Professional Documents
Culture Documents
CLINICAL GUIDELINES
DEPARTMENT OF OBSTETRICS
AND GYNAECOLOGY
SERDANG HOSPITAL
Contributors :
Dr.Wan Hamilton Bt Wan Hassan
Dr.Wan Norizah Bt Wan Musa
Dr.Juliana Bt Basuni
Edited By :
Dr.Wan Hamilton Bt Wan Hassan
CONTENTS PAGE
1 CLERKING OF OBSTETRICS PATIENTS IN THE PAC/WARDS
FETAL MONITORING
COMMON ANTENATAL CONDITIONS AT PAC
ANTENATAL PROBLEMS
Hypertensive Disorders in Pregnancy
Intravenous Antihypertensive Regime
Eclampsia
Anticonvulsant Therapy
Diabetes Mellitus in Pregnancy
Insulin Regime
Heart Disease in Pregnancy
Antibiotic Prophylaxis
Anticoagulant Therapy in Pregnancy
Guidelines for Management of HIV Patients
Antepartum Haemorrhage (APH)
Anaemia in Pregnancy
External Cephalic Version
Post Dates Pregnancy
Intrauterine Death
ESSENTIAL PREREQUISITES IN THE LABOUR ROOM
LABOUR PROBLEMS
FIRST STAGE OF LABOUR
Routine Intrapartum Care
Induction and Augmentation of Labour
Prostin (PGE2, Dinoprostone)
Oxytocin Augmentation / Induction Regime
Abnormal Progress of Labour
Intrapartum Fetal Monitoring
Pain Relief in Labour
Thromboprophylaxis in Labour
Prophylaxis for Acid Aspiration in Caesarean Section
Preterm Labour
Tocolytic Regime
Antenatal Steroid Therapy
Preterm Prelabour Rupture of Membranes (PPROM)
Perinatal Group B Streptococcus (GBS) Infection Prevention
Cord Prolapse
SECOND AND THIRD STAGE OF LABOUR
Normal Delivery
Episiotomy
Vaginal Breech Delivery
Twin Delivery
Instrumental Delivery
Ventouse Delivery
Forceps Delivery
Repair of Perineal Tears
Cervical Tears
Post-partum Haemorrhage (PPH)
Manual Removal of Placenta
Uterine Inversion
Shoulder Dystocia
GYNAECOLOGY PROBLEMS
Ectopic pregnancy
Puerperial sepsis
GENERAL MEASURES
Labour Room Ward Round
Red Alert System
Infectious Control Measures
Antimicrobial Use in Pregnancy
Paediatric Referrals
CLERKING OBSTETRICS PATIENTS IN
PAC / WARDS
2.1 GENERAL
• Hydration status, pallor, jaundice, cyanosis
• Height, weight
• Temperature, blood pressure and pulse rate
• Pedal edema. Varicose veins
• 22 weeks 500grams
• 28 weeks 1.0kg
• 32 weeks 1.5kg
• 34 weeks 2.0kg
• 36 weeks >2.5kg
• Assessment of liquor: adequate, excessive or diminished
• Fetal heart rate
2.4 VAGINAL EXAMINATION
If required and if there are no contraindications
3. PRELIMINARY INVESTIGATIONS
• Urine albumin, sugar, rapid test for HIV if not done
• Further investigations: dipstix for UFEME if suggestive of UTI,
dextrostix, urine ketones
• Other investigations to be carried out example GSH,GXM, FBC,
Renal profile, LFT, PT/APTT/INR
4. ADMISSION CTG
FETAL MONITORING BY
CARDIOTOCOGRAPHY (CTG)
1 IMPORTANT INSTRUCTIONS
4. CTG INTERPRETATION
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5. CTG CLASSIFICATION
Suspicious Features fall into one of the non-reassuring category and the remainder
of the features are reassuring
Pathological Features fall into two or more non-reassuring categories or one or more
abnormal categories
6.
DEFINITINS AND DESCRIPTION OF INDIVIDUAL FEATURES OF FETAL
HEART TRACES
Term Definition
1 Baseline fetal
heart The mean level of the FHR when this is stable, excluding
rate accelerations and decelerations. It is determined over a
time period of 5 to 10 minutes and expressed in bpm.
Preterm fetuses have values towards the upper end. A
trend to a progressive rise in baseline is as important as
the absolute values.
2 Normal baseline FHR 110-160bpm
Term Definition
12 Decelerations Transient episodes of slowing of FHR below the baseline
level of more than 15bpm and lasting 15 seconds or more
Prerequisites to IOL
• Ensure dates are correct
• Determine LMP, LCB, OCP usage, date of UPT test, early dating scan
• Review home-based or other antenatal records to see if uterine size
corresponds to dates.
• Thorough physical examination, determine uterine size and liquor
volume
• Perform CTG
• Assessment by scan for liquor volume. If AFI<6, to induce without delay.
• Perform a VE for cervical score
• If >7, ARM and syntocinon
• If <7, use Prostin
0 1 2
Station -2 -1 0
Risk of scar dehiscence are higher amongst women receiving oxytocin compared to
those who are not
• Spontaneous labour 0.5%
• Oxytocin use 0.8%
• Prostaglandin use 2.45%
Management:
• Keep patient NBM
• Monitor fetal heart closely with continuous CTG
• If reactive for augmentation and deliver vaginally
• If CTG is pathological to inform the MO/Specialist, the paediatrician and
anaesthetist will also be informed KIV for EMLSCS
• Ensure blood has been taken for GSH
• Thick meconium stained liquor: delivery must be expedited in most
appropriate manner (EMLSCS or instrumentation if criteria fulfilled).
Thick meconium if found in early labour must be delivered by
emergency LSCS.
• Meconium stained liquor in preterm infant, there will be a need to
exclude and treat Listeriosis
• All babies born with meconium staining must be attended by the
Paediatrics Medical Officer.
7. LEAKING LIQUOR
Management:
• Confirm diagnosis of PROM/PPROM
• Aseptic speculum examination with HVS and low vaginal swab
• Litmus paper test: red to BLUE
• Do not perform a digital VE if conservative management is planned.
• DIGITAL VE IS TO BE DONE ONLY BY MO/ Specialist
• Ultrasound for fetal well being and liquor volume. Look for presentation
and fetal anomalies.
