Obstetrics Emergencies: Revision ✅

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🚨 Obstetric emergencies are time-critical conditions that threaten the life of the mother, baby, or both. The safest approach is early recognition, call for senior help, ABCDE assessment, left lateral tilt/manual uterine displacement, IV access, bloods, group and save/crossmatch, fetal assessment where appropriate, and rapid obstetric/anaesthetic/neonatal involvement. In UK practice, follow local maternity emergency protocols, NICE guidance and RCOG Green-top guidance.

🚑 Immediate Generic Approach

• 📞 Pull emergency buzzer / call obstetric emergency team.
• 🔄 Use ABCDE: airway, breathing, circulation, disability, exposure.
• 🤰 Use left lateral tilt or manual uterine displacement to reduce aortocaval compression.
• 💉 Insert two large-bore IV cannulas if haemorrhage/shock suspected.
• 🧪 Send FBC, U&E, LFT, clotting, fibrinogen, group and save/crossmatch as appropriate.
• 🩸 Activate major obstetric haemorrhage protocol if bleeding or shock.
• 🫀 Continuous maternal observations and urine output monitoring.
• 👶 Assess fetal heart rate if fetus viable and maternal condition allows.
• 👩‍⚕️ Involve obstetrician, anaesthetist, midwife-in-charge, neonatology and haematology early.

🩸 Placenta Praevia

• Clinical presentation:
  • 🩸 Painless, bright red vaginal bleeding, usually in the second half of pregnancy.
  • 🤰 Soft, non-tender uterus.
  • 👶 Malpresentation or high presenting part may occur.
  • ⚠️ Maternal shock or fetal compromise if bleeding is heavy.
• Investigations:
  • 🖥 Ultrasound to confirm placental location.
  • 👶 Fetal monitoring if gestation viable and bleeding significant.
  • 🧪 FBC, clotting, fibrinogen, group and save/crossmatch if bleeding.
  • 🚫 Avoid digital vaginal examination until placenta praevia has been excluded.
• Management:
  • 🚨 Admit and stabilise if bleeding, pain, contractions or maternal/fetal compromise.
  • 🩸 IV access, bloods and crossmatch if bleeding.
  • 👶 Corticosteroids for fetal lung maturity if preterm birth risk, according to local policy.
  • 🗓 Planned caesarean birth if placenta covers or is very near the internal os.
  • 🚑 Emergency caesarean birth if major bleeding, maternal instability or fetal compromise.
  • ⚠️ Consider placenta accreta spectrum risk, especially with previous caesarean section and anterior low-lying placenta.

💥 Uterine Rupture

• Clinical presentation:
  • 🚨 Sudden severe abdominal pain, often during labour.
  • 👶 Abnormal fetal heart rate pattern is often the earliest sign.
  • 🩸 Vaginal bleeding may occur but can be concealed.
  • 📉 Maternal tachycardia, hypotension or shock.
  • ⬇️ Loss of fetal station or change in abdominal contour.
  • ⚠️ Risk factors: previous caesarean scar, VBAC, uterine surgery, obstructed labour, excessive uterotonic stimulation.
• Investigations:
  • Diagnosis is mainly clinical.
  • Continuous fetal monitoring if in labour and fetus viable.
  • Bloods and crossmatch; do not delay theatre for imaging if rupture suspected.
• Management:
  • 🚨 Immediate obstetric emergency call.
  • 🔪 Emergency laparotomy and delivery, usually by caesarean section.
  • 🩸 Major haemorrhage protocol, IV fluids and blood products.
  • 🧵 Surgical repair of uterus if possible; hysterectomy may be required for uncontrollable bleeding.
  • 👶 Neonatal team for resuscitation.

🌊 Amniotic Fluid Embolism

• Clinical presentation:
  • 🚨 Sudden collapse during labour, birth or early postpartum period.
  • 🫁 Acute hypoxia, respiratory distress or cyanosis.
  • 📉 Hypotension, shock or cardiac arrest.
  • 🧠 Seizures, agitation or altered consciousness may occur.
  • 🩸 DIC and severe bleeding often follow.
• Investigations:
  • Clinical diagnosis; no single confirmatory test.
  • ABG/VBG, lactate, FBC, clotting, fibrinogen, group and crossmatch.
  • ECG, CXR and echocardiography may support assessment and exclude other causes.
  • Consider differentials: PE, eclampsia, sepsis, haemorrhage, anaphylaxis, myocardial infarction.
• Management:
  • 🚨 Immediate resuscitation and obstetric emergency call.
  • 🫁 High-flow oxygen, airway support and ventilation if needed.
  • 🫀 Treat shock with IV fluids, vasopressors/inotropes and ICU input.
  • 🩸 Treat DIC with blood products guided by local major haemorrhage protocol, fibrinogen and coagulation results.
  • 👶 If maternal cardiac arrest and pregnancy is advanced, consider perimortem caesarean/resuscitative hysterotomy according to resuscitation guidance.

