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EMERGENCY
OBSTETRIC CARE
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Life Is Tough Enough
Without
Having Someone KickYou
From
The Inside.
Rita Rudner
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The moment a child is born, the mother is also born.
She never existed before. The woman existed, but the
mother, never. A mother is something absolutely
new.
Osho
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Age Old Indian Culture
Baby Birth Second Birth
MMR Not Highest But Quite High
2% Land
20% Deaths
Of Globe In India
One Death, >20-60 Disabled
CausesMultiple, Multilayered.
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Disorders Difficulties Dogmas
Pregnancy
Birth Specific
Post Birth
Preexisting Disorders.
Not Immune To Medical Surgical Disorders.
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WHO Estimates 515 000 Maternal Deaths Each
Year
More than one woman dies every minutefrom pregnancy-related causes
What Do Women Die Of? They Die Of Obstetric Complications That Need
Not Be Fatal
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DIRECT OBSTETRIC COMPLICATIONS
Hemorrhage 21%
Unsafe Abortion 14%
Eclampsia 13% Obstructed Labor 08%
Infection 08%
Other 11%
Account for about 3/4 of Maternal Deaths
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Causes of Maternal Deaths Worldwide
8%
8%
20%
Unsafe Abortion
24%
12%
15% 13%
Indirect
Other direct
Obstructed Labour
Haemorrhage
HTD
Infection
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INDIRECT OBSTETRIC COMPLICATIONS
Pre-existing Conditions, including Malaria,
Anemia and Hepatitis ,Increasingly HIV / AIDS
Account for about 1/4 of Maternal Deaths
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Obstetric Complications Occur Suddenly
Without Warning
If women do not receive medical treatment ontime, they will probably
Suffer disabilityOr Die
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Most Obstetric Complications
Can Neither
Be Predicted
Nor Prevented
But If Women Receive
Effective Treatment In Time,
Almost All Can Be Saved
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How Much Time Do We Have?
It is estimated that, if untreated, death
occurs on average in:
2 hours Postpartum Hemorrhage
12 hours Antepartum Hemorrhage
2 days Obstructed Labor
6 days Infection
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To Avert
Death and Disability
We Need To Ensure
That Women have Access To
Emergency Obstetric Care
(EmOC)
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How Can We Improve Access To EmOC?
By making sure
health facilities provide the services needed
to
save womens lives.
Eight key functions signal a facilitysability to provide EmOC
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Why EmOC -
Needs : Doctors competent in providing comprehensiveemergency obstetric care required to make first referral
units functional for 24 hrs. EMOC services.
Status now: Few public sector Obstetricians work in ruralareas.
Opportunity: Many public sector non specialized medicalofficers in rural areas.
Solution: To bridge gap, FOGSI + Govt. preparing nonspecialist medical officers to provide comprehensive
emergency obstetric care in rural India.
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EmOC Key FunctionsCover These Services:
Antibiotics(intravenous or by
injection)
Oxytocic Drugs(ditto) Anticonvulsants
(ditto)
Manual Removal of
Placenta
Removal of
Retained Products
Assisted Vaginal
Delivery Surgery (Cesarean
Section)
Blood Transfusion
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THE GOOD NEWSNot all these functions need hospitalsand doctors
Well-trained nurses and midwives canperform most functions at Basic EmOCFacilities
An Important Point
For Resource Poor Areas
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Objectives of Care During Labor and Childbirth
Protect the life of the mother and newborn .
Support normal labor and detect and treatcomplications in a timely fashion .
Support and respond to needs of the woman, her
partner and family during labor and childbirth
Normal Labor and Childbirth 19
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Birth Preparedness and Complication
Readiness for the Woman and Family
Recognize danger signs
Plan for managing complications
Save money or access funds Arrange transportation
Plan route
Plan place for childbirth
Choose provider
Follow instructions for self-care20
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Diagnose and manage problems and complications
appropriately and in a timely manner
Arrange referral to higher level of care if needed
Provide women-centered counseling about birth
preparedness and complication readiness
Educate community about birth preparedness and
complication readiness
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Complication Readiness
for the Provider
Recognize and respond to danger signs
Establish plan and determine who is in
authority to make decisions in case of
emergency
Develop plan for immediate access to funds
(savings or community loan)
Identify and plan for blood donors and
donationNormal Labor and Childbirth 22
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Ectopic Pregnancy
Risk Factors:Age
Parity
Previous induced abortion
Sterilization failurePID
Diagnosis
Triad - Amenorrhea, Bleeding, Pain
Positive Urine HCG +TVS (Colour Doppler) Placental Flow, Ring OfFire Diagnostic.
