Pregnancy & Childbirth Management Guidelines
Level- 2
A Guide For Nurses, Midwives and Doctors
1st Edition, 2010
Sultanate of Oman Ministry of Health Department of Family & Community Health Directorate General of Health Affairs
i ML-61
ACKNOWLEDGMENT
Contributors from the Department of Family and Community Health :
Dr. Yasmin Jaffar, Director of Family & Community Health
Dr. Nahida Al-Lawati, Senior Specialist
Dr. Jamila Al-Abri, Specialist
Dr. Manorama T. Vaswani, Senior Medical Officer
Dr. Salwa Jabbar Al-Shahabi, Specialist
Dr. M. V. Joseph
Contributors from the Department of Obstetrics & Gynaecology:
Royal Hospital: Dr. Noor Al- Mandhari, Senior Consultant Obst/Gyne, & Head of Dept.
Sur Hospital: Dr. Radha Sharma, Senior Consultant Obst/Gyne, & Head of Dept.
Nizwa Hospital: Dr. Ilham Moosa, Senior Consultant Obst/Gyne, & Head of Dept.
Sultan Qaboos University Hospital: Dr. Majida Al-Maaroof, Senior Consultant Obst/Gyne,
Contributors from the Nursing and Midwifery-DGHA:
Ms. Lynette Galloway
Contributors from the Primary Health Care:
Dr. Huda Anwar al-Lawati, Wilayat Muttrah, DHGS-Muscat
Dr. Badriya Al-Rashdi, Wilayat Bousher, DHGS-Muscat
Contributors from the Regional MCH Co-coordinators:
Dr. Hind Mohammed Hamdi, DGHS-North Sharqiya Region
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Contents Page
ACKNOWLEDGMENT ...... iii
ABBREVIATIONS ...... x
PREFACE ...... xv
CONTENTS OF THE MANUAL ...... xvi
DEFINITIONS OF DIFFERENT TYPES OF REFERRAL ...... xvii
SECTION 1: BASIC ANTE NATAL CARE ...... 1
I. ORGNIZATION OF ANTENATAL CARE: ...... 3
II. TASKS OF ANTENATAL CARE ...... 4
SECTION 2: COMPLICATIONS DURING PREGNANCY ...... 19
A- MEDICAL COMPLICATIONS IN PREGNANCY ...... 21
1. Anaemia...... 23
2. Hypertension in Pregnancy...... 26
3. Diabetes Mellitus in Pregnancy ...... 36
4. Urinary Tract Infections (UTI) ...... 40
5. Asymptomatic Bacteriuria: ...... 41
6. Vaginal Discharge during Pregnancy ...... 42
7. HIV in Pregnancy: ...... 45
8. Chicken pox (varicella) in pregnancy ...... 49
9. Pregnancy with RhD negative blood group ...... 51
10. ABO incompatibility...... 54
11. Cardiac problems in pregnancy ...... 54
12. Haemoglobinopathies in Pregnancy ...... 59
13. Gestational Trophoblastic Diseases (GTD) ...... 63
14. Thrombophalyxis Therapy in Pregnancy ...... 65
OBSTETRIC COMPLICATIONS ...... 73
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1. Vaginal Bleeding In Early Pregnancy ...... 75
2. Vaginal Bleeding in Later Pregnancy ...... 82
3. Fever during Pregnancy ...... 88
4. Abdominal Pain in Early Pregnancy ...... 89
5. Abdominal Pain in Later Pregnancy ...... 92
6. Missed abortion ...... 94
7. Multiple Pregnancy ...... 96
8. Hydrops Fetalis ...... 98
9. Small for gestational age (SGA)/ fetal growth restriction (FGR) ...... 100
10. Breech presentation...... 103
11. Decreased Fetal Movements ...... 104
12. Fetal Death ...... 104
13. Prelabour Rupture of Membranes (PROM) ...... 105
SECTION 3: NORMAL LABOUR AND INTRA-PARTUM COMPLICATIONS ...... 109
NORMAL LABOUR ...... 111
SUPPORTIVE CARE DURING LABOUR AND CHILDBIRTH ...... 111
ANALGESIC DRUGS DURING LABOUR...... 113
DIAGNOSIS AND CONFIRMATION OF LA BOUR ...... 113
DIAGNOSIS OF STAGE AND PHASE OF LABOUR ...... 114
NORMAL CHILDBIRTH ...... 122
CONTINUOUS ELECTRONIC FETAL MONITORING (EFM): ...... 125
INTRAPARTUM COMPLICTIONS ...... 127
1. Unsatisfactory Progress of Labour ...... 129
2. Malpositions nnd Malpresentations ...... 132 a 3. Shoulder Dystocia...... 141
4. Labour with an Overdistended Uterus ...... 143
5. Labour with a Scarred Uterus ...... 146
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6. Fetal Distress in Labour ...... 147
7. Prolapsed Cord ...... 149
8. Preterm Labour ...... 150
9. Ruptured Uterus ...... 152
SECTION 4: ROUTINE POST NATAL CARE & COMPLICATIONS ...... 155
ROUTINE POST NATAL CARE ...... 157
POST NATAL COMPLICATIONS ...... 163
1. Vaginal Bleeding After Childbirth ( Post Partum Haemorrhage) ...... 165
2. Fever after Childbirth ...... 168
SECTION 5: GENERAL PRINCIPLES OF CARE ...... 173
1. Rapid Initial Assessment ...... 175
2. Communicating With Talking With Women and Their Families ...... 177
3. Emergencies ...... 184
4. Shock ...... 185
5. Infection Prevention ...... 187
6. Replacement Fluids: Simple Substitutes for Transfusion ...... 188
7. Anesthesia and Analgesia ...... 190
SECTION 6: COMMON PROCEDURES ...... 193
1. External Cephalic Version (ECV) ...... 195
2. Induction and Augmentation of Labour ...... 197
3. Artificial Rupture of Membranes ...... 201
4. Vacuum Extraction ...... 201
5. Forceps Delivery ...... 205
6. Breech Delivery ...... 207
7. Episiotomy ...... 212
8. Manual Removal of Placenta ...... 216
9. Repair of Cervical Tears ...... 218
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10. Repair of Vaginal and Perineal Tears ...... 219
ANNEX I : DRUGS TO BE AVOIDED OR USED WI TH CAUTIOUS IN PREGNANCY ...... 223
Tables Table 1 Laboratory tests to be performed during ANC visits ...... 8 Table 2: Drugs contraindicated in pregnancy ...... 11 Table 3: Criteria for the delivery in primary care institute (only where delivery services are available) ...... 12 Table 4: Criteria for the delivery in secondary care ...... 12 Table 5: Criteria for the delivery in tertiary care ...... 14 Table 6: Tasks of ANC visits ...... 15 Table 7: Indications for referral to secondary care ...... 17 Table 8: M anagement of anaemia in pregnancy ...... 23 Table 9: Diagnosis of elevated blood pressure during pregnancy ...... 27 Table 10: Detection and m anagement of UTI in pregnancy ...... 40 Table 11: Specific management of vaginal discharge during pregnancy ...... 43 Table 12: Risk factors f or venous thromboembolism in pregnancy and puerperium:65 Table 13: Prophylactic &Therapeutic doses of LMWH ...... 67 Table 14: Summary of Protocol for Thromboprophylaxis for women with previous VTE +/-Thrombophilia:...... 71 Table 15: Diagnosis of vaginal bleeding in early pregnancy ...... 76 Table 16: Diagnosis and management of complications of abortion ...... 77 Table 17: Symptoms and signs of ruptured and unruptured ectopic pregnancy ...... 78 Table 18: Types of bleeding ...... 82 Table 19: Diagnosis of vaginal bleeding in later pregnancy and labour (antepartum haemorrhage) ...... 83 Table 20: Diagnosis of fever during pregnancy and labour ...... 88 Table 21: Diagnosis of abdominal pain in early pregnancy ...... 90 Table 22: Diagnosis of abdominal pain in later pregnancy and after child birth ...... 92 Table 23: Conditions during labour requiring immediate referral ...... 111 Table 24: Diagnosis of stage and phase of labour ...... 114 Table 25: Duration of each stage of labour ...... 118 Table 26: Diagnosis of unsatisfactory progress of labour ...... 129 Table 27: Diagnosis of malposition ...... 135 Table 28: Classification of FHR trace features ...... 148 Table 29: Tocolytic drugs to stop uterine contractions ...... 151 Table 30: Diagnosis of v aginal bleeding after child birth ...... 165 Table 31: Diagnosis of fever after childbirth ...... 168 Table 32: Rapid initial assessment & man agement considerations ...... 175 Table 33: Analgesia & anesthesia options ...... 192 Table 34: Calders modification of Bishop’s score: ...... 197 Table 35: Oxytocin infusion in primigravida ...... 199 Table 36: Oxytocin infusion in multigravida (< 7) and previous LSCS...... 199 Table 37: Oxytocin infusion in grandmultipara...... 200
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Figures Figure 1: Implantation of placenta at or near the cervix...... 86 Figure 2: Effacement and dilatation of the cervix...... 114 Figure 3: Abdominal palpation for descent of the fetal head ...... 115 Figure 4: Assessing descent of the fetal head by vaginal examination; 0 station is at the level of the Ischial spine (SP) ...... 116 Figure 5: Landmarks of the fetal skull...... 116 Figure 6: Occiput transverse positions ...... 117 Figure 7: Occiput anterior positions ...... 117 Figure 8: Well-flexed vertex ...... 117 Figure 9: Sample partogram for normal labour...... 120 Figure 10: Landmarks of the fetal skull...... 133 Figure 11: Occiput transverse position ...... 133 Figure 12: Occiput anterior positions ...... 134 Figure 13: Well-flexed vertex ...... 134 Figure 14: Occiput posterior ...... 135 Figure 15: Left occiput posterior ...... 135 Figure 16: Left occiput transverse ...... 135 Figure 17: Brow presentation...... 135 Figure 18: Face presentation...... 136 Figure 19: Face presentation...... 136 Figure 20: Compund presentation ...... 136 Figure 21: Breech presentation ...... 136 Figure 22: Frank breach presentation...... 137 Figure 23: Footling breach presentation ...... 137 Figure 24: Transverse lie ...... 137 Figure 25: Face presentation...... 138 Figure 26: Assistant pushing flexed knees firmly towards chest ...... 141 Figure 27: Grasping the humerus of the arm that is posterior and sweeping the arm across the chest...... 142 Figure 28: Initiating breastfeeding ...... 160 Figure 29: Attaching to breast...... 160 Figure 30: External version of a breech presentation ...... 197 Figure 31: Landmarks of the fetal skull...... 202 Figure 32: Applying the Malmstrom cup ...... 203 Figure 33: Applying traction ...... 204 Figure 34: Applying the left blade of the forceps ...... 205 Figure 35: Breech presentation ...... 207 Figure 36: Hold the baby at the hips, but do not pull ...... 208 Figure 37: Lovset's manoeuvre...... 209 Figure 38: Delivery of the shoulder that is posterior ...... 210 Figure 39: The Mauriceau Smellie Veit manoeuvre ...... 211 Figure 40: Single footling breech presentation, with one leg extended at hip knee 211 Figure 41: Infiltration of perineal tissue with local anaesthetic...... 213 Figure 42: Making the incision while inserting two fingers to protect the baby's head ...... 214 Figure 43: Repair of episiotomy...... 215 Figure 44: Introducing one hand into the vagina along cord...... 216 Figure 45: Supporting the fundus while detaching the placenta ...... 217 Figure 46: Withdrawing the hand from the uterus...... 217
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Figure 47: Repair of a cervical tear...... 219 Figure 48: Exposing a perineal tear...... 220 Figure 49: Repairing the perineal tears ...... 221 Figure 50: Closing the muscle wall of the rectum & anal aphincter ...... 222
Algorithm
Algorithm 1: Screening steps for gestational diabetes...... 36 Algorithm 2: Management of vaginal discharge during pregnancy...... 42 Algorithm 3: HIV testing in pregnancy ...... 45 Algorithm 4: Post-exposure management of chickenpox ...... 50 Algorithm 5: USG surveillance of multiple pregnancy of 28 weeks ...... 97 Algorithm 6: Diagnosis of SGA/ FGR...... 101 Algorithm 7: Medical & surgical management of PPH ...... 167
Boxes
Box 1: Prevention of pregnancy induced hypertension ...... 28 Box 2: Investigations to be performed for pregnancy induced hypertension ...... 29 Box 3: Magnesium sulfate schedules for management of convulsion in severe pre- eclampsia and eclampsia ...... 32 Box 4: Diazepam schedules for severe pre-eclampsia and eclampsia ...... 33 Box 5: Preparation of lignocaine 0.5% solution ...... 190
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ABBREVIATIONS
Antibody Screening Test ABS Abdominal Circumference AC Amniotic Fluid Index AFI Antenatal Care ANC Antepartum Haemorrhage APH Activated Partial Prothrombin Time APTT Artificial Rupture of Membranes ARM Atrial Septal Defect ASD Amniotic Fluid Volume AFV Twice a Day BD Body Mass Index BMI Blood Pressure BP Beats Per Minutes BPM Biophysical Profile BPP Blood Sugar BS Celsius c Complete Blood Count CBC Cubic centimetre cc Congestive Cardiac Failure CCF Centimetre cm Cytomegalovirus CMV Combined Oral Contraceptives COC Central Public Health Laboratory CPHL Cerebro Spinal Fluid CSF Cardiotocography CTG Central Venous Pressure CVP Dichorionic DC Department of Family and Community Health DFCH Disseminated Intravascular Coagulation DIC
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DVP Deep Vertical Pool dL Decilitre
DM Diabetes Mellitus
DNA Deoxyribonucleic Acid
ECV External Cephalic Version
EDF End Diastolic Flow
EFM Electronic Fetal Monitoring
EFW Estimated Fetal Weight
ELIZA Enzyme Linked Immunosorbent Assay EPI Extended Programme of Immunization
FBS Fasting Blood Sugar
FFP Fresh Frozen Plasma
FGR Fetal Growth Restriction
FHR Fetal Heart Rate
GBS Group B Streptococcus
GDM Gestational Diabetes Mellitus gm Gram
Hb Haemoglobin
HIV Human Immunodeficiency Virus
HVS High Vaginal Swab
ICT Indirect Coomb's Test
IM Intramuscular
INR International Normalized Ratio
ITP Idiopathic Thrombocytopenic Purpura
IU International Unit
IUCD Intrauterine Contraceptive Device
IUFD Intrauterine Fetal Death
IUGR Intrauterine Growth Restriction
IUI Intra-uterine Insemination
IV Intravenous
IVF In Vitro Fertilization
Kg Kilogram
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L Litre
LBW Low Birth Weight
LFT Liver Function Test
LMWH Low Molecular Weight Heparin
LSCS Lower Segment Caesarean Section
MC Monochorionic
Mcg Microgram
MCH Mother and Child Health mg Milligram ml Millilitre
mmHg Millimetres of Mercury
Mmol Millimoles
MR Mitral Regurgitation
MVP Mitral Valve Prolapse
NSAID Non Steroidal Anti-Inflammatory Drugs
NWCCP National Women & Child Care Plan
OD Once a Day
OGCT Oral Glucose Challenge Test
OGTT Oral Glucose Tolerance Test
PCR Polymerase Chain Reaction
PDA Patent Ductus Arteriosis
PGBS Post Glucose Blood Sugar
PHC Parent Health Centre
PIH Pregnancy Induced Hypertension
PID Pelvic Inflammatory Disease
PN Perinatal
PNC Post Natal Care
PPH Postpartum Haemorrhage
PPROM Premature Prelabour Rupture of Membranes
PR Pulse Rate
PRBC Packed Red Blood Cells
PROM Prelabour Rupture of Membranes
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QID Four Times a Day
RBS Random Blood Sugar
RFT Renal Function Test
RhD Rhesus D
RPHL Regional Public Health Laboratory
RR Respiratory Rate RT-PCR time polymerase chain reaction Real Time Polymerase Chain Reaction SBE Subacute Bacterial Endocarditis
SC Subcutaneous SCABU Special Care Baby Unit SGA Small for Gestational Age SOP Standard Operative Procedures STD Sexually Transmitted Diseases TID Three Times Daily TFT Thyroid Function Test TOF Tetrallogy of Fallot
TORCH Toxoplasmosis, Other, Rubella, Cytomegalovirus and Herpes
(Congenital Infections) TPHA Treponema Pallidum Haemagglutination Assay TT Tetanus Toxoid TTTs Twin-Twin Transfusion Syndrome UFH Unfractinonated heparin UTI Urinary Tract Infection VDRL Venereal Disease Research Laboratory VSD Ventricular Septal Defect VTE Venous Thromboembolism VZIG Z Varicella zoster Immuneglobulin WB Western Blot Test WBC White Blood Cells WHO World Health Organization
Microgram
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PREFACE
Oman has made significant achievement in reducing the infant mortality rate that has dropped from 64 in 1980 to 9.6/1000 live births in the year 2009. Maternal mortality ratio, since it's initiation of monitoring by Ministry of Health (MOH) in 1991, has also shown drop from 27.37 in 1991 to 13.4 per 100,000 live births (2009 MOH estimates).
Oman's current success story can be summarised as an outcome of 3 proven interventions: provision of antenatal service within easy access, strengthening the services and systems and, sustaining the standards of the health care delivery.
The National Women & Children Plan (NWCCP) was launched in 1987 with the aim of providing a National Antenatal Care (ANC), Peri-natal and Post-natal Care (PN & PNC) Services. Further, the service accessibility has been made easy by integrating them with primary health care.
Quality of health care delivery has been ensured by putting in place a standard client retained maternal health record and a parent health care facility based antenatal register, both providing information on the profile of each pregnant woman, her risks, problems, health care needs and, plans and management carried out during ANC, PN & PNC period, and their outcomes.
Further, health care provider's knowledge and skills are kept updated through provision of standard operative procedure manuals that give guidelines on the MoH policies and protocols and institutionalising pre and in-service training on the assessed job needs.
Development of these guidelines is another effort of Ministry of Health of Oman to keep providers knowledge updated with the best available evidences thus, ensuring the best possible standard of health care delivery. Hopefully, through this effort, a further reduction in the maternal mortality could be achieved, and some difference made in health indicators that have shown less discernable change over last half a decade, these are, stillbirth rate that has stalled at 8.9/1000 births, early neonatal mortality at 5.6 per 1000 live births and peri-natal mortality at 13.9 per 1000 births (2008 MOH data).
The Interventions incorporated in these guidelines are from the latest World Health Organization (WHO) guidelines on “Managing Complications in Pregnancy and Child Birth" A guide for doctors and midwives. In addition to above, some evidence based information has been taken from other internationally recognised resources, such as guidelines by The National Institute for Clinical Excellence (NICE) and the Royal College of Obstetricians and Gynaecology (RCOG).
As the provision of services has to be different at the different levels of health care systems, two separate standard operative guidelines have been developed (Level 1 for primary care and Level 2 for secondary health care). This guideline (Level 2) is designed for the use of doctors and nurses working at secondary care.
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CONTENTS OF THE MANUAL
Section 1 outlines the standard antenatal care for low risk woman and contains the organization of ANC care, the contents of the antenatal visits and the tasks of the antenatal care
Sections 2 deals with the common symptoms and management of common medical problems such as Anaemia, Hypertension, Diabetes, Urinary tract infection, Vaginal discharge, HIV and Chicken pox. It also covers the common obstetric complications encountered in the antenatal period such as bleeding, pain abdomen, fever, loss or decreased fetal movements and premature rupture of membranes.
Section 3 is a description of normal labour and childbirth, including use of the partogram and active management of the third stage of labour. This section aims to provide the health care worker with the information needed to differentiate between the normal process and a complication. This section also includes the common intra- partum complications and their management.
Section 4 this section describes the routine post natal care. It also outlines post natal check up for special conditions. Some of the postnatal complications are also discussed in this section.
Section 5 outlines clinical principles of managing complications in pregnancy and childbirth. It also contains general principles of care, including infection prevention, fluid replacement and local anaesthesia.
Section 6 describes some of the common procedures that may be necessary in some conditions. These procedures are not intended to be detailed “how-to do” instructions but rather a summary of the main steps associated with each procedure.
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DEFINITIONS OF DIFFERENT TYPES OF REFERRAL
Routine appointment: routine appointment given by the secondary care.
Early appointment: appointment should be given within two weeks or as requested by the referring doctor.
Urgent appointment: appointment should be given within 48 hours in consultation with the concerned department.
Emergency referral: Patient should be referred immediately. With I.V. line has been inserted, via an ambulance and a medical attendance (nurse, midwife or a doctor). The doctor on-call in the referring hospital should be informed by the phone.
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I. ORGNIZATION OF ANTENATAL CARE:
Antenatal care is the care provided to pregnant women from the health care system and aims primarily for:
! Detection of the factors that might increase the perinatal risks. ! Intervention to improve the outcome. ! Education of all who provide and receive the care. ! Help in making pregnancy and birth a positive life experience.
Who provides the care?
! Standardized antenatal care should be offered by the parent health centre (PHC) team for all pregnant women. Total of 6 visits should be achieved by the end of a normal pregnancy. ! Antenatal booking should be carried out in the parent health centre as soon as a woman is diagnosed to be pregnant. ! All pregnant women should be referred at 22-24 weeks to the obstetrician for routine assessment. ! Referral should be made to the obstetrician for high risk cases as outlined in Table 7.
Continuity of care
Continuity of care throughout the antenatal period should be ensured and preferably by the same team of whom the woman feels comfortable with (as in the case of health centres).
A system of clear referral paths exists in the Ministry of Health, each health care ! provider should be aware of it so that pregnant women who require additional care are managed and treated by the appropriate specialist in or outside the health institution. Clear management instructions should be provided by the obstetricians if a high ! risk patient was referred back to the primary health care for routine ANC care.
Where should antenatal care take place?
The antenatal care should be readily and easily accessible to all women and should be sensitive to the needs of individual women and the local community. The parent health institution of the family provides the ideal scenario for this.
Documentation of care / Maternal Health Record
Structured maternal records such as Maternal Health Record and ANC Register should be used for antenatal care. Both Maternal Health Record and ANC Register are being computerized on small scale projects and until it is nationalized both will have to continue. The standardized, national Maternal Health Record with an agreed set of parameters should facilitate health care providers to provide the recommended care to pregnant women. All clients should be allowed to carry their own Maternal Health Record issued to them at the time of first booking.
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Obstetrician should document over the recommendation section in the record if any specific future plans for the women during ANC or PNC period were indicated.
II. TASKS OF ANTENATAL CARE
Recent research has shown that reduction in the number of ANC visits to fewer structured visits in low risk cases does not affect the pregnancy outcome. Based on this, the number of ANC visits was reduced to 6 visits for low risk cases. (WHO Antenatal Care Randomized Trial, 2002).
A schedule consisting of 6 antenatal visits is considered to be adequate for uncomplicated pregnancy. Refer to Table 6 for the schedule of standardized ANC visits including the tasks that to be performed at each visit.
Each antenatal visit has a focused content. Longer time slots should be allocated to allow comprehensive assessment and discussion. This should be possible as the number of visits has been restricted to 6 visits in low risk cases.
At booking all women should receive appropriate information about the number and timing of antenatal visits and to be given an opportunity to discuss the schedule and the type of care with their health providers. The tasks of ANC care are the following:
1. RECORD PERSONAL INFORMATION
At the first visit all the personal information should be documented as per the ANC record.
2. HISTORY TAKING
At the first visit the history as per the Maternal Health Record parameters which includes current and previous obstetrical & gynaecological risks, medical history, current danger signs & symptoms, birth spacing history and family medical history should be documented (See Maternal Health Record for details).
Women should also be asked about (in the present pregnancy):
Exposure to radiation - Drugs in 1st trimester - Fever, rash in 1st trimester - Current medication -
3. CLINICAL EXAMINATION OF PREGNANT WOMEN
Measurement of weight and body mass index (BMI)
Maternal weight and height should be measured at the first antenatal appointment, and the woman’s Body Mass Index (BMI) to be calculated (weight [kg]/ height [m] ".
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If the BMI is < 19.8 or > 29 the nutritional status should be assessed. Maternal weight need not to be repeated at all visits routinely unless indicated or if the initial weight (at booking) was < 40 kg or > 80 kg.
Measurement of blood pressure
The blood pressure (BP) is recorded carefully at booking. If the diastolic blood pressure is above 90 mm (confirmed by two readings, 4 hours apart), the case should be graded as high risk and to be followed more closely. The BP should be repeated at all visits.
Systemic examination
This includes examination for jaundice, lymph nodes, thyroid, chest, cardiovascular system, abdomen, oedema, skeletal system and dental problems.
Breast Examination:
Both breasts should be inspected for any skin or nipple changes. Both breasts should be palpated for lumps.
Obstetric examination
The specific Obstetric examinations recommend at each visit include:
- Estimation of fetal size at each antenatal appointment to detect small or large for gestational age fetus. Symphasis-fundal height should be measured at each antenatal appointment from 24 weeks of gestation. A discrepancy of ! 4 cm between the fundal height and the gestational age is acceptable. Patient should be referred for growth scan and an obstetric opinion, by urgent appointment, if discrepancy was noted in two occasions 4 weeks apart. Fetal heart sounds are checked by fetal stethoscope or by doppler fetal heart - recorder (sonic aid) and fetal movements are assessed at all ANC visits. Fetal presentation should be assessed by abdominal palpation from 36 weeks - onward, when presentation is likely to influence the plan of delivery.
Routine assessment of presentation by abdominal palpation should not be offered before 36 weeks because it is not always accurate and might be uncomfortable. Suspected fetal malpresentation should be confirmed by an ultrasound assessment
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4. RISK GRADING
Risk grading should be done at every visit and to be updated in both the Maternal Health Record and the Antenatal Register.
If any of the listed conditions is present consider the woman at a high risk.
Current Obstetric & Gynaecological risks:
1. Age < 15 years or > 40 years. 2. Gestational diabetes mellitus. 3. Pregnancy induced hypertension (PIH). 4. Diastolic blood pressure is ! 90 mm Hg at current booking. 5. Antepartum haemorrhage. 6. Pelvic Tumour. 7. Current multiple pregnancy. 8. Intrauterine growth restriction (IUGR).
Previous Obstetric & Gynaecological risks:
1. Pre-eclampsia/Eclampsia. 2. Caesarean Section. 3. Preterm labour. 4. Premature rupture of membranes. 5. Three or more consecutive abortions during 1st trimester. 6. 2nd trimester abortion. 7. Postpartum haemorrhage. 8. Thrombosis, Embolus. 9. Infertility. 10. Surgery on Reproductive tract (Myomectomy, removal of septum, cone biopsy, cervical cerclage). 11. Low birth weight (LBW) (< 2500 gm). 12. Macrosomia (! 4000 gm). 13. Fetal or neonatal death. 14. Rh antibodies Isoimmunisation. 15. Malformation or chromosomally abnormal child.
Medical history
1. Hypertension 8. HIV Diabetes mellitus 9. Psychiatric disorders 2. Renal diseases 10. Epilepsy 3. Cardiac disease 11. Genetic disorders 4. Sickle cell diseases 12. Thyroid diseases 5. Thalassemia major 13. Other diseases or conditions which 6. Chronic Hepatitis need special attention. 7.
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Current danger signs & symptoms:
1. Severe pallor 7. Calf tenderness 2. Persistent headache 8. Difficult breathing 3. Blurring of vision 9. Vaginal bleeding/leaking 4. Generalized oedema 10.Persistent or severe abdominal pain 5. Convulsion 11.Unexplained persistent fever 6. Unilateral leg oedema
Every effort should be made to trace high risk ANC defaulters including home visits as per the need and feasibility
5. ULTRASONOGRAPHY IN ANC
If ultrasound is available at booking, ultrasonic assessments are recommended for all pregnant women to determine viability, gestational age in view of last menstrual period, and to determine number of fetuses. This will improve consistency of gestational age assessments during pregnancy. When expertise is available, women can be offered an anomaly scan at 22-24 weeks gestation.
Pregnant women can always be referred to the secondary care for scan if clinically indicated.
Crown–rump length measurement is to be used to determine gestational age up to 14 weeks. Beyond 14 weeks, head circumference or bi-parietal diameter is the preferable measurement.
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6. LABORATORY TESTS
There are certain tests to be conducted during each ANC visit as shown in the table below (! marks the test to be done)
Table 1 Laboratory tests to be performed during ANC visits
Test At 12-14 22-24 28-30 32-34 36-38 6 wks bookin wks wks wks wks wks PNC g
Blood group. Rh ! Factor
Haemoglobin ! ! ! ! (gm/dl)
VDRL !
TPHA (if VDRL + ve) HIV : ∀ Done ! ∀ Not done
Urine for:
Glucose !
Ketones !
Albumin !
! ! Microscopy
Blood Sugar Test:
Random !
OGTT (if needed): ! ! ! Fasting
! ! ! Post Prandial
OGCT !
Other Investigations:
Sickling (if not known) !
ABS* (if RH – ve) ! ! !
* Antibody screening test
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• Screening for syphilis should be offered to all pregnant women at booking because treatment of syphilis is beneficial to the mother and fetus. If pregnant women are found to have a positive VDRL:
# Confirm by performing TPHA. # In all sero-positive cases the sexual partner should be screened for syphilis.
• All registered women in ANC clinics will be subjected to testing for HIV:
# Verbal consent will be taken before collecting the blood sample, which will be following provision of pre-testing information to the woman.
• All women registering with ANC clinic must perform RBS or FBS if fasting. OGCT/OGTT will follow according to the results. See Algorithm 1.
# OGTT (oral glucose tolerance test): by using 75 gm of anhydrous glucose or 82.5 of glucose monohydrate. # OGCT (oral glucose challenge test): by using 50 gm of anhydrous glucose or 55 of glucose monohydrate.
• Women should be tested for blood group and Rh status at booking.
# If the pregnant woman was Rh-negative, partner should also be tested to determine whether the administration of anti-D prophylaxis is necessary. # ABS test is done in all cases of Rh-ve cases at booking, 28-30 weeks visit and then repeated at 36-38 weeks visit to look for a raising titre.
All pregnant women must be offered urine test for microscopy, glucose, ketones and albumin in the booking visit. Asymptomatic bacteruria is common in pregnant women and there is evidence that treatment of such cases will lead to better outcomes of pregnancy.
# If Urine microscope showed more than 20 WBCs per high power field, urine culture is to be done. # Urine for protein should be done whenever high blood pressure is detected (diastolic blood pressure ! 90 mmhg). # Mid stream specimen of the urine should be sent for culture in cases of symptoms of urinary tract infection. # Urine examination requires a clean–catch mid stream specimen to minimize the possibility of contamination. Patients should be educated on how to collect the spacemen.
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7. IMMUNIZATION
All women should be fully immunized with tetanus toxoid- 5 doses in order to prevent neonatal tetanus. Check women’s TT status and immunize as required. (See EPI SOP). Each woman should be followed up until she completes five doses of TT vaccination. Check women’s status of Rubella immunization, if not immunized or if immunization status is not known, immunize the woman after delivery and give advice not to conceive for the next 3 months in order to prevent Congenital Rubella Syndrome.
8. HEALTH EDUCATION
Pregnant women should be offered proper information and support to enable them to make informed decisions regarding their care. Women’s choices should be recognized as an integral part in the decision-making process. They must be offered opportunities to attend antenatal educational sessions and be given written information about antenatal care.
At the first contact, pregnant women should be offered information about: the pregnancy-care services and options available, lifestyle considerations, including dietary information. Health education leaflets should be offered as they are designed to provide information on many aspects related to pregnancy. Booklet No.1 should be given at booking, No.2 at 12-14 weeks visit and No.3 at 28 weeks visit.
9. DRUG PRESCRIPTION
All pregnant woman (Hb !11gm/dL) should be given a standard dose of ferrous sulphate, and folic acid daily if ∃ 12 weeks and folic acid only if < 12 weeks pregnant . All for indications and the smallest effective therapeutic dose should be used. The following table illustrates some drugs with their possible effect on the fetus:
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Table 2: Drugs contraindicated in pregnancy
Drug Harmful effects /Remarks
Warfarin Punctate chondroplasia
Avoid, especially in first trimester.
To discuss with cardiologist/ senior obstetrician before discontinuing it in patients with valvuler cardiac disease.
Heparin Overdoses may cause fetal haemorrhage. Prolonged dosage of unfractionated heparin causes maternal
osteoporosis.
Maternal benefit may outweigh risks.
Phenytoin, etc. IUGR, Mild microcephaly, Cleft palate
Maternal benefit may outweigh risk.
Amino- glycosides Ototoxic, especially for fetus
Tetracycline Deposited in teeth and bone.
Chloramphenicol In late pregnancy, may cause “gray-baby” syndrome
Metronidazole Advisable to avoid in first trimester.
Antimalarials Avoid unless blood smear is positive
Prostaglandin Avoid, especially in first trimester
Synthetase inhibitors
Synthetic oestrogen's to be avoided and progestogens
Glucocorticoids Cleft- lip/ palate. If maternal use is essential, try to reduce the dose.
See Annex I for the detailed list of drugs to be avoided or used with caution in pregnancy.
11 10
10. PLAN OF DELIVERY
The assessment for delivery should take place at every antenatal visit. The decision depends on the present and the past medical and obstetrical history.
The following tables illustrate the criteria for planning on the place of delivery:
Table 3: Criteria for the delivery in primary care institute (only where delivery services are available)
Parity 1-7
Normal weight (40-80 kg) and height ($152 cm)
Fundal height measurements corresponds to the gestational age
No significant medical diseases
No major pregnancy complications (present or past)
No previous still birth or neonatal death
No previous low birth weight baby (< 2500 g)
No previous high birth weight baby ($ 4000 g)
Adequate haemoglobin ($11 gm/dL)
Table 4: Criteria for the delivery in secondary care
History
Age < 15 years or > 40 years
Parity 8 upward
Primigravida
Height less than 152 cm
Body weight < 40 kg OR > 80 kg
Previous pregnancy problems
Previous still birth or neonatal death
Previous difficult delivery or prolonged labour (including third stage complications)
Previous low birth weight baby (< 2500 g)
Previous high birth weight baby ($ 4000 g)
History of infertility (primary or secondary) for ! 3 years Previous surgery on reproductive tract (myomectomy, removal of septum, cone biopsy, caesarean section, cervical cercelage)
12 11
Table 4: Criteria for the delivery in secondary care (Cont)
Current Medical History
Diabetes mellitus ( uncomplicated)
Essential hypertension*
Renal diseases with or without Hypertension
Sexually transmitted diseases
Haemoglobinopathies (sickle cell disease, Thalassemia Major)*
Other significant medical diseases
Current Obstetrical History
Antepartum haemorrhage
Pre-eclampsia
Polyhydromnios
IUGR (moderate)
Premature prelabour rupture of membranes (before 37 weeks)
Multiple pregnancy
Malpresentation
Cervical incompetence
Prelabour rupture of membranes (! 37 weeks)
Preterm labour (before 34 weeks)
Oligohydramnios
Anaemia (Hb < 11 gm/dL)
Postmaturity (! 42 weeks)
* Some cases might need to deliver in the tertiary care; cases should be evaluated according to the severity of the condition.
13 12
Table 5: Criteria for the delivery in tertiary care
Current medical History
Diabetes mellitus with severe complications
Heart disease (unless mild and well tolerated)
Renal disease with Hypertension, impaired renal function, or renal transplant
Positive cases of HIV and Hepatitis B
Current Obstetrical History
Rhesus antibodies
IUGR (severe)
Place of delivery of a fetus with abnormality (compatible with life) depends on the type of the abnormality. The delivery should be conducted in a place where SCBU facilities are available and the decision should be shared between the obstetrician and the paediatrician.
14 13
Table 6: Tasks of ANC visits
When Tasks
At • Profiling booking • A leaflet explaining to the mother all the services provided during this visit including: medical & obstetrical history, laboratory tests,
clinical examination, risk grading, ultrasound for dating and health education will be provided
• History taking • Clinical examinations; breast, systemic, weight, height, BMI, BP and fundal height
• Laboratory tests: Urine tests ( for albumin , ketones, glucose, microscopy), Hb, Blood group & Rh, , RBS ,.OGTT(if indicated) ,OGCT (if booking at 22-24 wks),VDRL,HIV , ABS test (if Rh-ve),
sickling test (if not known) • Ultrasound for dating ( if available)
• TT vaccination (if indicated) • Risk grading • Supplementation of folic acid
• Counsel on : Danger signs , exposure to X-Rays & teratogenic substance , clinic attendance, nutritional advice, information on pregnancy signs and symptoms
12-14 • Clinical examinations : BP, fundal height weeks • Laboratory tests: no routine laboratory tests at this visit. TT vaccination (if indicated) • • Risk grading • Supplementation of folic acid & iron
• Counsel on : Danger signs , diet and supplementation
22-24 • Clinical examinations: BP, fundal height ,fetal heart sounds, weeks asses fetal movement Obstetric • Laboratory tests: OGCT, OGTT (if indicated) visit • Risk grading • Supplementation of folic acid & iron
• Counsel on: Danger signs, diet, exercise, compliance of iron and managing common symptoms.
• Clinical examinations: BP, fundal height ,fetal heart sounds 28-30 weeks asses fetal movement • Laboratory tests: Hb, ABS test (if indicated) • Risk grading • Supplementation of folic acid & iron • Counsel on: Danger signs , preparation for lactation, fetal movement.
15 14
Table 6: Tasks of ANC visits (Cont)
32Table-34 6: Tasks� Clinicalof ANC visitsexaminations: (Cont) BP, fundal height ,fetal heart sounds, weeks asses fetal movement 32-34 •� Clinical Laboratory examinations:routine BP, fundal heighttests laboratory this visit ,fetal heart sounds, weeks • assesgradingmovementRisk fetal • SupplementationLaboratory tests:of no folicroutine acid laboratory & iron tests at this visit Table 6: Tasks• CounselgradingRisk visits on(Cont)of : Danger ANC signs, preparing for delivery including place • Supplementationfor delivery , signs ofof folic onsetacid of & iron labo ur • Counsel on : Danger signs, preparing for delivery including place 3632--3438 � Clinical examinations: BP, fundal height, ,fetalheart sounds, weeksTable 6: Tasks assesfor delivery fetal movement , (Cont) onset and ofpresentation, labour fetal lie and how many 36-38 �• fifth Laboratoryexaminations:routine palpableClinical BP, fundal labo height,ratory fetal tests this visitatheart sounds, weeks32-34 �• asses Laboratoryexaminations: fetal tests: Hb, BP, fundal height lie and howClinical ABSpresentation, movement and (if indicated)Risk ,fetal heart grading sounds,many weeks • Supplementation of folic acid & iron fifth gradingRisk fetalassespalpablemovement SupplementationDanger routine laboratoryindicated)delivery including place •� Laboratory tests:of folic acid & iron tests at this visitCounsel : Hb,signs, test (if forno ABS preparing • Co: signsunselgrading of signs offetalRisk Danger on ,foronset delivery , labourmovements , review by the
• Supplementationfolic on theobstetrician deliveredacid if of folic & ironexpected date , postnatal visit, 36-38 �• signs Counselexaminations:signs, of of labour, fetal height, fetal ,heart by theClinical preparingmovementsdelivery Danger BP, ,fundal advice.birth spacing for including reviewsounds, place weeks • Appointmentmovementdeliveredfor fetal , at 40 and the expected lie to how (ifassesdelivery presentation, ifsigns of onset of labourobstetrician fetaldat eandpostnatalmanynotweeks in the secondary care , be given visit, fifth palpable deliveredonsetthen)labour,signs of by of birth spacing advice. 36-38 �• Clinical Appointmentexaminations:weeks 40Hb, BP,in the (if indicated) fundalsecondaryfetalcareheart to be givenLaboratory ABS test sounds, height, (if not 40weeks • asses secondarymovementdelivered and presentation, fetal planand howby many then) weeks • Supplementationfifthdelivery.palpable of folic acid & iron
40 � LaboratorysecondaryDanger signs , fetal(ifmovements reviewthe the • In the tests: Hb, (if nottest delivered) ,plan for byCounsel : care yet indicated) weeks • obstetricianRiskdelivery.grading if not delivered on the expected date , postnatal visit, • Supplementation labour, birth spacing advice. signs of onset of of folic acid & iron • Appointment Dangerweeks in fetal movementscarereview given (if not Counsel : at 40 signs , the secondary , to be by the obstetriciandelivered by ifthen)delivered not on the expected date , postnatal visit, signs of onset of labour, birth spacing advice. 40 • AppointmentIn the secondary at 40 careweeksnot (if in yetthe delivered) secondary to care plan to be for the given (if not weeks delivereddelivery. by then)
• In the secondary care (if not yet delivered) to plan for the 40 weeks delivery.
15
16 15
11. REFERRAL TO SECONDARY CARE LEVEL
The routine ANC care is to be at the parent institution. All cases should be referred once to the secondary care at 22 to 24 weeks for assessment. In addition any woman with any conditions in Table 7 should be referred to secondary care. The table shows the time at which to refer the case.
Table 7: Indications for referral to secondary care
Risk factors for referral at booking
Medical history Obstetric/Gynaecological history
Hypertension Pre-eclampsia/ eclampsia
Diabetes Mellitus 3 or more consecutive 1st trimester abortions
Renal Disease Thrombosis/ Embolus
Cardiac disease RH isoimmunization
Sickle Cell Disease Malformation/ chromosomally abnormal child
Thalassemia Major Previous fetal and neonatal death
Chronic Hepatitis Surgery on reproductive tract
HIV Pelvic tumour
Psychiatric Disorders Previous preterm, low birth weight or macrosomia
Epilepsy Previous second trimester abortion/cervical incompetence
Genetic Disorders
Risk factors for later referral Time of referral
Previous APH/PPH At 24 weeks
Previous PROM At 24 weeks
Previous caesarean section At 32 weeks
Intrauterine growth retardation Whenever suspected/ detected
Multiple pregnancy Whenever suspected/ detected
Polyhydromnios/Oligohydromnios Whenever suspected/ detected
17 16
Table 7: Indications for referral to secondary care (Cont)
Other conditions needing Time of referral referral (not classified as risk
factors)
History of Thyroid disorders At booking
History of previous Hydatidiform At booking Mole
Conception following clomid At booking (after 2 years of infertility) or IUI or IVF
Pregnancy following prolonged At booking infertility (more than 3 years) with spontaneous conception
Previous obstructed labour At 32 weeks
Placenta previa At 32 weeks
Fetal malpresentation, unstable At 36 weeks by urgent appointment lie
If any significant medical or obstetric problems are detected (other than those mentioned) the doctors should use their clinical judgment for referral to secondary care level.
18 17
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1. Anaemia
Anaemia in pregnancy is defined as haemoglobin concentration of less than 11g/dL.
Routine supplementation
Each pregnant woman with normal Hb should receive from second trimester (second visit, 12-14 weeks) standard dose of ferrous sulphate 200mg daily and folic acid (5mg) once daily (given in the form of Fefol capsule).
Management
Anaemia is classified according to the level of Hb. Classification and management is shown in the table below:
Table 8: Management of anaemia in pregnancy
Assess Classify as Management
Hb. level
10-10.9 g/dL Mild Anaemia - Give daily dose of I capsule of Fefol; - Monitor Hb level and compliance every 4
weeks; - Health education;
- Investigate for other possible causes of
anaemia if no response to the treatment.
If gestational age < 34 weeks: 7- 9.9 g/dL Moderate • Anaemia One tablet of ferrous sulphate 3 times/day - (TID) + one tablet of folic acid. Monitor Hb level and compliance every 4 - weeks; Health education. - • If gestational age !34 weeks: Investigate for other possible causes of - anaemia; Consider parenteral iron therapy/blood - transfusion.
20
23
Table 8: Management of anaemia in pregnancy (Cont)
4- 6.9 g/dL Severe Anaemia • If no symptoms and gestational age < 34 weeks : I tablet of ferrous sulphate
(TID) + I tablet of folic acid, follow up within 2 weeks.
• If women is symptomatic and/or gestational age !34 weeks : consider
parenteral iron therapy/blood transfusion. • Investigate for other possible causes of
anaemia.
< 4 g% Very severe • Consider parenteral iron therapy/ blood Anaemia transfusion • Investigate for other possible causes of anaemia
Good compliance will result in rise of Hb by 2 g/dL in one month. Hence in all non responsive anaemia checking for compliance is essential which is mainly due to forgetfulness or side effects like nausea, vomiting and constipation.
Patients with mild intolerance (moderate anaemia): reduce the dose and gradually step up. If intolerance persists, try to change to Fefol once per day with meal.
Dietary advices
Explain the following to the woman:
• To take diet rich in iron & folate such as liver, kidney, heart, lean meat, egg yolk, shell fish, dried beans, legumes, dried fruits, green leafy vegetables, whole cereals and jaggery. • To take Vitamin C containing foods such as papaya, lemon, orange, mango etc. • Do not over cook green leafy vegetables. • Do not consume milk, tea or coffee with food or within two hours of taking iron tablets. • Do not take antacids with meals or within two hours of taking iron tablets. • Take iron tablet with meals (to reduce drug intolerance) and preferably with a glass of orange juice regularly.
SEVERE ANAEMIA
• Consider parenteral iron therapy/ blood transfusion. Give ferrous sulfate PLUS folic acid by mouth during pregnancy. • • Continue for 3-6 months postpartum. Investigate for other possible causes of anaemia, keep Vitamin B 12 deficiency in • mind being one of the common causes of anaemia.
24 21
Parenteral Iron Replacement Therapy
Formulation used:
Iron (III) Hydroxide saccharate complex (Iron Saccharate) (trivalent Iron: 100mg in ml ampoule).
Indications:
• Severe anaemia (Hb: 4 – 6.9 g/dl) and/or gestational age ∃34 weeks. • Very severe anaemia (Hb < 4 g/dl). • Impractical oral therapy with persistent GI intolerance or non-compliance.
Note: Monitoring of response by regular Hb and reticulocyte count is required.
Dose calculation:
1. Use the following table to calculate total dose:
BW (kg) Hb 60 g/L Hb 75 g/L Hb 90 g/L Hb 105 g/L Ampoule Ampoule Ampoule Ampoule 35 12.5 11.5 10 9 40 13.5 12 11 9.5 45 15 13 11.5 10 50 16 14 12 10.5 55 17 15 13 11 60 18 16 13.5 11.5 65 19 16.5 14.5 12 70 20 17.5 15 12.5 75 21 18.5 16 13 80 22.5 19.5 16.5 13.5 85 23.5 20.5 17 14 90 24.5 21.5 18 14.5
2. The total dose of iron can be calculated from the following formula:
Body weight (kg) X (normal Hb – actual Hb in g/l) X 0.24 + depot iron
Iron depot = 15 mg per kg up to a weight of 34 kg and a total of 500 mg above 34 kg.
Administration:
First day: 2.5 ml = 50 mg Fe (III) • Second day: 5.0 ml = 100 mg Fe (III) • Third day: 10.0 ml = 200 mg Fe (III) •
To be followed by 10 ml two times a week depending on haemoglobin level. •
Note: Not to be given for more than three times weekly.
25 22
• The dose may be given undiluted at rate of 20 mg/minute, after a test dose of 20 mg of iron has been given over 1 to 2 minutes. • Alternatively, 100 mg is diluted in a maximum of 100 ml of sodium chloride 0.9% and the first 25 mg given as a test dose over 15 minutes; the remaining portion is given at a rate not exceeding 50 ml per 15 minutes.
Watch for the adverse effects:
• Anaphylaxis • Headache • Nausea and vomiting • Cramps (specially leg cramps) • Flushing chills and fever, bronchospasm, circulatory collapse.
2. Hypertension in Pregnancy
Diagnosis of hypertensive disorders
The hypertensive disorders of pregnancy include pregnancy-induced hypertension and chronic hypertension (elevation of the blood pressure before 20 weeks gestation). Headaches, blurred vision, convulsions and loss of consciousness are sometimes associated with hypertension in pregnancy, but are not necessarily specific to it. Diastolic blood pressure is a good indicator of prognosis for the management of hypertensive disorders in pregnancy.
