1. OBSTETRIC EMERGENCIES
Dr Chro Najmaddin Fattah MBChB,DGO,MRCPI,MRCOG, MD

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. OBSTETRIC EMERGENCIES
ANTEPARTUM:
Umbilical cord prolapse
Umbilical cord compression
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
Expectant management if fetus immature and no active bleeding
Cesarean delivery
Urgent/emergent cesarean delivery for active or persistent bleeding or fetal distress
Regional/GETA

7. Placentation

9. PLACENTA ACCRETA/ INCRETA/PERCRETA
Linearly related to number of previous scars in presence of placenta previa
PP+unscarred uterus-5 % risk of accreta
PP+one previous C/D-24% risk of accreta
PP+two previous C/D-47% risk of accreta
PP+three previous C/D-40% risk of accreta
PP+four previous C/D-67% risk of accreta
Combination of placenta previa and previous C/D-Dangerous

10. 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
Percreta may require surgeons skilled in pelvic dissection

11. PLCANTA ACCRETA/ INCRETA/PERCRETA
GETA/Regional (CSE)
Good IV access/ A line
Level 1 or equivalent warmer
Cross matched blood
FFP/Cryo/Factor VII/Platelets
Emergency hysterectomy more blood loss than elective hysterectomy
Hemodilution/red cell salvage can be considered in Jehovah’s witness
Regional may be associated with reduced blood loss but may complicate treatment of hypotension in a bleeding patient.

12. PLACENTAL ABRUPTION I in 77 to 1 in 86 deliveries 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

13. 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

14. Placental Abruption

15. Placental Abruption

17. 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 C/D- Fetal distress or severe hemorrhage
Be prepared for massive blood loss with C/D
Couvelaire uterus may not contract after delivery
On rare occasions, internal iliac ligation/hysterectomy may be necessary

18. 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

19. 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 C/D may be necessary
Uterine repair/Hysterectomy depending on situation

20. RETAINED PLACENTA 1% of deliveries Ongoing blood loss
Manual exploration for removal
You need uterine relaxation and analgesia
Anaesthesia depending on clinical situation
Oxytocics after removal of placenta

21. 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

22. UTERINE ATONY Management (Important Points)
Vaginal bleeding > 500 ml
Manual examination of uterus
Volume resuscitation
Infusion of oxytocics + bimanual compression of uterus
Evaluation for retained placenta

23. 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

24. 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

25. 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
Epidural/MAC/GETA depending on the clinical scenario

26. 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
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)

27. Early decelerations

28. Variable decelerations

29. Variable decelerations - severe

30. Late Decelerations

31. Variable deceleration with late component

33. Fetal Tachycardia

34. Sinusoidal Pattern

35. UMBILICAL CORD PROLAPSE:
Definition
Umbilical cord prolapse exists when a loop of cord is present below the presenting part and the membranes are ruptured.
Incidence is approximately 0.2% of births
Risk of perinatal morbidity/mortality from asphyxia secondary to mechanical compression of the cord between the presenting part and the pelvis, or spasm of cord vessels secondary to cold or manipulation.

36. Cord Prolapse Occult Cord

37. Cord Prolapse True Prolapsed Cord

38. Risk Factors Fetal Malpresentation Prematurity Polyhydramnios
Multiple pregnancy
Anencephaly
Maternal
Contracted pelvis
Pelvic tumour
Other
Long cord
Sudden rupture of membranes, esp. if polyhydramnios

39. Management Obstetric Intervention amniotomy, FSE application
expectant management of PPROM
Recommendations
Diagnosis
Vaginal examination to confirm diagnosis of prolapsed cord and to ascertain cervical dilatation.
Call for help – senior midwife, obstetric registrar, anaesthetist
Determine that fetal heart present and monitor by CTG.

40. If fetus is viable -
• Discontinue Syntocinon, administer oxygen by face mask
• Make preparations for emergency Caesarean section - IV access, group and save
• Elevation of the presenting part of the fetus above the pelvic inlet will relieve cord compression. This can be achieved manually, in which case the hand should remain in the vagina until delivery. Alternatively the patient may be placed in the knee chest position, or the bladder may be filled with 500mls saline through a Foley catheter. The catheter should be clamped, then unclamped to allow bladder emptying when the skin incision is made at Caesarean section.

41. Anaesthesia
Delivery will usually be by Caesarean section under GA. However, where the bladder filling has been employed and there is no evidence of fetal distress, regional anaesthesia may be considered.

42. Vaginal delivery
If the cervix is fully dilated then instrumental delivery may be appropriate but should only be undertaken by experienced obstetric staff, i.e. Consultant or experienced SpR.
If no FH auscultated – confirm intrauterine death using ultrasound and aim for vaginal delivery.
If fetus of a non-viable gestation – discuss with senior obstetric staff and aim for vaginal delivery

43. Shoulder Dystocia
Bony prominence disorder where the anterior fetal shoulder becomes impacted behind the suprapubic arch of the maternal pelvis following the birth of the fetal head.

