obstetrical emergencies

1. Obstetrical EmergenciesObstetrical Emergencies
SAIMA HABEEBSAIMA HABEEB
Ph.D SCHOLARPh.D SCHOLAR

2. Anatomy & PhysiologyAnatomy & PhysiologyNetter;AtlasofHumanAnatomy

3. One life is lostOne life is lost
in the process ofin the process of
creating anothercreating another
becausebecause
it is obstetrical emergencyit is obstetrical emergency
which when unrecognizedwhich when unrecognized
and mishandledand mishandled
leads to Maternal deathleads to Maternal death

4. DefinitionDefinition
A suddenly developing severe lifeA suddenly developing severe life
threatening condition that isthreatening condition that is
related to pregnancy or deliveryrelated to pregnancy or delivery
which requires urgent medical orwhich requires urgent medical or
surgical therapeautic interventionsurgical therapeautic intervention
in order to prevent the likely deathin order to prevent the likely death
of woman.of woman.

5. An obstetrical emergencyAn obstetrical emergency::
 may occur anytime during pregnancy,may occur anytime during pregnancy,
delivery, or up to 6 weeks after child birth.delivery, or up to 6 weeks after child birth.
 may occur suddenly without any warning.may occur suddenly without any warning.
 is life threatening.is life threatening.
 Requires urgent action.Requires urgent action.
 The patient must be taken to a hospital orThe patient must be taken to a hospital or
first referral unit without any delayfirst referral unit without any delay..

6. Realize that every pregnancy faces theRealize that every pregnancy faces the
risks, even when the previous onesrisks, even when the previous ones
have been normalhave been normal
Every pregnant woman even if she is wellEvery pregnant woman even if she is well
nourished and well educated, can developnourished and well educated, can develop
sudden life threatening complications thatsudden life threatening complications that
require quality obstetric care.require quality obstetric care.

7. RememberRemember
 Excessive bleeding during child birth is dangerousExcessive bleeding during child birth is dangerous
 If quantity of blood lost is more than which can be heldIf quantity of blood lost is more than which can be held
in cupped palm, it is excessivein cupped palm, it is excessive
 Continuous flow of blood, whether or not placenta isContinuous flow of blood, whether or not placenta is
delivered, is dangerousdelivered, is dangerous
 Excessive blood loss, fast &feeble pulse, cold &clammyExcessive blood loss, fast &feeble pulse, cold &clammy
skin are signs of impending loss of consciousnessskin are signs of impending loss of consciousness
 If baby is not delivered within 12 hours of L/P, is anIf baby is not delivered within 12 hours of L/P, is an
emergencyemergency
 If placenta does not come out within 30 minutes ofIf placenta does not come out within 30 minutes of
delivery of baby, is an emergencydelivery of baby, is an emergency

8. Common EmergenciesCommon Emergencies
 HemorrhageHemorrhage
 Hypertensive DisordersHypertensive Disorders
 Acute AbdomenAcute Abdomen
 Umbilical Cord ProlapseUmbilical Cord Prolapse
 Shoulder DystociaShoulder Dystocia
 Vasa praeviaVasa praevia
 Amniotic fluid embolismAmniotic fluid embolism
 Postpartum psychosisPostpartum psychosis

9. Immediate ObstetricImmediate Obstetric
HemorrhageHemorrhage
CauseCause
 LacerationsLacerations
 AtonyAtony
 Abruptio (trauma)Abruptio (trauma)
 Retained placentaRetained placenta
 Previa/AccretaPrevia/Accreta
 RuptureRupture
 InversionInversion
 Sexual assaultSexual assault
IncidenceIncidence
 1:81:8
 1:20-1:501:20-1:50
 1:80-1:1501:80-1:150
 1:100-1:1601:100-1:160
 1:2001:200
 1:2000-1:25001:2000-1:2500
 1:64001:6400

10. HaemorrhageHaemorrhage

11. LacerationsLacerations
 First thing to be ruled out in bleeding postFirst thing to be ruled out in bleeding post
partum woman with a firm uteruspartum woman with a firm uterus
 Careful examination of the entire genital tractCareful examination of the entire genital tract
 Rarely results in massive blood lossRarely results in massive blood loss
 May be life threatening if extends to the retroMay be life threatening if extends to the retro
peritoneumperitoneum

12. Atony (PPH)Atony (PPH)
 Most common cause ofMost common cause of
significant blood losssignificant blood loss
due todue to retained placentaretained placenta
or its bitsor its bits
 Generally responds toGenerally responds to
uterine massage anduterine massage and
uterotonic drugsuterotonic drugs
(oxytonics).(oxytonics).

