Nursing care in Obstetrical emergencies

1. OBSTETRICAL
EMERGENCIES
Dr. Latha Venkatesan
Principal, Apollo COLLEGE OF
NURSING, CHENNAI

3. Introduction
• Obstetrical emergencies are life-threatening medical
conditions that occur in pregnancy or during or after labor
and delivery.
• Magnitude, Incidence
• Why its happening?
• Where is it happening?
• Who is responsible for it?
• How can we reduce it? Some tools….
• What is our role as Midwives?

4. Do you know?

5. Impossible
To Predict !
Rapidness Of The Diagnosis
!

6. Causes of Maternal Death

7. MATERNAL DEATH YEAR WISE

8. SDG goals and EPMM strategies
• Between 1990 and 2015, the global maternal mortality ratio (MMR) decreased
by 44%, from 385 to 216 maternal deaths per 100,000 live births.
• Despite this progress, the world still fell far short of the Millennium
Development Goals target of a 75% reduction in the global MMR by 2015.
• Maternal mortality reduction remains a priority under “Goal 3: Ensure healthy
lives and promote well-being for all at all ages” in the new Sustainable
Development Goals (SDGs) agenda through 2030.
• In February 2015, the World Health Organization published “Strategies
toward ending preventable maternal mortality (EPMM)” (EPMM Strategies), a
direction-setting report outlining global targets and strategies for reducing
maternal mortality under the SDGs

9. • Which is the MMR in TamilNadu?
• Type your answer in chat box

11. ANTE - PARTUM
PERIOD
INTRA PARTUM PERIOD POST PARTUM
PERIOD
• Ante partum
hemorrhage
• Eclampsia
• Ectopic pregnancy
• Vasa previa
• Uterine Inversion
• Cord prolapse
• Obstructed labour
• Uterine Rupture
• Shoulder dystocia
• Amniotic fluid embolism
• Post partum
hemorrhage
• Retained placenta
• Obstetrical shock
• Puerperal sepsis
IMPORTANT CONDITIONS IN OBSTETRIC EMERGENCIES

12. Placenta Previa
1in 300
deliveries
Obstructed
labour
1 to 2 % in
referral
hospitals
Abruptio
placenta
1 in 200
deliveries
Shoulder
dystocia
0.2 to 1 %
deliveries
Eclampsia
1 in 500 to
1 in 30
pregencies
Cord Prolapse
1 in 300
deliveries
Ruptured Uterus
I : 1500 to 2000
births
Postpartum
hemorrhage
4 to 6 %
INCIDENCE

13. Poll time
Why maternal deaths are happening due to Obstetrical emergencies?
Go to menti.com and enter the code 2165388

14. Current Indian population
The current population of India is 1,382,419,165 as of Saturday,
September 5, 2020, based on Worldometer elaboration of the latest
United Nations data.

15. RURAL HEALTH STATISTICS 2018-19
Sub centres Functioning Without ANM, HW

16. • Sixty per cent of primary health centers (PHCs) in India have
only one doctor while about five per cent have none.
• According to the Economic Survey 2018-19, tabled in the
Parliament on July 4, 2019.

17. PHCs without doctors, Pharmacist,Lab tech

18. Shortfall of Specialists at CHCs

19. Three Delays contribute to many maternal deaths
1. Delay in deciding to seek
care
2. Delay in reaching
appropriate care
3. Delay in receiving care at
the health facility

21. Emergency Obstetric Care (EmOC)
Emergency Obstetric Care is often discussed in terms of basic and
comprehensive care that is provided to a women with obstetric
complications.

