Obstetric Emergencies

A Practical Manual

Sanjeewa Padumadasa, Malik Goonewardene, Sanjeewa Padumadasa, Malik Goonewardene

• Publisher: CRC Press
• Year: 2021
• Print ISBN: 9780367543655
• eBook ISBN: 9781000407099
• Edition: 1
• Topic: Medicine
• Subtopic: Emergency Medicine & Critical Care

This is an ideal evidence based clinical guide to the essential principles and practical points arising from obstetric emergencies for residents, trainees, and obstetricians in practice. The concise text, illustrated with key diagrams, is from experienced educators and practitioners.
*Provides a concise illustrated guide to the key principles and practical points involved
*Gives trainees, residents, and obstetricians the practical information they need in an emergency *Supplies quick and easy reference to key points with illustrations

1

Overview of Obstetric Emergencies

Sanjeewa Padumadasa and Malik Goonewardene

An emergency is a serious and often unforeseen situation that demands immediate action. Obstetric emergencies can occur anytime during pregnancy, during delivery or after delivery. Therefore, it is important for healthcare givers to be aware of these life-threatening conditions and be prepared to manage them, if they do occur. Moreover, an obstetric emergency differs from other emergencies. Because pregnancy is physiological, the woman would have most probably been well before the emergency ensued, and there are two lives involved – that of the woman and the fetus. Although pregnant women are generally young, fit and able to recoup well, the physiological demands of pregnancy can reduce their vitality. While fetal survival depends mainly on the optimal management of the woman, the obstetrician may have to sacrifice the fetus by delivering at gestations below or around the threshold of viability, in order to save the woman, because the woman’s wellbeing takes precedence over that of the baby’s.

Early Identification, Communication and Teamwork in Obstetric Emergencies

Early recognition of a potential problem, as well as early involvement of experienced practitioners, are vital factors when it comes to the management of obstetric emergencies. The ‘Modified Early Obstetric Warning System’ (MEOWS) is a tool used to recognise early signs of complications, so that timely and appropriate interventions can be adopted before the woman deteriorates further, possibly resulting in a major catastrophic event.

Excellent communication and teamwork are pivotal to the success of management in a demanding situation, such as an obstetric emergency. The primary aim of communication is to exchange critical information about the woman in order to formulate a reasonable management plan promptly. The use of standardised communication protocols such as ‘Situation-Background-Assessment-Recommendation’ (SBAR) has led to an improvement when dealing with obstetric emergencies. Effective teamwork requires a team leader who is capable of bringing the best out of the team to ensure that the woman receives the best possible care in a given emergency scenario. Lack of communication and teamwork have been implicated as major contributors to perinatal and maternal morbidity and mortality.

Early activation of a rapid response team, which comprises a diverse range of clinicians and stakeholders, has been associated with a decrease in the incidence of maternal cardiac arrest and admission to intensive care units, as well as an improvement in the survival rate of hospitalised patients. In addition to the routine critical care team, there should be a practitioner who is competent in performing delivery and a practitioner who is competent in the resuscitation of the neonate. If the transfer of a critically ill pregnant woman to a specialised centre is deemed necessary, then arranging facilities for delivery of the fetus if needed during transit, is an important aspect of management of an emergency.

Many obstetric emergencies are extensively known, and management strategies are widely accepted. However, the chance of conferring substandard care is still possible when managing a stressful and time-sensitive situation, such as an emergency, even in the presence of a multitude of healthcare personnel. Developing and adhering to a clear, evidence-based plan of response that is tailor-made for the particular setting ensures that no essential tasks are omitted, and this also creates a relatively more controlled environment. However, as clinical management needs to be individualised, management guidelines may need to be modified according to the individual needs of different women.

Simulation-Based Training

In the management of obstetric emergencies, Simulation-Based Training (SBT) has a vital role in a background of compromised exposure of trainees to emergencies and increasing concerns about patient safety. It is an invaluable accompaniment, although it is not a substitute for a proper apprenticeship and clinical experience. In-house training is comparably more effective than outbound training. In-house training, if combined with drills, also provides a means of identifying strengths and weaknesses in the infrastructure within a particular unit, so that the administration can address possible existing practical issues. Regular drills are immensely helpful in increasing awareness and skills in rare obstetric emergencies.

Managing an emergency under the guidance of an experienced obstetrician provides the ideal platform for learning as well as ensuring that both lives concerned, that of the woman and the fetus, are in safe hands. A trainee must aspire to learn around the subject whenever dealing with an emergency. This will undoubtedly equip him/her with the skills necessary in dealing with an emergency better the next time around. The best textbook on obstetric emergencies is the situation itself, provided that the wellbeing of both the woman and the fetus are ensured.

Consent, Debriefing and Documentation

Obtaining informed written consent is preferable, but this may not be feasible when managing obstetric emergencies, and in some instances, verbal consent may be the most practical. However, in certain situations such as in perimortem caesarean delivery, obtaining any consent may not be possible, and the obstetrician is expected to act in the best interests of the woman. Debriefing the woman, the relatives and the staff involved forms a vital aspect of management of any emergency. The aim of good documentation is not only as a means of providing good defence against litigation, but also to provide a stimulus to promote safe practice, and its importance cannot be underestimated.

‘Good documentation – good defence, some documentation – some defence, no documentation – no defence, because if you did not document, you did not do it’.

