OBSTETRIC EMERGENCIES AND NEONATAL CARE By DR ZAKIA ZAHEEN ASSISTANT PROFESSOR LUMHS, JAMSHORO
OBSTETRIC EMERGENCIES AND
NEONATAL CARE
By
DR ZAKIA ZAHEEN
ASSISTANT PROFESSOR
LUMHS, JAMSHORO
Obstetrical Emergencies
These could be the best calls that you will ever go on or
the absolute worst nightmares you could ever
imagine!
General principles for minimizing an emergency
Promote good antenatal health Organized intrapartum care Tiage Communication and team working Documentation Risk management Emergency training
TOP OBSTETRIC EMERGENCIES
Antepartum haemorrhage Shoulder dystocia Instrumental deliveries Cord prolaps Post partum haemorrhage
Antepartum Haemorrhage
Bleeding at > 24weeksTop causes: Placental abruption Placenta praevia Uterine rupture Cervical lesion Vasa praevia Unexplained
Abruptio Placentae
The partial or complete detachment of a normally implanted placenta at more than 20 weeks.
Occurs in 0.5-2.0% of all pregnancies and will result in fetal death in 1 out of 400 cases of abruption.
Predisposing conditions include maternal hypertension, preeclampsia, multiple births, trauma, and previous abruption
Abrutio Placentae
Placenta Previa
Placental implantation in the lower uterine segment encroaching on or covering the cervix.
Occurs in approximately 1 in 200 to 1 in 400 deliveries with the highest incidence in preterm
births.
Associated with increased maternal age, multiple births, previous cesarean and placenta previa.
Placenta Previa
SIGN AND SYMPTOMS
Placental abruption Placenta praevia
Shock out of keeping with visible loss Shock in proportion to visible loss
Pain constant No pain
Tender, tense uterus (hypertonic) Uterus not tender (hypotonic)
Normal lie and presentation Both may be abnormal
Fetal heart absent/distressed Fetal heart usually normal
Coagulation problems Coagulation problems rare
Beware pre-eclampsia, DIC, anuria Small bleeds before large
Uterine Rupture
Spontaneous or traumatic rupture of the uterine wall.
Occurs in approximately 1 in 1400 deliveries with a 5 – 15% maternal mortality rate and a 50% fetal
death rate.
Abdomen is usually rigid with diffuse pain, fetal parts easily palpated through the abdominal
wall.
Emergency Patient Care
Call for help ABCs Oxygen therapy Place patient in left lateral recumbent position. Pass urinary catheter Take blood for relevant investigation Order for 4-6 unit of blood Monitor vital signs. Avoid vaginal examination
Specific management for Abruptio Placenta
Depends on gestational age and status of the mother and fetus With a live, mature fetus and if vaginal delivery
is not imminent, emergency S/C is preferred When there is small abruption with preterm
fetus, live, without compromise then very close observation with facilities for immediate intervention can be practice
With a dead fetus and stable mother induce labor for vaginal delivery
Specific management for Placenta previa
Avoid vaginal examination Cesaerean section under general
anaesthesia
Prolapsed Cord
Occurs when the umbilical cord slips down into the vagina or presents externally which can cause
fetal asphyxiation.
Occurs in approximately 1 in every 200 pregnancies and should be suspected when
fetal distress is present
Most common with breech presentations, premature membrane ruptures, large fetus, long
cord, multiple gestation, preterm labor
Patient Care
Place two fingers in vagina to relieve pressure off cord, raising fetus off cord.
Check cord for pulsations Mother in knee-chest or hips elevated position. Oxygen therapy Transport while keeping pressure off cord. Moist dressing to exposed cord, do not push
back into vagina. Refil bladder Immediately shift for S/C
Shoulder Dystocia
Occurs when the infant’s shoulders are larger than it’s head, most common with diabetic and obese
mothers.
Labor progresses normally with routine head delivery which will retract back into the perineum
because shoulders are trapped between the pubis and the sacrum.
