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OBSTETRIC EMERGENCIES AND NEONATAL CARE

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Presentation on theme: "OBSTETRIC EMERGENCIES AND NEONATAL CARE"— 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 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

11 Spontaneous or traumatic rupture of the uterine wall.
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

16 Prolapsed Cord.

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 >50% occur in normal weight babies
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 Maternal Neonatal Perineal injuries Brachial pluxus palsy
Anal sphincter damage Clavicle fracture PPH Humeral fracture Uterine rupture Fetal acidosis Symphyseal separation Hypoxic 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 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
Syntocinon Ergometrine Carboprost Misoprostol Surgical management Intra uterine balloon device B lynch suture if at Caesarean section Uterine artery embolisation/ligation Hysterectomy

37 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

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 indication Maternal & fetal indication
Fetal indications Exhaustion Relative CPD Bradycadia Maternal illness( cardiac, HTN) Malposition Non- reassuring CTG haemorrhage Malpresentation

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 Adress the patient
Adequate anaesthesia B: Bladder empty C: Cervix fully dilated

46 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)

47

48 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

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

50

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
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

57

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 Skin-to-skin contact and breastfeeding
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

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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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