Obstetric Guidelines and Labour Ward Protocols State of Palestine Ministry of Health Women's Health and Development Directorate Obstetric Guidelines and Labour Ward Protocols Fourth Edition, December,2016 Overall Supervision and coordination • Ms. Maha Awwad, Acting Director, Women Health and Development Directorate (WHDD) List of Contributors • Dr. Abdul-Razak A. El-Kurd, Jordanian Board, Saudi Board, FICS, Senior Consultant Obstetrician & Gynaecologist, MOH Adviser& Supervisor of OB/GYN service-Gaza. Assistant professor, Faculty of Medicine, Islamic University Gaza (IUG) • Dr. Ayesha M. AlRifai, PhD, MSN, RN, Associate professor of Health Policy, Regional Consultant Monitoring and Evaluation, Dean of Education Sciences Faculty , Principal Ramallah Women Training center- UNRWA • Dr. Bassam Akhdar M.D, Consultant obstetrician and gynecologist and laparoscopic surgeon –Makassed Hospital, Head of Department of OBGYN – Al-Quds Medical University, President of Palestinian society of obstetrician and Gynecologist. • Dr. Emad A. Abed, MD, Consultant obstetrician and Gynecologist, Head of OBGYN Department in Palestine Medical Complex MOH, Member of OBGYN committee in Palestine medical counsel, Lecturer of OBGYN in Al-Quds medical University • Dr. Hani M Mahdi, Palestinian Board of OBGYN, Consultant and head department OB/GYN, Maternity Hospital, Shifa Medical Complex. • Laila M Al-Masharfah, CNM, MPH. Nursing director, Maternity Hospital, Shifa Medical Complex. • Dr. Nazeeh M. Abed M.D, Consultant obstetrician and gynecologist, Director of PHC department North Hebron • Sabreen M. Nashabat, CNM, MPH, HCQM. Women Health and development department (WHDD) • Dr. Sahar Hassan PHD .CNM, Assistant Professor of women’s health Institute of community and public health Birzeit University • Dr. Said Sarahneh . M.D, Consultant obstetrician and gynecologist and IVF, Associate Professor Al-Quds medical University, Head of OBGYN committee and member of higher scientific committee in Palestine medical counsel ,Member of ARAB Board in OBGYN • Dr. Walid A. Abu Hatab, Turkish Board, Consultant Obstetrician &Gynaecologist, Director of Tahrir Maternity Hospital, Nasser Medical Complex. • Dr.Walid M Afana, PhD. OB/GYN, Consultant Obstetrician & Gynaecologist, Medical Director, Al-Helal Al-Emirati Maternity Hospital. Revision and Editing committee: Dr. Abdul-Razak A. El-Kurd, Dr. Bettina Bottcher. Dr. Emad A. Abed Dr.Walid A. Abu Hatab, Dr.Walid M Afana, Final editing and proofreading: Dr. Abdul-Razak A. El-Kurd Dr. Emad A. Abed Acronyms ABG Arterial blood gases AC Abdominal circumference APH Antepartum haemorrhage APS Antiphospholipid syndrome ARM Artificial rupture of membranes BF Breastfeeding BM Breast milk BMI Body mass index BP Blood pressure bpm Beats per minute BSP Blood sugar profile CBC Complete blood count CCT Controlled Cord Traction CS (C/S) Caesarean section CTG Cardiotocograph CVP Central venous pressure DAMA Discharge against medical advice DIC Disseminated intravascular coagulation DM Diabetes mellitus dpm Drop per minute D/W Dextrose/water ECV External cephalic version EDD Expected date of delivery ET Endotracheal tube FBC Full blood count FBS Fasting blood sugar FHR Foetal heart rate FSE Foetal scalp electrode GDM Gestational diabetes mellitus Hb Haemoglobin HBV Hepatitis B virus IM Intramuscular INR International normalised ratio IOL Induction of labour IUFD Intrauterine foetal death A36 IUGR Intrauterine growth restriction IV Intravenous IVAC Intravenous Access Control (intravenous infusion pump) HR Heart rate KFT Kidney function tests KVO Keep vein open LBW Low birth weight LFT Liver function tests LGA Large for gestational age LMP Last menstrual period LMWH Low molecular weight heparin LSCS Lower segment Caesarean section MAP Mean arterial pressure MCH Mother and child health MOH Ministry of Health NPO Nil per OS ('Nothing by mouth") N/S Normal saline OGTT Oral glucose tolerance test PAPS Primary antiphospholipid syndrome PPBS Post prandial blood sugar PPH Postpartum haemorrhage PPV Positive pressure ventilation PRN Prorenata "as the occasion arises, when necessary" PROM Premature rupture of membranes PTL Preterm labour RBS Random blood sugar RL Ringer lactate RPC Retained product of conception SB Stillbirth SC Subcutaneous SCBU Special care baby unit SGA Small for gestational age SHO Senior house officer SLE Systemic lupus erythematosus SROM Spontaneous rupture of membranes T◦ Temperature U&E Urea & electrolytes UNFPA United Nations Population Fund U/S Ultrasound VD Vaginal delivery VTE Venous thromboembolism WHO World Health Organization Table of contents No. Topic Page 1 Topic I: Normal Delivery 1 1. Admission of women in labor to Labor & delivery Unit 4 2.In the Labor Room - The First Stage of Labor 8 A. Normal care for women during the active phase 9 B. Pain relief for women during active phase of labor. 10 C. Partogram 11 D. Standing medication orders for labor & delivery. 