SHORT NOTES AND TREATMENT GUIDELINES IN OBSTETRIC &

GYNECOLOGY.

TABLE OF CONTENTS

1. MALARIA IN PREGNANCY----------------------------------------------1.
2. DM. IN PREGNANCY-----------------------------------------------------4.
3. CARDIAC DESEASE IN PREGNANCY-----------------------------------9.
4. SEVERE ANEMIA IN PREGNANCY--------------------------------------15.
5. HYPERTENSIVE DISORDERS IN PREGNANCY------------------------17.
6. PUERPERAL SEPSIS/INFECTION--------------------------------------25.
7. PELVIC INFLAMMATORY DISEASE (PID)-----------------------------28.
8. ECTOPIC PREGNANCY----------------------------------------------------31.
9. POSTTERM PREGNANCY-------------------------------------------------34.
10. MULTIPLE PREGNANCY--------------------------------------------------36.
11. BREECH DELIVERY-------------------------------------------------------39.
12. OBSTRUCTED LABOR----------------------------------------------------43.
13. INDUCTION OF LABOR (IOL)------------------------------------------47.
14. FETAL DISTRESS--------------------------------------------------------56.
15. ABORTION----------------------------------------------------------------57.
16. PROM-----------------------------------------------------------------------62.
17. APH & PPH-----------------------------------------------------------------65.
18. PREVIOUS SCAR----------------------------------------------------------77.
19. POST CAESAREAN SECTION-------------------------------------------79.
20.CERVICAL CANCER-------------------------------------------------------82.
21. OBSTETRIC FISTULA---------------------------------------------------86.

Athuman Jamal .
Clinical physiotherapy (KCMC), MD student (CUHAS) -2014
 MANAGEMENT OF MALARIA IN PREGNANCY
• Global health problem
• Affects young children and pregnant women
• Mostly caused by P.falciparum,
• 90% malaria caused by P.falciparum occur in sub-Sahara Africa.
• In areas of low transmission of P.falciparum, women do not acquire
substantial immunity, and are susceptible to episodes of severe malaria.
• Severe malaria in pregnancy is a/c
 Stillbirths
 Spontaneous abortions
 Maternal death
• In endemic areas, women has considerable immunity hence somehow
protected.
• However they may have asymptomatic infection enough to cause anemia
and high parasitemia.
• Parasitemia prevalence is high in second trimester
• Susceptibility to clinical malaria is higher in both 2nd & 3rd trimester.

WHO recommendations
 All endemic countries provide a package of interventions for prevention
and management of malaria in pregnancy, consisting of
1. Diagnosis and treatment for all episodes of clinical disease and anaemia.
2. Insecticide-treated nets for night-time prevention of mosquito bites and
infection. In highly endemic falciparum malaria areas, this should be
complemented by
3. intermittent preventive treatment with
• sulfadoxine–pyrimethamine (IPT/SP) to clear the placenta periodically of
parasites.

WHO recommends that all pregnant women at risk of P. falciparum

infection in areas of stable malaria transmission receive at least 2 doses
IPT, given at the first and second regularly scheduled ANC visit after
"quickening―
In areas where >10% of pregnant women are infected with HIV, a third
dose should be given at the last scheduled ANC visit.

IPT with SP has been shown to reduce placental malaria even in areas
with up to 50% reported SP resistance (measured as parasitological
failure at Day 14 in children under 5 years of age).
WHO therefore recommends all countries with highly endemic malaria
and less than 50% reported SP resistance to adopt IPT/SP as a policy.

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 • Contraindicated drugs
1. Tetracycline & doxycycline
2. Primaquine
3. Halofantrine

• The following ACTs are currently recommended:

— artemether-lumefantrine,
— artesunate + amodiaquine,
— artesunate + mefloquine,
— artesunate + sulfadoxine–pyrimethamine.

BMC GUIDELINE MANAGEMENT OF MALARIA IN PREGNANCY

Symptoms of uncomplicated Malaria in pregnancy.
 Fever or hx. Of fever lasting for a few days
 Headache
 Body malaise
 Joint pain
 Feeling cold shivering
 Loss of appetite
 Abdominal pains
 Nausea/Vomiting/Diarrhoea

Symptoms and signs of severe malaria in pregnancy

If the mother has three above symptoms and any of the following:
 Severe anaemia
 Jaundice
 Change of behavior (hallucinations, delusions, agitation)
 Convulsions (repetitive abnormal muscular movements)
 Altered consciousness or coma
 Haemoglobinuria (dark brown or positive Hb on dipstick urine)
 Acidosis
 Oliguria (reduced urine output) or acute renal failure
 Bleeding tendency (easy bleeding or oozing on bruising or setting a drip)
 Pulmonary oedema or difficulty in breathing
 Hypoglycaemia( low blood sugar i.e glucose <2.5mmol/L)
 Hyperparasitaemia ( 1000 asexual parasites per 200 WBC)

Severe malaria
Administer Quinine 10mg/kg body weight IV in 5% Dextrose 500 mL to run for
4 hours. Continue with Quinine 10mg/kg body weight every 8 hours.

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Discontinue Quinine infusion as soon as the patient is able to take by mouth and
continue with quinine tablets, 10mg/kg body weight by mouth every 8 hours to
complete 7 days of treatment.
Give blood transfusion if Hb is 7.0 g/dl or less, with features of heart failure
(elevated jugular venous pressure, basal crepitations and enlarged, tender liver)

Provide supportive nursing care:

 Monitor vital signs (BP, Pulse rate/respiratory rate and
temperature) every 15min until stable, then every 3 hours for 24
hours and then every 12 hours until discharge.
 Insert urethral catheter for continuous bladder drainage if in
coma or renal failure is suspected.
 Monitor input/output closely and record findings on an input/output
chart.

Conduct the following investigations:

 Blood slides (BS) for malaria parasites once a day until negative
 Blood sugar, Haemoglobin (Hb) level, White blood cell count, Total
and defferential, Blood culture if septicaemeia is suspected,
Cerebral spinal fluid examination if meningitis is suspected,
Urinalysis if parasitaemia and /clinical signs persist after three
days of Rx. With Quinine and if the pregnancy is not in that first
trimester;
 Administer Artemether 3.2mg/kg body weight IM as a loading
dose on the first day followed by 1.6mg/kg body weight once a day
for a minimum of 3days or until the patient can take by mouth to
complete a 7 day course

If injectable artemether is NOT available, give a 3-day course of ALU

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DIABETES IN PREGNANCY
Disorder with high plasma glucose levels where by the random blood glucose
level ≥200mg/dl (11mmol/l) and fasting glucose level ≥ 125mg/dl (7mmol/l).
Classify into 2 groups using white classification
Pre-gestational (overt) – diagnosed before pregnancy
 Type 1 diabetes mellitus
 Type 2 diabetes Mellitus
Gestational – diagnosed during pregnancy
 Type A1 – abnormal OGTT but normal blood glucose levels during fasting
and 2hour later after meal
 Type A2 – abnormal OGTT compounded by abnormal glucose levels during
fasting and/or after meals

1.Gestational Diabetes
Risk factors
i. History of gestational diabetes
ii. Impaired glucose tolerance
iii. Impaired fasting glycaemia
iv. Family history 1st degree relative with type 2 DM
v. Increased maternal age
vi. Ethnic background (African – American)
vii. Overweight
viii. History of large for gestation age baby delivery
ix. Smokers
x. Polycystic ovarian syndrome

Screening
Screening should be done at 24 – 28weeks of gestation.
Use 50g oral glucose challenge test followed by 75g(by WHO method) or
100g(by ACOG) oral glucose tolerance test.
Give 50g glucose loading oral dose, measure plasma glucose level after 1hour
without regarding the time of the day or time of the last meal
Blood glucose level ≥140mg/dl (7.8mmol/l) is diagnostic

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Oral glucose tolerance test

Time 100g glucose (WHO) 75g glucose (ACOG)

Fasting 95mg/dl 5.3mmol/l 95mg/dl 5.3mmol/l

1hr 180mg/dl 10.0mmol/l 180mg/dl 10.0mmol/l

2hr 155mg/dl 8.6mmol/l 155mg/dl 8.6mmol/l

3hr 140mg/dl 7.8mmol/l - -

Clinical presentation
 Increased thirst
 Increased urination
 Fatigue
 Nausea and vomiting
 Bladder infections
 Fungal infection
 Blurred vision

2.Pre-gestational diabetes
Check hemoglobin A1c level 2 months prior conception to predict the risk for
malformations.

Fetal effects

 Congenital malformations
 Preterm delivery
 Unexplained fetal demise
 Hydramnions
 Respiratory distress syndrome
 Hypoglycaemia
 Hypocalcaemia serum calcium level <8mg/dl in term infant
 Hyperbilirubinaemia and polycythemia
 Hypertrophic Cardiomyopathy
 Long term cognitive development
 Inheritance of diabetes

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Maternal effects
 Diabetic Nephropathy
 Diabetic retinopathy
 Diabetic neuropathy
 Preeclampsia
 Diabetic ketoacidosis
 Infections

Management
The goal for treatment is to reduce the risk of GDM for the mother and child.
Medical treatment
 Standard dietary management especially for type A1 to provide 2000 –
2500kcal with the exclusion of simple carbohydrates
 Physical exercises should be done preconception and during pregnancy.
 Glucose monitoring
o Self monitoring of blood glucose level can be done fasting and 1 or
2hours after breakfast, lunch and dinner
 Oral hypoglycaemic agents
o Glyburide
o Starting dose 2.5mg PO with morning meal, then you may increase
the dose by 2.5mg/wk with the max dose 10mg/day
o Switch to 12houly dose of max 20mg/d
o If not enough switch to insulin
NB: Metformin is contraindicated in pregnancy
o Insulin therapy
o 1st trimester 0.7 – 0.8U/kg/d
o 2nd trimester 0.8 – 1U/kg/d
o 3rd trimester 0.9 – 1.2U/kg/d
Intrapartum Management
Admit the patient at room 3 in labor ward.
In labor give Glucose infusion as 5% dextrose in lactated Ringer's solution or a
similar crystalloid at a rate of 125 mL/h (providing 6.25 g of glucose per hour)

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Do bedside glucose monitoring every 2–4 hours in early labor and every 1–2
hours in active labor.
Patients requiring insulin give 25 U in 250 mL saline (0.1 unit/mL) intravenously
(0.5–2.0 U/h).

Obstetrical management
Do Ultrasound to determine the fetal weight at 36weeks of gestation.
Early (at 38weeks) induction of labor can be done for trial of labor.
Elective Caesarian section should be done in macrosomic baby ≥4.5kg or
cephalopelvic disproportion.

Newborn management
Special care needs to be given to these newborns to maintain their glucose
levels. Inform the Pediatrician early when planning for delivery or before
delivery of the baby.
Treatment depends on the control of maternal blood sugar on the last part of
pregnancy and during labor, baby’s gestational age and overall health.
 Admit the baby to the neonatal ICU for close monitoring of the general
condition for atleast 24hours or more.
 Careful monitoring of blood glucose levels (Hypoglycaemia <45mg/dl)
every 30minutes in 1st 4 hours
 Giving a baby a quick source of glucose
o glucose/water mixture as early feeding 10%D - 60mls/kg/d for
term baby and 80mls/kg/day for preterm baby
o glucose intravenously - 10cc/kg of 5%D, 5cc/kg of 10%D, 2cc/kg
25D, 1cc/kg 50%D
 Check for hypocalcaemia
 In case of respiratory distress syndrome give oxygen or keep the baby on
ventilator.
 Care for any birth defect or injury.

Management of Diabetic ketoacidosis during pregnancy

These patients should be managed in a team with physician

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Laboratory assessment
Should be done at 1 – 2hour interval
o Arterial blood gases
o Glucose level
o Ketones
o Electrolyte levels
Insulin
Loading dose – 0.2 – 0.4U/kg i.v
Maintenance dose – 2 – 10U/h
Fluids
Isotonic sodium chloride 4 – 6L in first 12hours
First litre in first hour
500 – 1000ml/h for 2 – 4hours
250ml/hr until 80% replaced
Glucose
Begin 5%Dextrose in normal saline when glucose level reaches 250mg/dl
(14mmol/l)
Bicarbonate
Add 44mEq to 1L of 0.45normal saline if pH is <7.1

Sliding scale formula for Insulin therapy

This has to be used for hospitalized patients.

RBG (mmol/l) Soluble insulin

(IU)

2.5 – 6.5 -

6.5 – 8.5 4

8.5 – 12 8

12 – 14 10

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 14 – 16 12

16 – 20 16

20 – 24 20

>24 22

Follow up
Repeat OGTT at 6 – 12 weeks after delivery, if normal reassessed at 3-year
intervals.

MANAGEMENT OF CARDIAC DISEASES IN PREGNANCY

INTRODUCTION
Cardiac disease is an uncommon but potentially serious medical complication of
pregnancy.
A multidisciplinary approach involving close liaison and collaboration between the
obstetrician, cardiologist, anaesthetist, neonatologist, pediatric cardiologist
and, if appropriate, the cardiothoracic surgeon, is essential to achieve optimal
care in such pregnancies.

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DIAGNOSIS
The diagnosis and assessment of heart disease in pregnancy may be difficult
because the physiological changes of normal pregnancy can mimic cardiac
symptoms and signs and lead to the over diagnosis of cardiac diseases.
Appreciation of these changes, a high index of clinical suspicion, and timely
referral for cardiological assessment and investigations are mandatory.

Signs and Symptoms Indicative of Significant Cardiovascular Disease.

Symptoms Progressively worsening shortness of breath

Cough with frothy pink sputum
Paroxysmal nocturnal dyspnea
Chest pain with exertion
Syncope preceded by palpitations or exertion
Hemoptysis
Physical examination Abnormal venous pulsations
Rarely audible S1
Single S2 or paradoxically split S2
Loud systolic murmurs, any diastolic murmur
Ejection clicks, late systolic clicks, opening snaps
Friction rub
Sustained right or left ventricular heave
Cyanosis or clubbing

Electrocardiogram Significant arrhythmias

Heart blocks
Chest radiograph Cardiomegaly
Pulmonary edema

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INVESTIGATIONS
Most diagnostic cardiovascular studies are noninvasive and can be conducted
safely in pregnant women. In most cases, conventional testing (Imaging studies),
includes
 Electrocardiography
 Chest Radiography
 Echocardiography
 Accessory investigations include FBP, INCLUDING Hemogram, RBG,
Urinalysis, Serum Cholesterol and Serum creatinine.

The New York Heart Association (NYHA) functional classification has been
widely used and is largely based on limitation of physical activities and
associated symptoms.
 Class I Asymptomatic with ordinary activity
 Class II Symptomatic with ordinary activity
 Class III Symptomatic with less than ordinary activity
 Class IV Symptomatic at rest

MANAGEMENT
The principles of management that ensure a good pregnancy outcome include
pre-pregnancy counseling, recognition of risk factors, early diagnosis, close
obstetric and medical surveillance, anticipation, and prompt identification and
treatment of complications, the appropriate use of drugs, and timely delivery of
the baby. Management of peripartum cardiomyopathy is emphasized.

Management areas
Areas to be considered in the clinical approach to the woman with heart disease
who is pregnant or considering pregnancy:
 Risk stratification, Pre-conceptional
 Antepartum management,
 Peripartum management,

Pre-conceptional counseling
This is an important aspect of management or the cardiac patient planning a
pregnancy.
Prevent an unwanted pregnancy.

Risk assessment
 Poor functional status (NYHA class III or IV) or cyanosis
 Left ventricular systolic dysfunction (ejection fraction < 0.40)

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  Left heart obstruction (mitral valve area <2.0 cm2, aortic valve area < 1.5
cm2, or peak left ventricular outflow tract gradient> 30 mm Hg)

Antepartum Care
 The chief aim of management of the patient in pregnancy is to keep
patient within her cardiac reserve.
 Obtain detailed baseline information prior of pregnancy.
 Limiting activity is helpful in severely affected women with ventricular
dysfunction, left heart obstruction, or class III or IV symptoms.
 Hospital admission by mid-second trimester is advisable.

Anticoagulation therapy.
Anticoagulant drugs are essential in pregnant women with ;
 Mechanical prosthetic valves.
 Rheumatic heart diseases.
 Pulmonary vascular disease

At week 36 #
*Discontinue warfarin and Change to UFH.

At Delivery:
*Restart heparin therapy 4 to 6 hr after delivery if no contraindications
*Resume warfarin therapy the night after delivery if no bleeding complications
#if labor begins while the woman is receiving warfarin, anticoagulation should be
reversed and caesarean delivery performed

Monitoring
With dose adjusted UFH, the aPTT should be done at least twice for control.
Those on warfarin, the INR goal should be 3.0(range 2.5 to 3.5)

Labor and delivery

 Vaginal delivery should be advocated, with caesarean section reserved
for obstetric indications or when early delivery is essential for maternal
survival.
 Position the patient in labour in a lateral decubitus position, left or right,
thus reducing the volume shifts
 Relieve pain with epidural anaesthesia.
 Forceps or vacuum extraction should be considered at the end of the
second stage of labor to shorten and ease delivery.

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Give Antibiotic prophylaxis against infective endocarditis during labour in the
high-risk groups; patients with artificial heart valves including conduits, those
with surgically created aorto-pulmonary shunts, those with a previous history of
endocarditis, the cyanotic mothers and the heart allograft recipients.
Recommended prophylaxis:
 Ampicillin 2 g and gentamicin 1.5 mg/kg intravenously, 30 minutes
before delivery, and Ampicillin 1 g intravenously or amoxicillin 1 g orally
6 hours after delivery.
 Penicillin-allergic patients should receive vancomycin 1 g before delivery
and again 8 hours later, instead of Ampicillin.
 For long term prophylaxis for infective endocarditis Benzathine penicillin
[Penadur] 2.4MIU monthly should be given.

Postpartum monitoring
 Because hemodynamic do not return to baseline for many days after
delivery, patients at intermediate or high risk may require monitoring for
at least 72 hours postpartum.
 Fluid management must be meticulous, with extra attention given to the
patient during the immediate postpartum period, when autotransfusion
rapidly increases the central blood volume
 Contraception with Progesterone only pill have better side effect

PERIPARTUM CARDIOMYOPATHY
Peripartum cardiomyopathy is a dilated cardiomyopathy of an unknown cause.
Patients usually present with symptoms of congestive heart failure late in
pregnancy or in the early postpartum period. This is a diagnosis of exclusion and
is similar to idiopathic dilated cardiomyopathy that occurs in nonpregnant
adults.

The criterior for diagnosis are:

 Development of cardiac failure in the last month of pregnancy or within 5
months after delivery.
 Absence of an identifiable cause for the cardiac failure.
 Absence of recognizable heart disease prior to the last month of
pregnancy.
 Left ventricular systolic dysfunction demonstrated by classic
echocardiographic criteria such as depressed shortening fraction or
ejection fraction.
Common symptoms are Dyspnoea , orthopnea, cough, palpitations, and chest
pain

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Management basics
 Keep the patient in cardiac posture
 Closely monitor urine output
 O2 therapy for O2 saturation< 90% at room air
 Restrict intravenous fluids
 INTRAPARTUM , VAGINAL DELIVERY IS ADVOCATED, SHORTEN
SECOND STAGE BY FORCEPS OR VACUUM EXTRACTION

Medications
 Lasix deuresis, ..start with IV lasix 20-40 mg IV BD, may increase up to
80 mg tds if urine output remais low..If MAP< 65 mmhg consider ICU
transfer for ionotropic assisted deuresis.
 Digoxin: 0.125 daily for patients with low ejection fraction and/or atrial
fibrillation
 Morphine, 3-5 mg IV prn if features of pulmonary oedema
 Isosorbide mononitrate: May be used if signs of pulmonary oedema
 DO NOT USE Angiotensin-Converting Enzyme (ACE) Inhibitors like
Captopril in pregnancy, but can be used post partum if renal function is
re-assured!

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MANAGEMENT OF SEVERE ANEMIA IN PREGNANCY
Definition and classification:
 WHO defines anemia in pregnancy as Hb  11.0 g/dl.
 Mild Anemia: Hb 9g/dl – 10.9g/dl
 Moderate Anemia: Hb 7.1 - 8.9g/dl
 Severe Anemia: Hb 4.5 – 7.0g/dl
 Very Severe Anemia: Hb  4.5 g/dl

Signs and symptoms:

 Paroxysmal nocturnal dyspnoea
 Oedema of the body including face, lower limbs etc.
 Severe pallor of the mucous membranes
 Tachypnoea and signs of CCF may be present
At GA severe symptomatic anemia is an obstetric emergency.

Management:
Aims of management
 Correct anemia and improve Hb concentration to a safe level before the
patient goes into labour
 Avert CCF by increasing oxygen carrying capacity
 Admit the patient for investigation and Treatment
Investigations:
 Haemoglobin level estimation
 Red cell morphology and indices e.g. MCV, MCHC
 White blood cell count total and differential
 Blood slides for malaria parasites
 Stool microscopy for ova
 Urine analysis
 Sickling test and Hb electrophoresis where necessary

If the patient has signs of cardiac failure manage as follows:

 Nurse in a propped position
 Urgent group and cross-match and request for packed cells
 Give IV Frusemide 80-120mg stat to reduce pulmonary oedema while
waiting for blood transfusion.
 Administer oxygen if dyspneic
 Insert indwelling urethral catheter
Caution: Avoid setting a drip to keep “the vein open”. This may
accidentally lead to fluid overload and pulmonary edema if
inadevertently administered. However insert a cannular and keep an
open vein.

