Maternity emergencies

Maternity emergencies are pattern recognition under time pressure: which blood pressure and neuro cues mean seizure risk, which bleeding picture is ectopic vs mole vs abruption vs previa, which fundus picture means which hemorrhage action, and which labor event needs the oxytocin stopped or the presenting part lifted off the cord.

Preeclampsia: when it turns severe

Preeclampsia is new hypertension after 20 weeks with proteinuria or end-organ signs. The vessels are in a high-resistance, leaky state, so brain, liver, and placenta take the hit. The exam cares whether you can spot severe features and start seizure protection before you tidy every lab.

Why headache and visual changes matter: cerebral edema and vasospasm are the path to eclampsia. Why RUQ pain matters: hepatic swelling and HELLP risk. Exact antihypertensive drug choice and BP notify cutoffs follow facility protocol and obstetric orders. On the exam, treat severe-range BP plus cerebral or hepatic cues as the priority cluster. Delivery is the definitive cure when the obstetric team decides the timing; your job is to keep mother and fetus safe until that plan runs.

Magnesium sulfate

Magnesium is for seizure prophylaxis, not as a primary blood-pressure drug. It depresses neuromuscular transmission, which is why lost reflexes and slow respirations are toxicity, not “extra calm.” Keep the room quiet, use seizure precautions, and keep calcium gluconate ready as the antidote.

1. Stop the magnesium infusion.
2. Support airway and breathing.
3. Give calcium gluconate as ordered.
4. Notify the provider and continue close monitoring.

Oliguria matters because magnesium clears through the kidney. Falling urine output means the drug can accumulate even if the pump rate looks “normal.” Check reflexes and respirations on a schedule, not only when someone looks sleepy.

HELLP

Hemolysis, Elevated Liver enzymes, Low Platelets: often with right-upper-quadrant pain in a client who already has preeclampsia. Microangiopathic hemolysis and liver injury make this an obstetric emergency pathway, not a “watch overnight” finding. Bleeding risk rises as platelets fall; blood pressure and seizure precautions still apply. Anticipate labs, stabilization, and expedited delivery planning as ordered.

Mole, cerclage, TORCH crises, GDM crises

These high-risk pictures sit next to ectopic and preeclampsia on the same exam. Screening and everyday TORCH/GDM teaching live in Prenatal care. This chapter owns the crisis versions: hemorrhage and malignant-follow-up after a mole, a cerclage that is failing, active HSV at labor, and pregnant clients who are crashing glucose either direction.

A hydatidiform mole (gestational trophoblastic disease) is placental tissue growing without a viable fetus in the usual way. hCG is often markedly high, the uterus may measure larger than dates, fetal heart tones are absent, and the ultrasound story is a snowstorm or grape-like vesicles as tested. Dark bleeding or passing grapelike tissue is the bedside cue. This is not “a miscarriage, send her home with pads.” Risks include hemorrhage and later choriocarcinoma, so evacuation is the usual pathway and serial hCG must fall to negative and stay there. Teach reliable contraception until follow-up clears pregnancy; a new pregnancy confuses the hCG map. Do not start RhoGAM teaching as the only plan when the stem is mole; Rh status still matters after uterine evacuation, but the exam target is the mole pathway itself.

Cervical insufficiency is painless dilation in the mid-trimester that loses the pregnancy without a real labor story. A cerclage stitches the cervix closed. After placement, activity limits follow the obstetric order (often pelvic rest, no intercourse as taught). Report contractions, pelvic pressure, rupture of membranes, or bleeding now; a stitch plus ROM is an infection and labor pathway, not a “wait for the next visit” finding. The cerclage is usually removed near term so labor can proceed, or earlier if labor starts. Do not do a vigorous vaginal exam on a cerclage client unless the stem and the obstetric plan say so.

TORCH exposure teaching (litter box, live vaccines, CMV hygiene) belongs in prenatal care so this chapter does not double-teach it. The emergency overlay is active disease at birth: HSV lesions change route, varicella around delivery changes isolation, and untreated syphilis follows the obstetric/infectious-disease pathway in the stem. GDM diet teaching also stays prenatal; here you treat the pregnant client who cannot stay conscious or who is acidotic. Adult DKA sequencing deepens in Diabetes and glycemic emergencies; do not wait for a nonpregnant number before you escalate in pregnancy.

