Obstetrics & Gynecology

  1. Emergencies

  2. Non-Emergency

    Obstetric emergencies during pregnancy
    1. Miscarriage

      Symptoms and signs
      •Vaginal spotting or bleeding*
      •Cramping or abdominal pain
      •Fluid or tissue passing from the vagina
      Here are further guidelines.

    2. Placental abruption

      •Vaginal bleeding
      •Cramping, abdominal pain, and uterine tenderness
      Here are further guidelines.

    3. Placenta praevia

      •Painless vaginal bleeding during second or third trimester
      •For some, no symptoms
      Here are further guidelines.

    4. Pre-eclampsia and eclampsia

      •High blood pressure
      •Swelling of hands and face
      •Too much protein in urine
      •Stomach pain
      •Blurred vision
      Here are further guidelines.

    5. Preterm labor – Going into labor before 37 weeks of pregnancy

      •Increased vaginal discharge
      •Pelvic pressure and cramping
      •Back pain radiating to the abdomen
      Here are further guidelines.

    6. Abnormal Fetal lie, Malpresentation and Malposition
      Here are further guidelines.

    7. Ectopic pregnancy
      Here are further guidelines.

    8. Premature rupture of membranes (PROM)
      Here are further guidelines.

    9. Pregnancy Trauma
      Here are further guidelines.

    10. Obstetric emergencies during labour
    11. Shoulder dystocia –
      Here are further guidelines.

    12. Prolapsed umbilical cord
      Here are further guidelines.

    13. Placenta accreta
      Here are further guidelines.

    14. Labor that does not progress.

      •Perineal tears.
      •Problems with the umbilical cord.
      •Abnormal heart rate of the baby.
      •Water breaking early.
      •Perinatal asphyxia.
      Here are further guidelines.

    15. Spontaneous Vaginal Delivery
      Here are further guidelines.

    16. Rupture of the uterus
      Here are further guidelines.

    17. Inversion of the uterus
      Here are further guidelines.

    18. Amniotic fluid embolism
      Here are further guidelines.

    19. Postpartum Hemorrhage in Emergency Medicine
      Here are further guidelines.

    20. Response and management to other disasters

    21. Medico-legal issues.
      What are examples of medico-legal cases?

    22. Human Pregnancy Emergencies
      Maliciously impregnated (medico-legal case that needs emergency contraception).
      Here are further guidelines.

    23. Medical termination of pregnancy.
      Here are further guidelines.

    24. Pregnancy related problems
    25. Anemia / Level of hemoglobin
      Mild anemia 10.0-10.9 g/dl
      Moderate anemia 7.0-9.9 g/dl
      Severe anemia less than 7.0 g/dl
      Here are further guidelines.

    26. Fetal problems – Unborn baby has a health issue, such as poor growth or heart problems
      Here are further guidelines.

    27. Gestational diabetes – Too high blood sugar levels during pregnancy
      Here are further guidelines.

    28. High blood pressure (pregnancy related) – High blood pressure that starts after 20 weeks of pregnancy and goes away after birth
      Here are further guidelines.

    29. Hyperemesis gravidarum (HG) – Severe, persistent nausea and vomiting during pregnancy — more extreme than "morning sickness"
      Here are further guidelines.

    30. Infections during pregnancy
      Here are further guidelines.

    31. Health problems before pregnancy

      Eating disorders
      Epilepsy and other seizure disorders
      High blood pressure
      Overweight and Obesity
      Sexually transmitted infections (STIs)
      Thyroid disease
      Uterine fibroids
      Here are further guidelines.

    Abnormal Fetal lie, Malpresentation and Malposition
    Any suspected abnormal fetal lie or malpresentation should be confirmed by an ultrasound scan. This could also demonstrate predisposing uterine or fetal abnormalities.


    Abnormal Fetal Lie

    The lie, presentation and position of a fetus are important during labour and delivery.


    Lie – the relationship between the long axis of the fetus and the mother. Longitudinal, transverse or oblique

    Presentation – the fetal part that first enters the maternal pelvis. Cephalic vertex presentation is the most common and is considered the safest Other presentations include breech, shoulder, face and brow

    Position – the position of the fetal head as it exits the birth canal. Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) – this is ideal for birth Other positions include occipito-posterior and occipito-transverse.

    Note: Breech presentation is the most common malpresentation, and is covered in detail here.

