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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”.
BY MUKEREM.A 2007
. 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
BY MUKEREM.A 2007
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.
obstetricsII by mukerem
BY MUKEREM.A 2007
Cont…
BY MUKEREM.A 2007
Obstetric emergency cont…
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
BY MUKEREM.A 2007
Obstetric emergency cont…
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
BY MUKEREM.A 2007
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
BY MUKEREM.A 2007
GROUP DISSCUSSION
1) Do U think we can prevent Prolapseof the cord and cord presentation???
2) Which one is more risky 4 fetus???
BY MUKEREM.A 2007
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
Obstetric emergency cont…
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
BY MUKEREM.A 2007
Obstetric emergency cont…
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
BY MUKEREM.A 2007
Obstetric emergency cont…
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
Obstetric emergency cont…
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
obstetricsII by mukeremBY MUKEREM.A 2007
Obstetric emergency cont…
Management in the first stage of labor
1. An immediate caesarean section is performed if the fetus is alive
obstetricsII by mukeremBY MUKEREM.A 2007
Obstetric emergency cont…
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.
BY MUKEREM.A 2007
Obstetric emergency cont…
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.
obstetricsII by mukeremBY MUKEREM.A 2007
Obstetric emergency cont…
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.
BY MUKEREM.A 2007
Obstetric emergency cont…
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
BY MUKEREM.A 2007
Obstetric emergency cont…
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.
obstetricsII by mukeremBY MUKEREM.A 2007
Obstetric emergency cont…
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
BY MUKEREM.A 2007
Obstetric emergency cont…
Complications
Death due to cardiopulmonary collapse
DIC
Acute renal failure
obstetricsII by mukeremBY MUKEREM.A 2007
Obstetric emergency cont…
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
BY MUKEREM.A 2007
Obstetric emergency cont…
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.
obstericsII by mukerem
BY MUKEREM.A 2007
Obstetric emergency cont…
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
Obstetric emergency cont…
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
Obstetric emergency cont…
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
BY MUKEREM.A 2007
Obstetric emergency cont…
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
BY MUKEREM.A 2007
Obstetric emergency cont…
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
BY MUKEREM.A 2007
Obstetric emergency cont…
• 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
BY MUKEREM.A 2007
Obstetric emergency cont…
Management
1. Hysterectomy
2. Repair of the uterus.
BY MUKEREM.A 2007
Obstetric emergency cont…
GROUP DISSCUITON
1) How to Prevent rupture to uterus???
BY MUKEREM.A 2007
Obstetric emergency cont…
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