22. • For every 500,000 population, there should be at least four basic and
one comprehensive EmOC facilities.
• 100% of women estimated to have obstetric complications are treated in
EmOC facilities..
The WHO, UNICEF and
the UN Population Fund (UNFPA) recommended :

23. • India Readies A New Cadre Of Certified Midwives To Improve Maternal, Infant Care
(Sunaina Kumar February 7, 2019)
• 83% of all maternal deaths and newborn deaths could be averted with midwifery
care, (WHO ,2018).
• When midwives were the main providers of care during pregnancy, women were less likely
to give birth prematurely or lose their babies before 24 weeks of gestation, research by the
WHO has shown.
• Women attended on by midwives needed fewer epidurals, fewer assisted births and fewer
episiotomies, and were less likely to have caesarean births.
• Midwifery-led care is based on the principles of dignity, privacy and compassion for women
and respectful maternal care.
• The new guidelines on midwifery in India, released in December 2018, state that a
cadre of Nurse Practitioner in Midwifery (NPM) will be created that will be skilled in
accordance with International Confederation of Midwives standards. The NPM will be
a registered nurse-midwife with an additional 18 months of post-basic training in
midwifery.
Independent Nurse Midwifery Practitioner

24. Improve clinical decision making of nurses

25. Obstetric Triaging

26. • It is important that obstetrician–gynecologists prepare themselves by assessing potential
emergencies, establishing early warning systems, designating specialized first responders,
conducting emergency drills, and debriefing staff. Having such systems in place may
reduce or prevent the severity of medical emergencies.
• Schuler, L Katz (2019) conducted a descriptive study to evaluate the modified early
obstetric warning system (MEOWS) in women after pregnancies in a tertiary hospital in
Brazil. The study was conducted with 705 hospitalized women. Vital signs (systolic and
diastolic blood pressure, heart rate, respiratory rate, temperature) and lochia were
registered on medical records and transcribed into the MEOWS chart of physiological
parameters.
• On the graphic chart, the presence of at least one red alert or two yellow alerts were
triggered to indicate the need for medical evaluation. Although abnormalities were found in
the physiological parameters of 49.8% of the women identified from MEOWS triggers,
medical evaluation was only requested for three patients (0.8%).
• The study concluded that the application of this tool would result in a better care because
critical situations would be recognized and corrected quickly, avoiding unfavorable
outcomes.
Modified Early Obstetric Warning System(MEOWS)

27. Safe Child Birth checklist
Prevention and Early identification
WHO “safe Child Birth
Check List”
Danger Signs – be
alert and watchful
• Excessive bleeding
• Severe abdominal Pain
• Severe Head ache or visual
disturbances
• Breathing difficulty
• Fever or chills
• Difficulty in emptying
bladder
• Foul smelling vaginal
discharge

28. The golden rules of obstetric emergencies
Oxygen
administration
Left lateral
position
Resuscitation
and transfer of
the mother, as
the infant is
safer in utero.

29. Standards - Basic EmOC Functions
Performed in
a health
centre
without the
need for an
operating
theatre
• IV/IM antibiotics
• IV/IM oxytoxics
• IV/IM anticonvulsants
• Manual removal of
placenta
• Assisted vaginal delivery
• Removal of retained
products

30. Standards – Comprehensive EmOC
Functions
• All six Basic EmOC
functions plus:
• Caesarean section
• Blood Transfusion
Requires an
operation theatre
and is performed
in hospitals

31. CONDITIONS NEEDING EMOC
Ectopic pregnancy
Eclampsia
Umbilical cord prolapse
Shoulder dystocia
Amniotic fluid embolism
Obstetric Hemorrhage (APH & PPH)

32. Management of Ectopic Pregnancy
High flow O2
Treat for shock
IV access
Surgical intervention usually
required

33. Management of Eclampsia
Turn on side to avoid
aortocaval
compression.
Insert an airway and
give high-flow O2
(e.g.6 l/min)
Give 4g MgSO4 over
10-15 minutes
Consider urgent
delivery
Set up a 1g/h IV
infusion of MgSO4
and manage as
severe pre-
eclampsia

34. Management of Umbilical cord prolapse
(Arrange in Correct order)
1. Supportive Treatment, Keep the cord moist( wrap it with
sterile moist towel)
2.Elevate presenting part/ Fill bladder(500-750ml)
3.Keep the pt in knee/chest position or elevate buttock
4.Emergency C/S
5.Relieve pressure on cord

