PROTOCOLS AND

CLINICAL GUIDELINES

DEPARTMENT OF OBSTETRICS
AND GYNAECOLOGY
SERDANG HOSPITAL

Updated April 2012

Contributors :
Dr.Wan Hamilton Bt Wan Hassan
Dr.Wan Norizah Bt Wan Musa
Dr.Juliana Bt Basuni

Edited By :
Dr.Wan Hamilton Bt Wan Hassan

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CONTENTS PAGE

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1 CLERKING OF OBSTETRICS PATIENTS IN THE PAC/WARDS
FETAL MONITORING
COMMON ANTENATAL CONDITIONS AT PAC
ANTENATAL PROBLEMS
Hypertensive Disorders in Pregnancy
Intravenous Antihypertensive Regime
Eclampsia
Anticonvulsant Therapy
Diabetes Mellitus in Pregnancy
Insulin Regime
Heart Disease in Pregnancy
Antibiotic Prophylaxis
Anticoagulant Therapy in Pregnancy
Guidelines for Management of HIV Patients
Antepartum Haemorrhage (APH)
Anaemia in Pregnancy
External Cephalic Version
Post Dates Pregnancy
Intrauterine Death
ESSENTIAL PREREQUISITES IN THE LABOUR ROOM
LABOUR PROBLEMS
FIRST STAGE OF LABOUR
Routine Intrapartum Care
Induction and Augmentation of Labour
Prostin (PGE2, Dinoprostone)
Oxytocin Augmentation / Induction Regime
Abnormal Progress of Labour
Intrapartum Fetal Monitoring
Pain Relief in Labour
Thromboprophylaxis in Labour
Prophylaxis for Acid Aspiration in Caesarean Section
Preterm Labour
Tocolytic Regime
Antenatal Steroid Therapy
Preterm Prelabour Rupture of Membranes (PPROM)
Perinatal Group B Streptococcus (GBS) Infection Prevention
Cord Prolapse
SECOND AND THIRD STAGE OF LABOUR
Normal Delivery
Episiotomy
Vaginal Breech Delivery
Twin Delivery
Instrumental Delivery
Ventouse Delivery
Forceps Delivery
Repair of Perineal Tears
Cervical Tears
Post-partum Haemorrhage (PPH)

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Manual Removal of Placenta
Uterine Inversion
Shoulder Dystocia
GYNAECOLOGY PROBLEMS
Ectopic pregnancy
Puerperial sepsis
GENERAL MEASURES
Labour Room Ward Round
Red Alert System
Infectious Control Measures
Antimicrobial Use in Pregnancy
Paediatric Referrals

CLERKING OBSTETRICS PATIENTS IN

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 PAC / WARDS

1. DETAILED HISTORY IS REQUIRED

 DATES: Confirm date is correct

 Patient is sure of her LMP
 Normal flow at the said LMP, not spotting
 Periods are regular, not on OCP or breastfeeding
 Early dating scan <20 weeks
 Be cautious of multipara, immigrant, minority groups like Orang Asli , and
foreigners as their LMP are usually inaccurate

1.1 PRESENTING COMPLAINT

 Severity and complication of her present illness or complaints

 Example: signs and symptoms of impending eclampsia,
nephropathy/neuropathy in DM, signs of failure in heart disease, severity of
blood loss in APH….others.
 Review medical treatment, compliance and side effects of medication
 Any other relevant details
 Check on fetal movements

1.2 PREVIOUS PREGNANCIES AND OUTCOME

 Previous deliveries and interval between deliveries

 Any history of subfertility and treatment
 Maternal and fetal outcome of all deliveries
 Previous LSCS – type, indications, complications intraoperatively
 Previous instrumental deliveries – maternal or fetal injuries
 Previous stillbirths
 Previous congenital malformations. If so, any consanguineous marriage

1.3 MEDICAL AND SURGICAL HISTORY

 Any previous history of medical and surgical problems

 Admissions to ICU, any hospitalization
 Medications, compliance
 Allergies –very important

1.4 CHECK HOME-BASED CARD/ANTENATAL CARD THOROUGHLY/LOOK

FOR DISCREPANCIES

 Check name, age and parity

 Dates are correct: accuracy of LMP
 Early scan results especially before 20 weeks. This is important to ascertain
EDD
 Previous OCP, LCB, breastfeeding
 Check results of Blood group and Rh typing, HIV/VDRL status
 Previous obstetric history in details. Enquire on indications for operative
vaginal delivery, Caesarean section, maternal and fetal outcome.

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  Take note of past medical, surgical and family history
 Determine POA at first antenatal check-up. Findings at this visit
 Review trends and progress from subsequent follow-ups example:
haemoglobin, urine albumin and sugar, weight, blood pressure, fundal
height, serial scan and growth charts, fetal movement chart, any other
additional investigation or treatment.
 In the presence of a newly diagnosed medical disorder, take note of the
onset, treatment, compliance to medication, control of disease, referrals,
current investigations results and special plans for the pregnancy.

2. THOROUGH AND COMPLETE PHYSICAL EXAMINATION

2.1 GENERAL

 Hydration status, pallor, jaundice, cyanosis

 Height, weight
 Temperature, blood pressure and pulse rate
 Pedal edema. Varicose veins

2.2 SYSTEMS EXAMINATION

 Thyroid,
 Breasts examination
 Cardiovascular system
 Respiratory system

2.3 ABDOMINAL EXAMINATION

 Fundal height and symphysio-fundal height

 Time contractions
 Number of fetus
 Lie and presenting part
 Fetal weight estimation
 22 weeks 500grams
 28 weeks 1.0kg
 32 weeks 1.5kg
 34 weeks 2.0kg
 36 weeks >2.5kg
 Assessment of liquor: adequate, excessive or diminished
 Fetal heart rate

2.4 VAGINAL EXAMINATION

If required and if there are no contraindications

3. PRELIMINARY INVESTIGATIONS

 Urine albumin, sugar, rapid test for HIV if not done

 Further investigations: dipstix for UFEME if suggestive of UTI, dextrostix, urine
ketones
 Other investigations to be carried out example GSH,GXM, FBC, Renal profile,
LFT, PT/APTT/INR

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4. ADMISSION CTG

5. LIST DOWN ALL THE RISK FACTORS IDENTIFIED

 Patients with no antenatal follow-up/poor follow-up/defaulter

 Mothers less than 20 years old
 Unmarried mothers
 Immigrants
 First pregnancy
 Grandmultipara, P5 and above
 Bad obstetrics history eg recurrent miscarriages, preterm deliveries, no living
child, IUD, perinatal deaths
 History of subfertility
 History of previous LSCS
 History of MRP, PPH
 History of admission to ICU/HDW/prolonged post-partum stay
 History of birth trauma either tfetal injuries such as shoulder dystocia or maternal
injuries such as perineal tears, 4th degree tears etc
 History of big baby, preterm birth
 History of blood transfusion
 Any other abnormal obstetrics history
 Abnormal screening tests such as Rhesus negative, rare blood groups
 Presence of and/or history of medical disorders such as cardiac disease,
anaemia, thyroid disease, haematological disorders or Renal disease and others
 Previous surgical/gynaecological surgery: myomectomy, pelvic floor repair,
breast Ca, brain tumour, spinal operations, pelvic or hip accidents and others
 Hypertension/PIH/eclampsia
 Diabetes/GDM/others
 Any infectious status
 Antepartum haemorrhage
 PPROM/PROM
 Maternal pyrexia
 Induced/augmented labour
 Prolonged labour
 Operative deliveries
 Patients on regional anaesthesia
 Growth restricted fetus
 Oligohydramnios
 Suspected fetal distress or compromise
 Prematurity
 Isoimmunisation
 Multiple pregnancy
 Breech
 Meconium-stained liquour
 Post term pregnancy
 Other high risk factors identified

6. ENTER THE DIAGNOSIS AND DIFFERENTIALS

FETAL MONITORING BY
CARDIOTOCOGRAPHY (CTG)

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1 IMPORTANT INSTRUCTIONS

 An ADMISSION CTG is to be done on all cases 32 weeks and above on

admission to the PAC.
 CTG monitoring is to be done on high risk patients, preferably in a continuous
manner.
 The date and time on the CTG should be correctly set
 Set paper speed at 1cm/min
 Traces should be labelled with the mother’s name, date and hospital registration
number
 All CTG strips MUST be reviewed at 20-30 minutes interval. The findings must be
documented on the strip by the House Officer/Medical Officer
 Any intrapartum events that may affect the FHR should be noted on the trace.
 All abnormal CTGs must be informed to the Medical Officer/Specialist stat
 Intermittent CTG is to be done on all other cases in labour at least once in 4
hours. If not done, to document why: example CTG machines being used on
other high-risk patients, or delivery imminent
 All other patients not deemed high risk should be monitored by intermittent
auscultation as follows:
 Every 15-30 minutes (throughout and after contractions) in active first stage of
labour
 Every 5 minutes in active second stage

2 STEPS TO BE TAKEN IN AN ABNORMAL FHR TRACING

 Prepare the patient as if undergoing an operative delivery

 Look for the causative factors
 Check maternal pulse/blood pressure/hydration status/medications
 Check urine ketones, hydrate if indicated
 Turn on left lateral, there is no need for the administration of nasal oxygen
 Stop/reduce oxytocin augmentation/induction if in progress
 Do a vaginal examination; assess progress and stage of labour
 Exclude cord prolapse
 Expedite delivery with instrumentation if os is fully dilated and with no
ontraindications to vaginal delivery.
 ALL INSTRUMENTATION MUST BE INFORMED TO THE SPECIALIST PRIOR
TO INITIATION.
 The Paediatrician must also be informed
 Caesarean Section may be appropriate as indicated.
 HOUSE Officer on noting abnormal CTG to inform Medical Officer with the
following:
 Patient’s profile: age, parity, gestational age, any risk factors present
 Briefly inform previous obstetric history and progress of current pregnancy
 Physical examination and vaginal examination
 Duration of labour, whether any induction or augmentation undertaken.
 Colour of liquor
 Maternal medications
 Steps undertaken in view of abnormal CTGs as above

3. INTERNAL OR DIRECT MONITORING (FETAL SCALP ELECTRODE)

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  If the CTG is clearly pathological, do not ask for a repeat CTG as steps must be
undertaken to ensure safe delivery. Buying time is not an option.
 INTERNAL OR DIRECT MONITORING (FETAL SCALP ELECTRODE)
 Indicated when 1) external tracing inadequate for accurate interpretation 2)
monitoring of leading twin in twin pregnancy
 Internal CTG is to be done under aseptic technique
 Contraindications of fetal scalp electrode includes
 Face presentation
 Unknown presentation
 HIV seropositive/Hepatitis B,C
 Active genital herpes
 Suspected thrombocytopaenia/ITP

4. CTG INTERPRETATION

Baseline Variability Decelerations Accelerations

(bpm) (bpm)

Reassuring 110-160 >/=5 None Present

Non- 100-109 <5 for  Early decelerations

reassuring >40mins  Variable decelerations
 Single prolonged
deceleration up to 3
minutes

Abnormal <100  <5 for >90  Atypical variable

mins decelerations
 >18  Late decelerations
 Sinusoidal  Single prolonged
deceleration greater
than 3 minutes

5. CTG CLASSIFICATION

Normal All four features fall into the reassuring category

Suspicious Features fall into one of the non-reassuring category and the remainder
of the features are reassuring

Pathological Features fall into two or more non-reassuring categories or one or

more abnormal categories

6. DEFINITINS AND DESCRIPTION OF INDIVIDUAL FEATURES OF FETAL HEART

TRACES

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 Term Definition
1 Baseline fetal heart The mean level of the FHR when this is stable,
rate excluding accelerations and decelerations. It is
determined over a time period of 5 to 10 minutes and
expressed in bpm. Preterm fetuses have values
towards the upper end. A trend to a progressive rise in
baseline is as important as the absolute values.
2 Normal baseline FHR 110-160bpm

3 Moderate bradycardia 100-109bpm

Benign if with adequate variability and no decelerations
Other causes : post-term infant, occiput posterior
position
4 Abnormal bradycardia <100bpm
IF TRANSIENT : Fetal heart block or other conduction
defects
Maternal Systemic Lupus Erythematosus
Fetal Congenital Heart Disease
IF PROLONGED : Severe fetal hypoxia
5 Moderate tachycardia 161-180bpm
Usually benign if associated with normal fetal heart rate
variability
Other causes can be attributed to: Maternal fever,
dehydration or anxiety, maternal ketosis, maternal
medications such as anticholinergics (benadryl) and
sympathomimetics (terbutaline), presence of fetal
movements, preterm fetus, maternal thyrotoxicosis,
maternal anaemia

6 Abnormal tachycardia >180bpm

Chorioamnionitis (especially if with maternal fever)
Fetal arrhythmia or congenital defects (FHR >200 bpm

7 Baseline variability The minor fluctuations in baseline FHR occurring at

three to five cycles per minute. It is measured by
estimating the difference in beats per minute between
the highest peak and lowest trough of fluctuation in a
one-minute segment of the trace

8 Normal baseline Greater or equal to 5bpm between contractions

variability
9 Non-reassuring Less than 5bpm for 40 minutes or more but less than 90
baseline variability minutes

10 Abnormal baseline Less than 5bpm for 90 minutes or more

variability
11 Accelerations Transient increases in FHR of 15bpm or more and
lasting 15 seconds or more. The significance of no
accelerations in an otherwise normal CTG is unclear

Term Definition
12 Decelerations Transient episodes of slowing of FHR below the
baseline level of more than 15bpm and lasting 15
seconds or more

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13 Early decelerations Uniform, repetitive, periodic slowing of FHR with onset
early in the contraction and return to baseline at the end
of the contraction
14 Late decelerations Uniform, repetitive, periodic slowing of FHR with onset
mid to end of the contraction and nadir more than 20
secs after the peak of the contraction and ending after
the contraction. In the presence of a non-accelerative
trace with baseline variability < 5bpm, the definition
would include decelerations < 15bpm.
15 Variable decelerations Variable, intermittent periodic slowing of FHR with rapid
onset and recovery. Time relationships with contraction
cycle are variable and they may occur in isolation.
Sometimes they resemble other types of deceleration
patterns in timing and shape
16 Atypical variable Variable decelerations with any of the following
decelerations additional components:
i loss of primary or secondary rise in baseline rate
ii slow return to baseline FHR after the end of
contraction
iii prolonged secondary rise in baseline rate
iv biphasic decelerations
v loss of variability during decelerations
vi continuation of baseline rate at lower level
17 Prolonged An abrupt decrease in FHR to levels below the baseline
deceleration that lasts at least 60-90 seconds. These decelerations
become pathological if they cross two contractions ie
greater than 3 minutes
18 Sinusoidal pattern A regular oscillation of the baseline long-term variability
resembling a sine wave. This smooth, undulating
pattern, lasting at least 10 minutes, has a relatively
fixed period of 3-5 cycles per minute and an amplitude
of 5-15 bpm above and below the baseline. Baseline
variability is absent.

7. CORD BLOOD GAS ANALYSIS

 All babies delivered by instrumentation / LSCS/SVD with low Apgar Score must
have a cord blood gas analysis
 Paired samples (artery and vein) should be taken from the umbilical cord after
delivery. This is done from the umbilical cord sited in between the 2 clamps.
 Universal precautions must be practiced to prevent sharps injury
 If the cord blood analysis is not done for the cases stated, the reason must be
documented in the mother’s notes
 Inform a senior doctor stat if pH is <7.21.

COMMON ANTENATAL CONDITIONS IN PAC

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1. POST DATES PREGNANCY

If with no other obstetrical factors, patients should be induced at 40 weeks + 9 days.

Prerequisites to IOL
 Ensure dates are correct
 Determine LMP, LCB, OCP usage, date of UPT test, early dating scan
 Review home-based or other antenatal records to see if uterine size corresponds to
dates.
 Thorough physical examination, determine uterine size and liquor volume
 Perform CTG
 Assessment by scan for liquor volume. If AFI<6, to induce without delay.
 Perform a VE for cervical score
 If >7, ARM and syntocinon
 If <7, use Prostin

MODIFIED BISHOP SCORE

0 1 2

Cervical Dilatation Closed 1 cm 2 cm

Cervical Length 2 cm 1 cm Effaced

Consistency Firm Soft Stretchable

Station -2 -1 0

Position Posterior Axial Anterior

NB : A Bishop score of ≥6/13 is considered favourable for induction

 If unsure of dates/wrong date/no fetal or maternal compromise, manage

conservatively with frequent outpatient CTG/scan assessment (biweekly CTG,
weekly AFI)
 If risk factors are present such as reduced liquor, decreased fetal movements, non-
reactive CTG: induce labour immediately.
 Sweeping of fetal membrane at 40weeks or earlier reduce the need for induction of
labour without increasing the risk of ascending infection. This method can be
considered on a case-by-case basis.

2. REDUCED FETAL MOVEMENTS

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  Check the present pregnancy status
 Check the trends in her fetal movement/kick chart
 Rule out abruptio placenta
 Be very cautious and a higher threshold of intervention or surveillance if: any risk
factor for IUGR, history of subfertility, other APH, existing medical condition for
example PIH, GDM, renal disease, haematological disorders, recent infections.
Also previous history of bad perinatal outcome such as asphyxia, trauma,
neonatal death, stillbirth.

 A CTG must be performed if 32 weeks and above.

 This will be followed by an ultrasound to assess fetal well-being and liquor
volume by MO or Specialist.
 In a suspicious or pathological CTG, the MO/Specialist must be informed. An
ultrasound and doppler studies can be undertaken and the timing of delivery
determined. The patient must be immediately admitted.

 If the mother is high-risk as defined as above with a normal CTG, an ultrasound

and doppler study should be undertaken.
 Patient will be reassured with close fetal monitoring such as fetal movement chart
and twice weekly CTG if no abnormalities were detected in these studies.
 Admission for a 24 hour assessment may be done if equivocal results. Earlier
delivery may be advocated.

 In cases with no previous bad outcome and with a normal CTG, an ultrasound
assessment of liquor volume and growth parameters as well as strict fetal
movement chart is sufficient. The patient will be advised to TCA stat if fetal
movements are still reduced. Overnight assessment in the hospital may also be
undertaken. Close weekly follow-up is mandatory
 If the patient is anxious/distressed/logistic reasons, it is reasonable to admit the
patient for assessment and reassurance.

3. UTERUS LARGER THAN DATES

 Determine dates accurately

 Look for risk factors in past or present pregnancy
 Check findings of early scan
 Examine the fundal height and estimate liquor volume
 Ultrasound to exclude polyhydramnios, multiple pregnancies, congenital
anomaly, pelvic tumour
 Fetal biometry and fetal growth chart
 If there is fetal macrosomia, rule out GDM
 Further management depends on the underlying cause.

4. UTERUS SMALLER THAN DATES

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  Determine dates accurately
 Look for risk factors in past or present pregnancy
 Check findings of early scan
 Examine the fundal height, estimate liquor volume and fetal weight
 Ultrasound for fetal biometry, placental abnormalities, liquor volume.
 Plot growth chart
 CTG if > 28 weeks
 If IUGR is suspected, refer to the Specialist for further management
 Repeat CTG, do serial scan, growth chart

5. PREVIOUS CAESAREAN SECTION

Determine as accurately as possible the indications, complication of previous LSCS.

Old notes will need to be traced
Be certain of gestational age. Routine early scan is recommended
Option for elective LSCS if:
 2 or more previous LSCS
 Previous classical section
 Extensive tears in previous CS/inverted T incision
 Previous myomectomy with cavity entered
 Patient’s refusal for trial of vaginal delivery

Decide mode of delivery at 37 weeks/38 weeks

Intrapartum management for trial of vaginal delivery includes

 Nourishing fluids only
 IVD and good venous access
 Group, screen and hold
 Watch for signs/symptoms of impending uterine rupture such as maternal/fetal
tachycardia, scar pain/tenderness, fresh pv bleeding, haematuria, abnormal CTG,
ballooning of lower segment, secondary arrest
 Monitor with continous CTG if possible
 Epidural anaesthesia preferable
 Judicious use of oxytocin in induction or augmentation

Risk of scar dehiscence are higher amongst women receiving oxytocin compared to
those who are not
 Spontaneous labour 0.5%
 Oxytocin use 0.8%
 Prostaglandin use 2.45%

6. MECONIUM STAINED LIQUOR

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Treat as ominous unless proven otherwise by CTG

Management:
 Keep patient NBM
 Monitor fetal heart closely with continuous CTG
 If reactive for augmentation and deliver vaginally
 If CTG is pathological to inform the MO/Specialist, the paediatrician and anaesthetist
will also be informed KIV for EMLSCS
 Ensure blood has been taken for GSH
 Thick meconium stained liquor: delivery must be expedited in most appropriate
manner (EMLSCS or instrumentation if criteria fulfilled). Thick meconium if found in
early labour must be delivered by emergency LSCS.
 Meconium stained liquor in preterm infant, there will be a need to exclude and treat
Listeriosis
 All babies born with meconium staining must be attended by the Paediatrics Medical
Officer.

7. LEAKING LIQUOR

Patient complains of leaking

History of gushing out fluid, wetting bed/couch, persistent trickling of fluid per vagina

PROM (prelabour rupture of membranes) refers to rupture of membranes with leakage of

amniotic fluid occurring after 37 weeks without uterine contractions.

PPROM (preterm prelabour rupture of membranes) refers to rupture of the fetal

membranes before 37 weeks of gestation without uterine contractions
Both carry a high risk of ascending infection to the fetus

Management:
 Confirm diagnosis of PROM/PPROM
 Aseptic speculum examination with HVS and low vaginal swab
 Litmus paper test: red to BLUE
 Do not perform a digital VE if conservative management is planned.
 DIGITAL VE IS TO BE DONE ONLY BY MO/ Specialist
 Ultrasound for fetal well being and liquor volume. Look for presentation and fetal
anomalies.
 Pad chart,BP/PR, temperature chart, baseline FBC, baseline CRP
 Inform Paediatrician/NICU
 If patient progresses into labour or if labour is induced, the number of vaginal
examination should be limited to 4 hourly reviews unless indicated

Treatment
 If there is chorioamnionitis or fetal distress as evidenced by abnormal CTG,
meconium staining, Doppler studies : IMMEDIATE DELIVERY IS INDICATED
 Otherwise, it will depend on fetal maturity. Decisions must be made by the
specialist

In General:

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Gestation of >37 weeks
 Plan to deliver as soon as possible. Induce with prostin if cervix is not favourable/or
with no contra-indications.
 Start iv ampicillin 2gm stat than 1gm 6h till delivery (no need to wait for 12-24hours).
 In cases where there is allergy to penicillin: use iv vancomycin or iv erythromycin.
Check dosages with the pharmacist.

Gestation of <37 weeks

 CONSERVATIVE APPROACH with close monitoring
 Admission with 4 hourly vital signs, pad chart, EOD TWDC, daily CTG, weekly scan
for AFI
 Look out for evidence of chorioamnionitis : rising pulse rate and temperature, uterine
tenderness, purulent or change in colour of discharge, fetal tachycardia
 Start tablet EES 400mg BD x 10days
 IM Dexamethasone 12mg BD x 2 doses in preterm fetus, consider tocolytic therapy if
indicated
 Inform Paediatrics for risk assessment, counseling and ventilator status

8. ABDOMINAL PAIN IN PREGNANCY

This is a common complaint in pregnancy. The differentials includes

Physiological
 Round ligament pain
 Labour itself
 Exaggerated Braxton Hicks contractions

Pathological :
 Ectopic pregnancy
 Miscarriage
 Placenta Abruption
 Preterm labour
 Severe PE
 Uterine rupture
 Red degeneration of fibroids
 Torsion of ovarian cyst

 Heartburn
 Bowel colic
 Adhesion colic
 Appendicitis
 Cholecystitis
 Renal colic
 Irritable bowel syndrome
 Pancreatitis
 Acute fatty liver
 Mesenteric artery thrombosis/bowel ischemia

Good history taking and thorough physical examination will be required.

9. MATERNAL PYREXIA

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Diagnosed when the maternal temperature is more than 37.5 degrees C
Determine the cause with possibility of chorioamnionitis antenatally or intercurrent
infection ie URTI, UTI.
Institute measures to reduce maternal temperature like tepid sponging and paracetamol

Recognition:
 Fever: temperature 38degrees and above
 Warm extremities
 Fast breathing
 Fetal and maternal tachycardia
 Hypotension
 Altered mental state: confusion, restlessness
 Late diagnosis and treatment will lead to septic shock
 In patients where the temperature does not touch baseline/persistent fever: the
Specialist MUST be informed. The patient must be reviewed, assessed and treated
appropriately and aggressively.

Investigations include FBC, renal profile, UFEME and C&S, HVS C&S, septic workout if
the temperature exceeds 38 degrees C and all other relevant investigations.

Expedite delivery if indicated

The newborn must be referred to the Paediatrician.

