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- 2. HIMANI CHAUHAN Introductio n An obstetric emergency may arise at any time during pregnancy, labour and birth. Hospital care is needed for all obstetric emergencies, as the woman may need specialist care and an extended hospital stay. This may be because of the risk of a premature birth, the loss of a baby or increased risk to the woman's health.
- 3. HIMANI CHAUHAN Definitio n Obstetrical emergencies are life- threatening medical conditions that occur in pregnancy or during or after Labor and delivery.
- 4. Conditions- Causing Emergencies Vasa praevia Cord presentation and cord prolapse Shock Acute inversion of uterus Amniotic fluid embolism/anaphylactic syndrome of pregnancy Rupture of the uterus Shoulder dystocia
- 5. HIMANI CHAUHAN Vasa Previa •The actual incidence is extremely difficult to estimate, it appears that vasa previa complicates approximately 1 in 2,500 births. •It is a life threatening condition. •The term "vasa previa" is derived from the Latin; "vasa" means vessels and "previa" comes from "pre" meaning "before" and "via" meaning "way". In other words, vessels lie before the fetus in the birth canal and in the way.
- 6. Definition – Vasa Previa •It is an abnormality of the cord that occurs when one or more blood vessels from the umbilical cord or placenta cross the cervix but it is not covered by Wharton’s jelly. •It refers to the blood vessels, covered only with amnion and running between chorion and amnion which present first at the cervical os by crossing it ahead of the presenting part. •This condition can cause congestion to vessels and cause hypoxia to the baby.
- 7. Etiological Factors • Velamentous insertion of umbilical cord: in to the membranes at some distance from the edge of the placenta • Succenturiate Placenta: 1 or more accessory Placental lobe joined to the main mass of the placenta. • Low-lying placenta • Previous delivery by C-section.
- 8. Vasa Previa
- 9. Diagnosis • Vaginal Examination : Palpated- membranes intact • FHR synchronizes with Pulsations felt • Speculum Examination: visualize the blood vessel • USG • Fresh Vaginal Bleeding – at ROM due to ruptured Vasa Previa.
- 10. Management of Vasa Previa • Immediate Consultation the Physician. • Monitor FHR • 1st Stage of Labor- if Fetus is alive then Immediate CS • 2nd stage of Labor- induced quickly- Vaginal Delivery • Mode of delivery will be according to the condition of fetus and mother’s parity. • Pediatrician is must, Hb estimation after resuscitation. • Blood transfusion if needed.
- 11. Umbilical Cord- Presentation & Prolapse • Cord Prolapse has 3 clinical types of abnormal descend of the umbilical cord by the side of the presenting part. 1. Occult Prolapse: cord alongside, felt by fingers in vaginal examination. 2. Cord Presentation: slipped down below the presenting part, lies infront in the intact bag. 3. Cord Prolapse: lies infront of the presenting part, inside vagina or outside vulva after ROM.
- 12. Incidence and Predisposing Factors • About 1 in 300 Deliveries • Mainly in Parous women in higher parities. • Predisposing Factors: - Malpresentations: transverse- breech, complete (legs flexed) or footling, face and brow less common. - Prematurity: small size of fetus in relation to pelvis allow cord to slip, LBW <1500gm
- 13. Contd… - Multiple Pregnancy: Malpresentation of the second twin is common in Multiple pregnancy - Polyhydramnios : ROM- sudden gushing of liqour, cord swept down. - High Head : Spontaneous ROM - fetal head high- loop of cord may pass between uterine wall and fetus – lies infront of presenting part - Multiparity : presenting may not get engaged when ROM and Malpresentations are common- leads to slip of cord
- 14. Occult Prolapse
- 15. Diagnosis • Occult Prolapse: difficult to diagnose, variable deceleration of FHR on continuous fetal monitoring, persistent fetal souffle with irregular heart sounds. • Cord Presentation: feeling of pulsation of cord in intact membranes, decelerations of Fetal Heart Rate. • Cord Prolapse: felt below or beside the presenting part, loop cord visible at vulva, cord felt at vagina, high presenting part- felt at cervical os, fetus alive- pulsation felt between contractions.
