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Ppt obs emergecy.pptxydirnbduejguxjjdjidjdbuc
- 1. P.G COLLEGE OFNURSING SEMINAR ON OBSTETRIC EMERGENCIES PRESENTED BY ROSE KERKETTA M.SC NURSING FINAL YEAR
- 2. INTRODUCTION Obstetric emergencies referto sudden, unexpected, and often life-threatening situations that can arise during pregnancy, childbirth, or the postpartum period, requiring immediate medical attention and intervention. These emergencies can impact the health of the mother, the fetus, or both, and their occurrence necessitates rapid diagnosis, treatment, and often multidisciplinary care. Obstetric emergencies can arise due to a variety of factors, including complications with the pregnancy, labor, or delivery, as well as underlying maternal conditions.
- 3. DEFINITION An obstetricemergency is a medical situation that occurs during pregnancy, labor, or the postpartum period that requires immediate and urgent intervention to prevent serious health consequences or death. Obstetrical emergencies are life threatening medical conditions that occur in pregnancy or during labor or after delivery. Any acute condition related to pregnancy, childbirth or puerperium that poses a significant threat to maternal or fetal well-being and requires immediate medical or surgical intervention.
- 4. DIFFERENT OBSTETRIC EMERGENCIES Antenatal Vasa previa Ectopic Eclampsia Abruption placenta Amniotic fluid embolism Obstetric shock Intranatal Rupture of uterus Dystocia Cord prolapse Postnatal Uterine inversion PPH
- 5.
- 6. INCIDENCE The actual incidenceis extremely difficult to estimate, it appears that vasa previa complicates approximately 1 in 2,500 births. DEFINITION It is an abnormality of the cord that occurs when one or more blood vessels from the umbilical cord or placenta cross the cervix but it is not covered by Wharton's jelly. This condition can cause hypoxia to the baby due to pressure on the blood vessels. It is a life-threatening condition.
- 7. ETIOLOGY These vessels maybe from either Velamentous insertion of umbilical cord Placental lobe joined to the main disk of the placenta. Low-lying placenta Previous delivery by C-section. SYMPTOMS The baby's blood is a darker red color due to lower oxygen levels of a fetus Sudden onset of painless vaginal bleeding, especially in their second and third trimesters If very dark burgundy blood is seen when the water breaks, this may be an indication of vasa previa
- 8. DIAGNOSIS Painless vaginalbleeding Fetal bradycardia Membrane rupture Membrane over the colour- doppler vessel crossing the internal cervical os MANAGEMENT Antepartum The patient should be monitored closely for preterm labor, bleeding or rupture of membranes Steroids should be administered at about 32 weeks Hospitalization at 32 weeks is reasonable Take patient for emergency cesarean section if membranes are ruptured. Fetal growth ultrasounds should be performed at least every 4 weeks Cervical length evaluations may help in assessing the patient's risk for preterm delivery or rupture of the membranes
- 9. CONT.. Intrapartum The patientshould not be allowed to labor. She should be delivered by elective cesarean at about 35 weeks Delaying delivery until after 36 weeks increases the risk of membrane rupture Care should be taken to avoid incising the fetal vessels at the time of cesarean delivery If vasa previa is recognized during labor in an undiagnosed patient, she should be delivered by urgent cesarean. The placenta should be examined to confirm the diagnosis Postpartum * Routine postpartum management as for cesarean delivery. * If the fetus is born after blood loss, transfusion of blood without delay may be life-saving. * It is important to have O negative blood or type-specific blood available immediately for neonatal transfusion.
- 10. NURSING MANAGEMENT Assessbleeding, colour, amount Administer iv fluids Administer oxygen Strict vitals and FHS monitoring Prepare patient for caesarean section
- 11.
- 12. INTRODUCTION Abruptio placenta, alsoknown as placental abruption, is a serious medical condition in which the placenta partially or completely separates from the uterine wall before delivery. This separation can disrupt the flow of oxygen and nutrients to the fetus, potentially leading to life-threatening complications for both the mother and the baby. The condition typically occurs in the later stages of pregnancy, although it can sometimes happen earlier. It is often associated with symptoms such as vaginal bleeding, abdominal pain, and uterine contractions. However, in some cases, the bleeding may be concealed, leading to a more challenging diagnosis.