    The two most common fetal presentations: cephalic and breech.

    Risk Factors

    The risk factors for abnormal fetal lie, malpresentation and malposition include:
    Multiple pregnancy
    Uterine abnormalities (e.g fibroids, partial septate uterus)
    Fetal abnormalities
    Placenta praevia

    Identifying Fetal Lie, Presentation and Position

    The fetal lie and presentation can usually be identified via abdominal examination. The fetal position is ascertained by vaginal examination.


    Face the patient’s head

    Place your hands on either side of the uterus and gently apply pressure; one side will feel fuller and firmer – this is the back, and fetal limbs may feel ‘knobbly’ on the opposite side


    Face the patient’s head

    Palpate the lower uterus (above the symphysis pubis) with the fingers of both hands; the head feels hard and round (cephalic) and the bottom feels soft and triangular (breech)

    You may be able to gently push the fetal head from side to side

    The fetal lie and presentation may not be possible to identify if the mother has a high BMI, if she has not emptied her bladder, if the fetus is small or if there is polyhydramnios.


    During labour, vaginal examination is used to assess the position of the fetal head (in a cephalic vertex presentation). The landmarks of the fetal head, including the anterior and posterior fontanelles, indicate the position.

    Any suspected abnormal fetal lie or malpresentation should be confirmed by an ultrasound scan. This could also demonstrate predisposing uterine or fetal abnormalities.


    Abnormal Fetal Lie

    If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted – ideally between 36 and 38 weeks gestation.

    ECV is the manipulation of the fetus to a cephalic presentation through the maternal abdomen.

    It has an approximate success rate of 50% in primiparous women and 60% in multiparous women. Only 8% of breech presentations will spontaneously revert to cephalic in primiparous women over 36 weeks gestation.

    Complications of ECV are rare but include fetal distress, premature rupture of membranes, antepartum haemorrhage (APH) and placental abruption. The risk of an emergency caesarean section (C-section) within 24 hours is around 1 in 200.

    ECV is contraindicated in women with a recent APH, ruptured membranes, uterine abnormalities or a previous C-section.

    External cephalic version.


    The management of malpresentation is dependent on the presentation.
    Breech – attempt ECV before labour, vaginal breech delivery or C-section
    Brow – a C-section is necessary
    Face If the chin is anterior (mento-anterior) a normal labour is possible; however, it is likely to be prolonged and there is an increased risk of a C-section being required
    If the chin is posterior (mento-posterior) then a C-section is necessary

    Shoulder – a C-section is necessary


    90% of malpositions spontaneously rotate to occipito-anterior as labour progresses. If the fetal head does not rotate, rotation and operative vaginal delivery can be attempted. Alternatively a C-section can be performed.

    Footling presentation: There are single-footling or double-footling presentations depending upon whether the presenting part of the baby at delivery is just one foot or both feet?. Management of footling breech presentation.

    Elective caesarean section (ELCS) for a singleton breech at term has been shown to reduce perinatal and neonatal mortality rates.
    1. Failure to progress

    Prolonged labor, labor that does not progress, or failure to progress is when labor lasts longer than expected. Studies suggest that this affects around 8 percent of those giving birth. It can happen for a number of reasons.
    v The American Pregnancy Association define prolonged labor as lasting over 20 hours if it is a first delivery. For those who have previously given birth, failure to progress is when labor lasts more than 14 hours.

    If prolonged labor happens during the early, or latent, phase it can be tiring but does not usually lead to complications.
    v However, if it happens during the active phase, medical assessment and intervention may be needed.

    Causes of prolonged labor include:
    slow cervical dilations
    slow effacement
    a large baby
    a small birth canal or pelvis
    delivery of multiple babies
    emotional factors, such as worry, stress, and fear

    Pain medications can also contribute by slowing or weakening uterine contractions.

    If labor fails to progress, the first advice is to relax and wait. The American Pregnancy Association advise taking a walk, having a sleep, or running a warm bath.

    In the later stages, health professionals may give labor-inducing medications or recommend a cesarean delivery.

    2. Fetal distress

    “Non-reassuring fetal status,” previously known as fetal distress, is used to describe when a fetus does not appear to be doing well.

    The new term is recommended by the American College of Obstetricians and Gynecologists (ACOG), because “fetal distress” is not specific, and it may result in inaccurate treatment.

