OBSTETRIC EMERGENCY

Advisor:
dr. Bambang Susilo, Sp.OG
Arranged by:
Alfiani Jamilah (17710014)
Pujiastuti Wetang (17710023)
Nabila Kirara S (17710034)
Faridatul Afifah (17710042)
Emergency: Obstetric Emergency :
a situation which The case of obstetric
occur if they do not which if it is not get
immediately get help , handled immediately,
it will be worse and it will cause mortality
even cause mortality of the mother and the
fetus. This case is
the major cause of
the mother’s mortality,
the fetus and the new
born baby
 Early
Treatment of
assessment of Obstretric
obstretric
obstetric emergency case
emergency case
emergency case
 1. Shoulder
dystocia

OBSTETRIC
2. Abortus
EMERGENCY
b. placenta
3. Previa
Hemmoragic
Antepartum c. Solusio
placenta
 a. Uterine
Rupture

b. Uterine
Atony
4. HPP
OBSTETRIC c. Placenta
EMERGENCY Retention
5. PEB /
Eklamsi
d. Uterine
Inversion
 Prolaps
cordspinal
OBSTETRIC
EMERGENCY
Emboli of
amniotic fluid
A condition when after the head was born,
shoulder’s anterior could not pass under
symphisis pubis. It is an obstetric
emergency because the baby can be
mortality if the baby could not be born
 The baby’s head
has born but the
shoulder is
stucked, could
not pass

The head of
The baby’s
baby sticks on
head was born
the vulva or SYMPTOMS but there is no
even pulled
outer axis
again (turtle
rottation
sign)

Prolonged expulsive
phase
A • Ask for help

L • Lift maneuver Mc Robert

A • Anterior disimpaction of shoulder

R • Rotation of the posterior shoulder (maneuver

woodscrew)

M • Manual removal of posterior arm

E • Episiotomy

R • Roll over (maneuver gaskin)

It is required an assistant to help and well
understand about delivery mechanism, so
that get help immediately.
Thighs are flexed to abdomen direction
 ask mother to flex mother’s thighs so that
the two knees is close to chest, and
rotate both feet outward (abduksi)
 Massanti maneuver ( stressing on the area of
suprapubic) Dilak
 Do not perform a press oat the area of fundus
 It is conducted using abdominal approach, pressing
on suprapubic area using carpus which aims to press
the anterior shoulder so that it can enter below
symphisis.
 Meanwhile, pull the head of fetus to posterior caudal
direction steadily
 The next step is the same as head delivery
assistance
 Rubin maneuver
It is conducted using vaginal approach
 Put hand in vaginal posterior area
 Press the area of posterior aspect from
shoulder’s anterior get adduction
 Perform a head pull to posterior caudal
direction steadily ti deliver anterior
shoulder
It is performed by using twi fingers which opposites
to baby’s back
 Insert two fingers to vagina
 Posisite right hand on back of the baby hand and
the left baby hand is located in front of posterior
shoulder
 Posterior shoulder is rotated as much as 180
degree
 By doung that, posterior shoulder becomes
anterior shoulder and its position enter above part
of pelvis and change into posterior shoulder
 Anterior shoulder can be born
 Put assistant’s hand which is on the
opposite with baby’s back (Right hand on
right back and left hand on left back of
baby) to vagina
 Find posterior’s shoulder, search upper
arm and form elbow joint be flexed by
press fossa antecubital
 Hold forearm and form a rub movement
to baby’s chest
 Posterior shoulder can be born
Episiotomy is determined to give more
space to shoulder delivery.
Place mother on crawl position
 Diagnosis

Stop traction of head, immediately ask for help

McRobertmaneuver
(McRobert position, episiotomy if needed,
suprapubic pressure, head pull)

Rubin Maneuver
(McRobert position remains, rotates shoulder,
suprapubic pressure, head pull)

Deliver posterior shoulder, or crawl position, or

wood maneuver
Avoid 4P
1. Panic
2. Pulling (pulling head)
3. Pushing (pushing on fundus)
4. Pivoting (pivoting head sharply)
 Bone Fracture ( klavikula and humerus)
 Pleksus brakhialis injury
 Hypoxia which can cause a permanent
damage in brain
 A fatal servicalis bone dislocation can
also occur because performing pulling
and pivoting on head and neck
ABORTUS
 A threat or generating
conception result before fetal
can live out of womb, and as
limitation used in pregnancy
< 20 weeks or the fetal’s
weight < 500 gram .
 Hemmoragic
Necrosis

The result of
conception apart
from uterus

Uterus constracted

Conseption result
comes out

Pain, haemmorhage,
fluid volume deficit
 TYPES OF ABORTUS
According to Type
classification

