OBSTETRICS EMERGENCIES

Obstetrics Emergencies
Definition
- health problems that are life-threatening medical conditions for pregnant women and their
babies that occurs during pregnancy or during and after labour and delivery.
- an emergency is defined as a serious situation or occurrence that happens unexpectedly and
demands immediate action
(https://www.slideshare.net/mobile/hemnathsubedi/obstetric-emergencies)
- its definition implies that it is unforeseen; preparation and prevention should always be used to
reduce the risks of emergencies occurring.

Obstetric emergencies that may arise during pregnancy include:

a) miscarriage – the loss of a baby before 20 weeks gestation. A miscarriage cannot be stopped
once it has started.
b) ectopic pregnancy – where the fertilized egg implants in one of the fallopian tubes rather than
the uterus (womb). If the pregnancy causes a split in the tube, this can result in pain and serious
bleeding. Loss of or damage to the tube may affect the woman’s ability to become pregnant in
the future
c) placental abruption – where the placenta separates from the uterus before birth, causing
bleeding, pain and contractions
d) placenta previa – where the placenta attaches to the lower part of the uterus and partly or
completely blocks the neck of the womb. As a result, the mother may suffer vaginal bleeding
during pregnancy
e) pre-eclampsia and eclampsia – pre-eclampsia (or pregnancy-induced high blood pressure)
causes severe swelling from water retention. It can lead to kidney and liver failure.
f) premature rupture of membranes  (PROM) – where the bag of amniotic fluid breaks before
contractions or labour begin. This is an emergency if the waters break before 37 weeks of
pregnancy and lead to a major leak of amniotic fluid or infection of the amniotic sac.

Obstetric emergencies during labour

a) shoulder dystocia – where the baby's shoulders wedge in the birth canal after the birth of the
baby’s head. Depending on its position, the baby may start to lose oxygen
b) prolapsed umbilical cord – where the umbilical cord is pushed down into the cervix or vagina
before the baby is born. If the cord becomes compressed, the fetus does not receive enough
oxygen. The result may be brain damage or even death
c) placenta accreta – where the placenta is implanted too deeply in the uterine wall and cannot
come out after the baby is born
d) rupture of the uterus – where a weak spot in the uterus tears
e) inversion of the uterus – where a portion of the placenta remains attached to the uterine wall,
and pulls the uterus out 
f) amniotic fluid embolism – where fluid moves from the amniotic sac (bag of waters) and ends up
in the mother’s blood. This very rare complication can happen during pregnancy but usually
occurs during strong contractions in labour and causes serious complications including death of
the mother. 
(https://www.betterhealth.vic.gov.au/health/healthyliving/pregnancy-obstetric-emergencies)

VAGINAL BLEEDING
Definition
- any blood coming from the vagina (the canal leading from the uterus to the external genitals).
- first trimester  bleeding is any vaginal bleeding during the first three months of pregnancy.
Vaginal bleeding may vary from light spotting to heavy bleeding with clots.
- Any vaginal bleeding during the second and third  trimesters  of pregnancy (the last 6 months of a
9-month pregnancy) involves concerns different from bleeding in the first three months of the
pregnancy. Any bleeding during the second and third trimesters is abnormal.

- Bleeding from the vagina after the 28th week of pregnancy is a true emergency.  The bleeding
can range from very mild to extremely brisk and may or may not be accompanied by abdominal
pain.
-  Hemorrhage (another word for bleeding) and its complications are the most common cause of
death
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First-trimester bleeding isn’t always a problem. It may be caused by:
a) Implantation of the fertilized egg in the uterus.
b) Hormonal changes
c) Undetermined factors that cause no harm to the mother or baby.

More serious causes of first-trimester bleeding may include:

1. Miscarriage - women will have vaginal bleeding prior to the loss of the pregnancy.
2. Ectopic pregnancy - fertilized egg develops outside of the uterus, usually in the fallopian tube, it
may cause cramping and bleeding.
3. Molar pregnancy - known as a hydatidiform mole or trophoblastic disease, molar pregnancy is a
condition in which the pregnancy does not form properly.

Mid- or late-term bleeding may be caused by:

a) Trauma to the sensitized cervix, such as sexual intercourse or an internal exam.
b) Diseases of the vagina or cervix, including infections.
c) Unknown causes that pose no threat to the mother or baby.
d) Uterine fibroids or cervical polyps.

More serious causes of late-term bleeding may include:

1. Placenta previa. The placenta has implanted in the lower portion of the uterus and covers the
cervix and its opening.
2. Placenta abruptio. The placenta becomes detached, either partially or fully, from the uterine
wall.
3. Late miscarriage.
4. Preterm labor. Dilatation of the cervix associated with uterine contractions that occurs between
20 and 37 weeks of pregnancy is called preterm labor.

CAUSES OF FIRST TRIMESTER BLEEDING

I. Miscarriage
 is the spontaneous loss of pregnancy during the first 20 weeks of gestation. It is also called
"spontaneous abortion," or early pregnancy loss.
 most early miscarriages are a result of a developing fetus that is unhealthy and has no chance of
surviving to the end of pregnancy.

Several Types Of Miscarriage

1. Threatened miscarriage
- is showing signs that you might miscarry, that is called a ‘threatened miscarriage’. You may have
a little vaginal bleeding or lower abdominal pain. It can last days or weeks and the cervix is still
closed.
- The pain and bleeding may go away and you can continue to have a healthy pregnancy and
baby.
2. Inevitable miscarriage
 can come after a threatened miscarriage or without warning. There is usually a lot more vaginal
bleeding and strong lower stomach cramps. During the miscarriage your cervix opens and the
developing fetus will come away in the bleeding.

3. Complete miscarriage
 has taken place when all the pregnancy tissue has left your uterus. Vaginal bleeding may
continue for several days. Cramping pain much like labour or strong period pain is common –
this is the uterus contracting to empty.

4. Incomplete miscarriage
 Sometimes, some pregnancy tissue will remain in the uterus. Vaginal bleeding and lower
abdominal cramping may continue as the uterus continues trying to empty

5. Missed miscarriage
 the baby has died but stayed in the uterus.
 you may have a brownish discharge. Some of the symptoms of pregnancy, such as nausea and
tiredness, may have faded.
 No bleeding, closed cervix os, no fetal cardiac activity or empty sac

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6. Recurrent miscarriage
 A small number of women have repeated miscarriages. If this is your third or more miscarriage
in a row, it’s best to discuss this with your doctor who may be able to investigate the causes,
and refer you to a specialist.

(https://www.pregnancybirthbaby.au)

Some known causes of miscarriage included;

1. Chromosomal abnormalities 5. Autoimmune disease
2. Uterine abnormalities 6. Blood clotting
3. Infections and diseases 7. Other possible causes
4. Age of the mother

The most common signs of a miscarriage include:

1. spotting that lasts longer than three days
2. bleeding that may include clots or tissue
3. mild to severe pain and cramping in your back and abdomen
4. weight loss
5. fluid or mucus discharge from the vagina
6. a decrease in signs of pregnancy, such as breast tenderness, nausea, and vomiting

Miscarriage prevention:
1. Get regular prenatal care throughout your pregnancy.
2. Avoid alcohol, drugs, and smoking while pregnant.
3. Maintain a healthy weight before and during pregnancy.
4. Avoid infections. Wash your hands thoroughly, and stay away from people who are already sick.
5. Limit the amount of caffeine to no more than 200 milligrams per day.
6. Take prenatal vitamins to help ensure that you and your developing fetus get enough nutrients.
7. Eat a healthy, well-balanced dietwith lots of fruits and vegetables.

Treatment for a threatened miscarriage includes:

1. bed rest
2. avoiding sexual intercourse
3. treatment for any underlying conditions that may be causing the bleeding
4. an injection of the hormone progesterone
5. an injection of Rh immunoglobulin if your baby has Rh-positive blood and you have Rh-negative
blood

Some tissue present in your body, there are a few different treatment options:
a) expectant management, which is where you wait for the remaining tissue to pass naturally out
of your body
b) medical management, which involves taking medications to help you pass the rest of the
remaining tissue
c) surgical management, which involves having any remaining tissue surgically removed

Take your time to grieve for your loss, and ask for support when you need it. You may also want
to consider the following:
1. Reach out for help if you’re overwhelmed. Your family and friends may not understand how
you’re feeling, so let them know how they can help.
2. Store any baby memorabilia, maternity clothing, and baby items until you’re ready to see them
again.
3. Engage in a symbolic gesture that may help with remembrance. Some women plant a tree or
wear a special piece of jewelry.
4. Seek counseling from a therapist. Grief counselors can help you cope with feelings of
depression, loss, or guilt.
5. Join an in-person or online support group to talk with others who have been through the same
situation.

