1. OBSTETRIC/ MIDWIFERY
EMERGENCIES
MICHAEL OKUMU
DEPARTMENT OF MIDWIFERY

2. PROLAPSED UMBILICAL CORD

3. OUTLINE
• Definition of terms
• Risk factors to prolapsed cord
• Management of prolapsed umbilical cord

4. PROLAPSED UMBILICAL CORD
• An umbilical cord that precedes the presenting part of the
fetus is called a prolapsed umbilical cord.
• Occurs when the cord falls or is washed down through the
cervix into the vagina, becomes trapped between the
presenting part and the maternal pelvis
• Incidence-3% in vertex presentation and 3.7% in breech
presentation. May also be present in compound presentation

5. DEFINITIONS
• Cord presentation- Umbilical cord precedes the presenting
part with intact fetal membranes.
• Cord prolapse-The cord lies in front of the presenting part
with the fetal membranes ruptured.
• Occult cord prolapse- The cord lies alongside, but not in front
of the presenting part

6. PROLAPSED UMBILICAL CORD

7. RISK FACTORS
Any situation in which the presenting part is not well applied
to the cervix or not well down to the pelvis would allow for
the cord to slip in front of the presenting part.
High/ill fitting presenting part
In membrane rupture with high presenting part, the cord may
pass in between the uterine wall and the fetus. As the
presenting part descends, the cord becomes occluded in the
process

8. RISK FACTORS
Multiparity
Associated with Malpresentation and non-engagement of the
presenting part. With membrane rupture, the cord is likely to
prolapse.
Prematurity
Most preterms are below 1500 gms, the small fetal size allows
for more space and higher chances of prolapse

9. RISK FACTORS
Malpresentation
Most breech, shoulder and compound presentations are associated
with increased risk of prolapse. This is because of ill fitting presenting
part.
Multiple pregnancy
Associated with Malpresentation of the second twin and a high risk of
prolapse of the umbilical cord

10. RISK FACTORS
Hydromnios
Excessive amniotic fluid volume. High risk of prolapse especially with
spontaneous rupture of membranes

11. MANAGEMENT OF CORD
PROLAPSE

12. MANAGEMENT
Determined by the following
Pulsation of the umbilical cord
The stage of labor
Parity

13. IMMEDIATE ACTION( WITH A PULSATING
CORD)
• Prolapsed cord is an obstetric emergency, the midwife must
immediately SHOUT FOR HELP.
• The findings are immediately explained to the woman and
her partner, and the need for emergency care.
• Any oxytocin infusion is stopped.
• Oxygen is administered to prevent fetal hypoxia.

14. RELIEVING PRESSURE ON THE UMBILICAL
CORD
• There is need to relieve pressure to minimize cord
compression.
• This minimizes the risk of fetal hypoxia especially with the
preterms.
• The fingers are held firm in the vagina to hold the presenting
part off the cord.
• Change of position to that which avoids cord compression-
Knee chest position, trendelburg position or exaggerated
sim’s position

15. RELIEVING PRESSURE ON THE CORD
• Filling the bladder with 500 mls normal saline. Full bladder elevates
the presenting part- relieves pressure.
• Birth must be expedited, C-section is the preferred mode of delivery
for cases in first stage of labor.
• In second stage of labor for multigravida women, assisted vaginal
delivery is done if there is no contraindication.
• In the community setting, immediate referral to a CEMOC facility is
done.

16. MANAGEMENT
• Operating room and NBU must be prepared to receive an asphyxiated
baby.
READ ON COMPLICATIONS OF CORD PROLAPSE

17. RUPTURED UTERUS

18. OUTLINE
Review of anatomy and physiology
Definition
Causes
Clinical manifestation
Management
Complications

19. ANATOMY AND PHYSIOLOGY OF THE UTERUS
• A hollow pear shaped muscular organ
• Measures about 7.5x 5 x 2.5 and weighs about 60 gm in the
non-gravid state.
• Divided into 3-
the fundus/body
 isthmus
 cervix

20. FUNDUS/BODY
• Upper part is the corpus or body
• The part of the body above the area where the fallopian
tube enters the uterus(cornua)
• Measures about 5 cm in length

21. ISTHMUS
• Lies between the fundus and the cervix
• IS a narrow transition zone
• During pregnancy, the isthmus elongates to form the lower
uterine segment.

