Obstetrical emergency

Obstetric emergencies are critical medical situations that can occur during pregnancy, labour, or shortly after childbirth, necessitating immediate medical attention to safeguard the health and well-being of both the mother and the baby.  Some examples of these emergencies include;

• postpartum hemorrhage (PPH)
• vasa previa
• shoulder dystocia
• retained placenta
• adherent placenta and coagulopathy
• rupture of the uterus
• vulval hematoma
• presentation and prolapse of the umbilical cord
• uterine inversion
• amniotic fluid embolism
• shock

Postpartum hemorrhage

Introduction

Postpartum hemorrhage is a condition in which there is excessive bleeding from or into the genital tract at any time following the baby’s birth, up to six weeks after delivery. Hemorrhage may occur before, during, or after the delivery of the placenta. On average, the amount of blood loss following a vaginal delivery, cesarean delivery, and cesarean hysterectomy is approximately 500 mL, 1000 mL, and 1500 mL, respectively.

Any amount of bleeding from or into genital tract following birth of the baby up to the end of the puerperium, which adversely affects the general condition of the patient, evidenced by rise in pulse rate and falling blood pressure, is called postpartum hemorrhage. –Dc Dutta.

Incidence

The widely varying incidence of this condition is primarily due to the lack of uniformity in the criteria used for its definition. Specifically, the incidence is estimated to be about 4-6% of all deliveries.

Types

Primary PPH- Hemorrhage occurs within 24 hours following the birth of the baby. In the majority, hemorrhage occurs within two hours following delivery.

Secondary PPH- Hemorrhage occurs after 24 hours of the delivery of the placenta upto 6 weeks after the delivery is called secondary postpartum hemorrhage.

Primary PPH is divided into 2 types:

1. Third stage hemorrhage: This is primary hemorrhage that occurs after the delivery of the baby but before the expulsion of the placenta.
2. True primary PPH: This is hemorrhage that occurs after the delivery of the placenta at any time within 24 hours of the delivery of the baby. The majority of the cases of postpartum hemorrhage fall in this category.

Causes of primary PPH

The causes of postpartum hemorrhage are called the four Ts (tone, trauma, tissue and thrombin).

1. Uterine Atony:

Uterine atony is the leading cause of postpartum hemorrhage (PPH). It occurs when the muscles of the uterus fail to contract and remain relaxed after childbirth. The causes of uterine atony may include:

• Over-distension of the uterus due to factors such as a large baby, multiple pregnancies, or excess amniotic fluid (polyhydramnios).
• Rapid or prolonged labor, which can lead to uterine fatigue.
• Use of specific medications during labor, such as magnesium sulfate.
• Previous uterine surgeries or the presence of fibroids that can interfere with the uterus’s ability to contract.

2. Trauma:

Traumatic causes of PPH are related to physical injury or damage to the birth canal or surrounding tissues.

Causes of traumatic PPH can include:

• Tears/lacerations of the cervix, vagina, or perineum during childbirth.
• Instrument-assisted deliveries (e.g. forceps or vacuum extraction) that can cause tissue injury.
• Uterine rupture, which is a rare but serious condition where the uterine wall tears.

3. Tissue-Related Factors:

Tissue-related factors refer to issues with the placenta or other pregnancy-related tissues that can cause PPH.

Causes of tissue-related PPH can include:

• Placenta previa, where the placenta partially or completely covers the cervix.
• Placental abruption, which is the premature separation of the placenta from the uterine wall.
• Retained placental fragments, where pieces of the placenta or membranes are not expelled after childbirth.

4. Thrombin-Related Factors:

Thrombin is an enzyme involved in blood clotting. Abnormalities in the clotting process can lead to PPH.

Causes of thrombin-related PPH can include:

• Coagulopathies, which are conditions that affect the blood’s ability to clot properly e.g. hemophilia.
• Medications that interfere with blood clotting, such as anticoagulants.
• Disseminated intravascular coagulation (DIC), a rare condition where the body’s clotting system becomes overactive and consumes clotting factors.

Causes of secondary PPH

1. .Retained Placental Tissue: Sometimes, small pieces of the placenta or membranes can be left behind in the uterus after childbirth. This retained tissue can lead to infection and bleeding.
2. .Uterine Sub-involution: This occurs when the uterus does not return to its normal size and position after childbirth. It can be caused by infection, retained tissue, or other factors, and it can lead to prolonged bleeding.
3. Uterine Atony: While uterine atony is more commonly associated with primary PPH, it can also occur as a cause of secondary PPH if the uterus fails to contract properly after delivery.
4. Infection: Infections of the uterine lining (endometritis) or the reproductive organs (pelvic inflammatory disease) can lead to inflammation and bleeding.
5. Uterine Arteriovenous Malformations: These are abnormal connections between the arteries and veins in the uterine wall. They can develop after childbirth and cause persistent bleeding.
6. Cervical or Vaginal Lacerations: Tears or lacerations in the cervix or vagina that were not identified or adequately repaired during childbirth can cause bleeding days or weeks later.
7. Coagulation Disorders: Certain medical conditions, such as clotting disorders, can increase the risk of bleeding in the postpartum period.
8. Use of Medications: Some medications, such as anticoagulants or medications that affect blood clotting, can contribute to bleeding in the postpartum period.

Symptom of postpartum hemorrhage

• Persistent, excessive bleeding after delivery.