For recurrent miscarriage patients:

 blood tests to detect hormone imbalances
 chromosome tests, using blood or tissue samples
 pelvic and uterine exams
 ultrasounds
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II. Ectopic pregnancy
 occurs when the fertilized egg implants in some part of the body other than the uterus example
at fallopian tube.
 is also more prevalent in women whose fallopian tubes have been blocked or damaged due to
endometriosis, scarring after tubal surgery, pelvic inflammatory disease (PID), or a previous
ectopic pregnancy.
 Other risk factors include infertility, exposure to several STDs, smoking, and having an IUD in
place during conception.
 Signs and symptoms classically include abdominal pain and vaginal bleeding and pain may be
described as sharp, dull, or crampy
 can lead to severe, life-threatening internal bleeding.

Symptoms that are alarming and consult your doctor;

1. significant cramping or tenderness, usually on one side of the lower abdomen.
2. brown vaginal spotting or light bleeding.
3. heavy bleeding if the tube ruptures.
4. nausea and vomiting (which might be difficult to distinguish from morning sickness).
5. dizziness or weakness. (if the tube ruptures, a weak pulse, clammy skin, and fainting are
common.)
6. shoulder or neck pain (caused by the build up of blood under the diaphragm when the tube
ruptures)

Test for suspected ectopic pregnancy:

a) A series of highly sensitive pregnancy tests are administered to track the level of the hormone
HCG in your blood.
b) Ultrasound exams are also used to determine whether your pregnancy is developing in the right
place or if there is any fluid in the pelvis.
c) Laparoscopic surgery is another option to try to locate a pregnancy that may be ectopic. In this
procedure, the surgeon inserts a small camera through your belly button and looks at the tubes
and ovaries to see if there is an ectopic pregnancy.
Laparoscopy
- a surgical treatment which issmall incision is made in the lower abdomen, near or in the
navel.
Laparoscope
- a fiber-optic instrument inserted through the abdominal wall to view the organs in the
abdomen or permit small-scale surgery.

III. Molar pregnancy

 the result of a genetic error during the fertilization process that leads to a growth of abnormal
tissue within the uterus.
 called gestational trophoblastic disease (GTD), hydatidiform mole or simply referred to as a
“mole.”
 has the appearance of a large and random collection of grape-like cell clusters.

TWO TYPES OF MOLAR PREGNANCIES

a) Complete - only placental parts (there is no baby) and form when the sperm fertilizes an empty
egg.
- the egg is empty, no baby is formed.
- the placenta grows and produces the pregnancy hormone, HCG.
- an ultrasound will show that there is no foetus, only a placenta.

b) Partial - occurs when the mass contains both the abnormal cells and an embryo that has severe
birth defects.
- the fetus will be overcome by the growing abnormal mass rather quickly.
- extremely rare version of a partial mole is when twins are conceived but one embryo
begins to develop normally while the other is a mole..

Symptoms of a molar pregnancy

1. vaginal spotting or bleeding 4. early preeclampsia ( high blood pressure )
2. nausea and vomiting 5. increased HCG levels
3. develop rare complications like thyroid 6. no fetal movement or heart tone detected
disease
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How to know if you have molar pregnancy?
a) A pelvic exam may reveal a larger or smaller uterus, enlarged ovaries, and abnormally high
amounts of the pregnancy hormone HCG.
b) A sonogram will often show a “cluster of grapes” appearance, signifying an abnormal
placenta.

Treatment
1. Dilatation & curettage
2. Hysterectomy
3. HCG monitoring

Emotional management of molar pregnancy:

a) There will have to be a healing time for all involved, and grief will be experienced.
b) Recognize that people may try to console you with statements like, “Well at least it wasn’t a
baby.” This doesn’t help, but at least know that they are trying. Let them know what you need.
c) What makes this type of loss further different from a “ normal miscarriage ” or loss is the
continued concern of the mother’s health. Make sure that you stick with your follow-up
appointments.
d) Support groups and counselling may prove beneficial.

SERIOUS CAUSES OF LATE-TERM BLEEDING

I. Placenta Previa
 is a condition that occurs during pregnancy when the placenta implants itself in the lower part
of the uterus, obstructing the cervical opening to the vagina.
 the placenta remains in the lower portion of the uterus, partly or completely covering the
cervical opening and requires you to have a C-section and, in some cases, causes severe, and
even life-threatening bleeding or haemorrhage.
 It is more common in women who have uterine fibroids, an abnormally developed uterus, or
scarring of the uterine wall caused by previous pregnancies, cesareans, uterine surgery, or
abortions.
 main symptom is painless vaginal bleeding that often occurs near the end of the second
trimester or beginning of the third trimester.
 There is no abdominal pain or tenderness associated with the bleeding.
 The flow may be light or heavy, and the color may be bright red. The bleeding may stop on its
own but can start again days or weeks later.
 Don’t do internal examination (IE)
THREE TYPES OF PLACENTA PREVIA
1. Marginal - the placenta is located near the edge of the cervix but does not block it.
2. Partial - the placenta covers part of the cervical opening.
3. Complete - the placenta completely covers the cervical opening.

Causes Placenta Previa

1. inflammation, 5. endometriosis,
2. surgery (curettage abortion, cesarean 6. hypoplasia of the uterus,
section, removal of fibroids, etc.), 7. isthmic-cervical insufficiency,
3. multiple complications in previous 8. cervix inflammation,
childbirth. 9. multiple pregnancy
4. uterine fibroids,

Symptoms of Placenta Previa

a. Bleeding
1. Provoking factors for bleeding may 5. sexual intercourse,
include: 6. increased intra-abdominal pressure
2. physical exertion, caused by constipation,
3. sudden cough movement, 7. heat (hot bath, sauna).
4. pelvic examination,
b. Anemia
c. Low blood pressure
d. Pre-eclampsia

II. Placenta Abruptio

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  is the separation of the placenta from the inner wall of the uterus before the baby is delivered.
Alternate names are placental abruption and abruptio placentae.
 decreases the supply of oxygen and nutrients to the fetus, making it one of the leading causes of
fetal death in the third trimester.
 The most common symptoms are vaginal bleeding and painful contractions.

Types of Abruptio Placenta

1. Marginal abruptio with external bleeding
2. Partial abruptio with concealed bleeding
3. Complete abruptio with concealed bleeding

The amount of bleeding depends on how much of the placenta has detached.
1. If the separation is slight, you may experience light bleeding. Cramping or uterine tenderness
also occur.
2. If the separation is moderate, you may notice heavier bleeding. Your uterus feels tender and
firm, and your abdominal pain feels more severe.
3. If more than half the placenta detaches, you may experience very heavy bleeding. You may also
experience uterine contractions.
4. aware of other symptoms, such as abdominal cramping or severe pain, backache, and reduced
fetal movement.

Risk Factors for Placental Abruption

1. Preeclampsia or high blood pressure.
2. Trauma or contractions during labor
3. Labor induction drugs such as Pitocin and Cytotec increase the risk of placental abruption
because they cause uterine tachysystole (a complication in which contractions are stronger,
more frequent, or longer-lasting; this can cause the placenta to tear away from the uterus).
4. Sudden decompression of the uterus from events such as the delivery of the first child in
a multiples birth or premature rupture of membranes (mother’s water breaking too soon)
5. Accidental puncture of the placenta from a needle (e.g. amniocentesis)
6. Chorioamnionitis (an infection of the two membranes of the placenta – the chorion and the
amnion – and the amniotic fluid.)
7. Abnormal uterine blood vessels
8. Previous placental abruption
9. Mother over the age of 35 or younger than 20
10. Male baby
11. Elevated maternal serum alpha-fetoprotein in the second trimester
12. Other less common causes include cocaine use, uterine fibroids, injury to the uterus (e.g. car
accident), alcohol use, and cigarette smoking.

Complications of placental abruption

1. Premature birth 6. Blood clotting issues
2. Low birth weight 7. Maternal hemorrhage
3. Fetal growth restriction 8. Fetus not getting enough oxygen*
4. Maternal blood loss 9. Fetal death
5. Need for blood transfusion

Signs of Placental Abruption

1. Bleeding during the second half of pregnancy or excessive bleeding during labor
2. Mild or intense abdominal pain
3. Back pain
4. Uterine contractions during labor that last longer than normal
5. Uterine irritability
6. Uterus that becomes hard to the touch during labor
7. Disproportionately enlarged uterus
8. Identification of bleeding behind the placenta (retro-placental hematoma) on ultrasound
9. Debris in the amniotic fluid, thickened placenta, and collection of fluid around the maternal-fetal
membranes on ultrasound
10. Blood tests, such as a fibrinogen level and DIC, can help reveal the degree of abruption and
bleeding.
11. Maternal low blood pressure (hypotension) and fetal heart rate abnormalities suggest significant
placental separation that could result in severe oxygen deprivation or death.

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Small Amounts of Bleeding Can Signal a Larger Problem
Bleeding can be concealed and therefore not escape through the vagina; thus, when abdominal
pain and uterine contractions are present, a patient should be carefully evaluated for abruption even if
there is minimal or no vaginal bleeding.

