• In diarrhoea stool contains large amount of sodium chloride,potassium,bicarbonate along with water.

ELECTROLYTE CONTENT OF DIARRHOEA : [mEq/L]

FLUID &ELECTROLYTE ABNORMALITY IN DIARRHOEA IS SUMMARIZED BELOW: 

1. HYPOVOLEMIA :
2. Abnormal increased secretion of fluid into the small bowel [secretory diarrhoea due to GI infection e.g-E.coli,Vibrio Cholerae,Rota virus]
3.  Decreased absorption of fluid by intestine [osmotic diarrhoea due to purgatives like magnessium sulphate/malabsorption of glucose/lactate in children.
4. Additional loss of water can also occur due to associated vomiting/fever.
5. SODIUM DEFICIT :
6. Diarrhoea cause loss of  sodium,resulting in sodium deficit in all patients,but proportion of sodium loss as compared to water loss will decide serum sodium concentration and type of dehydration
7. In some infants with diarrhoea net loss of water is in excess of sodium which leads to hypertonic dehydration
8. If net loss of sodium is greater than loss of water,diarrhoea will cause hypotonic dehydration
9. HYPOKALEMIA :
10. Hypokalemia occurs because fluid lost in diarrhoea is rich in potassium.
11. Normally 8-15mEq potassium ions are excreted in             faeces daily.much greater loss occurs with diarrhoea
12. HYPERCHLOREMIA :
13. The ileal and colonic mucosa possesses a luminal chloride/bicarbonate exchanger that is capable of reabsorbing chloride in exchange of bicarbonate
14. So during diarrhoea when more bicarbonte is secreted,more chloride is absorbed from intestine causing hyperchloremia.
15. METABOLIC ACIDOSIS :
16. fluid secreted distal to pylorus is rich in bicarbonate.
17. Diarrhoea leads to large amount of bicarbonate secretion [30-45mEq/L] in the gut which is excreted,and leads to metabolic acidosis.
18. If diarrhoea causes severe hypovolemia or renal failure,renal compensation to loss of bicarbonate is lost and severe metabolic acidosis may develop rapidly.
19. Acidosis may also result from excessive production of lactic acid when patient has hypovolemic shock.
20. So hyperchloremic,hypokalemic,metabolic acidosis occurs in patients with diarrhoea.

TREATMENT :

• Specific treatment for control of diarrhoea
• Fluid therapy

AIM OF FLUID THERAPY IS :

• Correction of dehydration
• Correction of sodium deficit
• Correction of hypokalemia & metabolic acidosis.treatment of both need to be done simultaneously. If only metabolic acidosis is treated,due to its correction potassium will be shifted intracellularly. If patient is hypokalemic,only correction of the acidosis can precipitated dangerous hypokalemia

                         On the contrary,with out correction of acidosis, potassium supplementation can cause dangerous hyperkalemia.this is due to failure of potassium shift into the intracellular compartment even in state of potassium deficit of the body. 

