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Obstetric emergencies
1.
1Copyright © 2014
Well Woman Clinic. All rights reserved. 1 A holistic approach to Woman’s health Dr Nupur Gupta Dept of Obstetrics & Gynecology Paras Hospital, Gurgaon Obstetric Emergencies
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2Copyright © 2014
Well Woman Clinic. All rights reserved. 2 Our Team
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3Copyright © 2014
Well Woman Clinic. All rights reserved. 3 Emergency Obstetric Care To Avert Death and Disability… …We Need to Ensure that Women have Access To Emergency Obstetric Care (EmOC)
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4Copyright © 2014
Well Woman Clinic. All rights reserved. What is an Obstetric emergency? A suddenly developing pathologic condition in a patient, due to accident or disease, which requires urgent medical or surgical therapeutic intervention There are 2 patients; fetus is very vulnerable to maternal hypoxia
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5Copyright © 2014
Well Woman Clinic. All rights reserved. But we do know that of any population of pregnant women at least 15% will experience an obstetric complication … How Do We Know Which Women Will Experience Complications? WE DON’T
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6Copyright © 2014
Well Woman Clinic. All rights reserved. 6
7.
7Copyright © 2014
Well Woman Clinic. All rights reserved. 7
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8Copyright © 2014
Well Woman Clinic. All rights reserved. Hyperdynamic , hypervolumic , maternal circulation Cardiac output increases by 50% , blood volume by 45% (peak at 32-34 wks) 30% loss of fluid may be tolerated without any tachycardia PREGNANCY CHANGES
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9Copyright © 2014
Well Woman Clinic. All rights reserved. Obstetric Emergencies Maternal Fetal Both maternal & fetal High Mortality rate
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10Copyright © 2014
Well Woman Clinic. All rights reserved. Maternal Complications of Pregnancy First Trimester Second Trimester Third Trimester
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11Copyright © 2014
Well Woman Clinic. All rights reserved. First Trimester 1. Ectopic pregnancy 2. Abortion 3. Molar Pregnancy 4. Uterine rupture Second Trimester 1. Abortion Third Trimester 1. Placenta Praevia 2. Placenta Accreta 3. PPH 4. Uterine rupture 5. Inversion 6. Hypertensive crisis
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12Copyright © 2014
Well Woman Clinic. All rights reserved. Hypertensive Complications Haemorrhage Topics of Discussion
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13Copyright © 2014
Well Woman Clinic. All rights reserved. Pregnancy and hypertension/Toxaemia/PIH Single largest cause of maternal death worldwide Incidence- 7-12% ( 2nd most common cause after anaemia) Pre-eclampsia - HTN + proteinuria with or without edema > 20 weeks Eclampsia - preeclampsia with seizure
14.
14Copyright © 2014
Well Woman Clinic. All rights reserved. Pregnancy and hypertension Chronic hypertension - diagnosed pre-pregnancy or before 20 weeks or persisting > 6 weeks post-partum Gestational or late transient HTN - high BP in latter half of pregnancy or 24hrs after delivery without any signs of eclampsia & disappears within 10 days post-partum
15.
15Copyright © 2014
Well Woman Clinic. All rights reserved.
16.
16Copyright © 2014
Well Woman Clinic. All rights reserved. 16
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17Copyright © 2014
Well Woman Clinic. All rights reserved. SBP > 140 (or +20 from baseline or DBP >90 (or +10 from baseline) Proteinuria .3g/24h +/- Edema No Oliguria No Associated symptoms Normal lab No IUGR BP>160/90 Proteinuria >5g/24h Edema Present Oliguric Visual sym, abd pain, pulm. edema Lab (dec. plts, inc. LFT, inc. bili, inc. creatinine, increased uric acid) IUGR Mild Severe HYPERTENSION & PROTEINURIA IS THE HALLMARK Preeclampsia
18.
