Near Miss Situations in Labour Room
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Dr Surekha Tayade is Professor of Obstetrics and Gynecology, Mahatma Gandhi Institute of Medical Sciences , Sevagram
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Near Miss Situations in Labour Room
- 1. PROFESSOR, UNIT HEAD, MGIMS, SEVAGRAM Master Trainer, National Nodal center, Emergency Obstetrics Care Master Trainer, National Nodal center, Critical Care in bstetrics Master Trainer, National Nodal center, Maternal Near Miss Co- Leader, Maternal Death Audit, Quality Assurance at National & State Co leader , Maternal Near Miss, National & State Roll Over Member Global Women’s Health Task Force Member Global Women’s Towards Unity for Health Expert Committee Member, National Guidelines for Obstetrics HDU/ICU Expert Committee Member, National Guidelines for Maternal Near Miss Violence Against Women – Work in Community Through Global Health through Training , Education and Service (GHETS) Board Of Studies Member, PIMS, Deemed University
- 2. Near Miss Situations in Labor Room P R O F . S U R E K H A T A Y A D E M B B S , M D , D N B , M N A M S , F I C O G , F I M E , A M R C O G , F A I M E R F E L L O W , P H D M G I M S , S E V A G R A M
- 3. है तेरी मेहरबानी के अंधेरों से हम मुकर गए है तेरी मेहरबानी के बबन जाने ही हम संवर गए
- 4. Learning Objectives Understand –What is near Miss Enumerate situations of Near Miss in LR Case Scenario Based Learning of managing Near Miss .
- 5. The SAGA of Suffering अबला जीवन तेरी हाय यही कहानी ! आंचल में है दूध और आंखों में पानी
- 6. What is Near Miss
- 7. Maternal mortality is “Just the tip of iceberg” Vast base to the iceberg maternal morbidity remains undescribed
- 9. Near Miss is • “A woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of termination of pregnancy” • In practical terms, a very ill woman who would have died had it not been that luck and good care was on her side
- 10. EnumerateHypertensive Crisis Eclampsia Placenta Previa Placental Abruption Postpartum hemorrhage Postpartum Collapse Obstructed Labor Rupture Uterus Amniotic Fluid Embolism Retained Placenta Inversion of uterus Anemia with CCF Ectopic with Shock Medical disorder complicating Pregnancy Thromboembolism Toxicity Acute Pulmonary Edema
- 11. 1.Case Scenario Let’s start with the first one Sheela 22 year old, Primigravida unbooked , inadequate antenatal care, 36 weeks, Referred from district hospital with persistent (lasting 15 min or more), acute-onset, severe hypertension, BP 170/120 mm hg What is the condition? What is the drug of choice for management?
- 12. “ PRINCIPLES • Avoid drastic and sudden lowering of BP. • Maintain DBP : 90-100 mm Hg • Systolic BP > 110 mm Hg LABETALOL • Inj Labetalol : (ACOG 2016 – 1ST LINE) • 20 mg IV, if no response then 40-80mg every 20-30 min, max of 220 mg • for infusion: 1-2 mg/min HYDRALAZINE • Hydralazine (5 mg IV bolus then if needed, 5–10 mg IV every 10-20 min to a maximum of 45 mg) (FIGO 2016) NIFEDIPINE • Nifedipine tablet (10 mg orally every 20-30 min to a maximum of 30 mg) • (FIGO 2016) (RCOG 2011 -1ST LINE)
- 15. ACOG 2016
- 16. 2.Case Scenario Sheela convulses Would you give Magnesium Sulphate immediately? What is the algorithm to manage Eclampsia?
- 17. Check airway and intubate, if required Rapidly evaluate vital sign (pulse,BP,temperature). If pulse not palpable then CPR, intubate and resuscitate. If breathing then give Oxygen (4-6l) by mask or nasal canula. Investigation: Blood group, CBC with platelets, LFT, KFT Magnesium sulfate loading dose: 4 g IV as 8 ml of 50% solution diluted in 12 mL saline over 5 minutes. 10 gm of 50% solution, 5 g in each buttock as deep IM injection (can add 1 mL of lignocaine in same syringe. Maintenance dose of 5 gms IM 4 hourly in alternate buttock Labetolol -10-20 mg IV, then 20-80 mg every 20-30 min, max of 220 mg: for infusion: 1-2 mg/min Nifedipine 10-30 mg PO, repeat in 45 min if needed Hydralazine Inj. 5 mg IV or IM, later 5-10 mg every 30 min once BP is controlled repeat every 3 hours to a max 5 doses Monitor vital sign (pulse, BP & respiration > 16/min), patellar reflexes and urinary output > 30ml/hr Maintain strict fluid balance chart to prevent fluid overload. Provide maintenance dose of anti-convulsive and anti- hypertensive drugs Auscultate lung base hourly for rales ( indication of pulmonary edema) Plan delivery, Monitor progress of labour, LSCS for obstetric indication
- 18. What antihypertensive to provide with Magnesium sulphate? Can we give Magnesium sulphate & Nifedipine together? Nifedipine and Magnesium sulphate given together can cause acute fall in BP, gap should be there between these two drugs, and antihypertensive to be given after measuring BP
- 19. 3.Case Scenario Telephonic Call received from outreach hospital at Utavali Melghat. 24 year old Primigravida with 33 weeks gestation with Twins, referred from Dharni Govt hospital With Eclampsia Loading dose given, 2 gram additional given Patient continuously convulsing Status eclampticus How to manage?
