OBSTETRICAL

EMERGENCIES
Obstetrical Emergencies

Definition
An obstetrical complication or situation of serious and often
dangerous nature, developing suddenly and unexpectedly
and demanding immediate attention in order to save life.

[Link] and C. Lee, “ Obstetrical Emergencies”, in Obstetrics by Ten Teachers, S.

Campbell and [Link], Eds.,pp. 303-317, Arnold Publishers, 17th edition 2000.
1. VASA PREVIA- definition

Fetal vessels crossing or running in close proximity to the

inner cervical os. These vessels course within the
membranes (unsupported by the umbilical cord or placental
tissue) and are at risk of rupture when the supporting
membranes rupture.
journal of prenatal medicine
Vasa previa
 1. VASA PREVIA

 Fetal blood vessel lies over the OS in front of the

presenting part
 Fetal vessels run within the membranes close to internal
OS
 It has a high perinatal mortality
 Bleeding at the time of rupture of membrane and causes
fetal bradycardia.
 1. VASA PREVIA

 Itoccurs when fetal vessels from a velamentous insertion

of the cord cross the area of the internal OS to the
placenta.
 It also occurs when there is a succenturiate placenta
 Occurs in less than 0.2% of pregnancies
 1. VASA PREVIA

 Diagnosis

1. Vaginal examination
2. Speculum examination
3. USG
4. Fresh vaginal bleeding at the time of rupture of
membrane may be due to ruptured vasa previa
 1. VASA PREVIA

 Management
 If antenatal diagnosis –admission from 28-32 weeks
 Delivery by elective CS -35-37 wks after steroids
 High index of suspicion – colour Doppler-TVS-elective
CS
 1. VASA PREVIA

 Management
 In first stage of labour, if the fetus alive– emergency
caesarean section
 The mode of delivery will be depended on parity and fetal
condition.
 Immediate new born resuscitation
 Haemoglobin estimation needed after resuscitation
 2. PRESENTATION AND PROLAPSE
OF THE UMBILICAL CORD

Clinical types of abnormal descent of the umbilical cord

1. Occult prolapse
2. Cord presentation
3. Cord prolapse
Occult prolapse

The cord lies along side, but not in front of the presenting part and lies
in front of it in the intact bag of membranes
DC Dutta textbook of Obstetrics 2018
Cord presentation

The cord is slipped down below the presenting part and lies
in front of it in the intact bag of membrane.
DC Dutta textbook of Obstetrics 2018
CORD PROLAPSE- DEFINITION

 Cord prolapse is the condition where the umbilical cord

lies below the presenting part after rupture of membranes
Sheila Balakrishnan. Text book of Obstetrics. 2nd edition
 CORD PROLAPSE

 INCIDENCE

Overall incidence is about 0.5%

1 in 300 deliveries
Commonly seen in women have higher parity
 CORD PROLAPSE

 Aetiology

1. Malpresentations ( transverse and breech especially with

flexed leg or fooling and compound presentation)
2. Contracted pelvis
3. Prematurity
4. Twins
5. Polyhydramnios when membranes rupture.
 CORD PROLAPSE

 Aetiology

6. Placental factors
Battledore placenta and excessively long cord
7. Iatrogenic
Low rupture of membranes, manual rotation of the head,
ECV,IPV,
8. Stabilizing induction
9. Multipara
 CORD PROLAPSE

 Diagnosis

Occult prolapse
- Diagnosis is very difficult
- Persistence of variable deceleration of FHR in NST
 CORD PROLAPSE

 Diagnosis

Cord prolapse
 Cord palpated directly by fingers
 Cord Pulsation can be felt if the fetus is alive
 CORD PROLAPSE

 Prognosis

Fetal prognosis
1. Anoxia
2. The overall Perinatal mortality 15-50%
Maternal prognosis
3. Increased chance for operative delivery
4. Risk of anaesthesia, blood loss and infection
 CORD PROLAPSE

 ANTICIPATION AND EARLY DETECTION

1. Admission to the hospital at 37 weeks in unstable and
transverse lie
2. Internal examination
3. Surgical induction
4. Amniotomy should be done only after the presenting part fixes
5. Should exclude cord presentation or occult prolapse in
unexplained fetal distress during labour
 CORD PROLAPSE

 Management

Cord presentation
1. No attempt made to replace the cord
2. If immediate vaginal delivery is not possible or
contraindicated caesarean delivery is the best method
 CORD PROLAPSE

 Management

Cord prolapse
management is based on
 If baby living or dead
 Maturity of the baby
 Degree of dilatation of cervix
 CORD PROLAPSE

 Management if the baby living

1. Definitive treatment- Caesarean section
2. Immediate safe vaginal delivery is possible if the head is
engaged
If breech- breech extraction and in transverse lie it should
be completed by invernal version followed by breech
extraction
 CORD PROLAPSE

 Management if the baby living

3. immediate safe vaginal delivery is not possible
First aid management
 Minimize the pressure on the cord
 IV Fluid infusion
 O2 by face mask
 CORD PROLAPSE

