Case 13.2 – Labour (Obstetric Emergencies)

Cord Prolapse - Obstetric Emergency

Definition and Epidemiology

• Cord prolapse: Descent of the umbilical cord through the cervix alongside (occult) or past the presenting part (overt)
• Incidence: Relatively rare - approximately 1 in 500 deliveries (0.2%)
• True obstetric emergency: Requires immediate cesarean section

Pathophysiology

Morbidity and mortality relate to birth asphyxia due to:

• Cord compression: Umbilical cord compressed between presenting part and maternal pelvis
• Umbilical arterial vasospasm: Exposure to cold air and handling causes reflex vasoconstriction
• Result: Reduced or absent blood flow to fetus → fetal hypoxia → brain injury or death

Risk Factors

• Unengaged presenting part: High presenting part, especially with membrane rupture
• Malpresentation: Breech, transverse lie, oblique lie
• Malposition: Occipito-posterior (as in this case - LOP)
• Polyhydramnios: Excessive amniotic fluid allows cord to prolapse with sudden membrane rupture
• Preterm labour: Smaller presenting part doesn't fill pelvis
• Multiple pregnancy: Especially with second twin
• Low birth weight: Small baby
• Multiparity: Lax abdominal muscles, unengaged head
• Iatrogenic: Artificial rupture of membranes (amniotomy) with high presenting part

Diagnosis

• Visualization: Cord visible or palpable at introitus (overt prolapse)
• Vaginal examination: Cord felt alongside or below presenting part
• Pulsating cord: May be felt (indicates fetus still alive)
• Fetal distress: Sudden fetal bradycardia, severe variable decelerations on CTG after membrane rupture

EMERGENCY MANAGEMENT

Immediate Actions (Within Minutes)

1. Call for Help

• Emergency call: Senior obstetrician, anesthetist, theater team, neonatal team
• Code 1 (Category 1) cesarean section: Decision to delivery within 30 minutes (ideally <20 minutes)
• Alert operating theater: Prepare for emergency LSCS

2. Elevate Presenting Part to Relieve Cord Compression

MOST CRITICAL STEP - Do this immediately and continuously until delivery

• Manual elevation:
  • Experienced person (doctor/midwife) inserts hand into vagina
  • Push presenting part (fetal head or breech) upward and away from pelvis
  • Maintain continuous upward pressure
  • Keep cord above presenting part if possible
  • Continue until baby is delivered (even in operating room until cesarean section begins)
• Purpose: Relieves pressure on cord, allows blood flow to fetus

3. Maternal Positioning

• Knee-chest position (exaggerated Sims' position):
  • Mother on hands and knees with chest down, buttocks elevated
  • Uses gravity to move presenting part away from pelvis
  • Reduces cord compression
• Alternative: Steep Trendelenburg position
  • Head down, pelvis elevated 30-40 degrees
  • Useful during transfer to theater
• Lateral position if other positions not tolerated

4. Do NOT Replace Cord

• Do not attempt to push cord back into uterus (causes vasospasm)
• Handle cord minimally to avoid vasospasm
• If cord is protruding, wrap in warm, moist sterile gauze to prevent drying and cooling

5. Assess Fetal Viability

• Check for cord pulsations: Indicates fetal heart activity
• Continuous CTG monitoring if possible during transfer
• If no pulsations and fetal death confirmed: May proceed with vaginal delivery if appropriate

Concurrent Resuscitative Measures

6. Tocolysis (Stop Contractions)

If any delay to theater (e.g., awaiting anesthesia, OR not ready):

• Terbutaline: 0.25mg (250 micrograms) subcutaneous
  • Beta-2 agonist, relaxes uterus
  • Stops contractions that compress cord
  • Onset within 5 minutes
• Alternative: Salbutamol IV if terbutaline unavailable
• Purpose: Buys time by reducing cord compression during transfer

7. Maternal Oxygenation

• High-flow oxygen: 15L/min via non-rebreather mask
• Purpose: Maximize maternal oxygen saturation → improve oxygen delivery to fetus

8. IV Access and Fluid Resuscitation

• Two large-bore IV cannulas (14-16G)
• IV fluids: Crystalloid bolus (e.g., 500mL Hartmann's rapidly)
• Bloods: FBC, group and hold (in case of hemorrhage at CS)

Bladder Management

9. Fill Maternal Bladder (If Delay to Theater)

• Bladder filling: Instill 500-700mL sterile saline into bladder via catheter
• Purpose: Distended bladder elevates presenting part mechanically
• When useful: If significant delay expected (e.g., transfer to another hospital)
• Drain bladder before CS begins

Definitive Management - Delivery

10. Mode of Delivery

If Fully Dilated and Presenting Part Low

• Instrumental vaginal delivery may be considered
  • Vacuum or forceps
  • Only if delivery can be achieved within minutes
  • Requires vertex presentation, station +2 or below

If NOT Fully Dilated (As in This Case - 3cm)

• Emergency cesarean section (Category 1/Code 1 LSCS)
  • Decision to delivery interval: <30 minutes (ideally <20 minutes)
  • Continue manual elevation of presenting part until surgical delivery
  • General anesthesia often fastest (but regional anesthesia acceptable if can be achieved quickly)

Transfer to Theater

• Maintain continuous manual elevation during transfer
• Maintain maternal positioning (Trendelenburg or lateral)
• Continue oxygen
• Continuous CTG monitoring if possible

11. Neonatal Resuscitation Team

• Alert neonatal team: Be present at delivery
• Anticipate need for resuscitation: Fetus may have experienced hypoxia
• Prepare: Warmed resuscitation equipment, intubation equipment ready

Documentation

• Time of membrane rupture
• Time of cord prolapse diagnosis
• Fetal heart rate at diagnosis
• Interventions performed and times
• Decision to delivery interval
• Neonatal condition at birth (Apgar scores, cord gases)

Prognosis

• Perinatal survival: 70-90% if managed appropriately
• Key factors affecting outcome:
  • Promptness of recognition
  • Effective elevation of presenting part
  • Speed of delivery
  • Duration of cord compression
• Diagnosis-to-delivery interval: Shorter interval = better outcomes

Prevention

• Avoid amniotomy when presenting part is high or unengaged
• Controlled amniotomy: Small tear in membranes, allow slow drainage
• Immediate VE after spontaneous membrane rupture if risk factors present
• Continuous CTG monitoring after membrane rupture in high-risk cases

Summary Algorithm for This Case

1. Recognize emergency: Cord prolapse with pulsating cord visible
2. Call for help: Emergency team, Code 1 CS
3. Manual elevation: Insert hand, elevate head continuously
4. Position mother: Knee-chest or Trendelenburg
5. Oxygen: High-flow 15L/min
6. Tocolysis: Terbutaline 0.25mg SC (if delay)
7. Emergency CS: Only definitive treatment at 3cm dilatation
8. Continue manual elevation until baby delivered
9. Neonatal resuscitation: Team present at delivery

Key Points

• TRUE OBSTETRIC EMERGENCY - minutes matter
• Manual elevation of presenting part is the most critical intervention
• Continue elevation continuously until delivery
• Emergency CS if not fully dilated
• Speed is essential - aim for delivery within 30 minutes

Malpresentation and Malposition in Labour

Definitions

• Presentation: The part of the fetus that lies over the pelvic inlet (e.g., cephalic, breech, shoulder)
• Malpresentation: Any presentation other than vertex (well-flexed cephalic)
• Position: Relationship of the presenting part to the maternal pelvis (e.g., OA, OP, OT)
• Malposition: Suboptimal position of the presenting part (usually refers to OP or persistent OT)

