Obstetrics emergency 2 Uterine Causes of Obstetric Emergency Uterine rupture Uterine inversion Sudden Maternal Collapse Fetal Emergencies Umbilical cord accidents Shoulder dystocia

1. Diaa Mohammad Srahin
5th year Medical Student
Al-Quds University
Obstetrics & Gynecology
March / 2018
Dr. Bassam Al-Akhdar

3. Uterine rupture
disruption of the uterine musculature through all of
its layers.
 It is rare, occurring with an incidence of 0.03–0.3 per cent
 Complete separation of the wall of the pregnant uterus with or
without expulsion of the fetus
 It occurs mainly in association with a previous Caesarean
section.
 This is because scar tissue does not have the same inherent
strength as myometrium. However, scarring can also exist as a
result of previous uterine surgery, such as a surgical evacuation
of retained products of conception resulting in a perforation.

4.  The vast majority of cases occur during labour, usually
during late first stage or the active second stage.

5. Risk factors for uterine rupture
 Previous Caesarean section
 Previous uterine surgery
 Induction and augmentation of labour
 High parity
 Macrosomic fetus
 Placenta percreta
 Fetal version, e.g. breech extraction
 Congenital uterine anomaly, e.g. unicornuate
uterus

6. Clinical presentation
The most common findings are :
 Vaginal bleeding
 Abdominal pain
 Loss of fetal electronic heart rate signal
 Loss of station of fetal head
 Hematuria may be present if the uterus has ruptured
into the bladder

8. Diagnosis
 The diagnosis of uterine rupture is typically made at
laparotomy by observation of complete disruption of
all uterine layers with active bleeding.

9. Management:
 ABC.
 Stabilize the mother.
 Immediate laparotomy to deliver the baby.
 Repair versus hysterectomy…

11. Uterine inversion
 Rare complication occurring during the third stage of
labour.
 Incidence: 1:2000- 1: 6000
 The uterine fundus descends either the uterine cavity,
through the cervix, and very rarely beyond the
introitus .

12.  It is caused by traction on the umbilical cord before
the placenta has separated and can occur after vaginal
deliveries or Caesarean section.
 Associated factors are a fundal placenta, a short cord
and a morbidly adherent placenta.
 Risk factors : Myometrial weakness (most common)
and previous uterine inversion.

13. Diagnosis
 The prolapsed uterus stretching the cervix causes
vagal stimulation, thus the woman will demonstrate
signs of cardiovascular collapse and shock.
 Although haemorrhage is commonly present, the
symptoms will be out of proportion to the estimated
blood loss.
 The inverted uterus may be obvious at the introitus, but
other signs include the lack of a palpable uterus in the
abdomen

14. Management
 Resuscitate the patient using the structured ABC approach.
 It is very important not to remove the placenta if it is still attached as this
will increase the bleeding.
 Immediately replace the uterus through the cervix by manual compression.
 If that fails, hydrostatic pressure can be applied by pouring warmed saline
into the vagina, usually via a silc cup ventouse.
 Tocolysis may be helpful to relax the cervical ring.
 Surgery, to reposition the uterus from above, should be used as a last
resort.
 After replacement, uterine contraction is maintained with an oxytocic.

15. Johnson maneuver

19. Sudden maternal collapse
Maternal collapse refer to :
an acute event involving the cardiorespiratory systems
and/or brain, resulting in a reduced or absent conscious
level (and potentially death), at any stage in pregnancy and
up to six weeks after delivery
 Sudden collapse, as in non-pregnant adults, occurs due to
a multitude of reasons. Some will be benign, such as a
vasaovagal attack (simple faint) or an epileptic fit in a
known epileptic, but other causes are life threatening

20. Causes of Sudden maternal collapse
 Amniotic fluid embolism
 Pulmonary embolism
 Shock- including: sepsis, haemorrhage, anaphylaxis, etc.
 Cardiac causes, e.g.myocardial infarct
 Intracranial events: bleeds, thrombosis
 Biochemical causes: e.g. hypoglycaemia, hypoxia
 Anaesthetic events
 Uterine inversion

24.  There is no specific treatment
 cardiovascular and respiratory resuscitation and
correction of the coagulopathy

25. Pulmonary embolism
 leading cause of death among pregnant women in the
developed world
 Result of DVT- emboli travel through the venous system to
the lungs
 the source is most commonly in the lower extremities or
pelvis
 more common in the puerperium (two thirds)
 Treat (stabilization, oxygen, hemodynamic support) and
evaluate simultaneously

26. Findings
 Symptoms include chest pain and dyspnea (80%).
Physical and imaging findings include:
 tachypnea (90%)
 CXR often normal
 ABG showing low pO2 (but often in normal range)
 EKG may show tachycardia
 Right axis deviation but usually normal

28. Treatment
 Urgent resuscitation using the structured ABC approach
is needed. If PE is suspected, anticoagulation should be
instituted
 Low-molecular-weight heparin is the treatment of
choice for PE in pregnancy
 UFH is alternative if LMWH is not available or
contraindicated
 Warfarin is contraindicated because of teratogenicity
( embryopathy, miscarriage, stillbirth)

29. Fetal
Emergencies

30. Umbilical cord accidents
 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.

32.  Incidence: 1/500 deliveries
 occurs when the fetal presenting part does not fit well
into the maternal pelvis, giving ‘space’ for the cord to
prolapse when the membranes rupture

33. Risk factors for cord prolapse

34. Diagnosis
 Most commonly, it is diagnosed by
seeing the cord at the introitus.
 or feeling it during a vaginal
examination.
 an abnormal fetal heart rate
pattern.

35. Management
 Immediate management aims to minimize the pressure of
the fetal presenting part on the cord.
 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.
 Emergency Caesarean section is required unless the cervix
is fully dilated and an assisted vaginal delivery can be safely
and easily performed.

36.  move the woman on to all fours
with head down.
 Apply pressure vaginally to push
the presenting part out of the
pelvis.
 Emergency Caesarean section is
required unless the cervix is fully
dilated
Management

37. Fetal outcome
 Depends upon the gestation, other complicating factors
such as IUGR and for how long the cord has been
compressed.
 With a term baby and a prompt diagnosis in hospital-
excellent
 Total cord compression ˃ 10 minutes - cerebral damage
 If continued for around 20 minutes - death

38. Shoulder dystocia
 “The need for additional obstetric
maneuvers to release the shoulders
after gentle downward traction has
failed”.
 results in excessive morbidity for
both mother and fetus.
 Incidence: 0.6 % in the UK
 >50% occur in normal weight
infants (less than 4 kg)

40. Risk factors

41. Diagnosis
 Diagnosis is usually obvious when the shoulders fail
to deliver during the next contraction after delivery of
the head.
 It is sometimes preceded by the ‘turtle sign’, which is
the head appearing to be pulled back on to
the perineum at delivery.

42. SHOULDER DYSTOCIA COMPLICATIONS
• Maternal
 soft-tissue injuries
 anal sphincter damage
 postpartum hemorrhage
 uterine rupture
 symphyseal separation
• Neonatal
 brachial plexus palsy
 clavicle fracture
 humeral fracture
 fetal acidosis
 hypoxic brain injury

43. Brachial plexus palsies
Erb’s palsy
Klumpke’s
palsy

44. Managemnet