Some differential diagnosis of maternal pyrexia includes the following:

Probable Presentation Management

diagnosis
Cystitis Dysuria, frequency, fever, urgency, Tablet Augmentin 625mg BD x 1
suprapubic pain week
Acute Loin pain, chills and rigors, fever, IV cefuroxime 750mg TDS
pyelonephritis nausea and vomiting
Septic abortion Foul smelling vaginal discharge, IV cefuroxime 750mg TDS Plus IV
recent D&C, fever,t ender uterus, metronidazole 500mg TDS
chills and rigors
Chorioamnionitis Fever/chills, history of ruptured IV cefuroxime 750mg TDS plus IV
membranes, abdominal pain metronidazole 500mg TDS
Pneumonia Cough, fever, breathlessness, Tablet Azithromycin 500mg daily x3
pleuritic pain days plus tablet Augmentin 625mg
BD x 1week
Malaria Fever/chills, myalgia, enlarged D1-D3 Artequine. Refer Medical
spleen, anaemia
Hepatitis Fever, malaise, anorexia, nausea, Recognise and refer Medical
jaundice, hepatomegaly
H1N1 Refer MOH guideline Recognise and refer Medical
Dengue Refer MOH guideline Recognise and refer Medical
SARS Refer MOH guideline Recognise and refer Medical
Endometritis Tender uterus, fever, purulent PV IV Cefuroxime 750mg TDS and
(post-partum) discharge metronidazole 500mg TDS
Pelvic abscess Lower abdominal pain, persistent IV Cefuroxime 750mg TDS and
(post-op or post- fever, pyrexia of unknown origin, metronidazole 500mg TDS
partum) diarrhea, tender uterus
Mastitis Breast pain after 3-5days of delivery

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Breast abscess Discoloured, wedge shape area on iV Cloxacillin 500mg QID
breast
Wound Bloody and serous wound discharge IV Cloxacillin 500 mg qid
breakdown,
hematoma
Deep vein Spiking fever despite antibiotics, SC Heparin infusion
thrombosis tachycardia, calf tenderness,
swelling.

10. SINGLE MOTHERS/CONCEALED PRENANCY

 Many social, medical and legal issues

 Most cases are unbooked, a thourough history and physical examination warranted
 Antenatal screening to be undertaken including rapid test for HIV
 Universal precautions, biohazard
 Treatment must be without prejudice
 Avoid judgemental remarks and attitude
 Once delivered, refer to the social worker
 If under 16, a police report must be made once the patient has delivered safely
 If under 18, any consent or procedures must be informed to the parents or guardian.

18
ANTENATAL
PROBLEMS

19
 HYPERTENSIVE DISORDERS IN PREGNANCY

DEFINITION

Hypertension

 BP of 140/90 mmHg or more taken after a period of rest on two occasions.

 Rise of systolic blood pressure of 30 mmHg and/or a rise in diastolic blood pressure
of 15 mmHg compared to pre-pregnancy levels.
The Korotkoff phase V being used to define the end point.

Proteinuria

 ≥ 300 mg in a 24 hours urine collection or

 ≥ 1 gm/L (≥ 2+ on dipstick testing) in two randomly collected urine samples 6 hours
apart.

CLASSIFICATION

There are various classifications for Hypertension in Pregnancy. The most recent is by the
Australasian Society for the Study of Hypertension in Pregnancy (ASSHP) and endorsed
by the International Society for the Study of Hypertension in Pregnancy(ISSHP),2001.

1. Preeclampsia-eclampsia

Clinically diagnosed in the presence of de novo hypertension after gestational week

20, and one or more of the following

 Significant proteinuria
 Renal insufficiency: serum creatinine ≥ 90 μmol/l or oliguria
 Liver disease: raised transaminases and/or severe right upper quadrant or
epigastric pain
 Neurological problems: convulsions (eclampsia), hyperreflexia with clonus or
severe headaches, persistent visual disturbances (scotoma)
 Haematological disturbances: thrombocytopenia, coagulopathy,aemolysis
 Fetal growth restriction

This is followed by normalization of the BP by three months postpartum.

Oedema is no longer part of the definition of preeclampsia.
Either excessive weight gain or failure to gain weight in pregnancymay herald the
onset of preeclampsia.

2. Gestational hypertension

Hypertension alone, detected for the first time after 20 weeks pregnancy. The definition is
changed to “transient” when pressure normalizes postpartum.

20
3. Chronic hypertension

Hypertension diagnosed prior to gestational week 20; or presence of hypertension

preconception, or de novo hypertension in late gestation that fails to resolve postpartum.

4. Preeclampsia superimposed on chronic hypertension

This can be diagnosed by the appearance of any of the following in a woman with chronic
hypertension

 De novo proteinuria after gestational week 20

 A sudden increase in the severity of hypertension
 Appearance of features of preeclampsia-eclampsia, and
 A sudden increase in proteinuria in women who have pre-existing proteinuria early in
gestation

Secondary causes of hypertension

Renal
Chronic kidney disease
Polycystic kidney disease.
Glomerular disease (Primary Gromerulonephritis, Tubulointerstitial nephritis)
Nephrotic syndrome

Endocrine
Phaeochromocytoma
Acromegaly
Thyroid or parathyroid disease
Primary aldosteronism
Cushing syndrome
Conn’s syndrome

Autoimmune
Systemic lupus erythematosus
Systemic sclerosis
Vasculitides
Polyarteritis nodosa
Takayasu Arteritis
Vascular
Renovascular disease - renal artery stenosis, fibromuscular dysplasia
Coarctation of the aorta

Others
Sleep apnoea
Drug-induced or drug related – Cocaine, Amphetamines, Cyclosporin
Clonidine withdrawal, Phencyclidine

21
ANTENATAL MANAGEMENT

 Day care assessment should be considered if the diastolic blood pressure (DBP) is
between 90-100 mmHg and there is no proteinuria.
 If the diastolic is between 90-100 mmHg, the patient can be managed as outpatient
and the following are indicated:
 Full blood count, renal profile and uric acid
 Biweekly blood pressure monitoring
 Follow up patient in 1-2 weeks time

CRITERIA FOR ADMISSION

 DBP > 100 mmHg with or without antihypertensive therapy

 Significant proteinuria
 Evidence of maternal and fetal compromise
 Symptomatic patients
 Patient with biochemical complications

IN PATIENT MANAGEMENT

 Put the patient on pre-eclampsia (PE) chart.

 Four hourly blood pressure and pulse rate monitoring.
 Daily urine protein.
 Weekly weight.
 I/O chart if indicated.
 Watch for signs and symptoms of impending eclampsia.
 Daily palpation and fetal heart auscultation.
 Fundal height measurement weekly.
 Fetal movement chart, CTG and biophysical profile as indicated.
 Investigations:
 Full blood count
 Renal profile and uric acid
 Liver function test
 MSU examination
 MSU culture and sensitivity
 24 hour urine collection for creatinine clearance
 24 hour urine collection for protein
 Clotting studies (only if indicated)
 Ultrasound for fetal growth and well being
 Weekly haematological, renal and liver profile.
 Dexamethasone can be given at 26-34 weeks after consultation with the specialist.

ANTIHYPERTENSIVE THERAPY

 If DBP is ≥100 mmHg after 4 hours, antihypertensive should be started.

 First line oral anti-hypertensive therapy:

~ Alpha Methyldopa (Aldomet) 250 mg 8 hourly

Max. dose 1 g 8 hourly

~ Labetolol (Trandate) 100 mg 8 hourly

Max. dose 400 mg 8 hourly

22
 Double the initial dose if DBP remains ≥ 100 mmHg after 24-48 hour.
 Addition of another anti-hypertensive should only be done after the first-hypertensive
dose has been maximized.
 Second line oral anti-hypertensive therapy:

~ Nifedipine (Adalat) 10 mg 8 hourly

Max. dose up to 30 mg 8 hourly

ORAL HYPERTENSIVE THERAPY

Drug Class/ Type Dose Onset of Action Duration

Alpha Alpha–2 Agonist 250-1000mg 3 – 6H 24 - 48 H

Methyldopa

Labetolol Beta -Blocker 100-400 mg 30 min - 2H 4-6H

Nifedipine Calcium channel 10 – 30 mg 20 – 30 min 3-5H

Blocker

 Sublingual Nifedipine must be ordered by consultant only.

 Start paranteral anti-hypertensive therapy if MAP > 125 mmHg after discussion with
specialist.

Criteria for severe hypertension

 SBP>160mmHg or DBP>110mmHg on two occasions 6 hours apart

 Proteinuria of 3+ or > 3gm/L
 Oliguria (<400ml/24 hours)
 Headache, epigastric pain
 Cerebral or visual disturbances
 Hypereflexia
 Pulmonary oedema
 Impaired liver function
 Impaired renal function (increased serum creatinine of > 1.2 mg/dl)
 Retinal haemorrhage, exudates or papilloedema
 Thrombocytopenia
 IUGR

Aim of treatment

 To prevent cerebro-vascular accident to the mother.

 To prolong the gestational age to a desirable maturity without compromising maternal
health.

Management of severe hypertension

23
 Monitor patient in HDU
 Set up IV line for resuscitative measures
 Monitor BP, PR, RR and FHR every 15 minutes
 Test for proteinuria
 Close monitoring of fluid balance
 If DBP≥110 mmHg start paranteral anti-hypertensive infusion
 Continue oral antihypertensive and increase dosage if necessary
 Consider Magnesium Sulphate infusion
 Monitor urine output
 Fetal monitoring
 Administer steroid if preterm

Timing of delivery

 All patients on oral antihypertensive therapy should be delivered by 38 weeks.

 Those not requiring treatment can be allowed to carry on with the pregnancy up to 40
weeks provided there is no fetal compromise.
 Patient with severe pre-eclampsia but less than 34 weeks gestation – consider
prolongation of pregnancy until the baby is more mature.
 Patients with severe pre-eclampsia after 34 weeks, or with impending eclampsia or
eclampsia at any gestation – aim to achieve delivery within 6 hours after stabilization
of the blood pressure.
 The neonatologist should be alerted in all cases.

Mode of delivery

 Vaginal delivery should be aimed for in the absence of an obstetric contraindication.

 In cases of impending eclampsia and eclampsia, vaginal delivery should be
considered if this is deemed achievable within 6 hours.
 In other circumstances, caesarean section may be necessary.

INTRAPARTUM CARE

 Set up IV line.
 PE charting and monitor BP, PR half hourly.
 Monitor urine output 4 hourly (hourly if on MgSO4), testing for ketonuria and
proteinuria.
 Adequate analgesia – consider epidural analgesia.
 Strict fluid regime.

 Should not exceed 1 – 2 ml/kg/hr or 85 ml/hr whichever is lower

(crystalloids/colloids)
 Maintain urine output > 30 ml/hr (0.5 – 1 ml/kg/hr)
 When CVP is used the pressure should not be higher than 7 cm of H20

 CTG monitoring continuously.

24
 Monitor labour with partogram.
 Short first stage of labour (8 hours).
 Continue antihypertensive treatment if patient has been on treatment.
 IV Hydrallazine should be considered if DBP > 110 mmHg.
 Assist second stage if necessary.
 Avoid use of Syntometrine/Ergometrine. Syntocinon 5-10 units may be used in the
third stage.

POSTPARTUM CARE

Immediate post partum period

 Patient should be monitored in delivery suite for an hour post delivery

 Transfer to high risk postnatal ward (HDU)
 Continue with maternal monitoring
 Maintain strict I/O charting until the patient is discharged from HDU
 Fluid 85 ml/hour (2 litres / 24 hours)
 Consider thromboprophylaxis

First 24 hours

 Monitor BP, PR every 4 hours

 Continue antihypertensive as indicated
 Encourage early mobilization
 Encourage breast feeding
 Observe for maternal signs of deterioration
 Daily urine protein
 Repeat FBC, Renal Profile and uric acid +/- clotting studies 12 hours after delivery

After 24 hours

 Continue antihypertensive – aim for DBP below 100 mmHg

 Counsel patient:
 Compliance to medication
 Compliance to follow up
 To watch for signs of complications
 Contraception
 Discharge if stable

FOLLOW-UP

 If the patient is not on treatment, see 6 weeks later.

 If the patient is on antihypertensive therapy, see 2 weeks later to tail down or stop
treatment. Check her BP biweekly at her own clinic.
 Repeat renal profile and uric acid at 6 weeks if earlier results were abnormal.
 If BP is still high at 12 weeks, refer medical for further management.

INTRAVENOUS ANTIHYPERTENSIVE REGIME

25
HYDRALLAZINE (NEPRESOL) INFUSION REGIME

Rapid control

 IV Hydrallazine bolus 5-10 mg over 20 minutes.

 5 mg can be repeated every 20 minutes.

Maintenance

 Effective dose 1 – 10 mg/hr

 Syringe pump:
 50 mg (4 ml) Hydrallazine in 50 ml normal saline (1 mg/ml)
 Start at 5 ml/hr (5 mg/hr)
 Increase dose every 20 minutes by 1 ml until DBP is between 90-100 mmHg
 Maximum 10ml/hr (10 mg/hr)
 Drip infusion set:
 50 mg (4 ml) Hydrallazine in 500 ml normal saline
 Start at 10 dpm (3 mg/hour)
 Titrate at 5 dpm increasing every 20 minutes
 Maximum 40 dpm (12 mg/hr)

Tailing off

 Reduce the dose by half every 30 minutes

LABETALOL (TRANDATE) INFUSION REGIME

Rapid control

 IV Labetalol bolus 20 -50mg over 1 minute

 Repeat every 5 minute
 Maximum 200 mg

Maintenance

Effective dose 20– 160 mg/hr

 Syringe pump:
 200 mg (40 ml) Labetalol
 Start at 20 mg/hr (4 ml/hr) (40 mg by MOET, HUKM protocol)
 Increase dose every 30 minutes by 4 ml/hr
 Maximum 32 ml/hr
 Drip infusion set:
 200 mg (40 ml) Labetalol in 200 ml 5% Dextrose (1 mg/ml)
 Titrate at 5 dpm increasing every 30 min
 Maximum 60 dpm (180 mg/hr)

Tailing off

26
 Reduce the dose by half every 30 minutes
 Maintenance at 4 ml/hr for few hours before stop the infusion

Contraindications

 Bronchial asthma
 Congestive cardiac failure
 Heart blocks

PEARLS OF MANAGEMENT

 Maternal well being is priority.

 If the gestational age is more than 34 weeks consider delivery.
 Prolonging gestational age beyond 34 weeks is possible if there is no danger to the
mother.
 Pregnancy should be terminated at whatever gestation if the risk to the mother from
uncontrollable hypertension, liver or renal failure exceeds fetal risks.
 Combined medical care with neonatologist, physician, anaeshesiologist and
obstetrician.

References:

1) Lessons from the Malaysian CEMD 2005 Training Manual Hypertensive Disorders in
Pregnancy, MOH

2) Training Manual Hypertensive Disorders in Pregnancy, MOH

3) Clinical Practice Guidelines :Management ofHypertension (3rd Edition, Feb 2008)

4) Managing Obstetric Emergencies and Trauma Course Manual 2003

ALGORITHM ON MANAGEMENT OF PIH AND PE

27
 Pregnancy Induced Hypertension & Pre-Eclampsia

Admit for evaluation of mother and fetus

A B

Mild PIH/PE not requiring PIH/PE requiring treatment

treatment without fetal without fetal compromise
compromise

Discharge & Monitor as C Discharge & Monitor as

outpatient (shared care between outpatient at specialist ANC
Severe PIH/PE
hospital & health centre)

Manage in HDW/LW

If require
antihypertensive
treatment
Control BP with paranteral
antihypertensive

Refer to B

Symptomatic +/- evidence of fetal

/maternal compromise

No
Deliver by 38 weeks / earlier if fetal
Consider adding compromise
Dexamethasone
Delivery by 40 weeks/
earlier if fetal Immediate delivery
compromise
Urgent delivery

ECLAMPSIA

28
Definition

Occurrence of convulsions due to hypertensive disorders in pregnancy.

Sign and symptoms of impending eclampsia

 Severe frontal headache

 Vomiting
 Blurring of vision
 Epigastric pain
 Hypereflexia

Aim of management

 Control convulsions
 Stabilize blood pressure
 Optimize patient
 Deliver fetus

MANAGEMENT

 Call for help and medical assistance as soon as possible.

 ABC of resuscitation.
 Protect maternal airway, prevent patient injury.
 Left lateral positioning.
 Maternal resuscitation:
 Maximum oxygenation (mask or endotracheal oxygen)
 Intravenous access and judicious hydration
 Anticonvulsant therapy.
 Wait for convulsions to abate.
 Maternal post-ictal assessment.
 Blood tests (FBC, Coagulation profile, RP, LFT)
 Careful neurological examination
 Cervical examination
 Prophylactic anticonvulsant therapy to prevent subsequent seizures.
 Monitor BP, PR, RR and FHR every 15 min.
 Blood pressure control.
 Monitor input/output.
 Assess mother and fetus to decide mode of delivery.

Consideration prior to delivery of eclamptic patient

29
 Avoid stat caesarean section.
 Stabilize maternal hemodynamics and oxygenation.
 Assess Bishop Score, maternal and fetal well being once stable.
 Vaginal delivery usually yields the best outcome overall but caesarean section can
be undertaken if Bishop Score is low.
 Normalise coagulation profile prior to caesarean section.
 General anaesthesia is preferred.
 Pediatrician to standby.

POST PARTUM CARE

 Continuous nursing care in ICU/HDU for at least 24 hours post delivery.

 May require cerebral resuscitation.
 Maintain anticonvulsant for 24 hours after the last fit or delivery, which event is later.
 Continue antihypertensive treatment.
 Monitor input/output.
 Consider thromboprophylaxis.
 Encourage early mobilization.
 Encourage breast feeding.
 Observe for maternal signs of deterioration.
 Daily urine protein.
 Repeat FBC, Renal Profile and uric acid +/- clotting studies 12 hours after delivery.
 Counsel patient:
 Compliance to medication
 Compliance to follow up
 To watch for signs of complications
 Contraception
 Keep patient in the ward for 5 days before fit for discharge.

ANTICONVULSANT THERAPY

 The therapy of choice is magnesium sulphate. It is an effective cerebral depressant

and reduces neuromuscular irritability.
 The intravenous route is preferred to the intramuscular route, which is painful and is
complicated by local abscess formation.

MAGNESIUM SULPHATE THERAPY

Intravenous regimen

Loading dose: IV 4 gm MgSO4 slow bolus

 4 gm (8 ml) MgSO4 is diluted in 12 ml normal saline or sterile water to a total volume

of 20 ml.
 Given over 10 – 15 minutes (rapid injection causes cardiac arrest).
 If convulsions persist after 15 minutes, a further 2 gm (4 ml) MgSO 4 diluted in 6 ml
normal saline or sterile water and given over 15 minutes.

Maintenance dose: IV 1 gm/hr MgSO4

30
 Syringe pump:
 10 gm (20 ml) MgSO4 is diluted in 30 ml of 5% dextrose and infused at 5 ml
per hour (1 gm/hr)
 Drip infusion set:
 15 gm (30 ml) MgSO4 in 500 ml 5% dextrose run at 11 drops per minute.

The infusion is only continued if the following criteria are

satisfied:

 Patellar (knee jerk) reflex is present

 Respiratory rate > 16/min
 Urine output > 100 ml over 4 hours
 Serum magnesium level are within the therapeutic range
of 1.7 – 3.5 mmol/L ? 2-4mmol/L

Intramuscular regimen

Loading dose

 10 gm (20 ml) MgSO4 is injected intramuscularly.

 One half (5 gm or 10 ml) is injected into the upper outer quadrant of each buttock
manner (preceded by local anaesthesia if necessary) using 21 gauge needle.

Maintenance dose

 5 gm (10 ml) MgSO4 is injected deep intramuscular in each buttocks every 4 hours

Contraindications for Magnesium Sulphate therapy

 Cardiac disease
 Acute renal failure

Monitoring

 Patellar reflex
 After completion of loading dose
 Hourly whilst on maintenance dose
 Pulse oximetry
 To keep O2 saturation >90%
 Respiratory rate > 16/minute
 Perform magnesium level (therapeutic range 2-4 mmol/L (4-8 mg/dl)) if:
 Urine output < 100 ml/4 hours
 Urea > 10 mmol/L

Management of toxicity

31
 Loss of patellar reflex:
 Stop maintenance therapy.
 Send Mg level urgent.
 Withhold further Mg until patellar reflexes return or Mg level known.

 Oxygen saturation persistently <90%:

 Commence oxygen.
 Stop maintenance therapy and send Mg level.
 Obtain reassessment by anaesthetist.
 Cardiorespiratory arrest:
 Stop maintenance therapy.
 Institute CPR.
 Administer 10 ml 10% Calcium Gluconate (antidote) slow intravenous bolus
over 3 minutes.
 Immediate intubation and assist ventilation until resumption of spontaneous
respirations.
 Send Mg level urgent.

Recurrent seizures

 Treat seizure with a further bolus of IV MgSO4 2-4 g over 5 minutes.

 Take blood for Mg prior to additional bolus.
 If further seizures occur despite above consider:
 IV Diazepam 10 mg bolus followed by infusion
 Refer anaesthetist
DIAZEPAM (VALIUM) THERAPY

Rapid control

 IV Diazepam 10 mg over 1-2 minutes.

Maintenance dose

 40 mg diazepam diluted in 500 ml normal saline (glass bottle).

 Titrate at 10 dpm increasing every 15 min until patient is sedated but arousable.
 Maximum 40 dpm (9.6 mg/hr).

Referrence:

1) Lessons from the Malaysian CEMD, 200

2) Training Manual Hypertensive Disorders in Pregnancy, MOH

DIABETES MELLITUS IN PREGNANCY

32
Diabetes in pregnancy can be either gestational diabetes or established diabetes.
Gestational diabetes mellitus (GDM) is an abnormal glucose tolerance first diagnosed
during pregnancy irrespective of gestation.

Indication for MGTT

 History of diabetes in a first-degree relatives

 Maternal age > 25 years
 BMI > 27kg/m2
 Glycosuria on 2 occasions or in a single fasting urine sample or glycosuria in first
prenatal visist
 Previous history of gestational diabetes mellitus
 History of recurrent abortions
 History of unexplained stillbirth
 Previous big baby (birth weight > 4 kg)
 Congenital abnormality in a previous and current pregnancy
 Polyhydramnios
 Essential Hypertension , Pregnancy Induced Hypertension / current long term use of
steroid in current pregnancy
 Recurrent infection in pregnancy e.g. UTI, vaginal candidiasis

Diagnostic criteria

WHO 1980 criteria for diagnosis of diabetes or impaired glucose tolerance following a
75g oral glucose:

Diagnosis Fasting 2 hours post-prandial

(mmol/L)
(mmol/L)

Normal <6 < 7.8

Impaired glucose tolerance 6 – 7.8 7.8 – 11.0

Diabetes > 7.8 > 11.0

* American Diabetic Association (ADA) uses 5.6mmol/L for fasting

Screening should be done as early as possible in high risk patient and if the result is
normal repeat at 28 – 32 weeks.

PRE-PREGNANCY MANAGEMENT

33
 In established diabetic, it should be a planned event.
 Folate supplement.
 Good diabetic control to reduce the risk of congenital malformation.
 Ideally should have been converted to insulin before pregnancy is embarked.
 Assessment of complications (retinopathy, nephropathy, neuropathy).
ANTENATAL MANAGEMENT

 If a known diabetic on oral hypoglycaemic, it should be stopped immediately and

patient admitted after 3 days for a blood sugar profile.
 If patient diagnosed to have impaired glucose tolerance or diabetic range of blood
sugar from MGTT, a blood sugar profile must also be performed.
 Advice patient on her diet and reinforce on the importance of diet.
 Referral to dietitian.
 If abnormal blood sugar profile, start on insulin therapy depending of the blood sugar
level.
 Maintain blood sugar profile of 4 – 6 mmol/l.
 Repeat BSP every 3 days until satisfactory control.
 Self-monitoring at home if equipment available.
 Perform a detailed ultrasound in established diabetes or early onset GDM.
 Monitor for maternal complications of diabetes in pregnancy such as hypertension,
infections, hyperglycaemia, hypoglycaemia and worsening of retinopathy,
nephropathy or neuropathy.
 Monitor fetal growth and well being (fetal movement chart, ultrasound and CTG when
indicated).
 Serial ultrasound every 4 weeks to detect fetal complications such as macrosomia or
polyhydramnios.
 Determine the time and mode of delivery.
 In uncomplicated diabetes not on insulin therapy with normal fetal growth and well
controlled blood glucose level, delivery is aimed at 38 – 40 weeks.
 GDM / pre-existing diabetic on insulin therapy, delivery is aimed at 38 weeks or
earlier if indicated.
 If require preterm delivery, steroid therapy to enhance fetal lung maturation has to be
considered. In poorly control diabetic patients, it should be done in the hospital with 2
hourly blood glucose determinations. Insulin infusion may be required.
 Caesarean section is performed for obstetric indication.

INDUCTION OF LABOUR

Prostaglandin

 Pre-existing insulin dosage should be continued.

 Meals and snacks are allowed.

