High Risk Pregnancy And LabourDr. Jasmine MehtaFTG,Cl-1G.K.G.H.,Bhuj

High risk pregnancy and LabourPregnancy and labour is physiologicalYet, high risk pregnancy may end into

pathological status….leading to…Maternal and Neonatal mortalityGoal of FOGSI-BETI BACHAO,BETI PADHAOGoal of RCH- Safe motherhood

StatisticsWorld wide-6 lakh maternal

death per yearEvery min one

mother dies99% in developing

countries80% r preventable

India-MMR is 480 per `1

lakh live child birthMaternal morbidity

is 16 times that of mortality

Causes of maternal Mortality

Direct cause-75%

Hemorrhage 25%

Sepsis 15%

Unsafe abortion 13%

Eclampsia 12%

Obstructed labour

5%

Indirect-25% Anemia 20%

Cardiac disease,

hepatitis

Maternal mortality in our HospitalTotal deliveries in

last year-1451Total maternal

mortality-11 MMR-750 per one

lakh LCB

Cause No

PPH 6

Eclampsia 3

APH 1

Anemia 1

Abortion 10-20%

Ectopic pregnancy 0.66%

Vesicular mole 0,25%

Multiple pregnancy 1.25%

PET 10%

Placenta pravia 0.5 -1%

Abruptio placenta 0.5-1%

Anemia 40-80%

Cardiac disease- MC is MS(80%) 1%

Diabetes

Jaundice 0.04

HIV <0.5%

Rh negative mother 5-10%

Grand multipara 25%

High risk LABOURPreterm labour-5-10%Post term labour 10%Previous LSCS 10-12%CPD 20%Malposition MC-

BreechProlonged labour 2-4%Obstructed labour 1-

2%s

Shoulder dystociaPPH-1%Retained placentainversion of uterusRupture uterusPerineal tear

High risk pregnancy and Labour

ABORTIONThreatened Complete bed rest Inj. calmpose im statInj. RL/DNS AnalgesicsProgesterone support

Inevitable/Incomplete abortion

Replace blood loss with iv fluids and BT

Antibiotics<12wks:e&c, Misoprost 4tab

Inj. Prostodin

>12wks:Inj pitocin

Ectopic Pregnancy

Diagnose the iceberg by11/2 to 2mth of amenorrhea Mild bleeding p/vsevere abd pain and tendernessUPT+veSevere pallor/shock

Management:o2inhalatiion,iv fluids,antibiotics,and BT

APH

Pregnancy Induced HypertentionDiagnosisHigh risk consentAntihypertensive medicationIv lineSedation No inj methargin after deliveryInj. calmpose +Inj. lasix after deliveryBed side clotting test,<7min.

Warning Signs Of EclampsiaHeadacheBlurring of visionVomiting OliguriaRt sided abd pain

Eclampsia Gc poor signO2inhalation and suction

Inj. Mgso4:4gm iv diluted over 5min

5gm imRt buttock5gm imlt buttock2gm iv diluted if conv.again

Monitor:u/o>100ml in 4hrs,knee jerk+,Resp.rate >16/min.

Eclampsia AntihypertensiveFoley’s catheterization &strict u/o chartNo inj methargin after del.Inj. lasix after del.W/F shock after del.

AnemiaMild to moderate in early preg.Treat with oral iron therapySevere anaemia at term/labour

inj BTdon’t overload with iv fluidsstrict asepsis and antibiotic coverinj metergin imdel. In squatting positioninj prostodin/T.misoprost after del.strict w/f PPH

Cardiac DiseasePregnancy

regular Digitalis and suppt. Med.correct anaemia &any inf.vigilance for ccf Adequate rest/hospitalization

LabourInj. abs coverage for 5 days,bed rest,lt lat.post.

Cardiac DiseaseAvoid overloading of iv fluids <75ml/hrO2 inhalation sos 5-6lit/min

Strictly monitor pulse & spo2,p>110Vaccum del./forcep delNo inj methergin after del.give

T.misoprostInj. lasix after delStrictly w/f PPH,CCF

Cardiac DiseaseSquating or head up position is favourable

in cardiac patients

DiabetesInj. plain insulin infusion slowlyu/s every 2 hourlyAntibiotic coverage &strict asepsis Strict FHS monitoring w/f hypoglycemia Vigilance for shoulder dystocia,pphPostpartum antibiotics & feeding Look for 3cord vessel Pediatric opinion.

Rh Negetive MotherRegular anc care and USGClamp cord earlyAvoid manual removal of placenta No inj methargin Baby BgRh and paed opinionInj. Anti-D in 72 hrs if baby BgRh is+ve

Jaundice in PregnancyRule out DICStrict FHS monitoring Universal precaution during del.No inj metharginInj. vit K prior to del.Hepatitis B vaccine and Ig to babyOther STD

PPHAtonic: severe bleeding, uterus atonicTraumatic: fresh bleeding, uterus contractedDIC: bleeding from all sites, 5ml bed side

blood clotting test positive

Atonic PPHCall for help 2 iv line –wide bore/BT/iv inf.Bimenual massageInj. methargin iv,repeat every 15

min ,max3Inj. pitocin 30units at rate of

30drops/min,max 3 pintsInj. prostodin im,repeat after

15min.,max5, never iv.T.misoprost 5tab P/R.

Atonic PPH

Retained placenta

Inj.. pitocin 30 unit in one pintInj.. Prostodin IM statTab. Misoprost 3 tab P/RInj.. Pitocin 1 amp in cord veinManual removal of placenta

Obstructed labor

Do not miss –prolonged labor- moulding and caput ,bandle’s ring – hot vagina

Do foley’s catheterIV anti bioticsKeep one BT ready

Previous LSCS

Watch for scar tendernessSigns of imminent scar rupture: scar

tenderness, tachycardia, fetal distress, blood in urine

Do –stop bearing down –inj tidilan – inj BT

Shoulder dystociaDo not be panickyDo not give

traction headDo not apply

fundal pressureDo give supra

pubic pressure with abduction of thighs

Shoulder dystociaRotate posterior

arm to anterior position

Extraction of posterior arm

All procedures should not take more than five minutes

Inversion of uterusDo not employ any

method to expel placenta while uterus is relaxed

Do not pull cord while uterus is relaxed.

Ask pt to not to cough, sneeze or bear down while uterus is relaxed

Inversion of uterusManagementInj.. atropineIv fluidsSedativesReposition of uterusUterine packing