Obstetric emergencies

Obstetric emergencies.
British Medical Journal, May 15, 1999, by Geoffrey Chamberlain, Philip Steer

The management of emergencies is usually the responsibility of hospital 
obstetricians. As more maternity care is now given in the community, however, 
midwives, general practitioners, and paramedics may be involved and must know 
the outlines of management of emergencies and the possible side effects. If 
such a situation occurs outside the hospital then arrangements must be made 
to transport the woman to the obstetric unit safely and promptly.

All emergency protocols should have been considered beforehand and mutually 
agreed by obstetricians, midwives, general practitioners, and paramedics. 
verybody then knows their immediate priority, and hazards to the woman can 
be minimised.

Abruption of the placenta

An abruption is a death threat to the fetus and a hazard to the mother. When 
the placenta separates from its bed (probably because of the rupture of a 
malformed blood vessel), the damage to the fetus follows not just because of 
the barrier that the clot makes between the placental bed and villi but also 
because the release of prostaglandins causes a major degree of uterine spasm. 
This interferes with perfusion of the placenta, which remains attached. Blood 
tracking into the myometrium often goes as far as the peritoneum over the 
uterus, causing much pain and shock, with spasm of the uterine muscle.

In major degrees of placental abruption the woman is shocked well beyond the 
apparent amount of blood loss and needs urgent transport into hospital. A wide 
bore intravenous line should be set up and blood sent for cross matching of 
at least six units of blood. Until this blood arrives, other plasma expanding 
fluids, such as Haemaccel, should be used.

If the fetus is still alive and gestation sufficiently advanced, caesarean 
section is the best management. However, if the fetus is dead, conservative 
management can be pursued provided that the woman does not continue 
deteriorating--for example, by developing a coagulopathy. Most women with a 
severe abruption that kills the fetus will go into spontaneous labour soon 
and have an easy delivery, but caesarean section is occasionally necessary 
for maternal indications alone. Treatment must be aimed at the shock and at 
preventing disseminated intravascular coagulopathy.

Usually the placenta is implanted on the anterior wall of the uterus, but 
sometimes it is posterior when the abruption is less painful and not so severe 
that the mother is shocked; the fetus may still be at risk, however. Diagnosis 
in these cases is by recognition of the excessively frequent contractions 
produced by the prostaglandin release and the abnormal pattern of the fetal 
heart rate secondary to fetal hypoxia; these are best shown with 
cardiotocography, a priority investigation in all women admitted with 
abdominal pain in pregnancy.

Placenta praevia

The blastocyst occasionally implants in the lower part of the uterus. 
Stretching and thinning of the uterine muscle of the lower segment in the 
third trimester may sheer off part of the placental attachment. This is 
accompanied by painless bleeding.

Often the fetus is not affected by the first small bleeds, but they should be 
taken seriously for there is a risk that the mother could have a much larger 
bleed. Hence, women with bright red, painless vaginal bleeding are considered 
to have placenta praevia until proved otherwise and should be admitted to 
hospital. Vaginal ultrasound examination is the best technique for 
investigating possible placenta praevia, but, although it has a high 
sensitivity and specificity for central placenta praevia in the third 
trimester, it is much less precise in the late second trimester or for 
marginal placenta praevia. Management should therefore always be based on 
appropriate clinical judgment.

If placenta praevia is confirmed the woman should stay in hospital for at 
least 48 hours after the bleeding has stopped. Management is conservative, 
even to the level of giving blood transfusions for severe bleeds, until the 
fetus is mature (at about 36 weeks). Studies do not show any benefit in 
keeping women in hospital until delivery, provided that they have a telephone 
at home and live close enough to the hospital to be brought in by the 
emergency services within 20 minutes if they start bleeding again (Love et al,
1996). Unless it is very obvious--for example, a complete placenta praevia on 
ultrasound examination, together with a transverse lie of the fetus--placenta 
praevia is sometimes confirmed by examination under general anaesthesia in 
theatre, proceeding in most instances to caesarean section performed by a 
senior obstetrician. Occasionally, if the placenta is anterior and only just 
engaging in the lower segment, the membranes may be ruptured and a vaginal 
delivery expected, as the head coming down into the mother's pelvis will 
compress the bleeding placental bed against the back of the pubis symphysis. 
The same cannot be said for any degree of posterior placenta praevia.

After delivery, a postpartum haemorrhage is likely because the placental bed 
is situated over less well contracting uterine muscle and may well bleed 
despite oxytocic stimulation. This often requires blood transfusion.

