Labour ward emergencies

Published on 09/03/2015 by admin

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Last modified 09/03/2015

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Chapter 42 Labour ward emergencies

Up to 5% of deliveries have postpartum complications.

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

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

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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