18Copyright © 2014
Well Woman Clinic. All rights reserved. Management Goals Safety of mother & newborn Prevent Eclampsia Guidelines Hospitalization Definitive treatment being delivery Expectant management depends on maternal & fetal status, labour & gestational age
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19Copyright © 2014
Well Woman Clinic. All rights reserved. Antihypertensive drugs in PIH Antihypertensive drugs ↙ ↓ ↓ ↘ Nifedipine Hydralazine Labetalol Captopril ↓ ↓ ↓ ↓ Acts in 3 min. Arterial vasodilator rapid action Sublingual 25mg Peak at 1 hr. I/V bolus 5 mg I/V 10 mins acts in 5 min Oral (Sublingual) Oral 25 mg oral- 1 hr only used in post Upto 120 mg/day partum cases Divided 6 hrly Nitroglycerine drip
20.
20Copyright © 2014
Well Woman Clinic. All rights reserved. General Measures for management of Eclampsia Foley’s catheter, I/O chart Urine Albumin 4 hrly Vitals Eye pads Change of position 2hrly Fetal assessment Antibiotic cover Deep tendon reflexes Shift to ICU Railing cot Nasal O2 I/V 5% Dextrose or RL Investigations Mouth Gag Suction Slight head low position
21.
21Copyright © 2014
Well Woman Clinic. All rights reserved.
22.
22Copyright © 2014
Well Woman Clinic. All rights reserved. Eclampsia to treat convulsions: Magnesium Sulphate
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23Copyright © 2014
Well Woman Clinic. All rights reserved. Eclampsia to treat convulsions
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24Copyright © 2014
Well Woman Clinic. All rights reserved. Eclampsia to treat convulsions
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25Copyright © 2014
Well Woman Clinic. All rights reserved. Eclampsia to treat convulsions Next dose should be repeated (after checking the parameters) every 4 hrs 5gm I/M & continue till 24 hrs after delivery or after the last convulsion To prevent fit in severe pre-eclampsia give only I/M dose Other drugs- Diazepam, Pethidine, Promethazine, Chlorpromazine
26.
26Copyright © 2014
Well Woman Clinic. All rights reserved. Delivery within 12 hours of onset of convulsions
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27Copyright © 2014
Well Woman Clinic. All rights reserved.
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28Copyright © 2014
Well Woman Clinic. All rights reserved.
29.
29Copyright © 2014
Well Woman Clinic. All rights reserved. HELLP SYNDROME
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30Copyright © 2014
Well Woman Clinic. All rights reserved. 30 HAEMORRHAGIC/HYPOVOLUMIC SHOCK IN OBSTETRICS Antenatal - Ruptured ectopic pregnancy, APH, Incomplete abortion, Uterine perforation during evacuation, Uterine rupture, Abdominal wall hematoma Intranatal - uterine rupture Postnatal - PPH (primary, secondary) - Atonic,Traumatic, Retained tissue, Thrombosis, Acute uterine inversion
31.
31Copyright © 2014
Well Woman Clinic. All rights reserved. Ruptured Ectopic Pregnancy: A Surgical Emergency of Pregnancy One of the leading causes of first trimester maternal death Usually 5-8 weeks after LMP High Risk: History of ectopic, tubal surgery or sterilization procedure, Known tubal scarring or pathology
32.
32Copyright © 2014
Well Woman Clinic. All rights reserved.
33.
33Copyright © 2014
Well Woman Clinic. All rights reserved. INCOMPLETE/INEVITABLE ABORTION
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34Copyright © 2014
Well Woman Clinic. All rights reserved.
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35Copyright © 2014
Well Woman Clinic. All rights reserved.
36.
36Copyright © 2014
Well Woman Clinic. All rights reserved. CAUSES
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37Copyright © 2014
Well Woman Clinic. All rights reserved. PLACENTA PRAEVIA
38.
38Copyright © 2014
Well Woman Clinic. All rights reserved.
39.
39Copyright © 2014
Well Woman Clinic. All rights reserved.
