ENHANCING MIDWIFERY COMPETENCIES IN MATERNITY AND NEWBORN CARE

Pregnancy Complications

General Objectives

Describe best practices in identifying and providing initial management of:1. Hypertension in pregnancy2. Vaginal bleeding in early and

late pregnancy3. Prelabor rupture of membranes4. Preterm labor

I. HYPERTENSION IN PREGNANCY

Objectives 1. To describe the signs and symptoms of

hypertension in pregnancy2. To identify the risk factors and danger signs

for pre-eclampsia and eclampsia3. To discuss midwifery observation and care

of a woman with pre-eclampsia and eclampsia

PRE-ECLAMPSIADiagnostic Criteria

Hypertension after 20 weeksProteinuria 1+

Early detection by regular antenatal monitoring and careful follow-up is essential

HYPERTENSIONDiastolic BP > 90

mm Hg or more Diastolic BP is the point

when arterial sound disappears

Does not vary much with the woman’s emotional state

Cuff must encircle at least ¾ of the circumference of the arm.

Proteinuria

Urine should always be checked for protein when hypertension is found in pregnancy.

Other causes of protein in the urine UTI Kidney disease Urine contaminated with blood, amniotic fluid or

vaginal discharge Severe anemia Heart Failure

RISK FACTORS for Pre-eclampsia

Pre-eclampsia is more common in:PrimigravidYoung teens Women > 35 yearsObeseMultiple Pregnancy

Women with Diabetes H Mole Essential or renal

hypertension Previous history of

pre-eclampsia Family history of

hypertension

DANGER SIGNALS

Massive pitting pedal edema (generalized swelling)

Severe headacheEpigastric painVomitingVisual disturbance or

blurring of vision

Complications of Severe Pre-eclampsia

Small baby (IUGR)StillbirthAbruptio PlacentaHELLP syndromeEclampsia

ECLAMPSIA

Convulsions in a woman with pre-eclampsia

Convulsions may occur in pregnancy after 20 weeks

AOG, in labor during the first 48 hours

postpartum.

High incidence of maternal and perinatal mortality.

How Eclampsia Affects Mother and Fetus

Effects on mother Respiratory – pulmonary edema Heart Failure Cerebral vascular accidents Acute kidney failure Liver necrosis

HELLP syndrome Visual disturbance Injuries during convulsion

Effects on fetus IUGR Stillbirth

Reducing the Risk of Eclampsia

Pregnant women should come for antenatal care early – take baseline BP

Regular antenatal visits especially in the 3rd trimester

Measure BP at each visit and check urine for protein if diastolic BP>90 mm Hg.

REFER if proteinuria developsCounsel woman and family about danger signals

of severe pre-eclampsia

What to do when seizures occur

Call for medical helpAs soon as possible, clear airway and or give

oxygen at 4–6 L/min.Position the woman on her left side to reduce the

risk of aspiration of secretions, vomit and bloodStay with woman and protect her from injury but do

not restrain her

Immediately after the convulsion

Set up IVF – run at slow rateMonitor BP, pulse, respiration, level of

consciousness. Record.Insert urinary catheter to monitor urine output and

test for protein. Arrange for referral

Protect mother during transport

Put mother in any flat or low surface to prevent from falling during ambulation.

Observe proper maternal positioning and least stimulation during transport.

Never leave alone

II. VAGINAL BLEEDING

Objectives1. Identify the causes of bleeding in pregnancy2. Discuss the emergency treatment for

pregnant women with vaginal bleeding3. Proper referral

Vaginal Bleeding During Pregnancy

Assess the PREGNANCY STATUS EARLY PREGNANCY – uterus is below the umbilicus LATE PREGNANCY – uterus above umbilicus

Assess the AMOUNT OF BLEEDING HEAVY – pad or cloth is soaked in less than 5 minutes LIGHT

Assess for alert signs and symptomsProvide initial treatmentREFER

ALERT SIGNS/SYMPTOMS

Fainting History of expulsion of tissuesCramping/lower abdominal painTender uterusTender massUterus soft and larger than expected for AOG

REFER

• Early• This may be

abortion, ectopic pregnancy or molar pregnancy.

