What are the leading obstetric birthing emergencies?

Leading Obstetric Birthing Emergencies

The most critical obstetric birthing emergencies that require immediate recognition and intervention are postpartum hemorrhage, hypertensive disorders of pregnancy (including eclampsia), imminent delivery complications, cardiopulmonary arrest, obstructed labor, amniotic fluid embolism, umbilical cord prolapse, and trauma. These conditions represent the primary threats to maternal and fetal mortality and morbidity during labor and delivery 1, 2.

Primary Life-Threatening Emergencies

Postpartum Hemorrhage

• Postpartum hemorrhage is the leading preventable cause of maternal mortality worldwide and requires immediate recognition and treatment 2, 3.
• Administer oxytocin 5-10 IU via slow IV or intramuscular injection immediately at shoulder release or postpartum to prevent hemorrhage 2, 3.
• If bleeding occurs despite oxytocin, administer tranexamic acid 1 gram IV within 1-3 hours of bleeding onset (number needed to treat: 276 to prevent one maternal death) 2.
• Carboprost tromethamine is indicated for postpartum hemorrhage due to uterine atony that has not responded to oxytocin and uterine massage 4.
• Have large-bore IV catheters, fluid warmers, forced-air body warmers, and rapid infusion devices immediately available 1.

Hypertensive Disorders and Eclampsia

• Severe pre-eclampsia and eclampsia represent acute neurological and cardiovascular emergencies requiring immediate blood pressure control and seizure prophylaxis 1, 2.
• Coordinate immediately with emergency services to initiate antihypertensive treatment and magnesium sulfate administration 2.
• Administer magnesium sulfate as first-line therapy for eclamptic seizures 3.
• Monitor for HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), which can rapidly progress to multi-organ failure 5.

Maternal Cardiac Arrest

• Initiate standard ACLS protocols immediately with continuous left uterine displacement to relieve aortocaval compression 2.
• If maternal circulation is not restored within 4 minutes of arrest, begin perimortem cesarean delivery (hysterotomy) to improve both maternal and fetal outcomes 2, 6.
• The "4-minute rule" is critical—circulation must be restored or cesarean delivery initiated within this window 2.

Delivery-Related Emergencies

Imminent Delivery

• Systematically assess for multiparity, history of previous rapid or non-hospital delivery, regular painful uterine contractions, and urge to push 2.
• Perform cervical examination before contacting the receiving obstetric team to optimize triage 2.
• Position patient for McRoberts maneuver if shoulder dystocia is anticipated 2.

Obstructed Labor

• Assess for cephalopelvic disproportion before proceeding with augmentation, which occurs in 25-30% of active phase arrest cases 2, 6.
• Oxytocin augmentation is first-line treatment with 92% success rate for vaginal delivery when cephalopelvic disproportion is absent 2, 6.
• Insert neuraxial catheter early for anticipated difficult deliveries to avoid general anesthesia during crisis 2, 6.
• Consider reverse breech extraction for impacted fetal head during cesarean delivery, which may improve Apgar scores and reduce NICU admissions 2, 6.

Umbilical Cord Prolapse

• Cord prolapse is an unpredictable emergency with incidence of 1-6 per 1000 pregnancies and perinatal mortality of 6-10% in high-income countries 7.
• The urgency depends on fetal heart rate pattern—bradycardia is most urgent as cord arterial pH declines at 0.009 per minute with bradycardia-to-delivery interval 7.
• Elevate the fetal presenting part immediately using knee-chest position (most effective), bladder filling with 500 mL fluid, or Trendelenburg position 7.
• Proceed to urgent cesarean delivery unless vaginal delivery is imminent 7.

Rare but Catastrophic Emergencies

Amniotic Fluid Embolism

• Use cognitive aid checklist focusing on "ABC" principle: airway, breathing, and circulation support 2.
• Secure airway immediately if respiratory distress and seizure activity occur to prevent aspiration 3.
• Transfer to ICU immediately given multi-system involvement with respiratory failure, neurological compromise, and coagulopathy 3.
• Avoid prostaglandin F2α and ergometrine in patients with respiratory distress 3.

Trauma in Pregnancy

• Trauma represents a distinct category requiring specialized assessment for both maternal and fetal well-being 1.
• Maintain left uterine displacement during resuscitation to prevent aortocaval compression 2.
• Assess for traumatic placental separation and fetomaternal hemorrhage 8.

Airway Management Emergencies

Difficult and Failed Airway

• Have basic airway management equipment immediately available during neuraxial analgesia provision, including laryngoscope, endotracheal tubes, oxygen source, suction, self-inflating bag-mask, medications for blood pressure support and muscle relaxation, qualitative carbon dioxide detector, and pulse oximeter 1, 9.
• Portable equipment for difficult airway management must be readily available in the operative area 1.
• Use high-flow nasal oxygenation and appropriate neuromuscular drug selection for obstetric patients 9.
• Have a preformulated strategy for difficult airway intubation 1.

Anesthetic Complications

Neuraxial Anesthesia Emergencies

• Local anesthetic systemic toxicity, unusually prolonged neuraxial block regression, and neuraxial drug errors require immediate recognition 9.
• Administer non-particulate antacids, H₂ receptor antagonists, and/or metoclopramide before all surgical procedures for aspiration prophylaxis 2.
• Use dilute concentrations of local anesthetics with opioids to produce minimal motor block 2, 6.

Critical Pitfalls to Avoid

• Failure to recognize the 4-minute window for perimortem cesarean delivery during maternal cardiac arrest leads to poor maternal and fetal outcomes 2.
• Delaying tranexamic acid administration beyond 3 hours of bleeding onset reduces its effectiveness 2.
• Underestimating physiological changes of pregnancy complicates airway management during emergency cesarean delivery 6.
• Failing to maintain left uterine displacement during resuscitation perpetuates aortocaval compression 2.
• Not having hemorrhage management resources immediately available (large-bore IVs, rapid infusion devices, blood products) delays critical interventions 1.

System-Level Preparedness

• Establish direct contact between on-call obstetrician and emergency medical services for all potential obstetric emergencies 2.
• Ensure immediate availability of basic and advanced life-support equipment in labor and delivery units 6.
• Lack of standardized approaches to emergency obstetric care contributes to poor maternal outcomes 1.
• Emergency obstetric training for all personnel managing deliveries is essential 1.