Dr Surekha Tayade is Professor of Obstetrics and Gynecology, Mahatma Gandhi Institute of Medical Sciences , Sevagram

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

8. Morbidity>>>Mortality
The Continuum

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)

13. “IV Labetalol
Regime
ACOG 2016

14. “IV Hydralazine
regime
ACOG 2016

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?

22. The APH
Algorithm

23. Placenta
Previa
Type 1
and 2

24. Placenta
Previa Type
3 and 4

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?

28. Why
patient
survived?
Shifted with
accompanying
doctor
Immediate
appropriate
surgical
management
Availability
of blood
and
components
Critical
Care Unit

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?

34. Transfusion
Associated
Acute Lung
Injury

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