amniotic fluid embolism
Amniotic fluid embolism refers to the sudden entry of amniotic fluid into the maternal blood circulation during delivery, causing serious delivery complications such as acute pulmonary embolism, anaphylactic shock, disseminated intravascular coagulation, renal failure, or sudden death.
Amniotic fluid embolism is the most dangerous obstetric complication. Since this situation is often unpredictable before delivery, maternal conditions must be closely observed during delivery, especially when fetal death, macrosomia, placenta previa, placental abruption, excessive uterine contractions, etc. occur.
The incidence rate is 4/100,000 to 6/100,000, and the mortality rate is as high as 70-80%. Although the probability is low, once it occurs, it can easily lead to maternal death even with treatment.
Amniotic fluid embolism usually occurs during delivery or rupture of membranes, but it can also occur after delivery. It is more common in full-term delivery, but can also occur during mid-term induction of labor or forceps and curettage. Most of them have sudden onset and dangerous condition.
Basic conditions required for occurrence: increased intraamniotic pressure (uterine hypercontraction or tonic uterine contraction); premature rupture of membranes (2/3 for premature rupture of membranes, 1/3 for spontaneous rupture of membranes); cervix or uterus There are open veins or sinuses at the injury site.
Predisposing factors: Multiparous women often have a history of premature rupture of membranes or artificial rupture of membranes; common causes include excessive uterine contraction or improper application of oxytocin; placental abruption, placenta previa, uterine rupture, or amniotic fluid embolism during surgical delivery.
Clinical manifestations: After rupture of membranes during delivery, the mother suddenly develops irritability, chest tightness, difficulty breathing, cyanosis, increased heart rate, decreased blood pressure, pulmonary rales, shock, and coma.
Treatment principles: early diagnosis, early treatment, early use of heparin, and early treatment of pregnant uterus.
Treatment measures: anti-allergy, oxygen inhalation, alleviation of pulmonary hypertension, anti-shock, prevention and treatment of DIC, prevention and treatment of heart failure, prevention and treatment of multiple organ injuries, timely and correct use of antibiotics, and timely obstetric treatment.
Emission reduction measures
1. The membrane is not peeled off during manual rupture of membrane to reduce damage to the small blood vessels in the cervical canal.
2. Do not artificially rupture the membranes during uterine contractions.
3. Understand the indications for cesarean section, and pay attention to protecting the open blood vessels of the uterine incision before puncturing the amniotic membrane during the operation.
4. Master the indications for oxytocin application.
5. Cases of stillbirth and placenta detachment should be closely observed.
6. Avoid birth trauma, uterine rupture, cervical laceration, etc.
Uterine rupture
Uterine rupture is a tear in the body or lower segment of the uterus during childbirth or pregnancy. It is a serious obstetric complication that threatens the lives of both mother and child. Mainly died from massive hemorrhage and infectious shock.
Uterine rupture often occurs in women who have difficult labor, are elderly, have undergone surgery, or have uterine damage.female.
According to the cause of rupture, it can be divided into non-scarring uterine rupture and scarring uterine rupture.
reason:
Factors causing obstructive dystocia: pelvic stenosis, cephalopelvic disproportion, abnormal fetal position, fetal malformation, etc.
There is a history of uterine surgery and uterine lesions.
Inappropriate use of oxytocin during labor.
Improper operation of dystocia can cause injuries.
Clinical manifestations:
Threatened uterine rupture:
Because the descent of the presenting part is blocked and the labor process is prolonged, the strong uterine contraction gradually thickens and shortens the uterine body, while the lower segment passively stretches and becomes thinner, forming a ring-shaped depression between the two, gradually rising to the umbilicus or above, and the uterus gradually becomes thicker and shorter. The shape is gourd-like and is called a pathological uterine contraction ring.
If the mother has unbearable abdominal pain and presses the bladder for too long, she will experience symptoms such as irritability, shortness of breath, difficulty urinating, and blood in the urine. There was obvious tenderness in the lower uterine segment and changes in fetal heart rate.
Uterine rupture:
The mother suddenly felt a sharp pain like abdominal tearing, and then the uterine contractions disappeared. The pain was temporarily relieved, but she soon entered a state of shock. At the same time, the fetal movement stops, the fetal heart sound disappears, and the cervix retracts. Due to the stimulation of blood, amniotic fluid, and fetus, there is tenderness, rebound tenderness, muscle tension, and shifting dullness (+) throughout the abdomen.