Syntocinon

34
 Induction is started at 6.00 a.m.
 Keep nil by mouth.
 Omit morning dose insulin.
 Take blood investigations (FBC, GSH, RBS, BUSE).
 Start her on insulin infusion according to glucometer.
 If patient on diet modification only, insulin infusion is started only if glucose level ≥ 7.0
mmol/l.
 Monitor glucometer hourly and adjust her insulin regime according to sliding scale.
Blood sugar should be maintained 4 – 6 mmol/l.
 4 hourly RBS, BUSE, urine acetone.
 Start on partogram.
 Oxytocin regime as protocol.
 Labour should not be prolonged.
 Adequate analgesia.
 Should any additional intravenous fluids be necessary during labour, isotonic saline
or Hartmann’s solution should be used.
 Monitor fetus with intermittent CTG.

ELECTIVE CAESAREAN SECTION

 First on the list if possible.

 She should be fasted from 12 midnight.
 Omit morning dose subcutaneous insulin.
 Plasma glucose estimation is done at 6.00am.
 Insulin infusion is required as per sliding scale.

POSTPARTUM

 Perform glucometer to baby.

 Encourage early breast feeding.
 Refer baby to Paediatrician if fetal macrosomia (> 4kg) or persistent neonatal
hypoglycaemia (<2.6 mmol/l).
 Following delivery, if patient is GDM/IGT, insulin infusion can be stopped immediately
but monitor glucometer for initial 24 hours.
 If patient is a known case of diabetes, continue her insulin infusion until 1 hour after
resuming pre-pregnancy treatment which may be given once patient starts taking
orally.
 Advice on contraception.
 Perform MGTT at 6 weeks post partum in GDM/IGT patient.

35
INSULIN REGIME

Solution

Mix 50 units of soluble insulin / Actrapid and 50 ml of normal saline in a 50 ml syringe.

This gives a concentration of Insulin 1 unit/ml.

Insulin infusion requirement

Insulin infusion requirement should be based on the sliding scale regime.

Glucometer (mmol/l) Insulin infusion

<4 Omit insulin

4–7 1 unit / hour

7.1 – 10 2 unit / hour

10.1 – 15 3 unit / hour

15.1 – 20 4 unit / hour

All diabetic mothers in labour should have a maintenance drip Dextrose 5%, at
100ml/hour.

Add 1g KCL in each 500 ml of Dextrose 5%.

Any electrolytes imbalance should be corrected accordingly based on serial monitoring

of blood investigations.

36
 HEART DISEASE IN PREGNANCY

Heart disease remains the commonest non-obstetrics cause of maternal death in

Malaysia accounting for 10% of all maternal death in 1996. The most common disorders
are rheumatic valve disease, congenital heart disease and cardiomyopathy.

PRE-CONCEPTUAL COUNSELLING

 The effect of haemodynamic changes on the patient

 The effect of the cardiac disorder on fetal development
 The effect of maternal drugs on the fetus
 The risk of genetic transmission to the fetus
 The compliance of the patient
 Correction of significant heart lesions prior to pregnancy

THE NEW YORK HEART ASSOCIATION (NYHA) FUNCTIONAL CLASSIFICATION

CLASS SYMPTOMS

Class I No limitation of physical activity.

Class II Slight limitation of physical activity. Comfortable at rest. Ordinary

physical activity results in fatigue, dyspnoea or angina.

Class III Marked limitation of physical activity. Comfortable at rest but

minimal exertion lead to symptoms.

Class IV Inability to carry on any physical activity without symptoms

MORTALITY RISK ASSOCIATED WITH PREGNANCY

Low risk (Mortality <1%)

 Uncomplicated septal defects

 Pulmonary stenosis
 Aortic and mitral regurgitation
 Corrected transposition without other defects
 Acyanotic Ebstein’s anomaly
 Hypertrophic cardiomyopathy

37
Moderate risk (Mortality 5-15%)

 Prosthetic valves on anticoagulants

 Coarctation of aorta
 Univentricular circulation after Fontan operation

High risk (Mortality 25-50%)

 Pulmonary hypertension (pulmonary pressure >75% of systemic pressure)

 Eisenmenger syndrome
 Cyanotic heart disease
 Severe aortic stenosis (valve area < 1.0 cm2)
 Severe mitral stenosis (valve area < 1.0 cm2)
 Poor left ventricular function (LVEF <40%) irrespective of etiology
 Marfan syndrome (aortic root diameter >40mm)

ANTENATAL MANAGEMENT

 Assess maternal and fetal health.

 Assess maternal NYHA functional class.
 Confirm the clinical diagnosis.
 Combine management with cardiologist.
 Review the patient’s medication.
 Establish baseline hemodynamics (e.g. LVEF and pulmonary artery pressure by
echocardiogram, oxygen saturation).
 Consider elective termination of pregnancy in high risk group.
 Detection and treatment of aggravating factors including infections, anaemia,
hypertension and arrhythmias.
 Identify, admit and manage the complications of heart disease (e.g. heart failure,
worsening of the right to left shunt, thromboembolism and arrhythmias). They should
remain in hospital till delivery.
 Fetal echocardiogram if mother has congenital heart disease.
 Antibiotic prophylaxis during procedures.
 Admit all high risk patients during the third trimester.
 Determine the timing and mode of delivery – individualized after discussion with the
specialist physician, anaesthetist and obstetrician.
 Planned caesarean section may be offered to high risk situations.

LABOUR MANAGEMENT

First stage

 Spontaneous labour is preferred to induction.

 Combine management with cardiologist, anaesthetist, obstetrician and paediatrician.
 Supplemental oxygen.
 Encourage to lie in the lateral position to avoid caval compression.
 Careful haemodynamic monitoring throughout labour.
 Continuous ECG monitoring to detect arrhythmias.
 Arterial saturation by pulse oximetry.
 Blood pressure and pulse rate half hourly.

38
 Occasionally, central venous pressure measurements may be required.
 Close monitoring of fluid therapy to avoid pulmonary oedema.
 Regular auscultation of the lungs (2 hourly).
 If require augmentation, Oxytocin can be given in concentrated dose.
 Adequate pain relief with intravenous narcotics. Epidural is the technique of choice if
no contraindication.
 Prophylactic antibiotics to all patients susceptible to bacterial endocarditis.
 Fetal monitoring with CTG.
 LSCS for obstetrics reason.

Second stage

 Not to put in lithotomy position.

 Shortened second stage by instrumental delivery.

Third stage

 Avoid Syntometrine / Ergometrine.

 Give IM Syntocinon 10u at delivery of anterior shoulder.
 Try to minimise bleeding.
 Keep in HDU for 4 – 6 hours.

POST PARTUM MANAGEMENT

 Hospital stay depends on clinical status. Generally keep in ward for 5–7 days.
 Advice bed rest with allowance for normal activity as tolerated.
 Continue anticoagulant if required.
 Encourage breast feeding (except on ACE inhibitor / amiodarone).
 Advice on medical treatment, corrective surgery and follow up with the Cardiologist.
 Counselling for future pregnancy after consultation with Cardiologist.
 Advice on contraception (e.g. barrier method, progestogen only pills/ injectables,
IUCD, tubal ligation).

Antibiotic prophylaxis

Standard Regimen

Ampicillin IV or IM Ampicillin 2.0 gm +

Gentamicin IV or IM Gentamicin 1.5 mg/kg body weight (not to exceed
80mg) 30 mins before procedure, followed by:-
Amoxcillin 1.5 gm orally 6 hours after initial dose or
Amoxicillin repeat paranteral regime 8 hours after initial dose

Penicillin Allergic Patient

Vancomycin and IV Vancomycin 1.0 gm over 1 hour +

Gentamicin IV or IM Gentamicin 1.5 mg/kg body weight ( not to exceed
80 mg)
1 hour before procedure and repeat 8 hours later

39
ANTICOAGULANT THERAPY IN PREGNANCY

Indications

 Mechanical heart valves

 Deep venous thrombosis & thromboembolism
 Atrial fibrillation associated with structural heart disease
 Miscellaneous conditions (e.g. peripartum cardiomyopathy, primary pulmonary
hypertension, Eisenmenger syndrome, complex congenital heart disease)

ORAL ANTICOAGULANTS

 Warfarin during pregnancy is associated with warfarin embryopathy in 4-10% of

newborns.
 The likelihood of fetal complications appear to be significantly higher if the Warfarin
dose is more than 5 mg daily.

UNFRACTIONATED HEPARIN

 Does not cross the placenta.

 Requires paranteral administration.
 It requires the monitoring of the Activated Partial Thromboplastin Time (APTT).
 Can be given subcutaneously twice a day (dose adjusted to achieve APTT ratio of
1.5 – 2.5, checked 4 – 6 hours after injection) or intravenously.
 Complications related to long term Heparin use include abscesses, hematomas,
thrombocytopenia and osteoporosis.

LOW MOLECULAR WEIGHT HEPARIN (LMWH)

 Does not cross the placenta.

 Does not require APTT monitoring.
 Fewer complications of thrombocytopenia or osteoporosis.

Options during pregnancy

Option I: Combined Heparin & oral anticoagulants

 First trimester Unfractionated Heparin / LMWH

 Second trimester till 36th week Warfarin
 From 36th week Unfractionated Heparin / LMWH

Option II: Full dose Heparin throughout pregnancy

Option III: Continuous Warfarin therapy

 First trimester till 36th week Warfarin

 From 36th week Unfractionated Heparin / LMWH

40
 There is no completely safe method of anticoagulation during pregnancy.
 Should be counselled prior to conception.
 The choice of which should be decided in consultation with patient and her family.
 In patients with high risk of thromboembolism (e.g. mechanical heart valves and
mitral stenosis with atrial fibrillation) Option III is advocated.
 Should the patient choose Option I or Option II, she should be made aware of the
higher risk of valve thrombosis and thromboembolism.

Labour management

 Combine management with medical team.

 Insert IV cannula.
 Take blood group cross match, FBC, coagulation profile.
 Consider stop anticoagulation during labour and restart 6H after delivery.
 Consider FFP/vitamin K if last dose of Warfarin < 48 hours before labour.

Post partum management

 Continue Heparin for 3 days then change to Warfarin.

 Breast feeding is not contraindicated as secretion is insignificant in breast milk.

Reference:
Clinical Practice Guidelines on Heart Disease in Pregnancy, 2001

41
 GUIDELINES FOR MANAGEMENT OF
HIV MOTHERS

 The management of HIV positive women during pregnancy is multified, combining

infectious disease physician, obstetrical management, public health personnel to
ensure compliance and follow up.
 Counseling and social support should be enforce for optimal care.
 Mother-to-child transmission (MTCT) is the most common and important ource of HIV
infection in childhood. In the absence of any intervention, between 30% and 45% of
children born to HIV positive mothers will become infected with HIV; the lower end of
the range applies to higher income country settings, while the upper end of the range
applies to lower income, higher prevalence settings.
 Transmission is believed to be uncommon during early pregnancy, but the risk
increases sharply in late pregnancy and during labour and delivery.
 Overall, about 15-20% of children who acquire HIV infection from their mothers are
infected during the antenatal period, 50% during delivery and 33% through breast
feeding.
 With the use of ARV therapy, elective caesarean delivery and avoidance of
breastfeeding, the MCT will reduce the vertical transmission risk to below 2%.
 After delivery, the patient should be followed up by the physician.
 The baby will be followed up by pediatricians.

ANTENATAL MANAGEMENT

Screening

“Test unless refused” or “routine screening with the option to opt out” policy.

Notification

Notification of case to health department using designated form.

Under the Infectious Disease Act 342 (1988), health care providers are legally bound to
notify the local health authority anyone found to be HIV positive.

Counselling

Confidentiality must be respected and ensured.

 Personal prognosis based on lymphocyte subset and viral load, if available.

 Illicit drug use (where relevant).
 Counselling and HIV testing for the spouse / partner.
 Risk of Mother-to-child-transmission (MCTC).
 Neonatal prognosis, natural history of HIV in children.
 Benefits of ZDV therapy for mother and baby.
 Possible ZDV side-effects to mother and baby.
 No method of prenatal diagnosis as MCTC risk is highest during intrapartum.
 Breast feeding is contraindicated.

42
43
44
Clinical assessment

 History
 HIV/AIDS related symptoms (weight loss, anorexia, recurrent or prolonged
fever, recurrent diarrhea, cough etc)
 Previous pregnancies and clinical status of family members
 Past medical history (anaemia and liver disease may affect the decision to
commence ZDV)
 Social history
 Clinical examination
 HIV/AIDS related clinical signs such as oral thrush, oral hairy leukoplakia,
lymphadenopathy and other stigmata (skin manifestation, chest infection,
hepatosplenomegaly, anaemia, genital lesions eg. Herpes, cervical dysplasia)

Precautions for hospital staff in labour room and operating theatre

 Medical personnel handling the patient should be kept to a minimum.

 Staff should take appropriate precautions to avoid infection, although the danger
appears significantly less compared to Hepatitis B and C.
 Staff should exercise reasonable care to avoid accidentally injuring themselves by
wearing gloves and goggles during venepuncture. Biological specimens such as
blood and urine should be clearly labelled as biohazard. Wash their hand before and
after handling patient and contaminate items.
 A delivery room should be fitted with disposable laundry and equipment for mother
and infant.
 Impermeable gowns, caps, masks, gloves and goggles should be worn during
vaginal examination, amniotomy, delivery, cutting the cord and management of the
third stage.
 Disposable gowns and drapes should be utilized for the caesarean section and
delivery.
 Special needle (e.g. Protect Point) for caesarean section and episiotomy repair.
 Spilled blood, secretions and excretion should be immediately treated with undiluted
sodium hypochlorite (10% solution) and cleaned off with ample water after 5 – 10
minutes.
 Transabdominal / transvaginal ultrasound probe used should also be cleaned with
sodium hypochlorite. Transvaginal prove should be avoided if possible.
 The placenta should be chemically treated with formalin before disposal by
incineration:
 Completely immerse placenta in 10% formalin saline in a plastic bag for 24
hours. Puncture the plastic bag in several places before disposal.
 If placenta is required to be washed e.g. according to Muslim rites, the
placenta may be buried in cloth or paper immediately after washing.

45
MANAGEMENT OF HIV PREGNANT WOMEN

1) There should be a proper referral pathway for these patients to the combined clinic.

2) Interventions to reduce the risk of HIV transmission should be discussed with the
women. These measures would

 include the use of ARV therapy

 elective caesarean delivery
 avoidance of breastfeeding

3) All HIV positive women should be examined for genital infections and treated
appropriately. If negative, the examination should be repeated at 28 weeks.

4) Co-infections (Hepatitis B, Hepatitis C, syphilis, gonorrhoea, toxoplasmosis and

chlamydia) should also be screened in these women.

5) Invasive diagnostic procedures such as chorionic villous sampling, amniocentesis or

cordocentesis should be avoided where possible due to a possible risk of infection of
the fetus. External cephalic version of a breech fetus may be associated with
potential maternal-fetal circulation leaks and the advantages and disadvantages of
the procedure should be very carefully considered.

ARV therapy is given for two reasons during pregnancy

1) For the prevention of MTCT and

2) For the treatment of mother to prevent maternal disease progression (therapy
continued indefinitely after delivery)

Recommendations to start antiretroviral therapy

1) Women require antiretroviral therapy to prevent mother-to-child transmission of HIV

2) Women should be advised to take antiretroviral therapy during pregnancy and during
delivery
3) Combination of more than three or more antiretroviral drugs is recommended for all
HIV pregnant mothers to reduce mother-to child transmission of HIV
4) Antiretroviral therapy should be started as early as possible in pregnancy after the
first trimester
5) Adherence to antiretroviral therapy is of utmost importance in the success of
treatment
6) A detailed anomaly ultrasound should be performed for all foetus exposed to HAART
during the first trimester

The current treatment of pregnant women infected with HIV has evolved from
monotherapy to Highly Active Anti-Retroviral Therapy (HAART). Zidovudine (ZDV) has
been the most extensively studied ARV in pregnant women and forms a component of
treatment in most trials. This recommendation takes into consideration compliance,
logistic issues and a vertical transmission rate of 2%. However in selected patient triple
therapy, HAART, should be seriously considered.

Pregnancy should not preclude the use of optimal therapeutic regimens.

46
However, recommendations regarding the choice of antiretroviral drugs for treatment of
infected pregnant women are subject to unique considerations,includinG
 The potential effects of antiretroviral drugs on the pregnant woman,
 The potential short- and long-term effects of the antiretroviral drug on the fetus and
newborn.

Avoid the combination of Stavudine plus Didanosine as part of the triple Therapy
whenever possible, due to case reports of fatal lactic acidosis in pregnancy.

The decision to use any antiretroviral drug during pregnancy should be made by the
woman after discussing with her health-care provider the known and unknown benefits
and risks to her and her foetus. ARV should be initiated by Physician/ ID Physician
and /or Obstetrician. The patients will be monitored in the combined clinic.
Adherence to ARV therapy is of vital importance for the success of treatment and
pregnant women may need extra support and planning in this area, especially if there
are practical or psychosocial issues that may impact adversely on adherence.

Where ARV therapy is not required during pregnancy for maternal health, a combination
of three drugs to suppress HIV viral replication may be prescribed for the duration of
pregnancy and after delivery to reduce transmission: administered correctly, this will
preserve future maternal therapeutic options. In this scenario, ARV therapy is usually
discontinued at, or soon after delivery.

In most circumstances initiation of ARV therapy should be delayed until after the first
trimester unless early initiation is judged important for maternal health.

Delaying the initiation of HAART after the first trimester minimizes the risk of drug related
teratogenecity and usually results in better adherence as the nausea associated with
pregnancy has usually diminished by this time

Recommendations for HIV pregnant women with CD4 T cell count > 250 cells/Ul

 Short term antiretroviral therapy (START) should be initiated after the first trimester
 The preferred first line regime is zidovudine (ZDV), lamivudine (3TC) and
lopinavir/ritonavir
 Full Blood Count should be done 2 weekly for the first month and then monthly
 Modified glucose tolerance test (MGTT) should be done after initiating START
 CD4 count should be monitored 4 monthly
 Plasma HIV viral load should be done at 34-36 weeks of gestation
 Intrapartum intravenous zidovudine (ZDV) should be given
 The decision to stop or continue START (zidovudine+lamivudine+lopinavir/ritonavir)
post delivery should be individualized after discussion with the ID physician/physician

Recommendations for HIV pregnant women with CD4 T cell count < 250 cells/uL

 The preferred first line for HAART regime is zidovudine (ZDV), lamivudine (3TC) and
nevirapine (NVP)
 For women who have NVP intolerance or allergy, please refer to ifectious disease
physician
 Full Blood Count and Liver Function Test should be monitored two weekly for the first
month after initiating HAART and then monthly
 CD4 counts should be monitored 4 monthly in women on HAART

47
 Plasma HIV-1 RNA levels should be monitored in all women on HAART at baseline
and at 34-36 weeks gestation
 Intrapartum zidovudine (ZDV) should be given to women
 Zidovudine (ZDV), lamivudine (3TC) and nevirapine (NVP)/combination therapy
should be continued post delivery and for life for the mother
 Women with a CD4 + T-lymphocyte count of < 200/μl should receive PCP
prophylaxis with TMP/SMX (Trimethoprim-Sulfamethoxazole).

There is mixed evidence linking ingestion of Trimethoprim-Sulfamethoxazole (TMP/SMX:

co- trimxazole) and other sulfonamides in early pregnancy to increase risk of oral clefts,
neural tube defects, and cardiovascular and urinary tract abnormalities.

The benefit of improved morbidity and mortality with TMP / SMX prophylaxis
among these high-risk women may outweigh the small risk to the foetus.
Recommendations for women diagnosed in labour without prior therapy

Regardless of the mode of delivery, provide prophylactic ARVs as follows:

 Intrapartum intravenous zidovudine (ZDV)
- loading dose 2mg/kg body weight, then followed by 1mg/kg per hour infusion
until third stage of labour
 Oral lamivudine (3TC) 150mg q12H or 300mg once daily
 Single dose ral nevirapine (sdNVP) 200 mg during delivery

AND
 Continue oral zidovudine (ZDV) 300mg BD for one week to the mother
 3TC (lamivudine) 150mg q12H or 300mg once daily for one week post delivery
for the mother.

Recommendations for women stable on HAART

 Women should continue their HAART regime (unless they present in the first
trimester on efavirenz).
 Plasma HIV-1 RNA levels and CD4 should be monitored 4 monthly.
 They should receive careful, regular monitoring for potential toxicities.
 Intrapartum zidovudine (ZDV) should be given to women

Recommendation for management of ruptured membranes

The duration of ruptured membranes increases the risk of perinatal transmission

therefore Caesarean section is of doubtful benefit after 4 hours of membrane rupture

Recommendations for mode of delivery and viral load

 Elective caesarean section is recommended about 38 weeks for those not on

treatment, those who are on zidovudine monotherapy or those with START/ HAART
but with a viral load of more than 1000 copies/ ml.
 Those who are treated with START/ HAART with a viral load of less than 1000
copies / ml may opt for a vaginal delivery

48
Review by paediatrician

 The patient should be referred at least once to the Paediatrician before delivery to
allow them the opportunity to inform the mother on the follow up plan, ARV schedule
for the newborn and the importance of abstaining from breast-feeding.
 Newborn should be commence of syrup ZDV 2 mg/kg per dose every 6 hours,
beginning 8-12 hours after birth and continue throughout the first six weeks of life.
 There is 5% risk of neonatal transmission with breastfeeding. Therefore HIV positive
mothers must not breastfeed their babies

Recommendations for breastfeeding

 All HIV infected mothers should be advised not to breastfeed their infants as it is
associated with a higher risk of vertical transmission.
 Families should be counselled against mixed feeding at any time, as it has carries a
higher risk of mother-to-child transmission than exclusive breastfeeding or formula
milk feeding

Recommendations for post natal care

 Confidentiality should be maintained at all times regarding the patient’s diagnosis.

 Community health care personnel i.e. public health nurses should be informed when
a mother is discharged to their area and the potential complications.
 Community health care personnel should provide support and counselling to help the
mother to adhere to her antiretroviral regime
 Community health care personnel must help to ensure the mother and her baby
attend their follow up visits to the Infectious Diseases Clinic and Paediatric Clinic
 The health care provider should be vigilant for signs of depression.
 Breast feeding should be avoided and lactation suppression provided when
necessary

Recommendations for contraception

 The condom is the only contraceptive method proven to prevent both pregnancy and
sexual transmission of HIV.
 If an intra uterine device or hormonal contraception is to be considered, they must
be used together with the condom
 There is no medical indication for permanent sterilization of HIV infected individuals

Termination of pregnancy- no longer discuss in this current issue due to better

initial treatment options,

This is only considered if the mother’s life is in danger (terminal stage HIV disease).
Each case should be individually assessed by the attending physician or obstetrician and
gynaecologist. Referral to psychiatrist for mental health assessment should be
considered.

Reference:
1) Management protocol for the HIV-infected pregnant mothers, October 2004
2) Clinical Practice Guideline: Management of HIV Infection in Pregnant Women,
February 2008

49
 ANTEPARTUM HAEMORRHAGE (APH)

Definition

Any bleeding from the genital tract after 22 weeks of gestation

Causes
 Abruptio placenta
 Placenta Praevia
 Vasa Praevia
 Indeterminate APH
 Uterine rupture
 Local causes

General management
 Ask a quick but thorough history.
 Check BP and pulse rate.
 Assess amount of blood loss.
 Look for any evidence of hypovolaemic shock and activate Red Alert if necessary.
 Resuscitate patient.
 Two large bore (14G/16G) intravenous access lines for fluid resuscitation and blood
transfusion.
 Oxygen therapy (5L/min through ventimask).
 Full Blood Count (FBC).
 Coagulation profile.
 Group and crossmatch.
 Evaluate the pregnancy and cause of bleeding.
 Insert CBD to assess renal function/hydration.
 IM Rhogam in non-sensitized Rhesus negative patient.
 Further management depending on the cause and after discussion with specialist.

Pregnancy assessment
 Period of amenorrhoea
 Uterine size
 Uterine activity and tenderness
 Fetal condition & well being (perform CTG once mother is stable).
 Lie and presentation
 Placental localisation if not previously done
 Digital examination only after placenta praevia is ruled out by ultrasound

50
PLACENTAE PRAEVIA

Clinical presentation

 Painless per vaginal bleeding

 Soft and relaxed uterus
 High presenting part. Malpresentation is common.
 Fetal heart sound usually present

Management

 Patient’s assessment and resuscitation.

 Ultrasound scan examination should only be done after stabilizing the patient.
 Selected patient may require speculum examination (when patient has been
stabilized) to rule out cervical causes of bleeding.
 May require observation in HDU.
 Keep cross-match in reserve.
 Keep patient nil orally for the first 12 hours even if patient had only minimal bleeding.
 Monitor for any contractions or excessive bleeding.
 Consider steroid for fetal lung maturation if gestation < 36 weeks.

Indication for immediate delivery

 Profuse and life threatening bleeding irrespective of fetal viability or maturity.

