Every Mom’s Dream…...

OBSTETRICAL EMERGENCIES

Care is a state in which something does matter ; it is the source of human tenderness

DEFINITION

• AN UNFORESEEN COMBINATION OF CIRCUMSTANCES OR THE RESULTING STATE THAT CALLS FOR IMMEDIATE ACTION

• LIFE -OR -DEATH SITUATION

• INFREQUENT, UNANTICIPATED, UNPREDICTABLE NIGHTMARE

Patient -1

• A 38 weeks G4P3 lady presents with ROM and contractions. She is quite distressed and thinks the baby is coming out. You perform a pelvic examination and next to the head you feel a pulsatile cord…

Cord Prolapse• Presentation: Cord in front of presenting part

before the rupture of membranes• Prolapse: Cord in front of presenting part

after rupture of

membranes

Occult prolapse

Cord lying alongside the presenting part

Incidence (Anita pal, Kushgla, Sood 2006)

• Primigravida 0.45%• Multigravida 0.66% (Risk ratio

2:3)• Cephalic 0.3%• Frank breech 0.9%• Complete breech 5%• Footling 10%• Shoulder 15%• Contracted pelvis 4-6 times

Causes• Malpresentation - face, brow, breech and shoulder• Prematurity• Polyhydramnios• Multiple pregnancy• Long cord (90-100 cm)• PROM• CPD• Obstetric interventions - Amniotomy, Intrauterine

pressure catheter, scalp electrode, external cephalic version, PROM, expectant management in preterm

Dangers

• Mortality rate as high as 50%• Hypoxia• Spasm of vessels• Operative trauma to suboxgenated fetus• More with vertex than breech• Descent in front than behind• More in primi than multi

Diagnosis• Cord pulsations• CTG shows variable decelerations• Cord lying outside vulva• USG – cord loops• Fundal pressure

causes bradycardia• Violent activity of

baby • Meconium stained

liquor

Prevention

• Refer to level II care• USG for malpresentation and cord

presentation• Foetal mointoring• Avoid ARM in an unengaged head• PV exam after ROM

Management• Lift presenting part off the cord • Instruct NOT to push • Position patient

Knee chest

Trendelenburg

Exaggerated position

Knee chest position

Trendelenburg position

Exaggerated sim’s position

Management (cont..)• Full bladder (Vago 1970)• Vulval pad• Replacement of cord• Tocolysis (ritodrine)• Forceps (Cx fully dilated)• Second twin – internal podalic version

and breech extraction• Stat C-section• Occult: Aminoinfusion

Management (cont…)

• Funic Reduction–Manual replacement of cord into uterus–Cord gently pushed above presenting part

while other cord decompression techniques are applied

–Rapid vaginal delivery

Fetal Mortality

• Overall - 50%• 1st stage of labour - 70%• 2nd stage of labour -30%• Neonatal death - 4%• Perinatal mortality- 20%

< 5 minutes, prognosis good, > 5 mins, damage and death.

VASA PRAEVIA• Fetal blood vessel lies in front of presenting

part• Rupture

- exsanguination

of the fetus

Cause and Management

• Velamentous insertion

Fresh bleeding vaginally

with rupture of membranes• Management: Signs of fetal

distress

Stat C.S

Send cord blood for Hb estimation

PATIENT -2Mother is pushing with each contraction and the baby’s head starts to come out. However, with each push, the baby’s head comes out and then retracts back in towards the perineum. You quickly recognize this as the “turtle sign”

Obstructed labour• No advancement of presenting part

despite strong, uterine contractions• Causes:

Cephalo-pelvic disproportion

Malpresentation - shoulder/brow/persistent mento posterior

Deep transverse arrest

Pelvic mass

Fetal abnormalities - Hydrocephalus, conjoined twins

Causes

Malpresentation:

Signs of obstructed labour• Presenting part fails to advance• Cervical dilatation slow• Formation of retraction ring• Early rupture of membranes• Formation of elongated sac of forewaters• If neglected, dehydration, ketosis• Caput succedaneum and moulding• urine output decreases• fetal distress

Management

• Careful assessment of progress of labour• Correct hydration• Internal version• Forceps application• Stat C.Section

Shoulder Dystocia

• Incidence: 0.23% to 2.09%

• Impaction of fetal shoulders in maternal pelvis

• Head to body delivery time > 60s

Risk factors

• Maternal Diabetes Mellitus• Short stature• Macrosomia• Post-term• Obesity• Fetal shoulder circumference

40.9 ± 1.5cm Vs 39.5 ± 1.5 cm

Complications

Fetal morbidity:• Brachial plexus injury• Clavicular fracture• Facial nerve paralysis• Asphyxia• CNS injury• complication rate up to 20%

ManagementHelp – obstetrician, pediatricianEpisiotomyLegs – elevate (McRoberts)Pressure - suprapubicEnter vagina – Rubin’s and Woods’ screwRoll or Remove posterior armZavanelli, Clavicular# , Symphysiotomy

McRoberts Maneuver• hyperflexion of

maternal hips• Increases intrauterine

pressure (1,653mmHg - 3,262

mmHg)• Increases amplitude of

contractions (103mm Hg to 129mm

Hg)

All-Fours Maneuver(Gaskin Maneuver)• Ina May Gaskin (1976)• changes pelvic dimensions in a similar way to

McRoberts maneuver• apply downward traction to disimpact the

posterior shoulder

Suprapubic Pressure• direct posterior or oblique suprapubic

pressure

Rubin’s Maneuver• adduction of the most accessible shoulder• moves the fetus into an oblique position

and decreases the bisacromial diameter

Woods’ Cork Screw Maneuver

• Abduct posterior shoulder exerting pressure on anterior surface of posterior shoulder

Deliver posterior arm(Barnum Maneuver)

grasp the posterior arm and sweep it across the anterior chest to deliver

Zavanelli Maneuver

• cephalic replacement via reversal of the cardinal movements of labor

• fracture the anterior clavicle by pushing it against the pubic ramus or using a closed pair of scissors

• Symphysiotomy

Clavicular Fracture

Complications

• Maternal morbidity• 4th degree perineal lacerations• Cervical & Vaginal lacerations• Bladder injury• Postpartum hemorrhage• Endometritis

Patient - 3

• Mother in third stage of labour. Using the controlled cord traction, the midwife tries to deliver the placenta. Unfortunately, notices the descent of uterus instead of placenta.