Other signs of PPH are:

• Symptoms of a drop in blood pressure like dizziness, blurred vision or feeling faint.
• Increased heart rate.
• Decreased red blood cell count.
• Pale or clammy skin.
• Nausea or vomiting.
• Worsening abdominal or pelvic pain.

Diagnosis and test

1. Clinical Assessment- The healthcare provider performs a clinical assessment of the patient to evaluate her condition. Obtain patient’s medical history, previous pregnancies, and any known risk factors for PPH.
2. Visual Inspection-  Care provider inspect the vaginal bleeding to determine its severity. Check for signs of excessive bleeding, such as a saturated pad within a short period after childbirth.
3. Measurement of Blood Loss- To quantify the amount of bleeding accurately; the provider may measure the volume of blood loss using calibrated containers or pads. Blood loss of 500 ml or more within the first 24 hours after vaginal delivery or 1000 ml or more after a cesarean section is often used as a criterion for diagnosing PPH.
4. Vital Signs-  Blood pressure, heart rate, and respiratory rate will be monitored to assess the patient’s hemodynamic stability. A drop in blood pressure, an increased heart rate, or signs of shock may indicate severe PPH.
5. Physical Examination- Performed to assess the uterus, checking for uterine atony (common). Other potential causes of bleeding, such as genital tract trauma or retained placental tissue, will also be evaluated.
6. Laboratory Tests- Blood tests, including a complete blood count (CBC) and coagulation profile to assess the patient’s blood clotting function. These tests help identify any blood disorders or coagulation abnormalities.
7. Ultrasound: In some cases, to evaluate the uterus and identify any retained placental fragments or abnormalities in the uterine anatomy.

Management and treatment

Healthcare providers treat PPH as an emergency in most cases. Stopping the source of the bleeding as fast as possible and replacing blood volume are the goals of treating postpartum hemorrhage.

Some of the treatments used are:

• Uterine massage to help the muscles of the uterus contract.
• Medication to stimulate contractions. Most common medicine to help induce contractions if uterine atony is the cause of the bleeding. The most common drugs used are oxytocin, ergometrine or prostaglandins like misoprostol. 
• Removing retained placental tissue from the uterus.
• Repairing vaginal, cervical and uterine tears or lacerations.
• Packing uterus with sterile gauze or tying off the blood vessels.
• Using a catheter or balloon to help put pressure on the uterine walls.
• Uterine artery embolization.
• Blood transfusion.
• In rare cases, or when other methods fail, healthcare provider may perform a laparotomy or a hysterectomy.

Vasa previa

Vasa previa is indeed an obstetric complication in which the fetal blood vessels cross or run near the internal orifice of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue. This complication can pose a significant risk during labour and delivery.

 Incidence

Vasa previa is rarely reported and occurs in approximately 1 in 2,500 births. If not diagnosed prenatally, it can have a fetal mortality rate estimated to be as high as 95 percent.

Signs and symptoms of vasa previa

• painless vaginal bleeding,
• rupture of membranes,
• fetal bradycardia.

Diagnosis

Transvaginal ultrasonography: The diagnosis of vasa previa should be suspected based on the presentation or the results of routine prenatal ultrasonography. Typically, the diagnosis is confirmed through transvaginal ultrasonography.

Treatment and management

1. Continuous monitoring or non-stress testing every 6 to 8 hours is typically recommended for prenatal monitoring at around 30 to 32 weeks of pregnancy to detect cord compression.
2. Corticosteroids are administered to accelerate fetal lung maturity.
3. An emergency cesarean section is often indicated in the following situations: when premature rupture of the membranes occurs, when vaginal bleeding persists, or when the fetal status is non-reassuring.
4. If none of these issues are present, and labour has not yet started, a cesarean section may be considered between 34 to 37 weeks of gestation.

Complications

When the amniotic sac breaks, it can expose the unprotected veins and arteries of the umbilical cord, which can potentially rupture and lead to fetal hemorrhage. This is an accurate description of a potential complication when the amniotic sac (water) breaks during pregnancy.

Shoulder dystocia

When the fetal head is delivered but the shoulders become stuck and cannot be delivered, it is known as shoulder dystocia. The anterior shoulder becomes trapped behind the symphysis pubis, while the posterior shoulder may be lodged in the hollow of the sacrum or positioned high above the sacral promontory.

The overall incidence of shoulder dystocia varies between 0.2 and 1 percent.

Predisposing factors

• Fetal macrosomia
• Obesity
• Diabetes
• Post maturity
• Anencephaly
• Fetal ascites
• Abnormal pelvic anatomy
• Mid-pelvic instrumental delivery
• Multiparity

Warning signs and diagnosis:

While the delivery may have initially seemed uncomplicated, there may be concerns if the baby’s head advanced slowly and if the chin had difficulty sweeping over the perineum. After the head is delivered, it might appear as if it is trying to retract back into the vagina, a condition known as reverse traction.

This condition is diagnosed when the maneuvers typically employed by the midwife fail to achieve successful delivery. A definitive sign of this problem is the recoil of the baby’s head against the perineum, often referred to as the ‘turtle neck sign.

