1. ENHANCING MIDWIFERY COMPETENCIES IN MATERNITY AND NEWBORN CARE Pregnancy Complications

2. General Objectives Describe best practices in identifying and providing initial management of: 1. Hypertension in pregnancy 2. Vaginal bleeding in early and late pregnancy 3. Prelabor rupture of membranes 4. Preterm labor

3. I. HYPERTENSION IN PREGNANCY Objectives 1. To describe the signs and symptoms of hypertension in pregnancy 2. To identify the risk factors and danger signs for pre-eclampsia and eclampsia 3. To discuss midwifery observation and care of a woman with pre-eclampsia and eclampsia

4. PRE-ECLAMPSIA Diagnostic Criteria Hypertension after 20 weeks Proteinuria  1+ Early detection by regular antenatal monitoring and careful follow-up is essential

5. HYPERTENSION Diastolic 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.

6. 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

7. RISK FACTORS for Pre-eclampsia Pre-eclampsia is more common in: Primigravid Young teens Women > 35 years Obese Multiple Pregnancy Women with  Diabetes  H Mole  Essential or renal hypertension  Previous history of pre- eclampsia  Family history of hypertension

8. DANGER SIGNALS Massive pitting pedal edema  (generalized swelling) Severe headache Epigastric pain Vomiting Visual disturbance or blurring of vision

9. Complications of Severe Pre-eclampsia Small baby (IUGR) Stillbirth Abruptio Placenta HELLP syndrome Eclampsia

10. 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.

11. 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

12. Reducing the Risk of Eclampsia Pregnant women should come for antenatal care early – take baseline BP Regular antenatal visits especially in the 3 rd trimester Measure BP at each visit and check urine for protein if diastolic BP>90 mm Hg. REFER if proteinuria develops Counsel woman and family about danger signals of severe pre-eclampsia

13. What to do when seizures occur Call for medical help As 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 blood Stay with woman and protect her from injury but do not restrain her

14. Immediately after the convulsion Set up IVF – run at slow rate Monitor BP, pulse, respiration, level of consciousness. Record. Insert urinary catheter to monitor urine output and test for protein. Arrange for referral

15. 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

16. II. VAGINAL BLEEDING Objectives 1. Identify the causes of bleeding in pregnancy 2. Discuss the emergency treatment for pregnant women with vaginal bleeding 3. Proper referral

17. 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 symptoms Provide initial treatment REFER

18. ALERT SIGNS/SYMPTOMS Fainting History of expulsion of tissues Cramping/lower abdominal pain Tender uterus Tender mass Uterus soft and larger than expected for AOG

19. PREGNANCY STATUS Early This may be abortion, ectopic pregnan cy or molar pregnan cy. 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

20. PREGNANCY STATUS 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

21. 1. Placenta previa - abnormal implantation of the placenta at the lower uterine segment.

22. Classic sign Painless Vaginal Bleeding Uterus – soft, non- tender, with or without uterine contractions, fetus palpable

23. GENERAL MANAGEMENT Ask for Help! and URGENTLY MOBILIZE ALL AVAILABLE PERSONNEL

24. Abruptio Placenta Separation of a normally implanted placenta from the uterus before childbirth.

25. Abruptio Placenta RISK FACTORS 1. Maternal Hypertension, Pre-eclampsia, Chronic hypertension 2. Maternal age 3. Multiparity 4. Cigarette smoking. 5. Maternal trauma 6. Polyhydramnios 7. Poor nutrition

26. Abruptio Placenta BPH Ob-Gyn Classical Sign: UTERUS is HYPERTONIC or TENSE and TENDER on PALPATION ABDOMEN – “BOARD – LIKE IN RIGIDITY“

27. Pre-labor Rupture of Membranes Objectives of the session Define prelabor rupture of membranes (PROM) Review the criteria for diagnosis Describe initial management of PROM

28. 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

29. 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

30. What to do If (+) fever >38°C Foul smelling vaginal discharge No labor Rupture 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

31. 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 diagnosis Name the initial management of PTL

32. 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

33. Signs and symptoms of PTL Contractions Watery vaginal discharge Vaginal bleeding Low dull backache

34. How to diagnose Establish AOG Evaluate contractions Cervical assessment  Sterile speculum examination  Digital examination*

35. What to do Diagnose promptly and correctly Stabilize woman and fetus If woman is lying, encourage her to lie on her left side Check vital signs especially BP

36. 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)

37. Facilitate transfer the hospital with neonatal and obstetrical care

38. SUMMARY Recognition of pregnancy complications  Hypertension during pregnancy  Vaginal bleeding during pregnancy  Prelabor rupture of membrance  Preterm Labor Initial Management Prompt Referral