What are the initial steps in managing an obstetric (OB) emergency, such as postpartum hemorrhage, eclampsia, or placental abruption, in a pregnant patient?

Initial Management of Obstetric Emergencies

For postpartum hemorrhage, eclampsia, and placental abruption, immediate intervention follows the ABC principle (airway, breathing, circulation) with simultaneous activation of emergency protocols and preparation of hemorrhage management resources. 1, 2

Immediate Universal Steps for All OB Emergencies

First 60 Seconds: Simultaneous Actions

• Activate emergency response team and establish direct contact between on-call obstetrician and emergency medical services 2, 3
• Secure large-bore IV access (18-gauge or larger, preferably two lines) and initiate fluid resuscitation 1, 2
• Apply continuous fetal monitoring if fetus is viable (≥24 weeks), as fetal heart rate tracing provides real-time assessment of maternal end-organ perfusion 1
• Position patient supine with manual left uterine displacement using two-handed traction to relieve aortocaval compression—never use left lateral position as it reduces resuscitation efficacy 3, 4
• Administer 100% oxygen via non-rebreather mask and secure pulse oximetry 1

Critical Equipment Checklist (Must Be Immediately Available)

• Fluid warmers and forced-air body warmers (maintain maternal temperature >36°C for optimal clotting factor function) 1, 3
• Rapid infusion devices (hand-squeezed fluid chambers, pressure bags, or automatic infusion devices) 1, 2
• Airway management equipment: laryngoscope with assorted blades, endotracheal tubes with stylets, suction, self-inflating bag-mask, qualitative CO2 detector 1, 3
• Massive transfusion protocol access with 1:1:1 ratio of packed red blood cells:fresh frozen plasma:platelets 3, 4

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Postpartum Hemorrhage: Specific Management Algorithm

Prevention (Every Delivery)

Administer oxytocin 5-10 IU via slow IV or IM injection immediately at shoulder release or postpartum as first-line prophylaxis in every delivery 2, 3, 4, 5

Active Hemorrhage Protocol

Step 1 (0-3 minutes): If bleeding occurs despite oxytocin, immediately administer tranexamic acid 1 gram IV within 1-3 hours of bleeding onset (NNT: 276 to prevent one maternal death) 2, 3, 4

• Critical pitfall: Delaying tranexamic acid beyond 3 hours significantly reduces effectiveness 2, 3, 4

Step 2 (Simultaneous): Activate massive transfusion protocol 3, 4

• Transfuse packed red blood cells, fresh frozen plasma, and platelets in fixed 1:1:1 ratio 3
• Use blood products rather than crystalloid for volume resuscitation to avoid fluid overload 1
• In emergency situations, type-specific or O-negative blood is acceptable 1

Step 3: Administer additional uterotonics if bleeding continues 5, 6

• Oxytocin infusion: 10-40 units in 1,000 mL non-hydrating diluent, run at rate necessary to control uterine atony 5
• Consider methylergonovine (Methergine) for postpartum atony 6

Step 4: If hemorrhage remains intractable and banked blood unavailable or patient refuses transfusion, consider intraoperative cell salvage 1

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Eclampsia: Specific Management Algorithm

Eclampsia represents an acute neurological and cardiovascular emergency requiring immediate seizure control and blood pressure management. 2, 3

Seizure Management

Step 1 (Immediate): Administer magnesium sulfate as first-line therapy for eclamptic seizures 2, 3, 4

• Secure airway immediately if respiratory distress occurs to prevent aspiration 2
• Position patient to prevent injury during seizure activity 2

Step 2 (Simultaneous): Initiate antihypertensive treatment immediately to prevent intracranial hemorrhage (target MAP 65 mm Hg, though not specifically studied in pregnancy) 1, 2, 3, 4

• First-line agent: norepinephrine starting at 0.02 mg/kg per minute 1
• If MAP remains inadequate despite low-to-moderate norepinephrine dose (0.1-0.2 mg/kg per minute), add vasopressin 0.04 unit per minute 1
• Consider invasive arterial blood pressure monitoring 1

Step 3: Maintain strict fluid balance and clear documentation to avoid fluid overload 3, 4

Critical Considerations

• Fetal heart rate tracing may be expectantly managed during initial maternal stabilization, as most will improve with maternal hemodynamic optimization 1
• Coordinate immediately with emergency services for rapid response 2, 3, 4