 Fetus > 36 weeks gestation.
 Patient in labour.

Expectant management

 Light bleeding or has stopped.

 Fetus < 36 weeks. To complete antenatal steroid.
 Keep patient in ward until delivery.
 Cross match in reserve.
 Correct anaemia if present. Ensure haemoglobin ≥ 10 g/dl at all time.
 Elective caesarean section in placenta praevia major at 38 weeks by an experienced
operator.

51
ABRUPTIO PLACENTA

Clinical presentation

 Painful per vaginal bleeding

 Tense, tender and rigid uterus
 Fetal heart sound may be absent or fetal distress

Management

 Patient’s assessment and resuscitation.

 Correct coagulopathy if present with transfusion of blood and blood products.
 Assess fetal status.
 Plan for delivery after discussion with specialist.
 Factors need to be considered:
 General condition of the patient
 Haemodynamic stability
 Maturity of the fetus
 Favourability of the cervix
 Anticipate postpartum haemorrhage in all cases of abruptio placenta.

Vaginal delivery

 Favourable cervix
 Reactive CTG
 Intrauterine death (not to allow prolonged labour)

Caesarean section

 Unfavourable cervix
 Fetal distress
 Severe abruption (after resuscitation).
 Other obstetrics indication

52
 ALGORITHM FOR THE MANAGEMENT OF ANTEPARTUM HAEMORRHAGE

Antepartum vaginal bleeding

Massive bleeding

Call for help

Evaluate ABCs

Administer IV fluids

Administer supplemental oxygen

History and physical examination

Fetal monitoring

Severely Uterine pain? Inflammed cervix

Normal `bloody distressed fetus or discharge
show’ (especially if the
bleeding began
abruptly with the No pain or pain only Pain between Probable cervical
rupture of with contractions, contractions or infection
Routine membranes) non tender fundus tender fundus
evaluation

Culture and treat

as appropriate
Suspect placenta Consider Consider uterine
Suspect vasa praevia abruption rupture
praevia placentae

Consider urgent
Immediate
Monitor fetus and laparotomy
ultrasound
mother, supportive care
examination
ifavailable

Distressed fetus Death of fetus

Urgent caesarean Caesarean

delivery delivery if in Consider urgent Vaginal
labour caesarean delivery delivery
53
 ANAEMIA IN PREGNANCY

WHO: Haemoglobin level of < 11 g/dl

Malaysia: Haemoglobin level of < 10 g/dl

PROPHYLAXIS

Treatment for all mothers at > 16 weeks of gestation consisting of:

 Ferrous Fumerate 200mg daily

 Folic Acid 5 mg daily
 Vitamin B Complex 1 tab daily
 Vitamin C 2 tab (100 mg) daily

Antenatal management

Haemoglobin level Treatment

Mild (8 – 10 g/dl) Oral haematinics or paranteral iron therapy.

Moderate (6 – 8 g/dl) Depending on period of gestation:

 < 36 weeks gestation

Treat with oral haematinics or paranteral iron therapy.

If symptomatic admit to hospital.

 > 36 weeks gestation

Paranteral iron in therapy.

Consider blood transfusion.

Severe (< 6 g/dl) Blood transfusion with 2 units packed cells.

54
Investigations for anaemia

 Full blood count

 Full blood picture
 Peripheral blood film
 Serum iron level
 Total iron binding capacity
 Ferritin level
 Haemoglobin electrophoresis if required
 Serum folate if required
 Stool examination to exclude helminthic infection
 UFEME

ORAL HAEMATINICS THERAPY

 May be started prior to confirmation of iron deficiency anaemia.

 Haemoglobin level must be rechecked one month after commencement of oral iron
therapy.
 If haemoglobin level not increased:
Check compliance

 Check result investigation

 Iron deficiency confirmed: start paranteral iron therapy
 Iron deficiency not confirmed: investigate for other cause of anaemia.
Dosage

 Ferrous Fumerate 200mg tds

 Folic Acid 5 mg bd
 Vitamin B Complex 1 tab daily
 Vitamin C 2 tab (100 mg) bd

PARANTERAL IRON THERAPY

A. IMFERON / IRON DEXTRAN : category C FDA

Available in 2mL syringe dose amber vials ( for intramuscular / intravenous use ),
containing 50mg of elemental iron per mL.

Indications

 Not compliant to oral iron treatment

 Failed oral therapy
 Should only be given after iron deficiency anaemia has been confirmed.

Dosage

Dose= 0.0442 x (Desire Hb – Current Hb) x weight (kg) + 0.26 x weight (kg)

55
 In pregnancy, a further 10 ml Imferon is to be added to the dose.
 Given in divided doses
 A test dose ( 0.5 ml / 25 mg iron ) must be given prior to the full intramuscular /
intravenous dose. It is given in the hospital. Subsequent doses may be given at the
health centre/clinic - for intramuscular injection and as Day care treatment for
intravenous injection.
 Watch for anaphylactic reaction / other side effects.

INTRAMUSCULAR INJECTION

 It is given by deep intramuscular injections into the muscular mass of the upper outer
quadrant of the buttocks.
 To avoid injection or leakage into the subcutaneous tissue, a Z-track technique
( displacement of the skin laterally prior to injection ) is recommended.
 Divided doses of 4 ml ?? ( not to exceed 100 mg of iron / 2ml ) each to be given
daily or on alternate days into alternate buttocks until the total dose required has
been administered.

INTRAVENOUS INJECTION

 Should received test dose of 0.5ml ( administered at a gradual rate over at least 30
seconds )
 It is recommended to wait for an hour before the remainder of the initial therapeutic
dose is given
 Individual doses of 2ml or less may be given on a daily basis until the calculated
total amount required has been reached
 Given undiluted at a slow rate not to exceed 50mg ( 1mL ) per minute.
 Oral haematinics are not necessary when iron is given by paranteral route. However,
Folic acid 5 mg daily is given as a routine.
 Haemoglobin level must be rechecked one month from the commencement therapy.
If there is no increase in the haemoglobin level, further investigation must be done.

B. VENOFER ( IRON SUCROSE ) – category B FDA

 Available in 10 mL single use vials ( 200 mg elemental iron per 10ml ) , 5 mL single
use vials and 2.5 mL single use vials ( 20mg elemental iron per mL )
 Also contains approximately 30% of sucrose ( 300mg/mL)
 Side effects : hypersensitivity , hypotension , anaphylactic reaction, shortness of
breath , swelling in the hands / feet / ankles , blurring of vision , tinnitus , anxiety ,
confusion , diarrhea , constipation

Dosage

Dose = Pre pregnancy weight x ( target – current Hb ) x 0.24 + 500mg

Administered in divided doses intravenously , slow over 2-5 minutes or as infusion

( dilute with 0.9% NaCl at concentrations ranging from 1 mg to 2 mg of elemental iron
per mL )

56
Intrapartum management

 IV cannula in situ.
 Delay / avoid episiotomy unless absolutely necessary.
 Rapid and proper repair of episiotomy / perineal tear.
 Mild:
 GXM 2 units.
 Moderate:
 Consider slow intrapartum transfusion.
 GXM 2 units.
 Severe:
 Intrapartum transfusion of 2 units of packed cells slowly with IV Lasix 40 mg
in between each unit of blood transfused.
 GXM another 2 units.

Postpartum care

 Mild:
 Oral haematinics
 Moderate:
 Oral haematinics or
 Imferon injection
 Severe:
 To discuss with specialist regarding the need for transfusion

THALASSAEMIA

Recommendation

 MCH level of ≤ 27 pg should be used as a threshold for identification of carriers in

thalassaemia screening
 Diagnosis of thalassaemia should include PBF, haemoglobin electrophoresis, H-inclusion test
and HPLC
 DNA tests should be done when there is inability to confirm a haemoglobinopathy by
haematological tests
 Genetic counselling should be provided by an appropriately trained professional
 Prenatal diagnosis should be discussed regardless of religious and cultural background
 All thalassaemia patients with delayed puberty should be treated in an appropriate sequential
manner
 For induction of puberty, ethinyl oestradiol or conjugated oestrogen preparation can be used
in girls and testosterone injection in boys.

Antenatal management

 Supplement of 5 mg folic acid daily.

 Oral haematinics can be given if iron store is inadequate.
 Maintain haemoglobin 8 – 10 g/dl.
 Consider blood transfusion if haemoglobin cannot be maintained.
 Do not give paranteral iron.

57
 FLOW CHART SHOWING THE SCREENING FOR THALASSAEMIA AND Hb
VARIANT

Full blood count

MCV < 80
MCH < 27

Hb analysis
Treat with iron

Hb A2 Normal

Hb A2>4% Hb variants
eg: Hb E
Iron deficiency
Iron studies

Normal iron

DNA analysis

Alpha thal carrier Beta thal carrier

GENETIC COUNSELING

58
 RHESUS NEGATIVE MOTHER

The development of anti-D antibodies usually results from fetomaternal haemorrhages

occurring in Rhesus negative women who carry a Rhesus positive fetus. The
administration of anti-D Immunoglobulin (RhoGAM) has been widely practised.

ANTENATAL MANAGEMENT

 Antenatal follow up in hospital.

 Details of past medical/obstetric history:
 History blood transfusion
 History of induced/spontaneous abortion
 History of RhoGAM injection during previous pregnancy
 Blood group of previous babies
 Inform mother regarding the importance of Rhesus type and any sensitising event.
 Check husband’s blood group and Rhesus type.
 Regular Coomb’s test (indirect) at 28, 32 and 36 weeks.
 If the Coomb’s test is positive, the specialist should be informed and advise regarding
further management. Do not give RhoGAM to a patient who’s positive for antibodies.
 Routine antenatal RhoGAM in non-sensitised patient at 28 and 34 weeks or when
indicated.
 Advise for hospital delivery.
 Allow normal vaginal delivery if there is no obstetric contraindications.

Indications for antenatal RhoGAM

 Spontaneous abortion
 Threatened abortion
 Therapeutic termination of pregnancy
 Antepartum haemorrhage
 External cephalic version
 Trauma to abdomen
 Invasive prenatal diagnosis (e.g. amniocentesis, fetal blood sampling)
 Intrauterine death

INTRAPARTUM MANAGEMENT

 Check antenatal history.

 Inform the blood bank.
 Confirm 2 units of whole blood.
 Labour monitoring / augmentation as in normal case.
 Fetal monitoring.
 At delivery, take cord blood for:
 Haemoglobin
 ABO grouping
 Rhesus type
 Coomb’s test
 Serum bilirubin
 Inform paediatrician if the mother is sensitised.

59
POSTPARTUM CARE

 RhoGAM intramuscular should be given within 72 hours if:

 Baby is Rhesus positive
 Mother is Coomb’s negative
 If the RhoGAM was not given before 72 hours, every effort must
be made to administer RhoGAM within 9 – 10 days.
 Inform mother regarding the baby’s Rhesus status.
 Document if RhoGAM is given in the case records and patient home based card.

Dosage

 < 20 weeks gestation: 250 i.u.is recommended for prophylaxis following sensitising
events.
 ≥ 20 weeks gestation: At least 500 i.u. should be given for all events and followed
by Kleihaeur test to adjust dose of RhoGAM.
 Post partum: At least 500 i.u. must be given to every non-sensitised Rhesus
negative women and consider Kleihaeur test (e.g. caesarean section. MRP)

60
 MOTHER WITH ONE PREVIOUS SCAR

Current evidence indicates that 60 – 80% of women can achieve a vaginal delivery
following a previous lower uterine segment caesarean section. Patient who is going to
undergo a trial of scar must be counselled regarding the associated risk of such an
attempt.

Antenatal Assessment

 Booking for hospital delivery.

 Confirm the gestational age of current pregnancy.
 Obtain information regarding previous surgery.
 Ultrasound assessment of fetus especially placenta localization at or beyond 30
weeks gestation.
 Assess factors associated with current pregnancy.
 Exclude any contraindications for a trial of scar.
 Informed choice of patient.
 Clinical pelvimetry at 36 to 38 weeks for patients who have no previous experience of
vaginal delivery.
 Assessment by specialist prior to 37 weeks gestation.

Factors associated with previous operation

 Indication for the primary caesarean section

 Review the operation notes
 Type of uterine incision
 Intraoperative complications
 Postoperative complications
 Advice on discharge from the previous hospital about mode of delivery during
subsequent pregnancy
 Communication with previous obstetrician

Factors associated with current pregnancy

 Presentation.
 Lie of fetus.
 Number of fetus.
 Fetal weight estimation.
 Placenta localisation.

61
Contraindications to trial of vaginal delivery

 Previous LSCS for recurrent causes (e.g. contracted pelvis)

 Previous classical caesarean section or inverted `T’ incision uterine scar
 Previous hysterotomy
 Previous uterine rupture
 Past history of myomectomy involving entry of the uterine cavity or extensive
myometrial dissection
 Independent in current pregnancy (e.g. placenta praevia, abnormal lie, breech
presentation, twin gestation)
 Mothers who refuses trial of scar

Counselling

 General discussion on the overall risks and benefits of caesarean section vs trial of
vaginal delivery.
 Risk of uterine rupture.
 Risk of perinatal mortality and morbidity.

Induction of labour with Prostaglandin

 Prostaglandins may be used to ripen the cervix effectively and facilitate the induction
of labour.
 Selection of cases must be decided by specialist.
 Caution must be exercised for monitoring during the use of prostaglandins.

Augmentation of labour with Oxytocin

 Case selection must be decided by specialist.

 Use infusion pump/dropmat to regulate Oxytocin.
 Precautions during monitoring to accompany the use of Oxytocin.

Intrapartum management

 Labour must be conducted in a hospital with operating theatre facility.

 Review by medical officer / specialist.
 Note antenatal decision regarding mode of delivery.
 Clinical pelvimetry.
 Set IV cannula.
 Full blood count.
 Group and crossmatch two units of whole blood.
 Continuous CTG monitoring.
 Partogram to monitor for slow progress.
 Judicious use of Oxytocin in first stage (in consultation with specialist).
 Adequate pain relief (epidural is not contraindicated)

62
 Monitor for signs of impending uterine rupture:
 Rapid maternal pulse > 100/min
 Scar tenderness and pain
 Persistent abdominal pain
 Fetal distress
 Fetal tachycardia
 PV bleeding
 Allow 6 – 8 hours of labour with satisfactory progress.

Post partum care

 As in other normal vaginal delivery patient.

 Routine manual exploration of the uterus to palpate the lower segment after the
delivery of placenta should be reserved only for patients with abnormal bleeding.

63
 MANAGEMENT OF BREECH PRESENTATION
AT TERM

The incidence of breech presentation at term is around 3-4%. Management option for
breech presentation at term:

 External cephalic version

 Caesarean section
 Vaginal breech delivery

Role of ultrasound in breech presentation

 Confirm gestation
 Rule out multiple pregnancy
 Type of breech
 Attitude of breech
 Estimated fetal weight
 Amniotic fluid index
 Placenta localisation
 Fetal abnormality
 Uterine anomaly
 Uterine / pelvic pathology

EXTERNAL CEPHALIC VERSION (ECV)

ECV is considered to be an effective method of procuring cephalic presentation for a

safer labour and has been demonstrated to safely reduce the need for Caesarian
deliveries

It is done after 37 weeks gestation to reduce the risk of spontaneous version and reduce
risk of prematurity if the need arises to deliver baby in the event of fetal distress.

Tocolysis at ECV has been shown to increase the success rate for ECV. Beta agonists
are the best studied tocolytic and parenteral terbutaline use is commonly described.
Subcutaneous terbutaline had been used as accepted dosage of tocolysis

Inclusion criteria

 Viable, singleton breech

 Gestation > 37 weeks (check for early confirmation of gestation age)
 Intact membranes

64
 Not in established labour (contractions and cervix < 3cm dilated)

Exclusion criteria

 Known gross fetal anomaly

 Severe hypertension ( > 160/110 mmHg) or confirmed pre eclampsia)
 IUGR (EFW < 2kg or USG AC < 10 centile on growth chart)
 Oligohydramnios (AFI < 5)
 Antepartum haemorrhage within last 3 month
 Uterine scar from any source
 Known allergy to terbutaline
 Other potential obstetric indication for Caesarian delivery
 Placenta Praevia
 Suspected macrosomia > 4kg
 Uterine anomaly (small fibroids not causing obstruction are acceptable)
 Obstructive pelvic tumour
 Multiple pregnancy

Potential complications

 Fetal bradycardia
 Intrauterine death
 Rupture of membrane
 Rupture of uterus
 Antepartum haemorrhage
 Placental abruption
 Fetomaternal haemorrhage
 Failed ECV

Protocol

 Recruit suitable women from antenatal clinic

 Patient is given a date to come to PAC for external cephalic version on non elective
Caesarian section day ( eg : Monday , Tuesday or Thursday )
 Patient is advised to fast from 12mn previous day
 A nonstress cardiotocography (CTG) for 20 minutes is performed on arrival along
with full blood count and GSH
 An ultrasound is carried out for assessment of type of breech, position of fetal spine,
amniotic fluid index (AFI), estimated fetal weight, location of placenta
 Obtain informed and written consent
 Subcutaneous terbutaline 250mcg to be administered by a staff nurse or house
officer
 ECV is attempted 20 minutes after the administration of the medication
 The procedure is carried out within 5minutes or maximum of 3 attempts
 The forward roll or backward flip techniques are usedThe procedure is abandoned if
undue force was required, or the women become distress, or the mazimum attempts
or the limits are exceeded
 An ultrasound is performed after the procedure to confirm the presentation
 A non stress CTG is done after the procedfure for about 20-40 minutes

65
 If CTG is normal with no antepartum hameorrhage, leaking liquor or severe
abdominal pain, the patient is discharge with the fetal kick chart
 If CTG is suspicious or pathological, arrangement for an emergency Caesarean
section is done
 IM Rhogam in non sensitized Rhesus negative patient
 An appointment was given to patient to be seen in the antenatal clinic in 1 week
according to the usual prenatal care

ELECTIVE CAESAREAN SECTION

It is being opted for more frequently after the publication of Term Breech Trial.

Indication

 Need for caesarean section for other indication

 Patient requests for a caesarean section
 Hyperextended neck
 Footling breech
 IUGR
 Preterm breech with estimated birth weight < 2.5kg.
 Cephalopelvic disproportion
 Big baby >3.5kg
 Previous caesarean section
 Cord presentation
 Associated with another obstetrical problem

VAGINAL BREECH DELIVERY

A vaginal breech delivery by a skilled health provider is safe. It must be conducted in a

hospital with specialist and feasibility of operating theatre. An accurate assessment must
be made to ensure the success and safety of the procedure. Couple should be
counselled on the risk associated assisted vaginal breech delivery (head entrapment,
injury to baby, neuro-developemental delay, death).

Prerequisite for vaginal breech delivery

 No contraindications to vaginal delivery

 Adequate pelvis
 Estimated fetal weight between 2.0-3.8kg
 Fetus in frank (extended) or flexed breech
 No hyper-extended fetal neck
 No obstetric complications
 No previous scar
 Trained personnel available
 Delivery in tertiary centre

66
Methods of assisted breech delivery

 1st stage of labour is managed as other normal labour patients. Patient is

encouraged to bear down only when the cervical os is fully dilated.
 The patient is put in lithotomy position. The perineum cleaned and draped
 the perineum is infiltrated with lignocaine 1% at the episiotomy site if mother is not on
epidural analgesia
 Hands off technique is advised with avoidance of breech extraction.
 Patient is encouraged to bear down with each contraction
 When the buttock had descended on to the perineum, a medio –lateral episiotomy is
performed.
 The fetal legs which are in extended position are freed with digital pressure applied
on the popliteal fossa by the Pinard manoeuvre.
 The trunk is delivered and a loop of cord is brought down gently.
 Make sure the fetal back is always facing anteriorly.
 A sterile towel is wrapped around the fetal trunk and the mother is encouraged to
bear down until the anterior shoulder is visible at the introitus.
 Both the arms are delivered spontaneously unless in the presence of nuchal arm
whereby the Lovset’s manoeuvre is applied.
 The fetus is allowed to hang suspended by its own weight as the head enters the
pelvis to promote flexion.
 Delivery of the after-coming head maybe completed by either:

a) Mauriceau-Smellie-Veit manoeuvre

 The middle finger of the accoucher’s left hand is placed into the mouth of the
fetus and the 2nd and 4th finger on the malar eminence to promote flexion and
descend while counter pressure is applied to the fetal occiput with the middle
finger of the other hand.
 Traction on the cervical spine should be avoided to prevent fetal trauma and
extensions of the head.

b) Burns-Marshalls manoeuvre

 Both fetal legs are swung out and up towards the mothers abdomen with the
other hand keeping the vulva completely covered

c) Piper’s/ Neville Barnes forceps

 Once the hairline is visible, the baby’s feet are grasped and the body is kept
straight to take the weight of its neck
 The legs are swung outwards and upward to be held by an assistant, using a
towel to ascertain that the feet do not slip. The operator then applies the
Piper’s/Neville Barnes forceps and the head is slowly delivered
 The perineum should be guarded, to prevent rapid expulsion of the head
causing unnecessary tearing of the perineum.

 Oropharyngeal suction is done.

 The eyes are wiped with dry cotton swabs.

67
 The cord is clamped and cut and the baby is handed to the neonatologist for further
resuscitation.

References:

1. Royal College of Obstetricians and Gynaecologist. External cephalic version and

reducing the incidence of breech presentation. Guideline No20a. London : RCOG
Press; 2006
2. Hannah ME, Hanna WJ, Hewson SA, Hodnett ED, Saigal S., Willian AR. Planned
caesarian section versus planned vaginal birth for breech presentation at term : a
randomised multicentre trial. Term breech Trial Collaborative Group. Lancet 2000;
356 (9239) : 1375-83
3. Hoymeyr GJ, Kulier R. External Cephalic version for breech presentation at term.
Cochrane database Syst. Rev 2000; (2): CD000083
4. Hoymeyr GJ, Gyte G. Intervention to help external cephalic version for breech
presentation at term. Cochrane database Syst. Rev 2004; (1): CD000184
5. Dyson DC, Ferguson JE II, Hensleigh P. Antepartum external cephalic version under
tocolysis. Obstet Gynaecol 1986; 67:63-8
6. Richard Hayman. Breech Presentation. In: Obstetrics and Gynaecology. An
evidence-based text for MRCOG. Eds: Lusley DM, Baker PN. Arnold Publisher.
London. 35: 413-426

68
 EXTERNAL CEPHALIC VERSION (ECV)
HOSPITAL SERDANG PROTOCOL

Bbreech at term is common (incidence of 3-4%). ECV is considered to be an effective

method of procuring cephalic presentation for a safer labour and has been demonstrated
to safely reduce the need for Caesarian deliveries

Tocolysis at ECV has been shown to increase the success rate for ECV. Beta agonist
are the best studied tocolytic and parenteral terbutaline use is commonly described.
Subcutaneous terbutaline had been used as accepted dosage of tocolysis

Inclusion criteria

 Viable, singleton breech

 Gestation > 37 weeks (check for early confirmation of gestation age)
 Intact membranes
 Not in established labour (contractions and cervix < 3cm dilated)

Exclusion criteria

 Known gross fetal anomaly

 Severe hypertension ( > 160/110 mmHg) or confirmed pre eclampsia)
 IUGR (EFW < 2kg or USG AC < 10 centile on growth chart)
 Oligohydramnios (AFI < 5)
 Antepartum haemorrhage within last 3 month
 Uterine scar from any source
 Known allergy to terbutaline
 Other potential obstetric indication for Caesarian delivery
 Placenta Praevia
 Suspected macrosomia > 4kg
 Uterine anomaly (small fibroids not causing obstruction are acceptable)
 Obstructive pelvic tumour

Protocol

 Recruit suitable women from antenatal clinic

 patient is given a date to be admitted to antental ward for external cephalic version
on non elective Caesarian section on Wednesday for procedure on Thursday
 Patient is advised to fast from 12mn previous day
 A non stress cardiotocography (CTG) for 20 minutes is performed on arrival along
with full blood count and GSH

69
 An ultrasound is carried out for assessment of type of breech, position of fetal spine,
amniotic fluid index (AFI), estimated fetal weight, location of placenta
 Obtain informed and written consent
 Subcutaneous Terbutaline 250mcg to be administered by a staff nurse or house
officer
 ECV is attempted 20 minutes after the administration of the medication
 The procedure is carried out within 5minutes or maximum of 3 attempts
 The forward roll or backward flip techniques are used
 The procedure is abandoned if undue force was required, or the women become
distress, or the mazimum attempts or the limits are exceeded
 An ultrasound is performed after the procedure to confirm the presentation
 A non stress CTG is done after the procedfure for about 20-40 minutes
 If CTG is normal with no antepartum hameorrhage, leaking liquor or severe
abdominal pain, the patient is discharge with the fetal kick chart
 An appointment was given to patient to be seen in the antenatal clinic in 1 week
according to the usual prenatal care
 If CTG is suspicious or pathological, arrangement for an emergency Caesarian
section is done

References:

1. Royal college of obstetricians and gynaecologist. External cephalic version and

reducing the incidence of breech presentation. Guideline No20a. London : RCOG
Press; 2006
2. Hannah ME, Hanna WJ, Hewson SA, Hodnett ED, Saigal S., Willian AR. Planned
caesarian section versus planned vaginal birth for breech presentation at term : a
randomised multicentre trial. Term breech Trial Collaborative Group. Lancet 2000;
356 (9239) : 1375-83
3. Hoymeyr GJ, Kulier R. External Cephalic version for breech presentation at term.
Cochrane database Syst. Rev 2000; (2): CD000083
4. Hoymeyr GJ, Gyte G. Intervention to help external cephalic version for breech
presentation at term. Cochrane database Syst. Rev 2004; (1): CD000184
5. Dyson DC, Ferguson JE II, Hensleigh P. Antepartum external cephalic version under
tocolysis. Obstet Gynaecol 1986; 67:63-8

Prepared By :
Dr. Vani Subramaniam
O&G specialist
Serdang Hospital
Feb 2010

70
 POST DATES PREGNANCY

Post dates pregnancy is defined as pregnancy past 40 weeks of gestation. Patient with
sure of dates and no fetal distress can be induced at 40 weeks + 10 days. Some form of
fetal monitoring, e.g. fetal movement chart is advisable when pregnancy is past the
expected date.