Spontaneous Provokatus
Abortus Abortus

1. Abortus imminens Abortus Abortus

2. Abortus insipiens provokatus provokatus
3. Abortus complete terapetikus kriminalis
4. Abortus incomplete
5. Missed abortion
6. Abortus habitualis
7. Abortus infeksious
Abortus Imminens

is an initial stage of abortus threat occur. It indicates

pervaginam hemmorhage, utterine osteum is still
closed and the result of conception in uterus remains
good
Clinical symptoms:
 Pervaginam bleeding
 The age of prenancy<20 weeks
 Uterine ostium is close
 The size of uterus is based on the gestational age
 Gestational test is still +
 USG
1. Maintain pregnancy
2. Do not doing any excessive
physical activities
3. If there bleeding stops, check
the percentage of Hb and USG
4. If it does not stop, assess the
fetal condition using USG
Abortus Insipiens

Abortus which is threaten ing is recognized by

servics has been flat, uterine ostium has been
open, but the conception results still in the
uterine cavum and in the extraction process.
Clinical symptoms :
 Pervaginam hemmorhage is much
 The size of uterus is based on gestational
age
 Heartburn is often and strong
 Servicalis canalis is open
 Positive gestational test
1. Currete
2. Give ergometrin 0,2 mg/IM
3. If the gestational age >16 weeks, wait
for the conception result extraction
spontaneously, then infused 20 IU
oxytocin in 500ml NaCl
4. Speed 40 tpm
 Abortus
Complete

All conception reult has been

extracted from uterine cavum
on pregnancy < 20 weeks or
the weight < 500 gram,
uterine ostium has closed,
uterus has been smaller until
less bleeding
Procedure: give roborantia or
hematinic
 Abortus
Incomplete
half of conception results has been
extracted from utenine cavum and
the rest remains. Canalis Servicalis is
still open and tissues touched in
uterine cavum or protruding on
externum uterine ostium. Bleeding
usually is much and continously
occur until the patient fall for
hemmorhage shock.
Procedure:
1. Fix the general condition
2. Curretase
3. Symptomatic
4. Uterotonic (metergin, tab 3 x 1’)
Missed Abortion

It is indicated by the embryo has

been mortality in womb before 20
weeks and the overall conception
results is still stuck in womb.
Procedure:
1. Misoprostol provision
2. Curretase
3. Transfusion
4. Oksitosin infusion
 Abortus
Habitualis

Spontaneous Abortus which occurs 3 times or

more respectively. One of teh cause which often
found is servics incompetencia.
Procedure:
1. Examine pregnancy as early as you can
2. Provide servic fixation
 Abortus
Infeksious,
abortus septik
 Abortus accompanied by infection in genital organ.
While septic abortus is abortus accompanied by
infection on blood circulation or peritoneum.
 Can be fall into septic shock
 Procedure :
-infusion
-antibiotic
-currete by providing uterotonika
-ATS injection
-total hysterectomy
 DEFINITION

Hemoragic ante partum is a bleeding

in delivery canals after 28 weeks,
commonly categorized as bleeding in
trimester III.
 DEFINITION

Placenta previa is a placenta

implantation on abnormal area
(Under Uterus Segment) so that cover
half or all internum uterine ostium
which can cause hemmorhage in
gestational age >22 weeks.
 ETIOLOGY

 It does not clearly recognized

 Predisposition factors:
 multiparity and elderly (>35 years old)
Defect desidua vascularization
Defect/Endometrium stomuch tissue s
Big placenta
 Classification

 placenta previa totalis

 placenta previa parcialis
 placenta previa marginalis
 Placenta letak rendah
 CLINICA SYMPTOMS

 hemmorrhage without pain|

The first hemmorrhage is started when the gestational age is above 22
weeks.
The first hemmorrhage is not much and suddenly occur
 hemmorrhage repetition with more
bleeding
The lowest part of fetal has not enter
pelvis and often accompanied with
abnormal appearance
 DIAGNOSIS

 Anamnesa
 Physical examination
 Examination using tools:
inspekulo, USG (Accuration=
95%)
 MANAGEMENT

 Conservative treatment  Active treatment

1. Observation for 24 hours 1. Directly conducting

in delivery room sectio caesarea without
2. Fix KU,HB>10 2. Doble set up (DSU)
3. Give cortocosteroids for
fetal lungs maturity
4. If the hemmorrhage stops,
bed rest for 2 days
5. If tehre is no
hemmorrhage again,
patient are able to go
home
6. KIE
 Complication

 Hemmorrhage can cause

anemia or even shock
 placenta akreta
Premature birth and fetal
distress
 PROGNOSIS