If the diastolic blood pressure is 90 mm Hg or more on two consecutive readings taken four hours or more apart, diagnose hypertension. If urgent delivery must take place or if the diastolic blood pressure is 110 mm Hg or more, a time interval of less than four hours is acceptable :
- If hypertension occurs after 20 weeks of gestation, during labour and/or within 48 hours of delivery it is classified as pregnancy- induced hypertension; - If hypertension occurs before 20 weeks of gestation, it is classified as chronic hypertension.
Diastolic blood pressure alone is an accurate indicator of hypertension in pregnancy. Elevated blood pressure and proteinuria, however, defines pre-eclampsia.
26 23
Table 9: Diagnosis of elevated blood pressure during pregnancy
Presenting Symptoms Symptoms and Signs Probable and Other Symptoms and Sometimes Present Diagnosis Signs Typically Present
• Diastolic blood Chronic pressure 90 mm Hg or hypertension more during first 20
weeks of gestation
• Two readings of Pregnancy- diastolic blood pressure induced
90-110 mm Hg 4 hours hypertension apart after 20 weeks
gestation
• No proteinuria
• Two readings of Mild pre- diastolic blood pressure eclampsia,
90-110 mmHg 4 hours apart after 20weeks gestation
• Proteinuria
• Diastolic blood • Headache (increasing Severe pre- pressure 110 mm Hg or frequency, unrelieved by eclampsiaa
more after 20 weeks regular analgesics) gestation • Blurred vision
• Proteinuria • Oliguria (passing less than 400 mL urine in 24 hours)
Upper abdominal pain • (epigastric pain or pain in right
upper quadrant)
Hyperreflexia • • Pulmonary oedema
• Convulsions • Coma (unconscious) Eclampsia • Diastolic blood • Other symptoms and signs pressure 90 mm Hg or of severe pre-eclampsia more after 20weeks gestation • Proteinuria a If a woman has any one of the symptoms or signs listed under severe pre- eclampsia,
pregnancy-induced hypertension, there may be no symptoms and the ! onlyIn sign may be hypertension.
27 24
AAsmall proportion ofofwomen with eclampsia have normal blood pressure. Treatwomensmall with proportionwith until anotherconvulsionswomen of women as withAeclampsia women withhave eclampsia ififthey blood until another anotherpressure.they normal isdiagnosiswomen withTreat confirmed.confirmed. allA smallconvulsions isisproportioneclampsia women have with eclampsia if they normalpressure. blood until another Treatdiagnosis all women is confirmed. with convulsions as if they have eclampsia until another diagnosis is confirmed.
Remember:Remember: Remember: Remember:• • MildMild prepre-eclampsia-eclampsia often often has hasno symptoms. no symptoms. • • IncreasingaIncreasing aMild pre proteinuria proteinuria-eclampsia is is aoften has ofsignof worsening noofsymptoms. pre-eclampsia. • • Mild pre ofof the-eclampsiafeet hassignsymptoms. oftenisis a lower ofofthe extremitiesa of worsening notnot consideredtheis pre- eclampsia. and no not consideredOedema a reliableIncreasing sign proteinuria ofOedemaof • • preIncreasing-eclampsia. feetproteinuria sign of worsening isand lower not extremitiespre consideredOedema-eclampsia. of the a reliable sign of • • MildpreMild - eclaof theprempsia. feet-eclampsia may is mayprogress not consideredprogressextremities reliable Mildto severe severe and pre lower- eclampsia.pre -rapidlyeclampsia. toOedema Thesign The of • ofpre complications,-eclampsia. complications, to in inof pre-eclampsia including eclampsia, severemay progress increases rapidly pre greatly-eclampsia. in TheriskMildofsevere • prerisk-eclampsia. of complications,may progress rapidly including to severe eclampsia, greatly increases in TheMildpre-eclampsia. severe • • riskpreA of - eclampsia. signs with in severe includingA convulsionof with prepre signs-eclampsia-eclampsiaA complications,increases indicates signs ofeclampsia,indicates eclampsia. greatly eclampsia. These These • preAconvulsions: convulsion-eclampsia.convulsions: with signs of pre-eclampsia indicates eclampsia. These • A convulsions: with signs of pre-eclampsia indicates eclampsia. These ofconvulsions:- of- - regardlesscan occur of the severity of hypertension; - -- arecanof thedifficult severity regardless of absenceandare typically totopredict occur hypertension; absence ofofoccurof headache - - canarechanges;visual difficultregardlessororoccur changes;changes; the severity of and ofoccurvisual typically to predict hypertension;absence of headache - - occurare afterdifficultchanges; tochildbirth in of in theafter predict afterandchildbirth typically in about 25% ofocc urofvisual cases; childbirth in about absence 25% of headache - - are25% tonic ofare -afterclonic andchildbirth in about cases;resembleoroccur grand and mal convulsions ofvisual changes; of epilepsy; - - occurm ay recur childbirthtonic resemble-clonicrapid inin status epilepticus, and maysequence, inmay after rapidand in 25%grandcases;convulsionsstatus epilepticus, may endmay recur rapid in about as ofstatus epilepticu s, of may en dare and recur epilepsy;end as mal inin - - death;maydeath;aretonic recur-clonic and rapid resemble sequence,grand as inmalstatus convulsions epilepticus, andof epilepsy; may end in - - death;will notwill be in not be if if observed iswill not seque is alone;nce,rapid woman ifthe as in statusmay alone; recur epilepticus, and may end in - - death;notMayMay be befollowed be observed f byollowed that lastscoma alone;willby coma woman be followed that by is iflasts theminutes that lastsMayminutes or hours hoursdepending dependingonon - - theof willfrequencythe not befrequency of observedbythe woman convulsions. isconvulsions.lastsMay followed that if coma alone;minutes or hours depending on - Maybe frequencyfollowed comaofbyconvulsions. thatthe lasts minutes or hours depending on the frequency of convulsions. DoDo not not give givegive ergometrine ergometrineergometrine to womento to women women with with with pre pre- eclampsia,pre-eclampsia,-eclampsia, eclampsia eclampsia eclampsia or orhigh high or high bloodgive because pressure to womenergometrine riskofof convulsions increasesandeclampsia highbecause the with pre risk -convulseclampsia,ionsDo not becauseand cerebrovascular risk of convulsions and bloodaccidents.accidents. pressure because ergometrine it women the toincreases risk of convulsions with pre-eclampsia, and high eclampsiacereDo not give brovascular bloodaccidents. pressure because it increases the risk of convulsions and cerebrovascular accidents. MANAMANAGEMENTGEMENT OF OF OFPREGNANCY PREGNANCY PREGNANCY-INDUCED-INDUCED-INDUCED HYPERTENSION HYPERTENSION HYPERTENSION MANAGEMENT OF PREGNANCY-INDUCED HYPERTENSION MANAGEMENTof1:Box 1: Prevention OF PREGNANCYofpregnancypregnancy induced induced-INDUCED hypertension hypertension HYPERTENSION Box 1: Prevention of pregnancy induced hypertension Box 1: PreventionPreventionhypertensionof ofofpregnancy pregnancy -induced hypertension Prevention of pregnancy-induced hypertension • •Early detectionPreventionwith high riskmanagement is ishigh riskpregnancy factorand of- induced women hypertensionwith high risk criticalfactor is criticaltototo •theofthe ofmanagement ofmanagement management and pregnancy womenpregnancy with-induced- inducedhigh hypertensionrisk thehypertension is critical and factor andtoEarly theprevention detectionpreventionofof of • Earlyof womenshould management bewomen with theiswomen should pregnancy up given clearwomen-induced in up risk and hypertension critical ofmanagementshould bebefolloweregularly d high and givenfactorandpreventionclear totheconvulsions. These convulsions.detection and theinstructionsm on ofanagementThesepregnancy women should up regularly Educationwhen ofinstructions on when totoreturnreturn tototheir health- inducedtheirhypertension care and given ofofon when to return to their followedcare an d the E ducation provider.be health care Educationconvulsions.preventioninstructions clear convulsions.immediate familywhen to isis These so that they theymembers onlyimmediatemembers familyshould women return to theirequally health thatand important, given onlythat clearimmediateregularlyprovider. family isinstructions on theybe followedEducation up caresoonly of onunderstandthewhenmembers family ofof significancecare so that Education of ofis signsequally signs important,healthofprovider.instructions pregnancypregnancypregnancy- theinduced - inducedtoinduced return hypeto their hypertensiononlyhypertensionimmediatertension the immediateprogression but is fa supportmily they significance hypertensionbutalso help toincreaseto of signssocialimportant, socialpregnancy sosupport thatunderstandsupport the also -helpinduced equallyduring ofbut membershospitalization only ininprogression socialin changes ofwhensignificance the alsowork to activities needed.supportneeded.increase hypertensionunderstand pregnancy - inducedbut help of signshospitalizationand • •progressionRestricting calories, inRestricting changes but also help and fluids salt are doestoactivitiesRestricting calories, workintake increaseneeded. doesand when calories,NOT prevent and salt social supporthospitalization during pregnancy- •changesandRestricting and intake towork hypertension harmful toinduced calories, fluids and andactivitiessalt be harmfulwhen and may needed.does evenarebe harmful to NOT the fetus.prevent pregnancy- • Restrictinghypertensionfluidsinduced calories, andand may salt evenintakeharmfulbe does to the fetus. NOT prevent pregnancy- induced hypertension and may even be harmful to the fetus. 28 252525 25 25
Box 2: Investigations to be performed for pregnancy induced hypertension
• CBC • Renal Function Test (RFT). • Uric Acid • Liver Function Test (LFT). • If proteinurea is present: 24 hour Urine Collection for Creatinine Clearance. • Coagulation profile in severe pre-eclampsia or if platelets count is below 100 X 109
MILD PRE-ECALMSIA
GESTATION LESS THAN 37 WEEKS
If signs remain unchanged or normalize, follow up twice a week as an outpatient in the primary care for the monitoring of: blood pressure, fetal heart sound and urine for protein. Patient should be referred back to the secondary as emergency if any of the above was abnormal.
• Monitor blood pressure, urine (for proteinuria), reflexes and fetal condition. • Counsel the woman and her family about danger signs of severe pre-eclampsia or eclampsia. • Encourage adequate rest. • Encourage the woman to eat a normal diet (salt restriction should be discouraged). • Do not give anticonvulsants, antihypertensives, sedatives or tranquillizers. • If follow-up as an outpatient is not possible, admit the woman to the hospital:
- Provide a normal diet (salt restriction should be discouraged); - Monitor blood pressure (every 4-6 hours) and urine for proteinuria (daily); - Do not give anticonvulsants, antihypertensives, sedatives or tranquillizers unless blood pressure or urinary protein level increases; - Do not give diuretics. Diuretics are harmful and only indicated for use in pre- eclampsia with pulmonary oedema or congestive heart failure;
• If the diastolic blood pressure decreases to normal levels or her condition remains stable, send the woman home:
- Advise her to rest and to watch out for significant swelling or symptoms of severe pre-eclampsia; See her twice weekly to monitor blood pressure, urine (for proteinuria) and - fetal condition and to assess for symptoms and signs of severe pre-eclampsia;
If diastolic blood pressure rises again, readmit her; •
Start treatment with antihypertensives: - - First drug of choice: labetalol 100 mg twice daily, can be increased according to the blood pressure ( maximum dose: 1200 mg /24 hours [divided in TID or QID doses]). OR Methyldopa 250 mg three times a day,
29 26
can be increased to the maximum dose of 2 gm / day. - If BP is not controlled, add: hydralazine 25/50 mg OD. - If BP is still not controlled, add: adalat 20 mg OD/BD.
Note: Labetalol should be used in cautious in women with history of asthma, heart failure and preferably to be started after 30 weeks of gestation.
• If the signs remain unchanged, keep the woman in the hospital. Continue the same management and monitor fetal growth by symphysis-fundal height;
- If there are signs of growth restriction, consider early delivery. If not, continue hospitalization until term.
• If urinary protein level increases, manage as severe pre-eclampsia (see below).
Note: Symptoms and signs of pre-eclampsia do not completely disappear until after pregnancy ends.
GESTATION MORE THAN 37 COMPLETE WEEKS
If there are signs of fetal compromise (e.g. decreased amniotic fluid, growth restriction), assess the cervix and expedite delivery:
If the cervix is favourable (soft, thin, at least 3 cm dilated), rupture the - membranes with an amniotic hook and induce labour using oxytocin. If the cervix is unfavourable (firm, thick, closed), ripen the cervix using prostaglandins or a Foley catheter or deliver by caesarean section.
SEVERE PRE-ECLAMPSIA AND ECLAMPSIA
Severe pre-eclampsia and eclampsia are managed similarly with the exception that delivery must occur within 12 hours of onset of convulsions in eclampsia. All cases of severe pre-eclampsia should be managed actively and preferably in the regional/ tertiary hospital where laboratory facilities and ICU are available. Symptoms and signs of “impending eclampsia” (blurred vision, hyperreflexia) are unreliable and expectant management is not recommended.
Management during a convulsion
Gather equipment (airway, suction, mask and bag, oxygen) and give oxygen at 4-6 • L per minute. • Protect the woman from injury but do not actively restrain her. • Prepare anticonvulsive drugs.
General management
Start an IV line and infuse IV fluids (maintenance dose: 80 ml/hr or 1ml/kg/hr); • Give anticonvulsive drugs; • After the convulsion: •
30 27
- Position the woman on her left side to reduce risk of aspiration of secretions, vomit and blood; - Aspirate the mouth and throat as necessary;
• Monitor vital signs (pulse, blood pressure, and respiration), reflexes and fetal heart rate hourly; • If diastolic blood pressure remains above 110 mm Hg, give antihypertensive drugs. Reduce the diastolic blood pressure to less than 100 mm Hg but not below 90 mm Hg:
- Catheterize the bladder to monitor urine output and proteinuria. - Maintain a strict fluid balance chart (monitor the amount of fluids administered and urine output) to prevent fluid overload. • If urine output is less than 30 mL per hour: - Withhold magnesium sulfate and infuse IV fluids (normal saline or Ringer’s lactate) at 1 L in eight hours; - Monitor for the development of pulmonary oedema. • Never leave the woman alone. A convulsion followed by aspiration of vomit may cause death of the woman and fetus. • Auscultate the lung bases hourly for rales/ crepitations indicating pulmonary oedema. If crepitations are heard, withhold fluids and give frusemide 40 mg IV once. • Assess clotting status by sending coagulation profile.
All patients with severe pre-eclampsia and eclampsia should be started on ! prophylactic anticoagulation therapy.
Anticonvulsive drugs
A key factor in anticonvulsive therapy is adequate administration of anticonvulsive drugs. Convulsions in hospitalized women are most frequently caused by under- treatment. Magnesium sulfate is the drug of choice for preventing and treating convulsions in severe pre-eclampsia and eclampsia. Administration is outlined in Box 3.
All patients with severe pre-eclampsia plus/or eclapmsia should be ! managed in a regional or tertiary hospital where laboratory and Intensive Care Unit (ICU) facilities are easily accessible.
Therefore, once the patient is stabilized, arrange for transfer.
31 28
Box 3: Magnesium sulfate schedules for management of convulsion in severe pre- eclampsia and eclampsia
Loading dose
• Give 4 g of 50% magnesium sulfate solution in dilution, IV over 10-15 minutes.
Maintenance dose
• Give 5 g of 50% magnesium sulfate solution infusion at a rate of 1 gm/hr. • Continue treatment for 24 hours after delivery or the last convulsion, whichever occurs last.
CLOSELY MONITOR THE WOMAN FOR SIGNS OF TOXICITY.
Before repeat administration, ensure that:
• Respiratory rate is at least 16 per minute. • Patellar reflexes are present. • Urinary output is at least 25-30 mL per hour over four hours.
WITHHOLD OR DELAY DRUG IF:
Respiratory rate falls below 16 per minute. • Patellar reflexes are absent. • Urinary output falls below 30 mL per hour over preceding four hours. •
Keep antidote ready
In case of respiratory arrest: • Assist ventilation (mask and bag, anaesthesia apparatus, intubation). • Give calcium gluconate 1 g (10 mL of 10% solution) IV slowly until calcium • gluconate begins to antagonize the effects of magnesium sulfate and respiration begins.
32 29
Box 4: Diazepam schedules for severe pre-eclampsia and eclampsia
Note:! Use diazepam only if magnesium sulfate is not available.
Intravenous! administration
Loading! dose
! • Diazepam 10 mg IV slowly over two minutes. • If convulsions recur, repeat loading dose. ! Maintenance dose ! • Diazepam 40 mg in 500 mL IV fluids (normal saline or Ringer’s lactate) titrated to keep the woman sedated but reusable. ! • Maternal respiratory depression may occur when dose exceeds 30 mg in one hour: !
- Assist ventilation (mask and bag, anaesthesia apparatus, ! intubation), if necessary. - Do not give more than 100 mg in 24 hours. !
! • If convulsions are not controlled within 10 minutes, administer an additional 10 mg or more, depending on the size of the woman and her clinical response. Be prepared to assist ventilation. !
!
ANTIHYPERTENSIVE DRUGS
If the diastolic blood pressure is 110 mm Hg or more, give antihypertensive drugs. The goal is to keep the diastolic pressure between 90 mm Hg and 100 mm Hg to prevent cerebral haemorrhage. Following are the drug choices:
Hydralazine: • Initial dose: 5-10 mg I.V bolus & can be repeated every 10-20 - minutes, until mean BP <120 mmHg or diastolic BP is between 90- 100 mmHg; or up to total dose 25 mg. Maintenance dose: 40 mg in 500 ml of Hartmans solution, 4 mg per/hr - to maintain diastolic BP at 80- 90 mmHg.
Note: Continuous BP and fetal monitoring is essential as IV bolus can cause sudden fall of BP.
• labetolol: Initial dose: 50 mg (10ml) IV; can be repeated every 10-20 minutes - up to 200 mg. Maintenance dose: 200 mg in 200ml of normal saline at 20mg/hr; - 33 30
doubling every 30 minutes, until the mean BP <120 mmHg or diastolic BP around 90. Maximum dose is 160 mg/hr.
• Nifidipine (can be added if BP still not controlled): 20 mg oral, BD.
DELIVERY
Delivery should take place as soon as the woman’s condition has stabilized. Delaying delivery to increase fetal maturity will risk the lives of both the woman and the fetus. Delivery should occur regardless of the gestational age.
In severe pre-eclampsia, delivery should occur within 24 hours of the onset of symptoms. In eclampsia, delivery should occur within 12 hours of the onset of convulsion.
Assess the cervix:
• If the cervix is favourable (soft, thin, partly dilated), rupture the membranes with an amniotic hook and induce labour using oxytocin; • If vaginal delivery is not anticipated within 12 hours (for eclampsia) or 24 hours (for severe pre-eclampsia), deliver by caesarean section; • If there are fetal heart rate abnormalities (less than 110 or more than 160 beats per minute), deliver by caesarean section; • If the cervix is unfavourable (firm, thick, closed) and the fetus is alive, deliver by caesarean section.
Note: If caesarean section is performed, ensure that coagulopathy has been ruled out;
Avoid pethidine in all patients with severe pre-eclampsia and eclampsia, tramal should be given instead
POSTPARTUM CARE
Anticonvulsive therapy should be maintained for 24 hours after delivery • or the last convulsion, whichever occurs last; Continue antihypertensive therapy as long as the diastolic pressure is 110mm • Hg or more; Continue to monitor urine output as long as admitted; • Follow up at 2 weeks postnatal care with frequent BP readings. If BP readings • were normal, patient will be referred back to the primary care for routine PNC care. If BP readings were abnormal, continue BP monitoring till 6 weeks PNC visit. Women with persisting hypertension and proteinuria at 6 weeks may have renal • disease and should be referred to the physician.
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REFERRAL FOR TERTIARY LEVEL CARE
Consider referral of women who have:
• Severe pre-eclampsia, eclampsia. • Oliguria that persists for 48 hours after delivery; • Coagulation failure (e.g. coagulopathy or haemolysis, elevated liver enzymes and low platelets [HELLP] syndrome); • Persistent coma lasting more than 24 hours after convulsion.
CHRONIC HYPERTENSION
• Encourage additional periods of rest. • High levels of blood pressure maintain renal and placental perfusion in chronic hypertension; reducing blood pressure will result in diminished perfusion. Blood pressure should not be lowered below its pre-pregnancy level. There is no evidence that aggressive treatment to lower the blood pressure to normal levels improves either fetal or maternal outcome:
- If the woman was on anti-hypertensive medication before pregnancy and the disease is well-controlled, continue the same medication if acceptable in pregnancy; - If diastolic blood pressure is 110 mm Hg or more, or systolic blood pressure is 160 mm Hg or more, treat with antihypertensive drugs; - If proteinuria or other signs and symptoms are present, consider superimposed pre-eclampsia and manage as mild pre-eclampsia. • Monitor fetal growth and condition. • If there are no complications, deliver at term. • If pre-eclampsia develops, manage as mild pre-eclampsia or severe pre- eclampsia • If there are fetal heart rate abnormalities (less than 110 or more than 160 beats per minute), suspect fetal distress. • If fetal growth restriction is severe and pregnancy dating is accurate, assess the cervix and consider delivery:
Note: Assessment of gestation by ultrasound in late pregnancy is not accurate.
- If the cervix is favourable (soft, thin, at least 3 cm dilated), rupture the membranes with an amniotic hook and induce labour using oxytocin ; - If the cervix is unfavourable (firm, thick, closed), ripen the cervix using prostaglandins or a Foley catheter.
• Observe for complications including abruptio placentae and superimposed pre- eclampsia).
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3. Diabetes Mellitus in Pregnancy
All women registering with ANC clinic should be screened for Gestational Diabetes as shown in the following Algorithm:
Algorithm 1: Screening steps for gestational diabetes
ALL PREGNANT WOMEN
RBS/FBS at Booking
If RBS ! 7 or FBS> 5.5 If RBS < 7, FBS ! 5.5 Do OGTT at booking Do OGCT at 22-24 wks
If PGBS ! 7.8: If 2 hrs BS < 7.8: OGCT AT 22-24 wks Classify as D.M if < Normal 22 wks, Gestaional Diabetes if ! 22 wks
Do OGTT at 22-24 wks If 1 hr BS ! If PGBS < 7.8 7.8
Do OGTT Gestational at 22-24 Diabetes
wks unlikely
OGTT AT 22-24 wks
If the PGBS < 7.8 If PGBS ! 7.8 Gestational Classify as
Diabetes unlikely Gestational Diabetes
36 33
Remember:
• When performing GTT, If fasting blood sugar is ! 7 mmol/L , proceed with the 2 hr test without giving the glucose. • In patients with chronic diabetes mellitus, oral antidiabetis medications should be stopped as soon as patient is diagnosed to be pregnant.
GENERAL MANAGEMENT OF DIABETES IN PREGNANCY
• Classify & manage as high risk pregnancy; • Advice diet of 25 Kcal/Kg/day, and to avoid fast absorbing [refined] sugars; • Give insulin two times/ day if not controlled on diet alone. [Mixture of long acting and medium acting insulin].
In additions take the following steps
• Monitor fetal well being by serial ultrasound scans and CTG; fetal weight should be estimated by ultrasound in the last visit. This will provide fore-warning of possible shoulder dystocia; • Admit in hospital if necessary to control blood sugar levels, (and teach the patient how to inject insulin]; • Admit at 37-38 weeks for complete evaluation and plan of delivery; • Induce labour at 40 weeks if diabetic control is good and there are no other medical or obstetric complications.
Note: Induction of labour at 38 weeks or prior to that if previous history of stillbirth at term is present or if complication arises during the present pregnancy. The aim is for a vaginal delivery unless there is an indication for caesarean section. During labour soluble insulin is administered by a pump at a rate depending upon the capillary blood sugar checked at intervals. The aim is to keep the blood sugar at 4 – 7 mmol/L.
Note: In cases of pure gestation diabetes much lower doses of Insulin during labour may be required (or not required at all).
MANAGEMENT OF SPECIFIC FORMS OF DIABETES DURING LABOUR AND POSTPARTUM PERIOD:
GESTATIONAL DIABETES:
Patients controlled on diet alone:
Perform base line blood sugar and one more reading during labour, 2-4 hours • apart; • If RBS > 8 mmol/L, manage as insulin dependant diabetes mellitus; • Start dextrose saline or normal saline drip;
37 34
Postnatal care:
- Patient can be discharged home if OGTT is normal, FBS: (< 5.5 - 5.8 mmol/L) and 2 hours ! 7.8 mmol/L; - OGTT at 6 weeks PNC visit; - Refer to diabetic clinic if abnormal OGTT at 6 weeks.
Patients on Low dose Insulin
• Manage as above.
Patients on High Dose Insulin
• Manage as insulin dependent diabetes mallitus.
INSULIN DEPENDENT DIABETES MELLITUS
In Planned Induction
• Omit morning dose of the long acting insulin; • Patient can have snacks and short acting doses of insulin until labour is established; • Check fasting blood sugar If < 4 mmolL, infuse 5% dextrose 100ml/hr; • Check Blood Sugar every 1 hour. Commence insulin 20 U (Actrapid) in 20 ml of normal saline at 1 u/hr depending on sliding scale: - I U/hr if blood sugar 7-8 mmol/L. - 2 U/hr if blood sugar 8-10 mmol/L. - 3 U/hr if BS > 10 mmol/L. • Repeat blood sugar hourly for 4 hours, if stable repeat every 2 hours; • Check urine for ketones every 2 hrs; • Blood sugar should be kept between 4-6 mmol/L.
If in Labour
• Do a baseline blood sugar, if ∃ 7 mmol/L start insulin depending on sliding scale.
Postnatal care:
If patient delivers spontaneously, give subcutaneous insulin one-third - dose of antenatal requirement half an hour after meal on the 1st day, repeat fasting blood sugar on the 2nd day; Aim for postnatal pre-meal blood sugar of 7 – 8 mmol/L and post meal - blood sugar (2hours) up to 11 mmol/L; Follow up at 2 weeks and 6 weeks PNC (in fasting state). -
Cesarean Section
Elective LSCS: • Give the usual evening dose of insulin; - On the morning of the operation, omit the morning dose; -
38 35
- Do FBS, commence insulin if > 10 mmol/L by sliding scale and check blood sugar hourly. • Emergency LSCS: - Start IV of 5% Dextrose 500ml/ 4 hours, add K + 20 mol/L; - Insulin pump in separate infusion and adjust according to sliding scale.
Postnatal care:
- Continue insulin pump if required until patient resumes full diabetic diet, usual requirement is one third of the original dose. - Pump is to be stopped one hour after eating; - Collect 3 samples of blood (1 fasting, and 2 post-prandials) on 3rd and 4th day postpartum, maintain blood sugar levels as stated above; - Follow up at 2 weeks and 6 weeks.
NON- INSULIN DEPENDENT DIABETES MELLITUS [INSULIN ONLY DURING PREGNANCY]
Planned Induction or Emergency Labour:
• Manage as insulin dependent diabetes mellitus. • Postnatal care: - Perform FBS on the following day, if > 8 mmol/L, commence on oral hypoglycemic agents as on pre-pregnant dose. - Follow up at 2 weeks and 6 weeks PNC (in fasting state).
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4. Urinary Tract Infections (UTI)
Evidence based studies show that proper management of UTI during pregnancy will lead to better pregnancy outcomes. Undetected UTI is a common cause of preterm labour, IUGR and anaemia . The following table shows the detection and management of UTI during pregnancy:
Table 10: Detection and management of UTI in pregnancy
Assess (signs & Probable Management
symptoms) Diagnosis
Typical: Cystitis • Do urine test (microscopy and culture if indicated by the microscopy) - Dysuria - Increased • Encourage adequate rest
frequency and • Encourage increased fluid intake by mouth urgency of • Use paracetamol to decrease temperature urination • Start Antibiotics: Amoxycilline 500 mg by Other (atypical) mouth three times/day for 5-7 days ( to be
- Retropubic/ continued for 10 days if culture was suprapubic pain positive)
- Abdominal pain • Repeat urine culture after 1 wk of the last dose of the antibiotics( if the initial test was
positive).
If treatments fails, or if infection recurs
two or three times: • Check urine for culture and sensitivity (if
not already done), and treat with an appropriate Antibiotic for organism.
Start prophylaxis Antibiotics if infection recurs two or three times:
• Amoxycilline 250 mg by mouth once daily at bedtime for the reminder of pregnancy and two weeks postpartum.
Typical: Acute • If shock is present or suspected: initiate - Dysuria Pyelonephrits immediate treatment. - Spiking fever • Insert IV line and start IV infusions at the /Chills rate of 150 mL per hour. - Increased • Check urine culture and sensitivity. frequency and • Awaiting culture, treat with antibiotics: urgency of Ampicilline 2 g IV every six hours; until the urination women is fever-free for 48 hours. - Abdominal pain • Once the women is fever-free for 48 Other (atypical) hours, give amoxycilline 1 g by mouth
37
40
- Retropubic/ three times per day to complete 14 days of suprapubic treatment. pain Note: Clinical response is expected within - Loin pain 48 hours. If there is no clinical response in /tenderness 72 hours, re-evaluate results and antibiotic - Tenderness in rib coverage. cage For prophylaxis against further - Anorexia infections: - Nausea /vomiting • Amoxycilline 250 mg by mouth once daily at bedtime for the reminder of pregnancy and two weeks postpartum. Note: If there are palpable contractions and blood stained mucus discharge, suspect preterm labour.
5. Asymptomatic Bacteriuria:
• Usually diagnosed accidentally during the routine urine testing at the booking visit as patient is asymptomatic. • Should be treated as per the culture results, or with Amoxicillin 500 mg orally three times per day for 10 days. • Urine culture to be repeated 1 week after the last dose of the antibiotics.
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6. Vaginal Discharge during Pregnancy
Vaginal Infections in pregnancy are common and important because they can cause spontaneous abortion, pre-term labour and chorioamnionitis. Several infections such as gonorrhea, chlamydia, group B streptococci, HIV and herpes virus can be transmitted during labor directly to the fetus.
Diagnosis
For the diagnosis of vaginal discharge during pregnancy the following chart can be used :
Algorithm 2: Management of vaginal discharge during pregnancy
All pregnant patients complaining of vaginal discharge or vulval itching / burning
• History: duration, frequency, h/o similar problem with husband, abdominal pain, dyspareunia, dysuria and past h/o PROM and/or preterm labour. • Examination: - (by speculum): inspect for: abnormal discharge (colour, odour), valvovaginal erythema. - palpate for lower abdominal pain
History & examination • History of • History of suggestive of candidiasis: abnormal vaginal abnormal vaginal thick, cheesy white discharge* discharge* discharge that adheres to • History of lower • No lower the wall, no odour, vulvar abdominal pain abdominal pain and vaginal erythema
Treat as candidiasis • Perform vaginal • Perform vaginal swab swab
• Consider • Consider/ treat as chorioamnionitis, Trichomonas Follow up within 2 weeks endometritis) vaginalis/ Bacterial Vaginosis
* Abnormal vaginal discharge:
39
42
endometritis) vaginalis/ Bacterial Vaginosis
* Abnormal vaginal discharge: - Copious, malodorous, yellow-green discharge, pruritus, dysuria, vulvar and vaginal oedema & erythematic cervix (Trichomoniasis); 39 - Thin, off-white discharge, unpleasant “fishy” odour, increasing after sexual intercourse, normal appearance on examination (Bacterial Vaginosis); - Others (Gonococal, Chlamydia).
General Management
Patient suffering from vaginal discharge is unlikely to mention her complaint because of shyness and aversion to vaginal examination, or because of the lack of privacy in the clinic. Therefore, the doctor or the nurse should not forget to ask if there is a discharge “fee wasakh min taht?”
In patients with vaginal discharge, a speculum examination should be performed. It is very important to avoid hurting the patient during this examination. This could be achieved by the following measures:
- Patient’s thighs must be widely abducted. This calls for careful draping of the legs with covering sheet to help the patient to relax. - The Cusco speculum should be of the correct size and should be lubricated by smearing the blades thinly with a lubricant gel. It should be inserted deeply. - The blades should only be separated when the speculum has been inserted to its full depth to avoid stretching the sensitive vaginal introitus.
Specific management
Management of specific cases of vaginitis is illustrated in the following table:
Table 11: Specific management of vaginal discharge during pregnancy
Disease Treatment Remarks Candidiasis Drug option • If recurrent (more than 2 • Miconazole or clotrimazole times despite adequate vaginal suppositories 200 mg treatment): inserted in the vagina for 3 days # Perform vaginal swab to or confirm the diagnosis or • Clotrimazole 500 mg inserted in to diagnose other the vagina as a single dose possible organisms. Alternative # Counsel for hygiene. # Perform OGTT to exclude • Nystatin suppositories. Each diabetes. contain 100,000 unit each night for 7-14 nights # Exclude other predisposing factors:
antibiotic use, use of antiseptic/antibiotic vaginal preparations or vaginal douching.
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• Routinely, treating the partner is not required but he should be treated in cases of recurrent infections in women.
Trichomonas Drug option: • If no response: add vaginalis/ metranidazole vaginal • Metronidazole 400-500 mg orally, Bacterial twice daily for 5-7 days suppositories, 500 mg at Vaginosis Or bed time for 3-7 days in addition to the oral 200-250 mg three times/day for 7 treatment. days • Partner should be offered treatment.
44 41
7. HIV in Pregnancy:
All women registering with ANC clinic should be screened for HIV as shown in the following Algorithm:
Algorithm 3: HIV testing in pregnancy
WOMAN at ANC clinic
AT ANC CLINIC • Verbal consent; • Collect 5 cc of blood sample in Serum Separating Tube (SST Tube Red cap with gel); • If PHC facility has laboratory, centrifuge the blood and separate the serum. Put in the plain tube before dispatching; • PHC facility with no laboratory send the whole blood; • Send the blood/serum to the Regional Public Health Laboratory (RPHL).
• Send theAT blood/serum REGIONAL PUBLICsample toHEALTH the regional LABORATORY public healthlaboratory (RPHL) (RPHL) ELISA test
If ELISA test - negative, Inconclusive Positive no further test is required Result ELISA test Report to PHC facility
REFER TO CENTRAL PUBLIC HEALTH LABORATORY (CPHL) At DARSEIT
In case samples can’t be dispatched on the same day, keep it in the refrigerator at temp. 4-80 C. Transfer the sample within 24 hours. While transporting to RPHL ensure that appropriate temperature is maintained (4 - 80 C).
42 45
Algorithm 3: HIV testing in pregnancy (Cont)
CENTRAL PUBLIC HEALTH LABORATORY
Repeat test on the same sample sent from RPHL
Negative Inconclusive Positive
ELISA test: Result: ELISA test
Report on Re-bleed Negative after 3
Result months
Positive Western Blot
(WB) Test :
Confirm HIV infection If ELISA test & Urgently; request for re- WB still inconclusive: bleed sample to confirm RT-PCR patient’s identity
Report to DFCH and HIV/AIDS Control Section
&
PHC facility
46 43
Algorithm 3: HIV screening in pregnancy (Cont)
Reporting on results of HIV positive case by CPHL: Send report to DFCH and HIV/AIDS Control Section and PHC facility
DFCH: HIV/AIDS CONTROL SECTION - Data entry on the reported HIV Inform HIV focal physician +ve cases; - Compile and prepare the final report; - Follow up and monitoring of cases through MCH counsellor.
HIV counsellors (HIV/AIDS) :
HIV focal - Trace & counsel AT PHC physician: the contacts - Fill the (PR 83) (husband and HIV focal doctor: notification form; children < 15 years) and arrange - Follow up with - Break the news, counsel; for their testing; HIV counsellor; - Arrange referral to HIV focal - Liaise with MCH - Team up with physician at secondary health Obstetrician to counsellors. care level; manage the index - Maintain records of HIV +ve case; results. - Inform HIV MCH counsellors: counsellor; - Counsel the HIV positive - Screen contacts women; and manage as - Keep the record on the women per the need. and action taken; send to DFCH as and when requested; - Do follow up of the case;
- Liaise with HIV counsellors (HIV/AIDS) for case follow up.
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Remember:
• If HIV testing was not performed at the booking visit, for any reason, it should be done in the subsequent visit. • Counselling is one vital service to be provided following HIV screening. It will be offered at different points of contact and by a trained health provider using standard proper counselling materials. • Delivery should be arranged in a facility that matches mother's needs, i.e. secondary/tertiary. • HIV testing should be done during the labour/post-partum for women who have not been subjected to the test during the antenatal period (unbooked).
Specific Management:
Refer to HIV Testing in Pregnancy Standard Operative Procedure Guidelines.
48 45
8. Chicken pox (varicella) in pregnancy
Chicken pox (varicella) is caused by a highly contagious DNA herpes virus, which is transmitted by respiratory droplets and by direct personal contact with vesicle fluid. The incubation period is 1-3 weeks and the disease is infectious 48 hours before the rash appears till the vesicles crusts over (usually 5 days from the time the rash appear).
Pregnant women who have no history or uncertain history of previous infection must be advised to avoid contact with chickenpox patients and shingles during pregnancy and to immediately inform health care workers of potential exposure.
Risks associated with infection by varicella virus in pregnancy:
A) Maternal risks:
- Pneumonia: associated with high mortality rate. - Hepatitis - Encephalitis
B) Fetal risks;
- Fetal Varicella Syndrome* (very rare), if the mother developed the disease or acquired the infection before 20 weeks (up to 28 weeks in some cases) of pregnancy. - Varicella Infection of the Newborn: more likely if maternal infection occurs 1-4 weeks before delivery.
The risk of spontaneous abortion does not increase if chickenpox occurs in the first trimester
Problem:
Pregnant women presenting with history of contact wth chicken pox infected person.
Management:
See Algorithm 4 for post-exposure management of chickenpox
* Fetal Varicella Syndrome characterized by one or more of: skin scarring in a dermatomal distribution, eye defects (microphthalmia, chorioretinitis, cataracts), hypoplasia of the limbs, neurological abnormalities (microcephaly, cortical atrophy, mental retardation and dysfunction of bowel & bladder sphincter.
49 46
Algorithm 4: Post-exposure management of chickenpox
Maternal exposure to chickenpox during pregnancy
Administer VZIG, 625 U IM
Follow up
Develops chickenpox
Yes No
Severe disease Mild disease (skin (toxic, high fever, lesions mainly) No further therapy pneumonia, required
meningitis, >300 leasions) Give oral acyclovir, 800 mg 5 times per day for 7 days Administer acyclovir, 10 mg per kg IV every 8 hours for 5 789:9;<=>!?@&4A!B/C! days 3!&0!
Follow up Conditions in which referral to the tertiary care is needed (even in the absence of complications):
• Chronic lung disease; • On corticosteroids; • In the latter half of pregnancy; • Cigarette smoking.
Patient should be managed with the involvement of respiratory physician and intensive care specialist (depending on the severity of the case)
50 47
Remember: Remember: • Varicella Zoster Immunoglobulin (VZIG) should be given as soon as women • Varigivecellahistory the Zoster ofImmunoglobulin exposure. Yet, can (VZIG) be given should up tobe 10 given daysas fromsoonexposure.women as give the history of exposure. Yet, can be given up to 10 days from exposure. • Women should be managed as potentially infectious from 8 to 28 days after • WomenVZIG given. should be managed as potentially infectious from 8 to 28 days after • WomenVZIG given. should be instructed to notify early if a rash develops. • WomenBetter outcome should beof treatmentinstructed is to expected notify early if given if a rash within develops. 24 hours of developing • Betterthe rash. outcome of treatment is expected if given within 24 hours of developing • VZIGrash.the no therapeutic benefit once chickenpox has developed. • VZIG has no therapeutic benefit once chickenpox has developed. Women should be given an appointment for ultrasound after 5 weeks of Women should be given anhistory appointment of exposure for ultrasound after 5 weeks of history of exposure
9. Pregnancy with RhD negative blood group 9. Pregnancy with RhD negative blood group If a pregnant women is RhD negative, husband should be tested for Rh typing and Ifresultspregnant a should be womendocumentednegat is RhD the husbandHealthive,Maternal be If shouldRecord.testedtheforhusband Rh typing and is RhD resultsnegative,shouldfurther no be documented managementthe in is Maternal required. IfHealth husbandRecord.RhDthe is If positive, is RhD husband regular screeningnegative, nofor furtherRhD antibodies management by performing is required. coomb's If husband test is isrequired. RhD positive, a regular screening for RhD antibodies by performing coomb's test is required. Management Management • Coomb's test should be performed at the following intervals: • Coomb's test should be performed at the following intervals: - At first visit (booking) - At 28first-30 visit weeks (booking) visit At 28-30 weeks visit - At 36-38 weeks visit - At 36-38 weeks visit • If Coomb’s test showed to be positive, ICT titration should be performed at the • followingIf Coomb intervals:’s test showed to be positive, ICT titration should be performed at the following intervals: - Every 4 weeks until 28 weeks - Every 42 weeks untilfrom 28 28 weeks-34 weeks - EveryweeklyThen 2 weeksuntil fromdelivery 28-34 weeks - Then weekly until delivery • If the titre shows < 1:16: • If the titre shows < 1:16: - Continue ICT titration as above - ContinueDon’t allow ICT patient titration as go post abovedated - Don’t allow patient to go post dated • If the titre shows > 1:16, but not rising: • If the titre shows > 1:16, but not rising: - Follow the case with two weekly ultrasound to rule out Hydrops fetalis - DeliverytheshouldFollow case be two withplannedweekly37ultrasoundconsidering by weeks to rule out fetal fetalis allHydropsparameters - Delivery should be planned by 37 weeks considering all fetal parameters
48 51 48
• If titre is > 1:16 and rising: Refer to Tertiary care hospital. • If titre is > 1:16 and rising: Refer to Tertiary care hospital. Note: availability of O-Negative blood for Neonatal transfusion should be ensured. Note: availability of O-Negative blood for Neonatal transfusion should be ensured. Prophylaxis for women who are RhD negative: Prophylaxis for women who are RhD negative: Routine antenatal anti-D prophylaxis is indicated for all pregnant women who RoutineRhDantenatalare negative and whoanti- areD prophylaxis not isknown indicated to be for sensitisedpregnantRhD all to women who antigen are RhD negative and who are not known to be sensitised to RhD antigen
Antenatal Prophylaxis: Antenatal Prophylaxis: • 2 doses of 500 iu Anti D is given at 28 weeks and (34-36) weeks of gestation to • women2 doses who500 of areiu non Anti-sensitised. D given at 28 weeks and (34-36) weeks of gestation to • womennegativeareRhD who women non who-sensitised. have received routine antenatal prophylaxis should • receiveRhD negative additionalwomenAntiD who have receivedimmunoglobulin when they routine are undergoingantenatal prophylaxis any should receivepotential additional sensitising AntiD proceduresimmunoglobulin like ECV, when they amniocentesis are has anyorundergoingantepartum haemorrhage.potential sensitising procedures like ECV, amniocentesis or has antepartum haemorrhage. Prophylaxis following abortion: Prophylaxis following abortion: • Spontaneous miscarriage: • Spontaneous miscarriage: - Complete or incomplete after 12 weeks of gestation; - IncompleteorComplete abortion incompletebefore after 12 where weeksof there gestation; is dilatation and - Incompletecurettage. abortion before 12 weeks where there is dilatation and curettage. Note: Spontaneous complete Abortion before 12 weeks when there is no inNote:strumentation, Spontaneous need not complete receive antiAbortionimmunoglobulin.weeks D before 12 when there is no instrumentation, need not receive anti D immunoglobulin. • Therapeutic Termination of Pregnancy: • Therapeutic Termination of Pregnancy: - Irrespective of gestational age, all RhD negative, non-sensitised women - Irrespectiveshould receive of antigestational D immunoglobulin. age, all RhD negative, non-sensitised women should receive anti D immunoglobulin. • Ectopic pregnancy: whenever diagnosed. • ThreatenedEctopic pregnancy: abortion whenever diagnosed. • Threatened abortion - All non-sensitised RhD negative women with threatened abortion after - 12All weeksnon-sensitised of gestation; RhD negative women with threatened abortion after - 12All nonweekssensitised of gestation; RhD negative women with threatened abortion before - 12All weekssensitisednon of gestation RhDwhere negative the women bleedingwith is heavy threatenedrepeatedor abortion where or before 12thereweeksassociated is of gestation where abdominal the pain bleedingand heavy gestationor isrepeated approachingwhere 12 there is associated abdominal pain and gestation is approaching 12 weeks of gestation. weeks of gestation. Note: prophylaxis is not required if bleeding stops and fetus is viable. Note: prophylaxis is not required if bleeding stops and fetus is viable. - If bleeding continues intermittently after 12 weeks of gestation, anti D - immunoglobulincontinuesIf bleeding should be given intermittently6 at after 12 weeksweeks intervals.of gestation, anti D immunoglobulin should be given at 6 weeks intervals. Dosage: 250 iu (50m gm) before 20 weeks & 500 iu (100 gm) after that. 49 52 49 Prophylaxis following sensitising events before delivery:
• Invasive prenatal procedures (amniocentesis, chorionic villus biopsy, fetal blood
Dosage: 250 iu (50mgm) before 20 weeks & 500 iu (100 gm) after that.
Prophylaxis following sensitising events before delivery:
• Invasive prenatal procedures (amniocentesis, chorionic villus biopsy, fetal blood sampling); • Other intrauterine procedures like embryo reduction, insertion of shunts etc..; • Antepartum Haemorrhage (APH); • External Cephalic Version (ECV); • Closed abdominal injury; • Intrauterine Fetal Death (IUFD).
Dosage: 250 iu (50 γµ) if < 20 wks. 500 iu(100 γµ) if > 20 weeks.
Postnatal Prophylaxis
• At least 500 iu (100 γµ) should be given within 72 hours following delivery of an RhD positive infant.
Note: Blood sampling for grouping and RhD status of the infant should be performed immediately after birth.
Prophylaxis following transfusion of RhD positive blood components:
• RhD positive platelet transfusions:
Dosage: 250 iu anti D immunoglobulin to be given following every 3 adult doses of platelets concentrate.
Note: Patient with marked thrombocytopenia should be given anti D immunoglobulin by SC, instead of IM, to avoid haematoma formation.
In advertent transfusion of RhD positive blood: • If less than 15 ml is transfused, appropriate dose of anti D - immunoglobulin to be given; If more than 15 ml is transfused, it is preferable to give 2500 to 5000 iu. - Dosage: 500 iu of Anti D immunoglobulin will suppress immunization of 4 ml of RhD negative red cells. ( so dosage is calculated accordingly).
Note: When 2 units of RhD positive blood is given, exchange transfusion should be considered to reduce the load of RhD positive red cells in the circulation and the dose of anti D immunoglobulin is required.
Dosage: 500 iu of Anti-D immunoglobulin will suppress 8-10ml of fetal RBC.
Note: IV anti D immunoglobulin is indicated here ,IM preparation is not given as IV.
50 53 53
10. ABO incompatibility
ABO incompatibility usually arises when women’s blood group is O and develops either anti A, or anti B antibodies.
The women usually has a history of either:
- Blood transfusion; - Unexplained still birth; - Unexplained neonatal death; - Baby with severe jaundice in neonatal period.
Management:
• These women should be screened for antibodies by doing the indirect Coomb's test (ICT) at the following intervals:
- At first visit (booking). - At 28-30 weeks visit. - At 36-38 weeks visit.
• If Coomb’s test showed to be positive, titre should be checked:
- Every month until 28 weeks pregnant - Then every two weeks until 34 weeks - Then every one week until delivery.
• Women with a rising titre should be referred to the tertiary care for further investigation. • Women with a high titre may require induction of labour early.
11. Cardiac problems in pregnancy
Cardiac diseases has significant impact on both maternal and fetal morbidity and mortality.
Maternal Complications:
Pulmonary oedema - Pulmonary embolism - Congestive cardiac failure (CCF) - Subacute bacterial endocarditis (SBE) -
Fetal Complications:
Preterm labour - IUGR IUFD in poorly compensated cases. -
54 51
Classification: The severity of the disease at a particular time can be classified functionally as follows:
Grade I: No limitation of activity.
Grade II: Limitation of activity on heavy exertion.
Grade III: Limitation of activity on slight exertion.
Grade IV: Cardiac symptoms when at rest.
Management during Antenatal Period:
• Ask carefully about:
- Significant past medical history. - History of medical and/or obstetrical complications during previous pregnancies. - Drug history.
