PGIMER emergency

Obstetric management
guidelines
July 2020
First Edition May 2013
Second Edition May 2015
Third Edition July 2020
DEPARTMENT OF OBSTETRICS & GYNAECOLOGY
Postgraduate Institute of Medical Education and Research
CHANDIGARH
Deptt. of Gynae, PGIMER, Chandigarh
 Preface
The guidebook is meant to be a ready reference for the residents working in the
Labour room and should be followed as far as possible. However, the use of a
practice guideline for patient management is not a replacement for good
material judgment. Occasionally the management of an individual patient may
demand deviation from protocol for best medical practice. In such circumstances
a senior resident’s or consultant’s opinion should be sought and the rationale for
any deviation clearly documented

The Labour room practice guidelines have been developed as a result of group
consensus of the faculty and residents of department of Obstetrics &
Gynaecology, Post Graduate Institute of Medical Education and Research,
Chandigarh. These were prepared in May 2013 and have been updated in
August 2015 and July 2020.

These guidelines are based on International protocols modified according to the

local population, and available resources. The guidelines are designed solely for
use in the Labour room of PGIMER, Chandigarh.

In publishing these guidelines, no claims or warranties are made regarding

accuracy, applicability, suitability of use for other Obstetricians or care providers.
In addition no claim or warranty is made regarding outcome or results.

The guidelines are open to suggestion and revision. All possible scenarios,
'

issues and situations cannot be anticipated or addressed in a practice guideline

or protocol. While following the guidelines some unanticipated difficulties or
practical problems may be faced. Reporting of such situations and any other
suggestions to improve the protocols will be appreciated. The inputs may be
given to any faculty member of the department. We are always trying to improve
them so we may do the best job we can in treating our patients.

The department of Obstetrics & Gynecology, PGIMER reserves all rights

regarding external publication of our protocols or guidelines. These guidelines
are for internal use only.

Disclaimer: These guidelines are not valid for medico legal purposes

Deptt. of Gynae, PGIMER, Chandigarh

 Respectful Maternity Care

Childbirth is as old as the world, there’s nothing new. The

passage and passenger are the same, and forces and
mechanisms of labour are the same. Earlier there used to be
home deliveries where mothers used to deliver in familiar
surroundings in the midst of love, affection, care and they were
never afraid or anxious.

Subsequently midwives came into scene. Mid means ‘with’

and wife means ‘woman’ We used to see ‘Dayi in Hindi
movies, these were the midwives who were old and
experienced women. They had lot of compassion, care, love,
affection and experience but at the same time, there was more
of maternal and neonatal morbidity and mortality. Then good
antibiotics, good surgical techniques and hospitals came into
scene trying to look after physical health of the mothers. With
all these advances, institutional deliveries replaced home
deliveries. This led to decrease in morbidity and mortality, but
at the cost of emotional and mental health of the women.

The picture in the mind of a patient for a doctor in labour room

is of an experienced, soft spoken and elderly woman. But here
Deptt. of Gynae, PGIMER, Chandigarh
we have young doctors examining them who sometimes don’t
give them the respect and emotional support which they need
and expect. Always remember that we are sending a woman
physically alive but emotionally scarred for life with our
words, actions and body language”.

Every resident, faculty, nursing officer and other staff

working in the labour room who is attending to women in
labour, has to endorse Respectful maternity care in all forms
whether it is verbal or written.

Let us all take pledge to make this most beautiful moment of

childbirth a sweet and memorable experience for the mother.

Dr Vanita Suri
Professor & Head
Department of Obstetrics & Gynecology
PGIMER Chandigarh

Deptt. of Gynae, PGIMER, Chandigarh

 CONTENTS

SR. NO TITLE PAGE

A. Labour & Delivery

1 Respectful Maternity Care

-Dr Bharti Sharma, Dr Pooja Sikka

2 Labour room management in COVID era

- Dr Bharti Joshi

3 Spontaneous Labour at Term

- Dr P K Saha

4 Term Rupture of Membranes (TROM)

- Dr P K Saha

5 Intrapartum Fetal Monitoring

- Dr Japleen Kaur, Dr Rashmi Bagga

6 Labour Analgesia
-Dr Kajal Jain

7 Induction of Labour -
Dr Shalini Gainder

8 Operative Vaginal Delivery

- Dr Rashmi Bagga

9 Cesarean Section
-Dr P K Saha

10 Recommended Antibiotics
- Dr Rinnie Brar, Dr Rimpi Singla

B. Intrapartum Complications

11 Cord Prolapse
-Dr G R V Prasad

12 Shoulder Dystocia
-Dr S C Saha

Deptt. of Gynae, PGIMER, Chandigarh

 13 Postpartum Haemorrhage -
Dr Neelam Aggarwal

14 Third stage complications except PPH Dr

Manisha Meena

15 Complete Perineal Tear -

Dr Nidhi, Dr V Jain

C. Obstetrical Complications

16 Antepartum Haemorrhage -
Dr Jaswinder Kalra

17 Severe Preeclampsia -Dr Richa

Arora and Dr. V Jain

18 Eclampsia
-Dr V Jain

19 Preterm Labour -Dr Seema Chopra,

DrSnigdha Kumari

20 PTPROM
-Dr V Jain

21 Breech -Dr V
Suri, Dr Pooja Sikka

22 Twins -Dr
Rashmi Bagga

23 Previous Caesarean Section

-Dr Shalini Gainder

24 Intrauterine fetal death (IUFD )

-Dr Bharti Sharma, Dr Neelam Aggarwal

D. Medical & Surgical Complications

25 Anaemia -Dr
Minakshi Rohilla

26 Diabetes
-Dr V Jain

Deptt. of Gynae, PGIMER, Chandigarh

 27 Cardiac Disease
-Dr V Suri, Dr Pooja Sikka

28 Pulmonary Oedema -
Dr Rajesh, Dr V Suri

E. Miscellaneous

29 Severe Sepsis and Maternal Collapse

- Dr S C Saha

30 Use of Blood and Blood Component in Labour Room

-Dr Purnima, Dr Minakshi

31 Checklist for Intra-Hospital Transport or Critically Ill

Patients -Dr Kajal Jain

32 Protocol for Brought Dead Patient or Dead on Arrival

- Dr Akanksha

33 Post Partum IUCD -

Dr Raman Bansal , Dr V Jain

34 Medical Termination of Pregnancy

-Dr Neelam Choudhary, Dr Rashmi Bagga

Deptt. of Gynae, PGIMER, Chandigarh

 CONTENTS

SR. NO TITLE PAGE

1 Respectful Maternity Care 1

-Dr Bharti Sharma, Dr Pooja Sikka

2 Labour room management in COVID era - Dr Bharti Joshi 3

3 Spontaneous Labour at Term - Dr P K Saha 8

4 Intrapartum Fetal Monitoring 15

- Dr Japleen Kaur, Dr Rashmi Bagga

5 Term Rupture of Membranes (TROM) - Dr P K Saha 18

6 Induction of Labour - Dr Shalini Gainder 21

7 Operative Vaginal Delivery - Dr Rashmi Bagga 25

8 Complete Perineal Tear -Dr Nidhi, Dr V Jain 27

9 Thrombhoprophylaxis in Cesarean Section - Dr P K Saha 32

10 Cesarean Section Protocol -Dr P K Saha 34

11 Preterm Labour -Dr Seema Chopra 38

12 PTPROM -Dr V Jain 42

13 Breech in Labour -Dr V Suri, Dr Pooja Sikka 44

14 Twins in Labour -Dr Rashmi Bagga 48

15 Previous Caesarean Section -Dr Shalini Gainder 51

16 A.P.H. -Dr Jaswinder Kalra 55

17 P.P.H. -Dr Neelam Aggarwal 59

18 Cord Prolapse -Dr G R V Prasad 63

19 Shoulder Dystocia -Dr S C Saha 65

20 Anaemia in Labour -Dr Minakshi Rohilla 68

Deptt. of Gynae, PGIMER, Chandigarh

 21 Severe Preclampsia -Dr Richa Arora and Dr. V Jain 71

22 Eclampsia -Dr V Jain 78

23 Diabetic in Labour -Dr V Jain 82

24 Pregnancy With Cardiac Disease -Dr V Suri, 87

Dr Pooja Sikka

25 Pulmonary Oedema -Dr Rajesh, Dr V Suri 90

26 Management Of Severe Sepsis and Maternal Collapse 92

- Dr S C Saha

27 Use of Blood and Blood Component in Labour Room 103

-Dr Purnima, Dr Minakshi

28 Labour Analgesia -Dr Kajal Jain 110

29 Protocol for Brought Dead Patient or Dead on Arrival 119

- Dr Akanksha

30 Checklist for Intra-Hospital Transport or Critically Ill 120

Patients -Dr Kajal Jain

31 Recommended Antibiotics 125

- Dr Rinnie Brar, Dr Rimpi Singla

32 Magnesium Sulphate for Fetal Neuroprotection 128

- Dr Snigdha

33 MTP Protocol -Dr Neelam Choudhary 130

Dr. Rashmi Bagga

34 Management of woman with IUFD 133

-Dr Bharti Sharma, Dr Neelam Aggarwal

35 PPIUCD - Dr Raman Bansal , Dr V Jain 137

36 ANNEXURES 143

Deptt. of Gynae, PGIMER, Chandigarh

 RESPECTFUL MATERNITY CARE DURING
1 LABOUR AND CHILDBIRTH

- Dr Bharti Sharma, Dr Pooja Sikka

What is RMC?

Respectful maternal care is “the right of every woman to the highest attainable standard
of health, which includes the right to dignified, respectful health care at all health
systems around the world of childbearing woman throughout her pregnancy, during
labour and delivery, and post-natal period”.

How will you provide it?

Each component of RMC has to be observed. The components of RMC toolkit as

proposed by USAID/ Maternal and Child Health Integrated Program (MCHIP) 2013 are
as follows:

1. Abuse free care- Every woman has the right to be free from harm and ill treatment.
2. Consented care- Every woman has the right to information, informed consent and
refusal, and respect for her choices and preferences including companionship during
maternity care.
3. Confidential care- Every woman has the right to privacy and confidentiality.
4. Dignified care- Every woman has the right to be treated with dignity and respect.
5. Discrimination based on specific attributes free care- Every woman has the right
to equality, freedom from discrimination and equitable care.
6. Non-abandonment & non-denial of care- Every woman has the right to healthcare
and to the highest attainable level of health.
7. Non-detention at health facility– Every woman has the right to liberty, autonomy,
self determination and freedom from coercion.

Communicate well with your patient. She needs your support. It is a difficult time
for her.

1. Introduce yourself to the woman and address the woman by her name.
2. Offer the woman and her family the information they need in a clear and concise
manner in the language spoken by the woman and her family.
Deptt. of Gynae, PGIMER, Chandigarh1
3. Respect and respond to the woman’s needs, preferences and questions with a
positive attitude.
4. Support the woman’s emotional needs with empathy and compassion, through
encouragement, praise, reassurance and active listening.
5. Support the woman to understand that she has a choice and ensure that her choices
are supported.
6. Encourage a birth companion in the form of a female attendant to intermittently stay
by her side and encourage her to actively participate in the process of labor. This
might always not be possible in a busy labor room.
7. Always speak politely to both woman and her companion. Every laboring woman
demands dignity and respect.
8. Ensure that procedures are explained to the woman, and verbal or written consent
for pelvic examinations and other procedures (induction of labour) has to be
obtained from the woman.
9. Encourage the woman to express her needs and preferences, and regularly update
her and her family about what is happening, and asking if they have any questions
whenever feasible (eg. progress of labor).
10. Ensure the privacy and confidentiality.

REFERENCES

1.
owser D, Hill K. (2010). Exploring evidence for disrespect and abuse in facility-
based childbirth: Report of a Landscape Analysis. Boston, MA: URC-Traction
Project, Harvard School of Public Health.
2.
World Health Organization. WHO recommendation on respectful maternity care
during labour and childbirth.
3.
World Health Organization. WHO recommendations on intrapartum care for a
positive childbirth experience. World Health Organization; 2018 Jun 25.

Deptt. of Gynae, PGIMER, Chandigarh2

 2 LABOUR MANAGEMENT IN COVID 19 ERA

(NO CORRECTIONS IN THIS CHAPTER) - Dr Bharti Joshi

Labour management in Covid-19 era

Triaging

Triaging of all pregnant women at the screening area of Gynae

department – 3rd floor B block Nehru hospital. Covid-19 testing to be
done as per the departmental protocol. A pretest counselling to be done
&a written, informed consent to be taken.

Differentiated care pathways for further management according to

Covid testing report

Clean labor room (Green zone) – All Covid negative pregnant women
requiring emergency obstetrical care/ intervention to be managed in green
zone.

Yellow Zone (Maternity isolation) –All pregnant patients with unknown

Covid status or screen positive requiring obstetrical care to be managed.
All imminent deliveries with unknown status or screen positive to be
conducted in delivery unit of maternity isolation. Patients requiring HDU
care (APH, Eclampsia, PPH, heart disease etc.) to be directly admitted to
HDU of maternity isolation. Operative intervention of unknown status or
suspect to be done in maternity isolation OT, if report is awaited.
Deptt. of Gynae, PGIMER, Chandigarh3
Red Zone ( Nehru Extension Hospital )- All pregnant women with
Covid positive status to be managed.
General measures to be followed while caring for patients in all
areas.

✓ To take written Covid information consent from all patients at the

time of admission.
✓ All health care workers to follow hand hygiene & social
distancing norms strictly.
✓ All health care workers to don appropriate PPE according to the
working area at all times while managing patients and doff as per
the guidelines to protect themselves.(table1& 2)
✓ Strict adherence to the infection control practices.
✓ All patients to be instructed to wear face mask.
✓ Minimize the entry of patient’s attendants.
✓ To ensure frequent cleaning of labor room areas.
✓ Dedicated equipment i.e. CTG machine , USG machine or hand
held doppler to be used in each Zone & it should be
decontaminated after use.
✓ Biomedical waste disposal after the Covid report has come

Patient specific measures

✓ All patients irrespective of the working areas ( yellow, green and

red) to be managed as per the standard protocol.
Deptt. of Gynae, PGIMER, Chandigarh4
 ✓ Each patient to be kept in isolation unit or at a reasonable distance
from other patients
✓ Intrapartum management as per obstetrical profile
✓ No contraindication to labor analgesia
✓ If operative intervention required, better to do in regional
anesthesia
✓ Modified surgical safety check list as per working zone to be
followed.
✓ In order to protect newborns from risk of COVID-19 ,prior
information & coordination with the pediatrician to be ensured.
✓ Newborn care as per SOPS of pediatrics & try to collect mother’s
report as soon as possible
✓ Expedite discharge planning.

Management of Covid 19 pregnant women

• If Covid testing report of pregnant patient comes positive,

immediate isolation to be ensured. Immediate information to the
head of the department & departmental Covid committee.
• A standard protocol & predefined path to be followed for shifting
the patient to Nehru extension block.
• Patient in the NHE to be managed by the concerned unit & Nodal
officer NHE.

Intrapartum management

Deptt. of Gynae, PGIMER, Chandigarh5

 Once settled in an NHE isolation room, a full maternal and foetal
assessment should be conducted to include:

✓ Assessment of the severity of COVID-19 symptoms, which

should follow a multidisciplinary team approach including an
infectious diseases or medical specialist.
✓ Maternal observations including temperature, respiratory rate &
oxygen saturations.
✓ Confirmation of the onset of labour, as per standard care.
✓ Foetal heart rate monitoring using hand held doppler

Care in labour

• Monitor oxygen saturation frequently during labour &keep >94%, titrating oxy
therapy accordingly.
• Strict foetal heart monitoring in labour to be done. If indicated fetal status can
assessed with Ultrasonography.
• Mode of delivery not be influenced by the presence of COVID-19, unless the w
respiratory condition demands urgent delivery.
• In case of deterioration in the woman’s symptoms, make an individual assessm
regarding the risks and benefits of continuing the labour, versus emergency cae
birth if this is likely to assist efforts to resuscitate the mother
• An individualised decision to cut short second stage of labour in a symptomat
woman who is becoming exhausted or hypoxic
• Epidural analgesia to be preferred in labour to women to minimise the need for
anaesthesia
Deptt. of Gynae,ifPGIMER,
urgent operative
Chandigarhintervention
6 isneeded.
Postnatal Management

Considerations below for temporary separation:

• The risks and benefits of temporary separation of the mother from

her baby to be discussed with the mother. The option of breast
feeding to be discussed with her in detail explaining all pros &
cons.
• During temporary separation, mothers who intend to breastfeed to
be encouraged to express their breast milk to establish and
maintain milk supply.
• A separate isolation room for the care of the infant.
• If a mother and new-born do room-in and the mother wishes to
feed at the breast, she should put on a facemask and practice hand
hygiene before each feeding.
• Neonatal testing & care as per SOPS pediatrics.

Heparin prophylaxis

Asymptomatic / minimal symptoms

• Advise to keep herself hydrated & ambulatory.

• A clinical review to be attempted to assess the risk of

venous thromboembolism (VTE) & thromboprophylaxis

Deptt. of Gynae, PGIMER, Chandigarh7

 will be considered & prescribed on case to case basis. If

VTE score at admission is three or more, prophylaxis will

be given.

• Who are already on thromboprophylaxis because of some

indication, will continue to take same. Omit in active

labour & restart after 6 hours of normal delivery & 12

hours of caesarean, if no contraindication.

Moderate to severe symptoms

• All pregnant women to be considered for low molecular

weight heparin(LMWH) until delivery is expected in

next 12 hours. The heparin will resumed in postpartum

period after 6 hours of normal delivery & 12 hours of

caesarean after clinical assessment.

PPE Guidance Statement for use in PGIMER,

Chandigarh (Ver 6.2)
(05.06.2020)

Table 1- Guidelines for the use of PPE by HCWs in suspected/confirmed

COVID areas

Deptt. of Gynae, PGIMER, Chandigarh8

 Gloves Impervious Mask Visor/** Linen
bodysuit gown
hood

HDU, operating theatres

  N-95
 sterile
Triage, labour room
  N-95
 
Autopsy including
‘brought dead’ cases
  N-95
 
Collection
nasopharyngeal swab(s)
of
  N-95
 
Disposal of biomedical
waste
  N-95
 
HCWs
patients
transferring
and carrying
  N-95
 
samples

Handling/transfer of dead
body
  N-95
 

Table 2- Guidelines for the use of PPE by HCWs in non-COVID areas in

emergency and indoor

Gloves Impervious Mask Visor/ Linen gown

bodysuit
Hood**

Deptt. of Gynae, PGIMER, Chandigarh9

 Emergency (yellow
zone) *
  N-95
 
HDU§ (green zone)
  FFP1
 sterile
All in-patient areas
with no suspected
  Surgical
 
case (green
zone)**

Operating
theatres, labour
  FFP1/N95§
 sterile
room

Corridors
administrative
and
  Surgical
 
areas

• Use disposable plastic gown during AGP

• After emergency resuscitation – body suit should be doffed and new body suit should be
donned*
• Visor/hood – should be cleaned by 70% alcohol & maintained by end user**

Suggested references
• Government of India, Ministry of Health & Family Welfare,
Directorate General of Health Services (EMR Division). Revised
Guidelines on Clinical Management of COVID-19. [Online]
March 31, 2020. Accessed on April 5, 2020.

• The Royal College of Midwives, Royal College of Obstetrics and

Gynaecology, Royal College of Paediatrics and Child Health,
Royal College of Anaesthetists. Coronavirus COVID-19 Infection
in Pregnancy; Version 5. [Online] March 28, 2020. Accessed on
April 5, 2020.

Deptt. of Gynae, PGIMER, Chandigarh10

 • American College of Obstetricians and Gynecologists. Novel
Coronavirus 2019 (COVID-19) Practice Advisory [Online] March
13, 2020. Accessed on April 5, 2020.

• The Federation of Obstetric and Gynaecological Societies of

India. Good Clinical Practice recommendation on Pregnancy with
COVID-19 Infection; Version 1; [Online] March 28,
2020.Accessed on April 5, 2020.

Deptt. of Gynae, PGIMER, Chandigarh11

 3 SPONTANEOUS LABOUR AT TERM

-Dr. P. K. Saha

DIAGNOSIS OF LABOUR

The presence of regular and painful intermittent contractions, which are of increasing
frequency, duration and intensity, associated with a significant change in the effacement and
dilatation of the cervix. A diagnosis of labour should be made as soon as possible following
admission to the Labour Ward by an abdominal palpation and vaginal examination.

EXAMINATION AT ADMISSION

DETAILED HISTORY (Dating,Obstetrical history, past, personal history)

General Physical Examination(P/R,B/P,Pallor,Oedema, Jaundice,cyanosis,clubbing,

Systemic examination -chest, CVS, thyroid breast) and Obstetrical examination (Fundal
height,lie,presentation,liq,contraction,FHR)

CHECK ALL ANTENATAL INVESTIGATION.

PA examination:- Assess contractions (Mild contraction lasting for <20 sec each; Moderate
contraction lasting from 20 to 40 sec and strong contractions when each lasting for >40 sec);
Contractions are regular when at least 3 contractions occur in 10 minutes duration.

PV examination (Detail cervical and pelvic assessment- cervical consistency, effacement,

dilatation, status of membrane, color of liquor, cervical application to presenting part,
presentation, position, station and details of pelvic examination

ADMISSION NST

Reach a conclusion about the normalcy of the pregnancy when all examinations

Including record and laboratory investigation are completed.

ONCE LABOUR IS CONFIRMED

Administration of enema -Routine administration of enema is not indicated.

Shaving of pubic hair not required / clipping is only required.

Deptt. of Gynae, PGIMER, Chandigarh 12
What are the things to be monitored in labour?

PROGRESS OF LABOUR

Maternal monitoring

Fetal monitoring

PROGRESS OF LABOUR

By assessing the rate of cervical dilatation and descent of the presenting part.

A woman is in active phase of labour when the cervix is at least 4cm dilated, fully
effaced and her contractions are regular (4/10 mints lasting for > 30secs).

Although WHO no longer recommends Partogram Monitoring in all women in labor,

yet it can be plotted for better intrapartum monitoring. WHO considers active labor
when cervical dilatation exceeds 5 cm. However, PARTOGRAM IS COMMENCED AT
4 CM OF DILATATION.

Progress of Labour to be Plotted on regular interval to know when to intervene.

Vaginal examination to be offered every 4 to 6 hours to assess the progress of labor provided
contractions are regular. Abdominal examination is mandatory before P/V examination.

Be sure that the vaginal examination is really necessary and will add important
information to the decision-making process

ADDITIONAL VAGINAL EXAMINATIONS IN CASE OF

Fetal distress

Leakage P/V

Bleeding during labour(abruption)

Meconium on pad

Before any intervention like Instrumental delivery or LSCS in labouring patient

UTERINE CONTRACTIONS MONITORING

Contractions can be both quantitatively and qualitatively evaluated manually every 30mts
with the palm of the hand resting lightly on the uterus, the time of contraction onsetis

Deptt. of Gynae, PGIMER, Chandigarh 13

determined. Its intensity is gauged from the degree of firmness the uterus achieves. At the
height of effective contractions, the finger or thumb cannot readily indent the uterus during a
"firm" contraction. The time at which the contraction disappears is noted next. This sequence
is repeated to evaluate the frequency, duration, and intensity of uterine contractions. Half-
hourly documentation of frequency of contractions to be made.

MATERNAL MONITORING
Pulse rate hourly,
4 hourly temperature and BP
and BP hourly in 2 stage
(Change as per clinical needs)
Periodical check on pad: every half hourly,
Urine analysis for ketone in case of prolonged labour(>24hrs including latent & active phase)
Check hydration of the patient.
Careful evaluation and documentation of necessary administered drugs (oxytocin, antibiotics,
analgesics etc.) is important
FETAL MONITORING DURING LABOUR
Indications for the continuous EFM
• High risk pregnancies
• IOL and Augmentation of Labour.
• Premature Labour
• APH
• IUGR
• Oligohydramnios
• Hypertension.
• Abnormal FHR detected on Stethoscope
• Mal-presentation in Labour.
• DM
• Multiple Gestation.
• Previous CS.
• Prolonged ROM.(Defn)
• Meconium stained Liq.
Deptt. of Gynae, PGIMER, Chandigarh 14
Evaluation of the tracing every 15 minutes during the first stage of labor, and every 5 minutes
during the second stage in high risk
If it is not possible to monitor by CTG in High risk pregnancies fetal heart auscultation is
performed at least every 15 minutes during the first stage of labor and every 5 minutes during
the second stage.
In low risk pregnancy 30 minutes in first stage and then every 15 minutes during the second
stage. If CTG is used, the tracing is evaluated at least every 30 minutes during the first stage
and at least every 15 minutes during second-stage
When using Stethoscope Fetal heart rate should be checked immediately after a contraction
for 1 minute.
The maternal pulse should be palpated if a FHR abnormality is detected to differentiate the
two heart rates
In case of leakage look for colour of amniotic fluid (blood, meconium) and interpretation
accordingly.

ANTIBIOTICS IN NORMAL LABOUR AFTER RUPTURE OF MEMBRANE

• No antibiotic is required in normal Labour
Antibiotics to be given in case of any H/O unclean examination or any evidence of
chorioamnionitis or vaginal swab showing GrB streptococcus.

ORAL INTAKE:
Light food (biscuits) can be given before active phase. Food should be withheld during active
labour and delivery whereas Isotonic fluid (juice, tea, plain water) should be given.
Prolonged NPO is not recommended even for LSCS nowadays. According to ERAS
Protocol, light meal is allowed upto 6 hours and clear liquid upto 2 hours before LSCS.
Carbohydrate loading dose 2 hours before surgery has been shown to enhance post-operative
rapid recovery. However, ERAS protocols to be followed only after informing both senior
obstetrician and anesthesiologist.
INTRAVENOUS ACCESS: No IV fluid is required in uncomplicated labour. IV line to
be put in active labour or if analgesia is administered.

VOIDING OF URINE:
Patient should be encouraged to pass urine, if the bladder is distended and she cannot void,
catheterization is indicated.
MATERNAL POSITION

Deptt. of Gynae, PGIMER, Chandigarh 15

The normal Labouring woman need not be confined to bed early in labour. In bed, the
laboring woman should be allowed to assume the position she finds most comfortable—this
will be lateral recumbency most of the time. She must not be restricted to lying supine
because of resultant aortocaval compression. If sedation has been given the patient should
stay in bed.

ANALGESIA AS PER PROTOCOL

AMNIOTOMY
In normally progressing labour, amniotomy should not be performed routinely. If there
is any indication for amniotomy (IUGR, fetal distress, abruption) then head must be well
applied to the cervix and not be dislodged from the pelvis during the procedure to avert
umbilical cord prolapse.

MANAGEMENT OF THE SECOND STAGE OF LABOUR

Second stage is diagnosed when cx is fully dilated
Effective analgesia should be continued in second stage.
Frequently emptying the bladder is required. Catheterisation only if the patient is not able to
pass urine.
BP hourly
P/R half hourly
Rather than time limits, one should check.
Maternal and fetal condition.
Progress and descent of the fetal head
If there is no Urge to push or no active maternal efforts to push in 2nd stage then it is
passive 2 stage.
Duration of passive phase
Nulliparous woman – 1 hour
Multiparous woman – 1 hour
If it is > 1hr reassess
If there is Urge to push or active maternal efforts to push in 2 stage or fetal head is visible in
the perineum then it is active 2 stage.
Continue ongoing assessment

DELAY PUSHING IF THERE IS NO URGE TO PUSH

Active stage duration of upper limit

Deptt. of Gynae, PGIMER, Chandigarh 16

Nulliparous woman – 2 hours
Multiparous woman – 1 hour
FHR to be checked every 5mts/ after each contraction in active 2 stage.
If there is no descent of presenting part despite of pushing for one hour reassess patient.

