SISTER NIVEDITA GOVERNMENT NURSING COLLEGE

IGMC, SHIMLA

SUBJECT: OBSTETRICS AND GYNECOLOGICAL NURSING

PRESENTATION ON: OBSTETRICAL EMERGENCIES AND THEIR

MANAGEMENT

SUBMITTED TO: SUBMITTED BY:

Mrs. Prema Negi Archita Sharma

Lecturer MSc. (N) 1st Year

Obstetrics and Gynaecological Nursing SNGNC, IGMC

SNGNC, IGMC Shimla

Shimla

SUBMITTED ON:
 INDEX
SR. NO. CONTENT REMARKS
1. Introduction
2. Definition
3. Obstetrical emergencies during Pregnancy
4. Obstetrical emergencies during labour
5. Obstetrical emergencies during Postpartum
6. Causes of Obstetrical emergencies
7. Common Obstetrical emergencies
 Vasa Previa
 Ectopic pregnancy
 Cord prolapse
 Uterine inversion
 Amniotic Fluid embolism
 Shoulder Dystocia
8. Conclusion
INTRODUCTION
• Pregnancy is a journey in every woman’s life expecting a fruitful outcome.

• An emergency is a situation that poses an immediate risk to health life property or

environment. Most emergencies require urgent intervention to prevent the worsening
of the situation, although in some situations mitigation may not be possible and
agencies may only be able to offer palliative care for the aftermath.

• One such kind of emergency is obstetric emergency. Obstetrical emergencies may also
occur during active labour and after delivery (postpartum).

• The first principle of dealing with obstetric emergencies are the same as for many
emergency (to see the airway, breathing and circulation) but remember that in
obstetrics there are two patients; the foetus is very vulnerable to maternal hypoxia.
There are number of illnesses and disorders of pregnancy that can threaten the well-
being of both mother and child.

DEFINITION
 Obstetric emergencies are life-threatening medical problems that develop during
pregnancy, labor, or delivery.
 Obstetric emergencies are health problems that are life-threatening for pregnant
women and their babies.

OBSTETRICAL EMERGENCIES DURING PREGNANCY

 Abortion

 Ectopic pregnancy

 Placenta previa

 Vasa previa

 Placental abruption

 Preeclampsia & Eclampsia

OBSTETRICAL EMERGENCIES DURING LABOUR

 Amniotic fluid embolism.
 Inversion or Rupture of uterus.
 Placenta accreta.
  Prolapsed umbilical cord.
 Shoulder dystocia.
OBSTETRICAL EMERGENCIES DURING POSTPARTUM
 Postpartum hemmorhage.

CAUSES OF OBSTETRICAL EMERGENCIES

Obstetrical emergencies can be caused by a number of factors, including-

 Stress.
 Trauma.
 Genetic and other variables.

In some cases, past medical history, including previous pregnancies and deliveries, may help
an obstetrician anticipate the possibility of complications.

COMMON OBSTETRICAL EMERGENCIES

VASA PREVIA

 It is an abnormality of the cord that occurs when one or more blood vessels from the
umbilical cord or placenta cross the cervix but it is not covered by Wharton’s jelly.
 This condition can cause hypoxia to the baby due to pressure on the blood vessels.
 It is a life-threatening condition.

Etiology

These vessels may be from either

 Velamentous insertion of umbilical cord.

 Placental lobe joined to the main disk of the placenta.
 Low-lying placenta.
 Previous delivery by C-section.

Symptoms

 The baby’s blood is a darker red color due to lower oxygen levels of a fetus.
 Sudden onset of painless vaginal bleeding, especially in their second and third
trimester.
 If very dark burgundy blood is seen when the water breaks, this may be an indication
of vasa previa.
Diagnosis

PAINLESS VAGINAL DELIVERY FETAL BRADYCARDIA

CLASSICAL TRIAD

COLOUR DOPPLER- VESSEL

CROSSING THE MEMBRANE
MEMBRANE RUPTURE OVER THE INTERNAL CERVICAL
OS.

Management

 Antepartum
- The patient should be monitored closely for preterm labor, bleeding or rupture of
memberanes.
- Steroids should be administered at about 32 weeks.
- Hospitalization at 32 weeks is reasonable.
- Take patient for emergency caesarean section if membranes are ruptured.
- Fetal growth ultrasounds should be performed at least 4 weeks.
- Cervical length evaluations may help in assessing the patient’s risk for preterm
delivery or rupture of the membrane.
 Intrapartum
- The patient should not be allowed to labor. She should be delivered by elective
caesarean at about 35 weeks.
- Delaying delivery until after 36 weeks increases the risk of membrane rupture.
- Care should be taken to avoid incising the fetal vessels at the time of caesarean
delivery.
- If vasa previa is recognized during labor in an undiagnosed patient, she should be
delivered by urgent caesarean. The placenta should be examined to confirm the
diagnosis.
  Postpartum
- Routine postpartum management as for cesarean delivery.
- If the fetus is born after blood loss, transfusion of blood without delay may be life-
saving.
- It is important to have type specific blood available immediately for neonatal
transfusion.