MALPRESENTATIONS

Presenting Diameters - Critical Concept

Presentation/Position	Presenting Diameter	Size (cm)	Deliverability
Vertex (well-flexed OA)	Suboccipito-bregmatic	9.5	✓ Optimal - normal vaginal delivery
Face (extended)	Submento-bregmatic	9.5	✓ Possible if mento-anterior ✗ CS if mento-posterior
Normal Pelvis	AP & Transverse diameters	10-12	Reference
Occipito-posterior (OP)	Occipito-frontal	11.5	✓ Difficult - may deliver vaginally Higher risk operative delivery
Brow	Mento-vertical	13.5	✗ Usually requires CS (largest diameter)

Types of Malpresentation and Management

1. Breech Presentation (3-4% at term)

• Types: Frank (hips flexed, knees extended), complete (hips and knees flexed), footling (one or both feet presenting)
• Impact on labour:
  • Higher risk of cord prolapse (especially footling breech)
  • Risk of head entrapment (body delivers but head stuck)
  • Birth trauma
• Management: Usually planned CS; vaginal breech delivery in selected cases with experienced obstetrician

2. Transverse Lie / Shoulder Presentation (\<1%)

• Presenting part: Shoulder, arm may prolapse
• Impact: Vaginal delivery impossible
• Risk: Obstructed labor, uterine rupture if untreated
• Management: Emergency CS (cannot deliver vaginally)

3. Brow Presentation (Very rare)

• Presenting diameter: Mento-vertical (13.5cm) - largest diameter
• Impact: Too large to pass through normal pelvis
• Management: Usually requires CS (may convert to face or vertex spontaneously)

4. Face Presentation (Rare - 1 in 500)

• Mechanism: Complete extension of fetal head
• Types:
  • Mento-anterior: Chin toward symphysis pubis - may deliver vaginally
  • Mento-posterior: Chin toward sacrum - cannot deliver vaginally (CS required)
• Impact: Prolonged labor, facial edema in baby

5. Compound Presentation

• Definition: Fetal extremity (hand/arm) alongside presenting part
• Impact: May obstruct descent
• Management: Often resolves spontaneously; CS if persists

Summary: Malpresentation Management

Malpresentation	Usual Management
Transverse lie, shoulder	Emergency CS (cannot deliver vaginally)
Arm/footling breech	Emergency CS (high risk cord prolapse)
Brow	CS (may convert spontaneously; CS if persists)
Face mento-posterior	CS
Face mento-anterior	Vaginal delivery possible in some circumstances
Breech (frank/complete)	Usually planned CS; selected vaginal breech with experience

MALPOSITIONS - Focus on Occipito-Posterior (OP)

Occipito-Posterior Position

Definition and Epidemiology

• Definition: Fetal occiput directed toward maternal sacrum (posterior)
• Types: LOP (left occipito-posterior), ROP (right occipito-posterior), direct OP
• Incidence:
  • 10-20% at onset of labor
  • 5-8% at delivery (most rotate to OA during labor)
• More common in: Nulliparous women, android/anthropoid pelvis

Why OP Position is Problematic

1. Larger Presenting Diameter

• OP diameter: Occipito-frontal (11.5cm)
• OA diameter: Suboccipito-bregmatic (9.5cm)
• Result: OP presents 2cm larger diameter to pelvis → more difficult passage

2. Suboptimal Fit in Pelvis

• Fetal head less well applied to cervix
• Less effective cervical dilatation per contraction
• Slower progress

Impact of OP Position on Labour

Clinical Features

• High presenting part at term: Head may not engage before labor
• Prolonged pregnancy: Associated with post-dates pregnancy
• Severe back pain ("back labor"):
  • Fetal occiput presses against maternal sacrum
  • Continuous intense lower back pain
  • Pain may not ease between contractions
  • Very distressing for mother
• Slower cervical dilatation: Prolonged first stage
• Early urge to push: Premature bearing down (before full dilatation)

Effects on Each Stage of Labour

First Stage

• Prolonged latent phase: Head takes longer to engage
• Prolonged active phase: Slower dilatation (larger diameter, poor application to cervix)
• Higher rate of failure to progress: May require augmentation with syntocinon
• Increased need for analgesia: Severe back pain → higher epidural rate

Second Stage

• Prolonged second stage:
  • Larger diameter must navigate pelvis
  • Descent slowed
• Failure to descend: Head remains high despite adequate pushing
• Higher operative delivery rate:
  • Instrumental delivery (vacuum extraction preferred over rotational forceps)
  • Manual rotation (if experienced operator)
  • CS if failed operative delivery

Outcomes of OP Position

Possible Outcomes

1. Spontaneous rotation to OA (Most Common - 65-85%):
   • Head rotates during descent
   • Normal vaginal delivery follows
   • Labor may still be longer and more painful
2. Persistent OP with vaginal delivery (5-10%):
   • Direct OP delivery possible
   • Requires good contractions, adequate pelvis, maternal effort
   • Increased risk of: perineal trauma, 3rd/4th degree tears, postpartum hemorrhage
3. Instrumental delivery (20-30%):
   • Manual rotation + vacuum/forceps
   • Or direct OP instrumental delivery
4. Cesarean section (10-30%):
   • For failure to progress in first stage
   • For failure to descend in second stage
   • For failed instrumental delivery

Management of OP Position

During Labour

• Positional changes:
  • Hands and knees position
  • Forward-leaning positions
  • May encourage rotation to OA
• Adequate analgesia: Epidural often helpful for severe back pain
• Augmentation: Syntocinon if inadequate contractions
• Patience: Allow time for spontaneous rotation

Second Stage Options

• Await spontaneous delivery if progressing
• Manual rotation: Experienced operator manually rotates head from OP to OA
• Instrumental rotation: Vacuum extraction (can apply traction in any position)
• Direct OP delivery: Instrumental or spontaneous
• CS: If no descent or failed operative delivery

Maternal Outcomes

• Longer labor
• More painful labor (back pain)
• Higher epidural rate
• Higher intervention rate: Augmentation, operative delivery, CS
• Increased perineal trauma: 3rd/4th degree tears
• Higher PPH risk

Fetal Outcomes

• Generally good if managed appropriately
• Slightly increased risk of fetal distress in prolonged labor
• Caput and moulding common (but resolve)

Occipito-Transverse (OT) Position

• Normal at engagement: Head enters pelvis in OT
• Should rotate to OA as head descends
• Persistent OT (transverse arrest):
  • Failure of internal rotation
  • Head stuck in transverse position
  • Increased risk of failure to descend in second stage
  • Requires manual or instrumental rotation, or CS

Summary: Impact on Labour

Factor	OA (Normal)	OP (Malposition)
Presenting diameter	9.5cm	11.5cm (2cm larger)
First stage duration	Normal	Prolonged
Back pain	Minimal	Severe, continuous
Second stage duration	Normal	Prolonged
Spontaneous vaginal delivery	90%+	50-60%
Instrumental delivery	5-10%	20-30%
CS rate	10-15%	20-40%
Perineal trauma	Moderate	Higher (more 3rd/4th degree tears)

Key Points

• Malpresentations (brow, transverse lie, shoulder) usually require CS
• OP position is the most common malposition
• OP presents larger diameter (11.5cm vs 9.5cm)
• OP associated with: Prolonged labor, severe back pain, higher intervention rates
• Most OP positions rotate spontaneously to OA during labor
• Persistent OP increases risk of CS and operative delivery