• Fluid and electrolytes losses can be replaced either orally/intravenously.intravenous route is usually needed only for initial rehydration of patients with severe diarrhoea.
• ORAL REHYDRATION THERAPY :
• Oral rehydration therapy is easily available,simple to use and safe.
• It is preferred method of fluid replacement.losses due to diarrhoea can be effectively corrected by oral rehydration solutions[ORS].
• Readily available ORS provides sodium,potassium,chloride and bicarbonate along with glucose,which effectively corrects fluid and electrolyte abnormalities,and also provide calories.
• Glucose enhances sodium and secondary water transport across the mucosa of the upper intestine,even in presence of infective diarrhoea.
• Avoid correction of losses due to diarrhoea,totally with electrolyte free solutions.as it provides only fluid,but lacks electrolytes,it can cause hyponatremia and is not effective in correction of hypovolemia.
• INTRAVENOUS FLUID THERAPY :
• I.V fluid therapy is indicated when rapid correction of blood volume is required for severe dehydration and shock,inability of patient to take ORS due to persistent vomiting or ORT fails to correct volume depletion due to greater losses.
• The preferred I.V fluids to correct losses due to diarrhoea are ringers lactate and isotonic saline.
• RINGERS LACTATE SOLUTION :
• It is the best commercially available solution
• It is the preffered solution because it not only provides an adequate concentration of sodium but also provides bicarbonates for the correction of metabolic acidosis
• Its potassium & solution provides no glucose to prevent hypoglycemia.so the patient with diarrhoea may require additional potassium,glucose,and at times bicarbonate supplementation.
• ISOTONIC SALINE:
• It effectively corrects hypovolemia and provides sodium along with water. Isotonic saline does not contain potassium to replace potassium deficity or base to correct metabolic acidosis.
• So patient may require additional supplementtion of potassium[10-20mEq/L]and sodium bicarbonate [20-30mEq/L] to correct existing hypokalemia and metabolic acidosis.
• 5% DEXTROSE ;
• It is not an acceptable I.V fluid because it does not correct acidosis,hypokalemia,and sodium deficity
• 5% dextrose is not effective in correction of hypovolemia .
• Rapid infusion large volume of 5% dextrose also carries the risk of hyponatremia and hyperglycemia leading to osmotic diuresis
• However,dextrose 5%with 45mEq bicarbonate [2 amp-50ml of 7.5% of sodium bicarbonate] and 20-30mEq of potassium chloride is effective

• These are life threatening situations in obestric/midwifery practice which are unexpected, develop rapidly, relatively uncommon and fatal for women & foetus.

Conditions (severe)

1. Hypertensive disorders
2. Hemorrhage
3. Embolism threaten- risk of mother life
4. Prolapse umbilical cord- risk of foetus life 
5. In 20 th century death’s of mothers due to OBG emergency is very common

Essential qualities of mid wife in handling  OBG emergencies :

• Recognize problem and initiate emergency
• Remain alert
• Decision making skills
• Address both physiological & psychological needs of mother
• Reassure, explain & support the family
• Proper record maintaining & skillful in reporting
• Positive attitude
• Updated skills 

Check progress -1

1. Define obstetric emergency
2. List conditions included

OBG EMERGENCIES &THEIR MANAGEMENT:

• Rupture of uterus
• Vasa Previa cord presentation & cord prolapse
• Amniotic fluid embolism
• Shoulder dystocia
• Shock .
• RUPTURE OF UTERUS :
• Break in continuity of uterine wall any time beyond 28 weeks of pregnancy.

A.Uterine rupture during antenatal period

  Signs&symptoms

• Right abdominal pain ,shock, intrauterine death of foetus,vaginal bleed,

Fainting attack,collapse, absence of foetal heart rate.

Diagnosis- Laprotomy

Management-  resuscitation of mother

                            Preparation of emergency Laprotomy

                        Laprotomy include-repair of scar , repair with sterilization , hysterectomy.

B.Uterine rupture during intra natal period

         Signs & symptoms-severe constant lower Abdominal pain, vomiting, increase heart rate,foetal tachycardia,

• Some times scar rupture & women goes into shock

 Management– immediate C-section,                                                                                             

  Repair of year/hysterectomy , manage shock &give blood transfusion

C.Uterine rupture following obstructed labour

Signs& Symptoms – Severe& constant abdominal pain , Severe foetal distress .

Management – Treat shock, prepare for hysterectomy.

D.Incomplete rupture –

Treating of uterine wall but not perimetrium found after delivery, during caesarean , previous c.section.

  Signs& symptoms – Shock during 3 Rd stage of labour , abdominal pain

 Management -Immediate caesarean to deliver alive baby, management of shock, hysterectomy .

Check progress- 2

      1.Define rupture of uterus

      2.Cause of uterine rupture.

2.VASA PRAEVIA :

• Some of the Blood vessels that connect the umbilical cord to the placenta lie over /near the entrance of birth canal.
• When membranes around baby rupture these blood vessels can rupture to cause baby to lose a lot of blood 

Signs & symptoms – bleeding,foetal bradycardia, tachycardia, increase foetal movement

Management-

• Active labour vaginal delivery should be expedited
• Emergency C.section is permitted -If foetus is alive & mother is in first stage of labour
• Cord blood is collected for estimation of foetal HB 

3.CORD PRESENTATION & PROLAPSE :

Cord presentation- Presence of umbilical cord between fetal presenting part &the cervix with/without membrane rupture

Cord prolapse- Before/during birth,the umbilical cord can drop through the open cervix into vagina ahead of body.

