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EMERGENCIES
Obstetrical Emergencies
Definition
An obstetrical complication or situation of serious and often
dangerous nature, developing suddenly and unexpectedly
and demanding immediate attention in order to save life.
Diagnosis
1. Vaginal examination
2. Speculum examination
3. USG
4. Fresh vaginal bleeding at the time of rupture of
membrane may be due to ruptured vasa previa
1. VASA PREVIA
Management
If antenatal diagnosis –admission from 28-32 weeks
Delivery by elective CS -35-37 wks after steroids
High index of suspicion – colour Doppler-TVS-elective
CS
1. VASA PREVIA
Management
In first stage of labour, if the fetus alive– emergency
caesarean section
The mode of delivery will be depended on parity and fetal
condition.
Immediate new born resuscitation
Haemoglobin estimation needed after resuscitation
2. PRESENTATION AND PROLAPSE
OF THE UMBILICAL CORD
The cord lies along side, but not in front of the presenting part and lies
in front of it in the intact bag of membranes
DC Dutta textbook of Obstetrics 2018
Cord presentation
The cord is slipped down below the presenting part and lies
in front of it in the intact bag of membrane.
DC Dutta textbook of Obstetrics 2018
CORD PROLAPSE- DEFINITION
INCIDENCE
Aetiology
Aetiology
6. Placental factors
Battledore placenta and excessively long cord
7. Iatrogenic
Low rupture of membranes, manual rotation of the head,
ECV,IPV,
8. Stabilizing induction
9. Multipara
CORD PROLAPSE
Diagnosis
Occult prolapse
- Diagnosis is very difficult
- Persistence of variable deceleration of FHR in NST
CORD PROLAPSE
Diagnosis
Cord prolapse
Cord palpated directly by fingers
Cord Pulsation can be felt if the fetus is alive
CORD PROLAPSE
Prognosis
Fetal prognosis
1. Anoxia
2. The overall Perinatal mortality 15-50%
Maternal prognosis
3. Increased chance for operative delivery
4. Risk of anaesthesia, blood loss and infection
CORD PROLAPSE
Management
Cord presentation
1. No attempt made to replace the cord
2. If immediate vaginal delivery is not possible or
contraindicated caesarean delivery is the best method
CORD PROLAPSE
Management
Cord prolapse
management is based on
If baby living or dead
Maturity of the baby
Degree of dilatation of cervix
CORD PROLAPSE
Vertex Breech
FORCEPS/ BREECH
VACCUM EXTRACTION
3. SHOULDER DYSTOCIA
DEFINITION
Incidence
Incidence id 0.58%-0.70%
SHOULDER DYSTOCIA
Risk factors
PRELABOUR
• Previous shoulder dystocia
• Macrosomia > 4.5 Kg
• Diabetes
• Maternal BMI > 30
• Induction of labour
SHOULDER DYSTOCIA
Risk factors
INTRAPARTUM
• Prolonged 1st stage of labour
• Secondary arrest of labour
• Oxytocin augmentation
• Assisted vaginal delivery
SHOULDER DYSTOCIA
PREVENTION
MANAGEMENT
Mc Robert’s manoeuvre
Flexion and abduction of maternal hips, positioning maternal thigs on
her abdomen.
Low rate of complication and least invasive manoeuvre
With one assistant on either side women’s leg should be hyper
flexed combined with axial traction
Straightens the lumbosacral angle, rotates the pelvis cephalic, and
increases the relative AP diameter of the pelvis.
Success rate 70%
SHOULDER DYSTOCIA
Mc Robert’s manoeuvre
SHOULDER DYSTOCIA
Rotational manoeuvres
Internal rotation manoeuvres ( Woods manoeuvres)
Rotation can be most easily achieved by pressing on the easily
accessible fetal shoulder towards the fetal chest. The shoulder are
rotated into the wider oblique diameter
Progressively rotating the posterior shoulder 180 degrees in a
corkscrew fashion, the impacted anterior shoulder could be
released. This is frequently referred to us the Wood’s corkscrew
manoeuvre.
SHOULDER DYSTOCIA
Roll over technique
Gaskin manoeuvre
All four position
Success rate 83%
THIRD LINE MANOEUVRE
Cleidotomy
Symphysiotomy
Zavanelli’s vaginal replacement
SHOULDER DYSTOCIA
Documentation
Should be accurate and comprehensive
Time of delivery of the head and time of delivery of body, anterior
shoulder at the time of dystocia, manoeuvres performed their
timing, sequence.
Estimated blood loss
General condition of the baby
Fetal cord blood ABG
Neonatal assessment
4. MATERNAL COLLAPSE DEFINITION
REVERSIBLE CAUSE
4 H’s 4T’s
• Hypovolemia • Thromboembolism
• Hypoxia • Toxicity
• Hypothermia • Tamponade
MATERNAL COLLAPSE
CAUSE IN PREGNANCY
Bleeding
Hypoxia
Amniotic fluid embolism
Pulmonary embolism
Eclampsia and pre eclampsia
Magnesium toxicity
MATERNAL COLLAPSE
MANAGEMENT
1. Tilt
2. Airway
3. Breathing
4. circulation
MATERNAL COLLAPSE
CS indication
Cardiac arrest with no return of circulation within 4 mts
GA>24Wks / uterus above umbilicus
MATERNAL COLLAPSE
Management of anaphylaxis
Inj adrenaline 500mg (0.5 mi) 1/100 IM
Antihistamines
5. RUPTURE OF UTERUS - definition
Two types
1. Complete rupture
2. Incomplete rupture
RUPTURE OF UTERUS
Etiological classification
Rupture during labour
1. Preexisting uterine injury
2. Traumatic rupture
3. Spontaneous rupture
Rupture During pregnancy
Rupture of a previous Caesarean section Scar
RUPTURE OF UTERUS
Clinical features
Tachycardia
Tonic contraction
Pathological retraction ring
Hemorrhage
shock
RUPTURE OF UTERUS
Management