22. CERVIX
• Also called the neck of the uterus
• The lower position and measures 2.5 to 3 cm in length.
• The upper part is called the internal os while the lower part
is called the external os

23. UTERINE LAYERS
PERIMETRIUM
The outer peritoneal layer of serous membrane that cover
most of the parts of the uterus
It is continuous with the broad ligaments on either side of
the uterus.
MYOMETRIUM
The middle, thick muscular layer
Most of the muscle fibers are concentrated on the upper
part with numbers diminishing a towards the cervix

24. LAYERS OF THE UTERUS
MYOMETRIUM
Contains 3 types of smooth muscle fiber
1. Longitudinal fiber/outer-Found un the fundus, serves to
expel the fetus efficiently during childbirth.
2. Middle fibers-Contract after birth to compress blood
vessels-physiological third stage
3. Circular fibers-Form constrictions at the entrance of the
tubes, prevents reflux of menstrual blood and tissue into
the fallopian tube

25. LAYERS OF THE UTERUS
ENDOMETRIUM
Innermost layer of the uterus
Responsible for the variations seen during the menstrual
cycle
The layer shed during each menstrual cycle

26. STRUCTURE OF THE UTERUS

27. FUNCTIONS OF THE UTERUS
• Menstruation-endometrium is slough off with every
menstrual cycle
• Pregnancy-supports the growing fetus
• Labor and delivery-Muscles contract and the cervix dilated to
allow for expulsion of the fetus

28. UTERINE RUPTURE

29. DEFINITION
Refers to full thickness tear through the myometrium and
the serosa. May occur in a previously intact uterus or in one
with a previous caeserian section or myomectomy scar.
It is associated with
• Clinically significant uterine bleeding
• Fetal compromise
• Protrusion or expulsion of the fetus and/or the placenta into
the abdominal cavity

30. UTERINE RUPTURE
• Need for prompt caesarian delivery
• Uterine repair or hysterectomy.

31. UTERINE SCAR DEHISCENCE
• A separation of a pre-existing scar that does not disrupt the
overlying visceral peritoneum (uterine serosa) and that does
not significantly bleed form its edges. In addition, the fetus,
placenta and umbilical must be contained in one cavity

32. ETIOLOGY OF UTERINE RUPTURE
Scarred uterine rupture-History of C/S, hysterotomy,
myomectomy, excision of a uterine septum, metroplasty,
previous perforation of the uterus, forceps delivery and
hysteroscopy.
Unscarred Uterus rupture
Spontanous- Feto-pelvic disproportion, congenital uterine
anomalies, soft tissue obstruction.

33. UNSCARRED UTERINE RUPTURE CONT,
Traumatic
Surgical intervention-Internal version, forceps delivery,
forcible dilatation, MVA, destructive operations
Medical Interventions-Uterine hyper stimulation (oxytocin
during labor induction or augmentation)

34. INCIDENCE
• Occurs in 0.05% to 0.086% of all pregnancies
• Dehiscence is the most common
• Rarely seen in the developed countries in the absence of a
previous surgical scar
• More frequent in obstructed labor
• Uterine scar dehiscence is more common and rarely results
in major maternal and fetal complications

35. RISK FACTORS
• Previous uterine scar/uterine surgery
• Obstructed labor
• Difficult forceps delivery
• Undiagnosed cephalo-pelvic disproportion or
Malpresentation
• Grand multiparity
• Injudicious use of oxytocin in women with high parity
• Placenta percreta and increta

36. RISK FACTORS CONT,
• Short inter pregnancy interval-< 12 months OR is 1.26, 12-26
months OR is 1.0
• Induction of labor-OR is 2.06
• Height-< 159 cm OR is 2.09
• BMI

37. DIAGNOSIS
• Few warning signs with previous uterine scar
• In uterine dehiscence, prolonged fetal bradycardia is the first
sign. 8 % present with pain and 3% with bleeding
• Intact uterus-Atypical pain pattern, or pain previously
controlled by analgesia which becomes more severe should
be investigated more

38. CLINICAL PRESENTATION
• Sudden, severe abdominal pain-may decrease after rupture
• Bleeding-intra-abdominal and/or vaginal unless the fetus
blocks the pelvis
• Tenderness abdominally
• Easily palpable fetal parts
• No fetal presentation on VE
• Cessation of uterine contractions
• Abdominal distention/free fluid

39. CLINICAL PRESENTATION
• Abnormal uterine contour
• Rapid maternal pulse
• Absent fetal heart rate
• Haematuria
• Hypovolaemic shock

