Short stature
• Macrosomia
• Post-term
• Obesity
• Fetal shoulder circumference
40.9 ± 1.5cm Vs 39.5 ± 1.5 cm
 Complications
Fetal morbidity:
• Brachial plexus injury
• Clavicular fracture
• Facial nerve paralysis
• Asphyxia
• CNS injury
• complication rate up to 20%
 Management
Help – obstetrician, pediatrician
Episiotomy
Legs – elevate (McRoberts)
Pressure - suprapubic
Enter vagina – Rubin’s and Woods’
screw
Roll or Remove posterior arm
Zavanelli, Clavicular# ,
Symphysiotomy
 McRoberts Maneuver
• hyperflexion of
maternal hips
• Increases intrauterine
pressure
(1,653mmHg - 3,262
mmHg)
• Increases amplitude of
contractions
(103mm Hg to 129mm
Hg)
All-Fours
Maneuver(Gaskin
Maneuver)

•Ina May Gaskin

(1976)
•changes pelvic
dimensions in a
similar way to
McRoberts
maneuver
•apply downward
traction to disimpact
the posterior
shoulder
 Suprapubic Pressure
• direct posterior or oblique suprapubic
pressure
 Rubin’s Maneuver
• adduction of the most accessible shoulder
• moves the fetus into an oblique position
and decreases the bisacromial diameter
 Woods’ Cork Screw
Maneuver
• Abduct posterior shoulder exerting
pressure on anterior surface of posterior
shoulder
 Deliver posterior arm
(Barnum Maneuver)
grasp the
posterior arm
and
sweep it across
the anterior
chest to deliver
 Zavanelli Maneuver
• cephalic replacement via reversal of the
cardinal movements of labor
 Clavicular Fracture

• fracture the anterior clavicle by pushing

it against the pubic ramus or using a
closed pair of scissors

• Symphysiotomy
 Complications
• Maternal morbidity
• 4th degree perineal lacerations
• Cervical & Vaginal lacerations
• Bladder injury
• Postpartum hemorrhage
• Endometritis
 Patient - 3
• Mother in third stage of labour. Using the
controlled cord traction, the midwife tries
to deliver the placenta. Unfortunately,
notices the descent of uterus instead of
placenta.
 Uterine Inversion
• 1/20,000 deliveries
Causes:
• uterine atony (40%)
• Increase in intra
abdominal pressure
• Fundal attachment of
placenta (75%)
• Short cord
• Placenta accreta
• Excessive cord traction
 Degrees of uterine inversion
• 1st - Dimpling of
fundus, remains
above internal os
• 2nd - fundus passes
through the cervix,
but lies inside
vagina
• 3rd - (complete)
Endometrium with
or without placenta
is outside the vulva
 Dangers
• Shock - Neurogenic
Pressure on ovaries
Peritoneal irritation
• Hemorrhage
• Pulmonary embolism
• Infection
 Management
• Uterine relaxant (terbutaline 0.25 mg IV
followed by 2 g of MgSO4 over 10 min)
• Treat hypovolumeia
• Without placenta: Repositioning
Uterine Inversion
 Management(cont…)
• With placenta: Do not remove placenta
• Replace uterus
• Bimanual compression
• Hydrostatic pressure (O’Sullivan 1945)
• Start oxytocin
• Laparotomy
 Patient - 4
A mother in second stage of labour
suddenly complains of persistent pain,
and bleeding per vagina becomes profuse
and the monitor shows decelerations in
fetal heart rate.
RUPTURE UTERUS
 DEFINITION
Dissolution in the
continuity of the
uterine wall anytime
beyond 28
weeks of pregnancy

