emergency obstetrics

8/2/2019 Emergency Obstetrics

http://slidepdf.com/reader/full/emergency-obstetrics 1/9

INTRAPARTAL COMPLICATIONSOBSTETRIC EMERGENCIES

I. PRE-ECLAMPSIA

Diagnostic criteria1. Hypertension after 20 weeks (Diastolic BP more than 90 mm Hg)

2. Proteinuria 1+1. Risk factors for pre-eclampsia

1. Primigravid 6. Women with2. Young teens Diabetes3. Women > 35 years H Mole4. Obese Essential or renal HPN5. Multiple Pregnancy Family hx of HPN

2. Danger signals1. Massive pitting pedal edema (generalized swelling)2. Severe headache

3. Epigastric pain4. Vomiting5. Visual disturbance or blurring of vision

3. Complications of severe pre-eclampsia1. Small baby (IUGR)2. Stillbirth3. Abruptio Placenta4. HELLP syndrome5. Eclampsia

ECLAMPSIA

Convulsions in a woman with pre-eclampsia Convulsions may occur

• in pregnancy after 20 weeks AOG,• in labor• during the first 48 hours postpartum.

Effects on Mother Effects on fetus• Respiratory – pulmonary edema Small baby• Heart Failure Stillbirth• Cerebral vascular accidents• Acute kidney failure• Liver necrosis• HELLP syndrome

• Visual disturbance• Injuries during convulsion



Reducing the Risk of Eclampsia• Pregnant women should come for ANC early – take baseline BP• Regular antenatal visits especially in the 3rd trimester• Measure BP at each ANC visit and check urine for protein if diastolic

BP>90 mm Hg.• REFER if proteinuria develops• Counsel woman and family about danger signals of severe pre-eclampsia

What to do when seizures occur• Call for medical help• As soon as possible, clear airway and or give oxygen at 4 –6 L/min.• Position the woman on her left side to reduce the risk of aspiration of

secretions, vomit and blood• Stay with woman and protect her from injury but do not restrain her

Immediately after the convulsion• Set up IVF – run at slow rate• Monitor BP, pulse, respiration, level of consciousness. Record.• Insert urinary catheter to monitor urine output and test for protein.• Arrange for referral

During the transport• Put mother in any flat or low surface to prevent from falling during

ambulation.• Observe proper maternal positioning and least stimulation during

transport.• Never leave alone

II. VAGINAL BLEEDING IN DURING PREGNANCY Assess the PREGNANCY STATUS

i. EARLY PREGNANCY – uterus is below the umbilicusii. LATE PREGNANCY – uterus above umbilicus

Assess the AMOUNT OF BLEEDING

i. HEAVY – pad or cloth is soaked in less than 5 minutesii. LIGHT

Assess for alert signs and symptoms REFER!1. Fainting2. History of expulsion of tissues3. Cramping/lower abdominal pain4. Tender uterus5. Tender mass6. Uterus soft and larger than expected for AOG

Provide initial treatment

Pregnancy Status Amount of Bleeding Treatment Early pregnancy – uterusbelow umbilicus

This may be abortion,ectopic pregnancy ormolar pregnancy.

HEAVY (pad soaked in 5minutes or less), or withalert signs

• Reassure the woman• Insert IV line• IV fluids• Monitor vital signs• REFER• If the woman is bleeding HEAVILY

and referral center is far, give 0.2mg ergometrine IM



LIGHT, no alert signs

• Reassure• Give iron/folate• Review emergency plan• Follow up after 2 weeks

Late – uterus above theumbilicusThis may be placentaprevia or abruptio placenta

Any bleeding isdangerous!

Assess for alertsymptoms:

• DO NOT perform IE!• Insert IV line• Monitor vital signs• Reassure the woman, make her

comfortable• REFER

PLACENTA PREVIA ABRUPTIO PLACENTA Abnormal implantation of the placenta at thelower uterine segment

Separation of a normally implantedplacenta from the uterus beforechildbirth.

Classic Sign: Painless vaginal bleedingUterus is soft, non-tender, with or without contractions,fetus is palpable.