 Management if the baby living

• Bladder filling
• Lift the presenting part off the cord
• Postural treatment – elevated sim’s position with a pillow
under the hip/thigh
• Replace the cord into the vagina
 CORD PROLAPSE
 Temporary measures
• Presenting part is pushed up and away from the cord by a hand in
the vagina.
• Position- trendelenberg or knee chest position with hips elevated
and head low
• Palpation of the cord should be avoided
• USG and Cardiotocography
• Vago’s method of bladder filling
• O2 via mask
• If strong contraction tocolyics can be given
CORD PROLAPSE –Management
Cord prolapse

Baby alive Baby dead

And viable
Vaginal delivery not confirm by USS
Imminent
(temporary measures)
Vaginal delivery AWAIT SPONTANEOUS
CAESEREAN imminent LABOUR
SECTION

Vertex Breech

FORCEPS/ BREECH
VACCUM EXTRACTION
 3. SHOULDER DYSTOCIA
DEFINITION

Vaginal cephalic delivery that requires additional obstetric

manoeuvres to deliver the foetus after the head has delivered
and gentle traction has failed. Objective diagnosis of a
prolongation of head to body delivery time more than 60s.
Occurs when either anterior or less commonly posterior feel
shoulder impacts on the maternal symphysis or sacral
promontory respectively.
 SHOULDER DYSTOCIA

In true shoulder dystocia, the presentation is cephalic and

the head is born; but the shoulders cannot be delivered by
usual methods and there is no other cause for the dystocia.
Sheila Balakrishnan. Text book of Obstetrics. 2nd edition
 SHOULDER DYSTOCIA

 Incidence

Incidence id 0.58%-0.70%
 SHOULDER DYSTOCIA

Risk factors
 PRELABOUR
• Previous shoulder dystocia
• Macrosomia > 4.5 Kg
• Diabetes
• Maternal BMI > 30
• Induction of labour
 SHOULDER DYSTOCIA

 Risk factors
INTRAPARTUM
• Prolonged 1st stage of labour
• Secondary arrest of labour
• Oxytocin augmentation
• Assisted vaginal delivery
 SHOULDER DYSTOCIA

 Significance and complications

 Unpredictable and unpreventable obstetric emergency
1. BRACHIAL PLEXUS INJURY
 10% permanent neurological dysfunction
 Neonatal injury is the most common cause of litigation
due to shoulder dystocia
SHOULDER DYSTOCIA
 Complications
Lacerations of birth canal
Rupture uterus
PPH
 Fetal complications
Fetal death due to asphyxia
Meconium aspiration syndrome
Erb Palsy
Klumpke paralysis
 SHOULDER DYSTOCIA

 PREVENTION

Induction of labour doesn’t prevent shoulder dystocia in non

diabetic women with suspected macrosomic fetus. IOL at
term will reduce the incidence of shoulder dystocia in
overt/GDM mother
Elective LSCS in
 overt DM/GDM with EFW>4.5 KG
 Non diabetic with EFW>5kg(ACOG)
 SHOULDER DYSTOCIA -DIAGNOSIS

 Fetal head delivers but restitution doesn’t take place

 Turtle sign- the fetal head recoils back against the
perineum after it comes out of the vagina
 The shoulder fails to deliver with maternal pushing and
gentle axial traction from below
Warning signs in labour

 Slow progress of labour

 Secondary arrest of descent of the head
 Operative vaginal delivery
 Difficulty in crowning of the head
 Recoil of the head back against the perineum
 Failure of restitution
 SHOULDER DYSTOCIA

 MANAGEMENT

• Help- call for help

• Evaluate for episiotomy
• Legs-Mc Robert’s manoeuver
• Pressure- Suprapubic pressure
• Enter- rotation manoeuvres
• Remove posterior arm
• Roll over test
 SHOULDER DYSTOCIA
 MANAGEMENT

• Ask foe help

• Lift the buttocks, legs- Mc Robert’s manoeuver
• Anterior shoulder disimpaction –Suprapubic pressure
• Rotation of the shoulder- Wood’s manoeuver
• Manual removal of posterior arm
• Episiotomy
• Roll over test
 SHOULDER DYSTOCIA

Mc Robert’s manoeuvre
Flexion and abduction of maternal hips, positioning maternal thigs on
her abdomen.
 Low rate of complication and least invasive manoeuvre
 With one assistant on either side women’s leg should be hyper
flexed combined with axial traction
 Straightens the lumbosacral angle, rotates the pelvis cephalic, and
increases the relative AP diameter of the pelvis.
 Success rate 70%
 SHOULDER DYSTOCIA

Mc Robert’s manoeuvre
SHOULDER DYSTOCIA

Supra pubic pressure

 Reduces the bisacromial diameter and rotates the anterior shoulder
into wider oblique pelvic diameter
 Shoulder slips under the pubic symphysis with gentle traction
 Applied by assistant from the side of fetal neck in a downward
lateral direction
 Combined with routine traction and Mc Robert’s the success rate is
90%
SHOULDER DYSTOCIA