Nursing Management-

 Assess the bleeding, color, amount.

 Administer IV fluids.
 Administer oxygen.
 Strict vitals and FHS monitoring.
 Prepare patient for caesarean section.
 Reserve blood.

ECTOPIC PREGNANCY

 Any pregnancy where the fertilised ovum gets implanted & develops in a site other
than normal uterine cavity.
 Represent serious hazard to a woman’s health and reproductive potential.
 Requiring prompt recognition and early intervention.

Sites Of Ectopic Pregnancy

Risk factors

 History of PID
 History of tubal ligation
  Contraception failure
 History of infertility
 IUD use
 Previous induced abortion
 Tubal reconstructive surgery

Clinical features

 Pain
 Amenorrhea
 Vaginal bleeding- scanty dark brown
 Feeling of nausea, vomiting, fainting attack, syncope attack (10%)
 O/E- patient is restless in agony, looks blanched, pale, sweating with cold clammy
skin
 P/A- abdomen tense, tender mostly in lower abdomen, shifting dullness, rigidity may
be present.
 P/S- minimal bleeding may be present
 P/V- uterus may be bulky, deviated to opposite side, fornix is tender, excitation pain
on movement of cervix
 Pouch of Douglas may be full, uterus floats as if in water

Management of Ectopic Pregnancy

 Principle :
 Resuscitation and laparotomy and not resuscitation followed by laparotomy.
 Antishock treatment :
 Measures are to be taken energetically.
 Simultaneous preparation for urgent laparotomy
 Ringer solution (crystalloid) is started
 Arrangement for blood transfusion
 Even if blood is not available, laparotomy is to be done desperately.
 Laparotomy :
 Done when patient is hemodynamically unstable and there is evidence of rupture.
 The principle in laparotomy is “quick in quick out”.

UTERINE INVERSION

 When uterus turns inside out, it is called uterine inversion.

  Uterine inversion is the folding of the fundus into the uterine cavity in varying
degrees.

Classification

A. Types :
1. Incomplete inversion: when the fundus of the uterus has turned inside out, like toe
of socks, but inverted fundus has not descended through cervix.
2. Complete inversion: when the inverted fundus has passed completely through
cervix to lie within the vagina or lie often outside the introitus.
B. Degrees :
1. First degree: the uterus is partially turned out.
2. Second degree: the fundus has passed through the cervix but not outside the
vagina.
3. Third degree: the fundus is prolapsed outside the vagina.
4. Fourth degree: the uterus, cervix and vagina are completely turned inside out are
visible.

C. Universally :
1. First degree: incomplete inversion
2. Second degree: complete inversion in the vagina.
3. Third degree: complete inversion outside the vagina.

Causes

 Spontaneous
 Manual removal of placenta
 Cord traction and/or fundal pressure
 Uterine anomalies
  Short umbilical cord
 Placenta accreta
 Grand multiparity
 Fetal macrosomia
 Rapid labor and delivery
 Iatrogenic
 Due to mismanagement of the third stage of labor.
 Faulty technique in manual removal of placenta, while separating the retained
placenta from the wall, a portion may remain attached and as the placenta is
withdrawn, the fundus is also withdrawn.
 Pulling the cord when the uterus is atonic while combined with fundal pressure.
 Crede’s expression while the uterus is relaxed.

Clinical presentation

 Large boggy mass appears at introitus.

 With or without placenta attached.

Other sign and symptoms are as follows:

 Severe and sustained hypogastric pain in 3rd stage of labor.

 Shock
 Profound sweating with bradycardia.
 Hypotension.
 Rarely cardiac arrest.
 Hemorrhage.
 If left untreated, it may lead to – infection, uterine sloughing, peritoneal irritation.

Prevention

 Do not employ Any method to excel the placenta when the youth recipes relaxed.
 Patient should not be instructed to change her position.
 Pulling the cord simultaneously with fundal pressure should be avoided.
 Manual removal of placenta should be done in proper manner.
 Starting from the edge of Placenta, the placenta is separated by keeping the back of
the hand in contact with the Uterine wall with slicing movement of the hand.
Management Of Acute Inversion Of Uterus

 Delay in treatment increases the mortality, so number of steps are taken immediately
and simultaneously.

Before shock develops:

 When one is on the spot when the inversion happens try immediate manual
replacement, even without anesthesia if not easily available.