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  Transfuse packed cells only -500ml in 4-6hours. Discard the plasma
 Give frusemide 80mg half an hour before initiating a unit of blood
transfusion

NB: Hemolytic of blood will occur if left in room temperature for

more than 6 hours.
 Blood transfusion is a life saving –all efforts should be made to obtain
blood as soon as possible. It is recommended to transfuse only one unit in
24 hours. Reassess Hb and the patient 24 hours after transfusion to
decide if more blood is needed.
 During blood transfusion:
- Monitor BP, PR, and Temperature hourly
- Auscultate lung bases for fine crepitations and
- Observe for blood transfusion reactions.

Note: Indications for blood transfusions are:

 Very severe anemia at any gestation
 CCF at any gestation
 Severe anemia at or near term (36 weeks)
Severe anemia is most dangerous during labour and after the third stage of
labour, due to the increased cardiac workload during labour and the
“Autotransfusion” after delivery of the placenta.
Cardiac failure may start during these periods.

Management of severe anemia in labour

 Nurse in a propped up position
 Give IV Frusemide 80-120mg.
 Administer oxygen
 Give Analgesia e.g. morphine sulphate 10mg I.V
 Assist second stage of labour by lower cavity vacuum extraction
 No oxytocin or ergometrine unless the patient bleeds significantly. In
that case give oxytocin 5 IU intravenous
 Observe vital signs six hourly after delivery
 Initiate treatment of the underlying cause.
Note: DO NOT transfuse blood during labour.

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MANAGEMENT OF HYPERTENSION IN PREGNANCY
1.1. Definition of Hypertension in pregnancy:

Diastolic blood pressure of > 90mmHg or more on two readings at least 4 hours
apart OR one reading of diastolic Blood pressure of 110mmHg or more.
1.2. Grading of severity:
 Severe hypertension: DBP ≥ 110mmHg or Systolic blood pressure ≥
160mmHg, proteinuria +++ by dipstick, oliguria, imminent eclampsia and
HELLP syndrome. any one of these signifies Severe pre-eclampsia
 Mild hypertension: DBP < 110 mmHg without other indicators of Severe
pre-eclampsia.

2. Classification of Hypertensive Disorders Complicating Pregnancy

 Gestational hypertension
 Preeclampsia
 Superimposed preeclampsia(on chronic hypertension)
 Eclampsia
 Chronic hypertension

2.1. Gestational hypertension

 BP 140/90 mmHg for first time during pregnancy

 No proteinuria
 BP returns to normal < 12 weeks' postpartum
 Final diagnosis made only postpartum
 May have other signs or symptoms of preeclampsia, for example,
epigastric discomfort or thrombocytopenia

2.2. Preeclampsia
 BP 140/90 mmHg or higher with protein in urine.

2.3. Eclampsia
 Seizures that cannot be attributed to other causes in a woman with
preeclampsia

2.4. Superimposed Preeclampsia (on chronic hypertension)

 New-onset proteinuria 300 mg/24 hours in hypertensive women but no
proteinuria before 20 weeks' gestation

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2.5. Chronic Hypertension
 BP 140/90 mm Hg before pregnancy or diagnosed before 20 weeks'
gestation not attributable to gestational trophoblastic disease or
 Hypertension first diagnosed after 20 weeks' gestation and persistent
after 12 weeks' postpartum.

3.Outpatient management.
3.1. Selection of patients for outpatient care:
 GA < 38 weeks
 Mild hypertension DBP <110mmHg
 No significant proteinuria (+1 or less)

3.2. Investigation (at the time of case detection/diagnosis)

 Hb, WBC count and platelets
 Renal function test- Serum creatinine
 Obstetric Uss: gest. Age, lie and presentation, placental site, estimated
foetal weight, foetal viability.

3.3. Educate patient on danger signs of Pre-eclampsia and Eclampsia,

encourage additional periods of resting, initiation of daily fetal kick counting.
3.4. Weekly visits for:
 Monitor BP
 Monitor urine albumin
 Monitor maternal weight gain (normal weight gain not more than 0.5kg per
week).
 Fundal height measurement
 Review fetal kick count chart
 Non stress test
 Weekly pelvic/obstetric Uss

Admit to hospital for BP monitoring for selected patients with Unstable BP,
monitoring should be 2 hourly.

3.5. Plan elective delivery:

 40 weeks, if non proteinuric and hypertension remain mild.
 36 weeks, with decreased fetal activity.
 At 36 weeks and above with IUGR, demonstrated on serial scanning.

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4: In patient management:
4.1. Selection of patients for in-patient care:
 Severe hypertension at any gestation age
 Mild hypertension at term.

4.2. Delivery
Decision should be taken by register/ resident after consultation with specialist.
5.0. Pre-eclampsia
Management of Mild preeclampsia
5.1. At Term
Patient should be admitted
Do all baseline investigations:
 Urine for albumin
 RFTs: Serum creatinine, uric acid
 LFTs: ASAT and ALAT
 FBP: Red blood cell indices, WBC, platelets
 Coagulation profile: Bedside clotting time, PTT, APPT
 Blood smear for Malaria parasites

Assess cervical state (bishop score)

If favorable (score >6) and vaginal delivery possible, induce labour with oxytocin,
and If Unfavorable (with mild hypertension and reassuring fetal status),insert
intacervical catheter, then induce with oxytocin after 8 hours.
Deliver by C-section if induction fails.
5.2. Mild preeclampsia during labour
 Monitor progress of labor, maternal and fetal conditions using a
partograph
 Do all baseline investigations for preeclampsia
 Record input and urine output.
 Antihypertensive therapy as long as DBP >100mg (No antihypertensive if
DBP=90-100mmHg)
o Aldomet 250-500mg p.o 8hrly
o Hydrallazine mg p.o 8hrly.

5.3. Post delivery care

Fits can occur post delivery, therefore continue close monitoring and treatment
if necessary for at least 48 hours post delivery.
 Monitor Vital signs ( BP, PR,TEMP) 4 hourly.
 Fluid balance chart

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  Antihypertensive therapy as long as DBP >100mg (No antihypertensive if
DBP=90-100mmHg)
o Aldomet 250-500mg p.o 8hrly
o Hydrallazine mg p.o 8hrly.

Severe pre-eclampsia and eclampsia

5.4. Severe Pre-Eclampsia
Presence of one or more of the following signs and symptoms:

o Blood pressure 160 mmHg systolic or 110 mmHg diastolic on two

occasions at least 6 hours apart with the patient on bed rest.
o Proteinuria 5 g in a 24-hour urine collection or 300 mg per dl on
dipstick in at least two random clean-catch samples at least 4
hours apart.
o Oliguria (<500 ml in 24 hours).
o Cerebral or visual disturbances.
o Severe and persistent epigastric or right upper-quadrant abdominal
pain.
o Pulmonary edema or cyanosis.
o Thrombocytopenia.
o Fetal growth restriction
o Hyperreflexia

5.5. Eclampsia

 Occurrence of convulsions in a hypertensive pregnant woman or recently

delivered woman.

Severe Pre-Eclampsia and Eclampsia are managed similarly. Ultimate treatment

is delivery.

Exception: In Eclampsia delivery MUST occur within 12 hours of the onset of

convulsions.

All cases of severe Pre-Eclampsia should be managed ACTIVELY.

20
5.7. Management of Severe Pre-eclampsia and Eclampsia

 These patients need immediate management.” MOBILIZE HELP”.

 Registrar/ Resident on duty must be informed, who will discuss
management with Specialist.
 Do a quick assessment: vital signs (pulse, BP, and respiration)
 Secure airway
 If she is not breathing: intubate, assist ventilation by Ambubag.
 Give oxygen 4-6L/min. Suction of secretions to prevent aspiration, prone
position.
 If she is breathing: Give oxygen 4-6L/min.
 Prevent injuries
 After convulsions clean mouth and nose by suction. Check for bitten
tongue, it may swell.
 Secure i.v line
 Give anticonvulsant: Magnesium sulfate
 Loading dose: intravenous 4g of 25% Mgso4 IV 5 minutes, then
intramuscular 10g of 50% MgSO4, 5g in each buttock as deep i.m. with
1mL of 2% Lidocaine in the same syringe.
 Additionally: Position patient on her side, suction, monitor hourly; BP,
Urine output, respiratory rate, reflexes, FHR.
 If DBP is 110mmHg or more: Hydrallazine 10mg IV PRN until DBP <110
mmHg.
 Always, check for Mgso4 toxicity, before each successive maintenance
dose. Check for:
o Urine output > 30mL/hr
o Respiratory rate > 16/min
o Knee jerk reflexes are present.
 In case of respiratory arrest give Calcium glucose 1g IV slowly until
respiration begins.
 Magnesium Sulphate Maintenance dose:
o Intramuscular: 5g of 50%Mgso4 into alternate buttock 4hrly for
48hrs OR
o Intravenous: 1g of 25%Mgso4 IV hrly by continuous IV drip.
 Monitor urine output by indwelling catheter
 Monitor daily fetal kick count if the patient is not yet delivered, and
deliver when condition is stable.

21
Investigations:

 Urine for Albumin

 Liver function tests (ASAT, ALAT)
 Renal function tests (Serum creatine, Uric acid)
 Hb, WBC count and platelets.
 Serum electrolytes
 Obstetric Uss to estimate fetal weight, placental site, lie and
presentation.
 RBG and b/s for mps.

Medical management

For DBP of 110mmHg or more and especially < 120mmHg start antihypertensive
treatment: Aldomet 750 mg for 24 hrs in 4 divided doses, if DBP persist >
110mmHg with Aldomet alone, then combine with hydralazine 25-50mg.

For Severe Hypertension, DBP >120 mmHg or more:

 Treat as an emergency.
 Registrar/ second on call should be informed.
 Give Nifedipine sublingually 10mg 4hrly until DBP is < 110mmHg or
Hydrallazine 10mg IV bolus slowly, then 5mg i/v hourly until DBP
<110mmHg OR Hydralazine 60mmHg in 500mls of Ringers lactate
titrated against DBP using an infusion Pump until DBP<110 mmHg.

NOTE: All patients on i/v hydralazine should have an i/v line open with or
without i/v fluids.

Obstetric management:

 This should aim at delivering the woman at term or near term (GA 39
weeks), if mild PIH.
 Fetal monitoring (daily fetal kick-chart).
 Weekly obstetric Uss
 Twice weekly non-stress test.
 Daily urine albumin
 Plan Elective delivery (decision made by Registrar after consulting
specialist):
o At GA 37 completed weeks
o Severe persistent hypertension > 120mmHg at any GA
o Significant decrease or cessation of fetal activities

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SEVERE PRE-ECLAMPSIA AND ECLAMPSIA
Recognizing severe pre-eclampsia
 BP  160/110,
 Proteinuria 2+ or more
 Headache
 Blurred vision
 Epigastric pain
 Hyper reflexia
 Jittery
 Breathlessness (pulmonary oedema)
 Reduced urine output (less than 100 ml/4 hours)

Principles of management
Treat hypertension if systolic BP is 160 mmHg or over, or diastolic BP is 110
mmHg or over.
Aim to reduce BP to 130-140/90-100 mmHg
Commonly used antihypertensive drugs are:
Hydralazine,
Methyldopa and
Nifedipine

Consider the need for magnesium sulphate:

Magnesium sulphate is given if eclampsia seems imminent and/or there is
significant hyperreflexia (more than 3 beats) on clinical examination (severe
pre-eclampsia. MgSO4 is given in all cases of eclampsia ( fitting/convulsions)

Recognizing eclampsia
Convulsing (now or recently): tonic-clonic spasms like epilepsy, or unconscious.

Treatment:
Do not leave the woman on her own
Call for HELP
Place the woman into the left lateral position
Maintain airway at all times
Insert IV cannular and give fluids slowly (normal saline or ringer lactate) 1
litre in 6-8 hours
Start MgSO4 can be given I.M or I.V.
Loading dose: MgSO4 4g IV slowly over 10-15 minutes, follow promptly,
deep I.M injection 5gm each buttock/or 5gm alternate buttock. Give with
lignocaine in same syringe.

23
DO NOT give next dose of MgSO4 if any of these signs:
 Knee jerk absent
 Urine output 100ml/4 hours
 Respiratory rate 16 breaths/minute

N.B: Rapid injection may cause respiratory failure or death.

If respiratory depression (breathing 16/min ) occurs after MgSO4 , do
not give any more MgSO4. Give the antidote: Calcium gluconate 1g IV (10ml
10% solution) over 10 minutes.

If convulsions recur: After 15 minutes, give an additional 2g of MgSO4

(10ml of 20% solution) IV over 20 minutes, if convulsions still continue,
give Diazepam
DO NOT give 50% MgSO4 intravenously without diluting it to 20%.
If diastolic BP is 110mmHg or Systolic BP is 160mmHg or above, Give
Antihypertensive: Hydralazine 10mg IV slowly (3-4 minutes) if IV not
possible give IM.
Then 5mg IV every 30 min until diastolic BP is  110mmHg
DO NOT give more than 20mg in total
If Hydralazine is not available, give Labetalol or Nifedipine.

Pregnancy status: If a woman with eclampsia is pregnant, delivery should

take place as soon as the woman’s condition has stabilized, delivery should
occur regardless of the Gestational age. Emergency caesarean section is
done if vaginal delivery is not anticipated within 12 hours.

24
HOW TO GIVE MgSO4 IN MANAGING SEVERE PRE ECLAMPSIA AND
ECLAMPSIA.
Loading Dose:
Prepare 4g MgSO4 IV as 20% from 50% solution.
Using one 20ml syringe:
 Draw 8ml of 50% MgSO4
 Add 12ml of water for injection to make it 20ml of 20%
Give IV slowly over 5min.

Follow promptly with 10g as 50% MgSO4 deep IM:

Using two 10ml syringes:
 Draw 10ml of 50% MgSO4 into each syringe
 Add 1ml of 2% Lignocaine in each syringe
Give deep IM in each buttock (5g in 10ml)

If fits occur within 15min:

Using one 10ml syringe:
 Draw 4ml of 50% MgSO4 (2g)
 Add 6ml of water for injection to make it 10ml of 20%
Give IV slowly over 5min.

Maintenance Dose:
5g as 50% MgSO4 in alternate buttocks every 4hours.
Using one 10ml syringe:
 Draw 10ml of 50% MgSO4
 Add 1ml of 2% Lignocaine
Give deep IM in each alternate buttock every 4hours
Continue same treatment for 24 hours after delivery or last fit, whichever is
last.

Monitor for toxicity.

Withhold or delay MgSO4 if any of the following:
 RR 16 b/min.
 Patellar reflexes absent
 Urine output  30ml/hr.
If respiratory arrest occurs:
Assist ventilation with bag and mask OR call anaesthetist for intubation.
Give calcium gluconate 1g (10ml of 10%) IV Slowly over 2-5 minutes until
respiration begins.

25
 PUERPERAL SEPSIS
Definition
Puerperal sepsis/infection: General term used to describe bacterial infection
of the genital tract after childbirth/delivery.
OR.
Is an infection of the genital tract of the woman which occurs as a complication
of childbirth/delivery.
Infection may be limited to the cavity and wall of her uterus or it may spread
beyond to cause peritonitis, septicaemia, and death.

Primary sites of infection are: Perineum, Vagina, Cervix, and Uterus

Risk factors:

Prolonged labour, Preterm labour, PROM, Prolonged ROM 18hrs, Severe

bleeding, Retained product of conception, Abortion, Perinea tears, HIV
infection, Caesarean section, Multiple PV exam. in labour

Puerperal pyrexia/Fever: A temperature of 38oC or higher which occurs within

first 10days postpartum, exclusive of the first 24hrs and which is taken or
measured orally at least 4times daily.

Signs and symptoms of puerperal sepsis:

 Distended abdomen, Muscle guarding, Hyperactive bowel sounds,

Vaginally: she shows signs of recent childbirth or abortion, and may have
infected lacerations, Tender cervix with positive excitation test,
Thickened/swollen pouch of Douglas, Uterus tenderness, Fever (perhaps
with rigors), a rapid thready pulse, a low blood pressure and generalized
abdominal pain, Uniformly distended abdomen, tympanitic, silent, and
acutely tender.

Principal of management

1. RESUSCITATION
2. ANTIBIOTICS. Treat with Ceftriaxone 1g IV every 24 hours;
Gentamicin 5 mg/kg body weight IV every 24 hours; and
metronidazole 500 mg IV every 8 hours;.

3. MONITOR HER daily for signs of the spread of infection.

26
Note;

If she continues to bleed, she may have retained pieces of placenta.

 This is a common cause of puerperal sepsis, which will not resolve until
her uterus is empty.

 Give her antibiotics and curette her 24 hours later with great care!

 Use the largest curette which will be less likely to perforate her uterus.

 Curetting a large, soft, infected uterus is dangerous.

If her uterus is enlarged and tender, with a closed cervix, it may be full of
pus (pyometra).

This can occur 2 weeks or more after delivery. Drain her cervix with Hegar’s
dilators, is usually enough.

If she has a definite swelling at one side of her uterus, she has
parametritis.

If she has generalized peritonitis without any localizing signs, make a muscle
splitting incision as for appendicectomy in an iliac fossa.

Open her peritoneum, sweep gently with your finger, and insert a sump sucker.
Up to a litre of thin pus will probably escape.

If you enter an abscess cavity, gently free any adhesions and open up all loculi.
Lavage her abdominal cavity.

If her fever recurs after initial improvement, there is more pus somewhere
which must be drained, best through a midline incision.

If she recovers from the acute episode, but is left with a mass, she may
eventually need a need a full laparotomy, with the separation of adhesions and
the removal of a tubo-ovarian mass.

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 PELVIC INFLAMMATORY DISEASES : (PID)
Definition:

Infection of upper genital tract including,uterus (endometritis) ,fallopian tube

(salpingitis) ,ovaries (oophoritis) and pelvic peritoneum and parametrium.

There 2 types PID. i) Primary PID ii) Secondary PID.

Primary PID.Occurs when the disease is present in the pelvic organs.

 It is caused mainly by ascending infection(s).

 Organism responsible are mainly Neisseria Gonorrhoea and Chlamydia
infection.
 Other are Bacteria vaginosis ,anaerobic and aerobic bacteria.

Factors contributing to ascent of bacteria

(1) Uterine instrumentation eg insertion of IUCD, Endometrial biopsy

Evacuation..

(2) Hormonal changes during menses as well as menses itself.-cervical

alteration lead to loss of mechanical barrier.

Bacteristatic effect of cervical alteration is lost in onset of menses.

 Retrograde menstruation may favor ascent to the tube and peritoneum.

 Individual organism may have potential virulent factors associated with

pathogenesis of acute clamydia and gonorrhoea PID.

Secondary PID. Is the condition where by PID occur as complication of a

primary infection or post surgical procedure.

This includes: Post abortion sepsis, Post partum sepsis, Infected ectopic

pregnancy.
It can also be Pelvic infection complication of:

 Myomectomy.
 Abdominal hystrerectomy.
 Vaginal hystrerectomy.
 Tubal surgery.

28
  Tubal ligation.

The infectious organism are fecal in origin in most cases include: E.Coli,

Klebsiella, Salmonella, Proteus vulgaris, Stretococcus and so on

Risk factors for PID

 Single Young age 10 – 19yrs.

 Low social economic status.
 Multiple sexual partners.
 Previous Diagnosis.
 Endocervical test + ve for gonorrhoea or chlamydia.
 Associate with other STI.
 Sexual partner with gonorrhoea.

CLINICAL FEATURES

 Lower abdominal pain is the major complain.

 Abdominal swelling.

 Discharge or abnormal vagina bleeding.

 Elevated Pulse, Temperature with normal BP.

 Cervical discharge with sero sanguinous fluid or frank pus.

 Cervical excitation tenderness.

Pelvic mass.

 Pelvic abscess.

 TOM

DIAGNOSIS.

 Clinically by its features.

 Sonography-Transvagina Ultrasound (tubo ovarian abscess).

 Endometrial biopsy.

Indication for Hospitalization

 Suspect abscess.

 Generalized peritonitis.

 Temperature >38°C.

29
  Failed outpatient therapy.

 Resent intrauterine instrumentation.

 WBC >15,000.

 Nausea and vomiting precluding oral therapy

TREATMENT.

This depend on severity.

In Acute PID with exsanguinated patient the main stay of treatment is:

Resuscitation : Analgesic.eg. diclofenac. i/v fluids replacement if pt is

dehydrated.

 Active control of infection-Give parenteral Antibiotics.cefriaxone.

 Mild Acute PID- Pt. can be treated as outpatient with Syndromic

approach:-

Ciproflaxin 500mg i/v stat-Then Oral ciproflaxin 500mg BD x7/7.

Doxycycline 100mg bd x7/7.

Metronidazole 500mg i/v TDS for 24hrs -48hrs then oral 400mg TDSx7/7

 Also Ceftriaxone 250mg i/v stat. as single dose.

Second line

 Metronidazole 500mg I.V TDS X7/7.

 Gentamycin 80mg I.M BD x5-7/7

 Doxycycline 100mg I.V BD x7/7.

N.B: Metronidazole is contraindiated in first trimester of pregnancy so other

drugs should be instuted.

CHRONIC PID- Treatment is mainly analgesia and counseling.

Surgical Treatment can be done when there is-

 Severe dyspareunia or dysminorrhoea.

 Clinically severe disease.
 Lack of response to medical therapy.
 Tubo ovarian Abscess.

30
COMPLICATIONS OF PID.

Psychological trauma, Dysmenorrheal, Dyspareunia, Pelvic abscess, TOM, Severe

peritonitis, Tubal occlusion, Ectopic gestation, Divorce, Separation, Suicide.

