Obstetric Emergency

1. OBSTETRIC
Emergencies
Presenters:
Koo Yen Ee Charis
Muhamad Fitri Bin Che Aun
Supervisor:
Dr Dina

2. Obstetric Emergencies
a) Shoulder dystocia
b) PPH
c) Eclampsia
d) Cord Prolapse
e) Uterine rupture
f) Uterine inversion
g) Amniotic fluid embolism

3. Shoulder dystocia
• Definition:
Difficulty in delivery the shoulders requiring
special manoeuvres to deliver the shoulders after
unsuccessful attempt with application of
downward pressure of the head.

4. Shoulder dystocia
Risk factors for shoulder dystocia:
• Fetal macrosomia
• Maternal obesity
• Diabetes
• Post date pregnancy
• Previous shoulder dystocia
• Assisted delivery , prolonged 1/ 2nd stage

5. Shoulder dystocia
How do you detect shoulder dystocia during 2nd
stage?
• Head ‘bobbing’ i.e head coming down towards
introitus with pushing, but retracting well back
between contractions
• ‘Turtle sign’ at delivery i.e the delivered head
becomes tightly pulled back against the
perineum

6. Shoulder dystocia

7. Management of shoulder
dystocia
• H Help ! Activate Red alert! Note time
• E Episiotomy
• L Legs (McRobert’s manouevre)
• P Pressure applied - Suprapubic area
• E Enter the pelvis (e.g rotational manoeuvre)
• R Removal of posterior arm
• R Roll on all fours
HELPERR

8. McRoberts manoeuvre
• Hips are Abducted,
Flexed and Rotated
outwards
• Straighten
lumbosacral angle
• Rotate the
symphysis pubis
superiorly to
increase the AP
diameter

9. Suprapubic pressure
• Using flat of the
assistance hands
• Adducts the
shoulders and
reduces the
bisacromial diameter
-> dislodge the
anterior shoulder
underneath the
pubis symphysis

10. Shoulder dystocia
• 90% of shoulder dystocia is
resolved by McRobert’s
manouevre and Suprapubic
pressure alone

11. Shoulder dystocia – Reverse
Woodscrew manouevre
• Place hand on
posterior aspect
of posterior
shoulder, then
rotate shoulder
in clockwise
direction

12. Shoulder dystocia – Removal of
posterior arm
• Enter hand towards
posterior vagina to
local the posterior
shoulder, humerus,
press antecubital
fossa, flex the
forearm, grasp the
hand, sweep it
across the shoulders

13. Other manouevres
1. Fracture of the clavicles
2. Cephalic replacement -> LSCS
(Zavanelli’s manoeuvre)
3. All fours manoeuvre (rotate maternal
pelvis and disimpaction of anterior
shoulder under symphysis)

14. POST PARTUM
HAEMORRHAGE
(PPH)

15. Post partum
haemorrhage
• Death from hemorrhage still remains a leading
cause of maternal mortality.
• Hemorrhage was a direct cause of more than 20%
percent of 966 maternal deaths.
Report on the Confidential
Enquiries into Maternal Deaths in Malaysia
1997-2000

16. Post partum
haemorrhage
• Pn XY
• G5 P4 comes in
established labour
• Membranes
spontaneously rupture
on vaginal examination
• Patient delivers soon
after
• Blood loss “more than
usual” after placenta
delivered

17. Post partum
haemorrhage
• Excessive bleeding after the birth of the baby
• More than 500ml or enough to cause
hypotension and shock.
• Severe PPH >1,000ml
• Even small amount of blood loss can be life-
threatening for anemic women

18. Post partum
haemorrhage
• Primary PPH
Hemorrhage that
occurs within the
first 24 hours
postpartum
• Secondary
PPH
Bleeding after 24
hours and within
the postpartum
period

19. Post partum
haemorrhage
• Pn XY
• G5 P4 comes in
established labour
• Membranes
spontaneously
rupture on vaginal
examination
• Patient delivers soon
after
• Blood loss “more than
usual” after placenta
delivered
What are the
possible causes?