Incomplete uterine rupture: symptoms and signs may be atypical.
The diagnosis of complete uterine rupture is generally not difficult and can be confirmed based on the medical history, delivery process, clinical manifestations and signs. Incomplete uterine rupture can only be detected under close observation. Individuals with late pregnancy rupture can only be diagnosed if they develop signs and symptoms of uterine rupture.
method:
Threatened uterine rupture: Immediately inhibit uterine contraction: intramuscular injection of 100 mg pethidine is commonly used, and then prepare for surgical miscarriage to prevent uterine rupture.
Uterine rupture: Immediate tissue rescue, correction of shock, and caesarean section as soon as possible.
postpartum hemorrhage
Postpartum hemorrhage refers to vaginal bleeding exceeding 500 ml within 24 hours after delivery of the fetus. It usually occurs within 2 hours after delivery.
Postpartum hemorrhage is a serious complication during childbirth and one of the important causes of maternal death. It ranks first among the causes of maternal death in my country, with its incidence accounting for approximately 2% to 3% of the total number of births.
Reasons: postpartum uterine atony, placental factors, soft birth canal injury, coagulation dysfunction, etc.
Postpartum uterine atony
Maternal systemic factors (prolonged labor, excessive use of sedatives, systemic acute and chronic diseases) and local uterine factors (twin pregnancy, macrosomia, uterine malformations, uterine fibroids) result in the inability to effectively close the uterine wall sinus to which the placenta is attached.
Clinical manifestations: It usually occurs after the delivery of the placenta, with dark red blood or blood clots. The bleeding was intermittent. After massaging the uterus, the contractions improved and the bleeding was significantly reduced.
Occult bleeding may also occur. Bleeding outside the vagina is rare, but blood can accumulate in the vaginal or uterine cavity. At this time, the bottom of the uterus is bulging and soft. When the fundus of the uterus is compressed, a large amount of blood clots and blood gush out from the vagina, which is intrauterine bleeding.
method:
Massage the uterus on the abdominal wall.
Use uterotonics.
The uterine cavity is packed with gauze to stop bleeding.
Uterine artery ligation or subtotal hysterectomy.
retained placenta
30 minutes after the baby is delivered, the placenta has not yet been delivered, which is called retained placenta.
Clinical manifestations:
(1) Incomplete placental separation: The placenta is only partially separated from the uterine wall.
Retained placenta after separation: The placenta has been completely separated, mostly due to uterine atony or bladder fullness, and the placenta remains in the lower segment of the uterus, affecting uterine contraction and bleeding.
⑶ Remaining placenta or fetal membranes:
⑷ Placental adhesion: The placenta is fully or partially adhered to the uterine wall and cannot seal by itself.
⑸ Placenta accreta: Due to underdeveloped or even absent decidua, the placental villi directly implant into the myometrium to form placenta accreta.
⑹ Placental incarceration: The placenta has been stripped away, the uterus contracts uncoordinatedly to form a spasmodic narrow ring, and the placenta is embedded in the uterine cavity.
Treatment:
Under aseptic operation, perform manual placenta removal immediately to remove the placenta.
If there is some residual tissue, use a large curette to scrape off the residual tissue.
Those whose placenta accreta is difficult to separate should be prepared for subtotal hysterectomy.
Soft birth canal injury:
Cause: due to excessive fetal size and improper midwifery surgery, the perineum, vagina, cervix and even the lower segment of the uterus are lacerated.
Clinical grading of perineal laceration:
First-degree laceration: laceration of the perineal skin and mucosa around the vaginal opening, not reaching the muscle layer, and the amount of bleeding is not large.
Second degree laceration: perineal muscle layer laceration.
Third-degree laceration: The external anal sphincter is ruptured, even involving the anterior wall of the rectum.
Treatment: Check and expose the laceration site, suture in time to stop bleeding and prevent hematoma.
Coagulation dysfunction
Cause: The mother suffers from bleeding tendency diseases or pregnancy complications, which can affect coagulation or cause DIC, causing postpartum bleeding to be non-coagulable and difficult to stop bleeding.
Treatment principles: remove the cause and correct shock. Use drugs to improve coagulation function and transfuse fresh blood.
Premature rupture of membranes
If the fetal membranes rupture before labor, it is called premature rupture of membranes..