Failure to quickly deliver a baby when a placental abruption occurs can cause the baby to experience
severe oxygen deprivation (birth asphyxia), which can cause the following birth injuries/permanent
disabilities:
a) Hypoxic-ischemic encephalopathy (HIE): HIE usually involves damage to the basal ganglia,
cerebral cortex, or watershed regions of the brain, but it sometimes includes periventricular
leukomalacia (PVL)
b) Neonatal encephalopathy g) Learning disabilities
c) Permanent brain damage h) Motor disorders
d) Seizure disorders i) Microcephaly
e) Cerebral palsy (CP)
f) Developmental delays

III. Preterm Labour

 labour that begins at 20 weeks and before the 37th week is considered "preterm" or
"premature."

Risk Factors for premature labour

1. Preeclampsia
2. Maternal health problems such as kidney disease, diabetes, or heart disease.
3. Multiple pregnancy
4. Problems with the placenta, such as placenta previa or placenta abruptio.
5. Problems with the uterus, such as structural defects, an incompetent cervix, or fibroids.
6. Past preterm labor or delivery.
7. Short intervals (less than a year) between pregnancies.
8. Being younger than 18 or older than 40 during pregnancy.
9. PPROM (Preterm Premature Rupture of Membranes).
10. Other possible culprits include vaginal infections, poor nutrition, stress, depression, smoking,
and alcohol and drug abuse.

Symptoms of Preterm Labour

1. Uterine contractions, lower back pain, or pressure in your groin or upper thighs.
2. Fluid that leaks from your vagina in a trickle or a gush.
3. Spotting or vaginal bleeding.
4. A thick, mucousy discharge that's tinged with blood.
5. Abdominal cramping.
6. Severe or persistent headaches.
7. Dizziness or visual disturbances.
8. Fever or chills.
9. Frequent vomiting (more than twice a day).
10. Painful urination.
11. Yeast or other vaginal infections (yellowish or greenish discharge, itching, or a strong vaginal
odour).

Prevention - promote a healthy, full-term pregnancy. For example:

a) Seek regular prenatal care.
b) Eat a healthy diet.
c) Avoid risky substances.
d) Consider pregnancy spacing.
e) Be cautious when using assisted reproductive technology (ART).

If your health care provider determines that you're at increased risk of preterm labour, he or she might
recommend taking additional steps to reduce your risk, such as:
 Taking preventive medications. (INMT)
 Managing chronic conditions. Certain conditions, such as diabetes and high blood pressure,
increase the risk of preterm labour. Work with your health care provider to keep any chronic
conditions under control.

Vaginal Postpartum Bleeding (Postpartum Haemorrhage)

Definition
 Heavy bleeding after giving birth
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  most likely to happen the first 24 hours after delivery. But it can happen anytime within the first 12
weeks after your baby is born.
 It can cause a big drop in your blood pressure.
 excessive blood loss or postpartum bleeding is determined when a woman loses more than 500
ml of blood after vaginal birth and more than 1000 ml after a C-section. 
 Primary postpartum haemorrhage(PPH) – define as blood loss of 500 ml or more within 24 hours
after normal vaginal delivery.

Antenatal Risk factors

1. Overdistension of uterus (multiple 4. Previous CS
pregnancies, polyhydramnios, 5. Maternal anaemia (hgb-8g/dl or less)
macrosomia) 6. Pre-eclampsia
2. Grandmultipara 7. Pre-existing uterine malformations
3. Past history of PPH 8. Pre-existing coagulations
9. Prolonged preterm premature rupture of membranes/chorioamnionitis
10. Use of tocolytics

Intrapartum Risk Factors

1. Induction of labor 6. Operative vaginal birth
2. Prolonged labour 7. Retained placenta
3. Abruptio placenta 8. Prolonged oxytocin use
4. Placenta praevia
5. Placenta accreta or variant

4 T’s Causes of PPH

1. Tone- uterine atony
2. Trauma- includes lacerations of vagina and cervix, uterine inversion and uterine rupture
3. Tissue- refers to retained products of conceptions or clots
4. Thrombin- refers to acquired or inherit coagulopathy, especially disseminated intravascular
coagulopathy

Primary postpartum hemorrhage (PPH) medical prophylaxis

1. Oxytocin
2. Ergometrine and oxytocin/ergometrine
3. Misoprostol

Common causes of bleeding after cesarean delivery include:

 Uterian trauma  Uterine atony

 Placenta accreta  Lacerations

Symptoms or signs
1. Bright red bleeding beyond the third day 5. Chills
after birth 6. Clammy skin
2. Blood clots bigger than a plum 7. Rapid heartbeat
3. Bleeding that soaks more than one 8. Dizziness
sanitary pad an hour and doesn’t slow 9. Weakness
down or stop 10. Nausea
4. Blurred vision 11. Faint feeling

There are many different treatments for postpartum haemorrhage.

 Give you medicine to help your uterus contract

 Massage your uterus

 Remove pieces of the placenta still in your uterus

 Perform a laparotomy -- surgery to open your abdomen to find out the cause of bleeding and stop it

 Give you a blood transfusion -- blood is given to you through a tube that goes in a vein to help replace
blood you've lost

 Perform a hysterectomy -- surgical removal of the uterus

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  Give you a shot of a special medicine to stop the bleeding

 Have a radiologist do what's called a uterine artery embolization, which limits blood flow to your
uterus

 Use something called a Bakri balloon that's inflated inside your uterus and adds pressure to help slow
the bleeding/ uterine tamponade

 bimanual compression

Active management of the Third Stage of Labour

 is the best preventive strategy

 consist of prophylactic administration of uterotonic drugs upon delivery of infant, delivery of placenta
using controlled cord contraction and uterine massage after delivery of placenta.

Advantages of Active management of the Third Stage of Labour

a) Decreases length of third stage

b) Decreases likelihood of prolonged third stage
c) Decreases average blood loss
d) Decreases number of PPH cases
e) Decreases need for blood transfusion

SHOCK

 is a critical condition and a life threatening medical emergency

 results from acute, generalized, inadequate perfusion of tissues, below that needed to deliver the
oxygen and nutrients for normal function.

 The main symptom of shock is low blood pressure.

 Shock  prevention  includes learning ways to prevent  heart disease, injuries,  dehydration and
other causes of shock.

Causes

a) Heart conditions (heart attack, heart failure)

b) Heavy internal or external bleeding, such as from a serious injury or rupture of a blood vessel
c) Dehydration, especially when severe or related to heat illness.
d) Infection (septic shock)
e) Severe allergic reaction (anaphylactic shock)
f) Spinal injuries (neurogenic shock)
g) Burns

h) Persistent vomiting  or  diarrhea

MAIN TYPES OF SHOCK

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 1. Cardiogenic shock – happens when the heart is damaged and unable to supply sufficient blood to
the body. This can be the end result of a heart attack or congestive heart failure.

2. Hypovolemic shock - is caused by severe blood and fluid loss, such as from traumatic bodily
injury, which makes the heart unable to pump enough blood to the body, or
severe anemia where there is not enough blood to carry oxygen through the body.

3. Anaphylactic shock - is a type of severe hypersensitivity or allergic reaction. Causes

include allergy  to insect stings, medicines, or foods (nuts, berries, and seafood), etc.

4. Septic shock - results from bacteria multiplying in the blood and releasing toxins. Common
causes of this are pneumonia,  urinary tract infections, skin infections (cellulites), intra-
abdominal infections (such as a ruptured appendix), and meningitis.

5. Neurogenic shock- is caused by spinal cord injury, usually as a result of a traumatic accident or
injury.

Symptoms of all types of shock include:

a) Rapid, shallow breathing d) Dizziness or fainting

b) Cold, clammy skin e) Weakness
c) Rapid, weak pulse

Depending on the type of shock the following symptoms may also be observed:

 Eyes appear to stare  Low or no urine output

 Anxiety or agitation  Bluish lips and fingernails
 Seizures  Sweating
 Confusion or unresponsiveness  Chest pain

Treatment for shock depends on the cause:

a) Septic shock is treated with antibiotics and fluids.
b) Cardiogenic shock is treated by identifying and treating the underlying cause
c) Hypovolemic shock is treated with fluids (saline) in minor cases, and blood transfusions in severe
cases.
d) Neurogenic shock is the most difficult to treat as spinal cord damage is often irreversible.
Immobilization, anti-inflammatories such as steroids and surgery are the main treatments.
e) Anaphylactic shock is treated with diphenhydramine (Benadryl), epinephrine (an "Epi-pen"), and
steroid medications (solu-medrol).

Self-Care at Home
a) Call for immediate medical attention any time a person has symptoms of shock. Do not wait for
symptoms to worsen before calling for help.
b) While waiting for help or on the way to the emergency room, check the
person's airway, breathing and circulation (the ABCs). Administer CPR if you are trained. If the
person is breathing on his or her own, continue to check breathing every 2 minutes until help
arrives.
c) Do NOT move a person who has a known or suspected spinal injury (unless they are in imminent
danger of further injury).
d) Have the person lie down on his or her back with the feet elevated above the head (if raising the
legs causes pain or injury, keep the person flat) to increase blood flow to vital organs. Do not
raise the head.
e) Keep the person warm and comfortable. Loosen tight clothing and cover them with a blanket.
f) Do not give fluids by mouth, even if the person complains of thirst. There is a choking risk in the
event of sudden loss of consciousness.
g) Give appropriate first aid for any injuries.
h) Direct pressure should be applied to any wounds that are bleeding significantly.

