6.4 Obstetric Emergencies and Emergency Delivery

Preeclampsia, Eclampsia, and HELLP

Preeclampsia is new-onset hypertension after 20 weeks' gestation with proteinuria or other end-organ signs. Severe features include severe-range blood pressure (≥160/110 mmHg), severe headache, visual disturbances, right-upper-quadrant/epigastric pain, and hyperreflexia with clonus. Eclampsia is preeclampsia plus a tonic-clonic seizure. HELLP syndrome — Hemolysis, Elevated Liver enzymes, Low Platelets — is a severe variant signaled by RUQ pain and abnormal labs.

The drug answer the exam demands: magnesium sulfate is the first-line agent to prevent and treat eclamptic seizures — not lorazepam or phenytoin. A typical regimen is a 4-6 g IV loading dose over 20-30 minutes, then 1-2 g/hour infusion. Severe-range pressures are lowered with labetalol, hydralazine, or nifedipine. The only definitive cure is delivery.

Magnesium toxicity is a tested safety point. Monitor in this order of appearance:

The antidote is IV calcium gluconate. Stop the infusion, support ventilation, and give calcium for loss of reflexes, respiratory depression, or urine output <30 mL/hour.

Antepartum Bleeding: Abruption vs. Previa

Third-trimester bleeding splits into two tested entities. Placental abruption is premature separation of a normally implanted placenta: painful, dark-red bleeding with a rigid, tender, hypertonic uterus, often with fetal distress; it is associated with hypertension, trauma, and cocaine use, and can cause concealed hemorrhage and DIC. Placenta previa is a placenta covering or near the cervical os: painless, bright-red bleeding, a soft non-tender uterus.

The critical safety rule: in suspected previa, vaginal and digital cervical exams are contraindicated because they can provoke catastrophic hemorrhage — confirm placental location by ultrasound first.

For either, the nurse secures two large-bore IVs, type and crossmatch, continuous fetal monitoring, left lateral positioning, and prepares for possible emergent cesarean.

Emergency Delivery, Shoulder Dystocia, and Postpartum Hemorrhage

When delivery is imminent (crowning, urge to push), stay and assist: support the head, check for a nuchal cord, deliver the anterior then posterior shoulder, dry and warm the newborn, and clamp the cord. Shoulder dystocia — the anterior shoulder lodges behind the pubic symphysis after the head delivers (the 'turtle sign') — is an emergency. The first maneuver is McRoberts (hyperflex maternal hips onto the abdomen) plus suprapubic pressure; never apply fundal pressure, which worsens impaction.

Postpartum hemorrhage (PPH) is blood loss >1000 mL or any loss causing hypovolemia (often defined as >500 mL after vaginal or >1000 mL after cesarean delivery). The leading cause (the '4 Ts') is Tone — uterine atony — responsible for ~70-80%, followed by Trauma, Tissue (retained products), and Thrombin (coagulopathy). First nursing actions are vigorous fundal massage and IV oxytocin. Add tranexamic acid (TXA) to reduce death from bleeding, and additional uterotonics — methylergonovine (avoid in hypertension), carboprost (avoid in asthma), or misoprostol.

Resuscitate with fluids and blood, and consider bimanual compression as a temporizing measure.

Cord Emergencies and the Newborn

A few obstetric emergencies hinge on the umbilical cord and the newborn, and CEN tests the immediate nursing maneuver.

Umbilical cord prolapse occurs when the cord slips below the presenting part and is compressed, cutting fetal oxygen — suspect it with sudden fetal bradycardia after membrane rupture or a palpable cord on exam. The lifesaving action is to relieve pressure on the cord: place the mother in knee-chest or steep Trendelenburg position, and use a gloved hand to lift the presenting part off the cord while preparing for emergent cesarean. Do not push the cord back in, and keep an exposed cord moist.

For emergency delivery in the ED, the sequence is: support the perineum and control the head's delivery to prevent rapid expulsion, feel for a nuchal cord and slip it over the head (or clamp and cut if too tight), deliver the anterior shoulder with gentle downward traction then the posterior shoulder, and support the body as it delivers.

Immediate newborn care follows the Neonatal Resuscitation Program priorities: warm, dry, and stimulate; position the airway and clear secretions if needed; and assess heart rate, respiratory effort, and tone. A vigorous, crying newborn needs only routine care. If the heart rate is <100 bpm or the infant is apneic/gasping, begin positive-pressure ventilation — the single most important newborn resuscitation step. The Apgar score (appearance, pulse, grimace, activity, respiration) is documented at 1 and 5 minutes but does not direct resuscitation, which is driven by heart rate and breathing.

Throughout an emergency delivery, the nurse manages two patients, anticipates postpartum hemorrhage, and keeps the mother in left lateral tilt before delivery to optimize perfusion.