- 13. DEFINITION Abruptio Placentais premature separation of placenta from uterine wall. Abruptio placenta, also known as placental abruption, is a serious medical condition that occurs when the placenta separates from the inner wall of the uterus before childbirth. It is one form of antepartum haemorrhage where the bleeding occurs due to premature separation of normally situated placenta.
- 14. TYPES 1. Concealed abruptioplacenta: In this type, the blood from the detached placenta is trapped between the placenta and the uterine wall, leading to concealed bleeding. This blood may not be visible externally but can accumulate and cause significant internal bleeding. 2. Revealed abruptio placenta: In this type, the bleeding resulting from placental detachment is visible externally. This can manifest as vaginal bleeding during pregnancy. 3. Mixed abruptio placenta:The "mixed type" may indicate a situation where there are features of both concealed and revealed abruptio placenta, which can present unique challenges in diagnosis and management.
- 15. DEGREES OF ABRUPTIOPLACENTA There are typically three degrees of abruptio placenta: 1. Grade 1 (Mild): In Grade 1 abruptio placenta, there is minimal bleeding and only a small portion of the placenta has detached from the uterine wall. Symptoms may include mild abdominal pain and slight vaginal bleeding. 2. Grade 2 (Moderate): Grade 2 abruptio placenta involves more significant separation of the placenta from the uterine wall, leading to moderate bleeding. This can cause more intense abdominal pain and possibly signs of fetal distress, such as a rapid heart rate. 3. Grade 3 (Severe): Grade 3 abruptio placenta is the most severe form, involving a complete separation of the placenta from the uterine wall. This results in heavy bleeding, severe abdominal pain, and poses a serious risk to both the mother and the baby.
- 16. CAUSES 1. Trauma: Traumato the abdomen, such as from a car accident or a fall, can cause abruptio placenta. The force of impact can lead to the separation of the placenta from the uterine wall. 2. High blood pressure (hypertension): Chronic hypertension or pregnancy-induced hypertension (preeclampsia) can increase the risk of abruptio placenta. High blood pressure can damage the blood vessels in the uterus, leading to placental separation. 3. Drug use: Certain substances, such as cocaine or methamphetamine, can increase the risk of abruptio placenta. These drugs can constrict blood vessels, leading to decreased blood flow to the placenta and potential placental separation. 4. Advanced maternal age: Women over the age of 35 are at a higher risk of abruptio placenta compared to younger women. This increased risk may be due to age-related changes in the uterus or blood vessels. 5. Previous history of abruptio placenta: Women who have experienced abruptio placenta in a previous pregnancy are at a higher risk of experiencing it again in subsequent pregnancies.
- 17. CONT…. 6. Multiple pregnancies:The risk of abruptio placenta is higher in women carrying twins, triplets, or other multiples. This increased risk may be due to the larger size of the uterus and increased pressure on the placenta. 7. Uterine abnormalities: Anomalies in the shape or structure of the uterus can increase the risk of placental abruption. 8. Smoking: The chemicals in cigarettes can impair placental function and decrease blood flow to the placenta. 9. Placental abnormalities: Certain conditions affecting the placenta, such as placenta previa can increase the risk of abruptio placenta 10. Maternal clotting disorders: Conditions such as thrombophilia (a tendency to form blood clots) can increase the risk of placental abruption due to abnormal blood clotting in the placenta.
- 18. SIGN AND SYMPTOMS Vaginal bleeding: This is often the most prominent symptom. The bleeding may be sudden and severe, but in some cases, it can be concealed if blood pools behind the placenta. Abdominal pain or back pain Uterine tenderness: The uterus may feel tender or painful to touch Uterine contractions: Contractions may be present, either regular or irregular, and may feel stronger or more frequent than typical Braxton Hicks contractions. Fetal distress Hypovolemic shock Signs of preterm labor: In some cases, abruptio placenta can trigger premature labor, leading to symptoms such as regular contractions and cervical dilation.
