Emergency Obstetric Care

7/29/2019 Emergency Obstetric Care

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EMERGENCY

OBSTETRIC CARE


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Life Is Tough Enough

Without

Having Someone KickYou

From

The Inside.

Rita Rudner

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The moment a child is born, the mother is also born.

She never existed before. The woman existed, but the

mother, never. A mother is something absolutely

new.

Osho


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Age Old Indian Culture

Baby Birth Second Birth

MMR Not Highest But Quite High

2% Land

20% Deaths

Of Globe In India

One Death, >20-60 Disabled

CausesMultiple, Multilayered.

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Disorders Difficulties Dogmas

Pregnancy

Birth Specific

Post Birth

Preexisting Disorders.

Not Immune To Medical Surgical Disorders.


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WHO Estimates 515 000 Maternal Deaths Each

Year

More than one woman dies every minutefrom pregnancy-related causes

What Do Women Die Of? They Die Of Obstetric Complications That Need

Not Be Fatal


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DIRECT OBSTETRIC COMPLICATIONS

Hemorrhage 21%

Unsafe Abortion 14%

Eclampsia 13% Obstructed Labor 08%

Infection 08%

Other 11%

Account for about 3/4 of Maternal Deaths


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Causes of Maternal Deaths Worldwide

8%

8%

20%

Unsafe Abortion

24%

12%

15% 13%

Indirect

Other direct

Obstructed Labour

Haemorrhage

HTD

Infection


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INDIRECT OBSTETRIC COMPLICATIONS

Pre-existing Conditions, including Malaria,

Anemia and Hepatitis ,Increasingly HIV / AIDS

Account for about 1/4 of Maternal Deaths


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Obstetric Complications Occur Suddenly

Without Warning

If women do not receive medical treatment ontime, they will probably

Suffer disabilityOr Die


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Most Obstetric Complications

Can Neither

Be Predicted

Nor Prevented

But If Women Receive

Effective Treatment In Time,

Almost All Can Be Saved


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How Much Time Do We Have?

It is estimated that, if untreated, death

occurs on average in:

2 hours Postpartum Hemorrhage

12 hours Antepartum Hemorrhage

2 days Obstructed Labor

6 days Infection


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To Avert

Death and Disability

We Need To Ensure

That Women have Access To

Emergency Obstetric Care

(EmOC)


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How Can We Improve Access To EmOC?

By making sure

health facilities provide the services needed

to

save womens lives.

Eight key functions signal a facilitysability to provide EmOC


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Why EmOC -

Needs : Doctors competent in providing comprehensiveemergency obstetric care required to make first referral

units functional for 24 hrs. EMOC services.

Status now: Few public sector Obstetricians work in ruralareas.

Opportunity: Many public sector non specialized medicalofficers in rural areas.

Solution: To bridge gap, FOGSI + Govt. preparing nonspecialist medical officers to provide comprehensive

emergency obstetric care in rural India.


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EmOC Key FunctionsCover These Services:

Antibiotics(intravenous or by

injection)

Oxytocic Drugs(ditto) Anticonvulsants

(ditto)

Manual Removal of

Placenta

Removal of

Retained Products

Assisted Vaginal

Delivery Surgery (Cesarean

Section)

Blood Transfusion


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THE GOOD NEWSNot all these functions need hospitalsand doctors

Well-trained nurses and midwives canperform most functions at Basic EmOCFacilities

An Important Point

For Resource Poor Areas


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Objectives of Care During Labor and Childbirth

Protect the life of the mother and newborn .

Support normal labor and detect and treatcomplications in a timely fashion .

Support and respond to needs of the woman, her

partner and family during labor and childbirth

Normal Labor and Childbirth 19


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Birth Preparedness and Complication

Readiness for the Woman and Family

Recognize danger signs

Plan for managing complications

Save money or access funds Arrange transportation

Plan route

Plan place for childbirth

Choose provider

Follow instructions for self-care20


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Diagnose and manage problems and complications

appropriately and in a timely manner

Arrange referral to higher level of care if needed

Provide women-centered counseling about birth

preparedness and complication readiness

Educate community about birth preparedness and

complication readiness

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Complication Readiness

for the Provider

Recognize and respond to danger signs

Establish plan and determine who is in

authority to make decisions in case of

emergency

Develop plan for immediate access to funds

(savings or community loan)

Identify and plan for blood donors and

donationNormal Labor and Childbirth 22


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Ectopic Pregnancy

Risk Factors:Age

Parity

Previous induced abortion

Sterilization failurePID

Diagnosis

Triad - Amenorrhea, Bleeding, Pain

Positive Urine HCG +TVS (Colour Doppler) Placental Flow, Ring OfFire Diagnostic.