    Non-reassuring fetal status may be linked to:
    an irregular heartbeat in the baby
    problems with muscle tone and movement
    low levels of amniotic fluid

    Underlying causes and conditions can include:
    insufficient oxygen levels
    maternal anemia
    pregnancy-induced hypertension in the mother
    intrauterine growth retardation (IUGR)
    meconium-stained amniotic fluid

    It is more likely to occur in pregnancies that last 42 weeks or longer.

    Strategies that may help with during episodes of non-reassuring fetal status include:
    changing the mother’s position
    increasing maternal hydration
    maintaining oxygenation for the mother
    amnioinfusion, where fluid is inserted into the amniotic cavity to relieve pressure on the umbilical cord
    tocolysis, a temporary stoppage of contractions that can delay preterm labor
    intravenous hypertonic dextrose

    In some cases, a cesarian delivery may be necessary.

    3. Perinatal asphyxia

    Perinatal asphyxia has been defined as “failing to initiate and sustain breathing at birth.

    ” It can happen before, during or immediately after delivery, due to an inadequate supply of oxygen.

    It is a non-specific term that involves a complex range of problems.

    It can lead to:
    hypoxemia, or low oxygen levels
    high levels of carbon dioxide
    acidosis, or too much acid in the blood

    Cardiovascular problems and organ malfunction can result.

    Before delivery, symptoms may include a low heart rate and low pH levels, indicating high acidity.

    At birth, there may be a low APGAR score of 0 to 3 for more than 5 minutes.

    Other indications may include:
    poor skin color
    low heart rate
    weak muscle tone
    weak breathing
    meconium-stained amniotic fluid

    Treatment of perinatal asphyxia can include providing oxygen to the mother, or carrying out a cesarean delivery.

    After delivery, mechanical breathing or medication may be necessary.

    4. Shoulder dystocia

    Shoulder dystocia is when the head is delivered vaginally but the shoulders remain inside the mother.

    It is not common, but it is more likely to affect women who have not given birth before, and is responsible for half of all cesarean deliveries in this group.

    Health providers may apply specific maneuvers to release the shoulders:

    These include:
    changing the mother’s position
    manually turning the baby’s shoulders

    An episiotomy, or surgical widening of the vagina, may be needed to make room for the shoulders.

    Complications are usually treatable and temporary. However, if a non-reassuring fetal heart rate is also present, this may indicate other problems.

    Possible problems include:
    fetal brachial plexus injury, a nerve injury that may affect the shoulder, arms, and hand but usually heals in time fetal fracture, in which the humerus or collar-bone break, which usually heal without problems hypoxic-ischemic brain injury, or a low oxygen supply to the brain, which can, in rare cases, be life-threatening or lead to brain damage

    Maternal complications include uterine, vaginal, cervical or rectal tearing and heavy bleeding after delivery.
    v 5. Excessive bleeding

    On average, women lose 500 milliliters (ml) of blood during the vaginal delivery of a single baby. During a cesarian delivery for a single baby, the average amount of blood lost is 1,000 ml.

    It can occur within 24 hours after delivery or up to 12 weeks later, in the case of secondary bleeding.

    Around 80 percent of cases of postpartum hemorrhage result from a lack of uterine tone.

    Bleeding happens after the placenta is expelled, because the uterine contractions are too weak and cannot provide enough compression to the blood vessels at the site of where the placenta was attached to the uterus.

    Low blood pressure, organ failure, shock, and death can result.

    Certain medical conditions and treatments can increase the risk of developing postpartum hemorrhage:
    placental abruption or placenta previa
    uterine overdistention
    multiple gestation pregnancy
    pregnancy-induced hypertension
    several prior births
    prolonged labor
    the use of forceps or a vacuum-assisted delivery
    use of general anesthesia or medications to induce or stop labor

    Other medical conditions that can lead to a higher risk include:
    cervical, vaginal or uterine blood vessel tears
    hematoma of the vulva, vagina or pelvis
    blood clotting disorders
    placenta accreta, increta, or percreta
    uterine rupture

    Treatment aims to stop the bleeding as soon as possible.

    Options include:
    the use of medication
    uterine massage
    removal of retained placenta
    uterine packing
    tying off bleeding blood vessels
    surgery, possible a laparotomy, to find the cause of the bleeding, or hysterectomy, to remove the uterus

    Excessive bleeding can be life-threatening, but with rapid and appropriate medical help, the outlook is normally good.

