Complicated Puerperium Lecture Notes PDF

**LECTURE NOTE ON COMPLICATED MIDWIFERY II** **(ABNORMAL PUERPERIUM, BMP 311)** **THIRD YEAR, FIRST SEMESTER** **UNIT I** **Set 2019 Basic Midwives** **BY: MRS A. A. MOHAMMED** **Course outline** **INTRODUCTION** The course is designed to prepare the student to recognize those conditions which suggest deviation from normal during puerperium. It highlights the Midwives roles and responsibilities in early diagnosis, appropriate intervention and referral as necessary. It also emphasizes the Midwives role in emergency situations and operative intervention **Objectives** At the end of the course, the student should be able to: Demonstrate competence in the early diagnosis, appropriate intervention, including referral in complications occurring during puerperium. **Course Content** Unit I: Complications of Puerperium - Breast complications - Sub-involution - Wound abcess and haematoma - Primary and secondary post-partum haemorrhage - Puerperial pyrexia - Puerperal sepsis - Pelvic abcess - Endometrisis - Deep Venous Thrombosis (DTV)/Thrombophlebitis - Severe anaemia - Thrombophlebitis - Puerperial psychosis/depression - Shock - Amniotic fluid embolism - Disseminated intravascular coagulation (DIC) - Eclampsia - Retained placenta/product of conception Unit I: Complications of Puerperium - Breast complications - Sub-involution - Wound abcess and haematoma - Primary and secondary post-partum haemorrhage - Puerperial pyrexia - Puerperal sepsis - Pelvic abcess - Endometrisis - Deep Venous Thrombosis (DTV)/Thrombophlebitis - Severe anaemia - Thrombophlebitis - Puerperial psychosis/depression - Shock - Amniotic fluid embolism - Disseminated intravascular coagulation (DIC) - Eclampsia - Retained placenta/product of conception **Complications of puerperium** - Usually most women continue to enjoy good health during the puerperium, but infection or pre-existing ill health may interfere with the patient's well being. - The infection often manifests itself by elevation of the body temperature and other associated sign and symptoms. - Puerperal complications include many of those encountered during pregnancy, but there are some that are more common at this time. - Typical of these is puerperal pelvic infection---a well-known killer of postpartum women. Other infections include mastitis and breast abscesses. - Thromboembolism during the short 6-week puerperium is as frequent as during all 40 antepartum weeks. **BREAST COMPLICATIONS** - **ACUTE PUERPERAL MASTITIS** is inflammation of the breast, externally painful and may lead to abscess formation. - The most common infectious organism is staphylococcus aureus. - The most likely source and out breaks of skin and eye infections among babies are frequently due to staphylococcus aureus. - Organisms are transmitted by cross infection and can easily affect a whole part. **Sign and symptoms** - Occurs after the 8th postnatal day - The onset is rapid with a sharp rise in temperature which can reach as high as 40.5^O^C. - Rapid pulse - Throbbing pain and tenderness in the affected breast. - A wedge shaped, indurated and reddened area of the breast is seen on examination **Investigation and treatment** - A sample of breast milk is sent for bacteriological examination and abroad spectrum antibiotic as well as Analgesic is given until the causative organism is known - Breast feeding should be suspended if pus is found in the milk and the pump or hand expression. - The breast must be gently supported and large pads of cotton wool used to protect the painful infected area. - If the infection is mild, breast feeding may be continued as the anti infective properties of the milk protect the baby. **Breast Engorgement** - This is a condition occurring around 3^rd^ or 4^th^ day following childbirth in which the breasts become hard, edematous, painful and sometimes appear flushed. - It may be associated with maternal parexia. **Causes** **Inefficient feeding/suckling by the baby** - Poor suckling reflex - Incorrect attachment of baby to breast - Delayed breast feeding - Restricted breastfeeding due to baby's illness, maternal illness, or introduction of weaning - Sudden suppression of breastfeeding due to death of baby or reason associated with the mother. **Clinical features** **The mother experiences** - Hardness of the breast. - Edema of the breasts and flattening of the nipples making latching difficult. - Painful breast. - Pyrexia: 38^0^c/chills - Loss of appetite - Tender axillary lymph nodes. **Treatment** **If the woman is breastfeeding and the baby is not able to suckle:** - Encourage the woman to express milk manually or with pump. **If the woman is breastfeeding and the baby is able to suckle:** - Encourage more frequent breastfeeding using both breasts at each feeding. - Assist mother to achieve proper positioning and attachment of the baby to breast **Relieve measures before feeding:** - Apply warm compress to soften breast before feeding or encourage warm shower. - Gentle expression of breast milk manually and wet the nipples to help the baby latch properly and easily. **Relieve measures after feeding:** - Support breast with a binder or brassier - Apply cold compress to the breast between feeding to reduce swelling - Give analgesics e.g Ibuprofen 400mg, Parcetamol 1g to relieve pain and swelling **If the woman is not breastfeeding:** - Support breast with a binder or brassier - Apply cold compress to the breast to reduce swelling and pain - Avoid massaging or applying heat to the breast - Avoid stimulating the nipples - Give analgesics orally as needed - Do not restrict fluid intake as this does not affect milk production **Prevention:** - Educate on proper positioning and attachment - Feeding on demand - Ensure adequate emptying of the breast at each feeding. - acute puerperal mastitis may lead to abscess formation. - If this occurs the affected breast is extremely painful, edema\` is usually present and the breast becomes tense and red. - The axially glands become tender and enlarged. - The abscess must be incised and drained to prevent spread into other areas of breast which would cause damage. **OR** **BREAST ABSCESS** This is the accumulation of pus in the breast which can be due to breast infection. Most common in lactating women CAUSE IN LACTATING WOMEN 1. Mastitis 2. Untreated infection from the breast or from baby's mouth 3. Cracked nipple CAUSES OF MASTITIS IN NON LACTATING WOMEN 1. Cuts on breast tissue 2. Nipple piercing 3. Cracked nipple SIGN AND SYPTOMS 1. Pain 2. Redness 3. Swelling 4. Warm skin 5. Discharge of pus from the nipple 6. High fever DIAGNOSIS 1. History taking from the patient 2. Physical examination from head to toe 3. Breast ultra sound 4. Culture of breast milk 5. Breast tissue biopsy TREATMENT 1. Usually is surgical intervention to drain the pus. 2. The pus can also be drained through needle. 3. Analgesics and antibiotics are given COMPLICATION 1. Scaring 2. Asymmetrical breast 3. Changes to the nipple/breast tissue. 4. Internal sore called fistulas PREVENTION 1. Prompt treatment of mastitis **Prevention** - The best method of treatment lies in prevention. - Attention to hand washing and hygiene will both lower the incidence of infection among babies and reduce risk of breast infection in mothers. - Midwives and doctors must maintain cleanliness and wash their hands before attending to a mother or a baby. **CRACKED NIPPLES** **Causes** - Lack of cleanness and dryness of the nipples. - Vigorous suckling of a hungry baby in deficient lactating breasts. - Leaving the baby too long at the breast. - Repeated taking and leaving the nipple by the baby to breathe if its nose is obstructed by the breast. - Monilial infection. **Treatment** - Rest: the baby should not put on the affected breast till healing occurs while it is emptied manually. Gradual going back to the breast is recommended to prevent recurrence. - Hot fomentations. - Panthenol ointment or flavine in liquid paraffin: applied locally. **Galactocele** - It is a retention cyst of a large mammary duct due to its obstruction. - If it is persistent it is excised or aspirated. **INHIBITION OF LACTATION** **Indications** **Maternal:** - Decompensated heart failure. - Active pulmonary tuberculosis. - Acquired immune deficiency syndrome (AIDS). - Acute illness as pneumonia. **Foetal:** - Cleft palate. - Marked hare lip. - Marked prematurity - Death of the infant. **Methods** - Cold fomentations. - Restriction of fluids and diuretics. - Tight breast binders to prevent accumulation of milk. - Dopamine agonists: starting as early as possible for 14 days; - Bromocriptine (Parlodel) 2.5mg twice daily. - Lysuride (Dopergin) 0.2 mg twice daily. - Oestrogens: alone, with androgen or in contraceptive pills was used but they have the following disadvantages: - increase the risk of thrombo-embolic complications, - withdrawal bleeding usually occurs, - Lactation may return again andnot effective if not started immediately after delivery. **SUB INVOLUTION** - Is delay of the [uterus](https://en.wikipedia.org/wiki/Uterus) does not return to its pre-gravid state. ### Signs and Symptoms The condition may be asymptomatic. The predominant symptoms are: - Bulky or buggy soft uterus on palpation - Profuse, offensive and reddish brown lochia - Fundal height remains stationary for a few days - Rise in temperature. ### Causes ### Predisposing factors - Grand [multiparity](https://en.wikipedia.org/wiki/Parity_(biology)#Enumeration) - Over distension of uterus as in twins and hydramnios - Maternal health - [Caesarean section](https://en.wikipedia.org/wiki/Caesarean_section) - [Uterine prolapse](https://en.wikipedia.org/wiki/Uterine_prolapse) - [Retroversion](https://en.wikipedia.org/wiki/Retroversion) after the uterus becomes pelvic organ - [Uterine fibroid](https://en.wikipedia.org/wiki/Uterine_fibroid) ### Aggravating factors - Full bladder - Retained products of conception - Uterine sepsis, endometritis - Persistent [lochia](https://en.wikipedia.org/wiki/Lochia)/fresh bleeding **Management** - Take labour history - Admit, identify the cause and treat - Take high vaginal swab for culture and sensitivity - Early ambulation/postnatal exercises - General nursing care --observation of vital signs, nourishing diet, rest, personal hygiene, encourage exclusive breastfeeding **Medication** - Antibiotics e.gAmpicloxetc - Utero tonic e.gErgometrine, oxytocin - Analgesics/Antipyretics e.gPanadoletcs - Vitamins. **HAEMATOMA** - Intrauterine haematomas are blood accumulations that are subchorionic, retroplacental or both. - The results from numerous studies of the intrauterine haematoma are not unequivocal. - Today, the importance of intrauterine haematoma for [early pregnancy](https://www.sciencedirect.com/topics/medicine-and-dentistry/first-trimester-pregnancy) loss is played down. - Intrauterine haematomas do not have a deleterious effect on pregnancy outcome in a population with recurrent miscarriage. - But it seems reasonable to assume that if the haematoma lies under the placenta and cord insertion, it has the potential to lead to placental separation and abortion; and that also very large subchorionic haematomas may cause [uterine contractions](https://www.sciencedirect.com/topics/medicine-and-dentistry/uterine-contraction) with subsequent pregnancy loss. **Post-partum Haemorrhage** - Postpartum haemorrhage (PPH) is defined as a blood loss of 500 ml or more within 24 hours after birth. - PPH is the leading