Obstetric Emergencies

Obstetric Emergencies Unexpected collapse Bleep team – senior obs, anaesthetist, theatre team, paediatrician, midwifery sister, porter, junior staff A – head down, maintain airway, give O2 15l/min, attach pulseox B – assess & monitor, ventilate if required C – 2 grey/brown cannulae, FBC, Coag, X-match, U+E, LFTs. If haemorrhage – 1litre 0.9% saline stat Monitor – pulse, BP, O2 monitoring, UO, consider ECG, BM, central venous monitoring ID SCREAM HELP Inversion of uterus – in 3rd stage, can à profound hypotension Drugs – give naloxone if opiates Sepsis – Vasodilated, tachycardia, cyanosis, pyrexia CVA – PMH, N+V with headache, pre-eclampsia Ruptured uterus – sudden abdo pain, vaginal bleeding, fetal compromise, laparotomy required Embolism – Amniotic fluid (multips, precipitate labour, uterine stimulation, c-sect – sudden dyspnoea, fetal distress, hypotension, cardio-resp arrest & seizures). Pulmonary (pleuritic chest pain, dyspnoea, cough, haemoptysis, collapse) Anaphylaxis – cyanosis, hypotension, wheezing, pallow, prostration, tachycardia, urticaria Myocardial Infarction – chest pain, may be PMH Haemorrhage – ante/postpartum, bleeding often underestimated esp if concealed abruption (woody uterus), or uterine rupture (shock, cessation of contractions, loss of presenting part, fetal distress) Eclampsia – tonic-clonic seizure (with no PMH of epilepsy) Low Glucose – diabetic, pale, clammy. Give glucagons/dextrose Placental abruption – abdo pain, vaginal bleeding, coagulopathy, fetal distress Amniotic fluid embolism 1/8-30,000, 3rd highest cause of maternal mortality anaphylactic reaction to fetal antigens in maternal circulation 70% occur in labour, 11% post vaginal delivery, 19% post c-section Risk factors – multips, abruption, intrauterine death, precipiate labour, TOP, abdominal trauma, ECV, amniocentesis Symptoms - chills, shivering, sweating, anxiety, coughing Signs – cyanosis, hypotension, bronchospasm, tachypnoea, tachycardia, arrhythmias, MI, seizures, DIC Diagnosis – fetal squames in maternal lungs (at post mortem/bronchial washings). Diagnosis of exclusion Management – support CO & manage DIC, c-sect if undelivered. CXR (pul oedema), ECG (R. vent strain), ABG (metabolic acidosis). Aggressive fluid replacement, dopamine infusion to maintain CO, Rx as anaphylaxis, FFP & Cryo ppt, expect haemorrhage, transfer to ITU Prognosis – poor maternal & fetal outcome, both often neurologically impaired. Prolapsed umbilical cord More common with breech, esp footling breech (15-18%) Cord presentation - cord between membranes & presenting part prior to membrane rupture Prolapsed cord – as cord presentation but after membrane rupture (can be occult eg in vagina) Risk factors – malposition, prematurity, polyhydramnios, fetal growth restriction, placenta praevia, long cord, artificial ROM, being 2nd twin Physiology – cord compression & exposure to air (causing spasm) à hypoxia & fetal distress. CTG may show deep decelerations / single prolonged deceleration Management – if baby alive delivery baby immediately (forceps/ventouse if fully dilated, otherwise C-sect under GA). Transfer to theatre in head down/ knee chest position to prevent compression. Tocolytic to minimise contractions. If fetal death do not rush to deliver, allow to labour normally Prognosis – fetal mortality approx 10% Retained placenta Failure to deliver placenta within 30 mins of fetus. Increases risk of haemorrhage by 10 Occurs in 2-3% of deliveries, incidence increases with prematurity Placental delivery usually preceeded by lengthening of cord, rush of dark blood & increased uterine motility Placenta acreta (over invasion of the placenta) – Increta (myometrium), percreta (penetrates outer serosa & surrounding organs). Risk factors – previous retained placenta, high parity, advanced maternal age, placenta pravevia, previous C-sect, history of D&C / STOP, previous post partum endometritis Management – arrange theatre, syntocinon, rubbing up of contraction, breast feeding, manual removal in theatre with antibiotics Shoulder dystocia Incidence – 0.2%, rises with increasing birth weight to 10% over 4.5kg Fetal anterior shoulder becomes impacted behind symphysis pubis preventing delivery (after attempt of episiotomy & downward traction). Cord is compressed between fetal trunk & maternal pelvis. Risk factors – macrosomia, past dystocia, diabetes, post dates, obese mother, high parity, male fetus, prolonged 1st stage, secondary arrest (> 8cm), mid cavity arrest, forceps/ventouse, difficulty delivering chin Features – cord compression à hypoxia & rising pH. 50% deaths occur within 5 mins. Risk of brachial plexus injury (C5-T1, C5-6 = Erbs palsy, C7-T1 = Klumpke’s palsy) Management – HELPERR (Help, Episiiotomy, Legs, Pressure, Enter, Remove posterior arm, roll over) for no more than 30 sec per movement. Last resort actions are symphysiotomy, deliberate # of anterior clavicle, Zavanelli manoeuvre (replace head & perform C-section) Uterine inversion 1/2-20,000 leads to rapid maternal death due to vagal reaction of cervix + PPH due to uterine atony Physiology – iatrogenic (active management of 3rd stage) Presentation – blue/grey mass from/in vagina Management – replace ASAP, immediate resus, do not attempt to separate placenta, oxytocics cause uterine contraction & reduce blood loss Uterine rupture Complete – communicates with peritoneum Incomplete / uterine dehiscence – contained by visceral peritoneum Risk factors – previous C sect (rare in primips & multips with only vaginal delivery), ECV, congenital malformation of uterus, external trauma (eg RTA), obstructed labour, difficult manual removal of placenta Features – 70% CTG shows fetal distress, vaginal bleeding, abdominal pain, Management – delivery by immediate laparotomy, repair defect or hysterectomy