Obstetric Emergencies: A Practical Manual

Cover
Title Page
Copyright Page
Contents
Contributors
Overview of Obstetric Emergencies
	Early Identification, Communication and Teamwork in Obstetric Emergencies
	Simulation-Based Training
	Consent, Debriefing and Documentation
	Risk Management and Audit
	Conclusion
Umbilical Cord Prolapse
	Pathophysiology
	Risk Factors for Umbilical Cord Prolapse
	Prevention of Umbilical Cord Prolapse
	Diagnosis of Umbilical Cord Prolapse
	Diagnosis of Cord Presentation
	Management of Umbilical Cord Prolapse
		Assess for Fetal Viability
		Expedite Delivery
		Digital Elevation of the Presenting Part
		Filling the Bladder
		Positioning the Woman
		Other Measures
			Tocolytics
			Intrauterine Resuscitation Measures
			Relieving of Spasms of the Umbilical Cord Vessels
	Choice of Manoeuvres in Umbilical Cord Prolapse
	Care of the Newborn
	Prognosis of Umbilical Cord Prolapse
	Umbilical Cord Prolapse under Special Circumstances
	Key Points
	Bibliography
Eclampsia and Pre-Eclampsia with Severe Features
	Classification of Hypertensive Disorders of Pregnancy
	Pathophysiology of Pre-Eclampsia
	Prediction of Pre-Eclampsia
	Prevention of Pre-Eclampsia
	Clinical Features
	Investigations
		Evidence of Target Organ Damage
		Evidence of Fetal Growth and Wellbeing
		Special Investigations
	Management of Eclampsia or Pre-Eclampsia with Severe Features
		Antihypertensive Therapy
		Anticonvulsant Therapy
		Liver, Renal and Haematological Involvement
		Identifying Fetal Compromise
		Fluid Balance
		Delivery
		Management during the Postpartum Period
		Follow-Up
	Documentation, Debriefing, Risk management and Training
	Key Points
	Bibliography
Acute Fatty Liver of Pregnancy
	Introduction
	Pathogenesis
	Complications
	Diagnosis
		Clinical Features
		Differential Diagnosis
			Investigations
			Haematological Investigations
			Imaging Studies
			Histological Investigations
	Highlighted Main Distinguishing Features
	Management
		Initial Management
		Assessment of Fetal Wellbeing
		Administration of Corticosteroids and Magnesium Sulphate
		Delivery
		Postpartum Management
		Management of Complications
	Recurrence
	Monitoring of Neonate
	Key Points
	Bibliography
Cardiac Emergencies in Obstetrics
	Physiological Changes in the Cardiovascular System during Pregnancy
	Management
	Prevention
	Acute Exacerbation of Preexisting Cardiac Disease
	Acute Heart Failure
		Clinical Features
			Symptoms
			Signs
		Management
			Investigations
			Pharmacological Treatment
			Delivery
			Postpartum Period
			Follow-Up
		Peripartum Cardiomyopathy
			Pathogenesis
			Risk Factors
			Clinical Features
			Investigations
			Diagnosis
			Management
			Prognosis and Follow-Up
		Pregnancy-Associated Acute Myocardial Infarction
			Diagnosis
			Management
		Aortic Dissection in Pregnancy
			Pathogenesis
			Diagnosis
			Management
	Key Points
	Bibliography
Maternal Sepsis
	Definitions
	Prevention
	Causes
	Microbiology
	Pathophysiology
	Diagnosis
	Management
		Initial Stabilisation
		Investigations
			Microbiological Studies
			Imaging
		Antibiotic Therapy
		Thromboprophylaxis
		Maternal Monitoring
		Fetal Monitoring
		Delivery
		The Place of Perimortem Caesarean Delivery
	Intraamniotic Infection
		Risk Factors
		Prevention
		Pathogenesis
		Diagnosis
		Management
	Key Points
	Bibliography
Maternal Cardiorespiratory Arrest
	Causes of Maternal Cardiorespiratory Arrest