DURATION OF SECOND STAGE

Primi Multi
Epidural 3 hrs 2hrs
Without epidural 2 hrs 1 hr

Position in 2 stage - Use of an upright or lateral position compared with a supine or

lithotomy position is better
EPISIOTOMY
Decision to perform an episiotomy should be made judiciously. It is indicated if there is a
need to expedite delivery, instrumental delivery or if there is a threat of perineal injury.
Where an episiotomy is performed, the recommended technique is a mediolateral episiotomy

There is no justification for “routine” episiotomies

Episiotomy repair:
• Ensure adequate analgesia: This can be achieved by either topping up of epidural
analgesia or local infiltration.
• First repair the vaginal mucosa: RCOG recommends polyglactin(vicryl rapid) as the
suture material of choice. If not available: repair with chromic catgut 1-0.
• Use a large, round body needle and start above the apex of the cut or tear, as severed
vessels retract slightly. Use a continuous running (not locking) stitch to close the
vaginal mucosa. It may be necessary to place extra sutures to close lacerations.
• Interrupted sutures are then placed to close the muscle layer.
• Closure of the skin as follows: Interrupted mattress sutures should be taken using a
curved cutting needle. A continuous subcuticular stitch may be applied and produces
more comfortable results. Work from the apex to the fourchette getting good
apposition.
• Perform a gentle vaginal examination to check for any missed tears or inappropriate
apposition of anatomy.

Deptt. of Gynae, PGIMER, Chandigarh 17

 • Finally put a finger in the rectum to check that no sutures have passed through into
the rectal mucosa and that the sphincter is intact. If sutures are felt in the rectum they
must be removed and replaced.

Paediatrician must be present at all deliveries.

MANAGEMENT OF THE THIRD STAGE OF LABOUR

Active management of the third stage is recommended, which includes the use of oxytocin
(10 international units [IU] by intramuscular injection)/(10 U Oxytocin in 500ml NS 30 -40
drops/mt) after delivery of the baby. The umbilical cord should not be clamped earlier than is
necessary. Delayed cord clamping (60 seconds or when cord pulsation has ceased) may
benefit baby by reducing anaemia. Contraindication are asphyxiated baby, APH, PPH).
Controlled cord traction and fundal massage to be given. The third stage of labour is
diagnosed as prolonged if not completed within 30 Mts Negative Blood group of the mother–
send cord blood for baby Blood group and DCT test.
EXAMINATION OF THE PLACENTA
• The placenta should be examined for missing cotyledons or other evidence of
undelivered remnants.
• The membranes should be inspected for vessels that run blindly to an edge,
suggesting a succenturiate lobe that may not have been removed.
• When abnormalities of the placenta are suspected, pathologic evaluation is
warranted Asses approximate blood loss.
POSTPARTUM CHECK UP
Look for P/R,B/P, Respiration,Pallor, Height of uterus, Contractility, Chest examination,
Local examination, Amount of vaginal bleeding, Vulvar haematoma
DOCUMENTATION- DETAILS IN DELIVERY RECORD FORMS
• Subsequent vitals record every 15-30mts till 2 hours
• If Perineal Pain look for haematoma
• Patient should pass urine within the first two hours

Deptt. of Gynae, PGIMER, Chandigarh 18

 4 INTRAPARTUM FETAL MONITORING

-(NO CORRECTIONS IN THIS CHAPTER)

Dr Japleen Kaur, Dr Rashmi Bagga

Basic Principles of intrapartum fetal monitoring

1. Make a documented systematic assessment of the condition of the woman and fetus
(including cardiotocography [CTG] findings) at least every hour.
2. Assess and document contractions and all 4 features of fetal heart rate: baseline rate;
baseline variability; presence or absence of decelerations (and concerning
characteristics of variable decelerations* if present); presence of accelerations.
3. If it is difficult to categorise or interpret a CTG trace, obtain a review by a senior
obstetrician.
4. Take into account the following fetal factors while interpreting CTG : Any abnormal
presentation, including cord presentation transverse or oblique lie high (4/5–5/5
palpable) or free floating head in a nulliparous woman, suspected fetal growth
restriction or macrosomia, suspected anhydramnios or polyhydramnios.
5. Do not make any decision on the basis of CTG findings alone. Take into account the
following maternal factors
a) Maternal observations, including temperature, blood pressure and pulse
b) Whether there is meconium or blood in the amniotic fluid
c) Any signs of vaginal bleeding
d) The frequency of contractions
e) The stage and progress of labour
f) Parity
g) Any medication she is taking
6. Communicate regarding progress and any issues with the woman.
Interpretation of CTG trace

Deptt. of Gynae, PGIMER, Chandigarh 19

General Principles
1. Differentiate between maternal and fetal heartbeat
2. Baseline heartrate will usually be between 110 and 160 bpm
3. Intermittent periods of reduced variability are normal, especially during periods of
quiescence.
Use the following table to classify each of the 4 features (Baseline, baseline variability,
Accelerations, Decelerations) of the CTG trace

* Regard the following as concerning characteristics of variable decelerations: lasting more

Deptt. of Gynae, PGIMER, Chandigarh 20

than 60 seconds; reduced baseline variability within the deceleration; failure to return to
baseline; biphasic (W) shape; no shouldering.
† Although a baseline fetal heart rate between 100 and 109 beats/minute is a non-reassuring
feature, continue usual care if there is normal baseline variability and no variable or late
decelerations.
After classifying each feature of CTG, categorize the CTG as
1. Normal : All features are reassuring
2. Suspicious : 1 non-reassuring feature AND 2 reassuring features
3. Pathological : 1 abnormal OR 2 non-reassuring features
Management
1. Normal CTG : Continue same management
2. Suspicious CTG :Review the complete clinical picture, including maternal vitals.
Correct underlying causes such as hypotension or uterine hyperstimulation. #Conservative
measures:
(i) Oxygen by face mask,
(ii) Left lateral (avoid being supine) ,
(iii) IV fluids if woman is hypotensive,
(iv) Reduce or stop oxytocin
(v) Offer a tocolytic drug (s/c terbutaline 0.25 mg).
3. Pathological CTG: Inform Senior
a) Exclude acute events (Per vaginal examination for cord prolapse, excessive bleeding as in
abruption, uterine rupture)
b) #Conservative measures (as described above)
c) Review CTG after application of conservative measures
d) Offer digital fetal scalp stimulation. If acceleration is elicited, consider fetal status as
healthy and continue monitoring taking into consideration the clinical condition of mother.
If digital scalp stimulation does not lead to acceleration and CTG is still pathological,
consider expediting delivery. Mode of delivery to be decided keeping in view the maternal
status, other risk factors, cervical dilation etc.

Source: NICE guidelines on Intrapartum care for healthy women and babies, 2014

Deptt. of Gynae, PGIMER, Chandigarh 21

 5 TROM
- Dr. P. K. Saha
DEFINITION
Term Prelabour Rupture of Membranes is defined a rupture of the membranes prior to the
onset of labour at or beyond 37 weeks gestation.

ASSESSMENT
Initial assessment of women presenting with Term PROM should include
Confirmation of the diagnosis
Confirmation of gestation and presentation
Assessment of maternal and fetal wellbeing.
Digital vaginal examination should be avoided unless immediate induction is planned as this
has been shown to increase the rate of neonatal infection.
SPECULUM EXAMINATION
The cervical dilatation and the presence or absence of a prolapsed umbilical cord should be
noted.
If there is any suspicion of sepsis, swab should be taken from the cervix
If amniotic fluid is obviously draining from the cervix, no further action regarding confirming
PROM needs to be taken.
If there is no frank amniotic fluid visible, conduct a cough test to confirm liquor during
valsalva. If examination rules out PROM, the patient can be discharged from hospital unless
there is strong clinical suspicion of the diagnosis.
All non-cephalic presentations presenting with ruptured membranes at term must have a
digital vaginal examination to exclude cord prolapse.

ULTRASOUND EXAMINATION
An ultrasound examination may be a useful adjunct to diagnosis. Ultrasound examination
showing a markedly reduced amniotic fluid volume in the presence of normal fetal kidneys
bladder and the absence of IUGR is highly suggestive of ruptured membranes, however
normal amniotic fluid volume does not exclude the diagnosis.

Deptt. of Gynae, PGIMER, Chandigarh 22

MANAGEMENT OF CONFIRMED RUPTURE OF MEMBRANES
Women presenting with prelabour rupture of the membranes at term should be explained that:
the risk of serious neonatal infection is 1% rather than 0.5% for women with intact
Membranes.
60- 70% of women with prelabour rupture of the membranes will go into labour within 24
hours
Up to 24 hours of expectant management, in selected cases, may be considered after
discussion with patient. Induction of labour is appropriate approximately 24 hours after
rupture of the membranes
CRITERIA FOR WAITING 24 HOURS
➢ Term PROM with fixed cephalic presentation
➢ No signs of infection (maternal tachycardia, fetal tachycardia, fever, uterine
tenderness, foul smelling discharge)
• Normal CTG
• No cervical suture
• No internal examination done
UN-CONFIRMED RUPTURE OF MEMBRANES
If the diagnosis of PROM is in doubt, repeat the speculum examination, after a period of two
hours lying down. Check sterile pad for leakage.
NO EVIDENCE OF RUPTURE OF MEMBRANES
If there is no definitive evidence of PROM and no other risk factors, the woman can be
discharged and asked to follow up in OPD or to come CLR SOS.
IMMEDIATE TERMINATION OF PREGNANCY
If any evidence of infection
Presence of cx suture
H/O internal examination (Unclean)
Any high risk obstetrical & medical problems
Patient not willing for 24 hours expectant management

Deptt. of Gynae, PGIMER, Chandigarh 23

Pt already came after 24 hours of rupture of membrane.
In non-cephalic presentation LSCS to be done 6 hours of fasting if there is no maternal or
fetal compromise.
If there is evidence of infection in the woman, a full course of broad-spectrum intravenous
antibiotics should be prescribed
If there are no signs of infection in the woman, antibiotics should not be given to the woman,
even if the membranes have been ruptured for over 24 hours.
In case of chorioamnitis broad-spectrum antibiotics to be given
INDUCTION OF LABOUR
Only with oxytocin keeping in mind adequate time to be given for latent phase. Fetal
monitoring by continuous EFM

Deptt. of Gynae, PGIMER, Chandigarh 24

 6 INDUCTION OF LABOR
- Dr. Shalini Gainder
During history taking-
• Check the gestation, confirm dating
• Indication for induction of labor should be written in the work up
• Induction should be avoided if there are any contraindications to labour or vaginal
delivery. They include, but are not limited to the following:
▪ Placenta or vasa previa or cord presentation
▪ Abnormal fetal lie or presentation (e.g. transverse lie or footling breech)
▪ Prior classical or inverted T uterine incision
▪ Significant prior uterine surgery (e.g. full thickness myomectomy)
▪ Active genital herpes
▪ Pelvic structural deformities
▪ Invasive cervical carcinoma
▪ Previous uterine rupture
• Confirm Location of placenta , Review USG findings
INVESTIGATIONS
• Check Hb
• Confirm blood group
• Investigation as per clinical presentation
• Fetal heart at admission
Preparation of the patient
Explain her the method of cervical ripening agent and IOL and about when she is likely to
deliver.
Discuss regarding analgesia
Consent before induction if IOL done before 39 weeks.
All instruction to be entered in the instruction book for the staff nurse with name of the
patient, time and date.
Pre-induction documentation of
Maternal assessment and recording of vitals

Deptt. of Gynae, PGIMER, Chandigarh 25

Per abdominal examination includes
• Fundal height,
• presentation,
• presence of contractions ,
• fetal heart by auscultation
Per vaginal examination to document
• Bishop Score,

• pelvis adequacy characteristic,

• presence / absence of membranes,
• characteristic of amniotic fluid
• fetal presentation ,
• station of the presenting part
• position of posterior fontanelle to guide in assessing labor progress where possible.
Decision of cervical ripening
Preferably if Bishop score less than 6
STRIPPING OF MEMBRANES
⚫ When a vaginal examination is carried out to assess the cervix, membrane sweeping
can be done if termination of pregnancy is planned.
AMNIOTOMY
Can be used for Induction of labor / Augmentation of labor
Pre requisite - cervix should be favorable.
⚫ The presenting part should be well fixed in the pelvis.
⚫ After ARM check for presence of cord ,confirm fetal presenting part and position
and notify.
⚫ Note the colour of the fluid (clear, greenish, bloody).

Deptt. of Gynae, PGIMER, Chandigarh 26

 ⚫ After ARM, listen to the fetal heart rate during and after a contraction. If the fetal
heart rate is abnormal (less than 100 or more than 180 beats per minute), suspect
cord prolapse.
⚫ After ARM women can go in labour and contraction tend to increase therefore after
observing for 1 hour decision of dose of oxytocin can be decided.
⚫ She is likely to require lesser dose of oxytocin than she was requiring prior to
amniotomy. Start half the dose of oxytocin after amniotomy.
⚫ Amniotomy is to be done at more than 3 cms.
Dinoprostone gel
Dinoprostone gel 0.5mg is to be inserted using full aseptic precautions intracervically.
Patient is instructed to lie supine for next 30 minutes.
Instillation should follow monitoring of uterine activity and fetal heart especially when
contractions begin.
Dose can be repeated after 6 hours ( 6-12 hrs). Maximum doses allowed are 3 doses (ACOG).
⚫ No gel instillation if patient is already having contractions.

MISOPROSTOL FOR IOL

Dosage of 25ug is considered safe as initial dose
Repeated 6 hrs vaginaly (To be used after consultant’s decision)
Oral 25ugm misoprostol for labor induction repeated 2 hourly.
Number of doses and time interval between doses to be decided by treating physician.
Oxytocin should be started at not less than 4 hrs after last dose of misoprostol.

FOLEY’S CATHETER
Foleys catheter 18 F insertion with full aseptic precautions. Inflation of balloon using 30-50
ml saline can be left for not more than 12 hrs especially in previous LSCS.
Catheter can be expelled spontaneously, or has to be removed if leakage occurs or in 10-12
hours.

COMBINED MECHANICAL AND PHARMACOLOGICAL METHOD

A few RCTs have shown that concurrent use of mechanical and pharmacological method of
cervical ripening reduced in a significant increase in Bishop’s score and decreased failed
inductions (Hill et al, 2009: Carbone et al, 2013: Aduloju et al, 2016).

Deptt. of Gynae, PGIMER, Chandigarh 27

Combined method with intracervical 18F Foley’s catheter and Dinoprostone gel 0.5 mg can
also be instilled after discussing with consultant. Assessment to be done after 12 hours or
once Foley’s catheter is expelled.
Pre-requisite:- Bag of membranes must be intact.

OXYTOCIN
Preparation for use with infusion pump :
30 Units of oxytocin diluted in 500ml of Ringer Lactate (ACOG) to make a concentration of
60 milliunits /ml
1ml in 1 Hour means - 1ml/60milli U/ 60 minutes = 1milli U/minute
Therefore to begin at 3milli U / minute begin at 3ml /hour
Protocol used in LR : 3milliunits /hr starting dose with increment every 15 to 30 minutes upto
42 milliunits.
Amniotomy for augmentation can be done after 42 milliunits.
Contractions begin within 5 minutes of initiation of infusion and steady level is achieved in
4o minutes of beginning the infusion.
If contractions not established and fetal heart reassuring then dose may be increased upto 72
mU/ml with continuous fetal monitoring.
If cervix is unfavourable with a poor Bishop’s score of <6 and all other ripening agents are
contraindicated, then primimg dose of oxytocin can be started as follows:-
1 milliU / minute for 1 hour followed by 2 milliU / minute for 2 hours and then 3 milliU/
minute for 3 hours. Further doses are incremented as per routine oxytocin infusion protocol.

MONITORING
• Fetal heart should be auscultated using stethoscope and/ or on the monitor every 15
minutes during moderate contractions while being induced and every 5 minutes in
second stage of labor.
• Women undergoing IOL with Oxytocin should preferably have continuous fetal
heart monitoring.
• Maintain hydration and input output chart of the patient.
• Partograph should be plotted and it should guide in the diagnosis of dystocia.
If hyperstimulation occurs then oxytocin is stopped and it is to be restarted at half of the
previous the dose.
Decrease oxytocin if
Deptt. of Gynae, PGIMER, Chandigarh 28
 • Contractions occur at 1 minute interval
• Contractions persist for more than 2 minutes.
• Insufficient relaxtion between contractions.
• Decreasing the oxytocin dose to half rather than stopping may correct the abnormal
contraction pattern along with administration of oxygen, hydration and left lateral
position.
Stop Oxytocin if
• FHR abnormality
• Rupture uterus suspected
• Maternal hypotension

7 OPERATIVE VAGINAL DELIVERY

(NO CORRECTIONS) - Dr. Rashmi Bagga

INDICATIONS (ACOG) (no indication is absolute; C section remains an option)

1. Prolonged 2 SOL: (nullipara: 3 hrs with regional anesthesia; 2 hrs without anesthesia.
Multipara: 2 hrs with regional anesthesia; one hr without anesthesia)
2. Non-reassuring fetal status
3. Maternal cardiac or neurological disease: to shorten 2 SOL if Valsalva is contraindicated,
or pushing is ineffective

PREREQUISITES
1. Dr experienced in operative vaginal delivery
2. Cervix fully dilated, membranes ruptured, Vx (or after-coming head in breech)
3. Vx engaged: molding, extension of head, pelvic deformities, asynclitism may falsely
suggest engagement; leading bony part is at ischial spines BUT the BPD has not
passed through brim. no more than 1/5 fetal head should be palpable abdominally
4. Fetal size estimated; clinically adequate mid pelvis and outlet
5. Maternal analgesia / anesthesia is satisfactory (pudendal block may be used)

Deptt. of Gynae, PGIMER, Chandigarh 29

 6. Maternal bladder empty
7. Patient consenting (document indication and maternal and fetal assessment)
8. Option of performing an immediate CS available if complications arise
9. Mediolateral episiotomy given

CONTRAINDICATIONS
1. Fetal prematurity (esp ventouse <34 wks), fetal osteogenesis imperfecta,bleeding
diatheses
2. Unengaged head, unknown fetal position, malpresentation (eg, brow, face),
suspected fetal-pelvic disproportion

CLASSIFICATION OF FORCEPS (ACOG)

1. Outlet forceps: when scalp is visible at introitus without separating labia, fetal skull
has reached the pelvic floor, sagittal suture is in AP diameter or a ROA, ROP, LOA,
LOP position, the fetal head is at the perineum, rotation does not exceed 45 degrees
2. Low forceps: Vx is 2 cm or more below ischial spines (at least +2 cm station).
APPLICATION (read from text)
FORCEPS - Appropriately applied forceps lock easily and grasp the occiput anterior fetal
head such that blades are equidistant from sagittal suture & no maternal tissue is grasped.
Watch for Shoulder dystocia esp in macrosomic babies
VACUUM - Check manual & equipment in vacuum cupboard. Soft cups more likely to fail
but have fewer scalp injuries & cephalohematomas. Metal cups more suitable for occiput
posterior, transverse, difficult occiput anterior deliveries, soft cup for uncomplicated
deliveries. Apply cup on the flexion point, check for maternal 2 tissue entrapment, build
pressure 0.8 kg/cm

TRACTION- Traction with forceps (or vacuum) should be steady (not rocking.Traction
with forceps should be in the line of the birth canal. Traction with vaccum
should be perpendicular to the cup. Traction should be exerted with each contraction
and in conjunction with maternal efforts; the forceps can be relaxed between contractions to
reduce fetal cranial compression. In most cases, progress is noted with the first or second pull
and delivery occurs by the third or fourth pull. The procedure should be abandoned if descent
does not occur with appropriate application and traction.

Deptt. of Gynae, PGIMER, Chandigarh 30

SEQUENTIAL ATTEMPTS - multiple attempts using different instruments (vacuum,
different types of forceps) be avoided due to the greater potential for maternal and/or fetal
injury.
WHEN TO ABANDON THE PROCEDURE - if it is difficult to apply the instrument, or
descentdoes not easily proceed with traction (no descent over 3 pulls), or the baby is
notdelivered within a reasonable time (eg, 15 to 20 minutes)
AFTER DELIVERY- Assess mother for perineal, vaginal, urethral and cervical injuries
Neonatologist to assess baby for injuries (intracranial hemorrhage, bruises, abrasion,
lacerations, facial nerve palsy, cephalohematoma,retinal hemorrhage, subgaleal hemorrhage,
skull fracture.

Deptt. of Gynae, PGIMER, Chandigarh 31

 8 COMPLETE PERINEAL TEAR

- Dr. Nidhi , Dr. V. Jain

CLASSIFICATION OF ANAL SPHINCTER TEARS
1 : Laceration of vaginal epithelium or perineal skin only
2 : Involvement of perineal muscles but not the anal sphincter
3 : Disruption of sphincter muscles
3A : < 50% thichkness of EAS
3B : >50% thickness of EAS
3C : IAS also torn
4 : 3 degree tear with disruption of rectal mucosa

IDENTIFICATION OF ANAL SPHINCTER INJURY

• Every woman after vaginal birth should be examined systematically.
• Prior to suturing, where any degree of trauma requiring repair is identified, a rectal
examination to be carried out to exclude an anal sphincter tear.
• EAS should be palpated between two fingers - one in the vagina and one in the
rectum.
• If there is any degree of uncertainty consider assessment by a more senior doctor.
REPAIR OF THIRD AND FOURTH DEGREE TEARS
Principles
• Extensive tears and all third degree tears should be repaired with operating theatre
conditions under adequate analgesia.
• All fourth degree tears should be repaired in the operating theatre under regional or
general anaesthesia.
• Important to allow adequate muscle relaxation to retrieve retracted torn sphincter
muscle and enable repair without tension.

Deptt. of Gynae, PGIMER, Chandigarh 32

 • A consultant should be present. Intraoperative and postoperative broad-spectrum
antibiotics should be administered to prevent infection and risk of subsequent
complications such as anal incontinence and fistula.
• Recommended regimen : 2 gm cephalosporin and 500mg metronidazole intravenous
(IV) stat.
• Followed by: 5 days of oral Augmentin® Duo Forte 1 tablet twice a day.
• The full extent of the injury should be evaluated by a careful vaginal and rectal
examination in the lithotomy position and graded.
• When obstetric anal sphincter repairs are being performed, burying of surgical knots
beneath the superficial perineal muscles is recommended to prevent knot migration
to the skin

REPAIR OF IAS
• Should be repaired separately from the external sphincter.
• The internal anal sphincter lies between the external sphincter and the anal
epithelium.
• It is paler than the striated external sphincter & the muscle fibres run in a circular
fashion.
• The ends of the torn muscle are grasped with Allis forceps and an end-to-end repair
is performed with interrupted or mattress 3-0 PDS sutures or 2-0 Vicryl as it may
cause less irritation & discomfort.
REPAIR OF EAS
For EAS muscle either monofilament sutures such as polydiaxanone (PDS) or modern
braided sutures such as polyglactin (Vicryl®) can be used with equivalent outcome
Overlap Technique
• Torn ends of the EAS should be mobilised free.
• Approximately 2 cm of one end of the EAS should be laid over the other end in
a“double-breasted jacket” fashion.

Deptt. of Gynae, PGIMER, Chandigarh 33

Advantage :
• Overlapping allows for a greater surface area of contact between muscle.
• Thus if further retraction of the overlapped muscle ends were to occur, muscle
continuity would be maintained
End To End Repair
• Edges of the torn sphincter are identified
• Repaired in apposition with three or four interrupted mattress sutures.
• Compared with the overlap technique, lack of complete apposition is more likely to
occur with this technique.

End To End Repair

Muscles of the perineal body are reconstructed with interrupted Vicryl 2-0 sutures after
closing the vaginal epithelium with a continuous Vicryl 3-0 suture.
• The perineal skin is approximated with a Vicryl 3-0 subcuticular or mattress suture.
• A rectovaginal examination should be performed to confirm complete repairand to
ensure that all swabs have been removed.
• Per urethral catheter drainage for 24 hours.
• Detailed documentationto be done as it carries medico-legal implications.
TYPES OF SUTURES
• Anal Epithelium : vicryl 3-0
• IAS and EAS : PDS 3-0
• Perineal Muscle : vicryl 2-0 rapid
• Perineal Skin : vicryl 2-0 rapid

POST-OP CARE

Deptt. of Gynae, PGIMER, Chandigarh 34

 • Rest: Advise regular lying down rest periods during the day over the first six weeks
to assist in reduction of perineal descent, pain and swelling. Avoid prolonged
standing.
• Ice: Apply an ice pack for 20 minutes every 2 – 4 hours for the first 24 - 48 hours to
assist in reduction of swelling.
• Compression: Suggest wearing 2–3 pads for extra perineal support and firm fitting
underwear.
• Exercise: Commence pelvic floor exercises after 2-3 days or when comfortable to
aid in recovery.
• Avoid straining on the toilet.
• Analgesia: Ensure adequate pain relief, eg. NSAID's & oral Paracetamol. Rectal
analgesia should be avoided with 3rd and 4th degree tear repairs.
• Laxatives or stool softeners: Recommended with 3rd degree tears postoperatively
for about 7-10 days to maintain soft stool and avoid constipation.
• Lactulose 15 ml BD with ispaghula 1 sachet BD
• With 4th degree tears, post-operative laxatives are delayed due to rectal mucosal
injury.
• These patients are to be referred to the dietician, and commenced on a low residue
diet for approximately 7 days. The purpose of this is to have a delayed bowel motion
with a soft stool that is easy to pass.
DIETARY ADVICE
LABOUR ROOM PROTOCOLS 23
Should Take
• White bread, refined pasta and cereals, & white rice
• Limited servings of canned or wellcooked vegetables
• Moderate fresh fruits without peels or seeds
• Tender & well cooked meat, fish, eggs, and poultry
• Milk and yogurt (usually limited to two cups per day), mild cheese
• Butter, mayonnaise, vegetable oils
• Broth and strained soups from allowed foods
• Pulp free, strained, or clear juices

Deptt. of Gynae, PGIMER, Chandigarh 35

Should Avoid
▪ Whole grain bread or bran
▪ Yogurt containing fruit skins or seeds
▪ Raw vegetables except lettuce and other leaves
▪ Tough meat, meat with gristle
▪ Peanut butter
▪ Oatmeal Dried beans, peas, and legumes
▪ Dried fruits, berries, other fruits with skin or seeds
• Food containing whole coconut
• Juices with pulp
• Highly spiced food and dressings, pepper, hot sauces
• Caffeine, Nuts and Seeds
COUNSELLING
➢ Should be explained about nature of injury.
➢ Should be counselled about the risk of developing anal incontinence or worsening
symptoms with subsequent vaginal delivery.
➢ Prognosis following EAS repair is good, with 60–80% asymptomatic at 12 months.