cause of maternal mortality in low-income countries, and the primary cause of nearly one quarter of all maternal deaths globally. - Most deaths resulting from PPH occur during the first 24 hours after birth; the majority of these could be avoided through the use of prophylactic uterotonics during the third stage of labour and by timely and appropriate management. **Primary post-partum haemorrhage** Primary post-partum haemorrhage is the loss of **\>500 ml** of blood per-vagina **within 24 hours **of delivery. It can be classified into two main types: - **Minor PPH** -- 500-1000ml of blood loss - **Major PPH** -- \>1000ml of blood loss It is a major cause of obstetric morbidity and mortality worldwide. Aetiology and Risk Factors: --------------------------- The causes for primary post-partum haemorrhage can be broadly categorised by the **4 T's** -- **t**one, **t**issue, **t**rauma and **t**hrombin. **Tone** 'Tone' refers to **uterine atony**, which is the most common cause of primary post-partum haemorrhage. This is where the uterus fails to contract adequately following delivery, due to a lack of tone in the uterine muscle. **The risk factors for uterine atony include:** - **Maternal profile**: Age \>40, BMI \> 35. - **Uterine over-distension** -- multiple pregnancy, polyhydramnios, fetal macrosomia. - **Labour** -- [induction](https://teachmeobgyn.com/labour/delivery/induction-of-labour/), prolonged (\>12 hours). - **Placental problems** -- placenta praevia, placental abruption, previous PPH. **Tissue** 'Tissue' refers to **retention** of placental tissue -- which prevents the uterus from contracting. It is the second most common cause of 1° PPH **Trauma** This refers to damage sustained to the reproductive tract during delivery (e.g. vaginal tears, cervical tears). Risk factors include: - Instrumental vaginal deliveries (forceps or ventouse) - Episiotomy - C-section **Thrombin** 'Thrombin' refers to coagulopathies and vascular abnormalities which increase the risk of primary post-partum haemorrhage: - **Vascular **-- Placental abruption, hypertension, pre-eclampsia. - **Coagulopathies** -- von Willebrand's disease, haemophilia A/B, ITP or acquired coagulopathy i.e. DIC, HELLP. Investigations -------------- **The initial laboratory tests in primary post-partum haemorrhage include:** - Full blood count - Cross match 4-6 units of blood - Coagulation profile - Urea and Electrolytes - Liver function tests **Management** The management of primary post-partum haemorrhage should include the simultaneous delivery of TRIM: - Teamwork (immediate management) - Resuscitation (immediate management) - Investigation and monitoring (immediate management) - Measures to arrest bleeding (definite management) **Immediate management** - **Teamwork:** involve appropriate colleagues for minor and major PPH, including the midwife incharge and midwives, obstetricians, anaesthetists, blood bank, clinical haematologists and porters. Communication between the team and deligent documentation is vital. - **Investigation and monitoring:** investigations as above. Monitoring should include RR, O2 sats, HR, BP, temperature every 15 minutes. Consider catheterization and insertion of a central venous line. **Resuscitation** Resuscitate the patient via A-E approach **Airway** - Protect airway (may lose it with reduced level of consciousness) **Breathing** - 15L of 100% oxygen through non-rebreathe mask **Circulation** - Assess circulatory compromise (Cap refill, HR, BP, ECG) - Insert two large bore (14G) canulas and take blood samples - Start circulatory resuscitation. - Give cross-matched blood as soon as it is available. **Disability** - Monitor patient's Glasgow coma score (GCS) **Exposure** - Expose patient to identify bleeding sources **Definite management** The definite management of primary PPH is largely depends on the underlying cause: **Uterine atony** - **Bimanual compression to stimulate urine contraction** -- insert a gloved hand into the vagina, then form a fist inside the anterior fornix to compress the anterior uterine wall and the other hand applies pressure 0n the abdomen at the posterior aspect of the uterus (ensure the bladder is emptied by catherterisation) - **Pharmacological measures**-- act to increase uterine myometrial contraction. - **Surgical measures** -- intrauterine ballontamponade, haemostatic suture around uterus ( e.g B-lynch), bilateral uterine orminternal iliac artery ligation, hysterectomy (as a last resort). - Fig 3 - Management of PPH; (a) Bimanual compression, (b) Balloon tamponade. Management of PPH; (a) Bimanual compression, (b) Balloon tamponade. **[Trauma]** Primary repair of laceration, if uterine rupture: laparotomy and repair or hysterectomy. **[Tissue]** Administer IV Oxytocin, manual removal of placenta with regional or general anaesthetic, and prophylactic antibiotics in theatre. Start IV Oxytocin infusion after removal. **[Thrombin]** Correct any coagulation abnormalities with blood products under the advice of the haemotology team. **Secondary post-partum haemorrhage** **Secondary postpartum haemorrhage** is defined as excessive vaginal bleeding in the period from 24 hours after delivery to twelve weeks postpartum. **Aetiology and risk factors** The main causes of secondary PPH are: - Uterine infection- (known as endometritis) - Risk factors include Caesarean section, premature rupture of membranes and prolonged labour. - **Retained placental fragments or tissue** - **Abnormal involution of the placental site** (inadequate closure and sloughing of the spiral at the arteries at the placental attachment site). - **Trophoblastic disease** (very rare). A personal history of secondary PPH is a strong predictive factor; it has a recurrence rate of **20-25%.** ![Fig 1 - Placental site involution; the physiological occlusion and shedding of the spiral arteries. If this process is defective, secondary PPH can result.](media/image2.jpeg) Placental site involution: the physiological occlusion and shedding of the spiral arteries. If this process is defective, secondary PPH can result. **Clinical features** - The main symptom of secondary post-partum haemorrhage is excessive **vaginal bleeding**. In contrast to [primary PPH](https://teachmeobgyn.com/labour/puerperium/primary-post-partum-haemorrhage/) (an acute condition requiring immediate management), the bleeding in secondary post-partum haemorrhage is usually not as severe. - The patient may complain of spotting on-and-off for days after her delivery, with an occasional gush of fresh blood. However, approximately 10% of cases will present with **massive haemorrhage** -- and this can quickly lead to hypovolemic shock. - Additional clinical features will depend on the underlying cause. For example, women with **endometritis** may also present with fever/rigors, lower abdominal pain or foul smelling lochia (the normal discharge from the uterus following childbirth). - On abdominal examination, the patient may complain of lower abdominal tenderness (usually a sign of endometritis), or the uterus may still be high (sign of retained placenta). **Speculum examination** is important in order to assess the amount of bleeding, and a high vaginal swab should be taken at the same time. **Investigations** - If the patient is haemodynamically unstable or is bleeding heavily, then call for help and follow the resuscitation algorithm. - Resuscitation should be commenced prior to establishing a cause, and a senior a senior staff should be involved at the earliest opportunity **Labouratory tests** The appropriate labouratory tests include: - Full Blood Count - Urea and Electrolytes - C-Reactive Protein - Coagulation Profile - Group and Save Sample - Blood Cultures (if the patient is pyrexial) **Imaging tests** A pelvic ultrasound scan can assist in diagnosis of retain placental tissue. Management ---------- The mainstay of treatment in secondary PPH is with antibiotics and uterotonics: - **Antibiotics** -- usually a combination of ampicillin (clindamycin if penicillin allergic) and metronidazole. - Gentamicin should be added to the above combination in cases of endo**myo**metritis (tender uterus) or overt sepsis. - **Uterotonics** -- examples include syntocinon (oxytocin), syntometrine (oxytocin+ergometrine), carboprost (prostaglandin F2) and misoprostol (Prostaglandin E1). - **Surgical measures** should be undertaken if there is excessive or continuing bleeding (irrespective of ultrasound findings). In continuing haemorrhage, insertion of a balloon catheter into the uterus may be effective. - In the case of **massive secondary PPH**, management includes four components, which should be undertaken *simultaneously*. These are: i. Communication, ii. Resuscitation, iii. Monitoring and investigation (as described in the investigation section) and iv. Arresting the bleeding (with uterotonics/surgical measures, depending on the suspected cause). *Note: Any surgical evacuation of retained products of conception carries a high risk of uterine perforation (as the uterus is softer and thinner post-partum). It should involve a senior obstetrician in the planning and delivery of surgery.* ***Preventive measures of PPH*** ***Antenatal*** - Proper history taking during antenatal period to identify at risk patient - Women at risk should be encouraged to deliver in a well-equipped hospital under the management of a skilled midwife. - Proper nutritional counseling to prevent anemia, malnutrition and build her immunity - Encourage the use of routine drugs. - Laboratory investigations, such as Hb, PCV, MP etc. **Labour** - Empty bladder frequently - Employ the use of active management of second and third stage of labour - Routine use of oxytocicsin second stage of labour **Postnatal** - Put the baby to breast immediately after delivery within 30 minutes - Advice patient on family planning - Empower the woman (socioeconomically and educationally) **Complications** - Hypovolemic shock - Kidney failure - Brain damage - Sepicaemia - Anaemia - Asherman's syndrome - Shechah's syndrome - Mortality. **HAEMORRHAGE IN OBSTETRICS** - Obstetric haemorrhage is blood loss or bleeding during pregnancy labour, or within 42 days of termination of a pregnancy - Haemorrhage in pregnancy, labour and the early post-partum period is a major cause of maternal mortality worldwide. Haemorrhage is the number one cause of maternal death in Nigeria, Sixty percent of all pregnancy related deaths are said to occur during the first 24 HOURS AFTER DELIVERY (Li, 1996). - Haemorrhage in the first 4 hours after delivery accounts for the single largest number of maternal deaths. More than 150,000 maternal deaths are due to obstetric haemorrhage, accounting for 25% of maternal mortality. The commonest type of haemorrhage that is of serious concern is bleeding immediately after delivery (primary postpartum haemorrhage ) and is a major cause of maternal mortality worldwide. **Signs and symptoms of haemorrhage in obsterics:** 1. 2. 3. 4. 