1. Shock
-a complex syndrome involving a reduction in blood flow to the tissues
result in irreversible organ damage and progressive collapse of the circulatory system
If left untreated it will result in death.
Shock can be acute but prompt treatment results in recovery, with little detrimental effect on the woman.

2. In -effective treatment, or inadequate treatment, can result in a chronic condition ending in multisystem organ failure, which may be fatal
Shock can be classified as follows:
hypovolaemic: the result of a reduction in intravascular volume such as in severe haemorrhage during childbirth
septic or toxic: occurs with a severe generalized infection
cardiogenic: impaired ability of the heart to pump blood; in midwifery it may be apparent following a pulmonary embolism or in women with cardiac defects

3. neurogenic: results from an insult to the nervous system as in uterine inversion
anaphylactic: may occur as the result of a severe allergy or drug reaction.
hypovolaemic shock and septic shock,this will be discuss

4. Hypovolaemic shock
caused by any loss of circulating fluid volume as in haemorrhage, but may also, occur when there is severe vomiting.
Initial stage
-The reduction in fluid or blood decreases the venous return to the heart.
-The ventricles of the heart are inadequately filled, causing a reduction in stroke volume and cardiac output.
-As cardiac output and venous return fall, the blood pressure is reduced. The fall in blood pressure decreases the supply of oxygen to the tissues and cell function is affected.

6. Compensatory stage
-The fall in cardiac output produces a response from the sympathetic nervous system through the activation of receptors in the aorta and carotid arteries.
-Blood is redistributed to the vital organs. Vessels in the gastrointestinal tract, kidneys, skin and lungs constrict.
the skin becoming pale and cool.
- Peristalsis slows down, urinary output is reduced and exchange of gas in the lungs is impaired as blood flow diminishes.
-The heart rate increases in an attempt to improve cardiac output and blood pressure. The pupils of the eyes dilate.

7. - The sweat glands are stimulated and the skin becomes moist and clammy.
Adrenaline (epinephrine) is released from the adrenal medulla and aldosterone from the adrenal cortex.
-Antidiuretic hormone (ADH) is secreted from the posterior lobe of the pituitary. Their combined effect is to cause vasoconstriction, increased cardiac output and a decrease in urinary output. Venous return to the heart will increase but, unless the fluid loss is replaced

8. Progressive stage multisystem organ failure.
-Compensatory mechanisms begin to fail, with vital organs lacking adequate perfusion.
- Volume depletion causes a further fall in blood pressure and cardiac output.
-The coronary arteries suffer lack of supply and peripheral circulation is poor, with weak or absent pulses.

9. Final, irreversible stage of shock
Multisystem organ failure and cell destruction are irreparable and death ensues.
Effect of shock on organs and systems
compensate for loss of up to 10% of blood volume, by vasoconstriction.
When that loss reaches 20–25%, however, the compensatory mechanisms begin to decline and fail.

10. In pregnancy the plasma volume increases, as does the red cell mass
In pregnancy the plasma volume increases, as does the red cell mass. The increase is not proportionate, but allows a healthy pregnant woman to sustain significant blood loss at birth as the plasma volume is reduced
an antepartum haemorrhage, the woman is more
susceptible to experience a pathological effect on the body and its systems following a much lower blood loss during childbirth. Individual organs are affected as below

11. Brain
The level of consciousness deteriorates as cerebral blood flow is compromised.
- unresponsive to verbal stimuli and there is a gradual reduction in the response elicited from painful stimulation.
Lungs
Gas exchange is impaired
Levels of carbon dioxide rise and arterial oxygen levels fall.

12. Ischaemia within the lungs alters the production of surfactant and, as a result of this, the alveoli collapse.
Oedema in the lungs, due to increased permeability.
Atelectasis, oedema ,impair ventilation and gaseous exchange, leading ultimately to respiratory failure. This is known as adult respiratory distress syndrome (ARDS).

13. Kidneys
The renal tubules become ischaemic owing to the reduction in blood supply.
As the kidneys fail, urine output falls to less than 20 ml/hour.
The body does not excrete waste products such as urea and creatinine, so levels of these in the blood rise.
Gastrointestinal tract
The gut becomes ischaemic and its ability to function as a barrier against infection wanes.
Gram-negative bacteria are able to enter the circulation.

14. Liver
Drug and hormone metabolism ceases, as does the conjugation of bilirubin.
Unconjugated bilirubin builds up
jaundice develops.
liver fails to act as a filter.
a build-up of lactic acid and ammonia in the blood.
Death of hepatic cells releases liver enzymes into the circulation.