- 19. DIAGNOSIS Physical Examination Ultrasound: It can help visualize the placenta's position, thickness, and any signs of separation from the uterine wall. Ultrasound may also assess fetal well-being and detect any associated complications. Fetal Monitoring: Continuous fetal monitoring may be performed to assess the baby's heart rate patterns. Abnormal fetal heart rate patterns, such as late decelerations, may indicate fetal distress, which can be associated with placental abruption. Blood Tests: Laboratory tests may be conducted to assess the mother's blood clotting function and blood count. Coagulation studies, such as prothrombin time (PT) and partial thromboplastin time (PTT), can help identify any coagulation abnormalities that may contribute to or result from placental abruption. Clinical History: Obtaining a detailed clinical history from the mother, including any risk factors such as trauma, hypertension, smoking, drug use, or previous history of placental abruption, can aid in the diagnostic process. Maternal Hemodynamic Monitoring: Continuous monitoring of maternal vital signs, including blood pressure, heart rate, and oxygen saturation, can help assess the severity of placental abruption and guide treatment.
- 20. MANAGEMENT Prevention Aims Elimination ofthe known factors likely to reduce placental separation. Correction of anemia during antenatal period so that patient can withstand blood loss. Prompt detection and institution of the therapy to minimize the grave complications namely shock, blood coagulation disorders and renal failure. 1. Initial Assessment and Stabilization: maternal vital signs, fetal heart rate monitoring, and laboratory tests (such as complete blood count, coagulation studies, and blood type and crossmatch).
- 21. CONT… 2. Medical Management oFluid Resuscitation: Intravenous fluids should be administered to maintain adequate perfusion. o Blood Transfusion o Monitoring and Support: Continuous fetal monitoring and maternal vital sign monitoring are essential. Oxygen supplementation may be necessary to optimize maternal oxygenation and fetal oxygen delivery. 3. Surgical Management o Emergency Cesarean Delivery: In cases of severe placental abruption with fetal distress or maternal instability, prompt delivery via emergency cesarean section is often necessary to improve maternal and fetal outcomes. o Hysterectomy: In cases of life-threatening maternal hemorrhage that cannot be controlled by other means, hysterectomy (removal of the uterus) may be required to save the mother's life. o Manual Removal of Placenta: In cases where vaginal delivery is feasible and the placenta is partially separated, manual removal of the placenta under anesthesia may be performed.
- 22. CONT… 4. Postpartum Management oClose Monitoring: Both the mother and the newborn should be closely monitored in the postpartum period for signs of complications, such as hemorrhage, coagulopathy, or neonatal respiratory distress. o Pain Management: Adequate pain relief should be provided to the mother, especially if she has undergone cesarean delivery or manual removal of the placenta. o Psychological Support
- 23. COMPLICATIONS • Maternal hemorrhage •Hypovolemic shock • Disseminated intravascular coagulation • Fetal distress • Preterm birth • Placental insufficiency • Uterine atony • Maternal organ dysfunction
- 24.
- 25. DEFINITION An amnioticfluid embolism is rare but serious condition that occur when amniotic fluid, fetal material, such as hair, enters the maternal bloodstream. The body respond in 2 phases The initial phase is one of pulmonary vasospasm causing hypoxia, hypotension, pulmonary edema and cardiovascular collapse. The second phase sees the development of left ventricular failure, with hemorrhage and coagulation disorders and further uncontrollable hemorrhage INCIDENCE Amniotic fluid embolism syndrome is rare. Most studies indicate that the incidence rate is between 1 and 12 cases per 100,000 deliveries
- 26. ETIOLOGY A maternalage of 35 years Older Caesarean or instrumental vaginal delivery Polyhydramnios Cervical laceration or uterine rupture Placenta previa or abruption Amniocentesis Eclampsia Abdominal trauma Ruptured uterine or cervical veins Ruptured membranes
- 27. SIGNS AND SYMPTOMS Sudden shortness of breath Excess fluid in the lungs Sudden low blood pressure Sudden circulatory failure Life threatening problems with blood clotting (disseminated intravascular coagulopathy) Altered mental status Nausea or vomiting Chills Rapid heart rate Fetal distress Seizures Coma
- 28. DIAGNOSIS Chest X-ray.May show an enlarged right atrium and ventricle and prominent proximal pulmonary artery and pulmonary edema Lung scan: May demonstrate some areas of reduced radioactivity in the lung field. Central venous pressure (CVP) with an initial rise due to pulmonary hypertension and eventually a profound drop due to severe haemorrhage Coagulation profile: decreased platelet count, decreased fibrinogen and afibrinogenemia,prolonged PT and PTT, and presence of fibrin degradation products. Cardiac enzymes levels may be elevated Echocardiography may demonstrate acute left heart failure, acute right heart failure or severe pulmonary hypertension
- 29. MANAGEMENT Maintain systolicblood pressure > 90 mm Hg Urine output> 25 ml/hr Re-establishing uterine tone Correct coagulation abnormalities Administer oxygen to maintain normal saturation Intubate if necessary Initiate cardiopulmonary resuscitation (CPR) if the patient arrests. If she does not respond to resuscitation, perform a cesarean delivery Treat hypotension with crystalloid and blood products Consider pulmonary artery catheterization in patients who are haemodynamically unstable. Continuously monitor the fetus. Trauma to the uterus must be avoided during maneuvers such as insertion of a pressure catheter or rupture of membranes. Incision of the placenta during caesarean delivery should also be avoided
- 30. NURSING MANAGEMENT Giveimmediate and vigorous treatment Give oxygen by face mask Maintain normal blood volume through administration of plasma and intravenous fluids Prevent development of disseminated intravascular coagulation (DIC). Serious complications can occur Administer whole blood and fibrinogen Monitor the patient's vital signs.