🤱 Shoulder Dystocia

• Clinical presentation:
  • 🚨 Difficulty delivering the shoulders after the fetal head has delivered.
  • 🐢 “Turtle sign”: head retracts against the perineum.
  • ⏱ Delay in head-to-body delivery.
  • 👶 Risk of fetal hypoxia, brachial plexus injury and neonatal fracture.
• Diagnosis:
  • Clinical diagnosis at delivery.
  • No antenatal test reliably predicts all cases.
• Management:
  • 📞 Call for help and note time of head delivery.
  • 🚫 Stop maternal pushing temporarily and avoid excessive downward traction.
  • 🦵 McRoberts manoeuvre: hyperflex maternal hips onto abdomen.
  • ✋ Apply suprapubic pressure, not fundal pressure.
  • 🧤 Consider internal rotational manoeuvres and delivery of posterior arm if needed.
  • ✂️ Episiotomy may help access for manoeuvres but does not relieve bony obstruction by itself.
  • 👶 Neonatal team should attend if delay or compromise.

🧠 RCOG defines shoulder dystocia as a vaginal cephalic delivery requiring additional obstetric manoeuvres after the head has delivered and gentle traction has failed.

🩸 Postpartum Haemorrhage

• Definition:
  • Primary PPH: bleeding within 24 hours of birth.
  • Traditionally >500 mL after vaginal birth or >1000 mL after caesarean birth, but clinical condition matters more than estimated volume.
• Causes - 4 Ts:
  • 🧸 Tone: uterine atony - most common.
  • 🧩 Tissue: retained placenta or retained products.
  • ✂️ Trauma: genital tract laceration, uterine rupture, haematoma.
  • 🩸 Thrombin: coagulopathy, DIC, anticoagulants.
• Clinical presentation:
  • Heavy vaginal bleeding, clots or concealed bleeding.
  • Soft, boggy uterus suggests atony.
  • Tachycardia, hypotension, pallor, agitation or collapse.
• Management:
  • 🚨 Call major obstetric haemorrhage team.
  • 🔄 ABCDE, oxygen if needed, two large-bore cannulas, bloods and crossmatch.
  • 🧸 Uterine massage and ensure bladder is empty.
  • 💊 Uterotonics according to local protocol: oxytocin, ergometrine if not contraindicated, carboprost, misoprostol.
  • 🩸 Tranexamic acid early unless contraindicated, following local major haemorrhage guidance.
  • 🧩 Examine placenta and consider retained tissue.
  • ✂️ Inspect for genital tract trauma.
  • 🎈 Escalate to intrauterine balloon tamponade, theatre, compression sutures, interventional radiology or hysterectomy if bleeding persists.

📌 RCOG Green-top Guideline No. 52 covers prevention and management of postpartum haemorrhage in obstetric-led settings.

⚡ Eclampsia

• Clinical presentation:
  • Generalised seizure in pregnancy or postpartum, usually associated with pre-eclampsia.
  • Severe headache, visual disturbance, epigastric/RUQ pain, nausea or hyperreflexia may precede seizure.
  • Hypertension and proteinuria may be present, but eclampsia can occur even when preceding signs are subtle.
• Investigations:
  • BP monitoring and urine protein assessment.
  • FBC, platelets, U&E, creatinine, LFTs, clotting if severe disease.
  • Fetal assessment after maternal stabilisation.
  • Consider alternative causes of seizure if atypical: epilepsy, intracranial bleed, hypoglycaemia, sepsis, cerebral venous thrombosis.
• Management:
  • 🚨 Call obstetric emergency team, anaesthetist and senior obstetrician.
  • 🔄 ABCDE, protect airway, left lateral position, oxygen if needed.
  • 💉 Magnesium sulfate for seizure treatment and prevention of recurrence.
  • 📉 Treat severe hypertension with IV/oral antihypertensives according to local protocol, commonly labetalol, hydralazine or nifedipine.
  • 👶 Plan delivery once mother is stabilised; mode and timing depend on gestation, maternal/fetal condition and cervical/labour status.
  • 🏥 HDU/ICU-level monitoring if severe or ongoing instability.

📌 NICE NG133 covers hypertension in pregnancy and recommends antihypertensive management and specialist planning for pre-eclampsia/eclampsia; RCOG’s older severe pre-eclampsia guideline now directs clinicians to NICE guidance.

🪢 Umbilical Cord Prolapse

• Clinical presentation:
  • Visible or palpable cord below or beside the presenting part.
  • Sudden fetal bradycardia or recurrent variable decelerations, especially after membrane rupture.
  • Risk factors: malpresentation, high presenting part, polyhydramnios, prematurity, multiple pregnancy, artificial rupture of membranes.
• Diagnosis:
  • Clinical diagnosis by speculum/vaginal examination if suspected.
  • Continuous fetal monitoring if fetus viable.
• Management:
  • 🚨 Call emergency obstetric team immediately.
  • ✋ Manually elevate presenting part to relieve cord compression.
  • 🧎 Position mother knee-chest or left lateral with head down.
  • 💧 Consider bladder filling if transfer to theatre is delayed, according to local protocol.
  • 🚫 Avoid handling the cord more than necessary because vasospasm may worsen.
  • 🔪 Category 1 caesarean birth if fetus alive and vaginal birth is not imminent.
  • 👶 Expedite vaginal birth only if fully dilated and delivery is immediately achievable.