Predisposing factors- Multiparity ,prematurity , malpresentations that is breech, shoulder,brow,face,high head,long cord, multiple pregnancy.

Diagnosis- foetal bradycardia ,loop of cord may be visible at vulva ,

      Vaginal examination-immediately

Management-

• Delivery in possible speed to reduce mortality
• If foetus is alive and women in first stage of labour , immediate c.section
• Oxygen by mask – decrease foetal hypoxia
• 2^nd stage of labour- episiotomy 

Positions- 1.Knee- chest position

                   2.Exaggerated sims lateral position

                   3.Trendlenburg position 

    Check progress-3

  1.Explain signs& symptoms of Vasa praevia

 2.differentiate between cord presentation &prolapse

 3.How can you diagnose cord prolapse

 4.Explain to positions used to relieve pressure on umbilicus 

4.SHOULDER DYSTOCIA :

One /both of your babys  shoulder get stuck during vaginal delivery

Risk factors- Maternal age over 35 years ,high parity,past dated pregnancy, maternal pregnancy, maternal diabetes& gestational diabetes, large foetus with increased birth weight , oxytocin augmentation,prolonged labour& prolonged 2^nd stage of labour 

Warning signs& diagnosis: 

• Initially delivery may have been complicated,but the head may have advanced slowly
• Once head is delivered, it may look head is trying to recede back of vagina caused by reverse traction . usually diagnosed/suspeced when usual method used by midwife fails to deliver the baby
• Mac Roberts position .

5.AMNOTIC FLUID EMBOLISM :

• When amniotic fluid is forced into maternal circulation via uterus/ placental site forming embolism which obstructs pulmonary vessel’s leading to respiratory distress, circulatory collapse 

Causes: advanced maternal age , over estimation of uterus by drugs , uterine trauma, while performing c.section.

Signs& symptoms- Sudden onset of respiratory distress,chest pain,cough with pink sputum, hypotension & tachycardia,shock, vomiting, restless, anxiety, convulsions

Diagnosis- Detection of amniotic fluid in blood/on post-mortem examination of lungs

     Management- 

• Call for medical help
• Assist in immediate resuscitation
• Prepare for intubation & mechanical ventilation
• Arrange for I.V infusion of fluids & aminophylline
• Urinary catheter-measure hourly output
• Oxygen 8-10lit/min or resuscitation bag delivery 100% oxygen
• Prepare for emergency birth-once maternal condition stabilized

Check progress-4

1. What are risk factors involved in shoulder dystocia
2. Mention-warning signs& diagnosis of shoulder dystocia
3. Role of midwife in handling shoulder dystocia
4. Explain amniotic fluid embolism
5. What are predisposing factors for amniotic fluid embolism
6. List 3 signs & symptoms of amniotic fluid embolism

6.SHOCK :

• It is a condition of collapse due to failure of mother’s circulation system

Causes- Greyish blue / pale skin ,cold clammy skin, shivering,rapid breathing,rapid weak/slow pulse

      Flushed skin, decrease urinary out put 

Signs& symptoms-  hemorrhage ,

Non hemorrhagic shock due to – trauma, prolonged labour/psychological distress, fluid loss,septaecimia, pulmonary embolism.

Management-  Start resuscitative measures immediately ,

                            Maintain airway, Replace fluids &start I.v infusion

                           Administer oxygen

                           Record intake & output  

   Check progress-5

         1.Explain shock        2.Explain role of midwife in management of shock .

Some legal implications for emergency care : 

1. Take informed written consent before any treatment /action
2. Explain conditions to the patients family & possibility of death
3. Be sure about what, how, where &when of your actions
4. Reach help in time,take prompt & immediate action
5. Give BLS whenever indicated
6. Use standard protocol
7. Must complete the referral from
8. Record all drugs, intervention done on women
9. Maintain records- clear,legible,concise, accurate, pertinent & complete 

Check progress-6

1.list 6 legal tips for emergency care

2.Prepare a referral from to transfer a mother with any one OBG emergencies to a nearly community health center

In this OBG there are divided into types

ECLAMPSIA:

Eclampsia is the new onset of seizures or coma in a pregnant woman with pre eclampsia. These seizures are not related to an existing brain condition.