5. **Common causes of obsteric haemorrhage:** \(I) In pregnancy - - - - (II). Intra and postpartum: - - - - - **Predisposing factors:** These are risk factors that should put the health care provider especially the midwife at alert during pregnancy, labour and post partum. **Past illnesses or surgery:** - - - - **Previous histories of :** post partum haemorrhage, ruptured uterus, inverted uterus, retained placenta and five or more previous pregnancies. **Problems in present pregnancy:** - Placenta praevia - Placenta abruption - Pre-eclampsia /eclampsia - Foetal death in utero - Multiple pregnancy - Polyhydrammios, abdominal pain, contraction, bleeding, induced labour (by medicines or herbs) - Prolonged labour - Chorioammionitis and precipitate labour (lasting 3 hours or less) **Management of haemorrhage in obstetrics** The rule is that the slightest case of vaginal bleeding in pregnancy must be reported by the patient. **Nursing management** - Reassure the woman and her relatives - Inform the doctor - Take history of bleeding. - Examine the vulva, for amount of bleeding or products of conception, trauma or laceration. Examine uterus for contraction or retained placenta if just delivered. - Do not perform vaginal examination - Check bladder if full - Keep patient warm and treat for shock if present, - Stabilize patient with intravenous infusion of normal saline or Ringer\'s lactate, 1L to run over 8 hours if bleeding is moderate. lf bleeding is severe e.g in abroptio placentae, give at least 2L in the first hour, the first 1 L at the rate of 15-20 minutes - Relief pain with e.g. Fortwin 30mg IM - Check vital signs of pulse, respiration and blood pressure - Transfer or refer patient immediately, if no improvement in patient\'s condition, (in the company of a midwife) for specific management. *Consider the following causes for specific management* **(1) ECTOPIC PREGNANCY** Types: **(a) Un-ruptured ectopic** *Signs* / *Symptoms:* - Light bleeding - Symptoms of early pregnancy - Abdominal and pelvicpain - Closedcervix. **Ruptured ectopic:** - *Signs/Symptoms:* - Signs of shock - Collapse - Weakness; - Pulse 100 beats / minute or more, - Systolic blood pressure of90mmHg or less. - Acute abdominal and pelvic pain - Rebound abdominal tenderness - Pallor due to severe bleeding **Management** - - - - - 2\. **MOLAR PREGNANCY** This manifests as hydatidiform mole **Signs/Symptoms:** - Heavy bleeding - Dilated cervix, - Uterus large than dates and softer than normal - Partial expulsion of products of conception which resembles grapes, **Management** - If diagnosis is certain and MVA is available -perform Manual Vacuum Aspiration (have three syringes cocked and ready for use). If cervical di1atation; is needed, use a paracervical block. Once MVA is started, infuse oxytocin 20 units in 1L of Normal Saline or Ringer\'S Lactate at 60 drops per minutes to prevent haemorrhage. - if diagnosis is not certain and / or MVA is not available, stabilize with infusion and refer immediately. Bleeding after 22 weeks of pregnancy or in labour before childbirth 3\. **ABRUPTIO PLACENTAE** Signs / symptoms - severe bleeding after 22 weeks of pregnancy - intermittent or constant abdominal pain **Management** Reassure patients if conscious - Check vital signs - blood pressure, pulse, respiration and temperature - Treat for shock if present - Start IV infusion (two if possible) using a large-bore cannula. - Rapidly infuse normal saline or Ringer\'s Lactate at the rate of 1 L in 15 - 20 minutes - Give at least 2L of fluid in the first hour. - Refer urgently for surgical intervention. **(4) PLACENTA PRAEVIA** Signs/ Symptoms - - **Management** - - **(5) RUPTURED UTERUS** Signs /Symptoms - Bleeding, (intra-abdominal and/or vaginal) - Severe abdominal pain (may decrease Liter rupture) **Management** - - - - **(6) ABORTION** Overview of Abortion **Introduction** Abortion is the commonest cause of bleeding in early pregnancy and is one of the major causes of maternal deaths worldwide. **Definition:** Abortion is termination or loss of a pregnancy before 24 weeks of gestation. **Incidence** - Worldwide, an average of 35 in 1000 women of childbearing age (15-49 years) have an abortion each year.However, this rate changes from 10 per 1000 women in some countries to around 80 per 1000 women in others. - Despite variations in the legal statues of abortions in developed and developing countries, overall rates are quite similar for both. Worldwide, of the approximately 210 million pregnancies that occur each year, an estimated 38% are unplanned and a further 22% result in abortions. In developing countries, Nigeria inclusive, 182 million p[r]egnancies occur yearly, with an estimated 36% unplanned and 20% ending in abortions. - In Nigeria, it is estimated that about 40% of maternal deaths are from abortion and its complications. The gestational age at which pregnancy is usually terminated is between 6-12 weeks. - Abortion can lead to death contributing about 29% or cases in maternal mortality as well as maternal morbidity e.g Reproductive health infections and infertility. These unnecessary and highly preventable complications can occur, from miscarriages and induced abortions and or its management. The proportion of pregnancies ended by abortion is greatest at the beginning and at the end of a woman\'s child bearing life. The provision of quality post abortion care and counseling will contribute immensely to the reduction of maternal mortality. Henshaw et al, (1999). **FACTS ABOUT ABORTION:** **Worldwide:** - - - - - - - - - - **Causes of abortion:** **1. Maternal causes.-** - Maternal ill-health such as malaria, anaemia diarrhea /dysentery, tuberculosis, pyelonephritis, hypertension, diabetes. - Hormonal imbalance - Uterine malformation e.g Bi-cornuate uterus - Uterine infections e.g endometritis - Submucous fibroids - Cervical incompetency - Exposure to teratogenic chemicals - Effect of certain drugs e.g Oxytocin, Prostaglandin - Emotional disturbance or extremes of emotions such as grief or fright - Violent exercises. 2. **Foetal causes:** - - - - - **Signs and symptoms of Abortion** - History of missed period precede vaginal bleeding - the cardinal signs is bleeding per vaginam this may be slight or profuse depending on the nature of the abortion. - Pains patient may complain of backache and intermittent lower abdominal pain - Membranes may rupture and part of the products of conception may protrude the dilating cervical os (inevitable leabortion) - Bleedmg may be profuse and products retained in incomplete abortion - Reddish brown/yellowish green foul smelling vaginal discharge (in septic abortion) - On abdominal palpation, there is localized or generalized rebound and/or tenderness. If it is complicated with septicaemia, patient looks toxic and jaundiced. - Excessive blood loss will lead to anaemia; and shock - Signs of shock cold, clammy skin and extremities, rapid feeble pulse, and lowered blood pressure, air hunger respiration. - The general condition of the patient depends on the amount of blood loss and type of abortion. **Classification / Specific management of abortion:** **(1) SPONTANEOUSASORTION:** This is the loss of a pregnancy before 24 weeks of pregnancy (it is otherwise termed as miscarriage) it usually occurs naturally its own without any interference or may result due to disease or accident. **Stages of spontaneous abortion** \(i) **Threatened abortion:** This may progress to term or cannot be saved and become inevitable Signs and Symptoms - Light bleeding - Closed cervix - Uterus corresponds to dates **Management** - - - - - **(II) Inevitable abortion: T**he abortion is imminent and the pregnancy cannot be saved **Signs and Symptoms** - Heavy bleeding - Progressive dilation of the cervix - Uterus smaller than or corresponds to dates **Management** If pregnancy is less than 16 weeks, perform Manual Vacuum Aspiration (MVA) - - - - **If pregnancy is greater than 16 weeks** - Await sponteneous expulsion of products of conception. - If necessary to help expulsion, infuse Oxytocin 40 units in 1L of Normal Saline or Ringer\'s Lactaterun at 40 drops per minutes. - Perform MVA to remove any remaining products of conception. **(iii) Incomplete abortion:** Products of conception are not completely expelled. Usually the foetus is expelled but the placenta and membranes are retained. Signs and Symptoms - Persistent heavy bleeding - Dilated cervix - Uterus smaller than dates **Management** **If bleeding is light to moderate and pregnancy is less than 16 weeks** - - - **If bleeding is heavy and pregnancy is less than 16 weeks** - If MVA is available, perform MVA. - If MVA is not available, perform curettage - If MVA and curettage are not available stabilize with infusion and refer urgently. **If bleeding is heavy and pregnancy is greater than 16 weeks** - If MVA is available infuse Oxytocin 40 units in 1L Normal Saline or Ringer\'s Lactate 40 drops per minutes until expulsion of products of conception occurs. - If necessary, give Misoprostol 200ug vaginally every 4 hours until expulsion (do not give more than 800ug) - Perform MVA to remove any remaining products of conception. - Refer urgently. **(iv) Complete abortion:** The whole products of conception is expelled completely Complete abortion is commoner before the 8th week of pregnancy **Signs and Symptoms** - - Closed cervix - Uterus smaller than date - Uterus softer than normal **Management** - - - (v).**Missed abortion:** The foetus dies and is retained. There is painless brownish vaginal discharge. Manage as septic abortion. **Habitual abortion**: This is when there had been three or more consecutive spontaneous abortions. **Management:** Patient is admitted and confined to bed as soon as pregnancy is confirmed. Shirodicalstitches may be applied at a fixed time by the obstetrician to keep the pregnancy till term and removed before she falls into labour. **(2) INDUCED ABORTION:** This is purposeful or deliberate termination of pregnancy either by the woman herself or someone else with the aim orintention of other than live born infant, or to remove a dead foetus. Pregnancy may be induced for therapeutic or criminal purposes. induced abortion may be therapeutic or criminal as follow: - **Therapeutic abortion:** This is carried out by a qualified medical practitioner in the interest of the mother\'s life or her total wellbeing. The indication for this is usually medical conditions threatening the mother\'s life or is likely to cause gross foetal abnormalities e.g cardiac disease grade four. - **Criminal/Unsafe abortion:** This is illegal procurement of abortion, usually performed by unqualified persons (quacks) or persons lacking; necessary skills or in an environment lacking minimal infection prevention standard or both and having little regard for the consequences. - **Signs and Symptoms** - Fever / Chills - (2)Foul-Smelling vaginal discharges - Tender uterus. **Management** - Immediately give ampicillin 2g IV every 6 hours plus Gentamicin 5mg/kg body weight IV every 24-hours plus Metronidazole 500mg IVevery 8 hours untill woman is fever-free for 48 hours. - Prior to 16 weeks, if MVA is available, perform MVA - If after 16 weeks, and MVA is not available give antibiotics and refer immediately. **Nursing management of a patient with abortion** *NB: The rule* is *that the slightest cases of vaginal bleeding in pregnancy must be reported by the patient* - Reassure patient and relatives. - Take history of last menstrual periodto determine the (if conscious) gestational age of the pregnancy. - Show empathy. - Do not perform vaginal examination, - Treat for shock if in shock -- place patient in dorsal position and elevate foot of bed. - Give Oxygen 6 -- 8 litres per minutes if necessary. - Keep patient warm - Check vital signs temperate, pulse, Respiration and Blood pressure. Take Pulse and Respiration ¼ hourly. - Prevent hyprovolaemia by giving rectalfluid intravenous fluid (Normal Saline 0.9% in 500mls at 40 drops per