OBSTETRICAL

EMERGENCIES
 CORD
PROLAPSE
 DEFINITION

Cord prolapse:
Has been defined as descent of the umbilical
cord through the cervix alongside (occult) or past
the presenting part (overt) in the presence of
ruptured membranes.
 DEFINITION

Cord presentation is the presence of one or

more loops of umbilical cord between the foetal
presenting part and the cervix, without membrane
rupture.
 BACKGROUND/ INCIDENCE

 The overall incidence of cord prolapse

ranges from 0.1 to 0.6 %.
 With breech presentation, the incidence is just
above 1%.
1 in 300 delivery
 Male foetuses seem to be predisposed.
 The incidence is higher in multiple gestations.
 RISK FACTORS FOR CORD
PROLAPSE
 Several risk factors are associated with cord
prolapse .
They prevent close application of the presenting
part to the lower part of the uterus and/or pelvic
brim.
 Rupture of membranes in such circumstances
compounds the risk of prolapse.
 Cord abnormalities (such as true knots or low
content of Wharton’s jelly)
 Foetal hypoxia-acidosis may alter the turgidity of
the cord and predispose to prolapse.
 Risk factors for cord prolapse
 About half of cases of prolapse are due to some
form of obstetric manipulation (external cephalic
version, internal podalic version of the second
twin, manual rotation)
 The artificial rupture of membranes, particularly
with an unengaged presenting part also causes
cord prolapse.
 RISK FACTORS FOR CORD
PROLAPSE
 Malpresentation

 Contracted pelvis
 Low birth weight (weight <2.5 kg)

 Prematurity

 Twins

 Foetal congenital anomaly

 Hydramnios

 Placental Factor

 Iatrogenic

 Stabilizing induction
 TYPES OF CORD PROLAPSE
 Occult prolapse:
The cord is placed by the side of the presenting
part and is not felt by the fingers on internal
examination
 Cord presentation:

The cord is slipped down below the presenting

part and is felt lying in the intact bag of
membrane
 Cord prolapse:

The cord is lying inside the vagina or outside the

vulva following rupture of the membrane
PREVENTION OF CORD PROLAPSE
 Women with transverse, oblique or unstable lie
should be offered elective admission to hospital
at 37 weeks of gestation, or sooner if there are
signs of labour or suspicion of ruptured
membranes.
 Women with noncephalic presentations and PROM
should be offered admission.
PREVENTION OF CORD PROLAPSE

 In-patient care will minimise delay in diagnosis

and management of cord prolapse.

 Labour or ruptured membranes of an abnormal lie

is an indication for caesarean section.

 Foetal bradycardia is associated with cord

prolapse and their presence should prompt

vaginal examination.
 Speculum or digital vaginal examination should be
performed when cord prolapse is suspected,
regardless of gestation.
 Artificialrupture of membranes should be
avoided whenever possible if the presenting part
is unengaged and mobile
 Pressure on the presenting part should be kept
to a minimum in such women.
 Rupture of membranes should be avoided if on
vaginal examination the cord is felt below the
presenting part in labour (Cord presentation)
A caesarean section should be performed.
 MANAGEMENT OF CORD
PROLAPSE
 When cord prolapse is diagnosed:
 before full dilatation :
1. Assistance should be immediately called.
2. Venous access should be obtained,
3. Consent taken
4. Preparations made for immediate delivery in
theatre.
5. Manual replacement of the prolapsed cord
above the presenting part to allow continuation
of labour. This practice is now not recommended
 To prevent vasospasm, there should be minimal
handling of loops of cord lying outside the vagina
which can be covered in surgical packs soaked in
warm saline.
 To prevent cord compression, it is recommended
that the presenting part be elevated either
manually or by filling the urinary bladder.
 Cord compression can be further reduced by the
mother adopting the knee–chest position or
head-down tilt (preferably in left-lateral
position).
 Elevationof the presenting part is thought to
relieve pressure on the umbilical cord and
prevent mechanical vascular occlusion.
 Manual elevation is performed by inserting a
gloved hand or two fingers in the vagina and
pushing the presenting part upwards.
 Excessive displacement may encourage more
cord to prolapse.
 Remove the hand from the vagina once the
presenting part is above the pelvic brim, and
apply continuous suprapubic pressure.
 If the decision-to-delivery interval is likely to be
prolonged, then elevation through bladder filling
may be more practical.
 Bladder filling can be achieved quickly by
inserting the cut end of an intravenous giving set
into a Foley’s catheter.
 The catheter should be clamped once 500-750 ml
have been instilled.
 It is essential to empty the bladder again just
before any delivery attempt, be it vaginal or
caesarean section.
 Tocolysis can be considered while preparing for
caesarean section if there are persistent fetal
heart rate abnormalities after attempts to
prevent compression mechanically and when the
delivery is likely to be delayed.
 Although the measures described above are
potentially useful during preparation for delivery,
they must not result in unnecessary delay.
A caesarean section is the recommended mode of
delivery in cases of cord prolapse when vaginal
delivery is not safe, in order to prevent hypoxia.
VASA PRAEVIA
Fetal blood vessel lies in front of
presenting part
 ETIOLOGY
 Velamentous insertion of umbilical cord
 Succenturiate placenta
 DIAGNOSIS
 Painlessvaginal bleeding
 Fetal bradycardia
 MANAGEMENT
 Pregnancy > 37 weeks and bleeding recurrent –
delivery recommended
 Continuous fetal monitoring