 Maternal mortality 0,2-5%

 hemmorrhage, infection,
air embolism.
 Perinatal mortality7-25%
Solusio placenta is the partial or complete
removal of the placenta from the normal
implant site in the endometrial decidual layer
prematurely between week 20 and the birth of
a child.
 Classification
(Based on removed part)
Solusio placenta Solusio placenta Rupture sinus
parsialis: totalis: marginal:
If only half of If only the whole Only smalll part
them is removed placenta is of the edge
from the implant removed from placenta is
area. the implant area. removed
Bleeding out/open In/Hidden bleeding:
bleeding: Part of placenta around
leaks between placenta the bleeding is still stick
and miometrium on the cervix, blood does
slip under the ambiotic not come out from uterus,
membranecanalis but stuck between
servikalisvagina removed placenta and
uterus
Light Solusio placenta :
• - The sizeof removed placenta< 25 %.
• - The number of blood which come out usually less than250 ml.
• - The color of blood is black
• - Complication on mother and fetal does not exist

Medium Solusio placenta :

• - The sizeof removed placenta excesses 25 % but habe not reach
half of them(50%).
• - The nurber of blood which comes out is more than 250 ml but
has not reach 1.000 ml.
• - Symptoms and signs: stomuch ache continuously, DJJ
becomes fast, low blood pressure, and tachycardia
Heavy Solusio placenta :
- The removed placenta size has excessed 50%
• The amount of blood that came out has reached 1,000 ml or
more.
• - Bloodshed can be occuroutside and inside together.
• - Clinical symptoms and signs are obvious, the general state
of poor sufferers with shock, and almost all of the fetus has
died.
• -Complicated coagulopathy and kidney failure marked on
oligouri usually present.
The major cause Cocain
is not Hidramnion
recognised Users
The age increase and
parity Smoking
solusio placenta
Preeklampsia history

Chronical Hypertension
Alchoholic

KPD preterm
Uterine Mioma
Twin pregnancies
 Bleeding into desidua basalis  hematom
desidua removal size, compression,
placenta destruction which is located close
to it
 Arteri spiralis desidua pecah hematom
retroplacenta  getting bigger >>
broken blood vessels>> separated
placenta bleeding can not stop because
the contained uterus is incapable of
contracting to pinch the broken spiral artery
 in/out bleeding
 Bleeding accompanied by pain, also outside of
his
 Anemi and shock
The uterus like the board and the pain if it is
touched because the contents of the uterus filled
with blood gathered behind the placenta until
the uterus is stretched (uterus en bois).
Palpation is hard because the uterus is hard
The fundus of uteri is getting higher
Heart beat usually does not exist
On the toucher touched the amniotics stress
continuously(as the contents of the uterus
increase)
Bleeding from the birth canal with or without
pain (depending on the degree of placental
abruption)
• Palpability of uterus generally stress, palpation of fetal
parts occasionally difficult.

The fetus may be in good condition, fetal

distress or death (depending on the degree of
placental abruption).
• On deep examination if there is a palpable and prominent
opening of the amniotic membrane.
 Criteria Solusio placenta Placenta previa
Bleeding Dark red until brown Bright res
black repetitive
Continuosly Not pain
accompanied by pain
Not stress
Uterus Stress No tenderness
Fetal part untouchable
tenderness Seldom
Shock/anemia more often The same as the size of
Does not appropriate blood which comes out
with the size of blood
which come out Usually fetus is alive
Accompanied by location
Fetus 40% fetus has dead
abnormalities
Does not accompanied
with location Palpable placenta or
Deep examination abnormalities fornix touch has pad
The amniotic is between fetal and
prominent although it is examiner’s finger
not his
 Complication that can be appear from
uterus rupture itself is :
 hemmorrhage,
 Shock,
 Infection,
 Bladder or ureter trauma,
 Thromboflebitis,
 Disseminated Intravascular Coagulation,
 Hypofunction Hyphofisis or maternity.
 If the patient is still alive, infertility or
sterility may occur.
Post Partum Hemmorrhage
Hemmorrhage which more than 500cc
which occur after the baby born
pervaginam or more tahn 1,000 mL after
abdominal delivery.
 Hemmorrhage after
primary labor (after the
baby born and after the
first 24 hours labor)

Classification
Hemmorrhage after
secondary labor
(after first 24 hours of
labor)
The Cause of post partum hemmorrhage (4T):
1. Tone : Atonia Uteri
2. Trauma : Birth Canal wound
3. Tissue : Retention placenta, rest placenta
4. Trombin : congealed blood disorder
Symptom and signa Complication Diagnostic Process
- Uterus does not contract and mushy Shock Atony uterine
Congealed blood on servics or
lies on one back will impede
blood sheed
Fresh blood sheeds immediately after Pale Rip of birth canal
the baby is born Weak
Uterus contracts and hard Shivering
Placenta is complete
Placenta has not born after 30 minutes Abdominal cord breaks after Retention of placenta
bleeding soon excessive traction
Uterus conracts and hard Uterine inversio caused by
pulling
Further bleeding
placenta or half of membranes is not Uterus contracts but still high Retention of residual placenta
complete Fundus does not decrease
bleeding soon
Uterus is untouchable Neurogenik shock UterineInversion
Lumen of vagina is filled by mass Pale and confused
Umbilical cord appears (if placenta
Uterine Atony