Pre-requisites

 Sure of dates.
 Dating ultrasound (if unsure of dates).
 No adverse obstetrical factors (e.g. medical disease, subfertility, bad obstetric
history).
 Good fetal movement.
 Strict fetal kick chart.
 Uterus corresponds to dates during antenatal follow up.
 Clinically adequate liquor.
 Mother is informed regarding the decision and is satisfied.

Exceptions

 If liquor volume decreased clinically or AFI < 5 induce immediately.

 Decreased fetal movements (< 10 kicks over 12 hours) should be admitted and
monitored in wards or for delivery.

Unsure of dates

 Ensure strict fetal movement chart always.

 Induce at clinically estimated due dates of 40 to 41 weeks of gestation unless the
patient had an accurate early first trimester scan.

Methods of induction

71
 Prostaglandin
 Mechanical dilator (e.g. Dilapan)
 S&S (Sweep and stretch)
 Syntocinon

INTRAUTERINE DEATH

Confirmation of intrauterine death

Requires two personnel to confirm the fetal death before explaining to the parents.

Ultrasound features

 Absent fetal heart activity

 Non-pulsatile aorta
 Spalding sign – irregular overlapping of skull bones
 Absence of fetal movement
 Absence of colour Doppler for the fetal heart activity

ANTENATAL MANAGEMENT

 Explaination to couple
 Sympathetic approach
 IM Rhogam in non sensitized Rhesus negative patient
 Investigations to find the possible cause of death
 Discuss regarding treatment option

Investigations for the cause of death

 Anticardiolipin antibodies
 Lupus anticoagulant
 FBC
 Blood group / Rhesus group
 VDRL
 TORCH
 MOGTT at the time of IUD
 Discuss regarding post mortem

Treatment option

Depending on associated maternal risk:

72
 Awaiting spontaneous labour
 Induction of labour

Spontaneous labour

 Can be considered if no associated maternal risk such as:

 Silent abruption
 Pre-eclampsia
 Chorioamnionitis

 Explanation of maternal risk (e.g. infection, consumptive coagulopathy).

 Take clotting studies.
 Review clotting studies weekly.
 Ask patient to come as soon as possible if any symptoms or change her mind.

Induction of labour

 ≤ 20 weeks uterine size – Cervagem

 > 20 weeks uterine size – Prostin

LABOUR MANAGEMENT

 Aim for vaginal delivery.

 Caesarean section for obstetric indications.
 DIVC screening prior to induction of labour.
 Induction of labour as for viable pregnancy (refer to chapter on IOL).
 Adequate analgesia.
 Partogram.
 Prophylactic antibiotic (if prolonged labour or rupture of membranes).
 Watch for PPH.

POST PARTUM MANAGEMENT

Parent

 Offer bereavement counselling.

 Refer to psychiatrist if necessary.
 Allow them to be with the baby / take photo.
 Offer patient the option of isolation room after delivery.
 Suppression of lactation with a single dose of Cabergoline, 1 mg on first day after
delivery.
 Advice for any evidence of post-partum infection.
 Give appointment date at the postnatal clinic to:
 Reassess patient condition

73
  Review investigation
 Planned pregnancy when emotionally and physically prepared
 Contraception
 Pre pregnancy folic acid
 Advice on early booking

Baby

 A detailed description of the external morphology of the fetus must be documented

clearly in the notes.
 Identify the sex of the baby.
 Identification of `syndromes’ if possible in liaison with the Paediatrician.
 Take photo if dysmorphism.
 Relevant investigations (if possible) – fetal intracardiac or cord blood for:
 Culture and sensitivity
 Haemoglobin level
 Blood grouping
 Serum bilirubin
 TORCHES
 Fetal blood for karyotyping (in abnormal fetus).
 Post-mortem with parental consent.

Placenta

 The weight of the placenta

 Any abnormality (e.g. infarction, retroplacental clots, succenturiate lobe or evidence
of vasa praevia)
 Relevant investigations:
 Placental swab for culture and sensitivity
 Placental tissue for histopathology
 Document the number of arteries and veins present in the cord and any
abnormalities of the cord (e.g. cysts, true or false knots)

Perinatal Mortality Reports and burial permit

The form must be filled in by the medical officer immediately post delivery after
discussion with the specialist regarding the possible cause of death.

74
 ESSENTIAL PRE-REQUISITES IN
THE LABOUR ROOM

1. INTRAPARTUM NUTRITION AND HYDRATION

 All patients in labour must be assessed clinically for decreased fluid intake and
signs of dehydration which includes tachycardia, mild pyrexia and decreased tissue
turgor
 Light refreshments such as isotonic drinks, fruit juice, plain tea etc may be allowed
during early labour
 Intravenous fluids should be commenced after 6 hours if delivery is not imminent.
Suggested fluid regime is Hartmann’s solution and the total should not exceed
1500mls in 12 hours (caution in PIH cases)
 Mild ketonuria in labour is common
 Intravenous administration of dextrose 10% is contraindicated due to deleterious
effects on mother and baby (fetal hyponatremia, hypoglycaemia, decrease in
umbilical arterial blood pH)
 Effects of starvation includes:
 Ketosis, concentrated urine, haemoconcentration, prolongation of labour,
maternal discomfort

2. UNIVERSAL PRECAUTIONS

 Meticulous hand washing

 Appropriate PPE – mask, eye shield, apron, disposable caps, covered shoes
 Preferably double gloves
 Reduce risk of needle stick injuries: use protective instruments if available, needle
always on needle holder, disposal into a yellow sharps bin, be careful at all times
 Long cuffed surgical glove for MRP
 Correct procedures followed for all clinical waste disposal including placenta
 All other biohazard protocols to be in line with the hospital’s policy

3. PAEDIATRICS TEAM STANDBY

Communicate with the Paediatrics team for all high risk cases to ensure their presence
during delivery especially in the following cases:

 Emergency LSCS
 Selected elective LSCS
 Fetal distress

75
 Prolonged labour
 Meconium-stained liquour
 Prematurity
 Antepartum haemorrhage
 Prematurity
 GDM mothers
 Multiple pregnancies
 Instrumental deliveries
 IUGR
 Vaginal breech delivery

PLEASE REFER TO THE PERINATAL CARE MANUAL FOR A MORE

COMPREHENSIVE LIST

4. PAIN RELIEF IN LABOUR

Intramuscular pethidine

 Dose of 50-100mg im (1-2mg/kg) together with phernergan 25mg (0.5mg/kg)

 Administered in early labour and where delivery is not expected within 4 hours
 Side effects are drowsiness, nausea and vomiting
 The baby may require naloxone to treat respiratory depression if deliveed within 4
hours of pethidine injection.

Inhalation of Entonox

 Self-administered via face mask/mouth piece

 Inhale at the beginning of contraction, continue deep shallow breathing during
contraction and remove mask when contraction eases.
 Can be given at any time and in combination
 Side effects: drowsiness, nausea and vomiting

Epidural analgesia

 The Obstetric Epidural Service should be made available 24 hours a day.

 Of particular value in the following: PIH, cardiac disease, multiple pregnancies,
previous LSCS.

Psychological support to relieve anxiety by husband/ midwives

Supportive therapy i.e Aromatherapy, massage, soothing music is advocated.

Local anaesthesia

 Perineal infiltration using 10 mls of 1% lidocaine prior to performing an episiotomy.

ALWAYS aspirate the plunger before infiltration as IV infiltration may lead to
cardiac arrest.
 Pudendal block – to be performed by experienced personnel only

5. ANTIBIOTICS IN OBSTETRICS

PRIOR TO PRESCRIBING – ANY HISTORY OF ALLERGY MUST BE ELICITED

76
PPROM

Oral erythromycin (EES) 800 mg bd for ten days may be prescribed for women with
PPROM but not proven to be effective in spontaneous preterm labour (ORACLE 2)

PROM

iV ampicillin 2gm stat than 1gm 6h till delivery. Start as soon as possible.
Heart disease in pregnancy

Antibiotic prophylaxis for surgical procedures, labour and delivery. As the protocol above

GBS Carrier in labour

 All women with GBS positive should receive intrapartum IV Ampicillin 1g stat then
every 4hrly, or IV Clindamycin 900mg 8hrly if allergic to penicillin.
 Babies of GBS carrier need to be assessed by paediatrics team before discharge.

Prophylaxis for LSCS

Intravenous Augmentin 1.2 g stat dose at induction .

Prophylaxis for MRP, EUA, evacuation of haematoma, relaparotomy

Choice of :
 IV Augmentin 1.2g tds or
 IV Unasyn 750mg tds or
 IV Rocephine 1g daily
WITH IV metronidazole 500mg tds. All for 24 hours – 72 hours than change to oral

6. THROMBOPROPHYLAXIS FOR OBSTETRICS PATIENTS

Risk Group Type of patient Management

Low risk Uncomplicated pregnancy Early mobilization
Uncomplicated vaginal Adequate hydration
deliveries

Moderate ALL LSCS Early mobilization

risk Obesity, weight > 80kg Adequate hydration
TED stockings if with extra risk factors
such as restricted mobility, PIH, medical
conditions
One of the following anticoagulants till
discharge from the hospital
 SC heparin 5000iu bd or
 SC clexane(enoxaparin) 40mg daily
Anticoagulants are started within 8 hours
post-partum

High risk Extended operations such as Early mobilization

caesarean/post-partum Adequate hydration

77
 hysterectomy, laparotomy TED stockings
etc One of the following anticoagulant therapy
Lupus anticoagulant may be continued for 6 weeks
History of DVT, pulmonary  SC heparin 5000iu bd or
embolism, thrombophilia  SC clexane(enoxaparin) 40mg daily
Warfarin can be commenced 24-48 hours
after delivery

MANAGEMENT OF LABOUR

DUTIES OF MIDWIFE/STAFF MIDWIFE

 Document accurately the date and time of admission on the PAC admission form
 Check home-based card or other antenatal card. Note high risk factors.
 Check blood group/Rh and infectious status
 Note time of onset of contractions, leaking liquor and show on the PAC admission
form
 Check weight, height, BP, pulse, temperature and urine for sugar and albumin.
 Document past obstetric, medical, surgical, family history and others on OBS PER
103 form.
 Check contractions: frequency, duration and strength. Document in LPC
 Check fetal lie, presentation and engagement
 Check fetal heart rate
 Perform a vaginal examination if indicated
 Note colour of liquor if draining and any per vaginal bleeding
 Perform an ADMISSION CTG
 Inform House Officer/Medical Officer of any abnormalities IMMEDIATELY and
document the time.
 HIGHLIGHT all problems identified
 Assign a bed to the patient and ensure that the information is written on the review
board.

DUTIES OF HOUSE OFFICER/MEDICAL OFFICER/SPECIALIST

 Examine all cases within one hour of admission and document the date and time.
 Urgent and emergency cases MUST be attended STAT
 Cases that are electively admitted and with beds immediately available can be sent
up to the wards and be clerked there.
 Cases who are electively admitted with no beds available will be clerked in the
PAC.
 Note the findings by the midwifery staff
 Recheck antenatal history, confirm period of gestation, previous obstetric and
medical history.
 Take time and take a detailed history of present illness. Look out for problems/risk
factors.
 Note all the details in the home-based card, other antenatal cards and the referral
letter. This includes fetal movement and fetal growth charts.
 Thorough physical examination with systemic review .
 Abdominal examination to note contractions, uterine size, number of fetus, lie,
presentation, engagement, fetal heart rate, estimated fetal weight and liquor
volume.

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 Vaginal examination if not contraindicated. This is to note the dilatation and
effacement of the cervix, presenting part, station of the presenting part, state of the
membranes, colour and amount of liquor, degree of caput and moulding. Note if
there is any pelvic abnormalities.
 Review the CTG after every 20-30 minutes and document findings on the CTG
strip, with the date and time.
 Send the relevant investigations.
 Inform and consult the Medical Officer
 All clinical notes should be entered by the House Officer as soon as possible . HO
is responsible and accountable for each case after being clerked –clinical notes
entry and carried out all instruction management ordered by Medical Officer /
Specialist.
 Rounds by Medical Officer is frequent in PAC – ad hoc and 2-4 hourly.
 Rounds by Specialist will be done ad hoc and twice daily ( morning and evening
rounds )

79
FIRST STAGE OF
LABOUR

80
 ROUTINE INTRAPARTUM CARE

LABOUR WARD ADMISSION

Nursing staffs

 For non emergency case, patient will be first encountered by nursing staffs.
 Use appropriate language to acknowledge patient and accompany person.
 Note date and time of admission.
 Note time of onset of symptoms of labour.
 Check pulse, BP, temperature and complete record if necessary.
 Obtain urine for protein, sugar and ketones.
 Determine frequency, duration and strength of contractions.
 Check fetal lie, presentation and engagement.
 Listen to the fetal heart rate and its regularity.
 Perform admission CTG.
 Note the colour of liquor (if draining).
 If abnormality, inform the doctor as soon as possible and note time.

Medical officers

 Note the record already done by nursing staff.

 Look into the antenatal red card (colour coding).
 Take a complete antenatal history.
 Check the previous obstetric, gynaecological, surgical and medical history.
 Perform a thorough physical examination.
 Abdominal examination:
 Contractions
 Uterine size
 Number of fetus, lie and presentation
 Fetal heart rate
 Engagement
 Estimated birth weight
 Pelvic examination (after ruling out placenta praevia):
 Position, dilatation, effacement, length and consistency of cervix
 Attitude of fetal head
 Membranes, if ruptured, colour and amount of liquor
 Any cord presenting or prolapsed
 Caput and moulding
 Pelvimetry assessment
 If any problems, specialist should be consulted.

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DIAGNOSIS OF ESTABLISHED LABOUR

 Regular uterine contractions

 Fetal descent
 Dilatation of cervix > 3 cm

ACCOMPANYING PERSON

 Encourage husband or a close relative to be with the patient at all time (with the
nurse monitoring labour).
 Follow the guidelines and ask them to sign the appropriate form.

AMNIOTOMY / ARTIFICIAL RUPTURE OF MEMBRANES (ARM)

 Established labour or induction of labour

 Gestation above 36 weeks
 Cervix 3 cm dilated and head well applied
 If the head is not well applied, stabilizing ARM should be performed

FETAL MONITORING

Normal / low risk patients

 Intermittent auscultation with fetal stethoscope or hand held Doppler for 1 min every
15 min after the contractions.
 Intermittent CTG every 2 hours

High risk patients

 Continuous CTG

PAIN RELIEF IN LABOUR

 Psychological
 Inhalation
 Analgesics
 Pudendal nerve block
 Epidural
 Perineal infiltration

PARTOGRAM

 Commence all patients in labour on partogram to monitor progress of labour, once

she is in active labour, or earlier whenever necessary (e.g. induction of labour).
 Vaginal examination should be carried out at least once every 4 hours during the first
stage of labour and after rupture of the membranes.
 Ensure accurate and complete recording of information in the partogram.
 Progress of labour is assessed by:

82
  Measuring the rate of cervical dilatation
 Measuring fetal descent

Findings suggestive of satisfactory progress

 Regular, good contractions.

 Progressively increasing in frequency and duration.
 Rate of cervical dilatation, at least 1 cm per hour during active phase.
 Presenting part remains well applied to cervix.

AUGMENTATION OF LABOUR

 Decision by medical officer in normal cases.

 Decision by specialist in high risk cases.

FEEDING IN LABOUR

 Women in labour should be kept nil by mouth

 Sips of clear water can be allowed if necessary

HYDRATION

 When fluid therapy is indicated infuse Ringer’s lactate or dextrose saline at 500 ml
per 4 hours.
 Ensure patient passes urine / bladder is catheterised.
 Urine to be tested for ketone, protein and sugar.
 Correction is advised when urine analysis detected the presence of ketonuria.
 Start IV 5% Dextrose 300-500 ml then followed by Dextrose Saline or Hartmanns.
Treating ketonuria with excessive volumes of 5% or 10% dextrose can be dangerous:
 It causes hyponatremia in the mother
 It causes rebound hypoglycaemia and hyponatremia in the neonate
 It may result in haemolysis in the neonate

Intravenous cannula / group and save blood (GSH)

 Induction of labour
 Previous caesarean section
 Breech / Twin pregnancy
 Bad obstetrics history
 PIH / PE
 Diabetic
 IUD
 IUGR / fetal compromise
 Anaemia
 History of retained placenta

83
 Grandmultipara
 History of APH
 Patient at risk of PPH

INDUCTION AND AUGMENTATION

OF LABOUR

 nduction of labour is the artificial initiation of uterine contractions prior to their

spontaneous onset of labour.
 All decisions for induction of labour must be made by specialist.

Indications for induction of labour

 Post dates
 Diabetes in pregnancy
 Hypertensive disorders in pregnancy
 Intrauterine growth restriction
 Reduced fetal movement
 Twin pregnancy
 Unstable lie when the lie become stable
 Bad obstetric history
 Intrauterine death
 Gross fetal abnormality
 Prelabour rupture of membranes

Contraindications for induction of labour

 Contracted pelvis
 Previous Classical Caesarean Section / hysterotomy
 Cord presentation
 Placenta praevia
 Active herpes virus infection
 Fetal malpresentation
 Previous surgery for stress incontinence

Prerequisites

 Confirmation of gestation period age

 Reactive CTG
 Group and Cross Match 2 units of whole blood (GSH).
 Absence of contraindications
 Cervical score

84
Modified Bishop Score

0 1 2

Cervical Dilatation Closed 1 cm 2 cm

Cervical Length 2 cm 1 cm Effaced

Consistency Firm Soft Stretchable

Station -2 -1 0

Position Posterior Axial Anterior

Favourable cervix: ≥ 6 : IOL by ARM +/- augmentation of labour

Unfavourable cervix: < 6 : induction with Prostin

PROSTIN (PGE2, DINOPROSTONE)

Regime

 Primigravida - 3 mg Prostin
 Multigravida - 1.5 mg Prostin
 Maximum of 2 Prostin per day 6 hours apart for the first day
 The 3rd Prostin will be inserted early morning of the 2nd day
 Further Prostin insertion must be discussed and assessed by Specialist

Precautions

 Grandmultipara
 Previous LSCS
 Bronchial asthma
 Drug allergy

Monitoring
Every 30 minutes for
 Uterine contractions
 Fetal heart the first 2 hours

85
 Vital sign (BP / PR)
 Repeat CTG in the first hour of Prostin insertion

Complications

 Failed induction – occurs in 3%

 Uterine hyperstimulation
 Cord prolapsed – Vaginal examination must be performed immediately after SROM.
 Hyponatremia
 Abruption
 Iatrogenic prematurity
 Neonatal jaundice
 Post-partum haemorrhage

Management of uterine hyperstimulation

 Perform vaginal examination

 Remove any Prostin left in the posterior fornix
 Flush the posterior fornix with normal saline
 Perform CTG
 Consider Salbutamol/Terbutaline drip
 Terbutaline 250 mcg IV slowly over 5 minutes
 Salbutamol 5 mg in 500 ml Normal Saline at 10 dpm

AMNIOTOMY / ARTIFICIAL RUPTURE OF MEMBRANES (ARM)

Procedure

 Examine the abdomen and determine the lie, presentation and engagement.
 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.
 Wearing high-level disinfected glove, use one hand to examine the cervix and note
the consistency, position, effacement and dilatation.
 Use the other hand to insert an amniotic hook or a Kocher clamp into the vagina.
 Guide the clamp or 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 around the fingers.
 Note the colour of the fluid (clear, greenish or bloody). If thick meconium is present,
suspect fetal distress.
 After ARM, listen to the fetal heart rate during and after a contraction and perform
CTG.
 If good contraction is not established 2 hour after ARM, begin oxytocin infusion.

Complications

 Cord prolapse
 Malpresentation (if ARM is done with a high station)
 Abruptio placenta

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 Fetal heart rate abnormality

OXYTOCIN AUGMENTATION / INDUCTION REGIME

Oxytocin is used to increase the frequency or strength of uterine contraction ( at least 3

contractions in 10 minutes, each lasting up to 45 seconds) and correct incoordinate
uterine action.

Regime

 Dilute 10 units (1ml) Oxytocin + 500ml Normal Saline or 5% Dextrose (20mU/ml).

 Use either infusion syringe pump or IV drip infusion set (dropmat).
 Start infusion at 2mU/min.
 Increase every 30 minutes.
 Maximum infusion rate 32mU/min (32 dpm or 96ml/hr).
 12 mU/min usually establishes adequate contractions.

Approximate dose Drops per Volume infused

(mU/min) minute (ml/hr)

Primigravida 2 2 6

4 4 12

8 8 24

16 16 48

32 (max) 32 96

Multipara 2 2 6

4 4 12

8 8 24

16 (max) 16 48

Grandmultipara/ 2 2 6
Previous scar
4 4 12

8 (max) 8 24

* Note: 1 ml = 20 drops, 1 dpm = 3 ml/hr

87
** If desired contractions are not achieved at maximum infusion rate, further consultation
with specialist is required (40 units Oxytocin added to 500 ml Normal Saline for infusion
at 48 ml/hour (64 mU/min)).

Precautions

 Grandmultipara
 Previous scar
 Heart disease in pregnancy

Monitoring

 Blood pressure and pulse rate

 Contractions
 Fetal heart rate (every 30 minutes after contractions)

Management of uterine hyperstimulation

 Hydrate patient
 Ensure patient lie on her left side
 Perform CTG
 Stop Oxytocin infusion
 Consider Salbutamol/Terbutaline drip

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 ABNORMAL PROGRESS OF LABOUR

First stage

Onset of labour to full cervical dilatation:

 Latent phase
 Active phase

Partogram

 Chart progress of labour.

 Correct use of partogram will facilitate the diagnosis of dysfunctional labour and allow
appropriate management.

PROLONGED LATENT PHASE (> 8 HOURS)

 Correct reassessment is required.

 If not in labour, no action needs to be taken.
 If contractions persist and assessment showing labour is continuing consider
amniotomy and augmentation with Oxytocin.
 If assessment showed factors likely to lead to obstruction (e.g. macrosomia) or
evidence of fetal distress, delivery by caesarean section.

POOR PROGRESS IN ACTIVE PHASE

Signs

 Cervical dilatation < 1 cm/hour for 2 – 4 hours

 Poor descent of presenting part
 Presence of excessive caput / moulding
 May be malposition

Management

 Full assessment of the patient with bladder emptied.

 Hydrate patient well.
 Consider augmentation with Oxytocin.
 Contraction must be timed personally by the medical officer prior to deciding on
augmentation.
 Continuous CTG monitoring.

89
 Review as routine and consider caesarean section if still poor progress despite good
contraction for 4 hours or any evidence of fetal distress.
 If beyond action line, repeat vaginal examination after 2 hours. Progress < 1 cm/hour
between examinations, delivery is indicated most likely by caesarean section.
 Consult specialist if big baby is suspected.

Indications for earlier intervention

 Induction of labour
 Breech
 Twin pregnancy
 Intra-uterine death
 Pre-eclampsia
 Diabetes
 Cardiac disease
 Precious pregnancy
 Previous caesarean section

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 INTRAPARTUM FETAL MONITORING

Cardiotocogram (CTG) has been used widely for fetal monitoring to reduce hypoxic
intrapartum mortality and morbidity. However, there is debate regarding its benefit as
opposed to intermittent auscultation.

Admission test

CTG recording for a period of 20 minutes on admission should be done for patients with
gestation ≥ 32 weeks after discussion with the Medical Officer in charge of PAC.

Continuous monitoring

 Epidural analgesia
 Induction or augmentation of labour
 Prolonged labour
 Previous scar
 Abnormal admission CTG
 Meconium stained liquor
 Intrauterine infection
 Twin pregnancy / breech presentation
 IUGR / oligohydramnios
 Post term pregnancy
 PROM /APH
 Previous intrapartum death
 Bad obstetric history
 Maternal medical disease (e.g. hypertension, diabetes, severe anaemia)

All other patients not listed above should have an intermittent (2 hourly) CTG.