THROMBOPROPHYLAXIS IN CESAREAN
9 SECTION

- Dr P K Saha
1. All patient will require thromboprophylaxis (HIGH RISK) if there is any previous
VTE, anyone requiring antenatal LMWH and High-risk thrombophilia for at least 6
weeks’ postnatal with LMWH

Deptt. of Gynae, PGIMER, Chandigarh 36

2. At least 10 days’ postnatal prophylaxis with LMWH (INTERMEDIATE RISK)
if any of this factor is there
Caesarean section in labour
BMI ≥ 40 kg/m2
Readmission or prolonged admission (≥ 3 days) in the puerperium
Any surgical procedure in the puerperium except immediate repair of the perineum Medical
comorbidities e.g. cancer, heart failure, active SLE, IBD or inflammatory
polyarthropathy;nephrotic syndrome, type I DM with nephropathy, sickle cell disease, current
IVDU
3.THROMBOPROPHYLAXIS WITH LMWH IF TWO OR MORE FACTOR
PRESENT
• Age > 35 years
• Obesity (BMI ≥ 30 kg/m2)
• Parity ≥ 3
• Smoker
• Elective caesarean section
• Family history of VTE
• Low-risk thrombophilia
• Gross varicose veins
• Current systemic infection
• Immobility, e.g. paraplegia, long distance travel
• Current pre-eclampsia
• Multiple pregnancy
• Preterm delivery in this pregnancy (< 37+0 weeks)
• Stillbirth in this pregnancy
• Mid-cavity rotational or operative delivery
• Prolonged labour (> 24 hours)
• PPH > 1 litre or blood transfusion
• Two or more risk factor INTERMEDIATE RISK At least 10 days’ postnatal
prophylactic LMWH

Deptt. of Gynae, PGIMER, Chandigarh 37

Doses :LMWH enoxaparin 40 mg subcutaneously SC once daily

Or

• Unfractionated heparin
5000 units SC every 12 hours

Deptt. of Gynae, PGIMER, Chandigarh 38

10 CAESAREAN SECTION

- Dr. P K Saha
1. In all c section consultant obstetrician to be informed
2. In all elective section 8 hours of fasting is mandatory. PAC to be done whenever is
possible (S/R anaesthesia/consultant to be informed)
3. Assess the risk of surgery and anaesthesia (H/O any medical problems, all systemic
examination (specifically undiagnosed heart disease and lung), and check all
necessary investigations.
4. In any sick patient (like eclampsia, APH in shock) requiring LSCS need for post op
ventilation and facilities like availability for ventilator, ICU care must be enquired.
5. Consultant anaesthetist to be informed or may be called in case of maternal high risk
cases (like heart disease, eclampsia, adherent placenta and patient requiring multiple
transfusion etc.)
6. Written informed consent for LSCS(maternal risk for surgery & anaesthesia and
fetal prognosis to be explained in details, please refer to C section consent form)
7. Inform OT staff (CLR OT / EMG OT)
8. Inform neonatologist(S/R in case of high risk cases New born likely to be depressed,
extremely premature or malformation)
9. Inform concern CLR sister to receive the baby.
10. Arrange blood (at least 1 unit or more and blood component depending on patient
profile)
11. Give antibiotics before incision(Preferably 1 hr before) as per protocol
12. Antiemetic (Metoclopromide 10 mg), H2 blocker(ranitidine 50mg)
13. No shaving/only clipping of hair
14. Catheterisation to be done in all c section.
15. Use of WHO check list is must
16. Document C section in REPORT OF CAESAREAN SECTION PROFORMA

Deptt. of Gynae, PGIMER, Chandigarh 39

 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY, PGIMER,
CHANDIGARHCONSENT FOR CAESAREAN SECTION (EMERGENCY CS /
ELECTIVE CS)
Name_____________________________________ CR. NO. ___________________
Age___________ Diagnosis ______________________________________________
Planned Surgery ______________________________________________________
I have been explained in the language, I best understand about the disease. I am/my patient is
suffering from and the need for surgery i.e. emergency/elective caesarean section. I was
explained about the surgical procedure planned, its benefit, the expenses involved and other
possible treatment coptions available risks involved in not undergoing the surgery and also
the risks/complications that may be associated with the surgery. I was also explained about
the risks/complications that may occur specifically to me/my patient with this surgery in
general which include:
1._______________________________________________
2._______________________________________________
3._______________________________________________
I understand that this is not exclusive. I am willing/not willing for Tubal ligation along with
it. Knowing fully that it is a permanent procedure and approximately (0.3 to 0.8) % chance of
failure rate and if conceive there is a possibility of ectopic pregnancy.
I also understand that during the course of surgery unforeseen condition may necessitate
different procedures other than those explained to me. I therefore give my consent to perform
such other procedures that are in exercise of the surgeon's judgment necessary and desirable.
I also explained the prognosis of the baby in view of the disease (maternal/fetal) and the baby
may require neonatal intensive care which may not be available due to non-availability of bed
or ventilator in NICU. I also been explained the possible need for transfusion of blood and
blood product if condition arises and also explained the complication of these transfusion.
I give my consent for administration of such anaesthetic agents considered necessary or
advisable. Iunderstand that all forms of anaesthesia involve risk and there are possibilities of
complications, injury and sometimes death.

Deptt. of Gynae, PGIMER, Chandigarh 40

I give my consent to the photography of the procedure including appropriate portions of the
body for the medical scientific or educational purposes. I also consent to the disposal of any
tissue or body part that may be involved.
Having understood all the above, I give my valid consent for all the above out of my own free
will.
Thumb impression /Signature of the patient
________________________ ______________________________
(Witness full name) (Thumb impression/Signature of the
relatives) Please mention name & relation
Date_____________________ Signature of the Doctor

Deptt. of Gynae, PGIMER, Chandigarh 41

 DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY, PGIMER,
CHANDIGARH
REPORT OF CAESAREAN SECTION
Name__________________________ Age ____ Date of Surgery _______________
Ward ____________________________CR. NO. ____________________________
Pre operative Diagnosis __________________________________________________
Post operative Diagnosis _________________________________________________
Anaesthesia. GA/Spinal/Epidural
Operation: Emergency CS Elective CS
Surgeon: 1.________________________ Anaesthetist _________________
2. _______________________
Nurse _____________________________
Intra-operative findings:
Incision: Transverse Midline vertical
LUS Not well formed Well formed
LSCS/Classical (reason)
Liquor
Baby presentation: Vertex/Breech/Transverse/any other
Delivered as: Vertex/Breech/any other
Difficulty in delivering the baby
Any extension of uterine incision
Uterus closed in: one layer/two layer
Morphology of the uterus: Normal Abnormal Details
Bilateral tubes and ovaries
TL done / Not done
If done methods

Deptt. of Gynae, PGIMER, Chandigarh 42

Detail of any specific findings / Non routine steps
Hemostasis Assessed blood loss
Counts of instruments/MOPS complete/incomplete
Baby details:(Live born, Still born, Sex, Apgar score ,CMF)
Placenta and membrane : complete/Incomplete Weight : In case of Twin chronicity
Intraoperative vitals/ Urine output
Post-operative check up (immediate)
Pallor R/R P/R BP P/A Bleeding P/V
1st hour Pallor R/R P/R BP Chest
P/A Bleeding P/V Urine output Last hour
2nd hour Pallor R/R P/R BP
Chest P/A
Bleeding P/V Urine output Last hour

Deptt. of Gynae, PGIMER, Chandigarh 43

 11 PRETERM LABOUR

- Dr. Seema Chopra, Dr Snigdha Kumari

Suspect preterm labour in any patient presenting between 24 -34 weeks with mild
contractions, menstrual-like cramping, low back ache, pressure sensation in the vagina or
vaginal discharge of mucus, which may be clear, pink, or slightly bloody (ie, mucus plug,
bloody show)
INITIAL EVALUATION INCLUDES:
➢ Confirm gestational age
➢ Maternal vital signs (temperature, blood pressure, heart rate, respiratory rate)
➢ Fetal heart rate
➢ Examination of the uterus to assess firmness, tenderness, fetal size, and position
➢ Contraction frequency/duration/intensity
➢ Look for bleeding/leakage PV
➢ Speculum examination to confirm status of membranes, cervical dilation and
effacement
➢ Per vaginum examination to find cervical dilation and effacement after placenta
previa and PPROM have been excluded.
➢ Presence of fetal fibronectin in cervicovaginal secretions, positive (defined as
greater than 50 ng per mL)
➢ Ultrasound examination to look for fetal anatomic abnormalities, confirm the fetal
presentation, assess amniotic fluid volume, and estimate fetal weight.
➢ Transvaginal ultrasound to evaluate the cervix in all pregnancies when the diagnosis
of labor is uncertain
➢ Send urine R/E , culture
Observe over four to six hours
If uterine contractions are not increasing in frequency or intensity, cx <2cm dilated and
cervical length >30 mm - The woman is at low risk of preterm birth

Deptt. of Gynae, PGIMER, Chandigarh 44

 ➢ Confirm fetal well-being (eg, reactive nonstress test)
➢ Exclude the presence of an acute precipitating event (eg, abruption or overt
infection),
Repeat per vaginum examination to see if the cervix is not progressively dilating or effacing
Discharge the patients with instructions to follow-up in one to two weeks or if she
experiences additional signs or symptoms of preterm labor, or has other pregnancy concerns
(eg, bleeding, rupture of membranes, decreased fetal activity)
If there is increased frequency, intensity and duration of uterine contractions or cervix
is<30 mm on TVS or there is dilation and/or effacement of cervix. There is increased risk
of preterm birth
MANAGEMENT
Monitor vitals, uterine contractions and fetal heart rate, preferably continuous electronic
monitoring.
Corticosteroid 12-mg betamethasone IM 2 doses 24 hours apart. A first dose of antenatal
corticosteroids should still be administered even if the ability to give the second dose is
unlikely
TOCOLYSIS
Because tocolytic therapy generally is effective for up to 48 hours so only women with
fetuses that would benefit from a 48-hour delay in delivery should receive tocolytic
treatment. Women with preterm contractions without cervical change, especially those with
a cervical dilation of less than 2 cm, generally should not be treated with tocolytics.
Choose any of the following
1. NIFEDIPINE-30 mg stat,followed by10-20mg every 4-6 hrs Contraindications : known
hypersensitivity to the drug, hypotension, congestive heart failure Side effects : dizziness,
flushing, and palpitations
2. NTG PATCH
Apply 10 mg glyceryl trinitrate patch to the skin of the abdomen. After one hour, if there is
no reduction in contraction frequency or intensity,apply an additional patch. No more than
two patches are administered simultaneously. The patches can be left in place for 24 hours,
after which they are removed and the patient reassessed Side effects : dizziness, flushing, and
palpitations. maternal hypotension

Deptt. of Gynae, PGIMER, Chandigarh 45

3. MAGNESIUM SULPHATE
4-6 g IV load over 20 minutes, followed by a continuous infusion of 2 g/hour The infusion
rate is titrated based upon assessment of contraction frequency and maternal toxicity. The
infusion is continued until 12 to 24 hours of uterine quiescence is achieved.
Contraindications: Myasthenia gravis. Myocardial compromise, serum creatinine > 1.0
mg/dL
Side effects; Diaphoresis and flushing

4. ATOSIBAN is a specific oxytocin analogue that acts on oxytocin and

vasopressin receptors. The recommended regimen is a three-step procedure: an initial
bolus dose of 6.75 mg over 1 minute, followed by an infusion of 18 mg/hour for 3
hours, then 6 mg/hour for up to 45 hours (to a maximum of 330 mg)
INDOMETHACIN
50 to 100 mg orally or rectally followed at 8-hour intervals not to exceed a total
24-hour dose of 200 mg. Not to be given beyond 32 weeks of gestation.
Discontinue tocolytics
1. If labour progresses despite treatment. Or
2. 48 hours after administration of the first corticosteroid dose if contractions subside.
Contra-indications to inhibition of preterm labour
➢ Fulminant pre-eclampsia
➢ Severe abruptio placentae
➢ Foetal distress
➢ Severe chorioamnionitis
➢ Foetal demise or lethal foetal anomaly
➢ Other obstetric factors dictate that delivery should not be delayed
No role of antibiotics
MAGNESIUM ULPHATE for FETAL NEUROPROTECTION
For women between 24+0 and 33+6 weeks of pregnancy who are in established
preterm labour or having a planned preterm birth within 24 hours, discuss with the
woman (and her family members or carers as appropriate) the use of intravenous

Deptt. of Gynae, PGIMER, Chandigarh 46

magnesium sulfate for neuro protection of the baby. Give a 4 g intravenous bolus of
magnesium sulfate over 15 minutes, followed by an intravenous infusion of 1 g per
hour until the birth or for 24 hours (whichever is sooner). Delivery should NOT be
delayed in order to administer MgSO4 for fetal neuroprotection if there are
maternal and fetal indications for urgent delivery. If tocolysis has been employed to
arrest preterm labour, MgSO4 can be used once tocolysis has been discontinued, if
delivery becomes imminent. There is insufficient evidence for repeat course of
antenatal MgSO4 for fetal neuroprotection

IF THE LABOUR PROGRESSES

Avoid early amniotomy unless indicated
LSCS only for obstetrical indications
DELIVERY
Make an episiotomy for delivery if perineum is rigid
Instrumental delivery only if indicated, ventouse to be avoided.
Neonatologist to be informed about the gestational age

12 PTPROM

- Dr. V. Jain
HISTORY — Sudden gush of clear or pale yellow fluid from the vagina/ intermittent /
constant leaking of small amounts of fluid/ just a sensation of wetness within the vagina or on
the perineum.
PER SPECULUM EXAMINATION: Look for amniotic fluid coming out of the cervical
canal or pooling in the vaginal fornix. If amniotic fluid is not immediately visible, the woman
may be asked to cough or do Valsalva to provoke leakage of amniotic fluid from the cervical
os.
IF PROM IS NOT OBVIOUS AFTER VISUAL INSPECTION
1. Use pH paper on the vaginal fluid. Amniotic fluid has a pH range of 7.0 to 7.3
compared to the normally acidic vaginal pH of 3.8 to 4.2 OR

Deptt. of Gynae, PGIMER, Chandigarh 47

 2. Put a drop of vaginal fluid on a glass slide, air dry it and look for ferning under the
microscope. Ferning indicates presence of liquor
PV NOT TO BE DONE
USG to look for liquor volume, presentation, biometry, BPP, CMF, Placenta
Investigations: Hb, TLC, DLC, high vaginal swab, CRP
Antibiotic prophylaxis:
1. Ampicillin 2 g IV every six hours for 48 hours, followed by amoxicillin (500 mg
orally three times daily) for an additional five days. AND
2. Erythromycin 333 mg three times per day / one dose of Azithromycin (one gram
orally).
H/O Penicillin allergy
1. If the patient's history suggests a "low risk" for anaphylaxis (eg, isolated
maculopapular rash without urticaria or pruritus), then cefazolin 1 gIV8 hours for 48
hours, followed by cephalexin 500 mg orally four times daily for5 days. If the
patient's history suggests a "high risk" for anaphylaxis (eg, anaphylaxis, angioedema,
respiratory distress, urticaria, particularly if these symptoms occurred within 30
minutes of drug administration) Clindamycin 900 mg IV 8 hrly for 48 hours plus
gentamicin 1.5 mg/Kg 8hrly followed by oral clindamycin 300 mg every eight hours
for five days.AND
2. Erythromycin or azithromycin
STEROIDS: Betamethasone IM 12 mg, 2 doses 24 hours apart
CONTRAINDICATIONS OF EXPECTANT MANAGEMENT:
1. Maternal infection : Tachycardia, fever, uterine tenderness, foul smelling vaginal
discharge
2. Non reassuring NST
3. Patient in labour
4. Bleeding PV : abruption placentae
5. Cord prolapse present
6. Footling breech or transverse lie
7. IUFD,CMF incompatible with life If contraindications of expectant management
present / <26 weeks/>34 weeks terminate pregnancy
Deptt. of Gynae, PGIMER, Chandigarh 48
If none present patient is for expectant management. Observe for 24 hours.
MATERNAL MONITORING 4 HRLY: maternal pulse, temperature, uterine contractions,
vaginal discharge
Fetal monitoring: kick counts, FHR, non-stress tests, biophysical profile [BPP]
If monitoring fine shift toward after 24 hours
If contractions present for tocolysis for

Deptt. of Gynae, PGIMER, Chandigarh 49

 13 BREECH IN LABOUR

- Dr. V. Suri, Dr. Pooja Sikka

1. Booked/ supervised woman Unbooked/ Unsupervised woman
2. Booked pt.--- already decision taken for mode of delivery (confirm with the patient
again after evaluation)
3. Gestation
TERM BREECH
Labour Selection Criteria
1. For a woman with suspected breech presentation, pre- or earlylabour ultrasound
should be performed to assess type of breechpresentation, fetal growth and
estimatedweight, and attitude offetal head.
Contraindications to Labour/ Factors unfavourable for vaginal birth/ indications forCS.
In breech are the following.
i. Baby size more than 3.5 Kg.
ii. Footling breech/ Knee presentation (exception: cervical dilatation is full)
iii. Hyper extended (star gazing) head
iv. Breech with abruption (exception: cervix is fully dilated)
v. Clinically inadequate pelvis
vi. Previous CS (except pt. in II stage)
vii. Other contraindications to vaginal birth (e.g. placenta praevia,
a. Compromised fetal condition)
viii. Growth-restricted baby (usually defined as smaller than 2000 g)
2. If there is no contraindication to vaginal birth on clinical and USG,
Pelvic assessment should be done by SR.
3. Routine radiological pelvimetry is not necessary.
4. If all the criteria for vaginal delivery are fulfilled, the woman and her husband
should be counseled by the LR team.

Deptt. of Gynae, PGIMER, Chandigarh 50

Woman and her husband should be informed that:
a. Planned caesarean section carries a reduced perinatal mortality and early neonatal
morbidity forbabies with a breech presentation at term compared with planned
vaginal birth.
b. There is no evidence that the long term health of babies with a breech presentation
delivered at term isinfluenced by how the baby is born.
c. Planned caesarean section for breech presentation carries a small increase in serious
immediate complications for them compared with planned vaginal birth.
d. Planned caesarean section for breech presentation does not carry anyadditional risk
to long-term health outside pregnancy.
e. Long-term effects of planned caesarean section for term breechpresentation on future
pregnancy outcomes for them and their babies is uncertain
f. Women should be assessed carefully before selection for vaginal breech birth.
g. Women with unfavourable clinical features should be specifically advised of the
increased risk to them and their babies of attempting vaginal breech birth.
After counseling informed consent should be signed by the woman and husband.
LABOUR MANAGEMENT
▪ Labour induction / augmentation for breech presentation may be considered if
individual circumstances are favourable
▪ Encourage the woman to lie in left lateral position
▪ Continuous electronic fetal heart rate monitoring should be offered to women with a
breech presentation
▪ Maintain a partograph
▪ Ensure good uterine contractions
▪ Epidural analgesia/ opioid analgesia should be used.
• Avoid early bearing down
• Perform an immediate PV examination on rupture of membranes to exclude cord
prolapse
▪ Good progress in labour is the best indicator of adequate fetal-pelvic proportions.
▪ In labour Caesarean section should be considered if there is delay in the descent of
the breech at any stage.

Deptt. of Gynae, PGIMER, Chandigarh 51

II STAGE
▪ Always confirm by vaginal examination whether cervix is fully dilated or not before
shifting the woman to delivery table.
▪ Ensure presence of SKILLED obstetricians 2, one scrubbed for delivery and 1 by
woman's side, one Staff nurse, and SR neonatology and arrange equipment for
neonatal resuscitation, and a breech towel besides delivery set
▪ Shift to delivery table and put in lithotomy position.
▪ Continuous fetal heart monitoring in II stage
▪ ASSISTED BREECH DELIVERY IS TO BE PRACTICED IN ALL LIVE
FETUSES
▪ Effective maternal pushing efforts are essential to safe deliveryand should be
encouraged.
▪ Episiotomy should be performed when breech is climbing over perineum.
▪ Continuous FHR monitoring by auscultation after each contraction
▪ After delivery of trunk upto level of umbilicus, Loop of cord should be placed to one
side, away from pressure of presenting part
▪ Wrap the baby in breech towel
▪ Keep the back of baby anterior to avoid extension at head
▪ Baby is supported by pelvifemoral grip
▪ The arms should be delivered by sweeping them across the baby's face and
downwards or by the Lovset manoeuvre (rotation of the baby to facilitate delivery of
the arms).
▪ Burns-Marshall method with Suprapubic pressure by an assistant should be used to
assist flexion of the head.
▪ The Mauriceau-Smellie-Veitmanoeuvre should be considered, if necessary,
displacing the headupwards and rotating to the oblique diameter to facilitate
engagement.
A passive second stage without active pushing may last up to 90 minutes, allowing the
breech to descend well into the pelvis.Once active pushing commences, if delivery is not
imminent after 60 minutes, Caesarean section is recommended
Deptt. of Gynae, PGIMER, Chandigarh 52
PRETERM BREECH
Routine caesarean section for the delivery of preterm breech presentation should not be
advised. The mode of delivery of the preterm breech presentation should be discussed on an
individual basis with a woman and her husband. Where there is head entrapment during a
preterm breech delivery, lateral incisions of the cervix should be considered.
Informed consent for vaginal breech delivery
I/We have been informed that:
My baby is in breech presentation and I have two options for delivery ie, Planned Vaginal /
Planned cesarean section. I have also been informed that:
a. Planned caesarean section carries a reduced perinatal mortality and earlyneonatal
morbidity for babies with a breech presentation at term compared withplanned
vaginal birth.
b. There is no evidence that the long term health of babies with a breech presentation
delivered at term is influenced by how the baby is born.
c. Planned caesarean section for breech presentation carries a small increase in serious
immediate complications for the mother compared with planned vaginal birth.
d. Planned caesarean section for breech presentation does not carry any additional risk
to long-term health outside pregnancy.
e. Long-term effects of planned caesarean section for term breech presentation on
future pregnancy outcomes for the mother and the babies are uncertain. I have been
assessed by my doctor and found eligible for vaginal breech delivery. I have read the
information and have been explained by the attending Doctor in my own language
about the implications of vaginal delivery. I accord my consent for vaginal delivery
of my breech baby at my own risk.
Witness Patient's Signature/
Thumb impression

Deptt. of Gynae, PGIMER, Chandigarh 53

 14 TWINS IN LABOUR

- Dr Rashmi Bagga
ON ARRIVAL:
1. Examine : vitals, Per-abdomen, see for contractions,
2. Check history : records, investigations USGs to confirm twins,
amnionicity, presentation, placental location, additional risk factors
3. PV examination : cervical findings, presenting part, membranes, pelvic assessment
4. Choose delivery route based upon fetal presentation, amnionicity, PLUS presence/
absence of standard obstetrical indications for CS. The indications for elective CS in
twins are:
a. Monoamniotic twins (risk of entrapment is too great to permit vaginal
delivery)
b. Conjoined twins other than at gestations remote from term
c. Indications as for singleton pregnancies.
5. Previous CS : Trial of labour offered only if in spontaneous labor. As the most
common initial sign of uterine rupture is fetal heart rate changes, monitor both
fetuses by EFM
FETAL PRESENTATION:
Vertex-vertex: vaginal delivery
Vertex-nonvertex: vaginal delivery using internal or external version or breech extraction of
second twin. Contraindication to breech extraction: estimated wt of twin 2 is ≥20% than Twin
1
Twin 1= Breech: CS preferred (safety of vaginal delivery not confirmed by RCTs) but VD
may be contemplated in multiparas or women with advanced labour with a roomy pelvis.
Decision for mode of delivery when twin 1 is breech to be taken by a consultant
MANAGEMENT DURING LABOUR3
1. Lateral recumbent, arrange one unit blood, establish I/V access, send blood for Hbif
NA

Deptt. of Gynae, PGIMER, Chandigarh 54

 2. Monitor contractions and progress as per partogram.
3. EFM for both twins continuously during labour. Intermittent auscultation may not
reliably distinguish one twin from the other. Fetal heart rate of each twin can be
monitored using a single machine. EFM is particularly useful for assessing
wellbeing of second twin during the high risk period after delivery of the first twin.
4. Epidural analgesia: may be given as it provides good pain relief, does not cause
neonatal depression, is suitable anesthetic for uterine manipulation (eg, version) or
operative delivery
5. Oxytocin augmentation may be used if contractions are inadequate. Augmentation
dose is 6-9 mIU/min. Traditionally, oxytocin should not exceed21 mIU/ml (50% of
induction dose in singleton)
MANAGEMENT DURING DELIVERY
1. Inform neonatologist and assisting obstetrician
2. Delivery of the first twin of a diamniotic pair is similar to delivery of a singleton
except the umbilical cords should be marked with progressive numbers of clamps
(eg, one for the first twin birth, two for the second twin birth).
3. Second twin — After delivery of the first twin, contractions, the heart rate and
position of the second twin should be evaluated clinically by assistant.
Caution : NO methergin, NO oxytocin as part of AMTSL ie 10-20 units in 500 ml saline
4. Oxytocin augmentation of labour after delivery of the first twin may be needed due
to a temporary reduction in contraction frequency (3-9 mU/min)
5. If the second twin is vertex, wait for contractions, when vertex is fixed,
doamniotomy and wait for VD. Instrumental vaginal delivery is as per standard
indications
6. If the second twin is nonvertex, plan for external cephalic version, OR breech
extraction, OR internal podalic version and breech extraction of the second twin, if
necessary. The presence of an ultrasound machine in the delivery room may
beadvantageous for these. In case of cord prolapsed of twin 2, do IPV and
breechextraction
7. Interval between delivery of the two twins: As long as the fetal heart rate tracing
is reassuring, there is no duration of elapsed time from delivery of the first twinthat
necessitates intervention to deliver the second twin.

Deptt. of Gynae, PGIMER, Chandigarh 55

 8. The third stage of labour should be managed actively, with oxytocin infusion (10-20
units in 500 ml saline) being administered with the delivery of the secondtwin.
9. Two neonatologists should be present to receive the babies.
EXAMINATION OF THE PLACENTA
1. Examine the inter-twin placental membrane by teasing it into layers. Three
layers=dichorionic, two layers=monochorionic
POSTPARTUM
Continue oxytocin infusion for 3-4 hours &. watch vigilantly for uterine atonicity and PPH

Deptt. of Gynae, PGIMER, Chandigarh 56

 15 PREVIOUS CESAREAN SECTION

- Dr. Shalini Ganider

AT ADMISSION HISTORY TAKING SHOULD INCLUDE-
➢ Previous vaginal delivery or VBAC
➢ Number of previous cesarean deliveries
Inter pregnancy interval - less than or more than 18 months from previous delivery.
Previous cesarean section details
➢ Available or not
➢ Gestation of previous LSCS
➢ Indication of previous LSCS
➢ Type of uterine scar
➢ Intra operative whether lower uterine segment formed
➢ Uterine malformation
➢ Whether any extension , complication or difficulty
➢ Previous adhesions
➢ Uterine closure technique
➢ Previous postoperative fever or wound or cesarean complication
EXAMINATION
➢ Pallor
➢ Pulse
➢ Blood pressure
➢ Uterine contour
➢ Presentation
➢ Scar tenderness
➢ Contractions
➢ Fetal heart on auscultation.
INVESTIGATIONS
➢ Blood grouping cross matching
➢ Admission CTG

Deptt. of Gynae, PGIMER, Chandigarh 57

DECISION FOR VBAC / CESAREAN DELIVERY
➢ What patient wants ?
➢ Decision of the managing Unit.
SPECIAL CONDITIONS (Decision should be taken by consultant)
➢ Twins- not contraindicated if in spontaneous labour.
➢ Macrosomia – risk of failure, combined with previous no vaginal delivery increases
rupture risk.
➢ Maternal obesity, advanced age decrease success of VBAC.
➢ Previous scar extension - Upper segment extensions are contraindication for VBAC.
➢ Single layer closure.
➢ Beyond 40 weeks with poor bishop score , success of VBAC may be lower
➢ Previous preterm LSCS – Review records if LUS not formed then increased risk for
rupture If records are not suggestive or unavailable then women with previous
cesarean at less than 34 weeks should not be offered VBAC.
➢ Mullerian anomalies is not contraindication for VBAC.
➢ Previous two cesarean – VBAC allowed if she is in advanced labor, has a previous
VBAC explaining the increased risk of rupture.
CONTRAINDICATIONS - Previous classical cesarean, previous rupture.
IF PATIENT KEEN FOR VBAC
➢ Pelvis assessment by senior resident or consultant.
➢ Consultant should agree for VBAC and therefore should be informed.
➢ Review availability of space for VBAC if induction is planned.
➢ Whether patient is in spontaneous labour ?
➢ IV cannula is to be inserted when blood sent for cross matching.