40. MANAGEMENT
• SHOUT FOR HELP
• Position the woman on left lateral position
• Resuscitation
• Insert 2 large bore IV cannulae-G 16
• Infusion of crystalloids/colloids as clinically indicated. If
systolic BP is below 90mmHg,infuse 1 litre in 15-20 mins,
then infuse I litre over 30 mins
• GXM, request for 6 units of whole blood

41. MANAGEMENT
Collaborative
Obstetrician and anesthetist to review for emergency
surgery. Surgery should be done within 15 minutes of
diagnosis
Surgery could involve C-section with repair of the uterus,
sub-total hysterectomy or total hysterectomy depending on
the type of rupture.
Pre-op and post-op care remain the same as those of
C/section or laparotomy.

42. COMPLICATIONS
• Massive haemorrhage/DIC
• Hysterectomy
• Trauma to the fetus
• Damage to the bladder
• Ileus, infection

43. ACUTE UTERINE INVERSION

44. OUTLINE
Definition
Etiology
Classification
Management

45. UTERINE INVERSION
• A rare but life threatening condition in which the uterus falls
into the endometrial cavity. The uterus turns inside out of
the fundus into the uterine cavity.
• The condition carries a high risk of mortality due to
hemorrhage and shock.
• Complicates 1 in 20000 to 1 in 23000 deliveries, mostly low
risk deliveries.
• Incidence has increased 4-fold since the introduction of
AMSTL.

46. RISK FACTORS
• Mismanagement of the third stage of labor. Involves
excessive cord traction
• Combination of fundal pressure and cord traction in delivery
of the placenta
• Pathologically adherent placenta
• Fetal macrosomia
• Short umbilical cord
• Uterine atony

47. CLASSIFICATION
• First degree-The fundus reaches the internal os
• Second degree- The body or corpus of the uterus is inverted into the
uterine wall.
• Third degree- The fundus protrudes to or beyond the introitus and is
visible.
• Fourth degree-Total uterine and vaginal inversion. Both uterus and
vagina are inverted beyond the introitus

48. CLASSIFICATION OF UTERINE INVERSION

49. CLINICAL FEATURES
• Hemorrhage with or without shock.
• Shock may be initially neurogenic with signs of bradycardia and
hypotension. PPH eventually sets in.
• Shock may be disproportionate to blood loss-careful assessment for
the need for blood transfusion.
• Severe lower abdominal pains with a strong bearing down sensation

50. ASSESSMENT/EVALUATION
• Made clinically with bi-manual examination. The uterine
fundus is palpated in the lower uterine segment or in the
vagina.

51. MANAGEMENT
• Acute uterine inversion constitutes an obstetric emergency. CALL FOR
HELP IMMEDIATELY.
• Control of hemorrhage and restoration of hemodynamic instability.
• Signs of shock include
Weak rapid pulse (> 110 b/min)
Low BP-systolic < 90 mmHg
Pallor, rapid breathing, anxiety and confusion
Rapid breathing

52. MANAGEMENT OF SHOCK
• Insert 2 large bore branulas-G 16-18
• Infuse crystalloids rapidly-Ringers lactate or normal saline. Infuse 1
litre in 15-20 mins then 1 litre in 30 mins at the rate 30 ml/min.
• Continuous assessment of the woman's response to fluid therapy is
done
• Monitor pulse, BP every 15 mins
• Signs of improvement include stabilizing pulse rate, increasing systolic
BP, improving mental status and increasing urinary output

53. NON-SURGICAL MANAGEMENT
MANUAL REPLACEMENT
Should be attempted promptly
Johnson manoever
The uterus is lifted into the abdominal cavity above the level
of the umbilicus before repositioning.
The whole hand plus 2 thirds of the forearm is placed on the
vagina.
Holding the fundus in the palm of the and keeping the tips of
the fingers in the uterocervical junction, the fundus is raised
above the level of the umbilicus

54. MANUAL REPLACEMENT
• It may be necessary to apply digital pressure constantly for several
minutes.
• This places the uterine ligaments under tension, which relaxes and
widens the cervical ring and facilitates passage of the fundus through
the ring.