Risk Management and Audit

Risk management in healthcare is a systematic effort to uncover, mitigate and prevent risks in healthcare institutions. Sentinel events, which are unanticipated events in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients and which are unrelated to the natural course of the patient’s illness, need thorough investigation in an atmosphere of non-blame to prevent the event from recurring. Severe Acute Maternal Morbidity (also referred to as near misses), where a woman could have died but instead survived, also requires thorough investigation. There should be a robust and efficient system that encourages these incidents to be reported so that preventive measures and best practices can be instituted. Regular audits ensure that appropriate measures are in place for preventing and managing emergencies.

Conclusion

Medical practitioners are bound by the Hippocratic Oath, which states ‘primum non nocere’ – first, do no harm. Harm not only results from errors of commission, but also from errors of omission, such as failure to take preventive action. Although problems are anticipated and preventive measures are adopted, emergencies still occur unexpectedly. The need to be conversant with the skills and be equipped with the infrastructure in dealing with such emergencies cannot be undervalued. Although the rates of assisted vaginal breech delivery, instrumental vaginal delivery, internal podalic version and breech extraction, internal iliac artery ligation and emergency obstetric hysterectomy have dwindled in the recent past, it is imperative that an obstetrician is competent with these techniques which may be needed in both under-resourced and well-resourced settings. Obstetrics is an art as well as a science, and both aspects are equally important. An evidence-based and pragmatic approach to the management of obstetric emergencies is therefore presented in this book.

‘Skill is something one never knows when one may need it. It is better for one to have the skill and never get to use it than not have it and one day need it’.

2

Umbilical Cord Prolapse

Sanjeewa Padumadasa and Prasantha Wijesinghe

Umbilical cord prolapse is defined as the descent of the umbilical cord through the cervix, alongside (occult) or past (overt) the presenting part, in the presence of ruptured membranes. The incidence of umbilical cord prolapse has dramatically declined over the last century and ranges from approximately 1–6/1,000 live births today. It is believed that the increased use of caesarean delivery for unstable lie at term, reduction in rates of grand multiparity, increased use of prostaglandins for ripening of the cervix and a policy of delivering footling breeches by caesarean delivery have led to the decrease in the prevalence of umbilical cord prolapse today.

Umbilical cord prolapse could either be overt (complete) when the umbilical cord lies below the presenting part (Figure 2.1A), or occult (incomplete), when it lies adjacent to the presenting part but not below it (Figure 2.1B) and in the presence of ruptured membranes. Cord presentation refers to the situation in which the umbilical cord lies below the presenting part but above the cervix (Figure 2.1C). In cord presentation, the membranes are usually intact but, occasionally, the membranes could be ruptured yet the cord may not have prolapsed out as the cervix is not dilated. Cord prolapse is a more acute problem than cord presentation, and the danger of cord presentation is the risk of cord prolapse along with its serious consequences.

Figure 2.1 A – overt cord prolapse, B – occult cord prolapse, C – cord presentation.

Pathophysiology

The loop of the umbilical cord is compressed between the maternal pelvis and the presenting part, resulting in fetal hypoxia. This occurs even in occult cord prolapse. The degree of compression is greater in a cephalic presentation than in a non-cephalic presentation of the fetus. Furthermore, the umbilical cord vessels that are exposed to the colder temperature outside the vagina undergo vasospasm, which further reduces blood supply to the fetus. Total cord compression for more than 10 minutes can cause fetal cerebral damage, and more than 20 minutes of this can cause fetal death. The fetal condition can rapidly deteriorate if the fetus is already compromised, as in prematurity and fetal growth restriction.

Risk Factors for Umbilical Cord Prolapse

Umbilical cord prolapse can occur when the maternal pelvis is not completely filled by the fetal presenting part, e.g. in fetal malpresentation, such as breech or abnormal lie, i.e. transverse, oblique, unstable, or when the presenting part is not engaged. It may arise in the presence of multiparity, a small fetus, preterm labour, preterm prelabour rupture of membranes, fetal malformations, polyhydramnios, a low lying placenta and in the second twin.

In addition, obstetric interventions such as external cephalic version (as discussed in Chapter 27), internal podalic version and breech extraction (as discussed in Chapter 28), artificial rupture of membranes in the presence of a high presenting part, vaginal manipulation of the fetus with ruptured membranes and insertion of an intrauterine pressure catheter and Foley catheter induction of labour are associated with the risk of umbilical cord prolapse.

What is common amo...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Contributors
• 1. Overview of Obstetric Emergencies
• 2. Umbilical Cord Prolapse
• 3. Eclampsia and Pre-Eclampsia with Severe Features
• 4. Acute Fatty Liver of Pregnancy
• 5. Cardiac Emergencies in Obstetrics
• 6. Maternal Sepsis
• 7. Maternal Cardiorespiratory Arrest
• 8. Abnormal Labour
• 9. Instrumental Vaginal Delivery
• 10. Shoulder Dystocia
• 11. Difficult Caesarean Delivery
• 12. Complications of Obstetric Anaesthesia
• 13. Antepartum Haemorrhage
• 14. Primary Postpartum Haemorrhage
• 15. Secondary Postpartum Haemorrhage
• 16. Uterine Rupture
• 17. Uterine Compression Sutures
• 18. Uterine Devascularization
• 19. Emergency Obstetric Hysterectomy
• 20. Retained Placenta
• 21. Acute Uterine Inversion
• 22. Amniotic Fluid Embolism
• 23. Venous Thromboembolism in Pregnancy
• 24. Obstetric Anal Sphincter Injuries
• 25. Assisted Vaginal Breech Delivery
• 26. Twin Delivery
• 27. External Cephalic Version
• 28. Internal Podalic Version and Breech Extraction
• 29. Non-Reassuring Fetal Status
• 30. Resuscitation of the Newborn
• 31. Simulation in Obstetric Emergencies
• Index