Obstetric Emergencies

Pregnancy-Specific Emergency Management

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Obstetric Emergencies

Key Principle: Two Patients, One Life

Maternal resuscitation is fetal resuscitation

Left uterine displacement for all pregnant patients >20 weeks

Obstetric Emergency Algorithms

Eclampsia Management

Eclampsia Definition

Seizures in pregnancy with preeclampsia (HTN + proteinuria after 20 weeks)

Immediate Actions

  • Call for help: OB team, anesthesia, neonatology
  • Protect airway: Position patient on left side
  • Oxygen: 100% FiO2 via non-rebreather mask
  • IV access: Large-bore IV (18G or larger)
  • Monitor: Continuous fetal monitoring if possible

Seizure Management

  • Magnesium sulfate: First-line treatment
  • Loading dose: 4-6g IV over 15-20 minutes
  • Maintenance: 1-2g/hour IV infusion
  • Duration: Continue for 24 hours postpartum
  • Monitor: Deep tendon reflexes, respiratory rate, urine output

💊 Eclampsia Medications

Magnesium Sulfate
4-6g IV loading, then 1-2g/hour

First-line treatment for eclampsia. Prevents recurrent seizures.

Labetalol
20mg IV, then 40mg, then 80mg every 10 minutes

For severe hypertension (SBP >160 or DBP >110).

Hydralazine
5-10mg IV every 20 minutes

Alternative antihypertensive for severe hypertension.

Maternal-Fetal Considerations

  • Delivery: Definitive treatment - deliver within 24 hours
  • Fetal monitoring: Continuous if possible during seizure
  • Gestational age: Consider steroids if <34 weeks
  • Mode of delivery: Vaginal preferred unless obstetric indication for C-section
  • Postpartum: Continue magnesium for 24 hours

Postpartum Hemorrhage

PPH Definition

Blood loss >500mL after vaginal delivery or >1000mL after C-section

Assessment & Recognition

  • Vital signs: Tachycardia, hypotension, tachypnea
  • Blood loss: Visual estimation often underestimates
  • Uterine tone: Boggy uterus suggests atony
  • Lacerations: Inspect for cervical, vaginal, perineal tears
  • Retained products: Incomplete placenta or membranes

Initial Management

  • Call for help: OB team, anesthesia, blood bank
  • Large-bore IV: 2 IV lines (18G or larger)
  • Fluid resuscitation: Crystalloid bolus 1-2L
  • Uterine massage: Bimanual compression
  • Oxytocin: 10-40 units in 1L NS

💊 Hemorrhage Medications

Oxytocin
10-40 units in 1L NS

First-line uterotonic for uterine atony.

Methylergonovine
0.2mg IM every 2-4 hours

Second-line uterotonic. Avoid in hypertension.

Carboprost
0.25mg IM every 15-90 minutes

Prostaglandin F2α. Avoid in asthma.

Misoprostol
800-1000mcg rectally

Prostaglandin E1. Good for resource-limited settings.

Advanced Interventions

  • Uterine packing: Gauze or balloon tamponade
  • B-Lynch suture: Compression suture technique
  • Uterine artery embolization: Interventional radiology
  • Hysterectomy: Last resort for uncontrolled bleeding

Maternal Cardiac Arrest

Key Principle

Maternal resuscitation is fetal resuscitation. Focus on maternal survival first.

Left Uterine Displacement (LUD)

  • All pregnant patients >20 weeks: Apply LUD immediately
  • Manual displacement: Push uterus to the left
  • Wedge positioning: 15-30° left lateral tilt
  • Purpose: Relieve aortocaval compression
  • Continue: Throughout resuscitation

Modified ACLS for Pregnancy

  • CPR: Standard chest compressions (no modification needed)
  • Defibrillation: Standard energy levels
  • Medications: Standard ACLS medications
  • Airway: Consider early intubation
  • IV access: Above diaphragm preferred

Perimortem Cesarean Section

  • Timing: Begin within 4 minutes of arrest
  • Indication: Pregnant >20 weeks, no ROSC after 4 minutes
  • Location: Bedside or OR if available
  • Technique: Vertical midline incision
  • Goal: Deliver within 5 minutes of decision

Pregnancy-Specific Considerations

  • Physiological changes: Increased cardiac output, blood volume
  • Aortocaval compression: Relieved by LUD
  • Fetal monitoring: Not priority during maternal arrest
  • Medication safety: Most ACLS medications safe in pregnancy
  • Post-ROSC care: Consider delivery timing

Obstetric Emergency Key Principles

  • Maternal resuscitation is fetal resuscitation
  • Left uterine displacement for all pregnant patients >20 weeks
  • Call for help early - OB team, anesthesia, neonatology
  • Consider perimortem C-section if no ROSC after 4 minutes
  • Most emergency medications are safe in pregnancy
  • Delivery is definitive treatment for many obstetric emergencies

Reference Information

Source: American College of Obstetricians and Gynecologists (ACOG)

Guidelines: ACOG Practice Bulletins and Committee Opinions

Note: Regular simulation training is essential for obstetric emergency preparedness.