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
20% Deaths
Of Globe In India One Death, >20-60 Disabled Causes Multiple, Multilayered.
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Specific
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
15%
13%
Indirect
Haemorrhage
20%
24%
12%
8% 8%
Other direct
HTD
Obstructed Labour
Pre-existing Conditions, including Malaria, Anemia and Hepatitis ,Increasingly HIV / AIDS Account for about 1/4 of Maternal Deaths
Without Warning
If women do not receive medical treatment on time, they will probably Suffer disability Or Die
(EmOC)
Antibiotics
(intravenous or by injection)
Blood Transfusion
Well-trained nurses and midwives can perform most functions at Basic EmOC Facilities
Objectives of Care During Labor and Childbirth Protect the life of the mother and newborn .
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
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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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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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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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Significant 2 Decades.
0.56 %
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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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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 %
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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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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.
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
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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
Overall PPH
25 % of Maternal Mortality
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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
MANAGEMENT OF PPH
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
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.
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