14. AbruptionAbruption
 Delivery is generally indicted unless the fetus isDelivery is generally indicted unless the fetus is
very premature and both the mother and fetusvery premature and both the mother and fetus
are stableare stable
 Renal failure is the most common cause ofRenal failure is the most common cause of
maternal mortalitymaternal mortality
 Couvelaire uterus results dueCouvelaire uterus results due
to retroplacental clotsto retroplacental clots
 Restriction of physical activityRestriction of physical activity
 No vaginal doucheNo vaginal douche

15. PreviaPrevia
 Transvaginal ultrasound is highly accurate inTransvaginal ultrasound is highly accurate in
making diagnosismaking diagnosis
 Preterm delivery frequently needed due toPreterm delivery frequently needed due to
excessive blood lossexcessive blood loss
or fetal compromiseor fetal compromise

16. AccretaAccreta
 Most frequently seen now when a woman with aMost frequently seen now when a woman with a
previous c/section has placenta overlying theprevious c/section has placenta overlying the
uterine scaruterine scar
 Placenta is adhered to uterine wallPlacenta is adhered to uterine wall
 Manual removal isManual removal is
difficult and needdifficult and need
prompt hysterectomyprompt hysterectomy

17. InversionInversion
 Usually occurs when the placenta is fundallyUsually occurs when the placenta is fundally
implantedimplanted
 Occurs due to mismanagement of 3Occurs due to mismanagement of 3rdrd
stage ofstage of
labour,excessive cord traction, combining fundallabour,excessive cord traction, combining fundal
pressure and cord traction, applying fundalpressure and cord traction, applying fundal
pressure on atonic uterus, pathologically adheredpressure on atonic uterus, pathologically adhered
placenta, fetal macrosomia, short cord,placenta, fetal macrosomia, short cord,
precipitate labour.precipitate labour.
 Patient presents with shock, hemorrhage andPatient presents with shock, hemorrhage and
abdominal pain.abdominal pain.

18. InversionInversion

19. InversionInversion
 Don’t attempt to deliver placenta until thereDon’t attempt to deliver placenta until there
have been signs of separationhave been signs of separation
 Raise the foot endRaise the foot end
 Prompt replacement is generally easier.Prompt replacement is generally easier.
 Halothane or nitroglycerine are effective agentsHalothane or nitroglycerine are effective agents
to relieve pain.to relieve pain.
 Uterotonics (oxytocins) then needed toUterotonics (oxytocins) then needed to
contract the uteruscontract the uterus
 Instillation of 4-5 liters warm saline intoInstillation of 4-5 liters warm saline into
introits and then sealing with hand or softintroits and then sealing with hand or soft
ventouse capventouse cap..

20. Prompt replacement by pushing the fundusPrompt replacement by pushing the fundus
with palm of hand along vagina andwith palm of hand along vagina and
lifting the uterus towards umblicuslifting the uterus towards umblicus

21. Rupture of uterusRupture of uterus
 Frequently the result of uterine scar disruptionFrequently the result of uterine scar disruption
 Commonly occurs in patients who had previousCommonly occurs in patients who had previous
c/section,the multiparous woman receivingc/section,the multiparous woman receiving
oxytocins, mother who is subjected tooxytocins, mother who is subjected to difficultdifficult
forcep/vacuum operationforcep/vacuum operation, or internal uterine, or internal uterine
manipulation.manipulation.
 Incidence has increased with the increase ofIncidence has increased with the increase of
c/sectionsc/sections
 Perforation of non pregnant uterusPerforation of non pregnant uterus
can lead to rupture of uteruscan lead to rupture of uterus
in subsequent pregnanciesin subsequent pregnancies
(Howe-1993, Usta etal-2007)(Howe-1993, Usta etal-2007)