PREVENTION.

 Health education on avoiding acquisition of STI.

 Prevent lower genital tract infection from ascending to upper genital
tract.
 Prevent upper genital tract from leading to tubal dysfunction.
 Partner notification and Treatment if PID is secondary to STI.
 Appropriae management ..

MANAGEMENT OF ECTOPIC PREGNANCY

INTRODUCTION; Ectopic pregnancy refers to the implantation of a fertilized
egg in a location outside of the uterine cavity, including the fallopian tubes,
cervix, ovary, cornual region of the uterus, and the abdominal cavity.

Nearly 95 percent of ectopic pregnancies are implanted in the various segments

of the fallopian tube and give rise to fimbrial, ampullary, isthmic, or interstitial
tubal pregnancies, the ampulla is the most frequent site, followed by
the isthmus.

AETIOLOGY;
The following risk factors have been linked with ectopic pregnancy:
 Pelvic inflammatory disease (PID)
 History of prior ectopic pregnancy
 History of tubal surgery and conception after tubal ligation
 Use of fertility drugs or assisted reproductive technology
 Use of an intrauterine device
 Increasing age
 Smoking
 Salpingitis isthmica nodosum
 Others include previous diethylstilbestrol (DES) exposure, a T-shaped
uterus, prior abdominal surgery, failure with progestin-only contraception,
and ruptured appendix.

31
DIAGNOSIS
Ectopic Pregnancy is suspected when a woman presents with a combination of
the following:
Clinical:
 History of 6-8 weeks amenorrhea
 Symptoms of early pregnancy, including nausea, breast fullness, fatigue,
low abdominal pain.
 Pelvic pain and/or abnormal bleeding in the first trimester
 Shoulder tip pain
 Dizziness or spells of fainting due to hypovolemic shock
Signs
 Pallor out of proportion to degree of vaginal bleeding
 Hypotension
 Tachycardia
 Signs of shock, rapid pulse, cold extremities, restlessness, shallow and
deep breathing
 Other evidence of blood in the peritoneum.
 P/A: Distended, silent(doesn’t move with respiration), tender, muscle
rigidity, rebound tenderness, fluid thrill and shifting dullness
 PELVIC EXAMINATION :Scanty oozing of dark-red blood from external
os, Bluish cervix, cervical excitation positive, may have palpable adnexae

LABORATORY INVESTIGATIONS
 Hemogram; A hematocrit of less than 30% is found in about one fourth
of women with ruptured ectopic pregnancy at the time of rupture.[1]
 Chorionic Gonadotropin (B-HCG) Assays; The qualitative serum or urine
B-hCG assay is positive in virtually 100% of ectopic pregnancies. [1]

 Serum Progesterone Level; A single progesterone value exceeding 25

ng/mL excludes ectopic pregnancy with 97.5-percent sensitivity. Levels of
less than or equal to 5 ng/mL indicates a nonviable pregnancy, ectopic or
intrauterine, and excluded normal pregnancy with 100% sensitivity.

Ultrasound Imaging
 Abdominal Sonography; Sonographic absence of a uterine pregnancy, a
positive pregnancy test result, fluid in the cul-de-sac, and an abnormal
pelvic mass, ectopic pregnancy is almost certain. Fetal heart action clearly
outside the uterine cavity provides firm evidence of an ectopic pregnancy.
 Transvaginal US visualize an intrauterine pregnancy by 24 days post
ovulation, or 38 days after last menstrual period, which is about 1 week
earlier than transabdominal US.

32
 Diagnostic Procedures
Culdocentesis; Is performed by inserting a needle through the posterior fornix
of the vagina into the cul-de-sac and attempting to aspirate blood. When
nonclotting blood is found in a suspected ectopic pregnancy, the likelihood of a
ruptured ectopic pregnancy is high.

Laparoscopy; Allows assessment of the pelvic structures, size and exact

location of ectopic pregnancy, presence of hemoperitoneum and presence of
other conditions, such as ovarian cysts and endometriosis, which, when present
with an intrauterine pregnancy, can mimic an ectopic pregnancy. Furthermore,
laparoscopy provides the option to treat once the diagnosis is established.
Laparotomy is indicated when the presumptive diagnosis of ectopic pregnancy in
an unstable patient necessitates immediate surgery, or when definitive therapy
is not possible by medical management or laparoscopy.

MANAGEMENT
Emergency Treatment
Immediate surgery is indicated when the diagnosis of ectopic pregnancy with
hemorrhage is made. At least 2 units of whole Blood should be available because
transfusion is often necessary.
There is no place for conservative therapy in a hemodynamically unstable
patient.

Expectant Management
Restrict expectant management to women with these criteria:
 Decreasing serial B-hCG levels.
 Tubal pregnancies only.
 No evidence of intra-abdominal bleeding or rupture as assessed by vaginal
Sonography.
 Diameter of the ectopic mass not greater than 3.5 cm.
Medical Management
Methotrexate may be effective in the medical management of small, unruptured
ectopic pregnancies in asymptomatic women.
Dose; Single dose injection of 50 mg/m2 IM in a single injection or as a divided
dose injected into each buttock. Patient should be followed-up to measure B-
hCG values on day 4 and 7.

33
Surgical Management
Tubal surgery for ectopic pregnancy is considered conservative when there is
tubal salvage. Examples include salpingostomy, and fimbrial expression of the
ectopic pregnancy. Radical surgery is defined by salpingectomy.

POST-TERM PREGNANCY
Definition:
Sometimes it is called postmaturity or postdates.
Post-dates pregnancy is any pregnancy which extends beyond the woman’s due
date. True post-term pregnancy is defined by the World Health Organization as
a pregnancy of 42 completed weeks (294 days) or more, although the term is
more and more often used to refer to any pregnancy that goes beyond 41 weeks.

Complications
The prolongation of pregnancy (≥42 weeks) has been associated with increased
Perinatal Mortality rates. Other obstetrical and perinatal complications that are
found to be higher in post-term pregnancies include:
fetal distress, non-progression, operative delivery (both operative vaginal and
Caesarean), macrosomia, shoulder dystocia, low Apgar scores, and meconium
aspiration.

Pathophysiology and etiology.

Parturition (child birth) is a complex process that involves events within the
fetal brain, adrenals, placenta, amnion, and chorion.

The theorized mechanism of parturition begins with:

- A stimulus in the fetal brain, resulting in activation of the fetal
hypothalamic-pituitary axis (HPA).
- Adrenocorticotropic hormone (ACTH) production results in stimulation of
the fetal adrenal.
The fetal adrenal increases production of Dehydroepiandrosterone sulfate
(DHEAS) and cortisol.
- The presence of placental sulfatase in the placenta is required so that the
placenta can convert the DHEAS to estradiol.
- Estrogen is thought to be important in increasing myometrial activity, and
cortisol is thought to be important in stimulating prostaglandin output in
the placental tissues.
- Prostaglandins are important for myometrial contractility.

34
Several disorders may result in delayed parturition and postterm pregnancy.
These disorders are all similar in that they are associated with low estrogen
production.

These rare causes of postterm pregnancy include:

i. Congenital anomalies:
 Anencephaly : absence of the fetal cranium with gross abnormalities
associated with the fetal brain abnormal fetal HPA.
 primary fetal adrenal hypoplasia  Diminished production of DHEAS
and cortisol.

ii. Placental sulfatase: required to convert fetal DHEAS to estrogen.

Its Deficiency leads to decreased estrogen levels and a subsequent
delay in parturition.
iii. Maternal factors:
 Previous postterm pregnancy,
 Primiparity
 Elderly multiparae
iv. Wrong dates: especially if the woman cannot recall her LNMP.(most
common)
v. Biological variability (Hereditary) may be seen in the family

Diagnosis:
History:
 Calculation of gestational age by using her last normal menstrual period
(LNMP)
 1st or 2nd trimester Obstetric Ultrasound (USS done before 20 weeks of
gestation)
 Determine the time of fetal quickening. Most of times quickening may
start at around 16-18 weeks.
 Fundal height between X and Y at Booking

Examination: larger baby size.

Ultrasonography: can detect,
 Biparietal diameter more than 9.6 cm.
 Increased foetal weight.
 Oligohydramnios.
 Increased placental calcification.

35
Management
Delivery is indicated whenever post-term pregnancy is confirmed. But induction
of labour has to be preceded by doing a BISHOP score for favorability of the
cervix. Cervix is said to be favorable for induction if the BISHOP score is >6.

Induction of labour
If the conditions are favorable for vaginal delivery using:
1- Ripening the cervix by using intracervical catheter under traction
ballooned with 30-40 mls of water for injection.
2- Ripening the cervix by using 25µg of Misoprostol 6hrly in 24hrs inserted
in the posterior fornix can be used BUT misoprostol is not licensed for
Induction of labor in Tanzania by TFDA.
3- Amniotomy ± oxytocin.
For Primegravida: 5IU Oxytocin in 500mls of D5% or Lactated Ringers
For grandmultiparous women: 2.5IU oxytocin in 500mls of D5% or
Lactated Ringers

Caesarean section:
Iif conditions are not favorable for vaginal delivery, or if induction of labour
failed.

MULTIPLE PREGNANCY

INTRODUCTION
Multiple pregnancy is the development of more than one fetus in a womb. The
multiple gestation can either be twins or higher order multiples e.g. Triplets,
Quadruplets e.t.c.

36
Multifetal pregnancies are high-risk pregnancies.
The highest risk is in monochorionic/monoamniotic pregnancies.
They are complicated by higher incidence of hypertensive diseases, Anemia,
preterm labor, PROM, hypermensis gravidarum, placenta praevia,
polyhydramnions, and delivery complications such as placenta abruption,
operative delivery, malpresentation, cord accidents, postpartum endometritis

Antepartum Management
Confirm Diagnosis
 Fetal parts, palpation of more than two fetal poles
 Fundal Height palpation ( large for dates)
 Fetal heart sounds ascultated at more than one area on the maternal
abdomen
 Ultrasound to confirm multiple pregnancy, estimation of fetal weights
( Rule out IUGR, Prematurity), detection fetal lie and presentation of
both fetuses, assess Amniotic fluid volume
( R/O oligohydramnios/polyhydramnios)
 Diet (increased iron 100mg/day, folic acid 1mg/day) because of increased
demands in multiple pregnancies
 Regular visits to ANC
 Encourage bed rest enhance uterine perfusion and Prevention of Preterm
Delivery
 Advice on diet-increase protein, decrease salt intake.
 Counsel regarding risks such as anemia, hypertension, preterm delivery, and
growth restriction
 Identify Intrauterine Growth Restriction

Intrapartum management
 The second twin carries the highest perinatal risk as a result of breech
presentation and birth asphyxia. The latter may result from contraction or
partial separation of the placenta after delivery of the first twin or a longer
period during which the infant is subjected to the effects of aortocaval
compression.
 Similarly, with triplets and quadruplets, the possibility of malpresentation in
the later fetuses increases, increasing the requirement for version and
breech extraction, both of which procedures are associated with a high
incidence of morbidity-mortality
 Cephalic/Cephalic 80% will deliver vaginally; Continue monitoring second twin
and add oxytocin for augmentation of labor for second twin if required

37
 Cephalic/Noncephalic (2nd twin delivery)
 External cephalic version
 Internal podalic version and total breech extraction
 Assisted breech delivery

VAGINAL DELIVERY
 Delivery should be conducted by experienced staff .
 When a patient with a twin gestation presents in labor, ultrasound should
be used to establish fetal presentation and size.
 The fetal well-being should be evaluated with fetal heart monitoring, and
assessment of potential maternal complications, such as anemia,
hypertension, and polyhydramnios, should be accomplished.
 Continuous fetal-heart-rate monitoring is mandatory and should continue
after the delivery of the presenting infant.
 Vaginal delivery should be allowed for vertex/vertex twins regardless of
GA
 Vaginal delivery can also be attempted for Vertex/breech with second
twin in breech presentation weighing >1500g

CEASEREAN SECTION DELIVERY

 Elective caesarean section is recommended for breech first twins in view
of the risks of entanglement and those inherent in vaginal delivery of
breech singletons.
 Monoamniotic twins should be delivered by elective/Emergency caesarean
section.
 In vertex/breech twins with second twin in breech weighing <1500g as
breech extraction of second twin weighing <1500g is associated with head
entrapment
 Multiple pregnancy after previous lower segment C-Section
 Triplets and higher order multiple gestations are probably best delivered
by elective caesarean section.
 Interlocking twins should be delivered by C-section
 Conjoined twins should be delivered by C-section
 C-section in retained second twin (>1hr after delivery of first twin)
o Pediatrician should be consulted to review the multifetal babies especially
premature, congenital malformed and asphyxiated babies.
o Anticipate postpartum hemorrhage in multiple pregnancy delivery

38
 BREECH DELIVERY
It is of great importance when considering a vaginal breech delivery that the
mother has emotional stability, a high degree of confidence in her body as well
as in her midwife, and a high degree of motivation.
In attempting breech delivery, excellent communication and cooperation
between the mother and her birth attendant are important.

COMPLICATIONS OF BREECH LABOR & DELIVERY:

Greater incidence of cord prolapse, particularly with footlings,Pressure on the
cord in first stage,Increased incidence of premature placental separation,head
entrapment due to pushing before, or misdiagnosis of complete dilation, Injury
to the neck or head and increased danger of nerve damage if arms are swept up
over the head.

NO ATTEMPT AT VAGINAL DELIVERY SHOULD BE MADE UNDER THE

FOLLOWING CONDITIONS:
Suspected cephalo-pelvic disproportion (CPD),possibility of baby weighing over
3.5kgs or under 2.25 kgs,Post-term infant (over 40 weeks),Pre-term infant
(before 36 weeks),Prior history of CPD or necessity for forceps
delivery,Previous need for pitocin induction or augmentation.,Previous shoulder
dystocia,Previous history of protracted or obstructed labor in the first or
second stage, except posterior (face up) position,Possible intra-uterine growth
retardation (IUGR) and Any evidence of fetal distress.

BREECH SCORING INDEX:

When a decision is to be made as the feasibility of attempting a breech delivery,
this scoring index is of great help.This assessment is designed to be made at
the onset of labor

Points assigned 0 1 2

Parity Primagravida Multigravida

Gestational Age 39 weeks or more 37-38 weeks 36-37 weeks

Estimated Fetal Weight Over 3.5kg 3.0-3.5kg 2.2kg-3.0kg

Dilation 2 cm 3 cm 4 cm or more

Station -3 -2 -1 or lower

Previous Breech None One 2 or more

39
A score of less than three would indicate the need for a cesarean section. A
score of 4-5 would indicate that a careful review be made and would suggest
that one should proceed with caution. A score of five or better would indicate a
reasonable chance for a successful vaginal delivery.

There some moderating factors. If a multipara has had two nine pound babies
vaginally, and this baby is of similar size, she should do fine as long as the baby
does not go post dates. One point should be subtracted for footling breeches,
as they are somewhat difficult to manage.

Review for indications,ensure that all conditions for safe vaginal breech delivery
are met.

Review general care principles and start an IV infusion,provide emotional

support and encouragement,if necessary use a pudendal block.Perform all
manoeuvres gently without undue force

FRANK OR COMPLETE BREECH.

DELIVERY OF THE BUTTOCKS AND LEGS.

Once the buttocks have entered the vagina and the cervix is fully dilated, tell
the woman she can bear down with the contractions.
If the perineum is very tight, perform an episiotomy,let the buttocks deliver
until the lower back and then the shoulder blades are seen.
Gently hold the buttocks in one hand, but do not pull,if the legs do not deliver
spontaneously, deliver one leg at a time,push behind the knee to bend the
leg,grasp the ankle and deliver the foot and leg and repeat for the other leg.
Hold the baby by the hips,do not hold the baby by the flanks or abdomen as this
may cause kidney or liver damage.

DELIVERY OF THE ARMS.

ARMS ARE FELT ON CHEST.

Allow the arms to disengage spontaneously one by one,only assist if necessary.
After spontaneous delivery of the first arm, lift the buttocks towards the
mother’s abdomen to enable the second arm to deliver spontaneously.
If the arm does not spontaneously deliver, place one or two fingers in the elbow
and bend the arm, bringing the hand down over the baby’s face.

40
ARMS ARE STRETCHED ABOVE THE HEAD OR FOLDED AROUND THE
NECK.
Use the Lovset’s manoeuvre,hold the baby by the hips and turn half a circle,
keeping the back uppermost and applying downward traction at the same time,
so that the arm that was posterior becomes anterior and can be delivered under
the pubic arch.
Assist delivery of the arm by placing one or two fingers on the upper part of
the arm,draw the arm down over the chest as the elbow is flexed, with the hand
sweeping over the face.
To deliver the second arm, turn the baby back half a circle, keeping the back
uppermost and applying downward traction, and deliver the second arm in the
same way under the pubic arch.

BABY’S BODY CANNOT BE TURNED.

If the baby’s body cannot be turned to deliver the arm that is anterior
first, deliver the shoulder that is posterior.
Hold and lift the baby up by the ankles,move the baby’s chest towards the
woman’s inner leg.
The shoulder that is posterior should deliver,deliver the arm and hand.
Lay the baby back down by the ankles,the shoulder that is anterior should now
deliver.
Deliver the arm and hand.

DELIVERY OF THE HEAD.

Deliver the head by the Mauriceau Smellie Veit manoeuvre as follows:
Lay the baby face down with the length of its body over your hand and
arm,place the first and third fingers of this hand on the baby’s cheekbones and
place the second finger in the baby’s mouth to pull the jaw down and flex the
head.
Use the other hand to grasp the baby’s shoulders,with two fingers of this hand,
gently flex the baby’s head towards the chest, while applying downward
pressure on the jaw to bring the baby’s head down until the hairline is visible.
Pull gently to deliver the head,ask an assistant to push above the mother’s pubic
bone as the head delivers,this helps to keep the baby’s head flexed.
Raise the baby, still astride the arm, until the mouth and nose are free.

ENTRAPPED (STUCK) HEAD.

Catheterize the bladder,have an assistant available to hold the baby while
applying Piper or long forceps.

41
Be sure the cervix is fully dilated,wrap the baby’s body in a cloth or towel and
hold the baby up.
Place the left blade of the forceps,place the right blade and lock handles,use
the forceps to flex the baby’s head and deliver the head.
If unable to use forceps, apply firm pressure above the mother’s pubic bone to
flex the baby’s head and push it through the pelvis.

FOOTLING BREECH.
A footling breech baby should usually be delivered by caesarean section.
Limit vaginal delivery of a footling breech baby to; advanced labour with fully
dilated cervix, preterm baby that is not likely to survive after delivery,delivery
of additional baby(s).
To deliver the baby vaginally,grasp the baby’s ankles with one hand,if only one
foot presents, insert a hand (wearing high-leveldisinfected gloves) into the
vagina and gently pull the otherfoot down.
Gently pull the baby downwards by the ankles,deliver the baby until the
buttocks are seen then proceed with delivery of the arms

BREECH EXTRACTION.
Wearing high-level disinfected gloves, insert a hand into the uterus and grasp
the baby’s foot.
Hold the foot and pull it out through the vagina,exert traction on the foot until
the buttocks are seen.
Proceed with delivery of the arms,give a single dose of prophylactic antibiotics
after breech extraction.
- ampicillin 2 g IV PLUS metronidazole 500 mg IV;
- OR cefazolin 1 g IV PLUS metronidazole 500 mg IV.

POST-DELIVERY CARE.
Suction the baby’s mouth and nose,clamp and cut the cord,give oxytocin 10 units
IM within 1 minute of delivery and continue active management of the third
stage.
Examine the woman carefully and repair any tears to the cervix or vagina or
repair episiotomy

42
 OBSTRUCTED LABOUR
INTRODUCTION: Obstructed labour is the failure of labour to progress
despite having good uterine contractions. It is attributed to mechanical
obstruction resulting from abnormality in the passage (pelvis) or the passanger
(fetus).

CAUSES;
 Cephalopelvic disproportion (CPD) e.g Small pelvis, Contracted pelvis ,Big
baby and Deformed pelvis
 Abnormal presentations & positions e.g Brow presentation, Face
presentation, Shoulder presentation, Breech presentation Occipito-
posterior position
 Fetal abnormalities e.g Hydrocephalus, Locked twins and Fetal ascites
 Soft tissue abnormalities e.gTumors eg. fibroids in the lower segment of
uterus or cervix, Cervical stenosis and Transverse vaginal septum

PRESENTATION:
 It presents with 3 distensions: Gut (Hyperkalaemia), Bladder
( Compression), Lower uterine segment .
 There is oedema of the Vulva ( cannula syndrome) , Cervix and The lower
segment of the uterus.
 Both the mother & fetus will suffer of distress which will be evident
 Without prompt action fetal death may certainly occur.
 There is formation of ―Retraction ring‖ or ―Bandl’s ring‖
 By the time this stage is reached, the fetus will certainly be dead from
hypoxia, whilst the mother will be reaching the limits of her physical
endurance.
Late signs of obstructed labour:
 Mother is dehydrated, ketotic and in constant pain.
 Clinical signs include Pyrexia and Tachycardia.
 Abdominal palpation will be difficult because of maternal distress with
area over Lower segment particularly will be tender on touch.
 On vaginal examination the assessment of presenting part is complicated
by Presence of SEVERE CAPUT SUCCEDENUM and MOULDING.
 Urinary output is present and on insertion of catheter you notice urine
concentrated With blood.
In untreated case the possible outcomes are:
Secondary uterine inertia from uterine exhaustion
Generalized spasm or tonic contraction of the uterus, where the uterus makes
one last effort to overcome the obstruction.
Rupture of the uterus , often as a result of tonic contractions.

