What are the most common obstetric and gynecological emergencies, their management, and essential skills required for their diagnosis and treatment?

Essential Guide to Obstetric and Gynecological Emergencies for Internship

Most Common Life-Threatening Obstetric Emergencies

Focus your learning on postpartum hemorrhage, severe pre-eclampsia/eclampsia, imminent delivery, and maternal cardiac arrest—these represent the highest mortality risks and require immediate recognition and intervention. 1, 2

Postpartum Hemorrhage (PPH)

This is the leading preventable cause of maternal mortality worldwide and the most critical emergency you will encounter. 2

Prevention Protocol

• Administer oxytocin 5-10 IU via slow IV or IM injection immediately at shoulder release or postpartum in every delivery 1, 3
• This single intervention is your most powerful tool for preventing hemorrhage 4

Active Management When Bleeding Occurs

• Give tranexamic acid 1 gram IV within 1-3 hours of bleeding onset (number needed to treat: 276 to prevent one maternal death) 1, 2
• Delaying tranexamic acid beyond 3 hours significantly reduces effectiveness—this is a critical time window 1, 2
• Ensure immediate availability of large-bore IV catheters, fluid warmers, forced-air body warmers, and rapid infusion devices 1, 2
• Establish massive transfusion protocol access with blood bank 1

Critical Pitfall to Avoid

• Do not perform manual removal of placenta outside specialized structures except in severe uncontrolled hemorrhage, as technical difficulties and lack of adequate analgesia/aseptic conditions increase complications 5

Severe Pre-eclampsia and Eclampsia

These represent acute neurological and cardiovascular emergencies requiring immediate blood pressure control and seizure prophylaxis. 2

Immediate Management

• Administer magnesium sulfate as first-line therapy for eclamptic seizures 1, 2
• Initiate antihypertensive treatment immediately to prevent intracranial hemorrhage 1
• Coordinate immediately with emergency services 1, 4
• Maintain strict fluid balance and clear documentation 1, 4

Imminent Delivery Assessment

Systematically assess these four predictive factors in every pregnant patient in labor: 5, 1, 2

• Multiparity
• Previous rapid or non-hospital delivery
• Regular and painful uterine contractions
• Urge to push

Perform cervical examination before contacting the receiving obstetric team to optimize triage (i.e., transfer to maternity ward versus on-site delivery) 5, 1, 2

Shoulder Dystocia Management

• Position patient for McRoberts maneuver if shoulder dystocia is anticipated 1, 2

Maternal Cardiac Arrest

This follows the critical "4-minute rule" that determines maternal and fetal outcomes. 2, 4

The 4-Minute Protocol

• Initiate standard ACLS protocols immediately with continuous left uterine displacement to relieve aortocaval compression 1, 4
• Prepare for emergency cesarean delivery at 4 minutes regardless of gestational age if the uterus is at or above the umbilicus 1, 4
• Failure to recognize this 4-minute window leads to poor maternal and fetal outcomes 1, 2

Critical Pitfall

• Failing to maintain left uterine displacement during resuscitation perpetuates aortocaval compression and prevents successful resuscitation 2

Amniotic Fluid Embolism (Rare but Catastrophic)

Use the "ABC" cognitive aid checklist: Airway, Breathing, Circulation. 1, 2, 4

• Secure airway immediately if respiratory distress and seizure activity occur to prevent aspiration 1, 2, 4
• Transfer to ICU immediately given multi-system involvement with respiratory failure, neurological compromise, and coagulopathy 2, 4
• Avoid prostaglandin F2α and ergometrine in patients with respiratory distress 2

Most Common Gynecological Emergencies

Ectopic Pregnancy

This accounts for approximately 61% of acute surgical abdomen presentations in gynecology. 6

• Ruptured ectopic pregnancy is the most common gynecological surgical emergency 6
• Approximately 47.8% of cases undergo salpingectomy 6

Other Surgical Emergencies

• Twisted ovarian cyst (7.64% of acute abdomen cases) 6
• Hemoperitoneum and pyoperitoneum following gynecological surgeries (6.26%) 6
• Complications from unsafe abortion (64% of unmarried patients presenting with emergencies) 6

Essential Hand Skills for Your Rotation

Critical Procedural Skills to Master

1. Cervical Examination

• Essential for imminent delivery assessment 5, 1
• Perform before contacting receiving team to optimize triage 5

2. Large-Bore IV Placement

• Must be immediately available for hemorrhage management 1, 2
• Practice rapid placement under pressure 2