22. Rupture of uterus R/TRupture of uterus R/T
VACUUM/FORCEP DELIVERY IN PASTVACUUM/FORCEP DELIVERY IN PAST

23. Rupture of uterus R/TRupture of uterus R/T
previous caesarean sectionprevious caesarean section

24. Rupture of uterus on OT tableRupture of uterus on OT table

25. Ruptured UterusRuptured Uterus
 Uterine wall thins too much around cervix as fetusUterine wall thins too much around cervix as fetus
growsgrows
 Uterine wall rupturesUterine wall ruptures
 Fetus released into abd/cavityFetus released into abd/cavity
 Mortality to mother usuallyMortality to mother usually
5% to 20%5% to 20%
 Infant mortality over 50%Infant mortality over 50%
 Fetal deaths are reportedFetal deaths are reported
(Flannely etal-1993, Phelan-1990).(Flannely etal-1993, Phelan-1990).

26. Ruptured UterusRuptured Uterus

27. Ruptured UterusRuptured Uterus
Requires immediate surgeryRequires immediate surgery

29. Assessment FindingsAssessment Findings
 Previous uterine rupturePrevious uterine rupture
 Abdominal traumaAbdominal trauma
 Large fetusLarge fetus
 Born more than 2 childrenBorn more than 2 children
 Prolonged or difficult laborProlonged or difficult labor
 Tearing or shearing sensation in abdomenTearing or shearing sensation in abdomen
 Constant severe abdominal painConstant severe abdominal pain
 NauseaNausea
 Signs of shockSigns of shock
 Vaginal bleeding (minor, or heavy)Vaginal bleeding (minor, or heavy)
 Cessation of noticeable uterine contractionsCessation of noticeable uterine contractions
 Palpation of infant in abdominal cavityPalpation of infant in abdominal cavity

30. Rupture of uterus-managementRupture of uterus-management
 Immediate c/section to deliver live babyImmediate c/section to deliver live baby
 Surgical repair usually satisfactorySurgical repair usually satisfactory
 Hysterectomy option depends on theHysterectomy option depends on the
extend of traumaextend of trauma
 Preservation of uterus has reported inPreservation of uterus has reported in
successful future pregnanciessuccessful future pregnancies (O’Connor(O’Connor
&Gaughan-1993)&Gaughan-1993)

31.  Sexual AssaultSexual Assault
 EpidemiologyEpidemiology
 ~1 in 5 women will be raped in their lifetime~1 in 5 women will be raped in their lifetime
 Estimated that as few as 1 in 3 cases are reportedEstimated that as few as 1 in 3 cases are reported
 Recent study showed of 372 victims, only 7% hadRecent study showed of 372 victims, only 7% had
genital injuries. Majority had facial/extremity injuriesgenital injuries. Majority had facial/extremity injuries
 Rape is a crime of powerRape is a crime of power
 ManagementManagement
 Provide for patient’s physical and psychological wellProvide for patient’s physical and psychological well
being firstbeing first
 Non-judgmentalNon-judgmental
 Encourage preservation of evidenceEncourage preservation of evidence
 Provide supportive care as necessaryProvide supportive care as necessary

33. Emergency Care in haemorrhageEmergency Care in haemorrhage
 Monitor vitalsMonitor vitals
 Maintain patent AirwayMaintain patent Airway
 Ensure adequate circulationEnsure adequate circulation
 Treat for shockTreat for shock
 Replace and save blood soaked padsReplace and save blood soaked pads
 Save all tissueSave all tissue
 Provide emotional supportProvide emotional support
 Control bleedingControl bleeding
 Never place anything into vaginaNever place anything into vagina
 Sanitary napkin over vaginaSanitary napkin over vagina
 Immediate transport in left lateral recumbentImmediate transport in left lateral recumbent