43
MANAGEMENT
o Rehydrate the patient Aim: To maintain normal plasma volume and
prevent or treat dehydration and ketosis.
(a) Put up an IV line. Use a large bore cannula.
(b) If the woman is shocked, give normal saline or Ringer’s lactate. Run in
1 litre as quickly as possible, then repeat 1 litre every 20 minutes until
the pulse slows to less than 90 beats per minute, systolic blood pressure
is 100 mm Hg or higher. However, if breathing problems develop, reduce
to 1 litre in 4–6 hours.
(c) If the woman is not in shock but is dehydrated and ketotic, give1 litre
rapidly and repeat if still dehydrated and ketotic. Then reduce to 1 litre
in 4–6 hours.
(d) Keep an accurate record of all intravenous fluids infused, and urinary
output.
o Give antibiotics If there are signs of infection, or the membranes have
been ruptured for 18 hours or more, or the period of gestation is 37
weeks or less, give combination of broad spectrum antibiotics.(Ampiclox,
Metronidazole, Gentamycin). If the woman is delivered by caesarean
section, continue antibiotics until the woman is fever-free for 48 hours.
o Give supportive care
o Deliver the baby The doctor will assess the woman and her progress in
labour and decide on the mode of delivery.
Cephalopelvic disproportion:
If cephalopelvic disproportion is confirmed, delivery should be by caesarean
section.
If the fetus is dead: delivery should be by craniotomy if this is not possible,
delivery should be by caesarean section.
Other methods of delivery
 Vacuum extraction
 Symphysiotomy
 Special maneuvers in malpresented deliveries
 Outlet forceps
Post-delivery care
 Continued monitoring of temperature, pulse, BP and urine output & colour
 Monitor abdominal distension
 Continue with antibiotics
 Bladder drainage for at least 10days
 Check for peroneal nerve damage (obstetric palsy) and rehabilitate
appropriately
 Bear in mind the possibility of PPH
 Counsel the patient in regard to future pregnancies

44
 OBSTRUCTED LABOUR (PROTOCAL)
This implies mechanical obstruction and failure of progressive descent of the
presenting part, despite adequate uterine contractions.
Symptoms and signs
Early obstruction:
 Abnormal partographic findings (i.e. poor cervical dilatation and poor
descent of the presenting part)
 Foetal distress may or may not be present
 No descent of presenting part

Prolonged obstruction
 Maternal distress
 Bandl’s ring (distention of lower segment and formation of a retraction
ring)
 Uterine contractions may or may not be poor
 Fetal heart may be regular, irregular or absent
 Arrested fetal descent
 Swelling of the vulva
 Cervix may be fully dilated in case of obstruction at the outlet
 Excessive caput formation and severe moulding in cephalic presentation
 Offensive liquor if labour has been prolonged

MANAGEMENT OF OBSTRUCTED LABOUR

 Resuscitation:
Infuse intravenous (IV) fluids – Ringer’s lactate (RL) or normal saline
(NS) 1 – 2 L fast, using a large –bore cannula or needle.
 Insert urethral catheter for continuous bladder drainage
 Obtain blood for haemoglobin (Hb), grouping and cross-matching
 Give broad-spectrum antibiotics to cover gram positive, as well as gram-
negative organisms. The following alternatives are suggested:
1. Ampicillin 1g IV stat, followed by 500mg every 6hours PLUS
metronidazole 500mg IV every 8hours until patient can take orally.
Change to amoxicillin 500mg PLUS Metronidazole 400mg by mouth
every 8 hours for 5 days OR

2. Ampicillin 1g IV stat, followed by 500mg every 6 hours PLUS

Gentamicin 160mg IM stat followed by 80mg every 12 hours PLUS
Metronidazole 500mg IV 8 hourly OR

3. Cephalosporins: cefuroxine OR Ceftriaxone 1g once a day for 5

days.

45
 Deliver the mother by caesarean section (C/S)
 In case of prolonged obstruction or injured bladder or blood stained
urine, leave the urethral catheter for at least 7 days.

46
 INDUCTION OF LABOUR (IOL)
Definition:
Induction implies stimulation of contractions before the spontaneous onset of
labor, with or without ruptured membranes.
When the cervix is closed and uneffaced, labor induction will often commence
with cervical ripening, a process that generally employs prostaglandins to soften
and open the cervix.

Augmentation refers to enhancement of spontaneous contractions that are

considered inadequate because of failed cervical dilation and fetal descent.

It is a common procedure, about 20% of pregnant women will have labor induced
for a variety of reasons.
INDICATIONS.
 Induction should be considered when it is felt that the benefits of
vaginal delivery outweigh the potential maternal and fetal risks of
induction.
 Induction is indicated when the benefits to either mother or fetus
outweigh those of pregnancy continuation.
 These issues should be discussed with the woman prior to initiation of
induction.

Fetal factors:
 Post term pregnancy with a GA of 42 completed weeks.
 PROM
 Oligohydramnios
 Placenta abruptio
 suspected or proven chorioamnionitis
 potential fetal compromise
 significant fetal growth restriction,
 non-reassuring fetal surveillance/status (NRFS)
 Intrauterine Fetal Death (IUFD)

Maternal factors:
Medical conditions
 Diabetes mellitus (type 1)
 hypertensive disorders in pregnancy
 chronic hypertension
 renal disease,
 significant pulmonary disease,

47
This list is not meant to be all inclusive.
Induction is sometimes performed for
 ―social‖ or ―geographic‖ reasons,
 without a medical or obstetric (Maternal request)
The American College of Obstetricians and Gynecologists suggests that labor
may be induced for
 logistic reasons, including risk of rapid labour, distance from
hospital, and psychosocial reasons.
RISKS
Potential risks of induction include
 increased rate of Operative vaginal delivery, Caesarean birth,
 excessive uterine activity,
 abnormal fetal heart rate patterns,
 uterine rupture
 maternal water intoxication,
 delivery of preterm infant due to incorrect estimation of dates, and
 possibly cord prolapse with artificial rupture of membranes.

CONTRAINDICATIONS
The contraindications to induction of labour include contraindications to labour
or vaginal delivery.
Examples of this include:
 Relative contraindications
 previous myomectomy entering the uterine cavity,
 Previous uterine rupture,
 Abnormal fetal lie/presentation. Eg transverse lie and breech
presentation
 placenta previa, vasa previa,
 Polyhydramnios
 Maternal heart disease
 Multfetal pregnancy
 Previous classical or inverted T uterine incision

 Absolute contraindications
 invasive cervical cancer,
 active genital herpes infection and
 contracted pelvis

48
PREREQUISITES
Prior to initiation of induction the following should be assessed:
 indication for induction/any contraindications
 Gestational age
 cervical favorability (Bishop score assessment)
 assessment of pelvis and fetal size/presentation
 membrane status (intact or ruptured)
 fetal wellbeing/fetal heart rate monitoring prior to labour induction
 documentation of discussion with the patient including indication for
induction and disclosure of risk factors

CERVICAL RIPENING PRIOR TO INDUCTION

Cervical ripening is Softening, effacement, dilation of the cervix preceding
active labor.

The state of the cervix is one of the important predictors of successful labour
induction.

If the cervix is unfavorable (Bishop score ≤ 6), cervical ripening is warranted

prior to labour induction.

Methods of cervical ripening.

- Nonpharmacologic methods
a. Natural(Non-medical methods)
b. Mechanical methods
 Hygroscopic dilators
 Balloon catheters
- Pharmacological methods
 PGE1
 PGE2

A. NATURAL(NON-MEDICAL METHODS)
 relaxation technique:
 tell the Pt. To releive tension,relax use visual aids to show how
labor starts.
 Walking:
O Force of gravity puls the weight of the baby towards the birth
canaleffacement and dilatation of the cervix.

49
  Niple stimulation:
 Sexual intercourse
 It is related to prostaglandin content of the seminal fluid and the
occurrence of orgasm which stimulate uterine contractions

B.MECHANICAL METHODS
Mechanical methods of cervical ripening have been described,
 Hygroscopic dilators
 They absorb endocervical and local tissue fluids, causing the device
to expand about 3-5x within the endocervix
 They are either natural (e.g., Laminaria japonicum) or synthetic(e.g.,
Lamicel).

Note. Risks: fetal and/or maternal infection

 Balloon Dilators /EASI (extra-amnionic saline infusion)

 A fluid filled balloon is inserted inside the cervix.
 Effective for cervical ripening (compared to misoprostol, PGE2)
 The Balloon provide mechanical pressure directly on the cervix
which respond by ripening and dilation.
 Foley catheter with 30cc ballooning it results to rapid improvement
in Bishop score, shorter labor and lowers the rate of c/sec rate
4~46%

The mechanisms of action for mechanical methods

 mechanical pressure and
 increased prostaglandin production.

Advantages proposed
 simplicity of use,
 Potential for reversibility,
 and low cost.

FOLEY CATHETER
For cervical ripening, a no. 18 Foley catheter is introduced into the intracervical
canal under sterile technique past the internal os and the bulb is then inflated
with 30 to 60 cc of water. The catheter is then left in place until it
spontaneously falls out or up to 24 hours.
Some place a small degree of traction on the catheter by taping it to the inside
of the leg or infuse extra-amniotic saline through the catheter.

50
Contraindications to the Foley catheter include
 low lying placenta, with
 relative contraindications
 being antepartum bleeding,
 rupture of membranes,
 and cervicitis.
Compared with prostaglandin gel, several investigators have found that the
Foley catheter results in no difference in operative delivery rates or maternal
or neonatal morbidity.
Several studies have found that although the cervix may be 3 to 4 cm dilated
with the Foley catheter, this group was more likely to need oxytocin for
induction or augmentation.
Some studies noted a shorter induction to delivery interval with the Foley
catheter, while others noted no difference.

D.Pharmacological methods:
 Prostaglandin E2
 Dinoprostone is a synthetic analogue of prostaglandin E2.
 It is commercially available in three forms:
- a gel,
- a time-release vaginal insert, and
- a 10-mg suppository.
The gel and time-release vaginal insert formulations are indicated only
for cervical ripening before labor induction. However, the 10-mg
suppository is
indicated for pregnancy termination between 12 and 20 weeks and for
evacuation of the uterus after fetal demise up to 28 weeks.
I) Dinoprostone gel (predipil) 0.5 mg
Route/dosage: Cervical 0.5mg repeat in 6hr, permit 3doses
total

II) Dino prostone vaginal insert (Cervidil) 10mg

Route/dosage: posterior fornix, 10mg
Side effects of PGE2:
- Uterine hyperstimulation: Overactivity of the uterus as a result of IOL.
 Tachysystole (>5 contractions per 10 minutes for at least 20 mns
 uterine hypersystole/hypertonicity a contraction lasting at least
2 mns.

51
  Prostaglandin E1
Misoprostol (Cytotec) 100g or 200g. is a synthetic prostaglandin E1
 It has been used ―off label‖ for preinduction cervical ripening and
may
be administered orally or vaginally.

Route/dosage: vaginal, 25g

Contraindications
 Should not be used in women with previous CS because of increased
rates of uterine rupture

LABOUR INDUCTION AND AUGMENTATION

Several options are available for labour induction. These include
 amniotomy,
 oxytocin,
 prostaglandins, and
 mechanical methods of labour induction (such as sweeping membranes).

Stripping the membranes:

 Causes an increase in the activity of phospholipase A2 and

prostaglandin F2a (PGF2a).
 performed by inserting the index finger as far through the internal
os as possible and rotating twice through 360 degrees to separate
the membranes from the lower segment
 Risks include discomfort, infection, bleeding from undiagnosed
placenta previa ,and ROM.

Amniotomy

 Increases the release of endogenous prostaglandins

 The FHR is recorded before the procedure.
 The membranes are identified and a kocher is inserted through the
cervical os by sliding it along the hand & fingers & membranes are
ruptured.
 The nature of the amniotic fluid is recorded (clear, bloody, thick or
thin, meconium).
 The FHR is recorded after the procedure.

52
Risks of amniotomy:

i. Prolapse of the umbilical cord (0.5%)

ii. Chorioamnionitis: Risk increases with prolonged induction delivery
interval
iii. Postpartum hemorrhage: Risk is doubled compared with women with
spontaneous onset of labor
iv. Rupture of vasa previa

Oxytocin compared to prostaglandins for induction of labour

PGE should be used in preference to using oxytocin when induction of
labour is undertaken in either nulliparous or multiparous women with
intact membranes regardless of their cervical favorability.

Either PGE or oxytocin may be used when IOL is undertaken in nulliparous or

multiparous women who have ROM, regardless of cervical status, as they are
equally effective.
 A meta-analysis comparing PGE and oxytocin for IOL with favourable Cx
suggests that PGE reduce the likelihood of operative delivery and failed
induction, but increase the incidence of gastrointestinal side effects and
pyrexia.

Oxytocin regime protocol:

a. Low Dose Protocol
i. Prepare 5 IU of oxytocin/500 mL 5% dextrose.
ii. Start infusion at a rate of 1-1.5 mU/minute (6-9 mL/hr) and
increase by 1-1.5 mU/minute every 30 minutes until adequate
labor is established.i.e. three contractions in 10 mins, each
lasts between 60-90 seconds 1 mL = 15 drops
iii. This protocol have the advantage of < hyperstimulation but with
long induction delivery interval

b. High Dose Protocol:

i. Prepare15 IU of oxytocin/500 mL 5% dextrose.
ii. Start IV solution infusion at a rate of 4.5-6 mU/minute (9-12
mL/hour) and increased by 4.5 mU/minute every 30 minutes for
a maximum of 40 milliunits per minute.

53
 iii. This protocol have the advantage it results in shorter labor,
decreased intra-amniotic infections, and decreased rates of
c/section for dystocia but higher risk of hyperstimulation

Continuous electronic FHR monitoring during induction is essential to monitor

fetal response to labor and uterine response to the inducing agent.

If severe FHR abnormalities or hyperstimulation occurred,

decrease/discontinue the oxytocin infusion.

Contraindications for oxytocin regime

a. abnormal fetal presentation/Lie
b. uterine overdistention (hydramnios, large fetus ,or multiple fetus)
c. high parity ( >6 )
d. previous uterine scar

Side effects of oxytocin use

i. Uterine hyperstimulation and subsequent FHR abnormalities.
ii. Abruption placentae
iii. Uterine rupture.
iv. Water intoxication may occur with high concentrations of oxytocin
infused with large quantities of hypotonic solutions.
v. A rapid intravenous injection of oxytocin may cause hypotension

Management of uterine hyperstimulation

Uterine hypercontractility
 uterine hypercontractility without FHR changes included uterine
tachysystole (>5 contractions per 10 minutes for at least 20 minutes) and
uterine hypersystole/hypertonus (a contraction lasting at least two
minutes)
 In cases of uterine hypercontractility with a suspicious or pathological
cardiotocograph (CTG), secondary to oxytocin infusions, the oxytocin
infusion should be decreased or discontinued.
 In the presence of abnormal FHR patterns and uterine hypercontractility
(not secondary to oxytocin infusion) tocolysis should be considered.
 In cases of suspected or confirmed acute fetal compromise, delivery
should be accomplished as soon as possible, taking account of the severity
of the FHR abnormality and relevant maternal factors.

54
 Failure of induction
It is not uncommon for the first induction attempt to fail; Thus repeated (serial)
induction must be considered.
The criteria for a failed induction include;
 inability to establish a consistent labor pattern
 failure to affect cervical dilatation, effacement, or descent.
Should labor fail to start in one 6-h interval of induction with intact membranes
and both mother and fetus remain stable, efforts should cease for 6–18 h.
This will allow the mother and myometrium to recover. Another 6-hr attempt
should follow.
C/s should be considered when it fails with ruptured membranes

55
 FETAL DISTRESS
Definition: The term is too broad and vague to be applied with any precision to
clinical situations. Description of the fetal heart rate status are now described
as reassuring or nonreassuring.
"Reassuring" suggests a restoration of confidence by a particular pattern,
whereas "nonreassuring" suggests inability to remove doubt. These patterns
during labor are dynamic, such that they can rapidly change from reassuring to
nonreassuring and vice versa. It occurs when the fetus has not been receiving
enough oxygen.
This can occur with post maturity pregnancy or when complications of pregnancy
or labor occur. It is identified based on abnormal heart rate pattern in the
fetus.

Diagnosis.
Check the fetal heart rate using fetoscope or Doppler ultrasound device every
15minutes during labor and after each contraction in late labor.
The normal fetal heart rate is 120 – 160b/min.
Presentation.
 Decreased fetal movement felt by the mother
 Fresh meconium in the amniotic fluid
 Tachycardia >160b/min or bradycardia <120b/min (prolonged fall of FHR
>3min) especially during and after contraction
 Late deceleration
Causes:
 Abnormal position and presentation of the fetus
 Multiple births
 Shoulder dystocia
 Umbilical cord prolapse
 Nuchal cord
 Placental abruption
 Premature closure of the fetal ductus arteriosus
 Uterine rupture
Management.
 Give oxygen to the mother
 Establish intravenous line and give intravenous fluids preferably Ringers
lactate
 Turn the mother on her left side
 Look for the cause

56
Is the patient in second stage of labor? - Plan for Urgent delivery of the
baby Either by labor induction by amniotomy if membranes are still intact or
Vacuum extraction or forceps when in second stage or
Caesarean section if the patient is not in second stage.

Newborn management
 Inform the paediatrician immediately for the resuscitation of the
newborn
 Incase of low score (<7) admit the baby to NICU for close observation.

MANAGEMENT OF ABORTION
Definitions
1. Abortion is the loss of a pregnancy during the first 28 weeks of pregnancy,
at a time that the fetus cannot survive; the definition by gestational age varies
by country

An unsafe abortion is the termination of an unintended pregnancy by persons

lacking the necessary skills, or in an environment lacking the minimal medical
standards, or both. It is responsible for one in eight maternal deaths (15%).

Abortions are further categorized according to their degree of completion.

These categories include:

 Threatened abortion
 Inevitable abortion
 Incomplete abortion
 Complete abortion
 Missed abortion
 Septic abortion

SIGNS AND SYMPTOMS

Incomplete abortion should be considered in any woman of reproductive age
who has:
o Missed period (delayed menstrual bleeding—more than a month has
passed since her last menstrual period),
With either:
o Vaginal bleeding,

57
 o Cramping or lower abdominal pain similar to labor (contractions), or
o Partial Passage of pregnancy tissue (placental fragments).
o Dilated cervix and uterus smaller than dates

Septic abortion
If the patient has any of the following, either uterine or generalized infection
is very likely.

Symptoms
 History of previous unsafe abortion or miscarriage
 Lower abdominal pain
 Prolonged bleeding (> 8 days)
 General discomfort (flu-like symptoms)
Signs
 Fever (temperature > 38o C), chills or sweats
 Foul-smelling vaginal discharge
 Lower abdominal tenderness (with or without rebound tenderness ††)
 Cervical motion tenderness on bimanual examination

Begin treatment as soon as possible, before attempting uterine evacuation.

After initiating treatment, uterine evacuation should be done promptly because
retained products of conception (POC) are most likely the source of the
infection.

 Take blood for culture and sensitivity,

 FBP, HB, BGXM
 Then empirically Give the patient with TRIPLE Therapy antiobiotics
immediately before taking her to theatre for evacuation while waiting for
c/s rersults

1. I/V Ampicillin 1g stat then 500mg 6hrly for 72hrs then oral ampiclox
500mg tds for 5/7 OR I/V Ceftriaxone 1g BD For 72hrs then oral
ampiclox 500mg TDS for 5/7
2. I/V Metronidazole 1g stat then I/V 500mg 8hrly for 72hrs; then switch
to oral metronidazole 400mg tds for 5/7
3. I/V Gentamycin 160mg stat then I/V Gentamycin 80mg BD for 7/7
In septic shock give parenteral antibiotics for at least 5/7

Intra-Abdominal Injury and peritonitis

If the patient has any of the signs listed below with any of the symptoms, she
may be suffering from an intra-abdominal injury, such as a perforated uterus.

58
Symptoms
 Nausea/vomiting
 Shoulder pain
 Fever (temperature > 38o C)
 Abdominal pain, cramping
Signs
 Distended abdomen
 Decreased bowel sounds
 Rigid (tense and hard) abdomen
 Rebound tenderness
 Guarding
When combined with signs of shock (decreased blood pressure and rapid pulse
and respiration), the possibility of major intra-abdominal bleeding (e.g., uterine
perforation) must be considered.

