Obstetric Emergencies ppt

Assessment of Fetal Well-Being

• Electronic Fetal Monitoring (EFM): Used to assess fetal oxygenation.
• Fetal Heart Rate (FHR) Variability: Normal variability indicates fetus is likely well-oxygenated and without metabolic acidosis.
• Common Indications for EFM and Testing: Diabetes, hypertension, fetal growth restriction, multiple gestation, post-term pregnancy, decreased fetal movement, systemic lupus erythematosus, oligohydramnios/polyhydramnios, alloimmunization, prior fetal demise, preterm rupture of membranes.
• Types of Testing: Fetal kick counts, serial growth sonograms (every 3-4 weeks), umbilical artery Doppler assessment, non-stress test (NST), biophysical profile (BPP), modified BPP (NST + amniotic fluid index).

Non-Stress Test (NST)

• Reactive NST: Two or more FHR accelerations of 15 bpm or more above baseline for at least 15 seconds in a 20-minute period, indicating the fetus is healthy.
• Non-Reactive NST: No accelerations in the 20-minute period, suggesting non-reassuring fetal status requiring additional testing.

Biophysical Profile (BPP)

• Assess Fetal Well-being: Evaluates factors reflecting fetal well-being and status over time, including NST, fetal tone, fetal breathing movements, fetal body movements, and amniotic fluid.
• Scoring and Interpretation:
  • Normal (8-10): Healthy fetus, continue usual pregnancy care.
  • Low (6-8): Repeat the test in 12-24 hours.
  • Abnormal (4 or less): Indicate fetal distress, requiring further testing, possible induction, or cesarean section

Intrapartum Emergencies

Umbilical Cord Prolapse

• Definition: Umbilical cord is positioned between the presenting part and cervix.
• Cause: Cord compression results in decreased/absent blood flow.
• Risk Factors: Premature rupture of membranes before fetal head engagement, breech presentation.

Shoulder Dystocia

• Definition: Failure to deliver fetal shoulders despite downward traction on fetal head.
• Causes: Obstruction of anterior shoulder by symphysis pubis, impaction of posterior shoulder on maternal sacral promontory, increased resistance between fetus and vaginal walls.
• Maneuvers: Episiotomy, McRoberts maneuver (hip hyperflexion and abduction), suprapubic pressure, delivery of posterior shoulder and arm, use of Woods screw, Rubin maneuver, Gaskin maneuver, Zavanelli maneuver (if required, emergency C-section).
• Risk Factors: macrosomia (large baby), diabetes

Placenta Previa

• Diagnostic Timing: Routinely found by ultrasound during anatomy scan (~20 weeks); rechecked around 28 weeks, or as needed.
• Characteristics: Typically painless bleeding; bleeding frequently subsides if no labor; no digital exam.
• Management: Ultrasound to identify placental location (transvaginal may be more accurate) if unsure. Speculum exam to evaluate vaginal bleeding but NOT a digital cervical exam. Delivery by planned cesarean section around 36-38 weeks.

Vasa Previa

• Definition: Umbilical vessels cross the internal os (opening of the cervix).
• Severity: High perinatal mortality rate (50%) with vaginal delivery.
• Management: Urgent planned cesarean section.

Abnormal Placental Implantation (Placenta Accreta Spectrum)

• Definition: Abnormal placental trophoblast invasion into the myometrium (uterine muscle).
• Types: Accreta (superficial invasion), increta (deep invasion), percreta (invasion through the uterine wall).
• Risk Factors: Prior uterine surgery or curettage, placenta previa

Placental Abruption

• Definition: Premature separation of placenta after 20 weeks' gestation.
• Types: Total or partial.
• Causes: Bleeding between uterine lining and placental maternal side.
• Risk Factors: Maternal hypertension, smoking, maternal age/parity, cocaine abuse, prior placental abruption, Preeclampsia, multiple gestation, preterm premature rupture of membranes, polyhydramnios.
• Fetal Consequences: Hypoxia (reduced oxygen), maternal hypotension, reduced placental surface area.
• Clinical Presentation: Vaginal bleeding, abdominal pain, tachysystole (frequent contractions,), non-reassuring fetal heart rate, concealed bleeding (amount of bleeding may not reflect severity).

Uterine Rupture

• Definition: Complete tear of all uterine layers.
• Incidence: ~1-2% after low transverse incisions, ~3% after classical incisions.
• Risk Factors: Prior cesarean section or other uterine surgery, oxytocin hyperstimulation, trauma, prior pregnancies.
• Symptoms: Vaginal bleeding, abdominal tenderness, tachycardia abnormal fetal heart rate, cessation of uterine contractions, loss of fetal station, decreased/absent contractions.
• Management: Emergency surgical intervention.

Postpartum Hemorrhage (PPH)

• Definition: Excessive blood loss after vaginal delivery (>500 mL) or cesarean delivery (>1000 mL).
• Incidence: ~3-5% of deliveries.
• Types: Primary (within 24 hours), secondary (24 hours to 12 weeks postpartum).
• Risk factors: Prolonged labor, chorioamnionitis, preeclampsia, uterine atony.
• Causes (Four T's): Uterine atony, retained placenta/membranes, trauma, coagulopathy
• Prevention: Active management of the third stage of labor, oxytocin after delivery, uterine massage, gentle cord traction.
• Recognition: Estimate post-delivery blood loss (visual vs. quantitative), monitor for hypotension, tachycardia, or pain; rule out intra-abdominal blood loss.

Management of Uterine Atony

• Medications: Oxytocin, Methylergonovine (Methergine), prostaglandin F2α analogue (Hemabate), Misoprostol (Cytotec), Tranexamic Acid (Lysteda)
• Procedures: Bakri balloon, B-Lynch suture, uterine artery embolization.