• Plan for combined management by cardiologist and senior obstetrician. • Regular visits with the obstetrician as follows:
- 4 weekly up to 28 weeks. 2 weekly from 28-36 weeks. - - Weekly from 36 weeks till delivery.
Detailed evaluation by cardiologist in early pregnancy and again at 28-30 weeks • and 36-38 weeks. Cardiac lesion should be confirmed by the cardiologist. Detection and correction of: anaemia, infection, toxaemia, excessive weight gain, • adequate dental care. SBE prophylaxis in invasive procedures. • Cardiac evaluation for functional class at booking and at each visit. •
Note: consider admission and evaluation by the cardiologist if functional classification was of grade 3 or 4.
Look for clinical evidence of congestive cardiac failure, arrhythmia, pulmonary • congestion, and respiratory infection. Avoid/ minimize aggravating factors. • Consider: anticoagulation/antibiotics. • Detailed cardiac anomaly scan in patients with congenital heart disease. • Growth scan between 32-34 weeks, serial growth scan only if indicated. •
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Counselling on the following should be provided during the antenatal period:
- To report immediately if developed fever, palpitation and breathing difficulty. - Contraception. - Risk of repeated pregnancies. - Sterilization if family completed.
Criteria for Admission:
- Signs and symptoms of congestive cardiac failure. - Arrythmia. - Anaemia. - Pregnancy induced hypertension. - Change of medication.
Intrapartum Management:
• Aim for vaginal delivery at term. Induction of labour and/or caesarean section is indicated only for obstetrical reasons. • Advise patient to maintain left lateral position. • Close fetal (CTG) and maternal (vitals) monitoring. In high risk cases, senior physician/cardiologist and anaesthetist should be involved. • Attach monitor and give oxygen intermittently or continuously (according to the case). • Monitor progress of labour, shorten second stage of labour. • Carefully watch for:
- Symptoms of dyspnoea, palpitation and chest pain. - Evidence of CCF (monitor pulse oximetry, lung for evidence of congestion).
Note: early involvement of cardiologist should be sought if there is any evidence of CCF or arrhythmia.
• Provide adequate sedation, epidural anaesthesia is recommended, with careful monitoring of fluid balance.
Note: control fluid infusion to 80-100ml/hr. Avoid overloading circulation.
In cases of post partum haemorrhage, oxytocin infusion should be the first line of • management as ergometrin is contraindicated. In cases of mitral stenosis; intravenous frusemide 20-40 mg IV should be given • at the end of second stage. Provide prophylactic antibiotics (whenever indicated) in labour, prior to induction • of labour and before the anaesthesia in cases of elective caesarean section.
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Postpartum Management:
• Watch for any evidence of infection. • Closely monitor for CCF within the first 72 hours following delivery. • Low risk patients ( small ASD, MVP, MR) could be discharged after 24-48 hours. • In high risk cases, patients should stay in hospital for 3-5 days, according to patient's condition. • Review previously discussed contraceptive plan. • Continue thromboprophylaxis in cases indicated. • Follow up in cardiology clinic after 4-6 weeks.
SBE prophylaxis: Gentamycin, 120 mg IM single dose + ampicilline 2 gm IV initially then 1 gm 6 hours later.
In those who are sensitive to penicilline; vancomycin 1 gm IV to be given over 15 minutes (single dose) + gentamycin 120 mg IM.
Indications for SBE prophylaxis:
- Prosthetic cardiac valves; - Previous bacterial endocarditis; - Tetrollogy of fallot; - Acquired valvular dysfunction; - Hypertrophic cardiomyopathy; - Mitral valve prolapse with mitral regurgitation and or thickened leaflets.
SBE prophylaxis not recommended in:
- Isolated secundum atrial septal defect; - Surgical repaired atrial septal defect (ASD), ventricular septal defect (VSD) or patent ductus arteriosis (PDA); - Mitral valve prolapse (MVP) without regurgitation; - Previous rheumatic heart disease without valvular dysfunction; - Cardiac pacemakers; - Physiological, functional or innocent murmer.
Management of Cases with Prosthetic Valve on Anticoagulant Therapy:
- Continue Warfarin all through pregnancy; Warfarin can be changed to heparin in selective cases only and after - discussion with the cardiologist; Follow up with regular INR estimation ( in a range of 2.5-3.5); - Plan delivery after 37 weeks. -
Prior to Delivery:
Admit to hospital; - Stop Warfarin; -
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- Start heparin (unfractionated 20,000- 40,000 iu) per 24 hours. in 2 divided doses SC.; - Monitor heparin with APTT twice the control value 4-6 hours after first dose.
Or Start:
- LMWH therapeutic dose: tinzaparin 165/kg/day in two divided doses + enoxeparin 1mg/kg/day in 2 divided doses; - Perform INR 48 hours after stopping warfarin aiming at < 2; - Start induction 5-7 days after stopping warfarin; - Recommence heparin 6 hours after delivery or surgery in therapeutic doses; - Recommence warfarin about 12 hours after delivery, start with 10mg. for 2 successive days, 5 mg third day. Perform INR 72 hours after commencing warfarin; - Stop heparin when INR in the therapeutic range (>2.5); - Adjust warfarin dose before sending patient home. If INR is low, repeat test 48 hours after adjusting the dose.
Management of Cases with Cardiomyopathy:
- Pregnancy is usually poorly tolerated. - Should be managed mainly by the cardiologist with the input of obstetrician. - High risk of: heart failure, irreversible left ventricular dysfunction and fetal loss. - Termination of pregnancy should be suggested and offered by the cardiologist. - Bed rest, digitalis, diuretics, anticoagulation therapy and sodium restriction is advocated. - Hydralazine/nitrates to be considered in refractory cases. - Prognosis guarded, especially if crdiomyopthy persists more than 6 months postpartum.
Instructions to The Patient Discharged on Warfarin:
- Report to hospital immediately if any signs of bleeding. - Should not take double dose of warfarin the following day if dose was missed the previous day. - Should be taken on empty stomach, at least half an hour before or after a meal. - Preferably to be taken same time every day. - Avoid green leafy vegetables and alcohol. - On the day checking for INR, warfarin to be taken after the test so it will not interfere with adjustment of the dose.
Contraception Advice:
• Weigh risks of temporary forms of birth control with regard to benefits in each woman. • Patients with valvualr lesions (especially aortic): oral contraceptive pills or tubal ligation are the recommended methods.
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• Patients with mechanical valves and on chronic warfarin therapy: progestin or tubal ligation is recommended. • IUCD is contraindicated in the following conditions due to the risk of endocarditis:
- Patients with valvular lesions. - Patients with mechanical valves. - Patients with PDA, TOF, VSD.
• Patients with ASD: IUCD or progestin is recommended. • Patients with VSD/PDA/pulmonary valvular lesions: oral contraceptive pills or progestins are recommended. • Patients with coarctation of aorta: barrier methods or progestins are recommended. • TOF: tubal ligation or progestins are recommended. • Peripartum cardiomyopathy: tubal ligation is recommended.
12. Haemoglobinopathies in Pregnancy
These disorders result from inherited defects in the formation of haemoglobin. If a defect is inherited from both parents (homo-zygos disease) the effects are much more serious.
The abnormal haemoglobin’s involved include Hb S, Hb C and Hb Thalassemia.
Problems Caused by These Disorders
• Clinically, the most serious problems are seen in homozygous sickle cell disease S/S, Hb S/C and Hb S / Thalassemia. • There is an overall fetal loss of about 45 percent in these conditions due to the following:
- Spontaneous Abortion - Preterm delivery - Intrauterine growth restriction
• Maternal death can occur from cardiac failure due to severe anaemia and from thrombo-embolic complications. • Other maternal complications include:
- Upper Urinary Tract infections Pulmonary infections - - Puerperal sepsis Pre-eclampsia -
Preventive Measures:
Laboratory tests for abnormal haemoglobin should be performed in all cases of • unexplained persistent anaemia.
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• Sickle red blood cells have shortened life. Extra Folic acid is required to help replace these cells, and should always be prescribed in these patients throughout pregnancy. • Iron supplement should not be given routinely to sickle cell disease patients.
Antenatal Management of Pregnancy With Sickle Cell Disease:
Booking Visit:
• Detailed history of the disease including complications & surgeries in the past. • Course of previous pregnancies, outcome & any complications should be known. • Husband’s haemoglobinopathy status to be evaluated if not done. Couples should be referred for counselling if husband was found to be carrying any haemoglobinopathy. • Examination to note blood pressure, height, weight and determine splenic size. • Refer for haematologist opinion when indicated. • Patient should be explained to report immediatly if developed symptoms of crisis, infection or dyspnoea.
Investigations:
• CBC, blood group, antibody screen, Hb electrophoresis, reticulocyte count. • Liver function test (LFT), urea & electrolyte • HIV/ hepatitis Antigen B & C. • Serum ferrtin if anaemic • Urine culture & sensitivity
Follow Up Investigations :
• Repeat CBC, Hb electrophoresis, reticulocyte count, urine C/S once in each trimester. • Repeat the following at each crisis: CBC, reticulocyte count, Hb electrophoresis LFT, urea & electrolyte.
At Term (37-38) Weeks :
• CBC, Hb electrophoresis, reticulocyte count to decide the need for blood transfusion or exchange transfusion prior to labour.
Frequency of Antenatal Visits:
Four weekly during 1st & 2nd trimester; • Two to 3 weekly in early 3rd trimester; • Weekly > 36 weeks. •
Frequency of Obstetric Ultrasound:
Dating scan at 11-14 weeks; • Anomaly scan at 20 - 22 weeks; •
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• Growth scan at 28-30 weeks followed by 2-3 weekly till term in addition to Fetal Doppler study if indicated; • Fetal weight estimation at 37-38 weeks .
Medication:
• Folic acid 5 mg OD; • Iron supplement may be given to women with anaemia and low ferritin levels; • Low dose aspirin if indicated with high platelets count ( > 1000x109/l); • Prophylactic antibiotics in post spleenectomy patients: Penicillin V 250 mg BD & Proguanil 200 mg OD.
When to Refer to Tertiary Care:
If complications arise:
• Recurrent Sickle cell crisis • Acute infection • Acute chest syndrome
At 34 – 36 weeks of gestation: for complete assessment. CBC, Hb Electrolysis, reticulocyte count to be checked prior to the referral and results to be sent with the patient.
Plan of Delivery:
• Spontaneous onset of labour awaited till term if no associated complications. • Planned delivery at 37 -38 weeks / Induction of labour if indicated e.g.in cases of intrauterine growth restriction or recurrent severe crisis. • Vaginal delivery is preferred and caesarean section may be planned for obstetric indications.
Sikle Cell Crisis:
Sickle cell “crisis” can occur when small vessels are blocked by clumps of • abnormal red blood cells. The symptoms are severe abdominal and bone pain, with fever, leukocytosis and hepato-megaly. crises are precipitated by ; •
Hypoxia - Metabolic acidosis - Dehydration - Infection - Extremes of temperature -
Management of Crisis in Pregnancy:
Patient should be admitted and managed jointly by physician and haematologist. • Hydration: 5% dextrose or 0.45% saline with 5% dextrose 3-4 L/day if cardiac • status is normal.
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• Oxygen by face mask. • Analgesia:
- Mild pain: oral NSAIDS or Paracetamol. - Moderate to severe pain; parenteral Narcotics as below: - Loading dose: (Morphine) 0.1mg/kg IV. If no response after 15 minutes, give a second dose of 0.05 mg/kg. Another 0.05 mg/kg can be repeated in another 15 minutes; - Background maintenance infusion: Infusion rate 0.04 mg/kg = 40 microgram/kg/hr, syringe pump 10mg (5 ampoules) + 45 ml saline; - Extra boluses: 0.01mg = 10 mcg/kg (if break through pain) in 10-15 min; - After 4-6 hrs: calculate the dose requirement i.e. hourly Infusion + demand dose and step up the hourly infusion rate; - Follow up Analgesia; narcotic infusion should be replaced as soon as possible with oral analgesics; - Start oral analgesics while patient is on morphine infusion; - Decrease the infusion dose by 20% per day and stop parenteral analgesia when you reach < 50% of the recommended dose; - When reducing, reduce the dose first before reducing the frequency; - If pain increases while reducing the infusion rate, increase oral analgesic dose. Oral analgesics should be given regularly 4 -6 hourly;
• Antibiotic: continue prophylactic antibiotic. Other antibiotics to prevent and/or control infection may be considered. • Heparin to be considered in all cases. • Transfusion: If anaemia becomes severe. Direct blood transfusion or exchange transfusion may be considered.
Antepartum Fetal Surveillance Tests during Sickle Cell Crises:
• The use of opiates to treat Sickle cell pain affect nonstress testing and biophysical profile scores. • Caution must be taken when interpreting the results because they may not be predictive of increased perinatal morbidity and mortality in the absence of other findings.
Intrapartum Management
• Adequate hydration to avoid dehydration; • Analgesia: Epidural analgesia if available (especially in primigravida), Narcotic analgesics or Entonox inhalation may be given; • Anitibiotic prophylaxis especially in operative deliveries to avoid sepsis, • Adequte oxygenation in labour to avoid hypoxia; • Continous Fetal monitoring till delivery; Prolonged labour to be avoided. •
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Postpartum Management
• Hypoxia & dehydration should be avoided in immediate postpartum periods; • Analgesics: NSAIDs and tramadol; • Prophylactic Heparin for 5 days; • Postnatal stay in ward for 2-3 days; • Postnatal review is planned after 6 weeks & follow up with haematologist /physician later.
Birth Spacing:
• POP for the first 6 months with breast feeding. • Depot Medoxyprogesteron acetate inj. • COCs. • IUCD should be avoided due to risk of infection. • Barrier methods (high failure rate). • Sterilization (with respect to patient desire).
13. Gestational Trophoblastic Diseases (GTD)
Pregnancy related disorders arising from abnormal placental trophoblastic cells. Can be classified into:
• Molar pregnancies: - Partial mole. - Complete hydatiform moles. • Malignant conditions: - Invasive mole. - Choriocarcinoma. - Placental site trophoblastic tumours (very rare).
Management of Molar Pregnancy:
At Admission:
- Clinical evaluation; - Ultrasound to confirm diagnosis; - Serum %−ΗΧΓ titer; - CBC; Thyroid function test (TFT) if evidence of thyrotoxicosis; - - Urea, electrolyte and uric acid if blood pressure is high; - Blood group & Rh factor for patient and husband (if not known). Chest X-ray if indicated -
Treatment:
Suction evacuation is the method of choice; - There is no clinical indication for the routine second uterine evacuation in the - management of molar pregnancies;
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- Medical termination of complete hydatiform mole including cervical preparation prior to suction should be avoided; - Avoid oxytocic infusion till evacuation has been completed unless the patient is having a significant bleeding; - Partial mole, if the fetus is large, could be terminated medically.
Management of special conditions:
• Twins pregnancy of viable fetus and partial mole: allow pregnancy to proceed. • Twins of viable fetus and complete hydatiform mole is associated with: - Reduced live birth rate by 25%; - Increased risk of complications e.g.preeclampsia and haemorrhage; - Subsequent need for chemotherapy increases by 20% ; - May be allowed to proceed after appropriate counselling.
At Discharge:
- CBC if transfused or had significant vaginal bleeding. - Counselling about regular follow up and contraception.
Follow Up:
- First follow up: 2 weeks after discharge; - Vaginal examination to be performed at 1st visit; - Ultrasound at 4 weeks unless patient is symptomatic; - %−ηχγ titres once in 2 weeks till the titer < 5 iu/l, then monthly for the first year and then 3 monthly during the second year.
Note: %−ηχγ might be detectable until 20-22 weeks following evacuation of hydatiform mole.
Early normalization of %−ηχγ is a good prognostic factor
Advice regarding:
Contraception: women should be advised not to conceive until %−ηχγ level has • been normal for 6 months. • Combined oral contraceptive pill and hormone replacement therapy are safe to used but preferably after %−ηχγ levels have reverted to normal. • Before that advise the use of barrier contraceptive method.
Management of Trophoblastic tumours:
To be managed in a tertiary care hospital by medical oncologist.
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14. Thrombophalyxis Therapy in Pregnancy
Risk assessment for VTE is essential for all women, it should be done at the following circumstances:
- In early pregnancy/ preconception. - If pregnant women is admitted to the hospital or developed other inter current problems. - Before/during labour.
Table 12: Risk factors for venous thromboembolism in pregnancy and puerperium:
Pre-existing: New onset or transient: Previous VTE Surgical procedure in pregnancy or puerperium e.g. evacuation of retained
products of conception
Thrombophilia Hyperemesis Congenital antithrombin deficiency Dehydration Protein C deficiency Ovarian hyperstimulation syndrome Protein S deficiency Multiple Pregnancy, assisted reproductive therapy
Factor V leiden Systemic infection (requiring antibiotics or admission to hospital )
Prothrombin gene variant Immotility ( ! 3 days bed rest) Acquired (antiphospholipids Pre-eclampsia syndrome)
Lupus anticoagulant Excessive blood loss ( > 1 litre) requiring transfusion
Anticardiolipin antibodies Long-haul travel Age over 35 years Prolonged labour Obesity (BMI > 30 Kg/m2) either Midcavity instrumental delivery pre-pregnancy or in early pregnancy
Parity ! 3 Caesarean section smoking Immobility after delivery
Gross varicose veins Postpartum wound infection Paraplegia Sickle cell disease Inflammatory disorders e.g.
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inflammatory bowel disease Some medical disorders e.g. nephrotic syndrome, certain cardiac diseases Myeloproliferative disorders e.g. essential thrombocytopenia, polycythemia vera
Indications for antenatal prophylaxis with LMWH:
• Women with ∃ 3 current or persisting risk factors other than VTE & thrombophilia and managed as out patient. • One or two risk factors only in certain cases e.g. extremely obese hospitalized woman. • ! two risk factors during the antenatal period and managed as in-patient.
Antenatal thromboprophylaxis:
• Should begin as early in pregnancy as practical. • Should be continued until delivery unless a specific risk factor is removed or disappears. • LMWH is of choice for antenatal thrombo- prophylaxis, as is affective and safer than UFH.
Indications for postpartum thrombophylaxis:
All women should be assessed after delivery for the risk factors listed in Table 12
Indication Management Two or more persisting risk factors LMWH for 7 days after delivery Three or more persisting risk factors graduated compression in addition to LMWH BMI > 40 kg/m2 LMWH for 7 days after delivery Emergency caesarean section LMWH for 7 days after delivery Elective caesarean section with one LMWH for 7 days after delivery or more additional risk factor Asymptomatic heritable or acquired LMWH for 7 days after delivery, could thrombophilia be extended to 6 weeks if positive family history or other risk factors
present History of VTE before the current LMWH for 6 weeks following delivery pregnancy
Timing and duration:
Should be started as soon as possible after delivery, providing there is no • postpartum hemorrhage. • Should be continued for 6 weeks in high risk women.
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Both warfarin and LMWH are safe when breast feeding
Remember:
• All women should be encouraged to mobilize both during labour and postpartum; • Dehydration should be avoided; • Women should be repeatedly assessed for risk factors for VTE if they develop intercurrent problems or require surgery or readmission in the puerperium; • Women receiving LMWH antenatally should usually continue prophylactic doses of LMWH until 6 weeks postpartum, but a postnatal risk assessment should be done. If receiving long-term anti-coagulation with warfarine, this can be started when the risk of hemorrhage is low. • Women who have additional persisting (lasting more than 7 days postpartum) risk factors, such as prolonged admission or wound infection, thromboprophylaxis should be extended for up to 6 weeks or until the additional risk factors are no longer present.
Note: COCs are contraindicated for the first three months postpartum in women with risk factors for VTE.
Table 13: Prophylactic &Therapeutic doses of LMWH
PROPHYLAXIS ENOXAPARIN DELTAPARIN TIZAPARIN
Body weight 40mg daily 5000 U daily 4500 U daily (50-90 Kg) Body weight < 20mg daily 2500 U daily 3500 U daily 50 kg
Body weight 60 mg daily 7500 U daily 7000 U daily* (90-130 kg)
Body weight 80 mg daily 10,000 U daily 9000 U daily* (131-170 kg)
Body weight > 0.6 mg/kg/day 75 U/kg/day 75 U/kg/day* 170 kg
Higher prophylactic 40mg 12 hourly 5000 U 12 4500 U 12 hourly dose hourly Therapeutic Antenatally:1 Postnatally: Antenatally & dose mg/kg 12 hourly 100 U/kg OR postnatally: 175 Postnatally: 1.5 200 U/kg/day U/kg/day mg/kg/day
* may be given in two divided doses
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Contraindications to LMWH:
LMWH should be avoided, discontinued or postponed in women who are at risk of bleeding after careful consideration of the balance of risks of bleeding and clotting. Risk factors for bleeding are:
• Women with active antenatal or postpartum bleeding; • Women considered at increased risk of major haemorrhage (such as placenta previa); • Women with a bleeding diathesis, such as von willebrand’s disease, haemophilia or acquired coapgulopathy; • Women with thrombocytopenia (platelet count less than 75 X 109); • Acute stroke in the last 4 weeks (ischaemic or haemorrhagic); • Severe renal disease (glomerular filtration rate less than 30 ml/minute/1.73 m2); • Severe liver disease (prothrombin time above normal range or known varices); • Uncontrolled hypertension (blood pressure greater than 200 mmHg systolic or greater than 120 mmHg diastolic).
Intrapartum care for women on thromboprophylaxis:
• Once the woman is in labour or thinks she is in labour, she should be advised not to inject heparin, further doses after assessment only. • For women receiving high prophylactic or therapeutic doses of LMWH, reduce to thromboprophylactic dose on the day before induction of labour or elective CS and continue in this dose during labour. • LMWH should not be given for at least four hours after the epidural catheter is inserted or removed. • Avoid cannula insertion or removal within 10-12 hours of the last dose.
Excess blood loss and blood transfusion are considered as risk factors for VTE, thromboprophylaxis should be commenced or reinstituted as soon as the risk of haemorrhage is reduced, till then mechanical device, UFH should be used.
Thromboprophylaxis following CS:
• Risk assessment Prior to CS is mandatory; • Should be started within 3-4 hours postoperative; • In women who have had elective caesarean section, If there are no additional risk factors: early mobilization and adequate hydration are the only recommended measure; • All women who have had an elective caesarean section who have one or more additional risk factors, should be considered for thromboprophylaxis with LMWH for 7 days after delivery. • All women who have had an emergency caesarean section should be considered for thromboprophylaxis with LMWH for 7 days.
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• Women with multiple risk factors should be given graduated compression stocks in addition to LMWH. • For selected high risk patients in whom sufficient risk factor persists, extend prophylaxis up to 4-6 weeks postpartum after discharge from hospital.
Women delivered by elective caesarean section have at least double the postpartum risk of VTE compared with vaginal birth. Women delivered by emergency caesarean section have double the risk of postpartum VTE compared with elective caesarean section and four-fold increased risk compared with women delivered vaginally.
Thrombophylaxis in high risk conditions:
• Women at high risk of VTE in pregnancy, such as those with previous VTE, should be offered prepregnancy counselling and a prospective management plan for thromboprophylaxis in pregnancy. • Women with previous VTE should be screened for thrombophilia before pregnancy • Regardless of their risk of VTE, immobilization and dehydration of women during pregnancy, labour and puerperium should be avoided.
In Women with previous single VTE and transient risk factor, but no Thrombophilia:
• No medical prophylaxis indicated but clinical surveillance is essential , consider graduated compression stocking and antenatal low dose aspirine. • Postpartum prophylaxis with low molecular weight heparin (LMWH) for six weeks.
Women with:
- Previous recurrent VTE or; - Previous VTE with family history of VTE in first degree relative or; - VTE in unusual site such as axillary vein or; - VTE associated with pregnancy or estrogen:
Should be offered thromboprophylaxis with LMWH antenatally & for 6 weeks postpartum.
Women with a previous VTE and Inherited Thrombophilia:
Should be offered antenatal prophylaxis with LMWH and for 6 weeks • postpartum.
• Expert heamatological advice is essential.
Women with inherited Thrombophilia but no previous VTE:
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• Should be offered antenatal prophylaxis with LMWH and for 6 weeks postpartum. • Expert heamatological advice is essential.
Women with inherited Thrombophilia but no previous VTE: • Antenatal thromboprophylaxis is not always necessary, except for those with:
- Compound heterozygote defects or; 66 - Homozygous for defects or; - Anti thrombin deficiency or; - Other risk factor.
• All should be considered for graduated compression stocking during pregnancy & 6 weeks post-partum prophylaxis.
Acquired thrombophilia (antiphospholipid syndrome):
Antiphospholipid syndrome is defined as the presence of a lupus anticoagulant and/or anticardiolipin and/or β� 2-glycoprotein 1 antibodies of medium to high titre on two occasions 12 weeks apart (persistently positive), in association with a history of thrombosis (which may be arterial or venous) or adverse pregnancy outcome (defined as three or more unexplained miscarriages before 10 weeks of gestation, a fetal death after 10 weeks of gestation or a premature birth [before 35 weeks] due to severe pre-eclamptic toxaemia or intrauterine growth restriction).
Women with acquired thrombophilia ( Antiphospholipid Syndrome) and history of VTE: should receive antenatal and postnatal thromboprophylaxis with LMWH. Best managed in collaboration with hematologist.
Women with persistent antiphospholipid antibodies with no previous VTE and no other risk factors or fetal indications for LMWH: may be managed with close surveillance antenatally but should be considered for LMWH for 7 days postpartum.
Management of Obstetric complications of Antiphospholipid Syndrome: following options are suggested:
• Heparin in prophylactic dose as soon as pregnancy is confirmed and continued postpartum, plus: • Low dose aspirin antenatally from 12 to 36 weeks; • Heparin in Prophylactic dose and low dose aspirine from the point of diagnosis of pregnancy.
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Table 14: Summary of Protocol for Thromboprophylaxis for women with previous VTE +/-Thrombophilia:
RISK PREVIOUS VTE +/- PROPHYLAXIS THROMBOPHILIA
Very High Previous VTE +/- Antenatal high prophylactic or thrombophilia on long term therapeutic dose of LMWH & 6 warfarin. weeks postpartum with LMWH/ Warfarin • Previous recurrent VTE not HIGH on long term Warfarin; Antenatal and 6 weeks • Previous VTE+Trombophilia; Postpartum prophylactic
• Previous VTE+family h/o VTE LMWH
or
• Asymptomatic Thrombopilia.
• Single Previous provoked VTE Consider antenatal LMWH but without thrombophilia, family routinely not recommended. h/o other risk factors; Moderate Postpartum: at least 7 days • Asymptomatic thrombophilia with LMWH, can be extended (except antithrombin up to 6 weeks if positive family deficiency, compoundcombined history or other risk factors defect,homozygpous factor V Leiden or prothrombin gene defect ).
Women with Mechanical prosthetic valve: See management of cardiac diseases in pregnancy Page 5154
Measures for Long distance travel( specially by air more than 4 hours):
- Ensure good hydration - Restrict alcohol and coffee intake - Regularly carry out simple leg exercise and take occasional walk during travel; - In patients with high risk (previous VTE, DVT, thrombophilia, recent surgery, immobilization etc.), graduated compression stocking +/- single dose of Aspirin 150mg or LMWH before travel in prophylactic dose, - Patient on warfarin should continue to take it.
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1. Vaginal Bleeding In Early Pregnancy
Problem
• Vaginal bleeding occurs during the first 22 weeks of pregnancy.
General Management
• Perform a rapid evaluation of the general condition of the woman, including vital signs (pulse, blood pressure, respiration, temperature). • If shock is suspected, immediately begin treatment. Even if signs of shock are not present, keep shock in mind as you evaluate the woman further because her status may worsen rapidly. If shock develops, it is important to begin treatment immediately. • If the woman is in shock, consider ruptured ectopic pregnancy. • Start an IV line and infuse IV fluids
Diagnosis
• Consider ectopic pregnancy in any woman with anaemia, pelvic inflammatory disease (PID), threatened abortion or unusual complaints about abdominal pain.
Note: If ectopic pregnancy is suspected, perform vaginal ultrasound.
• Consider abortion in any woman of reproductive age that has a missed period (delayed menstrual bleeding with more than one month having passed since her last menstrual period) and has one or more of the following: bleeding, cramping, partial expulsion of products of conception, dilated cervix or smaller uterus than expected. • If abortion is a possible diagnosis, identify and treat any complications immediately.
70
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Table 15: Diagnosis of vaginal bleeding in early pregnancy
Presenting Symptom and Symptoms and Signs Probable Diagnosis Other Symptoms and Signs Sometimes Present & Management Typically Present
• Light* bleeding • Cramping /lower Threatened abortion abdominal pain • Closed cervix Uterus corresponds to • Uterus softer than normal • dates
• Light bleeding • Fainting Ectopic pregnancy
• Abdominal pain • Tender adnexal mass Closed cervix Amenorrhoea • • • Uterus slightly larger than • Cervical motion normal tenderness
• Uterus softer than normal
• Light bleeding • Mild cramping/ lower Complete abortion abdominal pain • Closed cervix History of expulsion of • Uterus smaller than dates • products of conception • Uterus softer than normal
• Heavy** bleeding • Cramping/lower Inevitable abortion abdominal pain • Dilated cervix • Tender uterus • Uterus corresponds to dates • No expulsion of products of Conception
Cramping/lower • Heavy bleeding • Incomplete abortion abdominal pain • Dilated cervix Partial expulsion of • Uterus smaller than dates • products of conception
Nausea/vomiting • Heavy bleeding • Molar pregnancy • Dilated cervix • Cramping/lower abdominal pain • Uterus larger than dates Uterus softer than normal • Ovarian cysts (easily • ruptured)
* Light bleeding: takes five minutes or longer for a clean pad or cloth to be soaked. ** Heavy bleeding: takes less than five minutes for a clean pad or cloth to be soaked
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Table 16: Diagnosis and management of complications of abortion
Symptoms and Signs Complication Management • Lower abdominal pain Infection/sepsis • Start antibiotics: ampicillin 2 g IV every • Rebound tenderness six hours PLUS • Tender uterus gentamycin 5 mg/kg • Prolonged bleeding body weight IV every • Malaise 24 hours PLUS Fever metronidazole 500 • • Foul smelling vaginal mg IV every eight discharge hours until the woman is fever-free for 48 • Purulent cervical hours discharge • Arrange for immediate • Cervical motion suction evacuation. tenderness
• Cramping/abdominal Uterine, vaginal or bowel • Perform laparoscopy pain injuries to repair the injury • Rebound tenderness • Abdominal distension • Rigid (tense and hard) abdomen • Shoulder pain • Nausea/vomiting • Fever
THREATENED ABORTION
• Medical treatment is usually not necessary. • Advice the woman to avoid strenuous activity and sexual intercourse but bed rest is not necessary. • If bleeding stops, follow up in antenatal clinic. Reassess if bleeding recurs. • If bleeding persists (> 3-4 weeks), assess for fetal viability or ectopic pregnancy (by ultrasound). Persistent bleeding, particularly if associated with larger than expected uterus, may indicate twins or molar pregnancy.
INEVITABLE ABORTION
• Await spontaneous expulsion of products of conception and then evacuate the uterus to remove any remaining products of conception; • If necessary, infuse oxytocin 40 units in 1 L IV fluids (normal saline or Ringer’s lactate) at 40 drops per minute to help achieve expulsion of products of conception. • Ensure follow-up of the woman after treatment.
INCOMPLETE ABORTION
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• If necessary, infuse oxytocin 40 units in 1 L IV fluids (normal saline or Ringer’s lactate) at 40 drops per minute to help achieve expulsion of products of conception. • Ensure follow-up of the woman after treatment.
INCOMPLETE ABORTION • Perform ultrasound. If showed evidence of product of conception and/or endometrial thickness was > 15 mm, arrange for suction evacuation. 72
COMPLETE ABORTION
• Confirm by ultrasound. • Offer symptomatic treatment for pain.
Following any abortion women should be properly counseled on the importance of birth spacing. Birth spacing methods should be offered before discharge.
ECTOPIC PREGNANCY
An ectopic pregnancy is one in which implantation occurs outside the uterine cavity. The fallopian tube is the most common site of ectopic implantation (more than 90%).
Symptoms and signs are extremely variable depending on whether or not the pregnancy has ruptured. Ultrasound is the best tool to diagnose ectopic pregnancy.
The availability of sensitive and specific radio immunoassays of beta human chorionic gonadotrophin (%-hCG), and high resolution Tran's vaginal ultrasound allow early detection of ectopic pregnancies.
Table 17: Symptoms and signs of ruptured and unruptured ectopic pregnancy
Unruptured Ectopic Pregnancy Ruptured Ectopic Pregnancy
Symptoms of early pregnancy Collapse and weakness • • (irregular spotting or bleeding, Fast, weak pulse (110 per minute • nausea, swelling of breasts, bluish or more) discoloration of vagina and cervix, Hypotension softening of cervix, slight uterine • Hypovolaemia enlargement, increased urinary • frequency) Acute abdominal and pelvic pain • • Abdominal and pelvic pain Abdominal distension*. Rebound tenderness • • Pallor
* Distended abdomen with shifting dullness may indicate free blood.
Differential diagnosis
Threatened abortion ( the most common). • Acute or chronic PID. • Ovarian cysts (torsion or rupture). • • Acute appendicitis. 78 73
Management must be tailored to the clinical conditions & future infertility requirements of the women
Expectant management:
Indications:
• Clinically stable women with minimal symptoms. • %−ηΧΓ < 1000 iu/l (1500- 2000 iu/l in some situations). • No visible (intra or extra-uterine) pregnancy on trans-vaginal ultrasound examination. • Clinically stable asymptomatic women with:
- Ultrasound diagnosis of ectopic pregnancy - No evidence of blood in the pouch of Douglas - Less than 100 ml of fluid in the pouch of Douglas - Decreasing serum %−ηΧΓ, with initial level less than 1000 iu/l.
Follow up:
• Women should be observed for 48-72 hours. • First week :
- Twice %−ηΧΓ (should reach less than 50% of it's initial level within 7 days). - Trans-vaginal ultrasound (reduction in the adnexal mass by 7 days).
• Thereafter: weekly %−ηΧΓ and transvaginal ultrasound examination until serum %−ηΧΓ levels are less than 10-20 iu/l.
Consider active intervention if:
• Symptoms of ectopic pregnancy occur. • Serum %−ηΧΓ levels rise above the initial levels or if levels start to plateau.
Women should be given clear information about the importance of compliance with follow up & should be within easy access to the treating hospital.
Medical management
Indications:
79 74
Women should be given clear information about the importance of compliance with follow up & should be within easy access to the treating hospital.
Medical management
Indications:
• Trans-vaginal ultrasound findings of complex adenexal mass less than 3-4 cm with no intra-uterine sac, fetal pole or cardiac activity. • Initial %−ηΧΓ levels < 3000 iu/l. • Patient is haemodynamically stable, asymptomatic or minimally symptomatic with positive pregnancy test. • When: %−ηΧΓ levels > 1500 but < 3000 iu/l, complex adenexal mass without 74 intra-uterine gestation sac with the presence of risk factors.
Note: The presence of cardiac activity in an ectopic pregnancy should be considered a contraindication to medical therapy.
Informed consent should be taken after appropriate counselling, which includes pain, failure rate, possibility of emergency surgery at any time, the need for another injection and the need for follow up.
Following should be done prior to the treatment with methotrexate:
• Initial %−ηΧΓ level; • Initial Trans-vaginal ultrasound; • Identify unruptured ectopic pregnancy < 3-4 cm; • LFT, RFT & CBC; • Anti D immunoglobulin in Rh negative women; • Strict observation for vital signs and symptoms of rupture of ectopic pregnancy.
Initial dose of methotrexate: 50mg/m2 I.M.
Follow up:
• %−ηΧΓ and Trans-vaginal ultrasound should be repeated on day 4, 6 and 7 after taking the initial dose of methotrexate:
- If ! 15% decline in %−ηΧΓ between day 4 &7, give 2nd dose of methotrexate on day 7. - If > 15% decline in %−ηΧΓ between day 4 & 7, follow up weekly until %− hCG is below 10-20 iu/l.
Possible adverse effects: the single intramascular injection of methorexate is associated with mild transient side effects, but persistent complications are virtually absent;
Abdominal pain. • Impaired liver function. • Stomatitis & enteritis. • Bone marrow suppression. • 80
Surgical Management:
• Cross-match blood and arrange for immediate laparotomy. Do not wait for blood before performing surgery. • At surgery, inspect both ovaries and fallopian tubes:
- If there is extensive damage to the tubes, perform salpingectomy (the bleeding tube and the products of conception are removed together). This is the treatment of choice in most cases; - Rarely, if there is little tubal damage, perform salpingostomy (the products of conception can be removed and the tube conserved). This should be done only when the conservation of fertility is very important to the woman, as the risk of another ectopic pregnancy is high.
Follow up:
• Follow up with %−ηΧΓ levels every week till levels become negative (if salpingostomy done). • Correct anaemia with ferrous sulfate one tablet/day for six months. • Schedule a follow-up visit at four weeks.
Remember:
• Patients should be counseled on birth spacing for 3 months. Condoms and COC are the preferable methods to be used. Progestin dependant methods and IUCD are contraindicated following ectopic pregnancy. • Patient should be advised on the importance of early booking in the next pregnancy as early scan should be performed to exclude ectopic pregnancy.
MOLAR PREGNANCY
Molar pregnancy is diagnosed by ultrasound ( bilateral luteal cyst) and raised %−ηΧΓ.
Immediate Management
• Perform the following tests: %−ηΧΓ, LFT and chest x-ray. • Prepare the patient for suction evacuation by performing CBC and Cross matching of 2 unites of blood. • Perform suction evacuation under general anaesthaesia. • Send the products for histopathology examination. • Infuse oxytocin 20 units in 500 ml of IV fluids (normal saline or Ringer’s lactate) at 60 drops per minute to prevent haemorrhage once evacuation is under way.
Subsequent Management
• %−ηΧΓ should be repeated every 2 weeks until normal (< 5 iu/l). • If normal levels are reached within 8 weeks, the prognosis is very good , but monthly testing must continue for 6 months. Provided %−ηΧΓ level remains normal during this time, the patient can then embark on another pregnancy.
81 76
• If a rapid fall in %−ηΧΓ level does not occur. 2 weekly tests must be continued. As long as there is a progressive fall to normal levels within 6 months, the prognosis is usually good, but monthly testing should continue during the first year, and 3 monthly tests during the second year. • Women should be advised not to conceive until their %−ηΧΓ level have been normal for 6 months. • The women should be advised to use condoms till %−ηΧΓ is negative, than COC can be started.
2. Vaginal Bleeding in Later Pregnancy
Problems
• Vaginal bleeding after 22 weeks of pregnancy. • Vaginal bleeding in labour before delivery.
Table 18: Types of bleeding
Type of Bleeding Probable Diagnosis Action
Blood-stained mucus Onset of labour Proceed with management (show) of normal labour and
childbirth
Determine cause using Any other bleeding Antepartum haemorrhage Table 19
General Management
• Call for help. Urgently mobilize all available personnel. • Perform a rapid evaluation of the general condition of the woman, including vital signs (pulse, blood pressure, respiration, temperature).
Do not do a vaginal examination at this stage
• If shock is suspected, immediately begin treatment. Even if signs of shock are not present, keep shock in mind as you evaluate the woman further because her status may worsen rapidly. If shock develops, it is important to begin treatment immediately. • Insert two large IV lines ( No. 14-16), and infuse IV fluids.
Initial Management:
• Determine gestational age by last menstrual period or by early scan report if available. • Ask for history of: trauma, coitus, amount and character of bleeding, association with pain or regular uterine contractions, rupture of membranes, and previous vaginal discharge. • Perform ultrasound and connect CTG if available & if maternal condition permits. • Collect blood for haemoglobin, complete82 blood count, grouping and cross 77 matching. If bleeding is severe at least 4 units of blood must be cross matched. • Alert the laboratory for urgent need of blood. • If placental abruption is suspected, order for RFT, electrolyte and coagulation
available. • Determinehistorygestationaltrauma,Ask for of: age by lastamount coitus,and period menstrual or of early character report bybleeding,scanassociation if withavailable. pain or regular uterine contractions, rupture of membranes, and previous • vaginalAsk for discharge. history of: trauma, coitus, amount and character of bleeding, association • Performwith pain ultrasound regular uterineand connectcontractions,available CTG if rupture if maternal & conditionof membranes, permit s.and previous • vaginalCollect discharge. blood for haemoglobin, complete blood count, grouping and cross • matching.ultrasoundPerform If bleeding isand severe connect atCTG leastif units4availablebloodmaternal of & if must be cross conditionmatched. permits. • CollectAlert theblood laboratory for haemoglobin, for urgent need complete of blood. blood count, grouping and cross • matching.If placental If abruptionisbleeding issevere suspected, at least orderunitsforof 4 RFT, must bloodelectrolytecross be andmatched. coagulation • Alertprofile. the laboratory for urgent need of blood. • IfInsertplacental urinary abruption catheter andsuspected,input/output is maintain order for RFT, chart.electrolyte and coagulation • Checkprofile. PR, BP, RR and amount of bleeding every 15 minutes. • InformInsert responsibleurinary catheter relative and maintainfeto about input/output-maternal chart. condition, risk involved and plan of • Checkmanagement. PR, BP, RR and amount of bleeding every 15 minutes. • Inform responsible relative about feto-maternal condition, risk involved and plan of management. Once placenta previa is excluded, per speculum and vaginal examination can be done if essential Once placenta previa is excluded, per speculum and vaginal examination can be done if essential
Table 19: Diagnosis of vaginal bleeding in later pregnancy and labour (antepartum haemorrhage) Table 19: Diagnosis of vaginal bleeding in later pregnancy and labour (antepartum haemorrhage) Presenting Symptom and Symptoms and Signs Probable Diagnosis Other Symptoms and Sometimes Present & Management
PresentingSigns Typically Symptom and Symptoms and Signs Probable Diagnosis Other SymptomsPresent and Sometimes Present & Management Signs Typically • BleedingPresent after 22 • Tense/tender uterus Abruptio placentae
weeks gestation • Decreased/absent fetal • Tense/tender uterus Abruptio placentae • Bleedingretained(may be after 22 in the movements. uterus)weeks gestation • FetalDecreased/absent distress or absentfetal (may be retained in the • • Intermittent or constant fetalmovements. heart sounds uterus) abdominal pain • Fetal distress or absent • Intermittent(intra-constant • AbdominalShock distension/ free Ruptured uterus Bleeding or • fetal heart sounds • abdominal and/or Abdominal distension/ free Ruptured uterus painBleeding (intra- • Shock vaginal)abdominal and/or Abnormalfluid uterine contour • • vaginal)abdominalSevere pain • Abnormalabdomen contour Tender uterine • Severe(may decreaseabdominal after pain • TenderShock abdomen rupture)decrease after (may • Shock palpable fetal parts rupture) Easily Absentpalpablemovements • Easily fetal fetal parts Absent heartmovements • and fetalfetal sounds Rapid maternalsounds • and fetal heart pulse Rapid maternal pulse • Bleeding after 22 Bleeding may be Placenta praevia • • • weeksBleedinggestation after 22 • precipitatedBleeding may bybe intercourse Placenta praevia 78 weeks gestation • precipitateduterusintercourseRelaxed by
• RelaxedShock uterus 78 • ShockpresentationFetal not in • Fetalpelvis/lowerpresentation uterinenot pole in feelspelvis/lower empty uterine pole • feelsNormalempty fetal condition • Normal fetal condition ABRUPTIO PLACENTA ABRUPTIO PLACENTA 83 Abruptio placentae is the detachment of a normally located placenta from the uterus beforeAbruptiotheplacentaedelivered.detachment fetus is is the of a normally located placenta from the uterus before the fetus is delivered.
• Fetal presentation not in pelvis/lower uterine pole feels empty • Normal fetal condition
ABRUPTIO PLACENTA
Abruptio placentae is the detachment of a normally located placenta from the uterus before the fetus is delivered.
Can be described into four grades:
Grade 0: Asymptomatic and incidentally observed retro placental clot.
Grade 1: Pain and uterine irritability, but no fetomaternal compromise.
Grade 2: Fetal compromise or distress, but no maternal compromise.
Grade 3: characterized by uterine tetany, maternal compromise and fetal demise.
Grade 1 to 3 may have either revealed or concealed haemorrhage
Management:
• Transfuse as necessary, preferably with fresh blood. • If bleeding is heavy (evident or hidden) or if any maternal or fetal compromise, deliver as soon as possible:
- If the cervix is fully dilated, deliver by vacuum extraction; - If vaginal delivery is not imminent, deliver by caesarean section. Note: In every case of abruptio placentae, be prepared for postpartum haemorrhage
• If bleeding is light to moderate (the mother is not in immediate danger), 79 the course of action depends on the fetal heart rate:
- If fetal heart rate is normal or absent, rupture the membranes with an amniotic hook:
- If contractions are poor, augment labour with oxytocin; - If the cervix is unfavourable (firm, thick, closed), perform caesarean section.
- If fetal heart rate is abnormal (less than 110 or more than 160 beats per minute):
- Perform rapid vaginal delivery; - If vaginal delivery is not possible, deliver by immediate caesarean section.
If operative delivery is indicated, normalization of maternal condition and clotting system with blood products (red cells, platelets, FFP & cryoprecipitate) prior to surgery is essential.
! 84
COAGULOPATHY clotting system with blood products (red cells, platelets, FFP & cryoprecipitate) prior to surgery is essential. !
COAGULOPATHY
Coagulopathy is both a cause and a result of massive obstetric haemorrhage. It can be triggered by abruptio placentae, fetal death in-utero, eclampsia, amniotic fluid embolism and many other causes. The clinical picture ranges from major haemorrhage, with or without thrombotic complications, to a clinically stable state that can be detected only by laboratory testing.
Note: In many cases of acute blood loss, the development of coagulopathy can be prevented if blood volume is restored promptly by infusion of IV fluids (normal saline or Ringer’s lactate).
• Treat the possible cause of coagulation failure; • Use blood products to help control haemorrhage;
- Give fresh whole blood, if available, to replace clotting factors and red cells; - If fresh whole blood is not available, choose one of the following based on availability:
- Fresh frozen plasma for replacement of clotting factors (15 mL/kg body weight); - Packed (or sedimented) red cells for red cell replacement; - Cryoprecipitate to replace fibrinogen; - Platelet concentrates (if bleeding continues and the platelet count is less than 20,000). 80
PLACENTA PRAEVIA
This is the condition in which placenta is partly or completely situated at lower uterine segment Figure 1
Grades of placenta praevia:
Grade I: placenta in lower pole but doesn’t reach internal os;
Grade II: lower edge of placenta reaches internal os but doesn’t cover it;
Grade III: the placenta covers os partially;
Grade IV: placenta covers os completely.
Note: Only in grade I vaginal delivery can be allowed.
Screening and Diagnosis:
If routine second trimester scan shows low lying placenta:
• In asymptomatic minor placenta praevia: repeat scan at 34-36 weeks. • In major degree of placenta praevia: repeat scan at 32 weeks; to clarify the diagnosis and plan for delivery.
85
Figure 1: Implantation of placenta at or near the cervix · If the uterus cannot be repaired, perform subtotal hysterectomy (page ScreeningIf routine andsecond trimesterDiagnosis: tear showsscan low lying extendsthe cervixP through-103). placenta: If the and vagina, total hysterectomy may be required. If•routineIn asymptomatic second trimester minor placenta scan shows praevia: low repeatlying placenta:at scan 34-36 weeks. • In major degree of placenta praevia: repeat scan at 32 weeks; to clarify the diagnosisPLACENTA PRAEVIA • In asymptomaticand planminor for placenta delivery. praevia: repeat scan at 34-36 weeks. • In major Placentadegree placenta ofpraeviaimplantation is praevia: of repeatthe scanplacenta or 32 at theatnear cervix weeks; to (Figclarify the diagnosis andS-3). plan for delivery.
