Protocols of managing Obstetric Emergencies

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Dr Ombonye Omweri (Mbchb) , a medical officer at Lifecare Hospital – Bungoma

Bungoma

By Dr Ombonye Omweri

Obstetric Emergencies are life threatening situations during pregnancy that may affect the mother, baby or both. They can occur during the antenatal period, perinatal, during or after delivery. They pose great danger to the otherwise health mothers. Management must therefore be fast to avoid mortality or poor outcomes.

Normal pregnancy lasts for a period of 9 months or 40 weeks. Due to some of these obstetric emergencies, note that we can have early termination of pregnancy and the baby is unlikely to survive depending on the gestational age. The discussion can therefore be based on the pregnancy stages, or what is medically termed as trimesters.

The first trimester is a period from day one of the last normal menstrual period to the end of the 12th week. Second trimester begins from 13 to 28 weeks, roughly 4- 6 months. Third trimester begins from 29 to 40 weeks or up to 9 months.

  • Miscarriage or abortion

It is the commonest occurrence in early pregnancy. This is when the fetus dies before 20 weeks of pregnancy.

Miscarriage can be induced or spontaneous. Induced abortion is self-terminated whereas spontaneous abortion may have an underlying cause or predisposing factor leading to the expulsion of the products of conception.

Some of the causative factors include: chromosomal abnormalities, cervical incompetence, rhesus incompatibility, trauma or falls, infections such as urinary tract infections, thyroid abnormalities or certain drugs which are not safe during pregnancy.

It can further be classified as complete, incomplete, missed, threatened or septic abortion. Complete abortion: all the products of conception have been expelled. The mother may however continue to experience some vaginal bleeding and effects of blood loss such as dizziness, fatigue and headache. This needs fluids replacement, transfusion if necessary.

Incomplete abortion has some of the products of conception in utero and therefore bleeding and lower abdominal pains as well as effects of blood loss will be experienced. Complete evacuation by manual vacuum evacuation or medications must be done.

Fluids replacement, pain control and prophylactic antibiotics may also be necessary. Missed abortion has the fetus dead or did not form. The uterus and other POCs are still in the uterus and have to be evacuated as well.

Threatened abortion presents with per vaginal bleeding as well as lower abdominal pains or cramps. However, the cervical is still closed and therefore this pregnancy can be conserved. Bed rest, analgesics, fluids and addressing the predisposing factor is necessary.

  • Ectopic pregnancy.When the fertilized egg attaches itself outside the uterus. Fallopian ectopic pregnancy is the commonest. Implantation can also occur in the abdominal cavity, in few cases. Surprisingly, intra-abdominal pregnancy can be supported until term period before an explorative laparotomy is done to extract the baby, placenta is left in situ.

Ectopic pregnancy is rare but life threatening. Its risk factors include:

  • Salpingitis- infection of the tubes which may be due to infections, inflammatory conditions causing partial or complete tubal blockage.
  • Asherman syndrome. Scarring of the tubes.
  • Previous surgery in the pelvic area or tubes which may have caused adhesions
  • Other predisposing factors include: previous ectopic pregnancy, age above 35 years, several induced abortions, pelvic inflammatory disease, endometriosis among others.

The diagnosis of ectopic pregnancy is clinical, supported by ultrasound findings- Pelvic or transvaginal ultrasound. The clinical presentations include:  per vaginal bleeding that may be heavier than the normal periods, lower abdominal pains, amenorrhea.

Once a diagnosis of ectopic pregnancy is made, urgent surgery is necessary. Avail blood before the operation as it may be highly required. At times, medical management of ectopic pregnancy using methotrexate may be considered with a very close follow up. This depends on the medical criteria.

Ante-partum Hemorrhage

Implies to vaginal bleeding after the 20th week of pregnancy. Commonly as a result of placenta abruption or placenta previa. Placenta abruption is the premature separation of the placenta, whereas placenta previa is a low lying placenta.

They have clinical features which clinicians use in distinguishing to determine the management. Of importance to note is that both may cause blood loss and the plan of care therefore depends on the types. Other causes of antepartum hemorrhage include: cervical ectropion, placental edge bleed.

Pre-eclampsia and Eclampsia

Pre-eclampsia refers to elevated blood pressures after the 20th week of pregnancy. Other markers like proteins in urine, the clinical signs and symptoms are used complete this diagnosis. In severe cases, patients will present with upper abdominal pain, headache, blurred vision and massive oedema.

With these, urgent medical intervention is required to control the blood pressures. Uncontrollable pressures cause intrauterine growth restriction or death in severe cases. Pressure control with close follow up, more antenatal clinics should be done. For severe preeclampsia, an elective cesarean section once the baby is more than 34 weeks of pregnancy should be planned.

  Eclampsia refers to high blood pressures after 20 weeks of pregnancy associated with convulsions. It is a rare but life threatening condition that can occur during the second or third trimesters.

Coagulopathies may set in its sequalae. For this reason, a good delivery plan must be planned for, with a possibility of the mother ending up in the intensive care unit should complications arise especially after cesarean section.  The definitive management of eclampsia is termination of pregnancy regardless of the gestational age.

The mother’s wellbeing is prioritized. After controlling the convulsions and blood pressures, the mother can either be induced or taken in for a cesarean section as an emergency depending on the parameters.