INTERPRETATION OF CTG

Reassuring CTG trace

 Baseline heart rate : 110- 150 bpm

 Baseline variability : 10- 25 bpm
 Accelerations : 2 or more in 20 minutes. Each of at least 15 bpm lasting at least 15
seconds
 Decelerations : Absent

91
Non-reassuring CTG trace

 Baseline fetal heart rate (FHR) 160 – 180 bpm or 100 – 110 bpm
 Baseline variability < 5 bpm for ≥ 40 min but less than 90 min
 Early decelerations
 Variable decelerations
 Single prolonged deceleration up to 3 minutes

Abnormal CTG trace

 Baseline fetal heart rate < 100 bpm and > 180 bpm.
 Sinusoidal pattern ≥ 10 min
 Baseline variability < 5 bpm for ≥ 90 min
 Atypical variable decelerations
 Late decelerations
 Single prolonged deceleration > 3 minutes

Categorisation of CTG trace

Category Definition

Normal A CTG where all four features fall into the reassuring
category

Suspicious A CTG whose features fall into one of the non-reassuring

categories and the remainder of the features are
reassuring

Pathological A CTG whose features fall into ≥ 2 non-reassuring

categories or ≥ 1 abnormal categories

Reviewing CTG

 All the CTG done must be reviewed by the medical officer.

 Endorsed with date, time and name of doctor.
 Comment on all components of the CTG

Management of abnormal tracing

 Try to determine cause.

 Ensure patient is in the left lateral position.
 Oxygen to patient.
 Rehydrate patient.
 Check maternal pulse, BP, temperature and medication.
 Stop Oxytocin drip, if any.
 Inform anaesthetist if on epidural.

92
 Consider internal CTG if poor contact.
 Assess cervical dilatation, exclude cord prolapse.
 Expedite delivery if os is full and no contraindication.
 Otherwise assess situation, LSCS may be required.

PAIN RELIEF IN LABOUR

Adequate pain relief is important for patients in labour. Optimally, the choice of analgesia
during labour should be discussed with the patient during antenatal period.

NON-PHARMACOLOGICAL

 Emotional support to relieve anxiety

 Antenatal classes
 Breathing techniques
 Friendly and reassuring attitude of labour room staff
 Companionship in labour
 Touch and massage

INHALATION ANALGESIA (ENTONOX)

 Mixture of 50% Nitrous Oxide and 50% Oxygen.

 Does not completely eliminate contraction pain but significant pain relief in 50%
patients.
 Use a clean mask for each patient and place mask correctly over patients face.
 Instruct patient to start breathing the gas (normal rate but deep breath) as the patient
feels tightening of the uterus (Entonox has a latent period of 15 seconds).
 Not effective if patient starts inhalation at the point when the pain starts.
 Continue breathing in Entonox till pain ceases.

PARENTERAL ANALGESIA

IM / IV Pethidine

 1 mg per kg bodyweight (but not more than 100 mg) 6 hourly

 Normal dose 75-100 mg

IM Morphine

 0.1 mg per kg bodyweight

Complications

93
 Maternal:
 Respiratory depression.
 Pruritus
 Nausea and vomiting. Combined with Metoclopramide (Maxolon) 10mg or
Promethazine HCL (Phenergan) 25mg IM or IV for anti-emetic effect.

 Newborn:
 respiratory depression. IM/IV Naloxone is the antidote (0.1 mg/kg
bodyweight. Repeated doses maybe required to prevent recurrent respiratory
depression.

EPIDURAL ANAESTHESIA

 To liaise with anaesthetist if a patient request / requires epidural analgesia.

 Consider this in cases such as patient with heart disease, pre-eclampsia and multiple
pregnancy.
 Require continuous monitoring of BP / pulse with fetal heart rate

LOCAL BLOCK

Pudendal nerve block

 0.5% Lignocaine infiltration 10 – 15 ml on / near pudendal nerves either side.

 Can be done by perineal or vaginal approach.

Perineal infiltration

 1% Lignocaine, 10 – 15 ml injected into the posterior fourchette.

94
 THROMBOPROPHYLAXIS IN LABOUR

Pulmonary thromboembolism is one of the direct causes of maternal death. In the most
recent Confidential Enquiries into Maternal Death (2000), it is the cause of death. The
risk is increased by 6 folds and continues after delivery into the puerperium.

All health care providers should consider pain in the leg, chest pain and dyspnoea in an
otherwise healthy woman to be due to thrombosis or pulmonary embolism until proven
otherwise and ensure that appropriate treatment is instituted.

Risk factors for venous thromboembolism in pregnancy

Low risk

 Uncomplicated pregnancy
 Elective caesarean section
 No other risk factors

Moderate risk

 Age >35 years

 Obesity, ≥80 kg at booking BMI > 29
 Parity >4
 Prolonged labour ≥12 hours
 Gross varicose veins
 Concurrent infection
 Pre-eclampsia
 Immobility prior to labour for ≥4 days
 Mid-cavity instrumental delivery
 Emergency caesarean section
 Major current medical illness e.g. heart disease, nephrotic syndrome

High risk

 Patient with ≥3 moderate risk factors.

 Extended major pelvic or abdominal surgery (e.g. caesarean hysterectomy, surgery
>3 hours).
 Patient with family history of DVT / pulmonary embolism or thrombophilia.
 Paralysis of lower limbs.
 Patient with antiphospholipid antibody or lupus anticoagulant.

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THROMBOPROPHYLAXIS FOR VAGINAL DELIVERIES

Low risk

 Early mobilization
 Adequate hydration

Moderate risk

 S/C Enoxaparin 40mg daily or

 S/C unfractionated Heparin 5,000iu BD
 Given as soon as possible after delivery provided there is no PPH.
 Use graduated elastic compression stockings immediately if heparin is
contraindicated.
 Continue for 3 – 5 days.

High risk

 S/C Enoxaparin 40mg daily or

 S/C unfractionated Heparin 7,500-10,000iu BD
 Plus graduated elastic compression stockings
 Continue for 3 – 5 days
 Patients with a past history of venous thromboembolism or underlying thrombotic
problem, should continue for a minimum of 6 weeks

THROMBOPROPHYLAXIS FOR CAESAREAN SECTIONS

Low risk

 Early mobilization
 Adequate hydration

Moderate risk

 S/C Unfractionated Heparin 5,000iu BD or

 S/C Enoxaparin 40mg daily
 Starting after caesarean section
 Withold until 4 – 6 hours after insertion or removal of epidural catheter. The first
postpartum dose can be given after insertion but before removal of the epidural
catheter.
 Use graduated elastic compression stockings immediately if heparin is
contraindicated.
 Continue for 3 days or till full mobility

High risk

 S/C Unfractionated Heparin 5,000 units BD or

 S/C Enoxaparin 40mg daily
 Plus graduated elastic compression stockings

96
 Starting after caesarean section
 Continue for 3 days or till full mobility
 Patients with a past history of venous thromboembolism or underlying thrombotic
problem, should continue for a minimum of 6 weeks

PROPHYLAXIS FOR ACID ASPIRATION

Regional anaesthetic techniques such as spinals and epidurals reduce the risk of acid
aspiration. However prophylaxis for acid aspiration is still mandatory in anticipation of the
need for general anaesthesia.

 The use of clear oral antacids is effective in raising the pH of gastric secretion.
 H2 receptor antagonists reduce gastric acid volume. When administered
intravenously, care should be taken to administer the dose over 5-10 minutes to
avoid the potential for hypotension especially with Cimetidine.
 IV Metoclopromide 10 mg/dose is used as a prophylactic to increase lower
esophageal sphincter tone.

Elective caesarean section

 Oral Ranitidine 150 mg or Cimetidine 400 mg the night before surgery.

 Oral Ranitidine 150 mg or Cimetidine 400 mg on the day of surgery preferably 3
hours or more before surgery.
 Oral Sodium Citrate solution (0.3 molar) 30 ml before leaving for the operation
theatre.

Emergency caesarean section

 IV Ranitidine 50 mg or IV Cimetidine 200 mg as soon as the decision is made for

caesarean section. The drug should be given over 10 minutes.
 Oral Sodium Citrate solution (0.3 molar) 30 ml before leaving for the operation
theatre.
IV Metoclopromide 10 mg may also be administered at the same time as Ranitidine or
Cimetid

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 PRETERM LABOUR

Diagnosis

 Palpable uterine contractions before 37 completed weeks:

 Occurring once every 10 minutes
 Lasting at least 30 seconds
 Present for at least 60 minutes
 With or without evidence of cervical effacement / dilatation

Predisposing factors

 Past history of preterm labour

 Uterine anomalies
 Multiple pregnancy
 Fetal anomaly
 Intrauterine death
 Infection
 Ruptured membranes

Assessment

 Confirm accuracy of gestational age.

 Assessment of predisposing factor or causes
 General condition of patient including her cardiovascular and thyroid status
 Abdominal examination:
 Determine uterine contraction
 Fundal height assessment
 Fetal lie
 Vaginal examination:
 Cervical scores
 To perform HVS
 Ultrasound examination:
 Fetal weight estimation
 Fetal anomaly
 Placental site
 Amniotic fluid index
 Urine microscopy

98
Management

 Antenatal steroid with IM Dexamethasone 12mg 12hrly for 2 doses

 Suppression of labour with tocolysis
 Counsel patient regarding her condition and plan of management.
 Paediatrics team to be informed if delivery is imminent, especially when ventilator
may be required.

Aim of tocolysis

 To allow time for completion of antenatal steroid therapy (24hr from 1st dose)
 In-utero transfer to a another hospital for the benefit of baby

Contraindications of tocolysis

 Chorioamnionitis
 Interauterine death
 Fetal abnormality/fetal distress
 Maternal cardiac disease
 Hyperthyroidism
 Antepartum haemorrhage
 Advanced labour (os > 5 cm)
 Hypertension
 Diabetes mellitus To discuss with specialist

Pre-requisites for starting tocolysis

 Normal viable fetus

 No maternal medical contraindication for labour suppression
 Normal maternal ECG
 Baseline random blood sugar level (RBS)
 Baseline serum electrolytes (BUSE)
 CTG if gestation > 32 weeks

TOCOLYTIC REGIME

TERBUTALINE SULFATE (BRICANYL) INFUSION REGIME

 Increase infusion every 15 minutes.

 Maximum infusion rate 80 drops per minute (240 ml/hr).

It may be given in the form of either S/C or IM 250 mcg stat to reduce intensity of uterine
contraction. This may also be achieved by nebuliser with Bricanyl.

99
 Infusion syringe pump Dropmat
Terbutaline 2.5mg (5ml) + 45 ml 2.5mg (5ml) + 500 ml Dextrose
Dosage Dextrose 5% or Normal 5% or Normal Saline
(g/min) Saline
Drop per ml/hr Drop per minute ml/hr
minute (dpm)
(dpm)
2.5 g/min 1 dpm 3 ml/hr 10 dpm 30 ml/hr
5 g/min 2 dpm 6 ml/hr 20 dpm 60 ml/hr
7.5 g/min 3 dpm 9 ml/hr 30 dpm 90 ml/hr
10 g/min 4 dpm 12 ml/hr 40 dpm 120 ml/hr
12.5 g/min 5 dpm 15 ml/hr 50 dpm 150 ml/hr
15 g/min 6 dpm 18 ml/hr 60 dpm 180 ml/hr
17.5 g/min 7 dpm 21 ml/hr 70 dpm 210 ml/hr
20 g/min 8 dpm 24 ml/hr 80 dpm 240 ml/hr

SALBUTAMOL SULFATE (VENTOLIN) INFUSION REGIME

 Increase infusion every 15 minutes.

 Maximum infusion rate 90 drops per minute or 270 ml/hr (45 g/min)

Infusion syringe pump Dropmat

Salbutamol 5mg (10ml) + 40 ml Dextrose 5mg (10ml) + 500 ml Dextrose
dosage 5% or Normal Saline 5% or Normal Saline
(g/min) Drop per ml/hr Drop per ml/hr
minute minute
(dpm) (dpm)
5 g/min 1 dpm 3 ml/hr 10 dpm 30 ml/hr
10 g/min 2 dpm 6 ml/hr 20 dpm 60 ml/hr
15 g/min 3 dpm 9 ml/hr 30 dpm 90 ml/hr
20 g/min 4 dpm 12 ml/hr 40 dpm 120 ml/hr
25 g/min 5 dpm 15 ml/hr 50 dpm 150 ml/hr
30 g/min 6 dpm 18 ml/hr 60 dpm 180 ml/hr
35 g/min 7 dpm 21 ml/hr 70 dpm 210 ml/hr
40 g/min 8 dpm 24 ml/hr 80 dpm 240 ml/hr
45 g/min 9 dpm 27 ml/hr 90 dpm 270 ml/hr

Maintenance

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 If contraction cease, maintain dose for 2 hours, then taper down by 1/3 of dose and
maintain at that rate for 12 hours.
 If stable, reduce the dose further by 10 drops per minute every 30 minutes till
discontinue.
 Maximum duration of infusion is 24 hours.
 Increase the drip rate if contractions recur during the weaning period.
 Oral therapy can be considered if patient respond to infusion.

Monitoring

 Maternal pulse (every 15 minutes)

 Blood pressure
 Maternal temperature every 4hrly
 Contraction every 1/2hrly
 Auscultation of lungs every 4hrly
 Continuous cardiac monitoring
 RBS (6 hourly) or glucometer 4-6 hrly
 BUSE (potassium levels-daily)
 FHR ( not more than 180/minute )
 Input/output charting

Complications

 Fetal tachycardia
 Palpitation
 Headache
 Maternal tachycardia
 Maternal hypotension
 Maternal pulmonary edema
 Hypokalemia
 Hyperglycemia

Cessation of tocolysis
 Symptoms of intolerance (e.g. palpitation, severe tremor, chest pain, vomiting,
severe headache and restlessness).
 Maternal heart rate > 120 bpm.
 Maternal SBP<90mmHg or DBP < 60mmHg.
 Sign & symptom of pulmonary oedema.
 FHR > 180bpm.
 Maternal hypokalaemia
 Uterine contractions persist despite maximum infusion for 6-8 hours

ORAL NIFEDIPINE (ADALAT)

 20 mg of Nifedipine given as a stat dose.

 Followed by another 20 mg every 30 minutes if contractions persist.
 Maximum dose of 80 mg.

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Maintenance

 Oral Nifedipine 20-40 mg tds starting 8 hours of the last dose.

Contraindications

 Hypertension in pregnancy

Care after tocolysis

 Bed rest for 24-48 hours after infusion and discharged after 72 hours, if no
contractions only.
 Vital signs/FHR and uterine activity are done hourly for 6-12 hours.
 If patient goes into labour, to discuss with the neonatologist regarding possibility of
delivery.

ANTENATAL STEROID THERAPY

Corticosteroid therapy for fetal lung maturation should be considered and discussed with
the specialist, in patients who are at high risk of premature delivery at 24 to 36 weeks
gestation.

Indications

 Possible diagnosis of preterm labour

 Preterm premature rupture of membrane
 Antepartum haemorrhage
 Planned preterm delivery at <36 weeks gestation e.g. for fetal compromise, SGA

Precautions

 Diabetes mellitus
 Hypertension
 Concomitant tocolysis as there is a risk of pulmonary oedema

Dosage

 IM Dexamethasone 12 mg bd for one day.

 Allow 12 hours following 2nd dose if planned for delivery.
 There is benefit of steroid if it has been administered for a minimum of 4 hours from
the first dose.
 Repetition of steroids should be done only in consultation with specialist.

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 PRETERM PRELABOUR RUPTURE OF
MEMBRANE (PPROM)

Definition

Spontaneous rupture of membranes before the onset of regular uterine contractions

occurring before 37 completed weeks.

Diagnosis

 History suggestive of leaking liquor

 Visualisation of the pooling liquor
 Litmus paper test (red litmus paper turn into blue)

Initial Management

 Confirm accuracy of gestational age.

 Confirm diagnosis of leaking.
 Assess for sign and symptoms of infection.
 Use strict aseptic technique when examining the patient.
 Perform speculum examination with a sterile speculum.
 Do not perform a digital examination if the patient is not in labour.
 Take HVS for C&S.
 When rupture of the membranes is not obvious amniotic fluid index assessment is
needed.
 CTG if gestation ≥ 32 weeks.
 Blood for FBC and C-reactive protein (if available).
 Admit patient to the ward for monitoring and conservative management.
 IM Dexamethasone 12 mg bd for one day if no evidence of infection.
 Oral erythromycin (EES) 800mg bd for ten days.

Monitoring

 Stictly 4 hourly temperature

 Maternal pulse rate
 Uterine contractions and abdominal pain

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 Fetal heart rate monitoring
 Pad chart and colour of liquor
 TWC biweekly
 Ultrasound fortnightly for fetal growth
 If unexplained pyrexia or abdominal pain consider delivering the patient

CHORIOAMNIONITIS

Criteria

 Temperature >380 C

And 2 other criteria:

 Malodorous liquor
 Uterine/adnexal tenderness
 Leukocytosis
 Maternal tachycardia >120 bpm
 Fetal tachycardia >160bpm

Management

 To perform septic work out for the mother.

 Delivery of fetus irrespective of gestation.
 Appropriate paranteral antibiotics (after discussion with the specialist):
 IV Ampicillin 2 gm QID
 IV Gentamicin 5 mg/kg body weight every 24 hours
 ± IV Metronidazole 500 mg TDS
 If the Bishop score is not favourable, consider Prostin.
 Perform amniotomy and Syntocinon infusion if the Bishop score is favourable.
 If caesarean section is performed, pack the pelvic gutters to contain spread of
infection.
 Send placenta for C&S to reconfirm sensitivity of organism.
 The newborn must be referred to paediatrician.
 Continue the antibiotics until afebrile for 48 hours, then switch to oral antibiotics.
 Encourage breast feeding.
 Counsel patient:
 Risk of secondary PPH and endometritis in the puerperium and to come to
hospital immediately if any symptoms.
 Contraception.

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ALGORITHM FOR MANAGEMENT OF PPROM

Rupture of membranes

Confirm gestation and diagnosis

< 36 weeks gestation ≥ 36 weeks gestation

In labour Not in labour In labour Not in labour

Consider: Conservative
Wait for 24 hours
management:
 Tocolysis
 Steroids  Steroids
 Prophylactic  Prophylactic
antibiotic antibiotic
Spontaneous Not in
labour labour

Allow labour

Close monitoring

Stop leaking

Continue leaking /
Discharge chorioamnionitis
& monitor 105
in ANC
 Induction /
Delivery

Induce as
indicated

PERINATAL GROUP B STREPTOCOCCUS (GBS)

INFECTION PREVENTION

GBS is recognised as the most frequent cause of severe early onset infection in newborn
infants. Intrapartum antibiotic has been shown to significantly reduce the risk of early-
onset but not late-onset disease. GBS is also an important cause of maternal intrapartum
and postpartum infections.

Screening

Routine antenatal screening is not recommended. It can be done obtaining:

 High and low vaginal swabs

 Rectal swabs
Taken both, higher detection rate

ANTEPARTUM PROPHYLAXIS

If detected incidentally, antenatal treatment is not recommended routinely unless:

 Proven carrier planned for any procedure e.g. cervical cerclarge.

 Symptomatic pregnant women.
 Heavy colonization as evidenced by positive urine culture for GBS.

These women do not need to be rescreened once identified and require intrapartum
antibiotic prophylaxis.

INTRAPARTUM PROPHYLAXIS

It is offered to all women with identified risk factors without universal screening:

 Preterm labour (<37 weeks gestation).

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 Term labour (>37 weeks gestation) with prolonged rupture of membranes > 18 hours.
 Maternal fever during labour (>38oC orally).
 Previous infant with GBS disease.
 Previously documented GBS bacteriuria.

Antibiotics for intrapartum prophylaxis

 IV Ampicillin 1 gm stat and 500 mg 6 hourly until delivery.

 Last dose being given after delivery
 IV Erythromycin 500 mg stat and 6 hourly, if allergic to penicillin.

Management of newborn infant

 Consult the paediatrician if mother require antibiotic prophylaxis during delivery.

 May require close observation and antibiotics after delivery.

Special circumstances

 Antibiotic prophylaxis for GBS is not required for women undergoing planned
caesarean section in the absence of labour and with intact membranes.
 Antibiotic prophylaxis for GBS is unnecessary for women with PPROM unless they
are in established labour. Intrapartum prophylaxis is required once in labour.
 If chorioamnionitis is suspected, broad spectrum antibiotic therapy must include an
agent active against GBS.

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 CORD PROLAPSE

Cord presentation is when the cord lies below the level of the presenting part and it is
said to have prolapsed following rupture of the membranes and its release into the
vagina

Risk factors

 High presenting part

 Polyhydramnios
 Footling or flexed breech
 Transverse lie
 Prematurity
 Multiple pregnancy
 Multiparity

Prevention

 Admission for patient with unstable or transverse lie in the last three weeks of
pregnancy.
 Avoid artificial rupture of membranes before the fetal pole has become deeply
engaged.
 Early vaginal examination following spontaneous rupture of the membranes.

Management

 Confirm the viability of fetus by auscultation, daptone or ultrasound (absence of

pulsation in prolapsed cord is unreliable as spasm of the cord vessels may make
pulsations difficult to feel).
 Place mother in a head-down position and put 2 pillows under mother’s buttock so as
to dislodge the presenting pole from the pelvis to avoid cord compression.

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 Maintain the vaginal examination fingers within vagina and push the presenting part
up to prevent further prolapse of the cord and its compression.
 The cord should be handled as little as possible.
 If the cord is still within the vagina, attach a sanitary pad firmly to the vulva to prevent
the cord from coming out further and from being exposed to the environment.
 If it has prolapsed through the introitus, gently replaced in the vagina.
 Give mask/nasal oxygen to the mother at 4-6 litres/min.
 Inflate the maternal urinary bladder with 500ml of sterile saline via a Foley’s catheter.
 Tocolytics may be given if the uterus is contracting e.g. SC or IM Bricanyl 250
microgram (1/2 ampule).
 Mode of delivery of the baby is decided by fetal viability and state of cervical
dilatation.

Viable fetus

 If cervix is < 8 cm dilated, arrangement should be made as quickly as possible for

immediate caesarean section.
 If cervix is 8 cm an instrumental delivery / vacuum extraction may be attempted
(after discussing with specialist).

Non viable fetus

 Allow spontaneously vaginal delivery if cephalic or breech presentation.

 A transverse lie will require caesarean section despite fetal death.

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 SECOND AND
THIRD STAGE OF
LABOUR

110
 NORMAL DELIVERY

Symptoms / signs

 Woman has the urge to push

 Os at 10 cm to the delivery of the baby
 Steady descent of fetus through the birth canal

Management of second stage

 Patient in dorsal or lithotomy position.

 Ensure intravenous access in patients with risk of PPH.
 Gowning is necessary to conduct delivery.
 Clean and drape patient prior to delivery.
 CTG monitoring in high risk case.
 Catheterisation if required.
 Check that suction apparatus is functioning while preparing to conduct delivery.
 Encourage patient to bear down.
 Generally allow:
 One hour for primigravida
 Half an hour for multiparous woman
 With epidural can be allowed for 120 minutes provided CTG reactive
 Use local anaesthesia for episiotomies.
 To control birth of the head, place the fingers of one hand against the baby’s head to
keep it flexed.
 Support the perineum as the baby’s head delivers.
 Suction the baby’s mouth and nose.
 Feel for the umbilical cord around the neck.
 Allow the head to turn spontaneously before delivering the rest of the body.

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 Deliver one shoulder at a time to reduce tears.
 Place the baby on the mother’s abdomen once delivered. Thoroughly dry the baby,
wipe the eyes and assess the breathing.
 Neonatal resuscitation in required cases.
 Clamp and cut the umbilical cord.
 Wrap the baby in a dry cloth.

Management of third stage

 Palpate the abdomen to rule out the presence of additional babies.

 Active management of third stage of labour (i.e. prophylactic oxytocics
administration, controlled cord traction and uterine massage).
 Intramuscular Syntometrine / Syntocinon when anterior shoulder of fetus is delivered.
 Give intravenous infusion of 40 units Oxytocin in high risk cases for PPH.
 Cord blood for G6PD and thyroid function test for all babies.
 Deliver the placenta with controlled cord traction.
 Check the placenta for completeness.
 Examine the perineum carefully and repair any tears to the cervix or vagina or repair
episiotomy.
 Note the blood loss.
 Document the progress of the delivery in the delivery form.
 Encourage breast feeding within one hour of delivery.

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 EPISIOTOMY

Indications

 Complicated vaginal delivery such as breech, shoulder dystocia, instrumental

deliveries.
 Scarring resulting from female genital cutting / mutilation or poorly healed third
or forth degree tears.
 Fetal distress.
 Primigravidas.
 Premature deliveries.
 Rigid perineum.