Causes: abnormal fetal position or cephalopelvic disproportion; twins, polyhydramnios; abdominal trauma, sexual intercourse or fetal membrane infection in late pregnancy.
Clinical manifestations:
⑴Pregnant women feel that liquid suddenly flows out of the vagina, often more sometimes less, intermittently, and the vulva can be seen wet with liquid. The amniotic sac was not palpable during vaginal examination, and fluid was seen flowing out of the presenting part when pushing up, and the fluid was mixed with vernix.
⑵PH measurement: When the pH of vaginal fluid is ≥7.0, it means the fetal membranes are ruptured.
⑶ Vaginal fluid smear examination: Aspirate the fluid from the posterior vaginal fornix for microscopic examination, and fern-like crystals may be seen, or fetal epithelial cells may collect vellus hairs after staining.
Treatment measures:
Depends on the gestational age and fetal condition.
If the pregnancy is not full term and the fetus is immature, expectant therapy can be used until 35 weeks of pregnancy. This includes lying in bed, raising the buttocks or lying on the side to prevent umbilical cord compression or prolapse; giving dexamethasone to promote fetal lung maturation, and applying antibiotics and uterine relaxants to suppress uterine contractions. The pregnancy is continued under strict sterile conditions and close monitoring.
For those who are more than 36 weeks pregnant, it is advisable to terminate the pregnancy as soon as possible. If there is no cephalopelvic disproportion, abnormal fetal position, or umbilical cord prolapse, you can wait for natural labor. If there is no contraction after 24 hours, you should induce labor. If there is intrauterine infection or intrauterine fetal distress, regardless of gestational age, the pregnancy should be terminated immediately by cesarean section.
Umbilical cord prolapse
After the fetal membranes rupture, the umbilical cord protrudes from the vagina or vulva, which is called umbilical cord prolapse.
When the fetal membranes have not ruptured, the umbilical cord is in front of or on one side of the presenting part, which is called umbilical cord presentation (or latent umbilical cord prolapse).
Causes of occurrence:
Any factors that cause poor presentation connection and leave a gap can lead to it. Such as abnormal fetal presentation, cephalopelvic disproportion, polyhydramnios, twins, premature birth, excessively long umbilical cord, etc.
Clinical manifestations:
Fetal heart rate changes: accelerated, slowed or irregular, which can be relieved by changing body position or raising the buttocks.
When the membrane has not been ruptured, vaginal or anal examination can be performed, and a pulsating cord-like object can be palpated; if the membrane has been ruptured, part of the umbilical cord can be touched or seen during vaginal examination.
Fetal heart rate electronic monitoring: Variable deceleration indicates umbilical cord compression.
Treatment:
Once umbilical cord prolapse occurs, it can lead to fetal distress, intrauterine fetal death, and increase the chance of surgical delivery.
① The umbilical cord is pulsating, indicating that the fetus is alive, and surgery should be performed immediately to end the delivery.
② If the fetus is dead, you can wait for natural delivery.
Abnormal amniotic fluid
At term, the amniotic fluid is translucent, milky white liquid, with a small amount of vernix and other substances visible. If the fetus is hypoxic, the fetus\’s anal sphincter can be relaxed, allowing meconium to be discharged into the amniotic fluid. The amniotic fluid will be dark green, yellow-green, or brown. If membrane rupture occurs, the color of the amniotic fluid can be directly observed from the outflowing amniotic fluid. is abnormal, if the fetal membranes have not ruptured, the doctor will use specialWith this instrument, you can see the condition of amniotic fluid.
As long as meconium is present in the amniotic fluid, it indicates that the amniotic fluid is abnormal. During labor, if meconium is found in the amniotic fluid, the fetal heart rate must be carefully observed. If the fetal heart rate is also abnormal at the same time, the fetus is more likely to be depressed at birth due to hypoxia.
Even if the fetal heart rate is normal, if there is a lot of meconium in the amniotic fluid and is dark green, or if the amniotic fluid has meconium and is thick and sticky, the fetus may inhale such amniotic fluid into the lungs, and meconium aspiration may occur easily. pneumonia or more serious cases require early termination of pregnancy. When abnormal amniotic fluid occurs, the doctor will choose the most appropriate method based on the progress of the mother\’s labor. If the uterine opening is fully dilated, the fetus can be delivered from the vagina as quickly as possible. If the uterine opening is very small, cesarean section can only be used to deliver the baby. Fetus.