- 31.
- 32. DEFINITION Shock isa critical condition and a life-threatening medical emergency. Shock results from acute, generalized, inadequate perfusion of tissues, below that needed to deliver the oxygen and nutrients for normal function ETIOLOGY Hypovolemia (Haemorrhage (occult/overt), hyperemesis, diarrhoea, diabetic acidosis, peritonitis, burns.) Sepsis Cardiogenic (cardiomyopathies, obstructive structural, obstructive non-structural, dysrhythmias) Anaphylaxis Distributive (Neurogenic-spinal injury, regional anesthesia
- 33. DIAGNOSIS There isno laboratory test for shock A high index of suspicion and physical signs of inadequate tissue perfusion and oxygenation are the basis for initiating prompt management Initial management does not rely on knowledge of the underlying cause. INITIAL MANAGEMENT Maintain ABC Airway should assure - oxygen 15 lt/min Breathing-ventilation should be checked and support if inadequate Circulation- (with control of hemorrhage) Two wide bore canulla - Restore circulatory volume Reverse hypotention with crystalloid- Crossmatch Arrange and give blood if necessary See for response such as, vital sign
- 34. 1) HYPOVOLEMIC SHOCK Thenormal pregnant woman can withstand blood loss of 500 ml and even up to 1000 ml during delivery without obvious danger due to physiological cardiovascular and haematological adaptations during pregnancy. ETIOLOGY * Antenatal - Ruptured ectopic pregnancy * Incomplete abortion, Placenta previa * Placental abruption, Uterine rupture * Post partum Uterine atony, Laceration to genital tract, Chorioamnionitis * Coagulopathy, Retained placental tissue.
- 35. SIGN AND SYMPTOMS Mildsymptoms * Headache * Fatigue * Profuse sweating * Dizziness Moderate symptoms * Cold or clammy skin * Pale skin * Rapid, swallow breathing * Rapid heart rate * Little or no urine output * Confusion * Weakness * Weak pulse * Blue lips and fingernails *Light headedness *Loss of consciousness
- 36. MANAGEMENT * Basic shockmanagement then treat specific cause * Laparotomy for ectopic pregnancy *Suction evacuation for incomplete abortion *Management of uterine atony *Repair of laceration *Management of uterine rupture. Stop oxytocin infusion if running *Continuous maternal and fetal monitoring * Emergency laparotomy with rapid operative delivery * Cesarean hysterectomy may need to perform if hemorrhage is not controlled. * Management of uterine inversion. Replacement of the uterus needs to be undertaken quickly as delay makes replacement more difficult. * Administer tocolytics to allow uterine relaxation. Replacement under taken (with placenta if still attached)-manually by slowly and steadily pushing upwards, with hydrostatic pressure or surgically
- 37. 2) CARDIOGENIC SHOCK Cardiogenic shock in pregnancy is a life threatening medical condition resulting from an inadequate circulation of blood Pregnancy puts progressive strain on the heart as progresses Preexisting cardiac disease places the parturient at particular risk. Cardiac related death in pregnancy is the second most common cause of death in pregnancy SIGN AND SYMPTOMS * Chest pain * Nausea and vomiting *Dyspnoea *Profuse sweating * Confusion/disorientation * Palpitations
- 38. SIGN AND SYMPTOM *Faintness/syncope * Pale, mottled, cold skin with slow capillary refill and poor peripheral pulses. * Hypotension (remember to check BP in both arms in case of aortic dissection). * Tachycardia/bradycardia. *Raised JVP/distension of neck veins. *Peripheral oedema. *Quiet heart sounds or presence of third and fourth heart sounds. * Heaves, thrills or murmurs may be present and may indicate the cause, such as valve dysfunction. * Bilateral basal pulmonary crackles or wheeze may occur *Oliguria
- 39. MANAGEMENT • Re-establishment ofcirculation to the myocardium Minimising heart muscle damage and improving the heart's effectiveness as a pump Administer Oxygen (02) therapy to reduces the workload of the heart by reducing tissue demands for blood flow. Administration of cardiac drugs such as Dopamine, dobutamine, epinephrine, norepinephrine. 3)SEPTIC SHOCK * This is sepsis with hypotension despite adequate fluid resuscitation. To diagnose septic shock following two criteria must be met: * Evidence of infection through a positive blood culture. * Refractory hypotension-hypotension despite of adequate fluid resuscitation.
