PRESENTED BY:

MIRIAM D. PATTUGALAN, RN, RM,MSN

Faculty, School of Nursing and Allied
Health Sciences
 DEFINITION FOR MIDWIFERY
CRITICAL CARE
The provision of concentrated care, both physical,
psychological, and social on a one to one basis in
an acute situation, where a woman's condition
has or is at risk of deteriorating and where
advanced management such as drug therapy,
more invasive forms of monitoring and
interpretation of results are required on a
frequent basis
 Obstetric emergencies DEFINES AS:
> are life threatening medical conditions that
occur in pregnancy or during or after
labor and delivery.
 REMEMBER THAT IN OBSTETRICS
EMERGENCIES:
There are two patients to consider:
Mother
Fetus
-- so consider both mother and
fetus at risk.
Census says that:
About 15% of all pregnant woman develops a
potentially life threatening that calls for skilled care
and some will require a major obstetrical interventions
to survive
EVERY PREGNANCY IS A RISK
EVERY PREGNANT IS AT RISK
RAPID INITIAL ASSESSMENT:
ASSESS :
1. Airway and Breathing :
Look for
> Danger Signs : cyanosis (blueness) respiratory
distress
Examine for: Skin pallor ,
lungs : wheezing
or rales
2. Circulation : Maybe signs of
shock
Danger signs:
Examine: skin color and clammy
: pulse fast (110 or more) and weak
: blood pressure: low (systolic less
than 90 mm Hg)
3. VAGINAL BLEEDING:
CLASSIFY EITHER AT EARLY PREGNANCY, LATE
OR AFTER PREGNACY.
> Danger signs: ASK IF:
Pregnant length of gestation
- recently given birth
 - placenta delivered
EXAMINE:
> vulva: amount of
bleeding, placenta
retained, obvious tears
Uterus: atony
> Bladder : full
> Consider the following :
Early Pregnancy
> abortion, ectopic pregnancy, molar pregnancy
Late pregnancy: abruption placenta, ruptured
uterus, Placenta Previa
AFTER CHILD BIRTH:
Consider:
> atonic uterus
> tears of cervix and vagina
>retained placenta
>inverted uterus
4. UNCONSCIOUS OR CONVULSING
MOTHER
> Ask If: pregnant, and length of gestation
Examine: blood pressure: High ( diastolic 90
mmHg or more) (PIH or Eclampsia)
Temperature : 38 C or more
Consider this as cases of : malaria, tetanus
5. Dangerous Fever:
Danger Signs: ASK If: weak. Lethargic,
frequent and painful urination.
Examine: temperature: 38 C or more,
Neck: stiffness
Lungs: shallow breathing,
Vulva: purulent discharge,
6. ABDOMINAL PAIN
Ask If: Mother is pregnant; length of gestation
Examine the ff:
> BP : low (systolic less than 90 mm Hg) Pulse:
fast (110 0r more) (Ruptured Uterus, Ectopic
Pregnancy etc.
Temperature : 38 C or more, - Signs of UTI
 Common Cases of obstetric
emergencies
1. Shock is characterized by failure of the circulatory
system to maintain adequate perfusion of the vital organs
Signs and Symptom
-Diagnose shock if the following s/s are present:
> fast, weak pulse (110 /minute or more)
> Low BP ( systolic less than 90 mm Hg)
Other Signs and Symptoms
> Pallor ( especially of inner eyelid, palms or around
mouth)
> Sweatiness or cold clammy skin
> rapid breathing ( rate of 30
breaths per minute or more)
> anxiousness, confusion, or unconsciousness
> scanty urine output ( less than 30 ml per hour).
Management
IMMEDIATE MANAGEMENT:
> SHOUT FOR HELP. Urgently
mobilize all available personnel.
> Monitor Vital Signs
>If
> woman is unconscious, turn her onto her side to
minimize the risk of aspiration if she vomits, and to
ensure that an airway is open.
> Elevate the legs to increase return of blood to
the heart ( if possible, raise the foot end of the
bed.)
SPECIFIC MANAGEMENT
> Start an IV infusion. Rapidly infuse IV fluids (
Normal Saline or Lactated Ringers) initially at the
rate of 1 L in 15-20 minutes.
 INTERVENTIONS:
Note: A more rapid rate of infusion is required in the
management of shock resulting from bleeding. Aim to
replace two to three times the estimated fluid loss.

