Dr. Hem Nath Subedi
• 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
• In obstetrics, emergencies can be classified as
maternal (occurring antenatally and post-natally)
• 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
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
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
• 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
• 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.
• 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):
Management of specific obstetric
• Haemorrhage Obstetric haemorrhage can
occur antenatally or post-natally, and both can
present as obstetric emergencies.
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
• Placent a previa
• Abruptio of placenta
• 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.
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.
• 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
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
• 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).
• 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.
• Uterine inversion is a rare complication
occurring during the third stage of labour. It
has a reported incidence of between 1:2000
• The uterine fundus descends either the
uterine cavity, through the cervix, and very
rarely beyond the introitus.
• 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
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.
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:
– chest pain
– feeling cold
– restlessness, distress and panic
– pins and needles in the fingers
– nausea and vomiting.
• 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
• Major abnormalities of the fetal heart rate, in
particular prolonged fetal bradycardia, call for
immediate delivery, usually by Caesarean section.
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
• 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
• 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.
• 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.
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’.