AMNIOTIC FLUID EMBOLISM

Mizan-Tepi University
midwifery

At the end of this session students will

be able to: Define AFE
Discuss on predisposing factor of AFE
Assess and manage AFE
Prevent AFE

Definition
This condition occur when amniotic
fluid containing meconium, vernix
and fetal cells enter the maternal
circulation under pressure between
the placenta and the uterine wall and
forming an embolus which obstructs
one of the pulmonary arterioles or
alveolar capillaries.

Predisposing factor
1.precipitate labor
This considered being the most common
cause hypertonic contraction which occurs
in this type of labor force amniotic fluid into
the maternal circulation through a break in
the membrane or placenta.
2.Over stimulation of uterus
Excessive use of oxytocin drugs or
prostaglandin may cause hypertonic uterine
action.
3.Uterine trauma
e.g. uterine rupture.

Sign & symptoms

1.Sudden onset of maternal respiratory
distress such as severe dyspnea and
cyanosis
2.Cardiovascular
collapse,tachycardia,hypotension and
cardiac arrest
3.convulsion.
4.Heamorrage
Usually result of DIC
Amniotic fluid is rich in thromboplastin
which attracts fibrinogen

Management
1.Oxygen administration by facemask
4lt/min
2.Suction
3.Resuscitation equipment should be at
hand
4.If she is undelivered the FHR should be
monitored continuously
5.Treat hemorrhage

Complication
Death due to cardiopulmonary collapse
DIC
Acute renal failure.

RUPTURE OF THE UTERUS

Mizan-Tepi University
midwifery

At the end of this session students will

be able to: Define rupture of uterus
Explain the causes of rupture of uterus
Classify ruptured uterus
Assess and manage ruptured uterus

Definition
Is a tear in the uterine wall
Two types of tear(rupture)
A. Complete rupture:-when the overlying
peritoneal coat is torn and bleeding
and fetus is under abdominal skin.
B.Incomplete rupture:-when the
peritoneum remains intact and
bleeding tracks under the peritoneal
cavity.

Causes
Obstructed labor
Separation of the previous c/s scar
Trauma due to operative manipulation
Unwise use of oxytocin
Extension of an old cervical tear
Silent rupture of uterus
Definition:-rupture of previous c/s
scar known as silent rupture

Sign of a silent rupture

Rise in pulse above 90beat/min
Pain over the old scar and tenderness
Slight vaginal bleeding and vomiting
Shock which comes on very slowly
Labor will not progress soon in FHB.
Abrupt rupture
Definition:-rupture in obsructed labor
known as abrupt rupture

Sign of abrupt rupture

History of obstructed labor
Bandles ring is seen before rupture
The contraction is very strong with
either little or no relaxation between
them
The contraction suddenly stop
Vomiting of dark brown vomits
No FHB

Diagnosis
History of OL
Derangement in v/s
Tender abdomen
No FHB
Vaginal bleeding
No fetal movement
No uterine contraction
High head
Sign of shock & dehydration

Management at health center

Lie patient flat
Put up iv drip
Give pethidine
Bring donors
Go with patient
Refer

PREVENTION
Constant and careful ANC
Refer OL
Delivery should be at health
institution
Care with pitocin use
Care during manipulation
Avoid giving pitocin for previous
classical c/s scar

SHOULDER DYSTOCIA
Mizan-Tepi University
midwifery

At the end of this session students will

be able to: Define shoulder dystocia
Assess and manage shoulder
dystocia
Prevent shoulder dystocia

Definition
Shoulder dystocia is inability to deliver
the shoulders after the fetal head has
been delivered despite the
performance of routine obstetric
maneuvers.
It is an acute obstetric emergency
requiring prompt, skillful management
to avoid significant fetal damage and
death.

Risk assessment
Shoulder dystocia cannot be predicted.
Be prepared for shoulder dystocia at
all deliveries, especially if a large baby
is anticipated. Predisposing factors
include:
Macrosomia
Diabetes mellitus
Women with previous history of
macrosomic babies
Obesity

Complications
Birth asphyxia and metabolic acidosis,
shock, renal failure, seizure
Neurological damage, mental
retardation, cerebral palsy etc.
Traumatic birth injuries: fracture of the
humerus and clavicle;
Injury to the brachial plexus (Erbs palsy)
Maternal complication of the cervix,
vagina and perineum that may lead to
excessive bleeding

Diagnosis
The fetal head is delivered but
remains tightly applied to the vulva
The chin retracts and depresses the
perineum.
Traction on the head fails to deliver
the shoulder, which is caught behind
the symphysis pubis.

Management
Make an adequate episiotomy to reduce
soft tissue obstruction and for
manipulation.
In the lithotomy position, ask the woman
to flex both thighs, bringing her knees as
far up as possible towards her chest.
Ask two assistants to push her flexed
knees firmly up onto her chest
(McRoberts maneuver).
After wearing high-level disinfected
gloves undertake the following
maneuvers to deliver the shoulder:

 Apply firm, continuous traction

downwards on the fetal head to move
the shoulder that is anterior under the
symphysis pubis.
Avoid excessive traction on the head as
this may result in brachial plexus injury.
Have an assistant simultaneously apply
suprapubic pressure downwards to
assist delivery of the shoulder.

 If the shoulder still is not delivered,

insert a hand into the vagina and
apply pressure to the shoulder that is
anterior in the direction of the babys
sternum to rotate the shoulder and
decrease the shoulder diameter.
If needed, apply pressure to the
shoulder that is posterior in the
direction of the sternum.

 If the shoulder still is not delivered

despite the above measures, insert a
hand into the vagina; grasp the
humerus of the arm that is posterior;
and, keeping the arm flexed at the
elbow, sweep the arm across the
chest.
This will provide room for the
shoulder that is anterior to move
under the symphysis pubis.

 If all of the above measures fail to

deliver the shoulder, the last options
is to fracture the clavicle to decrease
the width of the shoulders and free
the shoulder that is anterior; apply
traction with a hook in the axilla to
extract the arm that is posterior.

Prevention
Even though shoulder dystocia can not be
predicted, the complication of shoulder can
minimized by:
Fetal weight estimation at term and, if the
estimated weight of the fetus is 4 or more Kg,
elective cesarean delivery is effected.
Fetal weight estimation is especially required
among women with:
diabetes mellitus,
previous history of macrosomic babies, obesity
big abdomen.
Avoid mid-pelvic manipulation in the second
stage
Adequate training of providers.

THANK FOR
YOUR ATTENTION