Obstetric Emergencies – GCC Nursing Guide

Evidence-based clinical reference for obstetric emergency recognition and management. Aligned with RCOG, WHO, and MBRRACE-UK guidelines, with GCC-specific contextual considerations for the DHA, DOH, and SCFHS nursing workforce.

RCOG Guidelines WHO Protocols MBRRACE-UK Emergency Care GCC Context

Obstetric Emergency Overview & Assessment

MBRRACE-UK: Leading Causes of Maternal Mortality (UK Reference) Thrombosis/Thromboembolism · Cardiac Disease · Sepsis · Pre-eclampsia/Eclampsia · Haemorrhage. Indirect causes (cardiac, neurological) now exceed direct obstetric causes. All are largely preventable with timely recognition.
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MEWS – Modified Early Obstetric Warning Score
Obstetric-specific trigger thresholds
ParameterLow (score 1)Medium (score 2)High (score 3)
Systolic BP (mmHg)90–10080–89 or 150–159<80 or ≥160
Diastolic BP (mmHg)–95–109≥110
Heart Rate (bpm)100–110111–129≥130 or <40
Respiratory Rate21–2425–29≥30 or <10
Temperature (°C)35–3638–38.9≥39 or <35
SpO₂ (%)–95–96<95
Urine output–<30 mL/h for 2h<30 mL/h for 4h
Neurological–Confusion/agitationUnresponsive/seizure
Score ≥2 single parameter or ≥3 aggregate → immediate senior review. Score ≥5 → critical care review.
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ABCDE Approach in Pregnancy
Modifications from standard assessment
A
Airway — Same as standard. Consider aspiration risk (relaxed lower oesophageal sphincter). RSI for intubation. Difficult airway more common in late pregnancy.
B
Breathing — Same assessment. Note: tidal volume increased ↑40%, minute volume ↑50%. SpO₂ target ≥95%. PaCO₂ normally lower (3.7–4.2 kPa) due to hyperventilation.
C
Circulation + LEFT LATERAL TILT 15–30° — Relieves aortocaval compression by gravid uterus. IV access × 2 large bore. Remember: hypotension is a late sign; obstetric patients compensate until 30–35% blood loss.
D
Disability + FETAL WELLBEING — Always assess fetal heart rate (CTG/Doppler). Maternal deterioration = fetal deterioration. Check blood glucose.
E
Exposure + FUNDAL HEIGHT — Estimate gestation by fundal height (at umbilicus ≈ 20 weeks; at xiphisternum ≈ 36–40 weeks). Relevant for perimortem CS decision (≥20 weeks).
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Physiological Changes Affecting Assessment
Normal pregnancy adaptations
  • Blood Pressure: Lower in 2nd trimester due to oestrogen/progesterone-mediated vasodilation. Returns to baseline at term. Do not dismiss "normal" BP in a previously hypertensive patient.
  • Heart Rate: Increases 10–20 bpm above pre-pregnancy baseline. Resting HR of 90–100 bpm can be normal near term.
  • Haemoglobin: Dilutional anaemia — nadir at 30–35 weeks. Normal Hb 10.5–11 g/dL in pregnancy (UK threshold). Do not compare to non-pregnant values.
  • Respiratory Rate: Largely unchanged, but tidal volume ↑40%, minute ventilation ↑50%, functional residual capacity ↓20%. Respiratory alkalosis compensated by metabolic acidosis.
  • Cardiac Output: Increases 40–50% by third trimester. GFR rises 50% — creatinine normally lower.
  • WBC: Physiologically elevated (up to 16×10⁹/L) in pregnancy and labour — do not rely on WBC alone for sepsis diagnosis.
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WHO Surgical Safety Checklist – Obstetric Adaptations
For caesarean section and obstetric procedures

Sign In (Before Anaesthesia)

  • Patient identity, consent, procedure site confirmed
  • Anaesthesia equipment/medication check complete
  • Antacid prophylaxis administered (e.g., sodium citrate + ranitidine)
  • Blood group/crossmatch available; blood products ordered if high risk
  • Fetal heart rate confirmed; gestation and presentation documented

Time Out (Before Skin Incision)