Culdocentesis Or Colpocentesis

Used To Be Important Now X23


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Non-contrast MR T2W1 Sensitive,

Specific Highly Accurate

Sensitivity To Fresh Haematoma

Laparoscopy Gold Standard ; Enables Therapy

All Said Clinical + Intusion

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NINE MONTHS NINE PROBLEMSRISKS, JEOPARDIES & SURVIVAL

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Therapy

Surgery Main Ideal Approach? Evidence

Laparoscopy For Some. Laparotomy For

Others Medical Management.

Methotrexate Effective Unruptured Size(


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Septic Abortion

13-15% Maternal Mortality

Induced Abortion law - 1971

But Problems Persist

- Policy Makers

- Program Managers

- Clinicians

- Social Scientists

- Society

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Septic Abortion Ctd.

Local,0.22% Births

0.14% Of Obstetric Admissions,

Critically ill SA10% Case fatality

Diagnosis Delayed Therapy Delayed.

Evacuation

Laparotomy

Hysterectomy.

Right Therapy Right Time28


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Placenta Previa

Major Cause Of Hemorrhage Frequency- 0.7% Births,

Risk Factors?

Outcome Management Strategies, Hemorrhage

Preterm Births

C.S.

In Type I -7%

Type II Anterior Placenta Previa 36.1% ,

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Placenta Previa Ctd

Maternal Neonatal Survival Significant 2 Decades.

Perinatal Mortality 2.7 % 0.56 %

Judicious Extension of Expectant Management.

Blood Transfusion

Improvement in Neonatal Care.

Availability of Ventilator SupportReduction In Prematurity, Intrauterine Hypoxia Essential.

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Placental Abruption

Etiology Hypertensive Disorders+?

Major Cause Of Hemorrhage Deaths

Diagnosis:-Dilemma

With New Technology No Problem

Dangerous For Mother, Baby.

-

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NINE MONTHS NINE PROBLEMSRISKS, JEOPARDIES & SURVIVAL

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Placental Abruption Ctd.

PPH Kills If Precautions Not Taken.

-MMR -PMR

Timely Appropriate Management.

CS Even For Dead Baby

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Hypertensive Disorders

12-15 %

Unknown Etiology Mortality, Morbidity

HELLP- 5-25%

Lipid/Carbohydrate Metabolism

Severe Morbidity No. 1

Maternal mortality No. 1

Severely Ill- Near Miss

Eclampsia 9 %,

Eclampsia with HELLP 6 %

Preclampsia 2 %

Multiple Organ Failure 43 % 35


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Hypertensive Disorder Ctd.Eclampsia

Primary Concern For Mother.Expediting Delivery

Conservative Management

Carefully Selected, Close Supervision ?

Preterm Fetal Maturity

Without Risk To Mother,

Resources Scarce For Very Very LBW

Some Babies Died In UteroStill Improved Perinatal Outcome

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Rupture Uterus

Major Causes

1. Scar rupture

2. Malpresentation + Normal Presentation Obstructed

+2Twins + Retained Second Twin, Transverse Lie

3. Hydrocephalus

4. Morbidly Adherent Placenta Previa

Maternal Death Case-

Multiple Problems

Previous ectopic, Twins, Placenta Previa Accreta

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Management of Rupture Uterus

The Identification Or Suspicion Of UterineRupture Must Be Followed By An Immediate AndSimultaneous Response From The ObstetricTeam.

Surgery Should Not Be Delayed Owing ToHypovolemic Shock Because It May Not BeEasily Reversible Until The Hemorrhage IsControlled.

Upon Entering The Abdomen, AorticCompression Can Be Applied To DecreaseBleeding.

Oxytocin Should Be Administered To Effect Uterine


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Oxytocin Should Be Administered To Effect UterineContraction To Assist In Vessel Constriction And ToDecrease Bleeding.

