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Abruptio placentae

Abruptio placentae
Abruptio placentae
Definition:
it is one form of APH where the bleeding occurs due to premature saperation of normally situated placenta.

Varieties_
1 reveled 2 concealed 3 mixed..

Etiology_
the prevalence is more common with 1 high birth order,advancing age of mother,poor socio economic states,malnutrion,smoking.
Hypertension in pregnancy is most imp factor.Trauma,sudden uterine decompression,short cord,sick placenta,folic acid deficiency,torsion of uterus are associted with.



Pathogenesis_
premature saperation of placenta is intiated by haemorrage into d decidua basalis. Clinical featurs_Reveal type_abdo discomfort or pain followed by vaginal bleeding.Continous dark coloured bleeding.General condn proportionate bleeding.Pallor,uternie ht proportinate to period of gastestion.,fHS present.
Mixed type. Acute intese pain in abdomen,shock is pronounced,sever pallor.Uterine ht disproportionally enlarge and globular.,uterus tense tender.

Management._
prevetion aim at elimination of known factor,correction of anaemia,therapy to minimise comlication.
Treatment-
Revealed type!!If pt is in labore the ARM is done and oxytocin is added if necessacasy.Resucciate the pt.
2 -if pt is nt in labour_>37wk-ARM and oxytocin.
<37wk_if bleeding stop try to continue the pregnancy upto 37 wk.But if bleedinag continue,ARM and oxytocin..
Conceled typeg_bld transfusion,periodic coagulation profile,urine output,fetal monitoring.Then ARM and oxytocine.If there is no response. Or fetal distress cs is done..

3rd Stage of Labor


3rd stage of labor
3rd stage of labor
Management

3rd stage is d most crucial stage of labour.

Principles undrlying managment of 3rd stage r
-to ensur strict vigilance
-to folow d managment guidlines strictly in practice
-to prevent complications, d imp one being PPH

A) Expectant managment (Traditional)-
in dis managment, d placental sepration & its descent in2 vagina r alowd 2 ocur spontaneously. Minimal asistanc may b givn for d placental expulsion if it needed

#constant watch is mandatory & patient shudnt b left one



#if mother is delivered in lateral position, she shud b changd 2 dorsal position 2 note features of placental sepration & 2 asses amt of bld loss

a hand is placed ovr fundus
i) to recognise signs of sepration of placenta
ii) to note state of uterine activity-contraction & relax^
iii) to detect cupping of fundus whch is an early evidnc of inversion of uterus

Desire 2 fiddle wid fundus / massage uterus is strongly 2 b condemned
Placenta is seprated widin min folowing birth of baby.
Pt is expected 2 expel placenta widin 20 min wid aid of gravity

Expulsion of placenta- only wen features of placental sepration & its descent in2 lowr segmen r confirmd, pt is askd 2 bear down simultnously wid hardening of uterus.
Raisd intra-abdo presur is often adequat 2 expel placenta.
If pt fails 2 expel, 1 can safely wait upto 10 minutes if der is no bleding.
As soon as placenta pases thru introitus it is graspd by hands & twistd round & round wid gentle traction so dat membranes r stripped intact.
If membranes threaten 2 tear, dey r caught hold of by sponge holding forceps & in similr twisting movts rest of membrans delivrd.
Gentleness, practice & care r prerequisites for complete delivry of membrans.
If spontaneous expulsion fails / is nt practicable, becoz of delivry undr anaesthesia, any 1 of folowing methods can b usd to expedite expulsion

Assisted expulsiön
i) controld cord traction (modified Brandt-Andrews method)
in dis palmar surfac of fingers of left hand is placed abov pubic symphysis approx @ junction of uper & lowr uterine segment. Body of uterus is pushed upwrds & backwrds, 2wrds umbilicus while by rt hand steady tension is givn in downwrd & backwrd dir^ holding clamp until placenta coms outsid introitus. Uterine elev^ facilitats expul^ of placenta. Procedur is 2 b adoptd only wen uterus is hard & contractd
ii)Fundal pressure- fundus is pushd downwrds & backwrds aftr placing four fingers bhind fundus & thumb in front using uterus as a sort of piston
Presur must b givn only wen uterus bcoms hard
If baby is macerated / premature dis methd is prefrable 2 cord traction


uterus is massaged 2 mak it hard, whch facilitates expul^ of retaind clots if any
Inj Oxytocin 5-10units IV or methergin 0.2mg givn IM

Exam of placenta membrans & cord
-Placenta placed on a tray & is washed out in running tap water 2 remov bld & clots
-Maternal surface is first inspected for its completeness & anomalies
-Membranes chorion n amnion r 2 b examind carefuly for completnes n presenc of abno vessels indicativ of succenturiate lobe
-Amnion is shiny but chorion is shaggy
-two umbilicl arteries n one umbilicl vein confirmd
-an oval gap in chorion wid torn ends of bld vessls running up2 margin indicats a missing succenturiate lobe
#Vulva, vagina, perinium inspectd for injuries n 2 b repaired
#4th stage- pulse, BP, behavior of uterus n any abnorml vaginl bledings is 2 b watchd at least for 1 hr aftr delivry

B)Active management of 3rd stage

THE UNDERLYING PRINCIPLE IN ACTIVE MANAGEMENT = it is to excite powerful uterine contractions following birth of anterior shoulder by parenteral oxytocin which facilitates not only early seperation of placenta but produces effective uterine contractions following its seperation.