- 20. Questions I asked the Senior Resident Is there a competent anesthesist Do You have arrangement for Blood and Components Availability of Oxygen Ventilator Available Oxytocics Advice- Go ahead, Take consent, Explain situation to relatives Give GA, Do Cesarean section Outcome -Survival Team effort Preterm babies with team effort survived Patient on ventilator for two days, recovered with no residual morbidity
- 21. 4.Case Scenario Radha , 20 year old , 35 weeks of pregnancy ,G2 P1L1A0 has Bleeding Per vaginum and her uterus appears tense and tender , BP 130/90 mmHg Could it be abruption ? Or do you need to rule out Placenta Previa? Is it possible to do this clinically? What is the algorithm to manage Placental Abruption?
- 25. “ “If you can keep your head when all around you are losing theirs, it’s just possible you haven’t grasped the situation.”
- 26. “
- 27. 4.Case Scenario G2P1L1, Prev LSCS ( 4 yr old male child), nurse by profession, wife of anesthetist, shifted from private hospital ( doctor accompanied), in a state of shock. History of 28 weeks IUD terminated with misoprostol, post delivery excessive bleeding, oxytocics, bimanual massage and 1 unit blood transfusion given. Pulse /BP unrecordable , pt shifted directly to OT. On exploration bucket handle tear of Cervix, sutured , still bleeding continued, laparotomy done, vertical posterior wall tear of lower segment extending from below, hysterectomy done, Bilateral internal iliac ligation done. After closure we could still find oozing from vagina , hence vagina packed with adrenaline soaked pack. Patient managed in critical care unit. Received total 22 transfusions, including blood, FFP, Platelets. 3 days patient on ventilator. Vaginal packing done twice. Outcome – survival , no residual morbidity What are learnings from this case? What are guidelines to manage Postpartum hemorrhage?
- 29. “
- 30. Uterine Massage Bimanual Uterine Compression Drugs Oxytocin 10 IM- 20-40 U IV in 500 -1000ml at 125 ml/hr Ergometrine 0.2-0.4 mg IV repeat after 15 mins, 8 hourly max 5 doses Misoprostol 400-800 mcg per rectal Carboprost 250 ug Im every 15 mins max 8 doses Tranexamic acid 1 gm IV Surgical Intervention Removal of Retained placenta Repair of tears Uterine packing Ballon Tamponade Brace Sutures Step vise devascularisation Arterial embolisation Hysterectomy
- 31. “ ▪ Surgical intervention »»Removal of retained placenta »»Repair of tears »»Uterine packing »»Balloon tamponade »»Brace sutures »»Step wise devascularization »»Arterial embolization Hysterectomy
- 32. “ ▪ Documentation is very important ▪ Protocols followed, ▪ Team approach all need documentation
- 33. Kanta had atonic PPH during her second delivery, managed with massive blood transfusion, uterotonics and noninvasive bimanual compression Bleeding stops She is now managed in critical care Unit and is under level two care During next two hours of monitoring We find her respiration is becoming laboured and SPO2 falls , blood pressure falls Anesthetist and Physician team available Patient intubated Echo done – shows left ventricular failure Acute pulmonary Odema and TRALI is suspectedWHAT IS TRALI? How do you manage?
- 35. TRALI Stop transfusion Support patient Intubate Edema fluid investigated for protein CBC, DC, chest X-ray Hypoxemia Hypotension Acute Respiratory distress Pulmonary edema With 6 hours of transfusion Adequate Respiratory and hemodynamic Supportive management
- 36. 30 year old Dulari, unbooked, Primigravida was brought to Utavali Hospital , Melghat at 38 weeks with labor pains,4-5 cm dilated liquor was on higher side , she progressed normally during the next few hours. During second stage , patient collapsed. What could be the cause? Business Finance Leader Economy Risk Profit Rise Idea
- 38. Second Gravida primigravida, booked case, gave history that her mother had PPH when she was born and due to intractable bleeding , her mother died when giving birth to her. Patient apprehensive throughout pregnancy, reassured, all possible high risk factors ruled out. Red Alert written on patient’s case sheet. At term, patient came in labour. Progressed well. Middle of night telephonic call received, patient delivered ,but while removing placenta she has gone in shock. Acute uterine inversion suspected. Prompt management. Immediate reposition advised, done. Patient attended immediately by senior consultant, reposition, resuscitation, Blood transfusion, Oxytocics, critical care management Never ignore any symptom, any apprehension of patient Be Alert
- 39. Survival of acute severe morbidly ill patient Team effort Multidisciplinary approach Infrastructure of HDU/ICU Skilled Health personnel with dedication
- 40. Striving for dedicated care with Excellent Infrastructure of MCH Wing MGIMS, Sevagram
- 41. Place your screenshot here Team Approach
- 42. Efforts to contribute in Reducing Maternal Morality and morbidity in India . Training Of Health Care Professionals in HDU ICU Management Train of Non specialists in EMOC
- 43. We continue in our mission of fighting for survivors
- 44. Thanks !!Any questions? You can find me at stayade@mgims.ac.in