The failure of muscle fibers of uterus

miometrium to contracts and shorten,
usually happen right after baby is born
until 4 hours after labor. Uterine Atony can
cause great bleeding and hypovolemic
shock may occur.
1. Absolut and relative overdistency uterus
2. Inhibition contracts because of drugs
3. Placenta’s position is low
4. Bacterial toxin (chorioamnionitis,
endometritis, septicemia),
5. Hypoxia caused by hypoperfusion on
abruptio placenta and
6. Hypotermia which caused by masssive
resuscitation
 Uterine
Atony

Uterus massage and bimanual compression

Oxytosin 10 IU – 20 IU inRL 500 cc 20-40 drops,
Ergometrin 0,2 mg
Identify source
of other
hemmorrhage:
Bleeding still laceration birth
occur canal Recidual
fragment of
Succes coagulopathu
sful placenta
Uterus does not
contract

Bimanual Compression
Transfusion Aorta compression
Further care abdominalis
and strict Misoprostol 400mcg
observation rektal
  Kompresi bimanual
 Kompresi aorta
abdominalis
 Misoprostol
400mcg rektal

Successful Not successful

Transfusi
Rawat lanjut Uterus
dan Tampon
observasi
ketat
Uterine artery
ligation or
hysterectomy
Placenta
Retention

Being endured of have not born the

placenta untik more than 30 minutes after
the baby is born. Majority removing
placenta removal is caused by uterus
contract obstruction.
Classification

Placenta Incretta Placenta Accerata

Placenta
Incarcerata
Placenta Accreta
 villi
chorialis placenta implantation until
reach/pass myometrium layer
 Placenta which has not born and still
stick on servix because of weak servix
contracts to remove placenta .
1. Separation/ Partial 2. Incarcerata Placenta
Accreta a. Hard uterus consistency
a. Springy uterus consistency
b.TFU is as high as umbilical b. TFU 2 fingers under
Form of uterus is discoid umbilical
D.Medium-high bleeding c. Form of uterus is globular
e.Umbilical cord partly d. Medium hemmorrhage
streched e. Umblical cords streched
f.Uterine Ostium open out
g.Separated placenta partly f. Uterine ostium is open
removed g. Placenta separation has
h.Shock often been removed
h. Rarely shock
3. Acreta placenta
a. Uterus consistency is enough
b. TFU is as high as umbilical
c. The form of uterus discoid
d. Less/no hemmorrhage
e. Umbilical cord does not strech
f. Uterine Ostium is open
g. Placenta separation entirely attached.
h. Completely rarely shock, except because of
inversion by strong pulling on umbilical
cord.
Post partum with placenta retention.
1. Palpation of the uterus : How is uterus contracts and
high fundus uterus
2. Examine placenta and amniotics : Is it complete or not.
3. Perform cavum uteri to find :
- remaining placenta and amniotic
- tear of cervix.
- Succenteriate placenta.
4. Inspeculo : to see tear of cervix, vagina, and varices
which is broken
5. Laboratorium examination: checks the blood,
hemoglobin,, clot observation test (COT).
1. give oxytocin 20-40 unit in 1000ml 0,9 % NaCl fluids or RL 60
drops /minutes and 10 units of IM. It is continued by oxytocin of 20
units in 1000 mL of 0,9 % NaCl / RL 40 drops/minutes until the
bleeding stops.
2. perform a controlled umbilical cord.
3. Pulling umbilical cord conterolled does not successful, perform
a careful manual placenta
4. Give ampisilin 2gr IV and 500 mg IV of metronidazole
5. Recommend to teh hospital if great bleeding compication or
infection occur
 Placenta
Retention

placenta placenta placenta

Incereta accareta incacerata

fluothane /
Exploras ether
generak
anesthesia
Fully Partly
Hysterecto planted planted
my placenta can
Manual
placenta be extracted

Majority of Uterotonica
placenta planted observation
1. Hemmorrhage
2. Infection because of maternal thing
3. Incarcerata placenta can be occur
4. Polip placenta may occur
5. Vicious degeneration of choriocarcinoma
6. Neurogenic Shock
Uterine Rupture is the rip of cervix during
gestational age is more than 28 weeks

