Emergencies that occur in pregnancy or during or after labor and delivery.
main emergencies are
Ectopic Pregnancy
Uterine Inversion
Obstetrical Shock
Cord Prolepses
Amniotic Fluid Embolism
Postpartum Hemorrhage
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Obstetrical Emergencies
1. GUIDED BY : MAJ. SARAVANA ESWARI
CLINICAL TUTOR
PRESENTED BY : N/CDT PRIYANKA GIRI
IV YEAR BASIC B.SC NURSING
2. Obstetrical emergencies are life-threatening
medical conditions that occur in pregnancy or during
or after labor and delivery.
The main emergencies include-
I. Ectopic Pregnancy
II. Uterine Inversion
III. Obstetrical Shock
IV. Cord Prolepses
V. Amniotic Fluid Embolism
VI. Postpartum Hemorrhage
4. “Any pregnancy where the fertilised ovum
gets implanted & develops in a site other
than normal uterine cavity”.
Represent serious hazard to a woman’s
health and reproductive potential
Requiring prompt recognition and early
intervention.
5. ECTOPIC PREGNANCY : is one in which
fertilized ovum is implanted & develops outside
normal uterine cavity
.
6.
7.
8. Increased due to PID, use of IUCD, Tubal
surgeries, and ART
Ranges from 1:25 to 1:250
Average range is 1 in 100 normal pregnancies.
Late marriages and late child bearing ->2%
ART -> 5%
Recurrence rate - 15% after 1st, 25% after 2
ectopics
9. History of PID
History of tubal ligation
Contraception failure
History of infertility
IUD use
Previous induced abortion
Tubal reconstructive surgery
10. Acute
Unruptured
Subacute
Acute eptopic pregnancy
Fortunately less common (30%)
Associated with cases of tubal rupture or tubal
abortion with massive intraperitoneal
hemorrhage.
11. Classical triad is present in 50% of pt with rupture
ectopic.
- PAIN:- most constant feature in 95% pt
- variable in severity and nature
- AMENORRHOEA:- 60-80% of pt
- there may be delayed period or slight spotting at the
time of expected menses.
- VAGINAL BLEEDING: - scanty dark brown
Feeling of nausea,vomiting,fainting attack, syncope
attack(10%) due to reflex vasomotor disturbance.
12. O/E:- patient is restless in agony, looks blanched,
pale, sweating with cold clammy skin.
Features of shock, tachycardia, hypotension.
P/A:- abdomen tense, tender mostly in lower
abdomen, shifting dullness, rigidity may be
present.
P/S:- minimal bleeding may be present
P/V:- uterus may be bulky, deviated to opposite
side, fornix is tender, excitation pain on
movement of cervix.
POD may be full, uterus floats as if in water.
13. PRINCIPLE:
“Resuscitation and laparotomy and not resuscitation
followed by laparotomy”.
Antishock treatment:
• measures are to be taken energetically
• Simultaneous preparation for urgent laparotomy.
-ringer solution (crystalloid) is started
-arrangement for blood transfusion.
-Even if blood is not available laparotomy is to be
done desperately.
15. Acute pain related to distention of fallopian tube.
Risk for Deficient Fluid Volume related to
bleeding from a ruptured ectopic pregnancy.
Powerlessness related to early loss of
pregnancy secondary to ectopic pregnancy.
17. When Uterus Turns Inside Out, It Is Called
Uterine Inversion.
Uterine inversion is the folding of the fundus
into the uterine cavity in varying degrees.
19. A. TYPES :
1) Incomplete Inversion:
When fundus of uterus has turned inside out,
like toe of socks, but inverted fundus has not
descended through cervix
2) Complete Inversion:
When the inverted fundus has passed
completely through cervix to lie within the vagina
or lie often outside the introitus.
20. B. DEGREES
First degree: The uterus is partially turned out
Second degree: The fundus has passed
through the cervix but not outside the vagina
Third degree: The fundus is prolapsed outside
the vagina
Fourth degree: The uterus, cervix and vagina
are completely turned inside out and are visible
21. Universally…
First Degree : Incomplete Inversion
Second Degree : Complete inversion in the
vagina
Third Degree : Complete inversion outside the
introitus
22. Manual removal of placenta
Cord traction &/or fundal pressure
Uterine anomalies
Short umbilical cord
Placenta Accreta
Grand Multiparity
Fetal macrosomia
Rapid labor and delivery
23. Due to mismanagement of third stage of
labor…
Faulty technique in manual removal of placenta
While separating retained placenta from the
wall, a portion may remain attached and as the
placenta is withdrawn, the fundus is also
withdrawn.