- 17. Risks to Mother and Fetus • Maternal Risks: it is incidental due to emergency operational delivery – risks of anesthesia, blood loss and infection. • Fetal Risks: Anoxia – acute placental insufficiency, blood flow occluded – due to mechanical compression by presenting part, uterine wall or pelvis wall and due to vasospasm of umbilical cord- exposure or irritation – outside vulva. • More danger- vertex presentation, prolapse through anterior side of pelvis and cervix is partially dilated.
- 18. Management of Cord Presentation • Discontinue vaginal examination- reduce risk of ROM • Summon Medical help immediately • Do Auscultation of Fetal Heart sound frequently by continuous electronic monitoring • CS is the method of delivery • Keep in exaggerated Sim’s position to minimize cord compression during delivery
- 20. Management of Cord Prolapse • Immediate Action: - Call for urgent assistance - Give explanation about condition and treatment - Stop oxytocin if administered - Baby alive- immediate mgt- minimize cord compression and prepare for delivery - Gloved finger must be introduced in to the vagina to lift the presenting part of the cord. Place inside the vagina until definitive treatment is initiated
- 21. Contd… • Postural treatment is given until delivery either vaginally or CS. Exaggerated Elevated Sim’s position with pillow under the hip. • Elevate the foot end of the bed. • High Trendelenburg or knee- chest position will be tiring or distress to the mother. • If cord outside the vagina, replace in to the vagina to minimize vasospasm, irritation and to maintain the temperature. • Much of the cord is outside, cover them with sterile wet gauze to prevent spasm due to draughts.
- 22. Cord Prolapse
- 23. Definitive Management • Baby is sufficiently matured enough to survive, CS is the ideal and immediate management. • If CS is not possible, baby is premature- reposition of the cord. • Cervix must be half dilated and wrap the cord in a large roller gauze piece and push manually the cord above the presenting part under general anesthesia – Vertex presentation and more risks. • Head engaged- forceps delivery, breech- breech extraction. • Baby dead- allow labor and do spontaneous termination.
- 24. HIMANI CHAUHAN Shoulder Dystocia It is the failure of the shoulders to spontaneously traverse the pelvis after delivery. The anterior shoulder may get trapped behind the symphysis pubis while the posterior shoulder may be in hallow of sacrum or high above sacral promontory.
- 25. Contd… • Not a common emergency. • Incidence varies from 0.37 to 1.1. • Risk Factors: Maternal Diabetes, Large Babies, large fetus, family history of large siblings, Maternal obesity, Maternal age over 35 years, High Parity. • Warning Signs: head delivered easily, but chin sweeps with difficulty, turtle sign- after delivery of head, it looks like trying to going back in to the vagina, caused by shoulder traction.
- 26. Contd… • Diagnosis: failed delivery and midwives maneuvers. • Cannot be predicted until head is born. • Management: Stay Calm and get mother’s cooperation . - There must be a obstetrician, anesthetist, pediatrician. - Readiness to manage immediate postpartum.
- 27. Maneuvers to Dislodge Shoulder • Check Position and rotate them in to oblique diameter of the pelvis. • Instruct mother not to push. • Rotation: place all fingers of one hand on side of the baby’s chest, and all the fingers of other hand on baby’s back on opposite side and press with pressure needed to move the baby. • Use whole hand for needed strength. • Do not move the head to avoid brachial or cervical nerve plexus injury or fracture of cervical vertebrae.
- 28. Contd… • Apply downward and upward pressure is applied on the sides of the baby’s head, while another person applies suprapubic pressure. • The person who gives suprapubic pressure must stand on the footstool to get greater force. • Don’t do wrong fundal pressure, which in turn complications more on the delivery of the fetus and mother. • Baby not delivered- cut or enlarge episiotomy
- 29. Contd… • Catheterize the women to empty bladder. • Exaggerated Lithotomy position. • Do Vaginal Examinations after head is born to understand causes of shoulder dystocia- short umbilicus, Large baby, locked twins, conjoined twins, bandl’s ring. • If moderate shoulder dystocia apply suprapubic pressure and deliver the baby.
