What are the key topics to cover when presenting on OBGYN (Obstetrics and Gynecology) emergencies to Physician Assistant (PA) students?

OBGYN Emergencies: Presentation Outline for PA Students

I. Life-Threatening Hemorrhagic Emergencies

A. Postpartum Hemorrhage (PPH)

PPH is the leading preventable cause of maternal mortality worldwide and must be recognized and treated immediately. 1

Prevention & Immediate Management

• Administer oxytocin 5-10 IU via slow IV or IM injection at shoulder release or immediately postpartum as first-line prophylaxis 2, 1
• If bleeding occurs despite oxytocin, give tranexamic acid 1 gram IV within 1-3 hours of bleeding onset (NNT: 276 to prevent one maternal death) 1
• Delaying tranexamic acid beyond 3 hours significantly reduces effectiveness 1

Essential Resources (Must Be Immediately Available)

• Large-bore IV catheters 3, 1
• Fluid warmers and forced-air body warmers 3, 1
• Rapid infusion devices (hand-squeezed chambers, pressure bags, automatic infusers) 3
• Massive transfusion protocol 3
• Blood bank resources with established protocols 3

Second-Line Uterotonics

• Carboprost tromethamine (Hemabate) 250 mcg IM for refractory uterine atony 4
• Avoid prostaglandin F2α and ergometrine in patients with respiratory distress, hypertension, or cardiovascular disease 2, 4
• Methylergonovine as alternative if no contraindications 5

Surgical Interventions

• Uterine massage and bimanual compression 2
• Balloon tamponade (Bakri balloon) 2
• Uterine artery embolization if hemodynamically stable 2
• Surgical ligation of uterine/internal iliac arteries 2
• Emergency hysterectomy as last resort 6

B. Placental Abruption with DIC

Vaginal delivery is preferable when fetal demise has occurred to minimize surgical risks in severe coagulopathy. 5

Immediate Stabilization

• Establish large-bore IV access and activate massive transfusion protocol immediately 5
• Obtain CBC, type and crossmatch (minimum 4 units), coagulation panel, fibrinogen, platelets 5
• Maintain maternal temperature >36°C (clotting factors fail below this threshold) 5
• Transfuse in 1:1:1 ratio (RBCs:platelets:plasma), preferring cryoprecipitate over FFP to minimize volume overload 5

Labor Management

• Oxytocin infusion to augment contractions and expedite delivery 5
• Consider tranexamic acid to reduce blood loss 5
• Prepare uterotonics for immediate postpartum use 5

When Cesarean Becomes Necessary

• Only indicated if maternal hemodynamic instability or uncontrolled hemorrhage despite resuscitation 5
• Never attempt forced placental removal if accreta suspected—this triggers profuse hemorrhage 5
• Have cell salvage technology available 5

II. Hypertensive Emergencies

A. Severe Preeclampsia/Eclampsia

These represent acute neurological and cardiovascular emergencies requiring immediate blood pressure control and seizure prophylaxis. 1

Immediate Management

• Administer magnesium sulfate as first-line therapy for eclamptic seizures 3, 1
• Initiate antihypertensive treatment immediately to prevent intracranial hemorrhage 1
• Coordinate with emergency services for rapid response 1

HELLP Syndrome Recognition

• Triad: Hemolysis, Elevated Liver enzymes, Low Platelets 3
• Presents with epigastric pain, nausea/vomiting, upper abdominal tenderness 3
• Maternal mortality ranges 2-24% 3
• Requires platelet transfusion if count <50,000/mm³ before surgery 3
• Consider fresh frozen plasma to increase plasma volume 3

III. Catastrophic Cardiopulmonary Emergencies

A. Amniotic Fluid Embolism (AFE)

AFE presents with sudden cardiorespiratory collapse during labor or within 30 minutes after placental delivery, with case fatality exceeding 50%. 3

Recognition & Initial Response

• Incidence: 1.9-6.1 per 100,000 births 3
• Use cognitive aid checklist focusing on ABC principle: Airway, Breathing, Circulation 3, 1
• Secure airway immediately if respiratory distress and seizure activity occur to prevent aspiration 2, 1

Circulation Management

• Designate timekeeper to call out times at 1-minute intervals 3
• If no pulse, start CPR with manual uterine displacement or lateral tilt 3
• Use backboard for effective compressions 3
• If no pulse at 4 minutes, START perimortem cesarean delivery (resuscitative hysterotomy) 3

Critical Interventions

• Anticipate uterine atony, DIC, and hemorrhage 3
• Administer oxytocin prophylaxis plus other uterotonics as needed 3
• Avoid prostaglandin F2α and ergometrine in respiratory distress 2, 1
• Transfer to ICU immediately given multi-system involvement 2, 1

B. Maternal Cardiac Arrest

The 4-minute window for perimortem cesarean delivery is critical—failure to recognize this leads to poor maternal and fetal outcomes. 1

Physiological Considerations

• Estimate gestational age: uterus at pubic symphysis = 12 weeks, at umbilicus = 20 weeks, at xiphisternum = 36 weeks 3
• Fundal height may be poor predictor due to obesity, multiple gestation, polyhydramnios 3
• Pregnancy causes rapid desaturation with apnea 3

