Obstetrics: Emergencies

• Approach: Recognising the Sick Pregnant Woman | Maternal Collapse and Cardiac Arrest
• Bleeding: Postpartum Haemorrhage | PPH: Step-by-step Management | Major Obstetric Haemorrhage and DIC
• Birth emergencies: Shoulder Dystocia | Umbilical Cord Prolapse | Uterine Rupture | Uterine Inversion | Unexpected Breech Birth
• Medical emergencies: Eclampsia | Severe Hypertension | Maternal Sepsis | Amniotic Fluid Embolism | Other Causes of Collapse | Acute Abdominal Pain in Pregnancy | Trauma in Pregnancy
• Revision: Drug Reference Table | Spot the Emergency | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🚨 Obstetric emergencies are rare, sudden, and often affect two patients at once. Young, fit pregnant women compensate well and then deteriorate quickly, so early warning signs are subtle. The approach is always the same: call for help early (obstetric emergency call — senior midwife, obstetrician, anaesthetist, neonatologist), use ABCDE with left lateral tilt or uterine displacement, and follow well-practised drills.
Your four questions for every patient: Is she shocked — what are the MEOWS observations telling me? Is she bleeding (visible or concealed)? Is the baby compromised — and does delivering help the mother? Have I called the right team and declared the emergency clearly?

Recognising the Sick Pregnant Woman

• Normal changes can mislead — slightly higher heart rate, lower BP, mild breathlessness and raised white cells are normal; but don't dismiss real warning signs.
• Use the maternity early warning score (MEOWS or the national MEWS chart) for every pregnant or recently pregnant woman.
• Red flags:
  • Tachycardia over 100–110 (often the first sign of bleeding or sepsis).
  • Breathing rate over 20; low oxygen saturation.
  • Low BP (a late sign — up to a third of blood volume can be lost first).
  • Fever or low temperature.
  • Confusion, agitation, drowsiness.
  • Severe headache, chest pain, abdominal pain, or pain needing repeated strong analgesia.
  • Reduced urine output.
• Aortocaval compression — from about 20 weeks, the womb compresses the vena cava and aorta when she lies flat, reducing cardiac output by up to a third. Use a left lateral tilt (15–30°) or manual uterine displacement to the left.
• Airway — higher risk of difficult intubation and aspiration (oedema, delayed stomach emptying); early senior anaesthetic input.
• Oxygen — pregnant women desaturate quickly (less reserve, higher oxygen demand).

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Maternal Collapse and Cardiac Arrest

• Causes — the 4 Hs and 4 Ts, plus obstetric causes:
  • Haemorrhage (the commonest) — PPH, APH, ruptured ectopic, uterine rupture, liver or splenic rupture.
  • Thromboembolism — PE.
  • Amniotic fluid embolism.
  • Eclampsia and intracranial haemorrhage.
  • Sepsis.
  • Cardiac — cardiomyopathy, MI, aortic dissection, arrhythmia.
  • Drug toxicity — local anaesthetic toxicity, magnesium toxicity, high spinal block, anaphylaxis.
  • Hypoglycaemia; hypoxia; vasovagal and aortocaval compression.
• Cardiac arrest — adapted resuscitation (Resuscitation Council UK):
  • Call the obstetric and neonatal arrest teams; note the time.
  • Manual uterine displacement to the left (or left lateral tilt on a firm surface) from about 20 weeks.
  • Standard CPR — hand position may need to be slightly higher on the sternum; early intubation by an experienced anaesthetist; large-bore IV access above the diaphragm.
  • Standard defibrillation and drugs.
  • Resuscitative hysterotomy (perimortem caesarean) — if the womb is at or above the umbilicus (about 20 weeks or more) and there is no return of circulation, start by 4 minutes and deliver the baby within 5 minutes of arrest. It is done to help resuscitate the mother (relieves aortocaval compression), at the place of arrest.
  • Look for and treat reversible causes.

⚠️ Safety Pearl: In cardiac arrest after 20 weeks, the baby is delivered to save the mother. Don't move her to theatre — resuscitative hysterotomy should be done where she is, within 5 minutes.