FIGURE S-3 Implantation ofFigure the placenta at or near the cervix. 1: Implantation of placenta at or near the cervix
Figure 1: Implantation of placenta at or near the cervix
Antenatal Management: Warning: Do not perform a vaginal examination unless preparations • If possible,haveaim been to allowmade for immediatepregnancy to caesareanprogress section. Aclose careful to term speculum to achieve maximum examinationfetal maturity. may be performedElective shouldCS to ruleout be other deferred causes ofto 38bleeding weeks such to as minimize neonatal morbidity.cervicitis, trauma, cervical polyps or cervical malignancy. The presence of • Patients these,with however, major pla doescenta not rule praevia with out praevia. placenta previous history of bleeding, should be admitted from· Restore34 weeks blood of volumegestation. by infusing IV fluids (normal saline or Ringer’s • Patients with majorlactate). placenta praevia but no previous history of bleeding can be managed as out patient provided: 81 · Assess the amount of bleeding: - Close -proximityIf bleeding to the is hospitalheavy and continuous, and constant arrange presence for caesarean of a deliverycompanion 81is guaranteed.irrespective of fetal maturity (page P-43); - Detailed counselling and informed consent is obtained from the woman.
Prolonged inpatient care can be associated with an increased risk of thromboembolism:
• Gentle mobility and the use of prophylactic thromboembolic stockings should be encouraged. • Prophylactic anticoagulation should be reserved for those at high risk of thromboembolism and, in these cases, unfractionated heparin is to be preferred over the longer-acting low molecular weight preparations.
DELIVERY
• Plan delivery if:
- The fetus is mature; - The fetus is dead or has an anomaly not compatible with life (e.g.anencephaly); - The woman’s life is at risk because of excessive blood loss.
• If bleeding is light or if it has stopped and the fetus is alive but premature, consider expectant management until delivery or heavy bleeding occurs. 86 82
Note: Women with placenta praevia are at high risk for postpartum haemorrhage and placenta accreta/increta, a common finding at the site of a previous caesarean scar.
Antenatal scan with Doppler should be performed in woman with placenta previa who are at increased risk of placenta acreta, where this is not possible such women should be managed as if having adherent placenta (acreta, increta, percreta)
When to proceed with vaginal delivery:
- The diagnosis of placenta praevia is inconclusive. - Grade 1 or 2 anterior praevia is suspected in patients with ongoing but not life threatening uterine bleeding.
When to proceed with caesarean section:
- Placental edge less than 2 cm from the internal os, especially if it is posterior or thick. - Grade 3 and Grade 4 placenta praevia.
For anterior placenta, perform scan prior to CS to localize segment where amniotic sac can be approached without having to incise through the body of placenta.
• 4 Units of blood should be arranged prior to the CS.
• The procedure should be carried by the most experienced obstetrician & anaesthetist, in presence of senior neonatologist. • If developed bleeding during the procedure from the placental site:
- Under-run the bleeding sites with sutures; - Infuse oxytocin 20 units in 1 L IV fluids (normal saline or Ringer’s lactate) at 60 drops per minute.
If bleeding occurs during the postpartum period, initiate appropriate management. This may include uterine artery ligation or hysterectomy.
Patients with major placenta praevia/ placenta accrete should be managed in the tertiary care
3. Fever during Pregnancy 87 83 Problem
• A woman has fever (temperature 38°C or more) during pregnancy or labour. Patients with major placenta praevia/ placenta accrete should be managed in the tertiary care
3. Fever during Pregnancy 3. Fever during Pregnancy Problem Problem • A woman has fever (temperature 38°C or more) during pregnancy or labour. • A woman has fever (temperature 38°C or more) during pregnancy or labour.
General Management General Management • Encourage bed rest. • Encourage increased fluid intake by mouth. • Give paracetamol 1 gm. • Encourage increased fluid intake by mouth. • Give paracetamol 1 gm.
DiagnosisDiagnosis of fever during pregnancy and labour
Table 20: Diagnosis of fever during pregnancy and labour Presenting Symptom and Symptoms and Signs Probable Other Symptoms and Sometimes Present Diagnosis Presenting Symptom and Symptoms and Signs Probable Other Symptoms and Sometimes Present Diagnosis Signs Typically • Dysuria • Retropubic/ suprapubic pain Cystitis • Increased frequency • Abdominal pain Cystitis and urgency of • Increased frequency • Abdominal pain and urgency of • urination Acute • Spiking fever/chills • Loin pain/tenderness pyelonephritis • Dysuria • Retropubic/ suprapubic pain Acute • Increased frequency • Tenderness in rib cage pyelonephritis and urgency of urination •• pain/tenderness • Tenderness in rib cage • Nausea/ vomiting and urgency of urination • Anorexia •• Foul-smelling vaginal •• Nausea/abdominal pain Septic abortion discharge in the first • Rebound tenderness • Foul-smelling vaginal • Lower abdominal pain Septic abortion • discharge in the first • Purulent cervical discharge • Tender uterus • Prolonged bleeding • Fever • Fever/chills •• Purulent cervical discharge Chorioamnionitis •• Abdominal pain • Foul-smelling watery • Tender uterus • Fever/chills after 22 Chorioamnionitis •• History fetal heartfluid • Foul-smelling watery •• Tendervaginal bleeding • Abdominalafter 22 • Rapid fetal heart rate • weeks •• Consolidationbleeding Pneumonia • Difficulty in breathing • Congested throat To be referred • Cough with • Rapid breathing and treated by a expectoration • Consolidation Pneumonia • Difficultypain breathing • Congested throat To be referred ominal Pain in Early Pregnancy • Cough with • Rapid breathing 4 • . A b R d h and treated by ao the tertiary care physician n c h i /
r a l e s • Encourage bed rest. Problem
Diagnosis 4. Abdominal experiencing Pregnancy in the first 22 weeks of pregnancy. Table 20:
Signs Typically Present Present • Dysur ia • Retropubic/ suprapubic pain urination Dysur ia • Retrop ub ic/ sup rapub ic p ain
• Spiking fever/chills LoinAnorexia •• IncreasedAbdominal frequency pain
Abdominal pain Lower vomiting
22 weeks • Prolonged bleeding Fever • Rebound tenderness 22 weeks
History of loss of fluid Tender uterus
discharge Rapidof loss of rate weeks Light uterus discharge pain Fever Light vaginal 84
84 physician • Fever Rhonchi/ rales Chest
expectoration • Chest pain 88
• The woman is Pain Earlyabdominal pain • Cough with • Rapid breathing and treated by a physician expectoration • Rhonchi/ rales • Chest pain
4. Abdominal Pain in Early Pregnancy
Problem
• The woman is experiencing abdominal pain in the first 22 weeks of pregnancy. Abdominal pain may be the first presentation in serious complications such as abortion or ectopic pregnancy.
General Management
• Perform a rapid evaluation of the general condition of the woman, including vital signs (pulse, blood pressure, respiration, temperature). • If shock is suspected, immediately begin treatment. Even if signs of shock are not present, keep shock in mind as you evaluate the woman further because her status may worsen rapidly. If shock develops, it is important to begin treatment immediately.
Note: Appendicitis should be suspected in any woman having abdominal pain. Appendicitis can be confused with other more common problems in pregnancy which causes abdominal pain (e.g. ectopic pregnancy, abruptio placentae, twisted ovarian cysts, pyelonephritis).
85
89
Diagnosis
Table 21: Diagnosis of abdominal pain in early pregnancy
Presenting Symptoms and Symptoms and Signs Probable Other Symptoms and Signs Sometimes Present Diagnosis Typically Present • Abdominal pain • Palpable, tender discrete mass Ovarian cyst • Adnexal mass on vaginal in lower abdomen examination • Light vaginal bleeding
• Lower abdominal pain • Abdominal distension Appendicitis
• Low-grade fever • Anorexia • Rebound tenderness • Nausea/ vomiting
• Paralytic ileus
Increased white blood cells • • No mass in lower abdomen
• Site of pain higher than expected
Retropubic/ suprapubic pain • Dysuria • Cystitis Increased frequency and • urgency of urination • Abdominal pain
Dysuria Retropubic/ suprapubic pain Acute • • • Spiking fever/ chills • Loin pain/ tenderness pyelonephritis
• Increased frequency and • Tenderness in rib cage urgency of urination Anorexia • • Abdominal pain • Nausea/ vomiting
• Low-grade fever/ chills • Rebound tenderness Peritonitis
• Lower abdominal pain • Abdominal distension
• Absent bowel sounds • Anorexia
• Nausea/ vomiting
• Shock
• Abdominal pain • Fainting Ectopic Light bleeding Tender adnexal mass pregnancy • • • Closed cervix • Amenorrhoea
• Uterus slightly larger than • Cervical motion tenderness normal
• Uterus softer than normal
90 86
Management
OVARIAN CYSTS
Ovarian cysts in pregnancy may cause abdominal pain due to torsion or rupture. Ovarian cysts most commonly undergo torsion and rupture during the first trimester.
• If the woman is in severe pain, suspect torsion or rupture. Perform immediate laparotomy.
Note: If findings at laparotomy are suggestive of malignancy (solid areas in the tumour, growth extending outside the cyst wall), the specimen should be sent for immediate histological examination and the woman should be referred to a tertiary care centre for evaluation and management.
• If the cyst is more than 10 cm and is asymptomatic:
- If it is detected during the first trimester, observe for growth or complications till after 16 weeks. - If it is detected during the second trimester, remove by laparotomy to prevent complications.
• If the cyst is between 5 and 10 cm, follow up. Laparotomy may be required if the cyst increases in size or fails to regress. • If the cyst is less than 5 cm, it will usually regress on its own and does not require treatment.
APPENDICITIS
• Give a combination of antibiotics before surgery and continue until the woman is postoperative and fever-free for 48 hours;
- Ampicilline 2 g IV every six hours; - PLUS gentamicin 5 mg/kg body weight IV every 24 hours; - PLUS metronidazole 500 mg IV every eight hours.
• Perform an immediate surgical exploration (regardless of stage of gestation) and perform appendectomy, if required.
Note: Delaying diagnosis and treatment can result in rupture of the appendix, which may lead to generalized peritonitis.
• If there are signs of peritonitis (fever, rebound tenderness, abdominal pain), give antibiotics as for peritonitis.
Note: The presence of peritonitis increases the likelihood of abortion or preterm labour.
91 87
• If the woman is in severe pain, give pethidine 1 mg/kg body weight (but not more than 100 mg) IM or IV slowly or give morphine 0.1 mg/kg body weight IM. • If appendectomy done after 28 weeks gestation, tocolytic drugs may be needed to prevent preterm labour.
5. Abdominal Pain in Later Pregnancy
Problems
• The woman is experiencing abdominal pain after 22 weeks of pregnancy. • The woman is experiencing abdominal pain during the first six weeks after childbirth.
General Management
• Perform a rapid evaluation of the general condition of the woman, including vital signs (pulse, blood pressure, respiration, temperature). • If shock is suspected, immediately begin treatment. Even if signs of shock are not present, keep shock in mind as you evaluate the woman further because her status may worsen rapidly. If shock develops, it is important to begin treatment immediately.
Note: Appendicitis should be suspected in any woman having abdominal pain. Appendicitis can be confused with other more common problems in pregnancy which cause abdominal pain. If appendicitis occurs in late pregnancy, the infection may be walled off by the gravid uterus. The size of the uterus rapidly decreases after delivery, allowing the infection to spill into the peritoneal cavity. In these cases, appendicitis presents as generalized peritonitis.
Diagnosis
Table 22: Diagnosis of abdominal pain in later pregnancy and after child birth
Presenting Symptom and Symptoms and Signs Probable Diagnosis Other Symptoms and Sometimes Present Signs Typically Present
• Palpable contractions Cervical dilatation and Possible preterm • • Blood-stained mucus effacement labour
discharge (show) or • Lighta vaginal bleeding watery discharge before
37 weeks
Palpable contractions • Cervical dilatation and Possible term • Blood-stained mucus effacement labour • discharge (show) or • Light vaginal bleeding
watery discharge at or after 37 weeks
Intermittent or constant Shock Abruptio placentae • •
92 88
• Palpable contractions • Cervical dilatation and Possible term • Blood-stained mucus effacement labour
discharge (show) or • Light vaginal bleeding watery discharge at or
after 37 weeks
• Intermittent or constant • Shock Abruptio placentae abdominal pain • Tense/tender uterus
• Bleeding after 22 • Decreased/ absent fetal 88 weeks gestation (may movements
be retained in the • Fetal distress or absent fetal uterus) heart sounds
• Severe abdominal pain • Shock Ruptured uterus (may decrease after • Abdominal distension/ free rupture) fluid • Bleeding (intra- • Abnormal uterine contour abdominal and/or • Tender abdomen vaginal) • Easily palpable fetal parts Absent fetal movements and • fetal heart sounds
• Rapid maternal pulse
• Abdominal pain • History of loss of fluid Chorioamnionitis
• Foul-smelling watery • Tender uterus vaginal discharge after 22 • Rapid fetal heart rate weeks gestation • Light vaginal bleeding • Fever/chills
• Abdominal pain • Retropubic / suprapubic pain Cystitis
Dysuria -7• • Increased frequency and urgency of
urination • • Retropubic/suprapubic pain Acute Dysuria Loin pain/tenderness pyelonephritis • • • Abdominal pain • Tenderness in rib cage
• Spiking fever/chills • Anorexia Increased frequency • Nausea/vomiting and urgency of urination • • Abdominal distension • Appendicitis Lower abdominal pain • Low-grade fever • Anorexia • Twisted pedinculated Rebound tenderness • Nausea/vomiting fibroids Paralytic ileus • • Redgeneratin Increased white blood cells • of fibroids No mass in lower abdomen •
Site of pain higher than expected • • Lower abdominal pain Light vaginal bleeding Endometritis • Fever/chills • Shock • Purulent, foul-smelling lochia • Tender uterus
93 89
• Lower abdominal pain • Poor response to antibiotics Pelvic abscess and distension • Swelling in adnexa or pouch • Persistent spiking fever/ of Douglas chills • Pus obtained upon • Tender uterus culdocentesis
• Lower abdominal pain • Rebound tenderness Peritonitis
• Low-grade fever/chills • Abdominal distension • Absent bowel sounds • Anorexia
• Nausea/vomiting
Shock
-7• b • Abdominal pain • Ovarian cyst • Adnexal mass on Palpable, tender discrete vaginal examination mass in lower abdomen • Light vaginal bleeding
a Light bleeding: takes five minutes or longer for a clean pad or cloth to be soaked b Ovarian cysts may be asymptomatic and are sometimes first detected on physical examination.
6. Missed abortion
Problem:
Absent fetal heart activity and/or cessation of pregnancy related symptoms before 24 weeks of pregnancy.
Diagnosis: • By ultrasound: # Intrauterine sac ( < 20 mm mean diameter) with no obvious yolk sac or fetus, OR # Absence of fetal heart activity in a pregnancy with a crown-rump length of < 6 mm.
Note: A repeat ultrasound examination at an interval of 1 to 2 weeks is necessary to confirm the diagnosis.
If the gestational sac is smaller than expected for gestational age, the possibility of incorrect dates should be considered, especially in the absence of clinical features of threatened abortion. A repeat scan should be arranged after a period of at least 7 days and to be performed by an experienced person.
94 90
General management:
• Perform CBC, coagulation profile, bloog group, Rh status and sickling (if not known), save serum. • Counsel women thoroughly on her condition and on the different methods of management. • Consider medical or surgical management. • Offer expectant management only in the following conditions: # 24 hour phone advice service and admission services are available. # Women’s easy access to the health facility is guaranteed. # Women is fully aware of her condition and the alarming signs such as heavy bleeding or severe pain which will require immediate attendance to the hospital. • Expectant management should not be extended beyond two weeks.
Surgical management:
• By suction evacuation under anaesthesia. • If infection is suspected, evacuation should be delayed for 12 hours to allow intravenous antibiotic administration. • Prostaglandins can be administered prior to the procedure to ripen the cervix: # Misoprostol 200 mcg vaginally, 2 to 3 hours prior to the procedure. # PGE2 1 mg 2 to 3 hours before the procedure (If misoprostol not available).
Medical management:
• If # 12 weeks: misoprostol 800 µg vaginally, every 24 hours. Total of three doses can be given. • Between 12-24 weeks: misoprostol 400 µg vaginally, every 4 hours. Total of five doses can be given. • In cases of vaginal leaking and high WBC, same dose to be given orally. • If history of previous LSCS: half the original dose should be given.
Note: If endometrial thickness prior to the treatment with misoprostol was more than 15 mm, patient will need follow up once every week until endometrial thickness is normal (7-8 mm).
Remember:
• Medical management with misoprostol should only be ordered by the most senior doctor in the department (Sr. specialist/ Consultant). Patients who are Rh negative should be given anti D immunoglobulins. • Products of conception to be sent for histopathology. • Patient should be managed as in-patient. •
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7. Multiple Pregnancy
General Management:
• Documentation of chorionicity should be done as soon as diagnosis is confirmed and preferably by late first trimester (10-14 weeks). • Counsel about possibility of Anaemia, Preterm labour, PIH, GDM ,APH, IUGR ,IUFD. • In case of monochorionic (MC) twins counsel about fetal problems like conjoined twins, twin reversal arterial perfusion sequence, acute polyhydramnios & twin-twin transfusion sundrome (TTTs) and need for frequent antenatal visits and hospitalization if complications develop. • Screening for hypertension and gestational diabetes. • Hospitalization & referral to higher centre if develops complications. • Counseling at 34-36 weeks about possible mode of delivery, analgesia & intrapartum care In view of increased risk of IUFD. • Elective delivery is recommended in uncomplicated MC twin at 36 weeksandandatat 38-38- 39 weeks in dichorionic (DC) twin pregnancy.
Screening for fetal abnormalities and well being:
• Screening for trisomy by measuring nuchal translucency at 12 weeks by ultrasound. • Ultrasound at 16 weeks & then 4 weekly for MC twin to exclude discordant growth & TTT Syndrome. • Screening for structural anomaly by 20-22 weeks with extended view of fetal heart. • Assessing fetal growth & wellbeing by USG during each antenatal visit which includes fetal measurements, fetal activity, lies and amniotic fluid volume assessment. If one or both fetuses are small additional information is obtained about fetal wellbeing by umbilical artery doppler & CTG.
Cases of multiple pregnancy should be followed up by a senior obstetrician
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Algorithm 5: USG surveillance of multiple pregnancy of ! 28 weeks
Look for: weight of fetus, amniotic fluid, Doppler of umbilical artery if growth discordance
Concordance of Complications: Discordance of weight and • Discordance of weight > 15% weight >25% or amniotic fluid AC < 5th OR percentile • AC* 5th to 10th percentile OR • Oligohydromnios (DVP** 1-3 cm) • Normal Doppler Refer to the Monochrionic Dichorionic tertiary
USG 2 weekly MonochrionicMonochrionic Dichorionic
USG weekly Two or more One complication: complications: USG 2 weekly weekly USG
* Abdominal circumfernace ** Deep vertical pool
Note: Calculation of % of EFW discordance: (EFW of larger twin – EFW of smaller smaller twin) x 100 devided by EFW of smaller twin.
Intrapartum Management:
Indications for caesarean section:
• First twin non vertex, • Previous CS with 1st Breech ( Previous CS with both cephalic: mode of delivery controversial ,scar dehiscence rate 0-3%, Vaginal delivery in properly selected cases), • Monoamniotic twins ( elective at 34 weeks),
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• Placenta previa, • Certain congenital anomalies, • Possible interlocking twins (if 1st twin non vertex), • Conjoined twins, • Triplets and higher order multiple pregnancy, • All other indications which are applicable to singleton pregnancy.
Suitability of vaginal delivery :
• Both cephalic. • First cephalic, as presentation of second twin is likely to change. • Low birth weight fetus under (weight < 1500 g).
8. Hydrops Fetalis
Hydrops fetalis (i.e., fetal hydrops) is a serious fetal condition defined as abnormal accumulation of fluid in 2 or more fetal compartments, including ascites, pleural effusion, pericardial effusion, and skin oedema. In some patients, it may also be associated with polyhydramnios and placental oedema.
Hydrops fetalis has been a well-recognized fetal and neonatal condition due to Rhesus (Rh) blood group isoimmunisation of the fetus. The term nonimmune hydrops to identify those cases in which the fetal disorder was caused by factors other than isoimmunisation.
Non Immune hydrops fetalis: A consequence of many heterogeneous disorders such as:
- Cardiovascular malformations, - Chromosomal abnormalities; - Congenital infections; - Multiple congenital anomalies.
Investigations necessary in cases of hydrops:
• Complete and detailed fetal and placental ultrasound done by an experienced Ultrasonographer; • Fetal echocardiography screening; • Doppler Blood Flow Studies (umbilical artery, middle cerebral artery, aorta).
Blood investigations :
Blood type and group; • Complete blood count; • Bacteriological studies; • CMV, VDRL; • TORCH & Parvovirus titres; • Indirect Coombs to rule out immune aetiologies; • Antiphospholipid, anticardiolipid and lupus anticoagulant antibodies; •
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• Antibody screen (AChR, anti RO & LA, etc.); • Kleihauer-Bethke test (if available) to eliminate the possibility of a fetomaternal haemorrhage; • Red blood cell enzymopathies; • G6PD; • OGTT/ Glycosylated/ Hb; • Haemoglobin electrophoresis; • Alfa feto protein serum levels.
Amniocentesis (Patient may be sent to tertiary care hospital if she is wishing to undergo the procedure):
• Karyotype analysis; • Amniotic fluid analysis with cultures / PCR; • Alfa feto protein of the amniotic fluid.
If indicated, following investigations may be requested.
• Metabolic tests (Gaucher's, Tay-Sachs, GM1 Gangliosidosis); • Restriction endonuclease for Alpha thalassemia; • Amniotic fluid supernatant analysis (glycosaminoglycans, oligosaccharides, free sialic acid and acid hydrolase activities); • Biochemical, molecular, cytogenetic, virological, bacteriological studies of cultured amniotic fluid, fetal and placental tissue cells; • Electron microscopy and enzyme assays (for instance, sialidase, B-Glucosidase, B-Galactosidase and Glucuronidase) in cultured fibroblasts.
Fetal and placental studies (May be done as indicated in individual cases):
• Fetal blood for investigation of :
- Type and Group; - Karyotype (also on chorionic villi); - Complete blood count; - Direct and indirect Coombs; - Viral Screen / TORCH IgM, parvovirus; - Serum protein levels; - Abnormal Hb studies; - Red blood cell enzyme mutations; - Arterial blood gases; - Molecular genetic studies (mitochondrial and metabolic disorders).
Postnatal investigations
• X-Rays (complete babaygram) with examination of the chest, abdomen, cranium, long-bones lengths, deformation and calcification.
Counselling of couple and Mode of delivery
99 95 Postnatal investigations
• X-Rays (complete babaygram) with examination of the chest, abdomen, cranium, long-bones lengths, deformation and calcification.
Counselling of couple and Mode of delivery
• Mostly cause of hydrops is not known due to limited investigations availability. 95 • Information about possibility of intrauterine, intrapartum or neonatal death needs to be discussed with the couple. Progress of labour may be prolonged, due to scalp and neck oedema ( as part of general anasarca ), as flexion is not easily possible. • Hydrothorax or ascites may be severe and may be aspirated in active labour or at the time of delivery to encourage descent of fetus. • Caesarean delivery may be considered over difficult vaginal delivery especially when there is gross scalp oedema to prevent maternal injuries & morbidity. • Genetic counselling & prediction of recurrence is possible, if cause of hydrops is known as genetic or chromosomal disorder. Viral infections, cord accidents, fetal tumours and structural congenital anomalies etc. may not be recurrent. • Early booking, first trimester nuchal translucency at 11 to13+6 weeks and a detailed anomaly scan are indicated in next pregnancy.
9. Small for gestational age (SGA)/ fetal growth restriction (FGR)
Problems:
• Small for gestational age: Growth at the 10th or less percentile for weight of all fetuses at that gestational age. SGA fetuses are small for gestational age but are not pathologically small. • Fetal growth restriction: a condition in which a fetus is unable to achieve its genetically determined potential size.
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Diagnosis:
Algorithm 6: Diagnosis of SGA/ FGRFDR
Suspected SGA/FGR
Perform Ultrasound: Abdominal Circumference and/or Estimated Fetal weight is below 10th centile
Yes No
Perform Umbilical Exclude artery doppler SGA/FGR
Normal Reduced Absent/Reversed EDF* EDF
Perform ultrasound for C) Manage as SGA D) Manage as liquor volume with reduced EDF SGA with absent or reversed EDF
B) Manage as SGA with Normal Reduced normal Doppler but reduced liquor volume
A) Manage as SGA with normal Indices
* End diastolic flow
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Management:
A) SGA with normal indices:
• Monitor as out patient clinic.
• If the estimated fetal weight (EFW) is between 3rd and 10th centile, with no risk facotrs: rescan in 4 weeks to check growth velocity. • If the EFW is between 3rd and 10th centile, with other risk factors: rescan in 3 weeks. • If EFW ic < 3rd centile: - Perform detailed scan; - Consider karyotyping; - Screen for congential infections (in cases of recurrent SGA); - Rescan in 2 weeks.
• Can be delivered at term.
At the next scan:
• If the growth velocity & other indices are normal, continue routine follow up in the ANC clinic; • If indices are normal, but growth velocity is reduced, consider karyotyping and congenital infection screening; • If growth velocity is reduced & doppler or liquor reduced, manage accordingly.
Note: Growth velocity should be determined by 10 mm per week increase in abdominal circumference.
B) SGA with normal doppler but reduced liquor volume:
If ∃ 37 weeks gestation, consider delivery; • If < 37 weeks gestation, repeat scan in 2 weeks and manage as SGA with normal • indices.
C) SGA with reduced end diastolic flow (EDF):
Repeat growth scan in 2 weeks; • Repeat umbilical artery doppler weekly; • Taking gestational age and other risk factors into account, consider • cardiotocography (CTG) or biophysical profile (BPP) monitoring. Monitoring should be more frequent than twice weekly if EFW/ abdominal circumference is less than 3rd centile, • Consider delivery if greater than 36 weeks with evidence of poor growth velocity or further deterioration in the uterine artery doppler; • Give antenatal steroids if delivery is planned and less than 34-36 weeks of gestation.
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D) SGA & absent or reversed EDF:
• Admit and monitor as in-patient; • Give antenatal steroids; • Deliver if more than 32 weeks gestation or prior to that according to the condition; • Monitor with daily or twice daily CTG; • Monitoer with weekly multivessel doppler, consider delivery if there are umbilical vein pulsations or reversed ductus venosus pulsations.
Note: advice the patient on daily fetal movement count. At least 10 movements should be felt within 24 hours.
Abnormal findings of liquor volume on ultrasound:
• Amniotic fluid index of less than 5 cm, as measured in the four quadrants.
Delivery before 36 weeks of gestation should be planned in a unit where optimal neonatal expertise & facilities are available
10. Breech presentation
Problem:
Women presenting at 36 weeks of pregnancy or later with breech presentation of the infant.
Management:
Assess fetal condition by performing ultrasound, look for the following: •
Confirm the diagnosis - Assess fetal weight - Amniotic Fluid Index (AFI) - Congenital anomalies - Placenta localisation - Neck hyperextension (star gazing) -
Assess the possibility of conducting vaginal breech delivery, following are • the unfavourable factors:
Clinically inadequate pelvis - Footling or kneeling breech presentation - Large baby (EFW more than 3500 gms) - IUGR (EFW less than 2000 gms) - Hyperextended fetal neck in labour - Previous LSCS - Unavailability of a trained clinician - Others: (placenta previa, compromised fetal condition) -
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• Women should be counselled in details regarding the choice of birth, following issues should be clearly explained:
- Benefits and risks for current and future pregnancies (planned caesarean section versus planned vaginal delivery); - Caesarean section carries a reduced perinatal mortality and early neonatal morbidity for babies with a breech presentation at term compared with planned vaginal birth; - Planned caesarean section for breech presentation carries a small increase in serious immediate complications compared with planned vaginal birth.
• Plan for External Cephalic Version, see page 184.
11. Decreased Fetal Movements
Problem
• Fetal movements are less than 10 movements per 12 hours.
Diagnosis:
1. History:
• Check when last had food or fluids • Check maternal activity • Check for any significant risk factors
2. Examination: • Check fetal heart rate • Perform CTG • Perform scan, check liquor volume
Management:
If < 28 weeks, or gave history of not taking food: • - Advice her to take food and observe for the next 1 hour; - Check for fetal heart sounds/ movements and manage accordingly. If ∃ 28 and < 34 weeks: • - If examination is normal and no history of risk factors: discharge with kick chart. - If any abnormality; manage accordingly. If ∃ 34 weeks: admit for monitoring after discussion with the 2nd on call. •
12. Fetal Death
Problem
Loss of fetal movements after 24 weeks of gestation and/or if fetus is ! 500 gm.
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It may be the result of fetal growth restriction, fetal infection, cord accident or congenital anomalies. Where syphilis is prevalent, a large proportion of fetal deaths are due to this disease.
General Management
• Perform baseline CBC and coagulation profile. • Confirm the diagnosis (clinically by sonic aid and/or by ultrasound). • Enquire the exact date of fetal death (time of loss of fetal movements). • Explain the problem to the woman and her family. • Follow up the women weekly for coagulation profile. • Induction of labour is planned according to the availability of the drug and the experience of the obstetricians.
Do not rupture the membranes due to the risk of infection
13. Prelabour Rupture of Membranes (PROM)
Problem:
Rupture of membranes with vaginal loss of amniotic fluid before labour has began. It can occur either when the fetus is immature (before 37 weeks): Premature prelabour rupture of membranes(PPROM) or when it is mature (term): (PROM).
Diagnosis:
1. Maternal history: • Gestational age • Time of rupture of membranes • Presence of meconium stained liquor • Symptoms of infection: - Fever - Maternal tachycardia - Foul smelling vaginal discharge 2. Examination: • Sterile speculum examination: - Presence of pool of fluid in the vagina; - Nitrazine test: amniotic fluid will turn paper blue; - Microscopic examination of vaginal fluid show ferning due to sodium & potassium hypochloride and protein; - Examination for lanugo hair.
Note: Nitrazine test is the most practical and of help, but false positive rate is 17% due to contamination with urine, blood or semen.
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• Abdominal examination: determine fetal lie, presentation, heart rate and presence of contraction.
3. Investigation: • Complete blood count • High vaginal swab • Ultrasound for AFI, estimated fetal weight • Screening for congenital anomalies if not done earlier
Note: Oligohydromnios illustrated by ultrasound can be used to help confirm the diagnosis of PROM.
• Monitor for signs of chorioamnionitis: Pyrexia, tachycardia (maternal & fetal), leukocytosis, uterine tenderness and offensive vaginal discharge.
Digital examination should be avoided where PROM is suspected
Management of PROM
• If there are no signs of infection and membranes have been ruptured for ∃18 hours, give GBS prophylaxis: - Penicillin 3 g IV with the onset of labour, then 1.5 g four hourly; - If allergic to penicillin, give; clindamycin 900 mg IV 8 hourly; - Discontinue after delivery if there are no signs of infection.
Timing of delivery
• Labour can be induced between 24- 72 hrs after discussing with a senior obstetrician if patient has not gone into spontaneous labour. • Assess the cervix:
- If favourable, induce labour using oxytocin; - If cervix is unfavourable, ripen the cervix using prostaglandin .
Management of PPROM
If below 24 weeks: •
- Termination of pregnancy should be offered; - Expectant management can be offered, if patient is not keen on termination of pregnancy, provided the patient understands the risks of extreme prematurity: cerebral palsy, blindness, and bronchopulmonary dysplasia among others and the risks underlying intrauterine infection; - Start antibiotics: Erythromycin 250 mg orally 6 hourly x 7-10 days.
Between 24- 34 weeks: •
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- Administer steroids: Dexamethasone 12 mg IM, two doses 12 hours apart; - Start antibiotics: Erythromycin 250 mg orally 6 hourly x 7-10 days; - Women with uterine activity who require antenatal corticosteroid should be considered for tocolysis in absence of infection; - Continue expectant management & deliver by 34 weeks; - If membranes have been ruptured for ∃18 hours, give GBS prophylaxis.
• Between 34 -37 weeks: Induction of labour should be done immediately if patient not in active labour.
Timing of delivery
• Delivery should be considered at 34 weeks in absence of any infection; • Women should be counselled about the increased risk of chorioamnionitis versus decreased risk of serious respiratory problems, Special Care Baby Unit admission and LSCS.
Note: Patient should be followed up by a senior obstetrician.
Monitoring during expectant management:
• Signs and symptoms of chorioamnionitis (every 4-8 hours); • CBC twice a week; • HVS weekly; • Non stress test daily (after 28 weeks); • USG for AFI weekly and serial growth scans every 2- 3 weeks.
Management of Chorioamnionitis:
• Ampicillin 2 gm IV 6 hourly (Qid) + Gentamycin 5 mg/kg IV BD + Metronidazole 500 mg IV 8 hourly (TID). Continue antibiotics until woman is fever free for 48 hours. •
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109
!
NORMAL LABOUR
• Greet the woman and make her comfortable; • Perform a rapid evaluation of the general condition of the woman including vital signs (pulse, blood pressure, respiration, temperature); • Perform a rapid evaluation of the Maternal Health Record; • Assess fetal condition:
- Listen to the fetal heart rate immediately after a contraction; - Count the fetal heart rate for a full minute at least once every 15 minutes during the active phase and every five minutes during the second stage; - If there are fetal heart rate abnormalities (less than 110 or more than 160 beats per minute), suspect fetal distress. - If the membranes have ruptured, note the colour of the draining amniotic fluid. - Presence of thick meconium indicates the need for close monitoring and possible intervention for management of fetal distress. - Absence of fluid draining after rupture of the membranes is an indication of reduced volume of amniotic fluid, which may be associated with fetal distress.
Table 23: Conditions during labour requiring immediate referral
Condition Transfer to
Primigravida Secondary care
Fetal malpresentation Secondary care
Fetal distress (abnormal fetal heart Secondary care rate, thick meconium, blood stained liquor)
Ruptured membranes more than 24 Secondary care hours
Prolonged labour (poor dilatation Secondary care despite good contractions)
Prelabour rupture of membranes Secondary care
Premature labour (before 37 weeks) Secondary care
SUPPORTIVE CARE DURING LABOUR AND CHILDBIRTH
• Encourage the woman to have personal support from a person of her choice throughout labour and birth (if permissible in the institution):
Arrange seating for the companion next to the woman; -
Encourage the companion to give adequate support to the woman during - labour and childbirth (rub her back, wipe her brow with a wet cloth, assist her to move about). 105 Ensure good communication and support by staff: • 111 - Explain all procedures, seek permission and discuss findings with the woman;
Provide a supportive, encouraging atmosphere for birth that is respectful of the - woman’s wishes;
move about). move about). • Ensure good communication and support by staff: • Ensure good communication and support by staff: - Explain all procedures, seek permission and discuss findings with the woman; - Explain all procedures, seek permission and discuss findings with the woman; - Provide a supportive, encouraging atmosphere for birth that is respectful of the - womanProvide’sa wishes;supportive, encouraging atmosphere for birth that is respectful of the woman’s wishes; - Ensure privacy and confidentiality. - Ensure privacy and confidentiality. • Maintain cleanliness of the woman and her environment: • Maintain cleanliness of the woman and her environment: - Encourage the woman to wash herself or bath or shower at the onset of labour - Encourage(if possible thethe in woman providing to wash institute); herself or bath or shower at the onset of labour (if possible in the providing institute); - Clean the vulval and perineal areas before each examination; - Clean the vulval and perineal areas before each examination; - Wash your hands with soap before and after each examination; - Wash your hands with soap before and after each examination; - Ensure cleanliness of labouring and birthing area(s); - Ensure cleanliness of labouring and birthing area(s); - Clean up all spills immediately. - Clean up all spills immediately. • Ensure mobility: • Ensure mobility: - Encourage the woman to move about freely; - Encourage the woman to move about freely; • Encourage the woman to empty her bladder regularly. • Encourage the woman to empty her bladder regularly. Note: Do not routinely give an enema to women in labour. Note: Do not routinely give an enema to women in labour. • Encourage the woman to eat light meals. Nutritious liquid drinks are important, • Encourageeven in late labour.woman the to eat light meals. Nutritious liquid drinks are important, • Teachineven late breathing labour. techniques for labour and delivery. Encourage the woman to • breathebreathingTeach out more techniquesslowly than usuallabourrelax for and and with delivery.each expiration. Encourage the woman to • breatheHelp outwoman moreinslowly labourthan who usualanxious, is and relax fearful withor eachin pain: expiration. • Help the woman in labour who is anxious, fearful or in pain: - Give her praise, encouragement and reassurance; - Give her informationencouragementpraise, the process and and progress reassurance;of her labour; - ListenherGive to theinformation woman onandthe beprocess sensitiveand to her feelings.progress of her labour; - Listen to the woman and be sensitive to her feelings. • If the woman is distressed by pain: • If the woman is distressed by pain: - Encourage mobility; - Encourage mobility;companionher to massage her back or hold her hand and sponge - Encouragebetweenher face her companion contractions;massage her back or hold her hand and sponge her face between contractions; - Encourage breathing techniques; - Encourage breathing techniques;
106 106
112
- Encourage warm bath or shower; - Encourage warm bath or shower; - Analgesics should be given to all women who are distressed with pain in labour. ( - Analgesicsbelow for should type beanalgesicsof given to ).women who are distressed with pain in labour. ( see below for type of analgesics ). ANALGESIC DRUGS DURING LABOUR ANALGESIC DRUGS DURING LABOUR • If the woman is distressed by pain, allow her to walk around or assume any • Ifcomfortable the woman position. distressed Encouragepain,companion by her allow her walk to her massagearound or or any backassumesponge herEncouragcomfortablebetweene the to contractions.ofmassage back companionuse or andher breathing position. techniquessponge Encourage herallowface the woman betweentocontractions. take warm bath Encourageshower the if ofchooses. usesheFor most breathing and techniqueswomen, thisallow isthe enough woman to copetakewith to a the of warmpainbath labour. If if she showernecessary,chooses. give: For most women, this is enough to cope with the pain of labour. If necessary, give: - Entonax inhalation if valuable at the end of 1st stage and early in 2nd stage. - EntonaxWoman inhalationexpl should be if valuableained about the dizziness of as stage 1sta possibleandside earlyeffect.2ndin stage. - Pethidineshouldmg/kgWoman 1 be body weight explained (but about not moreas dizziness 100 thanpossible mg) IM every side effect.four hours - Pethidineas or 1 givemg/kg body morphine weight 0.1(but mg/kg notbody moreweight100 than IM; mg) IM every four hours - Promethazinegiveas needed 25 mg morphinevomiting IM if 0.1 mg/kg occurs.body weight IM; - Promethazine 25 mg IM if vomiting occurs. Note: Barbiturates and sedatives should not be used to relieve anxiety in labour. Note: Barbiturates and sedatives should not be used to relieve anxiety in labour. DANGER DANGER • If pethidine is given to the mother, the baby may suffer from respiratory depression. • NaloxoneIf pethidine is isthegiven antidote. the mother, the baby may suffer from respiratory depression. Naloxone is the antidote. • If there are signs of respiratory depression in the newborn, begin resuscitation • immediately.If there are signs of respiratory depression in the newborn, begin resuscitation immediately. - After vital signs have been established, give naloxone 0.1 mg/kg body weight - AfterIV to vitalnewborn;have the signs been established, give naloxone 0.1 mg/kg body weight IV to the newborn; - If the infant has adequate peripheral circulation after successful resuscitation, - naloxoneIf the infant canhasbeadequate given IM. Repeat peripheraled doses circulation may be after required successful prevent resuscitation, naloxonerecurrent canrespiratorygivendepressionRepeatedtodo be IM. (only be may as per advicesesgiven from bethe required to prevent neonatologist).respiratoryrecurrent depression (only to be given as per advice from the neonatologist). • If there are no signs of respiratory depression in the newborn, but pethidine was • givenIf there withinno are four signshoursrespiratory of of delivery, observe depression in the newborn, the baby butexpectantlypethidine for signs of was respiratorygiven within depression four hours andoftreat delivery, as above observetheytheoccur if baby expectantly for signs of respiratory depression and treat as above if they occur DIAGNOSIS AND CONFIRMATION OF LABOUR DIAGNOSIS AND CONFIRMATION OF LABOUR • Suspect or anticipate labour if the woman has: • Suspect or anticipate labour if the woman has: - Intermittent abdominal pain after 22 weeks gestation; - IntermittentPain often abdominal associated painblood with after- stained22 weeks mucusgestation; discharge (show); - WateryoftenPain vaginal associateddischargeblood with or sudden gush - stainedwater. mucusofdischarge (show); - Watery vaginal discharge or a sudden gush of water. • Confirm the onset of labour if there is: • Confirm the onset of labour if there is: 107 113 107
C-60 Normal labour and childbirth
- Cervical -effacement;cervical i.e.effacement progressive—the progressive andshortening of and thinning of thethecervix during labour;cervixand during labour; and - Cervical dilatation; i.e. the increase in diameter of the cervical opening measured- cervicalin centimetres. dilatation—the increase in diameter of the cervical opening measured in centimetres (Fig C-3 A–E). Effacement and dilatation of the cervix FIGU RE C-3F ig u re 2:Effacement and dilatation of the cervix
DIAGNOSISDIAGNOSISOF OF ANDSTAGE ANDSTAGE OF PHASE OF LABOUR
TABLE C-8 Diagnosis of stage and phase of laboura Table 24: Diagnosis of stage and phase of labour Symptoms and Signs Stage Phase
Symptoms and Signs FalseStage labour/ Phase · Cervix not dilated Not in labour
• Cervix not dilated False labour/ Not in labour · Cervix dilated less than 4 cm First Latent Latent • Cervix· Cervix dilated lessdilated 4–9 than3 cm cm First First Active · Rate of dilatation typically 1 cm per hour Active • Cervix ordilated more 3-9 cm First Rate ·of Fetal dilatation descent beginstypically 1 • cm per· hourCervix or fully more dilated (10 cm) Second Early (non- • Fetal·descent beginscontinues expulsive) Fetal descent · No urge to push
• Cervix fully dilated (10 cm) Second Early (non- Second Late (expulsive) · Cervix fully dilated (10 cm) expulsive) • Fetal·descent Presenting partcontinues of fetus reaches pelvic • No urgefloorto push · Woman has the urge to push • Cervix fully dilated (10 cm) The third stage of labour begins withSeconddeliveryof the baby and ends with the expulsionLate (expulsive) of • Presentingthe placenta. part of fetus reaches pelvic floor • Woman has the urge to push
Note: the third stage of labour begins with delivery of the baby and ends with the expulsion of the placenta.
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Normal labour and childbirth C-61
DESCENT DESCENT ABDOMINAL PALPATION ABDOMINAL PALPATION · By abdominal palpation, assess descent in terms of fifths of fetal head • By abdominalpalpable palpation,above the assesssymphysis pubisdescent in C-(Fig4 ofterms A–D):fifths of fetal head palpable above the symphysis pubis : - A head that is entirely above the symphysis pubis is five-fifths (5/5) - A headpalpablethat isentirely (Fig aboveC-4 A –B);the symphysis pubis is five-fifths (5/5) palpable. - A head that is entirely below the symphysis pubis is zero-fifths (0/5) palpable. - A head that is entirely below the symphysis pubis is zero-fifths (0/5) palpable. FIGURE C-4 Abdominal palpation for descent of the fetal head Figure 3: Abdominal palpation for descent of the fetal head
VAGINAL EXAMINATION VAGINAL EXAMINATION • Vaginal· If necessary, examination is usedvaginal assess examination may be descentby to assessusedthe relating level ofdescent by the fetal presentingrelating part theto level the Ischialof the fetal spines ofpresenting the part tomaternal the pelvisischial spines of the
Note: Whenmaternal there pelvis is a (Figsignificant C-5, page degree C-62). of caput or moulding, assessment by abdominal palpation using fifths of head palpable is more useful than assessment by vaginal exam.
115 109 Note: When there is a significant degree of caput or moulding, assessment by abdominal palpation using fifths of head palpable is more Note: When there is a significant degree of caput or moulding, assessmentuseful than by assessment abdominal by palpation vaginal usingexam. fifths of head palpable is more FIGUREusefulC-5 than Assessing assessment vaginal by descent of the exam. fetal head by vaginal FIGURE C-5 examination;Assessing 0descent stationfetalathead of the is the levelvaginal by of the ischial spine Figure 4: Assessing examination;descent(Sp) of thestation 0fetal is headby vaginal at the examination; level of the ischialspinestation 0 is at (Sp)the level of the Ischial spine (SP)
PRESENTATION AND POSITION PRESENTATIONPRESENTATION AND POSITION AND POSITION
DETERMINE THE PRESENTING PART DETERMINE THE THEPRESENTING PART · The most common presenting part is the vertex of the fetal head. If the • The most· The mostcommonis not the presenting is is the vertexaspresenting a If Ifvertex part, common manage part the of vertex malpresentation the fetal head. (Tablethethe vertex is not the presentingvertex the managenot S-73).presenting as manageS-12, part, pagepart,malpresentation. malpresentation (Table S-12, page S-73). If the vertex· If vertexIfis thethe part,the use usepresenting on the tovertex presenting the part,part,landmarks use on the the fetalfetallandmarks skull to· fetal skull on skull to determine the determine the position the fetal head in relation to position of determinethe fetal headthe position relation of of thethe fetal head maternal in pelvis.torelation to the thematernal pelvis pelvis (Fig(Fig C C-6).-6). FIGURE C-6 Figure 5: Landmarks of the fetal skull FIGURE C-6 Landmarks the fetalfetalskullskull
DETERMINE THE POSITION OF THE FETAL HEAD
• The fetal head normally engages in the maternal pelvis in an occipital transverse position, with the fetal occiput transverse in the maternal pelvis.
116 110 Figure 6: Occiput transverse positions · The fetal headnormallyFigure engages 6: Occiputtransverse in the positionsmaternalpelvis in an occiput N ormal lab our and ch ildbirt h C- 63 transverse position,Figure 6: with Occiput the transversefetal occiput transversepositions in the maternal DETERMINEpelvis THE(FigC-7). POSITION OF THE FETAL HEAD FIGUREnormally C- engages7 fetal in head the maternal·Occiput The transverse Figure 6: Occiputtransverse positions pelvispositions an occiput transverse position, with the fetal occiput transverse in the maternal pelvis (Fig C-7). FIGURE C-7 Occiput transverse positions
• With descent, the fetal head rotates so that the fetal occiput is anterior in the • Withmaternaldescent, pelvis ( fetal theocciput head anteriorrotatespositions that the fetal an). Failure is ofocciputocciputanteriortransverse in the • maternaltoWith descent,· With rotate theocciputtofetalocciputdescent, anterioranteriorpositions the rotates so that Failure that should be occiputmanagedocciput isocciput is as anterior istransverse occiput in posteriormaternal pelvis position. (thematernal maternalocciput occiput pelvis pelvis Failureanterior anterior ofC-8).(occiput Failure anterior of occiputpositionpositions positions,positions, rotate anFig an Fig occiput Cbe (occiput-8). managed anterioran Failure ). should as of transversethe an positionposterior rotate position.to an antransverse anterior position should position shouldocciput position occiput should anteriorocciputrotaterotatemanaged occiput be anterior positionas anocciputocciput • Withposteriordescent, position. fetal asan managed that the fetalFigure (page isanbebe7:the Occiput headocciputposterior position (page positions S-75).rotates anteriorocciput S-75).anterior in the maternal pelvis (occiputFigure anterior 7: Occiput anteriorpositions Failure of). positions an occiput transverse FigureFIGURE FIGURE7: rotate C - 8 shouldposition to an Occiput to anterior C-8 occiputanteriorOcciputpositions be managed as an occiput posterior position.
Figure 7: Occiput anterior positions
C-64 Normal labour and childbirth
· An additional feature of a normal presentation is a well-flexed vertex • An additional feature of a normal presentation is a well-flexed vertex with the • occiputadditionalthe C-9), the occiput lower infeaturevagina is vagina than the vertexAnnormal presentation lower (Fig of awith thethan well the-flexed sinciput. sinciput. with the • occiputadditionalAn lowerFIGURE Cthe-9 Well -flexed ofin vertex featurevaginaathan the sinciput. normal presentation is a well-flexed vertex with the occiput lower in the vaginaFigurethan 8:the sinciput.Well-flexed vertex Figure 8: Well-flexed vertex • An additional feature of normalaFigure presentation 8: Well-flexedvertex is a well-flexed vertex with the occiput lower in the vagina than the sinciput.
