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Introduction
to
obstetric emergencies
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Placenta previa
The abnormal implantation of theplacenta in the lower uterine segment
most common cause during the second
half of pregnancy
painless, bright red color without
warning
3 types based on degree internal
cervical os is covered by placenta
marginal; partial ;complete .
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Placenta previa (contd)
Maternal morbidity and mortality
Hemorrhage, infection, preterm labour
Fetal risks include malpresentation and
congenital anomalies ;
Diagnosis and medical management
Standard diagnosis is transabdominal
ultrasound examination
Accurate to 97%
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Placenta previa (contd)
Diagnosis and medical management
(contd)
N/C : woman may be hospitalized for closemonitoring
Bed rest
Elective cesarean section before onset ofdelivery
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Abruptio placenta
premature separation of the normallyimplanted placenta after the 20th week ofpregnancy or during labor
uterine tenderness, rigid, pain, N/V 3 types
partial separation with concealed bleeding;
complete separation with concealedbleeding;
partial separation with apparenthemorrhage.
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Abruptio placenta (contd)
Complications
anemia, fetal death,
disseminated intravascular coagulation Nursing Care
Early detection & monitoring
Prepare for Cesarean birth
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Maternal implication of abruptio
placentae
Damage to uterine wall
Trigger large amount of thromboplastin released into the maternalblood supply
Trigger the development of DIC and hypofibrinogenemia ; blood
no longer coagulate
Moderate to severe hemorrhage (hemorrhagic shock)
If not rapidly reversed, renal failure, shock and death
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Fetal-neonatal implication abruptio placentae
Perinatal mortality associated with abruptio placentae(25-35%) (Perry, 2000)
In completed separation , 100% mortality rate
In less severe case, the rate of survival depends on :
level of maturity and time of delivery. (best delivered
within 20 minutes)
Complication : preterm labor, anemia and hypoxia
Irreversible brain damage of the fetus
Prompt action of the health care team
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Prolapse cord
A prolapsed umbilical cord result when umbilicalcord precedes the fetal presenting part when rupture
of membrane occur and presenting part is not well
engaged in the pelvis.
Pressure is placed on the umbilical cord
Vessel carrying to and from the fetus are compressed
Fetal distress (The cord is further compressed with each
contraction if labour start )
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Premature rupture of membrane (PROM)
Def : spontaneous rupture of the membranebefore the onset of labor at any gestational
age.
Cause : unknown; women complains suddengush of fluid or a slow leak of fluid from the
vagina.
Cx: infection e.g chorioammionitis Fetal complications e.g congenital pneumonia,
sepsis and meningitis
Cord prolapse, oligohydramnios cord
compression
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PROM (contd)
Common diagnostic testing
Nitrazine text for the pH of vagina (from yellow to
blue; 7.1-7.3);
Ultrasound for women who are not in labour;
digital examination should not be performed to
determine fetal presentation in these women
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PROM Clinical Therapy
A laboring woman with confirm rupture
membrane should be kept bed rest until fetal
head is well engaged .
FHR should be monitored for at least 1 fullminutes after spontaneous rupture of
membrane or amniotomy performed
If fetal bradycardia detected, vaginal exam isperformed to rule out cord prolapse.
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PROM Clinical Therapy (contd)
If a loop of cord is discovered, the examiner s
gloved fingers must remain in the vagina to
provide firm pressure on the fetal head (to
relieve compression )
Provide oxygen to mother via face mask
Woman assume a kneechest position or bed
is adjusted to trendeleberg position
Fetal heart monitoring
Emergenc casearean birth may be required
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Preterm labor
Labor that occur between 20th and 37th
weeks of gestation
Most causes are unknown Treatment is to delay birth
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Preterm labor
Sign and Symptom frequent uterine contraction (every 10 mins)
menstrual -like cramps
feelings of pelvic pressure, constant orintermittent
low backache, constant or intermittent
change in vaginal discharge abdominal crampingdiarrhoea ruptured membranes
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Preterm labor
High risk group :
Single, young mother
Lower socio-economic statusHypertensive disorders of pregnancy
Gestational diabetes
Antepartum hemorrhage
Congenital malformation
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Tocolysis
Use pharmacological agents to stoppreterm birth
Tocolytics : -adrenergics (Ritodrine, ivi)magnesium sulfate (less S/E)
S/E: tachycardia, palpitations,
nervousness, n/v, headache ,
hypotension.
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Tocolysis
Watch out for s/s of pulmonary
oedema: shortness of breath, chest
tightness, dyspnea, rales and rhonchiNote: respiration
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Tocolysis
Research has demonstrated that a gain of24 hours to several days is the best
outcome that can be expected with the use
of tocolyticsBest reason to use tocolytic therapy is to
administer glucocorticoids in an effort to
accelerate fetal lung maturity and reduceseverity of respiratory complications in
infants born preterm
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Abnormal labour
Dystocia: abnormally slow or difficult delivery
Cephalopelvic disproportion (CPD):
Disproportion between the size of the fetal
head and maternal pelvis.