Preterm premature rupture of membranes, Premature rupture of membranes

PPROM is the rupture of membranes before 37 weeks of pregnancy which is the period considered as term or from which onset of labour is expected. PROM is the rupture of membranes as from 37 weeks of pregnancy, before the onset of labour.

Labour is marked by the onset of lower abdominal pains of increasing frequency and intensity radiating to the back as well as opening of the cervical. Both PROM and PRPROM are of concern as they may affect the baby’s well-being.

PPROM may lead to preterm labour with a preterm baby. Both may also increase the risk of meconium formation and chorioamnitis posing a great risk to both the mother and the baby. Conservative management is normally recommended with bed rest for at least 3 days, fluids replacement, cover of antibiotics and pain management if necessary. If in true labour then the plan of delivery should also be instituted.

 Emergency situations during and after delivery.

Emergency situations during delivery are quite common. Maternal, foetal or physiological factors play a role for a successful delivery. Some clinicians refer to the 4Ps- passenger(baby), pathway, power and physiological factors which may determine this outcome.

Ante-partum hemorrhage. We may have a low lying placenta (placenta previa) or premature separation (abruption placenta) occurring during labour. Both of these are causes of acute blood loss. Depending on the grades or clinical judgment with support of radiological investigations, a cesarean section may be indicated with supportive care.

Cord prolapse. The umbilical cord may come out of the uterus before or with the presenting part. This may compress the cord compromising blood flow to the baby posing a great danger.

Maneuvers such as reverse trendelenburg which are meant to reduce further compression should be done by the midwife as an urgent preparation for a cesarean section is done.

Breech presentation. Vertex or cephalic presentation is the normal presentation where the occiput comes first. If all other factors are normal, then spontaneous delivery should happen. Any other presentation is breech. There are types of breech and depending on this, maneuvers to deliver through the birth canal or preparations for an emergency cesarean section are considered. .

Obstructed labour:  Labour is considered obstructed when the presenting part of the fetus cannot progress into the birth canal, despite strong uterine contractions. Remember the 4Ps?

This involves the Path or the Passenger. The most frequent cause of obstructed labour is cephalo-pelvic disproportion – a mismatch between the fetal head and the mother’s pelvic brim. The fetus may also be large in relation to the maternal pelvic brim, such as the fetus of a diabetic woman, medically termed as macrosomia babies or simply babies large for gestational age.

Some other causes of obstructed labour may be malpresentation or malposition of the fetus (shoulder, brow or occipito-posterior positions). In rare cases, locked twins or pelvic tumours can cause obstruction.

Obstructed labour is a major cause of both maternal and newborn morbidity and mortality. The obstruction can only be alleviated by means of an operative delivery, either caesarean section or other instrumental delivery (forceps, vacuum extraction or simphysiotomy).

Maternal complications include intrauterine infections following prolonged rupture of membranes, trauma to the bladder and/or rectum due to pressure from the fetal head or damage during delivery, and ruptured uterus with consequent haemorrhage, shock or even death.

Trauma to the bladder during vaginal or instrumental delivery may lead to stress incontinence.

By far the most severe and distressing long-term condition following obstructed labour is obstetric fistula – a hole which forms in the vaginal wall communicating into the bladder (vesico-vaginal fistula) or the rectum (recto-vaginal fistula) or both.

Fistulae are commonly the result of prolonged obstructed labour and follow pressure necrosis caused by impaction of the presenting part during difficult labour. In the infant, neglected obstructed labour may cause asphyxia leading to stillbirth, brain damage or neonatal death.

Pronged labour:  Also known as failure to progress. When labour lasts for more than 18 hrs. Normal labour lasts for about 12-18 hours. Multiparous women can take even a shorter time, between 6-8 hours. All the causes of obstruction can cause prolonged labour.

Again the 4Ps, determine a good progress. Other causes that have not been mentioned above include:  cord around the neck, which interferes with descence of the baby, inadequate contractions. Emergency cesarean section has to be considered immediately to prevent a poor outcome for the mother or baby.

Post-partum Hemorrhage:   Refers to bleeding after delivery:  be it normal or delivery through a cesarean section. It is the commonest obstetric emergency. More common with home deliveries or Births Before Arrival- BBA.  It has the highest morbidity and mortality of all obstetric emergencies because of excessive blood loss. Causes can better be remembered with the 4Ts.

Tone.  Atony-the inability of the uterus to contract well after delivery. Common after cesarean section. Pharmacological agents and simple techniques such as uterine massage can help contract the uterus.

Tissue. If all the products of conception are not removed carefully, especially the placenta during the third stage of labour, bleeding may continue.

Tear. Cervical, uterine, vaginal or perineal tears can be a cause of excessive bleeding. Tears must therefore be repaired by suturing.

Thrombin/ Coagulopathies, patients with bleeding disorders as a result coagulation factors disorders are at a great risk of bleeding after delivery.

The management of PPH is basically identifying and correcting the cause of bleeding as well as transfusion.

Note that we can have bleeding up to 14 days after delivery. This is termed as secondary PPH. Infection is the cause of this. Management is by administration of injectable broad spectrum antibiotics and blood transfusion if necessary.

The writer is a medical officer at Lifecare Hospital -Bungoma…Email : ombonye@gmail.com/mercieobie@gmail.com