emergencies in obstetrics

1. KHUSHBOO BRAR
M.SC. (N) 2ND YEAR
OBSTETRICAL EMERGENCIES

2. Definition
Obstetrical emergencies are life threatening medical conditions that occur in
pregnancy or during or after labor and
delivery.

3. VASA PREVIA
It is an abnormality of the cord that occurs when one or more blood vessels from the umblical
cord or placenta cross the cervix but it is not covered by Wharton’s jelly.
This condition can cause hypoxia to the baby due to pressure on the blood vessels.it is a life
threatening condition.
It occurs in 1 in 2500 births.

4. ETIOLOGY
These vessels may be from either
Velamentous insertion of umblical cord
placental lobe joined to the main disk of the placenta.
Low-lying placentas
Previous delivery by C-section

5. SYMPTOMS
Sudden onset of painless
vaginal bleeding, especially
in their second and third
trimesters.
The baby’s blood is a
darker red color due to the
naturally lower oxygen
levels of a fetus.
If very dark burgundy
blood is seen when the water
breaks, this may be an
indication of vasa previa

6. Diagnosis
 The classic triad of the vasa praevia is
 antenatal sonography with color-flow Doppler reveals a
vessel crossing the membranes over the internal cervical os.
The diagnosis is usually confirmed after delivery on
examination of the placenta and fetal membranes.
membrane rupture
painless vaginal
bleeding
fetal bradycardia

7. TREATMENT
o Baby can be delivered by C- section between the 35th and 37thweek of pregnancy
o Hospitalization throughout third trimester is also recommended .
o Steroids are sometimes used to mature the lungs of the fetus if fetus is immature.

8. AMNIOTIC FLUID EMBOLISM
This rare but catastrophic condition occurs when amniotic fluid enters the
maternal circulation by uterus and placental site. The presence of amniotic
fluid in
maternal circulation trigger an
anaphylactic response.

9. The body respond in 2 phases.
The initial phase is one of pulmonary vasospasm causing hypoxia, hypotension, pulmonary
edema and cardiovascular collapse.
The second phase sees the development of left ventricular failure, with hemorrhage and
coagulation disorders and further uncontrollable hemorrhage.

10. CAUSES
Ruptured membranes
Ruptured uterine or cervical veins
Abdominal trauma
Amniocentesis.
A maternal age of 35 years or older
Caesarean or instrumental vaginal delivery
Polyhydramnios
Cervical laceration or uterine rupture
Placenta previa or abruption
Eclampsia
Fetal distress

11. SIGNS AND SYMPTOMS
Sudden shortness of breath
Excess fluid in the lungs
Sudden low
blood pressure
Sudden
circulatory
failure
Life-threatening problems with blood clotting (disseminated intravascular
coagulopathy)
Altered
mental status
Nausea or
vomiting
Chills
Rapid heart
rate
Fetal distress
SeizuresComa

12. TREATMENT
 Administer oxygen to maintain normal saturation. Intubate if necessary.
 Initiate cardiopulmonary resuscitation (CPR) if the patient arrests. If she does not respond to
resuscitation, perform a cesarean delivery.
 Treat hypotension with crystalloid and blood products.
 Consider pulmonary artery catheterization in patients who are hemodynamically unstable.
 Continuously monitor the fetus.

13. OBSTETRIC SHOCK
Shock is a critical condition and a life threatening medical emergency.
Shock results from acute, generalized, inadequate perfusion of tissues,
below that needed to deliver the oxygen and nutrients for normal
function.

14. CAUSES
Hypovolemia (Hemorrhage (occult
/overt), hyperemesis, diarrhea,
diabetic acidosis, peritonitis, burns.)
sepsis
Cardiogenic
(cardiomyopathies,
obstructive structural,
obstructive non -structural,
dysrhythmias, regurgitant
lesions).
Anaphylaxis
Distributive (Neurogenic-
spinal injury, regional
anesthesia

15. STAGES OF SHOCK
Stage1 Compensated
-- fall in BP and
cardiac output is
compensated by
adjustment of
homeostatic
mechanism.
 Stage2
Decompensate--
Maximal
compensatory
mechanism are
acting but tissue
perfusion is reduced.
Vital organ (cerebral,
renal, myocardial)
function reduced.
 Stage3
Irreversible--Vital
organ perfusion
badly impaired.
Acute tubular
necrosis, severe
acidosis, decreased
myocardial
perfusion and
contractility the
profound decrease
in perfusion leads to
cellular death &
Organ failure.

16. DIAGNOSIS

17. MANAGEMENT
Active management of shock should start as soon as it is suspected
Resuscitation follows
ABC
 An Airway--Patent airway is assured and high pressure oxygen (15 l/min) using mask/intra tracheal intubation and anesthesia machine.
 B Breathing--Ventilation checked and supported if needed.
 C Circulation
1. Insert two wide bore cannulas
2. Restore blood volume and reverse hypotension with crystalloids/colloids.
3. Initial request for 4-6 units of blood should be sent. O Rh negative blood may be transfused.

18. Monitor the response to therapy - Pulse, BP, SPO2, urine output & its ph.
 Position of patient - Head down and left lateral tilt to avoid aortocaval compression which may
further worsen the hypotension.

19. UTERINE INVERSION
Uterine inversion is a potentially fatal childbirth complication with a maternal survival rate
of about 85%.
It occurs when the placenta fails to detach from the uterus as it exits, pulls on the inside
surface, and turns the organ inside out.

20. ETIOLOGY
 The exact cause of uterus inversion is unclear.
 The most likely cause is strong traction on the umbilical
cord, particularly when the placenta is in a fundal location,
during the third stage of labor.

21. OTHER FACTORS MIGHT INCLUDE

22. GRADES OF INVERSION
INCOMPLETE
INVERSION - the top
of the uterus (fundus)
has collapsed, but the
uterus hasn’t come
through the cervix.
COMPLETE
INVERSION - the
uterus is inside-out and
coming out through the
cervix.
PROLAPSED
INVERSION - the fundus
of the uterus is coming out
of the vagina.
TOTAL INVERSION -
both the uterus and vagina
protrude inside-out (this
occurs more commonly in
cases of cancer than
childbirth)

23. DIAGNOSIS
 Prompt diagnosis is crucial and possibly lifesaving. Some of the signs of uterine inversion could include:
 The uterus protrudes from the vagina.
 The fundus doesn’t seem to be in its proper position when the doctor palpates (feels) the mother’s abdomen.
 The mother experiences greater than normal blood loss.
 The mother’s blood pressure drops (hypotension).
 The mother shows signs of shock (blood loss).
 Scans (such as ultrasound or MRI) may be used in some cases to confirm the diagnosis.

24. TREATMENT
Treatment options vary, depending on the individual circumstances and the preferences of the hospital staff, but could include:
 Attempts to reinsert the uterus by hand.
 Administration of drugs to soften the uterus during reinsertion.
 Flushing the vagina with saline solution so that the water pressure ‘inflates’ the uterus and props it back into position (hydrostatic correction).
 Manual reinsertion of the uterus while the woman is under general anaesthetic.
 Abdominal surgery to reposition the uterus if all other attempts to reinsert it have failed.
 Antibiotics to reduce the risk of infection.
 Intravenous liquids.
 Blood transfusion.
 Intravenous administration of oxytocin to trigger contractions and stop the uterus from inverting again.
 Emergency hysterectomy (surgical removal of the uterus) in extreme cases where the risk of maternal death is high.
 Close monitoring in intensive care for a few days, if necessary.