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ENHANCING MIDWIFERY COMPETENCIES IN MATERNITY AND NEWBORN CARE
Pregnancy Complications
General Objectives
Describe best practices in identifying and providing initial management of:1. Hypertension in pregnancy2. Vaginal bleeding in early and
late pregnancy3. Prelabor rupture of membranes4. Preterm labor
I. HYPERTENSION IN PREGNANCY
Objectives 1. To describe the signs and symptoms of
hypertension in pregnancy2. To identify the risk factors and danger signs
for pre-eclampsia and eclampsia3. To discuss midwifery observation and care
of a woman with pre-eclampsia and eclampsia
PRE-ECLAMPSIADiagnostic Criteria
Hypertension after 20 weeksProteinuria 1+
Early detection by regular antenatal monitoring and careful follow-up is essential
HYPERTENSIONDiastolic BP > 90
mm Hg or more Diastolic BP is the point
when arterial sound disappears
Does not vary much with the woman’s emotional state
Cuff must encircle at least ¾ of the circumference of the arm.
Proteinuria
Urine should always be checked for protein when hypertension is found in pregnancy.
Other causes of protein in the urine UTI Kidney disease Urine contaminated with blood, amniotic fluid or
vaginal discharge Severe anemia Heart Failure
RISK FACTORS for Pre-eclampsia
Pre-eclampsia is more common in:PrimigravidYoung teens Women > 35 yearsObeseMultiple Pregnancy
Women with Diabetes H Mole Essential or renal
hypertension Previous history of
pre-eclampsia Family history of
hypertension
DANGER SIGNALS
Massive pitting pedal edema (generalized swelling)
Severe headacheEpigastric painVomitingVisual disturbance or
blurring of vision
Complications of Severe Pre-eclampsia
Small baby (IUGR)StillbirthAbruptio PlacentaHELLP syndromeEclampsia
ECLAMPSIA
Convulsions in a woman with pre-eclampsia
Convulsions may occur in pregnancy after 20 weeks
AOG, in labor during the first 48 hours
postpartum.
High incidence of maternal and perinatal mortality.
How Eclampsia Affects Mother and Fetus
Effects on mother Respiratory – pulmonary edema Heart Failure Cerebral vascular accidents Acute kidney failure Liver necrosis
HELLP syndrome Visual disturbance Injuries during convulsion
Effects on fetus IUGR Stillbirth
Reducing the Risk of Eclampsia
Pregnant women should come for antenatal care early – take baseline BP
Regular antenatal visits especially in the 3rd trimester
Measure BP at each visit and check urine for protein if diastolic BP>90 mm Hg.
REFER if proteinuria developsCounsel woman and family about danger signals
of severe pre-eclampsia
What to do when seizures occur
Call for medical helpAs soon as possible, clear airway and or give
oxygen at 4–6 L/min.Position the woman on her left side to reduce the
risk of aspiration of secretions, vomit and bloodStay with woman and protect her from injury but do
not restrain her
Immediately after the convulsion
Set up IVF – run at slow rateMonitor BP, pulse, respiration, level of
consciousness. Record.Insert urinary catheter to monitor urine output and
test for protein. Arrange for referral
Protect mother during transport
Put mother in any flat or low surface to prevent from falling during ambulation.
Observe proper maternal positioning and least stimulation during transport.
Never leave alone
II. VAGINAL BLEEDING
Objectives1. Identify the causes of bleeding in pregnancy2. Discuss the emergency treatment for
pregnant women with vaginal bleeding3. Proper referral
Vaginal Bleeding During Pregnancy
Assess the PREGNANCY STATUS EARLY PREGNANCY – uterus is below the umbilicus LATE PREGNANCY – uterus above umbilicus
Assess the AMOUNT OF BLEEDING HEAVY – pad or cloth is soaked in less than 5 minutes LIGHT
Assess for alert signs and symptomsProvide initial treatmentREFER
ALERT SIGNS/SYMPTOMS
Fainting History of expulsion of tissuesCramping/lower abdominal painTender uterusTender massUterus soft and larger than expected for AOG
REFER
• Early• This may be
abortion, ectopic pregnancy or molar pregnancy.