Management of Breech Presentation at 36 Weeks

Background

• Breech incidence:
  • 25% at 28 weeks
  • 3-4% at term (37-40 weeks)
  • At 36 weeks: approximately 5-7%
• Many breech presentations spontaneously convert to cephalic before term

Types of Breech Presentation

Type	Description	Frequency	Vaginal Delivery Risk
Frank breech	Hips flexed, knees extended (feet near head)	65-70%	Lowest risk if attempting vaginal delivery
Complete breech	Hips flexed, knees flexed (cross-legged)	10-15%	Moderate risk
Footling/incomplete breech	One or both feet presenting first	10-25%	Highest risk - cord prolapse common

Historical Context: Term Breech Trial

• Pre-2000: Breech delivery mode decided individually based on maternal wishes, fetal size, pelvic adequacy, experience
• Term Breech Trial (2000):
  • Large randomized controlled trial (Hannah et al., Lancet 2000)
  • Compared planned CS vs planned vaginal delivery for breech at term
  • Found lower perinatal morbidity/mortality with planned CS
  • Result: Planned CS became standard for breech at term
• Post-2012: Results of Term Breech Trial questioned
  • Long-term outcomes showed no difference
  • Quality of intrapartum care variable
  • Renewed interest in vaginal breech delivery in selected cases with experienced operators

MANAGEMENT OPTIONS AT 36 WEEKS

Option 1: External Cephalic Version (ECV)

Definition

Manual manipulation of the fetus from breech to cephalic presentation through the maternal abdomen

Timing

• Nulliparous women: Offer at 36 weeks
• Multiparous women: Offer at 37 weeks
• Rationale: Balance between fetal size (easier when smaller) and prematurity risk

Technique

• Locate fetal poles by abdominal palpation
• Apply steady pressure to fetal buttocks and head
• Perform "forward somersault" so head moves down toward pelvis
• Usually performed with ultrasound guidance
• Tocolysis (e.g., terbutaline SC) used to relax uterus

Success Rate

• Overall success: 40-60%
• Multiparous: Higher success (60-70%)
• Nulliparous: Lower success (30-50%)
• Factors improving success:
  • Multiparity
  • Frank breech (vs complete/footling)
  • Adequate amniotic fluid
  • Maternal BMI <30
  • Experienced operator

Prerequisites for ECV

• ≥36 weeks gestation
• Singleton pregnancy
• No contraindication to vaginal delivery
• Adequate amniotic fluid
• Reactive non-stress test (CTG)
• Access to emergency CS if needed

Contraindications

• Absolute:
  • Need for CS anyway (e.g., placenta previa, previous classical CS)
  • Multiple pregnancy
  • Ruptured membranes
  • Abnormal CTG/fetal compromise
  • Significant antepartum hemorrhage within 7 days
  • Known uterine anomaly
• Relative:
  • Oligohydramnios
  • Fetal growth restriction
  • Pre-eclampsia
  • Scarred uterus (relative - increased risk)

Risks of ECV

• Emergency CS required: 0.5% (1 in 200)
  • Due to: placental abruption, fetal distress, cord accident
• Placental abruption: <0.5%
• Fetal bradycardia: 5-10% (usually transient)
• Fetomaternal hemorrhage: 2-6%
  • Give Anti-D to Rh-negative women after ECV
  • Kleihauer test to assess need for additional Anti-D
• Spontaneous rupture of membranes: Rare
• Spontaneous labor: Rare

Procedure for ECV

1. Pre-procedure:
   • Informed consent (discuss risks and benefits)
   • CTG (ensure reactive)
   • Ultrasound (confirm breech, assess liquor, locate placenta, exclude anomalies)
   • IV access
   • Anti-D if Rh-negative
2. Tocolysis: Terbutaline 0.25mg SC
3. Attempt ECV: Maximum 2-3 attempts, stop if painful or unsuccessful
4. Post-procedure:
   • CTG monitoring (30-60 minutes)
   • Anti-D administration if Rh-negative
   • Kleihauer test

After ECV

• If successful: Plan for vaginal delivery; ~5% revert to breech
• If unsuccessful: Discuss other options (planned CS, await spontaneous version, repeat ECV attempt)

Benefits of ECV

• Reduces need for CS by 50%
• Increases chance of vaginal delivery
• Avoids maternal morbidity associated with CS
• Cost-effective

Option 2: Planned Elective Cesarean Section at 39+ Weeks

Timing

• 39+0 to 39+6 weeks: Mandated timing for elective CS in many regions
• Rationale: Significantly reduces risk of transient tachypnea of newborn (TTN) compared to CS at 37-38 weeks

Indications for Planned CS

• Failed or contraindicated ECV
• Maternal preference for CS
• Footling or complete breech (not frank)
• Estimated fetal weight <2000g or >4000g
• Fetal anomalies (e.g., hydrocephalus)
• Other obstetric indications (e.g., placenta previa, previous CS)

Advantages

• Eliminates risk of intrapartum complications specific to breech
• Planned procedure with anesthesia team, senior obstetrician
• Avoids emergency CS in labor

Disadvantages

• Maternal morbidity of major surgery
• Longer recovery
• Implications for future pregnancies (scar)
• Increased risk TTN (though minimized at 39+ weeks)

Option 3: Planned Vaginal Breech Delivery

Current Status

• Offered in selected cases at centers with experienced clinicians
• Requires careful counseling about risks
• Strict selection criteria

Selection Criteria for Vaginal Breech Delivery

• Frank or complete breech (NOT footling)
• Estimated fetal weight 2500-3800g
• Flexed or neutral fetal head (not hyperextended)
• Adequate pelvis (clinical pelvimetry or CT/MRI pelvimetry)
• No other indication for CS
• Experienced obstetrician present
• Immediate access to CS
• Informed maternal consent

Risks of Vaginal Breech Delivery

• Cord prolapse (especially if footling)
• Head entrapment (body delivers but head stuck)
• Birth trauma: Brachial plexus injury, fractures, intracranial hemorrhage
• Birth asphyxia
• Higher perinatal morbidity than CS (though long-term outcomes similar)

Availability

• Many centers no longer offer vaginal breech delivery due to loss of experience
• Requires specific training and expertise

Option 4: "Wait and See" Approach

Description

• Do not perform ECV or book CS
• Await spontaneous version to cephalic (many breech at 36 weeks convert spontaneously)
• Reassess at 37-38 weeks
• If remains breech, offer ECV or CS

Rationale

• Significant proportion will spontaneously convert
• Avoids unnecessary intervention

Risk

• If spontaneous labor occurs while breech:
  • Emergency CS required
  • Possible cord prolapse if membranes rupture

Summary of Options at 36 Weeks

Option	Timing	Success/Outcome	Risks
1. ECV	36 weeks (nullip) 37 weeks (multip)	50% success rate Increases chance of vaginal delivery	0.5% emergency CS Small risk abruption, FMH
2. Planned CS	39+0 to 39+6	100% CS rate Avoids labor risks	Surgical morbidity Implications for future
3. Vaginal breech	Await labor	Selected cases only Requires expertise	Head entrapment, trauma Cord prolapse, asphyxia
4. Wait and see	Reassess at 37-38 weeks	Many convert spontaneously	Emergency CS if labor before conversion

Recommended Approach

1. At 36 weeks: Confirm breech by ultrasound
2. Counsel patient about all options
3. Offer ECV at 36-37 weeks (first-line recommendation)
4. If ECV successful: Plan vaginal delivery
5. If ECV unsuccessful or declined:
   • Option: Planned elective CS at 39+ weeks (most common choice)
   • Option: Consider vaginal breech delivery if strict criteria met and expertise available
6. If spontaneous labor before 39 weeks while breech: Emergency CS (unless criteria met for vaginal breech and expertise available)

Key Points

• ECV is first-line - offer to all women with breech at 36-37 weeks
• ECV reduces CS rate by 50% - safe and cost-effective
• Planned CS at 39+ weeks is standard if breech persists or ECV unsuccessful
• Vaginal breech delivery possible in highly selected cases with expertise
• Counsel about all options and respect maternal choice

Maternal Collapse at Delivery - Differential Diagnosis

Definition

Maternal collapse: Acute event involving the cardiorespiratory systems and/or brain, resulting in reduced or absent consciousness (and potentially death), at any stage during pregnancy and up to 6 weeks postpartum.