55. HYDROSTATIC PRESSURE
• The next intervention upon failure of the manual method.
• Uterine rupture must be excluded and is done on the
operating room.
• The woman is placed in the lithotomy position, warm saline
or isotonic sodium chloride is rapidly applied to the vagina
via a rubber tube or IV access while the hand blocks the
introitus
• The fluid distends the vagina and pushes the fundus upwards
to its natural position by hydrostatic pressure.

56. HYDROSTATIC PRESSURE CONT,
• The bag of fluid should be elevated to about 150 cm above the level
of the vagina to ensure sufficient pressure is applied.
• Maintain a tight seal at the introitus may be difficult, this can be
overcome by use of a Ventouse cup.
• Both hydrostatic pressure method and manual replacement should be
done after administered muscle relaxants including MgSO4 4-6 g slow
iv over 20 mins, nitroglycerine 100 micrograms slow iv or tarbutaline
0.25 mgs iv slowly.
• The drugs achieve uterine relaxation within 2-10 mins

57. SURGICAL MANAGEMENT
HUNTINGDONS OPERATION
The abdomen in opened and the inversion site is exposed. A
crater will be noted near the cervix with indrawn tubes and
round ligaments. Two forceps are introduced into the crater
on each side and gentle upward traction is exerted on the
forcep, with further placement of forceps on the advancing
fundus.
The uterus is pulled out of the constriction ring and restored
to its normal position

58. SURGICAL MANAGEMENT
HAULTAIN’S OPERATION
Cervical ring is incised posteriorly with a longitudinal
incision.
The rest of the steps follow the Huntingdon’s method
Once the uterus has been repositioned, all incisions on the
cervix, uterus and vaginas are closed with interrupted
sutures.
Uterotonics are given to maintain uterine contractions

59. SHOULDER DYSTOCIA

60. OUTLINE
• Definition
• Risk factors
• Diagnosis
• Management
• Complications

61. SHOULDER DYSTOCIA
• A complication of vaginal delivery in which the fetal
shoulders fail to deliver spontaneously after the head is
delivered.
• Shoulder dystocia cannot be predicted, complicates between
0.15%-2% of all deliveries.
• In a normal gynecoid pelvis, the inlet is at 12 cm in the A-P
diameter and 13 cm in the transverse diameter. The average
fetus has a bisacromial diameter of 12-15 cm and shoulders
are usually in an A-P position.

62. SHOULDER DYSTOCIA
• Although the bisacromial diameter is usually larger than the
transverse diameter of the pelvic outlet, no obstruction
occurs because the shoulders are compressible.
• If a bisacromial process is 16-17 cm, the shoulders may get
trapped in a normal sized pelvic outlet.

63. SHOULDER DYSTOCIA

64. RISK FACTORS
ANTENATAL RISK FACTORS
Maternal obesity
Maternal age over 35 years
ANTEPARTUM RISK FACTORS
Fetal macrosomia
Gestational diabetes
Excessive weight gain in pregnancy

65. RISK FACTORS
INTRAPARTUM RISK FACTORS
 Prolonged labor- First and second stage
 Instrumental delivery
 Labor dystocia

66. WARNING SIGNS
Difficulty with birth of the face or chin
The fetal head retracts against the perineum-turtle neck sign
Failure of the head to restitute
Failure of the shoulders to descend

67. MANAGEMENT-HELPERRR MNEMONIC
• H- Call for Help
• E- Give an adequate or generous episiotomy
• L- Legs to be put in Mcroberts position
• P-Apply suprapubic pressure
• E- Enter- Apply internal manouvers
• R- Remove the posterior arm
• R- Roll over to the all fours
• R-Repeat the process all over again

68. HELPERRR- SHOUT FOR HELP
• Upon identification of shoulder dystocia, the midwife
immediately shouts for help. This is an emergency that
requires immediate action.
• Appropriate equipment and personnel should be mobilized
immediately.
• The obstetrician, anesthetist to administer appropriate pain
relief and an individual expert in newborn resuscitation

69. EVALUATE FOR EPISIOTOMY
• Carefully evaluate for the need for an episiotomy.
• Not always required since this is a bony impaction and can
easily be relieved by Mcroberts maneuver and application of
suprapubic pressure.
• In the event that Mcroberts fail, then episiotomy becomes
necessary to create room for the clinicians hand

70. L-LEGS(MCROBERTS MANEUVER)
• The ideal first step in management.
• Requires flexing the maternal hips beyond 90 degrees with
abduction and external rotation to a position alongside the
maternal pelvis.
• The position flattens the sacral promontory and results in
cephalad rotation of the symphisis pubis. It is associated with
increased amplitude of contractions and increased uterine
pressure

71. MCROBERTS
• If successful, normal traction should deliver the head of the
baby.
• The maneuver has a success rate of 40-70%

72. MACROBERTS

73. P- SUPRAPUBIC PRESSURE
• External manual suprapubic pressure should be attempted for about
30 seconds with gentle traction continuing.
• The suprapubic hand is placed over the fetus anterior shoulder
applying pressure in a firm consistent manner in a CPR style.
• The shoulder will adduct or collapse anteriorly and pass under the
symphisis pubis.

