obstetrician must know,photos are taken from online only for teaching purpose

1. MONITORING
FOR
OBSTETRICIAN
Prof .Nandkishore Agrawal

2. Purpose
To augment the clinical observation and help to
take decision regarding administration of drug
and treatment, to serve patients for better
outcome.

7. Monitoring
• Labor room
• Post operative
• Co existing diseases and Emergencies

8. Types
• Clinical
• Equipment Hi-tech

9. Clinical Monitoring
Basis of patients care
• Constant presence
• Color of the skin
• Rate, depth and pattern of respiration
• Response to painful stimulus & pain relief
• Consciousness and orientation
• Muscle tone
• Pulse rate

10. Monitoring of cardiovascular system
Aim – Ensure adequate oxygen supply to tissues
Clinical - Color and warmth of skin
- Volume of pulse
- Good urine output
- Capillary refill time 3-5 seconds

11. Arterial Pressure
• Palpation
• Non invasive B.P. Monitoring - Manual
- Automatic

12. Monitoring of Respiratory system
Clinical –
• Color of nails, lips
• Movements of chest
• Rate and depth of respiration
• Respiratory sounds
• Auscultation of chest

13. Monitoring of Respiratory system
• Tidal volume
• Airway pressure
• SpO2
• Capnometer

14. Monitoring of nervous system
Clinical
• Consciousness
• Restlessness
• Involuntary movement or convulsions

15. Monitoring of metabolism
• Temperature
• Electrolytes – Na, K, Mg, Ca
• Blood gas analysis
• Blood glucose ,
• Ketones

16. Monitoring of Blood loss & Transfusion
Clinical Monitor
• Hb and PCV
• BT,CT , PT, ACT
• Platelets count

17. Monitoring in Recovery Period
Clinical…………….
• Pulse, Respiration , Temp.
• BP
• Urine output
• Consciousness
• Airway
• SpO2
• IV fluids
• Pain

21. PULSE
• Watch for TACHYCARDIA / BRADYCARDIA

22. • Tachycardia- >100 may lead to coronary Ischemia
•
• Causes- pain
• - hypotension
• May require treatment with beta or calcium blocker
• Other causes call Physician

23. • Bradycardia
• < 60/min treat if <50/min
• causes- inadequate reversal
• - hypoxia eg secretions, laryngo/bronchospasm
• - heart block etc
• Symptomatic treatment or
• T/t- inj. Atropine 0.6mg to 1.2 mg

24. • ?

25. Blood pressure
• Hypotension- SBP < 90 / 60 mm of Hg or 20% less than
baseline
• IV Fluid
• Vasopressor- Mephentermine , phenylephrine,

26. • Hypertension
• Blood pressure > 140/90 mm of Hg
• Pain may increase or may be known HT
• Give normal fluid, as total circulating volume is depleted
due vasoconstriction
• Anesthesia may cause sudden hyper or hypotension
• Never add any antihypertensive abruptly

27. WHY TO CONTROLL HT ?
• Risk of extreme hyper or hypo tension
• Damage to vital organs
• Pulmonary edema or stroke or renal damage
• bleeding

28. ?

29. Sp02
• Normal- 95 to 98 %
• < 93% interfere
• <90 % corresponding Pao2 is 60 mm of Hg ( N :95-
100mm Hg )

30. RESPIRATION
•
Normal rate- 12-20 /min
If Tachypnea > 25 look for cause
Pain
Hypoxia any other
start with OXYGEN

31. OXYGEN
DELIVERY
DEVICES
NASAL
CANNULA
VENTURI
MASK
NON
REBREATHER
PARTIAL
REBREATHER
SIMPLE MASK
31

32. NASAL CANNULA
a 1-6 L/min
b FiO2:- 0.24-0.44
c.PAO2:- Not predicted
SIMPLE MASK
a. 5-8L/min(minimum 5L to
flush C02 from mask)
b .FiO2:- 0.35-0.55
c .PAO2:-209-352mm of Hg
VENTURI MASK
a. As per nozzle
b. FiO2 :-0.24-0.5
c .PAO2 :-131-260 mm
ofHg
PARTIAL REBREATHER
a .6-10 L/min
b FiO2 :-0.50-0.70
c.PA02:- 260-459 mm of Hg
NON REBREATHER
a.6-10 L/min
b.FiO2:- 0.50- 1
c.PAO2 :-240 -673 mm ofHg
32

33. Bradypnea
•
• RR < 12 / min or labored respiration need to intubate
• Causes- inadequate reversal
• - narcotics
• May require IPPV

34. FLUID
• Total circulating blood volume is 70 ml/kg
• Allowable blood loss is 10 % for 11 gm/dl
• 20% for 12 gm/dl
• 30 % for 13 gm/dl
• With target of minimum Hb 10 gm/dl
• WHY?

35. • ?

39. REQUIREMENT OF AN INDIVIDUAL DAILY
• For an adult- 2ml/kg/hr
• Children - 4ml/kg/hr

40. • NORMAL IV SET 1ML= 15 drops
• PAEDIATRIC IV SET 1ML= 60 drops

41. Post operative Fluid therapy
• AIM OF FLUID THERAPY
• BP > 100/70 mm of Hg or MAP >60 mm Hg
• HR < 120/min
• Urine output = 0.5 -1 ml/kg/hr along with normal
temperature , warm skin , normal respiration and senses.
• How long to give fluids?---
• depends upon the type and nature of surgery.