• Pad chart,BP/PR, temperature chart, baseline FBC, baseline CRP
• Inform Paediatrician/NICU
• If patient progresses into labour or if labour is induced, the number of
vaginal examination should be limited to 4 hourly reviews unless
indicated
Treatment
• If there is chorioamnionitis or fetal distress as evidenced by abnormal
CTG, meconium staining, Doppler studies : IMMEDIATE DELIVERY
IS INDICATED
• Otherwise, it will depend on fetal maturity. Decisions must be made by
the specialist
In General:
Physiological
• Round ligament pain
• Labour itself
• Exaggerated Braxton Hicks contractions
Pathological :
• Ectopic pregnancy
• Miscarriage
• Placenta Abruption
• Preterm labour
• Severe PE
• Uterine rupture
• Red degeneration of fibroids
• Torsion of ovarian cyst
• Heartburn
• Bowel colic
• Adhesion colic
• Appendicitis
• Cholecystitis
• Renal colic
• Irritable bowel syndrome
• Pancreatitis
• Acute fatty liver
• Mesenteric artery thrombosis/bowel ischemia
9. MATERNAL PYREXIA
Recognition:
• Fever: temperature 38degrees and above
• Warm extremities
• Fast breathing
• Fetal and maternal tachycardia
• Hypotension
• Altered mental state: confusion, restlessness
• Late diagnosis and treatment will lead to septic shock
• In patients where the temperature does not touch baseline/persistent
fever: the Specialist MUST be informed. The patient must be
reviewed, assessed and treated appropriately and aggressively.
Investigations include FBC, renal profile, UFEME and C&S, HVS C&S, septic workout if
the temperature exceeds 38 degrees C and all other relevant investigations.
DEFINITION
Hypertension
• BP of 140/90 mmHg or more taken after a period of rest on two
occasions.
• Rise of systolic blood pressure of 30 mmHg and/or a rise in diastolic
blood pressure of 15 mmHg compared to pre-pregnancy levels.
The Korotkoff phase V being used to define the end point.
Proteinuria
CLASSIFICATION
There are various classifications for Hypertension in Pregnancy. The most recent is by the
Australasian Society for the Study of Hypertension in Pregnancy (ASSHP) and endorsed
by the International Society for the Study of Hypertension in Pregnancy(ISSHP),2001.
1. Preeclampsia-eclampsia
• Significant proteinuria
• Renal insufficiency: serum creatinine ≥ 90 µmol/l or oliguria
• Liver disease: raised transaminases and/or severe right upper quadrant or
epigastric pain
• Neurological problems: convulsions (eclampsia), hyperreflexia with clonus
or severe headaches, persistent visual disturbances (scotoma)
• Haematological disturbances: thrombocytopenia, coagulopathy,aemolysis
• Fetal growth restriction
2. Gestational hypertension
Hypertension alone, detected for the first time after 20 weeks pregnancy. The definition is
changed to “transient” when pressure normalizes postpartum.
3. Chronic hypertension
Hypertension diagnosed prior to gestational week 20; or presence of hypertension
preconception, or de novo hypertension in late gestation that fails to resolve postpartum.
This can be diagnosed by the appearance of any of the following in a woman with chronic
hypertension
Renal
Chronic kidney disease
Polycystic kidney disease.
Glomerular disease (Primary Gromerulonephritis, Tubulointerstitial nephritis)
Nephrotic syndrome
Endocrine
Phaeochromocytoma
Acromegaly
Thyroid or parathyroid disease
Primary aldosteronism
Cushing syndrome
Conn’s syndrome
Autoimmune
Systemic lupus erythematosus
Systemic sclerosis
Vasculitides
Polyarteritis nodosa
Takayasu Arteritis
Vascular
Renovascular disease - renal artery stenosis, fibromuscular dysplasia
Coarctation of the aorta
Others
Sleep apnoea
Drug-induced or drug related – Cocaine, Amphetamines, Cyclosporin
Clonidine withdrawal, Phencyclidine
ANTENATAL MANAGEMENT
IN PATIENT MANAGEMENT
ANTIHYPERTENSIVE THERAPY
~
Nifedipine (Adalat) 10 mg 8 hourly
Max. dose up to 30 mg 8 hourly
Aim of treatment
Timing of delivery
Mode of delivery
INTRAPARTUM CARE
• Set up IV line.
• PE charting and monitor BP, PR half hourly.
• Monitor urine output 4 hourly (hourly if on MgSO4), testing for ketonuria
and proteinuria.
• Adequate analgesia – consider epidural analgesia.
• Strict fluid regime.
First 24 hours
After 24 hours
FOLLOW-UP
Rapid control
Maintenance
Tailing off
Rapid control
Maintenance
• Syringe pump:
∼ 200 mg (40 ml) Labetalol
∼ Start at 20 mg/hr (4 ml/hr) (40 mg
by MOET, HUKM protocol)
∼ Increase dose every 30 minutes by
4 ml/hr
∼ Maximum 32 ml/hr
• Drip infusion set:
∼ 200 mg (40 ml) Labetalol in 200 ml
5% Dextrose (1 mg/ml)
∼ Titrate at 5 dpm increasing every 30 min
∼ Maximum 60 dpm (180 mg/hr)
Tailing off
Contraindications
• Bronchial asthma
• Congestive cardiac failure
• Heart blocks
PEARLS OF MANAGEMENT
References:
Manage in HDW/LW
If require
antihypertensive
treatment
Control BP with paranteral
antihypertensive
Refer to B
No
Deliver by 38 weeks / earlier if fetal
Consider adding compromise
Dexamethasone
Delivery by 40 weeks/
earlier if fetal Immediate delivery
compromise
Urgent delivery
ECLAMPSIA
Definition
Aim of management
• Control convulsions
• Stabilize blood pressure
• Optimize patient
• Deliver fetus
MANAGEMENT
ANTICONVULSANT THERAPY
Intravenous regimen
• Syringe pump:
∼ 10 gm (20 ml) MgSO4 is diluted in
30 ml of 5% dextrose and
infused at 5 ml per hour (1
gm/hr)
• Drip infusion set:
∼ 15 gm (30 ml) MgSO4 in 500 ml 5% dextrose run at 11 drops per
minute.
Intramuscular regimen
Loading dose
Maintenance dose
• Cardiac disease
• Acute renal failure
Monitoring
• Patellar reflex
∼ After completion of loading dose
∼ Hourly whilst on maintenance dose
• Pulse oximetry
∼ To keep O2 saturation >90%
∼ Respiratory rate > 16/minute
• Perform magnesium level (therapeutic range 2-4 mmol/L
(4-8 mg/dl)) if:
∼ Urine output < 100 ml/4 hours
∼ Urea > 10 mmol/L
Management of toxicity
•
Loss of patellar reflex:
∼ Stop maintenance therapy.
∼ Send Mg level urgent.
∼ Withhold further Mg until patellar
reflexes return or Mg level known.
Recurrent seizures
Rapid control
• IV Diazepam 10 mg over 1-2 minutes.
Maintenance dose
Referrence:
• Polyhydramnios
• Essential Hypertension , Pregnancy Induced Hypertension / current long
term use of steroid in current pregnancy
• Recurrent infection in pregnancy e.g. UTI, vaginal candidiasis
Diagnostic criteria
WHO 1980 criteria for diagnosis of diabetes or impaired glucose tolerance following a
75g oral glucose:
Screening should be done as early as possible in high risk patient and if the result is
normal repeat at 28 – 32 weeks.
