Obstetric emergencies part 1

Obstetric Emergencies

obstetricsII by mukeremBY MUKEREM.A 2007

Obstetric emergency cont…

Purpose: The purpose of this topic is to introduce students to an organized and effective approach in providing care to obstetric emergencies.

learning objectives:

• By the end of this chapter, the students will be able to:

• Describe key steps in rapid initial assessment of a woman with emergency problems.

• Outline key emergency management steps for specific obstetric emergency problems.

• Demonstrate steps in detection and management of “shock”.

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. Prolapse of the cord and cord presentation

Objectives

By the end of this session students should:

Know the definition of cord prolapse

Understand the risk factors associated with cord prolapse

Be confident to managing a mother with cord prolapse

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Obstetric emergency cont…1. Prolapse of the cord and cord presentation

Cord presentation:

This occurs when the umbilical cord lies in front of the presenting part with the membranes still intact

Cord prolapse. (Overt prolapsed cord):

In this case the cord lies in front of the presenting part and the membranes are ruptured.

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Cont…

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Occult cord prolapse:

The cord lies along side but not in front of the presenting part.

Funic occult:

The umbilical cord has prolapsed in front of the presenting part but not through the cervical Os in the presence of intact membranes

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Possible causes or predisposing factors

Any badly fitting presenting part

Malpresentaiton – is the most common cause

Breech presentation

Shoulder presentation

Face and brow presentations

Prematurity of the fetus. This condition offers space between the fetus and the pelvis

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Obstetric emergency cont…Amniotomy the cord swept due to gush of fluid

Multiple pregnancies – particularly second twin

Contracted pelvis

Poly hydramnios – the cord is liable to be swept down in a gush of liquor if the membrane ruptures spontaneously.

Lower implantation of the placenta

Abnormally long cord

Congenital abnormality of uterus

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GROUP DISSCUSSION

1) Do U think we can prevent Prolapseof the cord and cord presentation???

2) Which one is more risky 4 fetus???

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Clinical features

• Umbilical cord visibleat,orexternal to,thevaginal opening

• Evidence of membranes having ruptured

• A nonreassuring fetal status:

- change in fetal movement pattern

- Meconium in the amnioticfluid

(vaginal discharge may be stainedgreen)

- Fetal tachycardia

- Fetal bradycardia(morecommon)BY MUKEREM.A 2007


Diagnosis

1. Feeling of the cord during vaginal examination

2. An abnormal fetal heart rate particularly Bradycardia

3. Occasionally the loop of the cord seen at the vulva.

4. ultrasaund

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Management The treatment depends up on the;degree of cervical dilatationthe live of the fetusthe type of presentationEmergency Care 1. Insert a gloved hand in to the vagina and push the presenting part up to decrease pressure on the card and dislodge the presenting part from the pelvis

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2. Relieve pressure

Raise end of bed

Put mother knee chest position

Exaggerated sims position

3. Do vaginal examination note

Presentation; dilatation and pulsation of the cord.

4. If membranes intact avoid rupturing them. BY MUKEREM.A 2007


Complications

The risk to the fetus is hypoxia and death as a result of cord compression.

The risks are greatest in cephalic presentation than complete or footling breech and transveres lie.

Primgrvida than multigrvida



Management in the first stage of labor

1. An immediate caesarean section is performed if the fetus is alive



Management in the second stage of labor

If the lie is longitudinal and the cx is fully dilated forceps delivery or breech extraction may be done.

If there is any possibility that a vaginal delivery may be difficult a C/S should be performed.

If the fetus is dead with a longitudinal lie no urgent treatment required but spontaneous vaginal delivery should be a waited.

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NB:- In the community if the fetus is alive the woman should be transferred to hospital by ambulance immediately while the midwife relieves pressure on the cord as described above. The knee – chest position is uncomfortable for the woman to maintain for any length of time. An exaggerated simsposition is preferable.