SHOCK IN OBSTETRICS
Haemorrhagic (Hypovolemic Shock)
 The commonest cause of shock in obstetrics either appertaining alone or in association
with trauma.
 It is a kind of shock pertaining to massive blood loss.
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  The clinical syndrome that results from inadequate tissue perfusion which leads to
hypoxia and ultimately cellular dysfunction which manifests as lactic acidosis
 is a medical emergency where the body begins to shut down due to heavy blood loss. It
results from injuries that involve heavy bleeding.
Etiology
Blood loss
a) Trauma
b) Retroperitoneal bleed
c) Obstetrics haemorrhage
1. Ante partum
2. Postpartum
3. Ectopic pregnancy

Symptoms include:
1. anxiety 7. confusion
2. blue lips and fingernails 8. chest pain
3. low or no urine output 9. loss of consciousness
4. profuse (excessive) sweating 10. low blood pressure
5. shallow breathing 11. rapid heart rate
6. dizziness 12. weak pulse

Signs of internal hemorrhaging include:

1. abdominal pain 5. vomiting blood
2. blood in the stool 6. chest pain
3. blood in the urine 7. abdominal swelling
4. vaginal bleeding

Stages of Hemorrhagic Shock

a) Compensated
- Defense mechanism are successful in maintaining perfusion
Presentation:
a. Tachycardia
b. Decreased skin perfusion
c. Altered mental status
b) Uncompensated
- Defense mechanism begin to fail
Presentation:
a. Hypotension d. Agitation, restlessness &
b. Marked increase in heart rate confusion
c. Rapid & thread pulse
c) Irreversible
- Complete failure of compensatory mechanisms
- Marked loss of tissue perfusion cause cellular damage and death even in the presence of
resuscitation
(https:/www.slideshares.net/jayatheeswaranvijayakumar)
Common complications of hemorrhagic shock include:
kidney damage death
other organ damage

Note to remember:
1. primary treatment of hemorrhagic shock is to control the source of bleeding as soon as possible
and to replace fluid.
2. controlled hemorrhagic shock (CHS), where the source of bleeding has been occluded, fluid
replacement is aimed toward normalization of hemodynamic parameters.
3. uncontrolled hemorrhagic shock (UCHS), in which the bleeding has temporarily stopped because
of hypotension, vasoconstriction, and clot formation, fluid treatment is aimed at restoration of
radial pulse or restoration of sensorium or obtaining a blood pressure of 80 mm Hg by aliquots of
250 mL of lactated Ringer's solution (hypotensive resuscitation)

CLASSIFICATION OF HEMORRHAGIC SHOCK

Compensated Mild Moderate Severe
Blood Loss (mL) ≤1000 1000–1500 1500–2000 >2000
Heart rate (bpm) <100 >100 >120 >140
Blood pressure Normal Orthostatic Marked fall Profound fall
11
 change
Capillary refill Normal May be delayed Usually delayed Always delayed
Respiration Normal Mild increase Moderate Marked tachypnea:
tachypnea respiratory collapse
Urinary output >30 20–30 5–20 Anuria
(mL/h)
Mental status Normal or agitated Agitated Confused Lethargic, obtunded

MALPOSITION AND MALPRESENTATION

Malpositions
 are abnormal positions of the vertex of the fetal head (with the occiput as the reference point)
relative to the maternal pelvis.

Malpresentation
 fetus is in an abnormal position or presentation that may result in prolonged or obstructed
labour
 are all presentations of the fetus other than vertex.
 increase the risk for uterine rupture because of the potential for obstructed labour.

Causes of Malpresentations and Malpositions

1. Defects in the powers:
a) Pendulous abdomen: laxity of the abdominal muscles.
b) Dextro-rotation of the uterus: rotation of the uterus in anti-clock wise favours occipito-
posterior in right occipito-anterior position.
2. Defects in the passages:
a) Contracted pelvis. d) Uterine anomalies as bicornuate,
b) Android pelvis. septate or fibroid uterus.
c) Pelvic tumours. e) Placenta praevia.
3. Defects in the passenger:
a) Preterm foetus. f) Polyhydramnios.
b) Intrauterine foetal death. g) Coils of the cord around the neck
c) Macrosomia. favours face presentation.
d) Multiple pregnancy.
e) Congenital anomalies as
anencephaly and hydrocephalus.

Complications of Malpresentations and Malpositions

1. Premature rupture of membranes or its rupture early in labour
2. Cord presentation and prolapsed
3. Prolonged labour due to hypotonic or hypertonic inertia
4. Obstructed labour with higher incidence of rupture uterus
5. Increased incidence of instrumental and operative delivery.
6. Increased incidence of trauma to the genital tract.
7. Increased incidence of postpartum haemorrhage and puerperal infection
8. Increased incidence of perinatal mortality.

MALPOSITIONS
DIAGNOSIS
A. Determine the presenting part
1. The most common presentation is the vertex of the fetal head. If the vertex is not the
presenting part
2. If the vertex is the presenting part, use landmarks of the fetal skull to determine the
position of the fetal head

 LANDMARKS OF THE FETAL SKULL 

12
 B. Determine the position of the fetal head
a. The fetal head normally engages in the maternal pelvis in an occiput transverse position, with
the fetal occiput transverse in the maternal pelvis
          
 OCCIPUT TRANSVERSE POSITIONS 

b. With descent, the fetal head rotates so that the fetal occiput is anterior in the maternal pelvis.
Failure of an occiput transverse position to rotate to an occiput anterior position should be
managed as an occiput posterior position. 
OCCIPUT ANTERIOR POSITIONS 
           
                       
 

c. An additional feature of a normal presentation is a well-flexed vertex with the fetal occiput
lower in the vagina than the sinciput.
 
WELL-FLEXED VERTEX 

d. If the fetal head is well-flexed with occiput anterior or occiput transverse ( in early

labour), proceed with delivery.
e. If the fetal head is not occiput anterior, identify and manage the malposition
f. If the fetal head is not the presenting part or the fetal head is not well-flexed, identify and
manage the malpresentation

Factors that favour malposition

1. pendulous abdomen – in multiparae
2. anthropoid pelvic brim – favours direct ( O.P/O.A )
3. a flat sacrum – transverse position
4. the placenta on the anterior uterine wall

Diagnosis on labour
I. Abdominal examination
1. Lower part of the abdomen is flattened 3. Fetal limbs are palpable anteriorly
2. Difficult to palpate fetal back 4. Fetal heart may be heard in the flanks

II. Vaginal examination

1. Posterior fontanelle towards the sacral-iliac joint (difficult)
2. Anterior fontanelle is easily felt, if head deflexed
3. Fetal head may be markedly molded with extensive caput, making diagnosis correct station and
position difficult

MALPRESENTATIONS

Predisposing factors to malpresentation include:

13
 1. Prematurity 5. Abnormal fetus
2. Multiple pregnancy 6. Placenta praevia
3. Abnormalities of the uterus - eg, fibroids 7. Primiparity
4. Partial septate uterus

Signs Suggestive of Malpresentations

a) Pendulous abdomen.
b) Non-engagement of the presenting part in the last 3-4 weeks in primigravida
c) Premature rupture of membranes or its rupture early in labour.
d) Delay in the descent of the presenting part during labour.
e) Vaginal examination, X-ray or ultrasonography are more conclusive

Types of Malpresentation
1. Breech Presentation
a) Complete (flexed) c) Footling
b) Frank (extended)
2. Brow Presentation 5. Transverse lie and shoulder presentation
3. Face Presentation 6. Multiple pregnancy
4. Compound Presentation

1. Breech Presentation
 occurs when the buttocks and/or the feet are the presenting parts.

Types Of Breech Presentation

a) Complete breech is characterised by flexion of the legs at both hips and knee joints, so the legs
are bent underneath the baby.
b) Frank breech is the commonest type of breech presentation, and is characterised by flexion at
the hip joints and extension at the knee joints, so both the baby’s legs point straight upwards.
c) Footling breech is when one or both legs are extended at the hip and knee joint and the baby
presents ‘foot first’.

Diagnosis on labour
I. Abdominal Examination
 the head is felt in the upper abdomen and the breech in the pelvic brim.
 auscultation locates the fetal heart higher than expected with a vertex
 the whole back of a baby in the vertex position will move if you rock it at the fundus
 the head can be ‘rocked’ and the back stays still in a breech presentation.
II. Vaginal Examination
 the buttocks and/or feet are felt; thick, dark meconium is normal
 if the baby’s legs are extended, you may be able to feel the external genitalia and even tell the
sex of the baby before it is born.