Culdocentesis Or Colpocentesis
Used To Be Important Now X23
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Non-contrast MR T2W1 Sensitive,
Specific Highly Accurate
Sensitivity To Fresh Haematoma
Laparoscopy Gold Standard ; Enables Therapy
All Said Clinical + Intusion
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NINE MONTHS NINE PROBLEMSRISKS, JEOPARDIES & SURVIVAL
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Therapy
Surgery Main Ideal Approach? Evidence
Laparoscopy For Some. Laparotomy For
Others Medical Management.
Methotrexate Effective Unruptured Size(
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Septic Abortion
13-15% Maternal Mortality
Induced Abortion law - 1971
But Problems Persist
- Policy Makers
- Program Managers
- Clinicians
- Social Scientists
- Society
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Septic Abortion Ctd.
Local,0.22% Births
0.14% Of Obstetric Admissions,
Critically ill SA10% Case fatality
Diagnosis Delayed Therapy Delayed.
Evacuation
Laparotomy
Hysterectomy.
Right Therapy Right Time28
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Placenta Previa
Major Cause Of Hemorrhage Frequency- 0.7% Births,
Risk Factors?
Outcome Management Strategies, Hemorrhage
Preterm Births
C.S.
In Type I -7%
Type II Anterior Placenta Previa 36.1% ,
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Placenta Previa Ctd
Maternal Neonatal Survival Significant 2 Decades.
Perinatal Mortality 2.7 % 0.56 %
Judicious Extension of Expectant Management.
Blood Transfusion
Improvement in Neonatal Care.
Availability of Ventilator SupportReduction In Prematurity, Intrauterine Hypoxia Essential.
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Placental Abruption
Etiology Hypertensive Disorders+?
Major Cause Of Hemorrhage Deaths
Diagnosis:-Dilemma
With New Technology No Problem
Dangerous For Mother, Baby.
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NINE MONTHS NINE PROBLEMSRISKS, JEOPARDIES & SURVIVAL
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Placental Abruption Ctd.
PPH Kills If Precautions Not Taken.
-MMR -PMR
Timely Appropriate Management.
CS Even For Dead Baby
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Hypertensive Disorders
12-15 %
Unknown Etiology Mortality, Morbidity
HELLP- 5-25%
Lipid/Carbohydrate Metabolism
Severe Morbidity No. 1
Maternal mortality No. 1
Severely Ill- Near Miss
Eclampsia 9 %,
Eclampsia with HELLP 6 %
Preclampsia 2 %
Multiple Organ Failure 43 % 35
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Hypertensive Disorder Ctd.Eclampsia
Primary Concern For Mother.Expediting Delivery
Conservative Management
Carefully Selected, Close Supervision ?
Preterm Fetal Maturity
Without Risk To Mother,
Resources Scarce For Very Very LBW
Some Babies Died In UteroStill Improved Perinatal Outcome
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Rupture Uterus
Major Causes
1. Scar rupture
2. Malpresentation + Normal Presentation Obstructed
+2Twins + Retained Second Twin, Transverse Lie
3. Hydrocephalus
4. Morbidly Adherent Placenta Previa
Maternal Death Case-
Multiple Problems
Previous ectopic, Twins, Placenta Previa Accreta
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Management of Rupture Uterus
The Identification Or Suspicion Of UterineRupture Must Be Followed By An Immediate AndSimultaneous Response From The ObstetricTeam.
Surgery Should Not Be Delayed Owing ToHypovolemic Shock Because It May Not BeEasily Reversible Until The Hemorrhage IsControlled.
Upon Entering The Abdomen, AorticCompression Can Be Applied To DecreaseBleeding.
Oxytocin Should Be Administered To Effect Uterine
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Oxytocin Should Be Administered To Effect UterineContraction To Assist In Vessel Constriction And ToDecrease Bleeding.