40.
40Copyright © 2014
Well Woman Clinic. All rights reserved. Vaginal bleeding – bright red, painless & recurrent Soft pain free uterus Easy to feel uterus (floating head, breech or transverse No fetal distress AVOID INTERNAL EXAMINATION PLACENTA PRAEVIA SYMPTOMS & SIGNS Management is conservative – transfuse blood & prolong pregnancy till 36 weeks Delivery vaginal – anterior placenta & ARM, LSCS for posterior placentation
41.
41Copyright © 2014
Well Woman Clinic. All rights reserved. Placenta Praevia Ultrasound is highly accurate in making diagnosis (PPV 93%, NPV 98%)
42.
42Copyright © 2014
Well Woman Clinic. All rights reserved. 4 types according to distance from internal os - Partial - Low Lying - Marginal - Major or Complete
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43Copyright © 2014
Well Woman Clinic. All rights reserved.
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44Copyright © 2014
Well Woman Clinic. All rights reserved.
45.
45Copyright © 2014
Well Woman Clinic. All rights reserved.
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46Copyright © 2014
Well Woman Clinic. All rights reserved.
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47Copyright © 2014
Well Woman Clinic. All rights reserved. Abdominal pain Severe shock not proportionate to bleeding Vaginal bleeding, usually old blood Shock Uterus tense & spasmodic Tenderness Fetal parts are hard to feel Often fetal heart not heard SYMPTOMS SIGNS ABRUPTIO PLACENTAE ANTEPARTUM HAEMORRHAGE
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48Copyright © 2014
Well Woman Clinic. All rights reserved. It is a death threat to the fetus & a hazard to the mother Placental separation – blood clot – release of PGs – spasm – alters placental perfusion – blood tracks into the myometrium – serosa – pain & shock – uterine muscle spasm ABRUPTIO……..Mechanism & Pathology ABRUPTIO……..Emergency treatment Treat the shock – large bore IV line, Haemaccel, cross match blood Treat DIC – FFP, PRBCs Deliver the fetus - Emergency Caesarean if fetus is alive & mature - Vaginal delivery if cervix is favourable & fetus dead
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49Copyright © 2014
Well Woman Clinic. All rights reserved. Abruptio Placentae
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50Copyright © 2014
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51Copyright © 2014
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52Copyright © 2014
Well Woman Clinic. All rights reserved.
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53Copyright © 2014
Well Woman Clinic. All rights reserved. Abruption Delivery DIC occurs in 4-10% of cases and usually is apparent by 8 hours after onset Renal failure is the most common cause of maternal mortality
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54Copyright © 2014
Well Woman Clinic. All rights reserved.
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55Copyright © 2014
Well Woman Clinic. All rights reserved. Placenta Accreta Absence of decidua basalis and imperfect formation of the fibrinoid layer (Nitabuch) Increta in myometrial invasion Percreta the placenta goes through to the serosa Risk Factor - previous LSCS, D&C,
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Well Woman Clinic. All rights reserved.
