1. OBSTETRIC EMERGENCIES

2. OBSTETRIC EMERGENCIES
Maternal
Fetal
Both mother and fetus at risk

3. HEMORRHAGE PREPARTUM/INTRAPARTUM: Placenta previa
Placenta accreta/increta/percreta
Placental abruption
Uterine rupture
POSTPARTUM:
Retained placenta
Uterine atony
Uterine inversion
Birth trauma/laceration

4. NON REASSURING FETAL HEART RATE
ANTEPARTUM:
Umbilical cord prolapse
Umbilical cord compression
Uteroplacental insufficiency
AT DELIVERY:
Shoulder dystocia
Vaginal breech delivery (head entrapment)

5. PLACENTA PREVIA 1 in 200-250 deliveries Complete, partial or marginal
Most diagnosed early resolve by third trimester
ETIOLOGY:
Unknown
Previous uterine scar
Previous placenta previa
Advanced maternal age
Multiparity

6. PLACENTA PREVIA Painless vaginal bleeding-third trimester
Vaginal bleeding in 3rd trimester should be considered previa until proven otherwise
Ultrasound has eliminated the need of double set up to diagnose previa as in the past
Cesarean delivery
Expectant management if fetus immature and no active bleeding
Urgent/emergent cesarean delivery for active or persistent bleeding or fetal distress

7. PLACENTA ACCRETA/ INCRETA/PERCRETA
Placenta accreta, increta and percreta difficult to diagnose antepartum
Usually diagnosed when placenta doesn’t separate after cesarean or vaginal delivery
Color Doppler imaging or magnetic resonance imaging may diagnose the condition antepartum
Preoperative balloon catheters in internal iliac can be considered in cases diagnosed antepartum.
Prompt decision for hysterectomy

8. PLCANTA ACCRETA/ INCRETA/PERCRETA
Good IV access/ A line
Cross matched blood
FFP/Cryo/Factor VII/Platelets
Emergency hysterectomy more blood loss than elective hysterectomy
Hemodilution/red cell salvage can be considered.

9. PLACENTAL ABRUPTION I ETIOLOGY: Cocaine
Hypertension: Chronic or pregnancy induced
Trauma
Heavy maternal alcohol use
Smoking
Advanced age and parity
Premature rupture of membranes
History of previous abruption

10. PLACENTAL ABRUPTION Vaginal bleeding-Classical presentation
May not always be obvious
3000 ml or more blood can be sequestered behind placenta in concealed bleeding
Uterus can’t selectively constrict abrupted area
Decreased placental area-fetal asphyxia
1 in 750 deliveries-fetal death
Severe neurological damage in some surviving infants
Upto 90% abruptions-mild to moderate

11. PLACENTAL ABRUPTION
Problems: Hemorrhage, Consumptive coagulopathy, Fetal hypoxia, Prematurity
Low fibrinogen/ Factor V, Factor VII and platelets and increased fibrin split products
Management depends on severity of situation
Vaginal delivery-Fetus and mother stable
Urgent/Emergent LSCS- Fetal distress or severe hemorrhage
Be prepared for massive blood loss.
uterus may not contract after delivery
On rare occasions, internal iliac ligation/hysterectomy may be necessary

12. UTERINE RUPTURE Prepartum, intrapartum or postpartum ETIOLOGY:
Prior cesarean delivery especially classical cesarean scar
Rupture of myomectomy scar
Precipitous labor
Prolonged labor with cephalopelvic disproportion
Excessive oxytocin stimulation
Abdominal trauma
Grand multiparity
Iatrogenic
Direct uterine trauma-forceps or curettage

13. UTERINE RUPTURE Severe uterine or abdominal pain or shoulder pain
Disappearance of fetal heart tones
Vaginal or intraabdominal bleeding
Hypotension
VBAC: Change in uterine tone or contraction pattern and FHR changes and not pain during uterine rupture
Emergent SURGERY may be necessary
Uterine repair/Hysterectomy depending on situation

14. RETAINED PLACENTA 1% of deliveries Ongoing blood loss
Manual exploration for removal
You need uterine relaxation and analgesia
anesthesia depending on clinical situation

15. UTERINE ATONY Most common cause of postpartum hemorrhage
Follows 2-5% deliveries
ETIOLOGY:
Multiparity
Polyhydramnios
Macrosomia
Chorioamnionitis
Precipitous labor or excessive oxytocin use during labor
Prolonged labor
Retained placenta
Tocolytic agents
Halogenated agents >0.5 MAC