74. SUPRAPUBIC PRESSURE

75. ENTER-INTRODUCTION OF INTERNAL
MANEUVERS
Each of the maneuvers is designed to achieve one of the
following
Increase the functional size of the pelvis
Decrease the bi-sacromial diameter( Width of the presenting
shoulders)
Change the relationship of the shoulders-biacromial
diameter within the bony pelvis

76. INTERNAL MANEUVERS
Attempt to manipulate the fetus in order to rotate the
anterior shoulder into an oblique plane under the symphisis
pubis
RUBIN’S MANEUVER 1-ALLAN RUBIN( 1964)
The woman remains in McRoberts position
Both hands are placed suprapubically over the posterior
shoulder and continuous pressure is applied in a downward
lateral motion

77. INTERNAL MANEUVERS
RUBIN 1 CONT,
Pressure is then applied in a rocking motion. Gentle traction
is applied for 30 seconds.
Suprapubic pressure reduces the bisacromial diameter

78. INTERNAL MANEUVERS
RUBIN 2(ANTERIOR RUBIN)
Inserting 2 fingers of one hand vaginally behind the anterior
fetal shoulder and pushing the shoulder anteriorly towards
the fetal chest. The clinician can alternatively insert the
hand behind the posterior shoulder where there is more
space
Once the hand is in the vagina, it is slid over the fetal back to
the anterior shoulder and pressure applied

79. RUBIN’S MANEUVER
• Rubin argued that pressure will adduct or collapse the fetal shoulder
girdle reducing its diameter

80. WOOD’S SCREW MANEUVER
Described by Dr. C.E. Woods in 1943
Combined with Rubin 2 as the next course of action.
The provider uses the opposite hand to approach the
posterior shoulder from the front of the fetus and rotate the
shoulder towards the symphisis in the same direction as with
RUBIN 2.
In this combination, the provider has 2 fingers behind the
anterior shoulder and two fingers of the other hand in front
of the posterior shoulder

81. INTERNAL MANEUVERS
WOOD’S SCREW MANEUVER
The Rubin 2 maneuver collapses or flexes either the anterior
and posterior shoulders while the woods abducts and opens
the posterior shoulder.
With this movement, the shoulders rotate and deliver much
like the turning of a thread screw

83. INTERNAL MANEUVERS
REVERSE WOOD SCREW/POSTERIOR RUBIN
The fingers of the hand that had been on the front aspect of
the posterior shoulder is removed form the vagina.
The fingers of the opposite hand, which have been on the
posterior aspect of the anterior shoulder are slid down to lie
behind the scapula posterior to the shoulder.
Once placed on the posterior shoulder form behind, the
attempt is to rotate the fetus in the opposite direction as the
wood’s screw maneuver

84. INTERNAL MANEUVERS
REVERSE WOODS SCREW CONT,
This action rotates the fetal shoulders out of the impacted
position and into an oblique plane form which it can be
delivered

85. R-REMOVAL OF THE POSTERIOR ARM
• The obstetrician slides a hand along the fetal posterior
shoulders and arm, and the fetal forearm or wrist is grasped
and swept across the anterior fetal chest to effect delivery of
the posterior arm.
• If the forearm is not easily accessible, one can follow the
posterior fetal arm and put pressure in the ante-cubital
fossa, this leads to flexion of the arm, allowing access to fetal
forearm

86. REMOVAL OF THE POSTERIOR FOREARM
• With successful delivery of the arm, the axillo-acromial
becomes the presenting part, is 3 cm shorter and leads to
delivery of the anterior shoulder

87. ROLL OVER TO ALL FOURS
• Also called Gaskin Meneuver, was first described by Ms
Gaskin, a renown midwife in the US.
• The patient rolls over form the supine position to an all fours
position.
• Pelvic diameters increase when women change from the
dorso-recumbent position.
In the all fours position, the true obstetric conjugate increase
by upto 4 mm and the saggital measurement of the inlet
increases by upto 20 mm