Approach to Maternal Collapse

Initial Management - ABC Approach (Before Diagnosis)

DO NOT delay resuscitation to establish a diagnosis

Immediate Actions (First 60 Seconds)

1. Call for help: Emergency team (obstetrics, anesthesia, ICU)
2. Check responsiveness: "Are you okay?" Shake shoulders
3. Open Airway: Head tilt, chin lift (jaw thrust if trauma suspected)
4. Check Breathing: Look, listen, feel for 10 seconds
5. Check Circulation: Pulse (carotid or femoral), capillary refill
6. Begin CPR if cardiac arrest:
   • High-quality chest compressions (rate 100-120/min, depth 5-6cm)
   • Left lateral tilt or manual uterine displacement (relieve aortocaval compression if ≥20 weeks)
   • Consider perimortem CS if ≥20 weeks and no ROSC within 4 minutes
7. High-flow oxygen: 15L/min non-rebreather mask
8. IV access: Two large-bore cannulas
9. Monitor: Continuous ECG, SpO2, BP

DIFFERENTIAL DIAGNOSIS

Use mnemonic: "BEAUCHOPS" or systematic approach by system

OBSTETRIC CAUSES (Consider First)

1. Postpartum Hemorrhage (PPH)

• Definition: Blood loss >500mL vaginal delivery, >1000mL cesarean section
• Mechanism: Hypovolemic shock → collapse
• Timing: During or immediately after 3rd stage of labour
• Key features:
  • Visible heavy vaginal bleeding
  • Tachycardia, hypotension, pallor, cold peripheries
  • Uterine atony (soft, boggy uterus) - most common cause
• Management: See Question 6

2. Antepartum Hemorrhage (APH)

• Causes: Placental abruption, placenta previa, vasa previa
• Timing: Before delivery (\>20 weeks gestation)
• Placental abruption:
  • Painful vaginal bleeding (may be concealed)
  • Woody hard, tender uterus
  • Fetal distress or demise
  • Hypovolemic shock (blood loss may be underestimated if concealed)

3. Amniotic Fluid Embolism (AFE)

• Definition: Entry of amniotic fluid into maternal circulation → severe systemic inflammatory response
• Incidence: Rare (1 in 15,000-30,000 deliveries)
• Mortality: Very high (60-80%)
• Timing: During labor, delivery, or immediate postpartum (within 30 minutes)
• Classic presentation:
  • Sudden onset during labor or shortly after delivery
  • Triad: Hypoxia, hypotension, coagulopathy (DIC)
  • Respiratory distress, cyanosis
  • Cardiovascular collapse (profound hypotension, cardiac arrest)
  • Altered consciousness, seizures
  • Uncontrollable bleeding (DIC develops within minutes-hours)
• Diagnosis: Clinical (diagnosis of exclusion)
• Management: Supportive (ICU, mechanical ventilation, massive transfusion protocol, treat DIC)

4. Eclampsia

• Definition: Tonic-clonic seizures in woman with pre-eclampsia
• Timing: Antepartum (50%), intrapartum (25%), postpartum within 48h (25%)
• Features:
  • Generalized tonic-clonic seizure
  • May be preceded by warning symptoms: severe headache, visual disturbances, epigastric pain
  • History of pre-eclampsia (hypertension, proteinuria) - but 40% have no prior diagnosis
  • Post-ictal confusion, coma
• Complications: Cerebral hemorrhage, HELLP syndrome, placental abruption, maternal death
• Management:
  • Seizure control: Magnesium sulfate (4g IV over 5 mins, then 1g/hr infusion)
  • Airway protection, left lateral position
  • Blood pressure control (labetalol, hydralazine, nifedipine)
  • Delivery (definitive treatment - stabilize mother first, then deliver)

5. Pulmonary Embolism (PE) / Air Embolism

• Pulmonary embolism:
  • Pregnancy is hypercoagulable state
  • Sudden onset dyspnea, chest pain (pleuritic), collapse
  • Tachycardia, hypoxia, tachypnea
  • May have risk factors: prolonged immobility, previous VTE, thrombophilia
• Air embolism:
  • Air enters maternal venous system (e.g., during placental separation, CS)
  • Sudden cardiovascular collapse
  • Rare but rapidly fatal

6. Uterine Rupture

• Risk factors: Previous CS scar, high-dose syntocinon, obstructed labor, trauma
• Features:
  • Sudden severe abdominal pain
  • Cessation of contractions
  • Maternal tachycardia, hypotension (intra-abdominal bleeding)
  • Fetal distress or demise
  • Palpable fetal parts abdominally
• Management: Emergency laparotomy, resuscitation, often requires hysterectomy

7. Uterine Inversion

• Definition: Uterine fundus turns inside out
• Mechanism: Usually iatrogenic - excessive traction on cord with fundal pressure before placental separation
• Features:
  • Sudden profound shock (out of proportion to blood loss)
  • Severe lower abdominal pain
  • Mass visible/palpable at introitus (inverted uterus)
  • PPH
  • Vasovagal response (bradycardia, hypotension)
• Management: Immediate manual replacement under anesthesia, tocolysis to relax uterus

MEDICAL (NON-OBSTETRIC) CAUSES

8. Neurological

• Cerebral hemorrhage (intracerebral, subarachnoid):
  • Associated with severe hypertension, pre-eclampsia
  • Sudden severe headache ("thunderclap"), vomiting
  • Reduced consciousness, focal neurology
• Cerebral venous sinus thrombosis: Headache, seizures, focal deficits
• Seizures (non-eclamptic): Epilepsy, other causes

9. Respiratory

• Aspiration pneumonitis:
  • Aspiration of gastric contents (risk increased in pregnancy due to delayed gastric emptying)
  • Rapid onset respiratory distress
• Severe asthma: Acute exacerbation

10. Cardiovascular

• Myocardial infarction (MI):
  • Rare in pregnancy but can occur
  • Risk factors: smoking, hypertension, diabetes, cocaine use
  • Chest pain, dyspnea, collapse
• Peripartum cardiomyopathy:
  • Heart failure developing in last month of pregnancy or within 5 months postpartum
  • Dyspnea, orthopnea, peripheral edema
  • Can present acutely with pulmonary edema and collapse
• Arrhythmia: SVT, VT, VF

11. Endocrine/Metabolic

• Hypoglycemia: Diabetic on insulin, prolonged labor without adequate intake
• Thyroid storm: Rare; uncontrolled hyperthyroidism
• Addisonian crisis: Adrenal insufficiency