15. Management
Urgent resuscitation is needed to prevent the irreversible damage
The priorities are to:

16. Call for help:
Maintain the airway: if the woman is severely collapsed she should be turned on to her
side and 40% oxygen administered at a rate of 4–6 l/min. If she is unconscious, an airway should be inserted.
Replace fluids: two wide-bore intravenous cannulae should be inserted to enable fluids and drugs to be administered

17. cross-matching
A crystalloid solution such as normal saline, Hartmann's, or Ringer's lactate is given until the woman's condition has improved.
No more than 1000–1500 ml of colloid such as Gelofusine or Haemocel should be given in a 24 hours period.
Packed red cells
fresh frozen plasma are infused

19. the source of the bleeding needs to be identified and stopped.
Warmth: it is important to keep the woman warm, but not over warmed or warmed too quickly, as this will cause peripheral vasodilatation and result in hypotension.

20. Assessment of clinical condition.
A clear protocol for the management of shock should be used
staff on the critical care unit if the woman has been transferred there for subsequent care

21. Hypovolaemic shock in pregnancy will reduce placental perfusion and oxygenation to the fetus, resulting in fetal distress and possibly death
the fetal heart is present, to save the woman's life, this should be the first priority.
Detailed MEOWS observation charts including fluid balance should be accurately maintained.

23. Observations and clinical signs of deterioration in hypovolaemic shock
Assess level of consciousness in association with the Glasgow Coma Score (GCS). using eye opening, motor response and verbal response. A total of 15 points can be achieved, and one of <12 is cause for concern. Any signs of restlessness or confusion should be noted
Assess respiratory status using respiratory rate, depth and pattern, pulse oximetry and blood gases. Humidified oxygen should be used if oxygen therapy is to be administered for any length of time.

24. Monitor blood pressure continuously, or at least every 30 minutes
Monitor cardiac rhythm continuously.
Measure urine output hourly, using an indwelling catheter and urometer.
Assess skin colour including core and peripheral temperature hourly.

25. a central venous pressure (CVP)
haemodynamic measures of pressure in the right atrium are taken to monitor infusion rate and quantities.
The fluid balance recorded accurately.
Observe bleeding, including lochia, or oozing from a wound or puncture site.
haemoglobin and haematocrit
. A lateral tilt to prevent aortocaval compression if a gravid uterus is likely to compress the major vessels.

27. Key points for managing hypovolaemic shock
Call for help
Identify the source of bleeding and control
using two wide-bore cannulae
infuse intravenous fluid to correct loss
Assess for coagulopathy and correct
Manage the underlying condition

28. Central venous pressure
CVP is the pressure in the right atrium or superior vena cava and is an indicator of the volume of blood returning to the heart,
Normal CVP values will change with gestation, and can vary between +5 and+10 cmH2O.
Values within this range indicate that the vascular space is well filled and red cell transfusion would not be necessary.

29. monitoring of CVP aids assessment of blood loss with a negative value indicating the necessity for fluid replacement
CVP results are more useful clinically and are interpreted in conjunction with fluid balance and peripheral perfusion.

32. hypervolaemia or hypovolaemia, cardiac and renal failure may result.
Septic shock
Death and serious illness from pregnancy-related sepsis are rare.
earlier interventions in treatment of any underlying infection
Septic shock. Certain organisms produce toxins that cause fluid to be lost from the circulation into the tissues

33. .

34. beta-haemolytic Streptococcus pyrogenes (Lancefield Group A) (
This is a Gram-positive organism, responding to intravenous antibiotics, specifically those that are penicillin-based.

35. Gram-negative organisms Escherichia coli, Proteus or Pseudomonas pyocyaneus are common pathogens in the female genital tract.
The placental site and perineal wounds are the main points of entry for an infection associated with pregnancy and childbirth.
prolonged rupture of fetal membranes, birth trauma, septic abortion or in the presence of retained placental tissue.

36. Clinical signs tachypnoea tachycardia
pyrexia or extremely low temperature
rigors.,a temperature recording may appear normal if the woman has taken paracetamol as this will reduce pyrexia.
onfused or anxious, exhibiting a change in her mental state.
Abdominal pain and gastrointestinal symptoms are common in pelvic sepsis.

37. hypotension, develop in septic shock
Haemorrhage ,in septic shock due to disseminated intravascular coagulation (DIC)
MEOWS chart to determine

38. Management an anaesthetist and the critical care team
preventing further deterioration in the woman's condition
restoring circulatory volume
eradication of the infection.
intravenous antibiotics is essential
Replacement of fluid volume will restore perfusion of the vital organs

40. Fluid balance ,fluid overload may lead to fatal pulmonary or cerebral oedema.
maintaining high standards of care in clinical procedures.
A infection screening (a high vaginal swab, throat swab, midstream specimen of urine and blood cultures.)
Retained products of conception can be detected on ultrasound, and these can then be removed if they are apparent.
relatives should be kept informed of her progress.

42. Drug toxicity/overdose
should be considered as a cause in all cases of maternal collapse.
. Common sources of drug toxicity in midwifery and obstetric practice are local anaesthetic agents injected intravenously by accident and magnesium sulphate given in the presence of renal impairment