Cardiac disease in pregnancy is a volume-and-pump problem. Blood volume and cardiac output rise; a stenotic or poorly pumping left heart may not tolerate the extra preload. Keep the gravid uterus off the vena cava (left lateral). Watch for dyspnea, crackles, tachycardia, and chest pain that is not ordinary pregnancy breathlessness. Avoid stacking fluids “because she is dry” when the stem is already wet. Labor and the minutes after birth dump uterine blood back into the circulation (autotransfusion); that is a classic decompensation window. Activity limits, endocarditis prophylaxis when ordered, and a planned birth route follow cardiology-OB. The distractor lays a class III/IV client flat for a long tracing or treats postpartum fatigue as only sleep loss while the lungs fill.

Ectopic pregnancy

An ectopic pregnancy implants outside the uterine cavity, most often in a tube. The tube cannot stretch like a uterus, so growth risks rupture and massive intraperitoneal bleeding. Classic exam pattern: missed period or positive pregnancy test, unilateral pelvic or lower abdominal pain, and vaginal spotting. Referred shoulder pain, syncope, or rigid abdomen with instability means rupture until proven otherwise.

Why you do not send her home on ibuprofen alone: a soft abdomen on arrival can still rupture hours later. Rh-negative clients may need RhoGAM after bleeding events as ordered. Pain out of proportion with “just a miscarriage” language is a cue to think ectopic.

Abruption versus previa

Third-trimester bleeding splits into two high-yield patterns. Placental abruption is premature separation of a normally implanted placenta; blood can hide behind the placenta, so external bleeding may underestimate loss. Placenta previa is placenta covering or near the cervical os; when the cervix begins to change, bright blood appears without labor pain as the main story.

The exam loves the painless bright red previa trap: a nurse who does a digital exam “to check dilation” can worsen hemorrhage. For abruption, believe maternal vital signs and uterine tone; late decelerations and a rigid uterus beat a reassuring pad that is only lightly stained. Both pathways need fetal monitoring, IV access, blood-product readiness as ordered, and an obstetric team.

Postpartum hemorrhage: read the fundus

Young clients can keep a near-normal blood pressure while soaking pads because they compensate until they crash. Believe the pad, clots, and fundus, not a reassuring cuff alone. A pad soaked in about 15 minutes, clots larger than a golf ball, or a soft enlarged uterus are abnormal. Afterpains, a one-time gush on standing, and one pad over several hours can be expected. Deeper day-to-day fundus and lochia assessment also lives in Postpartum care.

Atony is failure of the myometrium to clamp spiral arteries at the placental site. Massage and empty bladder restore tone; oxytocin and other uterotonics support that clamp. A laceration bleeds from a torn vessel while the uterus is already firm, so more massage wastes time. Retained fragments prevent sustained contraction. Support the lower uterus during massage so you do not invert the uterus.

• Methylergonovine: avoid in hypertension; it is not a rapid IV-push drug.
• Carboprost (as tested): caution in asthma patterns.
• Escalate to second-line uterotonics, IV access, crossmatch, and surgical help if the uterus stays boggy.
• Quantify blood loss; do not wait for a “perfect” BP drop in a young mother.

Labor: true vs false, then the emergencies

Transition (about 8–10 cm) brings intense, frequent contractions, an urge to push, and irritability. That is expected late first-stage behavior, not by itself a hemorrhage cue. Detailed FHR pattern teaching also sits in Labour and fetal monitoring.

Membranes rupture and cord prolapse

When membranes rupture, fluid can wash the cord down beside or ahead of the presenting part, especially if the head is high. That is why fetal heart rate is the first check after rupture, before you mop the floor.

1. Check the fetal heart rate first after rupture (cord prolapse risk).
2. If the cord is felt or seen: call for help immediately.
3. Relieve pressure: lift the presenting part off the cord; place knee-chest or Trendelenburg.
4. Do not push the cord back in. Keep it moist per protocol and prepare for emergency birth.

Oxytocin tachysystole

Oxytocin can drive contractions too close together, leaving the placenta no time to reperfuse. Late decelerations with tachysystole mean the fetus is paying the price. Stop oxytocin first, then side-lying, oxygen and IV fluid bolus as ordered, and notify. Keeping the drip “a little longer to finish labor” is the classic miss.

FHR timing (exam shorthand)

How to reason under time pressure

1. Is this severe preeclampsia, HELLP, or magnesium toxicity right now?
2. Is bleeding ectopic, abruption, or previa?
3. Is the fundus boggy or firm, and does that match the bleeding?
4. Did membranes just rupture: what is the FHR?
5. Is oxytocin causing tachysystole with late decelerations? Stop it first.
6. Is this mole (no FHT, high hCG) or a cerclage that is leaking?
7. Is this a GDM glucose crash or pregnancy DKA, not “wait and see”?
8. Is this a known cardiac client with new crackles after birth (autotransfusion)?