PRE-PREGNANCY MANAGEMENT
INDUCTION OF LABOUR
Prostaglandin
POSTPARTUM
Solution
All diabetic mothers in labour should have a maintenance drip Dextrose 5%, at
100ml/hour.
PRE-CONCEPTUAL COUNSELLING
CLASS SYMPTOMS
Class III Marked limitation of physical activity. Comfortable at rest but minimal
exertion lead to symptoms.
ANTENATAL MANAGEMENT
LABOUR MANAGEMENT
First stage
Second stage
Third stage
• Hospital stay depends on clinical status. Generally keep in ward for 5–7
days.
• Advice bed rest with allowance for normal activity as tolerated.
• Continue anticoagulant if required.
• Encourage breast feeding (except on ACE inhibitor / amiodarone).
• Advice on medical treatment, corrective surgery and follow up with the
Cardiologist.
• Counselling for future pregnancy after consultation with Cardiologist.
• Advice on contraception (e.g. barrier method, progestogen only pills/
injectables, IUCD, tubal ligation).
ANTIBIOTIC PROPHYLAXIS
Standard Regimen
Indications
ORAL ANTICOAGULANTS
UNFRACTIONATED HEPARIN
Labour management
Reference:
Clinical Practice Guidelines on Heart Disease in Pregnancy, 2001
GUIDELINES FOR MANAGEMENT OF
HIV MOTHERS
ANTENATAL MANAGEMENT
Screening
“Test unless refused” or “routine screening with the option to opt out” policy.
Notification
Counselling
• History
∼ HIV/AIDS related symptoms
(weight loss, anorexia, recurrent
or prolonged fever, recurrent
diarrhea, cough etc)
∼ Previous pregnancies and clinical
status of family members
∼ Past medical history (anaemia and
liver disease may affect the
decision to commence ZDV)
∼ Social history
• Clinical examination
∼ HIV/AIDS related clinical signs
such as oral thrush, oral hairy
leukoplakia, lymphadenopathy
and other stigmata (skin
manifestation, chest infection,
hepatosplenomegaly, anaemia,
genital lesions eg. Herpes,
cervical dysplasia)
1) There should be a proper referral pathway for these patients to the combined
clinic.
2)
Interventions to reduce the risk of HIV transmission should be discussed with
the women. These measures would
3)
All HIV positive women should be examined for genital infections and treated
appropriately. If negative, the examination should be repeated at 28 weeks.
Avoid the combination of Stavudine plus Didanosine as part of the triple Therapy
whenever possible, due to case reports of fatal lactic acidosis in pregnancy.
The decision to use any antiretroviral drug during pregnancy should be made by the
woman after discussing with her health-care provider the known and unknown benefits
and risks to her and her foetus. ARV should be initiated by Physician/ ID Physician and
/or Obstetrician. The patients will be monitored in the combined clinic.
Adherence to ARV therapy is of vital importance for the success of treatment and
pregnant women may need extra support and planning in this area, especially if there
are practical or psychosocial issues that may impact adversely on adherence.
Where ARV therapy is not required during pregnancy for maternal health, a combination
of three drugs to suppress HIV viral replication may be prescribed for the duration of
pregnancy and after delivery to reduce transmission: administered correctly, this will
preserve future maternal therapeutic options. In this scenario, ARV therapy is usually
discontinued at, or soon after delivery.
In most circumstances initiation of ARV therapy should be delayed until after the first
trimester unless early initiation is judged important for maternal health.
Delaying the initiation of HAART after the first trimester minimizes the risk of drug related
teratogenecity and usually results in better adherence as the nausea associated with
pregnancy has usually diminished by this time
Recommendations for HIV pregnant women with CD4 T cell count > 250 cells/Ul
The benefit of improved morbidity and mortality with TMP / SMX prophylaxis
among these high-risk women may outweigh the small risk to the foetus.
Recommendations for women diagnosed in labour without prior therapy
AND
• Continue oral zidovudine (ZDV) 300mg BD for one week to
the mother
• 3TC (lamivudine) 150mg q12H or 300mg once daily for one week post
delivery for the mother.
Review by paediatrician
This is only considered if the mother’s life is in danger (terminal stage HIV disease).
Each case should be individually assessed by the attending physician or obstetrician and
gynaecologist. Referral to psychiatrist for mental health assessment should be
considered.
Reference:
1) Management protocol for the HIV-infected pregnant mothers, October 2004
2) Clinical Practice Guideline: Management of HIV Infection in Pregnant Women,
February 2008
Definition
Causes
• Abruptio placenta
• Placenta Praevia
• Vasa Praevia
• Indeterminate APH
• Uterine rupture
• Local causes
General management
• Ask a quick but thorough history.
• Check BP and pulse rate.
• Assess amount of blood loss.
• Look for any evidence of hypovolaemic shock and activate Red Alert if
necessary.
• Resuscitate patient.
• Two large bore (14G/16G) intravenous access lines for fluid
resuscitation and blood transfusion.
• Oxygen therapy (5L/min through ventimask).
• Full Blood Count (FBC).
• Coagulation profile.
• Group and crossmatch.
• Evaluate the pregnancy and cause of bleeding.
• Insert CBD to assess renal function/hydration.
• IM Rhogam in non-sensitized Rhesus negative patient.
• Further management depending on the cause and after discussion with
specialist.
Pregnancy assessment
• Period of amenorrhoea
• Uterine size
• Uterine activity and tenderness
• Fetal condition & well being (perform CTG once mother is stable).
• Lie and presentation
• Placental localisation if not previously done
• Digital examination only after placenta praevia is ruled out by ultrasound
PLACENTAE PRAEVIA
Clinical presentation
Management
Expectant management
ABRUPTIO PLACENTA
Clinical presentation
Management
Vaginal delivery
• Favourable cervix
• Reactive CTG
• Intrauterine death (not to allow prolonged labour)
Caesarean section
• Unfavourable cervix
• Fetal distress
• Severe abruption (after resuscitation).
• Other obstetrics indication
Massive bleeding
Evaluate ABCs
Administer IV fluids
Administer supplemental oxygen
Consider transfusion
Fetal monitoring
Consider urgent
Immediate laparotomy
ultrasound Monitor fetus and mother,
examination supportive care
ifavailable
PROPHYLAXIS
Antenatal management
<
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Treat with oral haematinics or paranteral iron therapy.
>
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Paranteral iron in therapy.
Available in 2mL syringe dose amber vials ( for intramuscular / intravenous use ),
containing 50mg of elemental iron per mL.
