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 180ยฐ
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