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