Indications
Dosage
Dose= 0.0442 x (Desire Hb – Current Hb) x weight (kg) + 0.26 x weight (kg)
INTRAMUSCULAR INJECTION
INTRAVENOUS INJECTION
Dosage
Intrapartum management
• IV cannula in situ.
• Delay / avoid episiotomy unless absolutely necessary.
• Rapid and proper repair of episiotomy / perineal tear.
• Mild:
∼ GXM 2 units.
• Moderate:
∼ Consider slow intrapartum transfusion.
∼ GXM 2 units.
• Severe:
∼ Intrapartum transfusion of 2 units of packed cells slowly with IV
Lasix 40 mg in between each unit of blood transfused.
∼ GXM another 2 units.
Postpartum care
• Mild:
∼ Oral haematinics
• Moderate:
∼ Oral haematinics or
∼ Imferon injection
• Severe:
∼ To discuss with specialist regarding the need for transfusion
THALASSAEMIA
Recommendation
Antenatal management
MCV <
80
MCH <
27
Hb analysis
Treat with iron
Hb A2 Normal
Hb
A2>4%
Iron deficiency
Iron studies
Normal iron
DNA analysis
DNA
analysis
GENETIC COUNSELING
ANTENATAL MANAGEMENT
INTRAPARTUM MANAGEMENT
POSTPARTUM CARE
Dosage
Antenatal Assessment
• Presentation.
• Lie of fetus.
• Number of fetus.
• Fetal weight estimation.
• Placenta localisation.
Counselling
Intrapartum management
The incidence of breech presentation at term is around 3-4%. Management option for
breech presentation at term:
• Confirm gestation
• Rule out multiple pregnancy
• Type of breech
• Attitude of breech
• Estimated fetal weight
• Amniotic fluid index
• Placenta localisation
• Fetal abnormality
• Uterine anomaly
• Uterine / pelvic pathology
Tocolysis at ECV has been shown to increase the success rate for ECV. Beta agonists
are the best studied tocolytic and parenteral terbutaline use is commonly described.
Subcutaneous terbutaline had been used as accepted dosage of tocolysis
Inclusion criteria
Exclusion criteria
Potential complications
• Fetal bradycardia
• Intrauterine death
• Rupture of membrane
• Rupture of uterus
• Antepartum haemorrhage
• Placental abruption
• Fetomaternal haemorrhage
• Failed ECV
Protocol
It is being opted for more frequently after the publication of Term Breech Trial.
Indication
a) Mauriceau-Smellie-Veit manoeuvre
b) Burns-Marshalls manoeuvre
References:
Tocolysis at ECV has been shown to increase the success rate for ECV. Beta agonist are
the best studied tocolytic and parenteral terbutaline use is commonly described.
Subcutaneous terbutaline had been used as accepted dosage of tocolysis
Inclusion criteria
Exclusion criteria
Protocol
References:
Post dates pregnancy is defined as pregnancy past 40 weeks of gestation. Patient with
sure of dates and no fetal distress can be induced at 40 weeks + 10 days. Some form of
fetal monitoring, e.g. fetal movement chart is advisable when pregnancy is past the
expected date.
Pre-requisites
• Sure of dates.
• Dating ultrasound (if unsure of dates).
• No adverse obstetrical factors (e.g. medical disease, subfertility, bad
obstetric history).
• Good fetal movement.
• Strict fetal kick chart.
• Uterus corresponds to dates during antenatal follow up.
• Clinically adequate liquor.
• Mother is informed regarding the decision and is satisfied.
Exceptions
Methods of induction
• Prostaglandin
• Mechanical dilator (e.g. Dilapan)
• S&S (Sweep and stretch)
• Syntocinon
INTRAUTERINE DEATH
Requires two personnel to confirm the fetal death before explaining to the parents.
Ultrasound features
ANTENATAL MANAGEMENT
• Explaination to couple
• Sympathetic approach
• IM Rhogam in non sensitized Rhesus negative patient
• Investigations to find the possible cause of death
• Discuss regarding treatment option
• Anticardiolipin antibodies
• Lupus anticoagulant
• FBC
• Blood group / Rhesus group
• VDRL
• TORCH
• MOGTT at the time of IUD
• Discuss regarding post mortem
Treatment option
Spontaneous labour
∼ Chorioamnionitis
Induction of labour
LABOUR MANAGEMENT
Parent
• Offer bereavement counselling.
• Refer to psychiatrist if necessary.
• Allow them to be with the baby / take photo.
• Offer patient the option of isolation room after delivery.
• Suppression of lactation with a single dose of Cabergoline, 1 mg
on first day after delivery.
• Advice for any evidence of post-partum infection.
• Give appointment date at the postnatal clinic to:
∼ Reassess patient condition
∼ Review investigation
∼ Planned pregnancy when emotionally and physically prepared
∼ Contraception
∼ Pre pregnancy folic acid
∼ Advice on early booking
Baby
Placenta
The form must be filled in by the medical officer immediately post delivery after
discussion with the specialist regarding the possible cause of death.
ESSENTIAL PRE-REQUISITES IN
THE LABOUR ROOM
1. INTRAPARTUM
NUTRITION AND
HYDRATION
2. UNIVERSAL
PRECAUTIONS
3. PAEDIATRICS TEAM
STANDBY
Communicate with the Paediatrics team for all high risk cases to ensure their presence
during delivery especially in the following cases:
• Emergency LSCS
• Selected elective LSCS
• Fetal distress
• Prolonged labour
• Meconium-stained liquour
• Prematurity
• Antepartum haemorrhage
• Prematurity
• GDM mothers
• Multiple pregnancies
• Instrumental deliveries
• IUGR
• Vaginal breech delivery
Intramuscular pethidine
Inhalation of Entonox
Local anaesthesia
5. ANTIBIOTICS IN
OBSTETRICS
PPROM
Oral erythromycin (EES) 800 mg bd for ten days may be prescribed for women with
PPROM but not proven to be effective in spontaneous preterm labour (ORACLE 2)
PROM
iV ampicillin 2gm stat than 1gm 6h till delivery. Start as soon as possible.
Heart disease in pregnancy
Antibiotic prophylaxis for surgical procedures, labour and delivery. As the protocol above
Choice of :
• IV Augmentin 1.2g tds or
• IV Unasyn 750mg tds or
• IV Rocephine 1g daily
WITH IV metronidazole 500mg tds. All for 24 hours – 72 hours than change to oral
6
.
