Every Mom’s Dream…...
OBSTETRICAL
EMERGENCIES
Care is a state
in which
something
does matter ; it
is the source of
human
tenderness
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)
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Primigravida
Multigravida
Cephalic
Frank breech
Complete breech
Footling
Shoulder
Contracted pelvis
0.45%
0.66% (Risk ratio 2:3)
0.3%
0.9%
5%
10%
15%
4-6 times
Causes
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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
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Mortality rate as high as 50%
Hypoxia
Spasm of vessels
Operative trauma to suboxgenated fetus
More with vertex than breech
Descent in front than behind
More in primi than multi
Diagnosis
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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..)
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Full bladder (Vago 1970)
Vulval pad
Replacement of cord
Tocolysis (ritodrine)
Forceps (Cx fully dilated)
Second twin – 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
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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
• Rupture
- exsanguination
of the fetus
Cause and Management
• Velamentous insertion
Fresh bleeding vaginally
with rupture of membranes
• Management: Signs of fetal
distress
Stat C.S
Send cord blood for Hb
estimation
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
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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
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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
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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
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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…)
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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.
Uterine Rupture
• 1/2000 deliveries
Types:
• Complete
• Incomplete
• Rupture Vs Dehiscense of
C.S scar
Rupture of lower uterine
segment
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)
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
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
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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
Amniotic Fluid Embolism
Risk factors
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Multiparity
Large fetus
Meconium in amniotic fluid
Intrauterine fetal death
Precipitate labour
Placental abruption
Intrauterine catheter
Rupture of uterus
Manifestations
• Phase I : Pulmonary vasospasm
Hypoxia
Hypotension
Cardiovascular collapse
• Phase II: Left ventricular failure
Pulmonary edema
Hemorrhage
Coagulation disorder
Management
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Intubation + Mechanical ventilation
CVP monitoring
Blood transfusion + I.V. Fluids
Dopamine 2-20mg/kg/min
IV Digitalization (0.1 - 1.0mg)
Prostaglandin
Morphine
Aminophylline
Hydrocortisone
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
• Promise postnatal debriefing
sessions
NURSE’S ROLE IN INTRAPARTUM
CARE
COUNSELLOR
CO ORDINATOR
ADVOCATE
NURSE MIDWIFE
MANAGER
RESEARCHER
CARE
GIVER
EDUCATOR
COMMUNICATOR
Interestingly, loving
care does not require
twice the time,but it
does require more than
twice the presence.”
- Erie Chapman
THEY
NEED YOU AND
YOUR CARE