12. Anaphylaxis

• Triggers: Antibiotics (beta-lactams), oxytocin, latex, blood products, anesthetic agents
• Features:
  • Rapid onset (minutes)
  • Urticaria, angioedema, bronchospasm, wheeze
  • Hypotension, tachycardia
  • Respiratory distress
• Management:
  • Stop trigger
  • Adrenaline 0.5mg IM (1:1000) - repeat every 5 mins if needed
  • IV fluids (rapid bolus)
  • Antihistamines, corticosteroids

13. Complications of Regional Anesthesia

• High spinal/total spinal:
  • Anesthetic spreads too high
  • Respiratory paralysis (cannot breathe)
  • Hypotension
  • Loss of consciousness
  • Management: Intubate and ventilate, IV fluids, vasopressors
• Local anesthetic systemic toxicity (LAST):
  • Accidental IV injection of local anesthetic
  • Perioral tingling, tinnitus, confusion
  • Seizures, arrhythmias, cardiac arrest
  • Management: Stop injection, Intralipid 20% (lipid emulsion therapy)

14. Sepsis

• Maternal sepsis: Chorioamnionitis, endometritis, UTI, pneumonia
• Features: Fever, tachycardia, hypotension, altered consciousness
• Septic shock: Profound vasodilation → circulatory collapse

Summary Table: Differential Diagnosis

Category	Diagnoses	Key Clues
Hemorrhage	PPH, APH, abruption, uterine rupture	Visible bleeding, tachycardia, hypotension, pallor
Hypertensive	Eclampsia, cerebral hemorrhage	Seizures, severe BP, headache, pre-eclampsia history
Thromboembolic	PE, air embolism, CVT	Sudden dyspnea, chest pain, hypoxia
Cardiac	MI, cardiomyopathy, arrhythmia	Chest pain, dyspnea, ECG changes
Anaphylaxis	Drug/latex allergy	Rapid onset, rash, wheeze, recent drug administration
AFE	Amniotic fluid embolism	Triad: hypoxia, hypotension, DIC during/after delivery
Iatrogenic	High spinal, LAST, uterine inversion	Recent regional anesthesia or cord traction
Sepsis	Severe infection	Fever, tachycardia, signs of infection
Metabolic	Hypoglycemia	Diabetic, prolonged labor, rapid response to glucose

Systematic Assessment After Initial Resuscitation

1. History: Events leading to collapse, pre-existing conditions, medications, allergies
2. Examination:
   • ABC assessment
   • Vital signs (HR, BP, RR, SpO2, temp, GCS)
   • Visible bleeding?
   • Uterine tone (soft/firm)?
   • Neurological examination
   • Cardiovascular/respiratory examination
3. Investigations:
   • Bloods: FBC, clotting, U&E, LFTs, glucose, group and cross-match, lactate, blood cultures
   • Arterial blood gas
   • ECG (12-lead)
   • CXR
   • CTG (fetal monitoring if fetus still in utero and viable)
   • Targeted imaging based on suspected cause (CT head, CTPA, echo)

Key Points

• Maternal collapse is an EMERGENCY - begin resuscitation immediately
• ABC approach first - do not delay for diagnosis
• Left lateral tilt or manual uterine displacement if ≥20 weeks (relieve aortocaval compression)
• Perimortem CS within 4-5 minutes if no ROSC and ≥20 weeks (improves maternal AND fetal outcomes)
• Consider OBSTETRIC causes first: PPH, AFE, eclampsia, abruption, PE, uterine rupture/inversion
• AFE is diagnosis of exclusion - triad of hypoxia, hypotension, DIC
• Anaphylaxis: Consider if recent drug administration - give adrenaline immediately
• Call for senior help early - multidisciplinary team (obstetrics, anesthesia, ICU)

Antepartum Hemorrhage (APH) - Systematic Approach

Definition

Antepartum hemorrhage: Vaginal bleeding from the genital tract from 20+0 weeks gestation until the onset of labour.

• Incidence: 3-5% of all pregnancies
• Significance: Associated with increased maternal and fetal morbidity and mortality

Classification by Severity

Severity	Blood Loss	Clinical Features
Minor (Spotting)	<500mL	Stable vital signs, no clinical shock
Major	500-1000mL	Maternal shock, tachycardia >100, hypotension, fetal distress
Massive	>1000mL or ongoing	Maternal collapse, coagulopathy (DIC), fetal death

Main Causes of APH

• Placenta previa: 30%
• Placental abruption: 20%
• Local causes (cervix/vagina): 10% (cervicitis, polyps, ectropion, trauma)
• Vasa previa: Rare but catastrophic
• Undetermined/unknown: 40%

APPROACH TO APH

IMMEDIATE MANAGEMENT (ABC - Before History)

If major hemorrhage or maternal/fetal compromise, stabilize first

Initial Actions

1. Call for help: Senior obstetrician, anesthetist, midwife
2. ABC assessment:
   • Airway: Patent?
   • Breathing: Respiratory rate, oxygen saturation
   • Circulation: Pulse, BP, capillary refill, signs of shock
3. High-flow oxygen: 15L/min non-rebreather mask if shocked
4. IV access: Two large-bore cannulas (14-16G)
5. Bloods: FBC, group and cross-match (minimum 4 units), clotting, U&E, LFTs, Kleihauer (if Rh-negative)
6. IV fluid resuscitation: Crystalloid bolus (500-1000mL Hartmann's or 0.9% saline) if shocked
7. Continuous monitoring:
   • Maternal: HR, BP, RR, SpO2, urine output (catheterize)
   • Fetal: Continuous CTG if ≥26 weeks and fetus viable
8. Position: Left lateral tilt (avoid aortocaval compression)

Major Hemorrhage Protocol

If bleeding is severe (\>1000mL or ongoing):

• Activate major hemorrhage protocol
• Involve hematology early
• Blood products: Red cells, FFP, platelets, cryoprecipitate (1:1:1 ratio)
• Prepare for emergency delivery (CS if fetal distress or maternal deterioration)

HISTORY

Characteristics of Bleeding

• Onset: Sudden or gradual?
• Duration: How long has bleeding occurred?
• Amount: Small spotting vs heavy (clots? soaked pads? quantify)
• Colour: Fresh red blood vs dark/old blood
• Provoked or spontaneous: After intercourse, trauma, or unprovoked?
• Ongoing or stopped: Continuous vs self-limiting

Associated Symptoms

Symptom	Suggests
Pain: Constant severe abdominal/back pain	Placental abruption
No pain: Painless bleeding	Placenta previa, vasa previa, local causes
Contractions/labour	Abruption, normal labour (not APH if in labour)
Reduced fetal movements	Fetal compromise (abruption)
Post-coital bleeding	Cervical causes (ectropion, polyp, carcinoma)
Recent trauma/accident	Traumatic abruption

Obstetric History

• Gestational age: EDD, current weeks
• Previous scans: Any known placenta previa or low-lying placenta on 20-week scan?
• Current pregnancy complications: Hypertension, pre-eclampsia, IUGR
• Parity: Previous deliveries

Risk Factors

For Placental Abruption

• Hypertension, pre-eclampsia
• Previous abruption (10-25% recurrence)
• Smoking, cocaine use
• Trauma (MVA, domestic violence)
• Polyhydramnios, multiple pregnancy
• Thrombophilia
• Advanced maternal age

For Placenta Previa

• Previous CS or uterine surgery
• Previous placenta previa
• Multiparity
• Multiple pregnancy
• Advanced maternal age
• Smoking

Other History

• Blood group: Rh status (need for Anti-D if Rh-negative)
• Previous APH or PPH
• Medications, allergies