- 40. ETIOLOGY Post cesareandelivery Prolonged rupture of membranes Retained products of conception Rupture membrane Intra-amniotic infusion Water birth Retained product of conception Urinary tract infection Toxic shock syndrome Necrotizing Enterocolitis
- 41. SIGN AND SYMPTOMS Abdominal pain Vomiting Diarrhoea Signs of sepsis Tachycardia, Pallor Clamminess-Peripheral shutdown Systemic inflammation Fever or hypothermia Tachypnoea Cold peripheries Hypotension Confusion Oliguria
- 42. MANAGEMENT Transfer toa higher-level facility Invasive monitoring will inevitably but necessary Obtain blood culture, wound swab culture and vaginal swab culture Start broad spectrum antibiotics Removal of infected tissues. 4) ANAPHYLYTIC SHOCK A serious rapid onset of allergic reaction that is rapid onset and may cause death It is a relatively uncommon event in pregnancy but has serious implications for both mother and fetus. ETIOLOGY Pharmacological agent-pen group of drugs Insect stings Foods Latex
- 43. SIGN AND SYMPTOMS Cutaneous-Flushing,pruritus, urticaria, rhinitis, conjunctiva erythema, lacrimation. Cardiovascular - Cardiovascular collapse, hypotension, vasodilation and erythema, pale clammy cool skin, diaphoresis, nausea and vomiting Respiratory- Stridor, wheezing, dyspnea, cough, chest tightness, cyanosis Gastrointestinal - Nausea vomiting, abdominal pain, pelvic pain. Central nervous system - Hypotension collapse with or without unconsciousness, dizziness incontinence Hypoxia causes confusion EMERGENCY MANAGEMENT Immediate * Stop administration of suspected agent and call for help * Airway maintenance * Circulation - Give epinephrine 1M and repeat every 5-15min in titrated until improvement. In severe hypotension intravenous epinephrine should be given. * Rapid intravascular volume expansion with crystalloid solution.
- 44. CONT… Secondary If hypotensionpersist alternative vasopressor agent should use. Atropine if persistent bradycardia If bronchospasm persist nebulize with salbutamol Antihistaminic All patient with anaphylactic shock should referred to critical care 5) DISTRIBUTIVE SHOCK • In distributive shock there is no loss in intravascular volume or cardiac function. • The primary defect is massive vasodilation leading to relative hypovolemia, reduced perfusion pressure, so poorer flow to the tissues. ETIOLOGY Spinal injuries- Neurogenic shock
- 45. SIGN AND SYMPTOMS *Hypotension *Bradycardia * Hypothermia * Shallow breathing *Nausea vomiting *No response to stimuli * Unconscious * Blank expression of patient MANAGEMENT * Resuscitation * Vasopressor agent and atropine may require in management because spinal injury leads bradycardia due to unopposed vagal stimulation. * Anesthesia -High spinal block * Basic ABC management- Ventilation if needed Administer iv fluids Iv steroid such as methylprednisolone *Immobilize the patient to prevent further damage
- 46.