    6. Malposition

    Not all babies will be in the best position for vaginal delivery. Facing downward is the most common fetal birth position, but babies can be in other positions.

    They include:
    facing upward
    breech, either buttocks first (frank breech) or feet first (complete breech)
    lying sideways, horizontally across the uterus instead of vertically

    Depending on the position of the baby and the situation, it may be necessary to:
    manually change the fetal position
    use forceps
    carry out an episiotomy, to surgically enlarge the opening perform a cesarian delivery

    Umbilical cord

    Problems with the umbilical cord include:
    become wrapped around the baby
    getting compressed
    emerging before the baby

    If it is wrapped around the neck, if it is compressed, or emerges before the baby does, medical help will probably be needed.

    7. Placenta previa

    When the placenta covers the opening of the cervix, this is referred to as placenta previa. A cesarian delivery is usually necessary.

    It affects around 1 in 200 pregnancies in the third trimester.

    It is most likely to occur in those who: have had previous deliveries, and especially four or more pregnancies previous placenta previa, cesarean delivery, or uterine surgery have a multiple gestation pregnancy
    are aged over 35 years
    have fibroids

    The main symptom is bleeding without pain during the third trimester. This can range from light to heavy.

    Other possible indications include:
    early contractions
    the baby being in breech position
    a large uterus size for the stage of pregnancy

    Treatment is usually:
    bed rest or supervised rest in the hospital, in severe cases
    blood transfusion
    immediate cesarean delivery, if the bleeding does not stop or if the fetal heart reading is non-reassuring

    It can increase the risk of a condition known as placenta accreta, a potentially life-threatening condition in which the placenta becomes inseparable from the wall of the uterus.

    The doctor may recommend avoiding intercourse, limiting travel, and avoiding pelvic examinations.

    8. Cephalopelvic disproportion

    Cephalopelvic disproportion (CPD) is when a baby’s head is unable to fit through the mother’s pelvis.

    According to the American College of Nurse Midwives, cephalopelvic disproportion occurs in 1 in 250 pregnancies.

    This can happen if:
    the baby is large or has a large head size
    the baby is in an unsual position
    the mother’s pelvis is small or has an unusual shape

    A cesarian delivery will normally be necessary.

    9. Uterine rupture

    If someone has previously had a cesarian delivery, there is a small chance that the scar could open during future labor.

    If this happens, the baby may be at risk of oxygen deprivation and a cesarian delivery may be necessary. The mother may be at risk of excessive bleeding.

    Apart from a previous cesarean delivery, other possible risk factors include:
    the induction of labor
    the size of the baby
    maternal age of 35 years or more
    the use of instruments in vaginal delivery

    Women who plan for a vaginal birth after previously having a cesarian delivery should aim to deliver at a health care facility. This will provide access to facilities for a cesarean delivery and blood transfusion, should they be needed.

    Signs of a uterine rupture include:
    an abnormal heart rate in the baby
    abdominal pain and scar tenderness in the mother
    slow progress in labor
    vaginal bleeding
    rapid heart rate and low blood pressure in the mother

    Appropriate care and monitoring can reduce the risk of serious consequences.

    10. Rapid labor

    Together, the three stages of labor typically last for 6 to 18 hours, but sometimes it lasts only 3 to 5 hours.

    This is known as rapid labor or precipitous labor.

    The chances of rapid labor are increased when:
    the baby is smaller than average
    the uterus contracts efficiently and strongly
    the birth canal is compliant
    there is a history of rapid labor

    Rapid labor can start with a sudden series of quick, intense contractions. This can leave little time in between for rest. They may resemble one continuous contraction.

    Disadvantages of rapid labor are that:
    it can leave the mother feeling out of control
    there may not be enough time to get to a health care facility it can increase the risk of tearing and laceration to the cervix and vagina, hemorrhage, and postpartum shock

    Risks for the baby include:
    aspiration of amniotic fluid

    a higher chance of infection if delivery takes place in an unsterile location

    If there are signs of rapid labor starting, it is important to: contact a doctor or midwife.
    use breathing techniques and calming thoughts to feel more in control remaining in a sterile place

    Lying down on the back or side may help.

    Can complications be fatal?

    Complications during can be life-threatening in parts of the world where there is a lack of proper health care.

    Worldwide, 303,000 fatalities were expected to occur in 2015.

