Management of Obstetric Emergencies

I. Hemorrhagic Emergencies

• The American College of Obstetricians and Gynecologists recommends administering oxytocin 5-10 IU via slow IV or IM injection at shoulder release or immediately postpartum as first-line prophylaxis for postpartum hemorrhage (PPH) 1, 2
• The American College of Obstetricians and Gynecologists suggests giving tranexamic acid 1 gram IV within 1-3 hours of bleeding onset (NNT: 276 to prevent one maternal death) for PPH management 1
• Delaying tranexamic acid beyond 3 hours significantly reduces effectiveness in PPH management 1
• Essential resources for PPH management include large-bore IV catheters, fluid warmers, and forced-air body warmers, as recommended by the American Society of Anesthesiologists 3, 1
• The American College of Obstetricians and Gynecologists recommends having rapid infusion devices, massive transfusion protocol, and blood bank resources with established protocols immediately available for PPH management 3

II. Hypertensive Emergencies

• The American College of Obstetricians and Gynecologists recommends administering magnesium sulfate as first-line therapy for eclamptic seizures in severe preeclampsia/eclampsia 4, 1
• The American Heart Association suggests initiating antihypertensive treatment immediately to prevent intracranial hemorrhage in severe preeclampsia/eclampsia 1
• The American College of Obstetricians and Gynecologists recommends coordinating with emergency services for rapid response in severe preeclampsia/eclampsia 1

III. Cardiopulmonary Emergencies

• The American Heart Association recommends using cognitive aid checklists focusing on ABC principle: Airway, Breathing, Circulation for amniotic fluid embolism (AFE) management 5, 1
• The American College of Obstetricians and Gynecologists suggests securing airway immediately if respiratory distress and seizure activity occur to prevent aspiration in AFE management 2, 1
• The American Heart Association recommends designating a timekeeper to call out times at 1-minute intervals and starting CPR with manual uterine displacement or lateral tilt if no pulse is present in AFE management 5
• The American College of Obstetricians and Gynecologists recommends preparing for emergency cesarean delivery at 4 minutes regardless of gestational age if uterus is at or above umbilicus in maternal cardiac arrest management 6

IV. Delivery-Related Emergencies

• The American College of Obstetricians and Gynecologists recommends manual vaginal disimpaction and fetal pillow as prevention techniques for impacted fetal head at cesarean delivery 7
• The American College of Obstetricians and Gynecologists suggests using assistant pushing head up from vagina, reverse breech extraction, and tocolysis as management techniques for impacted fetal head at cesarean delivery 7

V. Airway Management Considerations

• The American Society of Anesthesiologists recommends having rigid laryngoscope blades, videolaryngoscopic devices, and endotracheal tubes of assorted sizes immediately available for obstetric airway management 3
• The American Society of Anesthesiologists suggests considering neuraxial techniques over general anesthesia when possible and using aspiration prophylaxis in obstetric airway management 3

VI. System-Level Preparedness

• The American Heart Association recommends educating all staff about pregnancy-specific resuscitation modifications and identifying contact details to mobilize the entire maternal cardiac arrest response team 6, 1
• The American College of Obstetricians and Gynecologists suggests ensuring availability of equipment for cesarean delivery and neonatal resuscitation and stocking drugs commonly available in obstetric units 6
• The American College of Obstetricians and Gynecologists recommends establishing direct contact between on-call obstetrician and EMS 1

VII. Critical Pitfalls to Avoid

• The American College of Obstetricians and Gynecologists recommends having hemorrhage resources immediately available and not underestimating physiological changes of pregnancy to avoid poor outcomes 1
• The American College of Obstetricians and Gynecologists suggests recognizing the 4-minute window for perimortem cesarean and not delaying tranexamic acid beyond 3 hours to avoid poor outcomes 1
• The American College of Obstetricians and Gynecologists recommends avoiding forced placental removal with suspected accreta and not using prostaglandins in patients with respiratory distress or cardiovascular disease 8, 2

Management of Obstetric Emergencies

Hemorrhagic Emergencies

• The American College of Obstetricians and Gynecologists recommends transfusing packed red blood cells, fresh frozen plasma, and platelets in a fixed 1:1:1 ratio for acute hemorrhage, and maintaining maternal temperature >36°C using forced-air warmers, as clotting factors function poorly at lower temperatures 9
• The American College of Obstetricians and Gynecologists suggests re-dosing prophylactic antibiotics if blood loss ≥1,500 mL, and transferring to ICU for intensive hemodynamic monitoring in early postoperative period 9
• The American College of Obstetricians and Gynecologists recommends leaving placenta in situ if abnormal attachment is evident, and considering ureteric stent placement and urologic surgeon involvement if bladder invasion suspected 10, 11

Hypertensive Emergencies

• The European Respiratory Journal warns against using prostaglandin F2α in patients with asthma due to risk of severe bronchospasm, and avoiding ergometrine in patients with hypertension or cardiovascular disease 12

Ectopic Pregnancy

• The Annals of Emergency Medicine suggests obtaining quantitative β-hCG and transvaginal ultrasound for diagnosis, and considering medical management (methotrexate) vs. surgical management based on β-hCG level, mass size, presence of fetal cardiac activity, and patient reliability for follow-up 13
• The Annals of Emergency Medicine recommends hemodynamically unstable patients require immediate surgical intervention (diagnostic laparoscopy or laparotomy) 13

System-Level Preparedness

• The American College of Obstetricians and Gynecologists emphasizes the importance of having hemorrhage resources immediately available, and plans for managing or stabilizing placenta accreta spectrum cases, including establishing massive transfusion protocol with 1:1:1 ratio of PRBC:FFP:platelets 10, 11
• The American College of Obstetricians and Gynecologists recommends coordinating with receiving facility before transport, and stabilizing patients before transfer with temporizing maneuvers, tranexamic acid infusion, and transfusion with locally available products 10, 11