34. Hypertensive disordersHypertensive disorders
 Preeclampsia/EclampsiPreeclampsia/Eclampsi
 HTN, edema, proteinuriaHTN, edema, proteinuria
 Cause unknownCause unknown
 Eclampsia is above plus seizuresEclampsia is above plus seizures
 Occur from 20Occur from 20thth
week to 7 daysweek to 7 days
post partumpost partum
 Have been reported up to 26 daysHave been reported up to 26 days
 Most frequent in last trimesterMost frequent in last trimester
 Women in 20’s first time pregnancyWomen in 20’s first time pregnancy
 At risk mothers:At risk mothers:
 DiabetesDiabetes
 Heart diseaseHeart disease
 Renal problemsRenal problems
 HypertensionHypertension
 All gravid pt’s with HTN should be evaluatedAll gravid pt’s with HTN should be evaluated

35. Signs & Symptoms-PreeclampsiaSigns & Symptoms-Preeclampsia
 HypertensionHypertension
 EdemaEdema
 Excessive weight gainExcessive weight gain
 Extreme swelling of face, hands, and feetExtreme swelling of face, hands, and feet
 HeadacheHeadache
 Sensitivity to lightSensitivity to light
 Visual difficultiesVisual difficulties
 Pain in upper abdomenPain in upper abdomen
 Apprehension and shakinessApprehension and shakiness

36. EclampsiaEclampsia
 During seizure placenta can separate from uterineDuring seizure placenta can separate from uterine
wallwall
 Death can also result fromDeath can also result from
 Cerebral hemorrhageCerebral hemorrhage
 Respiratory arrestRespiratory arrest
 Renal failureRenal failure
 Circulatory collapseCirculatory collapse

38.  Preeclampsia/EclampsiaPreeclampsia/Eclampsia
 ManagementManagement
 Supportive for preeclampsiaSupportive for preeclampsia
 If EclampticIf Eclamptic
 Versed/diazepam 2.5-5 mg IV/IMVersed/diazepam 2.5-5 mg IV/IM
 Magnesium 2 gm IV over 5-10 minMagnesium 2 gm IV over 5-10 min
 Rapid transfer for deliveryRapid transfer for delivery
 Suction (if necessary)Suction (if necessary)
 If seizure begins, positive pressure ventilationIf seizure begins, positive pressure ventilation
 Transport in a calm and quiet manner as possibleTransport in a calm and quiet manner as possible
 Complications of Preeclampsia/EclampsiaComplications of Preeclampsia/Eclampsia
 Spontaneous hepatic/splenic hemorrhageSpontaneous hepatic/splenic hemorrhage
 End-organ failureEnd-organ failure
 AbruptioAbruptio
 Fetal compromiseFetal compromise

41. Acute abdomen in PregnancyAcute abdomen in Pregnancy
Acute abdominal pain can be due to:-Acute abdominal pain can be due to:-
 Ectopic Pregnancy (EP)Ectopic Pregnancy (EP)
 Ovarian cystOvarian cyst
 AppendicitisAppendicitis
 UTIUTI
 Abruptio placentaeAbruptio placentae
 Degenerating fibroidDegenerating fibroid
 CholecystitisCholecystitis
 Renal colicRenal colic
 pancreatitispancreatitis

42. Ectopic Pregnancy (EP)Ectopic Pregnancy (EP)
 Implantation of zygote outside the uterusImplantation of zygote outside the uterus
 95% occur in the fallopian tube95% occur in the fallopian tube
 Tubal rupture may occur due to:Tubal rupture may occur due to:
 Coital traumaCoital trauma
 Manipulation during examManipulation during exam
 Gestational age (9-16 wks)Gestational age (9-16 wks)
 SpontaneousSpontaneous
 Represents ~2% of pregnanciesRepresents ~2% of pregnancies
 Leading cause of maternal death in the first trimesterLeading cause of maternal death in the first trimester
 Any female of childbearing age with acuteAny female of childbearing age with acute
abdominal pain is said to have an ectopic pregnancyabdominal pain is said to have an ectopic pregnancy
until proven otherwiseuntil proven otherwise

43. Ectopic Pregnancy (EP)Ectopic Pregnancy (EP)

44.  Ectopic Pregnancy (EP)Ectopic Pregnancy (EP)
 Clinical PresentationClinical Presentation
AmenorrheaAmenorrhea
Bleeding/SpottingBleeding/Spotting Abdominal PainAbdominal Pain