Pulling the cord when the uterus is atonic while
combined with fundal pressure
Crede’s Expression while the uterus is relaxed
24. Large boggy mass appears at introitus
With or without placenta attached
Other signs and symptoms are as follows –
Severe and sustained hypogastric pain in 3rd stage
of labor
1. SHOCK
Extremely profound mainly neurogenic shock due to
A. Tension on the nerves due to stretching of the
infundibulo pelvic ligament.
B. Pressure on the ovaries as they are dragged with
the fundus through the cervical ring.
C. Peritoneal irritation
25. Profound sweating with bradycardia,
Hypotension
Rarely cardiac arrest.
2. Hemorrhage - After detachment of placenta
3. Pulmonary embolism
4. If left uncared it may lead to ..
Infection
Uterine sloughing
Peritoneal irritation
26. Commonly unmet,
The prognosis is extremely gloomy.
Even if patient survives, infection ,sloughing of
the uterus and chronic inversion with ill health
may occur.
27. Do not employ any method to expel the placenta
when the uterus is relaxed
Patient should not be instructed to change her
position.
Pulling the cord simultaneously with fundal
pressure should be avoided
Manual removal of placenta should be done in
proper manner.
28. 1) Starting from the edge of placenta ,
2) The placenta is separated by
a) keeping the back of the hand in contact with
the uterine wall.
b) with slicing movement of the hand.
29. Delay in treatment increases the mortality, So
number of steps are taken immediately and
simultaneously.
Before shock develops :
When one is on the spot when the inversion
happens TRY IMMEDIATE MANUAL
REPLACEMENT, even without anesthesia if
not easily available.
30. Principle :
“ The part of the uterus which has come
down last, should go back first ”.
31. If the diagnosis is made immediately after the
inversion has occurred, then that same degree of
relaxation of myometrium and cervix (which is
required for the inversion to occur) will allow
uterine replacement easily…
1. The gloved hand is lubricated with suitable
antiseptic cream and placed inside the vagina.
2. The uterine fundus with or without the attached
placenta, is cupped in the palm of the hand. The
fingers and thumb of the hand are extended to
identify margins of the cervix.
32. 3. The whole uterus is
lifted upwards towards
and beyond umbilicus.
4. Additional pressure is
exerted with the
fingertips systematically
and sequentially to push
and squeeze the uterine
wall back through the
cervix.
33. 5. Sustained pressure for 3-5 mins to achieve
complete replacement
6. Apply counter support by the other hand placed
on the abdomen
7. Once the fundus has been replaced keep the
hand in the uterus while rapid infusion of
oxytocin is given to contract the uterus.
Initially, bimanual compression aids in control of
further hemorrhage until uterine tone is
recovered.
34. 8. When the uterus is felt contracting, the hand is
slowly withdrawn.
If placenta is attached, it is to be removed only
after the uterus becomes contracted.
If the placenta is partially attached, it should be
peeled out before replacement of uterus.
38. Critical condition, 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.
Prompt recognition and management can
improve maternal and fetal outcome.
40. Requires teamwork—Senior anesthetist,
obstetrician, physician and hematologist are to
be summoned immediately.
Obstetrical units should have established
protocols for dealing with shock.
Active management should start as soon as it is
suspected or expected
Aiming for prompt restoration of tissue perfusion
and oxygenation.
41. Resuscitation follows---ABC
A Airway—
Patent airway is assured and high pressure
oxygen (15 l/min)using mask/intra tracheal
intubation and anaesthesia machine.
B Breathing—
Ventilation checked and supported if needed .
42. C Circulation—
1. Insert two wide bore cannulas
2. Restore blood volume and reverse hypotension
with crystalloids/colloids.
3. Initial request for4-6 units of blood should be
sent. Blood may be transfused
43. Monitor response to therapy - Pulse , BP, SPO2
/pulse oxymetry, urine output & pH .
Position of patient - Head down and left lateral
Avoid aortocaval compression
Which further worsen the hypotension.
45. The diagnosis of underlying cause and definitive
treatment is initiated once resuscitation is under
way.
Surgical/ obstetrical—
ectopic pregnancy, abortion, uterine perforation,
APH, uterine rupture. PPH, inversion of uterus.
Blood transfusion
46. The failure of heart to provide adequate output,
leads to tissue under perfusion.
Back pressure on lungs leads to Pulmonary edema.
Pregnancy puts progressive strain on cardiac
function as pregnancy progresses , the peak being
between 32-34 wks.
Pre existing cardiac disease further increases the
risk.