Physical Examination
During the physical examination it is important to:
 Check and record the patient's vital signs (i.e., temperature, pulse,
respirations, blood pressure)
 Note the general health of the woman (i.e., whether she is malnourished,
anemic or in general poor health)
 Examine her lungs, heart and extremities

Abdominal Examination
Check for:
 Masses or gross abnormalities
 Distended abdomen with decreased bowel sounds
 Rebound tenderness with guarding
 Suprapubic or pelvic tenderness

59
Figure below shows signs and symptoms of different stages of Abortion

Stages of Abortion
Diagnosis Bleeding Cervix status Uterine size Other signs

Threatened Slight to Closed Equal to dates UPT +Ve, Cramping,

Abortion moderate by LNMP Uterus soft
Inevitable Moderate to Opened Less than or Cramping, uterus
Abortion Heavy Equal to dates tender
by LNMP
Incomplete Slight to Opened (soft) Less than or Cramping,
Abortion heavy Equal to dates Partial expulsion of
by LNMP POC,
Uterus tender
Complete Little or None Less than Less or no cramping,
Abortion dates by LNMP Expulsion of POC
Completely,
Uterus firm
Missed None Equal to dates Regression of signs
Abortion or less and symptoms of
pregnancy
Septic Slight or Soft (opened Less than or Foul smelling PV
Abortion None or closed) Equal to dates Discharge, fever,
Hypotension,
suprapubic
tenderness e.t.c

60
 Figure below shows Steps to be involved in Evaluating and treating patients
with Incomplete Abortion
Presentation Initial steps (screening) If signs of shock
In a woman in a reproductive Assess for signs of shock present,
age who has: Rapid weak pulse immediately
Hx of delayed menses Low blood pressure treatment is
Vaginal bleeding Pallor or sweatiness required,
Cramping or LAP Rapid breathing After resuscitation
Passage of POC Anxiousness, confusion, proceed with
Unexplained fever Unconscious Medical
Fever T 38oC Evaluation

Medical Evaluation

History Date of LNMP, Duration and amount of bleeding, severity of

Cramping, type of contraception used, abdominal pain, shoulder
Pain, drug allergies, bleeding or clotting disorders

Physical Exam Vital signs, Exam of CVS, RS, Abdomen, and extremities,
Systemic problems indicating sepsis, intra-abdominal injury
Pelvic Exam Vaginal or cervical trauma, pus, pain on motion, uterine size,
Stage of abortion
Other Remove any POC, Determine tetanus status

Treatment

Moderate to PV bleeding Severe PV bleeding Intra-abdominal Infection (sepsis)

Clean pad not soaked Heavy bright blood injury Fever, chills, Foul smelling
after 5 min, fresh blood with or without Distended abdomen, PV discharge, Hx of unsafe
no clots, Blood mixed clots, Decreased bowel abortion,
with mucus Blood soaked pads, sounds, Tense and Abdominal pain, prolonged
towels, clothing and hard abdomen, PV Bleeding
pallor Rebound tenderness,
Treatment by Triple Guarding, N/V
antibiotic therapy and Treatment by Triple Shoulder pain,
Evacuation in OT, antibiotic therapy Fever, abdominal
Postabortion Family and Evacuation in pain, cramping Hb, WBC, platelet count,
planning and Links to OT, Postabortion serum urea & creatinine,
other Reproductive heath Family planning and endocervical swab for c/s
services Links to other Emergency Triple Antibiotic therapy
Reproductive heath Laparotomy plus Evacuation +/-
services Laparotomy

61
 PREMATURE RUPTURE OF MEMBRANES
Definition:
PROM is the rupture of the membranes prior to the onset of labour. Pre-term
PROM is the rupture of membranes prior to the onset of labour in a patient who is
at less than 37 weeks' gestation
Diagnosis:
1- History: of gush of fluid per vaginum that moist vulval pads, khangas and legs.
Drawback: Vulval pads can be moisted with urine or vaginal discharge which can be
mistaken with the amniotic fluid.

2- Examination of the patient:

Check for signs of infection e.g. maternal tachycardia, fever, uterine tenderness,
purulent vaginal discharge.
Fetal tachycardia may indicate infection following membrane rupture.
3- Sterile speculum examination:
 Under strict sterile conditions
 Visualization of amniotic fluid in the posterior vaginal fornix
 Passage of clear fluid from the cervical canal
 Check for color and smell of the leaking liquor
 Check for prolapse or presentation of umbilical cord
 Swab for culture and sensitivity, pooling test, fern test, nitrazine test

N.B. A digital examination should not be performed unless labour is to be

induced as cervical examination decreases latency and increases infectious
morbidity.

4- Investigations:
Laboratory analysis: White blood count (WBC) and Urinalysis
Ultrasound: Is an ideal non-invasive technique for the detection of the residual
amount of amniotic fluid.
Nitrazine paper test:
The colour turns from yellow to deep blue due to alkalinity of the amniotic fluid.
Drawback: blood, semen or vaginal infections are alkaline media give the same
result.

62
Fern test:
Visualization of fern-like pattern of dried amniotic fluid on a glass slide under
microscopy. Urine, semen and other contaminants may give a false positive test
result.

5-Complications:
 Preterm labour: with the risk of prematurity.
 Infection: chorioamnionitis, septicemia and foetal pneumonia.
 Foetal deformities and distress: due to oligohydramnios.
6-Management:
(1) Gestational age over 37 weeks:
- Women with pre-labour ROM at term (over 37 weeks) should be offered a choice
of immediate induction of labour or expectant management.
- In absence of infection, foetal distress and abnormal lie, wait for 24 hours as
about 90% of patients with PROM will pass into spontaneous labour. Prophylactic
antibiotic such as Erythromycin can be given during this period.
- Oxytocin 2.5-5IU in 500mls of D5% or Lactated Ringers 10,20…..60drops
increased after every 30minutes & titrated according to contractions responses
are used for induction of labour in patients did not pass into labour after 24 hours.

(2) Gestational age between 34-36 weeks:

- In absence of infection and foetal distress, wait for 48 hours as rupture of
membrane itself will accelerates lung surfactant production and hence lung
maturity.
- Induce labour after 48 hours with PGE2 if cervix unfavorable (BISHOP score < 6)
and /or oxytocins.
- Prophylactic antibiotics e.g. Erythromycin 500mg 12hrly for 7-10 days is given
during this period.
- Caesarean section is indicated in case of malpresentations < 36 weeks’ gestation.

(3) Gestational age between 28-34 weeks :(Tz setting less than 28 is pre-
viable)
In absence of infection, the main aim is to manage the case conservatively till the
34th week when lung maturity mostly occurs and the baby can survive.
 Serial evaluation for chorioamnionitis, labor, maternal and fetal well being
 Corticosteroids and antibiotics should be administered

63
Conservative management as follow:
i) Rest in bed as long as there is escape of liquor with restriction of efforts later
on particularly those that increase intraabdominal pressure. Bed rest to encourage
resealing
ii) Temperature is recorded every 4 hours.
iii) Observation for malaise, abdominal pain/flank pain, uterine tenderness, smell
and colour of escaped liquor on alternate day’s sterile speculum examination.
iv) Leucocytic count (FBP) may be done every other day.
v) Antibiotics are associated with a delay in delivery and a reduction in major
neonatal morbidity. Co-amoxiclav should be avoided in women at risk of pre-term
delivery because of the increased risk of neonatal necrotising enterocolitis.

 Erythromycin is a better choice. The recommended dose is 500mg qds for

7-10 days.

vi) Tocolytic drugs: are given if uterine activity starts. Example: atosiban,
nifedipine or ritodrine, may delay delivery by 48 hours and therefore enable time
for antenatal corticosteroids to be given. They should only be considered in the
presence of uterine activity.
vii) Corticosteroid therapy: is given for 48 hours if labour was imminent or will be
induced before 35 weeks.
 Dosage for Dexamethasone 6mg 12hrly in 48hrs or Betamethasone 12mg
12hrly in 24hrs.

N.B. Deliver immediately in presence of pathology: features of Chorioamnionitis,

Abruptio placenta and fetal death. In case of Chorioamnionitis, the patient should
be started on Broad spectrum antibiotics.

(4) Gestational age less than 28 weeks:

There is little chance of foetal survival and the condition is usually considered as
inevitable abortion.
 But termination may be an option depending on the gestational age and
amount of fluid loss.
 Initial Bed rest to encourage resealing should be provided
 Look for infection, abruption or active labor
 Serial Ultrasound to evaluate oligohydramnios, pulmonary hypoplasia; if so
INDUCTION with Oxytocin or dilatation & Evacuation.
 If no pathology consider conservative management.

64
 ANTEPARTUM HEMORRHAGE. (APH)
Definition: Bleeding from genital tract of a pregnant mother from 28weeks
until delivery.
This must be distinguished from show of labor and genital bleeding from
urethra or anus:-
CAUSES:
Main causes:
 Placenta praevia  Inevitable hemorrhage
 Abruptio placenta Accidental hemorrhage
Others:
 Vasa praevia
 Local lesion of the cervix or vagina
 Uterine rupture.

IMPORTANT INFORMATIONS FROM THE HISTORY

Mother should be asked:
 Whether bleeding follow intercourse, fall, trauma or domestic
violence.
 Whether the blood loss associate with abdominal pain or uterine
contraction.
 Whether was pure blood or mixed with amniotic fluid.
 Hx. of placenta praevia or abrutio placenta.

Risk factors for APH

ABRUTIO PLACENTA PLACENTA PRAEVIA VASA PRAEVIA UTERINE RUPTURE.

Previous Previous previa Valamentous Previous Classical

abruption cord insertion. uterine incision.

Hypertension Multparity Multiple Multparity

gestation
Trauma Advanced Injudicious use
maternal age of oxytocin.
Short umbilical Multiple
cord gestations.
SPROM

Tobacco
Polyhydramnious

65
CLINICAL CHARACTERISTICS.
CLINICAL FINDING PLACENTA PRAEVIA ABRUTIO PLACENTA

Onset May be gradual progressive Often abrupt,

unexpected
How evident Always external External or concealed
FHR Usually present May be present
Presentation Often malpresentation May be normal
Clinical signs of pre- Incidence is little Incidence
eclampsia.
Backache Absent Present
Colour of blood Bright red Dark red

Uterine characteristic.
Clinical findings Placenta praevia Abrutio placenta.

Pain Painless unless labour Intense and steady.

Tenderness Abscent Present
Tone Soft and relaxed Firm and relaxed
Shape Normal Enlarged and change
shape

GENERAL MANAGEMENT.
Call for help. Urgent mobilize staff available.

Patient hx. and quick assessment.

If in shock- Give 2 litres I/V fluids (R/L OR N/S) via 2 large bore cannula
in the first hour, then re asses signs of shock ¼ hrly.
If not in shock infuse fluid accordingly.
X-match at least 4 unit of blood and order H.B.

Avoid digital cervical exam until Ultra-Sound done to rule out placenta
previa.
If there is DIC give FFP and Platelet.
Timing and route of delivery.
Hysterectomy should be performed if bleeding from non contracting uterus
cannot be controlled.
66
PLACENTA PREVIA ABRUPTIO PLACENTA VASA PREVIA
Never appropriate to Insert Foley catheter Never appropriate to
allow vagina delivery. and monitor input and allow vaginal delivery.
output at least 30 to
60mls/hr.
Do emergency C/S if Analgesia by senior. Do emergency C/S as
bleeding or DIC soon as DX is made
Uncontrolled, pregnancy
at term, mother and
fetus unstable
Do Elective if pregnancy Do bed side clotting
is term and fetus test.(Normal within 7
stable. min) to exclude DIC
repeat after 1hr.
Conservative
Management if bleeding Monitor vital s
controlled, fetus is alive Signs, BP, P.R.
and premature.
Be aware of visible loss
Bed rest at hospital. which is only 1/3 of
total amount.
Ensure blood is Vaginal delivery if the
available. cervix is favourable and
no contraindication to
SVD.
Correct Anaemia –
Ferrous Sulphate Do artificial rupture of
200mg TDS and folic membranes(ARM)
acid until 6weeks post
delivery.
Give betamethasone Prime –augment labour
12mg OD for 48hrs or with oxytocin 5IU in
Dexamethasone 6mg OD 500mls of 5% dextrose
or 24hrs before 4 or R/L.
weeks.
Do elective C/S at Grand multipara 1.25IU
38weeks. in 500mls of 5%
Dextrose or R/L.

67
PLACENTA PREVIA ABRUPTIO PLACENTA VASA PREVIA
Monitor labour using Partogram.

Inform Pediatrician.

Give Betamethasone 12g if

appropriate.
After delivery estimate blood
loss including the retro placenta
clot.
-Continue with oxytocin 20IU in
500mls 5% Dextrose for 6hrs.
Give haematenics for 6 weeks.

Emergency C/S.
Fetus is alive.
There is heavy vaginal bleeding
threatening the mother
life(with normal clotting
profiles
There is other obstetric
indication for C/S

68
 POSTPARTUM HEMORRHAGE (PPH)
Definition
PPH is traditionally defined as blood loss greater than 500 mL during a
vaginal delivery or greater than 1,000 mL with a cesarean delivery. However,
significant blood loss can be well tolerated by most young healthy females,
and an uncomplicated delivery often results in blood loss of more than 500
mL without any compromise of the mother's condition.

N.B
Defining PPH is problematic and has been historically difficult. Waiting for a
patient to meet the PPH criteria, particularly in resource-poor settings or
with sudden hemorrhage, may delay appropriate intervention.
Therefore, any bleeding that has the potential to result in hemodynamic
instability, if left untreated, should be considered PPH and managed
accordingly.

Leading causes of PPH

Atony — The most common cause of PPH is uterine atony (ie, lack of
effective contraction of the uterus after delivery), which complicates 1 in
20 births and is responsible for 50% to 80% of cases of PPH.
Risk factors for uterine atony:
• Overdistension (multiple gestation, polyhydramnios, macrosomia)
• Uterine infection
• Drugs (uterine relaxants)
• "Uterine fatigue" after a prolonged or induced labor
• Uterine inversion
• Retained placenta or placental fragment (either a normally attached
placenta or placenta accreta) and clots.
If the uterus appears to be firmly contracted after delivery, then other
etiologies of hemorrhage should be considered. However, one should keep in
mind that a focal area of the uterus can be atonic, which is difficult to
appreciate on physical examination, or the uterus may not be maximally
contracted.

69
Trauma — Trauma-related bleeding can be due to lacerations (perineal,
vaginal, cervical, uterine), incisions (hysterotomy, episiotomy), or uterine
rupture. Lacerations are more common after instrumental delivery.

Coagulation defects — Acquired and congenital bleeding diatheses may be

associated with thrombocytopenia and/or hemostatic defects. Acquired
causes include severe preeclampsia, HELLP syndrome, abruptio placentae,
fetal demise, amniotic fluid embolism, and sepsis. Consumptive coagulopathy
may develop in women with severe hemorrhage.

Women at risk of developing PPH:

Every woman is at risk of developing PPH. BUT PPH has been found to
occur commonly in pregnant women with:
 Prolonged labour
 Oveerdistension of the uterus (multiple pregnancy, polyhydramnious,
macrosomia,fibroids in pregnancy
 Antepartum haemorrhage
 Deep general anaesthesia
 Grandmultiparity
 Previous h/o PPH
 Previous h/o operative delivery.

Prevention and management

The best prevention is active management of 3 rd stage of labor
 Immediately after delivery of anterior shoulder of the baby,
administer oxytocin 5 IU i.m,
 Then deliver placenta by controlled cord traction,
 Massage the uterus at regular intervals after placental delivery to
keep the uterus well contracted and firm (at least every 15 minutes
for the first two hours after birth).
 Routinely inspect the vulva, vagina, perineum, and anus to identify
genital lacerations. Inspect the placenta and membranes
 Teach the woman to massage her own uterus to keep it firm. Instruct
her on how to check her uterus and to call for assistance if her uterus
is soft or if she experiences increased vaginal bleeding.

70
  Encourage the woman to keep her bladder empty during the immediate
postpartum period

In patients at risk

 Inform a team on call ( registrar, intern doctor or resident and

specialist)
 Hb, Grouping and x-match 2 units of blood
 Insert i/v when patient approaches 2nd stage of labor.
 Encourage patient to micturate frequently.

Management of Primary PPH

Resuscitation and establishing the cause of bleeding must be done at the
same time.
1. Resuscitation
 Call for Help Mobilize at least one assistant
 Set up 2 I.V lines, using large cannula 16-18(2 litres of Hartmanns
solution) running fast in first 2 hours .Aim to raise Systolic BP to
above 90 mmHg. Fluids are essential. Don’t delay.
 X-match at least 4 units of blood, administer via 2 nd iv line
 Monitor response to treatment (1/2 hrly BP, Pulse, urine output)
 If blood loss more than 2 litres: Give 2 units of fresh frozen
plasma(FFP).
 Do bedside clotting time.
 Oxytocin infusion 20-40IU in 1L of R/L.

Identify cause of the bleeding

Assess Retained Uterine injuries coagulopathy
placenta or atony
membrane
Uterus contracting Soft, not Well Well
contracting contracted contracted
Placenta Incomplete or complete complete complete
retained
Perineum/vagina/ intact intact Tears seen No tears
cervix seen

71
2. For Retained placenta
 Perform CCT. If this fails:
 Take the patient to theatre for manual removal under general
anaesthesia.
 Call the specialist for further management (Explore the uterine cavity
carefully making sure all the remnants are removed.
 If this fails and heavy bleeding persists, suspect accreta.
 Replace lost blood immediately and recourse to hysterectomy.
 Consider additional 10 I.U of oxytocin i/v in 500mL of R/L OR
Ergometrine 0.5mg i.m if uterus is not contracting adequately.
 Post-Op: Ceftriaxone 1g 48hrs od.Monitor post –OP for sepsis and
continue treatment if necessary.

3. Placenta delivered BUT bleeding continues

 Palpate fundus of the uterus:
4. Fundus is SOFT(uterine atony)
 Empty the bladder.Try to rub up contractions and express blood clots
by uterine massage until well contracted.
 If this fails,give oxytocin 20-40IU in 500mL of DNS
 If bleeding persists give Ergometrine 0.5mg i.m if not contraindicated
 If these measures fail, do bimanual compression of the uterus and
report to specialist.
5. IF the fundus is Hard
 Inspect perineum, vagina and cervical tears.
 Repair 1st and 2nd degree tears with adequate light and local
anesthesia in labor ward,
 3rd and 4th degree tears under GA in theatre.
6. Disseminated intravascular coagulopathy(DIC)
 This diagnosis is reached when bed side clotting time is more than
7 minutes.
 Give at least 4 units of fresh blood and 2units of FFP(Fresh frozen
Plasma)

72
MANAGING SECONDARY PPH

Definition
 Secondary PPH is any abnormal or excessive bleeding from the birth
canal occurring between 24 hours and 6 weeks after birth.
 As this definition includes no reference to the volume of blood loss or
the condition of the woman, the spectrum of the condition can vary
from inconvenience to fatal. The extent of bleeding usually is less
than that seen with primary PPH (Alexander et al. 2002)

Causes
Abnormalities of placentation
 Subinvolution of the placental site
 Retained products of conception
 Placenta accreta
Infection
 Endometritis, myometritis, parametritis
 Infection / dehiscence of caesarean scar
Trauma
Rupture of vulval haematoma

N.B
Be aware of:
 Uterine fibroids (leiomyomata)
 Cervical neoplasm (rare)
 Uterine arteriovenous malformation (AVM) (rare)

Diagnosis
 Secondary PPH is a clinical diagnosis of exclusion, which may present
as slight to heavy bleeding (and rarely hypovolaemic shock) usually 7
to 14 days after birth.
 Check history for complications in previous pregnancies such as
preeclampsia, intrauterine growth restriction, spontaneous abortion,
retained placenta (retained products more common in these cases)
 Bleeding may also represent the initial menstrual period after
childbirth, (result of an anovulatory cycle) and may be heavy, painful
and prolonged

73
  Suspect Endometritis if the history includes uterine tenderness,
fever or foul lochia
 Secondary PPH in the first week may be related to coagulopathy,
especially von Willebrand’s disease

Management
Assessment
 Obtain history
 Check temperature, pulse and blood pressure
 Assess uterine size
 Assess clinical signs of blood loss +/- visual estimation of blood loss
 Establish intravenous (IV) access using 16 or 18 gauge cannulae and
commence IV resuscitation as indicated
 Commence oxygen via face mask as indicated

Investigations
 Hb and Grouping and then save serum. Cross match 2-4 units red
blood cells if marked bleeding
 Complete blood picture
 Serum hCG may be helpful to distinguish between retained placental
tissue or trophoblastic disease in cases where ultrasound does not
confirm diagnosis
 Coagulation profile as indicated
 Speculum examination – check status of cervical os and obtain
endocervical swab
Ultrasound
 Ultrasound (portable or formal) is indicated for all women who present
with a history of heavy bleeding during the first 6 weeks after birth
 Ultrasound is useful to identify clot or other debris in uterine
cavity / subinvolution of placental site

In a Stable condition
 Conservative management with bed rest and intravenous antibiotics as
indicated
 Surgical evacuation is first line management.
 Adherent material such as placenta tissue will need to be surgically
evacuated

74
Antibiotics
 Give Ampiclox 500mg i/v 8hrly for 24 hours, then orally (same dose)
for 6days
 Metronidazole 500mg i/v 8hrly for 24 hours, then orally 400mg 8hrly
for 6days
 Gentamycin 160mg i/v od stat, then 80mg i/v 12 hourly for 6days
N.B
 If patient is unable to take oral medications, continue with i/v
medications.
 Dose and type of antibiotics will change according to culture and
sensitivity results from endocervical swab.

Stabilisation of marked bleeding

Call for obstetric and anaesthetic assistance
Investigations as above
 Perform uterine massage
 Administer oxygen via face mask
 Lay the woman flat (may remain with legs bent or in lithotomy)
 IV access x 2 using 16 gauge cannulae
 Resuscitate with appropriate IV fluid, e.g. sodium chloride 0.9 %,
Hartmann’s solution (crystalloids) or When using crystalloid, the ratio
of resuscitative IV fluid required to blood lost is 3:1
 Avoid hypotension by adequate fluid replacement in relation to ongoing
measured blood loss
®
 Administer bolus dose of Syntocinon 10 IU IV
®
 Prepare and commence an oxytocin infusion (40 IU Syntocinon in
1000 mL Hartmann’s solution or sodium chloride 0.9 %)
®
 Consider Cytotec (misoprostol available as tablets 200 micrograms)
800 micrograms per rectum (Consult a specialist for an opinion)
 Bimanual compression if required
 Consider surgical intervention if unresponsive to medical
management(Consult a specialist for an opinion)
Surgical management
 Surgical management may include any of the following:
 Examination under anaesthetic (EUA)
 Dilatation and evacuation of products of conception and gentle
curettage
 Hysterectomy if bleeding does not stop.