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Placental Abruption: Specific Management Algorithm

Placental abruption requires rapid delivery to prevent maternal coagulopathy and fetal death, as prolongation of the abruption-delivery interval worsens maternal prognosis. 7, 8

Immediate Assessment and Stabilization

Step 1 (0-5 minutes): Assess severity and fetal status 7, 8

• Grade III abruption (fetal death in utero) indicates severe form with real risk of overt coagulopathy developing 7
• Overt coagulopathy with live fetus is uncommon but ominous when present 7

Step 2 (Simultaneous): Prepare for delivery 7, 8, 9

• Treatment should be directed toward obtaining rapid and atraumatic vaginal delivery 7
• Cesarean section indicated for: (1) uterine inertia prior to complete cervical dilatation, (2) severe consumption coagulopathy, (3) fetal distress with viable fetus 7, 8
• Optimum timing of cesarean delivery offers better prognosis even in cases with antepartum fetal death 9

Step 3: Anticipate and prepare for coagulopathy 7, 10

• Disseminated intravascular coagulation (DIC) accompanies over 80% of severe cases 1
• Initiate massive transfusion protocol with 1:1:1 ratio, but prefer cryoprecipitate over fresh frozen plasma to minimize volume overload risk 1
• Spontaneous reversal of coagulopathy can be anticipated once delivery occurs 7

Step 4: Monitor for postpartum complications 7

• Be vigilant for postpartum hemorrhage requiring immediate transfusion, oxytocics administration, and/or uterine manipulation 7
• Surgical intervention rarely indicated 7
• Observe for evolution of renal failure, pulmonary insufficiency, and panhypopituitarism over ensuing days and weeks 7

High-Risk Features Requiring Heightened Vigilance

• Older multiparous women have more complications, larger placental separations, and higher mortality 9
• Severity of eclamptic symptoms (if concurrent) influences extension of placental separation 9
• Preeclampsia, eclampsia, and multiparity increase risk 8

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Maternal Cardiac Arrest: The 4-Minute Rule

Failure to recognize the 4-minute window for perimortem cesarean delivery during maternal cardiac arrest leads to poor maternal and fetal outcomes. 2, 3, 4

Resuscitation Protocol

Step 1 (Immediate): Initiate standard ACLS protocols with continuous left uterine displacement by two-handed traction 3, 4

• Critical pitfall: Avoid left lateral position as it reduces cardiac massage efficacy; maintain supine position with manual leftward uterine displacement 3, 4

Step 2: Designate timekeeper to call out times at 1-minute intervals 2

Step 3: Prepare for emergency cesarean delivery at 4 minutes if circulation is not restored, regardless of gestational age 3, 4

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System-Level Preparedness Requirements

Lack of standardized approaches to emergency obstetric care contributes to poor maternal outcomes. 2

Essential Protocols

• Establish direct contact protocols between on-call obstetrician and emergency medical services for all potential obstetric emergencies 2, 3, 4
• Ensure immediate availability of basic and advanced life-support equipment in labor and delivery units 2, 3, 4
• Establish massive transfusion protocol with 1:1:1 ratio of PRBC:FFP:platelets 3, 4
• Have hemorrhage management resources immediately available (large-bore IVs, rapid infusion devices, blood products) 1, 2, 4
• Ensure availability of equipment for emergency cesarean delivery and neonatal resuscitation 3

Training and Cognitive Aids

• Emergency obstetric training for all personnel managing deliveries is essential 1, 2
• Use cognitive aid checklists focusing on ABC principle for rare catastrophic emergencies like amniotic fluid embolism 1, 2
• Conduct debriefing soon after stabilization to identify system improvements and provide psychological support 1

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Transfer Criteria to Higher Level of Care

Decision to transfer should be made by multidisciplinary team considering: 1

• Persistent hypotension (MAP <65 mm Hg) 1
• Need for vasopressors 1
• Persistent hypoxia (oxygen saturation <92% on room air) 1
• Altered mental status 1
• Lactate level ≥4 mmol/L 1

Critical consideration: Stabilize patient before transport; if delivery is imminent, postpone transfer until after childbirth 1

• Avoid delays in transporting critically ill pregnant patient due to inability to monitor fetus—stabilizing the mother typically stabilizes the fetus 1