	Identification of Women at Risk of Cardiorespiratory Arrest
	Cardiopulmonary Resuscitation in a Pregnant Woman
		Activate Teams
		Relieve Aortocaval Compression by the Gravid Uterus
			Manual Left Uterine Displacement
			Tilt
		Airway and Breathing
		Supplemental Oxygen
		Chest Compressions
		Fluid Administration
		Defibrillation
		Medication
		Perimortem Caesarean Delivery
			Rationale
			Time Limits
			Technique
			Perimortem Caesarean Delivery or 'Resuscitative Hysterotomy'
	Place of Instrumental Vaginal Delivery
	Perimortem Hysterectomy
	Fetal Survival
	Continuing Care after Cardiorespiratory Arrest
	Documentation, Debriefing, Incident Reporting and Training
	Key Points
	Bibliography
Abnormal Labour
	Types of Abnormal Labour
	Poor Progress in the First Stage
	Causes of Poor Progress of Labour
	Power
	Passage
	Passenger
		Malpositions of the Vertex
		Fetal Attitude
		Asynclitism
		Malpresentations
			Face and Brow Presentations
			Face Presentation
			Brow Presentation
			Shoulder, Dorsal or Arm Presentation When the Lie is Transverse or Oblique
			Compound Presentations
	Provider and Patient Factors
	Identification and Management of an Abnormal First Stage of Labour
		Identify the Cause
		Provide Continuous Support to the Labouring Woman
		Amniotomy
		Oxytocin
		Carry Out Continuous Electronic Fetal Monitoring
		Reassess the Progress of Labour Following Intervention
		Caesarean Delivery
	Prolonged Second Stage
		Time Limits of the Second Stage
		Factors Affecting the Duration of the Second Stage
		Interventions for a Prolonged Second Stage
	Use of Ultrasound in Dysfunctional Labour
		Assessment of Fetal Position
		Assessment of Fetal Station
		Assessment of Fetal Attitude
	Precipitate Labour
	Complications of Abnormal Labour
	Key Points
	Bibliography
Instrumental Vaginal Delivery
	Indications for Instrumental Vaginal Delivery
		Maternal
		Fetal
		Non-Progressive Second Stage of Labour
	Conditions that Need to be Fulfilled for a Safe Instrumental Vaginal Delivery
		Operator and Setting
		Indication
		Consent
		Uterine Contractions and Maternal Pushing
		Abdominal and Vaginal Examination
		Maternal Position and Analgesia
		Empty Bladder
	Types of Instrumental Vaginal Delivery
	Non-Rotational Forceps Delivery
		Assemble the Forceps
		Application of the Blades of the Forceps in Occipitoanterior Positions of the Vertex
		Confirm Correct Application of Forceps - Occipitoanterior Positions
		Applying Traction
		Forceps Delivery in Occipitoposterior Positions
		Digital Rotation of the Vertex to a Direct Occipitoanterior Position
		Manual Rotation of the Vertex to a Direct Occipitoanterior Position
		Forceps Delivery in a Mentoanterior Position of a Face Presentation
		Forceps for Aftercoming Head of the Breech
		Completion of Delivery
		Checklist for Application of Forceps
		PROCEDURE - APPLICATION OF FORCEPS
	Rotational Forceps Delivery
		Rotational Forceps Delivery for Right Occipitotransverse Position
			Application of the Blades of the Forceps
		Other Methods of Application of the Blades of the Forceps
		Check for Correct Application
		Correction of Asynclitism
		Rotation Using Forceps
		Applying Traction
		After Completion of Delivery
	Vacuum Delivery
		Equipment Check
		Application of Vacuum Cup
		Anterior and Posterior Cups
		Creation of the Vacuum within the Cup
		Traction Application with the Vacuum Cup
		Complete Delivery
		When to Abandon the Procedure