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Postpartum Haemorrhage

• Definitions (RCOG):
  • Primary PPH — loss of 500 mL or more within 24 hours of birth.
  • Minor — 500–1,000 mL; major — over 1,000 mL (moderate 1,000–2,000; severe over 2,000) or clinical shock.
  • Secondary PPH — 24 hours to 12 weeks (see the Labour, Birth and Postnatal Care chapter).
• Causes — the "4 Ts":
  • Tone (about 70%) — the womb doesn't contract (uterine atony).
  • Trauma — tears (perineal, vaginal, cervical), uterine rupture, haematoma.
  • Tissue — retained placenta or membranes; placenta accreta.
  • Thrombin — clotting problems (DIC from abruption, AFE, sepsis, pre-eclampsia/HELLP; anticoagulants; inherited disorders like von Willebrand disease).
• Risk factors:
  • Antenatal — previous PPH, placenta praevia or accreta, abruption, multiple pregnancy, large baby, polyhydramnios, pre-eclampsia, anaemia, obesity, age over 40, fibroids, anticoagulants.
  • In labour — prolonged labour, oxytocin augmentation, instrumental birth, caesarean (especially emergency), retained placenta, chorioamnionitis, general anaesthesia.
• Prevention:
  • Treat anaemia before birth.
  • Active management of the third stage (oxytocin 10 IU IM).
  • Plan for high-risk women (IV access, group and save, senior staff, tranexamic acid, cell salvage at caesarean).
• Blood loss is often underestimated — measure (weigh swabs and pads); watch the observations; women can lose a lot before BP falls.

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PPH: Step-by-step Management

• Call for help — senior midwife, obstetrician, anaesthetist; activate the major obstetric haemorrhage protocol if over 1,000 mL with ongoing bleeding or shock.
• Resuscitate (ABC):
  • Lie flat; high-flow oxygen.
  • Two large-bore (14–16G) cannulas.
  • Bloods — FBC, clotting, fibrinogen, crossmatch (4–6 units), U&E, LFTs; point-of-care testing (ROTEM or TEG) if available.
  • Warmed fluids, then blood (O-negative or group-specific in an emergency).
  • Catheter for urine output; keep her warm.
• Stop the bleeding — find the cause (4 Ts):
  • Tone:
    • Rub up a contraction (fundal massage); bimanual compression.
    • Empty the bladder (catheter).
    • Oxytocin 5 IU slow IV (can repeat), then an oxytocin infusion (e.g. 40 IU over 4 hours).
    • Ergometrine 0.5 mg IV or IM — not in hypertension or pre-eclampsia.
    • Carboprost 250 micrograms IM, every 15 minutes up to 8 doses — not in asthma.
    • Misoprostol 800 micrograms sublingually.
    • Tranexamic acid 1 g IV (repeat after 30 minutes if bleeding continues) — give early (within 3 hours).
  • Trauma — examine for tears; repair in theatre if needed; pack haematomas.
  • Tissue — check the placenta is complete; manual removal or evacuation in theatre.
  • Thrombin — correct clotting (see below).
• If drugs fail — surgery or radiology (in theatre):
  • Intrauterine balloon tamponade (e.g. Bakri balloon) — first line.
  • B-Lynch compression suture (at laparotomy).
  • Uterine or internal iliac artery ligation.
  • Interventional radiology — uterine artery embolisation (if stable enough).
  • Hysterectomy — early if life-threatening (a senior decision; don't delay too long).
• Document carefully; debrief the woman and her partner; VTE prophylaxis afterwards; iron.
• Women who decline blood (e.g. Jehovah's Witnesses) — know their wishes in advance (advance decision), use cell salvage, IV iron, and early escalation to surgery.

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Major Obstetric Haemorrhage and DIC

• Fibrinogen falls early in obstetric haemorrhage (especially abruption and AFE) — a level under 2 g/L predicts severe bleeding.
• Blood products (guided by tests and clinical picture):
  • Red cells — aim Hb over 80 g/L.
  • Fibrinogen concentrate or cryoprecipitate — if fibrinogen under 2 g/L with ongoing bleeding.
  • Fresh frozen plasma — if PT/APTT prolonged (or after 4 units of red cells without results).
  • Platelets — keep over 75 × 10⁹/L.
  • Tranexamic acid.
• Cell salvage — collect and return the woman's own blood (especially at caesarean).
• DIC causes in obstetrics — placental abruption, amniotic fluid embolism, sepsis, pre-eclampsia/HELLP, retained dead fetus, massive transfusion, AFLP.
• After stabilisation — HDU or ICU; monitor for AKI, ARDS, Sheehan's syndrome; LMWH once bleeding settled.