16. UTERINE ATONY Vaginal bleeding > 500 ml
Manual examination of uterus
Volume resuscitation
Infusion of oxytocics + bimanual compression of uterus
Evaluation for retained placenta

17. OXYTOCIC DRUGS
Oxytocin:20-40U/L-Vasodilation, hypotension, hyponatremia, no benefit after 40 U
Methylergonovine:0.2 mg IM, Max. 0.4 mg- Vasoconstriction, ↑PA pressures, coronary artery vasospasm, hypertension, CVA, nausea and vomiting
Carboprost or hemabate (prostaglandin F2α analog): 0.25 mg IM or IU, Max 1.0 mg – Vasoconstriction, systemic and pulmonary hypertension, bronchospasm, V/Q mismatch, nausea, diarrhea
Misoprostol 800 mg PR. Minimal side effects

18. UTERINE INVERSION Uncommon problem
Results from inappropriate fundal pressure or
Excessive traction on umbilical cord especially if placenta accreta is present
Mass in the vagina
Uterine atony
Maternal shock and hemorrhage
Volume replacement
Analgesia for the procedure
Uterine relaxation for replacement
Oxytocics following replacement

19. BIRTH TRAUMA/LACERATIONS
Lesions range from laceration to retroperitoneal hematoma requiring laparotomy
Can result from difficult forceps delivery/
Precipitous vaginal delivery/
Malpresentation of fetal head (OP)/
Laceration of pudendal vessels/
Clinical presentation of postpartum bleeding with contracted uterus
Anethesia depending on the clinical scenario

20. FETAL HEART RATE
Baseline fetal heart rate, variability, decelerations or accelerations
Normal FHR: bpm
Tachycardia: Maternal fever, infection, terbutaline, atropine, hyperthyroidism, tachyarrythmia, hypoxemia
Bradycardia: Fetal autonomic response to baroreceptor or chemoreceptor stimulation
Fetal cardiac output: Rate dependent
Variability: Most reliable index of fetal well being; variability is baseline fluctuations in FHR over 2 cycles/min
Can be absent, minimal (<5 bpm), moderate (6-25 bpm) or marked (>25 bpm)

21. NON REASSURING FETAL HEART RATE (INTRAPARTUM)
UMBILICAL CORD PROLAPSE:
Acute fetal bradycardia
Cord palpable in vagina
Membrane rupture with head not well applied to cervix-High station/breech presentation
Push presenting part away from cervix
Emergency section.

22. NON REASSURING FETAL HEART RATE
UMBILICAL CORD COMPRESSION:
Variable decelerations
Nonreassuring if slow return to baseline or severe (<60 bpm from baseline for over 60 seconds) and repetitive
May be associated with ↓ amniotic fluid from ruptured membranes or oligohydramnios
Changing maternal position, oxygen, amnioinfusion, discontinuation of oxytocin may help
Expeditious delivery may be necessary
Regional/GAdepending on clinical scenario

23. NON REASSURING FETAL HEART RATE
UTEROPLACENTAL INSUFFICIENCY:
Late decelerations
Cause for concern if repetitive
Postdates, preeclampsia, diabetes, IUGR
Uterine resuscitation: change of maternal position, IV fluids, oxygen, discontinuation of oxytocin and administration of tocolytic agents (terbutaline)
Regional/GA depending on clinical scenario

24. NON REASSURING FETAL HEART RATE(AT DELIVERY)
SHOULDER DYSTOCIA:
Postterm pregnancy, diabetes, maternal obesity, macrosomia and shoulder dystocia in previous pregnancy
Extension of episiotomy/flexion of mother’s legs against abdomen, suprapubic pressure, fractures of clavicles
Anticipation: Epidural-relaxed perineum
surgery

25. NON REASSURING FETAL HEART RATE
BREECH (HEAD ENTRAPMENT):
True obstetric emergency
Smaller body pushed through partially dilated cervix trapping aftercoming head
Vaginal breech delivery-Discouraged
5% vs.1.6% deaths-Vaginal vs. C/D (Study in women)
Incisions in cervix to enlarge opening or skeletal muscle and cervical relaxation or CD
Epidural-prevents early pushing before cervix is fully dilated and relaxes the perineum
GA may be necessary for uterine and perineal relaxation

26. Thank you