It is anobstetrical
emergency.
• 1/2000 deliveries
Types:
• Complete
• Incomplete
• Rupture Vs Dehiscense of
C.S scar
 Causes
• Uterine injury sustained before current
pregnancy
C.S /hysterotomy/ repaired uterine
rupture/ Myomectomy
Uterine trauma - curette, sounds
Sharp or blunt trauma - accidents,
bullets, knives
Congenital anomaly
 Causes
Uterine injury during current pregnancy
• Before delivery
Intense spontaneous contractions
Labour stimulation
Intra-amnionic instillation
Perforation by internal catheter
External trauma - sharp or blunt
External version
Uterine overdistension - multiple
pregnancy
 Causes (cont…)
• During delivery:
Internal version
Difficult forceps delivery
Breech extraction
Difficult manual removal of placenta
Fetal anomaly
• Acquired:
Placenta increta / percreta
Retroverted uterus (sacculation)
 SIGN AND SYMPTOMS
• ANTENATAL Intrapartum Rupture of
RUPTURE OF uterus:
UTERUS:  Abdominal pain
 Vomiting
 Intermittent rightsided
 Supra pubictenderness
abdominal pain
 Tachycardia
Abdominal tenderness  Slight blood loss
 Failure of cervix to dilate with
Intrauterine fetaldeath contraction
 Fetal distress
shock
 DIAGNOSIS
• H/o of pregnant women related to any
previous uterine surgery
• Clinical manifestation
• Ultrasound of uterus
 Diagnosis
• Prolonged fetal decelerations (70.3%)
• Bleeding (3.4%) Pain (7.6%)

Monitor tracing demonstrating fetal heart rate decelerations, increase in

uterine tone, and continuation of uterine contractions in a patient with
 Management
Total Hysterectomy
Sub total hysterectomy
Simple repair
 PREVENTION
Early recognition &treatment of obstructed labour
 Proper use of oxytocin
Careful intrauterine manipulation
Proper management of pt with history of
caesarean section.
 COMPLICATION
IMMIDIATE
 Massive maternal hemorrhage & DIC.
 Post operative infection.

 Damage to Ureter
 Amniotic fluid embolism
 Pituitary failure.

LATE
 Intestinal obstruction
 Scar rupture in subsequent pregnancy.
 Patient 5
Mother has just delivered a male baby.
You wait for 30 minutes But no signs of
placental separation and descent is
present. Manual removal fails.
 Placenta Accreta
• Incidence: 1 in 2,562 deliveries
• Firm adherence of placenta to uterine wall
• partial or total absence of decidua basalis
• Placenta increta: Villi invade the myometrium
• Placenta percreta: Villi penetrate myometrium
 Risk factors
• Defective decidual formation
placenta previa
Previous cesearean scar
uterine curettage
• Grand multiparity
 Diagnosis and Management
• Dx in third stage of labour
• Maternal hemorrhage
• Treatment: Hysterectomy
 Patient 6
• A pregnant mother on oxytocin induction
suddenly becomes short of breath and
tachypneic. Vital signs drop and the
patient goes into asystolic arrest.
Amniotic Fluid Embolism
• Incidence: 1 in 3,500 to 1 in 80,000
• Amniotic fluid enters the maternal
circulation and reaches pulmonary
capillaries
• Through a tear in amnion and chorion
• Opening in maternal circulation
• Increased intrauterine pressure
 Risk factors
• Multiparity
• Large fetus
• Meconium in amniotic fluid
• Intrauterine fetal death
• Precipitate labour
• Placental abruption
• Intrauterine catheter
• Rupture of uterus
 PATHOPHYSIOLOGY
Amniotic fluid enters the maternalcirculation

Pulmonary vasospasm

Hypoxia

Hypotension

Cardiovascular collapse
 Left ventricular failure

Pulmonary edema

Hemorrhage

Coagulation disorder (DIC)

 Manifestations
• Phase I : Pulmonary vasospasm
Hypoxia
Hypotension
Cardiovascular collapse
• Phase II: Left ventricular failure
Pulmonary edema
Hemorrhage
Coagulation disorder
 DIAGNOSIS
• Detection of amniotic fluid inmaternal
circulation
• Postpartum examination
• Blood aspiration from CVPcatheter
• Fetal squamus have been found in maternal
sputum when stained with Nileblue
 Management
• Intubation + Mechanical ventilation
• CVP monitoring
• Blood transfusion + I.V. Fluids
• Dopamine 2-20mg/kg/min
• Prostaglandin
• Morphine
• Aminophylline
• Hydrocortisone
 MEDICALMANAGEMENT
• Admit the patient inICU
• Drugs :
 Pressors
 Inotropes
 Steroids
 SURGICALMANAGEMENT
1. Emergent
caesarean
delivery