minute. - If patient is bleeding with cloths or products of conception, give Ergomethrine 0.5mg or Misoprostol 400mg by mouth (repeat once after 4 hours if necessary) Synthometrine 1ml. - Attempt to remove the placenta. - If patient is having painful contraction, give analgesics e.g Fortwin 30mg intramuscularly - If conscious, give Paracetamol two tablets (1 em) thrice daily for 3 days start antibiotics e.g Ampicillin 500mg stat then 250mg 6 hourly for 5 days. - Give sedative e.g Valium 1 Omg orally. - Put patient on complete bed rest continue with close observation of vital signs. - Check abdomen for contraction and vagina for blood toss and offensive vaginal discharges - Check for evidence of attempted intervention - Perform manual vacuum aspiration MVA if available, if MVA is not available and pain persists or patient\'s condition does not stabilize within 24 hours of nursing intervention - Refer immediately for higher medical management. - If referred or discharged counsel on family planning - Counsel on safer sexual activities if septic abortion. **UNSAFE ABORTION** Definition - Unsafe abortion is defined as a procedure for the termination of an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking minimal medical standards or both. - Unsafe abortion is a response to an unplanned/unwanted pregnancy, which should have been prevented by access to quality family planning / child spacing services amongst others. **Methods used** - - **Incidence of unsafe abortion worldwide:** - 20 million yearly - More than 70,000 women die yearly, 23,000 of these occur in Sub-Saharan Africa - 1 out of 8 deaths related to pregnancy is due to unsafe abortion (WHO estimate). - Unsafe abortion accounts for 13% of all maternal death world wide - 40% of maternal death occur in Nigeria - For every maternal death 15 20 maternal morbidities occur - Up to 50% of the hospital resources are used in treating women admitted for complications of unsafe abortion. Illegal and unsafe abortions occur amongst young adolescents, poor women and rural women who usually try to induce their own abortions or use the services of unskilled practitioners applying sometimes highly dangerous traditional methods. 20 of 46 million induced abortions worldwide are unsafe. - An estimated 46 million women around the world have abortions each year. Over 20 million of these abortions are performed illegally and under unsafe conditions. There are about 610,000 unsafe abortions in Nigeria annually 40% of maternal deaths occur in Nigeria. **Groups commonly affected include:** - - Students - Divorcees up to 50% of the hospital resources are used in treating women admitted for complications of unsafe abortion - Single girls - Unemployed - Widows - Commercial Sex Workers **underlying reasons for induced abortions include:** - The non-usage of any family planning method by women, married and un-married or their partners. - The use of a method that provides insufficient protection against pregnancy. - Failure of a contraceptive method, - Lack of access to contraception or to a method. - Unwanted pregnancy due to financial difficulties, desire to continue schooling, fear of parent\'s reaction to a pregnant teenager at school - Lack of knowledge about Reproductive system - Single marital status - Too many children - Abandonment by the partner responsible for the pregnancy - Pregnancy resulting from incest - Lack of information to the public **Complications of unsafe abortion** *Immediate effect:* - - - - - - - ***After effect:*** - Ectopic pregnancy - Infertility - Chronic pelvic pain - Pelvic inflammatory disease (PID) - Marital disharmony - Emotional instability - Post abortion syndrome - Habitual abortion - Proness to cancer 0f the cervix and the uterus **Prevention of unsafe abortion** (To individual) i. - - ii. iii. **STRATEGIES FOR PREVENTION OF UNSAFE ABORTIONS** - Increase */* improve family planning counseling services - Government must ensure that family planning commodities be available, accessible and affordable at all levels of care. - Laws should be more liberal and accompanied by a broad range of policies and programmes to enhance Reproductive Health services. Improve sexuality and contraceptive education. - Expand support services for women and their families. Provision of access to quality post abortion services through the use of manual vacuum aspiration for treatment of complications. - Post abortion services must be established throughout the Federation to offer contraceptive counselling, education and services promptly to women who have had an abortion and encourage adolescents to delay sexual activity. - Young people must have access to relevant information and education on sexuality and family life issues as well as quality Reproductive Health services including family planning. - Liberalising abortion - where unsafe abortion exists, government must endeavour to create a consensus amongst the people in favour of addressing its harmful, social and health consequences. - Follow up and counsel on post abortion family planning needs: Help her select and obtain the most appropriate family planning method, if desired. - Comprehensive Reproductive Health care outlets e.g User-friendly outlets alternative to abortion. - Identify other RH services needed e.g. tetanus prophylaxis or booster, treatment for STI and / or cervical cancer screening. - Keeping the pregnancy, or taking baby to foster home after delivery **Treatment of unsafe abortion** - - - **PUERPERIAL PYREXIA** Puerperal pyrexia is defined as the presence of a fever, which is greater than or equal to 38°C, in a woman within six weeks postpartum. **Etiology** - A raised temperature accompanied by a raising pulse rate is a cardinal sign of puerperial infection. - Puerperial pyrexia arises from infection of genital or urinary tract - It can also be as a result of breast complications or inflammation of the veins. - Intercurrentinfections such as common cold - **Postoperative infection following caesarean section**: [lower segment caesarean section (LSCS)](https://patient.info/doctor/caesarean-section) is the most important risk factor for puerperal pyrexia; there is a significantly increased risk of postpartum sepsis, wound problems, urinary tract infections and fever following LSCS. **Presenting features may include**: - Painful, red suture line. - Deep tenderness on palpation. - Lochia pink/coloured. - **Deep venous thrombosis** **Investigations** A full history should be taken, to include a full history of the delivery - establish: - When the membranes ruptured. - The length of labour. - The instrumentation used. - Sutures required. - Whether the placenta was complete. - Whether there was any bleeding during or after delivery. History ------- - Take the patient\'s temperature and blood pressure. - Palpate the uterus to assess size and tenderness. - Assess any perineal wounds and lochia. - Examine the breasts. - Examine the chest for signs of infection. - Examine the abdomen. - Examine the legs for possible thromboses. Investigations -------------- - High vaginal swab. - Urine culture and microscopy. - Other swabs as felt necessary - eg, wound swabs, throat swabs. - FBC. - Blood culture x 2. - Ultrasound scan may be required to assist diagnosis of retained products of conception. - Sputum culture if indicated. MANAGEMENT ---------- ### General measures Ice packs may be helpful for pain from perineal wounds or mastitis. Rest and adequate fluid intake are required, particularly for mothers who are breastfeeding. The following signs and symptoms should prompt urgent referral for hospital assessment and, if the woman appears seriously unwell, by emergency ambulance: - Pyrexia (greater than or equal to 38°C). - Sustained tachycardia (≥90 beats/minute). - Breathlessness (respiratory rate ≥20 breaths/minute). - Abdominal or chest pain. - Diarrhoea and/or vomiting - may be due to endotoxins. - Uterine or renal angle pain and tenderness. - The woman is generally unwell or seems unduly anxious or distressed. ### Pharmacological Administration of intravenous broad-spectrum antibiotics within one hour of suspicion of severe sepsis, with or without septic shock, is recommended: - Analgesia may be required. - Antibiotics should be commenced after taking specimens and should not be delayed until the results are available. **SURGICAL** Surgical intervention may be required if it is thought that an abscess has formed, as in this case the fever will not settle until the abscess has been incised and drained. **Complications** The possible complications of the infection will depend on the site, although several complications such as [septicaemia](https://patient.info/doctor/sepsis-septicaemia-pro), [pulmonary embolus](https://patient.info/doctor/pulmonary-embolism-pro), [disseminated intravascular coagulation ](https://patient.info/doctor/disseminated-intravascular-coagulation)and [pneumonia](https://patient.info/doctor/pneumonia-pro) are common to all. Urinary tract infection may progress to pyelonephritis and renal scarring if left untreated. **Prevention** - Scrupulous attention to hygiene should be used during all examinations and use of instrumentation during and after labour. - Any GAS identified during pregnancy should be treated aggressively. - Some centres advocate the use of prophylactic antibiotics during prolonged labour. - Catheterisation should be avoided where possible. - Perineal wounds should be cleaned and sutured as soon as possible after delivery. - All blood losses and the completeness of the placenta should be recorded at all deliveries. - Early mobilisation of delivered mothers will help to protect against venous thrombosis. - New mothers should be helped to acquire the skills required for successful breastfeeding in order to reduce the risk of mastitis. **PUERPERAL SEPSIS** Sepsis *I* Infection is one of the major causes of maternal mortality and this occurs mostly in the puerperium. Definition of puerperal sepsis: This is any bacterial infection of the genital tract which occurs after the birth of the baby, usually after the first 24 hours. Pueral fever: This is a temperature of at least 380C on more than two occasions apart after delivery excluding the first 24 hours till 14 days postpartum **Common causes** - Malaria fever - Upper respiratory tract infection e.g catarrh - Pneumonia - Engorged breasts / Mastitis - Acute pyelonephritis - Endometritis (infection occurring inside the utrine lining) - Thrombophlebitis at the infusion site - Acute viral hepatitis - Deep venous thrombophletis - Tonsillitis / pharyngitis - Septi pelvic thrombophlebitis **Signs and symptoms** 1. 