AMOUNT OF BLEEDING
• HEAVY, or with alert signs
• LIGHT, no alert signs
TREATMENT• Reassure the woman
• Insert IV line• IV fluids• Monitor vital
signs • REFER• Reassure• Give iron/folate• Review
emergency plan• Follow up after
2 weeks
• Late• This may
be placenta previa or abruptio placenta
AMOUNT OF BLEEDING
• Any bleeding is dangerous!
• Assess for alert symptoms:
TREATMENT
•DO NOT perform IE!•Insert IV line•Monitor vital signs •Reassure the woman, make her comfortable•REFER
1. Placenta previa
- abnormal implantation of the placenta at the lower uterine segment.
Classic sign
Painless Vaginal Bleeding
Uterus – soft, non-tender, with or without uterine contractions, fetus palpable
GENERAL MANAGEMENT
Ask for Help! and URGENTLY MOBILIZE ALL
AVAILABLE PERSONNEL
Abruptio Placenta
Separation of a normally implanted placenta from the uterus before childbirth.
Abruptio Placenta
RISK FACTORS1. Maternal Hypertension,
Pre-eclampsia, Chronic hypertension
2. Maternal age 3. Multiparity4. Cigarette smoking.5. Maternal trauma6. Polyhydramnios7. Poor nutrition
Abruptio Placenta
BPH Ob-Gyn
Classical Sign: UTERUS is
HYPERTONIC or TENSE and TENDER on PALPATION
ABDOMEN –
“BOARD – LIKE IN RIGIDITY“
Pre-labor Rupture of Membranes
Objectives of the sessionDefine prelabor rupture of membranes (PROM)
Review the criteria for diagnosis
Describe initial management of PROM
Prelabor rupture of membranes (PROM)
Rupture of the bag of water prior to the onset of labor PROM when fetus is > 37
weeks Preterm PROM (PPROM)
when fetus is less than 37 weeks
Diagnosis
• ASK when did membranes rupture?•LOOK at pad for evidence of amniotic fluid or foul smelling vaginal discharge.
• If no evidence, ask her to wear a pad and check again in one hour.
•Measure temperature
•Routine vaginal examination is NOT recommended – increase risk of infection
What to do
If (+) fever >38°C Foul smelling vaginal
dischargeNo laborRupture membranes at
<8 months of pregnancy
Give antibiotic (Ampicillin 2 grams)
REFER to hospital
Rupture of membranes at >8 months pregnancy
Manage as woman in childbirth
Preterm Labor
Objectives: Define preterm labor (PTL) and
recognize its significance to infant mortality and morbidity
Enumerate the causes of preterm labor
Review the criteria for diagnosisName the initial management of PTL
Preterm Labor (PTL)
Definition:Labor before 8
completed months of pregnancy
more than 1 month before estimated date of birth
At 24 – 34 weeks gestation
Signs and symptoms of PTL
ContractionsWatery vaginal
dischargeVaginal bleedingLow dull
backache
How to diagnose
Establish AOGEvaluate contractionsCervical assessment
Sterile speculum examination
Digital examination*
What to do
Diagnose promptly and correctlyStabilize woman and fetusIf woman is lying, encourage her to lie
on her left sideCheck vital signs especially BP
PRETERM LABOR
If BP is normal and no heart problem
Give Nifedipine 10mg tablet orally (not under the tongue) every 6 hours until she reaches a CEmONC facility
Give Dexamethasone 6mg intramuscularly every 12 hours until she reaches a CemONC facility ( up to a total of 4 doses)
Facilitate transfer the hospital with neonatal and obstetrical care
SUMMARY
Recognition of pregnancy complications Hypertension during pregnancy Vaginal bleeding during pregnancy Prelabor rupture of membrance Preterm Labor
Initial ManagementPrompt Referral