THE MANAGEMENT OF

OBSTETRIC
EMERGENCIES
Joy L. Hawkins, M.D.
University of Colorado SOM
Denver, CO
(**I have nothing to disclose)
CRASH 2007 HAWKINS, JOY, MD

“If you can keep your head

when all about you are
losing theirs, it’s just
possible you haven’t
grasped the situation.”
Jean Kerr

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CRASH 2007 HAWKINS, JOY, MD

Vigilance is great, but you have

to remember that studies show
the half-life of vigilance is
about 15 minutes.

Author unknown

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PREVENTABILITY
A comprehensive review of maternal deaths in a
single state found that 40% could have been
prevented.
• Almost all deaths due to hemorrhage or
chronic disease were preventable.
• None of the deaths due to AFE or CVA were
considered preventable.
Obstet Gynecol 2005;106:1228

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HEMORRHAGE
Antepartum: Placenta previa/accreta/percreta
Placental abruption
Uterine rupture

Postpartum: Uterine inversion

Uterine atony
Birth trauma or lacerations

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Risk Factors in Obstetric Patients for

Transfusion vs. No Transfusion
Odds Ratio
Placenta accreta / placenta percreta ∞
Placenta previa 34
Placental abruption 16
Intrauterine fetal demise 8
Chorioamnionitis 7
Preeclampsia/eclampsia 7
Multiple gestation 6
Magnesium therapy 3
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“Lots of people confuse destiny with

bad management.”
Kin Hubbard

To avoid “bad management”, we should know:

• Risk factors
• Diagnostic criteria
• Obstetric management
• Anesthetic management

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PLACENTA PREVIA,
ACCRETA, and
PERCRETA

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PATIENT RISK FACTORS FOR

ABNORMAL PLACENTATION

Uterine fibroids
Prior cesarean section
History of postpartum hemorrhage
Multiparity

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RISK FACTOR: PREVIOUS CESAREAN

WITH PLACENTA PREVIA

Number of Prior C/S % With Accreta

0 5
1 24
2 47
3 40
4 67
Obstet Gynecol 1985;66:89

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DIAGNOSIS OF PLACENTAL
ABNORMALITIES
Placenta Previa
• Painless, bright red vaginal bleeding
• Ultrasound for location of placenta

Accreta/Percreta
• Antepartum: suspicious ultrasound → MRI
Obstet Gynecol 2006;108:573
• At delivery: placenta does not separate

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OB MANAGEMENT
Placenta Previa
• Cesarean delivery: elective (if stable) or
urgent (if hemorrhaging)

Accreta/Percreta
• Recognition and (probably) hysterectomy
• May need surgeons with experience in
bowel or urological surgery for percreta

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OB MANAGEMENT
• At the time of delivery when placenta accreta
is documented, the obstetrician can choose to
remove the placenta or leave it in place.
• Conservative therapy reduces hysterectomy
from 85→15%, DIC from 39→5% and
transfusion by half, but requires close
follow-up for increased risk of infection.
Obstet Gynecol 2004;104:531

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ANESTHETIC MANAGEMENT
FOR PREVIA
• Examine the airway in case emergent GETA is
required and provide aspiration prophylaxis.
• Ask OB about involvement with any previous
cesarean scar on ultrasound (risk of accreta).
• Place two large-bore IV lines and have warmers
(Level I) available.
• Assure that blood is type and cross-matched.
• What type of anesthetic?

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ANESTHETIC MANAGEMENT
FOR PREVIA
A review of 514 women with placenta previa found:
• No difference between general or regional anesthesia
in anesthetic or operative complications.
• General anesthesia was associated with ↑ EBL and
transfusions and ↓ postop Hgb.
• Greatest risk factor for hysterectomy was prior C/S.

Am J Obstet Gynecol 1999;180:1432

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ANESTHETIC MANAGEMENT
FOR PREVIA
A retrospective review of 350 consecutive cases of
placenta previa (60% using regional anesthesia,
40% using GETA) found:
• ↓ EBL with regional vs. GETA
• ↓ transfusion with regional
• No difference in incidence of hypotension
• Two spinals were converted to GETA 2o C-hyst
• Two GETA patients had thrombotic cx
Br J Anaesth 2000;84:725

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ANESTHETIC MANAGEMENT
FOR ACCRETA, PERCRETA
• Look for risk factors preop (hx C/S, previa).
• Type of anesthetic? Consider duration, blood
loss, availability of help.
• When recognized, get additional IV access,
pressure/warming systems, and blood
available.
• Have pressors and invasive monitoring
capability available.