Principle:

 “ The part of the uterus which has come down last, should go back first.”

Procedure:

 If the diagnosis is made immediately after the inversion has occurred, then that same
degree of relaxation of myometrium and cervix (which is required for the inversion to
occur) will allow you to replacement easily.
1. The gloved hand is lubricated with suitable antiseptic cream and placed inside the
vagina.
2. The uterine fundus with or without the attached placenta, is cupped in the palm of
the hand. Fingers and thumb of the hand are extended to identify margins of the
cervix.
3. The whole uterus is lifted upwards towards and beyond umbilicus.
4. Additional pressure is exerted with the fingertips systematically and sequentially
to push and squeeze the uterine wall back through the cervix.
5. Sustained pressure for three to 5 minutes to achieve complete replacement.
6. Apply counter support by the other hand placed on the abdomen.
7. Once the fundus has been replaced keep the hand in the uterus while rapid
infusion of oxytocin is given to contract the uterus. Initially, bimanual
compression Aids in control of further hemorrhage until you train tone is
recovered.
8. When the uterus is felt contracting, the hand is slowly withdrawn.
9. If placenta is attached, it is to be removed only after the uterus becomes
contracted.
10. If the placenta is partially attached, it should be peeled out before replacement of
uterus.
O’Sullivan’s Hydrostatic method O’Sullivan’s Hydrostatic method

Surgical Replacement of uterus

CORD PROLAPSE

Umbilical cord prolapse occurs when the umbilical cord comes out of the uterus with or
before the presenting part of the fetus.

Predisposing factors

 Mother
 Multiparity.
 CPD.
 Pelvic tumors.
 Placenta & cord
 Placenta Previa.
 Long cord.
 Rupture of membranes.
 Liquor
 Polyhydramnious.
 Fetal
 Prematurity.
 Multiple gestation.
 Anencephaly.
 Malpresentation (Breach, transverse lie, oblique).
 Iatrogenic prolapse
 ARM.
 Placement of forceps.

Clinical features

 Appearance of loop of umbilical cord.

 Pulsation of cord on V/E.
 Suspect in unexplained fatal distress.
 Variable deceleration.
 Prolonged bradycardia.

Management

 Fetal survival depends on swift action.

 Call for help- midwifery colleagues.
 Factors to consider:
 - Viability of fetus.
- Severe fetal abnormalities.
 Emergency delivery for a normally formed and mature fetus.

FIRST STAGE OF LABOR

 Emergency LSCS.
 Take measures to optimize fetal well-being maternal positioning.
 Multi-disciplinary approach.
 Teamwork.

SECOND STAGE OF LABOR

 Vaginal delivery- Depend on descent of head and rate of progress; parity.

 Instrumental delivery- depends on skill levels and confidence; descent of head and
rate of progress.
 Caesarean section-
 Take measures to optimize fetal well-being maternal positioning.
 Multi-disciplinary approach.
 Teamwork.

EMERGENCY PROCEDURES

 Elevation of the presenting part:

- Digital pressure
- Kneeling on all fours, buttocks uppermost, or
- Exaggerated sims (left lateral)
- Fill bladder with 500 ml saline.
- Tocolysis.

Do’s and Don’t’s

 Do
- Replace the cord into the vagina.
- Monitor the fetal heart rate.
- Informed the woman.
 Don’t
- Replace the cord inside the uterus.
- Handle the cord excessively.
MNEMONIC

 Call for help.

 Organise delivery.
 Relieve pressure on the cord.
 Deliver.

AMNIOTIC FLUID EMBOLISM

An amniotic fluid embolism is rare but serious condition that occur when amniotic fluid, fetal
material, such as hair, enters the maternal body bloodstream.

Risk factor

 Advanced maternal age

 Multiparity
 Meconium
 Cervical laceration
 Intrauterine fetal death
 Sudden fetal expulsion
 Polyhydramnios
 Uterine rupture
 Maternal history of allergy or atopy
 Macrosomia

Signs and symptoms

 Sudden shortness of breath

 Excess fluid in the lungs
 Sudden low blood pressure
 Sudden circulatory failure
 Life threatening problems
 Blood clotting (DIC)
 Altered metal status
 Nausea or vomiting
 Chills
 Rapid heart rate
 Fetal distress
 Seizures
  Coma

Laboratory Investigation

Non-specific Specific

 Complete blood count  Cervical histology

 Coagulation parameters  Serum tryptase

 ABG

 Chest X- Ray

 Electrocardiogram

 Echocardiogram

Management

 Management is symptomatic and supportive.