Favour a Breech Presentation during Labour

a) premature labour, beginning before the baby undergoes spontaneous inversion from breech to
vertex presentation
b) Multiple pregnancy, preventing the normal inversion of one or both babies
c) Polyhydramnios: excessive amount of amniotic fluid, which makes it more difficult for the fetal
head to ‘engage’ with the mother’s cervix
d) Hydrocephaly (‘water on the brain’) i.e. an abnormally large fetal head due to excessive
accumulation of fluid around the brain
e) placenta praevia
f) Breech delivery in the previous pregnancy
g) Abnormal formation of the uterus.

Risks of breech presentation

1. The fetal head gets stuck (arrested) before delivery
2. Labour becomes obstructed when the fetus is disproportionately large for the size of the
maternal pelvis
3. Cord prolapsed may occur, i.e. the umbilical cord is pushed out ahead of the baby and may get
compressed against the wall of the cervix or vagina
4. Premature separation of the placenta (placental abruption)
5. Birth injury to the baby, e.g. fracture of the arms or legs, nerve damage, trauma to the internal
organs, spinal cord damage, etc.

14
 6. may also result in trauma to the mother’s birth canal or external genitalia through being
overstretched by the poorly fitting fetal parts

Management
Intrapartum Management
a. Vaginal breech birth should take place in a hospital with facilities for emergency caesarean
section.
b. Labour induction for breech presentation may be considered if individual circumstances are
favourable.
c. Labour augmentation is not recommended.
d. Epidural analgesia should not be routinely advised; women should have a choice of analgesia
during breech labour and birth.
e. Continous electronic fetal heart rate monitoring should be offered to women with a breech
presentation in labour
f. Fetal blood sampling from the buttocks during labour is not advised
g. Caesarean section should be considered if there is delay in the descent of the breech at any
stage in the second stage of labour.
h. Failure of the presenting part to descend may be a sign of relative fetopelvic disproportion.
Caesarean section should be considered.
i. Women should be advised that, as most experience with vaginal breech birth is in the dorsal or
lithotomy position, that this position is advised.
j. Episiotomy should be performed when indicated to facilitate delivery
k. Breech extraction should not be used routinely
l. The arms should be delivered by sweeping them across the baby’s face and downwards or by
the Lovset manoeuvre (rotation of the baby to facilitate delivery of the arms).
m. Suprapubic pressure by an assistant should be used to assist flexion of the head. The Mauriceau-
Smellie-Veit manoeuvre should be considered, if necessary, displacing the head upwards and
rotating to the oblique diameter to facilitate engagement.
n. The aftercoming head may be delivered with forceps, the Mariceau-Smellie-Veit manoeuvre or
the Burns-Marshall method.
o. If conservative methods fail, symphysiotomy or caesarean section should be performed

2. Brow Presentation
 engagement is usually impossible and arrested labour is common. Spontaneous conversion to
either vertex presentation or face presentation can rarely occur, particularly when the fetus is
small or when there is fetal death with maceration.
 It is unusual for spontaneous conversion to occur with an average-sized live fetus once the
membranes have ruptured.
 is caused by partial extension of the fetal head so that the occiput is higher than the sinciput
 If the fetus is alive, deliver by caesarean section. 
 If the fetus is dead and: 
a. the cervix is not fully dilated, deliver by caesarean section;
b. the cervix is fully dilated:
c. Deliver by craniotomy
d. If the operator is not proficient in craniotomy, deliver by caesarean section.

Diagnosis
I. Abdominal Examination
 more than half the fetal head is above the symphysis pubis and the occiput is palpable at a
higher level than the sinciput.
II. Vaginal Examination,
 the anterior fontanelle and the orbits are felt.

Causes of Brow Presentation

1. Lax uterus due to repeated full term 5. Premature birth/low birth weight baby
pregnancy 6. Big baby
2. Multiple pregnancy 7. Fetal abnormality
3. Polyhydramnios 8. Multiple nuchal cords
4. Abnormal shape of the mother’s pelvis/
Cephalopelvic disproportion

Complications of brow presentation

1. Obstructed labour and ruptured uterus 3. Facial bruising
2. Cord prolapsed 4. Cerebral haemorrhage.
15
Management
When the baby is in brow presentation, the labor will not progress as it should and prolonged labor
can result in fetal distress, calling for an immediate C-section. However, if the baby picks up brow
presentation and your cervix is fully dilated, there are two procedures through which the doctors try to
avoid the need of C-section.

 Manual rotation: Doctor inserts his hand through the cervix and tries to flex the baby’s head

 Utilization of ventouse: Doctor uses the ventouse to flex the baby’s head by pulling during
contraction with maternal pushing. However, for using ventouse for flexing the baby’s head,

 The baby’s head should be engaged in the pelvis and should be in a front anterior
position

 The pelvis should have sufficient room to permit the ventouse cup to be inserted
posteriorly and to reach the occiput

 The success rate of these two methods depends on

 Ability and experience of the obstetrician

 How favorable is the position of the baby’s head inside the pelvis

 Available space inside the pelvis

3. Face Presentation
The chin serves as the reference point in describing the position of the head. It is necessary to
distinguish only chin-anterior positions in which the chin is anterior in relation to the maternal pelvis
Types of Face presentation
1. CHIN-ANTERIOR POSITION
If the cervix is fully dilated:
 allow to proceed with normal childbirth;
 if there is slow progress and no sign of obstruction, augment labour with oxytocin;
 if descent is unsatisfactory, deliver by forceps.
If the cervix is not fully dilated and there are no signs of obstruction, augment labour with
oxytocin. Review progress as with vertex presentation. 
2. CHIN-POSTERIOR POSITION
If the cervix is fully dilated, deliver by caesarean section.
If the cervix is not fully dilated, monitor descent, rotation and progress. If there are signs of
obstruction, deliver by caesarean section.
If the fetus is dead

Six positions in face presentation

1. Right mentoposterior
2. Left mentoposterior
3. Right mentolateral
4. Left mentolateral
5. Right mentoanterior
6. Left mentoanterior

Causes of face presentation

a) laxity (slackness) of the uterus after many previous full-term pregnancies
b) multiple pregnancy
c) polyhydramnios (excessive amniotic fluid)
d) congenital abnormality of the fetus (e.g. anencephaly, which means no or incomplete skull
bones)
e) abnormal shape of the mother’s pelvis.

Diagnosis
I. Abdominal Examination
 a groove may be felt between the occiput and the back.
II. Vaginal Examination
16
  the face is palpated, the examiner’s finger enters the mouth easily and the bony jaws are felt.

Complications
a) obstructed labour and ruptured uterus c) facial bruising
b) cord prolapsed d) cerebral haemorrhage

Management
a) do not attempt to convert face presentation to vertex
b) never apply vacuum extractor to face presentation
c) do not apply internal scalp electrodes
d) avoid oxytocin in most cases
e) consider large episiotomy if fetus delivers vaginally
 
4. Compound Presentation/ Rare Obstetric Events
 spontaneous delivery can occur only when the fetus is very small or dead and macerated.
arrested labour occurs in the expulsive stage.
 prolapsed of an extremity, usually a hand, along the presenting part, with both in the pelvis
simultaneously
 replacement of the prolapsed arm is sometimes possible:
Compound presentation can occur as a result
1. The fetal limb becoming trapped below the fetal head
2. The fetus not fully occupying the pelvis for some reason (possibly because it is small for
gestational age, the pelvis is large for fetal size, the patient presents with polyhydramnios, the
fetus is premature, or there are multiples)
3. Membranes that ruptured while the fetus is still high (premature rupture of membranes), which
can allow amniotic fluid to push a limb down before the head
4. In the case of multiples, a head of one baby exiting alongside of the other baby’s limb

Compound presentation has been associated with an increased risk of

1. arrested labor 2. dystocia
3. cord prolapse
4. injury to the presenting extremity

 Diagnosis
Using ultrasound examination

Management

 depends a great deal on patient-specific circumstances, there isn’t much data available to guide
general management of the condition.
 It is possible that the baby could reposition as labor continues. Commonly, the extremity will
retract during labor.
 But it is also likely that compound presentation will result in dystocia and arrested labor. If
compound presentation does not resolve with gentle pressure or on its own, a C-section
delivery should be used
 assist the woman to assume the knee-chest position
 push the arm above the pelvic brim and hold it there until a contraction pushes the head into
the pelvis.
 proceed with management for normal childbirth.
 if the procedure fails or if the cord prolapses, deliver by caesarean section

5. Transverse Lie and Shoulder Presentation

 if the woman is in early labour and the membranes are intact, attempt external version
 occur when the long axis of the fetus is transverse

 The shoulder is typically the presenting part.

 if external version is successful, proceed with normal childbirth;
 if external version fails or is not advisable, deliver by caesarean section
 monitor for signs of cord prolapsed. if the cord prolapses and delivery is not imminent, deliver
by caesarean section.
17
Note: Ruptured uterus may occur if the woman is left unattended  .

Diagnosis
I. Abdominal Examination
 neither the head nor the buttocks can be felt at the symphysis pubis and the head is usually felt
in the flank.
II. Vaginal Examination
 a shoulder may be felt, but not always. An arm may prolapse and the elbow, arm or hand may
be felt in the vagina.

