Obstetric emergencies
Antepartum haemorrhage
- Two major causes, placental abruption and placenta preavia, both involve placental separation
Placenta praevia
- Placenta occupies lower uterine segment and becomes detached as cervix effaces and dilates in late pregnancy
- In major degrees vaginal delivery is impossible
- Risk to fetus is mainly prematurity due to caesarean section
- There is also a risk of hypoxia due to placental separation but this is accompanied by maternal haemorrhage
- Risk of excessive bleeding is greater if the placenta is situated anteriorly
- Indications for delivery are;
- Reaching 37-38 weeks gestation
- A massive bleed (1500ml)
- Continuing lesser bleeding
Placental abruption
- Separation of a normally situated placenta from the uterine wall
- In most cases separation occurs at the edge of the placenta and tracks down to the cervix where it presents as vaginal bleeding
- The remaining cases are concealed and may present as uterine pain, maternal shock or fetal distress
- Fetur is at risk of hypoxia and premature delivery
- If fetus is alive delivery should be by Caesarean
Vasa praevia
- Rupture of the vessels on the fetal side of the placenta
- It is fetal blood which is lost
- Risk factors include placenta praevia and multiple pregnancy
- Very dangerous for fetus, requires rapid Caesarean section
Postpartum Haemorrhage
- Primary PPH is defined as being the first 24hr
- Secondary PPH is seen up to 6 weeks after delivery
- Excess loss is considered >500ml
- Most important cause is uterine atony when the uterus is not contracted
- To manage this massage uterus to aid contraction
- Give syntocinon and ergometrine and prostaglandin F2-alpha
- Other sources of bleeding may be the broad ligament, paravaginal bleeding or uterine rupture
- Secondary PPH is rarely life threatening
- Most often caused by retained products of conception and infection
Uterine Rupture
- Occurs most commonly in association with previous scarring of the uterus usually from caesarean sections
- Almost always occurs in labour
- Patient experiences continuous abdo pain
- Contractions stop
- Fetal heart rate pattern becomes abnormal
Amniotic fluid embolism
- Occurs when amniotic fluid enters maternal circulation
- Causes acute cardiorespiratory compromise and DIC
- Very rare 1 in 30,000
- Poor prognosis, 10% survival
Pre-eclampsia
- BP greater than 140/90 mmHg on separate occasions after the 20th week of pregnancy in a normally normotensive women
- Accompanied by significant proteinuria (>300mg in 25hr)
- Can proceed to eclampsia (convulsions)
- Can occur postpartum
- Symptoms of severe pre-eclampsia
- Frontal headache
- Visual disturbance
- Epigastic pain
- General malaise and nausea
- Restlessness
- Signs of severe pre-eclampsia
- Agitation
- Hyper reflexia and clonus
- Facial and peripheral oedema
- RUQ pain
- Poor urine output
- Give hydralazine or labetolol to lower BP
- Give magnesium sulphate to prevent fitting (can be reversed with calcium gluconate)
HELLP syndrome
- Combination of haemolysis, elevated liver enzymes and low platelet count
- Seen in 5-10% of cases of severe pre-eclampsia
- May be associated with:
- DIC
- Placental abruption
- Fetal death
- Significant maternal and fetal mortality
Fetal Emergences
Umbilical Cord accidents
- Cord presentation and prolapse are associated with prematurity and malrepresentations
- Arrange C-section
- Whilst doing so place mother in head down position as this relieves pressure on the umbilical vein
Shoulder dystocia
- Difficulty delivering fetal shoulders
- Generally anterior shoulder gets caught above the symphysis pubis
- After delivery of the head, restitution occurs and the shoulders rotate to the AP position, problems occur if the shoulder has not entered the pelvic inlet
- Risk factors
- Large baby
- Small mother
- Maternal obesity
- Diabetes
- Post-maturity
- Previous shoulder dystocia
- Prolongation of late first stage of labour
- Prolonged second stage of labour
- Risks to the baby are
- Cerebral damage if delivery is prolonged
- Stretching of the brachial plexus resulting in Erb’s palsy
- Shoulder dystocia drill
- Call for help
- Avoid excess traction at all times
- Hyper reflex and abduct the hips
- Apply suprapubic pressure
- Rotate the shoulders by internal manipulation
- Deliver the posterior arm
- Avoid – fundal pressure
                   turning patient into the left lateral position
                   inappropriate traction of head
- May require an episiotomy