Causes

The exact cause of eclampsia is not known. Factors that may play a role include:

• Blood vessel problems
• Brain and nervous system (neurological) factors
• Diet
• Genes

Eclampsia follows a condition called pre-eclampsia. This is a complication of pregnancy in which a woman has high blood pressure and other findings.

               Most women with pre-eclampsia do not go on to have seizures. It is hard to predict which women will. Women at high risk of seizures often have severe pre-eclampsia with findings such as:

• Abnormal blood tests
• Headaches
• Very high blood pressure
• Vision changes
• Epigastic pain

In pre -eclampsia it mainly causes the hypertension  during in the pregnancy time especially placenta  narrow and less blood flow it may leads to fetal death and also released pro-inflammatory proteins .

If patient with seizures in emergency :

ABC approach

Side rails, mouth gap to prevent

Inj.MGSO4

Inj.MGSO4 5grm dl plus 4 grms MGSO4 diluted to 20cc to given over 5to1

Foleys catheterisation  inj.mgso4 5mg deep IM every 4^th helt for jolus

Immediately delivery should be planned

Signs of MGSO4 toxicity

Values are:

V.o- less than 100

RR less than 18 min Absence of patellar re flux     

Post -partum hemorrhage :

Postpartum hemorrhage (also called PPH) is when a woman has heavy bleeding after giving birth. It’s a serious but rare condition. It usually happens within 1 day of giving birth, but it can happen up to 12 weeks after having a baby. About 1 to 5 in 100 women who have a baby (1 to 5 percent) have PPH.

Causes of post-partum hemorrhage:

The causes of postpartum hemorrhage are called the four Ts (tone, trauma, tissue and thrombin).

The most common causes of PPH are:

• Uterine atony: Uterine atony (or uterine tone) refers to a soft and weak uterus after delivery. This is when your uterine muscles don’t contract enough to clamp the placental blood vessels shut. This leads to a steady loss of blood after delivery.
• Uterine trauma: Damage to your vagina, cervix, uterus or perineum (area between your genitals and anus) causes bleeding. Using instruments like forceps or vacuum extraction during delivery can increase your risk of uterine trauma. Sometimes, a hematoma (collection of blood) can form in a concealed area and cause bleeding hours or days after delivery.
• Retained placental tissue: This is when the entire placenta doesn’t separate from your uterine wall. It’s usually caused by conditions of the placenta that affect your uterus’s ability to contract after delivery.
• Blood clotting condition (thrombin): If you have a coagulation disorder or pregnancy condition like eclampsia, it can interfere with your body’s clotting ability. This can make even a tiny bleed uncontrollable.

The most common drugs used are oxytocin, methylergonovine or prostaglandins like carboprost or misoprostol,INJ.Tranexa

Ruptured ectopic pregnancy:

Ruptured ectopic pregnancy is a devastating consequence of the implantation of embryos outside the uterus. The classic triad of ectopic pregnancy includes abdominal pain, amenorrhea, and vaginal bleeding, Progression of symptoms to severe abdominal tenderness, peritoneal signs, and shock is indicative of a ruptured ectopic pregnancy.

Causes of Ruptured ectopic pregnancy:

              An ectopic pregnancy occurs when a fertilized egg grows outside of the uterus. Almost all ectopic pregnancies—more than 90%—occur in a fallopian tube. As the pregnancy grows, it can cause the tube to burst

Conformation of pregnancy by UPT or USG for haematoperitoneum, Arrange

uterine inversion:

               Uterine inversion occurs when the uterine fundus collapses into the endometrial cavity, turning the uterus partially or completely inside out. It is a rare complication of vaginal or cesarean delivery, but when it occurs, it is a life-threatening obstetric emergency.

