Unconscious patient

Management

• first aid: left lateral position, clear airway, oxygen, intubation if required, assessing pulse, respiration, blood pressure, colour and fetal heart rate

• intravenous line, collecting blood for full blood count, electrolytes, blood sugar level, blood group and hold, coagulation profile, liver and renal function tests

• monitoring electrocardiograph, pulse, blood pressure, fetal heart rate

• treatment of the cause

Main causes

• supine hypotension

• epilepsy

• eclampsia

Other causes

• neurological: epilepsy, tumour, subarachnoid haemorrhage, local anaesthesia toxicity, total spinal anaesthesia (inadvertent massive subarachnoid dose of local anaesthesia)

• vascular: blood loss, myocardial infarction, hypertensive encephalopathy, thromboembolism and pulmonary embolus

• respiratory: amniotic fluid embolism

• endocrine: hyper/hypoglycaemia, addisonian crisis

• infective causes

• drugs

Postpartum haemorrhage

Primary postpartum haemorrhage

Primary postpartum haemorrhage is the loss of more than 500 mL blood within 24 hours of delivery. The incidence is 1%–5%.

In maternal mortality statistics in Australia, haemorrhage has been a major factor of direct maternal deaths. In these, postpartum haemorrhage was a significant contributor.

Summary of management of severe obstetric haemorrhage

• prompt restoration of circulatory volume

• accurate diagnosis of cause

• appropriate treatment to stop bleeding early

Amniotic fluid embolism

Incidence. Incidence is about 1 in 80,000. Previously, there was up to 85% maternal mortality and 40% fetal mortality. It presents with respiratory distress, and cardiovascular collapse. Of those who survive the first hour, 40% will develop a coagulopathy.

Pathophysiology

Amniotic fluid embolism can occur in any trimester and is due to changes in the normal anatomical relationship between the membranes, placenta and uterine wall, with disruption of the integrity of the uterine blood vessels.

In the maternal circulation, the amniotic fluid/debris is deposited in the lungs and causes pulmonary vasoconstriction, which is probably due to an anaphylactic-type reaction to the amniotic fluid/debris. Severe hypoxia occurs with acute left-sided heart failure; disseminated intravascular coagulopathy may also occur.

Risk factors

• hypertonic uterine action

• caesarean section

• polyhydramnios

• precipitate labour

• advanced maternal age

• grand multiparity

Presentation and diagnosis

• There is sudden collapse after rupture of membranes in labour with dyspnoea, pink frothy sputum and cyanosis, leading to shock and apnoea. Convulsions occur in 10%–20% of cases.

• The diagnosis is confirmed by finding fetal squames in the sputum or blood from central venous line, or at postmortem during examination of the maternal lungs when fetal squames and debris are present.

Thromboembolism and pulmonary embolism

(SeeCh 47 for further details.)

Clinical presentation of pulmonary embolism

• anxiety, tachycardia

• shortness of breath, apnoea, cyanosis and unconsciousness

• possible retrosternal chest pain, haemoptysis, pleural friction rub and a split-second heart sound

Emergency management

• resuscitate

• secure airway, oxygen, ventilate if necessary

• anticoagulate with standard or low-molecular-weight heparin

• surgery: employ embolectomy if the embolus is in the proximal part of the main pulmonary artery; if in inferior vena cava, insert umbrella filter

Prophylaxis

• in patients with a past history of deep venous thrombosis, obese patients and/or those who have an operative delivery (SeeCh 47)

Regional anaesthesia toxicity

Incidence. Incidence is up to 1 in 1000. Increased susceptibility in the pregnant woman is due to:

• increased blood flow to the spinal cord

• reduced epidural space because of distended vessels

• a rise in pressure in the epidural space with uterine contractions

Presentation

• Signs and symptoms may occur almost immediately and within up to 20 minutes of administering local anaesthesia.

• Patient complains of metallic taste, tinnitus, confusion and disorientation.

• Respiratory muscle paralysis and cardiac arrest may occur.

Management

• prevention

• intubation and ventilation

• fluid resuscitation

Eclampsia

(SeeCh 45 for further details on eclampsia/pre-eclampsia.)

Incidence. Incidence is up to 1 in 1500.

Presentation

• Presentation includes hypertension, hyperreflexia and clonus, headache, visual changes and seizures.

• 20% of patients with eclampsia have diastolic blood pressure <90 mmHg, urine dipstick test results of <2+ protein and normal reflexes.

• Up to 40% have no significant oedema.

• 70% of deaths are due to intracerebral haemorrhage.

• Three serious complications of eclampsia are cerebrovascular injury, pulmonary oedema and coagulopathy.

Management

• secure airway; ventilate if necessary

• stop seizure and prevent recurrence

• control blood pressure

• diagnose and correct coagulopathy

• prevent pulmonary oedema; maintain strict fluid balance

Inverted uterus

An inverted uterus occurs when the fundus of the uterus descends through the uterine body, cervix and vagina.