Management of shoulder dystocia

The HELPERR mnemonic devised by the American Academy for Family Physician for advanced life support in obstetrics to assist remembering a sequence of maneuvers to relieve shoulder dystocia. The midwife should follow this:

H: Call for help

E: Evaluate for episiotomy

L: Legs (the McRoberts’ manoeuvre)

P: Suprapubic pressure

E: Enter maneuvers (internal rotation)

R: Remove the posterior arm

R: Roll the patient 

Mc Roberts Maneuver

To perform the McRoberts maneuver, flex the thighs tightly towards the abdomen while simultaneously shifting the hips away from the body (hip abduction). This position helps move the pubic symphysis by up to approximately 2 cm and aids in flattening and widening the sacrum.

Suprapubic Pressure At the same time, have an assistant apply simultaneous suprapubic pressure downwards to assist in the delivery of the shoulder. This maneuver may help adduct the shoulder and guide it under the symphysis pubis. It’s essential to avoid applying fundal pressure, as this could further impact the shoulder and may lead to uterine rupture.

Rubin’s Maneuver

If the baby’s shoulder remains undelivered, perform Rubin’s Maneuver:

1. Insert a hand into the vagina and apply pressure to the anterior shoulder in the direction of the baby’s sternum. This action helps to rotate the shoulder and decrease its diameter.
2. If necessary, apply pressure to the posterior shoulder in the direction of the baby’s sternum.

Woods Screw Maneuver

In the Woods Screw maneuver, the anterior shoulder is pushed towards the baby’s chest, and the posterior shoulder is pushed towards the baby’s back, thereby orienting the baby’s head to somewhat face the mother’s rectum.

Gaskin Maneuver (Roll Over)

To perform the Gaskin maneuver, assist the mother in moving onto her hands and knees. The act of turning the mother can be one of the most beneficial aspects of this maneuver. This is particularly helpful when the impaction is at the pelvic inlet. Gravity assists by keeping the fetus against the anterior aspects of the mother’s uterus and pelvis. Delivery can be achieved by applying downward traction on the posterior shoulder or upward traction on the anterior shoulder.

Cliedotomy

If all other measures fail to deliver the anterior shoulder, another option is to fracture the baby’s anterior clavicle to reduce the width of the shoulder. This is achieved by applying pressure to the anterior clavicle against the symphysis pubis. After the baby is born, it is crucial to facilitate immediate and urgent newborn care or arrange for the transfer of the newborn.

Zabennli Maneuver

The Zavennli maneuver is an obstetric technique that involves pushing back the delivered fetal head into the birth canal in anticipation of performing a C-section in cases of shoulder dystocia.

Post-Procedure Care: Following the maneuver or any other procedure, it’s essential to provide appropriate post-procedure care, which may include:

• Repairing the episiotomy if performed.
• If needed, offering emotional support to the woman and her family following a traumatic birth and the potential loss of the newborn or injury to the baby.

Complications

Baby

• Asphyxia
• Brachial plexus injuries
• Fracture of clavical
• Fracture of humerus
• Sternomstoid hematoma during delivery
• Perinatal and neonatal death

Mother

• Post Partum Hemorrhage
• Trauma of the uterus, vagina, cervix or rectum (third or fourth degree tear)
• Bruising of the bladder.
• Hematomas
• Puerperal infection

Retained placenta

Retained placenta is a condition in which the placenta is not expelled from the uterus even 30 minutes after the delivery of the baby. The process of placental expulsion typically occurs in three stages: first, it separates from the uterine muscle; then it descends into the lower segment of the uterus and vagina; and finally, it is expelled from the body. Problems can potentially occur at any of these stages, leading to complications during the postpartum period.

Risk Factors

• Previous retained placenta
• Previous injury or surgery to the uterus
• Preterm delivery
• Induced labor
• Multiparity

Causes

• Placenta separated but not expelled
• Simple Adherent Placenta
• Morbid adherence of the placenta:
• Placenta Accreta
• Placenta Increta
• Placenta Percreta
• Constriction ring-reforming cervix
• Full bladder
• Uterine abnormality

Causes of Retained Placenta

Retained placenta can occur when the placenta separates from the uterine wall but is not expelled from the uterus. There are several causes;

• Failure to expel due to exhaustion or prolonged labour: Sometimes, a woman may be too exhausted after prolonged labor to effectively push out the placenta.
• Closure of the cervix: If the cervix closes prematurely, it can prevent the placenta from being expelled.
• Uterine constriction ring: A constriction ring in the uterus can impede the placenta’s passage and cause retention.

Simple Adherent Placenta

The placenta may fail to separate completely from the uterine muscle due to lack of contraction of the uterine muscles. This condition, called ‘uterine atonicity’ occurs in cases where the uterine muscles have become lax, either due to repeated pregnancy, prolonged labor or over-distension of the uterus during pregnancy, as in twin pregnancy. Simple Adherent Placenta is the commonest cause for retention of placenta.

Morbid adhesion of the placenta

 It can occur when the placenta is implanted deeply into the uterine muscles and thus fails to separate. The placenta can burrow upto different depths in the uterine muscle. In simple cases, it is only attached firmly to muscle and can be stripped off by hand. In severe morbid adhesion, the placenta can burrow through the full thickness of the muscle. In this case, the uterus may be needed to be removed (hysterectomy) to control the bleeding.

Types of morbid adhesion of the placenta

1. Placenta accrete: The placenta penetrates deep into the uterine endometrium and reaches the muscles but does not penetrate into the muscles.
2. Placenta increta: The placenta attaches even deeper into the uterine wall and penetrates into the uterine muscle.
3. Placenta percreta: The placenta not only penetrates through the full thickness of the uterine muscles but also attaches to another organ such as the bladder or the rectum. Placenta percreta is very rare.