THROMBOPROPHYLA
XIS FOR OBSTETRICS
PATIENTS
• SC
clexane(enoxaparin)
40mg daily
Anticoagulants are started within 8 hours
post-partum
MANAGEMENT OF LABOUR
Nursing staffs
Medical officers
FETAL MONITORING
• Continuous CTG
• Psychological
• Inhalation
• Analgesics
• Pudendal nerve block
• Epidural
• Perineal infiltration
PARTOGRAM
AUGMENTATION OF LABOUR
FEEDING IN LABOUR
HYDRATION
• Induction of labour
• Previous caesarean section
• Breech / Twin pregnancy
• Bad obstetrics history
• PIH / PE
• Diabetic
• IUD
• IUGR / fetal compromise
• Anaemia
• History of retained placenta
• Grandmultipara
• History of APH
• Patient at risk of PPH
• Post dates
• Diabetes in pregnancy
• Hypertensive disorders in pregnancy
• Intrauterine growth restriction
• Reduced fetal movement
• Twin pregnancy
• Unstable lie when the lie become stable
• Bad obstetric history
• Intrauterine death
• Gross fetal abnormality
• Prelabour rupture of membranes
• Contracted pelvis
• Previous Classical Caesarean Section / hysterotomy
• Cord presentation
• Placenta praevia
• Active herpes virus infection
• Fetal malpresentation
• Previous surgery for stress incontinence
Prerequisites
0 1 2
Station -2 -1 0
Regime
• Primigravida - 3 mg Prostin
• Multigravida -
1.5 mg Prostin
• Maximum of 2 Prostin per day 6 hours apart for the first day
rd nd
• The 3 Prostin will be inserted early morning of the 2 day
• Further Prostin insertion must be discussed and assessed by Specialist
Precautions
• Grandmultipara
• Previous LSCS
• Bronchial asthma
• Drug allergy
Monitoring
• Uterine contractions
• Fetal heart Every 30 minutes for
• Vital sign (BP / PR)
theinsertion
• Repeat CTG in the first hour of Prostin first 2 hours
Complications
Procedure
• Use the other hand to insert an amniotic hook or a Kocher clamp into
the vagina.
• Guide the clamp or hook towards the membranes along the fingers in
the vagina.
• Place two fingers against the membranes and gently rupture the
membranes with the instrument in the other hand.
• Allow the amniotic fluid to drain slowly around the fingers.
• Note the colour of the fluid (clear, greenish or bloody). If thick meconium
is present, suspect fetal distress.
• After ARM, listen to the fetal heart rate during and after a contraction
and perform CTG.
• If good contraction is not established 2 hour after ARM, begin oxytocin
infusion.
Complications
• Cord prolapse
• Malpresentation (if ARM is done with a high station)
• Abruptio placenta
• Fetal heart rate abnormality
OXYTOCIN AUGMENTATION / INDUCTION REGIME
Regime
Primigravida 2 2 6
4 4 12
8 8 24
16 16 48
32 (max) 32 96
Multipara 2 2 6
4 4 12
8 8 24
16 (max) 16 48
Grandmultipara/ 2 2 6
Previous scar
4 4 12
8 (max) 8 24
** If desired contractions are not achieved at maximum infusion rate, further consultation
with specialist is required (40 units Oxytocin added to 500 ml Normal Saline for infusion
at 48 ml/hour (64 mU/min)).
Precautions
• Grandmultipara
• Previous scar
• Heart disease in pregnancy
Monitoring
• Hydrate patient
• Ensure patient lie on her left side
• Perform CTG
• Stop Oxytocin infusion
• Consider Salbutamol/Terbutaline drip
ABNORMAL PROGRESS OF LABOUR
First stage
• Latent phase
• Active phase
Partogram
Signs
Management
• Induction of labour
• Breech
• Twin pregnancy
• Intra-uterine death
• Pre-eclampsia
• Diabetes
• Cardiac disease
• Precious pregnancy
• Previous caesarean section
INTRAPARTUM FETAL MONITORING
Cardiotocogram (CTG) has been used widely for fetal monitoring to reduce hypoxic
intrapartum mortality and morbidity. However, there is debate regarding its benefit as
opposed to intermittent auscultation.
Admission test
CTG recording for a period of 20 minutes on admission should be done for patients with
gestation ≥ 32 weeks after discussion with the Medical Officer in charge of PAC.
Continuous monitoring
• Epidural analgesia
• Induction or augmentation of labour
• Prolonged labour
• Previous scar
• Abnormal admission CTG
• Meconium stained liquor
• Intrauterine infection
• Twin pregnancy / breech presentation
• IUGR / oligohydramnios
• Post term pregnancy
• PROM /APH
• Previous intrapartum death
• Bad obstetric history
• Maternal medical disease (e.g. hypertension, diabetes, severe anaemia)
All other patients not listed above should have an intermittent (2 hourly) CTG.
INTERPRETATION OF CTG
* Baseline fetal heart rate (FHR) 160 – 180 bpm or 100 – 110 bpm
* Baseline variability < 5 bpm for ≥ 40 min but less than 90 min
* Early decelerations
* Variable decelerations
* Single prolonged deceleration up to 3 minutes
* Baseline fetal heart rate < 100 bpm and > 180 bpm.
* Sinusoidal pattern ≥ 10 min
* Baseline variability < 5 bpm for ≥ 90 min
* Atypical variable decelerations
* Late decelerations
* Single prolonged deceleration > 3 minutes
Category Definition
Normal A CTG where all four features fall into the reassuring
category
Reviewing CTG
Adequate pain relief is important for patients in labour. Optimally, the choice of analgesia
during labour should be discussed with the patient during antenatal period.
NON-PHARMACOLOGICAL
PARENTERAL ANALGESIA
IM / IV Pethidine
IM Morphine
• Newborn:
∼ respiratory depression. IM/IV Naloxone is the antidote (0.1
mg/kg bodyweight. Repeated doses maybe required to prevent
recurrent respiratory depression.
EPIDURAL ANAESTHESIA
LOCAL BLOCK
Perineal infiltration
Pulmonary thromboembolism is one of the direct causes of maternal death. In the most
recent Confidential Enquiries into Maternal Death (2000), it is the cause of death. The
risk is increased by 6 folds and continues after delivery into the puerperium.
All health care providers should consider pain in the leg, chest pain and dyspnoea in an
otherwise healthy woman to be due to thrombosis or pulmonary embolism until proven
otherwise and ensure that appropriate treatment is instituted.
Low risk
• Uncomplicated pregnancy
• Elective caesarean section
• No other risk factors
Moderate risk
High risk
Low risk
• Early mobilization
• Adequate hydration
Moderate risk
High risk
Low risk
• Early mobilization
• Adequate hydration
Moderate risk
High risk
Regional anaesthetic techniques such as spinals and epidurals reduce the risk of acid
aspiration. However prophylaxis for acid aspiration is still mandatory in anticipation of the
need for general anaesthesia.
