Obstetric emergencies

obstetrics emergencies are really devastating condition so some knowledge toward it will help to reduce maternal mortality.

1. Obstetric emergencies Dr. Hem Nath Subedi Resident

2. Definition An emergency is defined as a serious situation or occurrence that happens unexpectedly and demands immediate action . Although the definition implies that it is unforeseen, preparation and prevention should always be used to reduce the risks of emergencies occurring . In obstetrics, emergencies can be classified as maternal (occurring antenatally and post- natally ) and fetal.

3. Assessing the airway (A) First, check in the mouth for any obstructing material , such as blood or vomit, and remove using suction. Such obstruction is uncommon in obstetric patients. Next , open the airway by using either the head tilt and chin lift, or a jaw thrust . The head tilt and chin lift is carried out by placing a hand on the forehead and gently tilting back, and two fingers of the other hand under the chin and gently lifting.

4. Assessing breathing (B) and circulation (C ) Having opened the airway, the breathing should be assessed for 10 seconds by looking for chest movement and listening and feeling for signs of air movement. Although experienced clinicians may also feel the carotid pulse at this stage, the current resuscitation guidelines advise that lack of breathing also indicates a lack of circulation. If the airway is open and the patient breathing , high flow oxygen should be administered via a face mask.

5. If there is no circulation, or there is some uncertainty , cardiopulmonary resuscitation ( CPR) should be commenced immediately . This begins immediately with 30 chest compressions followed by two ventilation breaths. Administering chest compressions should be conducted with the patient in the left lateral position.

6. The reversible causes of cardiac arrest can be remembered as the ‘four Hs and the four Ts ’ and are given below (those in italics signify those most likely in pregnancy):

7. Management of specific obstetric emergencies Haemorrhage Obstetric haemorrhage can occur antenatally or post- natally , and both can present as obstetric emergencies.

8. Antepartum haemorrhage Antepartum haemorrhage (APH) is any bleeding occurring in the antenatal period after 20 weeks gestation . It complicates 2–5 per cent of pregnancies. Most cases involve relatively small quantities of blood loss, but they often signify that the pregnancy is at increased risk of subsequent complications, including postpartum haemorrhage . Placent a previa Abruptio of placenta

9. Placenta previa

10. Placenta praevia is defined as a placenta that has implanted into the lower segment of the uterus. It is now classified as either major, in which the placenta is covering the internal cervical os, or minor, when the placenta is sited within the lower segment of the uterus , but does not cover the cervical os.

11. In women who have had a previous caesearean section, there is a risk that the placenta implants into, and thus invades, into the previous scar. This is called a ‘morbidly adherent placenta ’ and there are three types: 1. Placenta accreta . Placenta is abnormally adherent to the uterine wall. 2. Placenta increta . Placenta is abnormally invading into the uterine wall. 3 . Placenta percreta . Placenta is invading through the uterine wall.

12. Placental abruption A placental abruption is separation of a normally sited placenta from the uterine wall. In most cases, the separation reaches the edge of the placenta, tracks down to the cervix and is revealed as vaginal bleeding. The remaining cases are concealed, and present as uterine pain and potentially maternal shock or fetal distress without obvious bleeding.

13. Postpartum haemorrhage Postpartum haemorrhage (PPH) is probably one of the most common obstetric emergencies. In the UK Confi dential Enquiry 2003–5, haemorrhage was the third most common cause of death. It is defined as: • Primary PPH. Loss of 500 mL blood from the genital tract within 24 hours of delivery. • Secondary PPH. Loss of 500 mL blood from the genital tract between 24 hours and 12 weeks post delivery .

14. Hypertensive disorders Pre- eclampsia is a disease of pregnancy characterized by a blood pressure of 140/90 mmHg or more on two separate occasions after the 20th week of pregnancy in a previously normotensive woman. This is accompanied by significant proteinuria (300 mg in 24 hours).

15. HELLP syndrome HELLP syndrome – a combination of haemolysis , elevated liver enzymes and low platelets – is seen in 5–10 per cent of cases of severe pre- eclampsia . It is more common in multiparous women. It may be associated with disseminated intravascular coagulation , placental abruption and fetal death.

16. Uterine inversion Uterine inversion is a rare complication occurring during the third stage of labour . It has a reported incidence of between 1:2000 and 1:6000 . The uterine fundus descends either the uterine cavity, through the cervix, and very rarely beyond the introitus .

17. Sudden maternal collapse Pulmonary embolism Amniotic fluid embolism

18. Pulmonary embolism Thrombosis is consistently the most common cause of maternal death. It is important to recognize that although PE is more common in the puerperium , it can occur at any time in the antenatal and post-natal period.

19. Amniotic fluid embolism Aetiology and epidemiology Amniotic fluid embolism is a rare cause of maternal collapse specific to pregnancy, believed to be caused by amniotic fluid entering the maternal circulation. This causes acute cardiorespiratory compromise and severe disseminated intravascular coagulation. In some cases , there may be an abnormal maternal reaction to amniotic fluid as the primary event. It is difficult to diagnose in life, and is typically diagnosed at postmortem, with the presence of fetal cells ( squames or hair ) in the maternal pulmonary capillaries. It caused 18 deaths in the 2003–5 maternal mortality report.

20. Diagnosis and management In the case of sudden collapse, management should be the structured ABC approach. Symptoms occurring just before the collapse may be helpful in diagnosis. Women may report the following symptoms: breathlessness chest pain feeling cold lightheadedness restlessness , distress and panic pins and needles in the fingers nausea and vomiting.

21. Fetal emergencies The fetus may be severely affected by any of the preceding maternal emergencies that occur before delivery. However, there are some emergencies that directly affect the fetus without major immediate physical compromise of the mother. Major abnormalities of the fetal heart rate, in particular prolonged fetal bradycardia , call for immediate delivery, usually by Caesarean section .

22. Umbilical cord accidents (cord prolapse) A cord presentation is defined as the presence of umbilical cord below the fetal presenting part when the membranes are intact. Cord prolapse is the presence of the cord below the presenting part when the membranes are ruptured.

23. Diagnosis Most commonly, it is diagnosed by seeing the cord at the introitus , or feeling it during a vaginal examination. However , an abnormal fetal heart rate pattern may suggest it, as compression of the umbilical vein between the presenting part and the pelvis, reduces or stops the flow of oxygenated blood to the fetus, causing deep variable decelerations, then bradycardia if the situation is not relieved.

24. Immediate management aims to minimize the pressure of the fetal presenting part on the cord, while plans are made to deliver the baby. This is achieved by moving the woman on to all fours with the head down, applying pressure vaginally to push the presenting part out of the pelvis, or by filling the bladder with 500 mL of saline.

25. With a term baby and a prompt diagnosis in hospital, the prognosis is usually excellent. If the cord prolapse occurs outside hospital , the fetus is likely to be dead by the time of admission . Total cord compression for longer than 10 minutes will cause cerebral damage and, if continued for around 20 minutes, death. These times will be shorter in a fetus that is already compromised for reasons such as prematurity or fetal growth restriction .

26. Shoulder dystocia Aetiology and epidemiology Shoulder dystocia is defi ned by the Royal College of Obstetricians and Gynaecologists (RCOG) as the need for ‘additional obstetric manoevres to release the shoulders after gentle downward traction has failed’.

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