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USE OF CELL SALVAGE

A multicenter review of 139 patients who were
auto-transfused during cesarean delivery compared
them to a control group receiving banked blood.
There was no difference in:
• Length of hospitalization
• Need for ventilatory support / A.R.D.S.
• Coagulopathy or amniotic fluid embolism
• Infectious morbidity
Am J Obstet Gyn 1998;179:715

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USE OF CELL SALVAGE

Cell salvage combined with blood filtration
produced blood samples equivalent to
maternal central venous blood.

Editorial: Until a large prospective

randomized study is done, cell salvage
during C/S should only be used when
necessary to preserve life – e.g., Jehovah’s
Witness, difficult crossmatch.
Anesthesiology 2000;92:1519 and 1531

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INTERVENTIONAL RADIOLOGY
• Prenatal diagnosis of placenta accreta /
percreta is now becoming more common
(vs diagnosis at delivery) → develop a
plan for potential major hemorrhage.
• Have a care conference in advance with
Anesthesiology, OB, nursing and
Interventional Radiology present.
Am J Obstet Gynecol 2005;193:1756
Anaesthesia 2006;61:248

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INTERVENTIONAL RADIOLOGY
• Case report: A Jehovah’s Witness patient
presented with placenta percreta invading the
bladder. After uterine and iliac catheters were
placed in IR, cesarean was performed. Placenta
was extensively adherent to uterus and
penetrating bladder wall. Uterine artery
embolization was performed and the placenta
left in place. At 3 months the uterus was empty
by ultrasound. Methotrexate was considered,
but was unnecessary.
Obstet Gynecol 2005;105:1247

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INTERVENTIONAL RADIOLOGY
In a series of 12 patients treated for massive
postpartum hemorrhage using selective
uterine artery embolization, the success rate
was 92%.
• One patient required hysterectomy.
• There were no maternal deaths.
• One patient has since had a normal
pregnancy and delivery.
Eur J Obstet Gynecol Reprod Biol 2003;10:29

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PLACENTAL
ABRUPTION

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RISK FACTORS FOR ABRUPTION

Hypertension, chronic or pregnancy-induced
Age > 35 years
Multiparity
Smoking
Cocaine use
Abdominal trauma
Premature rupture of membranes
Hx of previous abruption

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DIAGNOSIS OF ABRUPTION

• Vaginal bleeding with abdominal pain

• Uterine hypertonicity
• Fetal distress
• Retroplacental clot on ultrasound

The presentation can be quite variable

and difficult to diagnosis.

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OB MANAGEMENT OF
ABRUPTION
• Evaluate maternal stability (vital signs,
coagulation studies)
• Evaluate fetal well-being and maturity
THEN. . .
• If severe fetal distress and/or maternal
instability Æ urgent cesarean section
• If stable mother and fetus Æ induction
of labor and vaginal delivery

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ANESTHETIC MANAGEMENT
OF ABRUPTION
• Assure good IV access and blood
availability.
• Regional techniques are appropriate if
maternal volume status and coags normal.
• If GETA is indicated, consider induction
with etomidate or ketamine.
• Have several oxytocics available for
treatment of uterine atony.

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UTERINE RUPTURE

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RISK FACTORS FOR UTERINE

RUPTURE
Previous uterine surgery
Abdominal trauma – seat belt, fall
Uterine trauma - forceps, curettage
Grand multiparity
Fetal macrosomia
Fetal malposition

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DIAGNOSIS OF UTERINE
RUPTURE

Fetal distress (#1)

Cessation of uterine contractions (in labor)
Vaginal bleeding
Abdominal pain

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OB MANAGEMENT OF
UTERINE RUPTURE
Uterine repair vs. Hysterectomy

• Uterine rupture occurs in 1% of LCT

uterine incisions and 4-9% of classical
incisions.
• ACOG has practice guidelines for
management of VBAC.
Obstet Gynecol 2004;104:203

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ANESTHETIC MANAGEMENT
OF UTERINE RUPTURE

• Depends on ease of repair, but be

prepared for GETA and volume
replacement.

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UTERINE INVERSION

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UTERINE INVERSION

Risk Factors: Inappropriate fundal pressure

Excessive traction on the cord

Diagnosis: Perineal or vaginal mass

Massive hemorrhage
Shock and hypotension

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OB MANAGEMENT OF
UTERINE INVERSION

Replace the uterus as quickly as

possible, then begin oxytocic
drugs to induce contraction.

