EMERGENCY OBSTETRIC CARE

Life Is Tough Enough Without Having Someone Kick You From The Inside.

Rita Rudner

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

 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 Causes Multiple, Multilayered.
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Disorders Difficulties Dogmas

Pregnancy Birth Post Birth

Specific

Preexisting Disorders. Not Immune To Medical Surgical Disorders.

 WHO Estimates 515 000 Maternal Deaths Each Year

More than one woman dies every minute from pregnancy-related causes
What Do Women Die Of? They Die Of Obstetric Complications That Need Not Be Fatal

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

Causes of Maternal Deaths Worldwide

Infection Unsafe Abortion

15%

13%
Indirect

Haemorrhage

20%

24%

12%

8% 8%
Other direct

HTD

Obstructed Labour

INDIRECT OBSTETRIC COMPLICATIONS

Pre-existing Conditions, including Malaria, Anemia and Hepatitis ,Increasingly HIV / AIDS Account for about 1/4 of Maternal Deaths

Obstetric Complications Occur Suddenly

Without Warning
If women do not receive medical treatment on time, they will probably Suffer disability Or Die

Can Neither Be Predicted Nor Prevented

Most Obstetric Complications

But If Women Receive Effective Treatment In Time,

Almost All Can Be Saved

How Much Time Do We Have?

It is estimated that, if untreated, death occurs on average in:

2 hours 12 hours 2 days 6 days

Postpartum Hemorrhage Antepartum Hemorrhage Obstructed Labor Infection

To Avert Death and Disability

We Need To Ensure That Women have Access To

Emergency Obstetric Care

(EmOC)

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 facilitys ability to provide EmOC

Why EmOC Needs : Doctors competent in providing comprehensive

emergency obstetric care required to make first referral units functional for 24 hrs. EMOC services.

Status now: Few public sector Obstetricians work in rural

areas.

Opportunity: Many public sector non specialized medical

officers in rural areas.

Solution: To bridge gap, FOGSI + Govt. preparing non

specialist medical officers to provide comprehensive emergency obstetric care in rural India.

EmOC Key Functions

Cover These Services:

Antibiotics
(intravenous or by injection)

Oxytocic Drugs (ditto) Anticonvulsants

(ditto)

Removal of Retained Products Assisted Vaginal Delivery Surgery (Cesarean

Section)

Manual Removal of Placenta

Blood Transfusion

THE GOOD NEWS

Not all these functions need hospitals and doctors

Well-trained nurses and midwives can perform most functions at Basic EmOC Facilities

An Important Point For Resource Poor Areas

Objectives of Care During Labor and Childbirth Protect the life of the mother and newborn .

Support normal labor and detect and treat

complications 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

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-care
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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 donation
Normal Labor and Childbirth 22

Ectopic Pregnancy
Risk Factors: Age Parity Previous induced abortion Sterilization failure PID Diagnosis Triad - Amenorrhea, Bleeding, Pain Positive Urine HCG +TVS (Colour Doppler) Placental Flow, Ring Of Fire Diagnostic. Culdocentesis Or Colpocentesis Used To Be Important Now X
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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 PROBLEMS RISKS, JEOPARDIES & SURVIVAL

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Therapy Surgery Main Ideal Approach? Evidence Laparoscopy For Some. Laparotomy For Others Medical Management. Methotrexate Effective Unruptured Size(<4cm ) Expectant Can Be Fatal If Not Diagnosed & Treated Promptly.
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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 SA 10% Case fatality Diagnosis Delayed Therapy Delayed. Evacuation Laparotomy Hysterectomy.
Right Therapy Right Time
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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
Perinatal Mortality 2.7 % Blood Transfusion Improvement in Neonatal Care.

Significant 2 Decades.
0.56 %

Judicious Extension of Expectant Management.

Availability of Ventilator Support

Reduction 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 PROBLEMS RISKS, 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 %

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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 Utero Still 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 Uterine Rupture Must Be Followed By An Immediate And Simultaneous Response From The Obstetric Team. Surgery Should Not Be Delayed Owing To Hypovolemic Shock Because It May Not Be Easily Reversible Until The Hemorrhage Is Controlled.

Upon Entering The Abdomen, Aortic Compression Can Be Applied To Decrease Bleeding.

Oxytocin Should Be Administered To Effect Uterine Contraction To Assist In Vessel Constriction And To Decrease Bleeding. Hemostasis Can Then Be Achieved By Ligation Of The Hypogastric Artery, Uterine Artery, Or Ovarian Arteries.

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

When Rupture Occurs In The Body Of The Uterus, Bladder Rupture Must Be Ruled Out By Clearly Mobilizing And Inspecting The Bladder To Ensure That It Is Intact. This Avoids Injury On Repair Of The Defect As Well.

RETAINED PLACENTA
Delayed Referral, Haemorrhage Morbidly Adherent Placenta
Overall MMR PMR T Treatment is manual removal, General anesthesia with any volatile agent (1.52 minimum alveolar concentration (MAC)) may be necessary 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
Single Most Important Cause

Maternal Deaths Worldwide.

Fortunately Incidence

Overall PPH

25 % of Maternal Mortality

Timely management saves life

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PPH

MANAGEMENT OF PPH

MANAGEMENT OF PPH

Atonic PPH:
Bimanual massage,catheterisation,I/V crystalloids,blood transfusion 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

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

MANAGEMENT OF PPH

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.

RISK FACTORS
Induction and augmentation of labour Operative delivery Uterine rupture Amniotomy Abruptio placentae IUD Amnioinfusion

 Amniotic fluid may gain entry into maternal circulation during Spontaneous labour and delivery Amniotomy Lscs

Pathophysiology
Acute pulmonary vascular obstruction+hypertension=cor pulmonale LVF-hypotension, shock An acute inflammatory response disrupts the pulmonary capillary endothelium and alveoliventilation perfusion imbalance-hypoxiaconvulsions,coma

Diagnosis
Respiratory collapse,dyspnoea,cyanosis, hypoxia, pulmonary oedema. CVS-tachycardia ,hypotension,arrhythmias,cardiac arrest Uterine hypertonus Acute fetal hypoxia If the woman survives for more than 1 hr, -DIC

Treatment
Effective CPR Inotropic support Inj hydrocortisone500mg iv 6hrly t/t of DIC Plasma exchange,haemofiltration Fetus to be delivered within 10min

Pulmonary embolism
Leading cause of maternal deaths. DVTin legs or pelvis most common cause. S/STachynoea,dyspnoea,plueritic chest pain,cough, tachycardia, hemoptysis,temp>37 c Death-shock, vagal inhibition

Diagnosis
XRAY chest-diminished vascular markings in areas of infarction,elevation of dome of diaphragm,pleural effusion ECG-tachycardia,right axis shift,nonspecific STchanges D Dimer Doppler-to rule out DVT MRI

Pulmonary angiography Spiral CT-inv of choice MRA-100%sensitivity Ventilation-perfusion scan

Treatment
Resucsitation-cardiac massage, o2,iv fluids, Iv heparin bolus5000IU Morphine15mg Heparin is continued upto 40,000IU,maintain clotting time>12min Digitalis Recurrent attacks-embolectomy,caval filter,ligation of inf vena cava, ovarian veins

Summary
What , when where and why of Emergency obstetric care. Basic clinical features , diagnosis and management of emergency obstetric cases.

THANK YOU