AMOUNT OF BLEEDING

• HEAVY, or with alert signs

• LIGHT, no alert signs

TREATMENT• Reassure the woman

• Insert IV line• IV fluids• Monitor vital

signs • REFER• Reassure• Give iron/folate• Review

emergency plan• Follow up after

2 weeks

• Late• This may

be placenta previa or abruptio placenta

AMOUNT OF BLEEDING

• Any bleeding is dangerous!

• Assess for alert symptoms:

TREATMENT

•DO NOT perform IE!•Insert IV line•Monitor vital signs •Reassure the woman, make her comfortable•REFER

1. Placenta previa

- abnormal implantation of the placenta at the lower uterine segment.

Classic sign

Painless Vaginal Bleeding

Uterus – soft, non-tender, with or without uterine contractions, fetus palpable

GENERAL MANAGEMENT

Ask for Help! and URGENTLY MOBILIZE ALL

AVAILABLE PERSONNEL

Abruptio Placenta

Separation of a normally implanted placenta from the uterus before childbirth.

Abruptio Placenta

RISK FACTORS1. Maternal Hypertension,

Pre-eclampsia, Chronic hypertension

2. Maternal age 3. Multiparity4. Cigarette smoking.5. Maternal trauma6. Polyhydramnios7. Poor nutrition

Abruptio Placenta

BPH Ob-Gyn

Classical Sign: UTERUS is

HYPERTONIC or TENSE and TENDER on PALPATION

ABDOMEN –

“BOARD – LIKE IN RIGIDITY“

Pre-labor Rupture of Membranes

Objectives of the sessionDefine prelabor rupture of membranes (PROM)

Review the criteria for diagnosis

Describe initial management of PROM

Prelabor rupture of membranes (PROM)

Rupture of the bag of water prior to the onset of labor PROM when fetus is > 37

weeks Preterm PROM (PPROM)

when fetus is less than 37 weeks

Diagnosis

• ASK when did membranes rupture?•LOOK at pad for evidence of amniotic fluid or foul smelling vaginal discharge.

• If no evidence, ask her to wear a pad and check again in one hour.

•Measure temperature

•Routine vaginal examination is NOT recommended – increase risk of infection

What to do

If (+) fever >38°C Foul smelling vaginal

dischargeNo laborRupture membranes at

<8 months of pregnancy

Give antibiotic (Ampicillin 2 grams)

REFER to hospital

Rupture of membranes at >8 months pregnancy

Manage as woman in childbirth

Preterm Labor

Objectives: Define preterm labor (PTL) and

recognize its significance to infant mortality and morbidity

Enumerate the causes of preterm labor

Review the criteria for diagnosisName the initial management of PTL

Preterm Labor (PTL)

Definition:Labor before 8

completed months of pregnancy

more than 1 month before estimated date of birth

At 24 – 34 weeks gestation

Signs and symptoms of PTL

ContractionsWatery vaginal

dischargeVaginal bleedingLow dull

backache

How to diagnose

Establish AOGEvaluate contractionsCervical assessment

Sterile speculum examination

Digital examination*

What to do

Diagnose promptly and correctlyStabilize woman and fetusIf woman is lying, encourage her to lie

on her left sideCheck vital signs especially BP

PRETERM LABOR

If BP is normal and no heart problem

Give Nifedipine 10mg tablet orally (not under the tongue) every 6 hours until she reaches a CEmONC facility

Give Dexamethasone 6mg intramuscularly every 12 hours until she reaches a CemONC facility ( up to a total of 4 doses)

Facilitate transfer the hospital with neonatal and obstetrical care

SUMMARY

Recognition of pregnancy complications Hypertension during pregnancy Vaginal bleeding during pregnancy Prelabor rupture of membrance Preterm Labor

Initial ManagementPrompt Referral