Diagnosis
Predisposing factors
Assessment
Management
Aim of tocolysis
st
• To allow time for completion of antenatal steroid therapy (24hr from 1
dose)
• In-utero transfer to a another hospital for the benefit of baby
Contraindications of tocolysis
• Chorioamnionitis
• Interauterine death
• Fetal abnormality/fetal distress
• Maternal cardiac disease
• Hyperthyroidism
• Antepartum haemorrhage
• Advanced labour (os > 5 cm)
• Hypertension
• Diabetes mellitus To discuss with specialist
TOCOLYTIC REGIME
Maintenance
• If contraction cease, maintain dose for 2 hours, then taper down by 1/3
of dose and maintain at that rate for 12 hours.
• If stable, reduce the dose further by 10 drops per minute every 30
Monitoring
Complications
• Fetal tachycardia
• Palpitation
• Headache
• Maternal tachycardia
• Maternal hypotension
• Maternal pulmonary edema
• Hypokalemia
• Hyperglycemia
Cessation of tocolysis
• Symptoms of intolerance (e.g. palpitation, severe tremor, chest pain,
vomiting, severe headache and restlessness).
• Maternal heart rate > 120 bpm.
• Maternal SBP<90mmHg or DBP < 60mmHg.
• Sign & symptom of pulmonary oedema.
• FHR > 180bpm.
• Maternal hypokalaemia
• Uterine contractions persist despite maximum infusion for 6-8 hours
ORAL NIFEDIPINE (ADALAT)
Maintenance
Contraindications
• Hypertension in pregnancy
• Bed rest for 24-48 hours after infusion and discharged after 72 hours, if
no contractions only.
• Vital signs/FHR and uterine activity are done hourly for 6-12 hours.
• If patient goes into labour, to discuss with the neonatologist regarding
possibility of delivery.
Corticosteroid therapy for fetal lung maturation should be considered and discussed with
the specialist, in patients who are at high risk of premature delivery at 24 to 36 weeks
gestation.
Indications
Precautions
• Diabetes mellitus
• Hypertension
• Concomitant tocolysis as there is a risk of pulmonary oedema
Dosage
Definition
Diagnosis
Initial Management
Monitoring
CHORIOAMNIONITIS
Criteria
0
• Temperature >38 C
• Malodorous liquor
• Uterine/adnexal tenderness
• Leukocytosis
• Maternal tachycardia >120 bpm
• Fetal tachycardia >160bpm
Management
Rupture of membranes
Consider: Conservative
management: Wait for 24 hours
•
Toc •
oly Ste
sis roi
• ds
Ste • Spontaneous Not in labour
roi P labour
ds r
• o
Allow labour
P p
r
Close monitoring h
o yl
p a
h ct
yl ic
a a
Stop
ct leaking n
ic ti
a bi
n o
ti ti Continue leaking /
bi c chorioamnionitis
Discharge &
o
Discharge & chorioamnionitis
o
monitor in
ti
ANC
c
Induction /
Delivery
Induce as
indicated
GBS is recognised as the most frequent cause of severe early onset infection in newborn
infants. Intrapartum antibiotic has been shown to significantly reduce the risk of early-
onset but not late-onset disease. GBS is also an important cause of maternal intrapartum
and postpartum infections.
Screening
ANTEPARTUM PROPHYLAXIS
These women do not need to be rescreened once identified and require intrapartum
antibiotic prophylaxis.
INTRAPARTUM PROPHYLAXIS
It is offered to all women with identified risk factors without universal screening:
Special circumstances
Cord presentation is when the cord lies below the level of the presenting part and it is
said to have prolapsed following rupture of the membranes and its release into the
vagina
Risk factors
Prevention
• Admission for patient with unstable or transverse lie in the last three
weeks of pregnancy.
• Avoid artificial rupture of membranes before the fetal pole has become
deeply engaged.
• Early vaginal examination following spontaneous rupture of the
membranes.
Management
Viable fetus
arrangement should be
made as quickly as
possible for immediate
caesarean section.
• If cervix is ³8 cm an
instrumental delivery /
vacuum extraction may
be attempted (after
discussing with
specialist).
• Allow spontaneously
vaginal delivery if
cephalic or breech
presentation.
• A transverse lie will require
caesarean section
despite fetal death.
SECOND AND
THIRD STAGE
OF
LABOUR
LABOUR
NORMAL DELIVERY
Symptoms / signs
Indications
Procedures
• Aseptic techniques.
• Infiltrate the perineum with 1% lignocaine (if not under epidural) beneath
the vaginal mucosa, beneath the perineal skin and deeply into
the perineal muscle.
• Perform episiotomy when crowning of the presenting part and the
perineum is thinned out.
• Place two fingers between the baby’s head and the perineum.
• Starting at the mid-point of the fourchette, cut the whole depth of the
perineum with scissors preferably in a single cut, about 3 – 4 cm in the
mediolateral direction.
• Control the baby’s head and shoulders as they deliver, ensuring that the
shoulders have rotated to the midline to prevent an extension of the
episiotomy.
• Carefully examine for any extension and other tears.
Repair of episiotomy
• Should be carried out immediately after the delivery of the placenta and
with the patient in the lithotomy position.
• Apply antiseptic solution to the area around the episiotomy.
• The cervix and vagina are systematically inspected for lacerations and if
none are present, the apex of the vaginal incision is located.
• The suture material preferred is absorbable synthetic material
polyglycolic acid or polyglactin, over chromic catgut as it is
associated with less perineal pain, analgesic use, dehiscence
and re-suturing.
• Vaginal mucosa is closed with continuous 2/0 suture.
• The repair starts about 1 cm above the apex and suturing continue to
the level of the vaginal opening.
• At the opening of the vagina, the cut edges of the vaginal opening is
brought together
• The needle is threaded between the opposed vaginal edges a few
centimetres back and out through the incision and tied.
• The perineal muscle closed using interrupted 2/0 sutures.
• Skin closure is affected using interrupted or continuous subcuticular 2/0
sutures. Continuous subcuticular technique is associated with less
short term pain.
• Perform a vaginal examination to look for any foreign body left behind
and a rectal examination to make sure no stitches are in the rectum.
Complications
• Haematoma
• Infections
• Necrotizing faxciitis
• Wound breakdown
• Perineal pain
• Dyspareunia
VAGINAL BREECH DELIVERY
Assessment
• Cause of breech
• Fetal condition
• Fetal weight and attitude
• Maternal pelvis
• Maternal condition e.g. maternal disease
• Maternal / parental wishes
• Rule out contraindications:
∼ Need for caesarean section for other indications
∼ Flexed / footling breech
∼ Preterm breech
∼ Extended head
∼ Estimated fetal weight < 2500gm or > 3500gm
∼ Previous uterine scar
∼ Fetal abnormality which may cause dystocia
∼ Fetal compromise
∼ IUGR
Second stage
• Inform specialist
• Patient should not push until the cervix is fully dilated. Full dilatation
should be confirmed by vaginal examination.
• Patient in lithotomy position.
• Perineum is cleaned and draped.
