Post on 15-Dec-2015
transcript
Every Mom’s Dream…...
OBSTETRICAL EMERGENCIES
Care is a state in which something does matter ; it is the source of human tenderness
DEFINITION
• AN UNFORESEEN COMBINATION OF CIRCUMSTANCES OR THE RESULTING STATE THAT CALLS FOR IMMEDIATE ACTION
• LIFE -OR -DEATH SITUATION
• INFREQUENT, UNANTICIPATED, UNPREDICTABLE NIGHTMARE
Patient -1
• A 38 weeks G4P3 lady presents with ROM and contractions. She is quite distressed and thinks the baby is coming out. You perform a pelvic examination and next to the head you feel a pulsatile cord…
Cord Prolapse• Presentation: Cord in front of presenting part
before the rupture of membranes• Prolapse: Cord in front of presenting part
after rupture of
membranes
Occult prolapse
Cord lying alongside the presenting part
Incidence (Anita pal, Kushgla, Sood 2006)
• Primigravida 0.45%• Multigravida 0.66% (Risk ratio
2:3)• Cephalic 0.3%• Frank breech 0.9%• Complete breech 5%• Footling 10%• Shoulder 15%• Contracted pelvis 4-6 times
Causes• Malpresentation - face, brow, breech and shoulder• Prematurity• Polyhydramnios• Multiple pregnancy• Long cord (90-100 cm)• PROM• CPD• Obstetric interventions - Amniotomy, Intrauterine
pressure catheter, scalp electrode, external cephalic version, PROM, expectant management in preterm
Dangers
• Mortality rate as high as 50%• Hypoxia• Spasm of vessels• Operative trauma to suboxgenated fetus• More with vertex than breech• Descent in front than behind• More in primi than multi
Diagnosis• Cord pulsations• CTG shows variable decelerations• Cord lying outside vulva• USG – cord loops• Fundal pressure
causes bradycardia• Violent activity of
baby • Meconium stained
liquor
Prevention
• Refer to level II care• USG for malpresentation and cord
presentation• Foetal mointoring• Avoid ARM in an unengaged head• PV exam after ROM
Management• Lift presenting part off the cord • Instruct NOT to push • Position patient
Knee chest
Trendelenburg
Exaggerated position
Knee chest position
Trendelenburg position
Exaggerated sim’s position
Management (cont..)• Full bladder (Vago 1970)• Vulval pad• Replacement of cord• Tocolysis (ritodrine)• Forceps (Cx fully dilated)• Second twin – internal podalic version
and breech extraction• Stat C-section• Occult: Aminoinfusion
Management (cont…)
• Funic Reduction–Manual replacement of cord into uterus–Cord gently pushed above presenting part
while other cord decompression techniques are applied
–Rapid vaginal delivery
Fetal Mortality
• Overall - 50%• 1st stage of labour - 70%• 2nd stage of labour -30%• Neonatal death - 4%• Perinatal mortality- 20%
< 5 minutes, prognosis good, > 5 mins, damage and death.
VASA PRAEVIA• Fetal blood vessel lies in front of presenting
part• Rupture
- exsanguination
of the fetus
Cause and Management
• Velamentous insertion
Fresh bleeding vaginally
with rupture of membranes• Management: Signs of fetal
distress
Stat C.S
Send cord blood for Hb estimation
PATIENT -2Mother is pushing with each contraction and the baby’s head starts to come out. However, with each push, the baby’s head comes out and then retracts back in towards the perineum. You quickly recognize this as the “turtle sign”
Obstructed labour• No advancement of presenting part
despite strong, uterine contractions• Causes:
Cephalo-pelvic disproportion
Malpresentation - shoulder/brow/persistent mento posterior
Deep transverse arrest
Pelvic mass
Fetal abnormalities - Hydrocephalus, conjoined twins
Signs of obstructed labour• Presenting part fails to advance• Cervical dilatation slow• Formation of retraction ring• Early rupture of membranes• Formation of elongated sac of forewaters• If neglected, dehydration, ketosis• Caput succedaneum and moulding• urine output decreases• fetal distress
Management
• Careful assessment of progress of labour• Correct hydration• Internal version• Forceps application• Stat C.Section
Shoulder Dystocia
• Incidence: 0.23% to 2.09%
• Impaction of fetal shoulders in maternal pelvis
• Head to body delivery time > 60s
Risk factors
• Maternal Diabetes Mellitus• Short stature• Macrosomia• Post-term• Obesity• Fetal shoulder circumference
40.9 ± 1.5cm Vs 39.5 ± 1.5 cm
Complications
Fetal morbidity:• Brachial plexus injury• Clavicular fracture• Facial nerve paralysis• Asphyxia• CNS injury• complication rate up to 20%
ManagementHelp – obstetrician, pediatricianEpisiotomyLegs – elevate (McRoberts)Pressure - suprapubicEnter vagina – Rubin’s and Woods’ screwRoll or Remove posterior armZavanelli, Clavicular# , Symphysiotomy
McRoberts Maneuver• hyperflexion of
maternal hips• Increases intrauterine
pressure (1,653mmHg - 3,262
mmHg)• Increases amplitude of
contractions (103mm Hg to 129mm
Hg)
All-Fours Maneuver(Gaskin Maneuver)• Ina May Gaskin (1976)• changes pelvic dimensions in a similar way to
McRoberts maneuver• apply downward traction to disimpact the
posterior shoulder
Suprapubic Pressure• direct posterior or oblique suprapubic
pressure
Rubin’s Maneuver• adduction of the most accessible shoulder• moves the fetus into an oblique position
and decreases the bisacromial diameter
Woods’ Cork Screw Maneuver
• Abduct posterior shoulder exerting pressure on anterior surface of posterior shoulder
Deliver posterior arm(Barnum Maneuver)
grasp the posterior arm and sweep it across the anterior chest to deliver
Zavanelli Maneuver
• cephalic replacement via reversal of the cardinal movements of labor
• fracture the anterior clavicle by pushing it against the pubic ramus or using a closed pair of scissors
• Symphysiotomy
Clavicular Fracture
Complications
• Maternal morbidity• 4th degree perineal lacerations• Cervical & Vaginal lacerations• Bladder injury• Postpartum hemorrhage• Endometritis
Patient - 3
• Mother in third stage of labour. Using the controlled cord traction, the midwife tries to deliver the placenta. Unfortunately, notices the descent of uterus instead of placenta.