Procedures

 Aseptic techniques.
 Infiltrate the perineum with 1% lignocaine (if not under epidural) beneath the vaginal
mucosa, beneath the perineal skin and deeply into the perineal muscle.
 Perform episiotomy when crowning of the presenting part and the perineum is
thinned out.
 Place two fingers between the baby’s head and the perineum.
 Starting at the mid-point of the fourchette, cut the whole depth of the perineum with
scissors preferably in a single cut, about 3 – 4 cm in the mediolateral direction.
 Control the baby’s head and shoulders as they deliver, ensuring that the shoulders
have rotated to the midline to prevent an extension of the episiotomy.
 Carefully examine for any extension and other tears.

Repair of episiotomy

113
 Should be carried out immediately after the delivery of the placenta and with the
patient in the lithotomy position.
 Apply antiseptic solution to the area around the episiotomy.
 The cervix and vagina are systematically inspected for lacerations and if none are
present, the apex of the vaginal incision is located.
 The suture material preferred is absorbable synthetic material polyglycolic acid
or polyglactin, over chromic catgut as it is associated with less perineal pain,
analgesic use, dehiscence and re-suturing.
 Vaginal mucosa is closed with continuous 2/0 suture.
 The repair starts about 1 cm above the apex and suturing continue to the level of the
vaginal opening.
 At the opening of the vagina, the cut edges of the vaginal opening is brought
together
 The needle is threaded between the opposed vaginal edges a few centimetres back
and out through the incision and tied.
 The perineal muscle closed using interrupted 2/0 sutures.
 Skin closure is affected using interrupted or continuous subcuticular 2/0 sutures.
Continuous subcuticular technique is associated with less short term pain.
 Perform a vaginal examination to look for any foreign body left behind and a rectal
examination to make sure no stitches are in the rectum.

Complications

 Haematoma
 Infections
 Necrotizing faxciitis
 Wound breakdown
 Perineal pain
 Dyspareunia

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 VAGINAL BREECH DELIVERY

The frequency of breech presentation is high in preterm labour. Preterm breech is

dangerous combination as:

 There is an increased risk of cord prolapse

 The head is relatively larger than the trunk therefore there is an increased risk of
head entrapment

Assessment

 Cause of breech
 Fetal condition
 Fetal weight and attitude
 Maternal pelvis
 Maternal condition e.g. maternal disease
 Maternal / parental wishes
 Rule out contraindications:
 Need for caesarean section for other indications
 Flexed / footling breech
 Preterm breech
 Extended head
 Estimated fetal weight < 2500gm or > 3500gm
 Previous uterine scar
 Fetal abnormality which may cause dystocia
 Fetal compromise
 IUGR

115
Management of first stage

 Assess the favourable features for vaginal breech delivery.

 In some cases of footling breech / flexed breech in advanced labour (> 7cm without
contraindication) may be allowed to deliver vaginally.
 Discuss with patient regarding option of delivery and possible outcome.
 Rule out cord prolapse when membranes rupture.
 Blood group cross match.
 Artificial rupture of membranes (os > 3cm and breech well applied).
 Continuous CTG monitoring.
 4 hourly review and record progress of labour on a partograph.
 Augmentation of labour should be discussed with specialist.
 Caesarean section is required if progress of labour not satisfactory or fetal heart rate
abnormality.
 Passage of meconium when the breech is not engaged in early labour is ominous
and fetal distress should be excluded. Late passage of meconium in advanced labour
is due to compression of the breech and is not equated with fetal distress.

Second stage

 Inform specialist
 Patient should not push until the cervix is fully dilated. Full dilatation should be
confirmed by vaginal examination.
 Patient in lithotomy position.
 Perineum is cleaned and draped.
 Perineal infiltration with Lignocaine 1% if not under epidural.
 Patient is encouraged to bear down with each contraction.
 Episiotomy is performed when the buttock descend the perineum.
 Allow spontaneous delivery of the buttocks up to umbilicus. Gently hold the buttocks
but do not pull.
 The legs (if in extended position) are freed with digital pressure applied on the
popliteal fossa).
 Hold the baby by the hips with a sterile towel. Do not hold by the flanks or abdomen.
 The trunk is delivered and a loop of cord is brought down gently.
 Mother is encouraged to bear down until the anterior shoulder is visible at the
introitus.
 Both arms will deliver spontaneously unless the arms are stretched above the head
or folded around the neck, whereby the Lovset’s manoeuvre is applied.
 The baby is allowed to hang suspended by its own weight as the head entered the
pelvis.
 The aftercoming head should be delivered preferably by forceps. As soon as the
hairline is seen, the fetus is lifted at an angle of 45 0 to the mother’s abdomen by
assistant and Neville Barnes forceps applied. The forceps are applied from below
with the left blade first followed by the right.
 The handles locked easily. Using constant, gentle traction, the head is delivered
slowly, with the assistant guarding the perineum.

Post delivery care

116
 Suction of the baby’s mouth and nose.
 Hand the baby to the Paediatrician.
 Continue with active management of the third stage.
 Examine carefully and repair any tears to the cervix, vagina or episiotomy.

TWIN DELIVERY

Twin pregnancy is associated with greater risks to both mother as well as the fetuses
when compared from a singleton pregnancy.

FIRST STAGE

Haemoglobin level.
 GXM 2 units of whole blood.
 Insert intravenous cannula.
 Assess the presentation of the first twin.
 Partogram. Not to allow prolonged labour.
 Ensure good contraction.
 Augmentation after discussion with specialist.
 Provide adequate pain relief (preferably epidural).
 Continuous fetal monitoring of both fetus (internal and external monitoring).

SECOND STAGE

Delivery of the first twin

 Medical staff in attendance:

 Two O&G doctors
 Two paediatric doctors
 Two nursing staff
 Standby operating theatre
 Lithotomy position

117
 Aseptic technique
 Episiotomy
 Delivery of first twin as a singleton
 Clamp and cut the umbilical cord

Delivery of the second twin

 Assess the lie and presentation of the second twin by abdominal palpation, vaginal
examination and/or ultrasound assessment.
 The lie should be corrected to longitudinal either by external version or internal
podalic version.
 It can be turned into either in a cephalic or breech presentation.
 Consider starting Oxytocin infusion if uterine contractions are weak.
 Continue close fetal monitoring.
 Amniotomy can be performed when presenting part descended to avoid cord
prolapse.
 Deliver the fetus as cephalic or assisted breech delivery.
 If fetal distress developed and delivery cannot safely be achieved or if the second
twin fails to descend into the pelvis, emergency caesarean section is necessary.
 Clamp and cut the umbilical cord.
 IM Syntometrine 1 ml after delivery of the second twin. Ensure no undiagnosed triplet
before giving Syntometrine.
 Wait for signs of placenta separation an pull the cords together by CCT.
 Following placenta delivery to start on 40 units of Oxytocin infusion.
 Placenta has to be inspected for chorionicity and completeness.
 Check and repair the vaginal wall tears and episiotomy.
 Estimate the total blood loss.
 Document in case notes.

Indications for Caesarean Section

 Non-cephalic first twin

 Previous caesarean section
 Monochorionic monoamniotic twins
 Other obstetrics indication
 Patient’s request

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 INSTRUMENTAL DELIVERY

Options of instruments

 Ventouse
 Metal cup
 Silastic cup
 Forceps
 Wrigley forceps
 Neville Barnes forceps
 Kielland forceps

Indications

 Prolonged 2nd stage of labour

 Maternal distress
 Maternal heart disease
 Severe pre-eclampsia
 Fetal distress in second stage
 Delivery of the aftercoming head in breech (for forceps)

Pre-requisites

 Mother must be explained regarding the indication, procedure, expected outcome

and complications. Verbal informed consent obtained.
 Cephalic presentation
 Head should not be palpable per abdomen

119
 Satisfactory uterine contractions.
 CPD has been ruled out
 Mother in lithotomy position
 Strict aseptic technique
 Cervix is fully dilated
 Membrane is ruptured
 Vertex with no excessive caput or moulding
 Position must be determined and identified
 Adequate analgesia
 Fetal heart must be checked before the procedure and in between contractions
 Operator must be experienced
 Operator must know his/her limitation and be prepared to abandon the procedure
in case of difficulty

VENTOUSE DELIVERY

Procedure

 Patient in lithotomy position.

 Vulva and vagina cleansed and draped.
 Bladder catheterised.
 Vaginal examination is done to confirm the dilatation of the os, presentation, position
and station of the presenting part. The pelvis is clinically assessed to exclude
disproportion.
 The ears may be used as landmarks to determine the position. If the ears cannot be
reached, then the presenting part is still high. Thus the decision for instrumental
delivery has to be evaluated.
 Check the pump, hose and cup, fully assembled, for proper and maintained negative
pressure when the cup is applied to the palm of a gloved hand.
 Analgesia by pudendal block or local infiltration of 1% lignocaine over the episiotomy
site.
 The largest cup that can be inserted without traumatizing maternal tissue is chosen.
 Vacuum cup is lubricated and placed as close as possible to the occiput to
encourage flexion but the fontanelle must be avoided.
 Check the application. Ensure there is no maternal soft tissue within the rim.
 The vacuum is created with the pump and gradually increased by 0.2 kg/cm 2 every 2
minutes to a maximum pressure of 0.8 kg/cm2.
 Re-examine the vagina before traction to ensure no entrapment of soft tissue.
 Traction is applied during uterine contraction together with maternal effort of bearing
down in the axis of the birth canal.
 Initial direction is downwards and outwards and progressively changed to upwards
and outwards as head descent the birth canal. The traction is in a line perpendicular
to the cup.
 The thumb of one hand must be placed on the cup with the index finger on the fetal
scalp to assess potential slippage and descent of the vertex.
 Fetal heart rate and cup application are checked in between contractions.
 Episiotomy is done once the perineum is distended.
 The vacuum cup is released once the head is delivered.

120
 The baby is handed to paediatrician.
 Check for the extent of vaginal or cervical injury after delivery of the placenta.
 Record the procedure in the delivery note as well as complications.

Failure

 The head does not advance with each pull. Do not persist if no descent.
 The fetus is undelivered after three pulls
 The cup slips off the head twice at the proper direction of pull with a maximum
pressure

Tips

 The cup must not be applied more than twice.

 The head must at least descend with the first pull and advance with each subsequent
pull.
 The head must be completely delivered with no more than three pulls and within 15
minutes of first applying the cup.
 Should not be used at gestations of less than 36 weeks.

Fetal complications

 Artificial caput or chignon

 Cephalhaematoma
 Subarachnoid haemorrhage
 Scalp abrasions and lacerations
 Scalp necrosis (extremely rare)
 Intracranial bleeding (extremely rare)

Maternal complications

 Genital tract tears

 Post partum haemorrhage

FORCEPS DELIVERY

Procedure

 Patient is positioned and examined as in vacuum delivery.

 Analgesia by pudendal block or local infiltration of 1% lignocaine over the episiotomy
site.
 Assemble the blades before application. Ensure that the parts fit together and lock
well.
 Lubricates the blades of the forceps.
 Two fingers of the right hand are inserted into the vagina on the side of the fetal
head. The left blade is held with the left hand positioned parallel to the ipsilateral

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 inguinal ligament of the mother. It is slide gently between the head and fingers to rest
on the side of the head. This is followed by the right blade.
 If the head is not in direct OA or OP position, it must be rotated manually before the
blades applied.
 A biparietal, bimalar application is the only safe application.
 Depress the handles and lock the forceps.
 If the blade cannot be inserted or locked easily, remove the blades and reassess
position.
 Apply traction only during uterine contractions.
 Initial direction is downwards and outwards and progressively changed to upwards
and outwards as head descent the birth canal.
 Excessive traction force should never be used. Use only one hand to pull.
 Episiotomy is done once perineum is distended.
 Fetal heart should be checked in between the contractions.
 Remove the blades once the head is delivered.
 The baby is handed to paediatrician. Examine for any trauma or injury
 After delivery of the placenta, check for the extent of vaginal or cervical injury

Correct applications

 The sagittal suture should be perpendicular to the plane of the forceps shanks.
 The posterior fontanelle should be located midway between the blades and one
finger breadth above the plane of the shanks
 The fenestration of the blade should be barely felt and the amount of fenestration felt
on each side should be equal

Failure

 Fetal head does not advance with each pull. Do not persist if no descent.
 Fetus is undelivered after three pulls with no descent.

Tips

 Brute force must never be use during insertion, locking, traction and removal of
forceps.
 The head must at least descend after 2 tractions and abandon procedure if no
descent.
 The head must be completely delivered with no more than three tractions.
 Abandon the procedure if failure to insert the blades, failure to lock the blades or no
descent on traction.

Fetal complications

 Facial nerve injury

 Lacerations of the face and scalp
 Fractures of the face and skull

Maternal complications

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 Genital tract tears
 Post partum haemorrhage
 Uterine rupture

REPAIR OF PERINEAL TEARS

The vast majority of sphincter defects are unrecognised at delivery. Woman may suffer
loss of control over bowel movements and gas if torn anal sphincter is not repaired
correctly.

Definition

 1st degree: Injury involving the vaginal mucosa and connective tissue.
 2nd degree: Injury involving vaginal mucosa and perineal muscles.
 3rd degree: Injury involving the anal sphincter complex (external anal sphincter and
internal anal sphincter).
 4th degree: Injury involving the anal sphincter complex and rectal mucosa.

FIRST AND SECOND DEGREE PERINEAL TEARS

Management

 Most first degree tears close spontaneously without sutures.

 Put patient in lithotomy position.
 Infiltrate local analgesia if patient is not given epidural analgesia.
 Aseptic technique.
 Carefully examine the vagina, perineum and cervix.
 If the tear is long and deep through the perineum, exclude 3rd or 4th degree tear by:
 Place a gloved finger in the anus
 Gently lift the finger and identify the sphincter
 Feel for the tone or tightness of the sphincter

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 Change to clean glove and apply antiseptic solution to the area around the tear.
 Repair the vaginal mucosa using a continuous 2/0 suture. Use polyglycolic acid
(Dexon) or braided polyglactin (Vicryl) as compared to catgut because they produce
less subsequent pain and reduce the need for resuturing.
 Start the repair about 1 cm above the apex of the vaginal tear and continue to suture
to the level of the vaginal opening.
 At the opening of the vagina, bring together the cut edges of the vaginal opening and
bring the needle under the vaginal opening and out through the perineal tear and tie.
 Repair the perineal muscles using interrupted 2/0 suture. If the tear is deep, place a
second layer of the same stitch to close the space.
 Repair the skin using interrupted (or subcuticular) 2/0 sutures starting at the vaginal
opening.
 Perform a vaginal examination to look for any foreign body left behind and a rectal
examination to make sure no stitches are in the rectum.

THIRD AND FOURTH DEGREE PERINEAL TEARS

Risk factors

 Birth weight > 4 kg

 Occipito posterior position
 Nulliparity
 Induction of labour
 Epidural analgesia
 Prolonged second stage of labour
 Episiotomy
 Forceps delivery

Management

 If possible, repair should be done by specialist anorectal surgeons / experienced

obstetrician.
 Immediate repair give better results than delayed repair.
 Repair should be done in operation theatre.
 Patient should be put in lithotomy position.
 Area should be thoroughly cleaned and draped.
 Analgesia preferably regional or general anaesthesia.
 Adequate lighting and good assistant is mandatory.
 Prophylactic antibiotics (Ampicillin and Metronidazole) are required.
 Close inspection should be done to the perineum.
 Examine the vagina, cervix, perineum and rectum.
 Place a gloved finger in the anus, lift slightly, identify the sphincter or lack or it and
identify any tears in the rectum.
 Change to clean, high-level disinfected gloves.
 Identify the edge and apex of the wound.
 Remove any fecal material if present.

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 Close the rectal mucosa, using fine 3/0 or 4/0 interrupted sutures 0.5 cm apart to
bring together the mucosa.
 Place the suture through the muscularis and not all the way through the mucosa.
 Ensure the knots are outside the lumen.
 Cover the muscularis layer by bringing together the perirectal fascia layer with
interrupted sutures.
 Apply antiseptic solution to the area frequently.
 Identify and approximate the disrupted ends of the anal sphincter.
 Grasp each end of the sphincter with an Allis clamp (the sphincter retracts when
torn). The sphincter is strong and will not tear when pulling with the clamp.
 Repair the sphincter with two or three interrupted stitches using 3/0 suture. This is
best done with figure-of eight sutures.
 Use polyglycolic acid (Dexon) or braided polyglactin (Vicryl).
 Repair can be done by overlapping the muscle fibres or end to end suturing making
sure no defect in the circumference of the sphincter.
 Following repair, examine the anus with a gloved finger to ensure the correct repair
of the rectum and sphincter.
 Change to clean glove.
 Repair the vaginal mucosa, perineal muscles and skin as described earlier being
careful to obtain maximal hemostasis.

Post-procedure care

 Adequate analgesia.
 Continue with oral antibiotics (Ampicillin and Metronidazole) for 1 week.
 Give stool softeners (Lactulose) for 10 days.
 Avoid giving enemas or performing any rectal examinations for 2 weeks.
 Advice on sign and symptoms of infection.
 Follow up appointment at 6 weeks and enquire regarding incontinence to flatus,
liquids and solids and fecal urgency.
 Referral to colorectal surgeon if any problems.
 Advise on subsequent delivery:
 Subsequent vaginal delivery may worsen anal incontinence symptoms.
 If symptomatic, the option of elective caesarean section should be discussed.
 If asymptomatic, there is no clear evidence as to the best mode of delivery.
 Start the repair about 1 cm above the apex of the vaginal tear and continue to suture
to the level of the vaginal opening.
 At the opening of the vagina, bring together the cut edges of the vaginal opening and
bring the needle under the vaginal opening and out through the perineal tear and tie.
 Repair the perineal muscles using interrupted 2/0 suture. If the tear is deep, place a
second layer of the same stitch to close the space.
 Repair the skin using interrupted (or subcuticular) 2/0 sutures starting at the vaginal
opening.
 Perform a vaginal examination to look for any foreign body left behind and a rectal
examination to make sure no stitches are in the rectum.

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 CERVICAL TEARS

Management

 Patient in lithotomy position.

 Aseptic technique.
 Adequate lighting and good assistant.
 Anaesthesia is not required for most cervical tears.
 For tears that are high and extensive, may require repair in operating theatre.
 Ask an assistant to massage the uterus and provide fundal pressure to give better
exposure of the cervix.
 Examine the cervix carefully.
 Grasp the cervix with a sponge holder, starting at the 12 o’clock position.
 A second sponge holder is placed at 2 o’clock and the cervix examined between the
two.
 If intact, the first holder is moved to 4 o’clock.
 By working around the cervix in this way, the whole circumference can be examined
and tears identified.
 Apply the forceps on both sides of the tear and gently pull in various directions to see
the entire cervix.
 Tears must be repaired with full-thickness interrupted sutures about 1 cm apart,
ensuring that the apex is identified.
 Use chromic 0 catgut or polyglycolic acid sutures.
 An abdominal approach is needed to repair a tear of the cervix or upper vagina
where the apex cannot be identified and bleeding is occurring.

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 Ureteric injury can result from blindly placed deep sutures in the fornix.

POST PARTUM HAEMORRHAGE

Obstetric haemorrhage is the leading cause of death in pregnancy in Malaysia.

Prevention of mortality from haemorrhage mainly depends on prompt treatment of its
cause to prevent further bleeding and replacement of blood loss to maintain circulation.

Definition

Bleeding from the genital tract in excess of 500 ml following delivery.

Type

 Primary PPH: Occurring within 24 hours of delivery

 Secondary PPH: Occurring after 24 hours of delivery

Assessment of the amount of blood loss

1 tampon fully soaked 30 ml

1 sanitary pad fully soaked 120 ml

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PRIMARY PPH

Causes

 Uterine atony
 Genital tract trauma
 Retained placenta
 Coagulation defects
 Uterine rupture
 Uterine inversion
 Amniotic fluid embolism

Prevention

 Recognizing the high risk patient

 Awareness of the causes of PPH
 Routine use of oxytocics during third stage
 Early intervention and fluid/blood replacement

Management

 Resuscitative measures are to be carried out simultaneously with the assessment of

the patient and determination of cause of the PPH.
 Activate red alert system.
 Rapid evaluation of the patient’s general condition including vital signs.
 Correct hypovolaemia/hypotension:
 Set up a minimum of 2 IV lines (14 / 16 gauge).
 For major PPH (> 1000 ml of blood loss) a 3rd IV line or CVP line should be
considered.
 Stabilize patients with crystalloids or colloids.
 Transfuse blood when available as soon as possible.
 Take blood for full blood count, grouping and cross match (minimum of 4 units with or
without DIVC regime) and coagulation profile at the same time.
 Make sure the airway is open. Administer oxygen at 6 – 8 L/min.
 Insert CBD to monitor urine output.
 Monitor parameters closely:
 General condition
 Level of consciousness
 Blood pressure and pulse every 15 minutes
 Pad chart
 Maintain input/output chart
 Monitor fundal height
 PalpateManagement
the abdomen and of uterine atony
if the uterus is well contracted, the cause of bleeding is
likely to be genital tract trauma.

 Massage the uterus to produce contractions

 Empty bladder
 Start medical treatment if no response to prophylactic treatment
 Give IV Ergometrine 0.5 mg or IM Syntometrine 1 ml
 Give IV Syntocinon 40 units
128 in 500 ml normal saline at 40 dpm
 IM Carboprost 250 mcg. This can be repeated after 15 minutes up
to a maximum of 2-3 doses
 If the bleeding is persistent, the following measures should be instituted:
 Bimanual compression or the uterus
 Aortic compression
 Check placenta for completeness and look for cervical and vaginal lacerations.
 Specific cause of PPH should be managed accordingly.
 Trace the appropriate investigation results.
 Perform disseminated intravascular coagulation (DIVC) profile:
 Haemoglobin (Hb)
 Platelet counts (PC)
 Clotting time (CT)
 Prothrombin time (PT)
 Partial thromboplastin time (PTT)
 1 cycle of DIVC regime:
 4 units of blood
 2 units of fresh frozen plasma (FFP)
 6 units of cryoprecipitate
 4 units of platelets
 If bleeding continues in spite of specific measures, exploration under anaesthesia
may be necessary once the patient is optimized.
 If bleeding persists, patient may require surgical intervention.
 Surgical intervention by experienced doctor (uterine packing, brace suturing of
uterus, internal iliac artery ligation or hysterectomy).

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 ALGORITHM ON MANAGEMENT OF PPH

Determine cause

Uterine Uterine Retained Genital tract Coagulopathy

inversion atony placenta trauma

Manual / Massage Failed CCT Episiotomy Blood

hydrostatic uterus replacement
replacement Vaginal/ cervical cryoprecipitate
Ergometrine/ MRP with laceration
Syntometine/ Oxytocin Fresh frozen
plasma

Oxytocin Bleeding Accreta or Repair

infusion for persists uterine atony
6 hours

Uterine
rupture
Bimanual uterine
compression or suturing
 Brace
aortic compression
of uterus
 Internal iliac
artery ligation Laparotomy
Need to
Fails  Uterine 130
conserve uterus Simple repair or
tamponade
hysterectomy
Complete
Hysterectomy
Fails
family
 MANUAL REMOVAL OF PLACENTA

Diagnosis of retained placenta

Not able to deliver placenta by controlled cord traction within 30 minutes of delivery of
fetus.

Ensure that before making a diagnosis of retained placenta:

 Bladder is catheterised
 Syntometrine has been given
 Sufficient time is allowed

MANUAL REMOVAL OF PLACENTA MUST BE DONE IN OT

UNDER ANAESTHESIA

Pre-requisite

 Inform/counsel patient regarding manual removal of placenta (MRP).

 Set IV line.
 Group and cross match 2 units of whole

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 Vital sign monitoring before, during and after procedure.
 Resuscitate patient if she is in shock. Never attempt MRP in a shocked patient.
Stabilise patient first before attempting the procedure.

Procedure

 Patient in lithotomy position.

 Aseptic technique. Use sterile gown and long gloves.
 Vulva and vagina cleansed and draped.
 Bladder catheterised.
 Give a single dose of prophylactic antibiotics of IV Ampicillin 1g and IV Metronidazole
500mg
 Left hand moves up over the abdomen to support the fundus and provide counter-
traction during removal to prevent uterine inversion.
 Insert the right hand into the vagina and up into the uterus.
 If the os is closed, use fingers to dilate it. Insert the tip of the fingers through the
cervix. Spread the fingers repeatedly and ease the hand through the cervix.
 If cord is intact, use it as a guide to the placenta.
 Move the fingers of the hand laterally until the placental edge is located.
 Use the edge of the palm to gradually make a space between the placenta and the
uterine wall.
 Proceed slowly with lateral movement of the fingers to separate the placenta until
whole placenta is detached from the uterine wall.
 Fingers always pointing into the uterine cavity, away from the uterine wall.
 Inform specialist if the placenta does not separate from the uterine surface.
 Hold the placenta and slowly withdraw the hand from the uterus, bringing the
placenta with it.
 The abdominal hand continues to provide counter-traction to the fundus by pushing it
in the opposite direction.
 Palpate inside the uterine cavity to ensure that all placental tissue removed.
 Examine the placenta for complete removal.
 Give IM Ergometrine 0.5mg or IV Syntocinon 10 units.
 Massage the uterine fundus to encourage a tonic uterine contraction.
 Examine carefully and repair any tears to the cervix, vagina or episiotomy.