  • Team introductions; indication for CS confirmed
  • Antibiotic prophylaxis administered within 60 min
  • Uterotonic drugs drawn up and ready (oxytocin)
  • Neonatal team present for category 1/2 CS

Sign Out (Before Patient Leaves Theatre)

  • Instrument, swab, and needle counts confirmed
  • Specimen labelled and dispatched
  • Uterine tone and estimated blood loss documented
  • Post-operative VTE prophylaxis prescribed
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GCC-Specific Obstetric Context
Regional considerations for clinical practice

Consanguinity

  • First-cousin marriages common (20–50% in GCC)
  • Higher incidence of rare autosomal recessive disorders
  • Inherited thrombophilias (Factor V Leiden, prothrombin mutation) — increased VTE risk
  • Haemoglobinopathies: sickle cell, beta-thalassaemia — anaemia + VTE risk
  • Always take detailed family history

High Multiple Pregnancy Rate

  • High IVF utilisation in GCC → increased twin/triplet pregnancies
  • Multiple pregnancy ↑ risk: PPH, pre-eclampsia, preterm labour, malpresentation
  • Ovarian hyperstimulation syndrome (OHSS) possible in early pregnancy
  • Earlier delivery (elective CS at 37–38 weeks for twins)

Grandmultiparity (≥5 births)

  • More prevalent in GCC due to cultural norms and later family planning uptake
  • Major risk factors: uterine rupture, PPH (uterine atony), placenta praevia, abnormal placentation (accreta/increta/percreta)
  • Grand multiparity alone is an independent risk factor for catastrophic haemorrhage
  • Require consultant-led care and anaesthesia pre-assessment

Postpartum Haemorrhage (PPH)

>500 mL
Definition: vaginal birth
>1000 mL
Definition: caesarean section
80%
Uterine atony (Tone)
50%
Blood loss underestimated
Within 3h
TXA must be given
4T
The 4 T's – Aetiology of PPH
T
Tone — 80% Uterine atony. Uterus fails to contract after delivery. Risk: prolonged labour, multiparity, overdistension (twins, polyhydramnios), oxytocin augmentation, chorioamnionitis.
T
Tissue — 10% Retained placenta or membranes. Placenta accreta spectrum. Manual removal may be needed. Histology post-delivery.
T
Trauma — 5% Perineal/vaginal lacerations, cervical tears, uterine rupture, broad ligament haematoma, uterine inversion. Requires surgical repair.
T
Thrombin — 5% Pre-existing or acquired coagulopathy: DIC (from sepsis, abruption, AFE), ITP, von Willebrand disease, anticoagulant therapy.
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Recognition & Initial Response
Critical Point: Obstetric patients compensate haemorrhage extremely well. Tachycardia and hypotension are LATE signs — by the time BP drops, 30–35% blood volume may be lost.

Early Warning Signs

  • Tachycardia (HR >100) — often the first sign
  • Increasing uterine bleeding despite fundal massage
  • Clots passing per vagina
  • Patient feels faint, anxious, sweating
  • Visible lacerations or haematoma formation