Complete uterine rupture is tear on cervix

where there is direct relation between
amnion cavity and perytoneum cavity.
 Damage or anomaly uterus has been
exist before pregnant
-surgery on myometrium
-Coincidental uterus trauma
-congenital abnormalities
 Damage or abnormalities uterus which
occur during pregnancy.
- Before birthing
- During intrapartum period
- Gained womb defect
 Anomaly or pre-existing damage
 Trauma
 Complications of labor in uterine intact
 The uterus which has cesarean section in
previous labor
 Patients
at high risk for uterine rupture
Delivery labor get dystocia
Grande multipara
The use of oxytocin or prostaglandin to
speed labor
Pregnant patients who had previously
given birth by cesarean section or other
surgery on her womb
Current symptoms:
 Abdominal pain can be sudden, sharp
and like slashed by a knifeIf rupture
occur during labor, intermittent, strong
uterine construction may cease suddenly.
Patients complain of persistent uterine
pain
 Vaginal bleeding can be symptomatic
because of active bleeding from torn
blood vessels
 Cessation of labor and shock
 Shoulder pain may be associated with
intraperitoneal bleeding
1. The inner fingers can feel the surface of
the uterus and the wall of the slippery
stomach
2. Can grab the edge of the tear, usually
there is a front in the lower segment of
the uterus
3. Can hold the small intestine or
omentum through the tear
4. The mother's belly can be pressed
upward by the tip of the fingers
 Riwayat penyakit dahulu
Ruptur uteri harus selalu diantisipasi bila
pasien memberikan suatu riwayat paritas
tinggi, pembedahan uterus sebelumnya,
seksio sesarea atau miomektomi
 Pemeriksaan umum
Takikardi dan hipotensi merupakan
indikasi dari kehilangan darah akut,
biasanya perdarahan ekterna dan
perdarahan intra abdomen
Abdominal examination
 During labor, abnormal uterine contours or
sudden changes in uterine contour may
indicate fetal extraction. Uterine
contractions can stop abruptly and the
sound of the fetal heart suddenly
disappears
 At the time or soon to give birth, the
abdomen is often very soft accompanied by
loose pain indicating intraperitoneal
bleeding
Pelvic examination
 Towards birth, the presentation part
regresses and no longer palpated through
the vagina when the fetus has undergone
extrusion into the peritoneal cavity
 Vaginal bleeding may be great.
 The uterine rupture after delivery is
identified through manual exploration of the
lower uterine segment and the uterine
cavity. The lower uterine segment is the
most common site of rupture.
 Hipovolemic shock
 Sepsi
 Great infection
 Hysterectomy
1. Partial hysterectomy(subtotal).
2. TotalHysterectomy
3. Hysterectomy and bilateral
salfingo-ooforectomy
4. radical hysterectomy
 Hysterorafi
Histerorafi is an operative action by
scorching the wound and sewing it as well
as possible
 trauma

Laserasi Identify the

Uterine
traktus source of
rupture
genitalia bleeding

The level of Uterine

Explorative
tear value inversion
laptoptomy
Grade Grad Uterus
reparatio
1-2 ee 3-4 manual
n
reposition
Antisepsis on Manual
No placenta + If it fails+
tear area +
need to uterotonic nekrosis
anesthesia 10ml large necrosis
sewed a
lidokain 0,5 %