Rotational manoeuvres
Internal rotation manoeuvres ( Woods manoeuvres)
 Rotation can be most easily achieved by pressing on the easily
accessible fetal shoulder towards the fetal chest. The shoulder are
rotated into the wider oblique diameter
 Progressively rotating the posterior shoulder 180 degrees in a
corkscrew fashion, the impacted anterior shoulder could be
released. This is frequently referred to us the Wood’s corkscrew
manoeuvre.
SHOULDER DYSTOCIA
 Roll over technique
Gaskin manoeuvre
All four position
Success rate 83%
THIRD LINE MANOEUVRE
Cleidotomy
Symphysiotomy
Zavanelli’s vaginal replacement
SHOULDER DYSTOCIA

Documentation
 Should be accurate and comprehensive
 Time of delivery of the head and time of delivery of body, anterior
shoulder at the time of dystocia, manoeuvres performed their
timing, sequence.
 Estimated blood loss
 General condition of the baby
 Fetal cord blood ABG
 Neonatal assessment
 4. MATERNAL COLLAPSE DEFINITION

Maternal collapse is defined as an acute event involving the

cardio respiratory systems and/or brain, resulting in a
reduced or absent conscious level ( and potentially death) at
any stage in pregnancy and up to 6 weeks after delivery
 MATERNAL COLLAPSE
CAUSES

REVERSIBLE CAUSE
4 H’s 4T’s

• Hypovolemia • Thromboembolism

• Hypoxia • Toxicity

• Hypo/hyperkalemia and other • Tension pneumothorax

electrolyte disturbances

• Hypothermia • Tamponade
 MATERNAL COLLAPSE

 CAUSE IN PREGNANCY
Bleeding
Hypoxia
Amniotic fluid embolism
Pulmonary embolism
Eclampsia and pre eclampsia
Magnesium toxicity
 MATERNAL COLLAPSE

 MANAGEMENT

1. Tilt
2. Airway
3. Breathing
4. circulation
 MATERNAL COLLAPSE

CS indication
 Cardiac arrest with no return of circulation within 4 mts
 GA>24Wks / uterus above umbilicus
MATERNAL COLLAPSE

Management of anaphylaxis
 Inj adrenaline 500mg (0.5 mi) 1/100 IM
 Antihistamines
5. RUPTURE OF UTERUS - definition

Separation of the wall of the pregnant uterus with or without

expulsion of the fetus, that endangers the life of mother and
fetus.
RUPTURE OF UTERUS

Two types
1. Complete rupture
2. Incomplete rupture
 RUPTURE OF UTERUS

Etiological classification
 Rupture during labour
1. Preexisting uterine injury
2. Traumatic rupture
3. Spontaneous rupture
 Rupture During pregnancy
 Rupture of a previous Caesarean section Scar
 RUPTURE OF UTERUS

 Clinical features
Tachycardia
Tonic contraction
Pathological retraction ring
Hemorrhage
shock
RUPTURE OF UTERUS

 Management

Immediate laparotomy with simultaneous resuscitation

 Amniotic fluid embolism

 Occasionally, when the uterus is contracting strongly and there is

an opening between the amniotic sac and the uterine veins, a bolus
of amniotic fluid is pumped into the circulation. This passes
through the heart, and an accumulation of amniotic cells becomes
trapped in the pulmonary circulation. The amniotic fluid may cause
local disseminated intravascular coagulation, which may spread.
This rare condition can occur late in the last trimester or during
labour.
Amniotic fluid embolism

 Amniotic fluid embolism used to be diagnosed on histology only

after a postmortem examination but is now sometimes diagnosed
before death. The symptoms include collapse while having strong
contractions, shock without any blood loss, sudden dyspnoea, and
the production of frothy sputum. Treatment is supportive, with
steroids, intravenous plasma expansion, and urgent delivery. This
obstetric emergency is rare and has a bad prognosis for both mother
and fetus, usually owing to delay in diagnosis.
Journal article

Maternal and Fetal Outcome of Obstetric Emergencies in a Tertiary Health

Institution in South-Western Nigeria
 Prevention/effective management of obstetric emergencies will help to reduce
maternal and perinatal mortality in our environment. This can be achieved
through the utilization of antenatal care services, making budget for pregnancies
and childbirth at family level (pending the time every family participates in
National Health Insurance Scheme), adequate funding of social welfare services
to assist indigent patients, liberal blood donation, and regular training of doctors
and nurses on this subject.
 BIBLIOGRAPHY

1. Sheila Balakrishnan. Text book of Obstetrics. 2nd edition. New

Delhi: Para Medical Publisher; 2013 page no 356-358
2. Hiralal [Link] Dutta’s Textbook of Obstetrics.9th edition. New
Delhi: jay pee brothers publications Pvt. Ltd; 2018. page no 335-
342
3. King L T, Brucker C M, Kriebs M J. Varney’s Midwifery.5th
[Link] Noida:Jones and Bartlett India Pvt. Ltd;2014.
4. Gilbert SE. Manual of High Risk Pregnancy and Delivery.5th
edition. Missouri:MOSBY,Inc;2011