Blood Loss Estimation

  • Visual estimation underestimates by up to 50%
  • Calibrated drapes/collection pots preferred
  • Weigh blood-soaked swabs (1g ≈ 1 mL)
  • Shock index (HR/SBP): >0.9 suggests significant haemorrhage; >1.7 = critical
H
HAEMOSTASIS Mnemonic – PPH Management
H
Help — Call for senior midwife, obstetrician, anaesthetist, blood bank. Activate massive haemorrhage protocol if >1500 mL.
A
Assess and Resuscitate — ABCDE. IV access × 2 (14–16G). O₂ 15L via face mask. Position flat. Warmth. Catheterise. Cross-match.
E
Establish Aetiology — Identify the T: palpate uterus (atony?), inspect placenta (complete?), examine for lacerations, check coagulation.
M
Massage Uterus — Bimanual uterine compression. Fundal massage. Expel clots. Confirm uterine contraction.
O
Oxytocics — Oxytocin 10 IU IM/slow IV (first line). Ergometrine. Carboprost (PGF2α). Misoprostol. See uterotonic table below.
S
Shift to Theatre — If not responding. Intrauterine balloon (Bakri). Surgical options. Radiological interventional (uterine artery embolisation).
T
Tamponade — Intrauterine balloon tamponade. Bakri balloon (fill 250–500 mL saline). Condom catheter (resource-limited setting). Test: observe for continued bleeding above balloon.
A
Apply Compression Sutures — B-Lynch suture (brace suture). Hemostatic sutures (vertical/horizontal). Stepwise uterine devascularisation (uterine/ovarian artery ligation).
S
Systemic Pelvic Devascularisation — Internal iliac artery ligation (bilateral). Uterine artery embolisation (interventional radiology if haemodynamically stable).
I
Intensive Care / Hysterectomy — Peripartum hysterectomy is definitive treatment for uncontrollable haemorrhage. Emergency decision — do not delay. ICU admission post-operatively.
S
Summation / Documentation — Fluid balance, blood products, drugs administered. Debrief team. Inform patient and partner when stabilised.
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Uterotonic Drugs
DrugDose/RouteContraindicationsNotes
Oxytocin (Syntocinon)10 IU IM or slow IV
Infusion: 40 IU in 500 mL at 125 mL/h		Rapid IV bolus (hypotension)First-line. Maintenance infusion. Antidiuretic effect at high doses.
Ergometrine500 mcg IM or slow IVCONTRAINDICATED in hypertension/pre-eclampsiaSustained contraction. Nausea common. Not with cardiac disease.
Syntometrine1 amp IM (oxytocin 5 IU + ergometrine 500 mcg)Hypertension, cardiac diseaseCombined effect. Active management 3rd stage.
Carboprost (Hemabate, PGF2α)250 mcg IM every 15 min, max 8 dosesCONTRAINDICATED in asthmaBronchospasm risk. Monitor SpO₂. Reserve for refractory atony.
Misoprostol800–1000 mcg sublingual/rectalRelative: prior uterine surgery (cervical)Thermostable — resource-limited settings. Side effects: shivering, fever, diarrhoea.
TXA (Tranexamic acid)1g IV over 10 min; repeat 1g if bleeding continues at 30 min—Must be given within 3 hours of PPH onset. Reduces mortality. WHO Essential Medicine.
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Massive Transfusion Protocol
Activate when: Blood loss >1500 mL or anticipate ongoing major haemorrhage. Contact blood bank immediately.

1:1:1 Ratio Protocol

  • Red Blood Cells (RBC) : Fresh Frozen Plasma (FFP) : Platelets = 1:1:1
  • Target Hb ≥8 g/dL during active haemorrhage
  • Target fibrinogen >2 g/L (give fibrinogen concentrate/cryoprecipitate early)
  • Target platelets >75 × 10⁹/L (≥50 for surgery; ≥100 for neuraxial anaesthesia)
  • Target PT/APTT <1.5× normal

Haematological Targets

ParameterTarget
Haemoglobin≥8 g/dL
Fibrinogen≥2 g/L
Platelets≥75 × 10⁹/L
Temperature≥35°C
pH≥7.2
Calcium (ionised)≥1.1 mmol/L
Cell salvage (intra-operative) should be considered in all major obstetric haemorrhage and placenta praevia/accreta cases.

Eclampsia & Hypertensive Emergencies in Pregnancy

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Pre-eclampsia Classification

Pre-eclampsia (Diagnosis)

  • BP ≥140/90 mmHg on two occasions ≥4h apart, at ≥20 weeks gestation
  • Significant proteinuria: ≥300 mg/24h OR PCR ≥30 mg/mmol OR dipstick ≥2+
  • OR: BP ≥140/90 + any severe feature (see right)
  • Superimposed pre-eclampsia: known chronic hypertension + new proteinuria/organ damage

Severe Pre-eclampsia (Any ONE of:)

Severe BP: Systolic ≥160 OR Diastolic ≥110 mmHg
  • Neurological: Severe headache, visual disturbance (blurring, scotoma, photopsia), hyperreflexia
  • Hepatic: Epigastric pain or RUQ pain, elevated ALT/AST (>70 IU/L)
  • Renal: Rising creatinine (>100 μmol/L), oliguria
  • Haematological: Thrombocytopenia (<100 × 10⁹/L)
  • Fetal: Severe FGR, abnormal Dopplers, oligohydramnios
  • Pulmonary oedema
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HELLP Syndrome
Haemolysis · Elevated Liver Enzymes · Low Platelets
Severe variant of pre-eclampsia — requires prompt delivery. Can occur without hypertension or proteinuria. High maternal and perinatal morbidity.