ADVANTAGES=
1)to minimise blood loss approximately to 1/5 th
2)shorten duration of 3rd to half

The only disadvantage is slight increase in incidance of retained placenta nd conseqent increased incidance of manual removal.
Accidental administration during delivery of 1st baby in undiagnosed twins produces grave danger to unborn second baby caused by asphyxia due to tetanic contractions of uterus.Thus it is imperative to limit its use in twins only during delivery of second baby.

PROCEDURES = inj. ergometrine 0.25 mg or methergin 0.2 mg is given i.v.following birth of anterior shoulder.If administered prior to this there is chance of imprisonment of shoulder  behind pubic symphysis.This is followed by slow delivery of baby within 2-3 minutes. Placenta expected to be delivered following the delivery of buttocks. If placenta is not delivered instantaneously it should be delivered forthwith by controlled cord traction technique after clamping cord while uterus still remains contracted. He 1st attempt fails another attempt is made after 2-3 minutes failing which another attempt is made at 10 minutes. If still this fails manual removal is to be done.

LIMITATION=It should not be used in cardiac cases or severe pre eclampsia for fear of precipatating cardiac over load in former nd aggravation of bld pressure in latter.
It is certainly of value for cases likely to develope postpartum haemorrhage.

Thanks for Reading, keep Searching.

1 stage of labour

It starts from onset of true labour pain & ends with two dilatation of cervix. Also called cervical stage..
Duration-12 hours in primigravidae & 6 hrs in multiparae.


1 stage of labour
1 stage of labour

Events:-

a> dilatation & effacement of cervix
b> full formation of lower uterine segment
     aim=preparation of birth canal so as to facilitate expulsion of fetus in 2 stage
A> dilatation of cervix=
-in prelabour stage there may be little dilatation of cervix specially in multiparae
  factors which favours smooth dilatation=softening of cervix,accumulation of fluid in between collagen fibres,increased vascularity,breaking down of collagen fibres by collagenase & elastase, change in various glycosaminoglycans,

Factors Responsible:-

1) uterine contraction & retraction
2) bag of membranes=with the onset of labours membranes attached to the lower uterine segment are detached & with the rise  in intrauterine pressure during contraction there is herniation of membranes throgh cervical canal.

3) fetal axis pressure=there is tendency of straightning out of fetal vertebral column due to contraction of circular muscle of body of uterus.This allows fundal contraction to transmit through podalic pole into the fetal axis which helps opening up of cervical canal
4) Vis-a-tergo=final stage of dilatation.It is due to downward thrust of presenting part of fetus & upward pull of cervix over lower segment
B) effacement =process by which muscular fibres of the cervix are pulled upward & merges with the fibres of the lower uterine segment.
C) lower uterine segment formation= it is the part to which peritonium is loosely attached .When fully formed it measures about 7.5 to 10 cm from the internal os , cylindrical in shape.Factors responsible for thining of wall =relaxation of muscle fibres causing elongation , contraction & retraction of the muscle fibres of upper uterine segment  thereby drawing up of lower segment & cervix.,fetus pushed down causes further stretching of the wall called receptive relaxation.
Managment=
A)Principals=
1)non interferance with watchfull expectancy so as to prepare the patient for natural birth
2)to monitor carefully the progress of labour , maternal conditions ,fetal behaviour so as to detect any intrarapartum complication early
 B)preliminaries= basic evaluation of the current clinical condition , inquiry about onset of labour pains & leakage of liquor, general & obsetrical examination including vaginal examination , records of antenatal visits,investigations report,any specific treatment given
C)actual managment=
1)General-antiseptic dressing
            -encouragment & assurance
            -constant supervision
2)bowel-enema with soap & water or glycerine suppository.
     -given when rectum feels loaded on vaginal examination
3)rest & ambulation=if membranes are intact patient is allowed to walk about.This prevents venacaval compression & encourages descent of head.
     Ambulation can reduce the duration of labour ,need of analgesia , improves maternal comfort
4)diet= there is delayed emptying of stomach in labour. So food is withheld during labour
5)bladder care =patient is encouraged to pass urine by herself as full bladder inhibits uterine contractions & may lead to infection.If women can not go to toilet she is given a bed pan.
6)relief of pain= pethidine 50-100 mg im when the pains are well established in the active phase of labour .If necessary repeat after 4 hours.
Metoclopramide 10 mg im is given to combat vomiting due to pethidine.
 Drugs should not be given if delivery is anticipated within 2 hours
7)assessment of progress of labour & partograph recording=
 a)abdominal finding=uterine contractions -no of contractions in 10 min & duration of each contraction in seconds are recorded in the pastograph
b)pelvic grip=gradual disappearance of the poles of the head
c)shifting of the maximal impulse of the fetal heart beat downwards & medially
8)Fetal heart rate=done to note the fetal wellbeing
Rate ,rhythm & intensity noted every half hour in the first stage .Observations should be made immediately following uterine contraction .Count should be made for 60 sec.
9)continuous electronic fetal monitoring =recording of fetal heart action by fetal ECG& uterine contractions by tocography
10)vaginal examination -
-dilatation of cervix in cm in relation to hours of labour
-to note position of the head &  degree of flexino
-to note station of head in relation to ischial spine
-color of liquor
-degree of moulding of head
-caput formation
11)to watch maternal conditions-
-to record 2 hourly pulse ,BP,temperature
-observe the tongue periodically for hydration
-urine output ,sugar ,acetone
-iV fluids &drugs  

thanks for reading.      

MKRdezign

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