Postpartum haemorrhage

After a normal delivery a woman commonly loses up to 300 ml of blood. As her 
blood volume has increased because of fluid retention during pregnancy, this 
is a loss which can be coped with readily. However, a loss of [is greater 
than] 500 ml measured clinically in the first 24 hours is considered to be a 
primary postpartum haemorrhage. Blood loss is commonly underestimated by the 
attending practitioners. The mother should be watched carefully and 
treatments given to prevent any further loss.

If the uterus has not contracted firmly, manual stimulation may work by 
rubbing up a contraction, and a further oxytocic is given. If the placenta is 
incomplete the uterine cavity is explored for the remaining lobules whose 
presence in the uterine cavity may prevent the organ contracting down. If 
neither of these conditions exists, trauma to the lower uterus, cervix, or 
upper vagina may be the cause of the bleeding. Such traumas should be looked 
for (in theatre with a good light) and sutured appropriately. A rare cause of 
continuing primary postpartum haemorrhage is a rupture of the uterus. This 
needs diagnosis and treatment with either hysterectomy or abdominal resuturing.



After the first 24 hours, any bleeding is a secondary postpartum haemorrhage. 
It is commonly associated with infection, which should be treated vigorously 
with intravenous antibiotics. If it persists, suction evacuation of the uterus 
should be undertaken by a senior obstetrician; perforation of the soft uterus 
is a major risk in this situation.

A complication of severe and prolonged blood loss is a consumptive 
coagulopathy, when the mother's blood does not clot owing to interference with 
the clotting cascade. The continuing cooperation of a senior haematologist is 
essential. The mother continues to bleed not just from the placental bed but 
from other sites in the body. This needs firm and prompt correction so that 
full coagulation can be restored. Giving cryoprecipitate (frozen precipitate) 
provides the missing components.

Amniotic fluid embolism

Occasionally, when the uterus is contracting strongly and there is an opening 
between the amniotic sac and the uterine veins, a bolus of amniotic fluid is 
pumped into the circulation. This passes through the heart, and an accumulation 
of amniotic cells becomes trapped in the pulmonary circulation. The amniotic 
fluid may cause local disseminated intravascular coagulation, which may spread. 
This rare condition can occur late in the last trimester or during labour.

Amniotic fluid embolism used to be diagnosed on histology only after a 
postmortem examination but is now sometimes diagnosed before death. The 
symptoms include collapse while having strong contractions, shock without any 
blood loss, sudden dyspnoea, and the production of frothy sputum. Treatment 
is supportive, with steroids, intravenous plasma expansion, and urgent 
delivery. This obstetric emergency is rare and has a bad prognosis for both 
mother and fetus, usually owing to delay in diagnosis.

Inversion of uterus

Very rarely, if misapplied pressure has been used on the uterine fundus or 
traction on the cord of a non-separated placenta in a multiparous woman, the 
uterus can dimple and invert. This is a very shocking event as the fundus 
turns inside out and goes through the cervix into the vagina. Treatment 
requires an experienced obstetrician, who will try to return the uterus under 
general anaesthesia. This can be very difficult.

Infection

After delivery the genital tract has several sites of potential ingress of 
bacteria. The placental bed itself is a large raw area, and ascending 
infection from the lower genital tract may be assisted by previous 
intrauterine procedures--for example, forceps delivery. Infection of the 
cervix or, uncommonly, of the episiotomy site, may also occur; the breast can 
also be a site of infection in the puerperium.

Psychological conditions

Pregnancy and childbirth are times of high psychological stimulation. Any pre-
existing psychological disorder may be exaggerated at this time and requires 
treatment. Many women go through mood swings (blues) in relation to childbirth, 
which can usually be managed by sympathetic support. If postnatal depression 
persists for a week or so, mild antidepressants may be needed, and the 
Edinburgh postnatal depression questionnaire may be helpful in diagnosing the 
condition. If the condition continues, formal psychiatric help is needed.



At the extreme of the spectrum of disease a puerperal psychosis may occur; 
both the mother and her baby should be admitted to a dedicated maternity/
psychiatric unit as both are at risk. Here the mother can have expert 
psychiatric nursing and medical care while looking after her own baby. There 
is a 25% risk of recurrence in a future pregnancy.

Stillbirth and intrauterine death

In Britain 3-4 babies per 1000 are stillborn and another 3-4 per 1000 die in 
the first week of life. The grief reactions in both the woman and her partner 
need careful management by the midwifery and medical staff. The couple may go 
through a phase of anger; all hospital and community staff should be trained 
to cope with this. Midwifery and medical staff must be prepared to listen and 
offer their sympathies without attributing blame.