    The main causes are:
    unsafe termination
    eclampsia, leading to high blood pressure and seizures pregnancy complications that worsen at the time of delivery

    Appropriate health care can prevent or resolve most of these problems.

    It is vital to attend all prenatal visits during pregnancy, and to follow the doctor’s advice and instructions regarding pregnancy and delivery.
    Human Pregnancy
    Normal Pregnancy: A Clinical Review
    Obstetric and Gynecologic Emergencies: Diagnosis and Management
    Abortion Complications
    Abruptio Placentae
    Amniotic Fluid Embolism
    Asthma in Pregnancy
    Bacterial Vaginosis
    Breech Delivery
    Conization of Cervix
    Corpus Luteum Rupture
    Dysfunctional Uterine Bleeding in Emergency Medicine
    Dysmenorrhea in Emergency Medicine
    Emergency Contraception
    Early Pregnancy Loss
    Early Pregnancy Loss in Emergency Medicine
    Ectopic Pregnancy
    Ectopic Pregnancy in Emergency Medicine
    Elective Abortion
    Emergent Management of Abruptio Placentae
    Emergent Treatment of Endometriosis
    Hyperemesis Gravidarum
    Hyperemesis Gravidarum in Emergency Medicine
    Imperforate Hymen

    Q: How do you know when you are in labor?
    Q: What are the three stages of child birth labor?
    Medical termination of pregnancy.
    Who decides?
    Who terminates?

    Q: What are the indications of medical termination of pregnancy?
    A: In case the pregnancy is the result of rape or conspiracy.
    The woman could not cope with labor.
    Due to ailment, the woman would not be able to bring up the child with love and care.
    Even if any other person or group comes forward and takes responsibility for bringing up the baby, pregnancy can't go ahead.
    We are dealing with a human being.
    There is a difference between human pregnancy, family-centered maternity care, and poultry farms.
    Other medical indications.

    What should happen if these guidelines are violated?
    Dishonorable discharge from service with punishment.

    Who may violate these guidelines?
    Medical doctors, judges, director of health, secretary of health, head of the state, county, city, and others.

    Do you know any such situation or incident?

    Q: What is an episiotomy?
    Q: When is an episiotomy necessary?

    Cesarean section

    Q: What is a cesarean section?
    Q: When is a C-section needed?
    Q: What are the risks of C-section?
    Q: How is a C-section done?
    Q: How long does it take to recover from a C-section?
    Q: Why would I want to avoid a cesarean?
    Labor and Delivery in the Emergency Department

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    Q: What is infertility?
    A: If a couple is infertile, this means that they have been unable to conceive a child after 12 months of regular sexual intercourse without birth control.

    Here are further guidelines.

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    In vitro fertilization

    It is claimed that on July 25, 1978, the world's first 'test tube baby' was born.
    How many years did the couple have intercourse without birth control before it was decided to use in vitro fertilization?
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    What is the proof pregnancy was not due to in vivo fertilization, like a normal pregnancy?
    How long will it take them to answer before this technique is recommended to others?

    Do not get fooled by Nobel prizes.
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    Birth Control
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      Q: What is contraception?
      Q: What different types of contraception are there?
    Disease Prevention in Women
    Diseases More Common In Women
    Evaluation and Management of Cervical Abnormalities
    Fibrocystic Breast Condition
    Fertility, Birth Control and Infertility
    Female Anatomy
    Female Reproductive System
    Female Hormones
    Klinefelter Syndrome
    Menstrual Disorders
      Menorrhagia, or hypermenorrhea
      Postmenopausal bleeding
      Premenstrual syndrome
      Primary amenorrhea
      Secondary amenorrhea
    Menstrual Cramps
    Menstrual Cramps and PMS Medication Guide
    Management of Contraception
    Ovarian Cysts
    Paget's Disease of The Nipple
    Polycystic Ovary
    Premature Menopause
    Premature Ovarian Failure (POF)
    Premenstrual Dysphoric Disorder (PMDD)
    Premenstrual Syndrome
    Sexually Transmitted Disease
    Turner Syndrome
    Urinary Incontinence in Women
    Urine Infection
    Uterine Fibroids
    Uterine Growths
    Vaginal Delivery
    Vaginal Bleeding
    Vaginal Pain (Vulvodynia)
    Women's Health
    Women's General Health and Wellness
    Women's Cosmetic Concerns
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    Last Updated: November 14, 2020