Risk factors for transverse lie

1. Prematurity (this is the most 2. Multiparity

common risk factor for transverse 3. Placenta previa
lie at the time of delivery; babies 4. Polyhydramnios
are often in a transverse lie early in 5. Multiples pregnancy (e.g. twins)
pregnancy) 6. Pelvic, uterine, or fetal anomalies

Complications associated with transverse lie

1. Umbilical cord prolapse 7. Birth asphyxia (oxygen deprivation
2. Birth trauma around the time of birth, which can lead
3. Premature birth to forms of permanent brain damage
4. Uterine rupture such as hypoxic-ischemic
5. Maternal injury or death (e.g. from encephalopathy and cerebral palsy)
hemorrhage) 8. Septicemia - is a bacterial infection
6. Stillbirth spread through the entire vascular
system of the body.

Management of a fetus in transverse lie

1. If the fetus does not spontaneously rotate into a more favourable lie prior to term, intervention
will be necessary.
2. In some cases, it may be possible for a medical professional to manually rotate the fetus into a
head-first presentation. This may involve external version (pushing on the mother’s abdomen to
roll the fetus; typically medications are also involved) or internal version (reaching into the
mother’s uterus to move the fetus)
3. The medical team may also perform an amniotomy in order to induce labor after turning the
baby. In some cases (for example if version is unsuccessful) a C-section may be necessary (1).
Physicians should always be prepared for this possibility.

6. Multiple pregnancy
 when there is more than one fetus in the uterus.
 multiple pregnancies are twins (two fetuses), but there can also be triplets (three fetuses),
quadruplets (four fetuses), quintuplets (five fetuses), and other higher order multiples with a
declining chance of occurrence.

Types Of Twin Pregnancy

Twins may be identical (monozygotic) or non-identical and fraternal (dizygotic).
a. Monozygotic twins - develop from a single fertilised ovum (the zygote), so they are always the
same sex and they share the same placenta.
b. Dizygotic twins - develop from two different zygotes, so they can have the same or different
sex, and they have separate placentas. Figure 8.8 shows the types of twin pregnancy and the
processes by which they are formed.

Diagnosis of twin pregnancy

I. Abdominal Examination
a. The size of the uterus is larger than the expected for the period for gestation
b. The uterus looks round and broad, and fetal movement may be seen over a large area.
(The shape of the uterus at term in a singleton pregnancy in the vertex presentation
appears heart-shaped rounder at the top and narrower at the bottom.)
c. Two heads can be felt.
d. Two fetal heart beats may be heard if two people listen at the same time, and they can
detect at least 10 beats different
e. Ultrasound examination can make an absolute diagnosis of twin pregnancy

Consequences of twin pregnancy

18
 a. Women who are pregnant with twins are more prone to suffer with the minor disorders of
pregnancy, like morning sickness, nausea and heartburn.
b. Twin pregnancy is one cause of hyperemesis gravidarum (persistent, severe nausea and
vomiting).
c. Mothers of twins are also more at risk of developing iron and folate-deficiency anaemia during
pregnancy.

Complications
a. Pregnancy-related hypertensive disorders like pre-eclampsia and eclampsia are more common
in twin pregnancies
b. Pressure symptoms may occur in late pregnancy due to the increased weight and size of the
uterus.
c. Labour often occurs spontaneously before term, with premature delivery or premature rupture
of membranes (PROM).
d. Respiratory deficit (shortness of breath, because of fast growing uterus) is another common
problem.
e. Twin babies may be small in comparison to their gestational age and more prone to the
complications associated with low birth weight (increased vulnerability to infection, losing heat,
difficulty breastfeeding).

Management of women with malpresentation or multiple pregnancies

Any presentation other than vertex has its own dangers for the mother and baby. For this
reason, all women who develop abnormal presentation or multiple pregnancies should ideally have
skilled care by senior health professionals in a health facility where there is a comprehensive emergency
obstetric service. Early detection and referral of a woman in any of these situations can save her life and
that of her baby.

General Management
1. Make a rapid evaluation of the general condition of the woman including vital signs (pulse,
blood pressure, respiration, temperature).
2. Assess fetal condition:
3. Listen to the fetal heart rate immediately after a contraction:
4. Count the fetal heart rate for a full minute at least once every 30 minutes during the active
phase and every 5 minutes during the second stage;
5. If there are fetal heart rate abnormalities (less than 100 or more than 180 beats per minute),
suspect fetal distress.
6. If the membranes have ruptured, note the colour of the draining amniotic fluid:
7. Presence of thick meconium indicates the need for close monitoring and possible intervention
for management of fetal distress;
8. Absence of fluid draining after rupture of the membranes is an indication of reduced volume of
amniotic fluid, which may be associated with fetal distress.
9. Provide encouragement and supportive care.
10. Review progress of labour using a partograph.

SHOULDER DYSTOCIA

 is a birth injury (also called birth trauma) that happens when one or both of a baby’s shoulders
get stuck inside the mother’s pelvis during labor and birth.
 Dystocia - means a slow or difficult labor or birth.
 refers to a situation where, after delivery of the head, the anterior shoulder of the fetus
becomes impacted on the maternal pubic symphysis, or (less commonly) the posterior shoulder
becomes impacted on the sacral promontory.

Risk factors for shoulder dystocia include:

a. Macrosomia. This is when your baby weighs more than 8 pounds, 13 ounces (4,000 grams) at
birth. If your baby is this large, you may need to have a cesarean birth (also called c-section).
b. Having pre-existing diabetes or gestational diabetes. Diabetes is a medical condition in which
your body has too much sugar (called glucose or blood sugar) in your blood. Diabetes is a risk
factor for having a large baby.
c. Having shoulder dystocia in a previous pregnancy
d. Being pregnant twins, triples or other multiples
e. Being overweight or gaining too much weight during pregnancy
19
Conditions that are part of labor and birth also are risk factors for shoulder dystocia. These
include:
a. Getting a medicine called oxytocin to induce your labor (make your labor start).
b. Getting an epidural to help with pain during labor. An epidural is pain medicine you get through
a tube in your lower back that helps numb your lower body during labor
c. Having a very short or very long second stage of labor.
d. Having an assisted vaginal birth (also called operative vaginal birth). This means that your
provider uses tools, like forceps or a vacuum, to help your baby through the birth canal. Forceps
look like big tongs. Your provider places them around your baby’s head in the vagina to help
guide your baby out. A vacuum is a suction cup that goes around your baby’s head in the vagina
to help guide your baby out. This is the most common risk factor for shoulder dystocia.

Problems for the baby can include:

a. Fractures to the collarbone and arm
b. Damage to the brachial plexus nerves. These nerves go from the spinal cord in the neck down
the arm. They provide feeling and movement in the shoulder, arm and hand.
c. Damage can cause weakness or paralysis in the arm or shoulder. Paralysis is when you can’t feel
or move one or more parts of your body.
d. Lack of oxygen to the body (also called asphyxia). In the most severe cases, this can cause brain
injury or even death. This is rare.

Problems for the mother can include:

a. Postpartum hemorrhage (also called PPH). This is heavy bleeding after giving birth.
b. Serious tearing of the perineum (the area between the vagina and the rectum). Surgery may be
needed to repair the tearing.
c. Uterine rupture. This is when the uterus tears during labor. This is rare.

Risk Factors
Pre- Labour Intrapartum
1. Previous shoulder dystocia – increases 1. Prolonged 1st stage of labour
recurrence risk by x10 2. Secondary arrest (when there is initially good
2. Macrosomia – fetal weight above >4.5kg. progress in labour and then progress stops,
However 48% happen in babies weighing <4kg. usually due to malposition of the baby)
3. Diabetes – increases risk by x2-4 (due to 3. Prolonged second stage of labour (time whilst
increased risk of macrosomia – baby’s weight fully dilated and pushing)
distribution is disproportionately bigger in 4. Augmentation of labour with oxytocin
abdomen compared to head) 5. Assisted vaginal delivery (e.g forceps or
4. Maternal BMI > 30 Induction of labour ventouse)

Diagnosis
1. difficulty in delivery of the fetal head or chin.
2. failure of restitution – the fetal remains in the occipital-anterior position after delivery by
extension and therefore does not ‘turn to look to the side
3. TURTLE NECK‘ SIGN – the fetal head retracts slightly back into the pelvis, so that the neck is no
longer visible, a turtle retreated into its shell.

Treatment
I. Intrapartum
1. Proper diet or small frequent eating
2. Plan B discussed
3. Suspected large baby scheduled for C-section
II. During delivery
1. Press your thighs up against your belly ( McRoberts maneuver)
2. Press on your lower belly just above your pubic bone ( suprapubic pressure )
3. Help your baby’s arm out of the birth canal (Barnum Maneuver)
4. Reach up into the vagina to try to turn your baby (corkscrew manoeuvre)
5. Give you an episiotomy. This is not done routinely but only in cases in which a larger opening to
the vagina is helpful and the incision won’t affect the baby.

