Obstetric emergency part 3

Obstetric emergency cont…

Retained placenta

Adherent placenta

inversion of the uterus

BY MUKEREM.A 2007

Session Objectives

By end of session, students will be able to:

• Define retained placenta

• Discuss the causes, Management retained placenta

• Discuss the causes, Management Adherent placenta

• Describe the cause, management ,prevention and Complication of inversion of uterus

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7. Managing retained placenta

Retained placenta

Defn: - When placenta remain 30 minutes after delivery having left the upper uterine segment

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Causes:

Poor uterine action

Hourglass contraction – this is a constriction ring in the third stage caused by giving ergometrine and not expelling the placenta in time.

A full bladder

Mismanagement of the third stage.

i.e. – trying to expel the placenta before it has separated completely this may induce spasm of the lower uterine segment.

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Management

Manual removal of the placenta.

Steps for manual removal of the placenta

1. An intravenous infusion must first be sited with 20 Iu of ocytocin

2. An effective anesthesia by in progress

3. Manual removed is performed with full aseptic precautions.

4. With the left hand the umbilical cord is held BY MUKEREM.A 2007


5. While the right hand is inserted in to the vaginal and the uterus following the direction of the cord.

6. Once, the placenta is located the cord is released then left hand support the fundus abdominally.

7. Right hand will feel for a separated edge of the placenta. Then the fingers of the right hand are extended and the border of the hand is gently eased between the placenta and the uterine wall with the palm facing the placenta.

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8. Then with a sideways slicing movement the placenta is carefully detached.

9. When the placenta is completely separated the left hand rubs up a contraction and expels the right hand with the placenta in it’s grasp

10. The placenta should be checked immediately for completeness so that any further exploration of the uterus may be carried out without delay.

11. An oxytocic drug is given up on completion usually intravenous ergometrine 0.5mg.

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Manual Removal

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Adherent placentaDefn - When the placenta 30 minutes after delivery still has not separeted left the upper uterine segment or placenta implantation in which there is abnormally firm adherence in the uttering wall. As the consequence of partial or total absence of deciduas basalisCauses of adherent placenta When deciduas formation is defective. Associated condition includes implantation in the lower uterine segment, over a previous c/s scar, or other uterine incisions, or after uterine curettage and grand multiparty.

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Types of adherent placenta

Three types

1. Placenta accreta:- when placenta villi are attached to the myometrium

2. Placenta increta:- when placenta villi invadethe myometrium.

3. Placenta percreta:-when placenta villipenetrate through the myometrium.

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Management

If uterus is ‘not needed’ (further fertility not needed) – hysterectomy

If uterus is needed – doctor can remove it

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8. Managing inversion of the uterus

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GROUP DISCUSSION

• What is different between Prolaps of the Uterus and Inversion of the Uterus???

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Acute inversion of the uterus

Defn; Inversion means that the uterus has turned inside out

A rare but potentially life threatening complication of third stage of labour

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Causes

Causes are all connected to applying force to the uterine fundus when it is relaxed and the cervix is dilated.

Exerting controlled cord traction when the uterus is relaxed especially if the placenta is centrally sited in the fundus.

Forcibly attempting to expel the placenta by using fundal pressure when the uterus is atonic

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Combining fundal pressure and cord traction to delivery the placenta.

Multiparous mother followed delivery and who pushed vigorously or possibly has coughed or sneezed.

Short umbilical cord

Sudden emptying of the distended uterus

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Classification A. According to severity 1. First degree: The fundus reaches the internal os2. Second degree: The body or corpus of the uterus is

inverted to the internal os3. Third degree: The uterus, cervix and vagina are

inverted and are visibleB. According to time of the inversion 1. Acute: Immediately after delivery, with placenta still

attached. 2. Chronic: Inversion occur after the first 24 hours

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Sign and Symptoms

In serious cases the inner surface of the fundusappears at the vaginal outlet.

In less severe instances the fundus is dimpled

The fundus is not palpable abdominally

Sudden onset of shock is the out standing sing accompanied by severe pain which is caused by the ovaries being dragged in to the inverted uterus.

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Management 1. Help is summoned 2. The best chance of replacing the uterus occurs

immediately following the inversion. Pressure is applied first to the part nearest the cervix working upwards to the fundus on the principle of “Last out first in”.

3. No attempt is made to remove the placenta until the uterus is the right way out otherwise hemorrhage can not be controlled. An inverted uterus cannot contract and retract

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4. If replacement of a totally inverted uterus is not possible it should be gently placed inside the vagina to relieve traction on the ovaries and fallopian tubes.

Raising the foot of the bed will also help to relieve the tension and alleviate shock. And refer her to the nearest hospital.

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QUESTION ???

• What measures can we take to prevent of inversion of the uterus ?

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Prevention of inversion of the uterus

Proper management of the third stage

Avoid combining fundal expression and cord traction to delivery the placenta.

Do not pull on the cord unless the placenta has separated.

Do not leave the patient until the uterus is contracted and rounded.

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Complication of inversion of uterus

Shock – due to tension on the ovaries

Hemorrhage – the condition is worse attempt is made to remove the placenta while the uterus is not in the right way.

Infection

Paralytic ileus

Intestinal obstruction

Anemia and in some cases sterilityBY MUKEREM.A 2007

Obstetric emergency part 3

Health & Medicine

Transcript of Obstetric emergency part 3