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ANESTHETIC MANAGEMENT
OF INVERSION
• Uterine relaxation:
NTG (50-500 µg), terbutaline, GETA
• Analgesia:
Pre-existing epidural, ketamine, GETA
• Volume resuscitation
• Uterine contraction with oxytocics once the
uterus is replaced

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NITROGLYCERIN

Pros: Rapid onset, short duration

Minimal side effects (HA, ↓ BP)
Clinically effective

Cons: Mechanism?
Dose? Reported 50-1500μg
Requires dilution

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UTERINE ATONY

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RISK FACTORS FOR

UTERINE ATONY
Multiple gestation Precipitous labor
Macrosomia Prolonged labor
Polyhydramnios Augmented labor
Grand multiparity (>5) Chorioamnionitis
Maternal age > 40 Tocolytic agents
Halogenated
anesthetics

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OB MANAGEMENT OF
UTERINE ATONY

• Bimanual uterine compression and

massage
• Infusion of oxytocin
• Evaluation for retained placenta
• Use of other oxytocics

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OXYTOCIC DRUGS
Drug/Dose Side Effects
Oxytocin Vasodilation with IV bolus,
20-80 U/L hyponatremia
Methergine® Diffuse vasoconstriction,
(methylergonovine) pulmonary and systemic
0.2 mg IM hypertension, coronary
vasospasm, nausea

Hemabate® Bronchospasm, pulmonary

(prostaglandin F2α) hypertension, hypoxia,
250 μg IM nausea, diarrhea

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OXYTOCIN
• The ED95 of IV bolus oxytocin during
elective cesarean is 0.35U.
• The ED95 during cesarean delivery after
labor arrest (mean 9.8 hours of prior
oxytocin infusion) is 3U – 9 times higher!
• Oxytocin receptor desensitization from
exogenous oxytocin administration during
labor → alternative uterotonics may be
necessary and more effective.
Obstet Gynecol 2006;107:45

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OXYTOCIN REGIMENS
The “Confidential Enquiries into Maternal
Deaths, 1997-1999” describes two deaths in
which the anesthesiologist gave an IV bolus
of oxytocin after delivery with subsequent
maternal cardiac arrest and death. The
associated maternal conditions were:
• Postpartum hemorrhage with hypotension
• Pulmonary hypertension

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OXYTOCIN
Two abstracts evaluated hemodynamics after 5 units
IV bolus oxytocin in healthy women with spinal
anesthesia for cesarean.
• MAP ↓ 27%, HR ↑ 17 beats per minute
• Cardiac index ↑ 61% above baseline
• Systemic vascular index ↓ 39%
• No ↑ blood loss when given over 5 minutes

IJOA 2006;15:A-P01 and Anesthesiology

2006;105:A11
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COMPRESSIVE UTERINE
SUTURES

Obstet Gynecol 2005; 106:569

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ANESTHETIC MANAGEMENT
OF ATONY
• Volume Resuscitation
Large bore IVs, T&C, warmers, monitors
• Analgesia
Pre-existing epidural, ketamine, GETA
• Oxytocics
Know side effects!
• Move to O.R. sooner rather than later.
• Consider notifying Interventional Radiology.

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ANESTHETIC MANAGEMENT
The authors present a series of 12 cases using
recombinant factor VIIa for life-threatening
postpartum hemorrhage. They recommend its
use before resorting to hysterectomy in cases of
intractable PPH.
• At their hospital, the cost of one dose of rFVIIa =
50 units PRBC = an embolization procedure = 2
days of ICU treatment. Cost effective??
Br J Anaesth 2005;94:592

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FETAL DISTRESS

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CAUSES OF FETAL
DISTRESS

During labor: Umbilical cord prolapse

Umbilical cord compression→
variable decelerations
Uteroplacental insufficiency→
late decelerations

At delivery: Shoulder dystocia

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WHAT IS FETAL DISTRESS?

Obstetricians now use the term non-reassuring
fetal status (NRFHT) followed by a further
description of the findings (eg, deep variable
decelerations) because “fetal distress” is
imprecise, and fetal monitoring has a low
predictive value of neonatal outcome (99%
false positive!). “Birth asphyxia” is
nonspecific and should not be used.
Obstet Gynecol 2005;106:1469

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NORMAL UMBILICAL
CORD BLOOD GASES
VEIN ARTERY

pH 7.34 7.28
PO2 30 15
PCO2 35 45
Base deficit 5 7

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INTERPRETATION OF
UMBILICAL CORD GASES
NORMAL RESPIRATORY METABOLIC
ACIDOSIS ACIDOSIS
pH 7.25-7.40 Decreased Decreased

