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OBSTETRIC EMERGENCIES AND NEONATAL CARE By DR ZAKIA ZAHEEN ASSISTANT PROFESSOR LUMHS, JAMSHORO.

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Presentation on theme: "OBSTETRIC EMERGENCIES AND NEONATAL CARE By DR ZAKIA ZAHEEN ASSISTANT PROFESSOR LUMHS, JAMSHORO."— Presentation transcript:

1 OBSTETRIC EMERGENCIES AND NEONATAL CARE By DR ZAKIA ZAHEEN ASSISTANT PROFESSOR LUMHS, JAMSHORO

2 Obstetrical Emergencies These could be the best calls that you will ever go on or the absolute worst nightmares you could ever imagine!

3 General principles for minimizing an emergency  Promote good antenatal health  Organized intrapartum care  Tiage  Communication and team working  Documentation  Risk management  Emergency training

4 TOP OBSTETRIC EMERGENCIES  Antepartum haemorrhage  Shoulder dystocia  Instrumental deliveries  Cord prolaps  Post partum haemorrhage

5 Antepartum Haemorrhage Bleeding at > 24weeks Top causes:  Placental abruption  Placenta praevia  Uterine rupture  Cervical lesion  Vasa praevia  Unexplained

6 Abruptio Placentae  The partial or complete detachment of a normally implanted placenta at more than 20 weeks.  Occurs in % 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

7 Abrutio Placentae

8 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.

9 Placenta Previa

10 SIGN AND SYMPTOMS Placental abruptionPlacenta praevia Shock out of keeping with visible lossShock in proportion to visible loss Pain constantNo pain Tender, tense uterus (hypertonic)Uterus not tender (hypotonic) Normal lie and presentationBoth may be abnormal Fetal heart absent/distressedFetal heart usually normal Coagulation problemsCoagulation problems rare Beware pre-eclampsia, DIC, anuriaSmall bleeds before large

11 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.

12 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

13 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

14 Specific management for Placenta previa  Avoid vaginal examination  Cesaerean section under general anaesthesia

15 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

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17 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

18 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 kg and 5-7% in infant b/w kg >50% occur in normal weight babies

19 Shoulder Dystocia

20  Risk Factors  Prior shoulder dystocia  Post date pregnancy  Macrosomia  Short maternal structure  Abnormal pelvic anatomy  Prolong first stage or second stage  Instrumental deliveries

21 Complication MaternalNeonatal Perineal injuriesBrachial pluxus palsy Anal sphincter damageClavicle fracture PPHHumeral fracture Uterine ruptureFetal acidosis Symphyseal separationHypoxic brain injury

22 Recognition  Fetal head retract against perineum(turtle sign)  Gentle traction does not effect delivery  Proceed to HELPERR

23 Anterior shoulder

24 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 Rubin II Woodscrew Woodscrew  R: remove posterior arm  R: Roll on all four ( hands & Knees)

25 Supra pubic pressure

26 Robin’s meneuver

27 Removal of posterior arm

28 Maneuvers of last resort  Delibrate clavicle fracture  Zavenelli maneuver  Symphysotomy  Abdominal rescue

29 Postpartum Hemorrhage

30  Estimated blood loss ≥ 500ml  Primary: within 24hrs of delivery  Secondary: 24hrs-6weeks post delivery

31 Causes (4 Ts)  Tone: uterine atony  Tissue: retained placenta or retained products,  Trauma: cervical or perineal, or ruptured uterus,  Thrombin: coagulation disorder

32 Risk factors Antenatal 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

33 PPH – signs  Pale  Confused  Increased HR, reduced BP (late sign)  Reduced urine output  Obvious or hidden bleeding  Relax uterus

34 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

35  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

36  Medical management of atony with oxytocic medicines 1. Syntocinon 2. Ergometrine 3. Carboprost 4. Misoprostol  Surgical management 1. Intra uterine balloon device 2. B lynch suture if at Caesarean section 3. Uterine artery embolisation/ligation 4. Hysterectomy

37 Instrumental Deliveries % 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

38 INSTRUMENTS  Vacuum Malmstorm: historical,rigid metal cup Mityvac: soft plastic cup  Forceps Wringly, Simpson: all purpose forceps Piper, Kielland: for special indication

39 INDICATIONS Maternal indicationMaternal & fetal indication Fetal indications ExhaustionRelative CPDBradycadia Maternal illness( cardiac, HTN) MalpositionNon- reassuring CTG haemorrhageMalpresentation

40 Prerequisites for instrument  Vertex presentation  Cervix fully dilated  Membrane rupture  No known CPD  Willingness to abondon procedure

41 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

42 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

43 Contraindication for Vacumm  Sever prematurity  Breech,Face, Brow presentation  Transverse lie  Unengaged head  Delivery requiring excessive traction

44 Types of Vacuum extractor

45 Vacuum Application Remember A - J  A: Ask for help Ask for help Adress the patient Adress the patient Adequate anaesthesia Adequate anaesthesia  B: Bladder empty Bladder empty  C: Cervix fully dilated Cervix fully dilated

46  D: Determine position Determine position think shoulder dystocia think shoulder dystocia  E: equipment and extractor ready equipment and extractor ready  F: Apply cup over sagittal suture 3 cm in front of posterior frontanel ( FLEXION POINT) Apply cup over sagittal suture 3 cm in front of posterior frontanel ( FLEXION POINT)

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48  G: Gentle traction at right angle to plane of cup, during contraction Gentle traction at right angle to plane of cup, during contraction  H: halt traction after contraction with reduction of pressure halt traction after contraction with reduction of pressure Halt procedure if Halt procedure if disengagement of cup 3 times disengagement of cup 3 times No progress in 3 consecutive pulls No progress in 3 consecutive pulls

49  I: Evaluate for Incision(Episiotomy) at crowning Evaluate for Incision(Episiotomy) at crowning  J: Remove vacuum when Jaw visible Remove vacuum when Jaw visible

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51 Complication of Vacuum  May take longer time than forceps  Cephal haematoma  Subgaleal haematoma  Intracranianl haematoma

52 Post Vacuum care  Cervix and Vaginal examination  Check fetus for birth trauma  Vacuum operative notes

53 Forcep Delivery  Rapid delivery  Baby’s friendly  Can be use in mal presentation  Can be use for rotation  For application remember A- J

54  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

55 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

56  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

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58 Complications of Forcep  Genital tract trauma  Sphincter damage  Fetal facial nerve palsy  Forceps marks

59 Essential Newborn Care & Neonatal Care

60 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

61 The basic needs of a baby at birth  To be protected  To breath normally  To be warm  To be fed

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63 SKIN TO SKIN CONTACT

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67  Monitoring the baby During the first hour after complete delivery of the placenta the baby (and the mother) should be monitored every 15 minutes. 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 hourThe 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 The baby should be kept in skin-to-skin contact after delivery until breastfeeding takes place

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72 POSTNATAL WARD

73 Every day care of the baby -Breastfeed -warmth -Cord care -hygiene -Watching for danger signs

74 THANK YOU

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77 EXAMINATION OF BABY

78 ASSESS BREATHING

79  LOOK AT THE MOVEMENT  LOOK AT THE PRESENTING PART

80  LOOK AT THE ABDOMEN  Jaundice  Umblicus

81  LOOK FOR MALFORMATIONS  TONE  LOOK FOR SKIN PUSTULE  POSTURE

82  FEEL FOR WARMTH  WEIGH THE BABY  ASSESS BREASTFEEDING

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