Obstetric emergencies

1. Cord prolapse
2. Uterine rupture
3. PPH

Cord prolapse

Definition: 

1. overt umbilical cord presentation: umbilical cord lies infront of the presenting part and the membranes are intact. 

2. Overt umbilical cord prolapse: when the umbilical cord lies in front of the presenting part and the membranes have ruptured. 

3. occult umbilical cord presentation/ prolapse: the umbilical cord lies trapped beside the presenting part rather than below it

Risk Factors:

1. non- iatrogenic : fetal abnormal lie/malpresentation/breech, polyhydramnios, multiple pregnancy, prematurity, IUGR/SGA, high presenting part. 

2. iatrogenic: Amniotomy, placement of cervical ripening balloon catheter, vaginal manipulation of fetus with ruptured membranes.

3. External cephalic version. 

- complication: birth asphyxia (d/t cord compression or vasospasm)

Management:

- call for HELP! arrange OT!

- continue CTG

- relieve cord compression 

•  using position: knee to chest position/ Tredelenburd position/ cephalad gravitation
• help decrease blood flow, avoid fetal asphyxia and acidosis
• cord vasospasm -which caused by exposing to surrounding
• no oxytocin, only tocolytic agent: terbutaline 0.25mcg
• ***do not push back the cord 
• *** no amniotomy

 

- if you are doing VE: gentry push fetal head upwards, away from maternal pelvis (to relieve cord compression). use suprapubic pressure to keep fetus away from pelvis. 

- insert 500ml warm water in to urinig 

***1. discontinue oxytocin

        - administer tocolytic agents(s/c terbutaline 0.25mcg stat) if there are fetal brady

        - minimize excessive handling of the umbilical cord

        - if cord is outside, gently wrap the exposed cord with warm gauze. 

        2. never replace cord into uterus (causes vasopasm and fetal hypoxia)

        3. DONT remove examining fingers. 
        4. doppler ultrasound: to detect occult cord presentation

- deliver fetus ASoon/safeAP and 

- instrumental delivery if favourable

- breech extraction if favourable

- deflate bladder before peritoneal entry of C-section

Uterine rupture:

definition: separation of old uterine incision involving the entire thickness of uterine wall, with rupture of fetal membrane

- resulting in communication between uterus and peritoneal cavities

Uterine Dehiscence

- myometrial separation at site of uterine scar from previous surgery and uterine serosa remains intact. 

Causes:

1. spontaneous rupture, 

2. scar rupture, 

    - prior uterine surgery: C-section, myomectomy, 

    - D&C, hysteroscopy, forcep delivery, resection of uterine septum

3. traumatic rupture: 

    - uterine hyperstimulation (oxytocin- IOL)

    - obstructer labour: macrosomic baby, CPD

    - intrauterine manipulation (internal version, manual removal of adherent placenta)

Types:

1. completely rupture: extend through myometrium and serosal peritoneum

2. incomplete rupture: overlying peritoneum still intact, includes scar dehiscence

Symptoms:

• PV bleeding 
• suprapubic pain and tenderness
• shock
• undetectable fetal heart beat
• CTG sudden cariable/late deceleration before onset of fetal bradycardia
• easily palpable fetal body parts
• loss of station
• cessation of uterine contraction

Diagnosis via

1. ultrasonography: 

• protrude amniotic sac
• hematome
• endometrial/myometrial defect
• intraperitoneal fetal part
• hemoperitoneum/ free fluid

free fluid noted

https://www.cureus.com/articles/24288-spontaneous-uterine-rupture-secondary-to-morbidly-adherent-placenta-in-an-unscarred-uterus

Management

1. Intensive resus
2. emergency laparotomy
1. hysterectomy unless there are reasons to preserve uterus
2. rupture repair
3. Broad spectrum antibiotic
1. cephalosporin
2. flagyl (metronidazole)
4. Adequate post operative care

POST PARTUM HEMORRHAGE

DEFINITION:

- Blood loss of more than 500ml following vaginal delivery or > 1L after Caesarean section. 

- Primary PPH: loss blood within 24hrs post-partum

- Secondary PPH: loss blood after 24hrs post-partum, within 12 weeks postpartum

Causes: 4T (tone, trauma, tissue, thrombin)

Mx: 

• bleeding >1.5L --> can be seen in drop of BP
• tachycardia >100bpm
• 1st
• active resus
• uterine massage
• IM symptometrine
• 1ampule pitocin (max: 80u)
• IM hemabate
• then IVI 40u pitocin maintanence

*if uterine contracts after uteretonic drugs, continue with IVI of 40U pitocin in 500ml NS --> usually causes are uterine atony. 

*carboprost not given in bronchial asthma

* Hartmann 1L stat and check response (on acidosis, more lactate needed)

    - Hartmann's solution:  is a clear solution of sodium chloride, potassium chloride, 

                                      calcium chloride dihydrate and sodium lactate 60% in water.

 

 

Dose	Oxytocin	Ergometrine	15-Methylprostaglandin F2
Dose and route	IV : Infuse 20 IU in 1L IV fluids at 60 drops/min	IM or IV (Slowly) : 0.2mg	IM: 0.25mg
Continuing dose	IV : Infuse 20IU in 1L IV fluids at 40 drops.min	Repeat 0.2mg IM after 15 min If required, give 0.2mg IM or IV (slowly every 4 hours)	0.25mg every 15 minutes
Maximum dose	Not more than 3L of IV fluids containing oxytocin	5 doses (Total 1.0mg)	8 doses (Total 2mg)
Precautions/ Contraindications	Do not give as an IV bolus	Avoid in pre-eclampsia, hypertension, heart disease	Bronchospasm (CI in Broncial  Asthma)