Post procedure care

 Document the procedure including:

 Placenta/membranes: complete/incomplete/ragged edges;
 Estimated blood loss.
 Observe closely for a minimum of 1 hour till patient is stable before transfer to post
natal ward.
 Palpate uterine fundus to ensure that it remains contracted.
 Check for excessive lochia.
 IV Syntocinon (40 units in 500mls of Ringers lactate) infusion is given over 6 hours.
 Maintain infusion of IV fluids.
 Transfuse as necessary.

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 UTERINE INVERSION

Diagnosis

 Vaginal bleeding after delivery

 Slight or intense pain
 Uterine fundus not felt on abdominal palpation
 Inverted uterus apparent at vulva
 Can present with shock that was out of proportion to blood loss

Degrees of uterine inversion

 First degree: the fundus turning itself inside out but does not herniated through
level of internal os.
 Second degree: the fundus passes through the cervix and lies within the vagina.
This is the commonest type.
 Third degree: the entire uterus is turned inside out and hangs outside the vulva.

Management

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Repositioning the uterus should be performed immediately. With time, the constricting
ring around the inverted uterus becomes more rigid and the uterus more engorged with
blood.

 Initiate Red Alert.

 Commence on resuscitation.
 GXM blood.
 A 3rd degree inversion should be converted into a 2nd degree by positioning patient in
Trendelenburg position to maintain the inverted mass within the vagina instead of
leaving it hanging outside.
 Thoroughly cleanse the inverted uterus using antiseptic solution.
 Apply compression to the inverted uterus with a moist, warm sterile towel until ready
for the procedure.
 Immediate replacement should be performed without attempting to remove the
placenta from the inverted uterus.

Manual replacement

 Preferably done under general anaesthesia especially under the influence of

Halothane as it has a uterine relaxation effect, if unable to do so, to give intravenous
Pethidine and Diazepam in slow bolus.
 Aseptic technique.
 Grasp the uterus and push it through the cervix towards the umbilicus to its normal
position
 The other hand should be over the abdomen to apply counter support.
The part of the uterus that came out last (the part closest to
the cervix) goes in first and not the inverted uterine fundus

 If the placenta is still attached, perform manual removal after correction.

 If replacement is successful, give Ergometrine with the hand still within the cavity of
uterus until the uterus contracts.
 If correction is not achieved, proceed to hydrostatic correction.

Hydrostatic method of O’Sullivan

 Place the woman in deep Trendelenburg position (lower the head about 0.5 meters
below the level of the perineum)
 Prepare a high-level disinfected douche system with a double nozzle and a long
tubing (2 metres) and a warm water reservoir (3-5 litres)
 Identify the posterior fornix. The posterior fornix is recognised by where the rugose
vagina becomes the smooth vagina.
 Place the nozzle of the douche in the posterior fornix
 At the same time, with the other hand hold the labia sealed over the nozzle and use
the forearm to support the nozzle.
 Ask an assistant to start the douche with full pressure.
 The fluid distends the posterior fornix and increases the circumference of the orifice,
relieves cervical constriction and results in correction of the inversion.

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Combined abdominal-vaginal correction

 It is done when the above approaches failed or long standing cases

Post procedure care

 Give IM Ergometrine 0.5mg and maintain a slow Syntocinon infusion.

 Cover with single dose antibiotics of IV Ampicillin 1g and IV Metronidazole 500 mg
after correcting the inverted uterus.
 If there are signs of infection or the woman currently has fever to treat accordingly.
 Give adequate analgesia.

SHOULDER DYSTOCIA

Shoulder dystocia is an obstetric emergency. A definitive step must be taken to reduce

morbidity or mortality to the baby. There are 7 – 10 minutes to deliver the baby without it
suffering brain damage. A diabetic baby has even less reserve. The estimated incidence
is 0.3% of deliveries.

Definition

Difficulty or failure to deliver the fetal body after the delivery of fetal head following failure
of shoulders to traverse the pelvis after delivery of the head.

Risk factors

 Fetal factors:
 Estimated big baby more than 4 kg
 Previous history of shoulder dystocia
 Previous history of big baby
 Anencephaly
 Post term pregnancy

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 Maternal factors:
 Diabetic mother
 High maternal birth weight
 Maternal obesity more than 80kg
 High maternal weight gain
 Advance maternal age
 Abnormality of labour:
 Prolonged late active phase
 Prolonged second stage
 Excessive moulding
 Delayed in descent leading to mid pelvic instrumental delivery
 Turtle neck sign during second stage of labour

Prevention

Caesarean section has been suggested for diabetic women with a fetal weight estimated
to be above 4.0 kg and for non diabetic women with an estimated fetal weight above 4.5
kg and slow progress of labour.

Despite the highest degree of awareness of the risk factors, shoulder dystocia still occurs
unexpectedly. It is suggested that:

 Labour ward must have a written protocol

 Shoulder dystocia drill must be performed regularly
 Anticipation of the possibility among the birth attendants

Management

 Call for help. Initiate red alert.

 Patient in lithotomy position
 Make or enlarge the episiotomy

 McRobert’s manoeuvre
 Abduct hips, rotated outwards and flexed with the thighs touching the
abdomen and the two assistants holding a leg each
 Encourage maternal pushing
 Lateral neck traction / downward axial traction on the fetus

 Suprapubic pressure
 Pressure by assistant with the flat hand of the hand laterally in the direction
the baby is facing and posteriorly.

 Rotation of anterior shoulder

 Hand into posterior aspect of vagina. Moving it up to posterior aspect of
anterior shoulder.
 Push anterior shoulder from behind into oblique position.

136
 Rotation of the posterior shoulder (Cockscrew manoeuvre)
 Hand is inserted posteriorly into the vagina.
 Pressure is applied to the anterior aspect of the posterior shoulder in the
direction of the fetal back through 1800.

 Delivery of the posterior arm

 Whole hand is introduced posteriorly along the sacral curve.
 Left hand is used when the fetal back is toward the left, and the other way
round.
 From the posterior shoulder, the fetal arm is followed, and flexed in attempt to
reach the forearm, wrist or hand, then sweep the forearm over the fetal chest
and deliver the posterior arm.

 Cleidotomy

 Cephalic replacement (Zhavanelli’s procedure)

 This procedure is the last resort.
 Application of constant, firm pressure with the palm of the hand in a direction
to flex the fetal head and reverse the cardinal movement of labour so that the
head is returned in the OA position and maintained in a flexed from below
while caesarean is done

Do not waste time on protracted attempt with a single

manoeuvre or other inappropriate management

GYNAECOLOGY
137

PROBLEMS
 ECTOPIC PREGNANCY

A condition where the pregnancy is outside uterine cavity.

Site of ectopic pregnancy

 Ampulla of fallopian tube : 80%

 Isthmus of fallopian tube : 12%
 Fimbria of fallopian tube : 5%
 Interstitial of fallopian tube : 2%
 Abdomen : < 1%
 Ovarian : < 0.2%
 Cervix of uterus : < 0.2%

Probable cause

Ddelay in the passage of the fertilized ovum down the tube due to
 Pelvic inflammatory disease
 Gross pelvic pathology ; endometriosis

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 Congenital abnormality of the fallopian tube ; diverticula , hypoplasia
 IUCD

Clinical features

80% presented with hemodynamically stable condition.

Symptom : delayed menstruation with abdominal pain , shoulder tip pain , vaginal
bleeding

Sign

 Pallor
 Abdominal tenderness
 Abdominal distension
 vaginal examination – slight enlarged uterus , tender adnexae , positive cervical
excitation

Investigations

 UPT
 Ultrasound features
 Complex adnexal masses ( can be organized blood clots ) / live embryo in
adnexa ( 10 – 20% )
 Pseudogestational sac in uterus
 Empty uterus
 Fluid in POD

 Serum B hCG
 Level generally lower in ectopic pregnancy
 At level above 1500 iu/l, an ectopic pregnancy will usually be visualised with
TVS
 Level that plateau below 1000 iu/l, can either be a miscarriage / pregnancy of
unknown location.
 Serial hCG estimation can be done in difficult situation to exclude early ectopic
pregnancy
 Although a doubling hCG titre is often expected in a normal pregnancy , but
this can vary depending on gestation

In a patient who has delayed menstruation with positive UPT test and empty uterine
cavity on ultrasound should be highly suspected to have ectopic pregnancy

Management

 Assess the patient’s condition

 Blood should be taken for FBC , GSH/GXM ( depends on situation – conservative
management / surgical intervention ) , BUSE , Coagulation profile if necessary
 Intravenous assess for fluid / blood replacement
 In hemodynamically stable condition – laparoscopic approach ( salphingectomy /
salphingotomy depends on the presence of healthy contralateral tube with the need
for future fertility ) can be done.

139
 In hemodynamically unstable condition – urgent laparotomy should be arranged.
 If the diagnosis is uncertain
o The condition can be managed conservatively with serial follow up of hCG and
clinical symptom and sign.
o Diagnostic laparoscopy can also be performed for confirmation
 Medical management can opted in
o Asymptomatic patient
o Non viable fetus
o Gestational sac of less than 3 / 4 cm ??
o Unruptured tube without active bleeding
o hCG < 5000 iu/l.

Medical treatment of ectopic pregnancy

 Counsel patient regarding treatment

 Day 1 : IM Methotrexate 50mg/m2
 Repeat hCG on Day 4 and Day 7
o ( level is expected to fall by more than 15% between Day 4 and Day 7 )
 Repeat IM Methotrexate can be given if level does not fall as expected.
 Active management is indicated when patient becomes symptomatic , increment of
serial hCG level or development of suspicious ultrasonic findings to suggest
ruptured ectopic pregnancy.

PUERPERIAL SEPSIS

 Puerperal sepsis is any bacterial infection of the genital tract which occurs after the
birth of a baby. It is usually more than 24 hours after delivery before the symptoms
and signs appear.
 Pueperial pyrexia is defined as fever of 38 C ( 100.4 F ) that occur 24 hours after
delivery.
 Common infection in post partum period : endometritis , urinary tract infection ,
mastitis, breast abscess, pneumonia, wound infection – caesarean / episiotomy
wound and thrombophlebitis/thromboembolism .
 Symptom : Fever , abdominal pain , smelly / purulent lochia , perineal pain , breast
tenderness , productive cough or calf pain.
 Common organism : Streptococcus , staphylococcus , gram negative bacilli ,
anaerobes

Evaluation
 Thorough history of intra and post partum period – to reveal predisposing factors
suggesting of infection
 Physical examination focusing particularly on the likely areas of concern.

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 Investigation : FBC with differential , UFEME and culture , blood culture , Vaginal
swab culture. CXR and Sputum gram stain and culture should be done if
respiratory infection is suspected.

Treatment

 Broad spectrum antibiotic , recommended :

- 2nd or 3rd generation Cephalosporin eg : Cefuroxime 750mg IV q every 8H or
Cefoperazone 1g IV every 12H + Metranidazole 500mg IV every 8H for 3
days followed by oral treatment for 7 days
- B-lactam/ B-lactamase inhibitors eg : Ampicillin/Sulbactam 1.5g IV every 8H for
3 days followed by oral treatment for 7 days.
 Alternatives :
- Ampicillin 1g every 6H + Metranidazole 500mg IV every 8H + Gentamicin
5mg/kg IV every 24H for 7days

 Other treatment is guided by the cause of infection

Endometritis
 Broad spectrum antibiotic
 Encourage perineal hygiene

Wound infection
 Open, drain any pus, debride any non viable tissue and cleansing
 Sitz baths for episiotomy wound infections
 Wound may be left open to heal by secondary intention or secondary suturing later
after wound is healthy
Urinary tract infection

 Broad spectrum antibiotic

 Encourage hydration
 Perineal hygiene

Breast abscess

 Broad spectrum antibiotics

 Surgical referral
 Drainage

Pneumonia
 Broad spectrum antibiotics
 Chest physiotherapy
 Oxygen therapy should be guided by arterial blood gas and pulse oxymetry.

Deep Vein Thrombophlebitis / Thromboembolism

 Bbroad spectrum antibiotics
 Anticoagulant

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 Surgical therapy is reserved for medical failures.

GENERAL
MEASURES
142
 LABOUR ROOM WARD ROUNDS

 On call rosters will be prepared by the senior medical officer for a month’s duration
and must be ready at least one week prior to the beginning of the month.
 Doctors must work as a team at all times in caring for their patients.
 All doctors are expected to be familiar with the management protocols for labour
ward.
 Medical officers on duty should stay in the labour ward.
 All doctors on call must be contactable at all times.
 All new cases admitted to the labour ward must be reviewed by the medical officer in
charge of labour ward.
 Medical officers must conduct labour ward rounds at least every four hours. Any
abnormal findings must be informed to the medical officer in charge.
 Specialist in charge of labour ward must conduct rounds at least once in the morning
and once in the evening. The specialist on call conduct ward rounds during the
passing over at 5 pm and another additional round at 10 pm each night.

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  Medical officers on call must inform or consult specialist on call before performing
any instrumental deliveries and caesarean section.
 All specialists and medical officers on call must gather during the morning pass over
and inform regarding the problem case managed during on call time.
 The consultant in charge must be informed of all ill patients or any maternal or
intrapartum fetal deaths.
 The occurrence of any adverse event must be reported to the Head of Department by
the following morning.

RED ALERT CODE SYSTEM

Obstetrics Red code system is designed to establish a system of communication to

facilitate a fast, efficient and coordinated team management of selected obstetrics
emergencies. It is collaboration among various departments and units in Serdang
Hospital.

The departments and units involved are:

1. Obstetrics & Gynaecology ( Primary Team )

2. Paediatric ( Immediate resuscitation management of newborn baby)
3. Anesthesia
4. General Medical ( Obstetric Medical Emergencies eg. Respiratory arrest etc)
5. Cardiology ( Obstetric Cardiological Emergencies eg. Cardiac Arrest etc )
6. Emergency ( Obstetric Emergencies in Emergency Department )
7. Pathology – Blood Bank
8. Matron and Sister in charge / on call
9. Hospital Telephone Operator
10. Hospital Lobby Counter
11. Hospital Security Company

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Objectives

1. To institute a central notification system to improve patient outcomes by

facilitating rapid and coordinated responses from all relevant other personnel
in times of obstetrics or neonatal emergencies.
2. To overcome communication or logistic problems that lead to delay in
management of obstetrics emergencies or neonatal emergencies.

MOTHER EMERGENCIES

 Obstetric Embolism /Pulmonary Embolism / Amniotic Fluid Embolism

 Eclampsia
 Hypovolaemic shock
 Cardiac Arrest
 Massive Antepartum Haemorrhage
 Massive Postpartum Haemorrhage
 Maternal collapse from other cause
 Uterine Inversion / rupture

BABY EMERGENCIES

 Neonatal resuscitation required urgently

 Acute Fetal Distress
 Cord prolapse
 Shoulder Dystocia

Mula

Rangsang Obstetric Red Code :

Tekan butang merah di Dewan Bersalin
atau
S.O.S di PAC /lokasi lain(termasuk ED)
Jerit : <Kejadian> : Obstetrics Red Code
( Doktor /Jururawat )

Aktifkan Obstetrics Red Code; Cakap : Obstetrics Red Code<MOTHER/BABY >< Lokasi>
(Doktor/Jururawat melakukan panggilan telefon kecemasan)
*Kepada Hospital Operator ;Cakap : Obstetrics Red Code<Mother/Baby><Lokasi><Kejadian>

145
Panggil LOBI( ext : 5245 /1401) Telefon talian terus : # Panggil Hospital Operator
@ 5255 :
Untuk umum via PA system Panggil terus atau SMS untuk panggil
pasukan .
Mengikut kes
berkaitan
Umum: (Rujuk Panduan)
OBSTETRIC RED CODE :
<MOTHER / BABY><Lokasi>
O&G MO/Pakar/P.Perunding Cakap :
(ulang 3X)
(Pegawai Kaunter Lobi/ Tekan 9 seterusnya < No.Hand set > OBSTETRICS RED
CODE<:MOTHER/BABY>
Pegawai Keselamatan
Selepas pukul 9mlm) Rujuk No.Hand Set yang tertera. < LOKASI><KEJADIAN>
( Hospital
Operator )
(Doktor/Jururawat)

Respons kepada panggilan dengan segera dan bergegas ke

lokasi kejadian dalam masa 5 minit.
(Pakar Perunding , Pakar, Pegawai Perubatan , Penyelia
Jururawat , Ketua Jururawat terlibat )

Tamat

INFECTIOUS CONTROL MEASURES

OBJECTIVES

 To prevent major infections when providing services.

 To minimize the risk of transmitting serious blood borne diseases such as hepatitis B
and HIV to the woman and to service providers and staffs.

PRINCIPLES

 Every person (patient or staff) must be considered potentially infectious.

 Hand washing 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).

146
 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.

HANDWASHING

 Hand washing with soap and water is essential every time:

 Before and after examining a patient (or having any direct contact).
 Immediately 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.
 For any surgical procedures (a proper training must be given for the doctors
and staffs assisting)

GLOVES AND GOWNS

 Gloves are required when:

 Performing a procedure.
 Handling soiled instruments, gloves and other items.
 Disposing of contaminated waste items (cotton, gauze and dressings).
 A separate pair of gloves must be used for each woman to avoid cross-
contamination.
 Gloves that are cracked or have detectable hole or tears should not be used.
 Broken skin or open wounds must be covered with watertight dressings.
 Double gloves should be used for all operations, if possible, which could reduce the
amount of blood carried through if a glove is punctured.
 Long-cuffed gloves must be used for manual removal of placenta.
 Gowns or plastic apron which are clean but not necessarily sterile, should be worn
during all delivery procedures:
 If the gown has long sleeves, the gloves should be put over the gown sleeve
to avoid contamination of the gloves.
 Ensure that gloved hands (high-level disinfected or sterile) are held above the
level of the waist and do not come into contact with the gown.

SHARP INSTRUMENTS AND NEEDLES

 All staff must be aware of the infection risk from body fluids, blood, needles and
sharps, and must ensure that others are not exposed to these hazards.
 Use each needle and syringe only once.
 Do not leave needles and sharps lying around.
 Avoid recapping, bending or breaking needles prior to disposal.
 Do not dissemble needle and syringe after use.
 If a needle must be removed from the syringe or other device before discarding,
place the plastic sheath on a flat surface and single-handedly insert the needle into it.
Do not hold the plastic sheath during this procedure.
 Take a great care in recapping blood sampling barrel system needles or non
disposable syringes.
 Discard needles and other sharps in the sharps disposal bins only.

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 Reduce needlestick injuries by handling used needles as little as possible.
 Use an appropriate sized needle for the repair of episiotomy, together with a
technique using a needle holder.
 Passing all sharp instruments onto a receiver, rather than hand-to-hand at surgery
and avoid using fingers in needle placement.
 If a needle injury or other high-risk exposure to blood and body fluids occurs, report
the incident immediately.

LABORATORY SPECIMEN

 When blood or other specimens are taken, gloves must be worn.

 All laboratory specimens must be placed individually in plastic bags and as far as
possible kept upright during transportation.
 Specimens must be collected into securely capped, robust, leak-proof containers.
 Those who withdraw blood or other body fluids must ensure that the outside of any
specimen container is free from contamination.

SPILLAGES

 Blood spillages should be cleared up at once and decontaminated with hypochlorite.

 Wear non-sterile latex gloves and a plastic apron.
 Discard gloves, apron and paper towels into a yellow bag.
 Splashes of blood onto intact skin should be washed off at once with soap and water.

WASTE DISPOSAL

 The purpose of waste disposal is to:

 Prevent the spread of infection to hospital personnel who handle the waste.
 Prevent the spread of infection to the local community.
 Protect those who handle waste from accidental injury.
 Non contaminated waste can be disposed of according to local guidelines.
 All used disposable item should be placed in yellow plastic bags for incineration.
 Proper handling of contaminated waste is required to minimize the spread of infection
hospital personnel and the community:
 Wearing utility gloves.
 Transporting solid contaminated waste to the disposal site in covered
containers.
 Disposing of all sharp items in puncture-resistant containers.
 Carefully pouring liquid waste down a drain or flushable toilet.
 Burning or burying contaminated solid waste.
 Washing hands, gloves and containers after disposal of infectious waste.

148
 ANTIMICROBIAL USE IN PREGNANCY

Care should be taken when prescribing antibiotics in pregnancy. Certain antibiotics are
contraindicated in pregnancy. Beta-lactam antibiotics and macrolides are probably the
safest antibiotics to use in pregnancy.

Oral formulation can be considered after 48 – 72 hours depending on the clinical

response.

Conditions in Common Treatment Note

149
 pregnancy organism

Bacteriuria/ E. coli Oral Amoxycillin/

cystitis in Clavulanate 375 mg 8
pregnancy hourly for 10 days

Or

Oral Cephalexin 250 mg

orally, 6 hourly for 10
days

Acute E. coli IV Ampicillin 1 gm stat

pyelonephritis in dose followed by IV
pregnancy Ampicillin 500 mg 6 hourly
for 10 – 14 days

Or

IV Cefuroxime 750 mg 8
hourly for 10 – 14 days

Chorioamnionitis Group B IV Ampicillin 1 gm stat The patient

streptococcus, dose followed by IV should be
anaerobes, Ampicillin 500 mg 6 hourly delivered soon
Enterobacteriaceae for 7 days, and IV after the
Metronidazole 500 mg 8 antibiotics are
hourly for 7 days commenced.

Or

IV Cefoperazone 1 g 12 There is no
hourly for 7 days and IV role for
Metronidazole 500 mg 8 prophylactic
hourly for 7 days antibiotics in
patients with
premature
rupture of
membranes of
< 12 hours.

Puerperal and Streptococci, IV Ampicillin 1 gm stat In severe

post-abortal staphylococci, dose followed by IV infections
sepsis Enterobacteriaceae Ampicillin 500 mg 6 hourly consider
and anaerobes for 7 days, and IV initiating
Metronidazole 500 mg 8 therapy with an

150
 hourly for 7 days intravenous
third
Or generation
Cephalosporin
IV Gentamicin 60 mg 8
and
hourly for 7 days
Metronidazole
with the
possible
addition of
Gentamicin.

Retained
placental
tissue/products
of conception
should be
evacuated
after 6-8 hours
of antibiotic
cover.

Referrence: Lessons from the Malaysian CEMD 2005

PAEDIATRIC REFERRAL

INDICATIONS FOR ADMISSION OF NEWBORN FROM LABOUR ROOM /

OPERATING THEATRE TO NICU

1. All babies less than 1800 gm regardless of gestation, including from gynaecological
ward.
2. All babies less than 34 weeks of gestation.
3. All babies with birth weight more than 4500 gm.
4. All babies of mother with chorioamnionitis, either:
a. Foul-smelling liquor
b. Fever with leaking liquor (maternal temperature > 380C)
5. All babies with Apgar score less than 7 at 5 minutes.
6. All babies with respiratory difficulties.

151
7. All babies with major congenital abnormality, e.g. ambiguous genitalia.
8. All babies with major birth trauma, e.g. sub-aponeurotic haemorrhage (SAH),
shoulder dystocia, etc.

INDICATIONS FOR PAEDIATRIC DOCTOR TO STANDBY DURING DELIVERY

1. Fetal distress.
2. Cord prolapse.
3. Moderate / thick meconium-stained liquor.
4. Prematurity less than 34 weeks gestation.
5. Severe pre-eclampsia or eclampsia.
6. Antepartum haemorrhage.
7. Instrumental deliveries.

INDICATIONS FOR REFERRING NEWBORNS IN LABOUR ROOM/ MATERNITY

WARDS TO PAEDIATRIC DOCTOR

1. All babies of mother with prolonged rupture of membranes (> 18 hours)

2. All babies with G6PD deficiency or intermediate.
3. Babies with congenital abnormality, e.g. Down’s Syndrome, cleft lip / palate.
4. Onset of jaundice less than 24 hours of life.
5. Babies with feeding or respiratory problems.
6. All babies of diabetic mother on insulin.
7. All babies of mother who are Group B Streptococcus (GBS) carrier.
8. All babies of mother with significant medical condition, e.g.:
a. HIV positive
b. Rhesus negative mother
c. Mother with thyroid problems
9. Babies of mother with vertically transmissible diseases, e.g. syphilis (VDRL positive
mother with titre > 1:4 dilution)

INDICATIONS FOR REFERRAL TO PAEDIATRIC CLINIC

1. Babies with maternal Hepatitis B / carrier, Ig given to the baby, refer at 6-month-old
for HBsAg and Antibody level.
2. Babies with thalassaemic mother / carrier, refer at 6-month-old for Full Blood Picture.

152