EXAMINATION

General Examination

• Vital signs:
  • HR (tachycardia suggests hypovolemia)
  • BP (hypotension is late sign - pregnancy is hypervolemic)
  • RR, SpO2
  • Temperature (exclude chorioamnionitis)
• Appearance: Pallor, distress, signs of shock
• Hydration status: Mucous membranes, skin turgor, urine output

Abdominal Examination

• Inspection: Distension, scars (previous CS)
• Palpation:
  • Uterine tenderness: Localized or generalized tenderness suggests abruption
  • Uterine tone:
    • "Woody hard" uterus: Abruption (tonic contraction)
    • Normal soft uterus: Placenta previa
  • Fundal height: Appropriate for dates? Increasing fundal height suggests concealed abruption
  • Fetal lie and presentation
  • Engagement of presenting part: Non-engaged head may suggest placenta previa
• Auscultation: Fetal heart rate (Doppler or CTG)

IMPORTANT: DO NOT Perform Vaginal Examination

• NEVER perform digital vaginal examination (VE) until placenta previa excluded by ultrasound
• Reason: Digital VE can precipitate catastrophic hemorrhage if placenta is over os
• Exception: Speculum examination (visualize cervix only, do NOT insert fingers into os) may be performed cautiously if placenta previa excluded

Speculum Examination (Only if Placenta Previa Excluded)

• Visualize cervix: Look for local causes of bleeding
  • Cervicitis, cervical polyp, ectropion, trauma, cervical cancer
• Assess os: Closed or dilated?
• Observe blood: Fresh vs old, amount

INVESTIGATIONS

Immediate Investigations

• Ultrasound scan (USS): MOST IMPORTANT INVESTIGATION
  • Placental localization: Exclude or confirm placenta previa
  • Abruption: May see retroplacental clot (but USS has low sensitivity - abruption is clinical diagnosis)
  • Fetal wellbeing: Biophysical profile, amniotic fluid volume
  • Fetal growth: Estimated fetal weight, assess for IUGR
• Continuous CTG monitoring: (if ≥26 weeks and fetus viable)
  • Assess fetal heart rate pattern
  • Look for signs of fetal compromise (late decelerations, reduced variability, bradycardia)

Laboratory Investigations

• Full blood count (FBC):
  • Hemoglobin (may be normal initially - takes hours to equilibrate)
  • Platelet count (low in DIC)
• Group and cross-match: Minimum 4 units (6 units if major hemorrhage)
• Clotting screen:
  • PT, APTT, fibrinogen, D-dimer
  • DIC may complicate severe abruption (consumptive coagulopathy)
• Kleihauer test: (if mother Rh-negative)
  • Detects fetal cells in maternal circulation (fetomaternal hemorrhage)
  • Guides Anti-D dosage
• U&E, LFTs: Baseline renal and liver function
• Urine output: Catheterize if shocked (aim >0.5mL/kg/hr)

MANAGEMENT

General Principles

1. Stabilize mother first (ABC, resuscitation)
2. Assess fetal wellbeing (CTG, USS)
3. Determine cause (USS, history, examination)
4. Decide on delivery timing and mode based on:
   • Maternal condition
   • Fetal condition
   • Gestational age
   • Cause of bleeding

Specific Management Based on Cause

Placental Abruption

• Mild abruption (small, maternal and fetal stable):
  • Admit for observation
  • Continuous CTG monitoring
  • Serial USS (fetal growth, liquor)
  • Steroids if preterm (\<34 weeks)
  • Anti-D if Rh-negative
  • Conservative management if bleeding settles
• Severe abruption (major hemorrhage, maternal/fetal compromise):
  • Emergency delivery (usually CS unless imminent vaginal delivery)
  • Resuscitation with blood products
  • Involve hematology (DIC likely)
  • Inform NICU (preterm delivery, fetal compromise likely)

Placenta Previa

• Minor bleeding, maternal and fetal stable:
  • Admit (often requires prolonged admission until delivery)
  • Pelvic rest (no intercourse, no VE)
  • Serial CTG monitoring
  • Steroids if <34 weeks
  • Anti-D if Rh-negative
  • Plan elective CS at 37-38 weeks
• Major bleeding or fetal distress:
  • Emergency CS
  • Senior obstetrician (risk of major hemorrhage at CS)
  • Cross-match 4-6 units
  • Inform anesthetist, hematology, blood bank
  • Consider cell salvage

Vasa Previa

• Rare but high fetal mortality (fetal vessels crossing membranes over os)
• Fetal bradycardia after membrane rupture
• Emergency CS immediately (fetal emergency)

Undetermined Cause / Minor Bleeding

• Admit for observation (at least 24-48 hours)
• CTG monitoring
• USS (placental position, fetal wellbeing)
• If bleeding settles and no cause found, may discharge with plan for close outpatient follow-up
• Anti-D if Rh-negative

Adjunctive Management

• Anti-D immunoglobulin:
  • Give to ALL Rh-negative women within 72 hours of bleeding
  • Dose: Minimum 250 IU if <20 weeks, 500 IU if ≥20 weeks (adjust based on Kleihauer)
• Corticosteroids:
  • Betamethasone 12mg IM x2 doses (24 hours apart) if 24+0 to 34+6 weeks
  • Promotes fetal lung maturity
  • Consider up to 36+6 weeks if delivery likely within 7 days
• Tocolysis:
  • NOT routinely recommended in APH
  • May be considered in very select cases of preterm bleeding with no maternal/fetal compromise (expert consultation)

Indications for Emergency Delivery

• Maternal hemodynamic instability despite resuscitation
• Fetal distress (pathological CTG)
• Massive ongoing hemorrhage
• Severe abruption (woody hard uterus, DIC)
• Fetal death with maternal coagulopathy

Mode of Delivery

• Cesarean section:
  • Placenta previa (major or minor)
  • Fetal distress
  • Severe abruption with unfavorable cervix
  • Maternal compromise
• Vaginal delivery:
  • May be considered in abruption if maternal/fetal stable, favorable cervix, and continuous CTG monitoring possible
  • Expedite delivery (ARM, syntocinon augmentation)

Postpartum Care

• Risk of PPH: Higher after APH (especially abruption)
• Active management of 3rd stage: Syntocinon 10 IU IM/IV
• Monitor for PPH: Have uterotonic drugs ready
• Correct coagulopathy if present
• Debrief and counseling for future pregnancies

Summary Algorithm

1. Initial assessment: ABC, stabilize if shocked (O2, IV access, fluids, bloods)
2. History: Bleeding characteristics, pain, risk factors
3. Examination: Vital signs, abdominal exam (NO VE until USS done)
4. Investigations: USS (placental location), CTG, bloods (FBC, clotting, cross-match, Kleihauer)
5. Management:
   • If major hemorrhage or fetal distress → Emergency delivery
   • If stable → Admit, observe, Anti-D if needed, steroids if preterm, plan delivery based on cause and gestation

Key Points

• APH is potentially life-threatening - assess and stabilize ABC first
• NEVER do VE until placenta previa excluded by USS
• USS is key investigation - localizes placenta
• Abruption: Painful bleeding, woody hard uterus, fetal distress, DIC
• Placenta previa: Painless bleeding, soft uterus
• Anti-D for all Rh-negative women within 72 hours
• Emergency delivery if maternal instability, fetal distress, or massive hemorrhage