DECISION FOR VBAC

➢ Sign the consent for VBAC
➢ Explain the benefits which are more than risks

LABOUR INDUCTION
➢ Foleys is recommended method of cervical ripening.

Deptt. of Gynae, PGIMER, Chandigarh 58

 ➢ Amniotomy early is likely to lead to spontaneous onset of labour and avoid oxytocin
usage.
➢ Oxytocin as method of induction - Maximum dose used is 21-30 milliU/ minute.
➢ Augmentation – Duration not more than 6-8 hours. 0.5 cm dilatation / hour is
adequate dilation.
INTRAPARTUM MONITORING
➢ Careful monitoring and documentation of maternal pulse half hourly
➢ Continuous electronic monitoring of fetal heart.
MONITOR FOR
➢ Any sign of abdominal pain.
➢ Scar tenderness.
➢ Presence of any fetal heart deceleration.
➢ Any abnormal bleeding.
➢ Progress of labour should be documented on partograph.
➢ Maternal tachycardia
Decision for cesarean if any abnormal finding to suggest impending rupture
SECOND STAGE
➢ Careful monitor vitals and pulse.
➢ Fetal heart monitoring, decelerations should be assessed carefully as it may indicate
rupture and require early intervention.
➢ If second stage is prolonged and criteria for outlet forcep is fulfilled then forcep
delivery can be considered.
➢ Senior resident should be present when women undergoing VBAC delivers.
➢ Scar exploration is not mandatory.
➢ Bleeding should be assessed after delivery as it can indicate rupture.
➢ Any difficulty in placental expulsion should suggest unexpected placenta accrete.
POSTPARTUM
· Before shifting patient from the delivery table check for vitals and document.
· Reassess vitals after 1 hour of delivery and then hourly for 4 hours.
INFORMATION AND CONSENT FOR PATIENTS
WITH PRIOR CESAREAN SECTION(S)

Deptt. of Gynae, PGIMER, Chandigarh 59

The purpose of this form is to provide information regarding vaginal birth after cesarean
(VBAC) to mothers who have previously had a cesarean and to provide an opportunity for the
mother to choose VBAC after discussion with the obstetrician or provider. Please read the
following information carefully, discuss your concerns with your obstetrician or provider,
initial your choice, and sign this form in the area indicated below.
All mothers who have had one previous low transverse cesarean section are encouraged to
attempt a vaginal delivery unless the physician indicates otherwise. VBAC is also a
reasonable option if your previous records can not be obtained and it is unlikely that you had
a classical uterine incision. Successful, uncomplicated vaginal birth after cesarean (VBAC)
carries the lowest risk to both mother and baby as compared to repeat cesarean section.
However, I understand that if I choose a VBAC and end up having a cesarean during labor, I
have a slightly greater risk of problems than if I had a cesarean without labor. Not all women
will be able to have vaginal birth after cesarean section. The success rate for those attempting
vaginal delivery after a previous cesarean section is about 75%.
The most serious complication of attempting a VBAC is uterine rupture which occurs in less
than 1% of cases. In the case of uterine rupture, internal and/or external bleeding may occur
and may require blood transfusions and/or hysterectomy. Rarely fetal injury or death may
also occur. Elective repeat cesarean (the alternative to VBAC) also has some risks. Cesarean
section is a major operation and in some cases these can be injuries to the mother's bladder or
bowel or otherserious complications.
Patients who have had more than one cesarean will not be discouraged from attempting
vaginalbirth if they request. However, there may be a slightly increased risk of uterine rupture
in this group. I have read or have had read to me the above information above and I
understand it. I have discussed the alternatives with my physician or provider and I have
received all the information I want.
___________ I want to attempt a vaginal birth (VBAC) _____ I want a repeat cesarean
___________________________ _________________________
Patient's Signature Print Patient's Name
_______________________ _____________________
Cr. No._______________Date ______________ Witnessed by
Name of Doctor

16 ANTEPARTUM HEMORRHAGE (APH)

Deptt. of Gynae, PGIMER, Chandigarh 60
 - Dr. Jaswinder Kalra
At admission keep TWO major causes of APH in mind:
Placenta previa Placental abruption
Usually painless bleeding Bleeding with abdominal pain
High presenting fetal part or malpresentation Irritable/tender uterus
Fetal heart usually present unless bleeding is Severe cases have maternal
massive hypotension, fetal distress/fetal
demise
ULTRASOUND EXAMINATION IS MANDATORY TO DIAGNOSE/EXCLUDE
PLACENTA PREVIA.
Rapid assessment of maternal and fetal condition at presentation should be done.
MATERNAL CONDITION
• Any signs of shock- pallor, sweating, cold clammy, restlessness
• Pulse
• BP
• Uterine palpation—size, soft/hard, tender, presenting part high/engaged
DO NOT DO VAGINAL EXAMINATION TILL PLACENTA PREVIA IS
EXCLUDED BY
ULTRASOUND SCAN
FETAL CONDITION
• Presence/absence of fetal heart
Depending upon the severity patients can fall into one of the two categories:
• Minor- Bleeding is minor or settled and mother and fetus are not at risk.
• Major- Bleeding is moderate to severe and continuing and mother and fetus are at
risk.
CLINICAL MANAGEMENT:
History: A quick history in acute presentation (A detailed history once the clinical status is
stabilized)

Deptt. of Gynae, PGIMER, Chandigarh 61

Initial History- LMP, Details of any previous scan for placental localization, amount of
bleeding/precipitating factor, associated abdominal pain/ leakage of liquor and any
diminished fetal movements, past history of bleeding during the index pregnancy, any
previous surgery on the uterus (C. Section, hysterotomy, curettage, myomectomy)
MANAGEMENT OF ANTEPARTUM HEMORRHAGE:
After initial assessment further investigations need to be performed to ascertain the- Cause of
bleeding,establish other parameters, which will assist in planning on-going care and Timing
and mode of delivery.
INVESTIGATIONS:
• Full blood count
• Blood group, Rh status and crossmatching if needed
• Coagulation profile
• Give Anti D injection if Rh negative (300 microgram IM)
• Ultrasound examination
Excluding/diagnosing and grading the degree of placenta previa, assessment of fetal size,
liquor volume, fetal well being with BPP and umbilical artery Doppler velocimetry.
(Ultrasound is not always useful in diagnosis of Abruptio placenta, as acute abruption may
have the same echogenicity as placenta
• Administer steroids for fetal lung maturatiuon
CARE PLAN:
MINOR ANTEPARTUM HEMORRHAGE
If episode of bleeding is minor and settled and pregnancy is remote from term, patient is
managed conservatively with plan to monitor fetal well being and looking out for warning
signs such as decreased fetal movements, further bleeding or abdominal pain. If gestation is
36-37 weeks, termination of pregnancy can be planned
MAJOR ANTEPARTUM HEMORRHAGE
Major episode of bleeding should be treated promptly and adequately so that mother does not
go into hypovolaemic shock which in turn may result in DIC, Renal failure, hepatic failure,
ARDS, Fetal or maternal death.
Aims of management are:
• A quick initial assessment to assess degree and cause of bleeding

Deptt. of Gynae, PGIMER, Chandigarh 62

 • Prompt resuscitative measures by restoration of blood volume and oxygen carrying
capacity
• Restoration and maintenance of normal coagulation
• Decision on mode and timing of delivery
Ultrasound examination to check for placental location and fetal health is a vital initial
step in planning treatment and should be planned in ALL cases of APH
Obstetric blood loss is difficult to assess accurately (because it may be concealed abruption,
diluted by amniotic fluid). Hence look for one of the following signs which indicate major
blood loss:
i. Pallor, sweating, cold clammy skin
ii. Restlessness and confusion
iii. Hypotension and rapid pulse
iv. Blood loss over 1.5L
BEDSIDE MANAGEMENT:
i. Call for Help!
ii. Inform Consultant, Anesthetist, Pediatrician and Nursing team. Assign one resident
to collect blood and maintain sequential and chronological events.
iii. Start nasal oxygen 8L/min.
iv. Insert two intravenous cannulae (ICG).
v. Take 30 ml blood for-Full blood count, crossmatch 4-6 units of blood, coagulation
screening with CT, PTI, FDP and in case of suspected DIC
D-dimer, Blood urea and electrolytes
vi. Start the following 2 litres of normal saline, colloids upto 1.5 L if needed (Take
blood for cross matching before starting colloids) give cross-matched blood as soon
as possible
vii. Insert indwelling urinary catheter to monitor urine output; aim to keep above
30ml/hour
viii. One resident assigned to record amount of blood loss, Pulse rate, BP, CVP if line
inserted, continuous FHR monitoring if appropriate, fundal height and girth( for
abruption) Type and amount of fluid intake, urine output, drugs administered.
BLOOD TRANSFUSION:

Deptt. of Gynae, PGIMER, Chandigarh 63

 • Fresh blood is ideal but may not be feasible in view of screening requirements,
Packed cells and stored blood lack platelets and clotting factors,
• After transfusion of 6 units of whole blood, transfuse FFP/Cryoprecipitate to
compensate for platelets and Coagulation factors. Keep in mind that stored blood is
also source of thromboplastin which can lead to or worsen DIC if excessive amounts
transfused.
• Thrombocytopenia can also occur with massive whole blood transfusions, but
platelets need to be transfused if count below 50000 or there is continued blood loss.
Cold blood can increase risk of DIC, therefore blood warming needed in case massive
transfusion is required. Rapid blood transfusion is required in most cases using
compression cuff.
DELIVERY:
Delivery should be expedited if mother is at risk or if fetus is compromised. In most cases of
major hemorrhage immediate delivery is indicated. (If possible delay delivery for giving
steroids for fetal lung maturity—but not at the cost of maternal/fetal condition).
MODE OF DELIVERY IS DETERMINED BY :
• Cause and severity of bleeding
• Fetal maturity
• Degree of fetal distress
PLACENTA PREVIA-MAJORITY WILL NEED C SECTION.
Placental abruption- If fetus is dead-vaginal birth after stabilizing maternal condition. (ARM
and augmentation of labour) If bleeding continues and maternal condition cannot be
stabilized, deliver by quickest method; which would be C Section if vaginal delivery is not
imminent. C Section will also be required in the presence of viable fetus showing distress and
delivery not being imminent. Be prepared for management of PPH in all cases of APH.

Deptt. of Gynae, PGIMER, Chandigarh 64

 17 Postpartum Hemorrhage (PPH)

-Dr. Neelam Aggarwal

DEFINITION
PPH is classically defined as estimated blood loss >500ml within 24 hours after birth
(WHO) or bleeding associated with signs & symptoms of hypovolemia within 24
hours of birth.(ACOG2017).
TERMINOLOGY
Primary PPH PPH occurring within 24 hours of birth
Secondary PPH PPH from 24 hours to 12 weeks after delivery
Major PPH Bleeding exceeding 1000ml

SPECIAL CONSIDERATIONS

• PPH remains nightmare for an obstetrician regardless of the experience & skill

• Prevention of PPH by active management of third stage of labor must be

practiced in all.

• Early diagnosis, timely institution of rapid team based PPH management

protocol is the key to successful management.
Identify high risk women

• History of prior PPH

• Overdistended uterus (multiple pregnancy, fetal macrosomia,
polyhydramnios)
• Functional/anatomical abnormalities(APH, uterine fibroids, operative
delivery
• Uterine muscle pathology (prolonged labor, precipitate labor,
chorioamnionitis
• Coagulation disorders (Coagulopathy, I T P, on anticoagulants In such

Deptt. of Gynae, PGIMER, Chandigarh 65

 women, secure IV access early in Labour, keep blood crossmatched, be
vigilant for assessment of blood loss.

Even though these are high risk women BUT remember all women are at risk.
Practice preventive approach by active management of third stage in all.

PREVENTION : Actively manage third stage of labour ( AMTSL )

▪ Use of uterotonics - oxytocin 5 units IM or slow IV injection after delivery
of baby. If already IV infusion is on, add 10 units oxytocin in 500 ml N
saline and infuse at the rate of 30 drops per minute for atleast one
hour.
▪ Delivery of placenta by controlled cord traction
▪ Uterine massage after delivery.
If placenta not delivered –
Repeat second bolus of oxytocin, massage the uterus, expel blood clots and
try to deliver placenta by CCT. If not successful, prepare for manual
removal.

If excessive bleeding occurs, management by PPH protocol should be initiated.

MANAGEMENT PROTOCOL OF PRIMARY PPH

Principles - Management of PPH includes

Prompt diagnosis, Rapid team work approach
Simultaneous replacement, resuscitation &
Identification & management of the cause.
STEPS:
1. Call for HELP –

Deptt. of Gynae, PGIMER, Chandigarh 66

 Include senior obstetrician, nursing staffs, anesthetist, blood bank services and
delegate multi-tasking.

2. Ensure adequate I/V access,

Secure 2 I/V lines , at least one with wide bore cannula (16G) and
start NS in one line and oxytocin drip in the second with 20U in 500 ml
NS (100 -150 ml hr). 3 litres of fluids needed to replace 1 liter lost
blood.2 liters of 0.9% sodium chloride (NS) and 1 litre of colloid
(Hemeccel) can be transfused while awaiting blood.

▪ Send blood for CBC, PTI and cross match, Insert Foley’s catheter.

▪ Continuous vitals & urine output monitoring

▪ Shift unstable/potential unstable patient to CLR OT for resuscitation &

further management.

Identify the cause.

Remember 4 Ts. The Four T's mnemonic can be used to identify and address the four
most common causes of postpartum hemorrhage

Tone Uterine Atony

Trauma Laceration, Hematoma, Inversion,Rupture

Tissue Retained placenta

Thrombin Coagulopathies, DIC

Deptt. of Gynae, PGIMER, Chandigarh 67

Uterine atonicity: Most common cause
▪ Massage uterus, expel blood clots. Repeat bolus dose of oxytocin.
Continue oxytocin infusion with 20 units in 500 ml 0.9% sodium chloride at the
rate of 125 ml per hour.

▪ Arrange for cross- matched blood , send basic labs Hematocrit, platelets,
coagulogram. Insert Foley's catheter.

▪ Check that the placenta is complete.

▪ If no response to oxytocin infusion and there is no contraindication to

methergine i.e. severe hypertension or heart disease , give 0.25 mg
methergine IM or IV..Give 10 mg perinorm slowly IV with methergine to avoid
vomiting.

▪ If still no response, 800 microgram misoprostol sublingually.

▪ In case bleeding still continues , Trenaxamic acid 1 gram IV (slowly in 10 min)

CONTINUE BIMANUAL COMPRERSSION.

If still not controlled uterine tamponade with Bakri balloon Surgical intervention if
above not successful
UTERUS WELL RETRACTED BUT BLEEDING CONTINUED
▪ Trauma : explore genital tract for Perineal, vaginal, cervical, uterine trauma
and repair the lacerations, tears or rupture uterus. If uterine inversion
reposit.
▪ Tissue : If retained placental bits or membranes , to be removed may need
MRP under anaesthesia
UTERUS IS WELL RETRACTED; TRAUMA RULED OUT,
Thrombin

Consider coagulopathies, ITP, DIC.

Replace blood and components
SUPPORTIVE CARE
• Watch, closely for vital, Intake, output

Deptt. of Gynae, PGIMER, Chandigarh 68

 • Foley's catheter for output monitoring
• Replace blood
• Prophylactic antibiotics

• Brief the family

MAJOR PPH ( Blood loss >1000ml) with ongoing bleed

Follow major transfusion protocol.
In addition to all of the above,
Get CVP line inserted
Cross match multiple units of blood, & components, coagulation studies
Thromboelastography (TEG) if available.

SECONDARY PPH
Between 24 hours and 6 weeks postpartum
Secondary to atony due to retained products or infection
Principles of management
Uterotonics
Antibiotics &
Possible D & C

PATIENT REFERRED WITH PPH

Start resuscitation as above , inform the consultant ASAP.
SUGGEST KEEP PPH BOX ready in LR containing
Venflon No. 16, 18 1 each
IV set with 3-way adepter

Syringes no. 5ml , 10 ml 5each

Foley's catheter with urobag

Oxytocin 10 injections

Deptt. of Gynae, PGIMER, Chandigarh 69

Methergin 5 ampoules
Misoprostol 200 Microgram 6 tablets
Tranexamic acid 4 ampoules

Deptt. of Gynae, PGIMER, Chandigarh 70

 18 CORD PROLAPSE

- Dr. G. R. V. Prasad
50% of cases of cord prolapse follow some obstetric manipulation(ARM, ECV, IPV,
manual rotation of head etc.).
RISK FACTORS: Multiparity, low birth weight, prematurity, second of the twins,
polyhydramnios, abnormal lie, unengaged presenting part in labour, unstable lie,
stabilising inductions of labour, low lying placenta.
METHODS TO AVOID CORD PROLAPSE:
1. Consider elective admission -With transverse, oblique or unstable lie, elective
admission to hospital after 37 weeks of gestation should be discussed and
women should be advised to present quickly if there are signs of labour or
suspicion ofmembrane rupture.
2. Artificial membrane rupture should be avoided whenever possible if the
presenting part is mobile. Vaginal examination and obstetric intervention in
thecontext of ruptured membranes and a high presenting part carry the risk of
upward displacement and cord prolapse. Upward pressure on the presenting
part should be kept to a minimum in such women.
3. Rupture of membranes should be avoided if, on vaginal examination, the cord
is felt below the presenting part (Cord presentation) Possibility of cord
prolapse should be entertained if –

Unexplained foetal bradycardiae specially after recent ARM Cord is seen or felt at
pelvic exam

AFTER DIAGNOSIS OF CORD PROLAPSE :

1. To prevent vasospasm, there should be minimal handling of loops of cord
lying outside the vagina.
2. To prevent cord compression, it is recommended that the presenting part be
elevated either manually or by filling the urinary bladder with 500-750 ml
ofnormal saline.
3. Cord compression can be further reduced by head-down tilt (preferably in
leftlateralposition).Although the measures described above are potentially

Deptt. of Gynae, PGIMER, Chandigarh71

 useful during preparation for delivery, they must not result in unnecessary
delay.
FACTORS TO BE IMMEDIATELY ASCERTAINED:
▪ Cord pulsations/ foetal cardiac activity
▪ Cervical dilatation
▪ Presentation
If detected at the time of pelvic examination, immediately reposit the cord, keep a pad
at the introitus and take measures to minimise cord compression (check above) When
cord prolapse is diagnosed before full dilatation with foetal cardiac activity and if
foetus is of salvageable weight, assistance should be immediately called and
preparations made for immediate delivery in theatre. If it is a vertex presentation with
full cervical dilatation and criteria are met, forceps delivery may be immediately
undertaken. Otherwise arrange for quick caesareansection.
• Check for foetal heart just before caesarean section

Deptt. of Gynae, PGIMER, Chandigarh72

 19 SHOULDER DYSTOCIA

- Dr. S. C. Saha
Grave Emergency
Incidence: 0.58%-0.7%
PROBLEMS:
1. Birth asphyxia/acidosis/death if there is delay in delivery
2. Brachial plexus injury
Humarus/clavicle fracture if unskilled delivery
CAN YOU ANTICIPATE ?
a. Diabetes in pregnancy
b. Big baby
c. Obese mother
d. IOL/AOL
e. Prolonged 1st/2nd stage
f. Instrumental deliveries
g. Past history of shoulder dystocia
Most of the time unpredictable
How to identify?
Fetal head pressed over maternal perineum
Recession of head (Turtle neck)
Routine axial pull (pull along foetal spine) fails to deliver shoulder
Do Not Deviate Pull Laterally (increases risk of Brachial Plexus Injury)
MANAGEMENT: YOU HAVE GOT FULL FIVE MINUTES TO DELIVER
SHOULDER. BE QUICK! BE COOL!
1. Shout for “help” Say “Shoulder dystocia” Call senior most present,
neonatologist assistants,sisters

Deptt. of Gynae, PGIMER, Chandigarh73

 2. NO FUNDAL PRESSURE
NO MATERNAL PUSH (Beardown)
3. McRobert's Manoeuvre
Bring patient to the edge of delivery table, Flex & abduct thighs over maternal
abdomen It helps to straighter sacrum , rotates sym. Pubis upwards releasing
anteriorshoulder.
4. Episiotomy to gain access for internal manipulation
5. SUPRA PUBIC PRESSURE Downwards and laterally by assistants on
mother's side to rotate anterior shoulder to oblique diameter. (from the side of
fetal back ideally)
6. Usual axial pull to deliver shoulder
IF FAILS:
Internal Rotation of shoulder(Wood's /Rubin's Maneuvre)
Insert whole hand inside vagina rotate posterior shoulder 180 either from posterior or
anterior aspect.
Anterior shoulder may also be rotated to oblique diameter if more accessible.
Delivery of posterior shoulder along fetal chest in a straight line grabbing.
wrist(there is chance of humeral fracture)
3RD LINE:
Zavenellis maneuver (delivery by cesarean section after repositing head), only suitable
if
both shoulders are stuck at inlet.
Immediately after delivery:
1. Neonate needs to be checked/resuscitated. Check for fracture internal injury,
brachial plexus injury---Neonatologist is best person
2. Check for maternal injuries (cervical tear, vaginal laceration, episiotomy
extension, uterine rupture, bladder rupture)
3. Prophylactic oxytocin/prostaglandin
4. Look for sphincter injury
Deptt. of Gynae, PGIMER, Chandigarh74
(Do rectal examination)
DOCUMENTATION:
Proper records to be kept:
Who was present at delivery of head ?
Other staffs present at shoulder delivery
Mode of delivery – ventouse/forceps/spontaneous
Length of 1st/2nd stage
Shoulder dystocia diagnosed at time
Call for help- Yes/No Time
Head- shoulder delivery interval, time for each
Maneuvre required
Head facing maternal left /right
Which fetal shoulder was anterior left/right
Birth weight
AS
Injury if any
Cord blood gas:
Explanation to mother/relative
Yes/No
By whom

Deptt. of Gynae, PGIMER, Chandigarh75

 20 ANEMIA

- Dr. Minakshi Rohilla

1. Severe anemia is easy to identify on entrance to CLR in a white

and puffy pregnant woman.

2. Observe for tachypnoea or dysnoea while walking

3. Put her in comfortable position, and give oxygen via ventimask.

4. Attach her onto vital signs monitor for continuous monitoring of

vitals and O2 saturation.

5. Check referral slip (if any) to know cause of anemia or any

complication in pregnancy like antepartum hemorrhage.

6. Establish intravenous line, send blood sample for emergency

investigation and cross matching.

7. Save one EDTA sample in refrigerator for central lab

haemogram next day.

8. History eliciting cause and type of anemia should be emphasized

like (menorrhagia, inadequate iron, multiple pregnancy and
childbirth, easy bruisability petechiae, worm infestation etc).

9. Examination to confirm anemia and check for signs of heart

failure or pulmonary oedema (increased RR, pulse rate,
crepitations in the chest, anasarca).

Deptt. of Gynae, PGIMER, Chandigarh76

 10. Rule out cardiac disease by auscultation, ECG and cardiologist
opinion if required.

11. If anemia is mild to moderate (more than 8 gms), there are no

signs of heart failure, no signs of hypoxia, no ongoing blood
loss, no signs of serious bacterial infection there is no need of
immediate blood transfusion.

12. Transfuse packed red cells in case of severe anemia to maintain

Hb around 8 gms (Match pt name, CR no and blood group with
reaction form carefully).

13. Confirm labour, period of gestation, fetal presentation. get fetal

cardiotocography after stabilizing the mother. Note down
obstetric complication if any.

14. Management of first stage of labour-. comfortable position , pain

relief, oxygen inhalation, sedation antibiotic prophylaxis.

15. Get ABG analysis, x-ray chest with abdominal shield and
pulmonary consultation if pt is in pulmonary oedema.

16. Avoid prolongation of second stage of labour.

17. Active management of third stage of labour should be done (40

units of pitocin in concentrated form immediate after delivery,
controlled cord traction for delivery of placenta). Injection
Methergine should be avoided.

18. Any postpartum hemorrhage should be treated energetically, as

these patients tolerate bleeding very poorly.

Deptt. of Gynae, PGIMER, Chandigarh77

 19. Patient should be monitored carefully for any signs of cardiac
failure, till 24-48 hrs after delivery.

INDICATIONS FOR BLOOD TRANSFUSION -

1. To correct anemia due to acute blood loss.

2. Duration of pregnancy less than 34 weeks

Haemoglobin 5.0 g/dl or below, even without clinical signs

of cardiac failure or hypoxia.

Haemoglobin between 5.0 and 7.0 g/dl and in the presence

of the following conditions.

a) Established or incipient cardiac failure or clinical

evidence of hypoxia.

b) Pneumonia or any other serious bacterial infection.

c) Malaria

d) Pre-existing heart disease, not causally related to the

anaemia

3. Duration of pregnancy 34 weeks or more

Haemoglobin below 7.0 g/dl even without clinical signs of

cardiac failure or hypoxia.

Haemoglobin between 7.0 g/dl and 8.0 g/dl and in the

presence of the following conditions:

Deptt. of Gynae, PGIMER, Chandigarh78

 a) Established or incipient cardiac failure or clinical
evidence of hypoxia

b) Pneumonia or any other serious bacterial infection

c) Malaria

d) Pre-existing heart disease, not causally related to the

anaemia

The recent Royal College of Obstetricians and Gynaecologists

(RCOG) blood transfusion guideline recommends blood
transfusion in labor or immediate postpartum period if the Hb< 7
g/dL.

BLOOD TRANSFUSION

1. Patients with severe anaemia may be precipitated into

cardiac failure by infusion of blood or other fluids. If
transfusion is necessary, give one unit, preferably of red cell
concentrate, over 2 to 4 hours and give a rapid acting diuretic
( Furosemide, 40 mg IM),10 minutes prior to BT ( if there is
no history of immediate blood loss, no hypovolemia and
anemia appears chronic)

2. For first fifteen minutes blood transfusion should be very

slow, to detect the signs of the reaction at the earliest i.e. 1-2
mL/min or (60-120 mL/hour). After 15 minutes as rapidly as
tolerated; approximately 4 mL/min or 240 mL/hour. For
patients at risk of fluid overload, adjust flow rate to1
mL/kg/hour.
Deptt. of Gynae, PGIMER, Chandigarh79
 3. The administration of whole blood or red cells should be
started within 30 minutes of removing the pack from the
storage temperature of +2°C to +6°C. It should be completed
within 4 hours of starting the transfusion. Strict input, output
monitoring is required.

CAESAREAN DELIVERY

If caesarean delivery is required consider under high risk, and

should be considered only after stabilizing the mother and
discussion with consultant on call. Check TLC, and platelet
count to rule out possibility of rare type of anemia like leukemia,
aplastic anemia and ITP. Check CT, CRT and PTI also to rule
coagulation disorders as rare cause of anemia. For indication like
placenta previa with suspected accreta Hb should be around 10
Gms.

When elective Caesarean section is planned and there is a

history of:

o Antepartum haemorrhage (APH)

o Postpartum haemorrhage (PPH)

o Previous Caesarean section

✓ Haemoglobin between 8.0 and 10.0 g/dl: establish/confirm blood

group and save freshly taken serum for crossmatching.

