OBSTETRIC EMERGENCIES

Pengenalan asas mengenai OBSTETRIC EMERGENCIES

1. OBSTETRIC
EMERGENCIES
Disediakan Oleh : Nassruto

2. OBSTETRIC EMERGENCIES
Labour is like a mountain climbing........
LABOUR IS LIKE A MOUNTAIN CLIMBING….

3. OBSTETRIC EMERGENCIES
•PPH (POST PARTUM HAEMORRHAGE)
•APH (ANTE PARTUM HAEMORRHAGE)
•Eclampsia and severe pre-eclampsia
•Uterine inversion
•Uterine rupture
•Amniotic fluid embolism
•Post partum collapse
•Cord prolapse
•Shoulder dystocia

4. PPH
•Leading cause of maternal death in Malaysia.
•Bleeding > 500 cc from genital tract after delivery.
•Primary PPH – occurring within 24 hours of delivery.
•Secondary PPH – occurring after 24 hours.

5. Causes of primary PPH
•Atonic uterus
•Genital tract trauma
•Retained placenta
•Bleeding disorders

6. Uterine atony
•Resuscitation
•Rub up contraction, expel any clots, empty bladder.
•Give/ repeat oxytocin. Run oxytocin infusion. Consider
other drugs such as PG.
•Monitor patient closely.
•If bleeding persists, consider transferral or surgical
intervention.

7. Genital Tract Trauma
•Vaginal tear
•Cervical tear
•Bleeding episiotomy wound

8. Retained Placenta
•Resuscitation
•Removal of placenta

9. Bleeding disorders
•Rare
•Treatment as the cause

10. Causes of secondary
PPH
•Retained POC
•Endometritis

11. ANTEPARTUM HEMORRHAGE

12. DEFINITION
•Bleeding from the genital tract from 24 weeks till
delivery of the fetus.
•Causes :
•Placenta praevia
•Abruptio placenta
•Local cause
•Indeterminate APH
•Vasa praevia

13. Placenta praevia
•Placenta is located partially or wholly in the lower
segment.
•Painless PV bleed.
•Abdomen soft, malpresentation or presenting part high.
•No VE until confirmation.
•Confirmed by ultrasound.

14. GRADE 1 – THE PLACENTA JUST
ENCROACH ON THE LOWER
UTERINE SEGMENT.
GRADE 2 – THE PLACENTA
REACHES THE MARGIN OF THE
CERVICAL OS.

15. GRADE 3 – THE PLACENTA COVERS
PART OF THE OS.
GRADE 4 – THE PLACENTA IS
CENTRALLY PLACED IN THE LOWER
UTERINE SEGMENT.

16. DIAGNOSIS
•DIAGNOSIS IS BY ULTRASOUND

17. management
•Resuscitation
•IV lines and blood transfusion.
•Conservative or delivery depends on gestation, amount of
blood loss and whether patient having contraction.
•Delivery by CS for major placenta praevia

18. COMPLICATION
•PPH.
•PLACENTA ACCRETA
•IATROGENIC PREMATURE DELIVERY.

19. ABRUPTIO
PLACENTA
PREMATURE SEPERATION OF A PLACENTA
BEFORE THE DELIVERY OF THE FETUS.

20. RISK FACTOR
•TRAUMA
•PREVIOUS HISTORY OF ABRUPTIO
•MATERNAL HYPERTENSION
•CIGARETTE SMOKING
•UTERINE DECOMPRESSION

21. •Painful PV bleeding.
•Abdomen tense (dashwood rigidity), tender.
•Fetal part and heart may be difficult to palpate.
•Ultrasound may show evidence of retroplacental clots.
•Revealed and concealed type.
•Amount of loss may not be proportionate to degree of
shock.

22. Blood clots from premature
placenta separation
accumulate and sips into
muscle but the amount of
PV bleed may not be
proportionate to the amount
of placenta separation.

23. In revealed type, the amount
of blood loss is
proportionate to the degree
of placenta separation.

24. DIAGNOSIS
•HISTORY AND
PHYSICAL
EXAMINATION.
•ULTRASOUND – to rule
out placenta praevia and
retroplacental blood clots
may be seen as an area of
lucency.
•CTG – may show
evidence of fetal distress.

25. MANAGEMENT
•Resuscitation
•IV lines, blood transfusion and blood products
transfusion.
•If cervix favorable and no fetal distress aim for vaginal
delivery.
•If evidence of fetal distress, then for CS.

26. COMPLICATION
•Hypovolumic shock.
•Acute renal failure.
•Couvelairre uterus and uterine atony.
•PPH.
•DIVC.
•Perinatal morbidity and mortality.

27. APH- LOCAL CAUSE
•CAUSES : Polyp, erosion, infection or cancer of the
cervix.
•Needs treatment for polyp if excessive PV bleed.
•For cancer of cervix treatment depends on staging and
period of gestation.

28. APH – VASA PRAEVIA
•Bleeding from the fetal blood.
•Valemantous insertion of the blood vessels.
•PV bleed and evidence of fetal distress.
•Needs immediate delivery of the fetus.

29. UTERINE RUPTURE
•SPONTANEOUS
•TRAUMATIC
•PREVIOUS SCAR

30. UTERINE RUPTURE
•PREVIOUS SCAR IS COMMONEST. CLASSICAL C-
SECTION RISK IS 4-5%. LSCS RISK 0.2% TO 0.5%.
•FAILURE TO RECOGNISE OBSTRUCTED LABOUR.
•TRAUMATIC INSTRUMENTAL DELIVERY.

31. SIGNS AND SYMPTOMS
•Abdominal pain. Pain in between contraction.
•Cessation of contraction.
•Variable amount of vaginal bleeding.
•Unexplained tachycardia and shock.
•Fetal distress.
•Palpable fetal part or disappearance of presenting part
from pelvis.

32. MANAGEMENT
•Initial resuscitation.
•Emergency laparatomy.
•Repair of rupture or hysterectomy depending on factors
like stability of patient, completion of family and how
bad the rupture is.
•Future pregnancy- CS at 36-37 weeks.

33. UTERINE INVERSION
•Uterus become inverted partially (fundus above cervix )
or completely ( fundus below cervix ).
•Acute inversion occur in the first 24 hours.
•Causes include fundally implanted placenta, poor
management of third stage

34. DIAGNOSIS
•Pain, hemorrhage or shock in the presence of an inverted
uterus or indented uterus abdominally.
•Degree of shock may be out of proportion to the amount of
blood loss.

35. MANAGEMENT
•Immediate resuscitation.
•Manual replacement of the placenta.
•If fail, O’Sullivan hydrostatic method or manual
replacement under GA.
•After succesful replacement, judicious use of oxytocin
and MRP if placenta is still retained.

36. PREGNANCYPREGNANCY
IS IS
SPECIAL,SPECIAL,
LETLET
MAKE MAKE
IT IT
SAFESAFE
THANK YOU…………….THANK YOU…………….