Diagnostic Criteria

CriterionThreshold
LDH (haemolysis marker)≥600 IU/L
ALT (liver enzymes)≥70 IU/L
Platelets (low)<100 × 10⁹/L
Bilirubin (haemolysis)Often elevated
Blood filmSchistocytes (fragmented RBCs)

Clinical Presentation

  • RUQ or epigastric pain + nausea/vomiting
  • Malaise, headache
  • Jaundice (in severe cases)
  • Bleeding (DIC complication)
  • Liver rupture/haematoma (rare but life-threatening)
Management: Immediate delivery regardless of gestation if HELLP confirmed. Steroids (dexamethasone) may be used to improve platelets pre-operatively. Platelet transfusion if <50 × 10⁹/L for CS.
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Eclampsia – Immediate Management
Eclampsia: Tonic-clonic seizure(s) in a woman with pregnancy, or within 4 weeks postpartum. Call for HELP immediately.
1
Call for HELP — obstetric emergency team, anaesthetist, senior midwife
2
Position: LEFT LATERAL — protects airway, reduces aortocaval compression
3
Airway — open, protect. O₂ 15L via non-rebreather mask. Suction if required. NEVER insert airway adjunct during active seizure
4
Time the seizure. Do NOT restrain. Protect from injury. Most eclamptic seizures self-terminate within 2–3 min
5
IV access — large bore × 2. Bloods: FBC, U&E, LFT, urate, clotting, G&S
6
MgSO₄: Loading dose 4g IV over 5 minutes → maintenance 1g/hour infusion
7
Control severe hypertension: SBP ≥160 → treat within 30 min (labetalol/hydralazine/nifedipine)
8
Continuous CTG monitoring. Fetal bradycardia common during/after seizure — usually transient. Do not deliver in extremis unless fetal compromise persists >15 min
9
Deliver once mother stabilised — timing depends on gestation and response to treatment
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Magnesium Sulfate (MgSO₄) Protocol
First-line for eclampsia prevention and treatment
Indication: Severe pre-eclampsia (to prevent seizures) AND active eclampsia treatment. Continue for 24h after last seizure or delivery, whichever is later.

Dosing (Pritchard / Modified)

  • Loading: 4g IV in 100 mL 0.9% NaCl over 5 minutes 4g / 5 min
  • Maintenance: 1g/hour IV infusion via syringe driver 1g/h
  • Continue 24 hours after delivery or last seizure
  • Recurrent seizure on MgSO₄: give further 2–4g IV bolus

Toxicity Monitoring (HOURLY)

ParameterThresholdAction
Deep Tendon Reflexes (DTRs)Loss = 7–10 mmol/LStop infusion if DTRs absent
Respiratory RateDepression >12 mmol/L; <12 breaths/minStop infusion; prepare antidote
Urine Output<25 mL/hourReduce dose — MgSO₄ renally excreted
SpO₂<95%Stop infusion; O₂; antidote
Antidote: Calcium gluconate 10 mL of 10% solution IV over 3 min. Have drawn up at bedside at all times during MgSO₄ infusion.
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Antihypertensive Therapy for Severe Hypertension
Target: SBP 130–150 / DBP 80–100 mmHg
Threshold for treatment: SBP ≥160 or DBP ≥110 mmHg. Treat within 30–60 min. Avoid rapid drops — can cause placental hypoperfusion.
DrugRoute/DoseNotes
LabetalolIV: 20mg bolus, repeat/double every 10 min (max 300mg)
Oral: 200mg stat		Beta-blocker + alpha-blocker. Avoid in asthma. First-line IV in UK.
Hydralazine5mg IV slowly, repeat 5mg every 20 minDirect vasodilator. Tachycardia side effect. Preload with 500mL IV fluid.
Nifedipine (modified release)10–20mg oral; repeat after 30 min if neededCalcium channel blocker. Avoid sublingual (rapid fall). Modified release preparations preferred.
Methyldopa250–500mg oral TDSSafe in pregnancy. Oral only — for chronic management, not acute severe hypertension.
ACE inhibitors, ARBs, and atenolol are CONTRAINDICATED in pregnancy.