Uterine Inversion
• 1/20,000 deliveriesCauses:• uterine atony (40%)• Increase in intra
abdominal pressure• Fundal attachment of
placenta (75%)• Short cord• Placenta accreta • Excessive cord traction
Degrees of uterine inversion• 1st - Dimpling of
fundus, remains above internal os
• 2nd - fundus passes through the cervix, but lies inside vagina
• 3rd - (complete) Endometrium with or without placenta is outside the vulva
Dangers
• Shock - Neurogenic
Pressure on ovaries
Peritoneal irritation• Hemorrhage• Pulmonary embolism• Infection
Management• Uterine relaxant (terbutaline 0.25 mg IV
followed by 2 g of MgSO4 over 10 min)• Treat hypovolumeia • Without placenta: Repositioning
Uterine Inversion
Management(cont…)
• With placenta: Do not remove placenta• Replace uterus• Bimanual compression• Hydrostatic pressure (O’Sullivan 1945)• Start oxytocin• Laparotomy
Patient - 4
A mother in second stage of labour suddenly complains of persistent pain, and bleeding per vagina becomes profuse and the monitor shows decelerations in fetal heart rate.
Uterine Rupture• 1/2000 deliveries
Types:• Complete• Incomplete• Rupture Vs Dehiscense of
C.S scar
Rupture of lower uterine segment
Causes• Uterine injury sustained before current
pregnancy
C.S /hysterotomy/ repaired uterine rupture/ Myomectomy
Uterine trauma - curette, sounds
Sharp or blunt trauma - accidents, bullets, knives
Congenital anomaly
CausesUterine injury during current pregnancy• Before delivery
Intense spontaneous contractions
Labour stimulation
Intra-amnionic instillation
Perforation by internal catheter
External trauma - sharp or blunt
External version
Uterine overdistension - multiple pregnancy
Causes (cont…)• During delivery:
Internal version
Difficult forceps delivery
Breech extraction
Difficult manual removal of placenta
Fetal anomaly• Acquired:
Placenta increta / percreta
Retroverted uterus (sacculation)
Diagnosis• Prolonged fetal decelerations (70.3%)• Bleeding (3.4%) Pain (7.6%)
Monitor tracing demonstrating fetal heart rate decelerations, increase in uterine tone, and continuation of uterine contractions in a patient with uterine rupture monitored with an intrauterine pressure catheter.
Management
Total Hysterectomy
Sub total hysterectomy
Simple repair
Patient 5
Mother has just delivered a male baby. You wait for 30 minutes But no signs of placental separation and descent is present. Manual removal fails.
Placenta Accreta• Incidence: 1 in 2,562 deliveries• Firm adherence of placenta to uterine wall• partial or total absence of decidua basalis• Placenta increta: Villi invade the myometrium• Placenta percreta: Villi penetrate myometrium
Risk factors
• Defective decidual formation
placenta previa
Previous cesearean scar
uterine curettage• Grand multiparity
Diagnosis and Management
• Dx in third stage of labour• Maternal hemorrhage• Treatment: Hysterectomy
Patient 6
• A pregnant mother on oxytocin induction suddenly becomes short of breath and tachypneic. Vital signs drop and the patient goes into asystolic arrest.
Amniotic Fluid Embolism
• Incidence: 1 in 3,500 to 1 in 80,000• Amniotic fluid enters the maternal
circulation and reaches pulmonary capillaries
• Through a tear in amnion and chorion• Opening in maternal circulation• Increased intrauterine pressure
Amniotic Fluid Embolism
Risk factors
• Multiparity• Large fetus• Meconium in amniotic fluid• Intrauterine fetal death• Precipitate labour• Placental abruption• Intrauterine catheter• Rupture of uterus
Manifestations
• Phase I : Pulmonary vasospasm
Hypoxia
Hypotension
Cardiovascular collapse• Phase II: Left ventricular failure
Pulmonary edema
Hemorrhage
Coagulation disorder
Management
• Intubation + Mechanical ventilation• CVP monitoring• Blood transfusion + I.V. Fluids• Dopamine 2-20mg/kg/min• IV Digitalization (0.1 - 1.0mg)• Prostaglandin• Morphine• Aminophylline• Hydrocortisone
Be prepared, except the unexpected and above all, communicate
• Communicate congruently • Careful, sympathetic and
optimal communication• Avoid medical jargon• Psychological support- one member - Touch• “Talking through” the process• Smile of reassurance• Information and support to partners
Fear during labour• Worries that infant may die or
born with abnormality.• Review labour process• Provide with frequent progress
report• Personal availability of nurse• Promise postnatal debriefing
sessions
NURSE’S ROLE IN INTRAPARTUM CARE
NURSE MIDWIFE
COMMUNICATOR
EDUCATOR
CAREGIVER
MANAGER
ADVOCATE
COUNSELLOR CO ORDINATOR
RESEARCHER
Interestingly, loving care does not require twice the time,but it does require more than twice the presence.”- Erie Chapman
THEY
NEED YOU AND
YOUR CARE