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Guidelines for Pregnancy Care and Management of Common Obstetric Complications by Medical Officers

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Guidelines for Pregnancy Care and Management of Common Obstetric Complications by Medical Officers Guidelines for Pregnancy Care and Management of Common Obstetric Complications by Medical Officers Maternal Health Division Department of Family Welfare Ministry of Health & Family Welfare Government of India 2005 Guidelines for Pregnancy Care and Management of Common Obstetric Complications by Medical Officers Maternal Health Division Department of Family Welfare Ministry of Health & Family Welfare Government of India Printed with support form The John D. & Catherine T. MacArthur Foundation through The White Ribbon Alliance for Safe Motherhood, India PREFACE India through its National Population Policy 2000 and National Health Policy 2002 has set a goal to bring down the Maternal Mortality Ratio to 100/100,000 live births by the year 2010 from its current level of above 400 in most of the States. The National Health Mission launched by the Hon'ble Prime Minister on 12th April 2005 reiterates this commitment. It has been amply proven globally and more recently by our neighbouring countries that is it possible to accelerate the decline of Maternal Mortality by putting up into place skilled birth attendants (Midwives); operationalizing referral services and by strengthening institutions for handling obstetric emergencies. In case, India wants to achieve the stated goals of Maternal Mortality i.e. less than 100 by 2010, steps will have to be initiated to accelerate the decline of MMR which has remained virually stagnant at 400 plus since 1998. Under the Reproductive and Child Health programme, Phase II (RCH Phase II), therefore, a consicious decision has been taken to strengthen infrastructure, promote referral cases even by involving private sector and evidence based institutional best practices. To achieve the key results on skilled attendance at birth, it is imperative to train and empower MOs/ANMs/ LHVs as skilled birth attendants. In this regard, GOI has taken certain policy decisions which empower ANMs and LHVs to carry out certain emergency interventions after proper training and they have also been permitted to use drugs in specific emergency situations to reduce MMR. Under the RCH Phase-II, the Government of India envisages that fifty percent of the PHCs and all the CHCs in all the districts would be made operational as 24-hour delivery centres, in a phased manner, by the year 2010. These centres would be responsible for providing Basic Emergency Obstetric Care and Essential Newborn Care and Basic Newborn Resuscitation services round the clock. Almost all the States have laid emphasis on Basic Emergency Obstetric Care and Skilled Attendance at Brith in the Project Implementation Plans (PIP) for RCH Phase II. As such, the Medical Officers, who are in-charge of the these health facilities, would, therefore, have to be equipped enough to be able to handle the common obstetric emergencies and provide the required care such as the skills and knowledge required for the administration of parenteral oxytocics, antibiotics and anti-convulsant drugs, manual removal of the placenta and the conduction of assisted vaginal deliveries. The Maternal Health Division, Department of Health and Family Welfare has prepared these evidence based guidelines for pregnancy care and management of common obstetric complications that will enable the Medical Officers to perform their role, as anticipated under the Reproductive and Child Health programme, Phase II, in the Management of Common Obstetric Complications. I congratulate the Division and the other organisations, professional bodies and experts who have given whole hearted assistance for the development of these guidelines. I am sure that these guidelines, when implemented in word and spirit, will go a long way in reducing the enormous burden of maternal mortality in our country. (Prasanna Hota) Secretary (Health & Family Welfare) 24.06.2005 i ACKNOWLEDGEMENTS The Government of India is committed to achieve a reduction in maternal mortality to less than 100 per 100,000 live births by 2010. To achieve this goal, we will have to accelerate the implementation of interventions for reduction in mortality. The experience of countries like Sri Lanka, Thailand and Malaysia, has shown that this can be done through interventions and strategies such as Skilled Attendance at Birth, promoting institutional delieveries and operationalizing Emergency Obstetric Care at referral hospitals. These interventions are now part of Government of India's Reproductive and Child Health Programe - Phase II being implemented in the country. The Government of India envisages that fifty percent of the Primary Health Centres and all the Community Health Centres should be operationalised as 24-hour delivery centres by the year 2010. These centres will also be responsible for providing pre-referral emergency care for women who develop complications during delivery. The "Guidelines for Pregnancy Care and Management of Common Obstetric Complications by Medical Officers" will help Medical