Cord Prolapse, Shoulder Dystocia & Obstructed Labour

Cord Prolapse — Obstetric Emergency. Call for help immediately. Incidence: 1 in 500 deliveries. Goal: delivery within 30 minutes of diagnosis.
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Cord Prolapse – Immediate Management
1
Call for HELP — Obstetrician, anaesthetist, senior midwife, neonatal team, theatre team. State "cord prolapse" clearly.
2
Do NOT remove your hand. On diagnosis: insert gloved hand vaginally and MANUALLY ELEVATE the presenting part to relieve cord compression. Keep hand in situ until CS delivery.
3
Position: Knee-chest (most effective) OR Trendelenburg (head down, feet up) OR exaggerated Sims position (left lateral, right knee-chest) — gravity relieves cord compression.
4
Bladder filling: Fill bladder with 500 mL warm saline via urinary catheter — lifts presenting part. Effective temporising measure during transfer to theatre.
5
Cord care: If cord outside vagina — wrap in warm moist gauze. Do NOT attempt to replace cord back into uterus. Keep cord warm to prevent vasospasm.
6
Emergency CS: Category 1. Aim <30 min from diagnosis to delivery. Spinal or GA depending on urgency and time. Continuous CTG until delivery.
*
Tocolysis (e.g., terbutaline 0.25 mg SC) may be used to reduce contractions during transfer to theatre if uterine activity is worsening cord compression.

Risk Factors

  • Unstable lie / transverse or oblique presentation
  • Polyhydramnios (cord has more space)
  • Multiparity (less likely to be engaged)
  • Artificial rupture of membranes (ARM) with high presenting part
  • Cord presentation on ultrasound
  • Preterm labour (small baby, loose cord)
  • Long umbilical cord
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Shoulder Dystocia – HELPERR
Head delivered but anterior shoulder impacted behind symphysis pubis
Definition: Delivery requires additional obstetric manoeuvres after head delivery and gentle downward traction fails. Incidence: ~0.7% of vaginal deliveries. Risk of brachial plexus injury, fetal hypoxia, maternal trauma.
H
Help — Call obstetrician, anaesthetist, experienced midwife, neonatal team. Note time of head delivery. Do NOT apply fundal pressure.
E
Episiotomy — If needed for access to perform internal manoeuvres. Does not resolve bony impaction but improves access.
L
Legs — McRoberts' Manoeuvre — Hyperflexion of thighs onto maternal abdomen by two assistants. Flattens lumbar lordosis. Rotates symphysis superiorly. Effective in ~40% of cases. FIRST manoeuvre.
P
Pressure — Suprapubic — Assistant applies downward pressure to suprapubic region (not fundal). Dislodges anterior shoulder from behind symphysis. Apply with McRoberts simultaneously.
E
Enter — Internal Rotational Manoeuvres — Rubin II: pressure on posterior aspect of anterior shoulder. Woods Screw: pressure on anterior aspect of posterior shoulder. Aim to rotate to oblique diameter.
R
Remove Posterior Arm — Sweep posterior arm across fetal chest and deliver. Reduces diameter. Requires experienced operator. Risk of fetal humeral fracture.
R
Roll — All-fours (Gaskin Manoeuvre) — Turn mother to hands and knees. May dislodge posterior shoulder. Last resort before surgical options.
NEVER: Apply fundal pressure (worsens impaction). Pull on head laterally. Apply traction before manoeuvres attempted.
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Uterine Rupture

Risk Factors

  • Previous caesarean section (scar dehiscence/rupture)
  • Classical uterine scar (vertical incision) — highest risk
  • Grandmultiparity (>5 previous births) — weakened myometrium
  • Obstructed labour / malpresentation
  • Uterine hyperstimulation (oxytocin/prostaglandin misuse)
  • Uterine surgery (myomectomy, cornual resection)
  • Trauma (rare)

Clinical Signs

Sudden severe abdominal pain — often described as "ripping" or "tearing". Classic scar rupture may be more subtle (scar dehiscence = silent).
  • Cessation or change in uterine contraction pattern
  • Acute maternal haemodynamic deterioration (shock)
  • Sudden severe fetal bradycardia / loss of fetal heart rate
  • Recession of presenting part
  • Palpable fetal parts outside uterus
  • Haematuria (bladder involvement)
Management: Emergency laparotomy. IV access × 2, massive transfusion protocol, inform theatre. Repair vs. hysterectomy depending on extent and surgeon judgement.