- 31. McRobert’s Maneuver • Lie flat and knees up to chest as far as possible. • This is to rotate the symphysis pubis superiorly and creates gentle pressure using her own legs on her abdomen, which releases the impact on anterior shoulder. • Requires less pressure to accomplish delivery and less morbidity.
- 33. Suprapubic Pressure • Exert Supra Pubic Pressure on the side of the fetal back and toward the fetal chest. • Helps in addut the shoulder and push the anterior shoulder away from the symphysis pubis.
- 35. Rubin’s Maneuver • Identify the posterior shoulder on vaginal examination. • Then push the posterior shoulder in the direction of the fetal chest, which rotates the anterior shoulder away from the symphysis pubis. • Adducting the shoulders cause- reduction in the 12cm bisacromial diameter
- 36. Rubin’s Maneuver
- 37. Wood’s Maneuver • Insert the hands in to the vagina. • Identify the fetal chest • Exert pressure on the posterior shoulder, achieve rotation. • This abducts the shoulders, rotates them in to favourable diameter and enables the completion of the delivery.
- 38. Wood’s Maneuver
- 39. Zavanelli Maneuver • If wood’s manuever is not successful, then Zavanelli can be used. • It is the last hope to save the child. • Reversal mechanisms of delivery and re insert of fetal head in to the vagina . • Then delivery by CS.
- 41. Complications • Hemorrhage • Rupture of Uterus Maternal • Neonatal Asphyxia • Neonatal Death • Erb’s Palsy from Brachial Plexus injury Fetal
- 42. Hydrocephalus • Excessive accumulation of Cerebrospinal fluid in the ventricles with thinning of the brain tissue and enlargement of the cranium. • It occurs about 1 in 2,000 deliveries. • It is associated with other congenital malformations in one third of the cases. • Recurrence rate is 5% and breech presentation in 25% cases.
- 43. Hydrocephalus- Diagnosis • Head- larger, globular and softer than the normal head- like ping-pong ball squeezed feeling, high up and impossible to push down in to the pelvis. • FH sound high up the umbilicus. • X-Ray will reveal- Cranial Shadow- globular, Fontanels and sutures are visible, vault bones irregular thinning. • USG- dilatation of Lateral Ventricles and thinning of cerebral cortex. • Vaginal Examination- Gaping Sutures and Fontanels, Crackling Sensation on pressing head.
- 44. Management • Continue pregnancy till 36th weeks of gestation. • Induction after 36th week, done by ROM, Oxytocin when 3- 4cm dilatation, decompression of the head is done, using a sharp pointed scissors or perforator. • Breech Presentation: decompress the head by perforating the suboccipital region. • Exploration of the uterus after delivery of the head. • Spina Bifida- uterine dressing forceps, drew smythe catheter is passed through the opening, into the ventricle to drain the fluid.
- 45. Outcome/Prognosis • Fetus is extremely poor. • Born still birth or dies in neonatal period. • Babies who survive will be mentally defective. • Maternal prognosis is favourable. • Sometimes, obstructed labor, Early ROM before cervix dilatation because distension of lower segment by the head.
- 46. Neural Tube Defects • Anencephaly and Spina Bifida comprise 95% of neural tube defects (NTDs) and 5% Encephalocele. • Incidence is about 1 in 1000 births • Develops from deficient development of skull and brain tissue, face will be normal. • Pituitary gland absent or hypoplastic. • 70% female fetus, prevalent in first birth and in both young and elderly mother.