Risks of Retained Placenta

• There may be severe bleeding which may be life threatening.
• Attempts at manual removal of the placenta can cause multiple injuries to the mother such as like vulvar hematoma, perineal tears, cervical tears and vaginal wall tears.

Management

If the placenta remains undelivered after 30 minutes, the following steps should be considered:

• Ensure the bladder is empty.
• Encourage breastfeeding or nipple stimulation to trigger uterine contractions.
• Suggest a change in position, promoting an upright posture to aid placental expulsion.

If there is bleeding, take the following immediate actions:

• Notify the anesthetist.
• Insert a large-bore IV (18g) cannula.
• Place a urinary catheter.
• Initiate or continue an oxytocin infusion at a rate of 20 units in 1 liter with a drip rate of 60 drops per minute.
• Measure and meticulously record the blood loss.

Prepare the patient for transfer to the operating theater for manual removal of the placenta.

Management / Treatment of Retained Placenta

1. Treatment will depend on the cause of the retention of the placenta. If bleeding is present, active treatment is done to control the blood loss and support the general condition of the patient.
2. Controlled Cord Traction (CCT)
3. If the placenta is separated but not expelled, CCT should be carried out. In this method, the uterus is held in place or pushed up gently through the abdominal wall by the left hand. The cut umbilical cord hanging from the vagina is held in the right hand and pulled steadily and slowly to pull out the placenta.

Manual removal of the placenta

• The placenta may need to be removed manually if controlled cord traction fails. The patient is put under General Anesthesia in the Operation Theatre.
• Under all aseptic conditions, the sterile gloved hand is inserted into the uterus and the placenta is stripped from the uterine muscle gently and brought out.
• Introduce one hand into the vagina along cord
• Supporting the fundus while detaching the placenta

Hysterectomy: If the placenta is too deeply embedded into the uterine musculature

Post procedure care

• Observe the woman closely until the effect of IV sedation has worn off.
• Monitor the vital signs every 30 minutes for the next 6 hours or until stable.
• Palpate the uterine fundus to ensure that the uterus remains contracted.
• Check for excessive lochia.
• Continue infusion of IV fluids.
• Transfuse as necessary.

Complications of a Retained Placenta

• Uterine inversion
• Shock (hypovolemic)
• Postpartum hemorrhage
• Puerperal Sepsis
• Sub-involution
• Hysterectomy

Rupture of the uterus

Definition

Disruption in the continuity of all uterine layers (endometrium, myometrium and serosa) any time beyond the 22 weeks of pregnancy is called rupture of uterus.

Types

1. Complete: Rupture involves a tear in the wall of the uterus with or without expulsion of the fetus.
2. Incomplete: Rupture involves tearing of the uterus wall but not the perineum.

Causes

During pregnancy

• Weak scar after previous operations on the uterus
• History of C/S (vaginal birth after C/S)
• Myomectomy
• Excision of a uterine septum
• Previous perforation of uterus (Dilatation and curettage, hysteroscopy, forceps delivery).

During labour

• Uterine hyper-stimulation(oxytocin with pitocin induction or augmentation of labor)
• Obstructed labor(macrosomia, fetopelvic disproportion)
• Intrauterine manipulation(internal version, manual removal of an adherent placenta)
• Forcible dilatation(cervical tear)
• A weak scar(C-section or other operations).

Risk factors

• A uterine scar from previous C/S (most common)
• Myomectomy
• Dysfunctional labour
• Labour augmentation by oxytocin or prostaglandins
• High parity

Signs

Complete  rupture of previously non-scared uterus may be accompanied by sudden collapse of the mother, who complains severe abdominal pain.

• Severe abdominal pain, may occur suddenly at the peak of a contraction. The woman may describe a feeling that something gave way or ripped. Severe abdominal pain may decrease after rupture.
• Maternal pulse rise, simultaneously alternation in Fetal Heart Rate.
• Pathologic retracting ring.
• Features of hypovolemic shock (pulse increase, BP fall, paller, cool, clammy skin,  anxiety)
• May be evidence of fresh vaginal bleeding
• Abdominal distention/ free fluid
• Absent fetal movements and FHS
• Uterine contractions may stop and alter the abdominal contour.
• Easily palpable fetal part or fetus may felt in the abdominal cavity
• Collapse and shock depends on the extend rupture and the blood loss.

Incomplete rupture

Incomplete rupture may have a insidious onset or be silent and found only after delivery or during C/S. This types mainly associated with previous C/S.

Diagnosis

• Severe abdominal pain may decrease after rupture
• Bleeding (intra-abdominal and or vaginal)
• Shock
• Abdominal distention/free fluid
• Tender abdomen
• Easily palpable fetal part
• Absent fetal movements and FHS
• Constant pain is changed to dull aching pain with cessation of uterine contractions.

Prevention

A mother at risk of uterine rupture or with specific medical conditions should be referred to Comprehensive Obstetric and Newborn Care (CEONC) facilities.