• Perineal infiltration with Lignocaine 1% if not under epidural.
• Patient is encouraged to bear down with each contraction.
• Episiotomy is performed when the buttock descend the perineum.
• Allow spontaneous delivery of the buttocks up to umbilicus. Gently hold
the buttocks but do not pull.
• The legs (if in extended position) are freed with digital pressure applied
on the popliteal fossa).
• Hold the baby by the hips with a sterile towel. Do not hold by the flanks
or abdomen.
• The trunk is delivered and a loop of cord is brought down gently.
• Mother is encouraged to bear down until the anterior shoulder is visible
at the introitus.
• Both arms will deliver spontaneously unless the arms are stretched
above the head or folded around the neck, whereby the Lovset’s
manoeuvre is applied.
• The baby is allowed to hang suspended by its own weight as the head
entered the pelvis.
• The aftercoming head should be delivered preferably by forceps. As
0
soon as the hairline is seen, the fetus is lifted at an angle of 45 to the
mother’s abdomen by assistant and Neville Barnes forceps applied.
The forceps are applied from below with the left blade first followed by
the right.
• The handles locked easily. Using constant, gentle traction, the head is
delivered slowly, with the assistant guarding the perineum.
TWIN DELIVERY
Twin pregnancy is associated with greater risks to both mother as well as the fetuses
when compared from a singleton pregnancy.
FIRST STAGE
Haemoglobin level.
• GXM 2 units of whole blood.
• Insert intravenous cannula.
• Assess the presentation of the first twin.
• Partogram. Not to allow prolonged labour.
• Ensure good contraction.
• Augmentation after discussion with specialist.
• Provide adequate pain relief (preferably epidural).
• Continuous fetal monitoring of both fetus (internal and external monitoring).
SECOND STAGE
Options of instruments
• Ventouse
∼ Metal cup
∼ Silastic cup
• Forceps
∼ Wrigley forceps
∼ Neville Barnes forceps
∼ Kielland forceps
Indications
nd
• Prolonged 2 stage of labour
• Maternal distress
• Maternal heart disease
• Severe pre-eclampsia
• Fetal distress in second stage
• Delivery of the aftercoming head in breech (for forceps)
Pre-requisites
VENTOUSE DELIVERY
Procedure
Failure
• The head does not advance with each pull. Do not persist if no descent.
• The fetus is undelivered after three pulls
• The cup slips off the head twice at the proper direction of pull with a
maximum pressure
Tips
• The head must be completely delivered with no more than three pulls
and within 15 minutes of first applying the cup.
• Should not be used at gestations of less than 36 weeks.
Fetal complications
Maternal complications
FORCEPS DELIVERY
Procedure
• Patient is positioned and examined as in vacuum delivery.
• Analgesia by pudendal block or local infiltration of 1% lignocaine over
the episiotomy site.
• Assemble the blades before application. Ensure that the parts fit
together and lock well.
• Lubricates the blades of the forceps.
• Two fingers of the right hand are inserted into the vagina on the side of
the fetal head. The left blade is held with the left hand positioned
parallel to the ipsilateral inguinal ligament of the mother. It is slide
gently between the head and fingers to rest on the side of the head.
This is followed by the right blade.
• If the head is not in direct OA or OP position, it must be rotated manually
before the blades applied.
• A biparietal, bimalar application is the only safe application.
• Depress the handles and lock the forceps.
• If the blade cannot be inserted or locked easily, remove the blades and
reassess position.
• Apply traction only during uterine contractions.
• Initial direction is downwards and outwards and progressively changed
to upwards and outwards as head descent the birth canal.
• Excessive traction force should never be used. Use only one hand to
pull.
• Episiotomy is done once perineum is distended.
• Fetal heart should be checked in between the contractions.
• Remove the blades once the head is delivered.
• The baby is handed to paediatrician. Examine for any trauma or injury
• After delivery of the placenta, check for the extent of vaginal or cervical
injury
Correct applications
Failure
• Fetal head does not advance with each pull. Do not persist if no
descent.
• Fetus is undelivered after three pulls with no descent.
Tips
• Brute force must never be use during insertion, locking, traction and
removal of forceps.
• The head must at least descend after 2 tractions and abandon
procedure if no descent.
• The head must be completely delivered with no more than three
tractions.
• Abandon the procedure if failure to insert the blades, failure to lock the
blades or no descent on traction.
Fetal complications
Maternal complications
The vast majority of sphincter defects are unrecognised at delivery. Woman may suffer
loss of control over bowel movements and gas if torn anal sphincter is not repaired
correctly.
Definition
st
• 1 degree: Injury involving the vaginal mucosa and connective tissue.
nd
•2 degree: Injury involving vaginal mucosa and perineal muscles.
rd
• 3 degree: Injury involving the anal sphincter complex (external anal
sphincter and internal anal sphincter).
th
• 4 degree: Injury involving the anal sphincter complex and rectal
mucosa.
Management
Management
Post-procedure care
• Adequate analgesia.
• Continue with oral antibiotics (Ampicillin and Metronidazole) for 1 week.
• Give stool softeners (Lactulose) for 10 days.
• Avoid giving enemas or performing any rectal examinations for 2 weeks.
• Advice on sign and symptoms of infection.
• Follow up appointment at 6 weeks and enquire regarding incontinence
to flatus, liquids and solids and fecal urgency.
• Referral to colorectal surgeon if any problems.
• Advise on subsequent delivery:
∼ Subsequent vaginal delivery may worsen anal
incontinence symptoms.
∼ If symptomatic, the option of elective caesarean
section should be discussed.
∼ If asymptomatic, there is no clear evidence as to
the best mode of delivery.
• Start the repair about 1 cm above the apex of the vaginal tear and
continue to suture to the level of the vaginal opening.
• At the opening of the vagina, bring together the cut edges of the vaginal
opening and bring the needle under the vaginal opening and out
through the perineal tear and tie.
• Repair the perineal muscles using interrupted 2/0 suture. If the tear is
deep, place a second layer of the same stitch to close the space.
• Repair the skin using interrupted (or subcuticular) 2/0 sutures starting at
the vaginal opening.
• Perform a vaginal examination to look for any foreign body left behind
and a rectal examination to make sure no stitches are in the rectum.
CERVICAL TEARS
Management
Definition
Type
Causes
• Uterine atony
• Genital tract trauma
• Retained placenta
• Coagulation defects
• Uterine rupture
• Uterine inversion
• Amniotic fluid embolism
Prevention
Management
Determine cause
Uterine
rupture
Bimanual uterine
compression or aortic
compression
Laparotomy
Laparotomy
Need to conserve
Fails uterus Simple repair or
hysterectomy
•
Bra
ce
sut
Complete
uri
family
ng
of
ute
rus
Fails •
Int
ern
al
Hysterectomy
ilia
c
art
ery
liga
tion
•
Ute
rin
e
ta
mp
on
ad
MANUAL REMOVAL
e OF PLACENTA
Not able to deliver placenta by controlled cord traction within 30 minutes of delivery of
fetus.