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57Copyright © 2014
Well Woman Clinic. All rights reserved. Post-partum Haemorrhage: Primary Estimated blood loss > 500ml in normal & > 1000ml in LSCS Change in Haematocrit by 10% Any amount of blood loss that threatens woman’s haemodynamic stability In a woman with PIH, Anaemia, Dehydration, GDM, even small amount of blood loss can alter the situation
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58Copyright © 2014
Well Woman Clinic. All rights reserved. Primary PPH : Third Stage/True PPH
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59Copyright © 2014
Well Woman Clinic. All rights reserved. Post-partum Haemorrhage: Secondary
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60Copyright © 2014
Well Woman Clinic. All rights reserved. PPH: INCIDENCE Complicates 3.9% of vaginal deliveries & 6.4% of C-section deliveries 1/1000 deliveries in developing countries versus 1/100000 in developed countries
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Well Woman Clinic. All rights reserved. PPH: Incidence Cause Lacerations Atony Abruption Retained placenta Praevia Accreta Rupture Inversion Incidence 1:8 1:20-1:50 1:80-1:150 1:100-1:160 1:200 1:2000 1:2500 1:6400
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62Copyright © 2014
Well Woman Clinic. All rights reserved. Etiology of PPH: The 4 Ts to remember Tone - uterine atony Tissue - Retained tissue/clots Trauma - lacerations, rupture or inversion Thrombin - Coagulopathy
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63Copyright © 2014
Well Woman Clinic. All rights reserved. Risk factors for Haemorrhage H/O PPH in previous pregnancy APH Multiple pregnancies PIH (Pre-eclampsia, eclampsia, HELLP) Chorioamnionitis Hydramnios Fetal death Anaemia, Multiparity Uterine myoma Operative or assisted delivery Prolonged labour Precipitate labour Induction or augmentation Chorioamnionitis Shoulder dystocia Internal podalic version Acquired coagulopathy Antepartum Intrapartum
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64Copyright © 2014
Well Woman Clinic. All rights reserved. Risk factors for Haemorrhage Lacerations or extended episiotomy Retained placenta or placental abnormalities Uterine rupture Uterine inversion Acquired coagulopathy Postpartum
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65Copyright © 2014
Well Woman Clinic. All rights reserved. Prevention of PPH ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR Identifying risk factors & managing them accordingly Correct anaemia Effective management of High risk patients at tertiary care centre I/V access or blood transfusion Restrictive use of episiotomy
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66Copyright © 2014
Well Woman Clinic. All rights reserved. Active management of third stage Within one min. of birth give uterotonic (Inj. Oxytocin) Early clamping & cutting of cord Controlled traction on umbilical cord while applying counter traction on uterus Massage the uterus after delivery of placenta
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67Copyright © 2014
Well Woman Clinic. All rights reserved. Prevention of PPH during Caesarean Identify high risk patients Arrange and cross match blood Precautions during surgery to minimize blood loss Wait for spontaneous expulsion of placenta rather than manual shearing Rapid closure of uterine incision
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68Copyright © 2014
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70Copyright © 2014
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71Copyright © 2014
Well Woman Clinic. All rights reserved. Uterine atony It complicates 1 in 20 deliveries – most common cause Etiology Over distended uterus Uterine exhaustion Intra-amniotic infection Functional or anatomic distortion of uterus
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72Copyright © 2014
Well Woman Clinic. All rights reserved. Uterine atony Clinical risk factors Polyhydramnios Multiple gestation Macrosomia Induced labour Prolonged or rapid labour High parity Fever/PROM Fibroid uterus Placenta praevia
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73Copyright © 2014
Well Woman Clinic. All rights reserved. Uterine atony- management General management Obtain help Adequate venous access Foley’s catheter Monitor adequate renal perfusion Volume replacement- infuse crystalloid, FFP, platelets or cryoprecipitate Bimanual compression
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74Copyright © 2014
Well Woman Clinic. All rights reserved. Bimanual Compression
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75Copyright © 2014
Well Woman Clinic. All rights reserved.