35. Management of Umbilical cord prolapse
1. Keep the pt in knee/chest position or elevate buttock
2. Relieve pressure on cord
3.Elevate presenting part/ Fill bladder(500-750ml)
4. Supportive Treatment, Keep the cord moist( wrap it with
sterile moist towel)
5.Emergency C/S

36. Management of Shoulder Dystocia
McRoberts Maneuver
Episiotomy
Suprapubic pressure, Internal rotation ,Try
recovering posterior arm
Extreme measures (fracture the clavicle,
symphysiotomy, push the baby's head up and
do L.S.C.S (Zavanelli manoeuvre)

37. SHOULDER DYSTOCIA (HELPERR)

38. Amniotic Fluid Embolism
Amniotic fluid embolism (AFE) is a rare obstetric emergency in which the
amniotic fluid, fetal cells, hair, or other debris enter the maternal circulation,
causing cardio respiratory collapse.

39. Management of Amniotic Fluid Embolism
• Administer oxygen to maintain normal saturation.
• Intubate if necessary.
• Initiate cardiopulmonary resuscitation (CPR) if the patient arrests. If
she does not respond to resuscitation, perform a perimortem
cesarean delivery.
• Treat hypotension with crystalloid and
blood products

40. OBSTETRIC HAEMORRHAGE

41. Scenario
• A woman with 36 weeks of gestation arrives at labour room with
bleeding per vagina….
• How can u differentiate Placenta previa or Abruptio placenta with a
single question?

42. PLACENTA PREVIA

43. ABRUPTIO PLACENTA

44. Management of APH
• Confirm the diagnosis( Placenta previa/ Abruptio placenta)
• Placenta previa---Avoid per vaginal examination
• Abruptio placenta----- Avoid abdominal palpation
• Bed rest
• Follow ABC( Airway, Breathing and Circulation) principle
• If severe bleeding
- IV Ringer Lactate
- Blood grouping and cross matching
-Delivery irrespective of gestational age usually Cesarean section

45. Management of Uterine Rupture

46. CAUSES OF POST PARTUM HAEMORRHAGE
T- Tone
T-Trauma
T-Tissue
T-Thrombosis
T- Torsion

47. Initial action….

48. Call for
help
Give
oxygen,
IV fluids
Group& x
match
Treat the
cause
Immediate Management of PPH

49. •a.Oxytocin
•a. Bi manual compression
1. Retained Placenta
•b. Fresh blood
2. Laceration/Tear
•c. Reposition - Johnson'
maneuver/hydrostatic
pressure/ contract with
oxytocin
3. Atonic Uterus
•d. Remove
4. Uterine inversion
•e. Repair
5. Coagulation Defects
Management of PPH
(Match the following)

50. •d. Remove
1.Retained Placenta
•e.Repair
2.Laceration/Tear
•a. Oxytocin
•Bi manual compression
3.Atonic Uterus
•c. Reposition - Johnson'
maneuver/hydrostatic
pressure/ contract with
oxytocin
4.Uterine inversion
•b. Fresh blood
5.Coagulation Defects
Management of PPH

51. ROLE OF A NURSE IN OBSTETRICAL EMERGENCY
• Recognize the early signs of major obstetric complications
• Perform essential life-saving interventions
• Refer as appropriate and
• Provide high-quality, culturally appropriate, and considerate care,
including follow-up and linkages with other services.

52. Essential life –saving skills needed for Nurse
• Prevent infection by ensuring safe, clean delivery
• Diagnose and manage causes of antepartum and postpartum
haemorrhage
• Stabilization and referral
• Performance of manual procedures

53. Essential life –saving skills needed for Nurse-Cont.
• Use a partograph, identify prolonged or obstructed labour,and take
appropriate, timely action.
• Identify elevated blood pressure and proteinuria as signs of
eclampsia, provide emergency care, and refer.

54. It’s Game time

55. Cross Word puzzle

56. Cross Word puzzle

59. • Anticipate problem
• Cultivate a good relationship communicate with your obstetricians
• Be available and prepared:
Emergency O.R. set-up
Transfusion and monitoring
CONCLUSION