2. - - - - - - - - - - **Management:** 1. Rapid initial assessment -- Brief history e.g, of labour, onset of fever at time of delivery multiple vaginal examinations, manual removal of placenta etc 2. General examination i. ii. iii. iv. v. vi. vii. **Investigations** i. ii. iii. **Treatment** i. ii. iii. iv. v. **COMPLICATIONS** - Cerebral malaria - Meningitis - Septicaemia - Acute renal failure - Pelvic abscess - Breast absess **PELVIC ABCESS** A pelvic abscess is a life-threatening collection of infected fluid in the pouch of Douglas, fallopian tube, ovary, or parametric tissue. Usually, a pelvic abscess occurs as a complication after operative procedures. It starts as pelvic cellulitis or hematoma spreads to parametrial tissue. **Etiology** The pelvic abscess is a frequent complication of an infection of the lower genital tract, including pelvic inflammatory disease. Other causes subsumed in the etiology of pelvic abscess are operative procedures like: - Hysterectomy - Laparotomies - caesarian sections - induced abortion - Cancers of pelvic organs - trauma to the genital tract - Crohn disease complications and diverticulitis are other significant causes. The risk factor for the pelvic abscess is the same as of pelvic inflammatory disease like multiple sexual partners, sexually transmitted infection, intrauterine device, diabetes, low immune system. Other recognizable risk factors that have studied in developing post-surgical abscess classify as preoperative, intraoperative, and postoperative causes. **Signs and symptoms** - The clinical presentation of the pelvic abscess is highly variable. - Patients may present with a high-grade fever, - General malaise, - Nausea, - Vomiting, - Tachycardia, - Lower abdominal pain, - Vaginal discharge, - Vaginal bleeding, - Retention of urine, - Change in bowel habit. **Investigations** - The complete physical exam includes a thorough abdominal, vaginal, and rectal examination. - Superficial or deep abdominal tenderness on abdominal palpation may be indicative of peritonitis. - The comprehensive vaginal examination consists of the bimanual and speculum exam. - The bimanual vaginal exam should assess the size of the uterus, mobility, consistency, and adnexa. - The cervical motion tender is present; the uterus is tender, boggy, and most likely pushed anteriorly. - On the rectal exam, tenderness and bulging of the anterior rectal wall may be present. - Pelvic ultrasound is the first method of choice to evaluate a pelvic mass in the women of reproductive age group. - It can help in differentiating between the fluid-filled lesion and solid lesion. - It is a relatively easy and inexpensive method of imaging with no ionizing radiation. **Management** - All the patients with suspicious of pelvic abscess and diagnosis should be admitted to the hospital regardless of the size of the pelvic abscess. - All patients should be monitored closely for sepsis and rupture. - The initial approach to the treatment is Broad-spectrum antibiotics. - A multilocular abscess usually represents tubo-ovarian abscess and substantially respond well to Antibiotic treatment alone. **Conservative management** - Once diagnosed, a combination of parental antibiotic should be started to treat the mixed aerobic and anaerobic microbes. - The gold standard antibiotics regimen is the combination of clindamycin or metronidazole with an aminoglycoside, penicillin, or third-generation cephalosporins. **Surgical management and drainage of the pelvic abscess** - Recent evidence suggests that it is acceptable and beneficial for the patient to perform primary surgical drainage along with appropriate antibiotic coverage. - It decreases the length of stay of hospitalization and improves the fertility outcomes. Different techniques are available for surgical drainage of the pelvic abscess, but in the past, the preferred approach was laparotomy. - Many gynecologists still prefer this surgical route for the removal and the drainage of the surgical abscess. - Most of the gynecologist employs vertical incision in need for the proper visualization of abdomen and pelvis. **Complications** - The complication of a pelvic abscess includes ectopic pregnancy, the scar tissue from the previous inflammation and infection prevents the fertilized ovum to implant in the uterus and results in ectopic pregnancy. - Infertility is another prevalent complication, adhesion as a result of abscess and inflammation causes severe damages the fallopian tube and ciliary epithelium and ovary and results in infertility. - Chronic pelvic pain has seen in one-third of the patients, and pain is related to scarring and adhesions from the previous abscess and infection. **ENDOMETRISIS** **Endometritis** is [inflammation](https://en.wikipedia.org/wiki/Inflammation) of the inner lining of the [uterus](https://en.wikipedia.org/wiki/Uterus) ([endometrium](https://en.wikipedia.org/wiki/Endometrium)).It is the most common cause of [infection after childbirth](https://en.wikipedia.org/wiki/Postpartum_infections). It is also part of spectrum of diseases that make up [pelvic inflammatory disease](https://en.wikipedia.org/wiki/Pelvic_inflammatory_disease). **Signs and Symptoms** - [Fever](https://en.wikipedia.org/wiki/Fever), - Lower abdominal pain, - Abnormal [vaginal bleeding](https://en.wikipedia.org/wiki/Vaginal_bleeding) - [Discharge](https://en.wikipedia.org/wiki/Vaginal_discharge). **Types** Endometritis is divided into acute and chronic forms. - The acute form is usually from an [infection](https://en.wikipedia.org/wiki/Infection) that passes through the [cervix](https://en.wikipedia.org/wiki/Cervix) as a result of an [abortion](https://en.wikipedia.org/wiki/Abortion), during [menstruation](https://en.wikipedia.org/wiki/Menstruation), following [childbirth](https://en.wikipedia.org/wiki/Childbirth), or as a result of [douching](https://en.wikipedia.org/wiki/Douching) or placement of an [IUD](https://en.wikipedia.org/wiki/IUD). - Risk factors for endometritis following delivery include [Caesarean section](https://en.wikipedia.org/wiki/Caesarean_section) and [prolonged rupture of membranes](https://en.wikipedia.org/wiki/Prolonged_rupture_of_membranes). Chronic endometritis is more common after [menopause](https://en.wikipedia.org/wiki/Menopause). **Diagnosis** - The diagnosis may be confirmed by [endometrial biopsy](https://en.wikipedia.org/wiki/Endometrial_biopsy). - [Ultrasound](https://en.wikipedia.org/wiki/Ultrasound) may be useful to verify that there is no retained tissue within the uterus. **Management** - Treatment is usually with [antibiotics](https://en.wikipedia.org/wiki/Antibiotic). - Recommendations for treatment of endometritis following delivery, such includes: - - - - - **VENOUS THROMBOSIS** A **venous thrombus** is a [blood clot](https://en.wikipedia.org/wiki/Blood_clot) (thrombus) that forms within a [vein](https://en.wikipedia.org/wiki/Vein). **Classification** ### Common forms - [Superficial venous thromboses](https://en.wikipedia.org/wiki/Superficial_venous_thromboses) cause discomfort but generally not serious consequences, as do the [deep vein thromboses](https://en.wikipedia.org/wiki/Deep_vein_thrombosis) (DVTs) that form in the deep veins of the legs or in the pelvic veins. Nevertheless, they can progress to the deep veins through the [perforator veins](https://en.wikipedia.org/wiki/Perforator_vein). - When a blood clot breaks loose and travels in the blood, this is called a venous thromboembolism (VTE). The abbreviation DVT/PE refers to a VTE where a deep vein thrombosis (DVT) has moved to the lungs (PE or pulmonary embolism). - Since the veins return [blood](https://en.wikipedia.org/wiki/Blood) to the [heart](https://en.wikipedia.org/wiki/Heart), if a piece of a blood clot formed in a vein breaks off it can be transported to the right side of the heart, and from there into the [lungs](https://en.wikipedia.org/wiki/Lung). A piece of thrombus that is transported in this way is an [embolus](https://en.wikipedia.org/wiki/Embolus): the process of forming a thrombus that becomes embolic is called a *thromboembolism*. An embolism that lodges in the lungs is a [pulmonary embolism](https://en.wikipedia.org/wiki/Pulmonary_embolism) (PE). A pulmonary embolism is a very serious condition that can be fatal depending on the dimensions of the embolus. **Causes** - Venous thrombi are caused mainly by a combination of [venous stasis](https://en.wikipedia.org/wiki/Venous_stasis) and [hypercoagulability](https://en.wikipedia.org/wiki/Hypercoagulability)---but to a lesser extent endothelial damage and [activation](https://en.wikipedia.org/wiki/Endothelial_activation). - The three factors of stasis, hypercoaguability, and alterations in the blood vessel wall represent [Virchow\'s triad](https://en.wikipedia.org/wiki/Virchow%27s_triad), and changes to the vessel wall are the least understood. - Various risk factors increase the likelihood of any individual developing a thrombosis. ### ### ### ### Risk factors #### Acquired - Older age - Major surgery, orthopedic surgery, neurosurgery - Cancers, most particularly [pancreatic](https://en.wikipedia.org/wiki/Pancreatic_cancer), but not cancers of the lip, oral cavity, and pharynx - Immobilization, as in [orthopedic casts](https://en.wikipedia.org/wiki/Orthopedic_cast) the sitting position, and travel, particularly by air - Pregnancy and the postpartum period - Trauma and minor leg injury - Oral contraceptives - Hormonal replacement therapy - Some [autoimmune diseases](https://en.wikipedia.org/wiki/Autoimmune_disease) - [Nephrotic syndrome](https://en.wikipedia.org/wiki/Nephrotic_syndrome) - Obesity - Infection - HIV - [Chemotherapy](https://en.wikipedia.org/wiki/Chemotherapy) - [Heart failure](https://en.wikipedia.org/wiki/Heart_failure) #### Inherited - [Antithrombin deficiency](https://en.wikipedia.org/wiki/Antithrombin_deficiency) - [Protein C deficiency](https://en.wikipedia.org/wiki/Protein_C_deficiency) - [Protein S deficiency](https://en.wikipedia.org/wiki/Protein_S_deficiency) (type I) - [Factor V Leiden](https://en.wikipedia.org/wiki/Factor_V_Leiden) - [Dysfibrinogenemia](https://en.wikipedia.org/wiki/Dysfibrinogenemia) - Non O-[blood type](https://en.wikipedia.org/wiki/Blood_type) **Management** - The initial treatment for venous thromboembolism is typically with either [low molecular weight heparin](https://en.wikipedia.org/wiki/Low_molecular_weight_heparin) (LMWH) or [unfractionated heparin](https://en.wikipedia.org/wiki/Unfractionated_heparin), or increasingly with [directly acting oral anticoagulants](https://en.wikipedia.org/wiki/Anticoagulant#Directly_acting_oral_anticoagulants) (DOAC). - Those initially treated with heparins can be switched to other [anticoagulants](https://en.wikipedia.org/wiki/Anticoagulant) (warfarin, DOACs), although pregnant women and some people with cancer receive ongoing heparin treatment. - Superficial venous thrombosis only requires anticoagulation in specific situations, and may be treated with anti-inflammatory pain relief only. **Preventive measures** - Evidence supports the use of [heparin](https://en.wikipedia.org/wiki/Heparin) in people following surgery who have a high risk of thrombosis to reduce the risk of DVTs - In hospitalized people who have had a [stroke](https://en.wikipedia.org/wiki/Stroke) and not had surgery, mechanical measures **DIAGNOSIS OF ANAEMlA** - Screening of patient for anaemia. - Ask and listen: ask if she eats non-nutritive foods and not pica - their pregnancy has been closely spaced, - If she bruises easily - If she had haemorrhage with any pregnancy - Social and dietary history taking in Including date of last menstrual period - Physical examination - examine the conjunctiva, tongue, lips, palms of the hands nail beds and soles of the feet for pallor. - Blood specimen is obtained for sickling cells, malaria parasite (MP) Haemoglobin if8 gms or below, - Estimation of Packed Cell Volume (PCV) of blood - Stool is examined for ova of worms and parasites especially for *hookworm-Approximately 44 **million** Women are simultaneously pregnant and infected with hookworm.* All *estimated three to 5million of these pregnant women harbour hookworm infections that adversely influence intrauterine growth rates, prematurity, and birth weight, as well as anaemia and its consequences. Hookworm causes loss of blood and, therefore, iron in the stools, resulting in maternal anaemia.