 Emergency cesarean section

 Neonatal blood transfusion may be needed

AMNIOTIC
FLUID
EMBOLISM
 Amnioticfluid enters the maternal circulation
and reaches pulmonary capillaries

 Through a tear in amnion and chorion

 Opening in maternal circulation

 Increased intrauterine pressure

 RISK FACTORS
 Multiparity

 Large fetus
 Meconium in amniotic fluid

 Intrauterine fetal death

 Precipitate labour

 Placental abruption

 Intrauterine catheter

 Rupture of uterus
 MANIFESTATIONS
 Phase I : Pulmonary vasospasm
Hypoxia
Hypotension
Cardiovascular collapse
 Phase II: Left ventricular failure

Pulmonary edema
Hemorrhage
Coagulation disorder
 MANAGEMENT
 Intubation + Mechanical ventilation
 CVP monitoring

 Blood transfusion + I.V. Fluids

 Dopamine 2-20mg/kg/min

 IV Digitalization (0.1 - 1.0mg)

 Prostaglandin

 Morphine

 Aminophylline

 Hydrocortisone
RUPTURE OF
UTERUS
 DEFINITION

Disruption in the continuity of the all uterine

layers(endometrium, myometrium and serosa) any
time beyond 28 weeks of pregnancy is called
rupture of the uterus.
 TYPES

Complete

Incomplete

Rupture Vs Dehiscence
of C.S scar
 CAUSES
 Uterine injury sustained before current
pregnancy
 C.S /hysterotomy/ repaired uterine rupture/
Myomectomy
 Uterine trauma - curette, sounds

 Sharp or blunt trauma - accidents, bullets,

knives
 Congenital anomaly
 CAUSES
o Before delivery
 Intense spontaneous contractions

 Labour stimulation

 Intra-amniotic instillation

 Perforation by internal catheter

 External trauma - sharp or blunt

 External version

 Uterine over distension - multiple pregnancy

 During delivery:
 Internal version

 Difficult forceps delivery

 Breech extraction

 Difficult manual removal of placenta

 Fetal anomaly

 Acquired:

 Placenta increta / percreta

 Retroverted uterus (sacculation)

 DIAGNOSIS
 Prolonged fetal decelerations (70.3%)
 Bleeding (3.4%) Pain (7.6%)

Monitor tracing demonstrating fetal heart rate decelerations,

increase in uterine tone, and continuation of uterine
contractions in a patient with uterine rupture monitored with
an intrauterine pressure catheter.
 MANAGEMENT
Total Hysterectomy
Sub total hysterectomy
Simple repair
SHOULDER
DYSTOCIA
Impaction of fetal
shoulders in
maternal pelvis
 RISK FACTORS
 Maternal Diabetes Mellitus
 Short stature

 Macrosomia

 Post-term

 Obesity

 Fetal shoulder circumference

 MANAGEMENT
 Help- Obstetrician, pediatrician
 Episiotomy

 Legs- Elevated (McRoberts)

 Pressure- Suprapubic

 Enter vagina- Rubin’s and Wood’s screw

 Roll or Remove posterior arm

 Zavanelli

 Cleidotomy

 Symphysiotomy
 MCROBERTS MANEUVER
 hyperflexion of
maternal hips

 Increases intrauterine
pressure
(1,653mmHg - 3,262
mmHg)

 Increases amplitude of
contractions
(103mm Hg to 129mm
Hg)
 SUPRAPUBIC PRESSURE
 direct posterior or oblique suprapubic pressure
 RUBIN’S MANEUVER
 adductionof the most accessible shoulder
 moves the fetus into an oblique position and
decreases the bisacromial diameter
 WOODS’ CORK SCREW
MANEUVER
 Abduct posterior shoulder exerting pressure on
anterior surface of posterior shoulder
 DELIVER POSTERIOR ARM
(BARNUM MANEUVER)
grasp the posterior arm and sweep it across the
anterior chest to deliver
 ZAVANELLI MANEUVER
 cephalic replacement via reversal of the
cardinal movements of labor
 CLEIDOTOMY
 fracture the anterior clavicle by pushing it
against the pubic ramus or using a closed pair of
scissors