2. Bilateral uterine
artery
embolization
 NURSING MANAGEMENT
• Risk of impaired gas exchange related to
pulmonary edema secondary to maternal
respiratory distress.
• Ineffective tissue perfusion related to bronco
spam, cyanosis.
• Risk for injury towomen ad fetus related to
convulsion
• Deficit fluid volume related to blood loss
• Risk of infection related to blood loss
 RECENT ADVANCEMENT
• Current data from national AFEsuggest that
the process is more similar to anaphylaxis
than embolism and the term
ANAPHYLACTOID SYNDROME OF
PREGNANCY has been suggested because
fetal tissue or amniotic fluid component are
not universally found in women whopresent
sign and symptoms attributed to AFE.
OBSTETERICAL
 DEFINITION
• Shock is defined as a state of circulatory
inadequacy with poor tissue perfusion
resulting in generalized tissue hypoxia, leading
to dysfunction of organ andcells.
TYPES
 HYPOVOLEMICSHOCK
• When there is a loss of intravascular fluid
volume
• Or the volume is inadequate to fill the
vascular space
• Hemmorhagic
• Non-hemorrhagic
 PATHOPHYSIOLOGY
BLOODLOSS

HYPOVOLEMIA
1
PHASE
NEURO-
STIMULATION
ENDOCRINE
OF VMC
RESPONSE

TEMPORARYCOMPANSATORY
MECHANISM
 CARDIAC SQUEEZING TRANS
DIVERSION
CONTRA- OF BLOOD CAPPILARY
-CTION↑ OFBLOOD FROMMCU FILLING

ADEQUATETISSUEPERFUSION

IRREVE
R SIBLE
PHASE FAILS
 SEPTICSHOCK
• Systemic inflammatory response to a documentedor
suspected infection
• Occur due to :
Septic abortion
Pyelonephritis
Post-operative endometritis
• RISK:
Prolong ROM
CS
Retained products of miscarriage
Delivery in water
 Pathogenesis ofsepticshock

INFECTION

Gm –ve(70-80%) Gm +ve (20-30%)

AEROBIC AND ANAEROBIC

ENDOTOXIN (LYPOPOLYSACCHARIDE)

.NEUTROPHIL . MONOCYTE . MACROPHAGE .

ENDOTHELIALCELLS
 SIR
ENDOGENOUS AUTOCRINEAND
MEDIATORS PARACRINE

VASCULAR
EFFECTS
IRREVERSIBLE
PHASE

MYOCARDIAL
HYPOTENSION DEPRESSION
METABOLIC
ACIDOSIS

MULTIPLE ORGAN
FAILURE
 RISKFACTORS
Obesity
Diabetes
Anemia
Vaginal discharge
h/o PID
Amniocentesis
CS
Wound hematoma
Vaginal trauma
 CLINICALFEATURES

NEUROGENIC
ENDOTOXINSHOCK
SHOCK
REMAINALERT
NO PALLOR
FLUSHING OFFACE

FACEMAY BE TEMPRATURECHANGES

FLUSHED SKIN FEELWARM

 MANAGEMENT
• EMERGENCY

• MEDICAL :
Forhemorrhagicshock
Restore circulating volume
Maintenance of cardiac
efficiency
Oxygen
Pharmacological agents
Continuous monitoring
• For septic shock:
Antibiotics
I/v fluids
Blood pressure maintenance
Diuretics
Corticosteroids
 NURSINGMANAGEMENT
• Ineffective tissue perfusion related to shock.
• Risk of fluid loss related to sweating.
• Risk of impaired gas exchange related to
hypotension.
• Fear / anxiety related to unknown prognosis
of the disease.
Be prepared, except the unexpected
and above all,
communicate
• Communicate congruently
• Careful, sympathetic and
optimal communication
• Avoid medical jargon
• Psychological support- one member - Touch
• “Talking through” the process
• Smile of reassurance
• Information and support to partners
 Fear during labour
• Worries that infant may die or
born with abnormality.
• Review labour process
• Provide with frequent progress
report
• Personal availability of nurse
 NURSE’S ROLE IN INTRAPARTUM
CARE
COUNSELLOR CO ORDINATOR

CARE
ADVOCATE GIVER
NURSE MIDWIFE

EDUCATOR
MANAGER

RESEARCHER COMMUNICATOR
CONCLUSION