45. Assessment HistoryAssessment History Previous ectopic pregnanciesPrevious ectopic pregnancies
 History of PIDHistory of PID
 Missed menstrual cyclesMissed menstrual cycles
 Sudden, sharp, or knife-like abdominal pain localized onSudden, sharp, or knife-like abdominal pain localized on
one sideone side
 Vaginal spottingVaginal spotting
 Pain radiating to one or both shouldersPain radiating to one or both shoulders
 Tender, bloated abdomenTender, bloated abdomen
 Palpable mass in abdomenPalpable mass in abdomen
 Weakness or dizziness when sitting or standingWeakness or dizziness when sitting or standing
 Decreased BP. (late sign)Decreased BP. (late sign)
 Increased heart rateIncreased heart rate
 ShockShock
 Bluish discoloration around naval (late sign)Bluish discoloration around naval (late sign)
 Urge to defecateUrge to defecate

46.  Ectopic Pregnancy (EP)Ectopic Pregnancy (EP)
 ManagementManagement
 Pertinent historyPertinent history
 Missed mensesMissed menses
 Sexually activeSexually active
 Previous EP, STD, surgery, etc.Previous EP, STD, surgery, etc.
 Lower quadrant pain/tendernessLower quadrant pain/tenderness
 Avoid aggressive palpation/repeated examAvoid aggressive palpation/repeated exam
 Vital signsVital signs
 Orthostatic as appropriateOrthostatic as appropriate
 High flow OHigh flow O22
 Treat for shockTreat for shock
 PositionPosition
 IV accessIV access
 Surgical intervention usually requiredSurgical intervention usually required

47. Ovarian cystOvarian cyst
 Constitutes an emergency if it undergoes torsionConstitutes an emergency if it undergoes torsion
 Pain at onset-unilateral, intermittent & colicky.Pain at onset-unilateral, intermittent & colicky.
Then constant & severeThen constant & severe
 Back pain when cystBack pain when cyst
compresses behindcompresses behind
the uterusthe uterus
 May be febrileMay be febrile
 Cyst may ruptureCyst may rupture
and lead to peritonitisand lead to peritonitis
 Needs prompt surgicalNeeds prompt surgical
interventionintervention

48. AppendicitisAppendicitis
 Leads to spontaneous abortion and prematureLeads to spontaneous abortion and premature
labourlabour
 presents w/ pain-periumblical (rt side) andpresents w/ pain-periumblical (rt side) and
tendernesstenderness
 May rupture-peritonitisMay rupture-peritonitis
 Needs prompt surgeryNeeds prompt surgery

49. UTIUTI
 abrupt onset withabrupt onset with
-chills, rigors and high fever,-chills, rigors and high fever,
-low back ache, flank pain-low back ache, flank pain
-dysuria, sometimes haematuria-dysuria, sometimes haematuria
 Detected from urine testDetected from urine test
 Needs full hydrationNeeds full hydration
 Needs antibiotic therapyNeeds antibiotic therapy
 Care in feverCare in fever

50. Prolapsed CordProlapsed Cord
Umbilical cord presents firstUmbilical cord presents first
 Etiology-Etiology- long cordlong cord
 Cord wrapped around neckCord wrapped around neck
(may be multiple times)(may be multiple times)
 malpresentationsmalpresentations
 Be aware ofBe aware of twins!!!!twins!!!!
 Early ROMEarly ROM
 ManagementManagement
 Unwrap cordUnwrap cord
 If unable, clamp and cut cordIf unable, clamp and cut cord
 If oxytocin is going ,stop it.If oxytocin is going ,stop it.

51. Cord around neck causes fetalCord around neck causes fetal
distress anddistress and hypoxiahypoxia
if not removedif not removed

52. Prolapsed Cord- managementProlapsed Cord- management
Raise the cord by following measures:Raise the cord by following measures:
 Cord is pinched off between the head and vaginal wallCord is pinched off between the head and vaginal wall
 If cord lies outside, replace it gently to prevent spasm, wrap cordIf cord lies outside, replace it gently to prevent spasm, wrap cord
in moist sterile towel soaked with saline, then a warm dry towelin moist sterile towel soaked with saline, then a warm dry towel
to prevent heat loss and drying.to prevent heat loss and drying.
 Insert sterile fingers into vagina to gently lift head or buttocks toInsert sterile fingers into vagina to gently lift head or buttocks to
decrease pressure on cord and keep it elevated till deliverydecrease pressure on cord and keep it elevated till delivery
 GiveGive exaggerated Sims position (3), or knee chest position(1&2)exaggerated Sims position (3), or knee chest position(1&2)
to raise buttocksto raise buttocks