Presentation

• includes pain, bleeding

• a vaginal lump after placental delivery

• suspect uterine inversion if the cardiovascular shock is out of proportion to blood loss after delivery (due to a vasovagal response to visceral stimulation)

Risk factors

• overzealous cord traction

• fundal implantation site

• uterine atony

• short cord

• previous inversion: recurrence rate of up to 33%

Management

• resuscitation

• digital replacement, leaving placenta attached

• manual replacement with the aid of tocolytic agents

• O’Sullivan hydrostatic method

• operative procedures of manual removal of placenta and uterine exploration

Shoulder dystocia

Incidence. Incidence is 0.2%–0.4%.

Risk factors

• excess maternal weight gain

• association with gestational diabetes, with estimated fetal weight >4000 g

• unexplained intrauterine fetal death

• high maternal birthweight

• postdates: a 20% incidence of macrosomia with infants delivered at 42 weeks compared with 12% delivered at 40 weeks

• intrapartum risks: 45% diagnosed with failure to progress and prolonged second stage

Management

• Do not pull hard, as this will increase impaction.

• Obtain adequate assistance, including an anaesthetist, paediatrician and nursing staff.

• Episiotomy is required.

Mild shoulder dystocia

• Suprapubic pressure will force the shoulder into the oblique diameter of the pelvis.

• Wood’s manoeuvre: this involves a screwing motion by exerting pressure on the anterior surface of the posterior shoulder at the deltopectoral triangle.

Moderate shoulder dystocia

• Hibbard manoeuvre: press firmly against the head, jaw and upper neck, and direct the head towards the rectum. With surapubic pressure, the anterior shoulder is released.

• Delivery of the posterior arm proceeds by placing the hand in the vagina and applying pressure in the antecubital space to flex the baby’s arm.

Severe dystocia

• McRobert’s manoeuvre: involves sharp flexion of the mother’s thighs against her abdomen. This serves to straighten the sacrum relative to the lumbar spine and cause superior rotation of the symphysis. This may free the impacted shoulder.

Unconscious patient

Management

• first aid: left lateral position, clear airway, oxygen, intubation if required, assessing pulse, respiration, blood pressure, colour and fetal heart rate

• intravenous line, collecting blood for full blood count, electrolytes, blood sugar level, blood group and hold, coagulation profile, liver and renal function tests

• monitoring electrocardiograph, pulse, blood pressure, fetal heart rate

• treatment of the cause

Main causes

• supine hypotension

• epilepsy

• eclampsia

Other causes

• neurological: epilepsy, tumour, subarachnoid haemorrhage, local anaesthesia toxicity, total spinal anaesthesia (inadvertent massive subarachnoid dose of local anaesthesia)

• vascular: blood loss, myocardial infarction, hypertensive encephalopathy, thromboembolism and pulmonary embolus

• respiratory: amniotic fluid embolism

• endocrine: hyper/hypoglycaemia, addisonian crisis

• infective causes

• drugs

Postpartum haemorrhage

Primary postpartum haemorrhage

Primary postpartum haemorrhage is the loss of more than 500 mL blood within 24 hours of delivery. The incidence is 1%–5%.

In maternal mortality statistics in Australia, haemorrhage has been a major factor of direct maternal deaths. In these, postpartum haemorrhage was a significant contributor.

Causes

• retained products of conception, retained placenta

• uterine atony (most common cause)

• soft-tissue laceration

• coagulation defect

• uterine rupture

Management

• Prevention: routine use of oxytocin and an active management of the third stage can reduce postpartum haemorrhage by 40%.

• Resuscitation: the immediate danger is inadequate circulation, not reduced oxygen-carrying capacity. Therefore, restore circulatory volume with intravenous fluids and cross-match blood.

• Haemostasis: if coagulation or platelet count are abnormal, treat with fresh frozen plasma and platelets.

• Fundal massage can be used.

Medical treatment for atonic uterus

This involves an intravenous oxytocin bolus of initially 10 IU or ergometrine 250–500 μg. If haemorrhage is not controlled by simple methods, the woman requires a formal examination and exploration under anaesthesia. The genital tract is assessed for tears, retained products of conception and uterine rupture. If uterine atony continues after these causes are excluded, further medical treatment includes the use of rectal misoprostol, which may be effective in increasing uterine tone. Doses of up to 800 mg are used and maternal pyrexia should be monitored.

Surgical management of continuing postpartum haemorrhage

Uterine artery ligation has minimal complications and reduces the pulse pressure by 60%–70% to allow endogenous haemostatic mechanisms to control bleeding.

Internal iliac artery ligation

This is usually bilateral.

Uterine compression sutures

B-Lynch sutures used to compress the uterus are often effective.

Recombinant activated factor VIIa

This has been used effectively in uncontrolled bleeding.

Hysterectomy

Hysterectomy may be needed for persistent atony, morbidly adherent placenta or uterine rupture. If it is not due to placenta praevia, a subtotal hysterectomy may be the operation of choice, as there is a higher maternal mortality with total hysterectomy.

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