PO2 18-22 Usually stable Decreased

PCO2 40-50 Increased Usually stable

Base deficit 0-10 Usually stable Increased

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UMBILICAL CORD GASES

The threshold for pH and base deficit that
predict adverse neonatal sequelae are:
pH < 7.0
Base deficit ≥ 12 mmol/L
The metabolic component (base deficit) is the
most important variable associated with
subsequent neonatal morbidity.
Am J Obstet Gynecol 1999;181:867
Am J Obstet Gynecol 1997;177:1391

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UMBILICAL CORD GASES

ACOG Committee Opinion, November 2006:
“Moderate and severe newborn encephalopathy and
respiratory complications…increase with an umbilical
arterial base deficit of 12-16 mmol/L. Moderate or
severe newborn complications occur in 10% of
neonates who have this level of acidemia and the rate
increases to 40% in neonates who have an umbilical
arterial base deficit greater than 16 mmol/L.”
Obstet Gynecol 2006;108:1319

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CLOSED CLAIMS ANALYSIS

An analysis of claims for newborn brain
injury from the ASA Closed Claims Project
database found that in claims where
anesthesia might have contributed (<30%):
• 50% some delay by anesthesia was alleged.
• 17% maternal condition was involved.
• 8% poor communication contributed.
Anesthesiology 2006;105:A7

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OBSTETRIC MANAGEMENT
OF FETAL DISTRESS
Initiate attempts at intrauterine resuscitation:
• Change maternal position.
• Administer supplemental oxygen.
• Maintain / improve maternal circulation.
• Give a tocolytic for hypertonicity.
• Start an intrauterine infusion to relieve cord
compression.

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INTRAPARTUM ASSESSMENT
Using oximetry to assess fetal oxygen saturation,
what maneuvers improve fetal oxygenation
during intrauterine resuscitation?
• IV fluid bolus of 1000 ml: ↑ 5%
• Lateral position (vs. supine): ↑ 10%
• Maternal oxygen 10L by mask: ↑ 9%
Obstet Gynecol 2005;105:1362

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WHAT’S AN “EMERGENCY”
CESAREAN DELIVERY?
STABLE: to O.R. when the teams are
available; use any anesthetic options
Examples:
• Chronic uteroplacental insufficiency
(chronic HTN)
• Breech presentation with ruptured
membranes (no active labor)

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WHAT’S AN “EMERGENCY”
CESAREAN DELIVERY?
URGENT: to O.R. within 30 minutes; place spinal
or extend existing epidural
Examples:
• Dystocia
• Failed forceps
• Previous classical C/S in labor
• Active herpes with ruptured membranes
• Variable decels with prompt recovery

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WHAT’S AN “EMERGENCY”
CESAREAN DELIVERY?
STAT: to O.R. emergently – use general
anesthesia, regional is rarely practical
Examples:
• Massive hemorrhage
• Cord prolapse
• Agonal fetal distress

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UMBILICAL CORD
COMPRESSION

Variable decelerations vary in duration,

depth and shape from contraction to
contraction.

They are often associated with decreased

amniotic fluid: oligohydramnios, ruptured
membranes.

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OBSTETRIC MANAGEMENT
OF CORD COMPRESSION

• Change maternal position.

• Stop oxytocin if in use.
• Begin amnioinfusion to increase fluid.
• Use fetal scalp stimulation or sampling
to assess well-being.

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ANESTHETIC MANAGEMENT
OF CORD COMPRESSION

Anticipate need for expedited delivery

• Perform a preop evaluation.
• Administer aspiration prophylaxis.
• Place an epidural catheter or
“optimize” if epidural in place.
• Treat hypotension if indicated.

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UTEROPLACENTAL
INSUFFICIENCY
Late decelerations begin after the onset of the
contraction and end after the contraction is over.

Uteroplacental insufficiency may be associated with:

• Postdates gestation
• Hypertension
• Diabetes
• Intrauterine growth retardation
• Abruption

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OBSTETRIC
MANAGEMENT
• Improve oxygen delivery to fetus
Maternal O2 supplementation
Lateral position
Stop oxytocin and consider a tocolytic

• Expedite delivery

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ANESTHETIC MANAGEMENT

• When risk factors for uteroplacental

insufficiency are present, consider aspiration
prophylaxis and early placement of an
epidural catheter.

• General vs. regional anesthesia for cesarean

section depends on urgency.

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CONCLUSIONS

• Anticipate problems!
• Cultivate a good relationship and
communicate with your obstetricians.
• Be available and prepared:
Emergency O.R. set-up
Transfusion and monitoring capability
Difficult airway box

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