53. Prolapsed Cord- managementProlapsed Cord- management
 Evidence shows that full bladder also helpsEvidence shows that full bladder also helps (Houghton-(Houghton-
2006, Katz etal-1988).2006, Katz etal-1988).
 In these studies, self retained catheter is used to instill appIn these studies, self retained catheter is used to instill app
500-700ml of sterile saline into the bladder. The full500-700ml of sterile saline into the bladder. The full
bladder can relieve compression of the cord by elevatingbladder can relieve compression of the cord by elevating
the presenting part about 2cm above the ischial spinethe presenting part about 2cm above the ischial spine
until delivery by c/ section. The bladder would beuntil delivery by c/ section. The bladder would be
drained in OT immediately before delivery.drained in OT immediately before delivery.
 In community case should be transported to the hospitalIn community case should be transported to the hospital
in knee chest position/ exaggerated Sims position andin knee chest position/ exaggerated Sims position and
keep on checking for pulsation in the cordkeep on checking for pulsation in the cord

54. Shoulder DystociaShoulder Dystocia
 Failure of shoulders to traverse the pelvisFailure of shoulders to traverse the pelvis
spontaneously after birth of headspontaneously after birth of head
 Predisposed in post dated and fetal macrosomiaPredisposed in post dated and fetal macrosomia
 Risk factors in labourRisk factors in labour
 Oxytocin augmentationOxytocin augmentation
 prolonged labourprolonged labour
 operative deliveryoperative delivery
• Blood loss >100mlBlood loss >100ml
• Maternal death fromMaternal death from
ut rupture/haemorrageut rupture/haemorrage
• Neonatal asphyxiaNeonatal asphyxia

55. Sh. Dystocia /managementSh. Dystocia /management
 HELPERRHELPERR mnemonic to disimpact the shouldersmnemonic to disimpact the shoulders
 HHelp-change mothers positionelp-change mothers position
 EEpisiotomy need assessedpisiotomy need assessed
 LLegs in McRoberts positionegs in McRoberts position
 PPressure suprapubicallyressure suprapubically
 EEnter introitus for internalnter introitus for internal
rotationrotation
 RRemove posterior armemove posterior arm
 RRoll the woman over and try againoll the woman over and try again

56. Shoulder DystociaShoulder Dystocia
Mc Roberts position

57. Vasa PraeviaVasa Praevia
 Fetal vessel lies over the os infront of presenting partFetal vessel lies over the os infront of presenting part
 Occurs in valementous/ succenturiate placentaOccurs in valementous/ succenturiate placenta
 May rupture when memb ruptureMay rupture when memb rupture
and causes fresh vaginal bleedingand causes fresh vaginal bleeding
 Causes fetal exsanguinationCauses fetal exsanguination
unless fetus is born withinunless fetus is born within
a minutea minute
 Needs immediate c/sectionNeeds immediate c/section
if in Ist stage and immediateif in Ist stage and immediate
vaginal delivery if in IInd stagevaginal delivery if in IInd stage

58. fetal exsanguinationfetal exsanguination

59. Amniotic Fluid Embolus-AFEAmniotic Fluid Embolus-AFE
 Occurs when amniotic fluid enters the maternalOccurs when amniotic fluid enters the maternal
circulation as a result of:-circulation as a result of:-
 Termination of pregnancyTermination of pregnancy
 Abruptio placenta with open retroplacental vesselAbruptio placenta with open retroplacental vessel
 Precipitate labour with lacerated open cervical vesselsPrecipitate labour with lacerated open cervical vessels
 Amniocentesis with a traumatic tapAmniocentesis with a traumatic tap
 Intrauterine manipulationIntrauterine manipulation
 Mortality rates as high as 60-80%Mortality rates as high as 60-80%
 Higher if meconium stainedHigher if meconium stained
 Clinical PresentationClinical Presentation
 Sudden onsetSudden onset
 Cardiovascular collapseCardiovascular collapse
 SeizuresSeizures
 DICDIC
 Death usually sudden (<1hr.)Death usually sudden (<1hr.)