3. McRoberts Maneuver

• First-line intervention for shoulder dystocia 1, 2
• Position patient with thighs flexed and abducted 2

4. Uterine Massage and Bimanual Compression

• Critical for atonic uterus management 7, 8

5. Left Uterine Displacement Technique

• Essential during maternal resuscitation 1, 4
• Must be continuous during ACLS 4

Essential Imaging Skills

Ultrasound Competencies to Develop

Focus on point-of-care ultrasound for emergency assessment: 9

• Intrauterine pregnancy confirmation (to rule out ectopic pregnancy)
• Free fluid detection in abdomen (for ruptured ectopic or hemorrhage)
• Fetal heart rate assessment
• Placental location (for antepartum hemorrhage evaluation)

These basic ultrasound skills are critical for triage and emergency decision-making in resource-limited settings like mobile health caravans. 9, 10

Where to Gain Maximum Value During Your Rotation

Priority 1: Triage and Emergency Reception (Highest Yield)

This is where you will gain the most valuable experience for your stated goals. 5, 1, 2

• You will see the full spectrum of obstetric and gynecological emergencies 9, 10
• You will learn rapid assessment and decision-making under pressure 2, 4
• You will practice the imminent delivery assessment algorithm 5
• You will observe and participate in hemorrhage management protocols 1, 2
• You will learn to recognize severe pre-eclampsia and eclampsia 1, 2

Establish direct contact with the on-call obstetrician during your shifts to understand emergency coordination protocols. 1, 2, 4

Priority 2: Antenatal Care Department

This provides essential context for recognizing high-risk patients before emergencies develop. 10

• Learn to identify risk factors for postpartum hemorrhage 8
• Understand pre-eclampsia screening and early warning signs 10
• Practice systematic obstetric examination 4
• Learn to assess for cephalopelvic disproportion (occurs in 25-30% of active phase arrest cases) 1, 2, 4

Priority 3: Labor and Delivery Unit

This is where you will see the practical application of emergency protocols. 1, 2, 4

• Observe oxytocin administration for PPH prevention 1, 3
• Practice cervical examinations in active labor 5
• Learn to recognize obstructed labor (oxytocin augmentation has 92% success rate when cephalopelvic disproportion is absent) 1, 2, 4
• Understand when to escalate care 4

Priority 4: Gynecology Clinics (Lower Priority for Emergency Skills)

• Useful for understanding chronic conditions that may present acutely 10
• Less relevant for emergency and mobile health caravan preparation 6

System-Level Preparedness You Should Understand

These organizational factors directly impact maternal outcomes and are essential knowledge for any setting: 1, 2, 4

• Direct contact protocols between emergency services and on-call obstetrician 1, 2, 4
• Immediate availability of basic and advanced life-support equipment in labor and delivery units 1, 2
• Massive transfusion protocols with blood bank 1
• Cognitive aid checklists for rare emergencies (amniotic fluid embolism, maternal cardiac arrest) 1, 2, 4
• Emergency obstetric training for all personnel managing deliveries 1, 2

Lack of standardized approaches to emergency obstetric care contributes to poor maternal outcomes—understanding these systems is as important as clinical skills. 1, 2

Critical Medications to Know

Oxytocin

• Dose: 5-10 IU via slow IV or IM injection 1, 3
• Timing: Immediately at shoulder release or postpartum 1, 4, 3
• Indicated for prevention and control of postpartum bleeding or hemorrhage 3
• Must be under continuous observation by trained personnel 3
• Has intrinsic antidiuretic effect—consider water intoxication risk with continuous infusion 3

Tranexamic Acid

• Dose: 1 gram IV 1, 2
• Critical timing: Within 1-3 hours of bleeding onset 1, 2, 4
• Number needed to treat: 276 to prevent one maternal death 1

Magnesium Sulfate

• First-line therapy for eclamptic seizures 1, 2, 4
• Also used for seizure prophylaxis in severe pre-eclampsia 1, 4

Common Pitfalls to Avoid

• Not having hemorrhage management resources immediately available (large-bore IVs, rapid infusion devices, blood products) delays critical interventions 2
• Underestimating physiological changes of pregnancy complicates airway management during emergency cesarean delivery 2
• Delaying tranexamic acid beyond 3 hours reduces effectiveness 1, 2
• Failure to recognize the 4-minute window for perimortem cesarean delivery leads to poor outcomes 1, 2