🧬 HELLP Syndrome

• Meaning:
  • Haemolysis.
  • ELevated Liver enzymes.
  • LPow Platelets.
• Clinical presentation:
  • Epigastric or right upper quadrant pain.
  • Nausea, vomiting, malaise or flu-like symptoms.
  • Hypertension and proteinuria may occur but are not always dramatic.
  • Severe disease may cause DIC, placental abruption, liver haematoma/rupture, renal failure or pulmonary oedema.
• Investigations:
  • FBC and platelets.
  • LFTs: AST/ALT raised.
  • Haemolysis markers: LDH, bilirubin, blood film, haptoglobin if needed.
  • U&E, creatinine, uric acid, clotting, fibrinogen.
  • Urine protein assessment.
  • Fetal assessment once mother stabilised.
• Management:
  • 🚨 Admit under senior obstetric care; involve anaesthetics and haematology if severe.
  • 💉 Magnesium sulfate if severe pre-eclampsia/eclampsia risk.
  • 📉 Treat severe hypertension according to local protocol.
  • 🩸 Blood products if bleeding, DIC or very low platelets, guided by labs and procedure needs.
  • 👶 Delivery is definitive treatment, but timing depends on gestation and maternal/fetal condition after stabilisation.
  • 🏥 HDU/ICU care if severe disease or organ dysfunction.

🧨 Placental Abruption

• Clinical presentation:
  • Painful vaginal bleeding, abdominal pain or back pain.
  • Tense, tender or “woody” uterus.
  • Contractions or uterine hypertonus.
  • Fetal distress or absent fetal heart if severe.
  • Bleeding may be concealed, so shock can be worse than visible bleeding suggests.
• Investigations:
  • Clinical diagnosis; ultrasound may miss abruption.
  • FBC, clotting, fibrinogen, group and crossmatch.
  • Continuous fetal monitoring if viable fetus and active management planned.
• Management:
  • 🚨 Obstetric emergency call if significant bleeding, pain, shock or fetal compromise.
  • 🩸 Resuscitate, crossmatch and activate major haemorrhage protocol if needed.
  • 👶 Expedite delivery if maternal instability or fetal compromise.
  • 🧪 Monitor for DIC; fibrinogen may fall early in major obstetric haemorrhage.

🩸 Vasa Praevia

• Clinical presentation:
  • Classically painless vaginal bleeding after rupture of membranes with sudden fetal distress.
  • Bleeding is fetal in origin, so fetal compromise can occur with relatively small visible blood loss.
• Investigations:
  • Antenatal ultrasound with colour Doppler if risk factors or low-lying placenta/velamentous cord insertion.
  • In labour, suspect with bleeding plus fetal bradycardia after membrane rupture.
• Management:
  • 🚨 If suspected intrapartum with fetal compromise, urgent caesarean birth.
  • 🗓 If diagnosed antenatally, planned caesarean birth before labour/rupture of membranes under specialist care.

📊 Quick Comparison Table

📝 Exam Pearls

• 🩸 Painless bleeding = think placenta praevia.
• 🔥 Painful bleeding + tender uterus = think abruption.
• 🐢 Turtle sign = shoulder dystocia: McRoberts then suprapubic pressure.
• 🪢 Cord prolapse: lift presenting part off cord and expedite birth.
• ⚡ Eclampsia: magnesium sulfate first-line for seizures.
• 🧬 HELLP: epigastric/RUQ pain can be the clue before obvious deterioration.
• 🩸 PPH: remember the 4 Ts - tone, tissue, trauma, thrombin.
• 🚫 Never do a digital vaginal examination in antepartum bleeding until placenta praevia is excluded.

🧠 Teaching Note

Most obstetric emergencies are pattern-recognition plus resuscitation. Abruption is painful because blood dissects into the uterine wall and irritates the myometrium, whereas placenta praevia is often painless because the placenta overlies the lower segment/cervix. Cord prolapse and shoulder dystocia are fetal oxygen emergencies, so the priority is rapid mechanical relief of obstruction/compression. For eclampsia and HELLP, the mother must be stabilised first because maternal physiology is the baby’s oxygen supply.

📚 References & UK Resources

• NICE NG235 – Intrapartum care
• NICE NG133 – Hypertension in pregnancy
• RCOG Green-top 27a – Placenta praevia and placenta accreta
• RCOG Green-top 42 – Shoulder dystocia
• RCOG Green-top 52 – Postpartum haemorrhage
• RCOG Green-top Guidelines