Cardiac related death are 2nd most common
causes of death in pregnancy and commoner than
the direct leading cause , thromboembolism.
47. Early diagnosis of cardiac lesion.
Surgical correction of operable cardiac lesion,
before pregnancy is planned.
Medical control of decompensated cardiac
lesion by cardiac correction before pregnancy is
planned.
Avoiding Pregnancy/MTP at 6-8 wks if cardiac
condition is not under control.
Management of pregnancy in such patients by
the expert team of cardiologist and obstetrician .
48. Definition –
A serious allergic reaction that is rapid in onset
and may result in death.
Aetiology –
Pharmacological agents ,
Insect stings,
Foods,
Latex
50. 4. Gastrointestinal -
nausea , vomiting , abdominal pain .
5. C N S -
Hypotension causes collapse with/without
unconsciousness , dizziness , incontinence,
confusion and throbbing headache .
51. 1. Basic shock management -> ABC
2. Circulatory management
3. Primary (Special aspect)
- Stop administration of suspected substance and call for
help.
- IV 1ml injection of diluted
Adrenaline (1:1000)
- Early intra tracheal
- Supine/trendelenberg position with raised legs increases
venous return.
- Start vasopressor drugs and monitor BP.
Rapid infusion for plasma volume expansion , with
crystalloids
52. 4. Secondary
- Atropine may be given if significant bradycardia.
- If bronchospasm – nebulise /I V
Amino/Derriphyllin or Beta 2 agonist such as
Salbutamol , Inhaled Ipravent may be particularly
useful for treatment of bronchospasm in patients
on B-blockers.
- Antihistamines - IV Chlorpheniramine.
- Corticosteroids -Dexamthesone.
Referral to critical care unit.
53. Decreased cardiac output related to fluid volume
loss.
Impaired gas exchange related to change in the
alveolar capillary membrane.
Ineffective breathing pattern related to
bronchospasm.
55. Umbilical cord prolapse occurs when the
umbilical cord comes out of the uterus with or
before the presenting part of the fetus.
56. The overall incidence of cord prolapse ranges
from 0.1–0.6%.
In the case of breech presentation, the incidence
is higher at 1%.
The incidence is higher when there is a greater
percentage of multiple gestation.
58. Appearance of loop of umbilical cord
Pulsation of cord on V/E
Suspect in unexplained fetal distress
- Variable deceleration
- Prolonged bradycardia
59. Fetal survival depends on swift action
Call for help – midwifery colleagues
Factors to consider:
-Viability of fetus
-Severe fetal abnormalities
Emergency delivery for a normally formed and
mature fetus
60. Emergency LSCS
Take measures to optimize fetal well-
being(maternal positioning)
Multidisciplinary approach
Teamwork
61. Vaginal delivery
-Depends on descent of head & rate of progress;
parity
Instrumental delivery
-Depends on skill levels & confidence; descent of
head & rate of progress.
Caesarean section
-Take measure to ensure to optimise fetal wellbeing
-Multidisciplinary approach
-Teamwork
62. Elevation of the presenting part:
-Digital pressure
-Kneeling on all fours, buttocks uppermost, or
-Exaggerated Sims (left lateral)
-Fill bladder with 500mls saline
-Tocolysis
63.
64. DO
Replace the cord into
the vagina
Monitor the fetal HR
Inform the woman
DON’T
Replace the cord
inside the uterus
Handle the cord
excessively
65. Call for help
Organise delivery
Relieve pressure on the cord
Deliver
66. Fetal : impaired gas exchange related to
insufficient oxygen delivery secondary to cord
occlusion
Risk for injury related to early cord steps into
presenting part.
Fear related to perceived grave danger to fetus
and self obstetric emergency.
68. An amniotic fluid embolism is rare but serious
condition that occur when amniotic fluid, fetal
material, such as hair, enters the maternal
bloodstream.
69. Very uncommon, 1/20,000 births.
Though rare it comprises 10% of all maternal
death.
70. Advance maternal age
Multiparity
Meconium
Cervical laceration
Intrauterine fetal death
Sudden fetal expulsion
Polyhyramnios
Uterine rupture
Maternal history of allergy or atopy
Macrosomia
71. 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
72. NON SPECIFIC SPECIFIC
Complete blood count
Coagulation parameters
ABG
Chest x-ray
Electrocardiogram
Echocardiogram
Cervical histology
Serum tryptase
73. Management is symptomatic and supportive.
Targets- Maintaining oxygenation ,hemodynamic
support and correction of coagulopathy
Immediate Resuscitation- ABC
Airway and breathing
Administer 100% oxygen via a non- rebreathing
reservoir face mask
Prompt assessment, with control of the airway
and ventilation of the lungs with tracheal
intubation may be essential.