 INTRODUCTION

• Cholera is an acute diarrheal illness caused by infection of the intestine with the bacteria vibrio cholera
• It causes severe diarrhea lead to dehydration and if untreated death may occur.
• It spread by ingestion of contaminated food and water.

EPIDEMIOLOGY:

• It has become an increasing public health concern around the world.
• It kills an estimated 95000 people/year, and infects 2.9 m people

ETIOLOGY:

• Age & Low personal hygiene.                  
• Low immunity
• Low gastric acid levels
• Soil and water pollution
• Contaminated food and water

SIGNS & SYMPTOMS :

• Pain in abdomen
• Nausea
• Severe diarrhea ,watery diarrhea
• Dehydration
• Water electrolyte imbalance
• Lethargy (lack of energy)

TYPES:

1.RICE WATER DIARRHEA

       * It causes painless diarrhea & vomiting of clear fluid

       *Loss of 1L/HR

       *Without treatment death occurs with in 18hrs-7 days

2.CHOLERA GRAVIS

       *More severe

       *Loss of 6L/HR

       *Death with in 2-3 hrs

3.CHOLERA SICCA

       *Rare & severe

DIAGNOSIS

• Stool specimen
• Cholera toxin by culture
• Cholera rapid test dipsticks
• Rectal swab method
• Catheter swab method 

TREATMENT

   A.RE HYDRATION PHASE

• To restore normal hydration status
• Set rate of I.V infusion in severely dehydrated patients at 50-100ml/kg/hr.
• Lactate ringer solution is preferred    

   B.MAINTENANCE  PHASE 

• To maintain normal hydration status by replacing ongoing losses.
• Oral route is preferred, use of ORS at 500-1000ml/hr.

   C.ANTIBIOTIC TREATMENT

   Drug                             Adult                    Child

1.DOXY                           300mg                    –

2.TETRACYCLINE          500mg                  12.5mg/kg  QID -3 DAYS

3.COTRIMOXAZOLE     TMP-160              TMP-5mg/kg

                                        SMX-800              SMX-25mg/kg 

4.FURAZOLIDONE        100 mg                 1.25mg/kg

5.AZITHROMYCIN         1gm/PO               20mg/kg (<1gm)

6.ERYTHROMYCIN          –                          12.5mg/kg(6hrs/3 days)

IN PREGNANCY:

AZITHROMYCIN   –      1gm/OD

ERYTHROMYCIN  –      500mg/6hrs/3days

 D. ZINC SUPPLEMENT

• Increase absorption of water and electrolytes
• Boosts immune system

NON-PHARMACOLOGICAL TREATMENT

• Drink and use safe water.
• Washing hands with safe water.
• Use latrines.
• Cook food well.
• Use flush toilet.
• Proper washing of clothes.
• Using sanitizer and Mask.
• Use disinfectant in cleaning

VACCINATION

1.DUKORAL  

• 3ml/ single dose vial
• Not for children< 2years

2.SANCHOL

• Administrate orally in 2doses in gap of 14days
• Booster dose recommend after 2 years.

3.VAXCHORA

• Use in adults (18-64).

    ABOUT DRUGS

DOXYCYCLINE & TETRACYCLINE :

MOA- Inhibits bacterial protein synthesis by binding to 30S

 ribosomal subunits.

SE- Dizziness, fast heart rate, indigestion sore throat

CI- In pregnancy, breast feeding, liver and kidney dis function.

   Child< 12 years ( discoloration of teeth)

 COTRIMOXAZOLE :

MOA- Inhibits folic acid synthesis

SE- Rashes ,sore throat, SOB ,cough

CI-Pregnancy, renal patients

FURAZOLIDINE :

MOA-Bind to DNA &induce crosslinks

SE- lower B.P,  fever, joint pain

AZITHROMYCIN & ERYTHROMYCIN :

MOA-Binds to 50S subunit of bacterial ribosome

SE – abdominal pain

cI – liver problems, slow heart rate, myasthenia gravis

RED FLAGS:

• Hypovolemic shock

PIT FALLS:

• Other diarrheal infections
• Arsenic poisoning

PEARLS:

• Adequate hydration

 REFERENCE:

      www.webmd.com