Figure 8: Well-flexed vertex 111 111 111
117 111 ASSESSMENT OF PROGRESS OF LABOUR Once diagnosed, progress of labour is assessed by:
ASSESSMENT OF PROGRESS OF LABOUR
Once diagnosed, progress of labour is assessed by:
• Measuring changes in cervical effacement and dilatation during the latent phase; • Measuring the rate of cervical dilatation and fetal descent during the active phase; • Assessing further fetal descent during the second stage.
Progress of the first stage of labour should be plotted on a partogram once the woman enters the active phase of labour. A sample partogram is shown in Figure 9.
Table 25: Duration of each stage of labour
Stage of Labour Primigravida Multipara First stage 6--18 hours 2-- 10 hours First stage Second stage 30 minutes to 3 hours 5-- 30 minutes Third stage Third stage 0--30 minutes 0-- 30 minutes
VAGINAL EXAMINATIONS
Vaginal examinations should be carried out at least once every four hours during the first stage of labour and after rupture of the membranes. Plot the findings on a partogram.
• At each vaginal examination, record the following:
- Colour of amniotic fluid; - Cervical dilatation and effacement; - Descent (can also be assessed abdominally).
If the cervix is not dilated on first examination it may not be possible to diagnose • labour.
If contractions persist, re-examine the woman after four hours for cervical - changes. At this stage, if there is effacement and dilatation, the woman is in labour; if there is no change, the diagnosis is false labour.
In the second stage of labour, perform vaginal examinations once every hour. •
USING THE PARTOGRAM:
Fill all the required information in the front page of the Composite Obstetric Record •
Plotting the Partogram:
The partogram is designed to record all important information about the woman and • fetus during labour. It is a tool for making decisions.
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• The progress of labour is recorded as a simple graph with the time on the horizontal • Theaxis progressvariousand the of labour importantrecorded is of labourfeaturesa on with simple the time graphthe vertical axis.on the horizontal • Allaxisobservationsvarious and the such as BP, importantfetal heart, features labour ofuterine the vertical contractions axis. are charted by plotting • Alltheobservations value of thatsuch observation,fetal BP, on uterine heart,vertical against axis,contractionstheareappropriate charted bytime, plotting the horizontalvalue of that axis.observation, In this way on thetrends easil verticalyaxis, recognized.the against appropriate time, on • theThehorizontalof findings axis. every In this vaginal way trends examination are easily (cervixrecognized.and dilatation descent) are plotted • onThe the findings partogram. of every vaginal examination (cervix dilatation and descent) are plotted • Theon the midwife partogram. or doctor can see at a glance the condition of the mother and fetus, • andThe themidwife progress or doctor of labour. can see at a glance the condition of the mother and fetus, • Theand t hepartogram progress providesof labour. valuable guidance in the management of labour. • The partogram providesstarted when valuable the cervix guida isnce 3 cm in dilated.the management of labour. • EveryThe partogram 30 minutes: is started when the cervix is 3 cm dilated. • Every 30 minutes: - Count the fetal heart. - CounttheTime fetaluterine heart. contractions. - TakeTime the uterinematernal contractions. pulse. • Every- Take twothe maternalhours: pulse. • -Every Take twothe maternalhours: blood pressure. • Every- Take fourthe maternalhours: blood pressure. • -EveryTake hours:four maternal temperature. Take maternal temperature. - Test the urine. - PerformTest the vaginal aurine. examination. - Perform a vaginal examination. Use of Partogram in active management of labour: Use of Partogram in active management of labour: • Alert line: As soon as the cervix is found to be 3 cm or more dilated on vaginal • examination,AsansoonAlert line: Alertas islinethe cervix drawn is red in to foundobliquely cm or more3 upward,the on alongdilatedexpectedvaginal rate ofexamination,ofan dilatation 1 cm Alertperlinehour.drawn is in red obliquely upward, along the expected rate • Thedilatationlineof Alert of 1 cm indicates per the hour.expected rate of dilatation during the active phase of • Thelabour. Alert line indicates the expected rate of dilatation during the active phase of • If labour.on subsequent vaginal examination the cervical dilatation is to the right of the • AlertIf on subsequentdoctorvaginal line the should be informed examination it givesdilatation theascervical is theindicationtothat right is the labour of not progressingAlert line the as itdoctor should should be. be informed as it gives in indication that labour is not • progressingThe Action line as shouldit is drawn be.parallel to the alert line, 2 hours to the right. This shows • whenThe someAction action line isshould drawn be par taken.allel to the alert line, 2 hours to the right. This shows • whenIf, on somevaginal any action should assessment,taken.cervical be the dilatation is delayed 2 hours or more to • theonIf, anyright of vaginal the Alert assessment,onthethecervical line i.e. Action line or is dilatationb some actioneyond,delayed or more to 2 hours should be thetaken toright of theensure that lineAlertlabour i.e. on the progresses Action safely.line or beyond, some action should be taken to ensure that labour progresses safely.
119 113 113
Figure 9:Figure Sample partogrampartogramnormalnormal9: Sample for for labour labour
120 114 114
PROGRESS OF FIRST STAGE OF LABOUR
• Findings suggestive of satisfactory progress in the first stage of labour are:
- regular contractions of progressively increasing frequency and duration; - rate of cervical dilatation at least 1 cm per hour during the active phase of labour (cervical dilatation on or to the left of alert line); - cervix well applied to the presenting part.
• Findings suggestive of unsatisfactory progress in the first stage of labour are:
- irregular and infrequent contractions after the latent phase; - Or rate of cervical dilatation slower than 1 cm per hour during the active phase of labour (cervical dilatation to the right of alert line); - Or cervix poorly applied to the presenting part.
Unsatisfactory progress in labour can lead to prolonged labour
PROGRESS OF SECOND STAGE OF LABOUR
• Findings suggestive of satisfactory progress in the second stage of labour are:
- steady descent of fetus through birth canal; - onset of expulsive (pushing) phase.
• Findings suggestive of unsatisfactory progress in second stage of labour are:
- lack of descent of fetus through birth canal; - failure of expulsion during the late (expulsive) phase.
PROGRESS OF FETAL CONDITION
If there are fetal heart rate abnormalities (less than 110 or more than 160 beats • per minute), suspect fetal distress and manage accordingly.
PROGRESS OF MATERNAL CONDITION
Evaluate the woman for signs of distress:
If the woman’s pulse is increasing, she may be dehydrated or in pain. • Ensure adequate hydration via oral or IV routes and provide adequate analgesia. If the woman’s blood pressure decreases, suspect haemorrhage. • If acetone is present in the woman’s urine, suspect poor nutrition and give • dextrose IV.
NORMAL CHILDBIRTH
General methods of supportive care during labour are most useful in helping the woman tolerate labour pains 115 121 Ensure adequate hydration via oral or IV routes and provide adequate analgesia. • If the woman’s blood pressure decreases, suspect haemorrhage. • If acetone is present in the woman’s urine, suspect poor nutrition and give dextrose IV.
NORMAL CHILDBIRTH
General methods of supportive care during labour are most useful in helping the woman tolerate labour pains 115 • Once the cervix is fully dilated and the woman is in the expulsive phase of the second stage (when she feels the urge to push), encourage the woman to push. • Once the cervix is fully dilated and the woman is in the expulsive phase of the Note:second Episiotomy stage(when is no she longer feels recommended the urge topush), as routineaencoura thege womanprocedure. to is Therepush.no evidence that routine episiotomy decreases perineal damage, future vaginal Note:prolapse orEpisiotomy urinaryis incontinence. longer recommended as a routine procedure. There is no evidence that routine episiotomy decreases perineal damage, future vaginal prolapse or urinary incontinence.
Episiotomy should be considered in the case of: • Complicated vaginal delivery (breech, shoulder dystocia, forceps, vacuum Episiotomyextraction); should be considered in the case of: • ComplicatedScarring from vaginal female deliverygenital cutting (breech, or poorly shoulder healed dystocia, third fou forceps,rth degree vacuum tears;extraction); • ScarringFetal fromdistress. female genital cutting or poorly healed third or fourth degree tears; • Fetal distress. DELIVERY OF THE HEAD
DELIVERY• Ask the woman OF THE to pant HEAD or give only small pushes with contractions as the baby’s head delivers; • To control birth of the head, place the fingers of one hand against the baby’s head • Askto keepthe woman it flexed to (bent); pant or give only small pushes with contractions as the baby’s head delivers; • ContinueTo control to birth gently of supportthe head, the place perineum the fingersas the baby of one’s head hand delivers; against the baby’s head • Once the baby’s head delivers, ask the woman not to push; • Feelto keeparound it flexedthe baby (bent);’s neck for the umbilical cord: • Continue to gently support the perineum as the baby’s head delivers; • Oncecord theis head baby the’saround neck delivers,but is loose, ask theit to woman the# If slipnot overpush; baby’s head; • Feelfor thearound doubly the cord:baby’#s Ifaround the cord the is neck, tightumbilical neck clamp and cut it before unwinding it from around the neck. # If the cord is around the neck but is loose, slip it over the baby’s head; COMPLETION# If the cord OF is tightDELIVERY around the neck, doubly clamp and cut it before unwinding it from around the neck. • Allow the baby’s head to turn spontaneously; •COMPLETION After the OF turns,head DELIVERYplace a hand on each side of the baby’s head. Tell the woman to push gently with the next contraction; • ReduceAllow thebabytears’s delivering head toturn one spontaneously; shoulder time. • After the head turns, place a hand on each side of the baby’s head. Tell the Note:womanIf there istopush difficulty gently delivering with the nextthe shoulders, contraction; suspect shoulder dystocia. • Reduce tears by delivering one shoulder at a time. • Lift the baby’s head anteriorly to deliver the shoulder that is posterior. •Note: If thereSupport is restthe difficultyof the baby delivering’s thewith bodyone hand shoulders, as it slides suspect out. shoulder dystocia. • Place the baby on the mother’s abdomen. Thoroughly dry the baby, wipe the • eyesLiftthe babyand ’assesss the headbaby’s anteriorly to deliverbreathing: the shoulder that is posterior. • Support the rest of the baby’s body with one hand as it slides out. •Note: MostPlacethe babiesbaby on begin the crying breathingmother ’ s Thoroughlyabdomen.spontaneo dry the baby,usly within ofwipe 30 the seconds birth: eyes and assess the baby’s breathing: # If the baby is crying or breathing (chest rising at least 30 times per minute) leave Note: Most babies begin crying or breathing spontaneously within 30 seconds of birth: 122 116
# If the baby is crying or breathing (chest rising at least 30 times per minute) leave
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the baby with the mother; # If baby does not start breathing within 30 seconds, call for help and take steps to resuscitate the baby .
Anticipate the need for resuscitation and have a plan to get assistance for every baby
• Clamp and cut the umbilical cord immediately after delivery of the baby. • Ensure that the baby is kept warm and in skin-to-skin contact on the mother’s chest. Wrap the baby in a soft, dry cloth, cover with a blanket and ensure the head is covered to prevent heat loss. • If the mother is not well, ask an assistant to care for the baby. • Palpate the abdomen to rule out the presence of an additional baby(s) and proceed with active management of the third stage.
ACTIVE MANAGEMENT OF THE THIRD STAGE
Active management of the third stage (active delivery of the placenta) helps to prevent postpartum haemorrhage. Active management of the third stage of labour includes:
• Immediate oxytocin; • Controlled cord traction; and • Uterine massage.
Oxytocin
• Within one minute of delivery of the baby, palpate the abdomen to rule out the presence of an additional baby(s) and give oxytocin 10 units IM. • Oxytocin is preferred because it is effective 2 to 3 minutes after injection, has minimal side effects and can be used in all women. If oxytocin is not available, give ergometrine 0.2 mg IM.
Do not give ergometrine to women with pre-eclampsia, eclampsia, high blood pressure and cardiac conditions because it increases the risk of convulsions and cerebrovascular accidents
CONTROLLED CORD TRACTION
1. Clamp the cord close to the perineum using sponge forceps within one minute of delivery. Hold the clamped cord and the end of forceps with one hand; 2. Wait for signs of placenta separation: gush of blood and lengthening of the cord; 3. Place the other hand just above the woman’s pubic bone and stabilize the uterus by applying counter traction during controlled cord traction. This helps to prevent inversion of the uterus;
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4. Keep slight tension on the cord and await a strong uterine contraction (two to three minutes); 5. When the uterus becomes rounded or the cord lengthens, very gently pull downward on the cord to deliver the placenta. Continue to apply counter traction to the uterus with the other hand; 6. If the placenta does not descend during 30 to 40 seconds of controlled cord traction (i.e. there are no signs of placental separation), do not continue to pull on the cord:
# Gently hold the cord and wait until the uterus is well contracted again. If necessary, use a sponge forceps to clamp the cord closer to the perineum as it lengthens; # With the next contraction, repeat controlled cord traction with counter traction.
Never apply cord traction (pull) without applying counter traction (push) above the pubic bone with the other hand
7. As the placenta delivers, the thin membranes can tear off. Hold the placenta in two hands and gently turn it until the membranes are twisted; 8. Slowly pull to complete the delivery; 9. If the membranes tear, gently examine the upper vagina and cervix and use a sponge forceps to remove any pieces of membrane that are present; 10. Inspect the placenta to be sure none of it is missing. If a portion of the maternal surface is missing or there are torn membranes with vessels, suspect retained placental fragments; 11. If uterine inversion occurs, reposition the uterus; 12. If the cord is pulled off, manual removal of the placenta may be necessary.
UTERINE MASSAGE
• Immediately massage the fundus of the uterus through the woman’s abdomen until the uterus is contracted. • Perform uterine palpation and inspect for excessive vaginal bleeding every 15 minutes for the first two hours. • Ensure that the women has passed urine before shifting to the ward or discharge.
EXAMINATION FOR VAGINAL TEARS
• Examine the woman carefully and repair any tears to the cervix or vagina or repair episiotomy.
FOURTH STAGE ASSESSMENT
• Assess estimated blood loss at delivery. Measure vital signs. • Assess uterine tone; uterus should be firm, central and located at the • umbilicus. If uterus is deviated from central position, soft and/or distended,
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check the bladder, if palpable, encourage the mother to pass urine or insert a urinary catheter.
CONTINUOUS ELECTRONIC FETAL MONITORING (EFM):
Monitoring in uncomplicated pregnancy:
• In a healthy pregnant women, If admission CTG is recorded as reactive trace, intermittent auscultation is recommended and CTG may be repeated every 3 hours.
Indications to switch from intermittent to continuous fetal monitoring:
• Baseline fetal heart rate is < 110 or > 160 per minute on auscultation. • If decelerations noticed on auscultation. • If any intra-partum risk factors develop.
Indications of continuous EFM:
• Hypertension, diabetes, antepartum heamorrhage and other medical diseases. • Fetal conditions: prematurity, oligohydromnios, multiple pregnancy, breech presentation, Rh isoimmunisation, IUGR, Meconium stained liquor and post term pregnancy. • Intra-partum maternal conditions: vaginal bleeding in labour, intrauterine infection. • In labour: previous caesarean section, prolonged rupture of membranes, induced labour, augmented labour.
Signs of hypoxia indicating delivery:
• Reduced variability in between and during decelerations. Additional late decelerations. • • Gradual tachycardia. Failure to return to baseline after deceleration especially up to 100 bpm for 3 • minutes or < 80 bpm for 2 minutes.
During the 2nd stage of labour, decelerations of CTG tracing are seen due to compression of descending head into the pelvis. The FHR returns to baseline in between contractions and has normal variability in healthy fetus that is coping well with stress of labour.
If prolonged bradychardia in labour, consider:
Acute events: • - Cord compression/ prolapse. - Abruptio placentae. - Scar dehiscence/ ruptured uterus. Reversible causes: •
125 119 If prolonged bradychardia in labour, consider:
• Acute events: - Cord compression/ prolapse. - Abruptio placentae. - Scar dehiscence/ ruptured uterus. • Reversible causes: - Top up of epidural infusion. - Uterine hyper stimulation. 119 - Vaginal examination.
Management; follow 3, 6, 9, 12, 15minutes rule:rule:
• Call the doctor immediately for prolonged bradycardia for 3 minutes and review the clinical picture with previous trace. Treat the cause if appropriate. • By 6 minutes: expect recovery toward baseline. • By 9 minutes: prepare for operative delivery or forceps/ vacuum if cervix fully dilated and vertex below the spines. • By 12 minutes: delivery (by forceps/ vacuum) started. • By 15 minutes: baby is delivered.
Note: delay of 20 minutes or more may result in birth asphyxia.
Internal fetal monitoring:
• Indicated when external tracing is inadequate for accurate interpretation. • Contraindicated in the following cases: - Placenta praevia - Face presentation - Idiopathic thrombocytopenic pupura (ITP) - Acute genital herpes - HIV positive mother
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1. Unsatisfactory Progress of Labour
Problems
• Cervix not dilated beyond 4 cm after 8 hours of regular contractions. • Cervical dilatation is to the right of the alert line on the partograph. • The woman has been experiencing labour pains for 12 hours or more without delivery (prolonged labour).
General Management
• Perform rapid evaluation of the condition of the woman and fetus and provide supportive care. • Test urine for ketones and treat with IV fluids if ketotic. • Review partogram.
Diagnosis
Table 26: Diagnosis of unsatisfactory progress of labour
Findings Diagnosis Cervix not dilated False labour • • No palpable contractions or infrequent contractions Cervix not dilated beyond 4 cm after eight hours of Prolonged latent phase regular contractions
Cervical dilatation to the right of the alert line on Prolonged active phase the partograph:
• Secondary arrest of cervical dilatation and Cephalopelvic disproportion descent of presenting part in presence of good • contractions • Secondary arrest of cervical dilatation and Obstruction descent of presenting part with large caput, • third degree moulding, cervix poorly applied to
presenting part, oedematous cervix, ballooning of lower uterine segment, formation of retraction band or maternal and fetal distress
• Less than 3 contractions in 10 minutes, each Inadequate uterine activity lasting less than 40 seconds • • Presentation other than vertex with occiput Malpresentation or • anterior malposition Cervix fully dilated and woman has urge to push, Prolonged expulsive phase but no descent
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Management
FALSE LABOUR
• Examine for urinary tract or other infection or ruptured membranes and treat accordingly. • Discharge the patient if: - No signs of urinary tract or other infection; - No regular progressive contractions; - No cervical dilatation. • Encourage her to return if signs of labour recur.
PROLONGED LATENT PHASE
The diagnosis of prolonged latent phase is made retrospectively. When contractions cease, the woman is said to have had false labour. When contractions become regular and dilatation progresses beyond 4 cm, the woman is said to have been in the latent phase.
Misdiagnosing false labour or prolonged latent phase leads to unnecessary induction or augmentation, which may fail. This may lead to unnecessary caesarean section and chorioamnionitis.
If a woman has been in the latent phase for more than eight hours and there is little sign of progress, reassess the situation by assessing the cervix:
• If there has been no change in cervical effacement or dilatation and there is no fetal distress, review the diagnosis. The woman may not be in labour. • If there has been a change in cervical effacement or dilatation, rupture the membranes with an amniotic hook and induce labour using oxytocin. - Reassess every four hours; • If there are signs of infection (fever, foul-smelling vaginal discharge), maternal and/or fetal tacchycardia : - Augment labour immediately with oxytocin - Give a combination of antibiotics until delivery:
ampicillin 2 g IV stat, then 1 g IV every six hours; # PLUS metronidazole 500 mg IV every eight hours. #
PROLONGED ACTIVE PHASE
If there are no signs of cephalopelvic disproportion or obstruction and the • membranes are intact, rupture the membranes with an amniotic hook. • Assess uterine contractions: If contractions are inefficient (less than three contractions in 10 minutes, each - lasting less than 40 seconds), suspect inadequate uterine activity; If contractions are efficient (three or more contractions in 10 minutes, each - lasting more than 40 seconds) suspect cephalopelvic disproportion, obstruction, malposition or malpresentation. • General methods of labour support may improve contractions and accelerate progress. 130 123
CEPHALOPELVIC DISPROPORTION
obstruction, malposition or malpresentation. • General methods of labour support may improve contractions and accelerate progress.
CEPHALOPELVIC DISPROPORTION
Cephalopelvic disproportion occurs because the fetus is too large or the maternal pelvis is too small. If labour persists with cephalopelvic disproportion, it may become arrested or obstructed. The best test to determine if a pelvis is adequate is a trial of labour. Clinical pelvimetry is of limited value.
• If cephalopelvic disproportion is confirmed, deliver by caesarean section.
OBSTRUCTION
Note: Rupture of an unscarred uterus is usually caused by obstructed labour.
• If the fetus is alive, the cervix is fully dilated and the fetal head is at 0 station or below, deliver by vacuum extraction. • Deliver by caesarean section if: - fetal head is at -2 station; - If the fetus is alive but the cervix is not fully dilated or if the fetal head is too high for vacuum extraction; - If the fetus is dead.
INADEQUATE UTERINE ACTIVITY
If contractions are inefficient and cephalopelvic disproportion and obstruction have been excluded, the most probable cause of prolonged labour is inadequate uterine activity.
Inefficient contractions are less common in a multigravida than in a primigravida. Hence, every effort should be made to rule out disproportion in a multigravida before augmenting with oxytocin.
Rupture the membranes with an amniotic hook and augment labour using • oxytocin . • Reassess progress by vaginal examination two hours after a good contraction pattern with strong contractions has been established: If there is no progress between examinations, deliver by caesarean section. - If progress continues, continue oxytocin infusion and re-examine after two - hours. Continue to follow progress carefully.
PROLONGED EXPULSIVE PHASE
Maternal expulsive efforts increase fetal risk by reducing the delivery of oxygen to the placenta. Allow spontaneous maternal “pushing,” but do not encourage prolonged effort and holding the breath.
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• If malpresentation and obvious obstruction have been excluded, augment labour with oxytocin. • If there is no descent after augmentation: - If the head more than the the leading bony edge of the fetal head is below 0 station, deliver by vacuum extraction or forceps; - If the fetal head is more than 1/5 above the symphysis pubis or the leading bony edge of the fetal head is above 0 station, deliver by caesarean section.
2. Malpositions and Malpresentations
Malpositions are abnormal positions of the vertex of the fetal head (with the occiput as the reference point) relative to the maternal pelvis. Malpresentations are all presentations of the fetus other than vertex.
Problem
• The fetus is in an abnormal position or presentation that may result in prolonged or obstructed labour.
General Management
• Perform a rapid evaluation of the general condition of the woman, including vital signs (pulse, blood pressure, respiration, temperature). • Assess fetal condition: - Listen to the fetal heart rate immediately after a contraction:
# Count the fetal heart rate for a full minute at least once every 30 minutes during the active phase and every five minutes during the second stage; If there are fetal heart rate abnormalities (less than 110 or more than 160 # beats per minute), suspect fetal distress.
- If the membranes have ruptured, note the colour of the draining amniotic fluid:
Presence of thick meconium indicates the need for close monitoring and # possible intervention for management of fetal distress. Absence of fluid draining after rupture of the membranes is an indication # of reduced volume of amniotic fluid, which may be associated with fetal distress.
Provide encouragement and supportive care. • Review progress of labour using a partograph. •
Note: Observe the woman closely. Malpresentations increase the risk for uterine rupture because of the potential for obstructed labour.
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S-70 Malpositions and malpresentations S-70 Malpositions and malpresentations DIAGNOSIS DiagnosisDIAGNOSIS
DETERMINEDETERMINEDETERMINETHE THE T HE PARTPRES PRESENTING ENTINGPRESENTING PART PART • The·most·The common most common presentation the isis of presentation theThe mostvertex commonthe vertex the thefetal of the head. fetal the If head. the Ifvertex is not the presentingvertex is notthe part, Tabl seee 27.presentingvertexnot the part, see Table S-12, page S-73. • If the vertex is the presenting part, use landmarks of the fetal skull to determine · ·If thetheIf vertex vertex isthe is thepresenting presenting part, part, use use landmarks landmarks of the the fetalfetal skull toto the position of the fetal head (Figure 10) determine thethe position of of thethefetal head (Fig S-9). FIGURE S-9S-9 10: Landmarks of the ofFigureLandmarks of thefetal the skull fetal skull
DETERMINEDETERMINETHE THE OFPOSITION THE OFPOSITION THEHEADFETAL FETAL HEAD DETERMINE THE POSITION OF THE FETAL HEAD · The fetal head normally engages in the maternal pelvis in an occiput • The·fetalThe transverse head engages normallyin the inocciput pelviswithpelvisengages in occiputhead maternalfetalnormallyposition, transverse the fetal the an maternal maternal in in theocciputtransverse position, with the fetal occiput transverse in the maternal pelvis (Figure 11) transversepelvis (Fig position, S-10). with the fetal occiput transverse in the maternal FIGUREpelvis S- 10(Fig Figure S-10).Occiput 11: Occiput transverse positionstransverse position FIGURE S-10 Occiput transverse positions
· With descent, the fetal head rotates so that the fetal occiput is anterior in the maternal pelvis (Fig S-11). Failure of an occiput transverse position · With todescent, rotate to the anocciput fetal head anterior rotates that theposition be occiput should is fetal occiputmanaged as anterior in the posteriormaternal pelvisposition (Fig (page S-75).S-11). Failure of an occiput transverse position • With descent,to rotate the to fetal an occiput head rotates anterior so position that the should fetal occiputbe managed is anterior as an occiputin the maternalposteriorpelvis (Figure position 12) Failure(page ofS -an75). occiput transverse position to rotate to an occiput anterior position should be managed as an occiput posterior
position.
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Malpositions and malpresentations S-71 Figure 12: Occiput anterior positions FIGURE S-Figure11 Occiput anterior positions 12: Occiput anterior positions
· An additional feature ofanormal presentation isawell-flexedvertex · Anadditional feature of a normal presentation is a well-flexed vertex • An additional feature of (Figa Snormal-12), with fetalthepresentation occiput lower is thanin the the vagina sinciput.well -flexed vertex (Figure 13) FIGURE S-12 with the fetal occiput(Fig S-12), lower with in thethe fetalWellvagina-flexed vertex occiput than the sinciput.lower the vagina than the sinciput. FIGURE S-12 FigureWell13 : - flexed vertexWell -flexed vertex Figure 13: Well-flexed vertex
· If the fetal head is well-flexed with occiput anterior or occiput transverse (in early labour), proceed with delivery (page C-71). · If the fetal head is not occiput anterior, identify and manage the malposition (Table S-11, page S-72). · If the fetal head is not the presenting part or the fetal head is not well- flexed, identify and manage the malpresentation (Table S-12, page S-73).
• If the fetal· head If isthe fetalwell head-flexed is occiputwithwell with-flexed or occiputanterior occiput or (in anterior transverseocciputearly labour), proceedtransverse with delivery; (in early labour), proceed with delivery (page C-71). • If the fetal head is not occiput anterior, identify and manage the malposition (Table 27). · If the fetal head is not occiput anterior, identify and manage the • If the fetal malpositihead on the presenting(Table S-11,page part S- 72).or the fetal head is not well-flexed, identify and· Ifmanage the thefetal headmalpresentation the (Table 27). presenting part or the fetal head is not well- flexed, identify and manage the malpresentation (Table S-12, page S-73).
134 127
Table 27: 27:Diagnosis of of malposition Table 27: Diagnosis of malposition
SymptomsS-72 andand Signs MalpositionsandFigure malpresentations Symptoms andS- 72 Malpositions and malpr esentations Signs Figure S-72 TABLE S-11 Diagnosis of malpositions Malpositions and malpresentations OCCIPUT POSTERIORTABLE S- 11POSITION Diagnosis of malpositions TABLE S-11 Symptoms and Signsof malpositionsFigure 14: Occiput posterior OCCIPUTthe fetalPOSTERIOR occiputoccurs when POSITION the fetal occiput DiagnosisSymptoms and Signs Figure posterior in relationOCCIPUT14:FIGUREto S-13POSTERIORto the maternalmaternal Figurethe POSITION Occiput posterior occurs when the fetalOCCIPUTocciputoccursSymptoms when POSTERIOR theis fetaland occiputSigns POSITION is posterior FIGURE S-13 Figure posteriorpelvisin relation OCCIPUTtooccursthein relation whenmaternal POSTERIOR theto the fetal maternal occiput POSITION pelvis is posterior(Fig FIGURE S-13 in Srelation-13 andto Fig thematernalS-14). pelvis (Fig pelvis FigureFigure 1414 & Figure occurs&S-13Figure whenand the15Fig fetal S 15-14). occiput is posterior in relationOn to the maternal pelvis the Figure 14 & FigureS15-13and abdominalof the is flattened, examination, fetalFig S-14 ).Onpart the abd lower omen (Fig OnOn abdominal the abdomen is flattened,and examination, the fetalof are palpable anteriorlypartlimbs the lower thefetal On abdominalheart examination, flank.lowerfetal On abdominalof of the part of themay heardtheispartpartexamination, abdomen heardislowerheart abdomenmayis the in the flank.flattened, fetalfetal limbs are palpablelimbsflattened,are palpable anteriorly anteriorly fetal andandthe posterior fetal part of limbsabdomenpalpable anteriorly and posterior the Figure 15: Left occiput posterior limbs mayfetalpalpablefontanelle isand thebe easily feltmay be anteriorlyheardbe heard in in sacrumfontanelle andthetowards themayarefetalheartheart flank. theif FIGURE S-14 15: Left occiput posterior fetal heart may be heardOnanterior the may head be easilyexamination, feltthe in is deflexed.vaginal thefontanelle posteriorflank.Figure if FIGURE S-14 fontanellethe head is deflexed.towards the sacrum and the vaginal examination,anteriorFor fontanellemanagement, may see the theposterior easily S-75. felt if OnOn vaginal Forexamination, management, see be S-page75. posterior FIGURE S-14 On the fontanelle sacrumis headexamination, isthe thevaginal is towardsdeflexed. theposterior sacrum andand fontanellethe towardsfontanellesacr see bebeF or management, andthe isanterior the ummay may page S-75. easily the anteriorfeltfelttheif fontanelleif the headhead is ismay bedeflexed. easily felt if the head is deflexed.
OCCIPUT TRANSVERSE POSITION FIGURE S-15 OCCIPUT TRANSVERSEOCCIPUT the fetal occiputTRANSVERSE isoccurs when POSITIONPOSITION FIGURE S-15 Figure 16: Left occiput transverse occurs when theoccurstransversefetal when occiputtheto the fetal maternal occiput is is pelvis (Fig OCCIPUT TRANSVERSEoccurs when fetal transverse transverse (FigPOSITIONthe to the maternalS-15occiput ). If an occiput pelvis position transverse toOCCIPUTS-15). If maternal part of the TRANSFigure 16: S-15theVERSE maternall ater pelvisPOSITION first to persistsan occiput pelvis FIGURE positionthe into the transverseLeftocciput is occiput transverse persists into the later part of the first occurs when the fetal should is transverseIf .an of of t h e fet al shouldto be be ma nagethe dIf anst agew h enmaternalocciput l abo ur, o cciput mana gedi t Figure 16.16 o ccurs the mat ern al pel vis as as pelvistransversetran sv erse labour, itstage posterior position (Fig (page S-75). Figureposition. If an occiputinto the persists part ofS-15). If an the latertransverse part16 intoocciputtransverselaterposition (page ofan occiputposition posterior S-75). positionthe persiststhe first first stage stage stage the oflabour,partshould labour, labour, it should should first beas the firstmanagedstagemanaged of as labour, ananas an occiput shouldposteriorocciput occposterior bepositionbeiput managed (page posterior S-75). position. managedposition.as an occiputMalpositionsand malpresentations S-73 position. TABLE S-12 Diagnosis of malpresentations BROW PRESENTATION is caused FIGURE S-16 BROW PRESENTATION is caused by byFIGUREFigure 17:17:Figure S-16 BrowBrowpresentation BROW PRESENTATIONSymptoms and thecausedhead theSigns fetal head soFIGURE S-16 Figure ispartial extension of of fetal by so Figure 17: Brow presentation partial BROWextension the of theis is soPRESENTATION bythat fetal head thanthat the occiput is causedhigher than the the FIGURE S-16 that thepartial occiputsinciput ofextension fetalthehigher thethan head so that sinciputocciputFigure is17. 17.the higher than the sinciput Figure(Fig 17. S -16). On abdominal examination, moremorethanthan On more than On abdominalhalf the fetal head is isfetal more thehalfexamination,the fetal headhalf the head is aboabove ve the thethansymphysis half thesymfetaland thepubisphysis is thethe at apubis above head is pubispalpable andocciputandocciput the is is symphysispalpablehigher level than a higher atandhigherocciputthanthan thepubis at sinciput.levelthe level is the palpable sinciput.at a higher level than the sinciput.On vaginal examination, the anterior fontanelleOnOn vaginal and the examination, orbits theare felt. the anterior On vaginal examination,orbitsanteriorfelt. Forfontanellefontanelle and see page and aremanagement, the theorbits theS-76. felt. fontanelle and the orbits are felt. 128128 FACE PRESENTATION is caused by FIGURE S-17 hyper-extension of the fetal head so that135 128 neither the occiput nor the sinciput are palpable on vaginal examination (Fig S-17 and Fig S-18).
higherOn abdominallevel than examination,the sinciput. more than half the fetal head is above the symphysis On vaginalpubis theand occiputexamination, is the palpableanterior fontanellehigherand level the than theorbits are sinciput.felt.
For management,On vaginal examination, see page the S anterior-76. fontanelle and the orbits are felt.
FACEFor PRESENTATION management, see page S -is76. caused by FIGURE S-17 FACE PRESENTATIONhyper-extensionof thecaused by tfetalhat head soFIGURE S-17 18: Face neitherFACEarethe PRESENTATION occiput nor thesinciput caused byFigure FIGURE S-17 presentation hyper-extension ofpalpable the on headhyper - headextens sofetalionvaginal examinationof thesofetalthat (Fig that neither the occiputSand-17 the neitherS-18).norFig siniput occiput the noraresinciput are palpable on vaginal examinationpalpable on vaginal examination Figure (Fig On abdominalS-17 and Fig Sexamination,-18). a groove 18 &Figure 19. may be felt between the occiput and the On abdominal examination, a groove back.may be felt between the occiput and the back. On abdominal examination,On vaginal examination, the grooveface is may be felt betweenpalpated,On the examiner’s thethe examination,vaginalocciputfinger and the entersface is the mouthpalpated,easily the and theexaminer bony ’jawss finger are enters felt. the back. mouth easily and the bony jaws are felt. FIGURE19 S-18 For management, see page S-77. For management, see page S-77. FigureFIGURE S-18 -74 On vaginal examination, the face is Malpositions and malpresentations palpated, the examiner’s finger enters the mouth easily and the bony jaws are ABLE S-12 Cont. Diagnosis of malpresentations S-74 Malpositions and malpresentations
SymptomsTABLEandS- 12Signs Cont. Diagnosis of malpresentationsFigure
Symptoms and Signs Figure COMPOUNDCOMPOUNDPRESENTATION PRESENTATION occurs FIGURE S-19 occurs when anwhenan armCOMPOUND prolapsesarm PRESENTATION prolapses alongside the FIGURE Figure S- 1920Compund: presentation the presenting presentingpart. occurs when part. an arm prolapsedthe alongsideBothprolapsed the Both the presenting part. Both the prolapsed arm and the fetalarm head and the present the fetalfetalheadthepresentinin the pelvisarmsimultaneously and in Figure 20.the pelvis simultaneouslypelvis simultane(Fig Sously-19). (Fig S-19).
For management, see page S-78. For management, see page S-78.
BREECH PRESENTATION occurs FIGURE S-20 BREECHwhen PRESENTATION the buttocks and/or occurs the feet are thewhen Figure 21: Breech presentation the buttockspresenting and/or parts. the feet are the BREECH PRESENTATIONpresenting parts. occurs FIGURE S-20 On abdominal examination, the head is when the buttocks and/orfelt in the upperthe abdomen feet arethe and the breech presenting parts.On abdominal the pelvic brim. examination, Auscultationthe locates head is felttheinfetalthe heartupper higher abdomen than expected and with a the breechvertex presentation. brim. Auscultation On abdominal locatesexamination, the fetal the heart head is higher than felt in the upperOn abdomen vaginaland the a duringexaminationexpected withpresentation. vertexbreech labour, FIGURE S-21 the buttocks and/or feet are in the pelvic brim. Auscultation locatesfelt; thick, dark meconium normal. the fetal heart higherOn thanvaginal expected examination with a during vertex presentation.labour,Forthe management, buttocks and/orsee page feet S-79. are felt; thick, dark meconium is normal. COMPLETE (FLEXED) BREECH On vaginal examinationPRESENTATION during labour, occurs when bot hFIGURE S-21 legs are flexed at the hips and knees (Fig the buttocks and/or S-feet20). are felt; thick, dark meconium is normal. FIGURE S-22 FRANK (EXTENDED) BREECH 136 129 PRESENTATION occurs when both For management, seelegs page are flexed at S-79.the hips and extended at the knees (Fig S-21). when the buttocks and/or On abdominal examination, the headthe feet areis the presenting parts. felt in the upper abdomen and the breech in the pelvicOn abdominalbrim. Auscultationexamination, the locates head is the fetal heartfelt higherin the thanupperabdomen expected and withthe abreech vertex presentation.the pelvic brim. Auscultation locates the fetal heart higher than expected with a vertex presentation. On vaginal examination during labour, FigureFIGURE 22 S-21 COMPLETE (FLEXED) BREECH the buttocks and/or feet are felt; thick, FIGURE S-21 PRESENTATIONOn vaginal examinationoccurs when during both labour, legs dark meconiumthe buttocks is normal. and/or feet are felt; thick, are flexeddarkat the meconium hips is andnormal. knees Figure 21.For management, see page S-79. For management, see page S-79. FRANKCOMPLETE (FLEXED)(EXTENDED)(FLEXED)COMPLETE BREECH BREECH PRESENTATIONoccurs whenboth bothoccurs both when legs arelegs areflexed legs aretheflexed at the hipsthe and (Figflexedat athips hipsand knees extended knees at(Fig theS-20). kneesS-20). Figure 22. FIGURE S-22 FRANK (EXTENDED) BREECH FIGURE S-22 FOOTLING(EXTENDED) PRESENTATION occursFRANK BREECHPRESENTATION BREECHwhen both ocPRESENTATIONcurs whenlegs aare leg flexed occurs is extendedat the hipswhen and bothat theextende hip d at legs are flexedthe kneesat the and(Fig hipsS-21). extended at and the knee Figure 23. the knees (Fig S-21). FOOTLING BREECH PRESENTATIONMalpositions and malpresentations occurs when a leg is S-75 FOOTLINGextended BREECH at the hip and the knee (Fig PRESENTATIONS-22). occurs when a leg is extended at the hip and the knee (Fig S-22). TABLE S-12 Cont. Diagnosis of malpresentations TRANSVERSE LIE AND SHOULDER FIGURE S-23 Symptoms and Signs Figure 24: TransverseFigure lie PRESENTATION occur when the long axis of the fetusTRANSVERSE is transverse LIE Figure AND SHOULDER FIGURE S-23 PRESENTATION occur when the long 24. The shoulderaxis ofis the typically fetus is thetransverse (Fig S-23). presenting part.The shoulder is typically the presenting part.
On abdominalOnabdominalexamination, neitherexamination, neither the the head nor thehead buttocksnor the buttocks can can be befelt atthe symphysis pubis and the head is usually the symphysisf eltpubis in theand flank. the head is usually felt in the flank. On vaginal examination, a shoulder may be felt, but not always. An arm may On vaginal examination,prolapse and the aelbow, shoulder arm hand may may be felt, butbe notfelt in always. the vagina. An arm may prolapse and theFor elbow,management, arm see or page Shand-81. may be felt in the vagina.
MANAGEMENT Management OCCIPUT POSTERIOR POSITIONS OCCIPUT POSTERIOR POSITIONS Spontaneous rotation to the anterior position occurs in 90% of cases. Arrested labour may occur when the head does not rotate and/or descend. Delivery Spontaneous rotationmay beto the complicated anterior by positionperineal tears occurs ofextension anof case90%s. episiotomy. Arrestedlabour may occur when the head does not rotate and/or descend. Delivery may be complicated by perineal· If there tears or signs extension of obstruction of an thebut fetalepisiotomy. heart rate is normal, allow the woman to walk around or change position to encourage spontaneous rotation. • If there are signs of obstruction and the fetal heart rate is abnormal (less than 110 · If there are signs of obstruction and the fetal heart rate is abnormal or more than 160 beats per100minute) thanany stage, deliver by caesarean section. • If the membranes are180 intact, beats per rupture minute) at theany stage, membranes deliver by(less with than an or amniotic more hook. caesarean section (page P-43). • If the cervix is not fully dilated and there are no signs of obstruction, augment · If the membranes are intact, rupture the membranes with an amniotic labour with oxytocin.hook or a Kocher clamp (page P-17).
dilated and there are no signs of obstruction, · If the cervix is not fully 130 augment labour with oxytocin137 (page P-25).
• If the cervix is fully dilated but there is no descent in the expulsive phase, assess for signs of obstruction; - If there are no signs of obstruction, augment labour with oxytocin. • If the cervix is fully dilated and if: • If thethe cervixfetal fully ishead is not dilatedmorethere but than is above 1/5no the descentin the pubissymphysisexpulsive or the assess- phase, leading for signsbony of edge obstruction;fetal of the head is below 0 station, deliver by vacuum extraction or - forceps;If there are no signs of obstruction, augment labour with oxytocin. • If thethe cervixfetal fully is headdilated is more if:- andthan 1/5 above the symphysis pubis or the leading - bonythe edgeheadthe fetal of is not fetalmorehead is 1/5 thanabove 0above the station, deliver symphysiscaesarean by pubis or thesection leading . bony edge of the fetal head is below 0 station, deliver by vacuum extraction or BROW PRESENTATIONforceps; - the fetal head is more than 1/5 above the symphysis pubis or the leading In brow bonypresentation,theengagementis edge of fetal head isabove usually 0 station, impossible deliver byandcaesarean arrested labour section .is common. Spontaneous conversion to either vertex presentation or face BROWpresentation canPRESENTATION rarely occur, particularly when the fetus is small or when there is fetal death with maceration. It is unusual for spontaneous conversion to occur with an Malpositions and malpresentations S-77 Inaverage brow - sizedpresentation, live fetus once the engagementmembranes is usually ruptured. haveimpossible and arrested labour is common. Spontaneous conversion to either vertex presentation or face • Always deliver by caesarean section . presentation canDonotrarely occur,deliver particularly brow presentation by the whenfetusvacuum is small extraction, or outletwhen there is fetal death with maceration.forceps or symphysiotomy. It is unusual for spontaneous conversion to occur with an FACEaveragePRE-SENTATIONsized live fetus once the membranes have ruptured.
FACETheAlwaysserves by caesarean• chin PRESENTATION deliveras the reference pointsection . in describing the position of the head. It is necessary to distinguish only chin-anterior positions, in which the chin is anterior in The chin serves as the reference point in describing the position of the head. FACErelation toPRESENTATION the maternal pelvis (Figure 25, A) ,from chin-posterior positions (Figure 25, It is necessary to distinguish only chin-anterior positions, in which the chin is B). anterior in relation to the maternal pelvis (Fig S-24 A), from chin-posterior The chin positionsserves (Figas the reference S-24 B). point in describing the position of the head. It is necessary to distinguish only chin-anterior positions, in which the chin is anterior in relation (FigureFIGURE maternal25, A)to thepelvis S-24Face presentation ,from chin-posterior positions (Figure 25, Figure 25: Face presentation B).
Figure 25: Face presentation
Prolonged labour is common. Descent and delivery of the head by flexion may occur in the chin-anterior position. In the chin-posterior position, however, the fully extended head is blocked by the sacrum. This prevents descent and labour is arrested.
Prolonged Prolongedlabour iscommon. labour is common. Descent andDescent and delivery of of thedeliver byby ythe headhead flexion may occur in the chin-anteriormay occur position. the In chin position.-anterior Inchin theposition,-posterior however, chin-posterior the position,fully extended head is blockedhowever,by fullythe This sacrum. head extendedis blocked prevents by the labour descent prevents andsacrum. Thisarrested. descent and labour is arrested.
131 CHIN-ANTERIOR POSITION 138
· If the cervix is fully dilated: - Allow to proceed with normal childbirth (page C-71);
CHIN-ANTERIOR POSITION
• If the cervix is fully dilated: - Allow to proceed with normal childbirth; - If there is slow progress and no sign of obstruction, augment labour with oxytocin; - If descent is unsatisfactory, deliver by forceps. • If the cervix is not fully dilated and there are no signs of obstruction, augment labour using oxytocin. Review progress as with vertex presentation.
CHIN-POSTERIOR POSITION
• Always deliver by caesarean section.
COMPOUND PRESENTATION
Spontaneous delivery can occur only when the fetus is very small or dead and macerated. Arrested labour occurs in the expulsive stage.
• Always deliver by caesarean section.
BREECH PRESENTATION
Prolonged labour with breech presentation is an indication for urgent caesarean section. Failure of labour to progress must be considered a sign of possible cephalopelvic disproportion .
The frequency of breech presentation is high in preterm labour
VAGINAL BREECH DELIVERY
• A vaginal breech delivery by a skilled health care provider is safe and feasible under the following conditions: complete (Figure 21) or frank breech (Figure 22) ; - adequate clinical pelvimetry; - fetus is not too large; - no previous caesarean section for cephalopelvic disproportion; - flexed head. - Detailed counseling should be performed about the procedure. • Induction of labour may be considered if conditions are favorable. • Examine the woman regularly and record progress on the partograph. • If the membranes rupture, examine the woman immediately to exclude cord • prolapse.
Note: Do not rupture the membranes.
If the cord prolapses and delivery is not imminent, deliver by caesarean section. • If there are fetal heart rate abnormalities (less than 110 or more than 160 beats • per minute) or prolonged labour, deliver by caesarean section.
139 132
Note: Meconium is common with breech labour and is not a sign of fetal distress if the fetal heart rate is normal.
The women should not push until the cervix is fully dilated.
Full dilatation should be confirmed by vaginal examination. CAESAREAN SECTION FOR BREECH PRESENTATION
• A caesarean section is safer than vaginal breech delivery and recommended in cases of: - footling breech; - small or malformed pelvis; - very large fetus; - previous caesarean section for cephalopelvic disproportion; - hyperextended or deflexed head.
Note: Elective caesarean section does not improve the outcome in preterm breech delivery.
Caesarean section should be considered if there is failure in the progress in cervix dilatation, delay in the descent or abnormal cardiotocograph.
Complications
Fetal complications of breech presentation include:
• Cord prolapse; • Birth trauma as a result of extended arm or head, incomplete dilatation of the cervix or cephalopelvic disproportion; • Asphyxia from cord prolapse, cord compression, placental detachment or entrapped head; • Damage to abdominal organs; • Broken neck.
TRANSVERSE LIE AND SHOULDER PRESENTATION
• If the woman is in early labour and the membranes are intact, attempt external version; - If external version is successful, proceed with normal childbirth ; If external version fails or is not advisable, deliver by caesarean section. - • Monitor for signs of cord prolapse. If the cord prolapses and delivery is not imminent, deliver by caesarean section.
