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

Most Common Obstetric and Gynecological Emergencies and Essential Skills for Your Rotation

Critical Life-Threatening Obstetric Emergencies

Focus your emergency training on postpartum hemorrhage, severe pre-eclampsia/eclampsia, and maternal cardiac arrest—these are the leading preventable causes of maternal mortality and require immediate recognition within minutes. 1, 2

Postpartum Hemorrhage (Most Common)

Administer oxytocin 5-10 IU via slow IV or IM injection immediately at shoulder release or postpartum as first-line prophylaxis in every delivery. 1, 2, 3

• 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, 2
• Critical pitfall: Delaying tranexamic acid beyond 3 hours significantly reduces effectiveness 1, 2
• Ensure immediate availability of large-bore IV catheters (18-gauge or larger), fluid warmers, forced-air body warmers, and rapid infusion devices 1, 2
• Establish massive transfusion protocol access with your blood bank 2

Severe Pre-eclampsia and Eclampsia

Administer magnesium sulfate as first-line therapy for eclamptic seizures and initiate immediate antihypertensive treatment to prevent intracranial hemorrhage. 1, 2

• Coordinate immediately with emergency services for blood pressure control 1, 2
• Maintain strict fluid balance and clear documentation 2, 4
• Recognize this as an acute neurological and cardiovascular emergency requiring minutes, not hours 1

Maternal Cardiac Arrest (4-Minute Rule)

If the uterus is palpable at or above the umbilicus (≥20 weeks gestation), prepare for emergency cesarean delivery at 4 minutes if circulation is not restored—this is non-negotiable regardless of gestational age. 5, 1, 4

• Initiate standard ACLS protocols immediately with continuous left uterine displacement by two-handed traction 5, 4
• Critical pitfall: The left lateral position reduces cardiac massage efficacy; instead, maintain supine position with manual leftward uterine displacement 5
• Without left uterine displacement, external cardiac massage yields only 10% of normal pregnancy cardiac output 5
• Failure to recognize the 4-minute window leads to poor maternal and fetal outcomes 1, 2

Delivery-Related Emergencies

Imminent Delivery Assessment

Systematically assess for multiparity, history of previous rapid or non-hospital delivery, regular painful uterine contractions, and urge to push. 1, 2, 4

• Perform cervical examination before contacting the receiving obstetric team to optimize triage decisions 1, 2, 4
• Position patient for McRoberts maneuver if shoulder dystocia is anticipated 1, 2, 4

Obstructed Labor

Assess for cephalopelvic disproportion before proceeding with augmentation—this occurs in 25-30% of active phase arrest cases. 1, 2, 4

• Oxytocin augmentation is first-line treatment with 92% success rate for vaginal delivery when cephalopelvic disproportion is absent 1, 2
• Insert neuraxial catheter early for anticipated difficult deliveries to avoid general anesthesia during crisis 4

Rare but Catastrophic: Amniotic Fluid Embolism

Use cognitive aid checklist focusing on ABC principle: 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 1
• Avoid prostaglandin F2α and ergometrine in patients with respiratory distress 1

Common Gynecologic Emergencies

Acute Abdomen Presentations

Ruptured ectopic pregnancy accounts for approximately 61% of acute surgical abdomen presentations in gynecology. 6

• Twisted ovarian cyst represents 7.64% of cases 6
• Tubo-ovarian abscess, hemorrhagic ovarian cysts, and vulvovaginal trauma are other common presentations 7
• Salpingectomy is performed in approximately 47.8% of surgical emergency cases 6

Essential Hand Skills to Master

Critical Procedural Skills

Focus on these procedures during your rotation:

• Cervical examination technique for imminent delivery assessment 5, 1
• McRoberts maneuver positioning for shoulder dystocia 1, 2
• Manual left uterine displacement during resuscitation (two-handed traction technique) 5
• Large-bore IV catheter insertion (18-gauge or larger) 1
• Bimanual uterine compression for postpartum hemorrhage control 8

Medication Administration Skills

• Oxytocin administration: 5-10 IU slow IV or IM at shoulder release 1, 2, 3
• Tranexamic acid: 1 gram IV push within 1-3 hours of bleeding 1, 2
• Magnesium sulfate: Loading and maintenance dosing for eclampsia 1, 2

Essential Imaging Skills

Obstetric Ultrasound Basics

Learn to identify:

• Uterine height assessment (umbilicus = approximately 20 weeks gestation) 5
• Placental location and abnormalities (placenta accreta spectrum requires multidisciplinary team at tertiary center) 5
• Fetal presentation and position 4
• Free fluid in abdomen (ruptured ectopic pregnancy) 7, 6

Where to Gain Maximum Value During Your Rotation

Highest Yield Experiences

Prioritize triage and emergency reception first—this is where you'll see the most common emergencies and learn rapid assessment skills. 5

1. Triage/Emergency Reception (Highest priority):

   • Imminent delivery assessment 5, 1
   • Postpartum hemorrhage recognition 1, 2
   • Severe pre-eclampsia identification 1, 2
   • Acute abdomen triage 7, 6

2. Antenatal Care Department (Second priority):

   • Recognition of high-risk pregnancies requiring tertiary referral 5
   • Pre-eclampsia screening and monitoring 1, 2
   • Placenta accreta spectrum identification 5

3. Labor and Delivery Unit (Essential):

   • Shoulder dystocia management 1, 2
   • Postpartum hemorrhage protocols 1, 2
   • Emergency cesarean preparation 4

4. Gynecology Clinics (Lower priority for emergencies):

   • Ectopic pregnancy evaluation 6
   • Adnexal torsion recognition 7

Simulation Training Recommendation

Seek out simulation training on shoulder dystocia, breech delivery, twin pregnancies, and mechanical dystocia—this improves confidence, knowledge, and skills. 5

System-Level Preparedness You Should Understand

Establish direct contact protocols between on-call obstetrician and emergency medical services for all potential obstetric emergencies. 1, 2, 4

• Ensure immediate availability of basic and advanced life-support equipment in labor and delivery units 1, 2
• Understand massive transfusion protocols 2
• Know location of hemorrhage management resources (large-bore IVs, rapid infusion devices, blood products) 1
• Critical pitfall: Lack of standardized approaches to emergency obstetric care contributes to poor maternal outcomes 1, 2

Mobile Health Caravan Essentials

For resource-limited settings, prioritize:

• Oxytocin availability (can be given IM if no IV access) 3
• Tranexamic acid within 3-hour window 1, 2
• Magnesium sulfate for eclampsia 1, 2
• Large-bore IV catheters and crystalloid fluids 1
• Blood pressure monitoring equipment 2
• Ability to perform cervical examination 5, 1