- 47. Contd…
- 48. Diagnosis • First Half of Pregnancy: - Elevated α- Fetoprotein in Amniotic Fluid - Confirmatory test- USG • Second Half of Pregnancy: - Internal examination- face presentation - Confirmatory Test- USG and X-Ray
- 49. Complications • Hydramnios • Malpresentation – Face and Breech • Premature Labor • Tendency of postmaturity • Shoulder dystocia • Obstructed labor • Prevention: • Pre- Pregnancy counselling • Folic Acid supplements (1st Trimester- 12 weeks)
- 50. Management • Confirmed during pregnancy, termination of pregnancy • During labor, shoulder dystocia- managed by cliedotomy Other Conditions: 1) Enlargement of fetal Abdomen- due to acities, distended bladder, tumor or hernia. X- ray and USG reveals the condition by Buddha Position. Decompression of the abdomen will be done by trocar followed by spontaneos delivery. 2) Conjoined Twins.- causes surprise dystocia. These two causes dystocia and thereby emergency during labor.
- 51. Amniotic Fluid Embolism • It occurs when amniotic fluid enters the maternal circulation through a tear in the membranes or placenta. • Body responds in 2 phases: 1) Vasospasm hypoxia hypotension cardiovascular Collapse 2) Left Ventricular failure with Haemorrhage Coagulation Disorder Pulmonary Edema • High Morbidity and Mortality rate
- 53. Pathophysiology Presence of Thromboplastin rich liquor amnii in maternal circulation Blocks pulmonary arteries and triggers DIC Profuse bleeding per vagina/ venipuncture sites due to clotting defect
- 54. Causes/ Predisposing Factors • A tear in membranes • Hypertonic uterine activity • Procedures like insertion of intrauterine catheter, AROM • Placental Abruption • Breached barrier between maternal circulation and amniotic sac • CS, Ruptured Uterus, Termination of Pregnancy • Internal podalic version
- 55. Clinical Signs and Symptoms • Maternal respiratory distress • Severely dyspneic and cynosed • Maternal hypotension • Uterine hypertonia • Fetal distress due to hypoxia caused by hypertonic uterus • Cardiopulmonary arrest • Convulsions preceding to collapse
- 56. Management • It is an acute emergency condition with the above said clinical features • If mother collapsed, needs resuscitation immediately • Specific treatment is life support and high levels of oxygen administration • Mothers who survive may also suffer from neurological diseases
- 57. Complications • Maternal: - Disseminated Intravascular Coagulation (DIC) - Acute Renal Failure - Hypovolemic Hypotension • Fetal: - Fetal distress which leads to fetal death.
- 58. HIMANI CHAUHAN Rupture of Uterus A break in the continuity of the uterine wall anytime beyond 28 weeks of pregnancy is called rupture of uterus.
- 59. Contd… • It is described as Complete rupture and incomplete rupture. • Complete rupture is when there is tear in the wall of the uterus including the peritoneal coat and with or without the expulsion of fetus. • Incomplete rupture is when there is tear of the uterine wall without involving the perimetrium.
- 60. Contd…
- 61. HIMANI CHAUHAN Rupture of Uterus During Pregnancy It is usually complete rupture which involves the upper segment and occurs in later months of pregnancy.
- 62. HIMANI CHAUHAN Rupture During Labor •Intact Uterus, spontaneous rupture due to obstructed labor, it is termed as obstructive rupture. •It involves in lower segment, extends to upper segment through lateral side.
- 63. HIMANI CHAUHAN Scar Rupture •Dehiscence of existing uterine scar, involevs the uterine walls but the fetal membranes remains intact. •Fetus is retained in the uterus and not expelled in to the peritonela cavity. •Usually lower segment scar rupture happens. •Hysterotomy scar rupture in late months of pregnancy.
- 64. Causes • High parity • Injudicious use of Oxytocin • Obstructed labor • Neglected labor in previous CS • Extension of cervical laceration in to lower segment of uterus • Trauma – accident or injury • Perforation of non- pregnant uterus cause rupture in pregnancy subsequent • Previous Classical CS
- 65. Signs and Symptoms of Rupture S.NO Complete Rupture Incomplete Rupture 1 Abdominal Pain Sudden Collapse Insidious Onset and silent 2 Increased Maternal Pulse Rate Discovered after delivery or during delivery 3 Altered FHR and deceleration in Monitor strips Commonly associated with previous CS 4 Fresh vaginal bleeding Scanty blood loss with fibrous scar tissue 5 Uterine con tractions stops and abdominal contour gets alters Postpartum Haemorrhage after vaginal delivery 6 FH sounds may be lost Shock, fails to responds to treatment 7 Fetus palapable at abdomen 8 Shock according to the blood loss and extent of rupture
- 66. Management • Resuscitation followed by laparotomy done simultaneously. • Hysterectomy (quick subtotal). • Repair scar rupture. • Repair and sterilization (tubal ligation)in scar rupture having desired children. • Explanation and preparation of both mother and family are the challenging task a midwife must do, as they might have got the events suddenly.