88. ROLL OVER to ALL FOURS
Fetal shoulder often dislodges when turning from supine to
the all fours-movement alone may allow enough pelvic
change.
Gravitation change then aides in disimpaction of the
shoulder

89. ALTERNATIVES TO SALVAGE MANEUVERS
POSTERIOR AXILLIARY TRACTION
Helpful when the fetal arms are extended.
With each maneuver, the assistant should hold the fetal head
and flex it upwards towards the anterior shoulder
Menticoglov Maneuver
The middle finger is placed under the posterior fetal axillar
and downward-upward traction is applied which leads to
delivery of the posterior shoulder

90. POSTERIOR AXILLARY TRACTION
Posterior Axillary Sling Traction
A suction catheter or firm urinary catheter is used as a sling.
Traction is applied to the sling to deliver the posterior
shoulder followed by the arm.
Alternatively, the sling can be used to rotate the shoulder
can be used to rotate the shoulders by applying lateral
traction towards the baby’s back while the other hand is
placed on the anterior shoulder putting pressure on the fetal
chest

91. THE ZAVANELLI MANEUVER
• Requires reversal of the cardinal movements of labor-
derestitution, flexion and subsequent manual replacement
of the head into the vaginal canal, followed by a C/section.
• Continuous upward pressure is then maintained on the fetal
head until c/s is completed.
• Uterine relaxation with nitroglycerine and magnesium
sulphate is done, alternatively relaxation can be done with
halothane or general anesthetics

92. THE ZAVANELLI MANEUVER
 Before considering cephalic replacement, an operating team should
be in place.
NOTE- THIS MANEUVER SHOULD NEVER BE ATTEMPTED IF A NUCHAL
CORD HAS BEEN PREVIOUSLY CLAMPED AND CUT

93. SURGICAL INTERVENTIONS/HEROIC
MANEUVERS
SYMPYSIOTOMY
Surgical division of the fibrous cartilage of the symphisis pubis
Initiated when all other maneuvers have failed and C/S is not
available.
The woman lies in the lithotomy position, a Foleys catheter is
inserted.
Urethra is retracted laterally with the Foleys catheter

94. SURGICAL INTERVENTIONS/HEROIC
MANEUVERS
Skin and subcutaneous tissue are incised with scapel to the
level of the symphisis pubis as well as the anterior fiber.

95. SURGICAL INTERVENTIONS
CLAVICLE FRACTURE
Directed upward pressure on the mid-portion of the clavicle
will result in a fracture and reduce the bisacromial diameter.
The procedure carries the risk of injury to underlying
vascular and pulmonary structures.
Should be considered when the fetus is dead

96. SURGICAL INTERVENTIONS
ABDOMINAL RESCUE(ABDOMINAL SURGERY AND
HYSTEROTOMY)
A low transverse hystorotomy is performed, the fetal
shoulders are rotated to an oblique diameter through a trans
abdominal incision.
Once fetal shoulders are rotated, vaginal delivery is then
attempted

97. COMPLICATIONS
MATERNAL
 Uterine rupture
 Tears 3rd and 4th degree
 Rectovaginal fistula
 Post partum hemorrhage
NEONATAL
 Brachial plexus injury
 Fracture clavicle and humerus

98. COMPLICATIONS
NEONATAL CONT’
Hypoxia with permanent neurological damage

99. OBSTETRIC SHOCK

100. OUTLINE
Definition of obstetric/hypovolemic shock
Pathophysiology
Clinical features of shock
General approach to the management of clients with shock

101. DEFINITION
Circulatory collapse due to inadequate intravascular blood
volume
Leads to hemodynamic and metabolic collapse and failure of
the circulatory system to maintain adequate perfusion of
vital organs that results in decreased oxygenation of tissues
and reduced nutrient activity

102. MATERNAL MORTALITY IN KENYA
DIRECT CAUSES OF MATERNAL MORTALITY IN KENYA
1. Haemmorhage-44%
2. Obstructed labor-34 %
3. Eclampsia-13%
4. Sepsis-6%
5. Ruptured uterus-3%
Source-NCPD and UNFPA, Kenya Population Situation
Analysis, 2013

103. PATHOPHYSIOLOGY
• ↓ blood volume caused by blood loss → reduced cardiac
output and reduced organ perfusion.
• Severity of symptoms depends on amount of blood loss.
Loss ˂ 15 % , mild ↑in HR, no change in arterial pressure.
Loss between 15-40%, mean arterial pressure ↓, HR ↑.
Resuscitation efforts is enough to restore stability and reduce
long term consequences.
Blood loss > 40 % of total volume is life threatening-organ
failure and death.

