This chapter describes the types, key implications and management strategies of massive obstetric haemorrhage. Antepartum haemorrhage due to placental abruption and intrapartum haemorrhage due to uterine rupture are associated with increased perinatal mortality. Visible blood loss greater than 2 litres, ongoing bleeding are some key pointers of massive obstetric haemorrhage. Immediate management involves active resuscitation to ensure a patient airway, breathing and maintaining circulation with intravenous fluids, blood and blood products as well as correction of coagulopathy. In women who are not acutely compromised or bleeding severely, interventional radiology can be considered. If the bleeding is predominantly from the lower segment, a total abdominal hysterectomy is warranted. Women with massive obstetric haemorrhage often need multi-organ support. Hence, transfer to an intensive care unit or high dependency unit should be considered for monitoring. Thromboprophylaxis should be considered once the coagulation parameters return to normal.

This chapter discusses pre-term labour, abnormalities at different stages of labour, placenta accreta, and certains emergencies such as cord prolapse and shoulder dystocia. The management of threatened preterm labour is aimed at maximising neonatal survival by prolonging the pregnancy. The administration of corticosteroids 24 to 48 hours prior to delivery significantly improves perinatal morbidity and mortality. Oxytocin is commonly used in abnormal labour and effectively increases uterine activity and causes cervical dilatation. Uterine hyperstimulation is a common side effect of oxytocin administration and this is the reason for the incremental regime used to accelerate or induce labour. Retained placenta is a cause of major obstetric haemorrhage. Abnormal progress in the first and second stages of labour is associated with fetal malpresentations and malpositions. Shoulder dystocia is a very serious obstetric emergency and in current obstetric practice is a significant cause of perinatal morbidity and mortality.

Obstetric haemorrhage results in massive blood loss endangering the life of the mother, and the infant in the case of antepartum haemorrhage (APH). This chapter discusses placenta praevia, vasa praevia, postpartum haemorrhage (PPH), uterine atony, genital tract trauma, clotting disorders, and uterine inversion. The Confidential Enquiry into Maternal and Child Health (CEMACH) recommends that all obstetric units have a protocol for the management of obstetric haemorrhage; all individuals working in delivery units should be familiar with local guidelines. APH is a major cause of perinatal morbidity and mortality, including an increased risk of premature delivery. Placental abruption may be partial or complete separation and can occur at any stage of pregnancy. The intervention following placental abruption is dependent upon the severity of the abruption and the presence of fetal compromise. General anaesthesia with relaxation by volatile agents is the most proven anaesthetic technique to correct the inversion.

This chapter explains the indications for the Caesarean section organised into four categories. In principle, the considerations are that the decision to delivery time for category 1, where immediate threat to life of women or fetus, should be less than 30 minutes and mother's safety is paramount. The majority of deliveries are achieved through a low transverse abdominal skin incision and a transverse incision through the lower segment of the uterus. The chapter discusses the maternal or fetal compromise, the necessity of early delivery, and elective Caesarean section, explaining their ractical surgical steps, complications, and Caesarean hysterectomy. Instrumental delivery can be achieved through the use of vacuum extractor and forceps. Obstetricians should remain familiar with the technique of assisted vaginal breech delivery, as some patients will present with breech presentation in preterm labour or in advanced labour. Twin pregnancies have a higher incidence of pre-term labour, IUGR and preeclampsia.