Postpartum Hemorrhage (PPH) - Systematic Approach

Definition

• Primary PPH: Blood loss of ≥500mL within 24 hours of delivery (vaginal) or ≥1000mL (cesarean section)
• Secondary PPH: Abnormal bleeding from 24 hours to 12 weeks postpartum
• Incidence: 5-10% of deliveries
• Major cause of maternal mortality worldwide

Classification by Severity

Severity	Blood Loss	Clinical Features
Minor PPH	500-1000mL	Stable vital signs, minimal symptoms
Major PPH	1000-2000mL	Tachycardia, hypotension, shock
Massive PPH	>2000mL or ongoing	Severe shock, coagulopathy, risk of death

IMMEDIATE MANAGEMENT (ABC - Do This First)

PPH is an obstetric emergency - resuscitation takes priority over detailed history

Call for Help

• Emergency team: Senior obstetrician, anesthetist, theater team, blood bank
• Activate major hemorrhage protocol if massive (\>1500mL or ongoing)

Simultaneous Initial Actions

1. ABC assessment:
   • Airway: Patent?
   • Breathing: RR, SpO2
   • Circulation: HR, BP, capillary refill, signs of shock
2. High-flow oxygen: 15L/min non-rebreather mask
3. IV access: Two large-bore cannulas (14-16G)
4. Bloods:
   • FBC, group and cross-match (minimum 4 units, 6 units if major PPH)
   • Clotting screen (PT, APTT, fibrinogen, D-dimer)
   • U&E, LFTs, lactate
5. IV fluid resuscitation: Warmed crystalloid (1-2L Hartmann's or 0.9% saline rapidly)
6. Continuous monitoring: ECG, HR, BP (every 5 mins), SpO2, RR
7. Catheterize: Monitor urine output (aim >0.5mL/kg/hr)
8. Keep patient warm: Warmed blankets, warmed IV fluids (prevent hypothermia → worsens coagulopathy)
9. Position: Flat or Trendelenburg if shocked

HISTORY (Brief - Taken Concurrently with Resuscitation)

Immediate Relevant History

• Time of delivery: How long since delivery?
• Mode of delivery: Vaginal (SVD, instrumental) or CS?
• Estimated blood loss so far: Quantify (count soaked pads, weigh, visual estimate)
• Placenta delivered? Complete or incomplete?
• Membranes complete?

Risk Factors for PPH

Antenatal Risk Factors

• Previous PPH (strongest predictor - 10-15% recurrence)
• Multiple pregnancy
• Polyhydramnios
• Antepartum hemorrhage (placenta previa, abruption)
• Placenta previa, placenta accreta spectrum
• Large baby (macrosomia >4kg)
• Multiparity (≥4)
• Maternal age >35 years
• Obesity (BMI >35)
• Anemia (Hb <90 g/L)
• Clotting disorders
• Uterine fibroids

Intrapartum Risk Factors

• Prolonged labor (\>12 hours)
• Precipitate labor (\<3 hours)
• Augmented labor (syntocinon)
• Instrumental delivery (forceps, vacuum)
• Cesarean section
• Retained placenta
• Episiotomy, perineal tears (especially 3rd/4th degree)
• Induction of labor

EXAMINATION

General Examination

• Vital signs:
  • HR: Tachycardia (\>100 bpm suggests >1000mL loss; >120 bpm suggests >1500mL)
  • BP: Hypotension is LATE sign (pregnancy is hypervolemic - BP maintained until >30% blood volume lost)
  • RR: Tachypnea suggests shock
  • SpO2: Monitor oxygenation
• Appearance: Pallor, distress, cold clammy peripheries, altered consciousness
• Capillary refill: >2 seconds suggests poor perfusion

Abdominal Examination

• Uterine palpation:
  • Uterine tone:
    • Atonic (soft, boggy) uterus: Most common cause of PPH (80%)
    • Firm, contracted uterus: Suggests trauma or retained tissue
  • Fundal height: Should be at or below umbilicus immediately postpartum
• Tenderness: Suggests infection (secondary PPH) or uterine rupture

Perineal/Vaginal Examination

• Inspect perineum:
  • Episiotomy breakdown?
  • Perineal tears? (1st, 2nd, 3rd, 4th degree)
  • Vulval/vaginal hematoma?
• Speculum examination:
  • Source of bleeding: Cervical tear? High vaginal tear?
  • Visualize cervix (may need good light, assistant)
• Bimanual examination:
  • Assess uterine size and tone
  • Check for retained placental tissue (fragments in os or uterine cavity)

INVESTIGATIONS

Laboratory Investigations

• Full blood count (FBC):
  • Hemoglobin (may be normal initially - equilibration takes hours)
  • Platelet count
• Group and cross-match: 4-6 units
• Clotting screen:
  • PT, APTT, fibrinogen, D-dimer
  • Fibrinogen <2 g/L suggests coagulopathy (give cryoprecipitate)
  • Fibrinogen <1 g/L indicates severe coagulopathy
• Arterial blood gas (ABG):
  • Lactate (tissue perfusion marker - elevated in shock)
  • Base deficit (metabolic acidosis suggests severe hemorrhage)
  • Hemoglobin
• U&E: Renal function (risk of acute kidney injury in shock)

Bedside Tests

• Clot observation test (bedside clotting assessment):
  • Place 5-10mL blood in plain glass tube
  • Observe clot formation at 4-6 minutes
  • If no clot or clot breaks up easily → coagulopathy
• ROTEM/TEG: Point-of-care coagulation testing (if available)

Imaging

• Ultrasound:
  • Assess for retained products of conception
  • Identify uterine/broad ligament hematoma
• CT angiography:
  • If ongoing bleeding and source unclear
  • Identify bleeding vessel for interventional radiology embolization

MANAGEMENT

Systematic Approach: "4 Ts" Framework

Identify and treat the cause using the 4 Ts mnemonic:

1. TONE - Uterine atony (80% of PPH)
2. TISSUE - Retained placenta/membranes (10%)
3. TRAUMA - Genital tract trauma (7%)
4. THROMBIN - Coagulation disorders (3%)

1. TONE - Uterine Atony

Recognition

• Soft, boggy, poorly contracted uterus on palpation
• Most common cause of PPH

Management Steps (Escalating)

Step 1: Uterine Massage

• Bimanual uterine compression:
  • One hand in vagina pushes uterus up
  • Other hand on abdomen compresses fundus down
  • Provides direct mechanical tamponade
• Fundal massage: Rub uterus to stimulate contraction

Step 2: Uterotonic Drugs (Give in Sequence)

Drug	Dose & Route	Mechanism	Notes
1. Syntocinon (Oxytocin)	5-10 IU IV bolus (slow) Then 40 IU in 500mL over 4 hrs	Uterine contraction	FIRST LINE Causes hypotension if rapid bolus
2. Ergometrine	0.5mg IM or slow IV	Sustained uterine contraction	Contraindicated in hypertension Causes nausea/vomiting
3. Syntometrine	1 ampoule IM (oxytocin 5IU + ergometrine 0.5mg)	Combined action	Alternative to separate drugs
4. Carboprost (Hemabate)	0.25mg IM Repeat every 15 mins (max 8 doses = 2mg total)	Prostaglandin F2α Powerful uterine contraction	SECOND LINE Contraindicated in asthma Side effects: diarrhea, fever, bronchospasm
5. Misoprostol	800-1000 mcg PR or sublingual	Prostaglandin E1 Uterine contraction	THIRD LINE or when IM/IV unavailable Side effects: fever, shivering

Step 3: Mechanical/Surgical Interventions (If Medical Management Fails)