UTERUS is HYPERTONIC or TENSE andTENDER on PALPATIONABDOMEN – “BOARD-LIKE RIGIDITY“

RISK FACTORS1. Maternal age > 35 years old2. Previous cesarean section3. Multiparity4. Previous placenta previa5. History of uterine surgery, multiple abortions, D&C6. Cigarette smoking7. Large placenta in multiple gestation

1. Maternal Hypertension,Pre-eclampsia, Chronic hypertension

2. Maternal age3. Multiparity4. Cigarette smoking.5. Maternal trauma6. Polyhydramnios7. Poor nutrition

III. PRE-LABOR RUPTURE OF MEMBRANESRupture of the bag of water prior to the onset of labor

a. PROM when fetus is > 37 weeksb. Preterm PROM (PPROM) when fetus is less than 37 weeks

Diagnosis:• ASK when did membranes rupture?• LOOK at pad for evidence of amniotic fluid or foul smelling vaginal discharge.

• If no evidence, ask her to wear a pad and check again in one hour.• Measure temperature• Routine vaginal examination is NOT recommended – increase risk of infection



WHAT TO DO If (+) fever >38°C Foul smelling vaginal discharge No labor Rupture membranes at <8 months of

pregnancy

Give antibiotic (Ampicillin 2 grams) REFER to hospital

Rupture of membranes at >8 monthspregnancy

Manage as woman in childbirth

IV. PRETERM LABOR

DefinitionLabor before 8 completed months of pregnancy ;

more than 1 month before estimated date of birthbetween 24 – 34 weeks gestation

Signs and symptoms1. Contractions2. Watery vaginal discharge3. Vaginal bleeding4. Low dull backache

What to do1. Establish AOG2. Evaluate contractions3. Assess cervix

Sterile speculum examination Digital examination*

4. Stabilize woman and fetus5. If woman is lying, encourage her to lie on her left side6. Check vital signs especially BP7. If BP is normal and no heart problem:

Give Nifedipine 10mg tablet orally (not under the tongue) every 6 hours untilshe reaches a CEmONC facility

Give Dexamethasone 6mg intramuscularly every 12 hours until she reachesa CemONC facility ( up to a total of 4 doses)

8. Facilitate transfer the hospital with neonatal and obstetrical care

V. PROLONGED LABOR Causes of prolonged labor

1. Cephalopelvic disproportion: small or contracted pelvis or large fetus

2. Abnormal presentations (e.g. brow, shoulder associated with transverse lie)3. Malposition of the fetus4. Fetal abnormalities, e.g. hydrocephalus, encephalocele, locked twins5. Abnormalities of the reproductive tract



Effects of Prolonged Labor

Maternal Fetal Infection Uterine rupture Genital fistulas Maternal Death

Infection Asphyxia and traumatic injury to the baby

Stillbirth Neonatal death

Prolonged Latent Phaseo Diagnosis is made retrospectively

If contractions cease, the woman is in FALSE LABORo If cervix dilated less than 4 cm for more than 8 hours, reassess

If no sign of infection: may be observed further provided maternal andfetal status are good.

If with sign of infection: give antibiotics Ampicillin 2 grams p.o. and refer Prolonged Active Phase

o Cervix does not dilate 1 cm per houro Recognize slow progress of labor with a partograph: cervical dilatation to the

right of the alert line.o May be due to

1. Poor uterine contractions2. Malposition or malpresentation3. Disproportion between fetal size and pelvic size

o Reassess uterine contractionso If less than 3 contractions in 10 minutes, each lasting less than 40 seconds,

suspect inadequate uterine activity and refer to higher level careo If contractions are efficient (3 contractions in 10 minutes, each lasting

more than 40 seconds), suspect cephalopelvic disproportion, obstruction,

malposition or malpresentationo REFER to higher level care.

Before Transfero Start IV infusion to rehydrateo Give antibioticso Give supportive care*o Monitor maternal and fetal conditiono Ensure referral letter is completed and make transportation arrangements.

Contact the referral center to advise them of transfer.

Supportive Careo Make the patient comfortable.

o Encourage companion to rub the woman’s back, wipe her face and brow witha wet cloth, assist her to move abouto Explain all procedures to the woman, seek permission and discuss findings

with hero Encourage her to empty her bladder regularlyo Encourage breathing techniques.



VI. SHOULDER DYSTOCIA Predisposing Factor

Maternal Abnormal Pelvic Anatomy Gestational Diabetes

Post-term pregnancy Previous shoulder dystocia

Maternal obesity Short stature

FETAL o Suspected macrosomia

LABOR RELATED o Assisted vaginal delivery o Protracted active phase of

1st stage labor o Protracted second stage

labor

Diagnosis: TURTLE SIGN o Fetal head is delivered but remains tightly applied to the vulvao Chin retracts and depresses the perineum

Avoid 4Pso Pullo Pusho

Panico Pivot

Management of Shoulder Dystociao A – Ask for help (from the woman’s husband or labor companion, other

healthcare providers. Prepare for resuscitation of the baby.)o L – lift/hyperflex legso A – anterior shoulder disimpactiono R – rotation of posterior shouldero M – manual removal of posterior armo E – episiotomyo R – roll over onto “all fours”

McRobert’s Maneuver – Flex woman’s legssharply on her abdomen

Suprapubic pressure is applied with the heelof clasped hands from the posterior aspectof the anterior shoulder to dislodge it.