✓ Haemoglobin less than 8.0 g/dl: two units of blood should be

crossmatched and available.

Deptt. of Gynae, PGIMER, Chandigarh80

 1.

21 SEVERE PREECLAMPSIA

- Dr Richa Arora, Dr V Jain

■ Prime objectives :
– BP control to prevent intracranial hemorrhage and serious damage to
other vital organs
– Forestall convulsions
– Deliver a healthy newborn

Once the diagnosis is established, subsequent management will depend on-

• Maternal and fetal evaluation
• Gestational age
POG ≥34WEEKS
• Delivery soon after maternal stabilization.
PRETERM SEVERE PREECLAMPSIA <34 WEEK
Management depends on maternal and fetal condition. Decision to terminate
pregnancy or expectant management should be discussed with Consultant incharge.
MIDTRIMESTER SEVERE PREECLAMPSIA (BEFORE 24 WEEKS)
Delivery after maternal stabilization. Expectant management is not recommended.

Deptt. of Gynae, PGIMER, Chandigarh81

Deptt. of Gynae, PGIMER, Chandigarh82
Maternal and Fetal monitoring during expectant management
MATERNAL ASSESSMENT
■ Vital signs, fluid intake, and urine output
■ Symptoms of severe preeclampsia (headaches, visual changes, retrosternal
pain or pressure, shortness of breath, nausea and vomiting, and epigastric
pain)
■ Presence of contractions, rupture of membranes, abdominal pain, or bleeding
■ Laboratory testing (CBC and assessment of platelet count, liver enzyme, and
serum creatinine levels) should be performed daily
FETAL ASSESSMENT
■ Kick count and NST - daily
■ Biophysical profile twice weekly
■ Serial fetal growth monitoring should be performed every 2 weeks
■ Umbilical artery Doppler studies performed every 2 weeks if fetal growth
restriction is suspected
Indications For Delivery During Expectant Management
MATERNAL INDICATIONS FOR DELIVERY
■ Recurrent severe hypertension
■ Recurrent symptoms of severe preeclampsia
■ Progressive renal insufficiency (serum creatinine concentration >1.1 mg/dL
or doubling of the serum creatinine concentration in absence of other renal
disease)
■ Persistent thrombocytopenia or HELLP syndrome
■ Pulmonary edema
■ Eclampsia
■ Suspected abruptio placentae
■ Labor or rupture of membranes
FETAL INDICATIONS FOR DELIVERY
■ Gestational age of ≥34 0/7 weeks
■ Severe fetal growth restriction (ultrasonographic estimate of fetal weight ≤ 5
percentile)

Deptt. of Gynae, PGIMER, Chandigarh83

 ■ Persistent oligohydramnios (maximum vertical pocket less than 2 cm)
■ BPP of 4/10 or less on at least two occasions 6 hours apart
■ Reversed end-diastolic flow on umbilical artery doppler studies
■ Recurrent variable or late decelerations during NST
■ Fetal death
HYPERTENSIVE EMERGENCY- Acute onset, severe hypertension persistent for
15 minutes or more.
First Line Antihypertensive
• I/V Labetalol Or Hydralazine
• Oral Nifedipine (Immediate Release).

PROTOCOL FOR ORAL NIFEDIPINE

Oral Nifedipine 10 mg (Immediate release)

Repeat BP after 20
mins

BP>160/110mmHg, oral Nifedipine 20 mg

Repeat BP after 20
mins
BP>160/110mmHg, oral Nifedipine 20 mg
Repeat BP after 20
mins
BP>160/110mmHg, give IV Labetalol

Deptt. of Gynae, PGIMER, Chandigarh84

 PROTOCOL FOR IV LABETALOL

IV Labetalol- 20mg, over 2 minutes

Repeat BP after 20 mins

BP>160/110mmHg, IV Labetalol-40mg
Repeat BP after 20 mins

BP>160/110mmHg, IV labetalol- 80 mg
Repeat BP after 20 mins

BP>160/110mmHg, IV labetalol-80mg
Repeat BP after 20 mins

BP>160/110mmHg, give IV Hydralazine

Protocol for IV Hydralazine

IV Hydralazine- 5-10mg, over 2 minutes

Repeat BP after 20
mins

BP>160/110mmHg, IV Hydralazine-10mg
Repeat BP after 20
mins

BP>160/110mmHg,IV labetalol-20mg

Deptt. of Gynae, PGIMER, Chandigarh85

 • Oral labetolol-200mg followed by a repeat dose after 30 minutes may also be
used if IV access has not been initiated and Nifedipine is not available.
• Nifedipine should only be used Orally-Immediate Release. It should not be
punctured or administered sublingually.
• If BP is persistently >160/110mmHg, despite maximal dose of one drug,
second antihypertensive must be added and consultation sought from internal
medicine or anaesthesist.
• Once the BP threshold is achieved, repeat BP measurement every 10
minutes for 1 hour, then every 15 minutes for 1 hour, then every 30 minutes
for subsequent 1 hour, and then every hour for 4 hours.
• Sodium Nitroprusside should be reserved for extreme emergencies.

SEIZURE PROPHYLAXIS
Magnesium sulfate remains the drug of choice for seizure prophylaxis.
HELLP SYNDROME
Acronym for: Hemolysis ,Elevated Liver enzymes ,Low Platelet count
• POG≥ 34 0/7 weeks of gestation, delivery be undertaken soon after initial maternal
stabilization.
• POG≤ 33 6/7 weeks of gestation, delivery be delayed for 24–48 hours if maternal
and fetal condition remain stable to complete a course of corticosteroids.
MODE of DELIVERY
• The mode of delivery should be determined by fetal gestational age, fetal
presentation, cervical status, maternal–fetal condition and obstetric indication.
Intrapartum care
• Monitor BP hourly or more frequently (30 mins) if BP uncontrolled.
• Watch for sign symptoms of Imminent Eclampsia
• Continue antihypertensives during labor
• Use fluid judiciously. Do not cause volume overload. Limit maintenance
fluids to 80ml/hr unless there are other ongoing losses.
• Shorten the duration of second stage if BP uncontrolled.
• Practice AMTSL. Avoid Inj Ergometrine.
Deptt. of Gynae, PGIMER, Chandigarh86
 • For women with severe preeclampsia, the administration of intrapartum–
postpartum magnesium sulfate to prevent eclampsia is recommended.
POSTPARTUM
• BP to be monitored for at least 72 hours postpartum
• Avoid NSAIDS.
• Do not use Cabergoline for lactation suppression in patients with
hypertension.
Suggested Reading
• ACOG guidelines- Task force on Hypertension in pregnancy
• ACOG committee opinion NO 767- emergent therapy for acute onset, severe
hypertension during pregnancy and postpartum period
• NICE guidelines-Hypertension in pregnancy (NG-133)

Deptt. of Gynae, PGIMER, Chandigarh87

 22 ECLAMPSIA

- Dr. V. Jain
GOALS OF MANAGEMENT
1. Stabilize the patient
2. Control the convulsions
3. Control Blood pressure
4. Assess for termination of pregnancy
ON ARRIVAL
1. Check airway patency
If she is having a seizure
1. Roll patient onto her left side
2. Protect her from injury
3. Do suction of oral cavity if secretions are present
4. Give oxygen (8 to 10 L/min) via a face mask
AFTER A QUICK HISTORY & EXAMINATION SECURE IV LINE.
▪ Give magnesium sulphate (magsulph) before shifting her from trolley
▪ Draw blood for grouping cross matching, Hb, platelets, SERFT, LFT, Blood
sugar, coagulogram (clotting time,clot retraction time & PT,PTI,PTTK)
▪ Lactated Ringer solution to be administered at the rate of 60 mL to no more
than 125 mL per hour.The fluid rate to be reduced if oliguria/pulmonary
oedema develops
▪ Keep patient nil orally
▪ Send call for fundus examination & Chest X ray
TREATMENT OF CONVULSIONS
Magnesium sulphate may be given by intermittent intramuscular route or by
continuous intravenous infusion. Intravenous route is preferable as the
intramuscular injection is very painful.

Deptt. of Gynae, PGIMER, Chandigarh88

INTERMITTENT INTRAMUSCULAR INJECTIONS
If woman >50Kg
1. Give 4 g of magnesium sulfate as a 20% solution intravenously at a rate not
to exceed 1 g/min
2. Follow with 10 g of 50% magnesium sulfate solution with 1.0 mL of 2%
lidocaine, one half (5 g) injected deeply in the upper outer quadrant of both
buttocks through a 3 inch-long 20-gauge needle.
3. Every 4 hr thereafter give 5 g of a 50% solution of magnesium sulfate
injected deeply in the upper outer quadrant of alternate buttocks, but only
after ensuring that:
a. The patellar reflex is present,
b. Respirations are not depressed, Resp rate > 12 per minute, and
c. Urine output the previous 4 hr exceeded 100 mL
If woman weighs <50 Kg loading dose 4 g IV plus 6 g IM and maintenance dose
2.5 g IM every four hour may be given
CONTINUOUS INTRAVENOUS INFUSION - If platelet count is <1,00,000
1. Give 4- to 6-g loading dose of magnesium sulfate diluted in 100 mL of IV
fluid administered over 15–20 min
2. Begin1-2 g/hr in 100 mL of IV maintenance infusion depending on the
weight of the patient.
3. Monitor for magnesium toxicity 4 hrly Discontinue Magnesium sulphate 24
hr after delivery or the last convulsion, whichever occurs last.
FAILURE OF MAGNESIUM SULPHATE
If a woman has convulsion despite magnesium sulphate
1. One convulsion within 30 min. – no treatment
2. More than one convulsion within 30 min or convulsions after 30 min – give
anadditional 2-g dose of magnesium sulfate in a 20% solution slowly IV at a
rate not to exceed 1 g/min. May be given twice if required (at an interval of
15 mins).
If two such boluses do not control seizures:

Deptt. of Gynae, PGIMER, Chandigarh89

 1. Give phenytoin 4mg/mL NS (1 g phenytoin in 250 mL NS) at a rate of 25
mg/min. Patients should be on a cardiac monitor. Medication must be given
in a glucose-free solution to avoid precipitation.
2. Other option is Diazepam
Loading dose : Give diazepam 10mg IV slowly over 2 minutes. If convulsions recur,
repeat the loading dose.
Maintenance dose : Give diazepam 40mg in 500ml IV fluid (Ringer's lactate or
normalsaline) titrated to keep the woman sedated but able to be roused
Magnesium sulphate toxicity : If signs of toxicity occur
1. Withhold further magnesium sulphate
2. Give calcium gluconate 1 g (10 ml of 10% solution) over 3-5 minutes
intravenously
3. If respiratory depression persists, promptly intubate and put onventilator
TREATMENT OF HYPERTENSION
Indication: ≥ 160/105mm Hg, Goal : 140 to 155 / 90 to 105 mmHg.
• Labetalol: 10 or 20 mg intravenously followed by doubling the dose at 10-
minute intervals up to 80 mg for a maximum total cumulative dose of 220 to
230 mg (eg, 20 40-80-80 mg or 10-20-40-80-80 mg), Still uncontrolled –
Consider change ofantihypertensive. Labetolol is contraindicated in patients
with preexisting myocardial disease, decompensated cardiac failure, asthma.
• Nifedipine: 10-mg initial oral dose to be repeated in 30 minutes if necessary
upto a maximum of 50 mg. Side effects: tachycardia,palpitations, headaches,
facialflushing,and ankle edema.
• Nitroglycerine: Add 50 mg NTG in 500ml isotonic saline to achieve drug
concentration of 100μg/ml.Start @ 5 μg/min and increase dose rate by
5μg/min every 5 mins to max upto 200μg/min.Infusion rate @5μg/min
corresponds to 3ml/hr and for every increment by 5μg/min, increase rate by
3ml/hr.
Termination of pregnancy
Once the patient is settled (approx 1 hour after admission) catheterize the patient. Test
urine for albumin. Do cervical & pelvic assessment. If Bishop's score is>5 do ARM,
<5 seek second opinion
GENERAL CARE:

Deptt. of Gynae, PGIMER, Chandigarh90

 1. Any stimulus may precipitate a fit, so external stimuli such as noise, bright
lights and handling the woman are reduced to a minimum (Eclampsia room)
2. Suction apparatus and oxygen equipment must be ready for use by the
bedside
NURSING CARE
1. Patient must never be left alone
2. Turn the woman two–hourly to avoid hypostatic pneumonia
3. Give mouth care

OBSERVATION & MONITORING

1. Look for signs of restlessness or twitching which may herald the onset of
convulsion
2. Continuous vital sign monitoring or record pulse,respirations, blood pressure,
and urinary output hourly, Temperature recording four–hourly.
3. Transcutaneous pulse oximetry
4. Arterial blood gas analysis is required if the pulse oximetry results are
abnormal (oxygen saturation ≤92%).
INDUCE LABOUR OR LSCS ACCORDING TO INDICATIONS.
Maternal pain relief during Labour and delivery can be provided by either systemic
opioids or epidural analgesia Avoid methergine after delivery
INDICATIONS OF NEUROLOGY REFERRAL / NEUROIMAGING
1. Suspected eclampsia unresponsive to magnesium sulphate
2. Eclampsia with focal neurological deficit
3. Eclampsia with prolonged coma
4. Atypical presentation eclampsia ( < 20 weeks POG or > 48 hrs PP)
INDICATIONS OF INVASIVE HEMODYNAMIC MONITORING :
Woman with
1. Severe cardiac disease
2. Severe renal disease
3. Refractory hypertension
4. Oliguria

Deptt. of Gynae, PGIMER, Chandigarh91

 5. Pulmonary edema
INDICATIONS OF ANAESTHESIA REFERRAL
1. Deranged ABG
2. Unconscious patient
3. Recurrent convulsions
4. Suspected aspiration
5. For LSCS

23 DIABETES

- Dr. V. Jain

GOAL FOR INTRAPARTUM GLYCEMIC CONTROL: GLUCOSE LEVELS

BETWEEN 70 to 110 MG/DL
WHEN CAESAREAN DELIVERY IS PLANNED
▪ Schedule it for early morning.
▪ Give usual night time dose of intermediate-acting insulin or oral anti-diabetic
medication
▪ The morning dose of insulin or oral anti-diabetic agent is held and the patient
is given nothing by mouth.
▪ Normal saline is used for intravenous hydration before operative anaesthesia
▪ If surgery is delayed until the afternoon, basal insulin (about one-third of the
morning intermediate insulin dose) is given with a 5% dextrose infusion to
avoid ketosis.
▪ Glucose levels need to be monitored every one to two hours to adjust insulin
therapy. A short-acting insulin can be given, as needed to control
hyperglycemia, during this period.
▪ Preoperative antibiotics

Deptt. of Gynae, PGIMER, Chandigarh92

 ▪ Compression stockings for all. Heparin 5000 sc 12 hrly to be added,6 hrs
after Vsurgery if patient is obese
WHEN INDUCTION IS PLANNED
▪ Inductions should be scheduled to begin early in the morning
▪ Patient should take her usual night time dose of intermediate-acting insulin or
oral anti-diabetic medication
▪ During the ripening/latent phase, women are allowed a reduced caloric diet
(1200 to 1400 kcal) and pre-meal short-acting insulin is adjusted to the
capillary bloodglucose (CBG) level and the carbohydrate intake.
▪ IV fluids are not needed if oral intake is sufficient
▪ If oral intake is restricted or not adequate give IV fluids and insulin according
to the following protocols
▪ Be prepared for shoulder dystocia
table

Maternal plasma glucose IV insulin (units/hour) IV solution

mg/dL
Start of labour Hold Start normal saline
infusion
<70 mg/dL or active labour Hold 5 percent dextrose normal
saline (D5NS) at 100-150
>110 mg/dL Regular of short-acting
mL/hour
insulin at 1.25 units per
hour (10 units per 1000 mL
D5NS at 125 mL/hour)
FREQUENCY OF GLUCOSE MONITORING–capillary blood glucose
concentration
▪ GDM controlled on diet: On admission and then approx.. every four to six
hours
▪ DM on insulin every two to four hours during the latent phase, every one to
two hours during the active phase, and every hour during insulin infusion.
For women with type 1 Diabetes

Deptt. of Gynae, PGIMER, Chandigarh93

Maternal plasma glucose IV insulin (units/hour) IV solution
mg/dL
<70 (<3.9) 0.0 CBG <130 mg/dL 5 percent
71-90 (3.9-5.0) 0.5 Dextrose Lactated Ringers at
91-110 (5.1-6.1) 1.0 125 mL/hour)
111-130 (6.2-7.2) 2.0
131-150 (7.3-8.3) 3.0 CBG >130 mg/dL
151-170 (8.4-9.4) 4.0 Lactated Ringers at 125
171-190 (9.5-10.6) 5.0 mL/hour
>190 (>10.6) Check Ketones
POSTPARTUM:
▪ GDM on diet: No medication
▪ Women with type 1 diabetes who deliver vaginally and are able to eat require
about one-third to one-half of their prepartum insulin
▪ Women with type 2 diabetes may not require any medication during the first
24 to 48 hours postpartum. If they require insulin and are eating, they can be
started on0.6 units/Kg postpartum weight. Alternatively, oral agents, such as
metformin orglyburide, can be started after 24 to 48 hours and prior to
discharge.
▪ Post caesarean delivery, short-acting insulin is administered on a sliding scale
with the goal of maintaining glucose levels, about 140 to 160 mg/dL during
the first 24 to 48 hours.

Sliding insulin scale for postpartum management of glucose levels by regular insulin

Glucose Low dose Intermediate dose High dose

(mg/dL) (pre-pregnancy BMI <25; (pre-pregnancy BMI 25 to (pre-pregnancy BMI >35,
T1DM) 35, T2DM) T2DM)
AC or NPO HS AC or NPO HS AC or NPO HS
100 to 150 No insulin No insulin No insulin No insulin No insulin No insulin
151 to 200 1 unit No insulin 2 units No insulin 4 units 2 units
201 to 250 2 units No insulin 4 units 1 unit 8 units 4 units
251 to 300 3 units 1 unit 6 units 2 units 12 units 6 units

Deptt. of Gynae, PGIMER, Chandigarh94

 301 to 350 4 units 2 units 8 units 4 units 16 units 8 units
351 to 400 5 units 3 units 10 units 6 units 20 units 10 units

AC before meals, HS Bed time

DIABETIC KETOACIDOSIS
▪ DKA diagnostic criteria: serum glucose >250 mg/dl, arterial pH <7.3, serum
bicarbonate <18 mEq/l, and moderate ketonuria or ketonemia.
▪ Early signs of ketoacidosis: nausea, vomiting, abdominal pain,
andhyperventilation. The earliest symptoms of marked hyperglycemia are
polyuria, polydipsia, and weight loss.
▪ Assess vital signs, cardio respiratory status and mental status. Assess volume
Status: vital signs, skin turgor,urine output.
▪ After history and physical exam, obtain capillary glucose and check for urine
ketones.
▪ Obtain large bore IV (≥16 gauge) access. Begin one liter of 0.9 percent NaCl
over one hour.
▪ Draw ABG, CBC, urinalysis, serum glucose, RFT, electrolytes STAT. Obtain
electrocardiogram, chest X-ray, and specimens for bacterial cultures, as
needed.
▪ Stabilize the patient's airway, breathing, and circulation.
▪ Monitor using a cardiac monitor, and pulse oximetry.
▪ Monitor serum glucose hourly, and basic electrolytes, plasma osmolality, and
venous pH every two to four hours until the patient is stable.
▪ Determine and treat any underlying cause of DKA (eg, pneumonia or urinary
infection, myocardial ischemia).
▪ Follow the algorithm given below

Deptt. of Gynae, PGIMER, Chandigarh95

Serum Na+ should be corrected for hyperglycemia (for each 100 mg/dl glucose >100
mg/dl, add 1.6 mEq to sodium value for corrected serum sodium value). Δ An

Deptt. of Gynae, PGIMER, Chandigarh96

alternative IV insulin regimen is to give a continuous IV infusion of regular insulin at
0.14 units/kg/hour; at this dose, an initial IV bolus is not necessary.

24 CARDIAC DISEASE

-Dr. V. Suri, Dr. Pooja Sikka

1. Diagnosed case
a. CO booked
b. Referred case
2. Suspected case: immediate cardiology consultation and ECHO.
3. Type of heart disease: congenital, rheumatic, cardiomyopathy, rhythm
disturbance, others
4. Exact lesion: MS, MR, As, AR, MVP, MVR, Eisenmenger syndrome etc.
5. Assign NYHA class
6. Classify into risk category (Annexure 1)
7. Basic assessment of patient, cardiac status and fetus including USG if needed.
(evaluation by SR, consultant and cardiologist)
8. Decide mode of delivery. Vaginal delivery preferred. CS for obstetric indications
and few cardiac indications like: Marfan syndrome, Labour in a patient on oral
anticoagulants, severe aortic stenosis, severe pulmonary hypertension, some
cases ofcardiomyopathy with very less ejection fraction and acute intractable
heart failure.Decision for CS to be taken by consultant in charge in consultation
with cardiologist and anesthetist.
9. PAC IN FIRST 24 HRS OF ADM
10. Induction with oxytocin safe. Avoid misoprostol and cerviprime.
11. Inform the relatives about the risk profile and future plan of action.
12. ABG of all cyanotic patients and those in heart failure or respiratory distress at
admission.
FIRST STAGE:
13. Nurse in left lateral position or head end to be raised.

Deptt. of Gynae, PGIMER, Chandigarh97

14. Oxygen inhalation depending upon NYHA class.
15. Continuous monitoring of vitals. Chest auscultation every half an hour.
16. Restrict fluid intake by IV route. Orally no restriction. Around 100-150 ml per
hour. No restriction in Eisenmenger, cyanotic heart disease and aortic stenosis.
17. Input output record
18. CTG monitoring
19. Maintain a partogram
20. Liberal analgesia: opioid or regional (Epidural to be preferred).
21. Infective endocarditis prophylaxis for all/any type of structural cardiac lesion at
the time of ARM/ before expected delivery/ before CS (Whichever is applicable.
30-60 minutes) to all patients. 2gm ampicillin IV 3 doses 8 hourly / amoxicillin
after test dose + Gentamicin 1.5 mg/Kg IV 3 doses followed by oral
Amoxycillin for 5 days. If patient is sensitive to penicillin,cephalexin or 1st or
2nd generation cephalosporins can be given.
Do not follow AHA guidelines till our own study is available.
22. Avoid prolonged Labour (8-10hrs)
23. Limit PV examinations. Complete asepsis to be used.
24. Cardiologist on duty to be consultedsos. If unable to do so contact Dr. Rajesh
directly or contact unit III consultants (VS, NA, SC or PS)
25. Anticoagulation ,for those with prosthetic valves and for those who need DVT
prophylaxis to be discussed by SR with consultant in charge II stage, III stage
and after
26. Assist with OFD. Delivery to be conducted by senior JR under supervision of
SR.
27. Give inj Lasix and analgesia immediately after delivery. Active management of
III stage to prevent PPH.
28. If excessive blood loss give blood rather than fluids.
29. No methergin.
30. Oxytocin to be preferred over prostaglandins for PPH. In dire situations PGs can
be used.

Deptt. of Gynae, PGIMER, Chandigarh98

31. Episiotomy to be sutured under aseptic conditions.
PPIUCD NOT to be put
32. Strict monitoring of the patient for 6 hours post delivery.
33. LSCS to be done by consultant preferably.
34. CONSULTANT Anaesthesia to be called for LSCS. Cardiologist to be informed.
35. Discuss about tubal ligation with patient and husband.
36. Give heparin after 6 hours of delivery and 12 hours after CS to prosthetic valve
patients.
37. Please don't shift the patient out without consultant's opinion.

*Derived ACC/AHA Guidelines6 and Siu et al. 4,5 NYHA denotes New York Heart
Association

Deptt. of Gynae, PGIMER, Chandigarh99

 25 PULMONARY EDEMA

- Dr. Rajesh, Dr. Vanita Suri

HOW TO DIAGNOSE PULMONARY EDEMA DURING PREGNANCY?
▪ Increase in respiratory rate
▪ Increase in pulse/heart rate
▪ Basal crepitations in both lung fields
▪ systemic oxygen desaturation
▪ History of underlying heart disease helps in diagnosis of pulmonary edema.
Pulmonary edema should be differentiated with primary lung parenchymal
disease like lung infection. History of fever, increase counts, localized crepts
in lung fields, no improvement with empirical diuretic therapy, and
radiological patch in Chest X-ray favors pneumonitis.
Shift to HDU
WHAT CAUSES SHOULD BE SUSPECTED IN A PATIENT WITH
PULMONARY EDEMA?
Rheumatic heart disease(RHD) and peripartum cardiomyopathy( CMP) are the two
important causes, which should be suspected in any pregnant patient with pulmonary
edema. RHD—mostly it is mitral stenosis, sometime severe regurgitant lesions also do
present with pulmonary edema. Various risk factors for deterioration of RHD patient
during pregnancy are:-
1. Anemia and vitamin deficiency- should be corrected.
2. Fluid overload- Around 32 weeks of pregnancy with maximum hemodynamic
stress,during Peripartum period, when shift of placental blood into
maternalcirculation do occur. Needs increase doses of diuretic drugs.
3. Hyperthyroidism.
4. Atrial fibrillation with fast ventricular rate- (Digoxin 1 OD 5 days a week,
diltiazem in titrated doses for control of heart rate. If no IUGR, beta blockers
can be startedin addition to digoxin and beta blockers).
5. Pre-eclampsia.
Deptt. of Gynae, PGIMER, Chandigarh100
 6. Infection.Appropriate antibiotic coverage and delivery with all aseptic
precautions should be performed.
INFECTIVE ENDOCARDITIS PROPHYLAXIS IS A MUST.
Peripartum CMP- no definite murmur, increase CT ratio on Chest X-ray, and Echo
showing low ejection fraction favors Peripartum CMP. Again the above mentioned 6
risk factors should be corrected in these patients.
IF A DIAGNOSED PATIENT OF MITRAL STENOSIS GOES INTO PE,
WHAT SHOULD BE DONE?
▪ Propped up position
▪ Oxygen inhalation 2-4l/minute
▪ IV lasix 20 mg stat and to be repeated after consultation with SR Cardio
▪ Inj. Morphine IV 5-10 mg via slow inj at a rate of 2 mg/minute with
Phenergen 12.5 mg
▪ If AF with fast ventricular rate is present, drugs like digoxin, diltiazem and
beta blockers per orally to be given. IV doses and DC shock to be given in
consultation with SR Cardiology.
▪ Strict intake/output chart to be maintained.
▪ If marked stress is there, NIV support can be given.
▪ Every 15 minutes blood pressure and heart rate monitoring should be done.
▪ 1 hourly urine output to be measured.
▪ If cardiac monitor is available, it should be used to know the control of
ventricular\ rate in patients with AF with fast ventricular rate.
▪ Oxygen saturation probe to be used if available.
SR CARDILOGY ON CALL PHONE NO IS 859218.
Patient can be transferred to CCU depending upon seriousness of patient and
availability of bed.