14 3.Slow progress of labor A. Slow progress of labor 16 B. Oxytocin use during labor 17 C. External Foetal monitoring 18 D. NICHD Continuous Electronic Fetal Monitoring Stoplight 19 E. Augmentation of labor 21 4.Second & 3rd Stage of Labour 22 A. Preparation for normal delivery. 23 B. Management of second stage 24 C. Normal Third Stage of Labor. 28 D. Prevention of Postpartum Hemorrhage (PPH) 29 E. Immediate postnatal care after birth 32 F. Identification of Babies in Hospital (cot card) 33 5. From Delivery Room to Postnatal Ward 34 A. Transfer to Postnatal Ward 35 B. Postnatal care of mother following caesarean section 36 6. In Postnatal Ward : 37 A. Postnatal care after vaginal delivery 38 B. Postnatal care following caesarean section 39 C. Removal of sutures / clips / staples drain 42 7. Before leaving the hospital 43 A. Normal Discharge procedure 44 B. Discharge against medical advice 45 C. Transfer of a patient to another hospital 46 02 TOPIC 2 : Breastfeeding 48 1. Promotion of breastfeeding 49 A. Immediate initiation 50 B. Teaching & counselling of breastfeeding 50 C. Procedure of breastfeeding 51 D. Maintaining and encouraging breastfeeding 53 No. Topic 2. Care of the breasts A. After normal delivery 54 B. After C-section 55 3. Minor Breast Problems 56 A. Weak reflex 57 B. Flat nipples 58 C. Engorgement 59 D. Mastitis 60 E. Sore nipples 62 03 TOPIC 3: Essential Early Neonatal Care (EENC) 65 01. Early essential/Immediate new born care 66 0 to discharge care 66 02. Neonatal resuscitation flow chart 72 Neonatal resuscitation flow chart 76 4 Topic: 4 High risk cases, Part 1, Medical conditions 79 A. Anemia in Pregnancy 80 B. Diabetes 83 C. Urinary tract infection in pregnanacy 93 D. Heart disease 95 E. Bronchial Asthma 100 F. Thrombophilia 103 G. Prophylaxis against thrombo-embolism 108 H. Epilepsy 107 I. Patients with viral hepatitis or HIV 118 J. Management of sepsis in obstetrics 123 5 Topic 5: High risk cases, Part 2, Obsetric conditions 127 A. Management of pre-eclampsia with severe features 129 B. Antepartum Haemorrhage 138 C. Management of Pre-labor Rupture of Membranes 146 D. Management of preterm labour 149 E. Magnesium Sulphate in Prevention of Cerebral Palsy 152 F. Management of Breech Presentation at term 154 G. Management of twins labour at term 159 H. Management of previous uterine scar 161 6 TOPIC 6 : Emergency Obstetrics 163 A. Management of Eclampsia 164 B. Shoulder Dystocia 166 C. Cord Prolapse 171 D. Post Partum Haemorrhage 172 Massive Clood transfusion protocol 175 E. Ruptured Uterus 176 F. Amniotic Fluid Embolism 178 G. Shock in obstetric patient 179 No. Topic Page 181 07 TOPIC 7: Procedures 1. iv drug administration 182 2. Antibiotic prophylaxis in obstetrical procedures. 184 3. Induction of Labour 186 1. IOL with PGE2 187 2. IOL with PGE1 188 3. IOL with Artificial rupture of membranes 190 4. IOL with Oxytocin 191 5. Managegment of uterine tachysystole 193 6. IOL with cervical balloon 195 7. IOL for special cases 196 4. Analgesia – Anaesthesia 197 A. Local Anaesthesia 197 B. Epidural 198 5. Surgical procedures 200 A. Episiotomy 200 B. Episiotomy repair 201 C. Perineal repair 204 D. Preparation for caesarean section 207 E. Proccess in cases of elective or emergency caesarean section 208 6. Fetus 210 A. Fetal Death 210 7. Placenta 212 A. Placental disposal 212 08 Quality of Care 214 1. Structural approach 215 2. Process approach 221 3. Outcome approach 224 Topic 1: Normal Delivery Admission 1st Stage of Labor 2nd & 3rd Stage of Labor Transfer to Postnatal Ward Postnatal care Discharge 1 The Ways inside the Maternity Facility The different topics of this section present the activities performed in different places of the maternity facility. To make the manual more practical, these activities are described according to the place where these activities are achieved. Home Admission 1 Room Discharge 6 Postnatal Ward 5 Labour Room 2 Delivery 4 Room Transfer 3 N N° of Topic 2 Topic 1: Normal Delivery 1: In the Admission Room 2. In the Labor Room - 1st Stage of Labor a. Normal care for women during the active phase b. Pain relief for women during active phase of labor. c. The Partogram d. Standing medication orders for labor & delivery 3. progress of labor. a. Slow progress of labor. b. Oxytocin use during labor. c. External Foetal monitoring d. NICHD Continuous Electronic Fetal Monitoring Stoplight e. Augmentation of labor 4: In the Delivery Room-2nd& 3rd Stage of labor a. Preparation for normal delivery b. Management of second stage c. Normal Third Stage of Labor. d. Prevention of post partum hemorrhage e. Immediate postnatal care after birth f. Identification of babies 5: From Delivery Room to Postnatal Ward a. Transfer of the mother b. Transfer of the Baby 6: In Postnatal Ward: a. Postnatal care after vaginal delivery b. Postnatal care following caesarean section c. Removal of sutures /clips/staples drain 7: Before leaving the hospital a. Normal Discharge procedure b. Discharge against medical advice c. Transfer of a patient to another hospital 3 Topic 1 Normal delivery Subtopic 1 Admission of women in labor to Labor & delivery Unit Standard All women in true labor should be admitted to the hospital.