- 47. DEFINITION Shoulder dystocia isan obstetric emergency that occurs when, after the delivery of the fetal head, the anterior shoulder becomes impacted behind the maternal pubic symphysis, or occasionally the posterior shoulder becomes stuck on the sacral promontory, preventing further delivery of the body. INCIDENCE Occurs in approximately 0.2% to 3% of vaginal deliveries. Higher risk in macrosomic infants (>4,000 g), diabetic mothers, or those with a history of shoulder dystocia.
- 48. DEGREE OF DYSTOCIA 1.Unilateral: The Posterior shoulder enters the pelvic cavity while the Anterior shoulder hooked behind the symphysis pubis 2. Bilateral: Both Posterior & the Anterior shoulder do not cross the pelvic brim. CAUSES (RISK FACTORS) Shoulder dystocia is unpredictable, but several risk factors include: Maternal Factors: Obesity Diabetes mellitus Short stature Prolonged second stage of labor
- 49. CONT… Fetal Factors: Macrosomia(birth weight > 4,000–4,500 g) Post-term pregnancy Male fetus Labor & Delivery Factors: Instrumental delivery (e.g., vacuum or forceps) Induction of labor Prior history of shoulder dystocia
- 50. SIGNS AND SYMPTOMS Turtlesign: Retraction of the fetal head against the perineum after it has been delivered (resembles a turtle pulling back into its shell). Failure of the shoulders to deliver with gentle downward traction. Difficulty delivering the face and chin.
- 51. MANAGEMENT Principles: The goal isto relieve the impacted shoulder without causing fetal or maternal injury. Preliminary steps Call for help Drain the bladder Perform generous episiotomy Avoid 5P’S • Panic • Pulling • Pushing • Pressure on the fundus • Pivoting
- 52. CONT… Initial Steps (ALARMERmnemonic): A – Ask for help (call obstetric team, anaesthetist, paediatrician) L – Legs: McRoberts maneuver (hyperflex maternal hips onto the abdomen) A – Anterior shoulder disimpaction (e.g., suprapubic pressure) R – Rotation maneuvers (e.g., Rubin’s or Wood’s screw maneuver) M – Manual delivery of posterior arm E – Episiotomy (to gain access for internal maneuvers) R – Roll the patient (Gaskin maneuver – all fours position) Last-Resort Measures: Zavanelli maneuver (replace fetal head into vagina and perform C-section) Clavicle fracture (intentional to reduce shoulder diameter) Symphysiotomy (rare)
- 53. 1. Robert Maneuvers Flexionof maternal thighs into the abdomen Cephalic rotation of the pelvic free the anterior shoulder
- 54. 2. Suprapubic pressure Moderatesuprapubic pressure is often the only additional maneuver necessary to disimpact anterior fetal shoulder Strong pressure can only be exerted by an assistant
- 55. 3.Wood Screw maneuver General anesthesia should be administered The posterior shoulder is rotated to anterior position by a corkscrew movement. This is done by inserting two fingers into the posterior vagina simultaneously suprapubic pressure is applied Wood's Screw Maneuver
- 56. 4.Cliedotomy One orboth clavicles may be cut with the scissors to reduce the shoulder dystocia This is applicable to a living anencephalic baby In dead fetus 5.Zavanelli maneuver Pushing the fetus back to the uterus and delivered by ceasearean section
- 57. COMPLICATIONS Fetal Brachial plexusinjury (Erb’s palsy) Fracture (clavicle or humerus) Hypoxia or hypoxic-ischemic encephalopathy Death (rare but possible if delayed) Maternal Postpartum hemorrhage Perineal trauma (tears, episiotomy extension) Uterine rupture (rare)
- 58.