Maternal Sepsis, Cardiac Arrest & Resuscitation

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Maternal Sepsis Recognition
Modified obstetric sepsis criteria
Sepsis is a leading cause of maternal mortality. Group A Streptococcus (GAS / Strep pyogenes) is particularly lethal — progresses to septic shock within hours. High clinical suspicion is essential.

Obstetric Sepsis Trigger Criteria (Any 2+)

  • Heart Rate >100 bpm
  • Respiratory Rate >20 breaths/min
  • Temperature >38°C OR <36°C (hypothermia is sinister)
  • WBC >17 × 10⁹/L OR <4 × 10⁹/L (note: normal pregnancy WBC up to 16)
  • Suspected or confirmed infection source
  • Altered mental status / confusion

Common Sources in Obstetrics

SourceOrganism(s)Clue
Genital tractGroup A Strep (most lethal), E. coli, anaerobesOffensive lochia, uterine tenderness, recent delivery/PROM
UTI/PyelonephritisE. coli, KlebsiellaLoin pain, frequency, positive MSU
PneumoniaInfluenza, Pneumococcus, H. influenzaeCough, consolidation, SpO₂ ↓
Wound (CS/perineum)Staph aureus, GAS, MRSAWound erythema, dehiscence, discharge
Mastitis/breast abscessStaph aureusBreast engorgement, fever post-delivery
ChorioamnionitisMixed, E. coli, GBSMaternal fever + uterine tenderness + fetal tachycardia
6️⃣
Sepsis 6 in Obstetrics
To be completed within 1 hour of recognition
1
High-flow O₂ — 15L via non-rebreather mask. Target SpO₂ ≥95%. Do not withhold O₂ due to concern about hyperoxia in pregnancy.
2
Blood Cultures × 2 sets — before antibiotics. Also: FBC, U&E, LFT, clotting, lactate, blood gas, CRP, blood glucose. Genital swabs if appropriate.
3
IV Antibiotics within 1 hour — Broad spectrum. Co-amoxiclav/piperacillin-tazobactam + gentamicin (single daily dose). Add clindamycin if GAS suspected. Review with microbiology urgently.
4
IV Fluid Resuscitation — 500mL–1L crystalloid bolus (0.9% NaCl or Hartmann's). Reassess. Target MAP >65 mmHg. Avoid fluid overload — risk of pulmonary oedema in pre-eclampsia.
5
Serum Lactate — Target <2 mmol/L. Lactate ≥4 = septic shock (regardless of BP). Repeat after resuscitation.
6
Urine Output Monitoring — Catheterise. Target ≥0.5 mL/kg/hour (>30 mL/hour). Oliguria = organ hypoperfusion.
Source Control: Consider delivery if chorioamnionitis and not responding to antibiotics. Retained products of conception require evacuation. Wound collections require drainage.
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Maternal Cardiac Arrest & Perimortem Caesarean Section

CPR Modifications in Pregnancy

  • Aortocaval Compression: Manual LEFT LATERAL DISPLACEMENT of uterus by assistant — do NOT use wedge under right hip during compressions (reduces compression effectiveness)
  • Hand Placement: Slightly higher on sternum (displaced by gravid uterus)
  • Compression rate and ratio: Standard 30:2 — no changes
  • Defibrillation: No modifications — use standard ACLS doses
  • Drugs: Standard ACLS drugs — all appropriate. Adrenaline 1mg IV every 3–5 min
  • Airway: RSI/intubation — difficult airway anticipated. Cricoid pressure

Reversible Causes (4H + 4T) + Obstetric

  • Hypoxia · Hypovolaemia · Hypo/Hyperkalaemia · Hypothermia
  • Tension pneumothorax · Tamponade · Toxins · Thromboembolism
  • Amniotic Fluid Embolism (AFE)
  • Aortocaval compression
  • Eclampsia / MgSO₄ toxicity
  • Local anaesthetic systemic toxicity (LAST)

Perimortem Caesarean Section (PMCS)

Indication: Gestation ≥20 weeks AND >4 minutes of cardiac arrest without ROSC → prepare for PMCS. Aim: delivery within 5 minutes of cardiac arrest.
4min
Decision to perform PMCS if no ROSC
5min
Delivery of fetus → target ("4-minute rule" in obstetrics)
PMCS is performed to IMPROVE MATERNAL RESUSCITATION (not primarily for fetal survival), by relieving aortocaval compression and allowing effective CPR. Do NOT wait for theatre — perform at the bedside. Continue CPR throughout.