• Bladder is catheterised
• Syntometrine has been given
• Sufficient time is allowed
Pre-requisite
Procedure
Diagnosis
• First degree: the fundus turning itself inside out but does not herniated
through level of internal os.
• Second degree: the fundus passes through the cervix and lies within
the vagina. This is the commonest type.
• Third degree: the entire uterus is turned inside out and hangs outside
the vulva.
Management
Repositioning the uterus should be performed immediately. With time, the constricting
ring around the inverted uterus becomes more rigid and the uterus more engorged with
blood.
Manual replacement
SHOULDER DYSTOCIA
Definition
Difficulty or failure to deliver the fetal body after the delivery of fetal head following failure
of shoulders to traverse the pelvis after delivery of the head.
Risk factors
• Fetal factors:
∼ Estimated big baby more than 4 kg
∼ Previous history of shoulder dystocia
∼ Previous history of big baby
∼ Anencephaly
∼ Post term pregnancy
• Maternal factors:
∼ Diabetic mother
∼ High maternal birth weight
∼ Maternal obesity more than 80kg
∼ High maternal weight gain
∼ Advance maternal age
• Abnormality of labour:
∼ Prolonged late active phase
∼ Prolonged second stage
∼ Excessive moulding
∼ Delayed in descent leading to mid pelvic
instrumental delivery
∼ Turtle neck sign during second stage of labour
Prevention
Caesarean section has been suggested for diabetic women with a fetal weight estimated
to be above 4.0 kg and for non diabetic women with an estimated fetal weight above 4.5
kg and slow progress of labour.
Despite the highest degree of awareness of the risk factors, shoulder dystocia still occurs
unexpectedly. It is suggested that:
Management
• McRobert’s manoeuvre
∼ Abduct hips, rotated outwards and flexed with the
thighs touching the abdomen and the two
assistants holding a leg each
∼ Encourage maternal pushing
∼ Lateral neck traction / downward axial traction on
the fetus
• Suprapubic pressure
∼ Pressure by assistant with the flat hand of the
hand laterally in the direction the baby is facing
and posteriorly.
• Cleidotomy
ECTOPIC PREGNANCY
A condition where the pregnancy is outside uterine cavity.
Probable cause
Ddelay in the passage of the fertilized ovum down the tube due to
• Pelvic inflammatory disease
• Gross pelvic pathology ; endometriosis
• Congenital abnormality of the fallopian tube ; diverticula ,
hypoplasia
• IUCD
Clinical features
Sign
• Pallor
• Abdominal tenderness
• Abdominal distension
• vaginal examination – slight enlarged uterus , tender adnexae ,
positive cervical excitation
Investigations
• UPT
• Ultrasound features
∼ Complex adnexal masses ( can be organized blood
clots ) / live embryo in adnexa ( 10 – 20% )
∼ Pseudogestational sac in uterus
∼ Empty uterus
∼ Fluid in POD
• Serum B hCG
∼ Level generally lower in ectopic pregnancy
∼ At level above 1500 iu/l, an ectopic pregnancy will
usually be visualised with TVS
∼ Level that plateau below 1000 iu/l, can either be a
miscarriage / pregnancy of unknown location.
∼ Serial hCG estimation can be done in
difficult situation to exclude early ectopic
pregnancy
∼ Although a doubling hCG titre is often
expected in a normal pregnancy , but this
can vary depending on gestation
In a patient who has delayed menstruation with positive UPT test and empty uterine
cavity on ultrasound should be highly suspected to have ectopic pregnancy
Management
PUERPERIAL SEPSIS
Evaluation
• Thorough history of intra and post partum period – to reveal
predisposing factors suggesting of infection
• Physical examination focusing particularly on the likely areas of
concern.
• Investigation : FBC with differential , UFEME and culture , blood
culture , Vaginal swab culture. CXR and Sputum gram stain and
culture should be done if respiratory infection is suspected.
Treatment
Endometritis
• Broad spectrum antibiotic
• Encourage perineal hygiene
Wound infection
• Open, drain any pus, debride any non viable tissue and cleansing
• Sitz baths for episiotomy wound infections
• Wound may be left open to heal by secondary intention or
secondary suturing later after wound is healthy
Urinary tract infection
Breast abscess
Pneumonia
• Broad spectrum antibiotics
• Chest physiotherapy
• Oxygen therapy should be guided by arterial blood gas and
pulse oxymetry.
Objectives
MOTHER EMERGENCIES
BABY EMERGENCIES
Mula
Pegawai Keselamatan
Selepas pukul 9mlm) Rujuk No.Hand Set yang tertera. < LOKASI>
<KEJADIAN>
( Hospital
Operator )
(Doktor/Jururawat)
Tamat
OBJECTIVES
PRINCIPLES
HANDWASHING
• All staff must be aware of the infection risk from body fluids, blood,
needles and sharps, and must ensure that others are not exposed to
these hazards.
• Use each needle and syringe only once.
• Do not leave needles and sharps lying around.
• Avoid recapping, bending or breaking needles prior to disposal.
• Do not dissemble needle and syringe after use.
• If a needle must be removed from the syringe or other device before
discarding, place the plastic sheath on a flat surface and single-
handedly insert the needle into it. Do not hold the plastic sheath
during this procedure.
• Take a great care in recapping blood sampling barrel system needles or
non disposable syringes.
• Discard needles and other sharps in the sharps disposal bins only.
• Reduce needlestick injuries by handling used needles as little as
possible.
• Use an appropriate sized needle for the repair of episiotomy, together
with a technique using a needle holder.
• Passing all sharp instruments onto a receiver, rather than hand-to-hand
at surgery and avoid using fingers in needle placement.
• If a needle injury or other high-risk exposure to blood and body fluids
occurs, report the incident immediately.
LABORATORY SPECIMEN
SPILLAGES
WASTE DISPOSAL
Care should be taken when prescribing antibiotics in pregnancy. Certain antibiotics are
contraindicated in pregnancy. Beta-lactam antibiotics and macrolides are probably the
safest antibiotics to use in pregnancy.
Or
Or
IV Cefuroxime 750 mg 8
hourly for 10 – 14 days
Or
Retained
placental
tissue/products
of conception
should be
evacuated after
6-8 hours of
antibiotic cover.
PAEDIATRIC REFERRAL
1. Fetal distress.
2. Cord prolapse.
3. Moderate / thick meconium-stained liquor.
4. Prematurity less than 34 weeks gestation.
5. Severe pre-eclampsia or eclampsia.
6. Antepartum haemorrhage.
7. Instrumental deliveries.
23