Intrauterine Balloon Tamponade

• Devices: Bakri balloon, Rusch balloon, condom catheter
• Mechanism: Balloon inflated in uterus (250-500mL) provides tamponade effect
• Success rate: 80-90%
• Procedure:
  • Insert balloon into uterine cavity
  • Inflate with sterile saline (fill until bleeding stops, usually 250-500mL)
  • Monitor drainage via catheter
  • Leave in situ 12-24 hours

Uterine Compression Sutures

• B-Lynch suture: Vertical compression sutures around uterus
• Requires laparotomy
• Success rate: 70-90%

Pelvic Vessel Ligation

• Uterine artery ligation
• Internal iliac (hypogastric) artery ligation
• Requires surgical expertise

Interventional Radiology

• Uterine artery embolization:
  • Catheter-guided embolization of bleeding vessels
  • Success rate 85-95%
  • Preserves fertility
  • Requires stable patient, IR availability

Hysterectomy (Last Resort)

• Life-saving when all else fails
• Peripartum hysterectomy: Total or subtotal
• Decision made by senior obstetrician
• Consent (if possible) or best interests if emergency

2. TISSUE - Retained Placenta/Membranes

Recognition

• Incomplete placenta on inspection (missing cotyledon, torn membranes)
• Placenta not delivered within 30 minutes with active management (60 mins with physiological)
• Uterus firm but bleeding continues

Management

• Controlled cord traction: Attempt delivery with uterotonic cover (syntocinon)
• Manual removal of placenta (MROP):
  • Regional or general anesthesia
  • Strict aseptic technique
  • Hand inserted into uterus, placenta separated manually
  • Prophylactic antibiotics (co-amoxiclav or clindamycin)
• Exploration of uterine cavity: Ensure complete removal
• Curettage: If fragments remain (use large curette cautiously - risk of perforation)

3. TRAUMA - Genital Tract Trauma

Recognition

• Well-contracted uterus but ongoing bleeding
• Instrumental delivery, precipitate delivery, large baby

Types of Trauma

• Perineal tears: 1st, 2nd, 3rd, 4th degree
• Cervical tears: High vascularity → brisk bleeding
• High vaginal tears: Often lateral fornix
• Episiotomy breakdown
• Uterine rupture: Rare but catastrophic (previous CS scar, obstructed labor)
• Uterine inversion: Fundus turns inside out

Management

• Careful inspection: Good light, assistant, speculum, retractors
• Adequate analgesia: Regional/general anesthesia, local infiltration
• Surgical repair:
  • Perineal tears: Layered repair (vagina, muscle, skin)
  • Cervical tears: Ring forceps to grasp cervix, figure-of-8 sutures
  • Vaginal tears: Direct suturing (may be difficult to access)
• Uterine rupture: Emergency laparotomy, repair or hysterectomy

4. THROMBIN - Coagulation Disorders

Recognition

• Oozing from venepuncture sites, ongoing bleeding despite uterotonic drugs and uterine contraction
• Blood not clotting
• Prolonged PT/APTT, low fibrinogen (\<2 g/L), low platelets

Causes

• Dilutional coagulopathy: Massive transfusion (crystalloid dilutes clotting factors)
• Consumptive coagulopathy (DIC): Severe abruption, amniotic fluid embolism, sepsis
• Pre-existing clotting disorder: von Willebrand disease, hemophilia carrier, thrombocytopenia

Management

• Involve hematology urgently
• Activate major hemorrhage protocol
• Blood product replacement (1:1:1 ratio):
  • Red cells: O-negative (emergency) or cross-matched
  • Fresh frozen plasma (FFP): Replaces clotting factors (give 1 unit FFP per 1 unit RBC)
  • Platelets: Maintain platelet count >50 x 10⁹/L (\>75 if ongoing bleeding)
  • Cryoprecipitate: If fibrinogen <2 g/L (contains fibrinogen, Factor VIII, vWF)
• Tranexamic acid:
  • 1g IV over 10 minutes, repeat after 30 mins if needed
  • Antifibrinolytic (prevents clot breakdown)
  • WOMAN trial: Reduces death from PPH if given within 3 hours
  • Give early - most effective within first hour
• Recombinant Factor VIIa: Last resort (expensive, thrombotic risk)

Monitoring During Resuscitation

• Vital signs: HR, BP every 5 minutes
• Urine output: Hourly (aim >0.5mL/kg/hr)
• Oxygen saturation: Continuous
• Blood loss: Quantify (weigh pads, measure suction)
• Serial bloods: FBC, clotting, fibrinogen, ABG (lactate) every 30-60 mins
• Temperature: Prevent hypothermia (warmed fluids, blankets)

Multidisciplinary Team Involvement

• Senior obstetrician
• Anesthetist: Airway management, fluid resuscitation
• Hematologist: Blood product guidance
• Blood bank: Rapid provision of blood products
• ICU: If massive transfusion or organ support needed
• Interventional radiologist: Arterial embolization if available
• Theater team: Prepare for surgical intervention

Documentation

• Time of delivery, time PPH recognized
• Estimated blood loss (quantified)
• Interventions and times (drugs, procedures)
• Vital signs chart
• Blood products administered
• Surgical procedures performed
• Maternal condition and response to treatment

Postpartum Care After PPH

• Continued close monitoring: Observations every 15 mins initially, then hourly
• Serial FBC: Check Hb at 24-48 hours post-PPH
• Iron supplementation: Oral or IV iron for anemia
• Transfusion: If Hb <70 g/L (or <80 g/L if symptomatic)
• VTE prophylaxis: PPH is risk factor for thrombosis
• Debrief: Explain what happened, address concerns
• Plan for future pregnancies: Document in notes, counsel about recurrence risk (10-15%)

Prevention of PPH

• Active management of 3rd stage: Syntocinon 10 IU IM/IV with delivery of anterior shoulder
• Controlled cord traction
• Correct anemia in pregnancy
• Identify high-risk women: Previous PPH, known placenta previa/accreta
• Planned delivery in appropriate setting (e.g., placenta accreta in tertiary center)

Summary Algorithm for PPH

1. Recognize PPH: Blood loss ≥500mL vaginal delivery, ≥1000mL CS
2. Call for help: Emergency team
3. Resuscitate (ABC): O2, IV access x2, fluids, bloods, monitor
4. Identify cause using 4 Ts:
   • TONE: Uterine massage, uterotonics (syntocinon → ergometrine → carboprost → misoprostol) → balloon tamponade → surgery
   • TISSUE: Examine placenta, manual removal if retained
   • TRAUMA: Inspect genital tract, repair tears/lacerations
   • THROMBIN: Blood products (FFP, platelets, cryoprecipitate), tranexamic acid
5. Escalate if ongoing bleeding: Balloon tamponade → IR embolization → surgery (B-Lynch, vessel ligation, hysterectomy)
6. Involve MDT: Senior obstetrician, anesthetist, hematology, ICU

Key Points

• PPH is an obstetric emergency - act fast
• Resuscitate first - ABC, oxygen, IV access, fluids, blood
• Use "4 Ts" framework to identify and treat cause systematically
• Uterine atony (TONE) is most common cause (80%)
• Uterotonic drugs in sequence: Syntocinon → Ergometrine → Carboprost → Misoprostol
• Tranexamic acid reduces death - give early (within 3 hours, ideally within 1 hour)
• Major hemorrhage protocol - activate early if >1500mL loss
• Balloon tamponade often successful before surgical intervention
• Multidisciplinary approach essential