61. Amniotic Fluid Embolus-AFEAmniotic Fluid Embolus-AFE

62. Amniotic Fluid Embolus-AFEAmniotic Fluid Embolus-AFE
 ManagementManagement
 SupportiveSupportive
 Emergency resuscitationEmergency resuscitation
 OO22 by tight fitting maskby tight fitting mask
 Positive pressure breathing by trachealPositive pressure breathing by tracheal
intubationintubation
 Aminophyllin-200mg i/v slowlyAminophyllin-200mg i/v slowly
 Treatment of shockTreatment of shock
 Continuous assessment of urinary outputContinuous assessment of urinary output
 Better outcome seen in early transferBetter outcome seen in early transfer
(Tuffnell-2002)(Tuffnell-2002)

63. Psychosis/ DepressionPsychosis/ Depression
 Can occur at anytime during pregnancyCan occur at anytime during pregnancy
 May be severe enough to present a significantMay be severe enough to present a significant
suicidal risksuicidal risk
 Newborn care gets disturbedNewborn care gets disturbed
 Patients at risk:-Patients at risk:-
 previous severe neurosis or psychosis,previous severe neurosis or psychosis,
 past pregnancy associated with depression,past pregnancy associated with depression,
 exaggeration of lack of normal emotional responsesexaggeration of lack of normal emotional responses
to pregnancy,to pregnancy,
 severely disturbed marital & family relationship,severely disturbed marital & family relationship,
 physical handicap (imposes limitations),physical handicap (imposes limitations),
 stillborn, neonatal death, malformed babystillborn, neonatal death, malformed baby

64. Psychosis/ DepressionPsychosis/ Depression

65. ManifestationsManifestations
 EarlyEarly:-fatigue, exhaustion, irritability, frequent tearfulness,:-fatigue, exhaustion, irritability, frequent tearfulness,
insomnia, verbalization of feelings of worthless especiallyinsomnia, verbalization of feelings of worthless especially
concerning motherhood potentialconcerning motherhood potential
 LateLate (recognized due to severity): suspiciousness,(recognized due to severity): suspiciousness,
confusion, delusions, disturbed thought process, refusal ofconfusion, delusions, disturbed thought process, refusal of
food, severe insomnia, hyperactivity,, suicidalfood, severe insomnia, hyperactivity,, suicidal
preoccupationpreoccupation
 Management:Management:
 Psychiatric consultationPsychiatric consultation
 prompt therapy of any organic disorderprompt therapy of any organic disorder
 Sedatives to induce sleep and control hyperactivitySedatives to induce sleep and control hyperactivity
 Adequate patient supervisionAdequate patient supervision
 Adequate diet and fluidsAdequate diet and fluids

66. Preterm Labour-PTLPreterm Labour-PTL
 Incidence very high due to associated risk factorsIncidence very high due to associated risk factors
 Premature baby needs emergency care who is usuallyPremature baby needs emergency care who is usually
low birth weightlow birth weight
 Final outcome of preterm labourFinal outcome of preterm labour
Delivery of a :-Delivery of a :-pretermpreterm
-premature-premature
--small babysmall baby
WHOWHO yet needed Mothersyet needed Mothers
womb to grow fullywomb to grow fully

67. Associated Factors of PTLAssociated Factors of PTL
hypertensionhypertension
anemiaanemia

68. diabetesdiabetes

69. multifetal gestationmultifetal gestation hydramnioshydramnios

71. excessive physical exertionexcessive physical exertion

72. StressStress

73. SmokingSmoking
hukkahukka
alcoholalcohol
drugsdrugs

74. PollutantsPollutants

75. Low-socioeconomic statusLow-socioeconomic status

76. Teenage pregnancyTeenage pregnancy

77. Too close pregnanciesToo close pregnancies

79. Infections (fever)Infections (fever)

80. Uterine malformationsUterine malformations

81. Long travel/long standingLong travel/long standing

82. Warning symptoms of PTLWarning symptoms of PTL
-contractions:4-6
times per hour
-Low pelvic pressure
-Dull back pain
-Vaginal leaking

