1. Maternity Complications

2. Complications objective: Describe presentation and management of: Cervical shock Ectopic pregnancy Pre-eclampsia Eclampsia Prolapsed cord Placenta praevia Placenta abruption (APH) Shoulder dystocia Breech presentation Postpartum haemorrhage (PPH)

3. Ectopic Pregnancy: Missed menstrual period (6-8 weeks) Acute lower abdominal pain Spotty vaginal bleeding Shoulder tip pain Fainting Unusual bowel symptoms Signs of shock if ruptured

4. Ectopic Pregnancy Management : Time critical Cannulate Be prepared to manage and treat symptoms shock Analgesia Consider ectopic pregnancy in any woman of child bearing age with abdominal pain. Clinical presentation varies

5. Pre-eclampsia Cause unknown Causes vaso constriction Occurs second half of pregnancy onwards Predisposing factors – hypertension, age 35+ teenagers plus other factors Protein in urine BP 140/90 ++

6. Eclampsia: Seizures; Agitation (severe) - violent twitching Unconsciousness Photophobia Noise sensitivity Management:  Seizure management  Diazepam (Diazemuls –Stesolid)  Obstetrics unit – immediate delivery

7. Prolapsed Cord: Acute obstetric emergency More common in breech Higher risk of occurrence < 34 weeks Exposure to air will cause irritation and cooling which in turn produces vasospasm of the cord vessels Intermittent compression, compromises the foetal circulation Depending on its duration and degree of compression, foetal hypoxia, brain damage and even death can occur

8. Prolapsed Cord Management : Transport asap Use two fingers to replace cord gently in the vagina (JRCALC) Keep cord warm and moist Minimal handling Clinical judgement how to move from home to vehicle Entonox to reduce urge to push Modified Sims position or prone with knees to chest, buttocks raised

9. Suggested Positions for Transporting: Exaggerated Sims position Prone all fours

10. Miscarriage with Cervical Shock Definition: Non-completed expulsion of products of conception through the cervix i.e. incomplete miscarriage The presence of tissue in the cervix for anything other than a short period may cause a vagal reaction with collapse. Sepsis a possibility

11. Management of Cervical Shock Time critical High level oxygen therapy Removal of the remaining products from the cervix by medics in hospital is the key to reversing the shock IV cannulation – BP >90 systolic If bradycardia present administer Atropine.

12. Placenta Praevia : Occurs in the second and third trimesters 24 – 32wks Bleeding revealed and bright red Usually painless unless in labour 1 in 200 pregnancies Malpresentations are common Shock can develop Management: High oxygen Transport asap Fluid therapy to maintain 90 systolic

13. Placenta Abruption: Bleeding in late pregnancy – accompanied by severe continuous abdominal pain Signs of shock Associated with hypertension May be some external blood loss, most usually concealed Abdomen tender, uterus will feel rigid

14. Management Placenta Abruption : Time Critical Treat for shock Ask “when did you last feel baby move” Give fluid early rather than late, signs of shock in the pregnant female ominous as the uterus and the foetus tend to become under- perfused Evidences of 500ml blood start with a bolus of 250ml crystalloid

15. Shoulder Dystocia : Anterior shoulder stuck behind symphysis pubis If the shoulders not delivered within two contractions of the head being delivered – bring the mother into the McRoberts position Alternatively mother on all fours DO NOT PULL THE BABY’S HEAD! If the shoulders not delivered within a further two contractions transport asap

16. Breech: At 28 wks incidence 15% by term reduced to 3-5%

17. Breech: Malpresentations = where the vertex is not entering the pelvis first Results in prolonged labour – emergency delivery Higher rates of perinatal mortality and morbidity Footling presentation = higher risk of cord prolapse Extended (frank) breech = commonest type

18. Breech: Other Forms Face presentations Brow presentations Abnormal lie Actual Breech Delivery

19. Breech Management : Call for midwife IHCD Support in squatting or Recumbent & moved towards edge of the bed with legs supported in lithotomy position Avoid manipulation of the baby’s body – support only – stimulation may cause premature respirations JRCAL recommend if breech delivery transport nearest obstetrics unit ASAP, this is also the recommendation of the midwife (JRCALC overrides IHCD)

20. Postpartum Haemorrhage (PPH): Primary occurs at time of delivery Definition – 500mls + Causes ; –Uterine relaxation (atony) –Retained placental tissue –Genital tract trauma during delivery (tears of the perineum, vagina, cervix)

21. Primary PPH Management: Oxygen therapy Obvious perineal tears – apply direct pressure and pad Uterine bleeding = if soft & ‘atonic’ – feel for top of uterus usually around umbilical level massage with cupped hand in circular motion Treat for shock (normal parameters) however 500ml blood loss observed or altered mental status poor tissue perfusion, start 250ml crystalloid Transport asap

22. Secondary PPH: Occurs > 24 hours post delivery Usually retained placental tissue Possible uterine infection Bleeding usually less severe Consider midwife intervention or if severe treat for shock transport to obstetrics unit asap

23. Inversion of the Uterus Uterus comes down during the expulsion usually still attached to placenta Uncommon

24. Uterine Inversion Management: Time critical Never pull on the cord Do not attempt to replace uterus Wrap in swaps soaked in warm saline Oxygen therapy Transport asap Treat for shock

25. Any Questions?