104. COMPENSATORY MECHANISMS
BARORECEPTOR REFLEXES
Body senses ↓in BP through arterial and cardiopulmonary
baroreceptors.
Sympathetic adrenergic system is activated to stimulate the
heart→↑ HR and contractility and constricting of blood
vessels.
Cardiac output is redirected to vitals organs-brain and heart
necessary for survival

105. COMPENSATORY MECHANISMS
CHEMORECEPTORS
Reduced organ flow is leads to acidosis which is sensed by
chemoreceptors.
Chemoreceptor reflex further activates the sympathetic
adrenergic system reinforcing baroreceptor reflex. If
hypotension is severe, mean arterial pressures < 50 mmHg,
the brain becomes ischemic.
Intense sympathetic discharge reinforces autonomic reflexes.

106. COMPENSATORY MECHANISM

107. COMPESATORY MECHANISM
• Hypotension and sympathetic activation leads to humoral
compensation.
• Sympathetic stimulation of adrenal glands → release of
catecholamines (vasoconstrictors).
• Kidneys release more renin due to bleeding leading to increased
angiotensin II and aldosterone.
• This causes vasoconstriction, sympathetic activity, stimulation of
vasopressin, activation of thirst mechanism and increased
reabsorption of sodium and water to increase blood volume

108. COMPENSATORY MECHANISM

109. COMPENSATORY MECHANISM
• Hypotension, vessel constriction leads to fall in capillary
hydrostatic pressure. Causes shift of fluid from the capillary
to interstitial space.
• Less fluid leaves capillary, if pressure falls moderately,
reabsorption of fluid can occur from tissue back to capillary
plasma.
• The reabsorbed fluid contains electrolytes, protein-increased
plasma volume.
• The reabsorbed fluid causes hemodilution of blood,
Hematocrit levels fall.

110. CLINICAL FEATURES
• Weak rapid pulse rate> 110 beats/min
• Low BP systolic < 90 mmHg
• Pallor
• Sweating, cold clummy skin
• Rapid breathing
• Anxiety and confusion
• Unconsciousness
• Fetal distress

111. MANAGEMENT
• SHOUT FOR HELP
• Assess for Airway, Breathing and Circulation (A, B, C)
• Position the woman on the left lateral position if still pregnant.
Fluid management
• Secure an IV access, 2 large bore branulla, G 16 or Gauge 18
• Give fluids rapidly-1 litre in 15-20 minutes, then 1 litre in 30 minutes
• Monitor BP, pulse and shortness of breath or puffiness every 15
minutes

112. FLUID MANAGEMENT
• Reduce to 3 ml/minute(1 litre in 6-8 hours) if the pulse slows to < 100
b/min and systolic BP is ≥ 100 mmHg. Reduce to 0.5 ml/min if
breathing difficulty or puffiness occurs.
• Give fluids at moderate rates if severe abdominal pains, obstructed
labor, ectopic pregnancy is present. 1 litre in 2-3 hours
• Insert a urethral catheter and monitor urine output
• Maintain intake/output chart

113. MANAGEMENT
Keep the woman warm
Continuously assess the fetal condition
Lab investigations, FHG, Hematocrit, GXM
Consider blood transfusion based on extent of shock
Refer to a CEMONC site if in a BEMONC facility( Health
Centre)

114. REASSEMENT
Reassess response to IV fluid therapy within 30 minutes for
signs of improvement
Stabilizing pulse(90 beats/min or less)
Increasing systolic BP( 100 mmHg or more)
Improving mental status(Less confusion and anxiety)
Increasing urine output ( 30 mls/hour or more)
Adjust IV fluid therapy with improving of the condition
Continue treatment of the underlying cause

115. POST PARTUM
HEMMORHAGE(PPH)

116. OUTLINE
Definition
Incidence
Classification
Predisposing factors
Management
Complications

117. DEFINITION
• Excessive bleeding from the genital tract following delivery
• 500 mls following a vaginal delivery or 1000 mls following a
C/S.
• Any amount of bleeding that results in signs and symptoms
of hemodynamic instability.
• Definition is debatable-median blood loss following an SVD is
more than 500 mls.