Deptt. of Gynae, PGIMER, Chandigarh101

 26 SEVERE SEPSIS AND MATERNAL
COLLAPSE
- Dr. S C Saha
It is an acute event involving cardio respiratory system resulting in reduced or absent
conscious level during pregnancy or puerperium. Incidence being 0.14-6/1000
CAUSES OF MATERNAL COLLAPSE
Haemorrhage:
Uterine(antepartum haemorrhage/postpartumhaemorrhage)/incomplete abortion
splenicartery rupturehepatic rupture
Pulmonaryembolism:
Amniotic fluid embolism
Eclampsia Intracranial haemorrhage
Cardiac causes:
arrhythmiasmyocardial infarctioncardiomyopathy
Sepsis:
Drugs:
Magnesium sulphate local anaesthetic illicit drugs Hypoglycaemia, Aortic dissection
Hypovolaemia may be concealed e.g. abruptio (obstetric/other) or relative
hypovolaemia of spinal block; septic or neurogenic shock Hypoxia
Hypo/hyperkalaemia
Hypothermia
RESUSCITATION OF COLLAPSE
Physiological and physical changes in pregnancy which may alter resuscitation
measures/response:
Cardiovascular system
• Plasma volume Increased by up to 50%

Deptt. of Gynae, PGIMER, Chandigarh102

 • Dilutional anaemia: Reduced
oxygen-carrying capacity
• Heart rate Increased by 15–20 bpm Increased CPR circulation Cardiac output
Increased by40% : Increased CPR circulation
• Uterine blood flow 10% of cardiac output at term: Potential for rapid massive
haemorrhage
• Systemic vascular resistance Decreased : Sequesters blood during CPR
• Arterial blood pressure Decreased by 10–15 mmHg :Decreased reserve
• Venous return Decreased by pressure of gravid uterus on IVC: Increased CPR
circulationdemands
• Respiratory rate Increased : Decreased buffering capacity, acidosis more
likely
• Oxygen consumption Increased by 20% Hypoxia develops more quickly
• Residual capacity Decreased by 25% Decreased buffering capacity, acidosis
more likely
Arterial PCO2 Decreased :
Decreased buffering capacity, acidosis more likely
Laryngeal oedema Increased:
Difficult intubation
Gastric motility Decreased : Increased risk of aspiration
Lower oesophageal sphincter Relaxed : Increased risk of aspiration
Uterus Enlarged Diaphragmatic splinting : reduces residual capacityand
makesventilation more difficult
Aortocaval compression causes supine hypotension reduces venous return
andsignificantly impairs CPR
Weight Increases, large breasts may interfere with intubation,makes ventilation
moredifficult
Resuscitation

Deptt. of Gynae, PGIMER, Chandigarh103

 • Lateral tilt of 15 degree. Use wedge or manually tilt uterus to left ,important
after 20 weeks pregnancy. Wedge needs to be removed before defibrillation
• Airway needs to be protected as soon as possible
• Call anaesthetist as early as possible
• Use bag and mask till that time unless one is skilled enough to intubate
• Ensure large bore iv access- 14 gauze needle x2
• 100% oxygen by face mask/ tube.
• Cardiac massage in no breathing.Do not waste time palpating pulse
• Continue cardiac massage till cardiac rhythm can be confirmed
• Hand should be over centre of chest and be perpendicular to chest wall
• Chest compression:vetilation 30:2 if not intubated. If intubated ventilation
10/min. and compression 100/min.
• Early recourse to delivery after 20 weeks if resuscitation fails.
• Involve consultant early.
• Volume replacement is paramount in case of haemorrhage
• Abdominal ultrasound by a skilled operator can assist in the diagnosis of
concealed haemorrhage
• Defibrillation if required. Setting same as in non pregnant
• Throughout the resuscitation process, consideration should be given to the
cause of the collapse,so that continuing therapy can be directed towards the
specific cause to optimise outcome
• Resuscitation efforts should be continued until a decision is taken by the
consultant obstetrician, and consultant anaesthetist in consensus with the
cardiac arrest team.
• If there is no response to correctly performed CPR within 4 minutes of
maternal collapse or if resuscitation is continued beyond this in women
beyond 20 weeks of gestation, delivery should be undertaken to assist
maternal resuscitation. This should be achieved within 5 minutes of the
collapse even in presence of fetal death (rcog guideline)
SEPSIS
Deptt. of Gynae, PGIMER, Chandigarh104
 • Systemic inflammatory response to infection. Characterized by any two of the
following-Temp >38 degree C or<36 degC,Pulse>90 beat/ min, Resp rate>20
/min,PaCO2<32, WCC>12000/cmm or <4000/cmm or >10%immature forms.
• CAUSES : obstetric causes, mastitis, UTI, Cholecystitis, resp tract inf.,
appendicitis, malaria, post cvs, amniocentesis etc.
SEVERE SEPSIS
• Sepsis-induced hypotension
• Lactate above upper limits laboratory normal(>4mmol/l-36mg/dl)
• Urine output < 0.5mL/kg/hr for more than 2 hrs despite adequate
fluidresuscitation
• Acute lung injury with PaO2/FIO2 < 250 in the absence of pneumonia as
infectionsource
• Acute lung injury with PaO2/FIO2 < 200 in the presence of pneumonia as
infectionsource
• Creatinine > 2.0mg/dL (176.8 μmol/L)
• Bilirubin > 2mg/dL (34.2 μmol/L)
• Platelet count < 100,000 μL
• Coagulopathy (international normalized ratio > 1.5)
MANAGEMENT (modified from the Surviving Sepsis Campaign Resuscitation
Bundles)
Tasks to be performed within the first 6 hours of the identification of severe sepsis;
(Obtain blood cultures prior to antibiotic administration
Administer broad-spectrum antibiotic within 1 hour of recognition of severe sepsis
Measure serum lactate
In the event of hypotension and/or a serum lactate greater than 4 mmol/l:
• Prompt recognition and early aggressive therapy. Thorough history,
clinicalexamination. Cultures-blood,urine, high vaginal swab (may be
fallacious) beforestart of antibiotics (within 45 minutes).

Deptt. of Gynae, PGIMER, Chandigarh105

 • Hemogram ,blood biochem,eletrolytes,USG abdomen,ABG including
bloodlactate(>4 is a sign of tissue hypoperfusion).Chest x ray,
• Involve other subspecialists as and when required,
• CVP monitoring is important. Be aware of it''s limitations in pregnancy,. In
difficultsituations eg. Eclampsia+ sepsis pulmonary art wedge pressure may
be better.
• Goal directed therapy/CVP 8-12 mm Hg,MAP>= 65mmHg,Urine –
output>0.5ml/kg/h,mixed venous oxygen sat>70%. Heart rate decreasing in
responseto treatment.

• Blood culture from two sources-percutaneous puncture and one drawn

throughvenous access device (CVP line) before start of antibiotic
therapy.(within 45minutes of diagnosis) Vol. of blood drawn should be
10ml.Blood to be sent for bothaerobic and anaerobic culture

• Store the culture samples in freeze or freeze if samples can not be sent
tomicrobiology immediately.
ANTIBIOTICS :
Administration of intravenous broad-spectrum antibiotics within 1 hour of suspicion of
severe sepsis, with or without septic shock, is recommended as part of the Surviving
Sepsis resuscitation care bundle. Combination of either piperacillin/tazobactam or a
carbapenem plus clindamycin provides one of the broadest ranges of treatment for
severe sepsis. MRSA may be resistant to clindamycin, hence if the woman is or is
highly likely to be MRSA-positive, a glycopeptide such as vancomycin or teicoplanin
may be added until sensitivity is known.(RCOG)Cefotaxim+amikacin+clindamycin or
metronidazole may be first line if patient has not received any antibiotic before coming
to hospital (Departmental notice). Achieve a central venous oxygen saturation ≥ 70%
or mixed venous oxygen saturation ≥65%
FLUID THERAPY OF SEVERE SEPSIS
1. Crystalloids as the initial fluid of choice in the resuscitation of severe sepsis
and septic shock (grade 1B).
2. Against the use of hydroxyethyl starches for fluid resuscitation of severe
sepsis andseptic shock (grade 1B).

Deptt. of Gynae, PGIMER, Chandigarh106

 3. Albumin in the fluid resuscitation of severe sepsis and septic shock when
patientsrequire substantial amounts of crystalloids (grade 2C).
4. Initial fluid challenge in patients with sepsis-induced tissue hypoperfusion
withsuspicion of hypovolemia to achieve a minimum of 30 mL/kg of
crystalloids (aportion of this may be albumin equivalent). More rapid
administration and greateramounts of fluid may be needed in some patients
(grade 1C).Aim to achieve a central venous pressure of ≥ 8 mmHg
5. Fluid challenge technique be applied wherein fluid administration is
continued aslong as there is hemodynamic improvement either based on
dynamic (eg, changein pulse pressure, stroke volume variation) or static (eg,
arterial pressure, heartrate) variables (UG).In the event of persistent
hypotension despite fluid resuscitation orserum lactate > 4 mmol/L add
vasopressors.
VASOPRESSORS
1. Vasopressor therapy initially to target a mean arterial pressure (MAP) of 65
mm Hg (grade 1C).
2. Norepinephrine is the first choice vasopressor (grade 1B).
3. Epinephrine (added to and potentially substituted for norepinephrine) when
an additional agent is needed to maintain adequate blood pressure (grade 2B).
4. Vasopressin 0.03 units/minute can be added to norepinephrine (NE) with
intent of either raising MAP or decreasing NE dosage (UG).
5. Low dose vasopressin is not recommended as the single initial vasopressor
for treatment of sepsis-induced hypotension and vasopressin doses higher
than 0.03- 0.04 units/minute should be reserved for salvage therapy (failure to
achieve adequate MAP with other vasopressor agents) (UG).
6. Dopamine as an alternative vasopressor agent to norepinephrine only in
highly selected patients (eg, patients with low risk of tachyarrhythmias and
absolute or relative bradycardia) (grade 2C).
7. Phenylephrine is not recommended in the treatment of septic shock except in
circumstances where
a. norepinephrine is associated with serious arrhythmias,
Deptt. of Gynae, PGIMER, Chandigarh107
 b. cardiac output is known to be high and blood pressure persistently low or
c. as salvage therapy when combined inotrope/vasopressor drugs and low
dose vasopressin have failed to achieve MAP target (grade 1C).
8. Low-dose dopamine should not be used for renal protection (grade 1A).
9. All patients requiring vasopressors have an arterial catheter placed as soon as
practical if resources are available.
INOTROPIC THERAPY:
1. A trial of dobutamine infusion up to 20 micrograms/kg/min be administered
or added to vasopressor (if in use) in the presence of (a) myocardial
dysfunction as suggested by elevated cardiac filling pressures and low cardiac
output, or (b) ongoing signs of hypoperfusion, despite achieving adequate
intravascular volume and adequate MAP (grade 1C).
Corticosteroids:
Do not use intravenous hydrocortisone to treat adult septic shock patients if adequate
fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability
(see goals for Initial Resuscitation). In case this is not achievable, we suggest
intravenoushydrocortisone alone at a dose of 200 mg per day (grade 2C). In treated
patients hydrocortisone tapered when vasopressors are no longer required (grade 2D
Corticosteroids not be administered for the treatment of sepsis in the absence of
shock(grade 1D).
BLOOD PRODUCT ADMINISTRATION:
1. Once tissue hypoperfusion has resolved and in the absence of extenuating
circumstances, such as myocardial ischemia, severe hypoxemia, acute
hemorrhage, or ischemic heart disease, we recommend that red blood cell
transfusion occur only when hemoglobin concentration decreases to <7.0
g/dL to target a hemoglobin concentration of 7.0 –9.0 g/dL in adults (grade
1B).
2. Fresh frozen plasma not be used to correct laboratory clotting abnormalities
in the absence of bleeding or planned invasive procedures (grade 2D).
3. In patients with severe sepsis, administer platelets prophylactically when
counts are <10,000/mm3 (10 x 109/L) in the absence of apparent bleeding.

Deptt. of Gynae, PGIMER, Chandigarh108

 We suggest prophylactic platelet transfusion when counts are < 20,000/mm3
(20 x 109/L) if the patient has a significant risk of bleeding. Higher platelet
counts (≥50,000/mm3 [50 x 109/L]) are advised for active bleeding, surgery,
or invasive procedures (grade 2D).
Mechanical Ventilation of Sepsis-Induced Acute Respiratory Distress Syndrome
(ARDS)
1. Target a tidal volume of 6 mL/kg predicted body weight in patients with
sepsisinduced ARDS (grade 1A vs. 12 mL/kg).
2. Plateau pressures be measured in patients with ARDS and initial upper limit
goal for plateau pressures in a passively inflated lung be ≤30 cm H2O (grade
1B).
3. Positive end-expiratory pressure (PEEP) be applied to avoid alveolar collapse
at end expiration (atelectotrauma) (grade 1B).
4. Strategies based on higher rather than lower levels of PEEP be used for
patients with sepsis- induced moderate or severe ARDS (grade 2C).
5. That mechanically ventilated sepsis patients be maintained with the head of
the bed elevated to 30-45 degrees to limit aspiration risk and to prevent the
development of ventilator-associated pneumonia (grade 1B).
6. That noninvasive mask ventilation (NIV) be used in that minority of sepsis-
induced ARDS patients in whom the benefits of NIV have been carefully
considered and are thought to outweigh the risks (grade 2B).
7. That a weaning protocol be in place and that mechanically ventilated patients
with severe sepsis undergo spontaneous breathing trials regularly to evaluate
the ability to discontinue mechanical ventilation when they satisfy the
following criteria: a)arousable; b) hemodynamically stable (without
vasopressor agents); c) no new potentially serious conditions; d) low
ventilatory and end-expiratory pressure requirements; and e) low Fio2
requirements which can be met safely delivered with a face mask or nasal
cannula. If the spontaneous breathing trial is successful, consideration should
be given for extubation (grade 1A).
8. Against the routine use of the pulmonary artery catheter for patients with
sepsis-induced ARDS (grade 1A).

Deptt. of Gynae, PGIMER, Chandigarh109

SEDATION, ANALGESIA, AND NEUROMUSCULAR BLOCKADE IN
SEPSIS
1. Continuous or intermittent sedation be minimized in mechanically ventilated
sepsis patients, targeting specific titration endpoints (grade 1B).
2. Neuromuscular blocking agents (NMBAs) be avoided if possible in the
septicpatient without ARDS due to the risk of prolonged neuromuscular
blockadefollowing discontinuation. If NMBAs must be maintained, either
intermittent bolusas required or continuous infusion with train-of-four
monitoring of the depth ofblockade should be used
3. A short course of NMBA of not greater than 48 hours for patients with early
sepsis inducedARDS and a Pao2/Fio2 < 150 mm Hg (grade 2C).

GLUCOSE CONTROL:
1. A protocolized approach to blood glucose management in ICU patients with
severesepsis commencing insulin dosing when
2. Consecutive blood glucose levels are >180 mg/dL. This protocolized
approachshould target an upper blood glucose ≤ 180 mg/dL rather than an
upper targetblood glucose ≤ 110 mg/dL (grade 1A).
3. Blood glucose values be monitored every 1–2 hrs until glucose values and
insulininfusion rates are stable and then every 4 hrs thereafter (grade 1C).
4. Glucose levels obtained with point-of-care testing of capillary blood
beinterpreted with caution, as such measurements may not accurately
estimatearterial blood or plasma glucose values (UG).
RENAL REPLACEMENT THERAPY:
1. Continuous renal replacement therapies and intermittent hemodialysis
areequivalent in patients with severe sepsis and acute renal failure (grade 2B).
2. Use continuous therapies to facilitate management of fluid balance
inhemodynamically unstable

Deptt. of Gynae, PGIMER, Chandigarh110

BICARBONATE THERAPY:
1. Do not use sodium bicarbonate therapy for the purpose of improving
hemodynamicsor reducing vasopressor requirements in patients with
hypoperfusion-inducedlactic acidemia with pH ≥7.15 (grade 2B).
T. DEEP VEIN THROMBOSIS PROPHYLAXIS:
1. Patients with severe sepsis should receive daily pharmacoprophylaxis against
venousthromboembolism (VTE) (grade 1B). This should be accomplished
with dailysubcutaneous low-molecular weight heparin (LMWH). If creatinine
clearance is <30mL/min, use dalteparin (grade 1A) or another form of
LMWH that has a low degreeof renal metabolism (grade 2C) or UFH (grade
1A).
2. Patients with severe sepsis be treated with a combination of
pharmacologictherapy and intermittent pneumatic compression devices
whenever possible(grade 2C).
3. Septic patients who have a contraindication for heparin use
(eg,thrombocytopenia, severe coagulopathy, active bleeding, recent
intracerebralhemorrhage) should not receive pharmacoprophylaxis (grade
1B), but needmechanical prophylactic treatment, such as graduated
compression stockings orintermittent compression devices (grade 2C), unless
contraindicated.
STRESS ULCER PROPHYLAXIS:
1. Stress ulcer prophylaxis using H2 blocker or proton pump inhibitor be given
topatients with severe sepsis/septic shock/mechanical
ventilation/coagulopathy.
2. When stress ulcer prophylaxis is used, proton pump inhibitors rather than
H2RA
3. Patients without risk factors do not receive prophylaxis (grade 2B).
NUTRITION:

Deptt. of Gynae, PGIMER, Chandigarh111

 1. Administer oral or enteral (if necessary) feedings, as tolerated, rather than
eithercomplete fasting or provision of only intravenous glucose within the
first 48 hoursafter a diagnosis of severe sepsis/septic shock (grade 2C).
2. Avoid mandatory full caloric feeding in the first week but rather suggest low
dosefeeding (eg, up to 500 calories per day), advancing only as tolerated
(grade 2B).
3. Use intravenous glucose and enteral nutrition rather than total
parenteralnutrition (TPN) alone or parenteral nutrition in conjunction with
enteral feeding inthe first 7 days after a diagnosis of severe sepsis/septic
shock
ANTIMICROBIAL LIMITATIONS:
Co-amoxiclav : Does not cover MRSA, Pseudomonas or ESBL-producing organisms
Metronidazole : Only covers anaerobes
Clindamycin : Covers most streptococci and staphylococci, including many MRSA,
andswitches off exotoxinproduction with significantly decreased mortality Not renally
excreted or nephrotoxic
Piperacillin/tazobactam and carbapenems Covers most organisms except MRSA and
are renal sparing (in contrast to aminoglycosides)
Piperacillin/tazobactam does not cover ESBL producers
Gentamicin (as a single dose of 3–5 mg/kg) Poses no problem in normal renal function
but if doses are to be given regularly serum levels must be monitored.
Indications for admission of the woman to the ICU;(RCOG)
Cardiovascular : Hypotension or raised serum lactate persisting despite fluid
resuscitation suggesting the need for ionotrope support
Respiratory : Pulmonary oedema
Mechanical ventilation
Airway protection
Renal : Renal dialysis
Neurological : Significantly decreased conscious level
Deptt. of Gynae, PGIMER, Chandigarh112
Miscellaneous : Multiorgan failure
Uncorrected acidosis
Hypothermia

Deptt. of Gynae, PGIMER, Chandigarh113

 27 USE OF BLOOD AND BLOOD
COMPONENTS
- Dr. Purnima, Dr. Minakshi
Blood transfusion may be a life-saving procedure but it is not without risk.
The decision to transfuse blood should not be based on haemoglobin levels alone, but
also on the patient's clinical need.
CRITERIA FOR TRANSFUSION OF RED BLOOD CELLS:
IN CHRONIC ANAEMIA
A. Duration of pregnancy less than 36 weeks
1. Hb 5.0 g/dl or below, even without clinical signs of cardiac failure or
2. hypoxia
3. Hb between 5.0 and 7.0 g/dl and in the presence of the following
4. conditions:
• Established or incipient cardiac failure or clinical evidence of hypoxia
• Pneumonia or any other serious bacterial infection
• Malaria
• Pre-existing heart disease
B. Duration of pregnancy 36 weeks or more
1. Hb 6.0 g/dl or below
2. Hb between 6.0 g/dl and 8.0 g/dl and in the presence of the
followingconditions:
• Established or incipient cardiac failure or clinical evidence of hypoxia
• Pneumonia or any other serious bacterial infection
• Malaria
• Pre-existing heart disease.
If the Hb is 7–8 g/dl in postnatal period, where there is no continuing or threat of
bleeding, the decision to transfuse should be made on an informed individual basis. In

Deptt. of Gynae, PGIMER, Chandigarh114

fit, healthy, asymptomatic patients there is little evidence of the benefit of blood
transfusion.
INDICATIONS OF BLOOD TRANSFUSION IN ACUTE BLOOD LOSS :
a. estimated or anticipated blood loss > 15% of total blood volume
b. diastolic blood pressure < 60 mm Hg
c. systolic blood pressure decrease > 30 mm Hg
d. oliguria/anuria.
e. tachycardia (> 100 beats/minute)
f. mental status changes
g. shortness of breath, light headedness or dizziness with mild exertion
Blood loss of greater than 30% of blood volume causes significant clinical symptoms
but resuscitation with crystalloid alone is usually successful in young healthy patients
with blood loss of up to 40% of blood volume.
Start volume replacement with up to 2 litres of crystalloid. Follow plasma expanders
until the blood is available.
BLOOD ADMINISTRATION SETS
Mix the blood thoroughly by gentle inversion before use and then transfused through
an intravenous line approved for blood administration (which removes clots and small
clumps of debris that may form during collection and storage).
One standard administration set may be used for the administration of 2-4 units of red
blood cells.
Because of the risk of bacterial contamination, change the administration sets on
completion of the red cell transfusion or every 8 hours.
Never use an administration set used for red cells, subsequently for platelettransfusion
since the red cell debris trapped in the filter would trap platelets.
Don't add any medication to any blood component prior to its transfusion.
Don't warm blood components in hot water, in a microwave or on a radiator.
BEFORE TRANSFUSION
Prior to the administration of blood or blood components, the indications, risk, and
benefits of a blood transfusion and possible alternatives must be discussed with the
patient and documented in the medical record.

Deptt. of Gynae, PGIMER, Chandigarh115

Take informed consent
Check the identification of the patient.
Name , CR no , Blood Group and Unit number on the Reaction Form and the labels on
the bags should tally in addition to records in patients file.
If clots or froth - such bags are not to be transfused.
Check the expiry date of blood component(written on the bag whole blood/ packed
RBCS).
Pre-transfusion vitals should be recorded in reaction form and in the patients file.
Transfuse within 30 minutes of the issue from Blood Bank.
In patients with an elevated temperature, give an antipyretic and give time to have an
effect, postpone the transfusion as long as possible.
DURING TRANSFUSION
After starting transfusion, closely observe and monitor patient's vitals -
Every 5 mins for 15 mins
Every 15 mins for next half an hour
Every 30 mins for next 1 hr
Every hourly till the end of transfusion
30 mins post transfusion.
Maximum of 4 hrs should lapse for transfusing 1 unit of Blood.
TRANSFUSION REACTIONS
Immediate management
CATEGORY 1 : MILD (PRURITUS , RASH)
1. Slow the transfusion.
2. Administer antihistamine IM (chlorpheniramine 0.1 mg/kg or equivalent).
3. If no clinical improvement within 30 minutes or if signs and symptoms
worsen,treat as Category 2.
CATEGORY 2 : MODERATELY SEVERE ( FEVER, HEADACHE,
PALPITATION, DYSPNOEA)

Deptt. of Gynae, PGIMER, Chandigarh116

 1. Stop the transfusion. Replace the infusion set and start normal saline.
2. Notify the blood bank immediately.
3. Send blood unit with infusion set, freshly collected urine and new
bloodsamples (1clotted and 1 anti-coagulated) from vein opposite infusion
site withappropriate request form to blood bank and Laboratory for
investigations.
4. Administer antihistamine IM (e.g. chlorpheniramine 0.1 mg/kg or
equivalent)and antipyretic.
5. Give IV corticosteroids and bronchodilators if there are anaphylactoid
features(e.g. broncospasm, stridor).
6. Collect 24 hours urine for evidence of haemolysis.
7. If clinical improvement, restart transfusion slowly with new blood unit
andobserve carefully.
8. If no clinical improvement within 15 minutes or if signs and symptoms
worsen,treat as Category 3.
CATEGORY3 : LIFE-THREATENING(TACHYCARDIA, HYPOTENSION,
HEMOGLOBINURIA)
1. Stop the transfusion. Replace the infusion set and keep IV line open
withnormal saline.
2. Infuse normal saline (initially 20–30 ml/kg) to maintain systolic BP.
Ifhypotensive, give over 5 minutes and elevate patient's legs.
3. Maintain airway and give high flow oxygen by mask.
4. Give adrenaline (as 1:1000 solution) 0.01 mg/kg body weight by
slowintramuscular injection.
5. Give IV corticosteroids and bronchodilators if there are anaphylactoid
features(e.g. broncospasm, stridor).
6. Give diuretic: e.g. frusemide 1 mg/kg IV.
7. If hypotensive:
• Give further saline 20–30 ml/kg over 5 minutes
• Give inotrope, if available.

Deptt. of Gynae, PGIMER, Chandigarh117

 8. If urine output falling or Laboratory evidence of acute renal failure (rising
K+,urea, creatinine):
• Maintain fluid balance accurately
• Give further frusemide
• Consider dopamine infusion, if available
• Seek expert help: the patient may need renal dialysis.
9. If bacteraemia is suspected (rigors, fever, collapse), start broad-
spectrumantibiotics IV, to cover pseudomonas and gram positives.
STORAGE CONDITIONS
Temperature for storage of whole blood 4±2˚c.
If in domestic fridge, store in middle shelf below chiller tray, but never in freezer,
never more than 2 hrs.
Don't keep eatables/fluid in refrigerator which are used for storage.
Don't keep blood bags in unsterile packing during storage.
CRITERIA FOR TRANSFUSION OF PLATELETS :
1. Recent platelet count <10,000/L (for prophylaxis in stable, non febrile
patient),
2. < 20,000/L for prophylaxis with fever or instability.
3. Recent platelet count < 50,000/L :
Risk of hemorrhage or rapidly falling platelet count
4. Platelet dysfunction (prolonged bleeding time > 1.5 X the upper limit
ofnormal) with:
a. Petechiae
b. Purpura
c. Bleeding
d. Invasive or surgical procedure
DURING TRANSFUSION:

Deptt. of Gynae, PGIMER, Chandigarh118

 1. Platelets should be transfused as early as possible after issue from the deptt
(lessthan 30 mins)
2. Administer through a BT SET and should be returned back to the deptt if
notutilised, without any delay.
3. To be transfused within 20 minutes to 1 hour.
4. Check vitals before, during and after transfusion.
STORAGE CONDITIONS:
Temperature for storage of PRP/ PC/Apheresis platelets=22+2c in a platelet agitator
and incubator. Don't keep in refrigerator.
PRP /Platelet concentrate (3 days shelf life)
Apheresis platelet (5 days shelf life)
CRITERIA FOR THE TRANSFUSION OF FRESH FROZEN PLASMA:
PT and/or APTT > the upper limits of normal.
Those patients with a suspected coagulation deficiency (PT/PTT pending) who are
bleeding or at risk of bleeding from an invasive procedure.
Massive transfusion (>1 blood volume in 24 hours)
Disseminated intravascular coagulation
Warfarin therapy
Vitamin K deficiency
Liver disease

Deptt. of Gynae, PGIMER, Chandigarh119

Deptt. of Gynae, PGIMER, Chandigarh120
 28 LABOUR ANALGESIA

- Dr. Kajal Jain

OVERVIEW
1. Many patients may request relief of Labour pain. Pain of Labour and delivery
can be controlled by childbirth preparation techniques, non-pharmacologic
means or by pharmacologic means (including Labour epidural).
2. Choice depends on the circumstances of Labour and delivery, preferences of
the care provider and patient, and the judgement of the anesthesiologist.
3. We follow two methods: either parenteral opioids like pethidine, tramadol
when indicated OR epidural analgesia – LEA: SHOULD BE THE most
preferred technique
RATIONALE FOR PROTOCOL
To ensure best practices when caring for labouring women who are supported by
labour analgesia during labour.
To ensure women have the necessary information to make an informed decision
regarding labour analgesia.
The time from the anaesthetist being informed about a request for analgesia epidural,
until they are able to attend the woman, should not normally exceed 30 minutes, and
must be within1 hour except in exceptional circumstances. Reasons for any delay must
be clearly documented
EPIDURAL ANALGESIA
INDICATIONS
1. Maternal request
2. Pre eclampsia/hypertensive disease
3. Prolonged labour
4. Two or more babies inutero
5. Anticipated instrumental delivery
6. Diabetes Mellitus
7. Breech presentation for vaginal delivery
Deptt. of Gynae, PGIMER, Chandigarh121
 8. Significant respiratory disease

CONTRAINDICATIONS TO EPIDURAL ANALGESIA:

1. Refusal
2. Inadequate staffing
3. Untreated septicaemia or local infection at the proposed site of insertion.
4. Raised intracranial pressure
5. Uncorrected hypovolaemia
6. Coagulopathy or anticoagulant therapy
7. Platelet count should be greater than 80,000 /APTT ratio and INR should be
1.3 or less
8. Prophylactic low-molecular weight heparin within previous 12 hour
9. Spinal Bifida occulta, unless MRI scan has shown a normal cord anatomy.
3. Relative contraindications:
a. A suspicious or pathological CTG that has not had an obstetric review
b. Anatomical deformity, surgery or previous injury of the patient's back
c. Neurological disorders
d. Significant cardiac disease
e. Bacteraemia
PRE- EPIDURAL
1. Epidural analgesia should only be offered to women in established labour, as
determined by obstetrician (SENIOR RESIDENT/CONSULTANT).
2. All women should have PREFERABLY received the information regarding
painrelief in labour during the antenatal period.
Discuss following aspects in case you are counseling the patient for labour epidural
analgesia:
• LABOUR EPIDURAL ANALGESIA IS most effective form of pain relief
and is generally considered safe both for the mother as well as the baby.
• Reassure them that it does not cause any long term backache (one of the
most frequent reason of not opting regional anaesthesia)
• Does not lead to an increased C.section rate even if taken early in labour
Deptt. of Gynae, PGIMER, Chandigarh122
 • Generally patients will have > 90% of pain relief in the first stage of labour
and @ 60-70% in the second stage of labour if the top-ups are not withheld

• in a few cases (< 1%) resiting of the epidural catheter may be required in
case the catheter falls out or relief is inadequate

• DURA PUNCTURE AND POSTDURAL PUNCTURE HEADACHE

roughly is about 0.2 to 0.4%. ASK your anesthetist to discuss this in detail
including the need for epidural blood patch.