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Shoulder Dystocia

• What it is: After the head is born, the anterior shoulder gets stuck behind the mother's pubic bone, and gentle downward traction doesn't deliver the shoulders.
• Signs:
  • Difficulty delivering the face and chin.
  • The head is born but pulled back tight against the perineum — the "turtle sign".
  • Failure of restitution.
• Risk factors — macrosomia, diabetes, maternal obesity, previous shoulder dystocia, prolonged labour, instrumental birth, induction. (Most cases happen without risk factors.)
• Management — call for help and follow the drill (one way to remember: HELPERR):
  • H — Help: emergency call (midwife, obstetrician, neonatologist, anaesthetist); note the time the head was born.
  • E — Evaluate for episiotomy (to allow internal manoeuvres; it doesn't relieve the bony obstruction).
  • L — Legs: McRoberts manoeuvre — lie flat, hyperflex the hips (thighs to abdomen). Resolves many cases.
  • P — Pressure: suprapubic pressure from the side of the baby's back, to push the anterior shoulder down and in.
  • E — Enter (internal manoeuvres): rotate the shoulders (Rubin's II, Woods' screw).
  • R — Remove the posterior arm.
  • R — Roll onto all fours (Gaskin manoeuvre), then repeat manoeuvres.
  • Last resort — cleidotomy, symphysiotomy, Zavanelli manoeuvre (push the head back for caesarean).
• Avoid — fundal pressure (worsens impaction, uterine rupture) and excessive or lateral traction on the head.
• Complications:
  • Baby — brachial plexus injury (Erb's palsy — C5–C6, "waiter's tip" arm; most recover), clavicle or humerus fracture, hypoxic brain injury, death.
  • Mother — PPH, OASI.
• Afterwards — neonatal examination, debrief, careful documentation (time of head and body delivery, manoeuvres, who did what, which shoulder was anterior).

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Umbilical Cord Prolapse

• What it is: The cord comes down through the cervix below the presenting part after the membranes rupture. Compression and spasm of the cord cut off the baby's oxygen.
• Risk factors:
  • Abnormal lie (transverse, oblique, unstable), breech (especially footling).
  • High presenting part; artificial rupture of membranes with a high head.
  • Polyhydramnios; preterm birth; multiple pregnancy (second twin); multiparity.
• Diagnosis — cord felt in the vagina or seen at the vulva; sudden fetal bradycardia or variable decelerations after membranes rupture.
• Management:
  • Call for help; category 1 caesarean usually.
  • Relieve pressure on the cord:
    • Push the presenting part up with fingers in the vagina (hand stays in place until delivery).
    • Position — knee–chest (all fours with head down) or exaggerated Sims' (left lateral, head down, pillow under the left hip).
    • Fill the bladder with 500–750 mL saline via a catheter (lifts the head; empty before caesarean).
    • Tocolysis (terbutaline 250 micrograms SC) if contractions continue or delay.
  • Minimal handling of the cord (avoids spasm); keep it warm and moist inside the vagina if possible.
  • If fully dilated and birth imminent — instrumental vaginal birth may be quicker.
  • Neonatologist present.

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Uterine Rupture

• Risk factors — previous caesarean or uterine surgery (myomectomy), induction or augmentation (prostaglandins, oxytocin), obstructed labour, multiparity, trauma.
• Features:
  • Abnormal CTG — often the first sign (prolonged bradycardia).
  • Severe abdominal pain, especially if persisting between contractions; scar tenderness; shoulder tip pain.
  • Vaginal bleeding; haematuria.
  • Loss of station of the presenting part; easily felt fetal parts; contractions stop.
  • Maternal shock.
• Management: Call for help; resuscitate; stop oxytocin; immediate laparotomy (category 1) — deliver the baby, repair the womb or perform hysterectomy; major haemorrhage protocol.

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Uterine Inversion

• What it is: The womb turns inside out, usually during the third stage — often from excessive cord traction before the placenta separates, or fundal pressure.
• Features:
  • Shock out of proportion to blood loss (vagal response — bradycardia).
  • Severe pain; PPH.
  • Mass in the vagina or at the introitus; fundus can't be felt abdominally (or a dimple).
• Management:
  • Call for help; resuscitate.
  • Immediate manual replacement — push the fundus back up through the cervix (Johnson manoeuvre); the sooner the better. Don't remove the placenta if still attached until the womb is replaced.
  • Tocolysis or anaesthesia may help; hydrostatic replacement (O'Sullivan — warm saline into the vagina) if manual fails; surgery if needed.
  • Oxytocin after replacement to keep it contracted; antibiotics.