	Trial of Instrumental Vaginal Delivery
	Main Differences Between Forceps and Vacuum Delivery
	BD Odon device
	Key Points
	Bibliography
Shoulder Dystocia
	Factors Associated with Shoulder Dystocia
	Prevention of Shoulder Dystocia
	Complications
		Fetal Complications
			Asphyxia
			Brachial Plexus Injury
			Fractures
		Maternal Complications
			Genital Tract Lacerations
			Postpartum Haemorrhage
			Other Rare Maternal Complications
	Management
		First-Line Measures
			Shifting the Woman to the Lower Edge of the Bed and Placing Her in McRobert's Position
			Application of Suprapubic Pressure
		Second-Line measures
			Episiotomy
			Internal Manoeuvres
			Manoeuvres Involving Internal Rotation
			Manoeuvres Involving the Delivery of the Posterior Arm
			Delivery of the Posterior Arm Across the Fetal Chest
			Delivery of the Posterior Arm Using Traction on the Posterior Axilla
			Delivery of Posterior Arm and Rotation of the Fetal Trunk by 180°
			All-Fours Manoeuvre
		Third-Line Manoeuvres
			Cleidotomy
			Symphysiotomy
			Zavanelli Manoeuvre or Abdominal Rescue
		Choice of Manoeuvres in Shoulder Dystocia
		Post-Delivery Management
	Key Points
	Bibliography
Difficult Caesarean Delivery
	Second Stage Caesarean Delivery
		Risk Factors
		Complications
			Maternal
			Fetal
		Management in Case of a Deeply Impacted Fetal Head within the Maternal Pelvis
			Preparation
			Technique
			'Push' Disengagement Technique
			'Pull' Disengagement Technique
			Use of Fetal Head Elevators
			Patwardhan Technique
			Modified Patwardhan Technique
			Other Methods
			Post-Delivery Management
		Reducing the Incidence of Second Stage Caesarean Deliveries
	Difficulties at Caesarean Delivery (Apart from Second Stage Caesarean Delivery)
	Extension of the Uterine Incision
	Key Points
	Bibliography
Complications of Obstetric Anaesthesia
	Airway-Related Complications
		Aspiration
		Difficulty in Maintaining a Patent Airway
		Failure of Endotracheal Intubation
	Hypotension Following Induction of Anaesthesia
	Uterine Hypotonia
	Neonatal Depression
	Awareness
	Hypotension, Bradycardia and Hypoventilation Following Neuraxial Anaesthesia
	Post-Dural Puncture Headache
	Inadequate, Asymmetric Analgesia
	Neurological Injury
	Infections of the Central Nervous System
	Nausea and Vomiting
	Pruritus
	Backache
	Anaphylaxis
	Key Points
	Bibliography
Antepartum Haemorrhage
	General Principles of Management
	Placental Abruption
		Risk Factors for Placental Abruption
		Types of Placental Abruption
		Clinical features
		Management
		Recurrence Risk
	Placenta Praevia
		Risk Factors for Placenta Praevia
		Placental Localisation
		Clinical Features
		Management
		Mode of Delivery
		Caesarean Delivery
			Preoperative Preparation
			Surgical Technique
		Haemorrhage Following Delivery
		Vaginal Delivery in Placenta Praevia in the Presence of Fetal Death or Lethal Fetal Abnormality
		Vaginal Delivery in Cases of Placenta Praevia with Bleeding
	Placenta Accreta Spectrum Disorders
	Range of Placenta Accreta Spectrum Disorders
		Risk Factors for Placenta Accreta Spectrum Disorders
		Diagnosis of Placenta Accreta Spectrum Disorders
		Management of Placenta Accreta Spectrum Disorders
		General
		Timing of Delivery
		Preoperative Preparation
		Caesarean Delivery
		Caesarean Hysterectomy
			Bladder Injury
			Postoperative Management
		Conservative Management
		Expectant Management