75
N.B:
 If dilatation and suction curettage is required, administer antibiotics
for 6 to 12 hours before procedure to guard against bacteraemia,
unless heavy bleeding mandates urgent intervention
 It is important to avoid over vigorous curettage as this can result in
Asherman's Syndrome
 Send tissue for histopathology to exclude trophoblastic disease and
confirm diagnosis

76
 PREVIOUS SCARS
If a mother has had one Caesarean section the alternatives for her next
pregnancy are: An elective section, at 38weeks; Section in early labour or An
attempt at vaginal delivery (a ‘trial of scar’). How can you choose between
these three?

Note: ‟TWO CAESARS OR MORE, ALWAYS A CAESAR”

ONE ‘CLASSICAL’, ALWAYS A CAESAR

GENERAL MANAGEMENT
• Start an IV fluids
• Identify the reason for the uterine scar.

TRIAL OF SCAR
INDICATIONS.

(1) A patient who has had one lower segment Caesarean section, and the
reason for it is absent in this pregnancy. For example, it might have been
done for a malposition or malpresentation, maternal or fetal distress, or CPD
due to hydrocephalus, etc.

(2) The scar from a myomectomy (provided her uterine cavity was not
opened during the operation), hysterotomy, or uterine perforation during a
‘D and C’.

CONDITIONS.

She must have had not more than one previous Caesarean section,Caesarean
section must be available any time of the day or night, within one hour of the
decision to section her, Her pregnancy must have been normal, Her baby
must be a vertex presentation in the occipito–anterior position (some
obstetricians will do a trial of scar for a breech),There must be no fetal or
maternal distress.

CONTRAINDICATIONS.

Two or more previous lower segment Caesarean sections, One previous

classical Caesarean section, Any degree of CPD, or suspected CPD in this
pregnancy, as suggested by a true conjugate of <9 cm or a diagonal conjugate

77
of <11.5 cm, An occipito-posterior presentation, Any other form of
malpresentation, or obstetric complication, Sepsis following a previous
section is a relative contraindication only, Any need for an oxytocin drip.

METHOD.
Monitor progress of labour using a partograph
• If labour crosses the alert line of the partograph, diagnose the cause of
slow progress and take appropriate action:
- If there is slow progress in labour due to inefficient uterine contractions,
rupture the membranes with an amniotic hook or a Kocher clamp ;
- If there are signs of cephalopelvic disproportion or obstruction, deliver
immediately by caesarean section .
• If there are signs of impending uterine rupture (rapid maternal pulse,
persistent abdominal pain and suprapubic tenderness, fetal distress), deliver
immediately by caesarean section .
• If uterine rupture is suspected, deliver immediately by caesarean section
and if ruptured repair the uterus or perform subtotal hysterectomy.

Abandon the trial if: She crosses the alert line on the partograph , Her
pulse rises to 100b/min, She has pain between contractions, Her pain is
generalized, She has unexplained vaginal bleeding, Her uterine contractions
cease, She has rectal or vaginal tenesmus.

Examine her lower uterine segment vaginally immediately after delivery of

the placenta, so as to be sure that it has not ruptured.

If she has a postpartum haemorrhage, the scar in her uterus has probably
broken open; confirm this by doing a vaginal examination, and if ruptured, do
a laparatomy for repair.

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 POST CAESAREAN SECTION CARE
1. Intravenous fluids and diet
Day 0
 Give me I/V DNS 3L /24 hrs
 Adjust fluids if urine output falls below 30 mL/hr
 If the patient is fully awake and haemodynamically stable without
postoperative Paralytic ileus; start oral sips as early as after 8-
12hrs.
 In case of paralytic ileus give intravenous fluid and electrolyte
supplementation.
 If severe Paralytic ileus; nasogastric decompression is necessary.

Day 1 post-op -Stop I/V fluids and start oral sips

 Day 2 –Start light diet
 Day 3 and above –Resume normal diet

2. Prevention of Postoperative Infection

 Intravenous antibiotics such as ceftriaxone 1g stat or I/V Ampiclox 1g
stat then 500mg 8hrly/24hrs and metronidazole I/V 500mg
8hrly/24hrs started intraoperatively immediately after clamping and
cutting the umbilical cord.
 In prolonged labor with features of chorioamnitis such as foul smelling
liquor, maternal fever and fetal distress; add I/V Gentamycin 160mg
stat then 80mg BD for 72 hrs and prolong parenteral ceftriaxone and
metronidazole for 72hrs
 Delay and reduce dose of gentamycine for 6hrs if the patient had
general anesthesia with pancuronium (pavulon) to avoid additive effect
of curare (Prolonged neuromascular blockade).

3. Analgesics
 Intramuscular pethidine 100mg 6hrly / first 24hrs post-op, then oral
diclofenac 50mg tds for 5/7. OR oral piroxicam 20mg BD for 5/7
 Intraurethral catheterization
 Put Foley catheter for 24hrs and monitor urine output.
 Off catheter on day 1 post-op if there is the labor was not obstructed
 Keep catheter for at least 7 days for prolonged obstructed labor

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4. Ambulation
 Ambulation can be started as early as 6hrs if the patient is stable and
General anesthesia was used.
 If CS done under SAB, then patient should be bed ridden for 24hrs to
avoid post spinal anesthesia headache.
 The woman should get briefly out of bed with assistance at least
twice.
 By the second day she may walk without assistance.
 Early ambulation lowers the risk of venous thrombosis and pulmonary
embolism
5. Vital Signs
 After transfer to postnatal ward, the patient is assessed at least
hourly for 4 hours and thereafter, at intervals of 4 hours.
 Blood pressure, pulse, Respiratory rate, temperature, uterine tone,
urine output, and amount of PV bleeding are evaluated.
6. Wound Care
 The incision is inspected after day 3
 If the gauze is dry; don’t remove it till day 3
 Change dressing on day 3 or anytime it is wet
 Skin sutures should be removed on the fifth day if pfannenstiel
incision made; and seventh day in SUMI.
7. Breastfeeding and breast Care
 Breast feeding can be initiated as early as on the day of surgery.
 If CS was done under GA; delay B/F for at least 4hrs but B/F should
be started instantly following CS under SAB
 EBF if baby unable to suck or if mastitis occurs
 Discourage mixed feeding
 Counsel PMTCT-1 mother on breastfeeding options if not done
antenataly
 Tight and firm bra to elevate the breast and keep them in position
 Avoid expressing the breasts
 Avoid sponging the breasts

8. Hospital Discharge
 Unless there are complications during the puerperium, the mother
should be discharged on the third or fourth postpartum.

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 The mother's activities during the first week should be restricted to
self-care and care of her baby with assistance
 Counsel on contraception and next pregnancy to deliver at health
facility which offer emergency obstetric care as well as Birth
preparedness

81
 CARCINOMA OF THE CERVIX
Cervical carcinoma presents with abnormal uterine bleeding and vaginal
discharge which are the most common symptoms.
A cervical lesion may be visible on inspection as a tumor or ulceration and
cancer within the cervical canal may be occult.
Squamous Cell Carcinoma being the most common histological type and
which respond well to radiation therapy.

Clinical presentation
1. History
 Abnormal vaginal bleeding,
 Leukorrhea,
 History of postcoital bleeding
 Lower abdominal pain
 Weakness, weight loss, and anemia
2. Examination
 Assess General condition of the patient look for pallor, nutritional
status, and mental status including vitals.
 Systemic examination
 Do a clinical staging
o Speculum examination ( To visualize the mass)
o Recto-vaginal digital examination
o Vaginally – consistence of the mass, size of the uterus ,
extension of the mass
o Rectally – Sphincteric tone, rectal mucosa, mobility of the
cervical mass, parametrial involvement, plus pelvic side wall
involvement.
 Cervical lesion may be ulcerative, infiltrative enlarged
or fungating , irregular with firm/solid consistency
that may extend to the vagina, parametrium and pelvic
wall.
 Take a Punch/ wedge biopsy for histopathology (Remember
Histopathology results take more than 2 weeks to be available.

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  Pack the vagina to achieve haemostasis and remove the pack after
6 hours.
 Staging and Biopsy can be performed at Gynaecological Outpatient
Clinic (GOPD), Gynaecological ward (E4) or in theatre under
Anaesthesia (EUA).
Clinical staging of the cervical carcinoma

Differential Diagnosis
cervical ectropion, acute or chronic cervicitis, condyloma acuminata,
cervical tuberculosis, ulceration secondary to sexually transmitted
disease (syphilis, granuloma inguinale, lymphogranuloma venereum,
chancroid), abortion of a cervical pregnancy, metastatic choriocarcinoma
or other cancers, and rare lesions such as those of actinomycosis or
schistosomiasis.
Investigation and Imaging
 Haemoglobin / hematocrit
 ± Blood grouping and cross matching
 ± Chest X- Ray

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  ± Creatinine
 ± Pelvic Ultrasound
Treatment
1. Preliminary Treatment
 Blood transfuse if the patient is very pale example Haemoglobin of
4 g/dl or less, or there are symptoms and sign of heart failure.
 Give Iron supplements (FeSO4 200 mg orally thrice for 3 months
and Folic acid 5mg orally once dosage for 3 months).
 Antibiotics are given when there is evidence of infection
 Give analgesia for pain
2. Definitive treatment (according to stage of disease)
Stage 0 and Ia
 Cone biopsy
 Standard TAH
Stage 1b – IIa
 Radical hysterectomy + pelvic lymphadenectomy or
 Refer the patient to Ocean road cancer institute for Radiotherapy
therapy and ± adjuvant chemotherapy.
Stage IIb – IVa
 Refer the patient to Ocean road cancer institute for Radiotherapy
± adjuvant chemotherapy
Stage IVb
 Palliative treatment
o Radiation to control haemorrhage
o Counselling for terminal care
o Give analgesia for pain such as Tramadol PRN
o Correct anaemia
Follow up after treatment
Post treatment surveillance should be done
 Every 3 months in the first year
 Every 4 months in the second year and
 Every 6 months in 3–5years.

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This is specifically to patient treated at Bugando medical center with
surgery, who were not refereed to ORCI.
Referred patient to ORCI
Refer the patient with the following
 Referral letter
 A copy of histopathology results.

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 FISTULAE.

Definition: Is an abnormal communication between two epithelial surfaces of two hollow

organs.

Obstetric fistula (vaginal fistula) develops between either the rectum or vagina or
between the bladder and vagina.

A communication between the vagina and GIT/GUS results in continuous leakage of

faces and urine.

Types of Obstetric fistula:

i. Vesical vaginal fistula (VVF) - Abnormal communication between bladder and
vagina ( urine fistula)
ii. Rectovaginal fistula (RVF) - Abnormal communication between rectum and
vagina (stool fistula )
iii. Urethrovaginal fistula. ( UVF) - Abnormal communication between the
urethra and the vaginal.
iv. Uretovaginal fistula. - abnormal communication between ureter and vagina
v. Uterine vessicle fistula - abnormal communication between uterus and bladder

Risk factors of VVF

 Hereditary contracted pelvis.
 Early marriage: pelvis is not yet fully matured.
 Low socioeconomic status: women with VVF come almost exclusively from poor
families, Poor access to emergency obstetric care.
 Malnutrition: pelvis tends to be of a small build
 Acquired contracted pelvis: accident/traumatic, infections like polio or TB.

Etilogy of VVF.
 Direct trauma (pelvic surgical accidents)
 During obstetric or gynecological operations the bladder may be accidentally
injured.
It is mainly during:
 C/section, hysterectomy, forceps delivery , vacuum pump delivery

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  Obstetric injury/ prolonged neglected labor
 The fistula usually develops when a prolonged labor presses the unborn child
so tightly in the birth canal that blood flow is cut off to the surrounding
tissues, which necrotise and eventually rot away.
 Occurs when there is CPD, pressure necrosis (avascular necrosis) of maternal
tissue which is compressed against the pubic bone especially by the fetal
head
 Symptoms are seen 3-10 days post delivery.

 Neoplastic fistula.
Mainly due to;-
 Cancer of the cervix- stage IV.
 Cancer of urinary bladder.
 Cancer of the vagina.

 Infections.
Mainly due to:
 Granulomatous infections like TB ,Syphilis, Schistosomiasis,
lymphogranuloma due to chylamidia.

 Radiations
 Irradiation especially excessive, attacks actively dividing cells e.g.
transitional epithelial cells of the bladder this can cause cystitis ending to
perforation.

Pathogenesis of VVF.

 Childbirth
Most cases (up to 80%) of VVF occur when during a prolonged labor the unborn child
presses against the pelvis,

During normal labour the bladder is displaced upwards and the anterior vaginal wall,
bladder base, and urethra are compressed between the fetal head and posterior
surface of symphysis pubis.

87
Thus cutting off the blood flow to the vesicovaginal wall, which can result in tissue
necrosis (dead tissue) and the development of a hole between the vagina and the
urinary bladder.

This is often seen during unattended and/or prolonged labor, in very young women
whose pelvis is still too small for harboring a baby, or in malpresentation of the baby,
or due to poor uterine contractions during labor.
The devitalized area separates as a slough, usually between 3rd and 10th day of
puerperium with resulting fistula formation.

A similar process of continuous pressure between fetal head and sacrum may result in a
recto-vaginal fistula

 Hysterectomy or other gynecological surgery to the pelvic area

 Occasionally, a VVF can occur accidentally during surgery in the pelvic area,
especially, during extensive tumor surgery in case of a cancer of the cervix
or cancer of the uterus, or following myomectomy.

 It can also develop secondarily after radiation therapy for cancer treatment
 In certain countries of Africa, where female circumcision, also called female
genital mutilation, is still performed, a VVF is often a second or third
unwanted result of this traditional, yet brutal procedure.

 Uretero-vaginal fistulas tend to form as the result of surgical injuries.

 The anterior vagina and bladder are more at risk than the posterior vaginal
wall and rectum. Also the lateral vaginal walls and deeper intrapelvic
structures are at risk.
 Isolated RVF is very occasional. It happens mainly in 3rd degree perineal
tears.

 Violent rape
 VVF can result from a violent act of rape; VVF has become common in certain
wars where rape has been used as a weapon against women.

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CLASSIFICATION OF VVF
Kees Waaldijk classification
Waaldijk proposed a surgical classification of obstetric fistula, based on anatomical
and physiological location.
I. Fistula not involving closing mechanism.
II. Fistula involving closing mechanism.
A. without (sub) total involvement of the urethral
a) No circumferential defects
b) With circumferential defect.

B. with (total) involvement of the urethral

a) No circumferential defects
b) With a circumferential defect.

III. Miscellaneous e.g. Ureteral Vaginal and other exceptional fistulas

Circumferential fistula
- This is a fistula which results from extensive sloughing of the bladder neck on both
pubic and vaginal sides
- Thus, a circumferential sloughing with subsequent discontinuity of urethra and
bladder occurs,
- The intervening tissue being only epithelium which has grown over and become
adherent to periosteum on the back of the pubis.
- This fistula presents a particular challenge to the surgeon, because of extreme
difficult with exposure and technical problems with closure.

Further classification according to sizes.

 Small, 2cm.
 Medium, 2-3cm
 Large, 4-5 cm
 Extensive, 6cm.

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J. B. Lawson Classification….
VVF may be classified by anatomical site into:
a. High ( juxtacervical)
- High fistula or Juxta-cervical fistulas are those that are found directly above
or adjacent to the anterior cervical lip or at the anterior fornix with the
possibility of distal ureteric involvement.
b. Mid vaginal
- Mid-vaginal without involvement of either sphincter or trigone, and it is unusual
for this fistula to be adherent to bone.
c. Low (juxta urethral)
- Juxta-Urethral which involves bladder neck and upper urethra together with
damage to the sphincteric mechanism, and fixity to bone.
- This defect could be confined to the urethra with total urethral loss.
d. Massive Fistula,
- a combination of all three with extensive tissue loss. The ureteric orefices
commonly would be involved at the fistula margin and bladder may prolapse.

Clinical presentation of VVF

- The most common symptoms are urinary incontinence/ constant leakage of urine from
the vagina, (day and night) often exacerbated by physical activities.
- Unable to pass urine per urethra.
- In addition, the patient may experience irritation and itching of the vulva and
frequent, recurrent urinary tract infections.
- Reccurent episodes of cystitis or vaginitis
- Pelvic bone pain suggests osteitis pubis
- Foot drop, unsteady gait may be due to compression of the common peroneal nerve at
the level of the ischial tuberosity affecting:

90
  extensor hallucis longus
 extensor digitorum longus
 tibialis anterior
 peroneus longus, and brevis
- Some women may complain of hematuria or non-specific vaginal discharge.
- Upon a long-standing VVF, the patient may experience concurrent ureteric
involvement with symptoms such as fever, chills, flank pain or gastrointestinal
symptoms.

Note that;-
- Size and location of fistula determine degree of leakage
For a small fistula
 May only have slight positional dependent leakage or only at maximal bladder
capacity.
 May have recurrent UTI or abnormal urinary stream.
 Also may have ammonia odor

For Large fistula

 heavy leakage continually with ammonia odor
 irritation of vaginal mucosa and perineum which may result into encrustation

Complications of fistula presentations

i. Social and psychological pain
ii. Possible future inability to become pregnant.
iii. Bladder prolapse, stone formation, UTI
iv. Vaginitis, vagina, varying from loss of the anterior vaginal wall to vagina
stricture, circular stenosis and even atresia.
vi. Partial or complete loss of the labia minora/
vii. Loss of pelvic muscles tone
viii. Depression, low self esteem, insomnia
ix. Sexual dysfunction
x. Amenorrhea
xi. Marriage dysfunction

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Diagnosis and investigations of VVF.
From History: Consider the following guidelines;-
AIM:
- To know the cause of fistulae.

HPI
 ANC
- Level of health care at which she was attending, accesibility/ distance, booking time,
who attended her, # of visits, any health/ risk factors found during the visits.

 Labour
 Onset of labour: when, where and with whom (mother,traditional birth
attendant)
 When was the rupture of membrane from the onset of labour (infections)
 Duration of labour (usually one should deliver withi 12 hrs.)
 How long was she in labour before reaching the dispensary, duration of stay
 Was she referred and by who? what Was the means of transport? How long
was the trip?
 What was done at the peripheral hospital e.g. drip, antibiotics or delivery

 Delivery
 Where did she deliver
 Mode of delivery, was it by CS or SVD
 If vaginal was episiotomy done?
 Was the baby alive or dead
 What was the weight of the baby at birth
 Condition of the mother – was she unconscious/ febrile

 Post delivery
 Was she cathetirized for 10-14 days?
 Was she given antibiotics
 Was there PPH
 Hx. Of fever to R/o Chorioamnionitis

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  When did the urine start leaking
- immediately – trauma
- 3-10 days - obstruction
 Was there an urge to micturate during the onset of leakage
- YES – not a large VVF, or its a UVF
- NO - its a large VVF

 Determination of the associating factors;-

- History of lower limb weakness: to rule out obstructive neuropathy.
- History of amenorrhoea to rule out traumatic amenorrhea
- History of loin pain, dysuria to rule out ascending infection
- History of pain over the pubic bone to rule out osteitis pubis which is due to
inflamation
- History of terminal hematuria to rule out schistomiasis, genital ulcer due to
syphilis
- History of trauma
- History of night sweats, cough and fever to rule out TB – do CXR
- History of irradiation

EXAMINATION:
General
- Height < 150 cm are at risk of CPD, shoe size < 5 (45)
- Gait – obstructive neuropathy also rule out other causes example polio.
- State of the patient – depressed, smell of urine.
- CNS – visual acuity, fields, LLs for tone power and reflexes.

Pelvic examination:
- Ammoniacal smell
- Excoriation of the vulva or perineal skin which could be due to ammoniacal dermatitis
- Digital examination – palpate the vaginal wall and fistulae margins
- Speculum (SIMS) – look at the fistula opening with the patient in lithotomy position

INVESTIGATIONS
 Blood
 FBP + ESR + Hb, grouping and cross matching
 serum creatinine

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  Urine
 take it using sterile pipette.
 culture and sensitivity
 microscopy for schistosoma ova
 IVU
 To see ureters and renal calyceal system
 Pelvic X-ray – for osteitis pubis
 CXR to rule out infections to R.Tract due to malnutrition
3-swab test.
 You may insert 3 gauses 1 at justa,2 mid and 3lower of vagina near vulva
+ methylene blue dye into urinary bladder as the wetness will determine
position of fistula.,
-It may be necessary to instill methylene blue via a catheter and detect any staining on
a vaginally-placed tampon.
-If no methylene blue dye is found staining a vaginal pledget, then intravenous indigo
carmine should be administered; and if staining is detected, a ureterovaginal fistula
may be responsible. If the staining is found only at the string end of the tampon, then
the leakage probably represents urethral incontinence and not leakage from a
vesicovaginal fistula.

What is a dye test?

Dye test — The bladder is filled with a dyed solution and the patient is asked to cough
and bear down as the physician looks for signs of leakage in the vagina. Leakage may
also be detected on a tampon after physical exercise.

What is a Double dye test?

