Obstetric Emergencies

Always BE READY for obstetric emergencies! They often happen

QUICKLY and require QUICK ACTION and TEAMWORK!Think of how
you can RECOGNIZE OB emergencies and systematically DEAL WITH
them. Also think of how you can PREVENT Obstetric emergencies.

Think through the topics. . .

Whatis the problem? Define

What is the PATHOPHYSIOLOGY with this?

What are predisposing factors?—who is at risk?

would you recognize the problem—diagnosis?

Management—Nursing and Medical

Haemorrhage
this is the MOST important single cause of maternal deathin the
WORLD
Also a leading cause of maternal morbidity.
Goal:Prevent/Detect Haemorrhage
Haemorrhage
Worldwide-Haemorrhageis the MOST important cause of pregnancy-
related mortality. The majority of these deaths (88%) occur within 4
hours of delivery(showing they are a consequence of events occurring
in 3rdstageof labour.First hours postpartum are especially critical in
Dx and Mgt.
Failure to recognise
 Blood loss is often underestimated

In pregnancy signs of hypovolaemia may delay until losses are large!

Mothers can lose up to 30-35% of circulating blood volume (2000

mLs) beforeshowing signs of hypovolaemia

The mother compensates for blood loss by shutting off the blood
supply to the feto-placental unit.

Principles of managing PPH

REMEMBER: Delay means DEATH!

The bleeding is stopped

The woman is resuscitated or her condition is stabilized

Our Now let’s revise. . .
However remember: Haemorrhagecan occur in pregnancy, delivery
OR postpartum

Our emphasis Block 3 is labour and early postpartum

THIRDStage of Labour

P. 526 AfrEd2: Period from birth of babytill complete expulsion of

placenta andmembranes, involving separation, descent and expulsion
of placenta and membranes and control of haemorrhage from placenta
site.
Anatomy of Uterus
Name the structures which lie in front of and behind the uterus.

nteriorly) . . .

The rectum and Pouch of Douglas

Sagittal View-Female Reprod System

Anatomy of Uterus
The non-pregnant uterus is described as having two main parts.

UTERUS: Non-pregnant, Pregnant, and 2ndstage of labour

Non-pregnant Pregnant 2ndStage of labour

Anatomy of Uterus
Which fibres of the myometrium are important in controlling bleeding
in the 3rdstage of labour?

The OBLIQUE fibres which form the middle layer (see MylesAfrEd3
p101 for better oblique fibre picture)
Anatomy of Uterus

Anatomy of Uterus

In the upper part between insertion of the two fallopian tubes

Narrow area between the cavity of the body of the uterus and the
cervix
Anatomy of Uterus
Where is the internalos?
The narrow opening between the isthmus and the cervix
externalos?
The opening between the lower end of cervix into the vagina
Layers of Uterus
Cervix
Describe the difference between the non-pregnant and the pregnant
cervix
Non-pregnant cervix= firm and pink

Pregnant cervix= soft and purple(dark red/bluish)

During pregnancy what does the cervical canal contain?
A plug of mucus (“operculum”) which helps protect against infection
Cervix and Uterus
What causes these changes in pregnancy? (the soft and purple
cervix)

During pregnancy the uterus is described in two “functional” areas,

either above or below the isthmus. What are they called?
and lower segments
Uterus
How do the two segments of the uterus function differently during
the first stage of labour?

In which of the 2 segments are most obliquefibressituated?

UTERUS

Uterus
Does the placenta normally embed into the myometrium?
NO, Placenta normally does not normally embed beyond the decidua

What would happen IFthe placenta did embed into the myometrium?
The placenta would be retained since it would not separate from the
decidua in the normal way
Placenta (ch. 5) –3rded
Do fetal and maternal blood mix in the placenta?
 NO, Normally fetal and maternal blood are separated 4 layers inside
chorionic villi of placenta

Whose blood is in the cord of the placenta? Mother’s or baby’s –give

your rationale.
Whoseblood is in the cord?:Mother’s or baby’s? See AfrEd3:pp 63 & 66

Placenta (ch. 5)
How does the size of the placental sitechange during the 3rdstage of
labour?
Becomes smaller due to contraction and retraction of the uterine
muscle
What happens to the PLACENTA as the placental sitebecome smaller
and why?
The placenta begins to separate from the uterine wall since unlike
the uterus it is not elastic and cannot contract and retract
Placenta
How does the retroplacental clot further help separation?
It collects blood in the chorio-decidual space and helps to shear off
the placenta from the decidua
Placenta
 What are the physiologicsigns that placental separation and descent
have taken place?

e cord

Contraction of uterus with fundus rising abdominally

During what stage does this normally happen?

3rdSTAGE (between birth of baby and delivery of placenta and
membranes)
Change in shape of Uterus PP(See MylesAfrEd3 p533)

Placental Separation

“shiny schultze” (amnion-side of placenta)

“dirty Duncan” is when cotylydons deliver first.

 A midwife needs to be alert if placenta separation is Duncan. . .
Placenta
Describe the “Schultze” process of placental separation:

The placenta detaches from a central point and a retroplacental clot

is formed (usually enclosed in membranes when the placenta is
delivered).
Placenta

Schultz Expulsion, showing retroplacental clot

Placenta
Describe the Matthew Duncanprocess of placental separation:

The placenta detaches unevenly at or on its lateralborders. The blood

escapes so that separation is NOT helped by a retroplacental clot. The
placenta descends, slipping sideways, maternal surface first.

(see Picture of Duncan process of placental separation: AfrEd3 p.

347)
Placenta
What may be a hazard of the Matthew Duncanprocess of placental
separation?:
It may be associated with a low-lying placenta in uterus.

Blood loss is greater if low-lying and fewer oblique fibres in the lower
segment. (example: placenta praevia)
IMPORTANT: Examine Placenta and membrantes CAREFULLY
Exam placenta AND membranes to ensure that they have been
delivered complete. Be sure and document this.

Placenta
What is the normal blood flow through the placental site each
minute?

-800ml per minute

If bleeding is not controlled promptly, this is how quickly a woman

will lose blood! (She could loose 500 –800 mL of blood PER MINUTE!!!)

Control of Blood loss—Revise 3rdstage

 Describe how blood loss is controlledafter delivery of the placenta—
”physiologically”—ways the body itself attempts to achieve
Haemostasis.
Retractioncauses “living ligatures”to shorten, clamping blood vessels

Vigorous uterine contraction (pressure—as uterus contracts)

Transitory activation of coagulation

systems (revise 3rd stage-pp347-348)

Control of Blood loss—”Living ligatures”

Control of Blood loss

What happens IF blood clots are left behind in the cavity of the
uterus after delivery of the placenta?
 Name 2 factors which can interferewith control of bleeding.
Retained placenta or membranes or parts of these. (Also prolonged
labour, anaesthesia, analgesia, etc.)

Third stage
Why is ASEPTIC technique so important during the 3rd stage of
labour?
The placental site contains large venous sinuses with direct access
into general circulation

Thus infection can easily spread and rapidly lead to septicaemia. The
placental site is also warm and dark, making it an ideal place to
culture microorganisms.
A & P: Haemostasis-Third Stage
You have just revised the Anatomy and Physiology of the uterus and
how the body is normally able to achieve haemostasis in third stage of
labour.

Keep revising NORMAL Physiology of Haemostasis in 3rdstage

A & P: Haemostasis-Third Stage

Now go to the next Power Point to learn more about Post Partum
Haemorrhage