Obstetric emergencies

1. OBSTETRIC
EMERGENCIES
SDL 2
Done by: fuad bukhari, Faisal bukhari and abdulmajed
alomar

2. POSTPARTUM
HEMORRHAGE

3. Definition
■ blood loss in excess of 500 mL at the time of vaginal delivery or blood loss
in excess of 1000 mL following cesarean delivery.
■ the leading cause of maternal mortality.
■ Could be immediate or delayed.

4. causes

5. UTERINE ATONY
■ This is the most common cause of excessive postpartum bleeding. (75-80%)
■ Risk Factors. Rapid or protracted labor, chorioamnionitis, medications and
overdistended uterus.
■ Clinical Findings. A soft uterus (feels like dough) palpable above the umbilicus
■ Management. Uterine massage and uterotonic agents (e.g., oxytocin,
methylergonovine, or carboprost).

6. ■ Lacerations (15%) Risk Factors. Uncontrolled vaginal delivery, difficult delivery, and
operative vaginal delivery.
■ Clinical Findings. Identifiable lacerations (cervix, vagina, perineum) in the presence of
a contracted uterus.
■ Management. Surgical repair
■ Retained Placenta (5%)
■ Risk Factors. Accessory placental lobe and abnormal trophoblastic uterine invasion
(e.g., cervix, vagina, perineum).
■ Clinical Findings. Missing placental cotyledons in the presence of a contracted uterus.
■ Management. Manual removal or uterine curettage under ultrasound guidance.

7. approach
■ 1. All women in early labor who have risk factors for PPH should be identified and
their hemoglobin checked. For medium-risk women, their blood should be typed
and screened for irregular antibodies such as Rh and Kell. For high-risk women, 2
units of blood should be typed and crossmatched.
■ 2. As soon as the fetus has been delivered, an infusion of oxytocin (Pitocin) 10 to 40
U/L IV should be started and maintained during the first 6 hours postpartum.
■ 3. The vagina and perineum should be inspected to rule out any lacerations that
could cause excessive bleeding.
■ 4. The placenta should be carefully assessed at delivery to make certain there are
no missing cotyledons (lobules of placenta).
■ 5. The uterus should be evaluated by abdominal palpation during the first 1 to 2
hours before transfer to the postpartum unit.

10. UMBILICAL CORD
PROLAPSE

11. Definition
■ Descent of the cord to a level adjacent to or below the presenting part, causing
cord compression between cord and pelvis.
■ It is an obstetrical emergency because the prolapsed cord is vulnerable to
compression, which can compromise fetal oxygenation.
■ Incidence: 0.16-0.18%.

12. risk factors:
■ Prematurity
■ PROM
■ Malpresentation
■ Placenta previa
■ Polyhydramnios
■ Multiple gestation

13. Classification
■ overt umbilical cord prolapse:
■ descent of the umbilical cord below the presenting fetal part through the cervix and into
or beyond the vagina, This is the most common type of cord prolapse.
■ occult umbilical prolapse:
■ descent of the umbilical cord alongside the presenting fetal part, but has not advanced
past the presenting fetal part.

15. Clinical features
■ sudden decrease in fetal heart rate with variable decelerations.
■ the cord can be seen or felt on vaginal examination, particularly with overt cord
prolapse.

16. Management
■ Do not hold the cord or try to push it back into the uterus, elevate the presenting
part, avoid palpating the cord, Place the patient in knee-chest position, and
perform immediate cesarean delivery.
■ If fetal demise or too premature (<22 weeks), allow labor and delivery.

17. SHOULDER
DYSTOCIA

18. Definition
■ Occurs when the fetal head is delivered but the shoulders cannot be
spontaneously delivered with gentle downward traction
■ Due to impaction of the fetal shoulder behind the symphysis
■ Occurs in 0.6 to 1.4%
of deliveries

19. Shoulder Dystocia

21. Shoulder Dystocia
■ Diagnosis is made during the 2nd stage of labor
■ Turtle sign : The fetal head recoils back against
the perineum after it comes out of the vagina.
■ The shoulders fail to deliver with maternal pushing and gentle
downward traction.

22. ■ unilateral shoulder dystocia
the anterior shoulder that becomes impacted
behind the pubic symphysis
■ bilateral shoulder dystocia
very rare the posterior shoulder fails to descend below
the sacral promontory, so that both the anterior and posterior
shoulders are arrested .

23. How much time does one have to resolve a shoulder
dystocia before hypoxic brain happend ?
■ In general, the operator has up to five minutes to deliver a
previously well-oxygenated term infant before an increased risk of
asphyxial injury occurs.
■ After 5 minuet we have to do argent c/s

24. Management

25. episiotomy
■ episiotomy does not decrease risk of brachial plexus
injury and increases the risk of perineal trauma.
■ The only reason to perform an episiotomy is to eliminate soft
tissue resistance that is interfering with the ability to insert the
whole hand into the hollow of the sacrum posteriorly to
perform fetal maneuvers.

26. McRobert’s Maneuver :
■ Allows the shoulder to slide out beneath the pubic bone

27. Suprapubic pressure
Apply oblique pressure above the pubic bone with the heel of the
hands against the posterior aspect of the fetal shoulder
Fundal pressure and Maternal pushing
should not be employed.
It is may lead to further impaction
of the shoulders.

28. Rotational manavure
Woods' corkscrew maneuver
Apply pressure on anterior surface
of the posterior shoulder
rotating it 180 degrees
Done only if the posterior
Shoulder is accessible

29. Rotational manavure
■ Rubin maneuver :
■ Reverse Woods' corkscrew maneuver
The pressure is applied on the posterior
surface of the posterior shoulder

30. removal of the
posterior arm and shoulder
antecubital fossa is located and pressure of a
finger is applied in order to flex the arm.
The forearm is swept across the chest and face.
The hand is then grasped, to extend
along the fetal face, and delivered.
Major risk for humeral
fracture

31. Other manuevers
■ – Fetal clavicle fracture
■ – Rolling to “all fours” position
■ – Zavanelli
■ – Symphysiotomy

32. Fetal clavicle fracture
■ Often described but rarely performed
■ Fracture decreases the bisacromial diameter to effect
delivery of the shoulder
■ it Causes major damage to lungs ang major blood vessels

33. Rolling over to 'all fours' position
■ Gaskin maneuver
■ Increases pelvic dimensions , freeing the posterior shoulder easly

34. Zavanelli maneuver
reversing cardinal movements of labor
Fetal head is rotated to occiputanterior position, flexed,
rotated and pushed back up to the uterus

35. Symphysiotiomy
Involves dividing the ligaments between the
right and left pubic symphyseal bones
Increase of the transverse diameter of the
pubis adds 3 cms to the pelvic circumference
Complications
Injury to the urethra or bladder.
Vesico-vaginal or urethro-vaginal fistula
Difficulty of walking and unstable
pelvis usually improved by time.

36. Complication
Maternal Complications
Lower genital tract lacerations
Post-partum haemorrhage
Rectovaginal fistula
Fetal Complications :
Brachial plexus palsy
Clavicle fracture - Fracture of the humerus
Fetal hypoxia, with or without permanent neurological damage
Fetal death