OBSTETRICS EMERGENCY & IT’S MANAGEMENT

INTRODUCTION:-
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 birth. Hospital
care is needed for all obstetric emergencies, as the woman may need specialist care and an extended
hospital stay
DEFINITION:-
Obstetrical emergencies are life- threatening medical conditions that occur in pregnancy or during or
after labor and delivery.
THE IMPORTANT EMERGENCY CONDITIONS IN OBSTETRICS :-
1. Vasa praevia.
2. Presentation and prolapse of the umbilical cord.
3. Shoulder dystocia.
4. Rupture of the uterus.
5.amniotic fluid embolism.
6.acute inversion of the uterus.
7.shock in obstetrics.
1. VASA PREVIA
DEFINITION:-
Vasa previa is an obstetric complication in which
the fetal blood vessels cross or run near the internal
orifice of the uterus.
INCIDENCE:-1 in 2,500 births.
ETIOLOGY:-Velamentous insertion of umbilical cord
Placental lobe joined to the main disk of the placenta.,
Low-lying placenta, Previous C-section.
SYMPTOMS:-The baby’s blood is a darker red color due
to lower oxygen levels of a fetus
 Sudden onset of painless vaginal bleeding, especially in their second and third trimesters
 If very dark burgundy blood is seen when the water breaks, this may be an indication of vasa
previa.
DIAGNOSIS:-Classical triad , Painless vaginal bleeding, Colour doppler- vessel crossing the
membranes over the internal cervical os., Membrane rupture , Fetal bradycardia
MANAGEMENT:-Antepartum-
 The patient should be monitored closely for preterm labor, bleeding or rupture of membranes.
 Steroids should be administered at about 32 weeks.
 Hospitalization at 32 weeks is reasonable. Take patient for emergency cesarean section if
membranes are ruptured.
 Fetal growth ultrasounds should be performed at least every 4 weeks.
 Cervical length evaluations may help in assessing the patient’s risk for preterm delivery or
rupture of the membranes

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Intrapartum-
 The patient should not be allowed to labor. She should be delivered by elective cesarean at
about 35 weeks
 Delaying delivery until after 36 weeks increases the risk of membrane rupture.
 Care should be taken to avoid incising the fetal vessels at the time of cesarean delivery.
 If vasa previa is recognized during labor in an undiagnosed patient, she should be delivered
by urgent cesarean. The placenta should be examined to confirm the diagnosis
Postpartum
 Routine postpartum management as for cesarean delivery.
 If the fetus is born after blood loss, transfusion of blood without delay may be life-saving.
 It is important to have O negative blood or type-specific blood available immediately for
neonatal transfusion
NURSING MANAGEMENT
 Assess bleeding, color, amount
 Administer iv fluids, Administer oxygen, Strict vitals and FHS monitoring.
 Prepare patient for caesarean section, Reserve blood if (Hct >30%)
2. PRESENTATION & CORD PROLAPSE
There are three clinical types of abnormal descent of umbilical cord by the side of the presenting part:
Cord presentation- When cord is slipped down below the presenting part and is felt lying in the
intact bag of membranes.
Occult prolapse- the cord is placed by the side of the presenting part and is not felt by the fingers on
internal examination.
Cord prolapse- the cord is lying inside the vagina or outside the vulva following rupture of the
membranes.
INCIDENCE: - The incidence of cord prolapse is about 1 in 300 deliveries
ETIOLOGY:-Malpresentation- transverse lie & breech., Contracted pelvis, Prematurity
 Twins, Hydramnios, Placental factor- minor degree placenta praevia
 Iatrogenic- low rupture of the membranes, manual rotation of the head.
DIAGNOSIS:-
Occult prolapse-Difficult to diagnose.
 Persistence of variable deceleration of fetal heart rate pattern.
Cord presentation- Feeling the pulsation of the cord through the intact membrane.
Cord prolapse- The cord is palpated directly by the fingers and its pulsation can be felt if fetus is
alive.
 Cord pulsation may cease during uterine contraction, however returns after contraction passes
away.
MANAGEMENT:-
 Baby living or dead
 Maturity of the baby
 Degree of dilatation of the cervix
CORD PRESENTATION-
 Once the diagnosis is made, no attempt should be made to replace the cord.
 If immediate vaginal delivery is not possible or contraindicated, caesarean section is the best
method of delivery.
 A rare occasion when multipara with longitudinal lie having good uterine contractions with
cervix 7- 8cm dilated without fetal distress- watchful competency and delivery by forceps or
breech extraction
CORD PROLAPSE-
 Living baby
 Immediate take the mother for Caesarean section.
 Immediate safe vaginal delivery if- head is engaged