118. INCIDENCE
• Even with appropriate management, upto 5% of women will
experience PPH, 1% of vaginal deliveries will result in severe
PPH.
• The leading cause of maternal deaths in developing
countries , contributing to 25% of all deaths.

119. CLASSIFICATION
Primary PPH-Occurs within 24 hours of delivery, most
common.
Secondary PPH-occurs from 24 hours to 6 weeks postpartum

120. RISK FACTORS
ANTEPARTUM RISK FACTORS
History of PPH-10% recurrence
Nulliparity and grand multiparity
Coagulopathy
Abnormal placentation
Age> 30 years
Over distention of the uterus-Multiple pg, fetal macrosomia,
polyhydromnious

121. RISK FACTORS
LABOR RISK FACTORS
Prolonged labor
Pre-eclampsia
Fetal demise
Induction or augmentation
Use of MgSO4
Chorioamnionitis

122. RISK FACTORS
SURGICAL INTERVENTIONS
Operative vaginal delivery
C/section
Episiotomy

123. CAUSES OF PPH-THE 4 Ts
• Tone-Atonic uterus-70%
• Trauma-Tears, lacerations, hematomas, inversions, rupture-
20%
• Tissues-Retained tissues, invasive placenta-10%
• Thrombin-Coagulation disorders-1%

124. ATONIC UTERUS
Failure of the myometrium to contract and retract and to compress
torn blood vessels.
CAUSES OF ATONIC UTERUS
Incomplete placental separation
Retained placenta,membranes
Precipitate labor
Prolonged labor
Polyhydromnious, multiple pregnancy, macrosomia

125. ATONIC UTERUS-CAUSE
Placenta praevia and abruptio
Induction/ augmentation with oxytocin
Full bladder
Fibroids
Anaemia

126. SIGNS OF PPH
 Vagina bleeding and maternal collapse
 Subsequent signs
Pallor
Rising pulse and falling BP
Altered levels of consciousness
Enlarged uterus, “boggy” on palpation

127. MANAGEMENT OF PPH
SHOUT FOR HELP
A, B, C. Assess airway, breathing and circulation.
Evaluate for blood loss, blood loss more than 500 mls, visible
bleeding noted, BP falling and Pulse increasing.
Uterine massage, oxytocin 20 iu i.m, 30-40 iu in 500 mls
normal saline is started.
If the uterus is soft and boggy, carbetocin or misoprostal
should be considered

128. FLUID RESUSCITATION
• I.V access, 2 large bore brannula, start warm isotonic
crystalloid solution.
• Keep the woman warm and elevate the “leg” of the bed
• Foley catheter to monitor urine output
• CVP monitoring
• Bed side clotting test
• GXM, Packed cells should be transfused. If no response, FFP
is infused at a dose of 12-15 ml/kg

129. BIMANUAL COMPRESSION OF THE UTERUS
Applied when the uterus is soft, “boggy” and there is brisk
blood flow
The service provider places one hand over the lower
abdomen to massage the uterine fundus and one hand in
the vagina vault to massage the lower uterine segment
Two or more fingers of the vagina hand are typically used for
bimanual massage. Using the entire vaginal or fist to
compress the uterus may be necessary for severe atony

130. BI-MANUAL COMPRESSION

131. UTERINE TAMPONADE DEVICES
• Attempted to control bleeding while definitive treatment is arranged
or patient is being transported to another facility.
• A uterine balloon tamponed is placed through the cervix, filled with
water or normal saline.
• Works by pressing against the bleeding endometrium with a force
that exceeds the uterine arterial or venous pressure.
• Contraindicated in genital tract infection, allergy to latex

132. UTERINE TAMPONADE

133. B-LYNCH
A large needle with # 2 catgut is used to enter and exit the
uterine cavity at A and B. The suture is looped over the
fundus and then re-enters the uterine cavity posteriorly at C.
The suture should be pulled tightly at this point.
It then enters the posterior wall at D, looped back over the
fundus and anchored by entering the lower uterine segment
crossing the lower uterine cavity

134. B-LYNCH

135. B-LYNCH

136. HYSTERECTOMY
• The last resort in uncontrolled bleeding due to uterine atony

137. COMPLICATIONS
• READ ON THE COMPLICATIONS OF PPH