Note: Ruptured uterus may occur if the woman is left unattended
140 133
In modern practice, persistent transverse lie in labour is delivereddelivered by In moderncaesareanpersistentsection whether the dead.practice, transversefetus section whether labour the lie inis or alive delivered is dead. by caesarean section 3. Shoulder Dystocia whether the fetus is alive or dead. 3. Shoulder Dystocia Problem Problem • TThehe fetal head has been delivered but the shoulders are stuck and cannot be • Thedelivered. fetal head has been delivered but the shoulders are stuck and cannot be delivered. General Management General Management • Be prepared for shoulder dystocia at all deliveries,deliveries, especially if a large baby is • Be anticipated.prepared for shoulder dystocia at all deliveries, especially if a large baby is • anticipated.HaveHave several several persons persons available available toto help.help. • Have several persons available to help. Shoulder dystocia cannot be predicted Shoulder dystocia cannot be predicted
Diagnosis Diagnosis • The fetal head is delivered but remains tightly applied to the vulva. • • TheThe fetalchin chin retractshead retracts is anddelivered depressesdepresses but remainsthe the perineum. perineum. tightly applied to the vulva. • • TractionretractsThe chin on the and fails toheaddepressesdeliverperineum. the the shoulder,on the fails to the shoulder, which is caught behind the symphysis pubis. • symphysisTraction on pubis. the head fails to deliver the shoulder, which is caught behind the symphysis pubis. Management. Management. • Make an adequateadequate episiotomyepisiotomy to to reduce reduce soft soft tissue tissue obstruction obstruction and and to to allow allow space space • Makefor anmanipulation. adequate episiotomy to reduce soft tissue obstruction and to allow space • forWith manipulation. the womanWith the woman on her back, ask her to flex both thighs, bringing her knees as far • Withup thepossible as possiblewoman towardsback,chestontowards her her her ask chest her (Figure to(Figure flex26) 26) bothAskthighs,assistantsher Ask two two bringing assistants to push to push as herkneesher far upflexedpossibleas knees firmly upher towardsherknees firmly ontochest up her chest. (F igure 26) Ask two assistants to push her
flexed knees firmlyFigure up onto her26: chest. Assistant pushing Shoulder dystocia flexed knees firmly towards chest Figure 26: Assistant pushing flexed knees firmly towards chest FigureFIGURE26: S-26Assistant Assistant pushingflexed pushingflexed kneesknees firmly firmly towards chest
• Wearing sterile gloves: high-level disinfected or sterile gloves: · Wearing 141 • Wearing sterile gloves: Apply firm, continuous traction downwards on the fetal head to - 134 move the shoulder that is anterior under the symphysis pubis; 134 Note: Avoid excessive traction on the fetal head as this may result in 134 brachial plexus injury;
• Wearing sterile gloves:
- Apply firm, continuous traction downwards on the fetal head to move the 134 shoulder that is anterior under the symphysis pubis;
Note: Avoid excessive traction on the fetal head as this may result in brachial plexus injury;
- HaveApply anfirm,assistant continuoussimultaneouslydownwardssuprapubic traction apply on the fetal head pressureto move thedownwards to assistshoulderdeliveryisofanteriorshoulder; that the under the symphysis pubis;
Note: DoAvoid not exces applysivefundal traction onpressure.theThis fetal head as thiswill furthermaytheresult impact in shoulderbrachial and can plexus resultinjury;in uterine rupture.
• IfHave the shoulderassistant an still not delivered: simultaneously- apply suprapubic pressure downwards to - assistInsert deliveryintothe a hand of vagina; shoulder; - Apply pressure to the shoulder that is anterior in the direction of the baby’s Note: Dosternumnot apply to rotate fundal the pressure. shoulder Thisandwilldecreaseimpactdiametershoulder further the the of the and can shoulders; resultIfuterine in needed,rupture. apply- pressure to the shoulder that is posterior in the direction of the sternum. • If the shoulder stillstill not delivered:despite the above measures: - Insert a hand into the vagina; ShoulderS-85 dystociaGraspApply humerusthe thepressure shoulderthat to of the arm is posterior anterior and,in thekeeping direction the armthe of flexed baby at- ’s thesternum elbow, to rotatesweepthetheshoulderacrossdecrease arm and the chest. This will of the the diameterprovide room for shoulders;the - shoulderthat room forprovide to move underapply the anteriorpressure pubis under shoulder 27If needed,shouldersymphysisposterior is anterior theto the that is that movein the (Figure the ). direction of the sternum.symphysis pubis (Fig S-27). •Figure If the27: Graspingshoulder still the deliverednothumerus the theofdespitethat isarm posterior above measures:and sweeping the FIGUREinto theInsert the aarm hand across Grasping the ofSvagina;-27- humerus chest arm that is posterior and - Grasp the humerussweepingof thethe arm thatarm isacross posterior the and,chest keeping the arm flexed at the elbow, sweep the arm across the chest. This will provide room for the shoulder that is anterior to move under the symphysis pubis (Figure 27 ).
Figure 27: Grasping the humerus of the arm that is posterior and sweeping the arm across the chest
• If all of the above measures fail to deliver the shoulder, other options include: - Fracture the clavicle to decrease the width of the shoulders and free the shoulder that is anterior; - Apply traction with a hook in the axilla to extract the arm that is posterior.
· If all of the above measures fail to deliver the shoulder, other options • If all ofinclude:the above measures fail to deliver the shoulder, other options include: - Fracture the clavicle to decrease the width of the shoulders and free the shoulder- thatFracture is the clavicle anterior; to decrease the width of the shoulders and free - Apply the shouldertraction with hook thatanterior; is the axilla to extract the arm that is posterior. - Apply traction with a hook in the axilla to extract the arm that is posterior. 142 135
4. Labour with an Overdistended Uterus
Problem
• A woman in labour has an overdistended uterus or symphysis-fundal height more than expected for the period of gestation.
General Management
• Prop up the woman. • Confirm accuracy of calculated gestational age, if possible.
Diagnosis
• If only one fetus is felt on abdominal examination, consider wrong dates, a single large fetus or an excess of amniotic fluid. • If multiple fetal poles and parts are felt on abdominal examination, suspect multiple pregnancy. Other signs of multiple pregnancy include:
# Fetal head small in relation to the uterus; Uterus larger than expected for gestation; # More than one fetal heart heard with Doppler fetal stethoscope. #
Note: An acoustic fetal stethoscope cannot be used to confirm the diagnosis, as one heart may be heard in different areas.
• Perform ultrasound examination to:
Identify the number, presentations and sizes of fetuses; # Assess the volume of amniotic fluid. #
Management
SINGLE LARGE FETUS
Ask about a history of previous delivery of large baby: •
If yes, and she had no complications: manage as for normal labour. # If no, counsel for shoulder dystocia and other complications and give an # option of caesarean section.
If vaginal delivery was decided: anticipate and prepare for prolonged and • obstructed labour , shoulder dystocia and postpartum haemorrhage . • Monitor progress of labour.
Note: Avoid augmentation and instrumental delivery.
EXCESS AMNIOTIC FLUID
If cervix is favorable, rupture the membranes with an amniotic hook early in labour • 143 136
and release the fluid slowly (i.e. controlled ARM). • Checkreleaseand for the cordfluidprolapse slowly (i.e. controlled when ARM).membranes rupture. If the cord prolapses • Checkdeliveryand for is not cord prolapse imminent, when delivermembranes by caesarean section. rupture. If the cord prolapses and delivery is not imminent, deliver by caesarean section. MULTIPLE PREGNANCY MULTIPLE PREGNANCY � Insert intravenous line. •� Insert Perform:intravenous,grou CBC line. ping and save serum, others as per condition. • Perform: clinicalCBC ,groupingexamination and alongserum, save with othersultrasound per condition. evaluation for fetal • presentation,Perform clinical viability,examination placental site along,liquor withvolume ultrasound estimated evaluationfetal for weight.fetal • presentation,continuousEnsure viability,CTG placenta site ,liquorlmonitoring labour, inIf volume heart andfetalestimatedrate weight. fetal abnormal • Ensure(<110, continuous >160) the CTG 1st twin,monitoring manage in inlabour, as singleton,fetalwhereas If heart in twin if rate2ndabnormal (<110,abnormal>160) opt in the for 1st caesareantwin, section. manage as in singleton, whereas in 2nd twin if • abnormaladequateforGive opt analgesia caesarean ( section. preferably epidural). • ConsideradequateaugmentationGive analgesia ( oxytocin befoby preferablyre epidural).delivery of 1st twin for hypotonic • contraction.augmentationConsider by oxytocin before delivery of 1st twin for hypotonic • contraction.caesareanConsider section at any stage if either twin cannot be monitored. • ConsideranaesthetistInform caesareanand section senior atneonatologisteitherrequiredcannotduringmonitored. any if ( 2 twin be delivery ). • InformAt the anaesthetist time of delivery, andensure senior neonatologistthe availability of:2 ( required midwives, during Obstetricians, delivery ). delivery • sets,At the resuscitation time of delivery, setsensure ( 2 the each),availabilityCTGmidwives, twin of: machine & portable Obstetricia delivery ns,ultrasound sshouldresuscitationets, be ready . sets ( 2 each), a twin CTG machine & portable ultrasound • Delivershould Twinready be one . as singleton. Clamp & cut the cord and note time of delivery. • Deliver Twin one as singleton. Clamp & cut the cord and note time of delivery. Delivery of the first twin: Delivery of the first twin: • Check presentation: • Check presentation:
# If a vertex presentation, allow labour to progress as for a single vertex
# Ifpresentation.presentation, vertex allow labour to progress as for a single vertex # Anypresentation.malpresen tation, proceed with caesarean section.
# Any malpresentation, proceed with caesarean section. Delivery of the second twin: Delivery of the second twin: • Determine the lie of the second baby by: abdominal, vaginal examination and by • Determineneeded.lieUSG if the of the second baby by: abdominal, vaginal examination and by • EnsureUSG if continuous needed. fetal heart rate monitoring of the second twin. • EnsureIf lie is longitudinal continuous startfetal oxytocinheart rate monitoring infusion as pertheprotocol of second and twin.once presenting • partIf lie isisin the longitudinalperformoxytocin pelvis start ARM withinfusion contractions.protocol per and once presenting • Performpart is in Assisted the pelvis performdeliverywith Breech ARM / Vacuu contractions.m delivery according to the clinical • situationPerform if Assistedindicated.Breech delivery / Vacuum delivery according to the clinical • situationVaccum indicated.ifdelivery may be employed at slightly higher level than for singleton. • Vaccum delivery may be employed at slightly higher level than for singleton. Vertex Presentation Vertex Presentation • If the fetal head is not engaged, manoeuvre the head into the pelvis manually • (handsfetalIf the on head abdomen), is not if engaged possible., manoeuvre the head into the pelvis manually • (handsmembranesIf the on abdomen), areif intact, possible.rupture the membranes with an amniotic hook once • theIf theheadmembranespelvis. in the are intact, rupture the membranes with an amniotic hook once • thecontractionsIf head theare pelvis.inadequa te after birth of first baby, augment labour with oxytocin • contractionsescalationinadequateproduceIfusing rapid are to after birth of first baby, good contractionsaugment(three labour with 10contractionsoxytocin using rapid escalation to produce good contractions (three contractions in 10 137 144 137
minutes, each lasting more than 40 seconds). •• IfIfspontaneous delivery does not occur within 30 minutes of good contractions or ifif there are fetal heart rate abnormalities (less than 110 or more than 160 beats per minute), expedite delivery.
Breech Presentation
•• IfIf the baby is estimated to be of similar size of the first baby, consider breech extraction or vaginal breech delivery.
## IfIfthere are inadequate or no contractions after birth of first baby, escalate oxytocin infusion at aa rapid but controlled rate to produce good contractions (three contractions in 10 minutes, each lasting more than 40 seconds);
## IfIf the membranes are intact and the breech has descended, rupture the membranes with an amniotic hook;
## Check fetal heart rate between contractions. IfIf there are fetal heart rate abnormalities (less than 110 or more than 160 beats per minute), deliver by breech extraction.
•• IfIfvaginal delivery is not possible, deliver by caesarean section.
Note: Delivery of breech presentation should be conducted by an experienced obstetrician.
Transverse Lie
•• IfIfthe membranes are intact, attempt external version •• IfIf external version fails and the cervix is fully dilated and membranes are still intact, attempt internal podalic version:
Note: Do not attempt internal podalic version ifif the provider is untrained, the membranes have ruptured and the amniotic fluid has drained, or ifif the uterus is scarred. Do not persist ififthe baby does not turn easily.
Insert aahand into the uterus and grasp the baby’s foot; ## Gently rotate the baby down; ## ## Proceed with breech extraction; and release fetalfluid slowly controlledcontractions. • Check## Checkthefor cord heart prolapse rate(i.e.between when ARM).Check membranes heart rate rupture. between If the cord prolapses •• IfIfexternal version imminent,internal podaliccaesarean section.advisable or fails, deliver and delivery notfails and deliver by versionfails and version by caesarean section .. MULTIPLE PREGNANCY Management of third stage of labour: � Insert intravenous line. Perform:oxytocin ,groupingwithin save serum, othersdelivery ofcondition. baby. �• Give CBC as per the secondGive 10 IM andone minute of the second •• Perform clinical examinationofalong twins separately. evaluation for fetal Handle cord blood bothHandleand label cord blood both with ultrasound •• presentation,examineDeliver and the site check the the placenta; and (( byDeliver,liquor volumechorionicityestimatedexaminingand viability, check the by fetal weight. the • dividing membranes ) CTGfor monitoring in anastamosis.fetal heart rate abnormal continuous )and any vascular labour, IfEnsure and any vascular •• Anticipate(<110, >160) PPHinand the manage 1st twin, promptly. manage as in singleton, whereas in 2nd twin if abnormal opt for caesarean section. • Give adequate analgesia ( preferably epidural). • Consider augmentation by oxytocin before145 delivery of 1st twin for hypotonic 138138 contraction. • Consider caesarean section at any stage if either twin cannot be monitored. • Inform anaesthetist and senior neonatologist ( 2 required during delivery ).
• Start prophylactic oxytocin infusion, 20 units in 500 mL of normal saline over 4 hours. • Confirm that uterus is well contracted & retracted. • Monitor for vitals signs & vaginal bleeding.
Postnatal Care
• Offer longer hospital stay and extra support to assist the care of babies. • Screen for early signs of perinatal psychological disturbances which is increased in multiple pregnancy and to offer treatment. • Give adequate birth spacing advice and haematinics for three to six months.
5. Labour with a Scarred Uterus
Problem
• A woman in labour has a scarred uterus from a previous uterine surgery.
General Management
• Start an IV line and infuse IV fluids • Perform CBC • Cross match blood if haemoglobin is less than 11 gm/dL • Monitor the women closely for pulse and blood pressure
Specific Management
TRIAL OF LABOUR
• Ensure that conditions are favourable for trial of labour. • Regional analgesia not contraindicated. Continuous fetal monitoring is mandatory. • • Monitor progress of labour using a partograph. If cervical dilatation crosses the alert line of the partograph, diagnose the cause • of slow progress and take appropriate action:
If there is slow progress in labour due to inefficient uterine contractions, # rupture the membranes with an amniotic hook and augment labour using oxytocin .
Note: Augmentation of labour with oxytocin to be instituted after careful evaluation and consultation.
If there are signs of cephalopelvic disproportion or obstruction deliver # immediately by caesarean section .
If there are signs of scar dehiscence/ impending uterine rupture (rapid maternal • pulse, vaginal bleeding, frank haematuria, persistent abdominal pain and suprapubic tenderness, fetal distress), inform senior obstetrician and consider delivery by caesarean section.
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Induction of labour:
Box 5: use of cervical ripening agents (PGE2 Gel) for induction of labour
• Only two doses of 1 mg PGE2 gel to be used and decision to be made by senior obstetrician. 3rd dose should be used only at the discretion of the consultant. • Patient should be closely monitored for pulse and blood pressure. • CTG to be performed prior to PGE2 gel insertion and when contractions begin or 1 hour after the insertion if no contractions.
6. Fetal Distress in Labour
Problems
• Abnormal fetal heart rate (less than 110 or more than 160 beats per minute). • Thick meconium-stained amniotic fluid.
General Management
• Prop up the woman or place her on her left side. • Stop oxytocin if it is being administered. • Give oxygen 4-6 L by mask or nasal cannulae. • Start fetal monitoring by CTG.
Specific Management
According to the interpretation of the CTG (Table 28) •
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Table 28: Classification of FHR trace features
Feature Baseline Variability Decelerations Accelereations (bpm) (bpm) Reassuring 110-160 ∃ 5 None Present
Non- < 110 < 5 for 40- - Typical variable Absence of reassuring > 160 90 minutes decelerations accelerations with with > 50% of otherwise normal contractions for trace is of > 90 min. uncertain - Single significance. prolonged deceleration for up to 3 min. Abnormal < 100 < 5 for 90 - Either atypical min. variable > 180 ∃ Sinusoidal decelerations pattern with over 50% of contractions or 10 min. late decelerations, both for > 30 min. - Single prolonged deceleration for > 3 min.
•Normal: When all four features are classified as reassuring.
Continue observation and manage as normal delivery.
Suspicious: When one feature classified as non-assuring and the remaining features •classified as reassuring: • Ensure left lateral positioning of the women.
Revie# w quality of CTG:
# Check the abdominal electrode for poor contact; Consider inserting scalp electrodes if no proper recording with abdominal • electrode.
Control uterine hypercontractility: #
# Stop or reduce oxytocin infusion, if running; Consider tocolysis if recently received prostaglandin. Give S/C terbutaline 0.25 mg.
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• Check for maternal tachycardia/ pyrexia:
# If maternal fever detected, consider screening and treatment for infection.
# If pulse > 140 bpm, reduce tocolytic infusion.
# Check BP and administer 500 ml of crystalloid if appropriate.
Pathological: When two or more features classified as non-reassuring or one or more classified as abnormal:
• Delivery should be expedited in absence of additional tests e.g. fetal scalp blood sampling. • Urgency of delivery should be according to severity of FHR abnormality and relevant maternal factors. • Delivery should be accomplished within 30 minutes. • Following delivery, paired umbilical cord samples (artery and vein) should be taken and 1 and 5 minute Apgar scores should be recorded in the mother’s notes. (Cord ph to be taken whenever possible).
MECONIUM
• Meconium staining of amniotic fluid is seen frequently as the fetus matures and by itself is not an indicator of fetal distress. A slight degree of meconium without fetal heart rate abnormalities is a warning of the need for vigilance. • Thick meconium suggests passage of meconium in reduced amniotic fluid and may indicate the need for expedited delivery and management of the neonatal upper airway at birth to prevent meconium aspiration. • In breech presentation, meconium is passed in labour because of compression of the fetal abdomen. This is not a sign of distress unless it occurs in early labour.
7. Prolapsed Cord
Problems
• The umbilical cord lies in the birth canal below the fetal presenting part. • The umbilical cord is visible at the vagina following rupture of the membranes.
General Management
Give oxygen at 4-6 L per minute by mask or nasal cannulae. •
Specific Management
PULSATING CORD
If the cord is pulsating, the fetus is alive.
Diagnose stage of labour by an immediate vaginal examination; • If the woman is in the first stage of labour, in all cases: •
Wearing sterile gloves, insert a hand into the vagina and push the # 149 142
presenting part up to decrease pressure on the cord and dislodge the presenting part from the pelvis;
# Placepresentingother the part handtoondecreaseabdomenpressuretheonsuprapubicup the in the cord and to keep regiondislodge the presenting part part from out the of pelvis;the pelvis; # # OncePlace the other present handing on partthe is firmly abdomen held the inabovesuprapubicthe pelvic brim, to keep region remove the otherpresenting hand fromoutpart theof vagina.pelvis; the Keep the hand on the abdomen until # caesareanOnce the presentingsection; part is firmly held above the pelvic brim, remove the until # otherInflatehandbladderthe the from andvagina. transferKeepimmediately the hand on the abdomen for cae sarean section; caesarean section; Note: do# Inflate not replacethe bladder the and hand, transfer consider immediately minimal for handling caesarean of section; the cord.
Note: doavailable, give salbutamolconsider minimal handling oftwo minutes to reduce If not replace the hand, 0.5 mg IV slowly over the cord.# contractions; # If available, give salbutamol 0.5 mg IV slowly over two minutes to reduce # Perform immediate caesarean section. contractions;
• If the# Performwoman is immediate in the second caesarean stage of section. labour:
• If the# Expeditewoman is deliverysecondepisiotomylabour:vacuum in the with stage of and extraction or forceps; If breech presentation, perform breech extraction and apply Piper or long # Expedite delivery with episiotomy and vacuum extraction or forceps; # forceps to the after-coming head; # # IfPrepare breechfor presentation, resuscitation performnewborn.extraction the breech and apply Piper or long forceps to the after-coming head; # Prepare for resuscitation of the newborn. CORD NOT PULSATING
IfCORD the cord NOT notisPULSATING pulsating, the fetus is dead. Deliver in the manner that is safest for the woman. If the cord is not pulsating, the fetus is dead. Deliver in the manner that is safest for 8.the Preterm woman. Labour
8. Preterm Labour Problem
RegularProblem painful contractions, at least 1 in 10 minutes or 6 or more contractions in an hour associated with cervical dilatation and effacement. Regular painful contractions, at least 1 in 10 minutes or 6 or more contractions in an hourMake associated every with effort cervical to confirm dilatation theand gestationaleffacement. age of the fetus, preferably by ultrasound. Review maternal health record for previous ultrasound scans. Make every effort to confirm the gestational age of the fetus, preferably by ultrasound. Review maternal health record for previous ultrasound scans.
Management
Management Tocolysis
TocolysisThis intervention aims to delay delivery until the effect of corticosteroids has been achieved. This intervention aims to delay delivery until the effect of corticosteroids has been achieved.• Attempt tocolysis if:
• AttemptGestation if: less than 37 weeks; tocolysis is# Gestation is less than 37 weeks; # 143
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# The cervix is less than 3 cm dilated; # There is no chorioamnionitis, pre-eclampsia or active bleeding;
# There is no fetal distress.
• Confirm the diagnosis of preterm labour by documenting cervical effacement or dilatation over two hours. • Monitor maternal and fetal condition (pulse, blood pressure, signs of respiratory distress, uterine contractions, loss of amniotic fluid or blood, fetal heart rate, fluid balance, blood glucose, etc.).
Note: Do not give tocolytic drugs for more than 48 hours.
Corticosteroids
• If less than 34-36 weeks gestation, give corticosteroids to the mother to improve fetal lung maturity and chances of neonatal survival:
# Dexamethasone 12 mg IM, two doses 12 hours apart.
Note: Corticosteroids should not be used in the presence of frank infection.
Arrange for the baby to receive care at the most appropriate service with neonatal facilities. If possible, refer the woman before she gives birth.
Table 29: Tocolytic drugs to stop uterine contractions
Drug Initial Dose Subsequent Side Effects and Dose Precautions
Atosiban 6.75 IV mg bolus Infusion of 18 mg Duration of treatment over 1 min. per hour for 3 should not exceed 48 hours, then 6 mg hours and the total dose per hour up to 45 given during a full hours. course should preferably The infusion can not exceed 330 mg. be stopped 12 hours after cessation of contractions.
Emergency cervical cerclage
It is applied when findings are suggestive of cervical incompetence and the uterine
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cessation of of contractions. contractions.
Emergency cervical cerclage Emergencycontractions cervical ceased cercland noage signs of chorioamnionitis. The procedure should be contractions are ceased and no signs of chorioamnionitis. The procedure should be performed when findings are suggestive of contractionsIt appliedby anIt appliedby anwhenexperiencednoobstetrician.chorioamnionitis.incompetenceprocedure ceasedand signs of cervical The and theshould beperformed are ceased and signs of The should beare findings are suggestive of uterine performedcontractions by are an experiencedceased and obstetrician.chorioamnionitis.signs of The procedure should be performed by an experienced obstetrician. performedFetal assessment by an experience d obstetrician. Fetal assessment 144 Fetal assessment 144 •Fetal Confirm assessment fetal presentation. Fetal• Confirm asses fetalsment presentation. •• ConfirmEstimate fetal fetal presentation. weight. • Estimateumbilicalpresentation.Doppler when indicated. •• Estimate fetalpresentation.Doppler when indicated. • EstimateConfirm fetalumbilical fetal arteryPerform weight. weight. • Estimateumbilicalweight.Perform fetal artery Doppler when indicated. • Perform LABOUR TOartery Doppler when indicated. •ALLOWING Perform umbilical umbilicalarteryLABOUR TO PROGPROGRESSDopplerRESS when indicated. ALLOWING LABOUR TO PROGRESS •ALLOWING Allow labour LABOUR to progress TO if:PROGRESS ALLOWING• Allow labour LABOUR to progress TO PROGRESSif: • Allow labour to progress if: • Allow labour to progress if: • Allow# labourcervixprogressThe to is moreThe is more if:than 3 cm dilated; # ## The There cervix is activeis more bleeding; than 3 cm dilated; # # TheThere cervix is active is more bleeding;3 than cm dilated; ## Therecervixactivedistressed,fetus more thanis is bleeding;3 cm or hasfetus is dead or has dilated;an anomaly incompatible with survival; # # There isis chorioamnionitis active bleeding; ## Therefetuschorioamnionitisdeadis active bleeding;is distressed, or preor has-eclampsia. an anomaly incompatible with survival; # The fetus is distressed, dead or has an anomaly incompatible with survival; # Therefetuschorioamnionitisdeadpreis distressed, or or has an -eclampsia.anomaly incompatible with survival; # progressis chorioamnionitis of labour using or thepre -partograph;eclampsia. • MonitorThere progresschorioamnionitis is of labour usingor partograph; thepre-eclampsia.# •• MonitorIf labourprogress continues labourgesof and usingtationtheless is than 37 weeks, give prophylactic • If Monitorlabourprogress continues ofand labour gestation using thepartograph; weeks, give prophylactic •• Monitor antibiotics continuesof in order to labourgestation help reduceis less partograph;streptococcusgivepartograph; than 37 prophylactic • IfIf antibioticslabour labour progress continues in order to help and reducetheGroup gestationisGroupthan37 Bis lessweeks, B infectionstreptococcus37 weeks, in theand give infection usingprophylactic less in than the • antibioticscontinuesIfneonates: labour order to andhelpgestation reduce is less B Group 37 weeks, thanstreptococcus giveinfection in prophylactic the antibioticsneonates: in order to help reduce Group B streptococcus infection in the neonates:antibiotics in order to help reduce Group B streptococcus infection in the neonates:# Penicillin 3 g IV stat, then 1.5 g IV every 4 hours until delivery. neonates:# Penicillin 3 g IV stat, then 1.5 g IV every 4 hours until delivery. # If allergic to penicillin, give clindomycin 900 mg IV every 8 hours. ## Penicillin 3 g penicillin, give clindomycin 900 mg IV every 8 hours. # IfPenicillin allergic 3to gIV IV stat,stat, thenthen 1.5 g IV every 4 hours untiluntil delivery.delivery. # Penicillin to penicillin,then clindomycin 900hoursIV everydelivery. Note: Avoid# If allergicdeliveryto to penicillin,penicillin, give clindomycin clindomycin risks 900 ofmg intracranial IV every 8 bleedinghours. in the If allergic by vacuumgiveextraction, as the900 mg IV every 8 hours.by vacuum extraction, as the# pretermAvoidpreterm baby are deliveryhigh. high. vacuum extraction, as the risks of intracranial bleeding in the Note:Note: Avoidbaby aredelivery by by vacuum extraction, as the risks of intracranial bleeding in the pretermAvoidNote: baby are delivery high. by vacuum extraction, as the risks of intracranial bleeding in the •preterm Prepare baby for aremanagement high. of preterm or low birth weight baby and anticipate the preterm• Prepare baby for aremanagement high. of preterm or low birth weight baby and anticipate the • Prepareneed for for resuscitation. management of preterm or low birth weight baby and anticipate the • needPrepare for for resuscitation. management of preterm or low birth weight baby and anticipate the • Prepareneed for resuscitation. for management of preterm or low birth weight baby and anticipate the need for resuscitation. 9. needRuptured for resuscitation. Uterus 9. R uptur ed Uter us 9. Ruptured Uterus 9.Risk• Ruptured factors:Risk factors: Uterus• • Risk factors: •• RiskRisk factors:#factors:Grand multi para Grand# # Oxytocin administration ## GrandOxytoc multiin administration para # GrandMacrosomia multi para ## OxytocinGrandMacrosomia multi administration para # OxytocinOverdistended administration uterus ## OverdistendedadministrationOxytocinMacrosomia uterus # #Macrosomia Prolonged labour ## OverdistendedlabouruterusMacrosomiaProlonged # Overdistended uterus ### OverdistendedcephaloUndiagnosed uterusProlonged labourUndiagnosed pelvic disproportion or malpresentation # # Prolonged labour # ## Undiagnosed /Myomectomy disproportion or malpresentation # UndiagnosedPrevious CS cephalo /Myomectomy pelvicPlacenta percreta disproportion or malpresentation ## UndiagnosedPrevious CS cephalo/Myomectomy pelvic disproportion or malpresentation # PlacentaPrevious percretaCS /Myomectomy ### PlacentaPreviousPrevious CSpercreta Instrumentation/Myomectomy(Vigorous curettage) # # PreviousPlacenta percretaInstrumentation (Vigorous curettage) ## Previous Instrumentation Rudimentarycurettage) # Previous Instrumentation (Vigorous curettage) ### PreviousExternal cephalic Instrumentation version/ Internal podalic versionUterine Rudimentarycurettage) abnormalities, eg (Vigorous horn for the 2nd twin # ExternalUterine cephalicabnormalities, version/ eg Inter Rudimentarynal podalic version horn for the 2nd twin # Instrumental delivery in patient with previous # ## External abnormalities, eg Rudimentary version for the 2nd twin # InstrumentalcephalicExternal delivery patientversion/ withpodalic Internal previousversion LSCS for the 2nd twin # InstrumentalcephalicExternal delivery patientversion/ withpodalic Internal previousversion LSCS for the 2nd twin • RuptureInstrumental# Instrumental Spontaneouslydelivery in patient beforeprevious with previous LSduringCS labour or may be can occur delivery in patient with labour,LSCScan occur labour,# be • Rupture can occur Spontaneously before labour, during labour or may be • Rupture can occur Spontaneously 152 before labour, during labour or may 145be • Rupture can occur Spontaneously before labour, during labour or may 145be 145 145 145
silent as in Scar dehiscence. • Symptoms depend on the type of rupture (whether complete or incomplete and degree of involvement of vascular structures ).
Diagnosis:
• In monitored patients, CTG may show sudden bradycardia, prolonged decelerations or variable decelerations ( hence continuous monitoring in previous CS is necessary). • Bleeding and pain may not be present. • The most common manifestation of scar separation is prolonged deceleration ( 70%).
Management:
• Laparotomy should be undertaken by a senior obstetrician as rupture could involve bladder, uterine arteries and ureters. Consent for hysterectomy (if needed) should be taken prior to the procedure.
How to prevent rupture ?
• Identify the risk factors; • Outline the plan of management antenatally; • Maintain high index of suspicion in high risk cases like grand multiparity and over distended uterus; • Judicious use of Oxytocin; • Senior obstetrician involvement in decision making of induction by oxytocin in high risk cases; • Close monitoring in high risk cases.
Note: Avoid delay in intervention whenever warning signs appear and/or non progress of labour.
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!
ROUTINE POST NATAL CARE
Is the care given to the women and her baby for the first six weeks after delivery.
Aims of post-natal care:
• To promote the physical , mental & emotional health of the mothers and their babies. • To reduce the mortality and morbidity of mothers and their babies.
Ideally women should be kept for 24- 48 hours post partum in the hospital for observation
Tasks of postnatal care
Basic care: To ensure basic care of all new born.
Bonding: To assist bonding between mother and babies by rooming in and minimizing separation unless medically indicated.
Breastfeeding: To initiate breastfeeding within half to 1 hour of delivery and establishing it by supporting & counselling the mother.
Birth spacing: To counsel mothers about options for birth spacing in post natal period.
Education: To provide information on baby care including hygiene & child safety.
Basic care of newborns:
ENSURING WARMTH
At birth
Warm delivery room: Temperature should be 25-28º C, no draught. • Dry baby: immediately after birth, place the baby on a warm, clean and dry • surface. Dry the whole body and hair thoroughly, with a dry cloth. • Asses the newborn for the Apgar score. • Skin-to-skin contact: leave the baby on the mother’s chest (after cord cut) after birth for at least 2 hours. Cover the baby with a soft dry cloth. • If the mother cannot keep the baby skin-to-skin because of complications, wrap the baby in a clean, warm cloth and place in a cot. Cover with a blanket. Use a radiant warmer if room not warm or baby is pre-term.
Subsequently
Explain to the mother that keeping baby warm is important for the baby to remain • healthy.
148
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• Dress the baby or wrap in soft dry clean cloth. Cover the head with a cap for the first few days. • Ensure the baby is dressed or wrapped and covered with a blanket. • If the mother and baby must be separated, ensure that baby is dressed or wrapped and covered with a blanket. • Assess warmth every 4 hours by touching the baby’s feet: if feet are cold use skin-to-skin contact, add extra blanket and reassess. • Keep the room warm for the mother and baby. If the room is not warm enough, always cover the baby with a blanket and/or use skin-to-skin contact.
At home
• Explain to the mother that babies need one more layer of clothes than older children or adults. • Keep the room or part of the room warm, especially in cold climate. • During the day, dress or wrap the baby. • At night, let the baby sleep with the mother or within easy reach to facilitate breastfeeding.
HYGIENE
Eye care
• It is normal for a newborn baby to have some crusting or a little discharge.
• Wash the baby eyes with clean water.
Do not put any antibiotics unless advised by physician
Cord care
• Wash hands before and after cord care. Do not put anything on the stump. • Fold nappy (diaper) below stump. • Keep cord stump loosely covered with clean clothes. • If stump is soiled, wash it with clean water and soap. Dry it thoroughly with clean • cloth. If umbilicus is red or draining pus or blood, examine the baby and manage • accordingly. Explain to the mother that she should seek care if the umbilicus is red or draining • pus or blood.
Remember:
Do not bandage the stump or abdomen. • Do not apply any substances or medicine to stump. • Do not touch the stump unnecessarily. •
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Bath
At Birth:
• Only remove blood or meconium. • Do not remove vernix. • Do not bathe the baby before 12-18 hours.
Later and at home:
• Wash the face, neck, underarms daily. • Wash the buttocks when soiled. Dry thoroughly. • Bath when necessary. • Ensure the room is warm, no draught. • Use warm water for bathing • Thoroughly dry the baby, dress and cover after bath.
IMMUNIZATION
• Give all the required immunizations according to the national immunization schedule . • Give Vitamin A 200,000 IU to mother within 15 days after delivery, preferably before discharge. • Give Rubella Vaccine to mother if indicated. • Advise when to return for next immunization.
ENSURE NUTRITION THROUGH BREAST FEEDING
• Ask the mother to help the baby attach when the baby seems to be ready. Signs of readiness to suckle include opening the mouth, rooting or searching, looking around, and moving. • If the mother is ill and unable to breastfeed, help her to express breast milk and feed the baby by cup. • Explain to the mother how to hold her baby during breastfeeding. She should:
- Hold the baby in skin-to-skin contact, if possible; - Hold the baby's head and body straight so that the baby faces her breast, with the baby's nose near her nipple; - Support the baby's whole body, not just the neck and shoulders. - Explain to the mother how to encourage her baby to attach. She should:
Touch the baby's lips with her nipple; - Wait until the baby's mouth is opening wide; - Move the baby quickly onto her breast, so that the baby's lower lip is well - below the nipple.
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Figure 28: Initiating breastfeeding
• Assess attachment on the breast and suckling. Help the mother if she wishes. Especially if she is a first time or very young mother. Signs of correct attachment:
- Baby's chin touches the breast; - Baby's mouth is wide open with the lower lip curled out; - More of the areola is visible above than below the mouth; - Baby suckles with slow, deep sucks and pauses sometimes.
Figure 29: Attaching to breast
Neonatal screening:
• Blood should be collected for routine screening from umbilical cord at birth or by heel puncture subsequently. • Hearing test to be performed before discharge.
Documentation
Maternal Health Record: The details of labour should be entered in the Maternal Health Record.
Child Health Record: Every child must be issued a Child Health Record and all entries should be completed before discharge from the maternity ward. The child
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health checks done at birth should be done in the first 24 hours and be entered in the Child Health Record.
Post natal visits to clinic
• The mother should visit the health centre at 2 weeks and then at 6 weeks postnatal. The subsequent investigations to be performed at these visits: haemoglobin level (at 6 weeks only), blood pressure, pulse, temperature, urine microscopy (at 6 weeks only). Women should be examined by the doctor for: uterus, perineum, vagina/lochia, LSCS wound (if went under caesarean section) and breast & nipples. • Further counselling on breast feeding and lactation should be given at this stage. • Counselling on the appropriate methods of birth spacing should be re- emphasized on. • Iron should be given to all mothers for 3-6 months.
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1.1. Vaginal Vaginal Bleeding Bleeding After After Childbirth Childbirth ( Post(Post Partum Partum Haemorrhage) Haemorrhage) Post partum haemorrhage is defined as blood loss sufficient to cause Post partum haemorrhage is defined as blood loss sufficient to cause heamodynamic instability. heamodynamic instability. Problems Problems • Increased vaginal bleeding within the first 24 hours after childbirth (immediate Increased vaginal bleeding within the first 24 hours after childbirth (immediate • PPH). PPH). • Increased vaginal bleeding after after till • Increased vaginal bleeding after till postpartum (delayed PPH). postpartum (delayed PPH). • Continuous slow bleeding or sudden bleeding is an emergency; intervene Continuous slow bleeding orearly sudden and aggressively bleeding is an emergency; intervene early and aggressively
Prevention Prevention
Active management of 3rd stage of labour. • • • Active management of 3rd stage of labour. • Prophylactic Oxytocin. • ProphylacticEarly Cord Clamping.Oxytocin. • Early Cord Clamping. • • Controlled Cord traction. • ControlledInspection Cord of placenta traction. and lower genital tract. • Inspection of placenta and lower genital tract.
Active management of the third stage should be practised on all women in Active management of the third stage should be practised on all women in labourlabour because because it it reduces reduces the the incidence incidence of of PPH PPH due due to to uterine uterine atony atony Diagnosis Diagnosis Table 30: Diagnosis of vaginal bleeding after child birth Table 30: Diagnosis of vaginal bleeding after child birth
Presenting Symptom Presentingand Other SymptomSymptoms Symptoms and Signs and Other Symptoms Symptoms and Signs Probable Diagnosis and Signs Typically Sometimes Present Probable Diagnosis and Signs Typically Present Sometimes Present Present • Immediate PPHa • Shock Atonic uterus • Immediate PPHa • Shock Atonic uterus • Uterus soft and not ! • Uteruscontracted soft and not ! contracted • Immediate PPHa • Complete placenta Tears of cervix, vagina or • Immediate PPHa • •Complete Uterus contracted placenta Tearsperineum of cervix, vagina or • Uterus contracted perineum
• Placenta not delivered Retained placenta
• Placenta not delivered * Retained placenta withinwithin 30 30 minutes minutes after after • •Immediate Immediate PPH PPH
deliverydelivery • Uterus contracted• Uterus contracted • No tears in the genital • Notract tears in the genital tract
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• Portion of maternal • Immediate PPH* Retained placental surface of placenta • Uterus contracted fragments missing or torn membranes with vessels
• Retained placentalImmediateUterine fundus not • Shock Inverted uterus, • Uterus •contractedabdominal Portionfeltfelt on of maternalfragments Inverted • Immediateuterus PPH* Retained placental palpation apparent at vulva surface of placenta • Uterus contracted fragments • missingororintenseSlightSlight torn pain • Immediate PPH**
• membranesImmediatewith *Immediate PPH * • Shock Ruptured uterus • Shock vessels (bleeding is intraInverted-intra- uterus, •• Tender abdomen • Inverted abdominal and/or Inverted uterus, • Uterine fundus not • Shock RapidRapidmaternal apparent at vaginal) feltvulva on abdominal • pulseInvertedpulse uterus n • Immediatepalpationabdominal• PPH• SevereSevere** apparent at vulva
• Shock • Slight(maypain (may Ruptured decreasedecrease uterus • Immediate PPH ** after rupture) • Tender •Immediateabdomen PPH* • Shock Ruptured uterus *Bleeding• Rapid maternal(bleeding may be is light intra- if a clot• Tender blocks theabdomen cervix or if the woman is lying on her back. pulse abdominal and/or • Rapid maternal vaginal) **There may be no bleeding withpulse complete inversion. e • Severe abdominal Generalpain Management:(may decrease after rupture) f a clot blocks the• Call cervixfor if the woman help. Urgentlyis lying onallher mobilize back. all• availableCall personnel. •* Bleeding be if mayrapidclot evaluation of the is lying blocks on her general vitalPerform co ndition light womanwoman,of the the cervix or if theincludingback. of the vital ding with completesignsinversion. (pulse, blood pressure, respiration, tempreture). •**There Check be mayairwaynoand give oxygen •bleeding100% Check and give with completebyinversion.bag. oxygen mask/ • Insert 2 IV lines (14 G), take blood for CBC, clotting, cross match 4 units and start GeneralIV fluids.Management: y mobilize all available• Give warmed personnel. crystalloid & colloid as rapidly as needed while awaiting blood. luation of the general• Call for help. ofgive conditionUrgently woman, all much as rapidly� Once available themobilizeincludingavailable warmed blood as vital� Once available give warmed blood as much aspersonnel. rapidly as needed ressure, respiration,• ContinueaIntensiveevaluation tempreture). of the generalmonitoring of the warm: throughout• Perform Intensive &c ondition keep patientwoman,the warm:Continue rapid including vital ve 100% oxygen bysigns mask/(pulse, bag. blood pressure, respiration, tempreture). G), take blood •for CBC, Checkclotting, Urinary and givematch 4 units catheter andbystart-- Urinarycross(hourly 100%output). oxygenairway mask/ bag. • InsertO2 Vital take signs(14 blood-- G),saturation.2 IV lines & O2 for CBC, clotting, cross match 4 units and start loid & colloid as rapidlyfluids.ConsiderCVP lineawaiting blood. whileline-- as CVPIV (hazardous in DIC). warmed blood •as Give muchwarmed as rapidly crystalloid needed & colloid as rapidly as needed while awaiting blood. monitoring throughoutMonitor� Once keep the give warm: CBC:• &coagulation availablepatientprofile &• warmed profile & CBC: blood as much as rapidly as needed • Continue Intensive monitoring throughout & keep the patient warm: er (hourly output). -- Give FFP (2 units) if ∃ 4 units of PRBC transfused or if coagulation profile O2 saturation. - is isUrinaryabnormal. catheter (hourly output). P line (hazardous in DIC).Give-- Vital signs cryoprecipitatesatura & O2 given ifgiven tion.if fibrinogen < 1 g/l (2 packs). -- Consider CVPrarely (hazardous platelet < 50 x109/l). profile & CBC: Platelets needed if in DIC).Platelets are line needed if
Medical• Monitor Surgical& coagulation profilemanagement &Surgical CBC: units) if ∃ 4 units of PRBC transfused or if coagulation profile See Algorithm- Give 7forFFP(2 units)the medical if ∃ 4 units and ofsurgical PRBC management transfused7for or if coagulation profile ipitate given if fibrinogenis< 1abnormal. g/l (2 packs). arely needed ( if platelet- < 50Give x109/l). cryoprecipitate given if fibrinogen < 1 g/l (2 packs). - Platelets are rarely needed ( if platelet166 < 50 x109/l). 155155 nagement Medical & Surgical management medical and surgical management
Algorithm 7: Medical & surgical management of PPH
Check if the uterus is contracted
No Yes
• Catheterize urinary bladder; Take to theatre & do examination • Rub the uterus +/- bimanual under anaesthesia: compression; • Start the medical treatment: - If retained products: remove + - Give syntometrin (oxytocin 5 iu/ antibiotics. ergometrine 0.5 mg) IM injection; - If genital tract trauma: repair +/- - If still bleeding, start oxytocin drip (40 iu in vaginal pack. 0.9% NS IV) in 500 ml of normal saline; - If uterine inversion: reduce. - If bleeding still continues; give 15 methyl - If non of these: laparotomy & repair. prostaglandin F2 (carboprost), 250 ug IM
or directly into myomerium. Can be given at 15 minute interval (up to the total dose
of 2 mg); - if no response; administer rectal misoprostol (800-1000ug), if available.
If still bleeding
Hydrostatic balloon vaginally
inflated with 300-500 ml water
If still bleeding
- Team approach: senior obstetrician,
anesthetist, hematologist & radiologist. - Take to theatre & perform laparotomy. - Can press on aorta & wait for surgical
help. - Compression of uterus using B-Lynch
sutures. - Stepwise ligation of: uterine artery and branches of ovarian arteries, internal
iliac artery. - Vessel embolization (if available). - Hysterectomy (total / subtotal).
167 156
2. Fever after Childbirth
Problem
• A woman has fever (temperature 38°C or more) occurring more than 24 hours after delivery.
General Management
• Encourage bed rest. • Monitor vital signs, especially temperature every 4 hours. • Ensure adequate hydration by mouth or IV. • Give paracetamol 1 gm every 4-6 hours or as needed. • Start I.V. antibiotics : Augmentin 1.2 g TID + metronidazole 500 mg TID. (if there is no obvious identifiable cause, otherwise should be treated according to the cause). • If shock is suspected, immediately begin treatment. Even if signs of shock are not present, keep shock in mind as you evaluate the woman further because her status may worsen rapidly. If shock develops, it is important to begin treatment immediately.
Investigations
• Perform: CBC, high vaginal swab and urine culture. Do blood culture if two or more readings of temperature ∃ 38° C. • Perform ultrasound for pelvic.
Diagnosis
Table 31: Diagnosis of fever after childbirth
Presenting Symptom and Symptoms and Signs Probable Diagnosis Other Symptoms and Sometimes Present
Signs Typically Present
Fever/ chills Light vaginal bleeding Endometritis • • • Lower abdominal pain • Shock Purulent, foul-smelling • lochia • Tender uterus Lower abdominal pain • Poor response to Pelvic abscess • and distension antibiotics • Persistent spiking fever/ • Swelling in adnexa or chills pouch of Douglas • Tender uterus
157
168
• Low-grade fever/ chills • Rebound tenderness Peritonitis Lower abdominal pain Abdominal distension • • • Absent bowel sounds • Anorexia
• Nausea/ vomiting
• Shock
• Breast pain and • Hard enlarged breasts Breast engorgement tenderness • Both breasts affected • 3-5 days after delivery
• Breast pain and • Inflammation preceded Mastitis tenderness by engorgement • Reddened, wedge- • Usually only one breast shaped area on breast affected • 3-4 weeks after delivery • Firm, very tender breast • Fluctuant swelling in Breast abscess breast • Overlying erythema Draining pus • • Dysuria • Retropubic/ suprapic Cystitis pain • Increased frequency and urgency of • Abdominal pain urination • Dysuria • Retropubic/suprapuic Acute pyelonephritis pain • Spiking fever/ chills Increased frequency • Loin pain/ tenderness • and urgency of • Tenderness in rib cage urination • Anorexia • Abdominal pain • Nausea/ vomiting
• Spiking fever despite • Calf muscle tenderness Deep vein thrombosis antibiotics
• Fever • Consolidation Pneumonia • Difficulty in breathing • Congested throat • Cough with • Rapid breathing expectoration • Rhonchi/ rale • Chest pain
Specific Management
ENDOMETRITIS
Endometritis is infection of the uterus after delivery and is a major cause of maternal death. Delayed or inadequate treatment of endometritis may result in pelvic abscess,
169 158 • CoughDifficulty with in breathing • CongestedRapid breathing throat • Cough with • Rapid breathing • expectorationCough with • Rhonchi/Rapid breathing rale expectoration • Rhonchi/ rale • Chestexpectoration pain • Rhonchi/ rale • Chest pain Specific Management Specific Management ENDOMETRITIS ENDOMETRITIS Endometritis is infection of the uterus after delivery and is a major cause of maternal Endometritis is infection of the uterus after delivery and is a major cause of maternal death.Endometritis Delayed is orinfection inadequate of treatmentafter the uterus of deliveryendometritis and ismay result major in causepelvic maternalof abscess, death. Delayed or inadequate treatment of endometritis may result in pelvic abscess, peritonitis,death. septicDelayed shock, or inadequate deep vein treatment of thrombosis, pulmonaryendometritis result in pelvicmayembolism, pelvic chronicabscess, infection with recurrent pelvic pain and dyspareunia, tubal blockage and infertility. 158 158 • Transfuse as necessary. Use packed cells, if available. 158 • Give a combination of antibiotics until the woman is fever-free for 48 hours: - Ampicillin 2 g IV stat. then 1 gm every six hours; - PLUS IV gentamicin 5 mg/kg body weight/day, divided in 3 doses . - If fever did not settle within 48 hours: Add metronidazole 500 mg IV every eight hours; - If fever is still present 72 hours after starting antibiotics, re-evaluate and revise diagnosis. PELVIC ABSCESS
• Give a combination of antibiotics before draining the abscess and continue until the woman is fever-free for 48 hours. Ampicillin 2 g IV stat. then 1 gm every six hours; PLUS IV gentamicin 5 mg/kg body weight/day, divided in 3 doses . PLUS metronidazole 500 mg IV every eight hours. • If the abscess is fluctuant in the cul-de-sac, drain the pus through the cul-de-sac . If the spiking fever continues, perform a laparotomy. PERITONITIS • Consult surgeons for management. • Provide nasogastric suction. • Start an IV line and infuse IV fluids. • Give a combination of antibiotics until the woman is fever-free for 48 hours : Ampicillin 2 g IV stat. then 1 gm every six hours; PLUS IV gentamicin 5 mg/kg body weight/day, divided in 3 doses . PLUS metronidazole 500 mg IV every eight hours.