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  Immediate safe vaginal delivery not possible- First Aid
 First aid
 Bladder filling is done to raise the presenting part off the compressed cord.It is done by 400-
750ml of NS with a foley’s catheter, the ballon is inflated and catheter is clamped.
 Lift the presenting part off the cord.
 Postural treatment- exaggerated and elevated sims position or trendelenburg or knee chest
position. Replace the cord into the vagina to minimize vasospasm due to irritation.
 Dead baby
 Labour is allowed to proceed awaiting spontaneous delivery

3. SHOULDER DYSTOCIA:- It occurs when anterior shoulder become trapped behind the
symphysis pubis, while the posterior shoulder may be in the hollow of the sacrum or high above
the sacral promontory.
INCIDENCE:- The incidence vary between 0.37%- 1.1%
RISK FACTORS OF SHOULDER DYSTOCIA:- Fetal macrosomia, Obesity mother.
 Maternal diabetes, Post maturity of fetus, Multiparity, Anencephaly, Fetal ascites.

MANAGEMENT :- Stay calm and ensure mother's cooperation

 Request that an obstetrician, an anaesthetist neonatologist be called stat

 Request readiness of a full-scale new-borns resuscitation efforts

 Request readiness to manage an immediate postpartum haemorrhage.

The obstetrician may try the following manoeuvres to dislodge the shoulders and deliver the baby:

 HELP – obstetrician, pediatrician Episiotomy Legs – elevate Pressure - suprapubic Enter vagina
– (internal rotation). Roll the woman over and try again. Remove posterior arm

 McRoberts Maneuver
The Maneuver involves helping the woman to lie flat and to bring her knees up to her chest as far as
possible. This will rotate the angle of the symphysis pubis superiorly and use the weight of the
mother's legs to create gentle pressure on her abdomen releasing the impaction of the anterior
shoulder
 Suprapubic Pressure
Suprapubic pressure should be exerted on the side of the fetal back and toward the fetal chest. This
may help to adduct the shoulders and push the anterior shoulder away from the symphysis pubis.
 Rubin's Maneuver
The maneuver (Rubin, 1964) requires the midwife/ obstetrician to identify the posterior shoulder on
vaginal examination, then to push the posterior shoulder in the direction of the feral chest, thus
rotating the anterior shoulder away be symphysis pubis. By adducting the shoulders, this maneuver
reduces the 12 cm bisacromial diameter.
 Wood's Maneuver
The maneuver (Woods, 1943) requires the obstetrician to insert her/his hand into the vagina and
identify the fetal chest. Then, by exerting pressure on to the posterior fetal shoulder, rotation is
achieved. This maneuver abducts the shoulders, rotates them into a more favorable diameter and her
enables the completion of the delivery.
 Deliver posterior arm (Barnum Maneuver)- Grasp the posterior arm and Sweep it across the
anterior Chest to deliver

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COMPLICATION OF SHOULDER DYSTOCIA:-
FETAL COMPLICATION: - Asphyxia, Brachial plexus injury(erb`s palsy), Humerus facture,
clavicular fracture, High perinatal morbidity and mortality.

MATERNAL COMPLICATION: - PPH, Cervical, vaginal and perineal tear, High maternal
morbidity rate.