* - Urine specimen for culture and sensitivity. - Chest X Ray to rule out pulmonary tuberculosis especially in unbooked patients. - In severe anaemia, observe for signs of heart failure such as breathlessness (very marked dyspnoea), cough, oedema of ankles, enlarged liver and spleen, prominent jugular veins due to raised blood pressure, observe for signs of congestion in Lie bases of the lungs such as breathlessness and tiredness. **DEGREES OF ANAEMIA** Mild, moderate and severe **Mild anaemia:** The haemoglobin level is below 10.4 11.9gm/dl i.e. 8.1g/dl - - - - - **Moderate anaemia** This is when the haemoglobin estimation is or below 8.1gm/dl (i.e. between 7g/dl to 8.1g/dl) **MANAGEMENT** - - - - **Severe anaemie**; - - - **Management of mild to moderate anaemia** If the haemoglobin estimation is less than 8gm, re-book the patient. If the patient is 28 weeks on first visit with haemoglobin ofless than. 8gms she is referred to the doctor or hospital for complete investigation and treatment. - If the haemoglobin drops to 7gms/dl on 311y visit, treat for malaria and give iron supplement of ferrous sulphate 320mg daily. (60mg elemental iron) thrice daily. - Advice on diet rich in iron, protein vitamin C and folic acid. - Check haemoglobin at every visit until it rises above 8gms/dl. If it does not improve after one week, irrespective of her gestational age. - Refer immediately for further medical management - If signs of heart failure are present i.e dyspnoea, enlarged spleen, liver, and oedema of the -ankles and limbs, refer immediately to the hospital (if in a health centre) **Nursing management of severe anaemia** - Admit for rest if HB is below 6gm. - Start an IV infusion using a large-bore cannula or needle. - Infuse normal saline or Ringer\'s lactate at the rate of 1 Lover 8 hours. - Avoid giving sedatives. - Refer urgently for transfusion. (If not in the hospital). - Prop patients in bed allow for easy breathing and prevent congestion of the lungs. - Monitor maternal and foetal heart rates closely. - Check temperature, 4 hourly, pluse and foetal heart rate half hourly. - Monitor intake and output charts. - Record any abnormal variations. - Give high protein diet rich in green vegetables and vitamin C - Give fresh fruits and nourishing drinks to augument the diet. - Treat for hookworm, if in endemic area- give mebendazole - Provide iron (120mg) and folate (400 mcg) by mouth daily for six months. - Take blood for grouping and crossmatching - If haemoglobin is less than 7 g/L, this is a life threatening complication and urgent referral *is* needed - Start an IV infussion using a large-bore cannula or needle before referral. - Infuse Normal Saline or Ringer\'s Lactate at the rate of 1L over 8 hours. (refer with IV infusion isitu) **Medical management** - - - **In labour:** - Maintain strict asepsis - Give antibiotics if membranes have ruptured for more than 12 hours - Watch for signs of heart failure - Prevent delayed labour - Give episiotomy to shorten the second stage - Give syntometrine intramuscularly after delivery of the baby - Deliver the placenta by controlled cord traction - Examine intake and output chart in the first 48 hours post partum **Follow-up:** - - - - **Advice on discharge:** - Give information on food rich in iron, protein and vitamins. - Advice on use of iron supplements to augment diet - Educate on taking of iron drugs after meals with fruitjuices or vitamin C to enhance absorption - Remind her on family planning - Advice on keeping of aseptic techniques in order to avoid infection **Effect of anaemia on the foetus** - Increased incidence of preterm labour - Fetal distress - Low birth weight - Increased risk of perinatal mortality rate **Effect of anaemia the mother** - Increased incidence of maternal morbidity and mortality rate - Maternal distress (in labour) - Increased risk of post partum haemorrhage - Worsen existing maternal condition **Prevention of anaemia in prggnancy:** - identification of risk factors for haemorrhage and managing them appropriately. - use of iron supplements for all pregnant women throughout pregnancy - identification and treatment of malaria and worm infestations - Prophylactic treatment of malaria and worm infestation - Check for other signs of infections or diseases e.g Urinary tract infections, and pulmonary tuberculosis - Check haemoglobin - Emphasize personal and environmental hygiene - Advise on sleeping under treated nets to prevent mosquito bite - Advise on child spacing after delivery. - Focused ante natal care (four visits) with health education - Give health education about prevention of malaria - Use of insecticides Treated Nets (ITN s) - All pregnant women should sleep under ITNs - Educate on nutrition. - Advise to eat adequate diet rich in Iron, Folate and Vitamin C and Avoid drinks that decrease iron absorption e.g. tea, coffee - Provide micronutrient supplementation for up to 3 months after delivery - Minimum of 60mg of elemental iron and 400 meg of folate daily - Prevent malaria and hookworm infestation. - Presumptive treatment of hookworm infection - For all women living where hookworm prevalence is greater than 20%, if the woman has not received to have hookworm infection: - prescribe Mebendazole 100 mg by mouth twice daily for three days OR - give albendazole 400 mg by mouth once - mebendazole should be avoided in the first trimester **THROMBOPHLEBITIS** **Thrombophlebitis** is a [phlebitis](https://en.wikipedia.org/wiki/Phlebitis) ([inflammation](https://en.wikipedia.org/wiki/Inflammation) of a [vein](https://en.wikipedia.org/wiki/Vein)) related to a [thrombus](https://en.wikipedia.org/wiki/Thrombus) (blood clot). When it occurs repeatedly in different locations, it is known as **thrombophlebitis migrans** (migratory thrombophlebitis). **Clinical features** The following symptoms or signs are often associated with thrombophlebitis, although thrombophlebitis is not restricted to the veins of the [legs](https://en.wikipedia.org/wiki/Lower_limbs). - [Pain](https://en.wikipedia.org/wiki/Pain) (area affected) - Skin redness/[inflammation](https://en.wikipedia.org/wiki/Inflammation) - [Edema](https://en.wikipedia.org/wiki/Edema) ([ankle](https://en.wikipedia.org/wiki/Ankle) and [foot](https://en.wikipedia.org/wiki/Foot)) - [Veins](https://en.wikipedia.org/wiki/Vein) being hard and cord-like - Tenderness (leg) https://upload.wikimedia.org/wikipedia/commons/thumb/2/21/Deep\_vein\_thrombosis\_of\_the\_right\_leg.jpg/130px-Deep\_vein\_thrombosis\_of\_the\_right\_leg.jpg **Causes** - Thrombophlebitis causes include disorders related to increased tendency for [blood clotting](https://en.wikipedia.org/wiki/Blood_clotting) and reduced speed of blood in the veins such as prolonged immobility; - prolonged traveling (sitting) may promote a blood clot leading to thrombophlebitis but this occurs relatively less. - High estrogen states such as pregnancy, [estrogen replacement therapy](https://en.wikipedia.org/wiki/Estrogen_replacement_therapy), or oral contraceptives are associated with an increased risk of thrombophlebitis. - Specific disorders associated with thrombophlebitis include superficial thrombophlebitis which affects veins near the skin surface, - [Deep Vein Thrombosis](https://en.wikipedia.org/wiki/Deep_vein_thrombosis) which affects deeper veins, and [pulmonary embolism](https://en.wikipedia.org/wiki/Pulmonary_embolism). Those with familiar [clotting disorders](https://en.wikipedia.org/wiki/Coagulopathy) such as [protein S deficiency](https://en.wikipedia.org/wiki/Protein_S_deficiency), [protein C deficiency](https://en.wikipedia.org/wiki/Protein_C_deficiency), or [factor V Leiden](https://en.wikipedia.org/wiki/Factor_V_Leiden) are also at increased risk of thrombophlebitis. Thrombophlebitis can be found in people with [vasculitis](https://en.wikipedia.org/wiki/Vasculitis) including [Behçet\'s disease](https://en.wikipedia.org/wiki/Beh%C3%A7et%27s_disease). **Diagnosis** - The diagnosis for thrombophlebitis is primarily based on the appearance of the affected area. - Frequent checks of the [pulse](https://en.wikipedia.org/wiki/Pulse), [blood pressure](https://en.wikipedia.org/wiki/Blood_pressure), and [temperature](https://en.wikipedia.org/wiki/Temperature) may be required. - If the cause is not readily identifiable, tests may be performed to determine the cause, including the following: - - - **Management** - In terms of treatment for this condition the individual may be advised to do the following: *raise* the affected area to decrease [swelling](https://en.wikipedia.org/wiki/Swelling_(medical)), and relieve pressure off of the affected area so it will encounter less pain. - In certain circumstances drainage of the clot might be an option. In general, treatment may include the following: - Low molecular weight [heparin](https://en.wikipedia.org/wiki/Heparin) - [Warfarin](https://en.wikipedia.org/wiki/Warfarin) - [Surgery](https://en.wikipedia.org/wiki/Surgery) - Nonsteroidal anti-inflammatory medications ([NSAIDS](https://en.wikipedia.org/wiki/NSAIDS)) ([Ibuprofen](https://en.wikipedia.org/wiki/Ibuprofen)) - Support [stockings](https://en.wikipedia.org/wiki/Stockings) ### Complications In terms of complications, one of the most serious occurs when the superficial blood clot is associated with a [deep vein thrombosis](https://en.wikipedia.org/wiki/Deep_vein_thrombosis); this can then dislodge, traveling through the [heart](https://en.wikipedia.org/wiki/Heart) and occluding the dense [capillary](https://en.wikipedia.org/wiki/Capillary) network of the [lungs](https://en.wikipedia.org/wiki/Lungs) This is a [pulmonary embolism](https://en.wikipedia.org/wiki/Pulmonary_embolism) which can be life-threatening. **Prevention** - Prevention consists of walking, - drinking fluids - if hospitalized, changing of [IV lines](https://en.wikipedia.org/wiki/Intravenous). - Walking is suggested after a long period seated, particularly when one travels. **PUERPERIAL PSYCHOSIS** Puerperal (also known as postpartum or postnatal) psychosis is a very rare but severe mental health disorder that some women experience in the weeks after having a baby. The onset is rapid and usually occurs within the first few days after delivery. The symptoms are those of depressive psychosis, manic illness or in some cases schizophrenia. This illness most often affects primiparae. **Sign and symptoms** - The affected woman shows bizarre behavior, loses touch with reality and may suffer from hallucinations. - The onset of these symptoms may be heralded by a time of acute restlessness and inability to sleep. - Frequently the mother may deny that her baby belongs to her and in rare cases she may harm the baby. **Treatment s** - The illness must be treated promptly by admission to a psychiatry unit under the care of a consultant. - In most cases the baby will be able to accompany his mother into hospital and this should be encouraged if at all possible prompt psychiatric case is vital and skilled psychiatric nursing care is required including medical treatments. - With prompt treatment the prognosis is good but, unfortunately, it is likely that further episodes of the illness will occur throughout the woman's life around there is a high risk of recurrence in subsequent pregnancies. **OBSTETRIC SHOCK** SHOCK **INTRODUCTION:** - The organs and tissues of the body are supposed to be adequately supplied with blood to enhance