- 67. Shock • Shock is a critical condition and a life threatening medical emergency. • Shock results from acute, generalized, inadequate perfusion of tissues that needed to deliver the oxygen and nutrients for normal function
- 68. Etiology • Hypovolemia (Hemorrhage (occult /overt), hyperemesis, diarrhea, diabetic acidosis, peritonitis, burns.) • sepsis • Cardiogenic (cardiomyopathies, dysrhythmias). • Anaphylaxis • Distributive (Neurogenic- spinal injury, regional anesthesia
- 69. Diagnosis • There are no laboratory test for shock • A high index of suspicion and physical signs of inadequate tissue perfusion and oxygenation are the basis for initiating prompt management. • Initial management does not rely on knowledge of the underlying cause.
- 70. Initial Mnagement • Maintain ABC • Airway should assured - oxygen 15 lt/min. • Breathing – ventilation should be checked and support if inadequate • Circulation- (with control of hemorrhage) – Two wide bore cannula – Restore circulatory volume • Reverse hypotention with crystalloid. – Crossmatch, • Arrange and give blood if necessary. • See for response such as , vital sign
- 71. Hypovolemic Shock • The normal pregnant woman can withstand blood loss of 500 ml and even up to 1000 ml during delivery without obvious danger due to physiological cardiovascular and haematological adaptations during pregnancy.
- 72. Etiology • Antenatal : - Ruptured ectopic pregnancy - Incomplete abortion - Placenta praevia - Placental abruption - Uterine rupture • Post partum : - Uterine atony - Laceration to genital tract - Chorioamnionitis - Coagulopathy - Retained placental tissue.
- 73. Signs and Symptoms Mild symptoms can include: • headache • fatigue • nausea • profuse sweating • Dizziness
- 74. Contd… Severe symptoms, include:- • cold or clammy skin • pale skin • rapid, shallow breathing • rapid heart rate • little or no urine output • confusion • weakness • weak pulse • blue lips and fingernails • Light- headedness • loss of consciousness
- 75. Management • Basic shock management then treat specific cause. • Laparotomy for ectopic pregnancy • Suction evacuation for incomplete abortion • management of uterine atony • Repair of laceration • Management of uterine rupture – Stop oxytocin infusion if running • Continuous maternal and fetal monitoring
- 76. Contd… • Emergency laparotomy with rapid operative delivery • Caesarean hysterectomy may need to perform if haemorrhage is not controlled. • Management of uterine inversion. • Replacement of the uterus needs to be undertaken quickly as delay makes replacement more difficult. • Administer tocolytics to allow uterine relaxation. • Replacement under taken ( with placenta if still attached)- manually by slowly and steadily pushing upwards, with hydrostatic pressure or surgically
- 77. Cardiogenic Shock • Cardiogenic shock in pregnancy is a life- threatening medical condition resulting from an inadequate circulation of blood. • Pregnancy puts progressive strain on the heart as progresses. • Pre-existing cardiac disease places the parturient at particular risk. • Cardiac related death in pregnancy is the second most common cause of death in pregnancy.
- 78. Signs and Symptoms • Chest pain • Nausea and vomiting • Dyspnoea • Profuse sweating • Confusion/disorientation • Palpitations • Faintness/syncope • Pale, mottled, cold skin with slow capillary refill and poor peripheral pulses. • Hypotension
- 79. Contd… • Tachycardia/bradycardia. • Raised JVP/distension of neck veins. • Peripheral oedema. • Quiet heart sounds or presence of third and fourth heart sounds. • thrills or murmurs may be present and may indicate the cause, such as valve dysfunction. • Bilateral basal pulmonary crackles or wheeze may occur. • Oliguria
- 80. Management • Re-establishment of circulation to the myocardium, • Minimising heart muscle damage and improving the heart’s effectiveness as a pump. • Administer Oxygen (O2) therapy to reduces the workload of the heart by reducing tissue demands for blood flow. • Administration of cardiac drugs such as Dopamine, dobutamine, epinephrine, norepinephrine.