44. This picture shows the impaction of the anterior shoulder under the pubic arch and the posterior shoulder caught behind the coccyx in the lumbo sacral curve

45. Occurrence 0.3 – 1% birth weight 2500 – 4000gms
50% occur in babies of normal birth weight
As these figures demonstrate the incidence of shoulder dystocia is higher in babies of greater birth weight, however, it also occurs in babies of normal birth weight, so this is an emergency situation that we need to be prepared for. Know the signs of shoulder dystocia and activate help as soon as these occur.

46. Risk factors Antenatal Gestational Diabetes Short Stature
Previous shoulder dystocia
maternal wgt gain > 20 kgs
Pelvic anomalies
Fetal macrosomia
Postdates
Intrapartum
Prolonged second stage
precipitate labour
Instrumental birth
Head bobbing in second stage
Shoulder dystocia is more common when associated with condition that create a large baby in association with a small pelvis. So, gestational diabetes, especially when uncontrolled or undiagnosed where the baby is bigger than it’s expected normal weight or postdates where the baby has more opportunity for additional growth.
Forceps or vacuum may cause an abnormal descent of the body into the pelvis and prevent the body from rotating to enter the pelvis. The signs of shoulder dystocia are prolonged second stage or bobbing of the head – where the head retracts back after active pushing.

47. Identification of Shoulder Dystocia
Turtle sign following birth of the baby’s head. The baby’s head will retract right back against the perineum.
Baby does not birth using normal traction
Try and demonstrate the turtle sign

48. Risk Reduction Good diabetes control
Birthing women on all fours or in McRoberts or upright position where risk is identified / suspected
Elective C/S – need to increase the rate 5 to 6 fold to avoid 1 case of shoulder dystocia
IOL at term has not shown to reduce the rate
There is very little that can be done to reduce the incidence of shoulder dystocia, so you need to be aware of the signs and associated risk factors so you can be prepared for the event.
Birthing women on all fours or in McRoberts or upright can help expand the pelvic diameters and therefore reduce the incidence.
Keeping babies at normal birth weights can help, so good diet and diabetes control can help

49. Mortality/Morbidity Maternal 3rd – 4th degree tears
Genital tract trauma
Uterine atony – PPH
Fetal
# clavical
Erb’s palsy
Brachial nerve palsy
Hypoxia – Fetal blood pH will fall by 0.04/min, so a pH of 7.25 over 7 min will fall to 6.97
The morbidity is commonly associated with the manoeuvres needed to help birth the baby.
Maternal genital tract trauma as you may need to get both hands in
PPH is caused by the delay in second stage and the increasing uterine pressure that occurs while the baby is stuck
Fetal fractures as the posterior arm is removed or the shoulder fractures
Palsy’s can be reduced by decreasing the pressure exerted on the head and not over stretching the baby’s neck at birth.

50. Interventions Reduction Manoeuvres aim to
Increase the functional size of the pelvis (McRoberts)
Decrease the bisacromial diameter (Suprapubic Pressure and Rubins)
Change the relationship of the bisacromial diameter with the bony pelvis (Woodscrew)
The manoeuvres McRoberts, Rubins and Woodscrew all help with increasing the pelvic size, reducing the size of the shoulders presenting and changing the position of the shoulders in relation to the pelvis.

51. HELPERR© Help Evaluate for episiotomy
Call for help – at this point it is good to discuss who is available, particularly in some of the smaller units and that it is the role of the accoucheur to take control and provide clear and concise directions to all the helpers. If the acoucheur is not confident they should identify this and name the next responsible person.
An episiotomy is often difficult, however you need to be aware of the genital tract trauma that will be caused by some of the internal manoeuvres and an episiotomy could be helpful at this stage if it can be performed safely.
Someone to
Time and document
Keep the women informed and cooperating
Teaching the HELPPER mnemonic provides a systematic approach to cover all the manoeuvres available to help with a shoulder dystocia. However, in real life practice and individualised for each woman and each birth you may need to move your actions around a bit. For example, you may first want to check for the posterior shoulder before moving on, or you may be able to roll the woman over early to help dislodge the posterior shoulder. The purpose of the mnemonic is to provide a tool that easy to remember in times of emergency and provides a structure that everyone in the room is able to follow.