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Unexpected Breech Birth

• When it happens — undiagnosed breech in advanced labour, preterm birth, second twin.
• Key principles:
  • Call for help (obstetrician, neonatologist).
  • "Hands off the breech" — let the baby descend with maternal effort; avoid traction (it causes the arms to go up and the head to extend).
  • Upright (all fours) or semi-recumbent positions.
  • Manoeuvres if needed — Lovset's (arms), Mauriceau–Smellie–Veit (flexing the head), forceps to the after-coming head.
  • Head entrapment — the most dangerous complication (especially preterm, where the cervix may not be fully dilated).
• If not yet in advanced labour — caesarean is usually offered.

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Eclampsia

• What it is: Seizures with pre-eclampsia (BP may be only mildly raised or even normal, and seizures can happen before pre-eclampsia is diagnosed or up to weeks after birth).
• Warning symptoms — severe headache, visual disturbance, epigastric pain, clonus, confusion.
• Management:
  • Call for help; left lateral position; protect the airway; high-flow oxygen; don't restrain.
  • Magnesium sulfate — first-line anticonvulsant (better than diazepam or phenytoin):
    • Loading dose — 4 g IV over 5–10 minutes.
    • Maintenance — 1 g/hour for 24 hours (after the last seizure or birth, whichever is later).
    • Recurrent seizure — a further 2–4 g IV over 5–10 minutes.
  • Monitor for magnesium toxicity — hourly reflexes (patellar; loss of reflexes is the first sign), breathing rate, oxygen saturation, urine output (magnesium is renally excreted — reduce or stop in oliguria). Levels if concerns.
  • Antidote — calcium gluconate 10% 10 mL IV over 10 minutes (for breathing depression).
  • Control BP — IV labetalol, oral nifedipine or IV hydralazine; target under 150/100.
  • Fluid restriction — about 80 mL/hour (pulmonary oedema risk).
  • Deliver once the mother is stable (stop seizures and control BP first). Fetal bradycardia during a seizure usually recovers — don't rush to theatre with an unstable mother.
• Complications — aspiration, intracranial haemorrhage (CT if focal signs or reduced consciousness), cerebral oedema, PRES, HELLP, abruption, death.

💡 Clinical Pearl: Any first seizure after 20 weeks or after birth is eclampsia until proven otherwise — check BP and urine and give magnesium sulfate.

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Severe Hypertension

• BP 160/110 or more — treat urgently (within an hour) to prevent stroke (systolic BP is the main driver of intracranial haemorrhage).
• Options:
  • Oral nifedipine (immediate- or modified-release, per local protocol) or oral labetalol — if able to take oral medicines.
  • IV labetalol — bolus (e.g. 20 mg, repeated) then infusion.
  • IV hydralazine — give with a small fluid bolus (sudden hypotension and fetal distress).
• Target — below 150/100 (then 135/85); continuous CTG.
• Assess for pre-eclampsia and HELLP; magnesium sulfate if severe features.
• After birth — BP often peaks on days 3–5.

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Maternal Sepsis

• A leading cause of maternal death worldwide and important in the UK.
• Sources:
  • Genital tract — chorioamnionitis, endometritis, wound infection, retained tissue, septic miscarriage.
  • Urinary tract — pyelonephritis.
  • Breast — mastitis, abscess.
  • Chest — pneumonia, influenza, COVID-19.
  • Group A streptococcus — can progress very fast (toxic shock, necrotising fasciitis); often spread from children with sore throats.
• Features — fever or low temperature, tachycardia, fast breathing, diarrhoea and vomiting, abdominal pain, pain out of proportion, confusion, rash, offensive lochia; fetal tachycardia.
• Management — within 1 hour ("Sepsis Six"):
  • Oxygen.
  • Blood cultures and other cultures (urine, high vaginal swab, throat, wound).
  • IV broad-spectrum antibiotics — per local maternal sepsis policy (e.g. piperacillin–tazobactam, or co-amoxiclav with gentamicin; add clindamycin if group A strep or toxic shock suspected).
  • IV fluids.
  • Lactate and FBC.
  • Urine output (catheter).
• Also:
  • Source control — deliver the baby if chorioamnionitis, evacuate retained tissue, drain abscesses.
  • Early senior obstetric, anaesthetic and critical care involvement.
  • VTE prophylaxis.
  • Inform the neonatal team (the baby needs assessment and antibiotics).
  • Close contacts — antibiotic prophylaxis for household contacts of invasive GAS (UKHSA).