• If necessary, perform laparotomy for peritoneal lavage (wash-out). BREAST ENGORGEMENT Breast engorgement is an exaggeration of the lymphatic and venous engorgement that occurs before lactation. It is not the result of overdistension of the breast with milk. BREAST FEEDING • If the woman is breastfeeding and the baby is not able to suckle, encourage the woman to express milk by hand or with a pump to soften around the areola so the baby can latch on the breast. • If the woman is breastfeeding and the baby is able to suckle:
170 170 159
# Encourage the woman to breastfeed more frequently, using both breasts at each feeding;
# Show the woman how to hold the baby and help it attach;
# Relief measures before feeding may include:
# Apply warm compresses to the breasts just before breastfeeding, or encourage the woman to take a warm shower;
# Massage the woman’s neck and back;
# Have the woman express some milk manually before breastfeeding and wet the nipple area to help the baby latch on properly and easily;
# Relief measures after feeding may include:
# Support breasts with a binder or brassiere;
# Apply cold compress or cabbage leaves to the breasts between feedings to reduce swelling and pain;
# Give paracetamol 1 g by mouth as needed;
# If no response, report back within 24 hours.
NOT BREASTFEEDING
• If the woman is not breastfeeding:
Support breasts with a binder or brassiere; # Apply cold compresses to the breasts to reduce swelling and pain; # Avoid massaging or applying heat to the breasts; # Avoid stimulating the nipples; # Give paracetamol 1 g by mouth as needed; # Give Bromocriptine 2.5 mg oral two times per day (BID) for 5 days. # b If no response, report back within 24 hours. #
BREAST INFECTION
MASTITIS
Treat with antibiotics: •
Cloxacillin 500 mg by mouth four times per day for 10 days; # OR erythromycin 250 mg by mouth three times per day for 10 days. #
Encourage the woman to: •
Continue breastfeeding; # Support breasts with a binder or brassiere; # Apply cold compresses to the breasts between feedings to reduce swelling # and pain.
Give paracetamol 500 mg by mouth as needed. • If no response, report back within 24 hours. •
171 160
BREAST ABSCESS
• Refer to the surgeon for drainage + antibiotics. • Encourage the woman to:
# Continue breastfeeding even when there is collection of pus;
# Support breasts with a binder or brassiere;
# Apply cold compresses to the breasts between feedings to reduce swelling and pain.
• Give paracetamol 1g by mouth as needed.
172 161
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173
!
1. Rapid Initial Assessment
When rapidly assess her condition to determine her degree of illness.
Table 32: Rapid initial assessment & management considerations
Assess Danger Signs Consider
Airway and Look for: • Severe anaemia breathing • Cyanosis; • Heart failure
• Respiratory distress. • Pneumonia
Examine: • Asthma • Skin: pallor; • Pulmonary embolism
• Lungs: wheezing or crepitations.
Circulation Examine: Shock
(Signs of shock) • Skin: cool and clammy; • Pulse: fast (110 or
more) and weak; • Blood pressure: low
(systolic less than 90 mm Hg).
Vaginal bleeding Ask if: • Abortion (early or late • Pregnant, length of • Ectopic pregnancy pregnancy or after gestation • Molar pregnancy childbirth) • Recently given birth See Vaginal bleeding in • Placenta delivered early pregnancy Table 15 Examine: • Abruptio placenta • Vulva: amount of • Ruptured uterus bleeding, placenta • Placenta previa retained, obvious tears See Vaginal bleeding in • Uterus: atony later pregnancy Table 19 • Bladder: full Table 19 Do not do a vaginal • Atonic uterus examination at this • Tears of cervix and stage vagina • Retained placenta • Inverted uterus See Vaginal bleeding after childbirth Table 30 163 Unconscious or: Ask if • eclampsia convulsing • pregnant, length of malaria • gestation 175 epilepsy • Examine: tetanus • • blood pressure: high (diastolic 90mm Hg or See Management of
• Retained placenta • Inverted uterus See Vaginal bleeding after childbirth Table 30
Unconscious or: Ask if • eclampsia convulsing • pregnant, length of gestation • epilepsy
Examine: • tetanus • blood pressure: high (diastolic 90mm Hg or See Managementof of High grade fever Askmore);if: • UrinaryConvulsions tract Boxinfection 3
• Temperature:weak, lethargic 38° C or See page 37 • frequent,more. painful • endometritis High grade fever Askurinationif: • Urinarypelvicabscess tract infection
Examine:• weak, lethargic •See pageperitonitis 37 Box 3 • temperfrequent,ature: 38°Cpainful or • endometritisbreast infection more; urination See• pelvic Fever abscess after child birth •Examine:unconscious; Tableperitonitis • 31 • temperature:neck: stiffness; 38°C or • breast infection • lungs:more; shallow •See Fevercomplications after of child birth • unconscious;breathing, Tableabortion 31 • consolidation;neck: stiffness; See Vaginal bleeding in • abdomen:lungs: shallowsevere •early pregnancycomplications of Table 15 tenderness;breathing, abortion
consolidation; See Vaginal bleeding in • vulva: purulent • Pneumonia • abdomen:discharge; severe early pregnancy Table 15 tenderness; • breasts: tender. • vulva: purulent • Pneumonia discharge; Abdominal pain Ask• if:breasts: tender. • ovarian cyst 164 • Pregnant, length of • appendicitis gestation Abdominal pain Ask if: • ovarianectopic pregnancy cyst Examine:• Pregnant, length of • appendicitispossible term or preterm • gestationblood pressure: low • ectopiclabour pregnancy Examine:(systolic less than 90 • chorioamnionitispossible term preterm • bloodmm Hg)pressure: low • abruptiolabour placenta • (systolicpulse:fast less or(110 than 90 • chorioamnionitis • ruptured uterus more)Hg) • abruptio placenta • temperature:pulse: fast (110 or 38°C or • ruptured uterus more) • temperature:uterus: state 38°C of or pregnancymore • uterus: state of pregnancy
The woman also needs prompt attention if she has any of the following signs:
•The Blood woman-stained also mucusneeds promptdischarge attention or vaginal if she bleeding has any (show) of the withfollowing palpable signs: • Bloodcontractions-stained mucus discharge or vaginal bleeding (show) with palpable • cRupturedontractions membranes • RupturedPallor membranes Weakness • • Pa ll o r 1 7 6 • Weakness• Fainting • FaintingSevereheadaches • BlurredSevere headaches vision • VomitingBlurred vision The woman also needs prompt attention if she has any of the following signs:
• Blood-stained mucus discharge or vaginal bleeding (show) with palpable contractions • Ruptured membranes • Pallor • Weakness • Fainting • Severe headaches • Blurred vision • RespiratoryVomiting distress • AbnormalRespiratory movements distress (fits/ convulsions) • RespiratorymovemeRespiratoryAbnormalFever distress nts(fits/ convulsions) • • Respiratorymovements (fits/ convulsions) IMPLEMENTING• AbnormalRespiratoryAbnormal distress movements distress A RAPID (fits/ INITIAL convulsions) ASSESSMENT SCHEME • IMPLEMENTING• AbnormalAbnormal movements movements A RAPID (fits/ (fi INITIALts/ convulsions) convulsions) ASSESSMENT SCHEME 165 IMPLEMENTING A RAPID INITIAL ASSESSMENT SCHEME IMPLEMENTINGRapid initiation A RAPID ofINITIALAtreatment immediate SCHEMErequiresRapidASSESSMENT initiation RAPID INITIALrecognition SCHEME of immediatethe spec ific problem and quick action. This can be done by: Rapidand quick initiation action. of Thistreatment can be requiresdone requires by: immediate immediate recognition recognition of of the the specific specific problem problem Rapid quickinitiation action. This can be requiresimmediate recognition of the specific problem andTrainingRapidinitiationand quick action. all of of This treatmenttreatment can be requiresdone done by: by: immediate recognition of the specific problem and• Trainingaction.staffThisincludingdoneclerks, - can be by:This can be by:quick all -• guards, door-keepers or switchboard operators - to reactall staff including fashion (“sounddoor-keeperscallswitchboardfor o peratorshelp) when a • TrainingwomanTraining arrives all in staff an at agreed- theincluding facility upon clerks, with fashion an guards, obstetric (“sound door emergencythe-keeperscallswitchboard alarm,” or pregnancy operators • • Training- to react in an - at facility allarrives guards, obstetric oremergency including operatorswoman all staff -agreedtheuponclerks, fashion an ( “ sounddoor operatorsstaff clerks,with-keepersguards, the alarm,” orin an callswitchboardhelp)pregnancyagreed upon the alarm,” for when- to react for when when the facility notified that a woman is being help) when aa - complicationto react in an agreedor oragree emergencydtheupon facility fashion(“sound is with obstetricwomanemergency( “ansound the alarm,”emergency readinesspregnancy referred;for help) when a • Conducting or whenthe facility is drillsanwithobstetric emergency oror pregnancy • complicationclinicalwomanwomancomplicationclinicalConducting arrives arriveswhen at or orthe the stafffacilityemergency facility ensure is with notified beingat notified an that that aa woman woman isensurewiis theirbeingemergency referred;th readiness staff referred; at all • complicationlevels; or whenorthe facility is notified that aa woman is being readiness at all • Conductingcomplicationclinicallevels;Conducting clinicalor when theor emergency facility is notifiedwith drillsdrills withthat staff woman to ensure is being their readinessreferred;referred; at all • • Conductingis not drills to ensure clinicalaccessemergencyblocked and readinessEnsuring that or drills with to ensure readiness isor is(keysstaff not are and available) is inare to ensurelevels;Ensuring their equipmentatatallall that in • levels; levels;working• Ensuringorder order (daily accesschecks) checks) and blocked staff are properlyproperly available)available) andit;equipmentuse it; is in • • Ensuring normsaccessprotocols blockedknowingproperlyavailable) them)equipment isisina • workingworkingHavingEnsuringthat order norms(daily order (daily accessisisnotandchecks) protocols checks) and staff are and blocked(and are staffknowing (keys andHavingare are properly(keys that howtrained and howtraine not to (andd use totothem) use use it;to it; touseto recognizerecognizeand ina • genuinehow•Having genuine to useworkingemergency norms emerg encyand norms(daily protocolsand(andprotocolsand knowing (and checks) arehow properlyimmediately.use knowingproperlyimmediatel tostaff react how trained to use totoHaving it;it;them) to recognize y. them) a to recognize a • • genuinenorms and protocolsknowing knowing how totouse them) totorecognize aa HavinggenuineHaving emergency emergency and and (andhowprotocols knowing to react(and how knowingto react immediately.immediately. 2. genuineCommunicating emergency and knowing how Talkingto react With immediately. 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Ither family alsocan be a time of anxiety Pregnancytrusttypicallyconfidenceofiswoman and effectivelyjoy’s trusttypicallyaatime woman her be time ofbuild ofthewoman joywith ’swith isand concern.a anticipation.providers. anticipation.ItItcan Talking time in andhealth care andalso herfamily alsowoman becan can and timeofbuild canand help concern. anxiety Talking the effectivelyher and concern. Talking effectively withhealth care providers.familyand her can help build the womanand concern.’swhos trust developand and confidence confidence complications in in her her health maywomandifficultyaawoman care and providers. her womWomenan ’ s trust complicationshealthcarewho anddevelopconfidence haveproviders. her may difficultycareWomen talking to the provider and explaining their problem. It is the responsibility of the entire health care team to Women who develop complicationsresponsibilitymay have of difficulty the entire talking health to care the providerteam to and Womenexplaining who their develop problem. complications It is the may an haved put difficulty her at ease. talking Focusing to the provider and Womenspeak whowith thetheir developproblem. woman complications Itrespectfullyresponsibility is the may have difficulty of entire thetalking health to providertheonproviderand and the Womenexplai theningwhodevelopproblem.complications It the and put at ease.talking to team tospeak with their woman responsibilitydifficulty respectfully may haveher of the entire health Focusingtheoncare the team tothe health care provider woman and staff: explainingwiththeirhealthmeans with thatprovider theirproblem.the woman putproblem.respectfully ItItis respectf the responsibility ullyresponsibilityofthespeak and staff: of womancare herthe entireatthe ease. entire is healthcare the Focusing health putmeansspeak onteam oncare the to teamto woman that speak with the womancare provider and staff: herat ease. Focusing on the woman meansspeak with that thethe healthwomanhealth carerespectfully’srespectfully provider and and right put staff: put her at ease. Focusing on the woman mean• that sRespectthethe dignity andthat health woman caredignity ’andands provider to• andrightstaff:privacy; to • Are sensitive and responsive to the woman’s needs; • Respect AreRespectsensitivewoman the woman the and’sresponsive’s dignity dignity and toandthe rightright totowoman privacy; needs;’sprivacy; • • Respectnonabout the the woman’s - theArejudgmentalresponsiveand the woman’s to right to thatAre sensitive dignitydecisionsprivacy;needs; right toabout the that the woman and her family have • Aremade sensitive thus farandand responsivecare. responsive to thewoman ’s needs; woman and her family have • •• madeAreAre sensitive nonsensitivethusnon- judgmental-farjudgmental andregarding regarding responsive about about her her tocare. tothe the decisions decisions the woman woman ’needs;sthat that’s needs; the woman woman and and her her family family have have • • madenonAre thus- judgmentalregardingfar about the her care.decisions that the woman and her family have It is madeunderstandableregardingdisagreecare. thus far to her with a woman’s risky behaviour or a decision which It ismademadeunderstandable thus thus far far regarding regarding to disagree her her care. care. with a woman’s risky behaviour or a decision which has understandabledelaydisagreeseeking woman’s riskyacceptable, however, to which hasIt is resultedunderstandable in aa delay woman to disagreein seeking with care. a woman It is not’s behaviour riskyacceptable, however, or toa decision show a result which Itdisrespect for in awoman delay or in disregardawomanseeking for ’ s risky condition a result thathowever, to of her hasItisisunderstandable resultedunderstandabletoresulted in a correct delay todisagreeive disagree or counsellingin disregard seeking with with a care.for care.awoman medical a Itmedical It is ’iss not notriskybehaviour acceptable, condition acceptable,behaviour thator orisisbeen aadecision decisionhowever, dealtwhich show towhich of her with, behaviour. Provide corrective counselling medicalcomplicationthatbehaviour. Providedelay or disregardcare. isbeenresult medicalcomplicationthathowever, show totoshow in disrespect in seeking after or the condition hasmanagement a dealtof hernot acceptable,has of the resultedfoproblem.r a woman disregard fordisrespect with, aaduringbehaviour.not beforefor disregardthe Providewomanmanagementcounsellingproblem.the duringwoman afterdisrespect corrective or disregard counselling for corrective for amedicalmedical of for aafter condition complication condition that complication that has is aabeenbeen dealt hasis ofresult hernot with, resultdealt ofbefore her with, behaviour.not before Provid Provideor duringduringe corrective management management counselling of of the the problem. problem.after the complication has been dealt with, notRIGHTS before or duringnot OF before WOMEN or during management ofofthe problem. RIGHTS OF WOMEN RIGHTS OF WOMEN RIGHTSRIGHTSProvidersOF should WOMEN should be be aware of the rights of women when receiving maternity care Providersservices: should be aware of the rights of women when receiving maternity care Providersservices: should be aware of the rights of women when receiving maternity care Providers should be aware ofofthe rights ofofwomen when receiving maternity care services: services:• Every woman receiving care has a right to information about her health. • Every woman receiving care has a right to information about her health. • Every woman woman receiving receivinghas care the right hasdiscuss to discuss herinformation her concerns about in environmentan environment in which in which she woman receiving care has a right to 177information about her health. • •• EveryEveryfeelshe feelswoman confident.thes confident.the receiving right aa carerightwoman tocare discuss has has haswoman discussto herright concerns hasto information in an environmentabout her health. in which • • Everyshe feels feelswomanconfident.thewoman confident. has has right totodiscuss her concerns ininan environment ininwhich she feels confident. 166 166
Providers should be aware of the rights of women when receiving maternity care services:
• Every woman receiving care has a right to information about her health. • Every woman has the right to discuss her concerns in an environment in which she feels confident. • A woman should know in advance the type of procedure that is going to be performed. • A woman (or her family, if necessary) should give informed consent before 166 the provider performs any procedure. • Procedures should be conducted in an environment (e.g. labour ward) in which the woman’s right to privacy is respected. • A woman should be made to feel as comfortable as possible when receiving services. • The woman has a right to express her views about the service she receives.
When a provider talks to a woman about her pregnancy or a complication, s/he should use basic communication techniques. These techniques help the provider establish an honest, caring and trusting relationship with the woman. If a woman trusts the provider and feels that s/he has the best interests of the woman at heart, she will be more likely to return to the facility for delivery or come early if there is a complication.
COMMUNICATION TECHNIQUES
Speak in a calm, quiet manner and assure the woman that the conversation is confidential. Be sensitive to any cultural or religious considerations and respect her views. In addition:
• Encourage the woman and her family to speak honestly and completely about events surrounding the complication. • Listen to what the woman and her family have to say and encourage them to express their concerns; try not to interrupt. • Respect the woman’s sense of privacy and modesty by closing the door or drawing curtains around the examination table. • Let the woman know that she is being listened to and understood. • Use supportive nonverbal communication such as nodding and smiling. • Answer the woman’s questions directly in a calm, reassuring manner. • Explain what steps will be taken to manage the situation or complication. • Ask the woman to repeat back to you the key points to assure her understanding.
If a woman must undergo a surgical procedure, explain to her the nature of the procedure and its risks and help to reduce her anxiety. Women who are extremely anxious have a more difficult time during surgery and recovery.
EMOTIONAL AND PSYCHOLOGICAL SUPPORT
Emergency situations are often very disturbing for all concerned and evoke a range of emotions that can have significant consequences.
EMOTIONAL AND PSYCHOLOGICAL REACTIONS
How each member of the family reacts to an emergency situation depends on the:
• Marital status of the woman and her relationship with her partner; 178 167
• Social situation of the woman/couple and their cultural and religious practices, beliefs and expectations; • Personalities of the people involved and the quality and nature of social, practical and emotional support; • Nature, gravity and prognosis of the problem and the availability and quality of the health care services.
Common reactions to obstetric emergencies or death include:
• Denial (feelings of “it can’t be true”); • Guilt regarding possible responsibility; • Anger (frequently directed towards health care staff but often masking anger that parents direct at themselves for “failure”); • Bargaining (particularly if the patient hovers for a while between life and death); • Depression and loss of self-esteem, which may be long-lasting; • Isolation (feelings of being different or separate from others), which may be reinforced by care givers who may avoid people who experience loss; • Disorientation.
GENERAL PRINCIPLES OF COMMUNICATION AND SUPPORT
While each emergency situation is unique, the following general principles offer guidance. Communication and genuine empathy are probably the most important keys to effective care in such situations.
EMOTIONAL AND PSYCHOLOGICAL SUPPORT
AT THE TIME OF THE EVENT
• Greet the women and introduce yourself. • Listen need to discuss their hurt and sorrow. • Do not change the subject and move on to easier or less painful topics of conversation. Show empathy. • Tell the woman/family as much as you can about what is happening. Understanding the situation and its management can reduce their anxiety and prepare them for what happens next. • Be honest. Do not hesitate to admit what you do not know. Maintaining trust matters more than appearing knowledgeable. • If language is a barrier to communication, find a translator. • Do not pass the problem on to nursing staff or junior doctors. • Ensure that the woman has a companion of her choice and, where possible, the same care giver throughout labour and delivery. Supportive companionship can enable a woman to face fear and pain, while reducing loneliness and distress. • Where possible, encourage companions to take an active role in care. Position the companion at the top of the bed to allow the companion to focus on caring for the woman’s emotional needs. • Both during and after the event, provide as much privacy as possible for the woman and her family.
179 168
AFTER THE EVENT
• Give practical assistance, information and emotional support. • Respect traditional beliefs and customs and accommodate the family’s needs as far as possible. • Provide counselling for the woman/family and allow for reflection on the event. • Explain the problem to help reduce anxiety and guilt. Many women/families blame themselves for what has happened. • Listen and express understanding and acceptance of the woman’s feelings. Nonverbal communication may speak louder than words: a squeeze of the hand or a look of concern can say an enormous amount. • Repeat information several times and give written information, if possible. People experiencing an emergency will not remember much of what is said to them. • Health care providers may feel anger, guilt, sorrow, pain and frustration in the face of obstetric emergencies that may lead them to avoid the woman/family. Showing emotion is not a weakness. • Remember to care for staff who themselves may experience guilt, grief, confusion and other emotions.
SPECIAL SITUATTIONS:
MATERNAL MORTALITY
Death of a woman in childbirth or from pregnancy-related events is a devastating experience for the family and for surviving children. In addition to the principles listed above, remember the following:
AT THE TIME OF THE EVENT
• If death is inevitable, provide emotional and spiritual comfort rather than focusing on the emergency medical care. • Provide dignity and respectful treatment at all times, even if the woman is unconscious or has already died. • Complete ministry formalities (Maternal Death Notification Form).
AFTER THE EVENT
• Allow the woman’s partner or family to be with her. • Facilitate the family’s arrangements for the funeral, if possible, and see that they have all the necessary documents. • Explain what happened and answer any questions. Offer the opportunity for the family to return to ask additional questions.
SEVERE MATERNAL MORBIDITY
Childbirth sometimes leaves a woman with severe physical or psychological damage.
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AT THE TIME OF THE EVENT
• Include the woman and her family in the proceedings of the delivery if possible, particularly if this is culturally appropriate. • Ensure that a staff member cares for the emotional and informational needs of the woman and her partner, if possible.
AFTER THE EVENT
• Clearly explain the condition and its treatment so that it is understood by the woman and her companions. • Arrange for treatment and/or referral, when indicated. • Schedule a follow-up visit to check on progress and any further discussion or quiries.
NEONATAL MORTALITY OR MORBIDITY
While general principles of emotional support for women experiencing obstetrical emergencies apply, when a baby dies or is born with an abnormality some specific factors should be considered.
INTRAUTERINE FETAL DEATH OR STILLBIRTH
Many factors will influence the woman’s reaction to the death of her baby. These include those mentioned above as well as:
• The woman’s previous obstetric and social history; • The extent to which the baby was “wanted”; • The events surrounding the birth and the cause of the loss; • Previous experiences with death.
AT THE TIME OF THE EVENT (during labpur): labour
Make the women comfortable by providing adequate analgesia. • • Prepare the parents for the possibly disturbing or unexpected appearance of the baby (red, wrinkled, peeling skin). If necessary, wrap the baby so that it looks as normal as possible at first glance. Encourage the woman/couple to see and hold the baby to facilitate grieving. • • Avoid separating the woman and baby too soon (before she indicates she is ready), as this can interfere with and delay the grieving process. Arrange for paediatric review. •
AFTER THE EVENT
Allow the woman/family to continue to spend time with the baby. Parents of a • stillborn still need to get to know their baby. People grieve in different ways, but for many remembrance is important. Offer the • woman/family small mementos such as a lock of hair, a cot label or a name tag.
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• Where it is the custom to name babies at birth, encourage the woman/family to call the baby by the name they have chosen. • Allow the woman/family to prepare the baby for the funeral if they wish. • Encourage locally-accepted burial practices and ensure that medical procedures (such as autopsies) do not preclude them. • Arrange a discussion with both the woman and her partner to discuss the event and possible preventive measures for the future. • Women should not be kept in the obstetric ward, keep her in the gynaecology ward. • Provide bromorcriptine (to suppress breast milk) 2.5 mg bd for 5 days.
DESTRUCTIVE OPERATIONS
Cephalocentesis or other destructive operations on the dead fetus may be distressing and call for additional psychosocial care.
AT THE TIME OF THE EVENT
• It is crucial that you explain to the mother and her family that the baby is dead and that the priority is to save the mother. • Encourage the partner to provide support and comfort for the mother until she is anaesthetized or sedated. • If the mother is awake or partially awake during the procedure, protect her from visual exposure to the procedure and to the baby. • After the intervention, make arrangements so the baby can be seen and/or held by the woman/family if they wish, especially if the family is going to take care of the burial.
AFTER THE EVENT
• Allow unlimited visiting time for the woman’s companion. • Counsel the mother and her companion and reassure them that an alternative was not available. • Family planning should be provided, if appropriate.
BIRTH OF A BABY WITH AN ABNORMALITY
The birth of a baby with a malformation is a devastating experience for the parents and family. Reactions may vary.
• Allow the woman to see and hold the baby, when it is possible. Some women accept their baby immediately while others may take longer. Disbelief, denial and sadness are normal reactions, especially if the abnormality is • unpredicted. Feelings of unfairness, despair, depression, anxiety, anger, failure and apprehension are common. Remember to fill the Congenital Anomalies & Genetic Disorders Notification Form. •
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AT THE TIME OF THE EVENT
• Give the baby to the parents at delivery. Allowing the parents to see the problem immediately may be less traumatic. • In cases of severe deformity, wrap the baby before giving to the mother to hold so that she can see the normality of the baby first. Do not force the mother to examine the abnormality.
AFTER THE EVENT
• Discuss the baby and the problem with the woman and her family together, if possible. • Allow the woman and her partner free access to their baby. Keep the baby with the mother at all times. The more the woman and her partner can do for the baby themselves, the more quickly they will accept the baby as their own. • Ensure access to supportive professional individuals and groups.
PSYCHOLOGICAL MORBIDITY
Postpartum emotional distress is fairly common after pregnancy and ranges from mild postpartum blues (affecting about 80% of women), to postpartum depression or psychosis. Postpartum psychosis can pose a threat to the life of the mother or baby.
POSTPARTUM DEPRESSION
Postpartum depression affects up to 34% of women and typically occurs in the early postpartum weeks or months and may persist for a year or more. Depression is not necessarily one of the leading symptoms although it is usually evident. Other symptoms include exhaustion, irritability, weepiness, low energy and motivational levels, feelings of helplessness and hopelessness, loss of libido and appetite and sleep disturbances. Headache, asthma, backache, vaginal discharge and abdominal pain may be reported. Symptoms may include obsessional thinking, fear of harming the baby or self, suicidal thoughts and depersonalization.
The prognosis for postpartum depression is good with early diagnosis and treatment. More than two-thirds of women recover within a year. Providing a companion during labour may prevent postpartum depression.
Once established, postpartum depression requires psychological counselling and practical assistance. In general:
Provide psychological support and practical help (with the baby and with home • care). Listen to the woman and provide encouragement and support. • Assure the woman that the experience is fairly common and that many other • women experience the same thing. Assist the mother to rethink the image of motherhood and assist the couple to • think through their respective roles as new parents. They may need to adjust their expectations and activities. If depression is severe, consider referral to the psychiatrist. •
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POSTPARTUM PSYCHOSIS
Postpartum psychosis typically occurs around the time of delivery and affects less than 1% of women. The cause is unknown, although about half of the experiencing psychosis also have a history of mental illness. Postpartum psychosis is characterized by abrupt onset of delusions or hallucinations, insomnia, a preoccupation with the baby, severe depression, anxiety, despair and suicidal or infanticidal impulses.
Care of the baby can sometimes continue as usual. Prognosis for recovery is excellent but about 50% of women will suffer a relapse with subsequent deliveries. In general:
• Provide psychological support and practical help (with the baby as well as with home care). • Listen to the woman and provide support and encouragement. This is important for avoiding tragic outcomes. • Lessen stress. • Avoid dealing with emotional issues when the mother is unstable.
3. Emergencies
Emergencies can happen suddenly, as with a convulsion, or they can develop as a result of a complication that is not properly managed or monitored.
PREVENTING EMERGENCIES
Most emergencies can be prevented by:
• Careful planning; • Following clinical guidelines; • Close monitoring of the woman.
RESPONDING TO AN EMERGENCY
Responding to an emergency promptly and effectively requires that members of the clinical team know their roles and how the team should function to respond most effectively to emergencies. Team members should also know:
Clinical situations and their diagnoses and treatments; • Drugs and their use, administration and side effects; • Emergency equipment and how it functions. •
The ability of a facility to deal with emergencies should be assessed and reinforced by frequent practice emergency drills.
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INITIAL MANAGEMENT
In managing an emergency:
• Stay calm. Think logically and focus on the needs of the woman. • Do not leave the woman unattended. • Take charge. Avoid confusion by having one person in charge. • Call for help. Have one person go for help and have another person gather emergency equipment and supplies (e.g. oxygen cylinder, emergency kit). • If the woman is unconscious, assess the airway, breathing and circulation. • If shock is suspected, immediately begin treatment. Even if signs of shock are not present, keep shock in mind as you evaluate the woman further because her status may worsen rapidly. If shock develops, it is important to begin treatment immediately. • Position the woman lying down on her left side with her feet elevated. Loosen tight clothing. • Talk to the woman and help her to stay calm. Ask what happened and what symptoms she is experiencing. • Perform a quick examination including vital signs (blood pressure, pulse, respiration, temperature) and skin colour. Estimate the amount of blood lost and assess symptoms and signs.
4. Shock
Shock is characterized by failure of the circulatory system to maintain adequate perfusion of the vital organs. Shock is a life-threatening condition that requires immediate and intensive treatment.
Suspect or anticipate shock if at least one of the following is present:
• Bleeding in early pregnancy (e.g. abortion, ectopic or molar pregnancy); • Bleeding in late pregnancy or labour (e.g. placenta praevia, abruptio placenta, ruptured uterus); • Bleeding after childbirth (e.g. ruptured uterus, uterine atony, tears of genital tract, retained placenta or membranes ); • Infection (e.g. unsafe or septic abortion, chorioamnionitis, endometritis, acute pyelonephritis); • Trauma (e.g. injury to uterus or bowel during abortion, ruptured uterus, tears of genital tract).
SYMPTOMS AND SIGNS
Diagnose shock if the following symptoms and signs are present:
• Fast, weak pulse (110 per minute or more); • Low blood pressure (systolic less than 90 mm Hg).
Other symptoms and signs of shock include:
Pallor (especially of inner eyelid, palms or around mouth); •
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• Sweatiness or cold clammy skin; • SweatinessRapid breathingcold or (rateclammybreaths of 30 skin; per minute or more); • Anxiousness,Rapid breathing confusion (rate or30unconsciousness; breaths per minute or more); • Anxiousness,Scanty urine confusionoutput (less or thanunconsciousness; 30 mL per hour). • Scanty urine output (less than 30 mL per hour). MANAGEMENT MANAGEMENT IMMEDIATE MANAGEMENT IMMEDIATE MANAGEMENT • Call for help. Urgently mobilize all available personnel. • Call for help. Urgently mobilize all available personnel. • Monitor vital signs (pulse, blood pressure, respiration, temperature). • MonitorwomansiIf the vital (pulse,gns unconscious, blood turn her pressure, her side respiration, to minimize temperature). the risk of • aspirationwomanIf the if she vomits unconscious,ensure and to turn her an that her ontoairway side to open. minimize the risk of • aspirationKeep the if she womanvomitswarm and to do not butensure an airway that her, overheat is open.as this will increase • peripheralKeep the circula womantion and warmreduce but not blood her,supplyoverheat vital organs.this will increase • peripheralKeep the circulationhead low. and reduce blood supply to the vital organs. • Keep the head low. SPECIFIC MANAGEMENT SPECIFIC MANAGEMENT • Start an IV infusion (two if possible) using a large-bore (16-gauge or largest • available)Start an cannulaIV infusion or (twoneedle.possible)blood if Collect using a estimationfor large-bore of(16 -haemoglobinlargestgauge or and available)cross-matchcannulabefore just needle. of infusionCollectfluids:blood for estimation of haemoglobin and cross-match just before infusion of fluids: - Rapidly infuse IV fluids (normal saline or Ringer’s lactate) initially at the rate of - Rapidly1 L in infuseminutes;15-20 IV fluids (normal saline or Ringer’s lactate) initially at the rate of 1 L in 15-20 minutes; Note: Avoid using plasma substitutes (e.g. dextran). There is no evidence that Note:plasma Avoid substitutesplasma using are superior substitutes to (e.g. normaldextran). saline in the Thereevidence resuscitation of that plasmashockedsubstitutesand woman, dextran superior can to normalbe harmful large saline the indoses.resuscitation of a shocked woman, and dextran can be harmful in large doses. - Give at least 2 L of these fluids in the first hour; then give fluid replacement for - ongoingGive at losses.Lleast 2 of these fluids in the first hour; then give fluid replacement for ongoing losses. Note: A more rapid rate of infusion is required in the management of shock Note:resulting A frommore rapid bleeding. rate of Aimi to replacenfusion twois requiredthreethe to in times the estimated management fluid of shock loss.resulting from bleeding. Aim to replace two to three times the estimated fluid loss.
Do not give fluids by mouth to a woman in shock Do not give fluids by mouth to a woman in shock
• Continue to monitor vital signs (every 15 minutes) and blood loss. • ContinueCatheterize to themonitorbladder vital and (every signsmonitor 15 intake fluidminutes)and urine loss. bloodoutput. • GiveCatheterize oxygen the at 6bladder-8 L perand minutemonitormask by fluid or nasaland intake urinecannulae.output. • Give oxygen at 6-8 L per minute by mask or nasal cannulae.
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5. Infection Prevention
• Infection prevention has two primary objectives:
- Prevent major infections when providing services; - Minimize the risk of transmitting serious diseases such as hepatitis B and HIV/AIDS to the woman and to service providers and staff, including cleaning and housekeeping personnel.
• The recommended infection prevention practices are based on the following principles:
- Every person (patient or staff) must be considered potentially infectious; - Handwashing is the most practical procedure for preventing cross- contamination; - Wear gloves before touching anything wet, broken skin, mucous membranes, blood or other body fluids (secretions or excretions); - Use barriers (protective goggles, face masks or aprons) if splashes and spills of any body fluids (secretions or excretions) are anticipated; - Use safe work practices, such as not recapping or bending needles, proper instrument processing and proper disposal of medical waste.
HAND WASHING
• Vigorously rub together all surfaces of the hands lathered with plain or anti microbial soap. Wash for 15-30 seconds and rinse with a stream of running water. Or rub your hands with an antiseptic solution. • Wash hands:
- Before and after examining each patient (or having any direct contact); - After exposure to blood or any body fluids (secretions or excretions),even if gloves were worn; - After removing gloves because the gloves may have holes in them.
GLOVES AND GOWNS
Wear gloves: •
- When performing a procedure - When handling soiled instruments, gloves and other items; - When disposing of contaminated waste items (cotton, gauze or dressings).
A separate pair of gloves must be used for each woman to avoid cross • contamination.
A clean, but not necessarily sterile, gown should be worn during all delivery • procedures: - If the gown has long sleeves, the gloves should be put over the gown sleeves to avoid contamination of the gloves; -
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- Ensure that gloved hands are held above the level of the waist and do not come into contact with the gown.
BASIC PRINCIPLES FOR PROCEDURES:
Before any simple (nonoperative) procedure, it is necessary to:
• Gather and prepare all supplies. Missing supplies can disrupt a procedure. • Explain the procedure and the need for it to the woman and obtain consent. • Provide adequate pain medication according to the extent of the procedure planned. Estimate the length of time for the procedure and provide pain medication accordingly. • Place the patient in a position appropriate for the procedure being performed. The most common position used for obstetric procedures (e.g. manual vacuum aspiration) is the lithotomy position. • Wash hands with soap and water and put on gloves appropriate for the procedure. • If the vagina and cervix need to be prepared with an antiseptic for the procedure (e.g. manual vacuum aspiration):
# Apply antiseptic solution (e.g. iodophors, chlorhexidine) three times to the vagina and cervix using a high-level disinfected or sterile ring forceps and a cotton or gauze swab.
# Gently insert a sterile speculum or retractor(s) into the vagina;
• If the skin needs to be prepared with an antiseptic for the procedure:
# Apply antiseptic solution (e.g. iodophors, chlorhexidine) three times to the area using a high-level disinfected or sterile ring forceps and a cotton or gauze swab. If the swab is held with a gloved hand, do not contaminate the glove by touching unprepared skin; Begin at the centre of the area and work outward in a circular motion away # from the area; At the edge of the sterile field discard the swab. #
• Never go back to the middle of the prepared area with the same swab. Keep your arms and elbows high and surgical dress away from the surgical field.
6. Replacement Fluids: Simple Substitutes for Transfusion
Only normal saline (sodium chloride 0.9%) or balanced salt solutions that have a similar sodium replacement fluids. These should be available in all hospitals where IV replacement fluids are used.
Replacement fluids are used to replace abnormal losses of blood, plasma or other extracellular fluids by increasing the volume of the vascular compartment. They are used principally in:
Management of women with established hypovolaemia (e.g. haemorrhagic shock); •
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• Maintenance of normovolaemia in women with on-going fluid losses (e.g. surgical blood loss). • Maintenance of normovolaemia in women with on-going fluid losses (e.g. surgical INTRAVENOUSblood loss). REPLACEMENT THERAPY
IntravenousINTRAVENOUS replacement REPLACEMENT fluids are THERAPYfirst-line treatment for hypovolaemia. Initial treatment with these fluids may be life-saving and can provide some time to control bleedingIntravenous and replacement obtain blood forfluidstransfusionfirst are -becomesline treatmentnecessary.hypovolaemia. for Initial treatment with these fluids may be life-saving and can provide some time to control bleeding and obtain blood for transfusion if it becomes necessary. CRYSTALLOID FLUIDS
•CRYSTALLOID Crystalloid FLUIDSreplacement fluids:
• CrystalloidContainreplacementsimilar fluids:# concentration of sodium to plasma;
# Cannot enter cells because the cell membrane is impermeable to sodium; # # PassContainfromsimilar a the vascular concentration compartment of to sodiumthe to plasma; extracellular space (normally # onlyCannotquartercells enter of the volume because of cellcrthe ystalloid membraneinfusedimpermeable remains in to sodium; the vascular # compartment)Pass from the vascular compartment.compartment to the extracellular space (normally only a quarter of the volume of crystalloid infused remains in the vascular • To restore compartment) circulating compartment.blood volume (intravascular volume), infuse crystalloids in a volume at least three times the volume lost. • To restore circulating blood volume (intravascular volume), infuse crystalloids in a COLLOIDvolume FLUIDSat least three times the volume lost.
•COLLOID ColloidFLUIDS solutions are composed of a suspension of particles that are larger than crystalloids. Colloids tend to remain in the blood where they mimic plasma • proteinssolutionsColloid maintain areorcomposedcolloidsuspensionp raise the of a osmotic of of thatressureparticlesblood. are larger than • crystalloids.Colloids are Colloidsgiven usually tend toin aremain volumeinequal the to the blood blood where they volumemimic lost. many Inplasma protconditionseins where maintain the raiseorcapillarythepermeabilityosmoticincreased colloid pressure of (e.g.blood.trauma, sepsis), • Colloidsleakage are out usuallycirculation of the given a occur willvolu andme equaladditional the blood will infusionsvolume be In many lost.necessary conditions where capillary permeability is increased (e.g. maintain blood thevolume. trauma, sepsis), leakage out of the circulation will occur and additional infusions will be necessary to maintain blood volume. SAFETY
BeforeSAFETY giving any IV infusion:
•BeforeCheck giving the thatany seal the IV infusion: infusion bottle or bag is not broken; • Check the expiry date; • Check that the solutiontheseal of is clearinfusion and bottlefrombagvisible free not broken; particles. • Check the expiry date; • Check that the solution is clear and free from visible particles.
MAINTENANCE FLUID THERAPY
MAINTENANCE FLUID THERAPYsolutions, such as dextrose or dextrose in normal Maintenance fluids are crystalloid saline, used to replace normal physiological losses through skin, lungs, faeces and urine.Maintenance If is fluids anticipatedcrystalloid are that the woman solutions, will such receive as IV fluids dextrose 48 hoursinfor dextrose more, ornormal infusesaline, ausedbalanced to replace electrolyte normalsolution physiologicalpota (e.g. lossesssium through chlorideskin, 1.5 in lungs, 1 L IV faecesfluids) and urine.dextrose.anticipatedvolumewith If it is The that of woman will themaintenance fluids IV fluids receiverequired 48 hours or vary, byfora woman will more, infuseparticularlybalanced if the woman electrolyte has fever orsolution with high (e.g. ambient potassium chloride temperature 1.5 g in 1or L humidity,fluids)IV when178 losses will increase. 178 7. Anesthesia and Analgesia 189 PREMEDICATION
Premedication is required for procedures that last longer than 30 minutes. The dose with dextrose. The volume of maintenance fluids required by a woman will vary, particularly if the woman has fever or with high ambient temperature or humidity, when losses will increase.
7. Anesthesia and Analgesia
PREMEDICATION
Premedication is required for procedures that last longer than 30 minutes. The dose must be adjusted to the weight and condition of the woman and to the condition of the fetus (when present).
• Give pethidine 1 mg/kg body weight (but not more than 100 mg) IM or IV slowly or give morphine 0.1 mg/kg body weight IM.
LOCAL ANAESTHESIA
Local anaesthesia (lignocaine with or without adrenaline) is used to infiltrate tissue and block the sensory nerves.
• Because a woman with local anaesthesia remains awake and alert during the procedure, it is especially important to ensure:
Counselling to increase cooperation and minimize her fears; # Good communication throughout the procedure as well as physical # reassurance from the provider, if necessary; Time and patience, as local anaesthetics do not take effect immediately. #
• Emergency drugs and equipment (suction, oxygen, resuscitation equipment) should be readily available and in usable condition, and all members of the operating team trained in their use.
LIGNOCAINE
Lignocaine preparations are usually 2% or 1% and require dilution before use, see Box 4. For most obstetric procedures, the preparation is diluted to 0.5%, which gives the maximum5 effect with the least toxicity.
Box 4: Preparation of lignocaine 0.5% solution 5
Combine: • lignocaine 2%, one part; • normal saline or sterile distilled water, three parts (do not use glucose solution as it increases the risk of infection). Or • lignocaine 1%, one part; • normal saline or sterile distilled water, one part.
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GENERAL PRINCIPLES FOR ANAESTHESIA AND ANALGESIA
• The keys to pain management and comfort of the woman are:
# Supportive attention from staff before, during and after a procedure (helps reduce anxiety and lessen pain);
# A provider who is comfortable working with women who are awake and who is trained to use instruments gently;
# The selection of an appropriate type and level of pain medication.
• Tips for performing procedures on women who are awake include:
# Explain each step of the procedure before performing it;
# Use adequate premedication in cases expected to last longer than 30 minutes;
# Give analgesics or sedatives at an appropriate time before the procedure (30 minutes before for IM and 60 minutes before for oral medication) so that maximum relief will be provided during the procedure;
# Use dilute solutions in adequate amounts;
# Check the level of anaesthesia by pinching the area with forceps. If the woman feels the pinch, wait two minutes and then retest;
# Wait a few seconds after performing each step or task for the woman to prepare for the next one;
# Move slowly, without jerky or quick motions;
# Handle tissue gently and avoid undue retraction, pulling or pressure;
# Use instruments with confidence;
# Avoid saying things like “this won’t hurt” when, in fact, it will hurt; or “I’m almost finished” when you are not;
# Talk with the woman throughout the procedure.
• The need for supplemental analgesic or sedative medications (by mouth, IM or IV) will depend on:
# The emotional state of the woman; The procedure to be performed; # The anticipated length of the procedure; # The skill of the provider and the assistance of the staff. #
POSTOPERATIVE ANALGESIA
Adequate postoperative pain control is important. A woman who is in severe pain does not recover well.
Note: Avoid over sedation as this will limit mobility, which is important during the postoperative period. Good postoperative pain control regimens include:
Non-narcotic mild analgesics such as paracetamol 500 mg by mouth as needed; • Narcotics such as pethidine 1 mg/kg body weight (but not more than 100 mg) IM • or IV slowly or morphine 0.1 mg/kg body weight IM every four hours as needed; Combinations of lower doses of narcotics with paracetamol. •
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Note: If the woman is vomiting, narcotics may be combined with anti-emetics such as promethazine 25 mg IM or IV every four hours as needed.
See the following table for the analgesia and anesthesia options
Table 33: Analgesia & anesthesia options
Procedure Analgesia/Anaesthesia Options Breech delivery General methods of labour support Pudendal block
Caesarean section General anaesthesia Cervical tears (extensive) Pethidine Colpotomy/ Culdocentesis Local anaesthesia Craniotomy/ Craniocentesis Emotional support and encouragement
Diazepam Pudendal block
Dilation and curettage Paracervical block Pethidine
Episiotomy Local anaesthesia
Pudendal block
Forceps delivery Emotional support and encouragement
Pudendal block
Labour and childbirth General methods of labour support
Pethidine and promethazine
Laprotomy General anaesthesia Manual removal of placenta Pethidine Manual vacuum asoiration p Paracervical block Pethidine Perineal tears (first and second degree) Local anaesthesia Pudendal block Perineal tears (third and fourth degree) Pudendal block Local anaesthesia and pethidine
Symphysiotomy Local anaesthesia Uterine inversion (correction of) Pethidine General anaesthesia
Vacuum extraction Emotional support and encouragement Pudendal block
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1. External Cephalic Version (ECV) is the manipulation of the fetus, through the maternal abdomen, to a cephalic presentation.
• Can be performed at 36- 38 weeks in nulliparous women and at 37 – 38 weeks in multiparous women. Can be repeated after 1 week if the initial trial failed and there were no complications. • It should only be conducted where facilities for monitoring and immediate delivery such as caesarian section are available. • Women should be explained in details about the success and failure rates of ECV and about the potential complications such as preterm labour & preterm prelabour rupture of membranes ( if less then 37 completed weeks ) , abruptio placenta.
Maternal and fetal complications (very rare):
• Placental abruption. • Fetomaternal haemarrhage. • Transient fetal bradycardia. • Transient non-reactive cardiotocograph.
Absolute contraindications for ECV:
• Antipartum haemorrhage within the last 7 days. • Abnormal CTG. Major uterine anomaly. • • Rupture of membranes. • Multiple pregnancy.
Relative contraindications for ECV:
IUGR with abnormal Doppler. • Proteinuric pre-eclampsia. • Oligohydromnios. • Major fetal anomalies. • Previous caesarian section. • Unstable lie. •
Prior to the procedure:
Verbal consent should be obtained from the women. • Ultrasound: for fetal attitude and liquor. • Tocolysis may be helpful to increase success rate (salbutamol 2 puffs initially and • than 10-15 minutes after the start of the procedure). e
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The procedure:
• Have the woman lie on her back, and elevate the foot of the bed. • Listen to and note the fetal heart rate. If there are fetal heart rate abnormalities (less than 110 or more than 160 beats per minute):
- Do not proceed with external version;
- Manage as for fetal distress.
• Palpate the abdomen to confirm the presentation and position of the fetal head, back and hips. • To mobilize the breech, gently lift the lowest part of the fetus from pelvic inlet by grasping above the pubic bone (Figure 30, A). • Bring the head and buttocks of the fetus closer to each other to achieve forward rotation. Rotate the fetus slowly by guiding the head in a forward roll as the buttocks are lifted (Figure 30, B). • Listen to the fetal heart rate after every attempt of external version. If an abnormal fetal heart rate is detected:
- Have the woman turn on to her left side;
- Give oxygen at 4-6 L per minute by mask or nasal cannulae;
- Reassess every 15 minutes;
• If the procedure is unsuccessful, try again using a backward roll (Figure 30,D).