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76Copyright © 2014
Well Woman Clinic. All rights reserved. Uterine atony- Oxytocin Specific treatment Oxytocin infusion- first line treatment for PPH I/V bolus can cause severe hypotension & CVS side effects Dilute oxytocin prepared by adding 20-40 U to 1 lit. of crystalloid & infusion at rate 10 ml/min (200mu/min) up to 100-500 mu/min might be used
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77Copyright © 2014
Well Woman Clinic. All rights reserved. Uterine atony- oxytocin analogues Carbetocin synthetic analog of oxytocin with a half life 4-10 times longer than that of Oxytocin used as a single dose injection can be given I/V or I/M It appears to be more effective than continues infusion of oxytocin with similar safety profile Buctocin, Des- amnio-oxytocin
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78Copyright © 2014
Well Woman Clinic. All rights reserved. Ergometrine (Methyl ergonovine maleate) Ergot alkaloid Oral/IM/IV 0.2 mg onset of action within 10 mins. I/M or I/V 1-3 min SE- nausea, vomiting, weakness, paresthesias, chest pain CI - sepsis, HTN, heart disease, peripheral vascular diseases, liver & kidney diseases Can be repeated every 2-4 hrs up to maximum of 5 doses
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79Copyright © 2014
Well Woman Clinic. All rights reserved. Syntometrine Combination of oxytocin 5U & ergometrine 0.5 mg I/M No important clinical difference in effectiveness between syntometrine & I/V oxytocin in prevention of PPH Associated with higher risk of HTN & vomiting
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80Copyright © 2014
Well Woman Clinic. All rights reserved. Prostaglandin: PROSTODIN 15 Methyl PGF2a- I/M or intramyometrial, 250mcg Controls refractory PPH C/I- Asthma due to broncho-constriction activity, cardiac, renal & hepatic diseases S/E- nausea, vomiting, diarrhoea & pyrexia
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81Copyright © 2014
Well Woman Clinic. All rights reserved. Prostaglandin: MISOPROSTOL Synthetic PGE1 analogue Oral, P/V,/P/R, Sublingual Adverse affect- nausea, vomiting, diarrhoea, abdominal pain, chills, shivering, fever Routine oral 600 - 800mcg as effective as 10 u oxytocin Sublingual is as effective as I/V infusion of oxytocin
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82Copyright © 2014
Well Woman Clinic. All rights reserved. Surgical procedures for PPH Uterine packing Aortic compression using the pressure between the fist and vertebral column Stimulate uterine contraction - PGF2α injected locally in to the uterus or IM Balloon tamponade Suture techniques Internal iliac artery ligation Angiographic embolisation
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83Copyright © 2014
Well Woman Clinic. All rights reserved. 83 B Lynch Suture
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84Copyright © 2014
Well Woman Clinic. All rights reserved. Lacerations: Traumatic PPH First thing to be ruled out in bleeding post partum woman with a firm uterus Careful examination of the entire genital tract Rarely results in massive blood loss May be life threatening if extends to the retro peritoneum
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85Copyright © 2014
Well Woman Clinic. All rights reserved.
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86Copyright © 2014
Well Woman Clinic. All rights reserved. Rupture Uterus A potential obstetric catastrophe A major cause of maternal death Incidence: 1 in 1148 to 1 in 2250 Complete (Spontaneous & Traumatic) Incomplete
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95Copyright © 2014
Well Woman Clinic. All rights reserved. Inversion Usually occurs when the placenta is fundally implanted Prompt replacement is generally easier. Halothane or nitroglycerine are effective agents Uterotonics then needed to contract the uterus
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96Copyright © 2014
Well Woman Clinic. All rights reserved. AMNIOTIC FLUID EMBOLISM The initial response of the pulmonary vasculature to the presence of amniotic fluid is intense vasospasm resulting in severe pulmonary hypertension and hypoxaemia Amniotic fluid contains lipid-rich particulate material which stimulates a systemic inflammatory reaction. Leads to capillary leak & DIC
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97Copyright © 2014
Well Woman Clinic. All rights reserved. AMNIOTIC FLUID EMBOLISM Respiratory support – Oxygen (FiO2 0.6–1.0). CPAP or mechanical ventilation Cardiovascular support - controlled fluid loading and ionotropic support Haematological management - blood product therapy Treatment with cryoprecipitate
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98Copyright © 2014
Well Woman Clinic. All rights reserved. What can we do as Clinicians: THE WAY FORWARD? Establish obstetric emergency response teams 5 situations – PPH, APH, Shoulder dystocia, Emergency Caesarean, Eclampsia Conduct Obstetric Skills & Drills Training Labour Ward Drills IMPROVED TEAMWORK
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