- 81. Septic Shock • This is sepsis with hypotension despite adequate fluid resuscitation. • To diagnose septic shock following two criteria must be met • 1.Evidence of infection through a positive blood culture. • Refractory hypotension- hypotension despite of adequate fluid resuscitation.
- 82. Etiology • Post caesarean delivery • Prolonged rupture of membranes • Retained products of conception • Rupture membrane • Intra-amniotic infusion • Water birth • Retained product of conception • Urinary tract infection • Toxic shock syndrome • Necrotizing Fasciitis
- 83. Signs and Symptoms • Oliguria • Altered mental state • Abdominal pain – Vomiting – diarrohea • Signs of sepsis – Tachycardia ,Pallor • Fever or hypothermia • Tachypnea • Cold peripheries • Hypotension • Confusion
- 84. Management • Transfer to a higher level facility. • Invasive monitoring will inevitable but necessary • Obtain blood culture , wound swab culture and vaginal swab culture. • Start broad spectrum antibiotics. • Removal of infected tissues.
- 85. Anaphylactic Shock • A serious rapid onset of allergic reaction that is rapid onset and may cause death. • It is a relatively uncommon event in pregnancy but has serious implications for both mother and fetus. • Pharmacological agent- penicillin group of drugs. • Insect stings • Foods • Latex
- 86. Signs and symptoms • Cutaneous – Flushing, pruritus, urticaria , rhinitis, conjunctiva erythema, lacrimation. • Cardiovascular – Cardiovascular collapse, hypotension, vasodilation and erythema, pale clammy cool skin, diaphoresis, nausea and vomiting • Respiratory – Stridor, wheezing, dyspnea, cough, chest tightness, cyanosis • Gastrointestinal – Nausea, vomiting , abdominal pain , pelvic pain . • Central nervous system – Hypotension – collapse with or without unconsciousness, dizziness- incontinence – Hypoxia – causes confusion
- 87. Management • Immediate - Stop administration of suspected agent and call for help - Airway maintenance - Circulation – Give epinephrine IM and repeat every 5-15 min until improvement. - In severe hypotension, intravenous epinephrine should be given. - Rapid intravascular volume expansion with crystalloid solution.
- 88. Contd… • Secondary - If hypotension persist alternative vasopressor agent should use. - Atropine if persistent bradycardia - If bronchospasm persist nebulize with salbutamol - Antihistaminic - Steroids - All patient with anaphylactic shock should referred to critical care
- 89. Distributive Shock • In distributive shock there is no loss in intravascular volume or cardiac function. • The primary defect is massive vasodilation leading to relative hypovolemia, reduced perfusion pressure, so poorer flow to the tissues. • Etiology: Spinal injuries- Neurogenic shock
- 90. Sign and symptoms • Hypotension • Bradycardia • Hypothermia • Shallow breathing • Nausea vomiting • No response to stimuli • Unconscious • Blank expression of patient
- 91. Management • Resuscitation • Vasopressor agent and atropine may required in management because spinal injury leads bradycardia due to unopposed vagal stimulation. • Anesthesia -High spinal block • Basic ABC management – Ventilation if needed • Administer iv fluids • IV steroid such as methyl prednisolone • Immobilize the patient to prevent further damage
- 92. Acute Inversion of Uterus • It is an extremely rare but a life threatening complication in 3rd stage in which the uterus is turned upside out partially or completely. • The incidence is about 1in 20,000 deliveries. • The obstetric inversion is almost acute and complete one.