- 59. DEFINITION It occurs whenthe placenta fails to detach from the uterus as it exits, pulls on the inside surface, and turns the organ inside out. Uterine inversion is a potentially fatal childbirth complication with a maternal survival rate of about 85% INCIDENCE The incidence is about 1 in 20,000 deliveries ETIOLOGY The exact cause of uterus inversion is unclear. The most likely cause is strong traction on the umbilical cord, particularly when the placenta is in a fundal location, during the third stage of labor
- 60. DEGREES OF UTERINEINVERSION 1st Degree - Dimpling of fundus, remains above internal os 2nd Degree-fundus passes through the cervix, but lies inside vagina 3rd-Degree (complete)-Endometrium with or without placenta is outside the vulva DIAGNOSIS Prompt diagnosis is crucial and possibly lifesaving. Some of the signs of uterine inversion could include: * The uterus protrudes from the vagina. * The fundus doesn't seem to be in its proper position when the doctor palpates (feels) the mother's abdomen. * The mother experiences greater than normal blood loss. *The mother's blood pressure drops (hypotension) * The mother shows signs of shock (blood loss). * Scans (such as ultrasound or MRI) may be used in some cases to confirm the diagnosis
- 61. MANAGEMENT Before shock Urgentmanual replacement After replacement, the hand should remain inside the uterus until the uterus become contracted by parentral oxytocics The placenta should be removed manually only after the uterus becomes contracted Usual treatment of shock including blood transfusion should be arranged. After shock * Morphine 15mg IM, dextrose saline drip and arrangement of blood transfusion. * Push the uterus inside the vagina if possible and pack the vagina with roller gauze * Raised foot end of bed. * Replacement of uterus under general anaesthesia to be done. *Emergency hysterectomy (surgical removal of the uterus) in extreme cases where the risk of maternal death is high.
- 62.
- 63. DEFINITION Disruption in thecontinuity of the all uterine layers (endometrium, myometrium and serosa) any time beyond 28 weeks of pregnancy is called rupture of uterus. INCIDENCE The prevalence widely varies from 1 in 2000 to 1 in 200 deliveries TYPES OF TEAR (RUPTURE) 1. Complete Rupture II. Incomplete Rupture
- 64. CONT… Complete rupture: - *The peritoneum tears and the contents of the mother's uterus can spill into her peritoneal cavity. * It is suggested that delivery via caesarean section (C-section) should occur within approximately 10 to 35 minutes after a complete uterine rupture occurs. * The fetal morbidity rate increases dramatically after this period Incomplete: - *The mother's peritoneum remains intact. *The peritoneum acts as a channel for blood vessels and nerves. * An incomplete uterine rupture is significantly less dangerous with fewer complications to the delivery process
- 65. ETIOLOGY It is furtherdivided into: * Spontaneous * Scar rupture * latrogenic 1.Spontaneous During pregnancy * Previous damage to the uterine walls following D& C procedure * Manual removal of placenta • Thin uterine wall • Congenital malformation of uterus During labour * Obstructive rupture due to obstructed labour * Non obstructive rupture due to weakening of walls due to repeated previous birth 2.Scar rupture * Classical caesarean or hysterectomy scar.
- 66. CONT… 3.latrogenic During pregnancy Injudiciousadministration of oxytocin Use of prostaglandin for induction of abortion or labour Forcible external version Fall or blow on the abdomen During labour Internal podalic version Destructive operation Manual removal of placenta Application of forceps or breech extraction through incomplete dilated cervix Injudicious administration of oxytocin for augmentation of labour
- 67. SIGN AND SYMPTOMS Abdominal pain and tenderness Shock Vaginal bleeding Undetectable fetal heart beat Palpable fetal body parts Cessation of contractions Signs of intra-peritoneal bleeding The most common sign is the sudden appearance of fetal distress during labor Complete laceration of uterine wall Sharp pain between contractions - Contractions that slow down or become less intense Recession of the fetal head (baby's head moving back up into the birth canal) Bulging under the pubic bone (baby's head has protruded outside of the uterine scar) Sharp onset of pain at the site of the previous scar. Uterine atony (loss of uterine muscle tone) Maternal tachycardia (rapid heart rate) and hypotension
- 68. DIAGNOSIS *Ultrasonography is probablythe safest and most useful imaging technique during pregnancy. Sonographic findings associated with includes: ➤Extra peritoneal hematoma ➤Intrauterine bleed ➤Free peritoneal blood. ➤ Empty uterus ➤ Gestational sac above the uterus ➤ Large uterus mass with gas * Painful bleeding * Loss of FHS
- 69. MANAGEMENT Principles for thetreatment of uterine rupture includes: Intensive resuscitation Emergency laparotomy Broad spectrum antibiotics Adequate post operative care Intensive resuscitation Correct hypovolaemia from: - Haemorrhage Sepsis Dehydration Intravenous broad-spectrum antibiotics Cephalosporin Metronidazole combination Monitor to ensure adequate fluid and blood replacement Blood volume expansion may worsen the bleeding from damaged vessel and so the laparotomy should not be delay, once patient condition has improved.