Failure to progress: lack of progressive
dilataion / descent of the fetal presenting
part;
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Shoulder dystocia
An obstetrical emergency that occurs when
the axis of the fetal shoulders does not deliver
after the fetal head has been delivered.
Most anxiety provoking emergencies
Cx: PPH to mother; fetal injuries
Best management is prevention (DM, obesity,
macrosomia; oxytocin administraton,
instrumental delivery )
Special maneuver may help .
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Amniotic fluid embolism
Def: Entrance of amniotic fluid containing
particules of debris (e.g hair, skin,vernix or
meconium) into the maternal circulation,
resulting in hypoxemia, circulatory collapseand disseminated intravascular coagulation
(Chin , 2001; Ricci,2009)
Rare but is fatal event with sudden onset
Unable to predict or prevent
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Amniotic fluid embolism (contd)
Early identification is critical to improve
maternal and fetal outcomes.
Diagnosis: autopsy
Clinical presentation:
mother complains of difficulty breathing
s/s of cardiorespiratory arrest
Bleeding if DIC
Often unconscious and unresponsive
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Amniotic fluid embolism (contd)
Management
Immediate CPR
Intubate and oxygenate with 100% oxygen if
respiratory arrest
Place pulmonary artery catheter (Swan-Ganz
catheter) to monitor hemodynamic status
Treat cardiogenic shock by IV infusion Treat coagulopathy and blood loss
Monitor fetal conditioin, cesarean section as
needed
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Trauma in pregnancy
Physical trauma occurs in about 1 out of 12
pregnancies
Type:
blunt e.g car accident ; fall, domestic violence
penetrating trauma e.g knife wounds, gunshot
The clinical presentation depends on the
severity and the type of trauma
Placenta abruption may result from severe trauma
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Trauma in pregnancy
The initial management of the fetus is the
support of the maternal airway, breathing and
circulation
Once mother is stabilized, assess FHR and uteine contraction
by CTG (fetocardiotocography)
Abdominal USS
Determine C/S
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Emergency care for obstetric woman
Psychological support to the family
Explaine the situation and inform the need
of EOT,
Encourage husband / significant others to
stay with the women.
Prepare the EOT (NPO ,x-match, foley catheter,
skin preparation, consent , fetal heart
monitoring).
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Emergency care for obstetric woman
The well-being of the fetus depends entirelyon the status of mother .
Vital sign monitoring, report if there is any
abnormality.
Hypoxia and hypovolaemai must be treatedquickly and vigorously.
Patients who are in the last trimester ofpregnancy should be nursed wedged on tothe left side.
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Emergency C/S
Types of care to be delivered?
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The expectant family with loss
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Grieving the Loss
Grief is an individuals total response to a loss,including physical symptoms, thought, and
feelings, functional limitations and spiritual
reaction. Manifestation by certain behaviors such as
weeping or visiting a gravesite, which help the
person experience , accept and adjust to the
loss. The period of adjustment to loss is
known bereavement.
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Grieving the Loss (contd)
Parental and infant attachment can begin
before pregnancy with many hopes and
dreams for the future
Gestational age of baby influences neither
severity of grief response nor bereavement
process
When a baby dies, all members of a familyare affected, but no two family members
grieve in the same way
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Grieving the Loss (contd)
Assessment of each family membersperception and experience of loss is important
Therapeutic communication and counseling
techniques can help families identify theirfeelings, feel comfortable in expressing theirgrief, and understand their bereavementprocess
Nurses need to be aware of their own feelingsof grief and loss to provide a nonjudgmentalenvironment of care and support for bereavedfamilies
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Grieving the Loss (contd)
5 phases:
1. Denial of death of the fetus2. Anger resulting from feeling of loss,
loneliness and guilt
3. Bargaining4. Depression
5. Acceptance
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Grieving the Loss (contd)
Nursing Care- Prior to birth
Assess and identify the family membersability to adapt to the loss, social support &
care Prepare the family for the birth: encourage
the couple remain together as much as theywish
Explain details of the plan of care and allowthe option of labor preference
Encourage the partner to express their feelingand concerns
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Grieving the Loss (contd)
Nursing Care- After birth The woman is transferred to a quiet room away
from nursery
Support the family in viewing the stillborn infant Encourage the parents to see ,touch and name
the baby.
Allow the infant to remain with the family as longas the family desires.
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Grieving the Loss (contd)
Nursing Care - After birth (contd)
Offer remembrances of the baby for theparent to keep ( i.e. lock of hair, baby bracelet,
foot print, hand prints or even a photo helpparents accept the reality of babys death andpromoting grieving process
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Grieving the Loss (contd)
Nursing Caredischarge Focus on physical needs and adaptation of the
mother.
Facilating the familys grief work Provide an opportunities for religious or
spiritual support if required.
Refer to counseling services or communitysupport group