Parents should be encouraged to agree to a postmortem examination of the fetus 
and placenta by a skilled paediatric pathologist. Getting permission for this 
from the couple requires sensitivity. If a full postmortem examination is 
declined, a limited examination of the baby may be acceptable (x ray 
examination, computed tomography, blood samples from the heart area for 
chromosome analysis, and bacteriological swabbing of the relevant areas of 
the body).

Cultural attitudes of the parents influence these decisions and must be 
respected. It is probable that the couple will not object to full histological 
examination of the placenta.

Clinical features of abruption of the placenta

Symptoms
* Abdominal pain
* Severe shock with symptoms beyond vaginal blood loss
* Vaginal bleeding--usually old blood

Signs
* Shock
* Spasm of uterus--described as woody
* Tender uterus
* Fetal parts hard to feel
* Often no fetal heart is heard

Emergency treatment of abruption

Treat the shock
* Give oxygen
* Insert intravenous lines
* Arrange a cross match of 6 units of blood
* Give morphine (if fetus dead)

Deliver the fetus
* By caesarean section (if fetus is alive and gestation is mature)
* By rupturing membranes (if cervix is ripe or fetus is dead)

Treat disseminated intravascular coagulopathy
* Urgent haematological consultation
* Check platelet count
* Give cryoprecipitate (fresh frozen plasma)
* Transfuse with fresh blood if available

The first principles of dealing with obstetric emergencies are the same as for 
any emergency (see to the airway, breathing, and circulation), but remember that 
in obstetrics there are two patients; the fetus is very vulnerable to maternal 
hypoxia

Clinical aspects of placenta praevia

Symptoms
* Vaginal bleeding--bright red, painless, recurrent

Signs
* Soft, pain free uterus
* Easy to feel fetus--often high head, breech, or transverse lie
* No fetal distress

Do not do a digital vaginal examination

A speculum examination in an inpatient to exclude any local bleeding is 
acceptable

Management of primary postpartum haemorrhage

Preventive
* Intramuscular oxytocin at the end of the second stage of labour

Curative
* Repeat oxytocic administration
* Rub up a contraction
* Check completeness of the placenta--if it is not delivered or a lobule is 
missing, prepare for manual removal
* Bimanual compression
* Intramyometrial prostaglandin [E.sub.2] or carboprost
* Surgical ligation--uterine arteries, internal iliac arteries, or braces 
(or Lynch) suture of uterus
* Hysterectomy

Treating infections
* Infections manifest themselves by local inflammation (swelling and 
tenderness) and a raised temperature
* Treatment is local heat to the area, analgesia, and broad spectrum 
antibiotics until the results of bacteriological swabs are available
* Co-amoxiclav and erythromycin are both good choices because they deal with
penicillinase-producing staphylococci and streptococci, especially group B
* Metronidazole is often added for uterine infections
* If the infection persists, anaemia may follow, which may ultimately require 
a blood transfusion

Three levels of psychiatric state associated with childbirth

Postpartum blues (1 in 5 mothers)
* Transient and treatable by reassurance

Puerpural depression (1 in 10 mothers)
* Low mood, lack of energy, guilt, irritability, and insomnia
* Treated by counselling (midwives and health visitors)
* Antidepressants--refer to GP if depression continues

Puerpural psychosis (1 in 500 mothers)
* Affective, depressive, or manic behaviour; insomnia; confusion; perplexity
* Refer to psychiatrist and admit to mother and baby unit

Key references

* Love C, Wallace E. Pregnancies complicated by placenta praevia: what is 
appropriate management? Br J Obstet Gynaecol 1996;103:864-7.

* Department of Health. Confidential enquiries into maternal death (1988-1990).
London: HMSO, 1994:43-6.

* Douglas K, Redman C. Eclampsia in the United Kingdom. BMJ 1994;309:1395-400.

* James D, Steer P, Weiner C, Gonik B. High risk obstetrics. London: Saunders,
1999.

* SANDS (Stillbirth and Neonatal Death Society). Guidelines for professionals.
London: SANDS, 1991.

The ABC of Labour Care is edited by Geoffrey Chamberlain, emeritus professor 
of obstetrics and gynaecology at the Singleton Hospital, Swansea. It will be 
published as a book in the summer.

Philip Steer is professor of obstetrics and consultant obstetrician at 
Imperial College School of Medicine, Chelsea and Westminster Hospital, London.

BMJ 1999;318:1342-5 

COPYRIGHT 1999 British Medical Association in association with
The Gale Group COPYRIGHT 2000 Gale Group