			Adjuvant Therapy in Expectant Management
		Unexpected Diagnosis of Placenta Accreta Spectrum Disorder
	Vasa Praevia
		Clinical Features
		Diagnosis
		Management
	Key Points
	Bibliography
Primary Postpartum Haemorrhage
	Causes of Primary Postpartum Haemorrhage
		Uterine Atony
		Genital Tract Trauma
		Abnormalities in Tissue
		Abnormalities in Thrombin
	Prevention of Primary Postpartum Haemorrhage
	Early Recognition of Postpartum Haemorrhage
	Identification and Treatment of the Cause
	Management of Uterine Atony
		Fundal Massage
		Emptying of the Bladder
		Uterotonic Agents, in a Stepwise Manner
			Ergometrine
			Oxytocin
			Syntometrine
			Misoprostol
			Carboprost
		Tranexamic Acid
	Refractory Uterine Atony
		Uterine Balloon Tamponade
	Management of Trauma to the Genital Tract
		Vaginal Wall Lacerations
		Vestibular Tears
		Cervical Lacerations
		Paravaginal Haematomas
			Infralevator Haematoma
			Supralevator Haematoma
	Management of Tissue Abnormalities
	Management of Thrombin Abnormalities
	Management of a Very Severe Primary Postpartum Haemorrhage
		Multidisciplinary Management
		Resuscitation
		Massive Transfusion Protocol
		Procedures Used in the Management of Very Severe Postpartum Haemorrhage
		Bimanual Compression of the Uterus
		Aortic Compression
		Intraoperative Cell Salvage
		Pelvic Packing
		Radiological Procedures
		Recombinant Factor VIIa
	Monitoring of Vital Signs
	Post-Procedure Management
	Key Points
	Bibliography
Secondary Postpartum Haemorrhage
	Causes of Secondary Postpartum Haemorrhage
	Diagnosis
	Management of Secondary Postpartum Haemorrhage
		Resuscitation
		Investigation for Sepsis
		Identification of the Cause of Secondary Postpartum Haemorrhage
		Treatment for the Cause
			Retained Placental Tissue
			Endometritis
			Treatment of Rare Causes
	Prevention of Secondary Postpartum Haemorrhage
	Key Points
	Bibliography
Uterine Rupture
	Causes of Uterine Rupture
	Clinical Presentation of Uterine Rupture
	Management of Uterine Rupture
		General Principles
		Surgical Technique
		Control of Bleeding until Definitive Treatment is Instituted
		Repair of the Uterine Tear
		Hysterectomy
		Involvement of the Urinary Tract
		Postoperative Management
	Pregnancy Following Uterine Rupture
	Prevention of Uterine Rupture
	Key Points
	Bibliography
Uterine Compression Sutures
	General Principles
	B-Lynch Suture
	Other Types of Compression Sutures
		Vertical Compression Sutures
		Square Compression Sutures
	Combined Techniques
	Complications of Uterine Compression Sutures
	Key Points
	Bibliography
Uterine Devascularization
	Blood Supply to the Uterus
	Ligation of Uterine Arteries and Utero-Ovarian Anastomoses
		Procedure
	Internal Iliac Artery Ligation
		Indications for Internal Iliac Artery Ligation
		Current Role of Internal Iliac Artery Ligation
		Anatomy of the Internal Iliac Artery
		Physiology of Internal Iliac Artery Ligation
		Procedure of Internal Iliac Artery Ligation
		Surgical Technique
		Exteriorisation of the Uterus and Packing Off the Abdominal Viscera
		Opening into the Retroperitoneal Space
		Extending the Incision on the Posterior Pelvic Peritoneum
		Identifying the Internal Iliac Artery
		Ensuring that the Ureter is on the Medial Flap of the Peritoneum
		Clearing the Areolar Tissue around the Internal Iliac Artery
		Passing a Fine Right-Angled Forceps beneath the Internal Iliac Artery
		Preparation of the Suture for Ligation
