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Sexual and Reproductive Health Sexual and Reproductive Health Guide for the Care of the Most Relevant Obstetric Emergencies Guide for the Care of the Most Relevant Obstetric Emergencies Fescina R*, De Mucio B*, Ortiz El**, Jarquin D**. *Latin American Center for Perinatology Women and Reproductive Health **Latin American Federation of Societies of Obstetrics and Gynecology Scientific Publication CLAP/WR N° 1594-02 Latin American Center for Perinatology Women and Reproductive Health CLAP/ WR Sexual and Reproductive Health Cataloguing-in-Publication Data Fescina R, De Mucio B, Ortiz E, Jarquin D. Guide for the care of the most relevant obstetric emergencies. Montevideo: CLAP/WR; 2013. (CLAP/WR. Scientific Publication; 1594-02) ISBN: 1. Maternal Mortality - Prevention 2. Pregnancy Complications 3. Placenta Previa 4. Pre-Eclampsia 5. Pregnancy Complications, Infectious 6. Eclampsia 7. Postnatal care 8. Postpartum Hemorrhage 9. Pregnancy, High-Risk 10.Pregnancy, Ectopic I. CLAP/WR II.Title The Pan American Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. Applications and inquiries should be addressed to Editorial Services, Area of Knowledge Management and Communications (KMC), Pan American Health Organization, Washington, D.C., U.S.A. The Latin American Center for Perinatology, Women and Reproductive Health (CLAP/WR), Area of Family and Community Health, Pan American Health Organization, will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available. © Pan American Health Organization, 2013 All rights reserved. Publications of the Pan American Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights are reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the Pan American Health Organization concerning the status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the Pan American Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the Pan American Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the Pan American Health Organization be liable for damages arising from its use. Latin American Center for Perinatology, Women and Reproductive Health - CLAPWR Pan American Health Organization / World Health Organization – PAHO/WHO P.O Box 627, 11000 Montevideo, Uruguay Phone: +598 2 487 2929, Fax: +598 2487 2593 E-mail: [email protected] Web site: http://new.paho.org/clap BVS: http://perinatal.bvsalud.org/ Scientific Publication CLAP/WR 1594-02 Guide for the Care of the Most Relevant Obstetric Emergencies Sexual and Reproductive Health Contents Acknowledgements ....................................................................................7 Introduction.................................................................................................9 I. Serious hypertensive conditions in pregnancy ......................................13 1. Pre-eclampsia...................................................................................13 2. Eclampsia .........................................................................................19 II. Antepartum hemorrhage.......................................................................25 1. Ectopic pregnancy ............................................................................25 2. Abruptio Placentae ...........................................................................33 3. Placenta Previa.................................................................................41 III. Postpartum hemorrhage......................................................................47 IV. Severe obstetric infections..................................................................62 1. Septic Abortion .................................................................................62 2. Obstetric sepsis and septic shock.....................................................67 V. Cardiorespiratory arrest in pregnancy..................................................71 Guide for the Care of the Most Relevant Obstetric Emergencies Sexual and Reproductive Health Acknowledgements The publication herein has been technically possible thanks to the collaboration between the Maternal Mortality Committee of the Latin American Federation of Obstetrics and Gynecology Societies (FLASOG) and the Latin American Center for Perinatology /Women and Reproductive Health of the Pan American Health Organization (CLAP/WR-PAHO). The experts below collaborated in the drafting and review of the manual: Dr. María Fernanda Escobar Dr. Virna Patricia Medina Dr. Javier Carbajal Dr. Rafael Aguirre Dr. Suzanne Serruya The publication of this document was possible thanks to the finan- cial support of the Canadian International Development Agency (CIDA) and the Spanish Agency for International Cooperation for Development (AECID). Guide for the Care of the Most Relevant Obstetric Emergencies Sexual and Reproductive Health Introduction The document herein intends to be an accessible and user-friendly tool for the approach of the most frequent obstetric emergencies and urgencies. It addresses the main causes of maternal mortality, in the understanding that their correct diagnosis and management may prevent the death of pregnant women. The maternal mortality rate is an indicator of a population’s quality of life and health care, with most maternal deaths occurring in developing countries (99%). Poor schooling, inadequate nutrition, social support and health care are strongly associated with maternal mortality, which is considered an indicator of inequality between the rich and the poor. Moreover, maternal mortality is an evidence of gender inequalities, both in terms of access to education, nutrition and health care.1-4 This situation reflects the preventable nature of maternal death and the importance of establishing extra-sectoral actions to improve quality of life, and intra-sectoral measures to guarantee all the people’s quality and access to health care. A mother’s death is a human tragedy, a social injustice and a violation to the right to live. In many countries, maternal mortality is under-estimated as a result of a number of reasons that range from the practice of home births lacking an adequate health care, clandestine graveyards, and the paucity of skilled health staff capable of detecting and dealing with those cases. In addition, it is important to highlight that maternal death also entails severe consequences for the family and the community. It is associated with child neglect, malnutrition, violence and poor social development of families and communities, leading to high health care and social costs, in addition to being a serious threat to the development of communities and countries. Guide for the Care of the Most Relevant Obstetric Emergencies When seeking to prevent maternal deaths, there are several actions of key importance, including the list below: o Prevention of unwanted pregnancy. This includes access to fertility regulation methods and health actions aimed at preventing unsafe abortions. o Accessible and quality antenatal care. Enhancing access to control services and improving the quality of that control are high impact actions for the abatement of maternal mortality. o Adequate and humane care of deliveries and obstetric life- threatening events, including skilled monitoring of labor and delivery, as well as a timely diagnosis and proper management of the obstetric complications. o Adequate postpartum monitoring in search of complications, and with the purpose of establishing actions that promote health-related education. Most deaths are due to antepartum and postpartum bleeding, complications of abortion, pregnancy-related hypertensive disorders, sepsis, protracted or obstructed labor, uterus rupture and ectopic pregnancy. Some of these complications cannot be prevented; they are of acute onset, and may occur even in patients free of any risk factors. Hence the importance of recognizing these complications in a timely manner, to enable an immediate and adequate approach to prevent the woman’s status from worsening and to avoid her subsequent death. The maternal mortality rate may be strongly reduced through the implementation of proper evidence-based actions, well enforced through management protocols, and carried out by skilled health professionals. The analysis of the impact that issues like family planning, antenatal controls, delivery care provided by skilled staff, and management at obstetric emergency services have on MM reveals that access to obstetric emergency services and safe abortion services are significantly associated with a lower maternal mortality, and their impact is even greater than the availability
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