Obstetric Emergencies

Post-Partum Haemorrhage

This is diagnosed if there's:

• 500ml loss after vaginal delivery

• 1000ml loss after c-section

Risk factors - Previous PPH, Multiple pregnancy, Macrosomia, Prolonged 3rd stage, Induced/Augmented/Instrumental delivery, Polyhydramnios

Causes - 4 T's:

• Tone - Uterine atony – Most common cause

  • Contraction of uterus after delivery helps compress the vessels and slows down blood loss

• Trauma e.g. perineal tear

• Tissue - Retained placenta

• Thrombin - Coagulopathy

Prevention:

• Emptying bladder before delivery – full bladder can reduce uterine contraction

• Active management of 3rd stage with IM Syntometrine

Management:

Mechanical:

• Rubbing uterus through abdomen stimulates a contraction

• Catheterisation – A distended bladder prevents uterine contractions

Medical:

• Oxytocin

• Ergometrine – Stimulates smooth muscle contraction

  • Contraindicated in gestational hypertension as it raises BP

• Carboprost or Misoprostol – Prostaglandin analogue

  • Caution in asthmatics

• Tranexamic acid – Antifibrinolytic for high-risk patients

Surgical:

• Intrauterine balloon tamponade – Inflatable balloon into uterus to press against the bleeding

• B-Lynch suture around uterus to compress it

• Uterine artery ligation to reduce blood flow

• Hysterectomy – LAST RESORT - Will stop bleeding and may save the mother’s life

Secondary PPH - This is where there's excessive bleeding 24 hours – 12 weeks post-partum. It's most commonly caused by Retained Products of Contraception (RPOC) or Endometritis (infection). These patients should be investigated with a:

• TVUS done to check for retained products

• Endocervical/high vaginal swabs for infection

Maternal Sepsis

This is most commonly caused by Chorioamnionitis, which is an infection of the membranes in the uterus and amniotic fluid. It presents with abdominal pain, uterine tenderness, vaginal discharge, fever, and maternal/foetal tachycardia.

Another key cause to remember is UTI.

It's managed with:

• Sepsis 6 (Take – Lactate, Blood culture, Urine output. Give – O2, Abx, IVF)

• Emergency c-section if signs of foetal distress

Cord Prolapse

Here, the umbilical cord descends below the presenting part of the foetus, therefore causing cord compression → foetal hypoxia.

Risk factors - Abnormal foetal lie, Multiple pregnancy, Polyhydramnios

It should always be suspected when there are signs of foetal distress on CTG. It is diagnosed on examination of the cervix. It's important to avoid trying to push the cord back as it can cause vasospasm!

Management:

• Initially, it's important to try and relieve pressure on the cord:

  • Lie patient in left lateral position (with pillow under hip) or knee-chest position (on all fours) to draw foetus away from pelvis

  • Fill the bladder with fluid to push the foetal head away

• If these don't work, other options include:

  • Emergency instrumental delivery or C-section

  • Tocolytics to stop uterine contractions

Shoulder Dystocia

This is where the anterior shoulder becomes stuck behind the pubic symphysis.

Risk factors - Macrosomia, GDM, Anticipation, Maternal birth weight, Maternal obesity

• Anticipation - big baby, prolonged 1st/2nd stage, and instrumental delivery

It presents with:

• Difficult delivery of the face and head

• Failed descent of the shoulders following delivery of the head

• Failure of restitution where the head remains face downwards and doesn’t turn back sideways as expected after delivery of it

• Turtle-neck sign – Head is delivered but then retracts back into the vagina

The main complications that can occur here are:

• Foetal hypoxia (and subsequent cerebral palsy)

• Brachial plexus injury

• Perineal tears

• PPH

The 2 brachial plexus injuries that can occur here are:

• Erb palsy (C5/C6) - more common

• Klumpke palsy (C8/T1)

N.B. Erb’s palsy - C5 + C6 = 11 erbs and spices.