Laparotomy or hysterectom
Sew sfingter ani
hysterectomy y
and rectum
partition
 Inversion of uterine inversion is a condition
where the reverse of uterin into uterin cavum
which can generate pain and bleeding.
Factors that can cause uterine inversion:
1. Spontaneous because of the abdominal
pressure increases and when the uterine
fundus is still not well contracted
2. Crede placenta delivery, but the contraction
of uterine muscle has not been strong
3. The pull of the umbilical cord is an attempt to
give birth to the placenta
1. Light uterine Inversion (complete uterine Inversion)
• a condition where the uterus is pivitted so that the uterine
fundus in vagina with the mucous membrane in the outside
• Fundus enters uterine but it has not passed cervicalis canal
2. Medium uterine Inversion (incomplete Uterine Inversion)
• A condition where fundus flexs into and not out of uterine
ostium
• Fundus enters uterine cavum
• It has been in vagina
3. Heavy uterine inversion (Prolaps Inversion)
• a condition where the uterus about face out from vulva.
• uterine fundus has total inversion and visible from outside of
vagina
4. • It can be accompanied by placenta which is still attached
 The causes can be occus spontaneously
or because of action.
 Factor which eases the occurance is
uterus which is stingy, weak, its thin
separators; or patulous canalis cervikalis.
 The spontaneous one may occur on Yang
grandemultipara, uterine atony, the lack
of pregnancy tools and high intra
abdominal pressure (straining and
cough).
 Which because of the act can be caused by
excessive Crade, pulling umbilical cord and
on manual placenta which is induced.
Frequency; rarely seen, the amount of case is
1:20,000 labors.
 Three factors are required in the occurance of
uterine inversion, such as:
1. Weak Tonus muscle
2. Bend or pulling on fundus (Intra abdominal
pressure, hand pressure, umbilical cord pulling)
3. The loose of cervicalis canalis. So that the
uterine interversion may occur when cough,
clean or straining, also because of umbilical
 It is seen in Kala II or post partum by great pain
symptom;
 Large amount of bleeding uuntil shock, moreover
placenta still attached and half of them has been
removed, and strangulation and necrosis may occur.
 Deep examination
• if it is still incomplete, the area of uterus symphysis
is touched uterine fundus which sunken into the inside.
• If it is complete, above uterus symphysis is
palpably empty and in vagina is touched soft tumor
• uterine cavum has not exsist (backwards)
1. Spontaneously occur or because of an
excessive act of crede
2. Ligamentum infudibulopelvikum and
ligamentum rotundum pulling, pull the
perytoneum as well so taht it gnerates
deep pain
3. It can be followed by bleeding and shock
which trait is deep neurogenic
 In leading a labor, the possibility of uterine
inversion must be maintained.
 Pulling on umbilical cord before placenta
completely removed, do not perform or if
perform Crede nursing care must pay
attention on the requirements.
 If there are shock symptomps of uterine
inversion, so it should be fixed first using i.v
electrolite infusion and blood transfusion,
soon after reposition is performed
1. To minimize the possibility of vasovagal and bleeding,
immediate repositioning should be done immediately
2. Immediately do resuscitation action
3. If the placenta is still attached, do not remove
therefore this action will trigger severe bleeding
4. One technique of repositioning is to place the finger on
the posterior fornix, push the fundus of the uterus into
the vagina, push the fundus toward the umbilicus and
allow the uterine ligament to pull the uterus back to its
original position.
5. Some alternative techniques: by using 3-4 fingers
placed in the center of the fundus are pushed towards
the umbilicus until the uterus returns to its normal
position
6. After a successful repositioning, the inner hand must
remain inside and squeeze the uterine fundus. Give
oxytocin and after contractions, the inner arm may be
removed slowly to prevent the inversion of the uterus
from recurring
7. When vaginal reposition fails, repositioning is done
through
8. When it has been occurred, the therapy is:
 If there is bleeding or shock, give infusion and blood
transfusions and improve general circumstances
 After that immediately conduct a reposition or if
narcotics if needed
 If it is unsuccessful then performed a cooperative
action by vaginam (haultein surgery) or pervaginam
(surgery according to Spinelli).
 Outside of the hospital can be assisted by
repositioning lightly, i.e. with vaginal tampon, then
given antibiotics to prevent infection.
A pregnant complication which is
indicated by the appear of hypertension
≥ 160/100 mmhg accompanied by urine
protein or edema on gestitational age is
20 weeks or more
 Pregnancy of 20 weeks or more which sign as follows:

1. Systolic≥ 160 mmHg diastolic ≤ 110 mmHg, this high

tension does not decrease even though the pregnant
mother has been treated in hospital and bed rest
2. Urine protein≥5 gr/24 hours or qualitative 4+(++++)
3. Oliguria, the amount of urine production ≤500 cc/24 hours
or accompanied by the increase of blood creatinin
percentage
4. The presence of impending eclampsia symptoms: visual
impairment, cerebral disorders, epigasterium pain,
hyperflexia
5. The existence of HELLP Syndrome
H : hemolisis, E: elevated liver enzyme. LP: Low Platelet
a. PEB without impending eclampsia
b. PEB withimpending eclampsia,
symptoms:
 Headache,
 Eyes blur,
 vomitting,
 Epigastrium pain.
 Hb, PCV and peripheral blood
smear
 Uric acid of blood
 Trombosit
 Morphology of erythrocyte,
 Thrombocyte,
 Creatinin,
 Uric acid,
 ureum,
 sgot, sgpt,
 LDH,
 albumin and coagulation factors
 Provision of anti-seizure Mgso4 for prevention and
treatment, loading dose and maintenance by giving
 Provisison of anti hypertension
 Bed rest tilt to the left intermittently
 Infused RL or Dext 5%
 Therapi for complication

 Determine attitudes toward pregnancy:

 Expectative conservative, if pregnancy <37 weeks
 Actively aggressive, if gestational age ≥ 37 weeks
 Provision of anti-seizure Mgso4 for
prevention and treatment, loading dose and
maintenance
 Provision of antihypertensives
 The bed rests on a left tilt intermittently
 Infusion RL or Dext 5%
 Therapy for complications
 Determine attitudes toward pregnancy:
 Expectative conservative, if pregnancy <37
weeks
 Actively aggressive, if gestational age ≥ 37
weeks
 Primi gravida •Antiphospolipid
 Extreme age: too
young or too old. antibodies
 History of pre-
eclampsia •hiperchromocystenemia
 Chronic
•Mola hidatidosa
hypertension
 Kidney illness •Multiple pregnancies
 Obesity
 Gestational •ISK on pregnancy
diabetes, type I •Hydrops fetalis.
diabetes mellitus
 Fetal
Gangguan Ibu
disorder
Severe illness ailment

Hipovolemia  Vasoconstriction  Thrombocyte aggression

balance
Broken endotel Good encotel

Ischemia Improvement of STB Endotel cell

placenta deportation on final stadium of dysfunction
an illness
EC molecule adhesive
(Neutrofil deployment)