		Double Ligation of the Anterior Division of the Internal Iliac Artery
		Confirmation of an Intact External Iliac Artery
		Complications of Internal Iliac Artery Ligation
	Key Points
	Bibliography
Emergency Obstetric Hysterectomy
	Surgical Principles of Emergency Obstetric Hysterectomy
		Timing of Hysterectomy
		Mode of Anaesthesia
		Abdominal Entry
		Steps to Control Haemorrhage until Hysterectomy is Performed
		General Principles
		Surgical Technique
			Development of the Round Ligament and Fallopian Tube and Ovarian Ligament Pedicles
			Bladder Dissection
			Development of the Uterine Vessel Pedicles
			Development of the Utero-Sacral and Cardinal Ligament Pedicles
			Identification of the Cervix
			Securing the Angles of the Vagina and Closure of the Vaginal Cuff
		Total versus Subtotal Hysterectomy
		Additional Measures to Control Haemorrhage
		Postoperative Management
	Complications of Emergency Obstetric Hysterectomy
		Bladder and Ureteric Injury
		Disseminated Intravascular Coagulation
	Key Points
	Bibliography
Retained Placenta
	Causes of a Retained Placenta
	Management of a Retained Placenta
		General Measures
		Manual Removal of a Retained Placenta
		Intraumbilical Vein Injection of a Uterotonic Agent
	Trapped Placenta
	Placenta Accreta Spectrum Disorder
	Key Points
	Bibliography
Acute Uterine Inversion
	Degrees of Uterine Inversion
	Causes of Uterine Inversion
	Prevention of Acute Uterine Inversion
	Diagnosis
	Management
		Manual Replacement of the Uterus
		Hydrostatic Methods for Correction of Uterine Inversion
		Laparotomy
			A. Non-instrumental Atraumatic Stepwise Reduction of an Inverted Uterus
			B. Huntington's Technique
			C. Use of a Vacuum Cup to Correct Uterine Inversion
			D. Haultain's Technique
			E. Hysterectomy
			F. Combined Abdomino-vaginal Procedures
	Key points
	Bibliography
Amniotic Fluid Embolism
	Pathophysiology
	Risk Factors
	Clinical Features
	Differential Diagnosis
	Investigations
		Blood Tests
		Tests to Assess Cardiovascular and Respiratory systems
		Confirmatory Tests
	Management
		Initial Management
		Management of Coagulopathy
		Resuscitative Hysterotomy
		Close Monitoring
	Recurrence
	Prevention
	Future
	Key Points
	Bibliography
Venous Thromboembolism in Pregnancy
	Pathophysiology
	Risk Factors
	Prevention
	Clinical Features
	Investigations
		Deep Vein Thrombosis
		Pulmonary Embolism
	Treatment
		Acute Management
		Anticoagulant Therapy
		General Measures
		Significance of Temporary Inferior Vena Cava Filter
		Anticoagulant Therapy during the Time of Delivery
		Specific Measures during Delivery
		Management during the Postpartum Period and Follow-up
	Key Points
	Bibliography
Obstetric Anal Sphincter Injuries
	Classification of Perineal Injuries
	Risk Factors for Obstetric Anal Sphincter Injuries
		Parity
		Increased Birth Weight
		Malposition
		Duration of Labour
		Episiotomy
		Instrumental Vaginal Delivery
		Combination of Factors
	Prevention of Obstetric Anal Sphincter Injuries
		Episiotomy
		Perineal Protection
	Management of Obstetric Anal Sphincter Injuries
		Examination
		Repair
		Postoperative Care
	Follow-up after the Repair
		Endoanal Ultrasound Scan
		Anal Manometry
	Management of Subsequent Pregnancy Following Obstetric Anal Sphincter Injuries
	Key points
	Bibliography
Assisted Vaginal Breech Delivery
	Types of Breech
	Predisposing Factors for Breech Presentation
	Fetal Risks in Breech Presentation