Amniotic Fluid Embolism (AFE)

  • Catastrophic collapse during labour or immediately postpartum
  • Triad: cardiovascular collapse + coagulopathy (DIC) + hypoxia
  • Incidence: 1–2 per 100,000; mortality 20–60%
  • No specific treatment — aggressive supportive care: CPR, massive transfusion, O₂
  • Diagnosis of exclusion
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VTE in Pregnancy – Thromboprophylaxis

Risk Assessment (RCOG Green-top)

  • ALL pregnant women should have VTE risk assessment at booking, each admission, and postpartum
  • Highest risk period: postpartum (especially first 6 weeks)
  • CS carries higher VTE risk than vaginal delivery (emergency CS > elective CS)
  • Thromboprophylaxis LMWH should be started within 6–12h of birth (if no PPH)

LMWH Doses (Enoxaparin)

WeightProphylactic dose
<50 kg20 mg OD SC
50–90 kg40 mg OD SC
91–130 kg60 mg OD SC
>130 kg40 mg BD SC

DVT/PE in Pregnancy – Recognition

  • DVT: calf swelling, tenderness, redness — left leg more common (left iliac vein compression by gravid uterus)
  • Massive PE: sudden collapse, pleuritic chest pain, dyspnoea, tachycardia, RV strain on ECG
  • CTPA: investigation of choice (preferred over V/Q in 2nd/3rd trimester due to lower fetal dose)
  • Compression duplex USS: first-line for DVT diagnosis
Treatment: Therapeutic LMWH — weight-adjusted twice daily. Warfarin CONTRAINDICATED in 1st trimester and near delivery. Thrombolysis for massive PE causing haemodynamic instability.

GCC Context & Exam Preparation

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GCC Obstetric Practice – Key Considerations

Caesarean Section Rates

  • GCC CS rates: 40–60% in some tertiary centres (vs. WHO recommended 10–15%)
  • High elective repeat CS rate (VBAC less commonly offered)
  • Increases risk of placenta accreta spectrum in subsequent pregnancies
  • Higher risk of post-CS adhesions, bladder injury, and prolonged surgical time
  • DHA/DOH reporting requires documentation of CS indication

Consanguinity & Genetics

  • First-cousin marriages: up to 50% in some GCC communities
  • Autosomal recessive: haemoglobinopathies, metabolic disorders, congenital heart disease
  • Mandatory premarital screening in UAE, KSA (sickle cell, thalassaemia, HIV, Hepatitis)
  • Inherited thrombophilias more prevalent — VTE risk assessment critical
  • G6PD deficiency common — avoid oxidant drugs (e.g., avoid certain antibiotics)

Grandmultiparity in GCC

  • Grand multiparity (≥5 deliveries) more prevalent due to cultural and religious norms
  • Each additional pregnancy increases risk: uterine atony, PPH, placenta praevia, accreta, fetal malpresentation
  • Risk of uterine rupture increased with oxytocin augmentation in grandmultiparous women
  • Anaesthetic review essential pre-partum — anticipate surgical complexity

Access & Social Factors

  • Domestic staff (often South Asian or Southeast Asian) may have limited antenatal care access
  • Language barriers: Arabic, Urdu, Hindi, Tagalog — interpreter services critical
  • Late presentation common — unbooked or under-booked pregnancies
  • DHA/DOH mandate culturally competent care standards
  • Female staff preference culturally important — anticipate and accommodate
PPH Risk & Uterotonic Guide
Select all applicable risk factors and the current timing to calculate PPH risk level, recommended management protocol, uterotonics to prepare, IV access needs, blood product requirements, and escalation pathway.

Risk Factors Present

Current Timing

DHA / DOH / SCFHS Practice MCQs