Acute Oxidative stress by

Aterosis sitokin mediator

Shalloe trofoblas
invasion in Immune
Spiralis arteriy maladaptation/
genetic
abnormalities
Figure 1. integrated hypothesis of the preeclampsia
 placenta Normal

placenta Preeklampsia
 Suplementation dietary which contains:
a. Dietary supplementation containing fish oil
which rich of unsaturated fatty acids, Omega-3
PUVA
b. Anti-oxidants: Vitamin C, Vitamin E, B-
Carotene, Co Q10, N-Acetylcysteine, lipoic acid
c. Heavy metal elements: Zinc, magnesium,
calcium
 Clinical definition :
Eclampsia is preeclampsia
accompanied by a tonic-clonic
seizure followed by a coma
Eclampsia Management:
•Overcoming and preventing
seizures.
•Supportive therapy for maternal
stabilization
•Always keep in mind ABC (Airway,
Breathing, Circulation)
•Correction of hypoxemia and
acidemia
•Overcoming and preventing
complications, especially chronic
hypertension
Medical treatment
 Does not treated in a dark room
 Anti-hypertension medicine
• Anti-hypertension hydralazine/IV
• Nifedipin  30- 120 mg / hr
 Anti seizure medicine: magnesium
sulfat IV
 Diuretik : is given when edema
pulmonum exists.
 Fluid provision: 500 mL/6 hour
 Other things to note :
• Complication
• Edema pulmonum
• Oliguria
 PRE ECLAMPSIA AND ECLAMPSIA (PEE)

ECLAMPSIA
Preeclampsia
PEB+ Seizures
Hipertension : S > 160, D>110
Proteinuri : > 3 g/dl or> +3
Edema anasarka
Oliguri : < 400 ml/24 hour Hemodinamik Improvements
Epigastrium pain in 4-8 hours
Frontal pain
Visus distruction
Termination of pregnancy

Mg SO4 andNifedipin

Pervaginam SC

Controlled unccontrolled/ PK II is reached within 4-5 Ekl. Gravidarum.

Complication hours or as long as the Ekl. Parturientum wih
hemodynamic improvements
estimation of PK II > 8 hours
FDJP

<5 >5

SC < 35 mg > 35 mg

Conservative Labor induction

Figure 3. preeclampsia and eclampsia management

 Complication of PRE ECLAMPSIA NA DECLAMPSIA

ABLASIO RETINA LOUSY HEART PULMONUM EDEMA LOUSY KIDNEY

Visus decreases Short-winded Short-winded Oliguria < 400

tachycardia Rh wet smooth in basalt Anuri < 200
Diastolic noisy Hiposchemia Ureum ↑
Pansystolyc Ro: Creatinin ↑
Gallop/thrill
Aritmia
Ro : Cardiomegali

Conservative Positition of ½ sit Supportive balance

Reversibel within 3-7 days O2 of Diuretic Fluids
Positition of ½ sit Morphin ****
O2 fluid restriction Diuretik
Digoksin/cedilanid ** Increase h epressure
Minipres/nifedipin *** Onkotik :
Isosorbid dinitrat # Dekstran
Diuretik ##

* Decreases venous return to teh lungs  short-winded

** increase contractility, loose anxiety,
Decreases atrium pressure
*** Decreases pheriperal resistention
# improve heart cholateral
## Decreases preload

Figure 4. Complication of preeclampsia and

eclampsia
 Complication PRE ECLAMPSIA AND ECLAMPSIA | II

SOLUSIO placenta HELLP DIC

Uterus stresses Sub ikterik bleeding Manifestation:

Hemmorrhage-pervaginam Stomuch ache on right Hematuri, ptechie
Fetal emergency above part D.Dimer + 1 or
Shock >> on the 2nd-3rd days Protamin sulfat test+ 3
Hemolysis :
- Bilirubin ID > = 1,2 gr/dl
- Burr cell
Elevated liver enzym :
- SGOT > 70 u/l
- LDH > 600 u/l
Low platelet count :
- Trombosit < 100 rb

Look at the management of Fix underlying disease Heparinisation4 X

solusio placenta Supportive
Lab evauation/2 days
Provide trombocyte if< 20.000
Be careful of spontaneous
hemmorragic if < 10.000
5000 U  evaluate every 6
hours
4 X evaluation results
Heparinisation stops

Figure 5. Complication preeclampsia and Eclampsia II

 PER

Hospitalization

24-34 34-37 >37

weeks weeks weeks

Maternal and Amniosentesis for

fetal care lungs maturity

Cervics mature Cervics has not

mature

Cervics
Immature maturing
Steroid Mature

Outpatient
management birth
Birth

Expectative Maternal and fetal control;

management , control 1 outpatient management
x a week

Figure 6. Management approach for PER

 PEB

Come for giving birth:

- Feto-maternal evaluation
- MgSO4;
- Antihypertension therapy

Absolute indication for termination:

1. TD is not controlled
2. Bad condition of mother & fetus
3. Liver enzymes increase rapidly
4. Thrombocytopenia (<100,000 / cu
mm)
No absolute indication for termination

< 23 minggu 23-32 weeks 32-33 weeks > 33 weeks

Tawarkan terminasi corticosteroid amniocentesis;

corticosteroid if necessary BP Control
Kontrol TD
Daily fetal examination
Be born
Maternal control

TD COntrol

Terminatio for abnormal

fetal growth Figure 7. PEB Management
1. Umbilical cord appear
• When the umbilical cord is below the lowest part
of the fetus and the amniotic fluid is still intact
2. Umbilical cord soar
• When the umbilical cord exits through ruptured
membranes, cervix, and tevagina

3. Occult prolapse
• The umbilical cord is next to the lowest part of the fetus
down to the vagina. The center can be palpable or not, the
membranes may rupture or not
 Pressure on the umbilical cord by the lowest part of the fetus
and the birth canal will reduce or eliminate placental
circulation. If not corrected, this Complication can cause a
fetal death.
 Complete obstruction of the umbilical cord leads to an
immediate reduction in the fetal rate (variable deceleration).
When the obstruction disappears quickly, the fetal heart rate
will return to normal. However, if the obstruction persists
there is deselarsion followed by direct hypoxia to the
myocardium resulting in long deselary When allowed to
occur fetal death.
 Partial obstruction results in heart rate acceleration. Long-
term blood flow through the umbilical cord produces severe
prescribed acidosis and metabolic acidosis reduced fetal
oxygenation, persistent bradycardiaand eventual fetal death.
1. Looking at the umbilical cord comes out from vaginal
introitus

2. Palpable accidentally the umbilical cord at deep

examination

3. Auscultation sounds the fetal heart, irregular with a clear

bradycardia, especially related to the uterus contraction

4. Continuous monitoring of the fetal heart rate shows variable

variation

5.Pressure on the lowest part of fetal by manipulating external

towards upper pelviiccavity cause the reduction of heart beat
accidentally and generated umbilical cord compression
1. The mortality rate for premature infants with umbilical
cord prolapse is almost 4 times

2.If fetal emergency is proven by abnormal heart beat

Bila gawat janin dibuktikan oleh detak jantung yang
abnormal, the presence of amnionic fluid colored by
meconium, if the pulsation cord is weak, so that the
prognocis will be bad
3. The distance between the occurrence of prolapse and
childbirth is the most crisis factor for the live fetus

4. The recognition of prolapse soon improves the

chances of a fetus to live

5. The fetal mortality rate in umbilical cord prolapse or

latitude is as high as the head presentation. This
eliminates the estimate that in both fetal placement the
abnormal pressure on the umbilical cord is not strong
1. The discovery of umbilical cord prolapse requires rapid action

2. Rapid descriptions are essential to determine the best attitude to

take.

3. Vaginal delivery is immediately possible only when the complete

opening, the lowest part of the fetus, has stage stage and no CPD

4. The delivery of sectio cesarean is more attractive because it reduces the

risk of mother and fetus. Before preparing the lowest part of cesarean
section as well as minimized by knee chest, position Trendelenburg
4. If previously was given oxytocin, this
medicine must be stopped

5. Any types of prolapse umbilical cord, if the

requirements for vaginal delivery have not
been met, it is advisable to have caesarean
 Amniotic fluid embolism (AFE) is a
catastrophic obstetric emergency that
can present as sudden, profound, and
unexpected maternal collapse associated
with hypotension, hypoxaemia, and
disseminated intravascular coagulation
(DIC). It occurs when amniotic fluid, fetal
cells, hair, or other debris enter the
maternal circulation.
 Most cases of AFE (70%) occur during
labour, 19% during Caesarean section,
and 11% following vaginal delivery. It has
also been reported during early
gestation, second trimester abortions,
during amniocentesis, or following
closed abdominal injury.
 There are no proven risk factors. However,
the following appear to be associated with a
higher risk of developing AFE: advanced
maternal age; multiparity; meconium stained
liquor; intrauterine fetal mortality;
polyhydramnios; strong frequent or tetanic
uterine contractions; maternal history of allergy
or atopy; chorioamnionitis; microsomia; uterine
rupture; and placenta accreta
SYMPTOMS SIGNS

 Dyspnoea  Hypotension
 Cough  Fetal distress
 Headache  Pulmonary oedema/ARDS
 Chest pain  Cardiopulmonary arrest
 Cyanosis
 Coagulopathy
 Seizures
 Uterine atony
 Bronchospasm
 Transient hypertension
 oxygenation

Delivery of Haemodynamic
baby stability

MANAGEMENT

Coagulation Uterine tone