- Double dye test is useful for diagnosing vesicovaginal or ureterovaginal fistulae.
- For this test,the patient takes oral phenazopyridine (Pyridium) 200 mg TDS, and
indigo carmine or methylene blue is filled in to the empty urinary bladder via a
urethral catheter.

- Pyridium turns urine orange in the kidneys, and methylene blue (or indigo carmine)
turns urine blue in the bladder.
- A tampon is placed into the vagina. If the tampon turns blue, vesicovaginal fistula is
suspected.
- If the tampon turns orange, ureterovaginal fistula is suspected.

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- If the tampon turns blue and orange, suspect a combination of vesicovaginal and
ureterovaginal fistulae.

 Cystoscope
 tells the state of the bladder, may reflect mode of repair.
 EUA
 When: usually after 3months of onset of fistula
 Why: to know the site, size, number of fistulae and extent of tissue damage
around.
- it also helps to rule out RVF
-it also clearly classifies the fistula

Differential diagnosis of VVF.

i. Uretero-vaginal fistula
ii. Urethro-vaginal fistula
iii. Stress incontinence
iv. Overflow incontinence
v. Urgency incontinence

MANAGEMENT OF VVF.
Repair: Depends on the cause
Traumatic: repair immediatelyhigher chances of success
Obstructed labor: repair after 3months
Blood supply to fistula has improvedchance of success
Small fistula may heal spontaneously or decrease in size
Patient general condition will have improved as anemia will be now
under control, infection controlled.
To allow dead tissue sloughing
Most repairs are done transvaginally.

Conservative treatment:
Immediate management following delivery of prolonged obstructed labour
 Urethral catheterization:
 40-60% of small fistula heal following 4-6 weeks of catheterization.
- Antibiotics:

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In case of an obstetric fistula antibiotic is not needed since is due to pressure
necrosis, unless there is evidence of infection.

 Plenty of fluid, minimum of 6-8L/day.

 Debridement of slough or necrotic tissue if these are present, Sitz bath twice
daily with simple detergents
 It is reasonable to repair fistula as soon as it is reasonably clean.

Surgical treatment.
The goal of surgical repair of Vesicovaginal Fistula include
 adequate exposure
 good homeostasis
 wide mobilization of the bladder and vagina
 resection of devascularized tissue and removal of foreign body
 tension free closure, non-opposition of suture lines, and confirmation of a water
tight seal on bladder closure
 postoperative bladder drainage for 10-14 days with the help of a foley's
catheter.

Vesicovaginal Fistula surgically can either be treated by;-

A. vaginal approach
B. abdominal approach

Vaginal approach;-
- place the patient in Lithotomy position.

Advantage of transvaginal repair.

a) less morbidity.
b) quicker recovery.
c) safer and more comfortable to Patients.
d) higher success rate

Note that;- Indicated for type I-II fistulas

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Vaginal approach involves:
 excision of diseased tissue
 preparation of fresh edges,
 tension free closure
 bladder catheter drainage.
 Bladder is then closed using absorbable suture and the vagina closed with a
separate layer.
 Urethral catheter should be left in situ for at least 14 days

Abdominal approach (transabdominal )

Indications of abdominal approach involves;-
 higher fistula on the posterior wall.
 fistula adjacent to ureters.
 ureteric injuries requiring implantations or placement of stents.
 fistula requiring bowels for augmentation cystoplasty.
Ttransabdominal approach involves;-
- An infraumbilical incision is made which is carried down into the peritoneal cavity.
This method is used for the surgical repair of complex Vesicovaginal Fistula that may
be large or small but multiple in number.
- The abdominal approach may be facilitated by Cystoscopically guided placement of a
catheter thru the fistulous tract.
- The bladder will be exposed, ureteral stents should be placed if the fistula is in close
proximity to the ureteral orifice. The vagina and bladder will then be closed with
interrupted delayed absorbable suture in a double layer fashion.

GENERAL STEPS OF SURGICAL MANAGEMENT OF FISTULA;-

1. Anaesthesia:
 For most fistula patients, spinal anaesthesia is preferred, i.e. Bupivacaine 0.5%,
2 – 4 mls, at Lumbar 3 & 4).
2. Choice of surgical approach:
 Most urinary fistulae can be managed using a transvaginal approach.
3. Position:
 Patient is best placed in exaggerated lithotomy with legs flexed and slightly
abducted. The buttocks should be placed well over the edge of the table.
 The operating table should be tilted to sixty degrees with the head down. This
position eases access to the operation site as opposed to knee-chest position.
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4. Surgical principle
-The principles enunciated by Sims, emphasizing
 good exposure,
 wide mobilization,
 not sacrificing any tissue, and accurate approximation of the bladder with
mucosal inversion,
 suitable suture material (catgut 2/0,0 or vicryl 2/0 and 0),
 the sutures not to be tied too tightly are tenable.
- In addition, before closing the vagina, the integrity of the bladder repair is tested
for water-tightness using a dye, e.g. methylene blue.
- A self-retaining catheter is inserted for 14 days postoperatively to keep the
bladder empty as much as possible
- Nothing to enter the vagina for a further 3 – 4 months

PROBLEMS & COMPLICATIONS IN FISTULA SURGERY

INTRA-OPERATIVE
A. Difficult With Exposure of Fistula
 this is solved by exaggerated lithotomy position.
B. Narrow Introitus
 this is helped by a wide episiotomy or lateral vaginal incisions which also improves
access.
C. Patient defecating during surgery
 Pour a lot of water (chlorinated) down the perineum into a receiving bucket at
foot of table.
D. Extra hole(s) in bladder
 when discovered before or during dissection, the holes can be joined
E. Injury or Ligation to the Ureters
 prevented by taking time to find the ureters. Catheterize them if they are close
to the edge of fistula.
 Another precaution is to make a wider incision away from the fistula edge, to
avoid injury to ureter together if they are close.
F. Difficult to identify ureters
 Increase fluid input I.V. or give Lasix i.v. 10 mg stat. urine will then be seen
escaping through ureteric orifices.

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G. Haemorrhage
This may come from the following sites:
 from paravesical venous plexuses
 From uterine artery
 From haemorrhoidal artery
H. Ureteric probe may be lost into the ureter
 use an eyed probe
I. Broken needle(s)
 try to remove it; if you cannot find it, leave it! It will probably result in no harm.

POST-OPERATVE COMPLICATIONS
Pain:
 may be experienced at episiotomy. Give pain killers.
 Low abdominal pain, usually on second day – probably due to vaginal pack.
 Severe loin pain is more serious and implies ureteric obstruction.
 HEADACHE is usually due to post-spinal anesthesia – this depends on size of
Spinal needle. The bigger the needle, the greater the pain.

Haemorrhage:
 patient can continue bleeding from vagina postoperatively.
 remember the 3 potential sites of haemorrhage.
 Don't forget bleeding from episiotomy.
 Haemorrhage usually happens in first 24 to 48 hours. If you cannot find an
obvious bleeder pack the vagina.
 Otherwise send to theatre for ligation of bleeders under G.A. in lithotomy
position.
 TRANSFUSE with blood if significant loss.

Ureteral obstruction
 If patient shows signs of ureteral obstruction (loin pain and tenderness,
persistent fever, abdominal distension) an IVP should be done immediately
 An abdominal ultrasound may also help. If a complete ureteral obstruction is
diagnosed several options are available:
 the alternative is to perform laparotomy to relieve the obstruction, by exploring
the ureters and reimplanting them into bladder (ureteroneocystostomy)

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Breakdown of the repair
 This usually Happens about 7 to 10 days after repair
 If repair breaks down, large caliber catheter drainage should be reinstituted
and continued for several weeks

Post Repair Stress Incontinence

 Patients may continue to experience urinary incontinence through the urethra
after successful closure of fistula
 Such incontinence may be associated with a small bladder capacity as a result of
prolonged bladder drainage through the fistula

Urethral obstruction
 This may be due to oedema or fibrous tissue
 It may necessitate repeated catheterization
 If this does not succeed, urethral dilatation may be tried
 If this fails, a urethral resectoscope may be used
 Scarring of the bladder neck caused by the repair may interfere with normal
closing mechanism

Vaginal stenosis
 needs regular dilatation to avoid reclosure
Infections
 especially Malaria and Urinary Tract Infection are among the commonest.
these present with fever, vomiting and malaise.
 Infection of repair site (or haematoma) not as common as Malaria or UTI
present with purulent PV discharge:
Treated by Savlon Sitz bath plus a broad spectrum antibiotic.

Pre – operative preparation:

 Psychological support
 Correct anemia and any disease e.g. DM & HTN
 Improve nutrition for good healing
 Admit the patient a day before sugery/operation
 On admission nill arally,enema, Hb level, anaesthetic visit
 Sign a written conset.

100
Postoperative care:
After return from theatre:
- Pulse, BP & Temperature monitoring
- Check urine production, 24 hour chart.
- Check free drainage in catheter. (Cathetarize for 10 -14 days)
- Urine bag hanging on side of the bed.
- If catheter is blocked, rinse with 10 mls of fluid only: if still blocked, change
catheter, (similar or bigger size)
- I.V. DNS 4 liters in 24 hour
- Free oral fluids + diuretics to flash blood clots from the urinary bladder and to avoid
urinary caliculi.
- Bed rest
- Pain killer every 6 hours (e.g. pethidine 50 – 100mg)

1st Postoperative day

- Oral fluids – more than 4000 mls per day
- Bed rest
- Normal diet (unless RVF and ureteric fistulae)
- If drinking well, stop I.V. fluids
- Clean between the legs (by swabbing)
- Remove vaginal gauze if no episiotomy

2nd Post-operative day:

- Oral fluids as before
- Move the legs
- Out of bed
- Sitz bath, twice per day

3rd Post-operative day:

- As before
- Pelvic floor exercises
- Remove pressure gauze from labium if present

101
5th – 7th Post-operative day:
- Discharge with catheter and urine bag to VVF hostel to return on day 14 or when she
gets bed wetting or any other problems.

14th post-operative day:

- If healed, remove catheter
- Advise urination every 1 – 2 hours during the day
- If bed wetting, do dye test. If positive, leave catheter in for 1 – 6 more weeks.
- Usually they do not have to reattend unless they have symptoms e.g. leaking of urine.

Assessment of a successful repair:

 Should not wet the bed for 24hrs, Should not have dyspareunia.
 Should be able to conceive.
 Bladder capacity > 170 mls ―150-160‖
 No traumatic amenorrhea.
 Ability to have sex and enjoy
Instructions on Discharge:
- 3 months or more to elapse before vaginal intercourse to allow the scar to be strong
enough
- Should pass urine whenever she feels the need and at least once at night, Pelvic floor
exercises
- When pregnant, should book early at ANC and to deliver in hospital where a C/S can
be done

PREVENTION OF VVF.
Primary Prevention: Aiming at Preventing prolonged and obstructed labor.
 Use partogram to monitor progress of labor
 Improve immunization coverage to prevent Polio, TB
 Improve nutrition in girls during childhood to avoid contracted pelvis
 Education to women-ANC attendance, ANC – screening, hospital delivery –
 Health education to young girls to avoid early pregnancy.
 Improve infrastructures e.g. Roads
 Improve health facilities, obstetric services and personnel (train medical
personnel to recognize women at risk of VVF)

102
Secondary prevention: Aiming at preventing development of VVF after
prolonged/obstructed labor has occurred.
 Catheterize for 10-14 days
 Antibiotics
 Correct dehydration, anemia and nutrition status

Tertiary prevention.
Fistula has already occurred: Aim at providing good environment for either spontaneous
healing or successful repair.
 Counsel the patient, advice to use Vaseline paint to prevent skin excoriation,and
discharge her to return for repair 3/12 later
 Antibiotics, correct anemia, good nutrition
 Psychotherapy.
 Future delivery should be by C/S
 Advise the pt. to abstain from sexual intercourse for 6/12.

103
 THE UNITED REPUBLIC OF TANZANIA

STANDARD TREATMENT GUIDELINES

AND ESSENTIAL MEDICINES LIST

MINISTRY OF HEALTH AND SOCIAL WELFARE

FOURTH EDITION
MAY, 2013

1|Page
 STANDARD TREATMENT GUIDELINES 2013
TABLE OF CONTENTS
OBSTETRICAL/GYNAECOLOGICAL DISEASE CONDITIONS & CONTRACEPTION

1.0 INFECTION OF THE GENITAL-URINARY TACT ..................................................85

2.0 ABORTION ........................................................................................................................86
3.0 PREMATURE RAPTURE OF MEMBRANE ....................................................................87
4.0 PROPHYLAXIS FOR CAESARIAN SECTION ...........................................................88
5.0 NAUSEA AND VOMITING IN PREGNANCY ............................................................88
6.0 ANAEMIA DURING PREGNANCY ................................................................................89
7.0 HYPERTENSION IN PREGNANCY…………………………………………………………….………….….90
8.0 DIABETES IN PREGNANCY……………………………………………………………………………..………..93
9.0 HEART BURN IN PREGNANCY…………………………………………………………………………………..93
10.0 RESPIRATORY DISTRESS SYNDROME...................................................................94
11.0 STIMULATION OF LABOUR AND MYOMETRIAL RELAXATION………………….94
12.0 TERMINATION OF PREGNANCY……………………………………………………………………………96
13.0 PREGNANCY AND LACTATION……………………………………………………………….……………..96
14.0 PELVIC INFLAMMATORY DISEASE……………………………………………………………………..96
15.0 HORMONAL CONTRACEPTION………………………………………………………………………..…….97
16.0 ANTEPARTUM HAEMORRHAGE………………………………………………………………………………99
17.0 DYSMENRRHOEA………………………………………………………………………………………………….……101

Athuman Jamal Abed

Clinical physiotherapy (KCMC), MD student (CUHAS)
 CHAPTER FIVE

OBSTETRICAL/GYNAECOLOGICAL DISEASE CONDITIONS

&CONTRACEPTION
1.0 INFECTION OF THE GENITAL-URINARY TACT

1.1 Urinary Tract Infection during Pregnancy

Diagnosis
Whenever possible urine specimen for microscopy, and/ or culture and sensitivity tests should
be carried out before drug are initiated, except on acute conditions.

First Line:
A:Amoxycillin (O)500 mg every 8 hours for 5 days

Second Line:
A: Nitrofurantoin (O) 100 mg every 6 hours for 5 days with food
Plus
C: Amoxicillin +Clavulanic acid 625mg (O) 8hrly for 5 days

For Positive RPR or Syphilis during pregnancy

B: Benzathine penicillin B (IM) 2.4 MU weekly 3 doses.

For Penicillin allergic patients

A: Erythromycin (O) 500 mg every 6 hours a day for 14 days
OR
C: Azithromycin 500mg daily for 3 days

1.2 Vaginal Discharge during Pregnancy

Vaginal discharge during pregnancy can be physiological or due to infection.(Bacterial, fungal or
both). The infection is usually polymicrobial and necessitates the use of combined drugs.For
bacterial infections treatment options are:

A: Erythromycin (O) 500 mg every 8 hours for 10 days

OR
C: Azithromycin 500mg daily for 3 days
Plus
A: Metronidazole (O)400 – 500 mg every 8 hours for 8 hours for 7 days

For fungal infection (vaginal candidiasis) give:

A: Clotrimazole vaginal pessaries one noct for 6 days
OR
C: Miconazole vaginal pessaries once daily for 3 days

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CAUTION‼
 Avoid taking both drugs concomitantly if sides effects are intolerable
 Avoid metrondazole in the first trimester
 Avoid alcohol while taking metronidazole

2.0 ABORTION
It is interruption of pregnancy (expulsion of a fetus) before it is viable, legally at 28th week of
gestation. Clinical types are recognized according to findings when the patient is first seen.
These include: Threatened abortion, inevitable abortion, incomplete abortion, complete
abortion and missed abortion.

Diagnosis
 Clinical features will depend on the types of abortion
 Viginal bleeding which may be very heavy in incomplete abortion, intermittent pain
which ceases when abortion is complete and cervical dilation in inevitable abortion
 In missed abortion, dead ovum retained for several weeks while sympoms and signs of
pregnancy disappear
 When infected (septic abortion) patient presents with fever tachycardia, offensive
vaginal discharge, pelvic and abdominal pain.

Puerperal/Post abortal Sepsis

Pyrexia in women who has delivered or miscarried in the previous 6 weeks may be due to
puerperal or abortal sepsis and should be managed actively. Abdominal pain in addition to
pyrexia is strongly suggesstive. The uterus may need evacuation however parenteral antibiotics
must be administered before evacuation.

C: Ampicillin (I.V)1gm start

Plus
A: Metronidazole 500mg
Plus
A: Gentamycin 80mg stat
Patient should continue with the following oral antibiotics after evacuation for 5 to 7days

For Mild/moderate
A: Amoxycillin (O) 500mg every 8 hours for 10 days
Plus
A: Metronidozole (O)400 mg every 8 hours for 10 days
Plus
A: Doxycycline (O)100 mg every12hrs for 10 days

Treatment Guidelines for severe cases

 Body temperature higher than (380C)
 Marked abdominal tenderness are signs of severe post abortal sepsis

Drug of Choice:
A: Benzylpenicillin (I.V)2MU every 6 hours
Plus

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 B: Chloramphenicol (I.V) 500 mg every 6 hours
Plus
A: Metronidazole (O) 1 g twice daily

Note: If patient cannot swallow continue with parenteral treatment give Metronidazole
1 gm (PR) twice daily or IV/500 mg every 8 hours

Choice for parenteral antibiotics:

C: Ampicillin (IV) 500 mg every 6 hours
Plus
A: Gentamicin (IM) 80 mg every 8 hours
Plus
A: Metronidazole (O) or (PR) 1 g twice daily for the duration of 5 to 7 day

Note: Pelvic abscess may be suspected if after 48 hours no response, in this case
laparatomy or referral may be necessary

3.0 PREMATURE RAPTURE OF MEMBRANE

A) Prolonged Premature Rapture of Membrane (PROM): Rupture of membranes before
onset of labour.
B) Pre – term premature rupture of membrane (PPROM): Rupture of membranes before
term i.e. 37 completed weeks

Diagnosis/ clinical features

It characterized by leakage of watery fluid per vagina confirmed by performing a sterile
speculum examination.

General management
Give (IV) fluids Ringer’s Lactate OR Normal saline

Prolonged PROM for more than 12 hrs is a risk of ascending infection which leads to
chorioamnionitis (infection of chorion amnion and amniotic fluid)

Treatment
 PROM at term: Delivery with 24hrs
 PPROM: If no sign of infection, wait for foetal maturity and give prophylaxis

A: Amoxyllin 500mg (O) 6 hourly x 10days

OR
A: Erythromycin 500mg (O) 6 hourly 10 days.

If there are signs of infections-pyrexia, foul smelling liquor (chorioamnionitis)

C: Ampicillin 1g (IV) stat then 500mg 6 hourly for 5 to 7 days
OR
D: Ceftriaxone 1g (IV) daily for 5 days
OR
A: BenzylPenicilline (IV) 2MU every 6hrs

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 OR
C: Chloramphenicol (I.V) 500mg every 6 hours
Plus
A: Metronidazole 500mg 8hrly for 5 days

For urgent Delivery irrespective of gestational age

A: Benzylpenicillin (I.V) 2MU every 6 hours
Plus
C: Chloramphenicol (I.V) 500 mg every 6 hours until the patient is able to take
oral medication.

4.0 PROPHYLAXIS FOR CAESARIAN SECTION

Prophylactic use of antibiotics in women undergoing caesarean section reduces the risk of
infection-related complications and serious infection post operation.

Thirty minutes before operation

C: Ampicillin 1 g (I.V)
Plus
C: Metronidazole 500mg (I.V) start
OR
D: Ceftriaxone 1g (I.V) start.

Immediately before operation give

A: Benzylpenicillin (I.V) 5MU as a single dose
Plus
C: Chloramphenical (I.V) 1 g as single dose. Continue with antibiotics after
delivery for 3-5 days

Note: Use of antibiotics for prophylaxis during surgery, should be evaluated from
situation to situation and not generalized

5.0 NAUSEA AND VOMITING IN PREGNANCY

Nausea and vomiting of pregnancy is the most common medical condition in pregnancy women.
It commonly occurs between 5 and 18 weeks of pregnancy.

Management
 If vomiting is not excessive, advise to take small but frequent meals and drinks
 If persistent, vomiting cases, search for other reasons e.g. malaria, UTI, Multiple
pregnancy or molar pregnancy and gastritis
 Otherwise give:-
Drug of Choice:

A: Promethazine (O) 25 mg at night

OR

C: Metochlopramide (O)10mg 8hrly

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 OR

A: Chlorpheniramine (O) 4mg at night

In Severe cases
General management
Give Ringers Lactate depending on severity of dehydration; If possible check for electrolyte
imbalance.

Medicine of choice:
A: Promethazine (I.V) 25 - 50 mg 12 hrly
OR
C: Metochlopramide 10mg (I.V/I.M) 8hrly
PLUS
C: Omeprazole 20mg 12hrly (caution of its use in first trimester)
OR
D: Prochlorperazine (O) 5 mg up to 3 times per day

For Hyperemesis Gravidarum (Vomiting and dehydration): Admit and give

A: Dextrose 5% IV then Ringer lactate + Dextrose normal saline
Plus
A: Promethazine (I.M) 25 mg twice daily
OR
D: Prochlorperazine (I.M) 12.5 mg twice daily.