- 93. Varieties/ Types • First degree: there is dimpling of the fundus, which still remains above the level of internal os. • Second Degree: the fundus passes through the cervix but lies inside the vagina. • Third Degree: the endometrium with or without the attached placenta is visible outside the vulva. The cervix and the part of the vagina may also be involved in the process. • It is a complete inversion of uterus. • It may happen before or after separation of the placenta.
- 94. Causes • Spontaneous : localized atony on the placental site • Associated with sharp rise of intra abdominal pressure in coughing, sneezing or bearing down effect • Fundal attachement of the placenta • Short cord • Placenta accreta • Weakness of uterine wall
- 95. Contd… • Iatrogenic : mismanagement of 3rd stage of labor • - pulling the cord when uterus is atonic, along with fundal pressure • Fundal pressure while the uterus is relaxed • Faulty technique in manual removal
- 96. Risk factors • Uterine over enlargement • Prolonged labor • Fetal macrosomia • Morbid adherent placenta • Short umbilical cord • Tocolysis • Manual removal of placenta • Collagen disease- Ehler –Danlos Syndrome
- 97. Dangers of Inversion • Shock: due to neurogenic origin- tension on the nerve due to stretching of the infundibulopelvic ligament - Pressure on the ovaries as they are dragged with the fundus through the cervical ring - Peritoneal irritation • Hemorrhage : - detachment of the placenta • Pulmonary embolism • Uncared may lead to infection, uterine sloughing and a chronic one
- 98. S/S & Diagnosis • Acute lower abdominal pain with bearing down sensation • Signs – varying degrees of shock is a constant feature, - Abdominal examination – cupping or dimpling of the fundal surface - Bimanual examination – it shows the degree - Complete variety- a pear shaped mass protrudes outside the vulva with the broad end pointing downward and looking reddish purple in color. - Sonography – can confirm the diagnosis
- 99. Prognosis • Prognosis is extremely gloomy • Even if patient survives, infection sloughing of the uterus and chronic inversion with ill health may occur • Prevention : mismanagement of 3rd stage of labour must be avoided- do not pull the placenta when the uterus is relaxed to expel it. • Pulling the placenta along with fundal pressure must be avoided. • Manual removal of placenta according to the manner it must be done.(Controlled cord traction)
- 100. Management • Call for extra help • Before the shock develops, manual replacement of uterus without anesthesia by a skilled accoucheur(midwife). • Principal steps- Under GA, - to replace that part first, which is inverted last with the placenta attached to the uterus by steady firm pressure exerted by the finger. • To apply counter support by the other hand placed on the abdomen. • After replacement keep the hand remain inside the uterus until the uterus becomes contracted after parenteral oxytocin or PGF2 alpha .
- 101. Contd… • - the placenta must be removed manually only after the uterus becomes contracted. • How ever it can be removed earlier before replacing the uterus to its position also if, there is partial separation of placenta , and to reduce the bulk which will help in replacing the uterus easily and to minimize the blood loss • Arrange blood transfusion before shock.
- 102. After shock develops…Mgt will be… • Shock treatment must be initiated with urgent normal saline infusion and blood transfusion. • The inverted fundus lies on the palm of the hand with the finger placed near the uterocertical junction. When the pressure is exerted on the fundus, it gradually returns in to the vagina. • Then the vagina is packed with a antiseptic roller gauze. • Raise the foot end of the bed.
- 103. Contd… • Replacement of the uterus using hydrostatic method (O’Sullivan’s method) under GA. • It is more effective and less shock producing. • Method- inverted uterus is replaced into the vagina • Warm sterile fluid – 5 litres gradually instilled in to the vagina through douche nozzle • Block the vaginal orifice by operators palm supplemented by labial opposition around the palm by an assistant. • Otherwise a silicon cup is placed in to the vagina • The douche can be placed at 3 feet above uterus • The water distends the vagina and the consequent increased intravaginal pressure leads to replacement of uterus.
- 104. Mgt in subacute stage… • Improve general condition by blood transfusion • Control infection by antibiotics • Reposition of the uterus either manually or by hydrostatic method • If fails reposition may be done by abdominal operation (Haultain’s operation)
- 105. Thank you