20
 6. Do a c-section, other surgical procedures or break your baby’s collarbone to release his
shoulders. These are done only in severe cases of shoulder dystocia that aren’t resolved by
other methods.
7. Cleidotomy – fracturing the fetal clavicle
8. Symphysiotomy – cutting the pubic symphysis.
9. Zavenelli – returning the fetal head to the pelvis for delivery of the baby via caesarean section
10. Move the fetus into an oblique position and decrease bisocromial diameter

Management (HELPERR)
H - Obstetrician, Pediatrician
E – pisiotomy
L – egs elevate
P – ressure (suprapubic)
E – nter vagina
R – oll the woman over and try again
R – emove posterior arm

FETAL DISTRESS
 occurs when the fetus suffers oxygen deprivation and become hypoxic (deprived of an adequate
supply of oxygen)
 Immediate management can avoid permanent injury and  hypoxic-ischemic encephalopathy
(HIE) = (type of brain damage caused by insufficient oxygenated blood flow during or near the
time of birth)

Signs of Fetal Distress

1. decreased fetal movement in the womb
 Some regular pauses in movement are normal because babies sleep in the womb. However, if
the baby becomes less active or completely ceases to move, this may be a cause for concern. 
2. abnormal fetal heart rate
 In a healthy labor and delivery, the baby’s heart rate will drop slightly during a contraction, and
then quickly return to normal once the contraction is over
Examples Of Nonreassuring Patterns
 An abnormally fast heart rate (tachycardia)
 An abnormally slow heart rate (bradycardia)
 Abrupt decreases in heart rate (variable decelerations)
 Late returns to the baseline heart rate after a contraction (late decelerations fetal monitoring,
an abnormal fetal heart rate may be recognized in a non-stress test (NST) or a contraction
stress test (CST).

Contraction Stress Test (CST) Non-Stress Test (NST)

The fetal heart rate is recorded in response to Fetal heart rate is measured in response to fetal
the uterine contractions. movement, without putting any stress on the fetus.
Nipple stimulation or oxytocin is used to start a Uterine contractions are not triggered in this
uterine contraction. procedure.
The test results are read as negative (normal) or The test results are read as reactive (normal) or non-
positive (abnormal). reactive (abnormal).
It is expensive and cumbersome. It is cost-effective, quick, and safer.
Not commonly used nowadays. Preferably recommended by doctors nowadays.

ABNORMAL FETAL HEART RATE

 A normal fetal heart rate may slow during a contraction but usually recovers to normal as soon as the
uterus relaxes.
A very slow fetal heart rate in the absence of contractions or persisting after contractions is suggestive
of fetal distress. 
A rapid fetal heart rate may be a response to maternal fever, drugs causing rapid maternal heart rate
(e.g. tocolytic drugs), hypertension or amnionitis. In the absence of a rapid maternal heart
rate, a rapid fetal heart rate should be considered a sign of fetal distress.

Physicians may also classify NST results into categories:

1. Normal
2. Requiring further testing and possibly delivery
3. An emergency C-section is necessary
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3. abnormal results of biophysical profile (BPP)
 includes an ultrasound to assess fetal movement, breathing, tone, and amniotic fluid volume
 A total score of eight or higher is considered normal, unless the zero score relates to low
amniotic fluid. A score of four or lower indicates fetal distress and requires immediate action 
4. abnormal amniotic fluid level
oligohydramnios - abnormally low amniotic fluid and can lead to oxygen deprivation and birth
injuries like HIE and cerebral palsy (CP)
polyhydramnios - an abnormally high amniotic fluid volume and can also cause oxygen
deprivation and subsequent birth injuries.
5. vaginal bleeding
 it is important to note that a placental abruption can be present with no vaginal bleeding
(bleeding can be retained behind the placenta), but may still pose a serious risk.
 A placental abruption and other placental problems that cause bleeding require very close
monitoring, and in many cases, the mother should be admitted to the hospital and given
an emergency C-section
6. cramping
 Some cramping is relatively normal during pregnancy. This is because as the baby grows, the
uterus needs to expand
 some cases cramping is an indication of something more serious, such as miscarriage,
placental abruption, preeclampsia, a urinary tract infection, or preterm labor.
7. maternal high blood pressure
8. insufficient or excessive maternal weight gain
 a mother gains much less than what is typical, the fetus may be in distress and have a condition
called intrauterine growth restriction (IUGR)
 Excessive maternal weight gain is associated with giving birth to a baby that is abnormally large,

Causes of fetal distress

1. Abnormal fetal presentation 8. Hyperstimulation of the uterus due to
2. Forceps and vacuum extractor misuse Pitocin or placental abruption
3. Placental abruption 9. Uterus not resting in between contractions
4. Preeclampsia 10. Infections such as Group B strep (GBS)
5. Prolonged and arrested labor 11. Shoulder dystocia
6. Umbilical cord problems 12. Prolonged rupture of membranes or
7. Uterine rupture amniotic sac

Treating fetal distress

a. must skillfully and continuously monitor fetal well-being throughout pregnancy, labor, and
delivery.
b. They are responsible for recognizing and responding to signs of fetal distress. If a baby is in
distress, appropriate interventions may include the administration of oxygen, fluids, and
medication to the mother, or a change in the mother’s position.
c. an emergency C-section is required in order to remove the baby from the conditions causing the
fetal distress, especially if earlier interventions did not cause fetal heart tones to become
reassuring.  An emergency C-section should be performed within 3 to 18 minutes, depending on
the circumstances, and sometimes a lot sooner.
http://www.abclawcenters.com

Benefits of FHR monitoring include:

a. The ability to recognize the development of hypoxia (when the fetus does not receive adequate
amounts of oxygen) by analyzing patterns in the fetal heart rate
b. The ability to monitor the mother’s contractions
c. The ability to monitor the response of the fetus to hypoxia
d. A more positive outcome for high-risk deliveries

Potential precursors to fetal distress or non-reassuring fetal status may include:

1. Anemia (the most prevalent obstetric condition seen behind non-reassuring fetal status)
2. Oligohydraminos (a condition in which there is a lower level of amniotic fluid around the fetus)
3. Pregnancy Induced Hypertension (PIH)
4. Post-term pregnancies (42 weeks or more)
5. Intrauterine Growth Retardation (IUGR)
6. Meconium-stained amniotic fluid (a condition in which meconium, a baby’s first stool, is present
in the amniotic fluid which can block fetal airways)
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General Management
a. Prop up the woman or place her on her left side.
b. Stop oxytocin if it is being administered.
c. If a maternal cause is identified (e.g. maternal fever, drugs), initiate appropriate management.
d. If a maternal cause is not identified and the fetal heart rate remains abnormal throughout at
least three contractions, perform a vaginal examination to check for explanatory signs  of
distress:
e. If there is bleeding with intermittent or constant pain, suspect abruptio placentae;
f. If there are signs of infection (fever, foul-smelling vaginal discharge) give antibiotics as for
amnionitis;
g. If the cord is below the presenting part or in the vagina, manage as prolapsed cord.
h. If fetal heart rate abnormalities persist or there are additional signs of distress (thick meconium-
stained fluid), plan delivery:
i. If the cervix is fully dilated and the fetal head is not more than 1/5 above the symphysis pubis or
the leading bony edge of the head is at 0 station, deliver by vacuum extraction or forceps;
j. If the cervix is not fully dilated or the fetal head is more than 1/5 above the symphysis pubis or
the leading bony edge of the head is above 0 station, deliver by caesarean section.

CORD PROLAPSED
 means that the cord precedes the baby through the vagina
 when a baby's umbilical cord, or lifeline, gets squeezed and it cuts off the vital blood supply and
oxygen to your baby
 uncommon complication may be obvious (overt) or not (occult).

Cord prolapsed occurs in the presence of ruptured membranes, and is either occult or overt:
Occult (incomplete) cord prolapsed – the umbilical cord descends alongside the presenting
part, but not beyond it.
Overt (complete) cord prolapsed – the umbilical cord descends past the presenting part and is
lower than the presenting part in the pelvis.
Cord presentation – the presence of the umbilical cord between the presenting part and the cervix.
This can occur with or without intact membranes.