52. HELPERR © Legs – McRoberts manoeuvre
Drop the head of the bed and lie the woman flat
Each of the manoeuvres should be attempted for 30 seconds before moving to the next manoeuvre. The aim of McRoberts is to increase the functional size of the maternal pelvis by decreasing the lumbo-sacral curve. McRoberts manoeuvre alone will birth approximately 40% of all shoulder dystocias. Combined with McRoberts and supra-pubic pressure 50% of babies will birth.
Position the woman and ask her to flex her legs straight up over her abdomen, knees straight up towards nipples eg standing birth to deep squat, all fours to forward towards knees
You can get everyone to try this manoeuvre (at home) and to feel their own lumbo-sacral curve and how the shape alters when they move into McRoberts.

54. HELPERR © Pressure – suprapubic
CPR style pressure as a constant downward and lateral force over the anterior shoulder to facilitate adduction of the fetal shoulders and reduce the bisacromial diameter. Pressure is applied over the fetal back.
After 30 seconds a rocking motion of the hands can be tried to achieve the same outcome.
Take this chance to demonstrate on the pelvis. Adduction of the shoulders is an action that brings the shoulders closer together at the front of the body in order to reduce the size of the shoulders. This is an automatic response we all perform when we walkthrough tight spots and need to shrink our shoulders.
Continue McRoberts while this is being performed. This can be difficult as it doesn’t help access to with the woman’s legs in McRoberts so the person performing suprapubic pressure may need to stand up on something or kneel on the side of the bed

55. HELPERR © Enter manoeuvers Rubins’ 2 30 secs
Remove the bottom of the bed or turn the woman sideways to improve access to the perineum
Rubin’s 2 Manoeuvre just like supra pubic pressure aims to reduce the size of the bisacromial diameter by putting pressure on the anterior shoulder encouraging it to move over on to the fetal chest – adduction.
Where possible encourage the woman not to push during the enter manoeuvres

57. Your hands must enter from below the fetal head, like a scouts salute, as there is no room above the head for your hands to enter. Encourage everyone to get down low, perhaps kneeling on the floor to perform this manoeuvre.

59. Woods screw
Leaving the hand in with fingers on the anterior shoulder, the second hand is placed with fingers against the front of the posterior shoulders. The aim of this manoeuvre is to to rotate the shoulders into the obliques diameter.

60. Reverse Woods screw
This is the position of the hands for performing the reverse Woods Screw Manoeuvre for 30 secs. The fingers that were previously placed on the anterior shoulder are now slipped down to the posterior shoulder and the other hand is removed. The aim of this manoeuvre is to try to push the posterior shoulder in the opposite direction to the woods screw, pushing the shoulders into the opposite oblique diameter hopefully freeing the posterior shoulder to facilitate birth.

61. HELPERR © Remove the posterior arm x 30 secs
Roll the woman over & deliver the posterior shoulder x 30 secs
Removing the posterior arm is an attempt to flex the fetal posterior arm over the fetal chest freeing the shoulder to facilitate birth. The hand that was used for the reverse Woods Screw is then placed down the fetal arm to reach the elbow, flex the elbow to bend the fetal arm over the fetal chest.
The next manoeuvre – roll the woman over, can be used earlier in the process and may be helpful to be used following McRoberts if this is possible. The aim of this manoeuvre is to change the woman’s position, hopefully freeing the posterior shoulder for birth.

62. Other interventions
The following manoeuvres are in the scope of practice for medical officers:
Fracture the clavical
Zavanelli Manoeuvre
Symphysiotomy
The clavical can be fractured by placing deliberate upward pressure on the midportion of the fetal clavical in an attempt to reduce the bisacromial diameter and free the shoulders.
Zavanelli manoeuvre is replacement of the fetal head and then performing a C/S. The head is flexed and replaced in the uterus. Continuous upward pressure of the fetal head is required until the C/S is performed. Tocolysis can be of value with this manoeuvre.
Symphysiotomy is division of the fibrous cartilages of the symphasis pubis under local anaesthesia. The bladder needs to be empty and protected with one hand. The woman's legs need to be supported to avoid separation of the pelvis.

63. Practice Points Drop the head of the bed – lie the woman flat
Improve access for enter manoeuvres by removing the bottom of the bed or lying the woman sideways on the bed
Encourage NO pushing during enter manoeuvres

64. Documentation Timing Interventions Assistants Manoeuvres Outcomes:
maternal
neonatal (incl cord gases)
Documentation
all the procedures performed and the time it takes to perform each one
Condition of the baby at birth – resuscitation requirements
Cord artery and vein pH or lactate
Trauma for both the mother and baby
Need to debrief with the woman following the event and provide a clear description of the events as they occurred and what she can expect over the next few weeks.

65. Post Birth Considerations
Debrief with parents and support people
staff debrief
case review

66. BREECH (HEAD ENTRAPMENT
True obstetric emergency
Smaller body pushed through partially dilated cervix trapping aftercoming head
Vaginal breech delivery-Discouraged by ACOG
5% vs.1.6% deaths-Vaginal vs. C/D (Study in 2000 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
GETA may be necessary for uterine and perineal relaxation

67. Thank you