Officers to provide services to women in labour and obstetric emergencies thereby reducing maternal mortality. It would not have been possible to bring out these guidelines without the active interest and encouragement provided by Shri. P.K. Hota, the Secretary Health and Family Welfare, and I wish to convey my heart-felt gratitude to him for the same. I am also thankful to Ms. S. Jalaja, Additional Secretary, MoHFW and Mr. S.S. Brar, Joint Secretary, RCH for their support. The guidelines have been designed with inputs form various professional boides such as Federation of Obstetric and Gynaecological Societies of India (FOGSI), UN organizations, such as the WHO, UNFPA and UNICEF, Non governmental Organisations and other experts in the fields of Obstetrics and Gynaecology, Public Health and other specialties like Anaesthesiology and Pathology. I thank them all. The assistance and active involvement of the White Ribbon Alliance of India has been very helpful and I would like to thank Dr. Bulbul Sood, Co-chair WRAI and Dr. Aparajita Gogoi, National Coordinator, WRAI, and Senior Advisor, CEDPA, for the same. We would also like to acknowledge the John D and Catherine T MacArthur Foundation for supporting CEDPA and the WRAI in this initiative. A series of meetings were held over a period of nearly a year in order to finalize the guidelines and bring them out in the current form. It is not feasible to mention each and every name in this short acknowledgement, therefore, a 'List of Contributors' has been appended at the end of this doucment. I which to take this opportunity to thank each of the persons mentioned in the list for their help and contribution in bringing out the document. A special mention needs to be made of Dr. Dinesh Agarwal (Team Manager Technical Support Group & Technical Advisor, Reproductive Health, UNFPA), Dr. Arvind Mathur (National Co-ordinator, Family & Community Health, WHO-India), Dr. Bulbul Sood (Country Director CEDPA, India), Dr. Kamala Ganesh and Dr. Tank of FOGSI for lending their technical expertise and valuable time in drawing these guidelines. I would also like to place on record my appreciation for the hard work and untiring efforts put in by our senior programme officer Dr. Himanshu Bhushan, Assistant Commissioner (MH) and Dr. Narika Namshum, Assistant Commissioner (RSS) in getting these guidelines in present shape. My special thanks go to Dr. Anchita Patil and Dr. Rashmi Asif, Consultants for the mammoth task of writing and editing these guidelines. I gratefully acknowledge the secretarial assistance provided by Mrs. Rita Madaan, Shri Pradeep Kumar Sohpaul and Shri Sachin Kumar in putting together the document. (Dr. V.K. Manchanda) Deputy Director General Maternal and Child Health Division Ministry of Health and Family Welfare Government of India ii CONTENTS 1. Preface i 2. Acknowledgements ii 3. Abbreviations and units viii 4. Introduction x 5. About the Guidelines xi 6. Module 1: Management of normal pregnancy, labour and the postpartum period 1 Introduction to Module 1 1 1. Care during pregnancy—Antenatal care 3 2. Care during labour and delivery—Intrapartum care 23 3. Care after delivery—Postpartum care 37 4. Essential newborn care and basic newborn resuscitation 45 7. Module 2: Management of common obstetric complications 57 Introduction to Module 2 57 1. Vaginal bleeding (Haemorrhage) 59 (a) Abortions—Haemorrhage during early pregnancy 59 (b) APH—Haemorrhage during late pregnancy and labour 67 (c) PPH—Haemorrhage after childbirth 70 2. Hypertensive disorders of pregnancy 77 3. Prolonged/obstructed labour 93 4. Puerperal sepsis 99 5. Anaemia during pregnancy and in the postpartum period 103 6. Other problems during pregnancy 105 (a) Urinary tract infection 105 (b) Hyperemesis gravidarum 107 (c) Retention of urine 108 (d) Premature or prelabour rupture of membranes 109 7. Other problems during labour and delivery 113 (a) Preterm labour 113 (b) Foetal distress 115 (c) Prolapsed cord 117 (d) Twins 119 8. Other problems during the postpartum period 123 (a) Inversion of the uterus 123 (b) Breast problems: Mastitis and breast abscess 125 9. Management of shock 129 8. Module 3: Ensuring the quality of care 133 Introduction to Module 3 133 1. Counselling and supportive environment 135 2. Prevention of infection 137 iii 9. Annexure 145 1. Measuring the blood pressure 147 2. Abdominal examination in obstetrics 148 (a) Measuring the fundal height 148 (b) Determining the foetal lie and presentation 150 (c) Auscultating for the foetal heart sound (FHS) 154 3. Assessing the pelvis for any cephalopelvic disproportion (CPD) 155 4. Estimating the level of haemoglobin 159 5. Testing the urine for: 160 (a) The presence of protein 160 (b) The presence of sugar 160 (c) Bacteriuria 160 6. Prescribing drugs during pregnancy 161 7. Preparing “clean” gloves 164 8. Assessing cervical dilatation 165 9. Procedure for controlled cord traction (CCT) 166 10. Procedure for uterine massage and expulsion of clots 167 11. Examination of the placenta, membranes and the umbilical cord 168 12. Measuring the body temperature of the newborn 169 13. Equipment for resuscitation of the newborn 170 14. Inserting an IV line and giving IV fluids 172 15.
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