	Prerequisites for an Assisted Vaginal Breech Delivery
	Management of Labour
	The Technique for Assisted Vaginal Breech Delivery
	Delivery of the Breech and Legs
	Delivery of fetal abdomen
	Delivery of the Shoulders and Arms
		Delivery of Flexed Arms
		Delivery of Extended Arms
	Delivery of a Nuchal Arm
	Delivery of the Head
		Forceps to the Aftercoming Head
		Mauriceau-Smellie-Veit Manoeuvre
		Burns-Marshall Technique
	Difficulties Encountered during the Delivery of the Aftercoming Head of the Breech
		Extension of the fetal head
		Entrapment of the Fetal head
		Aftercoming Head of the Breech in the Occipitoposterior Position
		Head Stuck Inside the Pelvis
	Breech Extraction
	Acquisition of Necessary Skills in Conducting an Assisted Vaginal Breech Delivery
	Key Points
	Bibliography
Twin Delivery
	Factors that Influence the Mode of Delivery
	Timing of Delivery
	Management of Labour
		First Stage of Labour
		Second Stage of Labour
		Third Stage of Labour
	Locked Twins
		Management of Locked Twins
		Prevention of Locked Twins
	Key Points
	Bibliography
External Cephalic Version
	Procedure
	Factors for Success
	Complications
	Key Points
	Bibliography
Internal Podalic Version and Breech Extraction
	Procedure for Internal Podalic Version and Breech Extraction
	Possible Difficulties during the Procedure
	Complications
	Key Points
	Bibliography
Non-Reassuring Fetal Status
	Intrapartum Non-Reassuring Fetal Status
	Pathophysiology
	Identification
		Cardiotocography
			Fetal Heart Rate Decelerations
			Fetal Heart Rate Variability
			Intrapartum Cardiotocograph Patterns Associated with Fetal Hypoxia and Neurological Injury
			Infection, Inflammation and Fetal Heart Rate Abnormalities
			Inadvertent Monitoring of Maternal Heart Rate
		Fetal pH and Lactate Levels
		Fetal Electrocardiogram
	Techniques in Identifying Fetuses at Risk of Compromise in Labour
		Doppler Ultrasound Velocimetry
			Umbilical Artery Doppler Velocimetry
			Middle Cerebral Artery Doppler Velocimetry
			Cerebro-Placental Ratio
			Umbilical Venous Flow
		Other Antenatal Assessments
	Treatment
	Key Points
	Bibliography
Resuscitation of the Newborn
	Background
	Initiation of Breathing at Birth
	Pathophysiology of Apnoea and Gasping
	Prerequisites for Resuscitation of the Newborn
	Cord Clamping
	Steps of Resuscitation
		Initial steps
		Temperature Maintenance
		Inflation Breaths
		Ventilation Breaths
		Chest Compression
		Drugs
		Intubation
		Delivery Room Continuous Positive Airway Pressure (CPAP)
	Stopping Resuscitation
	Debriefing
	Challenging Scenarios Requiring Resuscitation
	Meconium Staining versus Meconium Aspiration
	Palliative Care on the Delivery Suite - Managing End of Life in Life-Limiting Situations
	Key Points
	Bibliography
Simulation in Obstetric Emergencies
	The Evolution of Simulation-Based Training in Obstetric Emergencies
	The Concept of 'Team Training'
	The Relevance of Simulation-Based Training in Obstetric Emergencies
		Setting
		Fidelity
		Resources
	Important Aspects of a Simulation-Based Training Programme
		Initial Design
		Providing an Environment Conducive to Learning
		Pretest
		Demonstration of Manoeuvres
		Areas Covered
		Soft Skills
		Debriefing
		Evaluation of Training Courses
		Frequency of Simulation-Based Training
		Review of the SBT Programme
	Simulation-Based Training in Resource-Poor Settings
	The Future
	Key Points
	Bibliography
Index