6.0 ANAEMIA DURING PREGNANCY

Definition: Hemoglobin level less than 11g/dl; Mild anaemia 9 – 11 g/dl; Moderate 7-8.9 g/dl;
Severe less than 7g/dl

Investigate for the following in case of anaemia

 Stool for ova and parasites
 Full blood count (FBC)
 Peripheral blood film for malaria parasites
 Urine for microscopy, culture and sensitivity test
 HIV test

Prophylaxis in antenatal Care

A: Ferrous sulphate (O) 200 mg 2-3 times per day
Plus
A: Folic acid (O) 5mg once daily

CAUTION‼ -Ferrous sulphate should be taken with or after food

-Where vomiting is experienced reduce dosage to tolerable level

Treatment for Mild to moderate anaemia

A: Ferrous sulphate (O) 200 mg 2-3 times per day
Plus
A: Folic acid (O) 5mg once daily

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General management for Severe Anaemia
 Admit to the hospital
 Give blood transfusion slowly
 Give frusemide 40mg- 80mg before blood transfusion
 Continue with haematinics as above

If patient has severe anemia in pregnancy the following clinical investigation should be done:
 Stool for ova and parasites
 Full blood count (FBC)
 Peripheral blood film for malaria parasites
 Urine for microscopy, culture and sensitivity test
 HIV test

7.0 HYPERTENSION IN PREGNANCY

7.1 Chronic Hypertension

This is also called primary hypertension / chronic hypertensionwhere elevation of blood pressure
occurs before pregnancy. systolic pressure raises to 140 – 159 mmHg and/or diastolic pressure
of 90 – 99 mmHg. The underlying cause of primary hypertension is not clear.

Drug of Choice:
A: Methyldopa 250 – 500 mg (O) every 6-8 hours daily

7.2 Pregnancy Induced hypertension (PIH)

 Rise in blood pressure during pregnancy of ≥140/90
 Pre eclampsia: Rise in blood pressure during pregnancy PLUS protenuria
 Eclampsia Occurance of convulsion (fits) in patient with pre eclampsia where other
causes of convulsion have been excluded

Treatment of Mild to moderate pre eclampsia

General measures
 Regular check of BP
 Monitoring of foetal wellbeing
 Monitoring of protenuria
 Advice on adequate rest
 Advise on regular use of cocoa containing food
 Exclude UTI
 Check urine for protein
 Count this as a high risk antenatal patient

Medicine
A: Methyldopa 250-500mg 8 hrly

OR

C: Nifedipine 10 mg 12 hourly

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Severe pre eclampsia
Criteria for diagnosis: Blood pressure ≥ 160/110; Severe headache, Epigastric/ retrosternal
pain, Blurring of vision, Hyperreflexia, Oliguria, Protenuria ≥5g/ 24hrs collection ( ≥+3 in dip
stick) and Intra uterine growth restriction (IUGR).

General measures
 Admit in the hospital
Give
B: Normal saline
Plus
C: Nifedipine 10-20 mg 12 hrly;
Plus
C: Hydralazine 10 mg (I.V) slowly
Plus
B: Magnesium sulphate 4gm (IV) in 20 mls of normal saline for 10-15 min
followed by 5gm of 50% MgSO4 in each buttock; Followed by 4gm of MgSO4 in
250 mls of normal Saline to run over 4hrs. Maintenance dose: 4gm of MgSO4 (IM
alternative buttock) 4hourly for 24hrs.
Deliver as soon as the BP is controlled.

Note: MgSO4 regimen should continue until 24 hrs after the last fit.

Eclampsia
General principle
 Control fits
 Control Blood pressure
 Deliver

General measures
 Keep the airway clear
 Fluid and electrolyte balance

Treatment
 Give magnesium sulphate as above
 Give anthypertensive as above
 Fluid management as above
 Deliver vaginally unless there is another obstetric indication for caesarean delivery

Mild PIH
Diastolic: 90 – 100 mm and no proteinuria

Advice bed rest

 Weekly antenatal clinic visits

A: Acetylsalicylic acid (O) 75 mg once daily

Moderate PIH
Diastolic: 100-110 mm, no proteinuria

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Treatment
A: Acetylsalicylic acid (O) 75 mg once daily. Plan immediate delivery at
gestation > 37 weeks

Admit and monitor BP up to 6 times per day, and give

A: Methyldopa (O) 250 – 500 mg every 6-8 hours daily

Severe PIH
Diastolic>110

Treatment
C: Nifedipine (Sublingually) 10 mg
The need for more doses indicates the urgency for delivery.

Pre-Eclámptica Toxemia (Proteinuria PIH)

Management
 Exclude UTI
 Check urine for protein daily
 Plan delivery at 37 weeks or before

Treatment
A: Acetylsalicylic acid 75 mg once daily
Plus
C: Hydralazine (IM) 12.5 mg
OR
C: Nifedipine (sublingual) 10 mg.

Imminent Eclampsia
This is proteinuria PIH characterized by visual disturbance or epigastria pain and or signs of
brisk reflexes.

Management
 Plan urgent delivery
 Prevent convulsions by
A: Diazepam (I.V – infusion) 40 mg diluted in 1 litre of Sodium chloride 0.9%
over 6 hours

Treatment
If diastolic pressure still >110 mm give antihypertensive:
C: Hydralazine 12.5 (I.M) intermittently
OR
C: Nifedipine (sublingually) 10 mg.

Eclampsia (Proteinuria PIH with Fits)

Treatment

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 A: Diazepam (IV infusion) 40 mg diluted in 1000 ml of normal saline infused over
6 hours
 If diastolic pressure> 110 mm give antihypertensive as above
 Plan urgent delivery

8.0 DIABETES IN PREGNANCY

Gestational diabetes develops in women during pregnancy because of insulin resistance or
insensitivity due to steroid hormones produced from the placenta. High blood sugar levels in the
mother’s body are passed through the placenta to the developing baby. This can cause health
problems. Gestational diabetes usually begins in the second half of pregnancy and goes away
after the baby is born.

Management
 Diabetic pregnant women require management before and throughout pregnancy
 Diabetes should be controlled by diet,oral hypoglycaemics and or Insulin
 Throughout pregnancy blood sugar should strictly be within the range of 4-6 mmol/L
 Insulin requirement will increase as pregnancy progresses
 During labour check blood sugar 4hourly in order to detect hypoglycaemia and manage
accordingly
 When labour induced give half the usual insulin dose first and start on IV infusion of
dextrose 5% at 125 ml per hour
 Manage the aptient on a sliding scale of insulin after labour
 Continue to monitor blood sugar after delivery in order to adjust insulin requirement

9.0 HEART BURN IN PREGNANCY

Heartburn (also called acid indigestion or acid reflux) is a burning sensation that often extends
from the bottom of the breastbone to the lower throat. It's caused by some of the hormonal
and physical changes in pregnant women.

Management
Pregnant women should avoid:
 Food and beverages that cause gastrointestinal distress
 Tobacco and alcohol
 Eating big meals; should eat several small meals throughout the day
 Drinking large quantities of fluids during meals
 Eat close to bedtime; they should give themselves two to three hours to digest food
before they lie down
 Sleep propped up with several pillows or a wedge. Elevating upper body will help keep
the stomach acids where they belong and will aid food digestion.

Treatment
A: Magnesium trisilicate (O) as needed
OR
C: Omeprazole 20 -40 once a day

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10.0 RESPIRATORY DISTRESS SYDROME
Respiratory Distress Syndrome is likely to occur in newborn and in premature labour before 36
weeks gestation.

Drug of choice
B: Hydrocortisome (IV) 250 mg repeats after 24 hours
OR
D: Dexamethasome (IV) 12 mg, two doses at an interval of 12 hours.

Note: If no delivery the course can be repeated after one week

CATION‼: Anemic patients under Beta stimulants and steroids are inclined to
congestive cardiac failure

11.0 STIMULATION OF LABOUR AND MYOMETRIAL RELAXATION

 Mycometrial stimulants should be used with great care before delivery especially in
porous women
 Use in obstructed labour should be avoided
 Oxytocics are indicated for:-
o augmentation of labour
o Induction of labour
o Active management of third stage of labour.
o Uterine stimulation after delivery

11.1 Labour Induction

For induction of labour use: Oxytocin IV the dose will depend on parity.
 Primigravida:
A: Oxytocin IV 5 IU in 500mls of fluid titrate at 15, 30, 60 drops per minute until
desired uterine contractions are attained
 Multiparous:
A: Oxytocin IV Starts with low dose eg 1.25 IU in 500mls of fluid titrate as
above. Regulate the dose according to response.
If no progress of labour is achieved give;

A: Oxytocin (IV) Initially 1 unit then 4 units in 1 litre Normal Saline at 15, 30, 60
drops per minute until regular contractions lasting for more than 40 secondly are
maintained
When 4 units are not enough to cause maintained constractions, and it is first pregnancy, the
dose can be increased to 16, 32 then 64 units in litre of Normal Saline each time increasing the
delivery rate through 15, 30 and 60 dpm.

11.2 Augmentation of Labour

If labour progress is not optimum labour augumentation is necessary. Can be achieved by:
A: Oxytocin as above
OR

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 Artificial rupture of membranes and Oxytocin
 If the membranes already ruptured and no labour progressing, the steps above should
be followed
 Obstructed labour could be the cause of labour failure.
Note: Rule out obstruction before augumenting labour with oxytocin

11.3 Myometrial Stimulation after Delivery

Post partum hemorrhage (PPH)
It is an excessive bleeding of more than 500ml after the third stage of labour and a major cause
of maternal mordidity and mortaility.

Major causes are;

 Uterine atony
 Tears of the vagina/vulva
 Retained products of conception
 Rarely rupture of the uterus
 Bleeding disorder (e.g coagulopathies, DIC)

Management
In order to prevent the occurrence of this condition, active management of the third stage of
labour (ATMSL) is mandatory. This involves the injection of an oxytocic after the delivery of the
foetus followed by controlled cord traction and uterine massage.

Treatment
Drugs of Choice:
A: Oxytocin (I.M) 10 I.U.
OR
A: Ergometrine (I.M) 0.25 – 0.5 mg
OR
A: Misoprostol 800 -1000 microgram (mcg) orally/rectally

Give Oxytocin (I.M) 5 units after delivery of the infant; when no response gives Oxytocin (I.V
infusion) 10-20 units in 1 litre of NS running at 10-20 drops per minute (dpm)

Second Choice: Ergometrine (IM) 0.5 mg after delivery of the infant, in the absence of
myometrial contraction and to prevent postparum hemorrhage

Note: Use Ergometrine cautiously in hypertensive heart disease patients.

11.4 Myometrial Relaxation

This is done to relax the uterus in order to:
 Relieve fetal distress immediately prior to ceasarian section
 Stop contraction of uterine in premature labour
 Prevent uterine rupture
 Perform external cephalic version

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Drug of Choice A: Salbutamol 4 mg (O) every 8 hours

Note
β -stimulants should NEVER be used if the patient had an antepartum hemorrhage
β -stimulants are CONTRA-INDICATED for the following
 With cardiac disease
 Severe anemia in pregnancy

12.0 TERMINATION OF PREGNANCY

Abortion is illegal in Tanzania except under the following legal conditions:
 Where there is a substantial threat to the woman’s health or life in continuing the
pregnancy
 Where there is a significant risk or it is known that the foetus has a serious medical
conditions or malformation
 Where the pregnancy results from rape and there is no intention to keep the pregnancy.

Recommended methods
 Routine Dilation and curettage - up to 7 weeks since last menstrual period
 Suction termination – Between 7-12 weeks since the last menstrual period
 Prostaglandin termination – after 12 weeks since the last menstrual period.

13.0 PREGNANCY AND LACTATION

General Guidelines
 All drugs, if possible, should be avoided during the first trimester
 Well known medicine and their use in pregnancy and lactation, which have been
documented as safe, should be preferred – AVOID new drugs
 Absence from a list of medicine not to be used in pregnancy or lactation does not
guarantee safety
 During pregnancy and lactation, medicines should be prescribed only if benefit
overweighs risk to the foetus or neonate.

14.0 PELVIC INFLAMMATORY DISEASES

Pelvic inflammatory disease (PID) occurs when there is infection in the female reproductive
organs. The infection can happen as an ascending infection from the vagina, after delivery
(puerperal sepsis), after an abortion (septic abortion), postmenstrual or after Dilation and
Curettage (D&C) operation. The common causative organisms are Neisseria gonorrhea,
Chlamydia trachomatis and Mycoplasma hominis. Endogenous bacteria e.g. gram-negative
aerobes and anaerobes like bacteroides, streptococcus, anaerobic streptococcus and E. coli may
also cause PID. The condition can either be acute, sub-acute or chronic.

Diagnosis
The main clinical features are lower abdominal pain, backache, vomiting, vaginal discharge,
menstrual disturbance, dyspareunia, fever, infertility and tender pelvic masses. PID predisposes
to ectopic pregnancy.

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Treatment
In acute PID gives Intravenous fluid (Ringers Lactate or Normal saline)
A: Ciprofloxacin (O) 500mg single dose,
Plus
A: Doxycyline (O) 100 mg every 12 hourly for 10 days
Plus
A: Metronidazole (O) 400 – 500 mg every 8 hours for 10 days.

Give an appropriate analgesic depending on the severity of the disease:

A: Diclofenac 50-100 mgevery 8 hours preferably after food
OR
A: Acetylsalicylic acid (O) 600 mg every 8 hours preferably after food
OR
A: Paracetamol (O) 500mg, 8 hourly.

In chronic PID
Give an appropriate analgesic diclofenac, ibuprofen aspirin or paracetamol depending on the
severity of the pain. Do not give antibiotics.

15.0 HORMONAL CONTRACEPTION

Oral contraceptives (oestrogen – progestogen combinaitons) are used primarily for prevention
of conception. It may also be used in treatment of dysfunctional uterine bleeding,
dysmenorrhea or endometriosis.

The goal of therapy in the use of these products for contraception is to provide optional
prevention of pregnancy while minimizing the symptoms and long term risks associated with
excess or deficiency of the oestrogen and progestogen components.The eligibility for hormonal
contraception can be obtained from nearest family planning clinic or unit.

15.1 Oral Contraceptives

They fall into two major categories:

Combined oral contraceptives) COCs)

A: Oestrogen 30 – 35 micrograms (as ethinyloestradiol)
“Low Dose”
A: Oestrogen 50 micrograms + progestogen
“ High Dose”
“Triphasic pills” – contain phased levels which closely mimic normal cyclical hormonal acitivity

 Lower oestrogen dose pills cause fever side effects than higher dose pills
 Mid-cycle spotting in patients on 30 microgram COCs can be managed by
changing to 50 microgram COCs
 Menstruation on COCs will be regular, light and short

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Progestogen Only Pills (POPs)
These contain norethisterone, or norethindrone or levonorgestrel. This type is suitable for
lactating mothers or women with mild or moderate hypertension. Menstrual irregularity is a
more common side effect.

Management
Follow up:
 Instruct women always to inform the doctor or nurse that they are on contraceptives
while attending clinic or hospital.
 Women on Oral Contraceptives need regular physical check-ups including blood pressure
measurement every six months e.g. if women develop depression after starting OC.
Need to Withdraw COCs or POPs
 Pregnancy
 Severe headaches especially associated with visual disturbances
 Numbness or paresis of extremities
 Unexplained chest pain or shortness of breath
 Severe leg pains
 Development of any of the absolute contra-indication conditions

Medicines Reducing the Effect of Oral Contraceptives

The following drugs are likely to reduce the effectiveness of OCs and woman may become
pregnant so the woman should be advised to use additional prevention method such as
condom.
 Hypnotic/sedatives anti-migraine medication, barbiturates, chloral hydrate, diazepam
 Antiacid: Aluminium hydroxide, magnesium hydroxide, magnesium trisilicate
 Anti TB as rifampicin
 Antiretroviral as Nevirapine and Retonavir
 Certain antibiotics as Ampicillin and other Penicillins and Tetracyclines.

Note
 For long term use of these drug “High Dose” COCs – 50 micrograms should be used
or other method of contraception

Drug made less effective by Oral Contraceptives

Prescribers might consider increasing the doses of the following drugs, known with careful
monitoring
 Anticonvulsant
 Ant diabetic agents
 Anticoagulants
 Antihypertensive agents (methyldopa)
 Corticosteroid
 Hypnotics, sedatives or other CNS depressants

Post Coital Contraception (“morning-after pill”)

The method is applicable mostly after rape and unprotected sexual intercourse where
pregnancy is not desired.Within 3 days (72 hours) of unprotected sexual intercourse, give

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 A: Combined oral Contraceptive ethinyloestradiol 100 mcg and levonorgestrel
500 mcg (2 high dose COC tablets)

OR
A: Ethinyloetradiol 30-35 mcg and levonorgestrel 150-250 mcg -3 tablets (3 low
dose COC tablets).
 Repeat this dose after twelve hours
 Advice to return to physician if menstruation does not occur within 3 weeks
 Give advice on contraceptive use
 Rape victims should also be given Erythromycin (O) 250 mg every 6 hours for 5 days
 Offer counseling

Long Term Hormonal Contraceptives

These contraceptives should be prescribed by Medical Doctors only or trained family planning
staff.

Injectable Contraceptive:
A: Medroxyprogesterone acetate IM 150 mg every three months

CAUTION‼ Avoid use in for severe hypertension and in women without proven
fertility

Implant Contraceptive (see FP manual for current implants in use)

“Norplant” Containing levonorgestrel in six silastic capsules is implented in the left upper
arm made local anesthesia.
“Norplant” Is effective for five years and is recommended for women who have completed
their family or nor ready for sterilization or those not able to take oestrogen containing
contraceptives.

Contraindications for Norplant

 Severe hypertension
 Thromboembolism
 Active liver disease
 Sickle cell anaemia
 Undiagnosed genital bleeding
 Severe headaches

16.0 ANTEPARTUM HAEMORRHAGE (APH)

CAUTION‼ all patients with APH must be managed in the hospital setting

Diagnosis
 Bleeding from the birth canal after the 28th week of gestation
 Main forms are placenta praevia and abruptio placenta
 Bleeding is painless in placenta praevia
 Bleeding may be visible or concealed in abruptio placenta
 Pain and shock in abruptio placenta correspond with degree of separation
 Placenta praevia

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 Placenta attached at the lower segment characterized by painless vaginal bleeding
 Abruption placenta
Premature separation of the placenta characterized by severe abdominal pain, shock,
foetal distress or foetal death.

General management
If patient is bleeding heavily or in shock:
 Vital signs (BP, pulse, temperature)
 IV line (two are better than one)
 Take blood (Grouping and cross matching, FBC, platelet count)
 Give (I.V) fluids quickly Ringer´s Lactate
 Give oxygen
 Send somebody for two or more units of blood
 Indwelling catheter
 Do ultrasound; if no placenta praevia, speculum and vaginal examination
 If rapid vaginal delivery is considered, prepare vacuum
 Add Oxytocin and amniotomy
 In most cases of placenta praevia CS is indicated. Give antibiotic prophylaxis before CS:
Ampicillin 1g I.V (single dose)PLUS Metronidazole 500mg I.V (single dose)

If patient in good condition:

 Observe closely for signs of worsening
 Do ultrasound; if no placenta praevia, speculum and vaginal examination
 Consider prolongation of pregnancy to term

Follow Up after delivery

 Close monitoring (vital signs, shock symptoms, uterus size and consistency)
 Check Hb 48 hours after delivery
 Inform patient about history (risks for further pregnancies, mode of delivery)
 Discuss possible modes of contraception before discharge

Management of Abruptio Placentae

 Open 2 IV lines
 Give Ringer Lactate or Normal Saline quickly
 Catheterization
 Blood grouping and crossmatch order enough blood
 Bed side clotting time
 In most cases there is already IUFD Induce with amniotomy and oxytocin infusion
 Give adequate analgesia

NB if the baby is alive at term or near term consider CS

 Expectant therapy
 Allow bed rest
 Blood grouping and cross-matching
 Active therapy delivery if foetus viable. If a major placental separation has occurred,
emergency delivery to minimize the possibility of disseminated
 Intravascular coagulation

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  Give blood when indicated.

17.0 DYSMENORRHOEA
Dysmenorrhoea is painful menstruation preventing normal activities and require medication.

There are 2 types of dysmenorrhoea:

 Primary (no organic cause). Typically, in primary dysmenorrhoea pain occurs on the first
day of menses, usually about the time the flow begins, but it may not be present until
the second day. Nausea and vomiting, diarrhoea and headache may occur.

 Secondary (pathological cause) e.g. PID and uterine polyposis and membranous (cast
of endometrial cavity shed as a single entity (rare).

Treatment
 Allow bed rest
 Give Analgesics such as
A: Ibuprofen 200-600 mg every 8 hours (maximum 2.4 g/day)
OR
A: Acetylsalicylic acid 300-600 mg every 4 hours
OR
A:Diclofenac 50-100mg 8-12 hourly
OR
C: Mefenamic acid 500mg 8 hourly
Plus
A: Hyoscine butylbromide 20mg 8hourly

Women with regular complaints can easily detect length of use during their periods (2-3
days usually sufficient)
 Treat the underlying condition if known

Note: For primary dysmenorrhoea patients may be advised to start taking Ibuprofen
one or two days before menses and continue for three to four days during menses to
minimize painful menstruation

18.0 INFERTILITY
This is failure to conceive after one year of regular coitus without contraception. It is classified
as primary when there has never been a history of pregnancy or it is secondary when there is
previous history of at least one conception.

Treatment
Treatment in all cases depends upon correction of the underlying disorder(s) suspected of
causing infertility whether primary or secondary.

Note: Refer infertile couple to Obstetrics/Gynecologist/ infertility specialists

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