Modified BLS/ACLS

• Manual uterine displacement or 15-30° left lateral tilt to relieve aortocaval compression 3, 1
• Failing to maintain left uterine displacement perpetuates aortocaval compression 1
• Consider move to OR only if accomplished in ≤2 minutes 3
• Prepare for emergency cesarean delivery at 4 minutes regardless of gestational age if uterus at/above umbilicus 3

IV. Delivery-Related Emergencies

A. Impacted Fetal Head at Cesarean

Impacted fetal head complicates up to 1 in 10 emergency cesarean deliveries and is associated with serious maternal and neonatal risks. 3

Definition & Risk Factors

• Occurs when obstetrician cannot deliver fetal head with usual technique, requiring additional maneuvers 3
• At least 5% of cesareans occur at full cervical dilatation 3
• Risk increases with prolonged first stage labor and low, wedged fetal head 3

Prevention Techniques (Before Uterine Incision)

• Manual vaginal disimpaction: hand in vagina to elevate head into abdomen 3
• Fetal Pillow: inflatable device to elevate head before incision 3

Management Techniques (During Cesarean)

• Assistant pushes head up from vagina 3
• Reverse breech extraction (deliver baby feet first) 3
• Tocolysis to relax uterus and facilitate disimpaction 3
• Balloon cephalic elevation device (Fetal Pillow) 3

Complications

• Maternal: hemorrhage, bladder/bowel injury, implications for future pregnancies 3
• Neonatal: skull fractures, brain hemorrhage, hypoxic brain injury, rarely perinatal death 3

B. Shoulder Dystocia & Breech Delivery

Program directors report lowest comfort levels with resident preparation for these emergencies. 7

Shoulder Dystocia

• Position patient for McRoberts maneuver if anticipated 1
• Requires simulation training for competency 7

Breech Delivery

• Assess for cephalopelvic disproportion before augmentation (occurs in 25-30% of active phase arrest) 1
• Oxytocin augmentation first-line with 92% success rate when CPD absent 1

V. Airway Management Considerations

A. Obstetric Airway Challenges

Physiological changes of pregnancy complicate airway management during emergency cesarean delivery. 1

Required Equipment (Immediately Available)

• Rigid laryngoscope blades of alternate design and size 3
• Videolaryngoscopic devices 3
• Endotracheal tubes of assorted sizes 3
• Endotracheal tube guides (stylets, light wands, forceps) 3
• Supraglottic airway devices (LMA, intubating LMA, laryngeal tube) 3
• Equipment for emergency surgical airway (cricothyrotomy) 3

Anesthetic Considerations

• Pulse oximeter and carbon dioxide detector mandatory 3
• Consider neuraxial techniques over general anesthesia when possible 3
• Aspiration prophylaxis essential 3
• Fentanyl 5 µg/kg IV to attenuate hypertensive response to intubation 3

VI. System-Level Preparedness

A. Pre-Event Planning

Lack of standardized approaches to emergency obstetric care contributes to poor maternal outcomes. 1

Essential Components

• Educate all staff about pregnancy-specific resuscitation modifications 3, 1
• Identify contact details to mobilize entire maternal cardiac arrest response team 3
• Ensure availability of equipment for cesarean delivery and neonatal resuscitation 3
• Stock drugs commonly available in obstetric units (oxytocin, prostaglandin F2α) 3
• Establish direct contact between on-call obstetrician and EMS 1

Training Requirements

• Emergency obstetric training essential for all personnel managing deliveries 3, 1
• Conduct multiprofessional simulation training for high-risk scenarios 3
• Perform emergency drills regularly 8
• Debrief staff after actual events to identify improvement opportunities 8

B. Cognitive Aids & Checklists

When faced with catastrophic, unfamiliar emergencies, providers find it difficult to think clearly—checklists prevent panic and chaos. 3

Implementation Strategy

• Keep checklists concise and uncluttered 3
• Single-page format, printable on standard paper 3
• Focus on immediate management in L&D unit 3
• Exclude items unlikely to be overlooked (summoning help, 100% O₂, IV access) 3
• Include version date for updates 3

VII. Critical Pitfalls to Avoid

Common Errors Leading to Poor Outcomes

• Not having hemorrhage resources immediately available (large-bore IVs, rapid infusion devices, blood products) delays critical interventions 1
• Underestimating physiological changes of pregnancy complicates emergency management 1
• Failure to recognize 4-minute window for perimortem cesarean 1
• Delaying tranexamic acid beyond 3 hours reduces effectiveness 1
• Attempting forced placental removal with suspected accreta triggers profuse hemorrhage 5
• Using prostaglandins in patients with respiratory distress or cardiovascular disease 2, 4

Temperature Management Pitfall

• Drug-induced fever from carboprost differs from endometritis 4
• Carboprost fever: onset 1-16 hours, resolves with discontinuation, no retained tissue, normal lochia 4
• Endometritis: onset day 3+, persistent without treatment, retained tissue, foul discharge 4
• Force fluids for drug-induced fever; avoid unnecessary antibiotics 4