ROTATION OF THE POSTERIORSHOULDER • Place the hand behind the posterior

shoulder of the fetus.

• Rotate the posterior shoulder 180degrees in a corkscrew manner so thatthe impacted anterior shoulder isreleased.

MANUAL REMOVAL OF THE POSTERIORARM

Arm is flexed at the elbow. Hand is graspedand swept across the chest and delivered.

ROLL OVER ON ALL FOURS

After shoulder dystocia 1. Remember the SIGNIFICANT risk of maternal injury (tears) and postpartum

hemorrhage2. Actively manage the third stage3. Inspect for and repair 1st or 2nd degree tear or lacerations4. Resuscitate the baby, examine for evidence of trauma5. Explain to the woman and all those involved in the delivery exactly what occurred

and what were done

6. Record Duration of attempts to resolve dystocia Maneuvers performed Condition of baby at delivery, description of injuries, bruises Time from delivery of fetal head to delivery of the body Documentation of the discussion with woman/relatives



VII. UMBILICAL CORD PROLAPSE

Umbilical cord lies in the birth canal below thepresenting part

Cord is visible at the vagina following rupture ofmembranes

General management: o Give oxygen at 4-6 liters per minute by maskor nasal cannula

If Cord is pulsating – fetus is alive o Diagnose stage of laboro Wear high level disinfected gloves. Insert

hand into the vagina and push presentingpart up to decrease pressure on the corddislodge presenting part from the pelvis.

o Place other hand on the abdomen in thesuprapubic region to keep the presenting partout of the pelvis

o

REFER If cord is not pulsating – baby is dead

o Give supportive care to the woman o Attempt vaginal delivery

VIII. POSTPARTUM HEMORRHAGE• Recognizing postpartum hemorrhage

o Bleeding >500 ml after childbirtho Pad or cloth soaked in less than 5 minuteso Constant trickling of blood

ORo Delivered outside health center and still bleeding

• What to do:o Call for extra helpo Massage uterus until it is hard and give OXYTOCIN 10 units IMo Give IV fluids with 20 units oxytocin at 60 drops per minuteo Empty the bladder: catheterize if necessaryo Check and record BP and pulse every 15 minuteso Establish cause of bleeding

• Causes of postpartum hemorrhageo Uterine atonyo

Tears of the cervix, vagina, or perineumo Retained placentao Retained placental fragmentso Inverted uteruso Ruptured uterus



Check if placenta is delivered.Placenta is not delivered Placenta is delivered o When uterus is hard, deliver

placenta by controlled cordtraction

o If unsuccessful and bleeding

continues – remove placentamanually and check placenta

o Give appropriate IM/IV antibiotics o If unable to remove placenta –

REFER urgently to hospital o During transfer, continue IV fluids

with 20 units oxytocin at 30drops/minute

o Check placenta o If placenta complete

Massage uterus to expressany clot

If uterus remains soft, giveOXYTOCIN 10 units IM

Continue IV fluids with 20units Oxytocin at 30drops/min

Continue uterine massageuntil it is hard

o If placenta is incomplete or notavailable for inspection:

Refer woman urgently tohospital

o Placenta is complete and vaginalbleeding continuous:

HOW TO MAKE PROPER REFERRALS

Referral must be TIMELY

STEPS TO FOLLOW:1. Give emergency treatment.

2. Discuss decision with woman, partner/spouse and relatives. Explain why patient isadvised to transfer.3. Help arrange transport of patient.4. Inform the referral center by mobile phone, landline or radio.5. Ensure support.6. Always send a referral letter with the patient. The referral must state the following:

Date and time; Emergency or Non-emergency Problems identified

Findings and action taken.7. If the hospital is far away (> 1 hour trip),

Give appropriate treatment on the way. Continue to monitor patient

Record all findings & treatment given.8. A relative or friend should accompany the patient → help look after the woman during

the journey.9. Do not delay. Go straight to the hospital.

Reference: Complications of Pregnancy Handout by Dr. Grace Tamano

7-Day Training Program for Midwives in Compliance with R.A. 7392

emergency obstetrics

Documents