42. ?

43. POST OPERATIVE MONITORING
• Spinal Anesthesia
• General Anesthesia
• MAC

44. NBM
• 6 hour fasting only
• If more give fluid 2ml/kg/h

45. Dehydration ?
• Will delay healing and recovery due increase viscosity
and decrease oxygen delivery

46. Post op management SA
• NBM – minimum 4 hr or as advised
• IVFluid- 2ml/kg/min or 100ml/hr or 30 drops/min
• ½ TPR
• Observe for limb movement ,if not recovered after within ,
6 hrs inform

47. Prevention of PDPH
• Preoperative hydration
• Needle size as small as possible 25 to 29 G
• Post operative fluids
• Keep the patient in supine position 48 hr

48. Treatment PDPH
• Hydration
• Strict bed rest
•
• Analgesics/ caffine
• w/f sign of meningitis
• Call concern

49. • ?

50. PROTOCOL DM
• A controlled patient only to be posted for elective surgery
• FBS - <126 mg/dl
• PBS - <180 mg/dl
• Hba1c - <7.5
• UK- negative

51. OHA
• A patient on OHA may be taken without shifting to
INSULIN in surgical procedure where oral fluid may be
commenced within 4 hrs after surgery
• It require minimum 5-7 days to shift
• NO ROLE OF SLIDING SCALE
• WITH HOLD ANTI DIABETIC AGENTS ON THE DAY
• HYPOGLYCEMIA MAY BE FATAL ( < 60mg/dl )

52. • Now even for DM GLUCOSE MAY BE GIEVEN UNDER
observation
• 2mg/kg/min
• NO ROLE OF NEUTRALIZING INSULIN DRIP
• IF NEEDED INSULIN TO BE GIVEN 1U/hr IIIT
• 50 U IN 50 ML NS
• CHECK CBG HOURLY

53. Risk with Hyperglycemia
• Reduces response of LEUKOCYTS
• Reduces PLATLET AGGREGATION AT WOUND SITE
• INCREASE OSMOLALITY hence viscosity
• REDUCES OXYGEN CARRYING TO VITAL ORGANS
• Uncontrolled patient infection risk may increase from 2%
to 42%

54. • IMPROPERLY CONTROLLED PATEINT MAY HAVE
KETOACIDOSIS OR HSS

55. Risk due to Hypoglycemia
• < 60 mg/dl, cells which are solely dependent on glucose
• RBC
• HEPATIC
• BRIAN
• SUPRA RENAL cell can not serviv

56. • ?

57. HYPERTHYROIDISM
• Increase BMR
• Thyroid storm
• May have delayed recovery or no recovery

58. HYPOTHYROIDISM
• Decreased BMR
• Sensitive to drugs
• Delayed recovery

59. URI or BRONCHOSPASM
• THIS MAY LEAD TO INTRA OR POST OPERATIVE
RESPIRATORY COMPLICATION LIKE
• Laryngospasm
• Bronchospasm
• Pneumonia
• Pulmonary edema
• Prolong ventilation

60. ANEMIA
• A condition where blood does not have enough healthy
red cells
• Normal range- 11 to 13 gm/dl (f)

61. • Mild- 10 to 11 gm/dl
• Moderate- 9.9 to 7 gm/dl
• Severe – < 7 gm/dl

62. Role of Haemoglobin
• To carry oxygen reduces by 50%
• To remove carbon di oxide
• Maintain PH

63. Complications
• Ischemia to vital organs
• Hyper dynamic cardiac failure
• Respiratory failure
• Post op IPPV OR DEATH

64. HELLP Syndrome
• H- HAEMOLYSIS
• EL- ELEVETED LIVER ENZYMS
• LP - LOW PLATELETS

65. Preeclempsia
• High blood pressure >140/90 with one are more
• Protein in urine
• Low platelet count
• Impaired liver function
• Sings of renal involvement
• Pulmonary edema

66. Monitoring
• Blood pressure
• Live function
• Kidney functions
• Platelet count
• Fetal USG
• Nonstress test
• Sings of fluid retention like chemosis, basal crypts ,fall in
Spo2

67. Eclempsia
• Stillbirth or neonatal death 22 -34 %
• Mother may have cerebral damage due to fibrinoid
necrosis of arterioles, microinfarcts and petechial
hemorrhages
• Intense vasospasm leads to pulmonary edema because
of pulmonary endothelial damage ,low osmotic pressure
and increased permiability

68. • Magnesium sulphate
• Diazepam
• Lorezepam
• Phenytoin sodium
• Sodium thiopantethol

69. Monitoring
• Cardiovascular
• Respiratory
• Deep tendon reflexes

70. TOXICITY
• 1.8 to 3 mmol/L - normal
• 3.5 to 5 mmol/L - therapeutic
• 5 to 6.5 mmol/L - respiratory paralysis
• 7.5 mmol/L - delayed cardiac conduction
• 12.5 mmol/L - cardiac arrest

71. Treatment
• 10% CALCIUM GLUCONATE 10 ML SLOWLY

72. •
• DO NOT RESTRICT FLUID IN ECLEMPSIA OR
HYPERTENSIVE PATIENTS AS THIS ARE LOW
CIRCULATING VOLUME STATE DUE VASOSPASM
GIVE NORMAL REQUIRED FLUID