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Amniotic Fluid Embolism

• What it is: A rare, often catastrophic reaction to amniotic fluid or fetal material entering the mother's circulation — during labour, at caesarean, or soon after birth.
• Features (sudden):
  • Breathlessness, hypoxia, cyanosis.
  • Hypotension and collapse; cardiac arrest.
  • Seizures; confusion.
  • DIC with massive bleeding (often follows within minutes).
  • Fetal distress.
• Risk factors — older age, induction, caesarean or instrumental birth, placenta praevia, abruption, multiple pregnancy, polyhydramnios.
• Diagnosis — clinical (a diagnosis of exclusion); no reliable test.
• Management: Supportive — ABC, intubation and ventilation, CPR (perimortem caesarean if arrest), inotropes, aggressive correction of DIC (fibrinogen, FFP, platelets), PPH management, ICU. Report to UKOSS.
• Prognosis — high mortality and serious morbidity, though survival has improved with rapid, coordinated care.

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Other Causes of Collapse

• Pulmonary embolism — sudden breathlessness, chest pain, hypoxia, tachycardia; treatment-dose LMWH; thrombolysis for massive PE with shock (pregnancy is not an absolute contraindication).
• Cardiac — aortic dissection (tearing chest pain, Marfan, hypertension), MI (including coronary artery dissection — SCAD — in late pregnancy and after birth), peripartum cardiomyopathy, arrhythmias. ECG, troponin, echo, CT angiography.
• Intracranial haemorrhage — sudden severe headache, reduced consciousness, focal signs (eclampsia, uncontrolled hypertension, aneurysm, AVM, CVST).
• Local anaesthetic systemic toxicity — after epidural top-up or large local infiltration: perioral tingling, tinnitus, agitation, seizures, arrhythmias, cardiac arrest. Stop injecting; airway; benzodiazepine for seizures; IV lipid emulsion (Intralipid 20%); prolonged CPR may be needed.
• High or total spinal block — after spinal or epidural: rapidly rising numbness, arm weakness, breathing difficulty, hypotension, bradycardia, loss of consciousness. Support breathing and BP (vasopressors).
• Magnesium toxicity — loss of reflexes, breathing depression; stop infusion, calcium gluconate.
• Anaphylaxis — antibiotics, latex, oxytocin (rare); IM adrenaline.
• Hypoglycaemia — diabetic mothers, AFLP.
• Vasovagal and aortocaval compression — usually brief; tilt to the left.

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Acute Abdominal Pain in Pregnancy

• Obstetric causes:
  • Early — ectopic pregnancy, miscarriage.
  • Later — placental abruption, labour (term or preterm), uterine rupture, chorioamnionitis, HELLP (epigastric), AFLP, fibroid degeneration ("red degeneration" — pain, low fever, tender fibroid in the second trimester; analgesia).
  • Ligament pain (round ligament — sharp groin pain in the second trimester; benign).
• Non-obstetric causes:
  • Appendicitis — the commonest surgical emergency in pregnancy; the appendix moves up as the womb grows (pain may be higher, in the right flank); higher perforation risk; ultrasound or MRI; laparoscopic appendicectomy is safe.
  • Pyelonephritis; UTI.
  • Ovarian torsion or cyst rupture (first trimester).
  • Gallstones and cholecystitis; pancreatitis.
  • Bowel obstruction; constipation; gastroenteritis.
  • Rectus sheath haematoma; splenic artery aneurysm rupture (rare, catastrophic).
• Imaging — ultrasound first; MRI (without gadolinium) is safe; CT is acceptable when needed (don't withhold necessary imaging).

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Trauma in Pregnancy

• Causes — road traffic collisions, falls, and domestic abuse (always ask privately).
• Principles:
  • Resuscitate the mother first — the best way to save the baby.
  • Left lateral tilt or manual uterine displacement (spinal board tilted if needed).
  • Large-bore access; blood loss is often concealed.
  • Necessary imaging (including CT) should not be withheld.
  • CTG for at least 4 hours after significant abdominal trauma (from viability) — abruption can be delayed.
  • Kleihauer test and anti-D if RhD-negative.
  • Check tetanus status.
• Specific risks — placental abruption, uterine rupture, preterm labour, fetal injury or death, fetomaternal haemorrhage.
• Seatbelt advice — lap belt below the bump, across the thighs; shoulder strap between the breasts.

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Drug Reference Table

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Spot the Emergency

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Exam-style Scenarios

1. Ten minutes after birth of a 4.2 kg baby after a 16-hour labour, a woman has lost 1,200 mL. The womb is soft and above the umbilicus. Pulse 125, BP 92/58.
Answer: Major primary PPH from uterine atony.