These risk factors include:

• Contracted pelvis.
• Previous Cesarean section (C/S), hysterectomy, or myomectomy.
• Uncorrected transverse lie of the baby.
• Multiparity with a pendulous abdomen.
• -Grand multiparity.
• -A known case of hydrocephalus in the baby.
• It’s essential to avoid the use of general anesthesia during external version to prevent undue force on the uterus and ensure the safety of the mother and baby.
• Any significant or undue delay in the progress of labour, especially in a multipara with a history of uneventful deliveries, should be viewed with concern and may require specialized care.
• Judicious selection of cases with previous C/S for vaginal delivery.
• Careful watch which are mandatory during oxytocin infusion either for induction/augmentation of labour.
• Internal podalic version should never done in obstructed labour, alternative to destructive operation.
• Attempt forceps delivery or breech extraction through incompletely dilated cervix should be avoided.
• Destructive vaginal delivery should be performed by skilled personnel.
• •Manual removal in morbid adherent placenta should be done by expert person.

Management

• Shout for HELP! Urgently mobilize all available personnel.
• Perform a rapid evaluation of the general condition of the women, including vital signs.
• If shock is suspected, immediately begin treatment.
• Even if signs of shock are not present, keep shock in mind and evaluate the woman further because her status may worsen rapidly. If shock develops, it is important to begin treatment immediately.
• General care principles and operative care principles are the same as C/S.
• Restore blood volume by infusing IV fluids (N/S, R/L) before surgery.
• Give a single dose of prophylactic antibiotics: Ampicillin 2gm IV or cefazolin 1gm IV.
• Insert Foley’s catheter and monitor urine output hourly or as indicated immediate C/S is performed in the hope of delivering a live baby.
• After the birth of the placenta, the extent of the rupture can be assessed. The choice between the options to perform a hysterectomy or to repair the rupture depends on the extent of the trauma and the mother’s condition.
• Infuse oxytocin 20 units in 1 L of IV fluid (N/S, R/S) at 60 drops/min until the uterus contracts, and then reduce to 20 drops/min.
• Provide psychological support to the mother and her family.
• Offer family planning counseling.

Prognosis

• Prognosis depends upon the manner in which labour is managed prior to the accident, types of rupture, morbid pathological changes at the site of the rupture and effective management. Lower segment scar rupture gives a comparatively better prognosis
• Maternal and fetal distress.

Vulval Hematoma

Collection of blood anywhere in the area between the pelvic peritoneum and the perineal skin is called pelvic hematoma. Depending upon the location of the hematoma, whether below or above the levator ani, is term as:

• Infra levator hematoma- common
• Supra levator hematoma- rare

Infra levator hematoma

 The commonest one is the vulval hematoma.

Etiology

• Improper hemostasis during repair of vaginal or perineal tears or episiotomy wound.
• Failure to take precaution while suturing the apex of the tear.
• Failure to obliterate the dead space while suturing the vaginal walls.
• Rupture of paravaginal venous plexus either spontaneously or following instrumental delivery.

Risk factors

• Episiotomy
• Instrumental delivery
• Primiparity
• Prolonged 2nd stage of labour
• Macrosomia
• Vulval varicosities

Symptoms

1. Persistent, severe pain on the perineal region
2. There may be rectal tenesmus or bearing down efforts when extension occurs to the ischio-rectal fossa. There may be even retention of urine

Signs

1. Variable degrees of shock may be evident.
2. Local examination reveals a tense swelling at the vulva which becomes dusky and purple in colour and tender to touch.

Treatment

• A small hematoma < 5 cm may be treated conservatively with a cold compress.
• Larger hematomas should be explored in the operating theater under General Anesthesia. Simultaneously, resuscitative measures are to be taken.
• The blood clots are to be removed, and bleeding points are to be secured. Usually, a generalized oozing surface is visible.
• The dead space is to be obliterated by deep mattress sutures, and a closed suction drain may be kept in place for 24 hours.
• Prophylactic antibiotics are to be administered.

Supra levator hematoma

Causes

1. Extension of cervical laceration or primary colporrhexis (vault rupture)
2. Lower uterine segment rupture
3. Spontaneous rupture of paravaginal venous plexus adjacent to the vault.

Diagnosis

1. The diagnosis is usually late as pain is not a noticed nature and also the vaginal bleeding.
2. Unexplained shock with features of internal hemorrhage following delivery raises the suspicion.
3. Abdominal examination reveals a swelling above the inguinal ligament pushing the uterus to the contralateral side.
4. Vaginal examination reveals;

• Occlusion of the vaginal canal by a bulge or
• A boggy swelling felt through the fornix.
• Rectal examination corroborates the presence of the boggy mass
• Ultrasound may be needed for exact localization of the hematoma.

Management

1. Usual treatment of shock is to be instituted and arrangement is made for laparotomy.
2. The anterior leaf of the broad ligament peritoneum is incised and the blood clot is scooped out. The bleeding points, if visible are to be secured and ligated.
3. Random blind sutures should not be placed to prevent ureteric damage.
4. If the oozing continues, one may have to tie the anterior division of the internal iliac artery.

Presentation and prolapse of umbilical cord

There are three clinical types of abnormal descent of the umbilical cord by the side of the presenting part. All these are placed under the heading 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 membranes.

Cord prolapsed: The cord is lying inside the vagina  or outside the vulva following rupture of the membranes.

Causes

• High head
• Multiparity
• Prematurity
• Mal-presentation
• Multiple pregnancies
• Polyhydramnious
• Placental factors – minor degree of placenta previa with marginal insertion of cord or long cord
• Iatrogenic- low rupture of membrane, manual rotation of head and version.