Hemostasis Can Then Be Achieved By Ligation OfThe Hypogastric Artery, Uterine Artery, Or Ovarian

Arteries.

Decision Must Be Made To Perform Hysterectomy OrTo Repair The Rupture Site.

When Rupture Occurs In The Body Of The Uterus,Bladder Rupture Must Be Ruled Out By ClearlyMobilizing And Inspecting The Bladder To Ensure ThatIt Is Intact. This Avoids Injury On Repair Of The Defect

As Well.


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RETAINED PLACENTA

Delayed Referral, Haemorrhage Morbidly Adherent Placenta

Overall MMR

PMR

T

Treatment is manual removal,

General anesthesia with any volatile agent (1.52minimum alveolar concentration (MAC)) may benecessary for uterine relaxation

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Retained placenta

E

On Rare Occasions, A Retained Placenta Is An

Undiagnosed Placenta Accreta, And Massive Bleeding

May Occur During Attempted Manual Removal.

PPH


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PPH

Single Most Important Cause

Maternal Deaths Worldwide.

Fortunately Incidence

Overall PPH 25 % of Maternal Mortality

Timely management saves life

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PPH


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MANAGEMENT OF PPH


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MANAGEMENT OF PPH


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Atonic PPH:

Bimanual massage,catheterisation,I/V crystalloids,bloodtransfusion

Methergin 0.2mg I/V, Oxytocin 10-40 IU in DNS,

I/MSyntometrine, Rectal Misoprostol upto1000ug,

I/M or intrauterine Carboprost 250ug every 15 min

upto 2 gm

Intra uterine packing, Ballon tamponade


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Surgical management of ATONIC PPH


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Surgical management of ATONIC PPH :under Anaesthesia at OT [stepwise devascularisation]

[i] ligation of bilateral Uterine artery-ascending branch

[ii] ligation of Ovarian and Uterine artery anastmosis

[iii]B-Lynch compression sutures and Multiple square sutures

[iv]ligation of Anterior division of Internal iliac artery

[v]Angiographic uterine artery embolisation

[vi] Sub total/Total Hysterectomy


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MANAGEMENT OF PPH


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AMNIOTIC FLUID EMBOLISM

AFEis rare.[1in 20,000 to 1in 80,000 deliveries]

Fatality rate-30%-80%

Accounts for 7%-10%of direct maternal

mortality in developed countries.


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RISK FACTORS

Induction and augmentation of labour

Operative delivery

Uterine rupture

Amniotomy

Abruptio placentae

IUD Amnioinfusion


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Amniotic fluid may gain entry into maternal

circulation during-

Spontaneous labour and delivery

Amniotomy

Lscs


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Pathophysiology

Acute pulmonary vascular

obstruction+hypertension=cor pulmonale

LVF-hypotension, shock

An acute inflammatory response disrupts the

pulmonary capillary endothelium and alveoli-

ventilation perfusion imbalance-hypoxia-

convulsions,coma


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Diagnosis

Respiratory collapse,dyspnoea,cyanosis,

hypoxia, pulmonary oedema.

CVS--

tachycardia ,hypotension,arrhythmias,cardiacarrest

Uterine hypertonus

Acute fetal hypoxiaIf the woman survives for more than 1 hr, -DIC


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Treatment

Effective CPR

Inotropic support

Inj hydrocortisone500mg iv 6hrly

t/t of DIC

Plasma exchange,haemofiltration

Fetus to be delivered within 10min


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Pulmonary embolism

Leading cause of maternal deaths.

DVTin legs or pelvis most common cause.

S/S-

Tachynoea,dyspnoea,plueritic chest

pain,cough, tachycardia, hemoptysis,temp>37

c

Death-shock, vagal inhibition


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Diagnosis

XRAY chest-diminished vascular markings inareas of infarction,elevation of dome ofdiaphragm,pleural effusion

ECG-tachycardia,right axis shift,nonspecificSTchanges

D Dimer

Doppler-to rule out DVT MRI


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Pulmonary angiography

Spiral CT-inv of choice

MRA-100%sensitivity

Ventilation-perfusion scan


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Summary

What , when where and why of Emergency

obstetric care.

Basic clinical features , diagnosis and

management of emergency obstetric cases.


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THANK YOU

Documents

Emergency Obstetric Care