their effective functioning, apart from oxygen and nutrients derived by these structures from blood circulation. - Certain pathophysiological conditions may bring about hypotension and subsequent reduction in blood supply to most vital structures in the body. - This state is accompanied by serious reduction in the delivery of oxygen and other essential substances to a level below what is needed for normal and effective cellularactivities. **Definition** - Shock is an abnormal physiological state in which there is wide spread, serious reduction of tissue perfusion that if prolonged will lead to generalized impairment of cellular function. - Shock has also been described as a clinical state of peripheral circulatory failure characterized by a fall in blood pressure. - Cellular destruction, and deterioration in tissue and organ functions are possible outcomes. **Causes of shock** - Loss of bodyfluid - Blood loss - Inadequate fluid intake - Congestive cardiac failure - Myocardial infarction - Pulmonary embolism - Cardiac arrhymias - Spinal anaesthesia - Infections with the release of endotoxins - Antigen -- antibody reaction with release of histamine. **Pathophysiology Of Shock** - The cardiac output and the peripheral vascular resistance normally maintain arterial blood pressure. - When there is reduction in cardiac output and a subsequent decrease in arterial pressure sufficient to produce a wide spread reduction in tissue perfusion, the body attempts to compensate for the changes that follows in the body. - The ultimate importance of this compensatory mechanism is to restore adequate circulation to the vital structure of the body. - The response of these systems, varies from individual to individual. - Vasoconstriction and increase in the heart rate with increase in both peripheral resistance and cardiac output causes additional blood circulation to the vital organs. - Haemodilution occurs due to secretion of antidiuretic hormone, and subsequent retention of fluid and sodium helps to improve blood volume. - Improved cardiac output and myocardial contractility occur due to increased production of carbon-dioxide occassioned by limited tissue oxygenation. - The increased carbon dioxide causes the coronary arteries to dilate resulting in increased myocardial perfusion. - When the compensatory mechanism can not effectively sustain the body‟s physiologic functioning, shock progresses and multiple physiological changes ensue. - A progressive shock produces multiple systemic changes as a result of decreased cardiac output, hypovolemia, and limited cardiac perfusion. - These changes produce alteration in oxygenation, fluid and electrolytes metabolism and the body‟s defence against bacterial invasion. - In the early stages cerebral hypoxia produces restlessness, apprehension, and anxiety, and may be replaced by apathy and confusion and verbal response becoming inappropriate as cerebral hypoxia increases. - In the irreversible stage, unconsciousness manifests with no response to painfulstimuli. - The skin is pale, cold and clammy reflecting poor perfusion of the superficial tissue and sympathetic activity to the sweat glands respectively. - There is cyanosis, showing a reduction in cardiac output and decreased oxygen saturation. Initially the pulse is rapid and thready, but later becomes slower, irregular and imperceptible. - In response to hypoxia, respirations increase in rate and depth. - In severe cases, there is depression of the respiratory centre resulting in shallow and irregular respiration. - Severe respiratory dysfunction accounts for complications such as atelectasis, pulmonary emboli, interstitial congestion and oedema. - The complication is referred to as „shock lung‟ or adult respiratory distress syndrome (ARDS). - Subnormal temperature is characteristic of shock. - This is due to reduction in cellular metabolism and heat production caused by hypoxia. However exception is noticed in septic shock. - Oliguria ensues due to decreased renal perfusion. - Urinary output might be less than 30mls per hour resulting in the retention of urea, nitrogen and creatinine. - Decreased bowel sounds indicating reduced peristalsis develops due to sympathetic in nervation and vaso constriction. - Reduction in tissue perfusion and the resulting hypoxia accounts for the anaerobic metabolism which causes accumulation of metabolic acids. - This eventually leads to acidosis. - Myocardial failure and cardiac arrhythmia may develop if acidosis isprolonged ![Screenshot 2024-12-13 104601.png](media/image4.png) **Normal Mitochondrial damage(swelling)** **Effects of shock** **Cellular effects of shock**. The cell swells and the cell membrane becomes more permeable, and fluids and electrolytes seep from and into the cell. Mitochondria and lysosomes are damaged, and the celldies. **Source:** Jones, D.A. et al, Medical--Surgical Nursing, A conceptual approach. Megraw-Hill, 1978, P. 959. **Common Types Of Shock** - **Hypovolaemic shock** (decrease in blood volume). This is due to a decrease in blood volume which may be caused by haemorrhage, dehydration due to vomiting and diarrhoea, loss of plasma in burns, inadequate fluid intake, excessive use of diuretics. - When intravascular volume drops, there is decrease in tissue perfusion, decreased venous return, and low cardiac output and blood flow through the tissue become sinadequate. - **Cardiogenic shock (decreased cardiac output).** This indicates a severe impairment in the efficiency of the heart as a pump. - There is decreased ability of the heart to pump out blood into circulation. - This results in decrease in stroke volume and cardiac output. Cardiogenic shock may be occassioned by congestive cardiac failure, pulmonary embolism, myocardial infaction, pneumothorax, cardiac arrhythmias, or pericardial tamponade. - **Neurogenic shock:** This develops as a response to autonomic nervous system activity resulting in reflex vasodilatation and loss of arteriolar tone with subsequent pooling of blood in the dilated vasculature. - This results in decreased venous return to the heart. - This type of shock is usually due to spinal anaesthesia, barbiturate injection, hyperrinsulinism, spinal cord injury, severe pain, accidental injury or extreme fright. - Septic or bacteraemic shock, toxic shock, anaphylactic shock occurs essentially following the same phenomena as in neurogenic shock. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. - Another characteristic is bradycardia, rather than the tachycardia that characterizes other forms of shock. - **Circulatory Shock:** Circulatory or distributive shock occurs when blood volume is abnormally displaced in the vasculature----for example, when blood volume pools in peripheral blood vessels. - The displacement of blood volume causes a relative hypovolemia because not enough blood returns to the heart, which leads to subsequent inadequate tissue perfusion. - The ability of the blood vessels to constrict helps return the blood to the heart. - Thus, the vascular tone is determined both by central regulatory mechanisms, as in tissue demands for oxygen and nutrients. - Therefore, circulatory shock can be caused either by a loss of sympathetic tone or by release of biochemical mediators from cells. - Pooling of blood in the periphery results in decreased venous return. - Decreased venous return results in decreased stroke volume and decreased cardiac output. - Decreased cardiac output, in turn, causes decreased blood pressure and ultimately decreased tissue perfusion. - **Septic Shock:** Septic shock is the most common type of circulatory shock and is caused by widespread infection. - The source of infection is an important determinant of the clinical outcome. - The greatest risk of sepsis occurs in patients with bacteremia (bacteria in bloodstream) and pneumonia. - Other infections that may progress to septic shock include intra-abdominal infections, wound infections, bacteremia associated with intravascular catheters. - **Anaphylactic Shock:** Anaphylactic shock occurs in patients already exposed to an antigen who have developed antibodies to it. - An antigen----antibody reaction provokes mast cells to release potent vasoactive substances, such as histamine or bradykinin, that cause widespread vasodilation and capillary permeability. - Therefore, patients with known allergies need to understand the consequences of subsequent exposure to the antigen and should wear medical identification that lists their sensitivities. - This could prevent inadvertent administration of a medication that would lead to anaphylactic shock. **Clinical Manifestation of Shock** **Diagnostic Tests** Diagnosis is usually based on the presenting symptoms and clinical signs. - ABG values: Will reveal metabolic acidosis caused by anaerobic metabolism. - Serial measurement of urinary output: Less than 30 ML/h is indicative of decreased perfusion and decreased renal function. **For septic shock:** - Serial creatinine and BUN levels: To assess for potential renal complications and dysfunction. - Serum electrolyte levels: Identify renal complications and dysfunctions as evidenced by hyper kalemia and hypernatremia. - Blood culture: To identify the causative organism. - WBC and ESR: Elevated in the presence of infection. **For hematogenic shock:** - CBC: Hematocrit and hemoglobin will bedecreased. **For anaphylactic shock:** - WBC count: Will reveal increase deosinophils. **Clinical manifestations** - Restlessness - Apathy and confusion - Unconsciousness - Rapid thready pulse followed by weakpulse - Decreased blood pressure - Increased respiratory rate, shallow respirations - Subnormal temperature - Cold and clammy skin - Decreased urinary output(oliguria) - Cyanosis - Decreased bowel sounds or absence of bowel sounds **F- management of shock** First aid management of shock In the presence of major external haemorrhage, - Stop the bleeding. - Apply firm pressure over the wound or artery involved. - Apply a firm pressure bandage. - Immobilize the extremity to control the bleeding. - Elevate the part. If heamorrage is internal: - Blood transfusion and surgery may be indicated. - Tourniquet is the last resort. Other actions include: - Keep the patient laid flat or place him on shock position (head lower than its feet) to improve blood supply to the brain. - Give analgesics to reduce pain. - Take patient to hospital as fast as you can - Keep crowd away from patient. - Give reassurance. - Keep patient warm. **Medical And Nursing Management Of Shock** Management in all types and phase of shock should include the following: - Fluid replacement to restore intravascular volume - Vasoactive medications to restore vasomotor tone and improve cardiac function - Nutritional support to address the metabolic requirements that are often dramatically increase in shock. **Assessment:** The management of shock should be rapid to prevent the condition from becoming irreversible. - A good and careful assessment of the patient‟s general/physical health status is paramount. - Blood pressure, respiration, pulse, urinary output, skin colour should be noted. - The blood pressure and pulse rate should be monitored every 15 minutes. - This reflects the cardiac functioning and cardiac output. - An indwelling catheter is passed to facilitate the measurement of the urinary output hourly. - In the adults, the urinary output is expected to range between 30-60ml/hour. - A decrease in this value indicates poor renal perfusion. - Oliguria may