Clinical findings

1. Vaginal examination: if the cord prolapsed it is necessary to detect whether it is pulsating i.e. living fetus or not. Pulsation can be felt if fetus is alive.
2. Ultrasound occasionally can diagnose cord presentation.
3. Occult prolapsed is rarely palpated during pelvic examination. This condition is suspected if persistence of variable declaration of FHR pattern detected on continuous fetal monitoring.
4. Abnormal fetal heart by auscultation
5. Cord prolapsed may be diagnosed simply by palpating loops of the cord in the vaginal canal during vaginal examination
6. A loop of cord may be visible at the vulva in cord prolapse
7. Cord presentation is also diagnosed by feeling of loops of cord through the membrane.

Diagnosis

Cord presentation- feeling of pulsation of the cord through the intact membrane

Cord prolapse- cord is palpated directly by fingers and its pulsation can be felt if the fetus is alive.

Management

Principle of management

• Relieve pressure on the cord.
• Find out the fetus is alive or dead.
• If alive, deliver immediately.
• If dead, and the pelvis and presentation are favorable await spontaneously delivery.

Management

Identifying a Prolapsed Cord and Providing Immediate Intervention:

Prolapsed cord is a critical obstetric emergency that requires prompt recognition and action. To identify a prolapsed cord and provide immediate intervention:

1. Assess the labour conditions:

• Determine if the fetus is preterm or small for gestational age.
• Check if the fetal presenting part is not engaged in the pelvis.
• Evaluate if the amniotic membranes are ruptured.

2. Monitor the Fetal Heart Rate (FHR):

• Periodically evaluate the FHR, especially after the rupture of membranes (spontaneous or surgical).
• Reassess the FHR in 5 to 10 minutes to detect any changes.

3.Notify the Healthcare provider:

• If a prolapsed cord is identified, immediately notify the physician or midwife.

4.Prepare for emergency Cesarean Section (C/S):

• In most cases, emergency C/S is the preferred route for delivery when a prolapsed cord is detected.

5.If the client Is fully dilated:

• In rare situations where the client is fully dilated and the fetal head is low, a vaginal delivery may be the most emergent option. In such cases:
• Encourage the client to push during contractions.
• Lower the head of the bed and elevate the client’s hips on a pillow, or place the client in the knee-chest position to minimize pressure on the cord.

6.Constantly assess cord pulsations:

• Continuously assess the pulsations of the prolapsed cord to monitor the fetus’s well-being.

7. Gauze and sterile Normal Saline (N/S) solution:

• Gently wrap gauze soaked in sterile normal saline solution around the prolapsed cord to keep it moist and reduce the risk of cord compression and injury.

8.Provide physical and emotional support:

• Offer reassurance and support to the laboring person and their family. Maintain a calm and reassuring presence.

9.Client and family education:

• After the situation is stabilized, provide the client and their family with information about the prolapsed cord, the emergency interventions performed, and the importance of immediate medical attention. Address any questions or concerns they may have.

Complications of cord prolapse

• Fetal distress
• Intrapartum fetal death
• Neonatal asphyxia
• Early neonatal death

Uterine inversion

The uterus is said to be inverted if it turns inside out during delivery of the placenta. Uterine inversion may occurs immediately postpartum or much less frequently during the puerperium. It is an extremely rare but a life threatening complication in 3^rd stage in which the uterus is turned inside out partially or completely.

Classification based on degree

First degree: there is dimpling of the fundus, which remains above the level of the internal os.

Second degree: the uterus is inverted and the fundus passes through the cervix but lies inside the vagina.

Third degree (complete): the endometrium with or without the attached placenta is visible outside the vulva. The uterus, cervix and part of the vagina are inverted and visible.

Classification based on the time of onset

Acute occurs immediately after delivery with the placenta still attached.

Sub acute and chronic inversion occurs after the first 24 hours.

Etiology

The inversion may be spontaneous or more commonly induced.

Spontaneous (40%): this is brought about by localized atony on the placental site over the fundus associated with sharp rise of intra abdominal pressure as in coughing, sneezing or bearing down effort. Fundal attachment of the placenta (75%), short cord and placenta accrete are often associated.

Iatrogenic: this is due to the mismanagement of the 3^rd stage of labour.

• Pulling the cord when the uterus is atonic specially when combined with fundal pressure.
• Crede’s expression while the uterus is relaxed.
• Faulty technique in manual removal.

Dangers

1. Shock is extremely profound mainly of neurogenic origin due to-

• tension on the nerves due to stretching of the infundibula-pelvic ligament
• pressure on the ovaries as they are dragged with the fundus through the cervical ring
• peritoneal irritation

2. Haemorrhage, specially after detachment of placenta

3. Pulmonary embolism

4. If left uncared for, it may lead to ;

• infection
• uterine sloughing
• chronic one

Diagnosis

Symptoms: acute lower abdominal pain with bearing down sensation.

Signs

1.Varying degree of shock is a constant feature.

2.Abdominal examination- cupping or dimpling of the fundal surface.

3.Bimanual examination not only helps to confirm the diagnosis but also the degree. In complete variety a pear shaped mass protrudes outside the vulva with the broad end pointing downwards and looking reddish purple in colour.

Prevention and management

Do not expel placenta when uterus is relaxed. Pulling the cord simultaneously with fundal pressure should be avoided. Manual removal should be done with caution.