74. Circulation
2 large bore IV lines,
Send blood for coagulation profile,
CBC, crossmatch,
Arrange 6units blood.
Left lateral tilt/Manual uterine displacement.
Hemodynamic support would include preload
optimization and vasopressors.
Fluid resuscitation with crystalloid/colloid to
optimize filling.
75. Infusion of an inotrope may be required to
maintain a mean arterial blood pressure and
achieve an adequate urine output.
An arterial line for continuous blood pressure
monitoring is essential, and the use of a non-
invasive cardiac output monitor may be helpful.
Continuously monitor the fetus.
Uterine tone –Pharmacologic agents such as
oxytocin, ergometrine and prostaglandins
carboprost and misoprost.
76. Coagulation:
Use of plasma, cryoprecipitate, and platelets to
be guided by clinical condition of the patient and
laboratory investigations.
Recombinant factor VII may be used, but one
should be careful as this can cause thrombotic
complications
Antifibrinolytics, like e-aminocaproic acid and
tranexamic acid, might be helpful but evidence
is lacking.
78. More than 500 ml of blood loss following normal
vaginal delivery of the fetus or 1000ml following
Cesarean section.
Clinically the amount of blood loss from or into
the genital tract which will adversely affect the
general condition of the patient
Hemorrhage leading to fall in hematocrit by
10%.
Incidence – 1- 4 %
79. 1] Primary
2] Secondary
Primary – bleeding occurs following delivery of
the baby up to 24 hours
Primary is two types:
A] Third Stage hemorrhage
B] True Post Partum hemorrhage
80. A] Third Stage hemorrhage:
Bleeding occurs before the expulsion of
placenta
Example- Placenta accreta, increta and percreta
& retained placenta
B] True Postpartum hemorrhage:
Occurs after the expulsion of placenta
81. Secondary or Delayed or Late Postpartum
hemorrhage:
Bleeding occurs following delivery of the baby
after 24 hours up to 6 weeks
84. Contributes for 80 % of PPH
Commonest cause of PPH
Cause – Faulty retraction of the uterus
Etiology:
1] Grand Multipara
2] Over- distension of uterus – Multiple
pregnancy, Hydramnios, big baby
3] Anemia
88. Vaginal bleeding may be revealed or concealed
Alteration in pulse, Blood pressure and Pulse
pressure
Flabby uterus in atonic uterus
89.
90. UTEROTONIC DRUGS
Routine oxytocin administration in third stage of
labour can reduce the risk of PPH by more than
40%
The routine prophylaxis with oxytocins results in
a reduced need to use these drugs
therapeutically
Management of the third stage of labour should
therefore include the administration of oxytocin
after the delivery of the anterior shoulder.
91. Early recognition of PPH is a very important
factor in management.
An established plan of action for the
management of PPH is of great value when the
preventative measures have failed
92. DRUG DOSE SIDE EFFECTS CONTRAINDICATION
OXYTOCIN 10 units IM/IMM
5units IV bolus
10 to 20 units/ litre
Usually none painful
contractions nausea,
Vomiting,
(water intoxication)
Hypersensitivity to drug
METHYLERGONOVINE
MALEATE
0.25mg IM/0.125mg IV
repeat every 5 mins as
needed max 5 doses
Peripheral vasospasm
Hypertension nausea,
Vomiting
Hypertension,
Hypersensitivity to drug
CARBOPROST
(15-METHYL PGF2alpha)
0.25 IM/IMM repeat every
15 mins as needed max 8
doses
Flushing, Diarrhea,
Bronchospasm, Nausea,
Vomiting, Restlessness,
Oxygen desaturation
Active Cardiac,
Pulmonary renal or
Hepatic disease,
Hypersensitivity to drug
VASOPRESSIN 20 units diluted in 100ml
normal saline=(0.2
units/ml)
Injected 1 ml at bleeding
site avoid intravascular
injection
Acute hypertension,
Bronchospasm, Nausea,
Vomiting, Abdominal
cramps, Angina,
headache, Vertigo, Death
with intravascular
injection
Coronary artery diseases
Hypersensitivity to drug
93. Fluid volume deficit related to vaginal bleeding
Ineffective tissue perfusion related to vaginal
bleeding
Anxiety / fear related to changes in
circumstances or the threat of death
Risk of infection due to bleeding
Risk of shock : hypovolemic related to bleeding