lead to anuria. - The hourly urinary output is useful in assessing patients‟ cardiovascular status. - Except in septic shock in which the body temperature may be elevated in the early stages, patients with other types of shock usually record a subnormal temperature and remains same as shock progresses. - The body temperature should be monitored continuously and recorded every 1-2hours. - The rate and volume of respirations should be monitored and recorded 15-30 minutes. - This is particularly important as hyperventilation occur in the early stages of shock while respiration may become slow, irregular and shallow as a result of ischaemia of the respiratory centre. - Secretions in the respiratory tract should be removed promptly through suctioning. - The skin should be observed for lessening of pallor, warmth and quick refilling of the capillaries and veins following compression which are signs of improvement. - Conversely signs of subcutaneous bleeding may indicate disseminated intravascular coagulation in severe shock, and especially that associated with sepsis. - The level of consciousness should be determined at regular intervals using Glasgow coma scale. - This reflects blood and oxygen supply to the brain. **Treatment:** Usually treatment is directed towards improving tissue perfusion and oxygenation as well as treating the specific cause accordingly. The contractile ability of the heart is strengthened to increase cardiac output in cardiogenic shock. Adrenalin is useful as a cardiac stimulant. Fluid Replacement Fluid replacement is administered in all types of shock. The type of fluids administered and the speed of delivery vary, but fluids are given to improve cardiac and tissue oxygenation. Fluid replacement is paramount in all types of shock especially in hypovolaemic shock. The fluids administered may include crystalloids (electrolyte solutions that move freely between intravascular spaces), colloids (large-molecule intravenous solutions), or blood components. Initially a crystalloid solution e.g. Ringers lactate solution or Normal saline is used. Colloid solutions of whole blood or fresh plasma may be used in conjunction with the crystalloid solutions. The aim is to expand intravascular volume. If the cause is due to haemorrhage efforts should be made to arrest bleeding by giving whole blood or fresh plasma so that blood pressure is raised and tissue perfusion restored. Close monitoring of the patient during fluid replacement is necessary to identify side effects and complications. The most common and serious side effects of fluid replacement are cardiovascular overload and pulmonary edema. Patients receiving fluid replacement must be monitored frequently for adequate urinary output, changes in mental status, skin perfusion, and changes in vital signs. Lung sounds are auscultated frequently to detect signs of fluid accumulation. Adventitious lung sounds, such as crackles, may indicate pulmonaryedema. **Vasoactive Medication Therapy** Vasoactive medications are administered in all forms of shock to improve the patient‟s hemodynamic stability when fluid therapy alone is inadequate. Specific vasoactive medications are prescribe to correct the particular hemodynamic alteration that is impeding cardiac output. These medications help to increase the strength of myocardial contractility, regulate the heart rate, reduce myocardial resistance, and initiate vasoconstriction. **Nutritional Support** Nutritional support is an important aspect of care for the patient with shock. Increased metabolic rates during shock increase energy requirements and therefore caloric requirements. The patient in shock requires more than 3,000 calories daily. The release of catecholamines early in the shock continuum causes glycogen stores to be depleted in about 8 to 10 hours. Nutritional energy requirements are then met by breaking down lean body mass. In this catabolic process, skeletal muscle mass is broken down even when the patient has large stores of fat or adipose tissue. Loss of skeletal muscle can greatly prolong the recovery time for the patient in shock. Parenteral or enteral nutritional support should be initiated as soon as possible, with some form of enteral nutrition always beingadministered. Stress ulcers occurs frequently in acutely ill patients because of the compromised blood supply to the gastrointestinal tract. Therefore, antacids, histamine-2 blockers (eg, famotidine \[Pepcid\], ranitidine \[Zantac\]), and antipeptic agents (eg, sucralfate 81 \[Carafate\]) are prescribed to prevent ulcer formation by inhibiting gastric acid secretion or increasing gastricpH. D. H- Nursing Diagnoses andInterventions Alteration in tissue perfusion: Peripheral, cardiopulmonary, cerebral, and renal related to impaired circulation secondary to decreased circulating blood volume. Nursing objective: Patient‟s VS, mentation, and physical findings are within acceptable limits. 1\. Assess and document peripheral pulse. Report significant findings such as coolness and pallor of the extremities, decreased amplitude of pulses, and delayed capillaryrefill. 2\. Monitor BP at frequent intervals; be alert to reading \>20 mm Hg below patient‟s normal or to other indicators of hypotension, such as dizziness, altered mentation, or decreased urinaryoutput. 3\. If hypotension is present, place patient in a supine position to promote venous return. Remember that BP must be at least 80/60 mm Hg for adequate coronary and renal artery perfusion. 4\. Monitor CVP (if line is inserted) to determine adequacy of venous return and blood volume; 4--10 cm H20 and usually considered adequate levels. Values near zero can indicate hypovolemia, especially when associated with decreased urinary output, vasoconstriction, and increased heart rate, which are found withhypovolemia. 5\. Observe for indicators of decreased cerebral perfusion such as restlessness, confusion, and decreased LOC. If positive indicators are present, protect patient from injury by raising side rails and placing bed in its lowest position. 82 Reorient patient as indicated. 6\. Monitor for indicators of decreased coronary artery perfusion such as chest pain and an irregular heart rate. 7\. Monitor urinary output hourly. Notify MD if it is \ 6. Can be applied by any trained health worker 6. Patient in the state of shock may benefit Mechanism of action of **Anti-Shock Garment** Diverts blood from lower extremities of the body to the vital organs like kidney, heart, lungs and brain. This results in translocation of up to 11.5 litres of blood from the lower body to the vital organs. It reduces haemorrhage in the tower body by overcoming the pressure in the capillary and venous system (15.25mm Hg.), thereby reducing blood flow to the lower parts of the body and decreasing arterial perfusion pressure to the uterus. This is comparable to that achieved by ligation of the internal iliac arteries. **INDICATIONS FOR ASG** Patients with severe blood loss with the signs and symptoms of shock e.g blood pressure *80/50mmHg,* rapid pulse 100 beats per minute if avaliable or absence of pheripheral pulses and un-recordable blood pressure. **Contraindications** - Pregnant patient with a live foetus. - When bleeding is from the chest region. - Patient with heart disease. **Who to apply the ASG** - Doctors - Nurses/Midwives - CHEW - Other health care personnel including drivers. **Procedures** Rules: It must be applied by a single person it is better applied on a flat surface. Application: NB: *It is advisable that the likely user of this device watch at least a practical demonstration session before frying it because \'wrongful application will not achieve the expected result on the patient:* - Patient should be made to lie on flat surface - Put on a pair of surgical gloves - Open the ASG on a flat surface - Apply 22, 33, 4 & 5 the patient should be placed on it and milking sure that the part of ASG labelled Navel (5) matches the patient\'s navel - wrap the garment from each end starring from the lowermost part of the leg (labeled 1) to the navel region, (You must ensure that Numbers 1 and 2 parts of the garment are below the knees: number 3 on-the thigh: number 4 on the pubic region: number 5 on the patient\'s navel, and the two flaps of number 6 applied over number 5) Do this one at a time on each side. - **Observations:** Monitor the patient\'s pulse rare and blood pressure every 15 minutes until she is stable (i.e pulse below 100 beats/minutc and or BP greater than 90/50mmHg), - **m**onitor the urinary output hourly, - Resuscitate the patientwith intravenous fluids e.g normal saline or ringer\'s lactate and/or blood as required (give 3mls of fluids for evcry 1ml of blood loss) to run fastly within 15 -- 20minutes (use blue cannula) - If you can not handle the patient then, refer the patient to the nearest health care facility with a doctor while still on ASG **OR** **OBSTETRIC SHOCK** **Shock** is the state of insufficient [blood flow](https://en.wikipedia.org/wiki/Blood_flow) to the [tissues](https://en.wikipedia.org/wiki/Tissue_(biology)) of the body as a result of problems with the [circulatory system](https://en.wikipedia.org/wiki/Circulatory_system). While obstetric shock refers to sudden collapse of a woman as a result of acute circulatory failure, due to complication of pregnancy, labour and puerperium. It is one of the obstetric emergencies. **Signs and symptoms** - Fall in blood pressure - Increase pulse - Cold clammy skin - Restlessness - Reduced tissue perfusion - Diminished urine output - Temperature - Increase pallor of the skin - Respiration. **Causes** - - - - - Haemorrhage - Trauma e.g ruptured uterus, obstructed labour, prolonged rupture of fetal membrane - Amniotic fluid embolism - Sudden reduction in the intra-abdominal pressure - Anesthesia - Infection **Puerperium** - - - - **Management** Treatment of shock is based on the likely underlying cause. - - - - - - - - - - - **Prevention** - Ensure that the patient goes into labour fit and well - All high risk cases should be handled in a well-equipped hospital by competent doctors/midwives - Careful monitoring of labour and prompt intervention when necessary - Avoid trauma, difficult instrumental delivery, prolongedlabour/obstructed labour. **ANAEMIA IN PREGNANCY** Anaemia is a common medical condition in which there is reduction below normal in the quality and quantity\' of the red blood cells (Haemoglobin below 10gm/dl/100mls)(less than 10g/dl) of bloods resulting in the decreased oxygen carrying capacity of tile blood. Anaemia results when there is inadequate production of, or excessive destruction of red blood cells. Physiologic anaemia occurs in pregnancy when there is haemodilution i.e. increased plasma volume (45%) and decreased erythrocyte volume (25%). Prevalence inpregnancy - Up to 50% in developing countries. Clinical features of anaemia +-----------------------------------+-----------------------------------+ | **Symptoms** | **Signs** | +===================================+===================================+ | Weakness/tiredness | Pallor of\'conjuctiva, gums. | | | tongue, nail beds, and or palms | | Dizziness | and soles of the feet | | | | | Breathlessness on mild exertion | Hepatomegaly | | | | | | Spleenomegaly | | | | | | Pedal oedema (Swelling oflegs) | | | | | | Prominent neck vein (in severe | | | anaemia) | +-----------------------------------+-----------------------------------+

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