20. The Four “T”
Tone
Tissue
Trauma
Thrombin

21. Tone
Etiology Risk factors
Uterus over
distension
Multiple pregnancy
Macrosomia
Polyhydramnios
Fetal abnormalities
Uterine muscle
fatigue
Prolonged labour
High parity
Previous history of PPH
Uterine infection/
chorioamnionitis
Prolonged rupture of membrane
Fever
Uterine distortion /
abnormality
Fibroid uterus
Placenta praevia

22. Tissue
Etiology Risk factors
Retained placenta /
membranes
Incomplete placenta at
delivery esp< 24 weeks
Previous uterine
surgery
Abnormal placenta Abnormal placenta on
ultrasound- accessory /
succinturiate lobe

23. Trauma
Etiology Risk factors
Cervical/vaginal/
perineal tears
Precipitious labour
Episiotomy
Operative delivery
Extended tear at
caesarean section
Malposition
Fetal manipulation
Deep engagement
Uterine rupture Previous uterine
surgery
Uterine inversion High parity
Fundal placenta
Excessive cord traction

24. Thrombin
Etiology Risk factors
Pre-existing clotting
abnormality
eg. Haemophilia/vonWille-
brand disease
History of coagulopathy /
liver disease
Acquired in pregnancy
▪ Immune
thrombocytopaenic
purpura (ITP)
▪ Preeclampsia with
thrombocytopaenia
(HELLP)
▪ DIC from PET, IUD,
abruption, sepsis
Bruising
Elevated BP
Proteinuria
Fetal demise
Antepartumhaemorrhage
Anticoagulation
Aspirin, heparin
History of deep vein
thrombosis / pulmonary

25. Management of PPH
▪ Rapid recognition
▪ Resuscitation
▪ Identification & treatment of
cause

26. Rapid Recognition
Blood
volume loss
Heart rate Systolic BP
(mmHg)
Symptoms
and signs
500 – 1000
ml
(10-15%)
Increased Normal Palpitation,
tachycardia
Dizziness
1000-1500
ml
(15-25%)
Increased + Slight fall
(80 – 100)
Weakness,
tachycardia,
sweating
1500 – 2000
ml
(25-30%)
Increased ++ Moderate
fall
(70-80)
Restlessness,
pallor,
oliguria
2000-3000
ml
(35-45%)
Increased
+++
Marked fall
(50-70)
Collapse, air
hunger,
anuria

27. Resuscitation
◆ Call for help / Red alert
Senior obstetrician, anaesthetists,
haematologists, hospital porter, blood bank, and
theatres
◆ High flow facial oxygen
◆ Assess airway and respiratory effort
◆ Two large-bore IV cannula
◆ Take blood – FBC, cross match, BUSE, coagulation
profile
◆ Start IV crystalloids to correct hypovolaemia

28. RESUSCITATION
• Catheterise and measure hourly urine output
• Blood transfusion – O rhesus negative blood used
immediately till cross matched blood is available
• Replace clotting factors
FFP ( 4 units for every 6 units of blood)
cryoprecipitate
recombinant activated factor VII if indicated

29. Identification and
treatment of cause
Tone
◆ Uterine massage
◆ Medication
Syntometrine / Sytocinon 10 units
Oxytocin 40 IU infusion
Carboprost 250 mcg IM / directly into
myometrium and repeat at 15 minutes interval
up to 8 doses
◆ Bimanual compression

30. PP
H
Bimanual Uterine
Compression

31. Compression of the
abdominal aorta

32. Aortic
compression

33. Identification and
treatment of cause
Tissue
• Empty uterus
• Remove placenta or retained tissue
• Currettage / manual removal of placenta
• Repair any genital tract injuries (including
cervical tears)
• Correct uterine inversion

34. Identification and
treatment of cause
Thrombin
• Correct coagulopathy/ replace factors
• Other measures:
• Uterine packing/ Balloon tamponade
• B- Lynch sutures / Ligation of uterine
arteries/internal Iliac arteries and ovarian
arteries
• Hysterectomy

35. Hydrostatic balloon catheter
(Rüsch catheter)

36. B-Lynch Suture

37. Internal iliac artery
ligation

38. Management of secondary post
partum haemorrhage
• Admit patient to hospital
• General resuscitative measures
• Start broad spectrum antibiotics after a high vaginal
swab has been taken for culture.
• Perform an ultrasound scan to rule out retained
products of conception.
• Do and trace coagulation profile.
• Exploration and evacuation of products of conception
after 12-24 hours of antibiotic coverage.
• If bleeding is excessive, consider emergency
evacuation after adequate resuscitation and initiating
antibiotic cover