Incidence varies by birth weight 0.3% in infant weighing b/w 2.5-4.0 kg and 5-7% in infant b/w
4.0-4.5 kg
>50% occur in normal weight babies
Shoulder Dystocia
Risk Factors Prior shoulder dystocia Post date pregnancy Macrosomia Short maternal structure Abnormal pelvic anatomy Prolong first stage or second stage Instrumental deliveries
Complication
Maternal Neonatal
Perineal injuries Brachial pluxus palsy
Anal sphincter damage Clavicle fracture
PPH Humeral fracture
Uterine rupture Fetal acidosis
Symphyseal separation Hypoxic brain injury
Recognition Fetal head retract against perineum(turtle
sign) Gentle traction does not effect delivery Proceed to HELPERR
Anterior shoulder
HELPERR Pnuemonic
H: help( staff, pediatrician, anaesthetist) E: evaluate for Episiotomy L: Legs (Macrobert position) P: Pressure (supra pubic) E: Enter in Pelvis to perform manuvers
Rubin II
Woodscrew R: remove posterior arm R: Roll on all four ( hands & Knees)
Supra pubic pressure
Robin’s meneuver
Removal of posterior arm
Maneuvers of last resort
Delibrate clavicle fracture Zavenelli maneuver Symphysotomy Abdominal rescue
Postpartum Hemorrhage
Estimated blood loss ≥ 500ml
Primary: within 24hrs of delivery
Secondary: 24hrs-6weeks post delivery
Causes (4 Ts)
Tone: uterine atony Tissue: retained placenta or retained
products, Trauma: cervical or perineal, or ruptured
uterus, Thrombin: coagulation disorder
Risk factorsAntenatal • Proven abruption
• Placenta praevia• Multiple pregnancy • Pre-eclampsia• Previous PPH• Obesity• Anaemia
Apparent during labour • Caesarean section• Instrumental delivery• Long labour > 12 hours • Pyrexia in labour• Retained placenta
• Mediolateral episiotomy
PPH – signs
Pale Confused Increased HR, reduced BP (late sign) Reduced urine output Obvious or hidden bleeding Relax uterus
PPH Management
Call for help ABC O2 inhalation Two Large bore IV access Take blood for FBC, coag, cross match Urinary catheter Identify cause(s) of PPH and manage Control bleeding Replace the blood loss
Ensure 3rd stage complete – if not MROP Rub uterine fundus to stimulate
contraction +/- bimanual compression if required to stop uterine bleeding
Assess for cervical/vaginal wall/perineal tears – if present, repair
Medical management of atony with oxytocic medicines
1. Syntocinon
2. Ergometrine
3. Carboprost
4. Misoprostol
Surgical management1. Intra uterine balloon device
2. B lynch suture if at Caesarean section
3. Uterine artery embolisation/ligation
4. Hysterectomy
Instrumental Deliveries
10- 15% of all vaginal deliveries require operative assistance
Instrumental deliveries is an important skill for managing emergency in second stage of labor
All maternity care provider should have knowledge and skill to use vacuum or forceps in emergency situations
INSTRUMENTS
Vacuum
Malmstorm: historical,rigid metal cup
Mityvac: soft plastic cup Forceps
Wringly, Simpson: all purpose forceps
Piper, Kielland: for special indication
INDICATIONS
Maternal indication Maternal & fetal indication
Fetal indications
Exhaustion Relative CPD Bradycadia
Maternal illness( cardiac, HTN)
Malposition Non- reassuring CTG
haemorrhage Malpresentation
Prerequisites for instrument
Vertex presentation Cervix fully dilated Membrane rupture No known CPD Willingness to abondon procedure
Where use what?
Outlet forceps or vacuum Fetal skull at pelvic floor Scalp visible between contraction
Low forceps and Vacuum Fetal skull at, or below, +2 station
Mid cavity forceps or vacuum Head engaged but above +2 station
Vacuum Delivery
Often instrument of preference Rival forceps in safety and efficacy Soft cup can minimize maternal and fetal
trauma Metal cup used for rotational problems
Contraindication for Vacumm
Sever prematurity Breech,Face, Brow presentation Transverse lie Unengaged head Delivery requiring excessive traction
Types of Vacuum extractor
Vacuum Application
Remember A - J A:
Ask for help
Adress the patient
Adequate anaesthesia B:
Bladder empty C:
Cervix fully dilated
D:
Determine position
think shoulder dystocia E:
equipment and extractor ready F:
Apply cup over sagittal suture 3 cm in front of posterior frontanel ( FLEXION POINT)
G:
Gentle traction at right angle to plane of cup, during contraction H:
halt traction after contraction with reduction of pressure
Halt procedure if
disengagement of cup 3 times
No progress in 3 consecutive pulls
I:
Evaluate for Incision(Episiotomy) at crowning J:
Remove vacuum when Jaw visible
Complication of Vacuum
May take longer time than forceps Cephal haematoma Subgaleal haematoma Intracranianl haematoma
Post Vacuum care
Cervix and Vaginal examination Check fetus for birth trauma Vacuum operative notes
Forcep Delivery
Rapid delivery Baby’s friendly Can be use in mal presentation Can be use for rotation For application remember A- J
A: Ask for help,adress patient,adequate anaesthesia
B: Bladder empty C: Cervix fully dilated D: Determine head position, think of
shoulder dystocia E: Equipment ready F: Forcep ready for application
Checking forcep application
Position For Safety Posterior frontanel midway b/w shanks,1
cm above plane of shanks Fenestration admit no more than one
finger tip Sutures: lambdoidal above and equidistant
from, upper surface of each blade; saggital is midline
G: Gentle traction with contraction in Pajot Maneuver. Force should be dowmward, backward and upward, forward.
H: Halt traction in b/w contraction I: Incision (Episiotomy) at Crowning J: remove forcep when jaw visible
Complications of Forcep
Genital tract trauma Sphincter damage Fetal facial nerve palsy Forceps marks
Essential Newborn Care&
Neonatal Care
Introduction
About 4 million newborns die under 4 wks of age
Nearly 75% die in the 1st wk and 40% in the 1st 24 hrs of birth.
Neonatal mortality rate is 57/1000 live births
The basic needs of a baby at birth
To be protected To breath normally To be warm To be fed
SKIN TO SKIN CONTACT
Monitoring the baby
• During the first hour after complete delivery of the placenta the baby (and the mother) should be monitored every 15 minutes.
• The mother and baby should remain in the delivery room for the first hour
Skin-to-skin contact and breastfeeding
• The baby should be kept in skin-to-skin contact after delivery until breastfeeding takes place
POSTNATAL WARD
Every day care of the baby
- Breastfeed
- warmth
- Cord care
- hygiene
- Watching for danger signs
THANK YOU
EXAMINATION OF BABY
ASSESS BREATHING
LOOK AT THE MOVEMENT LOOK AT THE PRESENTING PART
LOOK AT THE ABDOMEN Jaundice Umblicus
LOOK FOR MALFORMATIONS TONE LOOK FOR SKIN PUSTULE POSTURE
FEEL FOR WARMTH WEIGH THE BABY ASSESS BREASTFEEDING