Uterine Inversion

• 1/20,000 deliveriesCauses:• uterine atony (40%)• Increase in intra

abdominal pressure• Fundal attachment of

placenta (75%)• Short cord• Placenta accreta • Excessive cord traction

Degrees of uterine inversion• 1st - Dimpling of

fundus, remains above internal os

• 2nd - fundus passes through the cervix, but lies inside vagina

• 3rd - (complete) Endometrium with or without placenta is outside the vulva

Dangers

• Shock - Neurogenic

Pressure on ovaries

Peritoneal irritation• Hemorrhage• Pulmonary embolism• Infection

Management• Uterine relaxant (terbutaline 0.25 mg IV

followed by 2 g of MgSO4 over 10 min)• Treat hypovolumeia • Without placenta: Repositioning

Uterine Inversion

Management(cont…)

• With placenta: Do not remove placenta• Replace uterus• Bimanual compression• Hydrostatic pressure (O’Sullivan 1945)• Start oxytocin• Laparotomy

Patient - 4

A mother in second stage of labour suddenly complains of persistent pain, and bleeding per vagina becomes profuse and the monitor shows decelerations in fetal heart rate.

Uterine Rupture• 1/2000 deliveries

Types:• Complete• Incomplete• Rupture Vs Dehiscense of

C.S scar

http://catalog.nucleusinc.com/enlargeexhibit.php?ID=9961

Rupture of lower uterine segment

Causes• Uterine injury sustained before current

pregnancy

C.S /hysterotomy/ repaired uterine rupture/ Myomectomy

Uterine trauma - curette, sounds

Sharp or blunt trauma - accidents, bullets, knives

Congenital anomaly

CausesUterine injury during current pregnancy• Before delivery

Intense spontaneous contractions

Labour stimulation

Intra-amnionic instillation

Perforation by internal catheter

External trauma - sharp or blunt

External version

Uterine overdistension - multiple pregnancy

Causes (cont…)• During delivery:

Internal version

Difficult forceps delivery

Breech extraction

Difficult manual removal of placenta

Fetal anomaly• Acquired:

Placenta increta / percreta

Retroverted uterus (sacculation)

Diagnosis• Prolonged fetal decelerations (70.3%)• Bleeding (3.4%) Pain (7.6%)

Monitor tracing demonstrating fetal heart rate decelerations, increase in uterine tone, and continuation of uterine contractions in a patient with uterine rupture monitored with an intrauterine pressure catheter.

Management

Total Hysterectomy

Sub total hysterectomy

Simple repair

Patient 5

Mother has just delivered a male baby. You wait for 30 minutes But no signs of placental separation and descent is present. Manual removal fails.

Placenta Accreta• Incidence: 1 in 2,562 deliveries• Firm adherence of placenta to uterine wall• partial or total absence of decidua basalis• Placenta increta: Villi invade the myometrium• Placenta percreta: Villi penetrate myometrium

Risk factors

• Defective decidual formation

placenta previa

Previous cesearean scar

uterine curettage• Grand multiparity

Diagnosis and Management

• Dx in third stage of labour• Maternal hemorrhage• Treatment: Hysterectomy

Patient 6

• A pregnant mother on oxytocin induction suddenly becomes short of breath and tachypneic. Vital signs drop and the patient goes into asystolic arrest.

Amniotic Fluid Embolism

• Incidence: 1 in 3,500 to 1 in 80,000• Amniotic fluid enters the maternal

circulation and reaches pulmonary capillaries

• Through a tear in amnion and chorion• Opening in maternal circulation• Increased intrauterine pressure

Amniotic Fluid Embolism

Risk factors

• Multiparity• Large fetus• Meconium in amniotic fluid• Intrauterine fetal death• Precipitate labour• Placental abruption• Intrauterine catheter• Rupture of uterus

Manifestations

• Phase I : Pulmonary vasospasm

Hypoxia

Hypotension

Cardiovascular collapse• Phase II: Left ventricular failure

Pulmonary edema

Hemorrhage

Coagulation disorder

Management

• Intubation + Mechanical ventilation• CVP monitoring• Blood transfusion + I.V. Fluids• Dopamine 2-20mg/kg/min• IV Digitalization (0.1 - 1.0mg)• Prostaglandin• Morphine• Aminophylline• Hydrocortisone

Be prepared, except the unexpected and above all, communicate

• Communicate congruently • Careful, sympathetic and

optimal communication• Avoid medical jargon• Psychological support- one member - Touch• “Talking through” the process• Smile of reassurance• Information and support to partners

Fear during labour• Worries that infant may die or

born with abnormality.• Review labour process• Provide with frequent progress

report• Personal availability of nurse• Promise postnatal debriefing

sessions

NURSE’S ROLE IN INTRAPARTUM CARE

NURSE MIDWIFE

COMMUNICATOR

EDUCATOR

CAREGIVER

MANAGER

ADVOCATE

COUNSELLOR CO ORDINATOR

RESEARCHER

Interestingly, loving care does not require twice the time,but it does require more than twice the presence.”- Erie Chapman

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NEED YOU AND

YOUR CARE