39. • Pn AA, 21 y/o unmarried, G1P0 at 38 weeks
• Unbooked
• Post SVD day 2, developed tonic clonic seizure

40. Eclampsia
• New onset of grand mal seizure activity and/or
unexplained coma during pregnancy or
postpartum in a woman with signs or symptoms
of pre-eclampsia.
• Any convulsions in pregnancy should be treated
as eclampsia until proven otherwise.
• Incidence 1:2000 pregnancies.
• 1/3 occur postpartum (the highest risk being the
first 24-48 hours

41. 4 stages of eclampsia
1) Premonitory stage: Lasts 10-20 seconds, during which
the eyes roll or stare, the face and hand muscles may
twitch and there will be loss of consciousness
2) Tonic stage: 10-20 seconds, where the muscles go stiff,
the diaphragm is in spasm, the back arched, teeth
clenched and eyes bulge.
3) Clonic stage: Last 1-2 minutes, where there is violent
contraction and relaxation of muscles, foaming at the
mouth, deep noisy breathing, facial congestion, tongue
bitten by teeth.
4) Coma stage: Minutes to hours, deep state of
unconsciousness, rapid noisy breathing, further fits may
occur.

42. Differentials
• Epilepsy
• Infections – Cerebral Malaria, meningitis
• Subarachnoid or intracranial hemorrhage
• Cerebral tumor
• Septicemia

43. Risks
• Primigravida
• Family history of pre-eclampsia, previous pre-
eclampsia and eclampsia.
• Poor outcome of previous pregnancies, including
IUGR, abruptio placenta, or fetal death.
• Multiple gestations
• Teen pregnancy
• Age > 35
• Lower socioeconomic groups

44. • The incidences of signs/ symptoms before seizure
include:
-Headache (83%)
-Hyperactive reflexes (80%)
-Marked proteinuria (52%)
-Generalized edema (49%)
-Visual disturbances (44%)
-Right upper quadrant pain or epigastric pain (19%)

45. Principles of
management
• First priority is to stabilize mother : ABC (airway,
breathing, circulation)
• Most eclamptic seizures are self-terminating;
however, magnesium sulfate should be commenced as
soon as possible if not already in progress, according to
the protocol
• Hypertension should be controlled (IV route preferable)

46. MgSO4
• Relieves cerebral vasospasm
• Reduces the risk of seizures
• Intravenous:
- Loading dose: 4gm dilute with normal saline into 20ml,
slow IV bolus over 20 minutes.
-Maintenance 20gm dilute in 360mls normal saline,
infuse at rate of 20mls/hr (until 24 hours post delivery or
last seizure)
• Intramuscular - loading dose (10g) and maintenance (5g 4
hourly)

47. Monitoring MgSO4
toxicity
• Assess AVPU
• Deep tendon reflexes must be present
• Respiratory rate between 12 to 16/minute
• Oxygen saturation should be >95%
• Watch out for hypotension
• Urine output should be >30ml/hour(0.5ml/kg/
hr)

48. MgSO4 Antidote
• 1 gram calcium gluconate 10%, 10 ml slow IV
bolus over 3 minutes

49. Control severe
hypertension
• Treat hypertension if SBP > 160 or DBP>100.
• Aim to reduce SBP to 130-150 and DBP to 80-100.
• Avoid maternal hypotension

50. Postpartum care
• Avoid syntometrine in third stage of labour, use
oxytocin instead to avoid severe hypertension.
• Most patients will have to be monitored in HDU,
at least until completion of MgSo4 maintenence.
• Taper down dose of anti—hypertensives
gradually
• Contraception and spacing in next pregnancy,
with early booking

51. CORD PROLAPSE

52. Cord prolapse
Risk of cord prolapse:
• Fetal causes: malpresentation (complete /
footling breech, transverse and oblique lie),
prematurity, polyhydramnios, multiple
pregnancy, anencephaly
• Maternal causes: Contracted pelvis, pelvic tumors
• Sudden rupture of membrane in polyhydramnios
• PPROM

53. Cord prolapse

54. Clinical features

55. Clinical features

56. Clinical features
VARIABLE DECELERATION

57. Cord prolapse
management
• Call for HELP. Red Alert
• Abdominal examination: Assessment of fetal lie /
contraction present or not / CTG
• Vaginal Examination: Cord -> feel cord gentle,
presence of pulsations / not, placement of cord
back into the vagina if prolapsed outside, assess
dilatation of os
• Prevent cord from being compressed:
a) Knee chest position
b) Push away presenting part with fingers
c) Fill up bladder with normal saline