Risk Factors
The main risk factors for cord prolapse include:
1. Breech presentation – in a footling breech, the cord can easily slip between and past the fetal
feet and into the pelvis.
2. Unstable lie – this is where the presentation of the fetus changes between
transverse/oblique/breech and back.
a. If >37 weeks gestation, consider inpatient admission until delivery due to risk of cord
prolapse
3. Artificial rupture of membranes – particularly when the presenting part of the fetus is high in the
pelvis.
4. Polyhydramnios – excessive amniotic fluid around the fetus
5. Prematurity

Complications
1. Fetal Distress
2. Intrapartum Fetal Death
3. Neonatal Asphyxia
4. Early Neonatal Death

Prevention
Identify risk factors
I. Intrapartum
Controlled artificial rupture of the membranes (ARM) by senior medical or midwifery staff in
the following situations:
a. High, ill-fitting presenting part
b. Unstable lie
c. >Polyhydramnios
d. Ensure emergency theatre is available and consider the need to exclude cord presentation
on ultrasound before ARM
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 Diagnosis
 The presence of cord should be excluded during all routine vaginal examinations in labour
and after spontaneous rupture of membranes where risk factors are present or if fetal heart
rate abnormalities commence soon thereafter
 Diagnosis is usually made during a vaginal examination when the examiner - feels a soft,
usually pulsatile structure
 On examination, the cord may be presenting (alongside the presenting part), or prolapsed
(in the vagina or in the introitus)

II. Antepartum
 Speculum or vaginal examination immediately after rupture of the membranes for women
with a high risk of cord prolapsed
 If cord presentation or prolapsed is diagnosed, call for immediate medical assistance.
Immediate assessment of clinical circumstances: gestation, presentation, cervical dilatation,
fetal wellbeing
 Obstetric emergency management will depend on gestation and viability and discussion
with the woman If no cord pulsation or fetal heart heard, confirm presence or absence of
fetal heart with portable ultrasound
 In cases of viability, expedite birth and manage as below

Anaesthetic and theatre management

 The aim should be to deliver the baby as soon as possible in a manner that provides for safe
anaesthesia for the mother
 There is poor correlation between the decision-to-delivery interval and umbilical cord pH1.
 The 30-minute decision-to-delivery interval is the acknowledged target for category 1 caesarean
section
 It is acknowledged that patient safety and attention to the individual woman is more important
than fixation on time target.
 A focused anaesthetic assessment of the woman must be conducted before anaesthetising the
woman
 If the woman has a working epidural in place, there may be time for this to be topped up, by the
anaesthetist, either before or en-route to theatre, thus avoiding general anaesthesia
 The majority of caesarean sections, where there is a cord prolapsed and there is no epidural in-
situ, are performed under general anaesthesia.
 It is a high priority to move the woman to the operating room:
 Depending upon local circumstances, some procedures e.g. intravenous cannulation, obtaining
group and save and urinary catheterisation can be delayed until the woman is in the operating
theatre
 The usual prophylaxis to prevent the adverse effects of the aspiration of gastric contents should
still be given to the woman, e.g. sodium citrate plus ranitidine

III. Second stage of labour

 If the woman is in the second stage of labour and vaginal birth is feasible with the presenting
part at or below spines, the doctor should prepare for operative delivery (vacuum extraction or
instrumental)
 If immediate vaginal delivery is not feasible, expedite delivery with caesarean section
 Obtain arterial and venous cord blood gases immediately after delivery
 Cord not pulsating
 Confirm fetal death with ultrasound scan
 Allow labour to proceed as for vaginal birth of fresh stillbirth

UNSATISFACTORY PROGRESS OF LABOUR

 the latent phase is longer than 8 hours.
 cervical dilatation is to the right of the alert line on the partograph.
 the woman has been experiencing labour pains for 12 hours or more without delivery
(prolonged labour).

General Management
1. Make a rapid evaluation of the condition of the woman and fetus and provide supportive care.
2. Test urine for ketones and treat with IV fluids if ketotic.
3. Review partograph.

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Findings Diagnosis
a. Cervix not dilated
b. No palpable contractions/infrequent contractions - False labour
c. Cervix not dilated beyond 4 cm after 8 hours of regular contractions - Prolonged latent phase
d. Cervical dilatation to the right of the alert line on the partograph
 Secondary arrest of cervical dilatation and descent of presenting part in presence of
good contractions
 Secondary arrest of cervical dilatation and descent of presenting part with large caput,
third degree moulding, cervix poorly applied to presenting part, oedematous cervix,
ballooning of lower uterine segment, formation of retraction band, maternal and fetal
distress
 Less than three contractions in 10 minutes, each lasting less than 40 seconds
e. Presentation other than vertex with occiput anterior - Prolonged active phase
f. Cephalopelvic disproportion (CPD)
g. Obstruction
h. Inadequate uterine activity
i. Malpresentation or malposition
j. Cervix fully dilated and woman has urge to push, but there is no descent - Prolonged expulsive
phase

MANAGEMENT
I. FALSE LABOUR
 Examine for urinary tract or other infection or ruptured membranes and treat accordingly. If
none of these are present, discharge the woman and encourage her to return if signs of labour
recur.

II. PROLONGED LATENT PHASE

a. The diagnosis of prolonged latent phase is made retrospectively. When contractions cease, the
woman is said to have had false labour. When contractions become regular and dilatation
progresses beyond 4 cm, the woman is said to have been in the latent phase.
b. Misdiagnosing false labour or prolonged latent phase leads to unnecessary induction or
augmentation, which may fail. This may lead to unnecessary caesarean section and amnionitis.
c. If a woman has been in the latent phase for more than 8 hours and there is little sign of
progress, reassess the situation by assessing the cervix:
 If there has been no change in cervical effacement or dilatation and there is no fetal
distress, review the diagnosis. The woman may not be in labour.
 If there has been a change in cervical effacement or dilatation, rupture the membranes
with an amniotic hook or a Kocher clamp and induce labour using oxytocin or
prostaglandins
 Reassess every 4 hours
d. If the woman has not entered the active phase after 8 hours of oxytocin infusion, deliver by
caesarean section.
 If there are signs of infection (fever, foul-smelling vaginal discharge):
 Augment labour immediately with oxytocin;
 Give a combination of antibiotics until delivery: ampicillin 2 g IV every 6 hours;
 PLUS gentamicin 5 mg/kg body weight IV every 24 hours;
 If the woman delivers vaginally , discontinue antibiotics postpartum;
e. If the woman has a caesarean section , continue antibiotics PLUS give metronidazole 500 mg IV
every 8 hours until the woman is fever-free for 48 hours.

III. PROLONGED ACTIVE PHASE

a. If there are no signs of cephalopelvic disproportion or obstruction and the membranes are
intact,rupture the membranes with an amniotic hook or a Kocher clamp.
b. Assess uterine contractions:
 If contractions are inefficient (less than three contractions in 10 minutes, each lasting
less than 40 seconds), suspect inadequate uterine activity
 If contractions are efficient (three contractions in 10 minutes, each lasting more than 40
seconds) suspect cephalopelvic disproportion, obstruction, malposition or
malpresentation
c. General methods of labour support may improve contractions and accelerate progress.

IV. CEPHALOPELVIC DISPROPORTION - occurs because the fetus is too large or the maternal pelvis is
too small.

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 a. If labour persists with cephalopelvic disproportion, it may become arrested or obstructed. The
best test to determine if a pelvis is adequate is a trial of labour. Clinical pelvimetry is of limited
value.
b. If cephalopelvic disproportion is confirmed deliver by caesarean section.
c. If the fetus is dead:
 Deliver by craniotomy;
 If the operator is not proficient in craniotomy , deliver by ccaesarean section.

V. OBSTRUCTION
Note: Rupture of an unscarred uterus is usually caused by obstructed labour.
a. If the fetus is alive, the cervix is fully dilated and the head is at 0 station or below ,
 deliver by vacuum extraction;
b. If there is an indication for vacuum extraction and symphysiotomy for relative obstruction and
the fetal head is at -2 station:
 Deliver by vacuum extraction and symphysiotomy;
c. If the operator is not proficient in symphysiotomy ,
 deliver by caesarean section.
d. If the fetus is alive but the cervix is not fully dilated or if the fetal head is too high for vacuum
extraction ,
 deliver by caesarean section.
e. If the fetus is dead:
 Deliver by craniotomy;
f. If the operator is not proficient in craniotomy
 deliver by caesarean section.

VI. INADEQUATE UTERINE ACTIVITY - If contractions are inefficient and cephalopelvic disproportion
and obstruction have been excluded
a. Inefficient contractions are less common in a multigravida than in a primigravida. Hence, every
effort should be made to rule out disproportion in a multigravida before augmenting with
oxytocin.
b. Rupture the membranes with an amniotic hook or a Kocher clamp and augment labour using
oxytocin.
c. Reassess progress by vaginal examination 2 hours after a good contraction pattern with strong
contractions has been established:
 If there is no progress between examinations, deliver by caesarean section;
 If progress continues, continue oxytocin infusion and re-examine after 2 hours. Continue
to follow progress carefully.

VII. PROLONGED EXPULSIVE PHASE

Maternal expulsive efforts increase fetal risk by reducing the delivery of oxygen to the placenta.
Allow spontaneous maternal “pushing”, but do not encourage prolonged effort and holding the breath.
a. If malpresentation and obvious obstruction have been excluded ,
 augment labour with oxytocin.
If there is no descent after augmentation :
b. If the head is not more than 1/5 above the symphysis pubis or the leading bony edge of the fetal
head is at 0 station ,
 deliver by vacuum extraction or forceps
c. If the head is between 1/5 and 3/5 above the symphysis pubis or the leading bony edge of the
fetal head is between 0 station and -2 station :
 Deliver by vacuum extraction and symphysiotomy;
d. If the operator is not proficient in symphysiotomy ,
 deliver by caesarean section.
e. If the head is more than 3/5 above the symphysis pubis or the leading bony edge of the fetal
head is above -2 station,
 deliver by caesarean section.

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