Obstetric emergencies and preterm birth

Umbilical Cord Prolapse

• Definition: Descent of the umbilical cord through the cervix into the vagina alongside (occult) or ahead of (overt) the fetal presenting part following rupture of membranes.
• Pathophysiology: Mechanical compression of the cord between the presenting part and the maternal pelvis occludes umbilical blood flow, producing sudden, profound fetal hypoxia, prolonged bradycardia, and rapid asphyxia.
• Risk Factors: Unengaged presenting part, abnormal fetal lie (transverse, oblique), breech presentation (especially footling breech), prematurity, polyhydramnios, artificial rupture of membranes (ARM) with high presenting part, and multiple pregnancy.
• Emergency Management Protocol:
  1. Immediate Manual Elevation: A clinician immediately inserts a gloved hand into the vagina and manually pushes the fetal presenting part upward and away from the umbilical cord, maintaining continuous elevation until delivery in theatre.
  2. Relieve Pressure via Maternal Positioning: Place the mother in the knee-chest position or steep exaggerated left lateral / Trendelenburg position with pillows under the pelvis to allow gravity to shift the fetus away from the pelvic inlet.
  3. Avoid Handling the Cord: Do NOT attempt to push the cord back into the uterine cavity, as tactile manipulation triggers severe, irreversible umbilical arterial vasospasm. Protect the external cord with warm saline-soaked swabs.
  4. Expedite Delivery: Immediate Category 1 emergency caesarean section (target delivery within 15 to 30 minutes). Instrumental vaginal delivery is considered only if the cervix is fully dilated ($10\text{ cm}$) and the fetal head is at the pelvic floor with an experienced operator ready.

Critical Obstetric Emergencies Protocol Reference

• Uterine Atony (PPH): Diagnostic Clinical Features: Soft, boggy uterus above umbilicus, heavy vaginal bleeding $> 500\text{ mL}$; Immediate First-Line Interventions: Vigorous fundal massage, bimanual compression, IV oxytocin, Foley catheter; Secondary / Escalation Techniques: Ergometrine, carboprost, misoprostol, IV TXA, Bakri balloon, B-Lynch; Strictly Prohibited Actions: Never delay fluid resuscitation; avoid ergometrine in hypertension, carboprost in asthma
• Shoulder Dystocia: Diagnostic Clinical Features: Fetal head delivers and retracts tightly ("turtle sign"); failure of restitution; Immediate First-Line Interventions: Stop pushing, McRoberts manoeuvre (hyperflex legs), suprapubic pressure; Secondary / Escalation Techniques: Rubin II, Woods screw, deliver posterior arm, roll to all-fours (Gaskin); Strictly Prohibited Actions: Strictly avoid fundal pressure; avoid excessive lateral traction on fetal neck
• Cord Prolapse: Diagnostic Clinical Features: Visible/palpable pulsating cord in vagina; sudden severe fetal bradycardia; Immediate First-Line Interventions: Manual elevation of presenting part per vaginam, knee-chest position; Secondary / Escalation Techniques: Protect cord with warm moist gauze; transfer to theatre for category 1 C-section; Strictly Prohibited Actions: Never attempt to replace cord into uterus; avoid letting cord dry or cool down
• Uterine Inversion: Diagnostic Clinical Features: Mass in vagina, absent fundus on abdominal palpation, sudden shock/PPH; Immediate First-Line Interventions: Call emergency team, immediate manual replacement (Johnson manoeuvre); Secondary / Escalation Techniques: Uterine relaxants (glyceryl trinitrate) to facilitate replacement; then IV oxytocin; Strictly Prohibited Actions: Never administer uterotonics before repositioning; avoid pulling on placenta

Preterm labour and ruptured membranes

Symptoms before thirty-seven weeks require obstetric assessment of contractions, cervical change, membrane status, bleeding, infection and fetal wellbeing. Ask about fluid loss, pain and prior births. Use the local examination/testing pathway, including sterile speculum assessment where appropriate; avoid unnecessary repeated digital examination when membranes may be ruptured. Cervical length or selected biomarker testing can inform risk but must not override established labour or clinical deterioration. Distinguish threatened labour from actual progression and provide return precautions if discharged.

Coordinate neonatal services and in-utero transfer when appropriate and safe. Gestation, likelihood of birth and the current guideline determine antenatal corticosteroids, magnesium for neuroprotection and antibiotics for GBS or ruptured membranes. Tocolysis may briefly delay birth to permit steroids/transfer in suitable patients; it is not intended to stop labour indefinitely. Infection, significant bleeding, fetal compromise or another indication for delivery can make delay inappropriate. Manage PPROM through its gestation- and risk-specific pathway, with monitoring for infection and fetal concerns. Do not prescribe a fixed gestational regimen without confirming the current local guidance.

A patient with fluid loss and fever needs prompt infection and obstetric assessment rather than outpatient reassurance. Another with mild contractions but no cervical progression may have a risk-based review plan. Explain uncertainty and the signs of labour, bleeding, fever or reduced movements that require urgent return. Include transport and distance in the plan: a technically correct discharge instruction is inadequate if rapid reassessment is impossible. Queensland preterm labour and birth guideline.

A woman at 30 weeks with regular painful contractions and fluid leakage needs urgent obstetric assessment even if her first observations are normal. Confirm membrane status and fetal wellbeing, avoid repeated digital examinations after suspected rupture, and coordinate corticosteroids, antibiotics when indicated and neonatal transfer. Delivery is safer than prolonging pregnancy when infection or maternal/fetal compromise is present.

Primary references (checked 7 October 2026): RANZCOG intrapartum surveillance; Queensland preterm birth guideline.