Before the shock develops:  Urgent manual replacement even without anesthesia
Principles steps

1. To replace that part first which inverted last with the placenta attached to the uterus by steady firm pressure exerted by the fingers
2. To apply counter support with other hand placed on the abdomen.
3. After replacement hand should remain inside until the uterus becomes contracted by parenteral oxytocin or PGF2α .
4. Placenta is to be removed manually only after the uterus becomes contracted. The placenta may however be removed prior to replacement

– To reduce the bulk which facilitates replacement.

-If partially separated to minimize the blood loss.

5. Usual treatment of shock including blood transfusion should be arranged when required.

After the shock develops

Principles steps

1. Treatment of shock should be instituted with an urgent dextrose saline drip and blood transfusion.
2. To push the uterus inside the vagina if possible and pack the vagina with antiseptic roller gauze.
3. Raise the foot end of the bed.
4. Replacement of the uterus either manually or hydrostatic method under general anesthesia is to be done along with resuscitative measures. Hydrostatic method is quite effective and less shock producing.

Subacute stage

1. To improve the general condition by blood transfusion
2. Antibiotics are given to control sepsis
3. Reposition of the uterus either manually or by hydrostatic method may be tried
4. If fails, reposition may be done abdominal operation (Haultain’s operation)

Amniotic fluid embolism

It is a condition occur when amniotic fluid, debris, fetal squamous cells, mucus, vernix, meconium is forced into the maternal circulation via the uterus or placental site forming an embolus which obstruct on to the pulmonary arteries or alveolar capillaries leading to varying degree of respiratory distress and circulatory collapse. This is the rare but dramatic deadest complication of labour.

The body response in two phases.

The initial phase is one of pulmonary vasospasm causing hypoxia, hypotension and cardiovascular collapse.

The second phase sees the development of the left ventricular failure, with hemorrhage and coagulation disorder followed by pulmonary edema. Maternal mortality and morbidity are high with amniotic fluid embolism.

Pre-disposing factors

1. Rapid or precipitate labour:- most common cause of amniotic fluid embolism. The hypertonic contraction which occurs in this type of labour force amniotic fluid into the maternal circulation via a break in the membranes or placenta. The fore water may be intact but it may occur when they are ruptured. Amniotic fluid embolism may also occur in C/S.

2. Multiparity: embolism rarely occurs in primigravidae but in multigravidae (rapid contraction).

3. Over stimulation of the uterus: – Excessive use of oxytocin drugs may increase hypertonic uterine contraction.

4. Uterine trauma:- Before the amniotic fluid can enter into the maternal circulation, there must be a laceration in the membranes. This can occur at C/S, ruptured uterus, during intrauterine manipulation such as internal podalic version or during insertion of an intra uterine catheter. It can also occur in manual removal of the retained placenta.

5. A rent through fetal membrane as in marginal separation of placenta or placental abruption.

Pathogenesis

Small pulmonary vessels get plugged by squamous mucus, vernix or meconium → pulmonary vascular obstruction →pulmonary hypertension, pulmonary edema → hypotension; bradycardia → reduced cardiac output → cardiac failure.

Disseminated intravascular coagulation (DIC) develops:

Coagulation defect →severe PPH on delivery and other site hemorrhages.

Sign and Symptoms

1. Patient is usually multiparous and is in vigorous labour pain and is in the process of being delivered suddenly develop.
2. Sudden onset of maternal respiratory distress e.g. severe dyspnea, cyanosis, sign of pulmonary edema.
3. Maternal hypotension and uterine hypertonia. The latter will induce fetal distress and is in response to uterine hypoxia.
4. Signs of cardiovascular collapse: – rapid pulse rate without fluid loss, hypotension, and right sided cardiac failure.
5. Convulsions may present immediately preceding the collapse.
6. Blood coagulopathy develops following the initial collapse which cause severe post partum hemorrhage.

Diagnosis

• Amniotic fluid is detected in the maternal blood.
• In post-partum, amniotic fluid commonly found in the lungs.
• Maternal sputum contain fetal squamous.

Management

Emergency treatment

Treatment of respiratory distress and cardiovascular collapse. Includes:

• Oxygen inhalation
• Suction
• Resuscitation
• Monitor FHS.

Treatment of hemorrhage

• Monitor vital signs (pulse, BP, respiratory rate)
• If the mother has symptoms of DIC, there should be infusion of clotting factors.
• Management of coagulopathy.

Complications

• Mortality rate is very high up to 86% with 25% of death occurring in the first hour.
• Cardiopulmonary collapse.
• DIC (Disseminated intravascular coagulation)
• Renal failure due to excessive blood loss.

Obstetric shock

Shock is a complex syndrome involving a reduction in blood flow to the tissues with resulting dysfunction of organs and cells. It entails progressive collapse of the circulatory system and if left untreated, can result in death.

Shock can be acute but prompt treatment results in treatment or failure to initiate effective treatment can result in a chronic recovery with little detrimental effect on the mother. However, inadequate condition ending in multisystem organ failure, which may be fatal.

In midwifery, the term obstetric shock is collapse caused by the failure of the circulatory system. It occurs most commonly as a result of hemorrhage though it can be aggravated by pain, dehydration, and anemia and probably by fear.

Shock can be classified as:

1. Hypovolaemic shock
2. Cardiogenic shock
3. Neurogenic shock
4. Septic (endotoxic) shock
5. .Anaphylactic shock

1. Hypovolemic shock

This is caused by any loss of circulating fluid volume that is not compensated for as in hemorrhage, but may also occur when there is severe vomiting.

The hypovolaemic shock can also be classified into.