During the procedure:
Continuous pressure on the uterus should be limited to 5 minutes. • Abandon the procedure if mother complains of discomfort. • Confirm the success of the procedure by ultrasound. • Auscultate fetal heart sounds. •
After the procedure:
Perform cardiotocography for 30 minutes. Observe the women during this time. • Give Anti D 500 iu to Rh negative women. • Assess the patient after one week for conformation of the lie. • Discuss further attempts if ECV failed. •
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P-16 External version
FIGUREFigureof a a breech30: Externalpresentation.P version-5 ofbreech presentation
2. Induction and Augmentation of Labour
INDUCTION OF LABOUR
• Perform baseline CTG. • Do vaginal examination to assess the Bishop score and decide on method of induction.
Table 34: Calders modification of Bishop’s score:
0 1 2 3 Dilatation of internal os (cm) <1 1-2 2-4 >4 Length of cervix (cm) >4 2-4 1-2 <1
Consistency of cervix Firm Average Soft -
Position of cervix Posterior Mid.Anterior - -
Station of Head (cm) -3 -2 -1/0 +1/+2
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• Calculate the total dose from the summation of each parameter and classify as: - Unripe (unfavorable): 0-3 - Intermediate: 4-7 - Ripe (favorable): 8 -11
Induction in women with a favourable cervical score (bishop score > 6):
• Labour can be induced by two methods.
1. Intravaginal application of gel with 1-2 mg PGE2 ( preferable). 2. ARM followed by I.V Syntocinonoxytocin ( it may take longer to induce labour & therefore to be used only in special cases )
• Amniotomy should not be performed in the following conditions: - Presenting part is too high due to the risk of cord prolapse. - Breech with flexed legs.
1. PGE2 Gel doses
Doses Nullipara Multipara Grand Multipara
1st dose 2 mg 1 mg 1 mg
2nd dose 1 mg 1 mg 1 mg
3rd dose 1 mg 1 mg
Total dose 4 mg 3 mg 2 mg
Note: PGE2 induction in women with previous caesarean section should be with 1 mg and total dose 2 mg. 3rd dose insertion should be consulted with senior obstetrician.
In grand multipara , induction of labour with prostin should be after discussion with senior obstetrician.
• Induction should be carried out with caution in patients with:
Previous LSCS. - History of asthma (PGE2). - Grandmultipara. - Hypersensitive to PGE2. - Vaginal infections. -
2. Induction with ARM and oxytocin
Amniotomy should not be carried out until the cervix is ripe (Bishop score > 6). • Oxytocin is of little clinical value prior to Amniotomy. • Oxytocin should not be given until at least 6 hours after the last PG application (to • avoid hyper stimulation).
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Table 35: Oxytocin infusion in primigravida
Time after starting Oxytocin dose Volume infused ML\hr
(minutes) (Milliunits\min)
0 1 3 30 2 6 60 4 12 90 8 24 120 12 36 150 16 48 180 20 60 210 24 72 240 28 84 270 32 96
Note: Preparation to be made in dilution of 10 units in 500 ml of Hartman’s
Table 36: Oxytocin infusion in multigravida (< 7) and previous LSCS
Time after starting Oxytocin dose Volume infused ML\hr
(minutes) (Milliunits\min)
0 1 3 30 2 6 60 4 12 90 8 24 120 12 36 150 16 48 180 20 60
Note: preparation to be made in dilution of 5 units in 500 ml of Hartman’s
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Table 37: Oxytocin infusion in grandmultipara
Time after starting Oxytocin dose Volume infused ML\hr
(minutes) (Milliunits\min)
0 1 3 30 2 6 60 4 12 90 8 24 120 12 36
Note: preparation to be made in dilution of 5 units in 500 ml of Hartman’s
Uterine Hyper stimulation: 5 or more uterine contractions per minute.
Management:
• Continue CTG, insert IV line, give nasal oxygen. • Inform senior obstetrician. • Perform manual removal of PGE2 and normal saline wash of vagina. • If on Oxytocin infusion, stop immediately. • If accompanied by abnormal fetal heart rate, consider tocolysis. Suggested regimen is subcutaneous Terbutaline 0.25mg. • If fetal compromise is suspected, delivery should be accomplished as soon as possible with possible caesarian section.
AUGMENTATION OF LABOUR
• Should be considered in patients in established labour who are not progressing.
Primary dysfunctional labour: occurs following a normal latent phase when cervix dilates less than 1 cm/hour without a normal active phase being established. This is the commonest type of abnormal labour and is usually corrected by augmentation with IV oxytocin (Titration method) as described in induction of labour.
Secondary arrest:
Secondary arrest in active phase of labour is a dangerous problem particularly in • multipara. • There should be high suspicion of cephalo-pelvic disproportion and to overcome this disproportion by augmentation with oxytocin is likely to cause uterine rupture. Therefore oxytocin in a multipara with secondary arrest of labour is contra- indicated. • In primigravida a relative degree of CPD can be overcome by augmentation. • Failure of cervix to dilate over a 4-hour period is usually regarded as evidence of delay, which may need to be treated with oxytocin.
200 189
Augmentation in a normal uterine activity with slow progress:
• Check for: the presentation, position, lie and size of fetus. • Re-assess pelvis. • Beware of disproportion.
3. Artificial Rupture of Membranes
• Listen to and note the fetal heart rate. • Ask the woman to lie on her back with her legs bent, feet together and knees apart. • Gently clean the external genitalia with savlon. • Wearing sterile gloves, use one hand to examine the cervix and note the consistency, position, effacement and dilatation. • Use the other hand to insert an amniotic hook into the vagina. • Guide the hook towards the membranes along the fingers in the vagina. • Place two fingers against the membranes and gently rupture the membranes with the instrument in the other hand. Allow the amniotic fluid to drain slowly between the fingers. • Note the colour of the fluid (clear, greenish, bloody). If thick meconium is present, suspect fetal distress. • After ARM, listen to the fetal heart rate during and after a contraction. If the fetal heart rate is abnormal (less than 110 or more than 160 beats per minute), suspect fetal distress. • If membranes have been ruptured for 18 hours, and the delivery has not been anticipated, give prophylactic antibiotics to help reduce Group B streptococcus infection in the neonate:
- Penicillin 3 g IV with the onset of labour, then 1.5 g four hourly. - If allergic to penicillin, give; clindamycin 900 mg IV 8 hourly. - Discontinue after delivery if there are no signs of infection.
• If good labour is not established one hour after ARM, begin oxytocin infusion. • If labour is induced because of severe maternal disease (e.g. sepsis eclampsia), begin oxytocin infusion at the same time as ARM.
4. Vacuum Extraction
Indications:
• Delay in second stage of labour. • Fetal distress in second stage. • Maternal conditions requiring a short second stage. • Maternal exhaustion.
Contraindications
• Un-experienced operator Unable to achieve proper application • Face presentation •
201 190
• Gestation age < 34 weeks • Bleeding diathesis
Review for conditions:
• vertex presentation • term fetus • cervix fully dilated • fetal head is below 0 station or no more than 1/5 palpable above symphysis pubis • Empty bladder • Ruptured membranes
The Procedure:
• Check all connections and test the vacuum on a gloved hand; • Provide emotional support and encouragement. If necessary, Infiltrate local anaesthesia; • Wearing sterile gloves, assess the position of the fetal head by feeling the sagittal suture line and the fontanelles; • Identify the posterior fontanelle; P-28 Vacuum extraction Figure 31: Landmarks of the fetal skull FIGURE P-7 Landmarks of the fetal skull
· Apply the largest cup that will fit, with the center of the cup over the • Applyflexionthe point,largest 1 cup cm willthat fit,anterior to centerwiththe ththeeposterior cup overof fontanelle. flexion Thistheplacementpoint, 1 cmwill anterior promote to the flexion, posterior descent fontanelle. and autorotation This placement with traction will promote (Fig P flexion,-8). descent and autorotation with traction ( FIGURE P-8 Applying the Malmstrom cup
• Figure 32).
202 191 flexion point, 1 cm anterior to the posterior fontanelle. This placement will promote flexion, descent and autorotation with traction (Fig P-8).
GURE P-8 Applying the MalmstromMalmstrom cup
Figure ApplyingApplyingMalmstromMalmstrom cup Figure 32: Applying the Malmstrom cup
An episiotomy may be needed for proper placement at this time . If an episiotomy is not necessary for placement, delay the episiotomy until the head stretches the perineum or the perineum interferes with the axis of traction. This will avoid unnecessary blood loss. t at this timeepisiotomyapplication. necessaryplacement,placement,placementepisiotomy.time (page pisiotomyP-71).episiotomyepisiotomyperineum necessary interferesplacement,traction.traction. This episiotomy unnecessaryapplication.stretches checkperineumtissuesoft(cervixperineumvagina) issue interferes maximumthenegativeof traction. maternal avoid unnecessaryandblood • perpendicularthecreate createtheavacuumkg/cm2 negative pressurepressurecheck check the and checktractionapplication. directedvacuum line0.2thatkg/cm2trynegative pressure anddeflexiontheof • application.Increase onevacuumkg/cm2other,kg/cm2necessarilyapplication.application. ation. CheckIncreaseapplication. Ensurepressure,traction perpendicular softpelvictissuepelvic(cervixandor side or vagina)perpendicular thedirecteddirected scalp nexttiltedthecorrect correcttractiondeflexiondeflexion of ct the tilt or deflexionpotential slippage directeddescent other, vertex.necessarilynecessarilymidline). deflexion of he midline).With Between contractionscontraction,vacuum traction perpendicularperpendicular pressure andthe ular to the planeWiththeeach contraction, apply traction in a line perpendicular to the plane of the • - Figure Figurerate;33). finger onfingeron thenextscalpnext to during during traction to assess uring traction •to- Application of slippagedescentdescentvertex. vertex.cup during traction to assess • Between contractionscontractions check: vertex. • Between contractions check: - Fetal heart heart rate; - ApplicationApplicationcup.the cup. - Application of the cup.
203 192
92
192
Applying the cupFigure 32:
32:Figure 32:Figure 32: the the cup p
•
•• An episiotomy•• theAn e pisiotomy may bemay needed bethere needed isproper maternal proper soft placement at placement at this at vagina) . IfIf an • . rim. may be mayfor needed for delay the this until thisuntilanC heck An episiotomy Ensurebe for proper tissue (cervix or the headmay is notneeded forproper this the until . anbe needed forforno for proper episiotomy Ifat this headAn necessary for delay the If anepisiotomy· An within the isIf an episiotomy delay the the If the the or is notperineum interferes the pressureuntil the theWithan perineumperineum the perineum for episiotomy checkheadhead stretches necessary the perineum with theaxis ofuntil • stretches notcreate a theforor of 0.2 kg/cm2 negative with the and delay thepump, the vacuumplacem ent, delay with the axis of axis of This he axis of traction.stretchesapplication. This will unnecessaryunnecessary avoid unnecessaryblood perineum loss. interferes with the axis of traction. This •• will avoid the the 0.8 Ensure no is no or the or(cervixorCheck the the and is thematernal soft tissue (cervix or•• until the head loss. maternalapplication.IncreaseCheckvacuum blood kg/cm2 is no soft tissue vagina)application. Ensure Ensurethere (cervix •• vagina)withCheck the rim. Ensure thewithin there application. is no This in soft line of the pelvic axisor within the rim. the axis pressure, start tractionwillthe tissue (cervix or vagina)After within rim. With•• Withthetopump,acup.rim If .a fetal head is kg/cm2withinthevacuum pump, pump, vacuumof 0.2 of 0.2 kg/cm2negativeor of 0.2 and flexed well,With the not andthetilted to one side pressureloss.pump, application. create a in of will to correct the tilt or check• Withthe should be Increase vacuum to 0.8 the0.8 andnot and check in the midline).headthe to to 0.8 and checkthe •• the side or to check the the(i.e. •• With Aftermaximum negative andAfter••each contraction, pressur e, is traction thethe theofplane and axisandthe After vacuum 0.8 kg/cm2 start start maternal line the pelvic axisthe maximum negative 2there a line traction of line the ofthe the themaximum negative apply traction incheck application. of axis the· e of the pelvic• perpendicularAfterandcup perpendicular( to the cup.to pressure,Ifstart If cup. head traction is head in thetiltedis tilted sideoneto or side pelvicflexed flexednot well, flexed not flexed well, traction berim. inthat that toto try to the or orthetilt or well,within theshouldbeIf in athe in line try will cup toduringtilt the tilt assesstraction shouldtoPlaceshouldtraction acup. the fetal head is that will try side to orwill to oneline• Figure 33). finger on the headbe(i.e.to onesideline not will try to intiltside inside correct the midline).a of theother, not the theortraction the (i.e. toone thethe of (i.e. toheadshouldheadoneand or that thehead With side the the midline). plane ofplane ofeach each check: apply negative to the the· •• the •• With one other, of 0.2 kg/cm2 to the planeof the(i.e. create traction necessarily to thecontraction, applyWith pump, • cup rim ( rim ((of cup rim check theFetalrimapplication. (heart 33). PlacePlace aafingerscalpthescalpthe to the the cup cup the assess cuptraction traction to assess assess 33). Place thethe of the to theFigurea finger the cup. on of scalp of thepotentialpotential and and nextslippage potential slippage and check: of theBetween descent•• Between
-- Fetalrate; Fetal - rate; of- heart of the of necessarily in the midline). · With each contraction, apply traction in a line perpendicular to the plane of the cup rim (Fig P-9). Place a finger on the scalp next to the cup during traction to assess potential slippage and descent of the vertex. FIGURE P-9 ApplyingFigure 33: traction Applying traction
Note: · Between contractions check:
• Never use- the cupfetal to heart rate;actively rotate the baby’s head. Rotation of the baby’s head will occur -with applicationtraction; of the cup. • The first pulls help to find the proper direction for pulling; • Do not continue to pull between contractions and expulsive efforts; • With progress,TIPS and in the absence of fetal distress, continue the “guiding” pulls for a maximum of 30 minutes. ( Maximum of 3-4 pulls ). · Never use the cup to actively rotate the baby’s head. Rotation of the FAILURE baby’s head will occur with traction.
· Thefirst pulls help to find the proper direction for pulling. • Vacuum extraction failed if the: · Do not continue to pull between contractions and expulsive efforts. - Fetal head does not advance with each pull; - Fetus· isWith undelivered progress, andafter in threepullsthe with absence of fetal no distress, descent,after or 30 continue the minutes; - The cup“slipsguiding off” thepulls forhead atwice maximum at the properof 30 minutes. direction of pull with a maximum negative pressure.
• Every application should be considered a trial of vacuum extraction. Do not persist if there is no descent with every pull. • If vacuum extraction fails, perform a caesarean section.
Maternal complications:
• Tears/Lacerations of vagina ,Cervix.
Neonatal complications:
• Abrasions on the scalp. • Cephalhaematoma. • Intracranial haemorrhage. • Retinal haemorrhage. Skull fracture and Subgaleal haemorrhage (rare). •
204 193
Paediatrician should be present at delivery
After delivery:
• Rule out any soft tissue injury to mother; • Rule out any neonatal complications; • Counsel the parents regarding the artificial caput; • Fill the Procedure part on the partogram ( for documentation ).
FORCEPS DELIVERY P-33 5. Forceps Delivery · Review for conditions: Review for conditions: - vertex presentation or face presentation with chin-anterior or • Vertex presentationentrappedor face presentationafter-coming head in breechwith chin delivery-anterior or P -(page41); entrapped after- coming head in- breech cervix fully delivery; dilated; • Cervix fully dilated; • Fetal head at +2- orfetal+3 station head or +2 or 0/5 station+3palpable 0/5 theor above thepalpable pubis.symphysis symphysis pubis. At a minimum, Atthe a sagittalminimum, thesuture sagittal should be insuture the beshould theand midline and straight,midlinestraight, guaranteeing an occiput anteriorguaranteeing. For an occiputocciput anterior posterior or occiput position posterior advisable use toposition.ventouse. • Provide emotional· Provide emotionalsupport andsupport andencouragement. a If Ifnecessary,useuse local anaesthesia. pudendal block (page P-3). • Assemble the· Assemble forcepsbefore the beforeforceps application.Ensure thatapplication. thethat the Ensurefit fit parts partstogether and lock well. and lock well. • Lubricate the blades of the forceps. • Wearing sterile· gloves,Lubricate the insert twoblades the offingersforceps.the right hand into the vagina on the side of the ·fetalWearinghead. Slide high- levelthe leftdisinfected blade gentlyor sterile between gloves, the insert twohead and fingersof the fingers to rest on the siderightof the hand intohead the vagina(Figure ). 34on the side of the fetal head. Slide the left blade gently between the head and fingers to rest on the side of the head (Fig P-10). A bipolar, bimalar application is the only safe application. A biparietal, bimalar application is the only safe application. Figure 34: Applying the left blade of the forceps FIGURE P-10 Applying the left blade of the forceps
194 · Repeat the same manoeuvre on205 the other side, using the left hand and the • Repeat the sameright manoeuvre blade of the forceps on the other (Fig Pside,-11, usingpage Pthe-34). left hand and the right blade of the forceps. • Depress the handles and lock the forceps.
• Repeat the same manoeuvre on the other side, using the left hand and the right blade of the forceps. • Depress the handles and lock the forceps. • Difficulty in locking usually indicates that the application is incorrect or the position of the fetal head is not applicable for forceps delivery. In this case, remove the blades and recheck the position of the head. Reapply only if rotation is confirmed. • After locking, apply steady traction inferiorly and posteriorly with each contraction. • Between contractions check:
- Fetal heart rate: - Application of forceps.
• When the head crowns, make an adequate episiotomy, if necessary. • Lift the head slowly out of the vagina between contractions.
The head should descend with each pull. Only two or three pulls should be necessary.
FAILURE
• Forceps failed if:
- Fetal head does not advance with each pull; - Fetus is undelivered after three pulls with no descent or after 30 minutes.
• Every application should be considered a trial of forceps. Do not persist if the head does not descend with every pull. • If forceps delivery fails, perform a caesarean section.
Fetal complications:
Injury to facial nerves requires observation. This injury usually resolves • 195 spontaneously. • Lacerations of the face and scalp may occur. Clean and examine lacerations to determine if sutures are necessary. • Fractures of the face and skull require observation.
Maternal complications:
Tears of the genital tract may occur. Examine the woman carefully and repair • any tears to the cervix or vagina or repair episiotomy. • Uterine rupture may occur and requires immediate treatment.
6. Breech Delivery
Ensure that all conditions for safe vaginal breech delivery are met. • Review general care principles and start an IV infusion • Provide emotional support and encouragement. • Perform all manoeuvres gently and without undue force. • Delivery should be conducted by experienced206 obstetrician who is competent to • perform breech deliveries. Injury to facial nerves requires observation. This injury usually resolves spontaneously. ••· Lacerations genitalindications. EnsureExamineCleanconditions lacerationsvaginal breech determinetoif sutures are necessary.repair episiotomy. •• Fracturesrupture faceoccur skullrequiresobservation.treatment. · Review general care principles (page C-17) and start an IV infusion Maternal complications:
•• Ensure thatthe conditions for safe vaginalExamine deliverywoman carefully and repair • · ReviewProvide emotional supportrepair encouragement. If necessary, use •• Provide emotional support and encouragement. • Perform all manoeuvres gently and without undue force. • Delivery should be conducted by experienced obstetrician who is competent to
• Ensure that all conditions for safe vaginal breech delivery are met. COMPLETE generalFRANK principles and start an IV infusion • Provide emotional support and encouragement. • Perform all manoeuvres gently and without undue force. • Delivery should be conducted by experienced obstetrician who is competent to perform breech deliveries.
COMPLETE OR FRANK BREECH
Figure 35: Breech presentation
DELIVERY OF THE BUTTOCKS AND LEGS
• Once the buttocks have entered the vagina and the cervix is fully dilated, tell the • DELIVERY OF THE BUTTOCKSepisiotomy. LEGS • Let the buttocks deliver until the lower back and then the shoulder blades are tell the woman she can bear down with the contractions.
womanthe perineumdown verythe contractions. an episiotomy (page P-71). • If the perineum is very tight, perform an episiotomy. •· LetLet buttocksbuttocks deliver until backlower back shoulder bladesshoulder blades seen. seen.
· Gently hold the buttocks in one hand, but do not pull. 196 If the legs do not deliver spontaneously, deliver one leg at a time: Push behind the knee to bend the leg; Grasp the ankle and deliver the foot and leg; •
of the the face Repeat scalp may that for all woman the carefully other and leg.repairTearsReviewoffor tract may occur. occur. the and examinefor safe to any deliverytears the cervixare met. or vagina or Uterine of themay and and immediate
6. Breech Delivery (page C-21). Tears of allgenital tract may occur. breech the are met. any general care principles and start episiotomy.tears to the cervix or vagina and IV infusion a pudendal block (page requires immediate treatment.
6. Breech Delivery · performPerform manoeuvres gently and without undue force.
• Review OR careBREECH
COMPLETE OR FRANKFigure BREECH 35: Breech presentation FIGURE P-13 Breech presentation
woman she can bear down with the contractions. If the perineum is very tight, perform an AND
· seen.Once the buttocks have entered the vagina and the cervix is fully dilated, DELIVERY OF THE BUTTOCKS AND LEGS
• Once the buttocks have entered the vagina and the cervix is fully dilated, tell196 · If she can bear is with tight, perform
the the deliver until the lower the and then theand then the are are
· - - 207 -
• Gently hold the buttocks in one hand, but do not pull. • If the legs do not deliver spontaneously, deliver one leg at a time: P-38 Breech delive - Push behind the knee to bend the leg; - Grasp the ankle and deliver the foot and leg; - Repeat for the other leg.
Do notDonotpull pull the the baby while legs arethe arethe beinglegsbeing delivereddelivered.
• Hold the baby by · Holdflanks mayor abdomenthe as in (Figure liverthe Dohips, nothips, holdbabyshown byshown as this as causein Fig kidneydamage. or 36). P Do-14. baby the not hold by the thethe baby by the flanks or abdomen as this may cause kidney or liver damage. Figure 36: Hold the baby at the hips, but do not pull FIGURE P-14 Hold the baby at the hips, but do not pull
DELIVERY OF DELIVERY OF THEARMSARMS ARMS ARE FELT ON CHEST
ARMS•AREAllow the FELT ON CHESTarms to disengage spontaneously one by one. Only assist if necessary. • After spontaneous delivery of the first arm, lift the buttocks towards the mother’s abdomen enable · Allow disengage spontaneously one by one. Only assist • If the arm does not spontaneously deliver, place one or two fingers in the elbow if necessary.and bend the arm, bringing the hand down over the baby’s face.
· AfterARMS spontaneous ARE STRETCHED delivery ABOVETHE of HEADthe ORfirst arm,FOLDED lift theAROUND THE buttocksNECK towards the mother’s abdomen to enable the second arm to deliver spontaneously. 208 197 · If the arm does not spontaneously deliver, place one or two fingers in the elbow and bend the arm, bringing the hand down over the baby’s • After spontaneous delivery of the first arm, lift the buttocks towards the mother’s abdomen to enable the second arm to deliver spontaneously. • If the arm does not spontaneously deliver, place one or two fingers in the elbow and bend the arm, bringing the hand down over the baby’s face.
ARMS ARE STRETCHED ABOVE THE HEAD OR FOLDED AROUND THE NECK
Use the Lovset’s manoeuvre (Figure 34): 197 • Hold the baby by the hips and turn half a circle, keeping the back uppermost Breechand delivery applying downward traction at the same time, so that the armP-39 wasthat posterior becomes anterior and can be delivered under the pubic arch. • Ass· ist Assist delivery of deliveryof the bythe by arm arm or orplacing oneone twotwofingers ononthe upper part of the arm. Drawof the arm.the arm Draw thedown arm over the downover chest as the asis chest is with elbow elbowflexed,flexed, the hand sweepingwith theover thehand face. sweeping over the face. • To deliver the second arm, turn the baby back half a circle, keeping the back uppermost· To anddeliver the second applying arm, downwardturn the baby traction, and half back a thedeliver secondcircle, the keeping arm in the samebackway uppermostunder the pubicand arch.applying downward traction, and deliver the second arm in the same way under the pubic arch. Figure 37: Lovset's manoeuvre FIGURE P-15 Lovset’s manoeuvre
BABY’S BODY CANNOT BE TURNED
BABYIf ’theS babyBODY’sCANNOT body BEcannot be turned TURNED to deliver the arm that is anterior first, deliver the shoulder that is posterior (Fig P-16): If the baby’s body cannot be turned to deliver the arm that is anterior first, deliver· Holdthe shoulder and thelift babythat up is by posterior the 38): (Figure ankles. · Move the baby’s chest towards the woman’s inner leg. The shoulder that • Hold isand posterior lift the shouldbaby up deliver. by the ankles. • Move the baby’s chest towards the woman’s inner leg. The shoulder that is posterior· theDeliver arm andshould deliver. hand. • Deliver the arm and hand. 209
198
P-40 Breech delivery
· Lay the baby back down by the ankles. The shoulder that is anterior • Lay shouldthe baby now back deliver. down by the ankles. The shoulder that is anterior should now deliver. • Deliver· Delithe armver theand hand.arm and hand.
FIGURE P-16 Figure Delivery38: of the that shoulderis thatposteriorposterior
DELIVERY OF THE HEAD DELIVERY OF THE HEAD Deliver the head by the Mauriceau Smellie Veit manoeuvre (Figure 39 ) as follows: Deliver the head by the Mauriceau Smellie Veit manoeuvre (Fig P-17, page • LayP-41) the asbaby follows: face down with the length of its body over your left hand and forearm. • Place· theLay the first and baby downthirdface this fingersthe on of ofwith itshand body length over and baby place’s cheekbones your hand and the second finger in the baby’s mouth to pull the jaw down and flex the head. • Use thearm. other hand to grasp the baby’s shoulders. • With· two Place thefingers of this first hand, flexthird of thisgently headfingers thethe the baby chest’shand while on towardsbaby’s pulling on the jaw to bring the baby’s head down until the hairline is visible. • cheekbonesand to the the head. Pull gentlyplacedeliver second finger in the baby’s mouth to pull the jaw down and flex the head. · to the hand to grasp Note: Ask an assistant to push above the mother’s pubic bone as the head delivers. This helpsUsekeep otherbaby’s head flexed.the baby’s shoulders. • · the twostill astride the arm, until the flex thenose are free. RaiseWithbaby, fingers of this hand, gentlymouth and baby’s head towards the chest while pulling on the jaw to bring the baby’s head down until the · hairline is visible. Pull gently to deliver the head. Note: Ask an assistant to push above the mother’s pubic bone as the head delivers. This helps to keep the baby’s head flexed. · 210 199 Raise the baby, still astride the arm, until the mouth and nose are free.
Breech delivery ENTRAPPED (STUCK) HEAD FIGURE P-17Figure 39:The MauriceauSmellie Smellie Veit Veitmanoeuvre manoeuvre · Catheterize the bladder. · Have an assistant available to hold the baby while applying Piper or forceps. · Be sure the cervix is fully dilated. · Wrap the baby’s body in a cloth or towel and hold the baby up. · Place the left blade of the forceps.
· Place the right blade and lock handles.
ENTRAPPED HEAD ENTRAPPED (STUCK) HEAD · UseCatheterizeforcepsbladder.flex and deliver the baby’s head. • the to • · HaveCatheterize bladder.hold the baby while applying Piper or long · If forceps.unable to use forceps, apply firm pressure above the mother’s pu •bone · Be Havesure the cervixan assistant baby fully’ dilated.savailable head toand hold push it thebaby through the pelvis.while applying Piper or • Wrap theto babyflex’s thebody in a cloth or towel and hold the baby up. • Placeforceps. the left blade of the forceps. • Place the right blade and lock handles. • · UseBethe forcepssure tothe flex cervix and is deliver the babyfully’s head. dilated. FOOTLING• If unable BREECH to use forceps, apply firm pressure above the mother’s pubic bone to · flex Wrapthe baby the’s head baby and’s push body it throughin a thecloth or pelvis. towel and hold the baby up. A footling breech baby (Fig P-18) should usually be delivered by caesar FOOTLING BREECH section· (pagePlace the P- 43).left blade of the forceps. A · Place thefootling right blade and lock handles. breech baby (Figure 40) is usually be delivered by caesarean section. FIGURE P-18 Single footling breech presentation, with one leg Figure 40: Single footling breech presentation, with one leg extended at hip knee · Use the forceps to flex and deliver the baby’s head. extended at hip and knee · If unable to use forceps, apply firm pressure above the mother’s pu bone to flex the baby’s head and push it through the pelvis.
FOOTLING BREECH A footling breech baby (Fig P-18) should usually be delivered by caesare section (page P-43). FIGURE P-18 Single footling breech presentation, with one leg
extended at hip and knee
211 200
• Limit vaginal delivery of a footling breech baby to:
- Advanced labour with fully dilated cervix; - Preterm baby that is not likely to survive after delivery; - Delivery of additional baby(s) in multiple gestation.
• To deliver the baby vaginally:
- Grasp the baby’s ankles with one hand; - If only one foot presents, insert a hand into the vagina and gently pull the other foot down; - Gently pull the baby downwards by the ankles; - Deliver the baby until the back and shoulder blades are seen; - Proceed with delivery of the arms.
BREECH EXTRACTION
• Wearing sterile gloves (wear long gloves if available), insert a hand into the uterus and grasp the baby’s foot. • Hold the foot and pull it out through the vagina. • Gently pull on the foot until the back and shoulder blades are seen. • Proceed with delivery of the arms . • Give a single dose of prophylactic antibiotics after breech extraction:
- ampicillin 2 g IV PLUS metronidazole 500 mg IV;
POST DELIVERY CARE
• Suction the baby’s mouth and nose. • Clamp and cut the cord. • Give oxytocin 10 units IM within one minute of delivery and continue active management of the third stage. • Examine the woman carefully and repair any tears to the cervix or vagina or repair episiotomy.
7. Episiotomy
Episiotomy should not be performed routinely.
Episiotomy should be considered in the case of:
Complicated vaginal delivery (breech, shoulder dystocia, forceps, vacuum • extraction); • Primigravida if perineum tight; • Scarring of female genital.
212 201
• Review general care principles and apply antiseptic solution to the perineal area. • Provide emotional support and encouragement. Use local infiltration with lignocaine or a pudendal block. • Make sure there are no known allergies to lignocaine or related drugs. • When the head is at the perineum, Infiltrate beneath the vaginal mucosa, beneath the skin of the perineum and deeply into the perineal muscle (Figure 41) using about 10 mL 0.5% lignocaine solution.
Note: Aspirate (pull back on the plunger) to be sure that no vessel has been penetrated. If blood is returned in the syringe with aspiration, remove the needle. Recheck the position carefully and try again. Never inject if blood is aspirated. The woman can suffer convulsions and death if IV injection of lignocaine occurs.
• At the conclusion of the set of injections, wait two minutes and then pinch the incision site with forceps. If the woman feels the pinch, wait two more minutes and then retest.
Anaesthetize early to provide sufficient time for effect P-72 Episiotomy
Figure 41: Infiltration of perineal tissue with local anaesthetic FIGURE P-39 Infiltration of perineal tissue with local anaesthetic
• Wait· to Wait to performperform until: episiotomy until:
- t he perineum is thinned out; and - The perineum is thinned out; and - 3-4 -cm of 3 the–4cm baby of ’sthe babyhead’s visibleis head visible isduring contraction. a during contraction.
Performingan anepisiotomy will willcause cause bleeding. It not,not, It should should therefore, be therefore, be done too early.done to o early.
· Wearing high-level disinfected or sterile gloves, place two fingers between the baby’s head and the perineum. · Use scissors to cut the perineum about 3–4 cm in the mediolateral 202 direction (Fig P-40, page P-73). 213 Use scissors to cut 2–3 cm up the middle of the posterior vagina. · Control the baby’s head and shoulders as they deliver, ensuring that the ·
• Wearing sterile gloves, place two fingers between the baby’s head and the perineum. • Use scissors to cut the perineum about 3-4 cm in the mediolateral direction (Figure 42). • Use scissors to cut 2-3 cm up the middle of the posterior vagina. Episiotomy• Control the baby’s head and shoulders as they deliver, ensuring that the P-73 shoulders have rotated to the midline to prevent an extension of the episiotomy. • Carefully examine for extensions and other tears and repair (see below). FIGUR E P-40 Making the incision while inserting two fingers to Figure 42: Makingprotectthe incision the while insertingbabyhead’s two fingers to protect the baby's head
REPAIR OF EPISIOTOMY
Note: It is important that absorbable sutures be used for closure. Polyglycolic sutures are preferred over chromic catgut for their tensile strength, non-allergenic properties and lower probability of infectious complications and episiotomy breakdown. Chromic catgut is an acceptable alternative, but is not ideal.
· Apply antiseptic solution to the area around the episiotomy (page C-22). · If the episiotomy is extended through the anal sphincter or rectal mucosa, manage as third or fourth degree tears, respectively (page P-86). 214 203 · Close the vaginal mucosa using continuous 2-0 suture (Fig P-41 A, page P-74):
REPAIR OF EPISIOTOMY
• Apply antiseptic solution to the area around the episiotomy. • Additional infiltration of lignocaine may be required. • If the episiotomy is extended through the anal sphincter or rectal mucosa, manage as third or fourth degree tears, respectively. Repair should be done in the theatre and under general anaesthesia. • Close the vaginal mucosa using continuous (Vicryl Rapide 2.0 suture) (Figure 43):
- Start the repair about 1 cm above the apex (top) of the episiotomy. Continue the suture to the level of the vaginal opening; - At the opening of the vagina, bring together the cut edges of the vaginal opening; - Bring the needle under the vaginal opening and out through the incision and tie. Episiotomy P• -74Close the perineal muscle using interrupted 1-0 sutures (Figure 43). • Close the skin using interrupted or subcuticular Vicryl Rapide 2.0 suture (Figure 43).· Close Perform perthe rectum perineal muscleexamination to rule usingout sutures interrupted in the 2(Fig-0 sutures rectum. P-41 B). • Patient should be closely observed and checked for haematoma. • Provide· Close proper the skinanalgesia; using mefenamicinterrupted acid 500(or mg subcuticular) oral BD or 2to- 0beTID sutures given. (Fig P-41 C). Figure 43: Repair of episiotomy FIGURE P-41 Repair of episiotomy
COMPLICATIONS
· If a haematoma occurs, open and drain. If there are no signs of infection and bleeding has stopped, reclose the episiotomy. · If there are signs of infection,215 open and drain the wound. Remove 204 infected sutures and debride the wound: - If the infection is mild, antibiotics are not required; Give a single dose of prophylactic antibiotics (page C-35): ampicillin 2 g IV PLUS metronidazole 500 mg IV; 8. Manual Removal of Placenta • Reviewcefazolin principles, PLUSanmetronidazole 500 mg IV. • To be done in the theatre under general anaesthesia. HoldCatheterizeumbilical cordensurewith aisclamp. Pull the cord gently until i • Give a single dose of prophylactic antibiotics, ampicillin 1 g IV PLUS
• Hold the umbilical cord with a clamp. Pull the cord gently until it is parallel to the Wearing high-level disinfected if available), glovesother(use long gloves available), insert the other hand into the vagina and up into the ut
(Fig P-42). in care principles, general anaesthesia.
• Give a singleIntroducing oneantibiotics, ampicillin 1vaginaPLUSalong cord metronidazole 500 mg IV; • Hold the umbilical cord with a clamp. Pull the cord gently until it is parallel to the floor. • Wearing sterile gloves (use long gloves if available), insert the other hand into the vagina and up into the uterus (Figure 44 ).
Figure 44: Introducing one hand into the vagina along cord
Let go of the cord and move the hand up over the abdomen in order to support the fundus of the uterus and to provide counter-traction during removal to prevent inversion of the uterus (Figure 45).
Note: If uterine inversion occurs, reposition the uterus.
Move the fingers of the hand in the uterus laterally until the edge of the placenta is located. • If the cord has been detached previously, insert a hand into the uterine cavity. Let Explore the cordcavityand move cleavagehandidentifiedoverbetweenabdomen in ord support the fundus of the uterus and to provide counter-traction d removal to prevent inversion of the uterus (Fig P-43, page P-78) Note: If uterine inversion occurs, reposition the uterus. Note:Move uterineofinversion occurs,laterallyreposition the uterus (page P-9 is located. Move the fingers of the hand in the uterus laterally until the edge placenta isandlocated. wall. If the cord has been detached previously, insert a hand into the cavity. Explore the entire cavity until a line of cleavage is identif between the placenta and the uterine wall. · -
- 1 g IV and start IV infusion.OR general care
· the bladder that it empty.• parallelmetronidazole floor.IV;
floor. · • sterile gloves (use long gloves or sterileinsert the hand into 8. Manualthe vagina Removal and up ofintothe Placenta uterus (Figure 44 ).
• general Reviewdone the theatre underand start IV infusion.• To be • CatheterizeFigurebladderIntroducing thathand empty. vagina along cord IGURE P-42 dose of prophylactic hand into the IV
•
•
· go of entire until a line of the is up the the • Letplacenta go of and corduterinemove the hand up over the abdomen in order to support the fundus of the uterus and to provide counter-traction during removal to prevent inversion of the uterus (Figure 45).
• If the fingers the hand the uterus until the edge of the placenta · • If the cord has been detached previously, insert a hand into the uterine cavity. Explore the entire cavity until a line of cleavage is identified between the the uterine · 216 205
P-78 Manual removal of placenta
FIGURE P-43Figure 45: Supportingfundusfundusdetaching detaching the placenta
Detach the placenta from the implantation site by keeping the fingers tightly together and using the edge of the hand to gradually make a space between the placenta and the uterine wall. Proceed slowly all around the placental bed until the whole placenta is detached from the uterine wall. • Detach the placenta from the implantation site by keeping the fingers tightly · Detach placenta doesfrom implantationmake uterinekeeping thethefingers placentalateral movementwall.usingfingertips of the handofto graduallyremovea space from placental fragments (pagethe uterine wall.tissue is very adherent, suspect
· movement ofslowly fingertips at thelineplacental bedremove the placentalplacenta is detached from the uterineadherent, do not manipulate further, call senior
•· Hold the placenta slowly separate fromfromthe uterine surfacethe gentle • Withlateral movementcontinue fingertips counter-traction cleavage, remove placental fragmentsdirectioncontinue to provide counter-tractionadherent, suspect placentapushingaccreta and opposite laparotomythe handpossible subtotal Figure 46: Withdrawing the hand from the uterus hysterectomy (page P-103). FIGUREHoldP-44 placentaWithdrawing withdrawfromhand uterusthe uterus, bringing the placenta with it (Fig P-44). With the other hand, continue to provide counter-traction to the fundus by pushing it in the opposite direction of the hand that is being withdrawn. FIGURE P-44 Withdrawing the hand from the uterus
the the while while placenta
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·
·
·together the not the gradually siteaby betweenIf and using the edge the handseparate from the space surface by gentle tightly uterineand the the edge atandtogether of line cleavage, make • Proceed slowly all around the placental bed until the whole placenta is detached between placenta and S-32). If thethe uterinethewall. • If theplacenta accreta proceed to laparotomysurface possible subtotal Proceedhysterectomy the all around(page P - 103). of cleavage, until whole fragments. If the tissue is very wall. ·obstetrician. Hold the placenta and slowly withdraw the hand from the uterus, If anddoes notwithdraw the hand uterus, bringing by placentabringing with it (Figurethe placenta 46). with it (Fig P-44). the line of to the fundus bythe other hand, of the to provide ·pushing it inthe opposite (page the handIfthat istissuewithdrawn. to fundusWith the other hand, ofS-32). the being is very by it in the proceed direction of that being withdrawn. slowly the hand the the from· the
·
• Palpate the inside of the uterine cavity to ensure that all placental tissue has been removed. • Give oxytocin 20 units in 500 ml IV fluids (normal saline or Ringer’s lactate) at 60 drops per minute. • If there is bleeding, give ergometrine 0.2 mg IM stat. • Ask an assistant to massage the fundus of the uterus to encourage a tonic uterine contraction.
PROBLEMS
• If the placenta is retained due to a constriction ring or if hours or days have passed since delivery, it may not be possible to get the entire hand into the uterus. Extract the placenta in fragments using two fingers, ovum forceps or a wide curette.
POST PROCEDURE CARE
• Observe the woman closely until the effect of IV sedation has worn off. • Monitor vital signs (pulse, blood pressure, respiration) every 30 minutes for the next six hours or until stable. • Palpate the uterine fundus to ensure that the uterus remains contracted. • Check for excessive lochia. • Continue infusion of IV fluids. • Transfuse as necessary. • Give antibiotics:
- Augmentin 500 mg Oral, TID x 3 days, PLUS - Metronidazole 500 mg Oral, TID x 3 days.
9. Repair of Cervical Tears
• To be done in the theatre under general anaesthesia. • Review general care principles and apply antiseptic solution to the vagina and cervix. • Ask an assistant to gently provide fundal pressure to help push the cervix into view. • Use vaginal retractors as necessary to expose the cervix. • Gently grasp the cervix with ring or sponge forceps. Apply the forceps on both sides of the tear and gently pull in various directions to see the entire cervix. There may be several tears. • Close the cervical tears with vicryl No.1 suture starting at the apex (upper edge of tear), which is often source of bleeding.
218 207 Note: A laparotomy may be required to repair a cervical tear that has extended deep beyond the vaginal vault. FIGURE P-45 Repair of a cervical tear Figure 47: Repair of a cervical tear
10. Repair of Vaginal and Perineal Tears
There are four degrees of tears that can occur during delivery:
• First degree tears involve the vaginal mucosa and connective tissue. • Second degree tears involve the vaginal mucosa, connective tissue and underlying muscles. • Third degree tears involve complete transection of the anal sphincter. • Fourth degree tears involve the rectal mucosa.
REPAIR OF FIRST AND SECOND DEGREE TEARS
Most first degree tears close spontaneously without sutures.
• Review general care principles. • Provide emotional support and encouragement. Use local infiltration with lignocaine. If necessary, use a pudendal block. • Ask an assistant to check the uterus and ensure that it is contracted. • Carefully examine the vagina, perineum and cervix. • If the tear is long and deep through the perineum, inspect to be sure there is no third or fourth degree tear:
- Place a gloved finger in the anus; - Gently lift the finger and identify the sphincter; - Feel for the tone or tightness of the sphincter.
219 208
• Change to clean, high-level disinfected or sterile gloves. • If the sphincter is injured, see the section on repair of third and fourth degree tears. • If the sphincter is not injured, proceed with repair. • Apply antiseptic solution to the area around the tear. • Make sure there are no known allergies to lignocaine or related drugs. • Infiltrate beneath the vaginal mucosa, beneath the skin of the perineum and deeply into the perineal muscle using about 10 mL 0.5% lignocaine solution .
Note: Aspirate (pull back on the plunger) to be sure that no vessel has been penetrated. If blood is returned in the syringe with aspiration, remove the needle. Recheck the position carefully and try again. Never inject if blood is aspirated. The woman can suffer convulsions and death if IV injection of lignocaine occurs.
• At the conclusion of the set of injections, wait two minutes and then pinch the areaP-84 with forceps. If the woman Repair feels ofthe vaginal pinch, waitthen two more minutes andperineal tears retest. FIGURE P-46 Exposing a perineal tear Figure 48: Exposing a perineal tear
· Apply antiseptic solution to the area around the tear (page C-22). · AnaesthetizeMake sure thereearly tono knownprovide allergies sufficient to time lignocaine for or effectrelated drugs. Note: If more than 40 mL of lignocaine solution will be needed for the • Repair the vaginal mucosa using a continuous 2-0 suture: repair, add adrenaline to the solution (page C-39). - Start ·the repair Infiltrate about beneath 1 cm the above thevaginal apex (top) mucosa, of beneaththe of vaginaltheContinueskintear. perineum the sutureandto the deeply level into of the vaginal perineal muscleopening; using about 10 mL 0.5% lignocaine - At the opening of the vagina, bring together the cut edges of the vaginal opening; solution (page C-39). - Bring the needleNote: underAspirate (pullthe back vaginal the opening and outplunger) be the throughthat no sure tear perineal vessel has and tie. been penetrated. If blood is returned in the syringe with aspiration, remove the needle. Recheck the position carefully and try again. Never inject if blood is aspirated. The woman can suffer convulsions and death if IV injection of lignocaine occurs. · At the conclusion of the set of injections, wait two minutes and then pinch the area with forceps.220 If the woman feels the 209 pinch, wait two more minutes and then retest.
Anaesthetize early to provide sufficient time for effect. Repair of vaginal and perineal tears P-85
- Bring the needle under the vaginal opening and out through the perineal tear and tie.
FIGURE P-47Figure Repairing49: the thevaginal perineal tearsmucosa
• Repair the· perinealRepair muscles the perineal using muscles interrupted usinginterrupted 0-1 suture 2 -suture0(Figure 49). (Fig If the P- If48). tear is deep, place athe tearsecond is layer deep, of placethe same second layerstitch the to theofclose stitchsame space.to close the • Repair the skin usingspace. interrupted (or subcuticular) 0-1 sutures starting at the vaginalFIGUREopeningP (Figure-48 49).Repairing the perineal muscles • If the tear was deep, perform a rectal examination. Make sure no stitches are in the rectum.
REPAIR OF THIRD AND FOURTH DEGREE PERINEAL TEARS
• To be done in the theatre under general anaethesia and by a senior/ experienced obstetrician.
Note: The woman may suffer loss of control over bowel movements and gas if a torn anal sphincter is not repaired correctly. If a tear in the rectum is not repaired, the woman can suffer from infection and rectovaginal fistula (passage of stool through the vagina).
• Review general care principles. • Ask an assistant to check the uterus and ensure that it is contracted. • Examine the vagina, cervix, perineum and rectum. • To see if the· Repair anal sphincter the skin using is torn: interrupted (or subcuticular) 2-0 sutures starting at the vaginal opening (Fig P-49, page P-86).
- Place a gloved· If the finger tear the inwas anus deep, and perform lift a rectalslightly; examination. Make sure no - Identify the sphincter,areorin lack the ofrectum. it; - Feel the surface of the rectum and look carefully for a tear.
• Change to clean, high-level disinfected or sterile gloves. • Apply antiseptic solution to the tear and remove any faecal material, if present . • Repair the rectum using interrupted 2-0 sutures 0.5 cm apart to bring together the mucosa (Figure 50).
Remember: Place the suture through the muscularis (not all the way through the mucosa).
221 210 · Repair the rectum using interrupted 3-0 or 4-0 sutures 0.5 cm apart to bring together the mucosa (Fig P-50): Remember: Place the suture through the muscularis (not all the way through the mucosa). - Cover -theCover muscularis the layermuscularis bylayer bringing by bringing together the togetherlayer withfascial fascial layer interrupted sutures; with interrupted sutures; - Apply antiseptic solution to the area frequently. - Apply antiseptic solution to the area frequently. FIGUREFigure P-50 50: Closing the musclethe wall ofof the therectum & anal aphincter
• If the sphincter is torn:
- Grasp each end of the sphincter with an Allis clamp (the sphincter retracts when torn). The fascial sheath around the sphincter is strong and will not tear when pulling with the clamp (Figure 50 ); - Repair the sphincter with two or three interrupted stitches of 2-0 suture.
• Apply antiseptic solution to the area again. • Examine the anus with a gloved finger to ensure the correct repair of the rectum and sphincter. Then change to sterile gloves. • Repair the vaginal mucosa, perineal muscles and skin.
POST PROCEDURE CARE
• If there is a fourth degree tear, give prophylactic antibiotics:
- ampicillin 1 gm IV stat. then; augmentin 500 mg Oral, TID x 3 days - PLUS metronidazole 500 mg oral, TID x 3 days.
• Follow up closely for signs of wound infection. • Liquid diet for the first 24 hours. • Avoid giving enemas or rectal examinations for two weeks. • Give stool softener by mouth for one week, if possible. To be kept in the hospital for observation for at least 3-4 days. •
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