 Targets- maintaining oxygenation, hemodynamic support and correction of
coagulopathy.
 Immediate resuscitation ABC.
 Airway and breathing
 Administer 100 % oxygen via a non-rebreathing reservoir face mask.
 Prompt assessment, with control of the airway and ventilation of the lungs with
treated intubation may be essential.
 Circulation
 2 large bore IV lines
 Send blood for cognition profile
 CBC, Crossmatch
 Arrange 6 units blood
 Left lateral tilt/ Manual Uterine Displacement
 Hemodynamic support would include preload optimization and vasopressors
 Fluid resuscitation with crystalloid colloid optimize filling
 Infusion of an inotrop may be required to maintain a mean arterial blood pressure and
achieve an adequate urine output.
 An arterial line for continuous blood pressure monitoring is essential, and the use of a
noninvasive cardiac output monitor may be helpful
  Continuously monitor the fetus
 Uterine tone
 Pharmacological agents such as oxitocin, ergometrine, and prostaglandins carboprost
and misoprost.
 Coagulation
 Use of plasma cryoprecipitate, and platelets to be guided by clinical condition of the
patient and laboratory investigations.
 Recombinant factor VII may be used, but one should be careful as this can cause
thrombotic complications.
 Anti Fibrinolytics like E- Amino caproic acid and Tranexamic acid might be helpful
but evidence is lacking.

SHOULDER DYSTOCIA

When fetal head is delivered, but shoulders are stuck and cannot be delivered it is known as
shoulder dystocia.

Failure of the shoulders to traverse the palace spontaneously after delivery of the head.

The anterior shoulder becomes trapped behind on the Symphysis pubis, while posterior
shoulder may be in the hollow of the sacrum or high above the sacral promontory.

Predisposing factors

 Fetal macrosomia
 Obesity
 Diabetes
 Mid pelvic instrumental delivery
 Post maturity
 Multiparity
 Anencephaly
 Fetal ascitis

Warning Signs and Diagnosis

 The delivery may have been uncomplicated initially, but the head may have advanced
slowly and the chin may have had difficulty in sweeping over the perineum.
 Once the head is delivered it may look as if it is trying to return into the vagina which
is caused by reverse traction.
  Diagnosed when maneuvers normally used by the midwife failed to accomplish
delivery.

Management

DONT’S

- Do not be panicky
- Do not give traction over baby’s head
- Do not apply fundal pressure

DO’S

- Call for extra help

- Clear the infant’s mouth and nose
- Involve the anaesthesist and the pediatrician
- Perform episiotomy if not performed earlier
1. Pre-procedure steps and considerations:
- Shout for help
- Explain procedure
- Follow general principles of basic care and infection prevention
- Perform episiotomy
2. Perform Mc Roberts Maneuver:

3. Rubin’s Maneuver
- If the shoulder is still not delivered insert a hand into the vagina and apply pressure
to the anterior shoulder in the direction of the baby’s sternum to rotate the shoulder
and decrease the shoulder diameter.
- If needed, apply pressure to the posterior shoulder in the direction of the baby’s
sternum.
4. Wood’s Maneuver
 If the shoulder is still not delivered despite the above measures-
- Insert a hand into the vagina.
- Grasp the humerus of the posterior arm and keeping the arm flexed at the elbow,
sweep the arm across the chest, grasp the hand and deliver the entire arm.
- With one hand on each side of the fetal head, apply firm, continuous traction
downward to move the anterior shoulder under the symphysis pubis.
5. Cockscrew maneuver
- If the posterior arm can not be extracted, perform the cockscrew maneuver

6. Cleidotomy
 If all of the measures fail to deliver the anterior shoulder:
- Another option is to fracture the baby’s anterior clavicle to decrease the width of
the shoulder. This is done by pressing the anterior clavicle against the symphysis
pubis.
- After birth, facilitate urgent and immediate newborn care or transfer to the
newborn.
7. Post-Procedure care
- Repair the episiotomy.
 - If needed, provide emotional support to the woman and family following a
traumatic birth and possible death of the newborn or injury to the baby.

CONCLUSION
Obstetrical emergencies are a public health issue because of the severity of the prognosis they
impose on the mother and child. The management of emergencies is usually the responsibility
of hospital obstetricians. As more maternity care is now given in the community however
midwives, general practitioners and paramedics may be involved and must know the outlines
of management of emergencies and the possible side effects.
BIBLIOGRAPHY
Book reference:

 Dutta DC, Textbook of Obstetrics including Perinatology and Contraception, 8 th

Edition. New Delhi; Jaypee Brother’s Medical Publishers (P) Ltd. 2015. P. 517-519.

Net References:

 https://www.scribd.com/presentation/440194626/OB-EMERGENCIES
 https://www.scribd.com/presentation/500267456/Obstetric-emergencies
 https://www.slideshare.net/slideshow/obstetrical-emergencies-86930407/86930407