83. Problems of- low birth weight babyProblems of- low birth weight baby
-preterm baby-preterm baby
PTB easilyPTB easily bleedsbleeds,,
-has-has hyperbilirubinaemiahyperbilirubinaemia
Has-Has- poor defensepoor defense
mechanismmechanism
--poor thermoregulationpoor thermoregulation
--poor reflexespoor reflexes
- is asphyxiated- is asphyxiated
-has-has retinopathiesretinopathies,,
- is- is sluggishsluggish
-cannot suck or swallow-cannot suck or swallow
-has-has impaired F/E balanceimpaired F/E balance
andand renal functionrenal function..

84. Needs of premature babyNeeds of premature baby
-- oxygenoxygen
- Inj Vit K , antibiotics,- Inj Vit K , antibiotics,
steroidssteroids
-tube feeding/ i/v fluid-tube feeding/ i/v fluid
--position for easy--position for easy
breathing-15 degreebreathing-15 degree
(head turned to one side)(head turned to one side)
-suctioning using soft-suctioning using soft
suckersucker
-incubator or phototherapy-incubator or phototherapy
-warm environment-warm environment
-support to parents-support to parents

85. Keep the preterm baby well wrappedKeep the preterm baby well wrapped
and examine himand examine him

86. Things to RememberThings to Remember
 Stay calmStay calm
 Explain that you are trained to helpExplain that you are trained to help
 Ensure mothers comfort,Ensure mothers comfort,
modesty & peace of mindmodesty & peace of mind
 Be able to recognizeBe able to recognize
your limitationsyour limitations

87. Impact of obstetrical emergenciesImpact of obstetrical emergencies
 Woman may die or develop disabilitiesWoman may die or develop disabilities
 Children get orphaned due to maternal deathsChildren get orphaned due to maternal deaths
 Motherless children die 10 times moreMotherless children die 10 times more
 The care of children and other family members isThe care of children and other family members is
threatenedthreatened
 Children are less likely to receive HC and educationChildren are less likely to receive HC and education
 Girls in particular suffer. They drop out from schoolGirls in particular suffer. They drop out from school
to look after young siblingsto look after young siblings

88. What can be done to reduce Emergencies andWhat can be done to reduce Emergencies and
prevent maternal & fetal deathsprevent maternal & fetal deaths
 Empower woman ( to increase awareness andEmpower woman ( to increase awareness and
confidence in seeking AN services without delay)confidence in seeking AN services without delay)
 Enhance AN, health and nutrition interventionsEnhance AN, health and nutrition interventions
 Ensure access to H/C facility (blood banks)Ensure access to H/C facility (blood banks)
 Ensure skilled attendant during deliveryEnsure skilled attendant during delivery
 Provide quality care of associated problemsProvide quality care of associated problems
 Ensure rest/good sleep, personal/envir hygieneEnsure rest/good sleep, personal/envir hygiene
 Avoidance of noxious substancesAvoidance of noxious substances
 Avoidance of stress and physical exertionAvoidance of stress and physical exertion

89. Communities can do followingCommunities can do following
 Ensure availability of obstetrical services to allEnsure availability of obstetrical services to all
womenwomen
 Identify the nearest H facility with obs/ B/BIdentify the nearest H facility with obs/ B/B
servicesservices
 Coordinate with hospitals and B/B so to makeCoordinate with hospitals and B/B so to make
blood available in emergencyblood available in emergency
 Organize an emergency obs loan fund so that cashOrganize an emergency obs loan fund so that cash
is available in emergencyis available in emergency
 organize an emergency transport systemorganize an emergency transport system
 Identify all skilled birth attendantsIdentify all skilled birth attendants
 Ensure that all H/W are skilled in identifying signsEnsure that all H/W are skilled in identifying signs
of emergency like heavy bleeding, convulsions,of emergency like heavy bleeding, convulsions,
delayed delivery, retained placenta etcdelayed delivery, retained placenta etc