What are the management strategies for common obstetric complications?

Management Strategies for Common Obstetric Complications

The most effective management of obstetric complications requires a systematic approach focused on early identification, prompt intervention, and appropriate level of care to reduce maternal morbidity and mortality. 1

Hemorrhagic Complications

Postpartum Hemorrhage

• Implement massive transfusion protocol with ratio of 1:1:1 to 1:2:4 (packed red cells:fresh frozen plasma:platelets) 2
• Monitor fibrinogen levels and maintain >200 mg/dL
• Administer 1g IV tranexamic acid within 3 hours of delivery (repeat after 30 minutes if bleeding persists) 2
• Use oxytocin for uterine contraction during third stage of labor and to control postpartum bleeding 3
• Consider cell salvage with leucocyte depletion filter if available 2

Placenta Accreta Spectrum (PAS)

• Deliver at level III or IV maternal care center with multidisciplinary team 2
• Schedule delivery at 34-36 weeks gestation to avoid emergency hemorrhage 2
• Standard approach: cesarean hysterectomy with placenta left in situ 2
• Assemble team including maternal-fetal medicine specialist, experienced pelvic surgeon, anesthesiologist, blood bank personnel, interventional radiologist, and urologist 2

Hypertensive Disorders

Severe Preeclampsia/Eclampsia

• Administer magnesium sulfate for seizure prophylaxis
• Control blood pressure with antihypertensive medications (target <160/110 mmHg)
• Monitor for signs of end-organ damage
• Time delivery based on gestational age and maternal/fetal condition
• Implement severe hypertension bundle with standardized protocols 1

Sepsis

Management Protocol

• Administer broad-spectrum antibiotics within 1 hour of recognition:
  • First-line: carbapenem (meropenem) or extended-range penicillin/β-lactamase inhibitor (piperacillin-tazobactam) plus aminoglycoside (gentamicin) 2
  • Add vancomycin or linezolid if MRSA risk factors present 2
• Fluid resuscitation with balanced crystalloids (e.g., lactated Ringer's) 1
• Target MAP ≥65 mmHg with norepinephrine as first-line vasopressor 1
• Consider vasopressin (0.04 units/minute) for refractory shock 1
• Serial lactate measurements to assess response to treatment 2

Trauma in Pregnancy

Initial Management

• Primary survey prioritizes maternal stabilization
• Maintain maternal oxygen saturation >95% for adequate fetal oxygenation
• Place two large-bore (14-16 gauge) IV lines
• Displace gravid uterus off inferior vena cava (manual displacement or left lateral tilt) 4
• Administer O-negative blood for Rh-negative mothers until cross-matched blood available 4

Fetal Assessment

• Electronic fetal monitoring for at least 4 hours for viable pregnancies (≥23 weeks)
• Admit for 24-hour observation with adverse factors (uterine tenderness, vaginal bleeding, sustained contractions, abnormal fetal heart rate) 4
• Administer anti-D immunoglobulin to all Rh-negative pregnant trauma patients 4

Perimortem Cesarean Section

• Perform within 4 minutes of maternal cardiac arrest for viable pregnancies (≥23 weeks) to aid maternal resuscitation and fetal salvage 4

Medium and Long-Term Complications

Most Prevalent Post-Childbirth Conditions

• Dyspareunia (35%)
• Low back pain (32%)
• Urinary incontinence (8-31%)
• Anxiety (9-24%)
• Anal incontinence (19%)
• Depression (11-17%)
• Tokophobia (6-15%)
• Perineal pain (11%)
• Secondary infertility (11%) 1

Management Approach

• Extend care beyond traditional 6-week postpartum period
• Implement systematic clinical assessments and screening to identify at-risk women
• Provide prompt management for identified conditions 1

Anesthetic Considerations

Neuraxial Analgesia/Anesthesia

• Establish IV access before initiating neuraxial techniques
• Have resources available to treat complications (hypotension, systemic toxicity, high spinal)
• Have treatments available for opioid-related complications if used (pruritus, nausea, respiratory depression) 1

Difficult Airway Management

• Have basic airway management equipment immediately available during neuraxial analgesia
• Maintain portable equipment for difficult airway management in labor and delivery units
• Consider laryngeal mask airway or supraglottic airway device when tracheal intubation fails 1

Risk Assessment and Prevention

Continuous Risk Assessment

• Initiate risk assessment before pregnancy
• Reassess throughout pregnancy and postpartum period
• Address socioenvironmental and behavioral risks with timely intervention 1

Addressing Disparities

• Recognize impact of systemic racism and discrimination on maternal outcomes
• Combat implicit bias and structural racism at provider and healthcare system levels
• Ensure expanded insurance coverage before, during, and after pregnancy 1

Levels of Maternal Care

Appropriate Facility Selection

• Level I (basic care): Uncomplicated births with capability for emergency cesarean delivery
• Level II (specialty care): High-risk pregnancies with continuous availability of obstetrician-gynecologists
• Level III (subspecialty care): Complex maternal and fetal conditions with subspecialists available
• Level IV (regional perinatal health care centers): Comprehensive care for most complex conditions 1

Common Pitfalls to Avoid

• Delaying recognition, diagnosis, or referral of high-risk women
• Communication failures between care team members
• Inadequate training or resources for managing obstetric emergencies
• Neglecting medium and long-term complications beyond 6 weeks postpartum 1
• Failing to implement standardized protocols and bundles for obstetric emergencies 5
• Overlooking racial disparities in maternal care and outcomes 1