Symphysiotomy
 COMPLICATIONS
 Fetal morbidity
 Brachial plexus injury

 Clavicular fracture

 Facial nerve paralysis

 Asphyxia

 CNS injury
 COMPLICATIONS (MOTHER)
 Maternal morbidity
 4th degree perineal lacerations

 Cervical & Vaginal lacerations

 Bladder injury

 Postpartum hemorrhage

 Endometritis
OBSTETRIC
SHOCK
 DEFINITION

 Inadequate perfusion (blood flow) leading to

inadequate oxygen delivery to tissues
 TYPES OF SHOCK
 Hypovolemic Shock

 Cardiogenic Shock

 Neurogenic

 Anaphylactic Shock

 Septic Shock
In Obstetric cases shock is most
commonly due to either
hemorrhage or sepsis
 OBSTETRIC CAUSES OF
HYPOVOLEMIC SHOCK
 Bloodloss (obstetric haemorrhage) -Bleeing in
early pregnancy, Antepartum hemorrhage, Post
partum hemorrhage

 Fluidloss: Hyperemesis gravidarum, Diarrhea,

keto-acidosis.

 Plasma loss e.g Severe burns

 Splanchnicshock: sudden drop in intrauterine

pressure eg. Hydramnios
 STAGES OF SHOCK

 Compensated

 Uncompensated

 Irreversible
 COMPENSATED SHOCK

 Defense mechanisms are successful in

maintaining perfusion

 Presentation -Tachycardia, Decreased skin

perfusion, Altered mental status
 UNCOMPENSTATED SHOCK

 Defense mechanisms begin to fail

 Presentation - Hypotension, Marked increase in

heart rate Rapid, thready pulse Agitation,
restlessness, confusion.
 IRREVERSIBLE SHOCK
 Complete failure of compensatory mechanisms

 Marked loss of tissue perfusion cause cell

damage and death even in presence of
resuscitation.
 SHOCK: SIGNS AND
SYMPTOMS
 Hypotension

 Rapid weak pulse

 Pallor

 Sweating

 Cold clammy extremities

 Oliguria or anuria

 confusion
 INITIAL TREATMENT IN
SHOCK
 Secure, maintain airway
 Apply high concentration oxygen

 Assist ventilations as needed

 Place patient in the Trendelenburgposition

 Control obvious bleeding

 Prevent loss of body heat

 Restoration of Circulation Volume:

 Insert at least two large pore IV catheters
 Crystalloids for initial resuscitation (RL/NS/5%
dextrose), Colloids (Dextran 40)
 Achieve urine output of greater than 60ml/hr
 Blood:

 Order at least 6 units of red cells.

 Do not insist on cross matched blood if
transfusion is urgently needed
 Apply compression cuff to infusion pack.

 Monitor central venous pressure (7-12 mmHg)

and arterial pressure (65-95 mmHg )
 Drug Therapy (analgesics/Sodium bicarb
100mEq/ isoprenaline 1mg slow IV/Dopamine
2.5mg/kg/min /Digoxin)
 DIC treatment (heparin/FFP/platelets/clotting
factors)
 COMPLICATIONS OF
HYPOVOLEMIC SHOCK
1) Acute renal failure.

2) Pituitary necrosis (Sheehan‟s syndrome)

3) Disseminated intravascular coagulation

 SEPTIC SHOCK
 Causes:
Causes
 Septic Abortion
 PROM

 Trauma

 Post operative endomyometritis

 Retained placenta

 Puerperal sepsis

 Pyelonephritis

 Ogranisms:
E.Coli/proteus/pseudomonas/bacteroids
 SIGNS AND SYMPTOMS

 Hypotension

 Tachycardia

 Pyrexia

 Rigors

 Cold skin
 Cyanosis
 TREATMENT

 Restorationof circulatory functions

 Oxygenation

 Eradication of infection

 Broad spectrum Antibiotics

INVERSION OF
UTERUS
Uterus is turned inside out partially or
completely.
Causes:
 uterine atony
 Increase in intra abdominal pressure

 Fundal attachment of placenta

 Short cord

 Placenta accreta

 Excessive cord traction

 DEGREES OF UTERINE
INVERSION
 1st - Dimpling of
fundus, remains
above internal os
 2nd - fundus passes
through the cervix,
but lies inside
vagina
 3rd - (complete)
Endometrium with
or without placenta
is outside the vulva
 DANGERS
 Shock - Neurogenic
Pressure on ovaries
Peritoneal irritation
 Hemorrhage

 Pulmonary embolism

 Infection
 MANAGEMENT
 Uterine relaxant (terbutaline 0.25 mg IV
followed by 2 g of MgSO4 over 10 min)
 Treat hypovolumeia
 Without placenta: Repositioning
UTERINE INVERSION
 MANAGEMENT(CONT…)
 With placenta: Do not remove placenta
 Replace uterus
 Bimanual compression
 Hydrostatic pressure
 Start oxytocin
 Laparotomy