• Hemorrhagic shock: Associated with post-partum or post abortal hemorrhage, ectopic pregnancy, placenta previa, placenta abruption, rupture of the uterus and obstetric surgery.
• Fluid loss shock: Associated with excessive vomiting, distress or too rapid removal of amniotic fluid.
• Supine hypotensive syndrome: Associated with compression of inferior venacava by the pregnant uterus.
• Shock associated with DIC: IUFD syndrome and amniotic fluid embolism.

Clinical features of hypovolaemic shock

The body reacts to the loss of circulating fluid is stages as follows:

1. Initial stage: – Reduction in fluid or blood decreases the venous return to the heart.

• The ventricles are inadequately filled, causing a reduction in stroke volume and cardiac output.
• As cardiac output and venous return fall, the blood pressure is reduced.
• The drop in BP decreases the supply of oxygen to the tissue and cell function is affected.

2. Compensatory stage

• The drop in cardiac output produces a response from the sympathetic nervous system through the activation of aorta and carotid arteries cause receptors in the vasoconstriction,
• The blood is redistributed to vital organs. Vessels in GI, skin, kidney and lungs constrict. This response is seen by the skin becoming pale and cool, peristalsis slow, urinary output is reduced and impaired gas exchange in lungs.
• The heart rate increase to compensate cardiac output and blood pressure.
• Dilate pupils, the sweat glands are stimulated and the skin becomes moist and clammy.
• Adrenaline from adrenal medulla and antidiuretic hormone from posterior pituitary gland cause vasoconstriction which increase cardiac output and decreased urine output.
• Venous return to the heart will increase but, unless the fluid loss is replaced, will not be sustained.

3. Progressive Stage

• This stage leads to multisystem failure.
• Compensatory mechanisms begin to fail, with vital organs lacking adequate perfusion.
• The coronary arteries suffer lack of supply. Peripheral circulation is poor, with weak and absent pulses.

4. Final, irreversible stage of shock

• Multisystem failure due to stagnation of blood at the micro vascular level.
• Cell destruction are irreparable (irreversible)
• Death may ensue.

2. Cardiogenic shock

• Failure of left ventricular ejection. (Cardiac arrest – myocardial infarction).
• Failure of left ventricular filling. (Cardiac temponade, – pulmonary embolism).

3. Neurogenic shock

• Chemical injury: Associated with aspiration of gastro intestinal contents during GA especially in C/S.

• Drug induced: Associated with spinal anesthesia.

Sign and symptoms

The pathological factors are same as hypovolaemic shock. But in compensatory phase, it is very transient. In reversible phase, unlike hypovolaemic shock, paler absent; on the contrary; the face may be flushed. Temperature remains normal or subnormal.

4. Septic (endotoxic) shock

This is syndrome of collapse of circulation and inadequate tissue perfusion associated with bacteraemia. Associated conditions are septic abortion, chorino-amnioitis, pyelonephritis etc.

Sign and symptoms of septic shock

• Sudden onset of tachycardia, pyrexia, rigors and tachyponea
• Mother may exhibit a change in her mental state.
• Signs of shock including hypotension is developed
• Vasodilatation and continued hypotension leads to kidney damage
• Respiratory distress syndrome and DIC may occur
• Multisystem failure and even dead may occurs because of continued hypotension and myocardial depression.

1. Bacteria enter the bloodstream.
2. Endotoxin is released from the bacteria.
3. Chemical mediators (histamine, kinin, complement) are released.
4. Vasodilatation (widening of blood vessels) and vasoconstriction (narrowing of blood vessels) occur.
5. This process can lead to generalized vascular and cell damage, which is a characteristic feature of sepsis, a severe and potentially life-threatening condition.

Other possible causes of shocks are;

1. Amniotic fluid embolism
2. Pulmonary embolism
3. Hypertension and Pregnancy Induced Hypertension
4. Water intoxication related to prolonged infusion of syntocinon and antidiuretic action leads to hyponatremia usually prolonged administration of I/V dextrose.
5. .Adverse reaction to blood transfusion.

Management of shock

The basic management includes life saving measures which are:

• Keep patient in calm and quiet environment in head low position. SHOOT FOR HELP, warm woman to increase peripheral circulation & reduce blood supply to vital centers.
• Full assessment should be done and take quick appropriate action.
• Maintain airway, turn head on one side, use air way if patient is unconscious e.g. Vital sign, urine output.
• Oxygen administration 6-8 liter/minutes.
• Blood grouping, cross matching and other investigation.
• Treatment of hypovolemic shock (Hemorrhagic).

Basic management of hemorrhagic shock is to stop bleeding and replace lost fluid volume, prompt diagnosis and immediate resuscitation is essential to prevent multisystem failure.

1. Infusion and transfusion:- Start I/V infusion (N/S, R/L) crystalloids to replace fluid volume and give colloid (Haemaccel, Gelofusion) to increase plasma volume, if possible and available transfuse blood after grouping and cross matching.
2. Maintenance of cardiac efficiency: – by infusing 1000 ml in 15-20 min. initially and then slow down.
3. Administration of oxygen to avoid metabolic acidosis 6-8 litre/min to bring arterial PO₂ to normal level and reduce tissue hypoxia.
4. Control of bleeding: Specific surgical and medical treatment for control of hemorrhage should start along the general management of shock.
5. Monitoring: CVP, V/S, blood gas analysis, urine output, circulating blood volume etc.

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