DO NOT GIVE FLUIDS BY MOUTH TO A WOMAN IN SHOCK.

 DETERMINING THE CAUSE OF
SHOCK:
1. If heavy bleeding: Stop the bleeding by giving ( e.g.
oxytocic drug. Do uterine massage. If severe bleeding,
transfuse blood as soon as possible to replace blood loss.
2. If Infection is suspected as the cause of shock:
Collect appropriate samples ( blood, urine, pus) for microbial
culture before starting antibiotics.
3. If Trauma is suspected as the cause of shock,
prepare for surgical intervention.
REASSESSMENT
Signs of improvement include:
Stabilizing pulse rate ( rate
of 90 per minute or less)
REASSESSMENT.
> increasing BP ( systolic of 100 mmHg or more)
> improving mental status ( Less confusion or
anxiety)
Increasing urine output ( 30 ml per hour or more.)
If the womans condition improves adjust the rate
of infusion of IV fluids to 1 L in six hours.
If the
If thewomans condition
womans condition failsfails to
to improve
improve or stabilized do..
or stabilized do..
FURTHER MANAGEMENT
FURTHER MANAGEMENT
1. Continue IV fluids. (1L in six hours)
1.Continue
2. OxygenIVadministration
fluids. (1L inatsix
6-8 hours)
L per minute
2.Oxygen administration
3. Closely at 6-8 condition.
monitor the womans L per minute
4. Perform laboratory test if necessary.
3. Closely monitor the womans condition.
4. Perform laboratory test if necessary.
2. VAGINAL BLEEDING IN EARLY
PREGNANCY
TYPES OF ABORTION
1. THREATENED ABORTION
> Medical treatment is usually not necessary.
> Advise the woman to AVOID strenuous activity and
sexual intercourse, bed rest is not necessary.
II. INEVITABLE ABORTION
If pregnancy is less than 16 weeks, plan for evacuation
of uterine contents. IF not possible give:
ERGOMETRINE 0.2 mg IM or MISOPROSTOL 400 mcg
by mouth.
>If greater than 16 weeks:
infuse oxytocin 40 units in 1 L IV fluids (Normal
Saline or LR at 40 drops per minutes.
> give misoprostol 200mcg vaginally q 4 hours until expulsion.
But do not administer more than 800 mcg.
Ensure follow up of the woman after treatment.

III. COMPLETE ABORTION

> Evacuation of the uterus is usually not necessary
> Observe for heavy bleeding
> Ensure follow up of the woman after treatment.
2. ECTOPIC PREGNANCY
One in which implantation occurs outside cavity
Fallopian tube most common site ( 90 % )
S/S of UNRUPTURED PREGNANCY
> Symptoms of Early Pregnancy
(Irregular spotting or bleeding, nausea, swelling of
breast, bluish discoloration of vagina and cervix,
softening of cervix,
Signs and symptoms of RUPTURED
ECTOPIC PREGNANCY
Collapse and Acute abdominal and
weakness pelvic pain
Fast , weak pulse (110 Abdominal distention
per minute or more) Rebound tenderness
Hypotension and Pallor
Hypovolemia
IMMEDIATE MANAGEMENT
1. Cross Match blood and arrange for
immediate laparotomy. Do not wait for
blood before performing surgery.
If extensive damage to the tube-
perform Salpingectomy.
SUBSEQUENT MANAGEMENT
Prior to discharge counselling and
advice on prognosis
. Correct anemia with Ferrous sulfate or
ferrous fumarate 60 mg by mouth daily
for six months.
Schedule a follow up visit at four weeks.
3. MOLAR PREGNANCY
Is characterized by an abnormal
proliferation of chorionic villi.
IMMEDIATE MANAGEMENT
> If diagnosis of Molar
pregnancy, evacuate the uterus.
 Management:
Use of Vacuum aspiration.
Manual vacuum aspiration is safer and
associated with less blood loss.
The risk of perforation using a metal
curette is high.
> Infuse oxytocin 20 units in 1 L IV fluids
( NSS, LR) at 60 drops per minute to
prevent hemorrhage .
SUBSEQUENT MANAGEMENT:
Recommend a hormonal Family Planning
method for at least one year to prevent
pregnancy.
Follow up every eight weeks for at least one
year with urine pregnancy test because of the
risk of persistent trophoblastic disease or
choro carcinoma
If the urine pregnancy test is not negative after
8 weeks or becomes positive again within the
first year, urgently refer woman to a tertiary
care for further follow-up and management of
Choriocarcinoma.
VAGINAL BLEEDING IN LATER
PREGNANCY AND LABOUR
Problems:
> Vaginal bleeding after 22 weeks of
pregnancy
> vaginal bleeding in labor before delivery
ABRUPTIO PLACENTA
- is the detachment of a normally located
placenta from the uterus before the fetus
is delivered.
S/S
>Bleeding after 22 weeks gestation .
Intermittent or constant abdominal pain
Shock, Tense tender uterus, decreased
/absent fetal movement, fetal distress or
absent fetal heart sound
MANAGEMENT:
1. Transfuse as necessary, preferably with
fresh blood.
If bleeding is heavy (evident or hidden) deliver
as soon as possible.