3. Managing amniotic fluid embolism

Amniotic fluid embolism

This condition when amniotic fluid containing meconium, vernix and fetal cells enter the maternal circulation under pressure between the placental and the uterine wall and forming an embolus which obstructs one of the pulmonary arterioles or alveolar capillaries.

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Predisposing Factors

1. Rapid or precipitate labour

This considered being the most common cause. hypertonic contraction which occurs in this type of labour.

2. Over stimulation of the uterus.

Excessive use of oxytocin drugs or prostaglandins may cause hypertonic uterine action.

3. Uterine trauma

Eg. During uterine rupture and internal podalicversion. obstetricsII by mukerem

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Sign and Symptoms Sudden onset of maternal respiratory distress such as severe dyspeniaand cyanosis. Cardio vascular collapseTachycardia Hypotension Cardiac arrest ConvulsionsHemorrhage Usually result of disseminated intravascular coagulation. Amniotic fluid is rich in thromboplastin which attracts fibrinogen.



Emergency management 1. Anyone of the above symptoms is indicative of

an acute emergency. The doctor/midwife should immediately summon.

2. Oxygen administered by face mask 4 lt/min 3. Suction 4. Resuscitation equipment should be at hand 5. If she undelivered the fetal heart rate should

be monitored continuously.6. Treat hemorrhage

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Complications

Death due to cardiopulmonary collapse

DIC

Acute renal failure



4. Managing rupture of the uterus

Rupture of the uterus

The most serious complication in midwifery and obstetrics

It is often fatal for the fetus and may also be responsible for the death of the mother.

Defn :- This is where there is a tear in the uterine wall

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Two types of tear (rupture)

Complete rupture:- When the overlying peritoneal coat is torn and bleeding and fetus is under abdominal skin.

Incompletes:- When the peritoneum remains intact and bleeding tracks under the peritoneal cavity.

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Causes /Risk factors

Obstructed labour

Separation of previous C/S scar

Trauma due to operative manipulation

The unwise use of oxytocin

The extension of an old cervical tear.

Neglected labour

High parity BY MUKEREM.A 2007


Silent rupture of uterus

Defn: - rupture in previous c/s scare known as silent rupture.

Signs of a silent rupture

Rise in pulse above 90/min

Pain over the old scar and tenderness

Slight vaginal bleeding and vomiting

Shock which comes on very slowly

Labour will not progress soon

no FHB. BY MUKEREM.A 2007


Abrupt rupture

Defin:- rupture in obstructed labour know as abrupt rupture

Signs of abrupt rupture

History of obstructed labour

Bandl’s ring is seen before rupture

Vomiting of dark brown vomitus

No FHB

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Confirmation or diagnosis of rupture uterus History of obstructed labourV/S – B/P low with weak and rapid pulse Tender abdomen No FHBVaginal bleeding No fetal movement No uterine contraction High head Sign of shock and dehydration

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Management of a ruptured uterus in health Center

Lie patient flat

Put up iv drip

Give pethidine

Transvere her to the nearest hospital

Bring donors

Go with patient

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• Management of a ruptured uterus in the hospital

• 1. Lie patient flat

• 2. Blood group and cross match

• 3. Put Intravenous drip

• 4. Get patient to sign consent form

• 5. Give pre medication

• 6. Carry out doctor’s order

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Management

1. Hysterectomy

2. Repair of the uterus.

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GROUP DISSCUITON

1) How to Prevent rupture to uterus???

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Prevention of rupture uterus

Constant and careful antenatal care

Refere to hospital mother who has obstructed labour

Detect high risk mothers and select them for hospital delivery

Previous section must always delivery in Hospital

Care during manipulation

Careful observation of the mother in labour to exclude obstructed labour

Avoid giving pitocin for previous classical c/s scarBY MUKEREM.A 2007

BY MUKEREM.A 2007

Obstetric emergencies part 1

Health & Medicine

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