Obstetric Emergency

Definition: Emergency is term that denotes an unexpected or sudden occurrence demanding prompt action.

The list of potential and unexpected obstetric occurrences demands prompt action is extensive. 1.Placental abruption 2.Placental praevia 3.Post-partum haemorrhage * placenta accreta * uterine inversion * puerperal hematoma

4. Uterine rupture 5. Ectopic pregnancy 6. Hypovolaemia due to haemorrhage 7. Eclampcia 8. Amniotic and thromboembolism 9. Obstetric septic shock 10. Acute respiratory failure 11. Pre-Term labour 12. Shoulder dystocia

Post- Partum Haemorrhage Definition Increase blood loss during or following the 3rd stage of more than 600cc. Types-: 1. Primary post Partum haemorrhage 2. Secondary post Partum haemorrhage

Primary Post-Partum Haemorrahage Aetiology: A. Placental site bleeding I. Atonic post-partum haemorrhage A) The factors of predispoic to: 1. Prolonged labour - exhaustion 2. Antepartum haemorrhage 3. Anaemia Fibroid in uters 5. Full Bladder or rectum B. Trauma: Perineum, vulva, vagina and cervix

II. Retention of placenta - partially or complete support III. Hypofibrinogenaemia Clinical Picture A. General examination B. Abdominal Examination C. Vagincal examination

Prophylaxis Avoid predisposing factors A) During labour: a. Avoid traumatic delay delivry b. Proper Management of 3rd stage c. Avoid traction on cord d. Examine birth canal e. Bladder should be empty B) The patient should be observed 2 hours after delivery. C) Delivery in good hospital

Active Treatment 1. Blood Transfusion 2. Fibrinogen 4-10 gm I.V. 3. Double or triple strength plasma 4. Epsilon Amino caproic acid

Secondary Post-partum Haemorrhage Causes: 1. Retained part of placenta 2. Infection. 3. Submucous fibroid 4.Local gynae case - erosion 5. Puerperal inversion 6. Choriocarcinoms 7. Oestrogen withdrawal 8. Choriocarcinoma

Retained Placenta

Placenta failed to be expelled. A) Aetiology 1. Retention, separllted placenta 2. Atony of uterus 3. Contraction ring – hour glass contraction B. Retention of non-separated placenta 1. Atony of uterus 2. Abnormal adhesion of placenta

Clinical Picture 1.Bleeding 2. Atonic uterus 3. Vaginal examination * hour glass * placenta accreta * ruptu of the uterus

Treatment A. In case of uterine atony Ergometrine Massage of uterus Manual removal of placenta B. In case of contraction ring Deep anaesthesia Arrange nitrate inhalation C. In case of adherent placenta Manual removal. D. In case of rupture of uterus

Acute Puerperal Inversion The uterus is partially or completely turned inside out. Aetiology 1. Usually induced pressing fundus traction or cord 2. Spontaneous a. precipitation labour b.traction of fetus on short cord c. submucous fibroid Degree 1st deg 2nd deg 3rd deg

Clinical Picture Shock Bleeding un the placenta attached Pain Treatment A) Prophylaxis B) Active Treatment 1. Anti-shock measures 2. Blood transfusion 3. Reduce invasim

Shock in Obstetrics Types of shock Surgical shock Neurogenic Idiopathic obstetric shock Hypovolaemia shock Emdotoxic or septic shock

Clinical Picture 1. Hypotension 2. Tachycardia 3. Pallor 4. Cyanosis Treatment of shock

Hypofibrinegemia Aetioiogy 1. Concealed accidental haemorrhage 2. IUFD 3. Amniotic fluid embolism Fibrinogen gm IV Antifibrinolysin EACA 4-6 gm

Rupture of Uterus

Indication * Malpresentation * Big size baby * Pendulous * Weak uterine muscle * osteomalacia Aetiology: Rupture during pregnancy: Spontaneous 1. Rupture scar (upper segment ea rean section, myomectomy perforation) 2. Severe concealed accidental haemorrhage 3. Anterior sacculation - incarcerated R.V. gravid uterus 4. Rupture rudimentary haemorrhage of bicornuate uterus

Clinical Picture A. Rupture of uterus during pregnancy or early or in early in labour 1. Severe abdominal pain + sign and symptoms of internal haemorrhage 2. Abdominal - fetus is easly felt - FHS not heard 3. Vaginally - may be vaginal bleeding B. Rupture of the uterus late in labour 1. Spontaneous rupture due to obstructed labour (1) Before actu.1 rupture - impending rupture 2. When actu.al rupture occurs: a. Severe abdominal Pain - cessation of uterine contraction b. shock c. Abdominal fetus is easly felt

Site of Rupture 1. Rupture due to obstructed labour - involve lower uterine 2. Traumatic in late labour involve lower segment and usually incomplete 3. Rupture of upper segment scar - complete 4. Rupture of lower segment scar - complete - incomplete

Clinical Conditions allegedly associated with Utrine Rupture Casesarean Section Oxytocin Multipara Epidural anasthesia Abruptio placenta Mid forceps Breech version / extraction External trauma to the abdomen Pertomlon of uterus - D & C

Rupture during labour I. Spontaneous 1. Obstructed labour 2. Rupture of uterine scar 3. Idiopathic II. Traumatic 1. IPV after drainage 2. Destructive operdon 3. Forceps application II. Improper use of syntoclnon drugs

Types of Rupture 1. Complete 2. Incomplete

Clinical signs and symptome associated with uterine rupture 1. Fetal distress 2. Abdominal pain 3. Vaginal bleeding 4. Recession of presenting part 5. Uterine hypertonias 6. Altered uterine contour

Treatment Blood transfusion Labarotomy Complications A. Maternal 1. Shock 2. Haernorrhage 3. Sepsis 4. Paralytic ileus 5. Injury to the bladder