4. RUPTURE OF UTERUS
DEFINITION: -Disruption in the continuity of the all uterine layers (endometrium, myometrium
and serosa) any time beyond 28 weeks of pregnancy is called rupture of uterus.
INCIDENCE: -The prevalence widely varies from 1 in 2000 to 1 in 200 deliveries.
TYPES OF TEAR (RUPTURE):-
A- SCARRED UTERUS RUPTURE: -
i. Uterine scar dehiscence: Herniation of intact amniotic membrane into an existing uterine
scar
ii. Uterine scar rupture: separation of scar along entire length often with involvement of the
amniotic membranes
B- UNSCARRED UTERUS RUPTURE:-
i. Complete Uterine rupture: total disruption of the wall of the pregnant uterus with or
without extrusion of its content (when uterine cavity communicates directly with peritoneal
cavity)
ii. Incomplete Uterine rupture: partial disruption of the wall of the pregnant uterus without
extrusion of its content.
ETIOLOGY :

SIGN AND SYMPTOMS:-

 Abdominal pain and tenderness
 Shock
 Vaginal bleeding
 Undetectable fetal heart beat
 Palpable fetal body parts
 Cessation of contractions

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  Signs of intra-peritoneal bleeding
DIAGNOSIS:-
Ultrasonography is probably the safest and most useful imaging technique during pregnancy.
sonographic findings associated with includes:
 Extra peritoneal hematoma
 intrauterine bleed
 free peritoneal blood
 empty uterus
 gestational sac above the uterus
 large uterus mass with gas
 Painful bleeding.
 Loss of FHS
MANAGEMENT:-
Principles for the treatment of uterine rupture includes:
 Intensive resuscitation
 Emergency laparotomy
 Broad spectrum antibiotics
 Adequate post operative care
 Surgical options- Hysterectomy – Total & Sub-total
 Rupture repair- Occasionally one may be forced to repair
 Repair with sterilization

1. AMNIOTIC FLUID EMBOLISM -

DEFINITION:-
An amniotic fluid embolism is rare but serious condition that occur when amniotic fluid, fetal
material, such as hair, enters the maternal bloodstream.
The body respond in 2 phases –
 The initial phase is one of pulmonary vasospasm causing hypoxia, hypotension, pulmonary
edema and cardiovascular collapse.
 The second phase sees the development of left ventricular failure, with hemorrhage and
coagulation disorders and further uncontrollable hemorrhage
INCIDENCE:-
Amniotic fluid embolism syndrome is rare. Most studies indicate that the incidence rate is between 1
and 12 cases per 100,000 deliveries
ETIOLOGY:-
 A maternal age of 35 years, Older Caesarean or instrumental vaginal delivery
 Polyhydramnios Cervical laceration or uterine rupture, Placenta previa or abruption
 Amniocentesis , Eclampsia, Abdominal trauma
 Ruptured uterine or cervical veins, Ruptured membranes
SIGNS AND SYMPTOMS:-
 Sudden shortness of breath, Excess fluid in the lungs
 Sudden low blood pressure, Rapid heart rate, Fetal distress, Seizures, Coma
 Sudden circulatory failure Life- threatening problems with blood clotting (disseminated
intravascular coagulopathy), Altered mental status
DIAGNOSIS:-
1. Non-specific-
 Chest X-ray, Lung scan, Coagulation profile, Echocardiography
2. Specific-Cervical histology, Serum tryptase
MANAGEMENT:-

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  Management is symptomatic and supportive.
 Targets- Maintaining oxygenation, hemodynamic support and correction of coagulopathy
 Immediate Resuscitation- ABC
NURSING MANAGEMENT:-
 Give immediate and vigorous treatment.
 Give oxygen by face mask.
 Maintain normal blood volume through administration of plasma and intravenous fluids.
 Prevent development of disseminated intravascular coagulation (DIC). Serious complications
can occur.
 Administer whole blood and fibrinogen.
 Monitor the patient’s vital signs.
 Deliver the fetus as soon as possible

2. INVERSION OF THE UTERUS

It is an extremely rare but a life-threatening complication in third stage of labour in which the uterus
is turned inside out partially or completely.

INCIDENCE:- 1/20,000 deliveries

CLASSIFICATION:-
Inversion of Uterus is Classified in Mainly 3 Types :

A. According Types

B. According Degrees

C. According the Timing of Event

A. According Types

1) Incomplete Inversion: When fundus of uterus has turned inside out,

2) Complete Inversion: When the inverted fundus has passed completely through cervix to lie within
the vagina or lie often outside the Vaginal Wall.