If vaginal delivery is not imminent, deliver by

cesarean section
RUPTURED UTERUS
S/S: Bleeding (intra abdominal and /or vaginal)
: Severe abdominal pain ( may decrease after
rupture).
: Shock, abdominal distension/free fluid,
abnormal uterine contour. Tender
abdomen, Easily palpable fetal parts,
Absent fetal movements and fetal heart
sound, Rapid maternal pulse.
 Rupture of lower uterine segment into broad
ligaments will not release blood into the abdominal
cavity
 Management:
Restore blood volume by infusing IV
fluids.
Cesarean Section if woman is in stable
condition.
If uterus can be repaired with less
operative risk than hysterectomy would
entail. Only repair is done.
Because there is an increased risk of
rupture with subsequent pregnancies,
the option of permanent contraception
needs to be discussed with the woman
after the emergency is over.
PLACENTA PRAEVIA
- is implantation of the placenta at or
near the cervix
 Warning:
Do not perform a vaginal examination
unless preparation have been made for
immediate cesarean section.
Management:
1. Restore blood volume by infusing IV
fluids.
2. Assess the amount of bleeding:
Confirming Diagnosis:
> Ultrasound. - to locate the site of placenta,
> Plan Delivery if:
>the fetus is mature
> the fetus is dead or has an anomaly
not compatible with life . ( anencephaly)
> the woman life is at risk because of
excessive blood loss.
Note:

Women with placenta Previa are at high

risk for postpartum hemorrhage and
placenta accrete/increate, a common
finding at the site of a previous cesarean
scar.
Post partum hemorrhage
Vaginal bleeding in excess of 500 ml after child
birth.
Even healthy, non anemic women can have
catastrophic blood loss.
Continuous: slow bleeding or sudden
bleeding is an emergency : intervene early
and aggressively.
Atonic uterus : An atonic uterus
fails to contract after delivery.
> continue to massage the uterus.
> use oxytocic drugs which can be given
together sequentially.
Ex. (Oxytocin, methylergometrine, Methyl-
Prostaglandin)
Management:
> If bleeding continues:
> Check placenta again for completeness.
> If there are signs of retained placental
fragments, remove remaining placental
tissue.
Note:
> Do not give ergonometrine for
retained placenta because it cause
tonic uterine contraction, which may
delay expulsion.
> Ensure that the bladder is empty.
Cahetherize the bladder if necessary.
Inverted uterus
Repositioning of uterus done
immediately.
> If with severe pain give morphine
> Do not give Oxy toxic drugs until
inversion is corrected.
> Antibiotic for prophylactic ( single
dose)
 UMBILICAL CORD PROLAPSE:
Definition:
Umbilical cord prolapse exist when a loop of cord is present
below the presenting part and the membranes are ruptured.

Risk of perinatal morbidity/mortality from asphysia secondary

to mechanical compression of the cord between the
presenting part and the pelvis or spasm of cord vessels
secondary to cold or manipulation.
Cord Prolapse Occult Cord
CORD PROLAPSE
 MANAGEMENT
OBSTETRIC INTERVENTION
Place two fingers in vagina to relieve pressure off cord, raising fetus off cord.
Check cord for pulsations
Mother in knee chest or hips elevated position.
Oxygen therapy
Transport while keeping pressure off cord.
Moist dressing to esposed cord, do not push back into vagina.

If Fetus is viable
Discontinue syntocinon and administer Oxygen by mask
Prepare patient for emergency cesarean section.
Questions?
THANK
THANK
YOU!YOU!