• Emergency call; major haemorrhage protocol; two large-bore cannulas; bloods including fibrinogen; crossmatch.
• Rub up a contraction, bimanual compression, catheterise.
• Oxytocin 5 IU IV then infusion; ergometrine (if no hypertension); carboprost (if no asthma); misoprostol; tranexamic acid 1 g IV.
• If still bleeding — theatre: balloon tamponade, B-Lynch, embolisation, hysterectomy.

2. During a birth, the head delivers but the shoulders don't follow with gentle traction. The baby's head is pulled tight against the perineum.
Answer: Shoulder dystocia.

• Call for help; note the time; stop pushing.
• McRoberts and suprapubic pressure; then internal manoeuvres, posterior arm, all-fours.
• No fundal pressure; neonatal team; document; prepare for PPH.

3. A 22-year-old at 37 weeks with no antenatal problems has a tonic–clonic seizure. BP afterwards is 158/104 with 2+ protein.
Answer: Eclampsia.

• Left lateral, airway, oxygen; magnesium sulfate 4 g IV over 5–10 minutes then 1 g/hour.
• Control BP (IV labetalol or oral nifedipine); fluid restriction.
• Deliver once stable; monitor reflexes, breathing and urine output.

4. After ARM in a woman with polyhydramnios, the CTG shows a fetal heart rate of 70. A loop of cord is felt in the vagina. The cervix is 5 cm.
Answer: Cord prolapse.

• Call for help; category 1 caesarean.
• Elevate the presenting part manually; knee–chest or left lateral head-down; fill the bladder.
• Consider tocolysis; minimal cord handling.

5. A woman 3 days after caesarean has a temperature of 39 °C, pulse 128, BP 88/50, and severe abdominal pain. Her toddler had tonsillitis last week.
Answer: Maternal sepsis — suspected group A streptococcus.

• Sepsis Six within 1 hour; IV broad-spectrum antibiotics plus clindamycin.
• Cultures (blood, wound, vaginal, throat); lactate; fluids; critical care review.
• Look for source (wound, endometritis, collection); prophylaxis for household contacts if iGAS confirmed.

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Key Points

• Pregnant women compensate then crash — tachycardia and fast breathing come before low BP; use MEOWS.
• Tilt to the left or displace the womb from 20 weeks; call the obstetric emergency team early.
• Cardiac arrest after 20 weeks: resuscitative hysterotomy within 5 minutes, where she is.
• PPH is 500 mL or more in 24 hours; causes are tone, trauma, tissue, thrombin.
• PPH drugs: oxytocin, ergometrine (not in hypertension), carboprost (not in asthma), misoprostol, tranexamic acid.
• Then balloon tamponade, B-Lynch, embolisation or hysterectomy; correct fibrinogen early.
• Shoulder dystocia: help, McRoberts, suprapubic pressure, internal manoeuvres, posterior arm, all fours — no fundal pressure.
• Cord prolapse: lift the presenting part, knee–chest, fill the bladder, category 1 caesarean.
• Uterine rupture: abnormal CTG, pain, loss of station, shock — laparotomy.
• Uterine inversion: shock out of proportion — immediate manual replacement.
• Eclampsia: magnesium sulfate 4 g then 1 g/hour; calcium gluconate for toxicity; stabilise before delivery.
• Maternal sepsis: antibiotics within 1 hour; clindamycin if group A strep suspected; source control.
• AFE: sudden hypoxia, collapse and DIC — supportive care and aggressive clotting correction.
• Trauma: resuscitate the mother first; CTG for 4 hours; Kleihauer and anti-D; ask about domestic abuse.

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Guidelines and Further Reading

• RCOG Green-top Guideline 52: Prevention and management of postpartum haemorrhage
• RCOG Green-top Guideline 42: Shoulder dystocia
• RCOG Green-top Guideline 50: Umbilical cord prolapse
• RCOG Green-top Guideline 56: Maternal collapse in pregnancy and the puerperium
• RCOG Green-top Guideline 64a/64b: Bacterial sepsis in pregnancy and following pregnancy
• NICE NG133: Hypertension in pregnancy (severe hypertension and eclampsia)
• Resuscitation Council UK: Cardiac arrest in pregnancy
• PROMPT (PRactical Obstetric Multi-Professional Training) course manual
• MBRRACE-UK reports
• BNF — for current doses

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