• Other serious complications like paralysis etc. fortunately are very rare
Discuss the following if the patient / attendants are educated:
• Minimal prolongation of first and second stage duration (up to 45 to 60
min) is anticipated

• Increased incidence of assisted vaginal delivery may occur.

• It takes roughly about 30 -45 minutes to establish the epidural block and
hence analgesia
• The resident must ensure necessary information to make an informed
decision regarding the use of epidural analgesia and is given an opportunity to
ask questions.
4. It will be the responsibility of the Anaesthetist to obtain informed consent
prior tothe procedure.
5. Mothers at high risk of requiring a caesarean section, especially those with a
BMI >35, should be encouraged to consider an epidural sooner rather than
later.
6. When the woman requests epidural analgesia, the resident doctor should
informthe Anaesthetist on call (CLR DUTY: contact no 7087008794).
7. IT IS IMPORTANT TO ensure that a baseline cardiotocograph has been
performedand that the mother's pulse, blood pressure and respiratory rate
have been takenprior to commencing the procedure. She should also be
encouraged to empty herbladder.
ESTABLISHING THE PROCEDURE
1. A large bore I.V. cannula (>18G) must be sited prior to placing the
epiduralcatheter and an IV infusion may need to be commenced. IV fluid
Deptt. of Gynae, PGIMER, Chandigarh123
 (NS/RL) preload may beconsidered approx 500-750 mls if the patient is not
having severe preeclampsia
2. Patient should be shifted to CLR OT for performing the procedure in
sterileatmosphere.
3. Epidural insertion should be done under supervision of a
consultant/seniorresident
4. The choice of maintaining labour analgesia should be discussed and be
available
5. Analgesia may be maintained using regular manual intermittent
boluses/continuous infusion using syringe pumps.
6. Drug of choice is 0.1% bupivacaine with 2mcg/ml fentanyl. Individual
variationsfor the choice of concentrations are possible.
7. Throughout the epidural infusion ,the nurse should undertake half-hourly
bloodpressure, heart rate and respiratory rate readings in addition to the
intrapartumobservations and document findings accordingly.
8. Continuous fetal monitoring in labour should be maintained for a woman
withepidural analgesia as per unit RCOG/ACOG guidelines.
9. If adequate analgesia has not been achieved after 30 minutes
theconsultant/senior resident anaesthetist may be contacted. The junior
residentanaesthesia should assess the sensory level of the epidural every 60
minutes (usingan ice cube in a rubber glove) to determine the epidural block
height. If thewoman is unable to detect a cold sensation at or above the nipple
line (ThoracicLevel 4), the epidural infusion should be stopped immediately
as the epiduralblock is too high.
10. If the systolic blood pressure falls below 100 Hg or if the patient becomes
sleepyand difficult to rouse, the epidural infusion should be stopped
immediately andthe anaesthetist and obstetrician called.
11. Occasionally during labour there may be a sudden hypotensive episode.In
such instances, the resident should take the following action: -Turn the
woman on her sideIncrease the intravenous fluid rateGive oxygen via a face
maskCall the anaesthetist if the above action does not rectify the hypotension.

Deptt. of Gynae, PGIMER, Chandigarh124

DURING THE SECOND STAGE OF LABOUR
1. The resident should discuss with the woman whether she wants to feel
expulsivecontractions in order to know when to push.
2. If so, the bolus should be withheld to reduce the amount of epidural
drugsadministered, which will reduce some of the epidural analgesic effects.
3. Await the descent of the fetal head to the perineum and maternal involuntary
urgeto push. (Refusal to reduce the epidural rate is not a problem, as pain free
labourincludes all stages.
4. The woman should be advised however that the incidence of instrumental
deliveryis increased with the use of epidural in the second stage of labour.
5. If the woman has requested a pain free second stage, the resident doctor
shoulddelay encouraging the woman to push until the presenting part is on the
perineum,as long as fetal and maternal observations are within normal limits.
6. The duration of active pushing in the 2nd stage should be managed as per
therecent guidelines.
FOLLOWING DELIVERY INCLUDING THE THIRD STAGE OF LABOUR
The epidural catheter should be removed after the end of the third stage and any
necessary perineal repair.
DELAY IN OBTAINING AN EPIDURAL
1. The anaesthesia resident should examine the resources available, specifically
theavailabilities of the 1st on-Call /2nd on call Anaesthetist.
2. Alternative form of pain relief with the woman until the epidural service
isavailable should be offered.
3. The delay in obtaining an epidermal must be explained to the woman in
relation towork priorities.
4. This must be documented in the notes with the alternative pain
reliefdiscussed and the subsequent choice made.
INTRATHECAL/SPINAL LABOUR ANALGESIA
Subarachnoid administration of preservative free narcotic or local anesthetic can
provide rapid, potent analgesia. Specific settings where this may be ideal include:
Multiparous patients in active phase of Labour and making rapid progress. Patients
Deptt. of Gynae, PGIMER, Chandigarh125
whose level of discomfort makes it difficult for them to remain positioned for epidural
placement. Some cardiac lesions where narcotics may cause less drop in blood
pressure than traditional epidural. Patients where retaining full motor function is
desirable for possible ambulation; When tachyphylaxis or tolerance to epidural local
anesthetic has developed due to a prolonged infusion.
COMBINED SPINAL-EPIDURAL (CSE)
Epidural catheter can be placed at time of spinal, and infusion started without bolus
dosing, or can be dosed only after narcotic has worn off.
1. Spinal preservative free (PF) medications used 2-3ml:
a. Fentanyl 25 mcg
b. Bupivacaine 2.5 mg
2. Narcotic alone (fentanyl or sufentanyl) typically give analgesia lasting 60-120
min.Side effects:
a. Pruritis; treat with nalbuphine 5 mg IVP every 10 minutes times two
dosesprn.
b. Nausea; treat as above.
c. Hypotension, seen occasionally; treat as noted above for Labour epidurals.
d. Possible loss of motor strength, dorsal column function, proprioception, so
1:1 nursing recommended for ambulating patients.
PARENTERAL OPIOIDS FOR LABOUR ANALGESIA
OPIOIDS USED FOR LABOUR ANALGESIA
• More neonatal respiratory depression than meperidine.
• An active metabolite, Morphine-6-glucuronide, is produced in smaller
amounts.
• It has significant analgesic properties but is also a respiratory depressant.
• Intramuscular morphine given to newborns caused greater respiratory
depressionthan an equipotent dose of meperidine.
• The investigators attributed this observation to a greater permeability of
theneonatal brain to morphine.

Deptt. of Gynae, PGIMER, Chandigarh126

DOSE
• Dose: 2-5 mg IV 4 hourly5-10 mg IM 4 hourly
• Onset: 3-5 min IV20-40 min IM
• Duration: 3-4 hrs
PETHIDINE
Dose: 25-50 mg IV every 2-3 hours to a maximum of 100 mg, 50 to 75mg IM every
three to four hours
Onset: 5-10 min (i/v) 40-45 min (IM)
Duration: 2-3 hrs
For optimal pain relief with meperidine, an intravenous dose of 25mg together with an
intramuscular dose of 1-1.5mg/kg has been used with effect.
CONTRAINDICATIONS
Meperidine should not be administered to patients:
Taking MAOIs (monoamine oxidase inhibitors) (or have taken MAOIs in the past 14
days)
With known hypersensitivity or allergy.
With renal insufficiency (creatinine clearance less than 50 ml/min)
With untreated hypothyroidism, Addison's disease, or urethral stricture.
In patients with Sickle Cell Disease.
CONCERNS:
• Maternal nausea, vomiting, and sedation are common.
• Readily crosses the placenta by passive diffusion & equilibrates between
thematernal and fetal compartments within 6 minutes.
• Decreased FHR variability occurs 25 to 40 minutes after administration
andresolves within an hour.
• Meperidine is metabolized in the liver to produce
normeperidine,apharmacologically active metabolite that is a potent
respiratory depressant
• If meperidine is chosen as a labour analgesic, health care providers
shouldconsider the effects of its active metabolite, normeperidine, in an effort

Deptt. of Gynae, PGIMER, Chandigarh127

 toanticipate possible neonatal respiratory depressive effects beyond the half-
life ofthe original drug
TRAMADOL
• An atypical, weak, synthetic opioid, tramadol has low μ - opioid
receptoraffinity but also exerts gamma-aminobutyric acid–ergic (GABA-
ergic),noradrenergic, and serotonergic effects.
• Its potency is approximately 10% that of morphine.
• It causes no clinically significant respiratory depression at usual doses
• Less efficacy & more side-effects than with meperidine
DOSE
• Dose: 50-100 mg IV/IM
• Onset : 10 min IM
• Duration : 2-3 hrs
GENERAL RECOMMENDATIONS FOR OPIOID USE IN LABOUR
ANALGESIA
Must have the opioid antagonist naloxone readily available for administration if
neonatal respiratory depression occurs due to maternal opioid administration for labour
analgesia.
As the duration of action of naloxone is shorter than most opioids, neonates who have
received naloxone MUST be closely observed for at least 2 hour post administration
for signs of respiratory depression.
Neonates who have not received naloxone at birth but whose mothers received opioid
analgesia within four hours of delivery, MUST be observed for at least 2 hours post-
delivery.
It is important to remember that neonates who are not adequately warmed may not
show the signs of respiratory depression as readily.
Infants of mothers receiving long-term narcotics, methadone or who are suspected of
narcotic abuse should not receive nalaxone but should insteadhave appropriate
respiratory support and monitoring.
RESUSCITATION EQUIPMENT AND DRUGS
1. Essential supplies for block placement on Labour floor:
2. Electronic fetal monitor with BP,

Deptt. of Gynae, PGIMER, Chandigarh128

 3. ECG and pulse oximetry capability,
4. Intubation equipment : self-inflating bag and mask,
laryngoscope,endotracheal tubes, oral airways;
5. Drugs: thiopental, succinylcholine, ephedrine, adrenaline, atropine, intralipids
6. Suction tubing and tip,suction canister with functioning wall hook-up
7. Oxygen supply

Deptt. of Gynae, PGIMER, Chandigarh129

 29 BROUGHT DEAD PATIENT OR DEAD ON
ARRIVAL
- Dr. Akanksha

Confirm “Death on Arrival”; Make vigorous attempt to resuscitate

Make MLC Card and inform local police/SMO on duty

Complete history; Physical Examination. Findings to be noted in file.

Death Certificate – Cause of Death not to be mentioned; Mention that patient was
brought dead.

Medicolegal Autopsy is to be done; Body is sent to the mortuary maintaining the chain
of custody

Deptt. of Gynae, PGIMER, Chandigarh130

 30 CHECKLIST FOR INTRA-HOSPITAL
TRANSPORT OF CRITICALLY ILL PATIENTS
- Dr. Kajal Jain
NAME AGE CR. NO
REFERRING DOCTOR DOCTOR CONTACT NO
PLACE FROM WHERE THE PATIENT IS BEING TRANSPORTED
CLR OT HDU
Ward ICU
PLACE TO WHERE THE PATIENT IS BEING TRANSPORTED
ICU OT
DSA Dialysis unit
OTHERS
REASON FOR TRANSPORT
Intensive Care Embolization Dialysis
CLINICAL STATUS OF THE PATIENT JUST BEFORE TRANSPORT
GCS Pupillary reaction
Temp:
Febrile/Afebrile/Hypothermic
Is the patient on ventilator? (Yes / No)
If yes : On what support ?
Controlled ventilation
SIMV
Pressure support
SpO2:
ABG :

Deptt. of Gynae, PGIMER, Chandigarh131

 • Chest findings on auscultation (BILATERAL)

Air entry Crepts/ronchi

IS THE PATIENT HEMODYNAMICALLY STABLE ? (YES/NO)

For >/< 6 HOURS

BP: PR
Ionotropes: (Yes/No)
Name - Dose-

Urine Output (in last 12 hours)

Present Lab Reports

Haemogram:
RFT's
SE:
Blood Sugar:
Coagulation:
Others

Important medications of the patient is on:

• Sedatives/ anxiolytics : Midazolam / diazepam

• Morphine

• Magnesium Sulphate

Deptt. of Gynae, PGIMER, Chandigarh132

 • Beta-blockers

• Anti-arrhythmics

• Diuretics

• Anti-epileptics

• Muscle Relaxants

• Insulin

• Soda bicarbonate calcium

• Others

General patient care prior to transport :

• If the patient is unconscious, are the eyes properly bandaged?
• Is the Patient Sedated/Agitated/Calm
• If Agitated, has Sedation Been Offered (Time:)
Drug
Dose/Route
• Is the patient intubated/TT ? (Yes/No)
If yes – ETT size:
Is the cuff properly inflated? :
Mark at which it is fixed:
Is it properly bandaged / tied? :
Has its patency been checked ?:
Has proper suctioning been done just prior to shifting? :
• Is the patient on ventimask ? (Yes / No)
If Yes – O2 flow /L
FiO2

Deptt. of Gynae, PGIMER, Chandigarh133

 • Places where IV access is present:
Peripheral / Central
Gauge 20/18/16g
taped /secured
Flushed/Running/Capped
Is arterial line present ? (Yes / No)
If yes : Site:
Has it been flushed with Hep-saline prior to shifting?
Has it been properly capped and labelled in bold writing?
• Have the urine catheter and all drains, if present, been properly secured?

Transport Team
• Names doctor technician staff nurse
Accompanying the patient
If the patient is being shifted from OT, is the anaesthetist accompanying the patient?
• If No,Then Is The Accompaying Doctor Competent To Shift (Yes/No)
• Has the doctor on duty at the place where patient is being transported been
informed prior to shifting?
Checklist during Transport
• Has the oxygen cylinder been checked:
• Is transport vital sign monitor available?
• If yes, is it working
• If no, how is monitoring being done
• Is the patient being ventilated using Bains circuit or AMBU OR transport
ventilator during transport? (Yes / No)
If Yes : Is it properly functioning?
Are all its connections to the patient end as well as the oxygen source

Deptt. of Gynae, PGIMER, Chandigarh134

 secure?
Is a resident doctor ventilating the patient
• Are all IV lines / infusions running?
• If the patient is on ionotropes,are the infusions running?
Has the battery backup of infusion pumps been confirmed ?
Have the emergency drugs and equipment for intubation been checked ?
Is the patient adequately covered?
Checklist on reaching the place of transport
• Has the handover been properly given to the doctor on duty
• Have all the documents and file been handed over
Any adverse event during transport
Deasturation/cardiac arrest/accidental extubation
Checklist on receiving the patient
• Have you received proper over of the patient?
• GCS
• Vitals
• Chest condition on auscultation
• Are the infusions running?
• others

Deptt. of Gynae, PGIMER, Chandigarh135

 31 RECOMMENDED ANTIBIOTICS

- Dr Rinnie Brar, Dr Rimpi Singla

Obstetrics

Procedure Antibiotic Timing Alternate Remarks

Caesarean Inj Cefazolin 2gm 30 mts If NA Cefuroxime Same guideline for

section* i/v single dose, before 1.5gm. prophylaxis for
AST$ Incision If allergic: caesarean even if
Max, within clindamycin 600mg patient on alternate
therapeutic antibiotic
Dose 3gm if weight 60 minutes + gentamicin 4.5
for any other reason
of patient is > 100kg Min, 15 mts mg/kg (both single
dose)
Repeat dose of
Repeat dose if clindamycin
• Duration of • Duration of
surgery > 3hrs or surgery > 6hrs or
• Blood loss > • Blood loss >
1500ml 1500ml

Labor and Ampicillin 2gm iv Cefazolin 2gm initial To be given if:

delivery initial dose followed dose followed by
• Labor Starting At
(GBS by 1gm iv 4 hrly 1gm 8 hrly till
Less Than 37 Weeks
prophylaxis) delivery, Or
(Preterm Labor);
If allergic,
Vancomycin 1gm iv • Prolonged
12 hrly till delivery Membrane Rupture
(>18 hrs Before
Delivery);
• Fever during
Labor.
• History of
Having a Baby who
had GBS Infection
• UTI Caused by
GBS

Deptt. of Gynae, PGIMER, Chandigarh136

Pre term pre Ampicillin 2 gm IV
mature followed by 1 gm IV
rupture of 6 hourly for 48
membranes hours followed by
(PPROM) oral amoxycillin 500
<34 0/7 mg 8th hourly for 5
weeks days plus oral
erythromycin
stearate 250-500 mg
6th hourly for 7
days.
Infective Ampicillin 2 gm IV 3 doses; 8
endocarditis plus Gentamicin hours apart
prophylaxis# 80mg
Third and Inj Clindamycin If vaginal pack is
Fourth 600mg + kept:
Degree Gentamicin
Perineal 4.5mg/kg; Single
Injury Dose Inj Clindamycin
600mg 8hrly +
Gentamicin 1.5mg/kg
8 hrly or,
Cefuroxime 1.5gm 12
hrly + metronidazole
500mg 8 hrly for 24
hrs
Instrumental Clindamycin 600mg
delivery 8hrly + Gentamicin
(Only if 1.5mg/kg or,
pressure Cefuroxime 1.5gm
pack is kept) 12 hrly
+metronidazole
500mg 8 hrly for
24 hrs
Rescue Inj Ampicillin 2gm
encerclage single dose

Broad spectrum Antibiotics (excluding cefazolin or cefuroxime) may be continued in

post operative period in case of prolonged rupture of membranes, prolonged second
stage or at surgeon’s discretion (with documented justification) and de-escalated
according to signs symptoms and culture reports.
* Same prophylaxis even if patient on alternate therapeutic antibiotic for any other
reason

Deptt. of Gynae, PGIMER, Chandigarh137

$ All penicillin group and cephalosporins to be given after sensitivity testing
# IE prophylaxis to be given in following situations:
1. Patients with prosthetic cardiac valve or prosthetic material used for cardiac valve
repair
2. Patients with previous infective endocarditis
3. Patients with CHD
○ Unrepaired cyanotic CHD, including palliative shunts and conduits
○ Completely repaired congenital heart defect repaired with prosthetic material or
device, whether placed by surgery or by catheter intervention, during the first 6
months after the procedure.
○ Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic
patch or prosthetic device
Under no circumstances, breach in aseptic precautions, like autoclaving time, proper
cleaning of the operating room between surgeries etc., shall be permitted.
Spectrum of coverage
Cefazolin: Gram-positive bacteria: methicillin-susceptible Staphylococcus aureus
(MSSA), coagulase – negative Staphylococci, penicillin-susceptible Streptococcus
pneumoniae, Streptococci spp. Gram-negative bacteria: Moraxella catarrhalis,
Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis
Clindamycin: Streptococcus spp., Staphylococcus spp., H. influenzae, M. catarrhalis,
Bacteroides spp., (Clostridia spp. of variable susceptibility) Prevotella spp.,
Fusobacterium spp., Veillonella spp., Chlamydia trachomatis
Gentamicin: aerobic gram-negative bacilli, Gram-negative bacteria
Cefuroxime: Gram positive cocci, Gram negative bacilli, some anaerobes (BV)

Deptt. of Gynae, PGIMER, Chandigarh138

 33 MEDICAL TERMINATION OF
PREGNANCY (MTP)
Dr Neelam Choudhary, Dr. Rashmi Bagga
Pre-abortion Evaluation:

• History: LMP, UPT, M/H, O/H, any Medico-Surgical disorders (MSD), any
attempt /medication for abortion, contraception last used, inj TT (No booster
dose if last inj TT within 2 yrs )
• Examination: General physical, Systemic & Pelvic
• Confirm pregnancy & determine gestational age
• Investigations: Hb, Urine for albumin & sugar, Blood Group – ABO & Rh,
HIV, UPT only if indicated, USG : 1st trimester if indicated, 2nd trimester for
placental localization. "Special investigations to be done if indicated"
• Counseling:
- Counselor should be warm, respectful, Good listener, Non-
judgmental
- Maintain confidentiality and privacy
- Encourage women to ask questions
- Decision for MTP - help her reach the decision she will
least regret
- Details of Method options available (Surgical or Medical)
- Explain details of Chosen method
- Need for Contraception
• Consent:
- Patient’s consent on Form C
- Informed written consent mentioning all risks of MTP
- Guardian’s consent if minor (age <18 yrs) or mentally ill
-
• Prophylactic Antibiotics:
Peri-abortion antibiotic prophylaxis: RCOG 2011, CAC (GOI) 2018:

Deptt. of Gynae, PGIMER, Chandigarh139

 - Doxycycline 100 mg orally BD for 7 days OR Azithromycin 1 g
orally
+
Metronidazole 800 mg orally (or 1 g rectally) one day prior or 2-3
hrs before abortion procedure

- RCOG 2015 : Doxycycline 200 mg orally single dose OR

Azithromycin 500 g orally single dose, within 2 hours before
abortion procedure

Abortion Procedures (followed at PGIMER):

First Trimester
o Vacuum Aspiration (Annexure-1 )
o Medical Method (Annexure-2)
Second Trimester
o Medical Method (Annexure-3)
o Mifepristone ± EAS ± Oxytocin (Annexure-4)
Post-abortion Care:
• Observation x 4-6 hrs
• Monitor vitals soon after abortion; after 1 hour, after 4 hours
• Watch for bleeding P/V, pain abdomen, side- effects of drugs
• Inj Anti-D if indicated (Rh negative, ICT negative women)
• Analgesics: Tab Ibuprofen 400 mg / Tab PCM 500mg (repeat 8 hrly if
needed)
• Antibiotics as mentioned above
• Lactation suppression in 2nd trimester (Tab.Cabergolin 0.5mg, 2 tabs stat if
no contraindication)
• Tab IFA
• Dietary advice:
o if no nausea, allow sips of water after 2-3 hours
o If anesthesia was given, sips of water after 4-6 hours
o Later increase to tea / biscuit / juice

Deptt. of Gynae, PGIMER, Chandigarh140

 o Normal meal after 8-10 hours (dinner)
• Ask her to visit emergency if has severe abdominal pain/ vomiting/ fever/
bleeding (soaks 2 full size pads in 1hr x 2 consecutive hrs)
• To restrict activity x 3days
• Provide suitable contraception
• Follow-up visit at 1- 2 weeks
MAINTAINANCE OF ALL RECORDS is mandatory (Form C, I, II & III, OPD
file, indoor file, discharge card, MTP OT register). These are secret documents and
should not be accessible to all.
Form I should be signed by thedoctor/ doctors who has/ have taken the
decision/performed procedure within 3 hours.
Form II should also be filled & to be sent to appropriate authorities.
Form III is Admission Register in MTP OT.
Comprehensive Abortion Care (CAC) 2018 (GOI) mentions that:
❖ Reporting requirement to the appropriate authorities/ concerned authority in
the hospital, for minors seeking termination of pregnancy under POCSO Act,
2012. For details please refer Comprehensive Abortion Care 2018 (GOI).

❖ USG (if required) must be done in accordance with the PCPNDT Act.

❖ Universal Precautions for Infection prevention should be followed.

ANNEXURE- 1

VACUUM ASPIRATION (VA) : up to 12 weeks (safer up to 10 wks)

• Day care procedure (except in complicated patients i.e. MSD)
• Pre-procedure cervical priming preferred– Tab Misoprostol 400 ugm P/V 3-4
hrs or S/L 2-3 hrs before procedure or Tab Mifepristone 200 mg 12-24 hrs
before procedure (RCOG 2015)
• Ask the patient to empty her bladder
• Secure I/V line
• Analgesia /Sedation: Fortwin (pentazocine 30mg) plus phenargan
(promethazine 25mg) - I/M or slow I/V after dilution, Para cervical block is
optional

Deptt. of Gynae, PGIMER, Chandigarh141

 • Lithotomy position, parts are cleaned and draped
• Confirm uterine size and position by P/V examination
• Place Sim’s speculum to retract the posterior vaginal wall
• Hold the anterior lip of cervix with volsellum/ tenaculum
• Clean the cervix with antiseptic solution (betadine)
• Uterine sound not to be used.Dilate cervix gradually with dilators starting
from no. 3 or 4 mm up to the required number according to POG

• Choose appropriate size of Karman’s cannula (CAC 2018 GOI)

Uterine Size Preferred cannula Size
4-6 weeks 4-6 mm
7-9 weeks 6-10 mm
9-12 weeks 8-12mm

• Attach cannula to electric suction machine, insert the cannula in the uterine
cavity
• Switch on the suction machine & build pressure up to 25–26 inches/ 600–
660 mmHg
• Aspirate the POC with controlled movements of cannula (to & fro and
rotatory)
• Suction machine to be switched off before removing cannula from the uterus
• Suction evacuation is considered complete if:
- No more POC coming out in cannula & air
bubbles appear
- Minimal bleeding
- Gritty sensation
- Gripping of cannula
- Decrease in the size of the uterus
• Check curettage only if required
• Practice followed in PGIMER: Oxytocin infusion (20 U/500 ml NS) started
just before starting the suction, PLUS: Tab. Misoprostol 400 ugm rectally
after procedure
• Optional: Inj. Methergin 0.2 mg I/M if required
• Watch for bleeding P/V
• Remove all the instruments, clean the parts and cover the patient
• Inspection of the POC is to be done

Deptt. of Gynae, PGIMER, Chandigarh142

 ANNEXURE-2
Medical Method ( Ist Trimester):
• Drugs Used:
Tab. Mifepristone (200 mg)
Tab. Misoprostol (200 ugm)
• Contraindications (WHO 2012, NFI 2011, CAC 2018): Anemia Hb<
8gm%, chronic/Acute adrenal or hepatic failure, Severe renal / Respiratory
disease, inherited porphyria, ectopic pregnancy or undiagnosed adnexal mass,
uncontrolled hypertension or seizure disorder, glaucoma, allergy to drugs
Caution and clinical judgment for women with current long term systemic
corticosteroids, bleeding disorders, pre-existing heart disease or
cardiovascular risk factors, IUCD in situ (to be removed before giving
medical method), fibroid uterus, prev uterine scar, anti-tubercular drugs(
these may decrease the efficacy of drugs)
• In India, MTP by Medical Method is approved up to 9 weeks POG

Dosage Schedule:
Day-1:
• Mifepristone 200 mg orally, to be given under supervision in OPD
• Observe the pt x 1 hr, if she vomits within ½ hr, repeat tab Mifepristone
200mg
• Inj Anti-D 50ugm is given I/M if indicated (Rh negative, ICT negative)
• Analgesics: Tab Ibuprofen 400mg & / or Tab PCM 500-650mg, Antiemetic:
Tab Perinorm 10mg (if required)
• Access to emergency x 24hrs
• To attend emergency if: severe pain abdomen/ vomiting/ fever/ excessive
bleeding P/V
• Return to facility on day 3 (36-48 hrs after Mifepristone)

Day-3: Misoprostol is administered under supervision as given below:

Gestation Up to 7wks >7-9wks (>9- <12wks)

Dose of 400ugm 800 ugm WHO Guidelines : (Medical

Misoprostol Oral/vaginal/ Vaginal/SL management
SL of abortion, 2018)

800 ugm Vaginal/SL/Buccal

Deptt. of Gynae, PGIMER, Chandigarh143

 *Repeat doses of Misoprostol can
be considered when needed to
achieve success of the abortion
process.

