Intrapartum Obstetric Emergencies

Non-haemorrhagic obstetric shock

The causes of non-haemorrhagic obstetric shock (pulmonary thromboembolism, amniotic fluid embolism, acute uterine inversion and sepsis) are uncommon but responsible for the majority of maternal deaths in the developed world. Clinically suspected pulmonary thromboembolism should be treated initially with heparin and objective testing should be performed. If the diagnosis is confirmed, heparin is usually continued until delivery, following which anticoagulation in the puerperium is achieved with either warfarin or heparin. Amniotic fluid embolism is a rare complication of pregnancy, occurring most commonly during labour. The management of amniotic fluid embolism involves maternal oxygenation, the maintenance of cardiac output and blood pressure, and the management of any associated coagulopathy. Acute uterine inversion arises most commonly following mismanagement of the third stage of labour. The shock in uterine inversion is neurogenic in origin, although there may also be profound haemorrhage. The management of this condition includes maternal resuscitation and replacement of the uterus either manually, surgically or by hydrostatic pressure. Genital tract sepsis remains a significant cause of maternal death, the most common predisposing factor being prolonged rupture of the fetal membranes. The management of septic shock in pregnancy includes resuscitation, identification of the source of infection and alteration of the systemic inflammatory response.

A six-year retrospective analysis of shoulder dystocia and delivery of the shoulders

OBJECTIVE

To investigate the diagnosis, incidence and management of shoulder dystocia.

DESIGN

Retrospective review of all the deliveries between 1988 and 1993 which were coded on the computer data base as 'moderate difficulty with the shoulders' or 'shoulder dystocia'.

SETTING

A teaching hospital in the south of England.

PARTICIPANTS

The study population consisted of 15,658 women who had cephalic vaginal deliveries of babies weighing > 2.5 kg. The sample consisted of the 257 women reported to have moderate difficulty with the shoulders or shoulder dystocia at delivery.

FINDINGS

There was a significant fall in the reported incidence of shoulder dystocia during the period under investigation. Eighty-six (1.1%) of the deliveries between 1988 and 1990 were reported to have been complicated by shoulder dystocia. In 1991 a second option was introduced to allow both shoulder dystocia or moderate difficulties with the shoulders to be coded after delivery. Following this change in categorisation, the incidence of shoulder dystocia was reduced to 30 (0.6%) reported cases in 1992-1993. Over the same period the reported incidence of moderate difficulty rose significantly from 29 (1.1%) in 1992 to 60 (2.4%) in 1993 (P < 0.001). Disparity was noted between the experience of practitioners and contemporary definitions of shoulder dystocia and this was highlighted by the number of reported cases of moderate difficulty. In this study practitioners used the term shoulder dystocia in a general sense to describe a range of difficulties encountered with the delivery of the shoulders and they identified many varied manifestations. In comparison, contemporary literature describes shoulder dystocia as a discrete entity.

KEY CONCLUSIONS

Shoulder dystocia is a complex clinical scenario and perceptions of the incidence may be influenced by alterations in the delivery technique and changes in the diagnosis and documentation.

IMPLICATIONS FOR PRACTICE

The application of traction may interfere with the normal mechanisms of labour and the spontaneous birth of the shoulders, whilst increasing the risk of trauma to the baby. It may be unnecessary to use such interventions routinely in the care of normal labouring women.

Uterine inversion after nitroglycerin use during cesarean delivery

Intravenous nitroglycerin was used to provide uterine relaxation for cesarean delivery of a macrosomic infant. The procedure was complicated by uterine inversion, and subsequent uterine atony. While several other factors may have contributed to the uterine atony, nitroglycerin administration might have played a role. Further, while nitroglycerin was helpful in facilitating the delivery of the macrosomic infant, the risk of uterine inversion must be considered.

Out-of-hospital deliveries: a five-year experience

INTRODUCTION

Prehospital providers regularly encounter patients with obstetrical emergencies. This study determined the frequency and outcome of out-of-hospital deliveries in an urban, all advanced life support (ALS) emergency medical services (EMS) system.

METHODS

Retrospective review of all out-of-hospital records that involved women delivering babies in the care of prehospital providers from 1984-1988. The EMS system answered an average of 62,000 calls during the study period. The records of these patients were identified through a computer database.

RESULTS

A total of 81 out-of-hospital deliveries (1.4/month) occurred during the study years. The average age of the mothers was 24 years, and the average gestation period was 30 weeks. The women had an average of three previous pregnancies and two previous deliveries, and 10 were primagravida. Seventy-two (89%) of the deliveries occurred in the home. The paramedics encountered a variety of obstetrical and neonatal complications in 34% of the patient encounters. Nine neonates were delivered prior to the arrival of the paramedic team. Twenty-four neonates had Apgar scores calculated, and the one- and five-minute scores averaged eight and nine respectively. Five of the mothers had no prenatal care. Maternal complications included four patients noted to be hypertensive with the delivery, nine patients had some degree of vaginal bleeding, and in 33 patients, the prehospital providers did not deliver the placenta in the field. An EMS physician was in attendance for only two of the out-of-hospital deliveries.

DISCUSSION

In this urban EMS system, out-of-hospital deliveries, especially pre-term deliveries, are a common event. There appears to be a significant number of neonatal complications that confront paramedics. Generally, the paramedics were deficient in their documentation of the neonatal assessment. Continuing educational programs for paramedics should include reviewing normal and complicated vaginal deliveries as well as ALS measures for neonates. Protocols for obstetrical emergencies need to be developed and subjected to quality improvement measures.

CONCLUSIONS

Paramedics, especially those in urban settings, are likely to encounter obstetrical and neonatal emergencies and a significant number of associated complications. Emergency medical services systems and medical directors should have in place continuing educational programs, patient-care protocols, and continuous quality improvement measures to evaluate the care rendered to patients having out-of-hospital deliveries.