Maternity
Complications
Complications objective:
•Describe presentation and management of:
•Cervical shock
•Ectopic pregnancy
•Pre-eclampsia
•Eclampsia
•Prolapsed cord
•Placenta praevia
•Placenta abruption (APH)
•Shoulder dystocia
•Breech presentation
•Postpartum haemorrhage (PPH)
Ectopic Pregnancy:
•Missed menstrual period (6-8weeks)
•Acute lower abdominal pain
• Spotty vaginal bleeding
Shoulder tip pain
Fainting
Unusual bowel symptoms
Signs of shock if ruptured
Ectopic Pregnancy Management:
•Time critical
•Cannulate
•Be prepared to manage andtreat symptoms shock
•Analgesia
•Consider ectopic pregnancyin any woman of child bearingage with abdominal pain.Clinical presentation varies
Pre-eclampsia
•Cause unknown
•Causes vaso constriction
•Occurs second half ofpregnancy onwards
•Predisposing factors –hypertension, age 35+teenagers plus other factors
•Protein in urine
•BP 140/90 ++
Eclampsia:
•Seizures;
•Agitation (severe) - violent twitching
•Unconsciousness
•Photophobia
•Noise sensitivity
Management:
Seizure management
Diazepam (Diazemuls –Stesolid)
Obstetrics unit – immediate delivery
Prolapsed Cord:
•Acute obstetric emergency
•More common in breech
•Higher risk of occurrence < 34 weeks
•Exposure to air will cause irritation andcooling which in turn produces vasospasmof the cord vessels
•Intermittent compression, compromisesthe foetal circulation
•Depending on its duration and degree ofcompression, foetal hypoxia, braindamage and even death can occur
Prolapsed Cord Management:
•Transport asap
•Use two fingers to replacecord gently in the vagina (JRCALC)
•Keep cord warm and moist
•Minimal handling
•Clinical judgement how tomove from home to vehicle
•Entonox to reduce urge topush
•Modified Sims position orprone with knees to chest,buttocks raised
Suggested Positions forTransporting:
Exaggerated Sims position
Prone all fours
Miscarriage with Cervical Shock
•Definition: Non-completed expulsion ofproducts of conception through the cervix i.e.incomplete miscarriage
•The presence of tissue in the cervix foranything other than a short period may causea vagal reaction with collapse.
•Sepsis a possibility
Management of Cervical Shock
•Time critical
•High level oxygen therapy
•Removal of the remaining products from thecervix by medics in hospital is the key toreversing the shock
•IV cannulation – BP >90 systolic
•If bradycardia present administer Atropine.
Placenta Praevia:
•Occurs in the second andthird trimesters 24 –32wks
•Bleeding revealed andbright red
•Usually painless unless inlabour
•1 in 200 pregnancies
•Malpresentations arecommon
•Shock can develop
Management:
High oxygen
Transport asap
Fluid therapy to maintain 90 systolic
Placenta Abruption:
•Bleeding in late pregnancy –accompanied by severecontinuous abdominal pain
•Signs of shock
•Associated with hypertension
•May be some external bloodloss, most usually concealed
•Abdomen tender, uterus willfeel rigid
Management Placenta Abruption:
•Time Critical
•Treat for shock
•Ask “when did you last feel baby move”
•Give fluid early rather than late, signs ofshock in the pregnant female ominous as theuterus and the foetus tend to become under-perfused
•Evidences of 500ml blood start with a bolusof 250ml crystalloid
Shoulder Dystocia:
•Anterior shoulder stuck behindsymphysis pubis
•If the shoulders not deliveredwithin two contractions of thehead being delivered – bring themother into the McRobertsposition
•Alternatively mother on allfours
•DO NOT PULL THE BABY’SHEAD!
•If the shoulders not deliveredwithin a further twocontractions transport asap
Breech:
At 28 wks incidence 15%by term reduced to 3-5%
Breech:
•Malpresentations = where thevertex is not entering thepelvis first
•Results in prolonged labour –emergency delivery
•Higher rates of perinatalmortality and morbidity
•Footling presentation =higher risk of cord prolapse
•Extended (frank) breech =commonest type
Breech: Other Forms
•Face presentations
•Brow presentations
•Abnormal lie
Actual BreechDelivery
Breech Management:
• Call for midwife IHCD
•Support in squatting or
•Recumbent & moved towards edge ofthe bed with legs supported inlithotomy position
•Avoid manipulation of the baby’sbody – support only – stimulation maycause premature respirations
•JRCAL recommend if breech deliverytransport nearest obstetrics unitASAP, this is also therecommendation of the midwife(JRCALC overrides IHCD)
Postpartum Haemorrhage (PPH):
•Primary occurs at time of delivery
•Definition – 500mls +
•Causes;
–Uterine relaxation (atony)
–Retained placental tissue
–Genital tract trauma during delivery (tearsof the perineum, vagina, cervix)
Primary PPH Management:
•Oxygen therapy
•Obvious perineal tears – apply direct pressure andpad
• Uterine bleeding = if soft & ‘atonic’ – feel for top ofuterus usually around umbilical level massage withcupped hand in circular motion
•Treat for shock (normal parameters) however 500mlblood loss observed or altered mental status poortissue perfusion, start 250ml crystalloid
•Transport asap
Secondary PPH:
•Occurs > 24 hours post delivery
•Usually retained placental tissue
•Possible uterine infection
•Bleeding usually less severe
•Consider midwife intervention or if severetreat for shock transport to obstetrics unitasap
Inversion of the Uterus
•Uterus comes downduring the expulsionusually still attachedto placenta
•Uncommon
Uterine Inversion Management:
•Time critical
•Never pull on the cord
•Do not attempt to replace uterus
•Wrap in swaps soaked in warm saline
•Oxygen therapy
•Transport asap
•Treat for shock
Any Questions?