In India Medical Method is not

approved for this gestation.

Additional dose of Misoprostol to be repeated (CAC 2018 GOI, up to 9weeks) if:

*she vomits within half-an-hour of the intake of oral Misoprostol
*no bleeding or very light vaginal bleeding even after 24 hours of Misoprostol
administration
*she has excessive bleeding during the abortion process. If the bleeding does not
get controlled even after the repeat dose of Misoprostol, surgical evacuation may
be considered

• Pt. remains under observation x 4-6 hrs (up to 8wks POG)

• Patient is kept indoor till abortion when POG is 8+ to 12 wks
• Monitor vitals every 2 hrly
• Watch for side effects: nausea, vomiting, diarrhea, fever & give treatment if
required
• Watch for start of bleeding and expulsion of POC
• P/V is done before discharging the patient, if POC partially expelled- remove
them digitally (CAC 2018)
• Antibiotics & Analgesics : As mentioned earlier, on the day of misoprostol
• If stable, pt is to be sent home explaining what to expect, whom and where to
report in case of no bleeding in 24 hrs, excessive-bleeding or any other
problem

Day-14:
• Review of symptoms/experience of patient
• Clinical exam and USG to confirm the completeness of abortion (ET usually
1cm or less suggests complete abortion in an asymptomatic woman)
• Advise Contraception
• Next FU – SOS or after next periods or as applicable to contraception

Deptt. of Gynae, PGIMER, Chandigarh144

 ANNEXURE-3

MEDICAL METHOD ( 2nd TRIMESTER):

Drugs used: T. Mifepristone (200mg)

T. Misoprostol (200ug)
➢ Second trimester abortion is done up to 20 weeks
➢ Rule out contraindications for medical method
➢ Comprehensive Abortion Care (CAC) 2018 GOI states thatUse of
Mifepristone and Misoprostol for second trimester terminations is not yet
approved in India. However, WHO and international evidences recommend
the use of Mifepristone and Misoprostol as being a safe and effective method
for second trimester terminations. The WHO recommended protocol is given
in CAC 2018.

Procedure:

Day 1:
• T. Mifepristone 200 mg given orally under supervision (OPD basis,
admit if any MSD)
• Keep the patient under supervision x 1 hr, if she vomits within ½ hr
repeat tab Mifepristone 200mg
• Access to emergency x 24hrs
• Ask her to attend emergency if she has pain abdomen, uterine
contractions, bleeding or leakage P/V, fever, vomiting
• Strictly instruct her not to take tab misoprostol at home
• Ask her to return to facility after 36-48 hrs

Day 2 (OPTIONAL, After Consultant’s review):

• T. Mifepristone 200 mg (2nd dose) given orally under supervision

(This regimen was observed to reduce the IAI and Misoprostol
requirement in 100 women as compared to one dose of Mifepristone
and achieved successful abortion in all 100 women (IAI 10.44 vs.
13.75 hours, p=0.013 & Misoprostol doses 1.92 vs. 2.26, p=0.02,
MD thesis, Dr Usham Shantikumar Singh, Dec. 2018).
Deptt. of Gynae, PGIMER, Chandigarh145
Day 3:
• Admit the patient
• Antibiotics as mentioned earlier
• P/V examn to see any changes in cervical findings
• Misoprostol is administered as detailed below:
Gestation 12+ to 16 weeks 16+ to 20weeks

Dose of 400 ugm Vaginal/SL, 6hrly x 3 • 200ugm Vaginal/SL, 6hrly x 3

Misoprostol doses in 24 hrs doses in 24 hours
Prev 1 CS: • The second dose may be
(14+ - 16weeks POG) increased to 400ugm if
Start with Misoprostol dose of response is inadequate with
200ugm p/v 6hrly x 3 doses, 200ugm i.e. no uterine
may increase the further dose of contractions, only after
Misoprostol to 400ugm if consultant’s review.
response is inadequate with • Dose of Misoprostol is not to
200ugm, only after consultant’s be increased in case of prev.
review CS

• Doses can be scheduled as: - 8am- 2pm- 8pm

• Analgesia - Inj. Fortwin 30 mg (or pethidine 50 mg) plus Inj. Phenargan 25
mg I/m
• Constant monitoring of patient (vitals 2 hourly)
• P/V to be done at the time of each Misoprostol dose to assess progress of
labor
• Due dose of misoprostol is to be decided after assessing the cervical findings
and checking for establishment of ut. Contractions, it can be withheld if
regular mod. uterine contractions are established i.e. 3 in 10 minutes.
• In case of hypertonus / tachysystole (5 contractions in 10 minutes or 8
contractions in 20 minutes or single contraction lasting for >2 minutes),
withhold Misoprostol. Give tocolytic as Inj. Terbutaline 0.25 mg S/c or
NTG transdermal patch 5mg. Decision for further misoprostol to be taken by
consultant.

Deptt. of Gynae, PGIMER, Chandigarh146

 • Repeat T. Mifepristone 200 mg if patient does not abort within 3 hrs after the
3rd dose of Misoprostol followed by the same Misoprostol schedule 12 hrs
later (RCOG 2015)
• Once fetus is expelled, cut the cord & place the fetus in a sterile dish
Placental expulsion:
• Option 1 (CAC 2014 GOI) usually practiced in PGIMER:
o After expulsion of fetus, oxytocin infusion with 20 U/500 ml of NS
started @ 20-30 drops /minute OR Misoprostol 400-800ugm is given
oral / Sublingual / PR
o If there is no bleeding, wait for spontaneous expulsion of placenta
for 1 hour, otherwise remove it manually or with ovum forceps
• OPTION 2 (CAC 2018 GOI):
o Placenta should be expelled within two hours of fetal expulsion. If
placenta remains in the uterus, one of the following options should
be used:
- Sublingual/ rectal Misoprostol, 400 ugm
- High-dose oxytocin for two hours (20 units in 500 ml
saline), at 50 ml/hr I/V
• Inj. Methergin 0.2mg given I/M only if there is excessive bleeding after
expulsion of placenta
• Check curettage only if indicated
• Watch for bleeding P/V, any vaginal, cervical or uterine injury
• Make sure uterus is well contracted & bleeding is minimal
• Clean the parts & cover the patient
• Examine the fetus along with placenta & note down the findings, send for
autopsy & HPE respectively
If no abortion in 48 hrs: Patient to be reviewed critically to rule out: uterine rupture,
uterine malformation, rudimentary horn pregnancy, abdominal pregnancy, unnoticed
abortion already happened.
If cervix is still firm & internal os remains closed despite giving multiple doses of
Mifepristone & Misoprostol, an alternative method of cervical ripening may be used.
It is mandatory not to start high dose oxytocin without giving adequate time interval to
wash off the Misoprostol (about 24 hours).

Deptt. of Gynae, PGIMER, Chandigarh147

Prev. one caesarean – same protocol as above except that for POG 16 + to 20 weeks,
each dose of Misoprostol not to be increased more than 200 ugm in case of prev one
CS.
Previous 2 CS: Annexure 4
ANNEXURE-4

Mifepristone ± EAS ± Oxytocin (2nd TRIMESTER)

This method is used in women:

• with Prev 2 CS (* in previous 3 or more CS, decision to be taken by
consultant)
• In whom Medical method (as described in Annexure 3) is contra-indicated
Before starting the procedure:
• Rule out contraindications for Mifepristone (Intra-cervical Dinoprostone
gel 0.5mg may be used when Mifepristone is contraindicated but only after
consultant’s opinion)
Procedure:
Day 1:
• Admit the patient
• Start antibiotics as mentioned previously
• P/v - To assess cervical findings
• Tab Mifepristone 200mg given orally under supervision
• Intra-cervical Dinoprostone gel 0.5mg may be used when
Mifepristone is contraindicated but only after consultant’s opinion.
Dinoprostone gel is better avoided in prev 2CS

Day 2 (OPTIONAL, After Consultant’s review):

• T. Mifepristone 200 mg (2nd dose) given orally under supervision
(This regimen was observed to reduce the IAI and Misoprostol
requirement in 100 women as compared to one dose of Mifepristone
and achieved successful abortion in all 100 women (IAI 10.44 vs
13.75 hours, p=0.013 & Misoprostol doses, 1.92 vs 2.26 p=0.02, MD
thesis, Dr Usham Shantikumar Singh, Dec. 2018)
Day 3:
• Reassess the pt (this may be on Day 2 if Dinoprostone gel was used
i.e. 12-15hrs after Dinoprostone gel)
• Under AAP, 14/16/18 Fr Foley’s catheter is introduced into extra-
amniotic space through the cervix

Deptt. of Gynae, PGIMER, Chandigarh148

 • Foley’s bulb is inflated with 25-30 ml of normal saline and catheter
is pulled out so that bulb fits snuggly at internal os
• Extra amniotic normal saline (EAS) is instilled through catheter @
10 ml/week, max. up to 150 ml, with 50 ml syringe with luer lock
• Catheter is clamped or a knot is put so that EAS does not escape out
• Strap the Foley’s to thigh in taut position
• Start oxytocin infusion after 2 hours as below:

OXYTOCIN INFUSION PROTOCOL FOR MIDTRIMESTER ABORTION

BY SYRINGE INFUSION PUMP

OXYTOCIN SOLUTION : 120 Units In 500 ml Normal Saline

Infusion pump setting Oxytocin dose
(in ml/hr) (in mU/minute)
5 20
10 40
15 60
20 80
25 100
30 120
35 140
40 160
45 180
50 200

Increment Interval = Every 30 to 45 minutes till adequate ut.

Contractions established (3 contractions in 10 minutes)

Monitoring
• Monitor vitals one hourly
• Watch for Ut. Contractions / vaginal bleeding or leaking / Foley’s expulsion
• Keep input / urine output record (high dose oxytocin may cause hyponatremia
due to anti-diuretic effect)
• Serum electrolytes to be done 6 to 12 hourly
• P/V 6 to 8 hrly to see the progress of labour by assessing cervical dilatation,
effacement and bulging or ruptured membranes. Also assess position of fetus,

Deptt. of Gynae, PGIMER, Chandigarh149

 and sacculation of fetus in lower uterine segment or its ballooning with
inadequate cervical dilatation which may result in bucket handle tear
• Remove Foley’s after 24 hrs if not expelled & continue oxytocin
• Analgesia - offered as mentioned earlier
• Follow steps after fetal expulsion as written previously
REMEMBER:
• Careful monitoring is needed as uterine contractions are difficult to assess in mid-
trimester, and rupture may be missed
• Max. dose of oxytocin = 200 mU/minute, If need arises to increase it further, then
the decision is to be taken by unit consultant

MTP in Women with Various Medical Conditions (CAC 2018 GOI)

None of the conditions mentioned below is a contraindication to the abortion
procedure. However, precautions need to be taken while performing a procedure on
women with these conditions:

If very low haematocrit or haemoglobin, be prepared to treat

Anaemia appropriately. In cases of Hb < 7gm%, MTP should be done at
a higher centre with appropriate facilities
Heart disease Refer to an appropriate higher facility
PGE1 analogues should be used in case of post-abortal atony,
excessive bleeding or cervical priming
Asthma The woman should be stable and not have an acute asthmatic
attack prior to the procedure
Blood-clotting Refer a woman with clotting disorder to an appropriate higher
disorders facility with EmOC services, including blood transfusion
High blood-glucose levels are not dangerous, but ketoacidosis
should be avoided.
The insulin dose will probably not be changed if the procedure
Diabetes is performed under local anaesthesia.
The woman should take her usual dose of anti-diabetic
medication on the day of the abortion procedure.
Give an injection of oxytocin 10 units I/M, if required, for
Hypertension excessive bleeding
The woman should take her usual dose of anti-seizure
Seizure disorder medication on the day of the abortion procedure
Thyroid disease The woman should continue with her daily medication

Deptt. of Gynae, PGIMER, Chandigarh150

Renal disease Women with active renal disease should be referred to an
appropriate health facility

Deptt. of Gynae, PGIMER, Chandigarh151

 34 INTRAUTERINE FETAL DEATH

- Dr Bharti Sharma, Dr Neelam Aggarwal

Definition Intrauterine fetal death (IUFD) is death of a fetus of more than 20 weeks
of gestation or weight of more than 500gm prior to complete expulsion or extraction
from mother.

Evaluation
1. Confirmation Of IUFD
• Confirm IUFD by ultrasound
• Along with fetal heart, look for any gross congenital malformation, amount of
liquor, fetal parameters, features of hydrops & retroplacental clot.
Detailed History & examination
• Detailed history of presenting symptoms, past medical history, obstetric and
family history with emphasis on risk factors. (table1)

Table :1 Risk factors for still births

A. Current pregnancy B. Past Obstetric C. Past Maternal D. Family History
Advanced maternal age History Medical history Familial disorders
Nulliparity Previous still birth Thrombo-embolic Recurrent abortions
High Pre pregnancy Unexplained IUFD disorders VTE
weight Recurrent abortions Diabetes mellitus Pulmonary
Inadequate prenatal care History of Chronic embolism
Obstetrics Cholestasis abruption in Hypertension History of child born
Gestational diabetes previous pregnancy Thrombophilia with congenital
mellitus IUGR in previous Autoimmune anomaly, or
Pre eclampsia – pregnancy disease abnormal karyotype
Eclampsia Pre eclampsia Epilepsy Child of documented
Rupture of membranes Anemia developmental delay
Pre term labor Maternal Cyanotic in family
Multiple pregnancy heart disease Consanguinity
Lower socioeconomic
status
Smoking/ alcohol
consumption/ drug abuse
Deptt. of Gynae, PGIMER, Chandigarh152
• Confirmation of gestational age either by dating or ultrasound.
• Clinical examination to detect conditions like hypertension, anemia, jaundice
fever, intrauterine growth retardation, large baby, abruption and chorioamnionitis .
2. Breaking the bad news
• Break the bad news to woman and her family members in empathetic manner; try
to explain the cause of IUFD wherever possible without blaming anybody.
3. Laboratory Investigations
• Complete Hemogram with platelet count, coogulogram and biochemistry to rule
out pre eclampsia or occult DIC or Sepsis.
• Blood group and Anti D to be given Rh negative pregnancies at the time of
diagnosis of IUFD
• Bile acids to be done in women with history suggestive of obstetrics cholestasis or
unexplained still birth.
• Maternal random blood glucose and maternal HbA1c to diagnose occult
gestational diabetes mellitus because after IUFD, even gestational diabetic
woman will have normal glucose tolerance within few hours.
• Thyroid function, viral serology (HIV, HbsAg) and VDRL if not done in antenatal
period.
• Blood culture, urine culture, vaginal & cervical swab to be sent in suspected
infection cases only.
• Thrombophilia workup should be reserved for cases of FGR, placental disease or
unexplained still births.

Management

• After the diagnosis of IUFD and routine investigations, mother should be

explained about the option of expectant versus immediate management
depending upon her current condition and previous obstetric history.
• Immediate delivery is advised in cases of sepsis, pre eclampsia, abruption and
rupture of membranes.
• Women, who opt for expectant management, should be stable with intact
membranes and no evidence of pre eclampsia, bleeding and infection.

Deptt. of Gynae, PGIMER, Chandigarh153

Method of Induction

• In unscarred uterus a combination of mifepristone and prostaglandin preparation

has been recommended as first line intervention as per RCOG.Check for any
contra-indication
Single 200 mg dose of Mifepristone followed byMisoprostol (24 -48 hours later)
vaginally or orally (100 micrograms 4-6 hourly before 26+6 weeks , 25–50
micrograms 4-6 hourly at 27+0 weeks or more up to 24 hours)
• For woman with previous lower segment cesarean section, safety and benefits
with associated risks should be assessed by the consultant.
Mifepristone 200 mg, two doses 24 hours apart can be considered as it
increases the chance of labor significantly within 72 hours (avoiding the use of
prostaglandin).Consultant to be involved for any drug dose modification.
In cases of previous cesarean , monitoring is most important as earliest sign
of scar dehiscence i.e. fetal heart abnormality is not applicable so look for
maternal tachycardia, scar tenderness, vaginal bleeding , hematuria , receding of
presenting part in vaginal examination or sudden collapse.
• Labour analgesia as per protocol
• Birth companion should be preferably allowed with woman with IUFD for
support during labor
• Antibiotic prophylaxis is not recommended in routine except in cases of sepsis
where broad spectrum antibiotics should be given
Summary of management

IUFD

EXPECTANT MANAGEMENT IMMEDIATE MANAGEMENT

(85% go into spontaneous labour
within 3 weeks of diagnosis)

Unstable
Stable mothercoagu
Willing for expectant Abruption
Preeclampsia
management
Ruptured membranes
Infection

Deptt. of Gynae, PGIMER, Chandigarh154

 Coagulation profile, platelet count & fibrinogen
levels TWICE WEEKLY

Delivery: Vaginal route is preferred , cesarean for maternal indications only

Unscarred Uterus
1.Mifepristone + Misoprostol- Previous one LSCS
1st line Method of Mifepristone
2.Prostaglandin E2 . Induction Consultant opinion must
3. Mechanical methods

Post delivery

• External examination of fetus, placenta & cord

• Infantogram/ X ray of the fetus if indicated
• Autopsy Examination after informed written consent of parents. Autopsy form
should be complete with relevant history, examination and ultrasound
findings.
• Fetal & placental tissue for karyotype in selected cases.
• Fetal & placental microbiology in cases of suspected sepsis
Post Partum

• Lactation suppression
➢ Breast support
➢ Cabergoline: single dose of 1 mg (0.5mg 2 tablets) to be
given within 24 hours of delivery
➢ Contraindications for cabergoline: Hypertensive diseases
of pregnancy and hepatic disease
➢ B-long (Pyridoxine): 100 mg 2 tablet TDS for 5 to 7 days
in women where cabergoline is contraindicated.
Deptt. of Gynae, PGIMER, Chandigarh155
• Contraception advice to be given
• Psychological support.
• Thromboprophylaxis should be considered in patient with associated risk factors.
Follow up

• Post partum follow up visit should be planned after complete investigations so

that a clinician can inform the cause of still birth, associated risk factors, chances
of recurrence and measures for prevention.

35 POSTPARTUM IUCD

- Dr Ramandeep Bansal, Dr Vanita Jain

Ref: reference Manual MOHFW, GOI 2018

Client Assessment & counseling for PPIUCD

First Assessment
Second
When: During ANC / initial Assessment Take written
assessment When: immediately consent
For:Assessing the prior to insertion prior to
eligibilityRule out conditions For: assessing no procedure.
which prevent insertion of adverse changes as
IUCD like MEC –category 3,4 a result of delivery

Technique of insertion
Post placental insertion of the IUCD is done immediately following delivery of the
placenta, within 10 minutes. Post placental insertion can be done by two techniques:
1. Instrumental insertion (Fig 1): the IUCD is held in a suitably long forceps
without a lock (eg. long placental forceps).

Deptt. of Gynae, PGIMER, Chandigarh156

 Fig 1 Fig 2
2. Manual post placental insertion (Fig 2): the IUCD is held in the provider’s hand
as shown in Fig.2 and inserted to the uterine fundus. The provider should use long
gloves that reach midway up the arm for the protection of both the provider and
the woman.

Steps for insertion of IUCD.

1. Inspect perineum, labia and vaginal walls for lacerations. If lacerations are not
bleeding heavily, The IUCD should be inserted prior to the repair of the
lacerations.
2. Retract the posterior wall of the vagina with Sim’s speculum. Clean the cervix
with antiseptic solution twice using two separate cotton swabs with Povidone
Iodine or Chlorhexidine. Wait for two minutes. Gently grasp the anterior lip of the
cervix with the ring forceps up to the first lock.
3. Using a NO TOUCH technique, Grasp IUCD with long placental forceps in the
sterile package. Hold it just on the edge of the placental forceps. Apply gentle
traction on the anterior lip of the cervix and insert IUCD into lower uterine cavity.
4. Once the placental forceps is in the lower uterine cavity, lower the ring forceps
that is holding the anterior lip of the cervix. Move the left hand to the woman’s
abdomen and push the entire uterus superiorly (upward) to straighten out the angle
between the vagina and the uterus, so that the instrument can easily move upwards
towards the fundus. The ring forceps is now removed.

Deptt. of Gynae, PGIMER, Chandigarh157

5. Gently move placental forceps upward towards the fundus following the curve of
the uterine cavity, without applying excessive force keeping the instrument
closed.
6. Confirm that the end of placental forceps has reached the fundus by feeling the
resistance and thrust of theinstrument at the fundus of the uterus with the left
hand.
7. Open placental forceps and release the IUCD at the fundus. Sweep placental
forceps to side wall of the uterus. Stabilize the uterus using base of hand against
lower part of body of uterus.
8. Slowly remove placental forceps from uterine cavity, keeping it slightly open.
Counter traction is applied to stabilize the uterus. Take particular care not to
dislodge the IUCD as placental forceps are removed. Stabilize the uterus until the
forceps are completely out of the uterus
9. Examine the cervix to ensure that there is no bleeding and IUCD is not visible at
the os.
If it is seen protruding from cervix or the strings appear to be very long then the
IUCD has not been adequately placed at the fundus then using same forceps
remove the IUCD and repeat steps of insertion using aseptic procedures.

Intra-cesarean:
1. After the placenta is removed, insert the IUCD through the uterine incision and
place at the uterine fundus either manually or using a regular ring forceps, and
close the uterine incision.
2. DO NOT attempt to pass the strings of the IUCD through the cervical os before
closure of the uterus as this will displace the IUCD and leave it lower down in the
uterine cavity.
3. DONOT fix the IUCD with a ligature.

Follow up care

➢ To visit post partum clinic after 6 weeks on Wednesday

➢ To follow early in case of :
• Excessive bleeding per vaginum
• Foul smelling discharge per vaginum

Deptt. of Gynae, PGIMER, Chandigarh158

 • Severe abdominal pain or fever

Medical Eligibility Criteria For IUCD Insertion

Category 1 Conditions : May be used in following conditions

• Postpartum < 48hrs

• Age > 20 yrs,Parity ≥ 1
• Irregular menstrual bleeding (metrorrhagia)without heavy bleeding
• Post abortion ( 1st trimester-surgical)
• H/o ectopic pregnancy
• Cigarette smoking,Obesity, Cardiovascular disease risk factors(older
age,stroke,IHD,DM)
• SLE
• Hypertension or H/o HT, Thromboembolic disease (past or present),
Hyperlipidemia
• Uncomplicated valvular heart disease
• Headache( migraine with or without aura) , Epilepsy, Depression
• Benign ovarian tumors, Fibroid ,not distorting uterine cavity
• CIN, Benign breast disease/ breast cancer( past or present)
• Women taking antibiotics or anticonvulsants
• Anemia – mild to moderate
• Liver diseases
- Viral hepatitis - acute/ chronic,
-Cirrhosis – mild to severe
-Liver tumors – Benign / malignant
• Thyroid , GB diseases , diabetes,Malaria
• Non –pelvic tuberculosis, H/o PID
• Previous pelvic surgery including previous Cesarean section

Category 2 conditions: May be used after consultant’s opinion

• Age < 20 years, Nulliparity

• Heavy or prolonged vaginal bleeding ,Severe dysmenorrea

Deptt. of Gynae, PGIMER, Chandigarh159

 • Complicated valvular heart disease ( PAH ,AF ,infective endocarditis )
(use antibiotic prophylaxis prior to insertion)
• Lupus on immunosuppressive therapy
• Endometriosis
• High risk of HIV, Women who are HIV infected and on ARTand clinically
well
• Severe Anemia ( thalassemia or iron- deficiency),sickle cell disease
• Increased risk STIs with nonpurulent discharge
Category 3 and 4: 2 Do not insert PPIUCD
Category 3 conditions

• Between 48 hours and six weeks postpartum

• Chorioamnionitis
• Prolonged rupture of membranes (ROM)> 18 hours
• AIDS, but no antiretroviral therapy or access to care
• High individual risk of chlamydia and gonococcal infection (partner has
current purulent discharge or STI)
• Ovarian cancer
• GTN ( decreasing or undetected β-HCG levels)
• Lupus with severe thrombocytopenia

Category 4 conditions
• Puerperal sepsis
• Immediate post septic abortion
• Unresolved postpartum haemorrhage. Once the haemorrhage is controlled,
and the woman is stable, the IUCD can be inserted at that time or can be
inserted the following day
• Current PID, Gonorrhea, or Chlamydia
• Acute purulent (pus-like) discharge
• Distorted uterine cavity
• Known pelvic tuberculosis
• GTN –persistently increasing β-HCG levels
• Unexplained vaginal bleeding
• Genital tract cancer (cervical or endometrial)

Deptt. of Gynae, PGIMER, Chandigarh160

Eligibility check list and consent form for PPIUCD

Yes No
Whethershe stilldesiresPPIUCD

Review her antenatal recordsand be certain that she is an yes No

appropriate candidate for IUCD

Review the course of her labor and deliveryand ensure that

none of the following conditions are present :
a) Chorioamnionitis (during labor) No Yes
b) > 18 hours from rupture of membrane to No Yes
delivery of baby
c) Unresolved postpartum hemorrhage No Yes
I have received all the information regarding PPIUCD and I understand it. I have
discussed alternatives with my physician or provider and I am willing for PPIUCD
insertion.

Patient’s signature________________ Date__________________

Witnessed by________________________ Date _______________

Provider’s signature ___________________ Date_________________

Deptt. of Gynae, PGIMER, Chandigarh161

LABOUR ROOM PROTOCOLS NOTES
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Deptt. of Gynae, PGIMER, Chandigarh162
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Deptt. of Gynae, PGIMER, Chandigarh163

_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Deptt. of Gynae, PGIMER, Chandigarh164

_____________________________________________________________________
_____________________________________________________________________

Deptt. of Gynae, PGIMER, Chandigarh165