58. Cord prolapse – Knee chest
position

59. Cord prolapse further
management depends on:
• Lie of fetus
• Fetal viability
• Dilatation of os

61. Uterine rupture
• Definition: Loss of the integrity of the wall of the
uterus
• Complete / Incomplete
• Life-threatening emergency often resulting in
fetal death, and maternal death from massive
intra-abdominal haemorrhage

62. Uterine rupture
: Risk factors
• Antepartum:
Previous uterine trauma /
surgery
Classical caesarean
section
External trauma
Congenital abnormal
uterus
• Intrapartum:
Previous caesarean
section
Oxytocin use
Precipitate delivery
Obstructed labour
Operative vaginal
delivery
Shoulder dystocia
Breech extraction

63. Uterine rupture : Clinical
features
• Maternal tachycardia
• Vaginal bleeding
• Continuous abdominal
pain
• Easily palpable fetal parts
• High presenting part
• Significant CTG changes
(70%)
• Variable deceleration
• Bradycardia
• Poor variability
• Tachycardia

64. Uterine rupture : management
• Activate red alert
• Resuscitation
• Prepare for immediate
emergency laparotomy

65. Uterine inversion
• Inversion is rare but may
lead to maternal death
• Varying degrees of
inversion- fundus may
pass through the cervix
• Occurs with active
management of the third
stage – cord traction

66. Uterine inversion
RISK FACTORS:
• Improper management of
the third stage
• Previous history
• Fundal placenta
implantation
• Uterine atony
CLINICAL FEATURES:
• Complete inversion:
uterus appear as blusih
grey mass protruding
from vagina
• Vasovagal / neurogenic
shock – BP low out of
proportion to any blood
loss
• Abnormally shaped
uterine fundus
• Vaginal examination

67. Uterine inversion :
management
• Red alert
• Resuscitation & Replace
the uterus as quickly as
possible
• Do not separate the
placenta as this will cause
PPH!!
• Methods available:
• Manual replacement
• O’Sullivan hydrostatic
technique
• Laparotomy – reposition

68. Amniotic fluid
embolism
• Most catastrophic conditions that can occur in
pregnancy.
• Rare
• Mortality at 30 minutes was 85%
• Bolus of amniotic fluid enter the maternal
circulation – anaphylactoid reaction to fetal
antigens

69. AMNIOTIC FLUID
EMBOLISM
SYMPTOMS
• Chills
• Shivering
• Sweating
• Coughing
SIGNS
• Cyanosis
• Hypotension
• Bronchospasm
• Tachypnoea
• Tachycardia
• Arrhythmias
• Seizures
• DIVC

70. Risk factors
• Multiparity
• Placental
abruption
• Intrauterine death
• Precipitated
labour
• Termination of
pregnancy
• Abdominal
trauma
• External cephalic
version
• Amniocentesis

71. Clinical features
•

72. Management
• Aggressive monitoring and ICU admission
• About maternal & fetal hypoxia
• Pharmacologic therapy
• Fluid support
• Correct coagulopathy as needed

73. Management ----
Monitoring
• SpO2
• EKG
• Arterial line
• Fetal monitor if onset prior to delivery
• Echocardiography
• CVP alone is not sufficient
• Pulmonary artery catheterization

74. Management ----
Maternal Hypoxia
• Secure airway
• Intubation & Ventilation
• Small tidal volume (6 ~ 8 ml/kg)
• Normocapnia (~32 mmHg)
• PEEP

75. Management - Fetal
Hypoxia
• 65% fatal AFES present before delivery
• Prevention of Fetal Hypoxia
• Maternal PO2 keep > 47 mmHg; best above 65
mmHg
• Fetal umbilical vein PO2 >32 mmHg
• Fetal compensation by elevated Hb level &
cardiac output
• Immediate delivery decreases fetal
morbidity

76. Management
• Pharmacologic Therapy
• Inotropic & vasoactive agents
• Norepinephrine
• Dopamine
• Dobutamine (often use norepinephrine in
combination)

77. Management
• Fluid management
• Pulmonary artery catheter insertion first, if
possible
• Avoid exacerbating pulmonary edema
• Initial management with vasopressor is
preferred
• Correct coagulopathy with blood product as
needed