Hemostasis Can Then Be Achieved By Ligation OfThe Hypogastric Artery, Uterine Artery, Or Ovarian
Arteries.
Decision Must Be Made To Perform Hysterectomy OrTo Repair The Rupture Site.
When Rupture Occurs In The Body Of The Uterus,Bladder Rupture Must Be Ruled Out By ClearlyMobilizing And Inspecting The Bladder To Ensure ThatIt Is Intact. This Avoids Injury On Repair Of The Defect
As Well.
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RETAINED PLACENTA
Delayed Referral, Haemorrhage Morbidly Adherent Placenta
Overall MMR
PMR
T
Treatment is manual removal,
General anesthesia with any volatile agent (1.52minimum alveolar concentration (MAC)) may benecessary for uterine relaxation
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Retained placenta
E
On Rare Occasions, A Retained Placenta Is An
Undiagnosed Placenta Accreta, And Massive Bleeding
May Occur During Attempted Manual Removal.
PPH
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PPH
Single Most Important Cause
Maternal Deaths Worldwide.
Fortunately Incidence
Overall PPH 25 % of Maternal Mortality
Timely management saves life
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PPH
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MANAGEMENT OF PPH
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MANAGEMENT OF PPH
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Atonic PPH:
Bimanual massage,catheterisation,I/V crystalloids,bloodtransfusion
Methergin 0.2mg I/V, Oxytocin 10-40 IU in DNS,
I/MSyntometrine, Rectal Misoprostol upto1000ug,
I/M or intrauterine Carboprost 250ug every 15 min
upto 2 gm
Intra uterine packing, Ballon tamponade
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Surgical management of ATONIC PPH
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Surgical management of ATONIC PPH :under Anaesthesia at OT [stepwise devascularisation]
[i] ligation of bilateral Uterine artery-ascending branch
[ii] ligation of Ovarian and Uterine artery anastmosis
[iii]B-Lynch compression sutures and Multiple square sutures
[iv]ligation of Anterior division of Internal iliac artery
[v]Angiographic uterine artery embolisation
[vi] Sub total/Total Hysterectomy
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MANAGEMENT OF PPH
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AMNIOTIC FLUID EMBOLISM
AFEis rare.[1in 20,000 to 1in 80,000 deliveries]
Fatality rate-30%-80%
Accounts for 7%-10%of direct maternal
mortality in developed countries.
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RISK FACTORS
Induction and augmentation of labour
Operative delivery
Uterine rupture
Amniotomy
Abruptio placentae
IUD Amnioinfusion
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Amniotic fluid may gain entry into maternal
circulation during-
Spontaneous labour and delivery
Amniotomy
Lscs
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Pathophysiology
Acute pulmonary vascular
obstruction+hypertension=cor pulmonale
LVF-hypotension, shock
An acute inflammatory response disrupts the
pulmonary capillary endothelium and alveoli-
ventilation perfusion imbalance-hypoxia-
convulsions,coma
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Diagnosis
Respiratory collapse,dyspnoea,cyanosis,
hypoxia, pulmonary oedema.
CVS--
tachycardia ,hypotension,arrhythmias,cardiacarrest
Uterine hypertonus
Acute fetal hypoxiaIf the woman survives for more than 1 hr, -DIC
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Treatment
Effective CPR
Inotropic support
Inj hydrocortisone500mg iv 6hrly
t/t of DIC
Plasma exchange,haemofiltration
Fetus to be delivered within 10min
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Pulmonary embolism
Leading cause of maternal deaths.
DVTin legs or pelvis most common cause.
S/S-
Tachynoea,dyspnoea,plueritic chest
pain,cough, tachycardia, hemoptysis,temp>37
c
Death-shock, vagal inhibition
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Diagnosis
XRAY chest-diminished vascular markings inareas of infarction,elevation of dome ofdiaphragm,pleural effusion
ECG-tachycardia,right axis shift,nonspecificSTchanges
D Dimer
Doppler-to rule out DVT MRI
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Pulmonary angiography
Spiral CT-inv of choice
MRA-100%sensitivity
Ventilation-perfusion scan
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Summary
What , when where and why of Emergency
obstetric care.
Basic clinical features , diagnosis and
management of emergency obstetric cases.
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THANK YOU