Obstetric & Birthing Emergencies

Critical Out-of-Hospital Management

Positional & Medical Emergencies

Supine Hypotension Syndrome (Aortocaval Compression)

Pathophysiology: The heavy uterus compresses the inferior vena cava and aorta when the mother is supine, reducing venous return to the heart and decreasing cardiac output.

Management: Position the patient in the Left Lateral Tilt (approx. 15-30°) or full left lateral position. Avoid supine positioning during transport at all costs.

Pre-eclampsia & Eclampsia

Pre-eclampsia: Hypertension (>140/90) plus multi-system involvement (proteinuria, oedema, headache, visual disturbances, RUQ pain).

Eclampsia: The onset of generalized tonic-clonic seizures in a patient with pre-eclampsia.

Management:
  • Minimize stimuli (lights/sirens).
  • Magnesium Sulphate: The drug of choice for seizure prophylaxis and treatment (as per CPGs).
  • Support ABCs; position left lateral to maintain placental perfusion.

Malpresentation

Breech Presentation

Delivery where the buttocks or feet are the presenting part. High risk of head entrapment and cord prolapse.

Management:
  • Hands Off the Breech: Do not touch the baby until the level of the umbilicus to avoid triggering premature breathing or extension of the head.
  • Position: Mother in lithotomy or all-fours (Gaskin maneuver).
  • Lovset Manoeuvre: If arms are extended.
  • Mauriceau-Smellie-Veit (MSV) Manoeuvre: If the head is stuck; fingers on the malar bones to flex the head.

Dystocia & Cord Issues

Shoulder Dystocia

Signs: "Turtle Sign" (head delivers then retracts against the perineum). A true obstetric emergency where the anterior shoulder is impacted against the symphysis pubis.

HELPERR Mnemonic:
  • H - Help: Call for backup/MICA.
  • E - Evaluate: Consider episiotomy (midwifery/clinical scope).
  • L - Legs: McRoberts Manoeuvre (knees to chest).
  • P - Pressure: Suprapubic pressure (Rubin I).
  • E - Enter: Internal manoeuvres (Rubin II / Woods Screw).
  • R - Remove: Remove the posterior arm.
  • R - Roll: Roll the patient to all-fours (Gaskin).

Cord Prolapse

The umbilical cord drops through the cervix ahead of the baby, leading to compression and foetal hypoxia.

Management:
  • Relieve Pressure: Manually push the presenting part (head) off the cord. Do not remove hand until at hospital.
  • Position: Knee-chest position or exaggerated Sim's position.
  • Keep Cord Warm: If cord is external, wrap loosely in warm, saline-soaked gauze. Do not attempt to push it back in.

Nuchal Cord

Cord wrapped around the baby's neck. Common and often managed by slipping the cord over the head. If too tight, it may require clamping and cutting before the body is delivered.

Haemorrhage (APH & PPH)

Antepartum Haemorrhage (APH)

Bleeding from the genital tract after 24 weeks gestation.

Condition Pathophysiology Presentation
Placenta Praevia Placenta is low-lying, covering or near the internal os of the cervix. Painless, bright red vaginal bleeding. Uterus is soft.
Placental Abruption Premature separation of a normally situated placenta. Painful, dark red bleeding (may be concealed). "Woody," tender uterus.

Postpartum Haemorrhage (PPH)

Loss of >500mL blood following delivery. Causes are the 4 T's: Tone (Atony), Tissue (Retained placenta), Trauma (Tears), Thrombin (Clotting issues).

Management:
  • Fundal Massage: Rub the uterus to encourage contraction.
  • Oxytocin/Syntometrine: Pharmacological uterine stimulants.
  • Bimanual Compression: External/Internal compression if massage fails.
  • Breastfeeding: Encourages natural oxytocin release.
  • Fluid resuscitation for shock.

Structural & Multiple Pregnancy

Uterine Inversion

The uterus turns inside out, often due to excessive cord traction in the 3rd stage. Can cause profound neurogenic shock and haemorrhage.

Management: Do not remove the placenta if still attached. Gently attempt to replace the uterus or cover with moist pads and transport immediately.

Uterine Rupture

A tearing of the uterine wall. High mortality risk. Associated with previous C-section scars or trauma.

Signs: Sudden sharp abdominal pain, cessation of contractions, recession of the presenting part, and signs of shock.

Multiple Pregnancy (Twins/Triplets)

Increased risk for all of the above (PPH, malpresentation, cord prolapse, and pre-eclampsia).

Management: Prepare for multiple resuscitations. Clamp and cut the cord of the first twin immediately to prevent blood loss from the second twin via the placenta.