- 70. CONT.. Intravenous broad-spectrumantibiotics Cephalosporin Metronidazole combination Monitor to ensure adequate fluid and blood replacement Blood volume expansion may worsen the bleeding from damaged vessel and so the laparotomy should not be delay, once patient condition has improved. Surgical options * Hysterectomy-Treatment of choice except any other compelling reasons to preserve the uterus #Total #Sub-total *Rupture repair # Occasionally one may be forced to repair #Repair with sterilization
- 71. NURSING MANAGEMENT * Monitorfor the possibility of uterine rupture * In the presence of predisposing factors, monitor maternal labor pattern closely for hyper tonicity or signs of weakening uterine muscle * Recognize signs of impending rupture, immediately notify the physician, and call or assistance * Assist with rapid intervention. If the client has signs of possible uterine rupture; vaginal delivery is generally not attempted. * Monitor maternal blood pressure, pulse, and respirations also monitor fetal heart tone * If the client has a central venous pressure catheter in place, monitor pressure to evaluate blood loss and effects of fluid and blood replacement. * Insert a urinary catheter for precise determinations of fluid balance. * Obtain blood to assess possible acidosis. * Administer oxygen, and maintain a patent airway. * Restore circulating volume using one or more IV lines. * Evaluate the cause, response to therapy, and fetal condition
- 72.
- 73. INTRODUCTION There are threeclinical types of abnormal descent of the umbilical cord by the side of the presenting part: * Cord presentation * Occult prolapse * Cord prolapse Cord presentation- When cord is slipped down below the presenting part and is felt lying in the intact bag of membranes. Occult prolapse- the cord is placed by the side of the presenting part and is not felt by the fingers on internal examination. Cord prolapse- the cord is lying inside the vagina or outside the vulva following rupture of the membranes INCIDENCE The incidence of cord prolapse is about 1 in 300 deliveries
- 74. ETIOLOGY *Malpresentation- transverse lie& breech * Contracted pelvis * Prematurity *Twins * Hydramnios *Placental factor-minor degree placenta praevia * latrogenic-low rupture of the membranes, manual rotation of the head * Stablising induction DIAGNOSIS OCCULT PROLAPSE * Difficult to diagnose. * Persistence of variable deceleration of fetal heart rate pattern. CORD PRESENTATION Feeling the pulsation of the cord through the intact membrane
- 75. CONT… CORD PROLAPSE * Thecord is palpated directly by the fingers and its pulsation can be felt if the fetus is alive. * Cord pulsation may cease during uterine contraction, however returns after the contraction passes away. MANAGEMENT Protocol is guided by: *Baby living or dead * Maturity of the baby * Degree of dilatation of the cervix
- 76. CONT… CORD PRESENTATION * Oncethe diagnosis is made, no attempt should be made to replace the cord. * If immediate vaginal delivery is not possible or contraindicated, caesarean section is the best method of delivery. *A rare occasion when multipara with longitudinal lie having good uterine contractions with cervix 7-8cm dilated without fetal distress-watchful competency and delivery by forceps or breech extraction.
- 77. CORD PROLAPSE Living baby *Immediate take the mother for Caesarean section *Immediate safe vaginal delivery if-head is engaged *Immediate safe vaginal delivery not possible- First Aid First aid Bladder filling is done to raise the presenting part off the compressed cord.lt is done by 400- 750ml of NS with a foley's catheter, the ballon is Inflated and catheter is clamped. Lift the presenting part off the cord Postural treatment exaggerated and elevated Sim's position or Trendelenburg or knee chest position Replace the cord into the vagina to minimize vasospasm due to irritation. Dead baby Labour is allowed to proceed awaiting spontaneous delivery
- 78. CONCLUSION Obstetrical emergencies aresudden, unpredictable and potentially life-threatening conditions that arise during pregnancy, labor, delivery or the postpartum period. Timely identification and immediate and effective management are critical to ensure the safety of both mother and baby. These emergencies require skilled multidisciplinary care, rapid decision- making and access to emergency intervention. Effective management of obstetrical emergencies ultimately leads to better health outcomes and safer childbirth experiences.