B. According Degrees

1) First degree/ Incomplete Inversion: The uterus is partially turned out, Inverted fundus up to
cervix

2) Second degree / Complete inversion in the vagina: The fundus has passed through the cervix but
not outside the vagina, Body of uterus protrudes through cervix into vagina

3) Third degree / Complete inversion outside the Vagina: The fundus is prolapsed outside the
vagina, Prolapse of inverted uterus outside vulva.

C. According to Timing of Event

1) Acute: It occurs within 24 hrs of delivery.

2) Sub-acute: It presents between 24 hrs & 4 wks. of delivery.
3) Chronic: It presents beyond 4 wks. of delivery or in non-pregnant stage
CAUSES:
 uterine atony (40%)
 Increase in intra-abdominal pressure
 Fundal attachment of placenta (75%), Fundal implantation of placenta
 Short cord, Placenta accreta, Excessive cord traction, Congenital predisposition

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  Either Spontaneous OR Iatrogenic causes.
SIGN & SYMPTOMS
 Hemorrhage (94%)
 Severe abdominal pain in 3rd stage
 Hypotension with Bradycardia: shock out of proportion to the blood loss (neurogenic due to
increased vagal tone)
 Uterine fundus not palpable abdominally
 Mass in the vagina on vaginal examination.
Management:-
 Uterine relaxant (terbutaline 0.25 mg IV followed by 2 g of MgSO4 over 10 min)
 Treat hypovolemia
 Without placenta: Repositioning
 With placenta: Do not remove placenta
 Replace uterus, Bimanual compression, Hydrostatic pressure (O’Sullivan 1945)
 Laparotomy
7. SHOCK IN OBSTETRIC:-
DEFINITION:-
A state of circulatory inadequacy with poor tissue perfusion resulting in generalized cellular hypoxia .

IMPORTANT SHOCK IN OBSTETRIC:-

i. Hypovolaemic Shock.
ii. Septic Shock.
i. HYPOVOLAEMIC SHOCK:-
DEFINITION: -
The result of a reduction in intravascular volume such as in severe obstetric haemorrhage.

PRESENTING FEATURES OF HYPOVOLUMIC SHOCK

ORGAN SYSTEM EARLY LATE

BP Normotensive or Hypotensive Hypotension

PULSE Tachycardia Same

RESPIRATION Normal Tachypnoea

RENAL Oliguria Acute Renal Failure

SKIN Cold & Clammy Cold & Clammy

Mental Status Normal Disorientation

MANAGEMENT HYPOVOLAEMIC SHOCK:-

 Maintain airway- oxygen 6 to 8 l/m.
 Restore circulatory volume- 2lit of crystalloid then colloid. Not more then 1000-1500ml in a
day.
 Warmth.
 Arrest haemorrhage.
ii. SEPTIC SHOCK:-

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DEFINITION:-
It occurs with a severe generalized infection.

PRESENTING FEATURES OF SEPTIC SHOCK

ORGAN SYSTEM EARLY LATE

BP Normotensive or Hypotensive Hypotension

PULSE Tachycardia Tachycardia

RESPIRATION Tachypnoea, Pulmonary edema Tachypnoea

RENAL Oliguria Acute Renal Failure

SKIN Warm Cold & Clammy

Mental Status Normal Disorientation

MANAGEMENT OF SEPTIC SHOCK:-

 Replacement of fluid volume.
 Identify the source of infection.
 Infection screening should be carried out- vaginal swab, urine and blood cultures
 Aseptic technique should be maintained.
 Antibiotic should be given.

ROLE OF A NURSE IN OBSTETRICAL EMERGENCY :-

 Recognize the early signs of major obstetric complications
 Perform essential life-saving interventions
 Refer as appropriate and
 Provide high-quality, culturally appropriate, and considerate care, including follow-up and
linkages with other services.
Essential life –saving skills needed for Nurse
 Prevent infection by ensuring safe, clean delivery
 Diagnose and manage causes of antepartum and postpartum haemorrhage
 Stabilization and referral
 Performance of manual procedures
 Use a partograph, identify prolonged or obstructed labour, and take appropriate, timely action.
 Identify elevated blood pressure and proteinuria as signs of eclampsia, provide emergency
care, and refer.

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